Effects of policies or interventions that influence the school food environment on children's health and nonhealth outcomes: a systematic review

CONTEXT

Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children's dietary intake may help address this double burden of malnutrition.

OBJECTIVE

This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children's health and nonhealth outcomes.

DATA SOURCES, EXTRACTION, AND ANALYSIS

Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

CONCLUSIONS

Seventy-four studies reporting 10 different comparisons were included. The body of evidence indicates that interventions addressing the school food environment may have modest beneficial effects on certain key outcomes. Nutrition standards for healthy foods and beverages at schools, interventions that change how food is presented and positioned, and fruit and vegetable provision may have a beneficial effect on the consumption of healthy foods and beverages. Regarding effects on the consumption of discretionary foods and beverages, nutrition standards may have beneficial effects. Nutrition standards for foods and beverages, changes to portion size served, and the implementation of multiple nudging strategies may have beneficial effects on energy intake. Regarding effects of purchasing or selecting healthier foods, changes to how food is presented and positioned may be beneficial. This review was commissioned and supported by the WHO (registration 2020/1001698-0). WHO reviewed and approved the protocol for the systematic review and reviewed the initial report of the completed systematic review.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020186265.

Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: A systematic review and meta-analysis

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.

Registration

PROSPERO ID: CRD42020159003.

The effect of school feeding programme on class absenteeism and academic performance of schoolchildren in Southern Ethiopia: a prospective cohort study

OBJECTIVE

Ethiopia recently scaled up the implementation of a school feeding programme (SFP). Yet, evidence on the impact of such programmes on academic outcomes remains inconclusive. We evaluated the effect of the SFP on class absenteeism and academic performance of primary school students (grade 5-8) in Sidama zone, Southern Ethiopia.

DESIGN

This prospective cohort study enrolled SFP-beneficiary (n 240) and non-beneficiary (n 240) children 10-14 years of age from sixteen public schools and followed them for an academic year. School absenteeism was measured as the number of days children were absent from school in the year. Academic performance was defined based on the average academic score of the students for ten subjects they attended in the year. Data were analysed using multivariable mixed effects negative binomial and linear regression models.

SETTING

Food insecure districts in Sidama zone, Southern Ethiopia.

PARTICIPANTS

SFP-beneficiary and non-beneficiary children 10-14 years of age.

RESULTS

The mean (sd) number of days children were absent from school was 4·0 (sd 1·5) and 9·3 (sd 6·0), among SFP beneficiaries and non-beneficiaries, respectively. Students not covered by the SFP were two times more likely to miss classes (adjusted rate ratio = 2·30; 95 % CI 2·03, 2·61). Pertaining to academic performance, a significant but small 2·40 (95 % CI 0·69, 4·12) percentage point mean difference was observed in favour of SFP beneficiaries. Likewise, the risk of school dropout was six times higher among non-beneficiaries (adjusted rate ratio = 6·04; 95 % CI 1·61, 22·68).

CONCLUSIONS

SFP promotes multiple academic outcomes among socio-economically disadvantaged children.

The Nature and Nurture of Child Development

Although the reduction of child morbidity and the promotion of physical growth are important and necessary aspects of child development, these criteria by themselves do not define the adequacy of children's development. There are also behavioural-developmental criteria that emphasize the promotion of competence. the competent individual is one who can effectively adapt to and interact with his or her environment. Traits that define individual competence fall into five domains: cognitive skills, temperament/personality, motivation, self-perceptions, and interpersonal style. These domains are not completely independent, and there is at least partial overlap. the expression of individual differences in competence is partially moderated by context. Further, not all children achieve competence. Over time some children fall further and further behind their peers in their developmental course. in understanding what biological and psychosocial factors influence the development of individual differences in competence, four principles are critical.

First, most aspects of individual competence are multidetermined. This means that interventions designed to facilitate development must be multifocal in nature, integrating influences from different domains. Second, influences upon children's development tend to be specific in nature. This emphasizes the importance of targeting specific interventions to specific outcomes. Third, individual developmental influences rarely operate in isolation from each other. Developmental risk factors tend to cluster together, as do developmentally protective influences. the extent of the impact of a given developmental risk factor will depend, in part, on the degree to which this risk factor covaries with other risk factors. Fourth, developmental risk and protective factors operate across time. Early exposure to developmental risks may increase the individual's susceptibility to later risk factors (sensitizing) or may limit the degree to which the individual can profit from later exposure to protective factors such as intervention (blunting). Early exposure to developmentally protective factors may attenuate the impact of later exposure to developmental risk factors (steeling).

