Latest evidence on impacts and implementation of school meal programmes
Details
Journal: Cochrane
Year: 2025
Authors: Elizabeth Kristjansson; Michael Dignam; Anita Rizvi; Muna Osman; Olivia Magwood; Deborah Olarte; Juliana FW Cohen; Julia Krasevec; Tanya Grover; Patrick R Labelle; Jennifer A Garner; Laura Janzen; Sydney Rossiter; Omar Dewidar; Beverley Shea; Vivian Welch; George A Wells
Abstract
School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta‐analyses, providing a more comprehensive picture of the effectiveness of school feeding.
Objectives
1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide.
2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged.
Search methods
We searched 17 subject‐specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top‐up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews.
Eligibility criteria
We included individually randomized, cluster‐randomized, and cross‐over trials, as well as longitudinal non‐randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced‐price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years.
Outcomes
Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), and overweight/obesity.
Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia.
We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow‐up.
Risk of bias
We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster‐RCTs, and for cross‐over trials. We evaluated the quality of NRSIs using the School‐based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale.
Synthesis methods
We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta‐analyses used random‐effects generic inverse variance.
We conducted equity subgroup analyses by sex and socioeconomic status.
We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs.
Included studies
We included 40 studies with 83 reports. There were 13 RCTs (12 cluster‐randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low‐ and middle‐income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta‐analyzed or reported 14.
Synthesis of results
Low‐ and middle‐income countries (LMICs)
School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster‐RCTs, 5587 participants; high‐certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI −0.06 to 0.11; P = 0.61; I2 = 54%; 3 cluster‐RCTs, 3417 participants; low‐certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster‐RCTs, 5200 participants, high‐certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI −2.64% to 2.97%; P = 0.91; I2 = 81%; 3 cluster‐RCTs, 3566 participants; low‐certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I2 = 0%; 2 cluster‐RCTs, 3678 participants; moderate‐certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I2 = 0%; 3 cluster‐RCTs, 2132 participants; moderate‐certainty evidence).
Two cluster‐RCTs assessed change in obesity/overweight. One 10‐month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty.
Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review.
High‐income countries (HICs)
One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group.
Equity analyses
The equity (subgroup) analyses by sex and by socio‐economic status were all non‐significant. There were only two studies in each subgroup analysis; they were likely underpowered.
Authors' conclusions
In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain.
We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co‐ordination of research, and that researchers and interest holders work together to identify a core set of outcomes.
Details
Journal: Foods
Year: 2022
Authors: Emanuele Batistela dos Santos; Dayanne da Costa Maynard; Renata Puppin Zandonadi; António Raposo; and Raquel Braz Assunção Botelho
Abstract
Considering the importance of schools for sustainable food offers and the formation of conscientious citizens on sustainability, this systematic review aimed to verify the recommendations on sustainability in school feeding policies and the sustainability practices adopted in schools.
The research question that guided this study is “what are the recommendations on sustainability in school feeding policies and the sustainability practices adopted in schools?”. This systematic review was prepared according to PRISMA, and its checklist was registered in PROSPERO. Specific search strategies for Scopus, Web of Science, Pubmed, Lilacs, Google Scholar, and ProQuest Dissertations & Theses Global were developed. The included studies’ methodological quality was evaluated using the Meta-Analysis Statistical Assessment and Review Instrument (MASTARI). A total of 134 studies were selected for a full reading. Of these, 50 met the eligibility criteria and were included in the systematic review.
Several sustainability practices were described. The most cited are school gardens and education activities for sustainability. However, actions carried out in food services were also mentioned, from the planning of menus and the purchase of raw materials (mainly local and organic foods, vegetarian/vegan menus) to the distribution of meals (reduction of organic and inorganic waste: composting, recycling, donating food, and portion sizes). Recommendations for purchasing sustainable food (organic, local, and seasonal), nutrition education focused on sustainability, and reducing food waste were frequent; this reinforces the need to stimulate managers’ view, in their most varied spheres, for the priority that should be given to this theme, so that education for sustainability is universally part of the curricula.
The importance of education in enabling individuals to promote sustainable development is reaffirmed in Sustainable Development Goal 4 (SDG 4). The development of assessment instruments can help monitor the evolution of sustainable strategies at schools and the main barriers and potentialities related to their implementation.
