School feeding

School feeding programs increase weight and school attendance of students

 

Photos by: Yuri Kozyrev (R), Alejandro Lipszyc (L)

 

Why is school feeding important? 
 

  • Early malnutrition and/or micronutrient deficiencies can negatively affect children’s physical, mental and psychosocial health. These deficiencies have been linked to poorer cognitive functioning. School feeding programs are designed to improve attendance, achievement, growth and other health outcomes by providing food to socio-economically disadvantaged children in high- and low- and middle-income countries. 

Does it work? 

  • In lower income countries, school feeding increases weight and school attendance, and may increase height gain. Children who were fed at school also improved math achievement more than controls who did not receive food at school. 

 Equity – does it work in the disadvantaged? 

  • All of the participants in the included studies were disadvantaged children therefore school feeding programs are effective at improving health and cognitive outcomes in disadvantaged children. 

  • School feeding programs may be more effective for more disadvantaged or malnourished children  

Intervention Delivery 

  • The studies included in this review provided school feeding through meals (breakfast or lunch) or through snacks/milk. 

  • The review does not report on the effectiveness of delivery mechanisms, but found that timing of the meal may be important. Meals provided outside of regular school hours (i.e. breakfast) may have lower compliance. 

Population and Setting 

  • All included studies were conducted in low-, and higher income countries with disadvantaged children. 

Summary of Findings [SOF] Table: School feeding to improve the physical and psychosocial health of disadvantaged students 

Patient or population: Disadvantaged children between ages 5 and 19 
Settings: Schools in developed and developing countries 
Intervention: School feeding 
Comparison: No school feeding 

Outcomes 

Comparator (control) 

Intervention vs. control mean difference 
(95% CI) 

No of Participants 
(studies) 

Quality of the evidence 
(GRADE) 

Developing Country 

 

 

 

 

Weight gain (kg) – RCT 

The mean weight gain in the control group ranged from 1.87 to 10.1 kg 

MD 0.39 kg more  (0.11-0.67) 

1462 (3) 

 

Weight gain (kg) – CBA 

The mean weight gain in the control group ranged from 0.97 to 2.28 kg 

MD 0.71 kg more (0.48-0.95) 

984 (4) 

 

Height gain (cm) – RCT 

The mean height gain in the control group ranged from 3.38-12.2 cm 

MD 0.38cm more  
(-.032-1.08) 

1462 (3) 

 

Height gain (cm) – CBA 

The mean height gain in the control group ranged from 3.2 to 5.24 cm 

MD 1.43 cm more (0.46-2.41) 

986 (4) 

 

Full scale IQ – CBA 

The mean full scale IQ for the control group was 95.8. 

MD 3.90 points higher (-2.88-10.68) 

231 (1) 

 

Developed Country 

 

 

 

 

Weight gain (kg) – developed country 

The mean weight gain in the control group was 5.12 kg 

MD 0.13 kg more  
(-0.23-0.49) 

520 (1) 

 

Height gain (cm) – developed country 

The mean height gain in the control group was 9.18 cm 

MD 0.28 cm more  
(-0.01-0.57) 

520 (1) 

 

Adverse events: None reported 

Relevance of the review for disadvantaged communities 

School feeding programs increase weight and school attendance of students. 
All of the participants in the included studies were disadvantaged children therefore school feeding programs are effective at improving health and cognitive outcomes in disadvantaged children. These programs may be more effective for disadvantaged or malnourished children.

Findings 

Interpretation 

Equity – Which of the PROGRESS groups examined 

 

The review reported subgroup analyses for age and sex but were unable to complete a planned subgroup analysis by socioeconomic status due to lack of SES stratified data.  

The results found that school feeding programs may be more effective at younger ages, for students 5-6 or 9-10 years old. Policymakers may consider focusing on younger age groups for school feeding programs.  

There was generally little evidence for difference in effectiveness by sex. 

One included study found that meals including protein (meat) resulted in greater weight gain in boys than girls. Another study found greater gains in height for girls. More studies are needed that examine whether different foods will affect boys and girls differently and ensure that there is a balance to ensure gains for both. 

Studies were conducted in both low and higher income countries. All of the participants were classified as disadvantaged. Low income country participants were ‘predominantly disadvantaged’ according to the following criteria: from rural area, from urban low SES community, or is 30% of the samples of children were underweight or stunted. Undernourished children, showed greater gains in short-term cognitive performance than well-nourished children. 

The included studies suggest that school meals are more effective for those who are more in need. As such, implementation of the intervention may reduce inequalities. 

Equity Applicability 

 

The review does not report on the effectiveness of different delivery mechanisms for school feeding. The studies included in this review provided school feeding through meals (breakfast or lunch) or through snacks/milk.  

Many factors can impact the effectiveness of school feeding programs: the design of the program, the energy, protein and fat content of the provided meals or snacks, compliance with the program, and the home environment. Policy makers and practitioners will have to determine the most suitable delivery mechanism, frequency, and timing within the local setting.   

The review did not assess the role of co-interventions on effectiveness. However, school feeding is expected to have greater improvements if the learning and living environments of the children are also improved. Schools need to have basic amenities, such as adequate materials and supplies 

Other studies are needed for policy makers and practitioners to make decisions on how school feeding might relate to other nutritional, health and environmental interventions. 

School meals are an important tool to increase school attendance and nutrition. They should be used in combination with other interventions. 

Cost-equity 

 

The review did not report on the cost-effectiveness of school feeding overall or in each disadvantaged group, due to insufficient data 

The cost of school feeding may be variable based on local conditions outside of research settings.  Policymakers planning to implement school feeding need to consider the cost of the meals/snacks/milk to be provided as well as the other resources needed to prepare, serve, and store the food items. 

Monitoring & Evaluation for PROGRESS Groups 

 

School meals resulted in small improvements in weight, school attendance, math performance, and behaviour. Improvements in height were seen mostly in children younger than eight years of age. 

School feeding is recommended for increasing weight, school attendance, math performance, and behavior in disadvantaged students aged five to nineteen 

To meet the needs of the target population, it is important that foods be appealing, culturally acceptable and locally available. Piloting a school feeding program is important to identify and address specific nutritional issues and needs of the target population.  Effective delivery and process evaluation is important, as well as the encouragement of full participation. An unexpected adverse effect of school feeding is substitution.  – The home diet may be reduced for children who receive food at school. This may reduce the effectiveness of school feeding. Other possible confounders are energy content of meals, and student compliance. 

Implementation of a school feeding program needs to include an evaluation to ensure the effectiveness of the intervention. Policy makers need to monitor the program to ensure that possible adverse effects, such as substitution are detected as well as identify any other confounders. The studies from high-income countries found that compliance was lower than expected which will impact the program’s effectiveness. 

Who is this summary for? 
  • People making decisions about the use of school feeding for disadvantaged students. 
This summary is based on the following systematic review: 
Kristjansson B, Petticrew M, MacDonald B, Krasevec J, Janzen L, Greenhalgh T, Wells GA, MacGowan J, Farmer AP, Shea B, Mayhew A, Tugwell P, Welch V. School feeding for improving the physical and psychosocial health of disadvantaged students. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD004676. DOI: 10.1002/14651858.CD004676.pub2.  
What is a systematic review? 
  • A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies. 
This summary includes: 
  • Key findings from research based on one systematic review 
  • Considerations about the relevance of this research for low and middle income countries 
Not included: 
  • Recommendations 
  • Additional evidence not included in the summarized systematic review 
  • Detailed descriptions of the interventions or their implementation.

Comments on this summary? Please contact Jennifer Petkovic.