Principles underlying the nature and nurture of individual competence emphasize the need to use an IT-AT intervention strategy (Integrate Target Across Time). This means the need to integrate multi-domain interventions, target our intervention strategies to different contexts, risk conditions, and outcomes, and provide for recurring interventions across time to maximize the chances of long-term gains in individual competence.

The Effects of Breakfast and Breakfast Composition on Cognition in Children and Adolescents: A Systematic Review

Breakfast is thought to be beneficial for cognitive and academic performance in school children. However, breakfast is the most frequently skipped meal, especially among adolescents. The aim of the current article was to systematically review the evidence from intervention studies for the effects of breakfast on cognitive performance in children and adolescents. The effects of breakfast were evaluated by cognitive domain and breakfast manipulation. A total of 45 studies reported in 43 articles were included in the review. Most studies considered the acute effect of a single breakfast (n = 34). The acute studies looked at breakfast compared with no breakfast (n = 24) and/or comparisons of breakfast type (n = 15). The effects of chronic school breakfast program interventions were evaluated in 11 studies. The findings suggest that breakfast consumption relative to fasting has a short-term (same morning) positive domain-specific effect on cognition. Tasks requiring attention, executive function, and memory were facilitated more reliably by breakfast consumption relative to fasting, with effects more apparent in undernourished children. Firm conclusions cannot be made about the acute effects of breakfast composition and the effects of chronic breakfast interventions because there are too few studies and these largely report inconsistent findings. This review also highlights methodologic limitations of the existing research. These include a lack of research on adolescents, few naturalistic breakfast manipulations or testing environments, small samples, and insensitive cognitive tests.

Association between breakfast consumption and educational outcomes in 9-11-year-old children

Objective

Breakfast consumption has been consistently associated with health outcomes and cognitive functioning in schoolchildren. Evidence of direct links with educational outcomes remains equivocal. We aimed to examine the link between breakfast consumption in 9–11-year-old children and educational outcomes obtained 6–18 months later.

Design

Data on individual-level free school meal entitlement and educational outcomes (Statutory Assessment Tests (SATs) at Key Stage 2) were obtained via the SAIL databank and linked to earlier data collected on breakfast consumption. Multilevel modelling assessed associations between breakfast consumption and SATs.

Setting

Trial of the Primary School Free Breakfast Initiative in Wales.

Subjects

Year 5 and 6 students, n 3093 (baseline) and n 3055 (follow-up).

Results

Significant associations were found between all dietary behaviours and better performance in SATs, adjusted for gender and individual- and school-level free school meal entitlement (OR=1·95; CI 1·58, 2·40 for breakfast, OR=1·08; CI 1·04, 1·13 for healthy breakfast items). No association was observed between number of unhealthy breakfast items consumed and educational performance. Association of breakfast consumption with educational performance was stronger where the measure of breakfast consumption was more proximal to SATs tests (OR=2·02 measured 6 months prior to SATs, OR=1·61 measured 18 months prior).

Conclusions

Significant positive associations between self-reported breakfast consumption and educational outcomes were observed. Future research should aim to explore the mechanisms by which breakfast consumption and educational outcomes are linked, and understand how to promote breakfast consumption among schoolchildren. Communicating findings of educational benefits to schools may help to enhance buy-in to efforts to improve health behaviours of pupils.

Outbreak of mass sociogenic illness in a school feeding program in northwest Bangladesh, 2010

BACKGROUND

In 2010, an acute illness outbreak was reported in school students eating high-energy biscuits supplied by the school feeding programme in northwest Bangladesh. We investigated this outbreak to describe the illness in terms of person, place and time, develop the timeline of events, and determine the cause and community perceptions regarding the outbreak.

METHODS

We defined case-patients as students from affected schools reporting any two symptoms including abdominal pain, heartburn, bitter taste, and headache after eating biscuits on the day of illness. We conducted in-depth interviews and group discussions with students, teachers, parents and community members to explore symptoms, exposures, and community perceptions. We conducted a questionnaire survey among case-patients to determine the symptoms and ascertain food items eaten 12 hours before illness onset, and microbiological and environmental investigations.