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Journal: International Journal of Environmental Research and Public Health
Year: 2022
Authors: Caitlin Wall; Terezie Tolar-Peterson; Nicole Reeder; Marina Roberts; Abby Reynolds; Gina Rico Mendez
Abstract
Malnutrition and hunger can lower a child’s ability to learn effectively. Many countries in Africa experience high rates of childhood undernutrition, and school feeding programs are a common tool used to address this challenge. A systematic review was conducted to evaluate the effect of school-provided meals on educational outcomes in preschool and primary school children. Specific outcomes of interest in this review included test scores, attendance, and enrollment rates. PubMed and Scopus were used for an electronic search of relevant studies. Studies included in this review were randomized and non-randomized controlled trials, prospective cohort studies, controlled before-after studies, and pre/post-test design studies published in the past 10 years in English in sub-Sahara Africa. Findings from the nine studies included in this review suggest a positive correlation between school feeding programs and educational outcomes. Although mealtime may reduce classroom time, the benefits of providing a meal outweigh the potential loss of learning time because hungry children may not learn as effectively. In conclusion, it is recommended that school meal programs be implemented and expanded. To improve general wellbeing and learning capabilities of children, school meals should be employed starting at a young age. More research on school feeding programs is needed concerning the preschool age group (2–5 years), as there is a limited amount of information in this area.
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Journal: Nutrients
Year: 2021
Authors: Juliana F. W. Cohen; Amelie A. Hecht; Gabriella M. McLoughlin; Lindsey Turner; Marlene B. Schwartz
Abstract
The school environment plays an important role in children’s diets and overall health, and policies for universal free school meals have the potential to contribute to positive child health outcomes. This systematic review evaluates studies examining the association between universal free school meals and students’ school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published in economically developed countries published through December 2020 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters’ Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. A total of 47 studies were identified and the Newcastle-Ottawa Scale (NOS) was applied to assess bias. Nearly all studies examining universal free school meals found positive associations with school meal participation. Most studies examining universal free school meals that included free lunch found positive associations with diet quality, food security, and academic performance; however, the findings of studies examining only universal free breakfast were mixed. Research findings were similarly mixed when examining attendance as an outcome. Concerns about adverse outcomes on student BMI were not supported by the literature; in fact, several studies detected a potentially protective effect of universal free school meals on BMI. Research examining the impact of universal free meals on school finances was limited, but suggest that lower-income school districts in the U.S. may have positive financial outcomes from participation in universal free school meal provisions. Additionally, providing free meals to students may be associated with improved household incomes, particularly among lower-income families with children. Further research is needed to examine the financial implications of universal free meals for both school districts and families. Overall, universal free school meals may have multiple benefits for students and countries should consider universal free school meal provisions with strong nutrition guidelines.
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Journal: Journal of Global Health
Year: 2021
Authors: Dongqing Wang; Sachin Shinde; Tara Young; Wafaie W Fawzi
Abstract
Background: School feeding programs are ubiquitous in low- and middle-income countries (LMICs) and may have critical implications for the health and education of school-age children and adolescents. This systematic review aimed to assess the impacts of school feeding on educational and health outcomes of children and adolescents in LMICs.
Methods: Interventional studies on the effects of school feeding on nutritional and health outcomes of children and adolescents receiving primary or secondary education in LMICs were included. MEDLINE, EMBASE, CINAHL, the Cochrane Library, and grey literature were searched (through December 2019) to identify eligible studies. We included randomized controlled trials and controlled before-after studies on school feeding conducted in LMICs among children and adolescents aged 6 to 19 who received primary or secondary education. Two reviewers independently conducted study selection, data extraction, and risk of bias assessment. Meta-analyses were performed for outcomes available in three or more independent studies. Subgroup analyses were conducted by study design and school feeding modality whenever possible.
Results: Fifty-seven articles met the inclusion criteria for the review, including 44 randomized controlled trials and 13 controlled before-after studies; 19 articles were included in the meta-analysis. School feeding resulted in a significant increase in height (mean difference = 0.32 cm; confidence interval (CI) = 0.03, 0.61; P = 0.032) and weight (mean difference: 0.58 kg; 95% 95% CI = 0.22, 0.93; P = 0.001) over 12 months, compared to those in the control groups. School feeding also resulted in a significant increase in the percentage of school days attended (2.6%; 95% CI = 1.2%, 3.9%; P < 0.001).
Conclusions: School feeding is an important approach to improving the health and education outcomes of children and adolescents living in LMICs. More well-designed research is needed to establish further the effectiveness of school feeding for nutritional outcomes and academic achievement.