RESULTS

Among 142 students seeking hospital care, 44 students from four schools qualified as case-patients. Of these, we surveyed 30 who had a mean age of 9 years; 70% (21/30) were females. Predominant symptoms included abdominal pain (93%), heartburn (90%), and bitter taste (57%). All students recovered within a few hours. No pathogenic Vibrio cholerae, Shigella or Salmonella spp. were isolated from collected stool samples. We found no rancid biscuits in schools and storage sites. The female index case perceived the unusually darker packet label as a "devil's deed" that made the biscuits poisonous. Many students, parents and community members reported concerns about rumors of students dying from biscuit poisoning.

CONCLUSIONS

Rapid onset, followed by rapid recovery of symptoms; female preponderance; inconsistent physical, microbiological and environmental findings suggested mass sociogenic illness rather than a foodborne or toxic cause. Rumours of student deaths heightening community anxiety apparently propagated this outbreak. Sharing investigation results and reassuring students and parents through health communication campaigns could limit similar future outbreaks and help retain beneficiaries' trust on nutrition supplementation initiatives.

Early-stage primary school children attending a school in the Malawian School Feeding Program (SFP) have better reversal learning and lean muscle mass growth than those attending a non-SFP school

In developing countries, schoolchildren encounter a number of challenges, including failure to complete school, poor health and nutrition, and poor academic performance. Implementation of school feeding programs (SFPs) in less developed countries is increasing and yet there is mixed evidence regarding their positive effects on nutrition, education, and cognition at the population level. This study evaluated cognitive and anthropometric outcomes in entry-level primary school children in Malawi with the aim of generating evidence for the ongoing debate about SFPs in Malawi and other developing countries. A total of 226 schoolchildren aged 6-8 y in 2 rural Malawian public primary schools were followed for one school year. Children attending one school (SFP school) received a daily ration of corn-soy blend porridge, while those attending the other (non-SFP school) did not. Baseline and post-baseline outcomes included the Cambridge Neurological Test Automated Battery cognitive tests of paired associate learning, rapid visual information processing and intra-extra dimensional shift, and anthropometric measurements of weight, height, and mid-upper arm circumference (MUAC). At follow-up, the SFP subcohort had a greater reduction than the non-SFP subcohort in the number of intra-extra predimensional shift errors made (mean 18.5 and 24.9, respectively; P-interaction = 0.02) and also showed an increase in MUAC (from 16.3 to 17.0; P-interaction <0.0001). The results indicate that the SFP in Malawi is associated with an improvement in reversal learning and catch-up growth in lean muscle mass in children in the SFP school compared with children in the non-SFP school. These findings suggest that the Malawian SFP, if well managed and ration sizes are sustained, may have the potential to improve nutritional and cognitive indicators of the most disadvantaged children.

School food, politics and child health

OBJECTIVE

An analysis undertaken jointly in 2009 by the UN World Food Programme, The Partnership for Child Development and the World Bank was published as Rethinking School Feeding to provide guidance on how to develop and implement effective school feeding programmes as a productive safety net and as part of the efforts to achieve Education for All. The present paper reflects on how understanding of school feeding has changed since that analysis.

DESIGN

Data on school feeding programme outcomes were collected through a literature review. Regression models were used to analyse relationships between school feeding costs (from data that were collected), the per capita costs of primary education and Gross Domestic Product per capita. Data on the transition to national ownership, supply chains and country examples were collected through country case studies.

RESULTS

School feeding programmes increase school attendance, cognition and educational achievement, as well as provide a transfer of resources to households with possible benefits to local agricultural production and local market development. Low-income countries exhibit large variations in school feeding costs, with concomitant opportunities for cost containment. Countries are increasingly looking to transition from externally supported projects to national programmes.

CONCLUSIONS

School feeding is now clearly evident as a major social programme in most countries with a global turnover in excess of $US 100 billion. This argues for a continuing focus on the evidence base with a view to helping countries ensure that their programmes are as cost-effective as possible. Clear policy advice has never been more important.

School feeding programs in developing countries: impacts on children's health and educational outcomes

School feeding programs (SFPs) are intended to alleviate short-term hunger, improve nutrition and cognition of children, and transfer income to families. The present review explores the impact of SFPs on nutritional, health, and educational outcomes of school-aged children in developing countries. Peer-reviewed journal articles and reviews published in the past 20 years were identified and screened for inclusion. Analysis of the articles revealed relatively consistent positive effects of school feeding in its different modalities on energy intake, micronutrient status, school enrollment, and attendance of the children participating in SFPs compared to non-participants. However, the positive impact of school feeding on growth, cognition, and academic achievement of school-aged children receiving SFPs compared to non-school-fed children was less conclusive. This review identifies research gaps and challenges that need to be addressed in the design and implementation of SFPs and calls for theory-based impact evaluations to strengthen the scientific evidence behind designing, funding, and implementing SFPs.

Benefits of Breakfast for Children and Adolescents: Update and Recommendations for Practitioners

A number of studies report health benefits for children and adolescents who consume breakfast. Breakfast skipping is fairly common in children and adolescents and increases as children age. Breakfast can enhance children's diets by positively contributing to daily nutrient intake, augmenting intake of key nutrients such as fiber and calcium, and provides an opportunity to help meet the recommendations of the Dietary Guidelines for Americans. Breakfast also is associated with more healthful food choices. Cross-sectional studies support that eating breakfast more often may help children and adolescents maintain a healthful weight. However, the results from longitudinal studies are inconclusive and suggest that more research is needed to clarify this relationship, including understanding the mediating effects of initial weight status, dieting behavior, and physical activity levels. Breakfast consumption may provide some benefit toward cognitive function and academic achievement, but more research is needed. Breakfast is one facet of a healthy lifestyle that may help contribute to the short- and long-term health and well-being of children and adolescents. Health practitioners can promote healthy breakfast consumption in children and adolescents by addressing barriers to eating breakfast and focusing on individuals who may be more likely to skip breakfast on a regular basis.

Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents

Breakfast has been labeled the most important meal of the day, but are there data to support this claim? We summarized the results of 47 studies examining the association of breakfast consumption with nutritional adequacy (nine studies), body weight (16 studies), and academic performance (22 studies) in children and adolescents. Breakfast skipping is highly prevalent in the United States and Europe (10% to 30%), depending on age group, population, and definition. Although the quality of breakfast was variable within and between studies, children who reported eating breakfast on a consistent basis tended to have superior nutritional profiles than their breakfast-skipping peers. Breakfast eaters generally consumed more daily calories yet were less likely to be overweight, although not all studies associated breakfast skipping with overweight. Evidence suggests that breakfast consumption may improve cognitive function related to memory, test grades, and school attendance. Breakfast as part of a healthful diet and lifestyle can positively impact children's health and well-being. Parents should be encouraged to provide breakfast for their children or explore the availability of a school breakfast program. We advocate consumption of a healthful breakfast on a daily basis consisting of a variety of foods, especially high-fiber and nutrient-rich whole grains, fruits, and dairy products.

Community-Based School Feeding during Indonesia'S Economic Crisis: Implementation, Benefits, and Sustainability

The Indonesian Government initiated a community-based national school-feeding program in 1996. Implementation was decentralized and involved multiple participants. In 1998 we evaluated the implementation of the program and the perceived benefits for community stakeholders using a survey of principals in 143 randomly selected schools and follow-up with in-depth interviews and observations in a subsample of 16 communities. The evaluation covered the period of the 1998 Asian economic crisis, affording the opportunity to assess its impact on the program. The program was implemented in all targeted schools, with excellent community participation. Feeding was sustained through the crisis, in spite of a dramatic escalation in food costs. The families of schoolchildren, farmers, and those who prepared food received economic benefits. The snacks replaced those sold at schools and were of better nutritional value. The children benefited because the snacks compensated for losses in the home diet resulting from the economic crisis. Characteristics of the program that may be important in explaining its success include the involvement of a range of community stakeholders, engagement with existing village administrative structures, scope for local community adaptation and innovation, and the use of local foods that dispersed benefits and ensured sustained implementation during the crisis.

Epidemiologia do desenvolvimento cognitivo de escolares em Jequié, Bahia, Brasil: procedimentos de avaliação e resultados gerais

Este artigo descreve metodologia, aplicação e utilidade do teste das Matrizes Progressivas de Raven e do Teste de Sondagem Intelectual (TSI), comparando-os ainda com o rendimento escolar do aluno, em Jequié, Bahia. O Raven, que avalia o raciocínio não-verbal, foi aplicado a 374 escolares (7 a 17 anos). Somente 231 TSI foram respondidos porque requeriam habilidades de leitura e escrita. Foram coletadas notas escolares para todos os participantes. Um questionário avaliando recursos da escola e perfil do professor foi respondido por duzentos professores. Os escores dos testes Raven e TSI apresentaram uma boa correlação entre si (r = 0,53, p < 0,001) porém menor com as médias escolares (r = 0,22, p < 0,001 e r = 0,12, p < 0,07 respectivamente). Os escores do Raven e do TSI apresentaram baixas correlações com os conceitos escolares. A média de escores, tanto no teste Raven como no TSI, foi maior entre os meninos, sendo superior o desempenho das meninas nas notas escolares. De maneira geral o nível de desempenho cognitivo encontrado está aquém do esperado em crianças do grupo de idade analisada.

Breakfast and performance

Evidence suggests that the effect of fasting on performance is not uniform, but it is dependent on the basal nutritional status of the subject. Breakfast consumption has a short-term effect in improving selected learning skills, especially work memory. School breakfast programmes have a positive effect on the nutritional status of children, on school attendance and probably on dropout rates. The effect of breakfast consumption on school performance depends on the interaction between the programme, student characteristics (malnutrition) and school organisation. Unless the school setting guarantees a minimum quality standard, the benefits of breakfast consumption will not be evident in performance in complex areas like language or maths.

Improving iron absorption from a Peruvian school breakfast meal by adding ascorbic acid or Na2EDTA

BACKGROUND

Iron-fortified school breakfasts have been introduced in Peru to combat childhood iron deficiency.

OBJECTIVE

We evaluated whether iron absorption from a school breakfast meal was improved by increasing the ascorbic acid content or by adding an alternative enhancer of iron absorption, Na2EDTA.

DESIGN

In a crossover design, iron absorption from test meals was evaluated by erythrocyte incorporation of 58Fe and 57Fe. The test meals (wheat bread and a drink containing cereal, milk, and soy) contained 14 mg added Fe (as ferrous sulfate) including 2.0-2.6 mg 58Fe or 4.0-7.0 mg 57Fe.

RESULTS

Geometric mean iron absorption increased significantly from 5.1% to 8.2% after the molar ratio of ascorbic acid to fortification iron was increased from 0.6:1 to 1.6:1 (P < 0.01; n = 9). Geometric mean iron absorption increased significantly from 2.9% to 3.8%, from 2.2% to 3.5%, and from 2.4% to 3.7% after addition of Na2EDTA at molar ratios relative to fortification iron of 0.3:1, 0.7:1, and 1:1, respectively, compared with test meals containing no added enhancers (P < 0.01; n = 10 for all). Iron absorption after addition of ascorbic acid (molar ratio 0.6:1) was not significantly different from that after addition of Na2EDTA (molar ratio 0.7:1).

CONCLUSIONS

Ascorbic acid and Na2EDTA did not differ significantly in their enhancing effects on iron absorption at molar ratios of 0.6:1 to 0.7:1 relative to fortification iron. Additional ascorbic acid (molar ratio 1.6:1) increased iron absorption significantly. Increasing the molar ratio of Na2EDTA to fortification iron from 0.3:1 to 1:1 had no effect on iron absorption.

Breakfast: a review of associations with measures of dietary intake, physiology and biochemistry

The present paper reviews the literature on breakfast to consider reported association between breakfast and nutritional, physiological and biochemical variables. The contribution of breakfast to achieving nutrition targets for fat, carbohydrate and dietary fibre intakes is also examined as are the potential effects of fortified breakfast cereals on intakes of micronutrients and nutritional status. Breakfast consumption, particularly if the meal includes a breakfast cereal, is associated with lower intakes of fat and higher intakes of carbohydrate, dietary fibre and certain micronutrients. These findings may be relevant to population groups which could be at risk from low intakes of certain micronutrients, but further clarification of benefit is needed from studies of nutritional status. Associations between breakfast consumption and lower cholesterol levels have been reported, while lower body weights have been seen amongst breakfast eaters. It is concluded that breakfast consumption is a marker for an appropriate dietary pattern in terms of both macro- and micronutrients, particularly if breakfast cereals are included in the meal.

Does breakfast make a difference in school?

This article reviews selectively the literature on the effects of breakfast on cognition and school performance. The focus is on studies published in refereed journals after 1978 that tested those effects on well-nourished and nutritionally at-risk children. In at-risk subjects (defined by clinical history and anthropometry), a morning and overnight fast had adverse effects on cognition, particularly the speed of information retrieval in working memory. Contradictions in the data from different studies prevent definitive conclusions on whether well-nourished children experience similar functional deficits. Nonetheless, available information suggests that brain function is sensitive to short-term variations in the availability of nutrient supplies. Moreover, well-conducted evaluations suggest that the availability of feeding programs in public schools throughout the academic year increases the probability that children will eat breakfast and improve their educational status.