School feeding programs in developing countries: impacts on

children's health and educational outcomes

Lamis H Jomaa, Elaine McDonnell, and Claudia Probart
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 identied and screened for
inclusion. Analysis of the articles revealed relatively consistent positive eects of
school feeding in its dierent 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 identies
research gaps and challenges that need to be addressed in the design and
implementationof SFPs and calls for theory-based impact evaluations to strengthen
the scientic evidence behind designing, funding, and implementing SFPs.
2011 International Life Sciences Institute
INTRODUCTION
Hunger is an ongoing problem that aects more than 1.2
billion people who do not have enough to eat in the world
today.
1
The recent global economic crisis, uctuations in
food prices in 20062008, wars and political conicts, and
devastating natural disasters have deprived millions of
people of access to adequate food. Most of the individuals
aected are in the most impoverished regions of the
world. Previous eorts by heads of states, international
organizations, and local agencies to address poverty and
hunger-related issues resulted in the UN Millennium
Declaration (2000). The goals outlined in the declaration
were established to eradicate poverty, alleviate hunger,
reduce gender inequalities, improve health and longevity,
overcome environmental degradation, and most impor-
tantly, develop global partnerships to achieve the goals.
2
Education and health were central components of
the roadmap towards implementing the stated goals. The
rst millennium development goal (MDG) emphasized
the eradication of extreme poverty and hunger, whereas
the second and third MDGs focused on achieving uni-
versal primary education and overcoming gender dis-
parities in primary and secondary education. The UN
declaration and its roadmap have set the platform for
global trends and national eorts to meet the MDGs
within a reasonable timeframe (mostly by 2015) and the
World Bank (WB) and its development partners, includ-
ing the World Food Program (WFP), took more rapid
steps to meet these goals and launched the Education for
All (EFA) Fast Track Initiative (FTI) in 2002. The main
objective of EFA FTI was to help low-income countries
meet the MDGs, particularly the education for all goal.
3
Despite the major eorts exerted, the progress towards
universal primary education (2
nd
MDG) has been slow
and uneven. More than 121 million school-aged children
are still out of school, and two-thirds of them are girls
living in rural areas in the most vulnerable regions of the
Aliations: LH Jomaa, E McDonnell, and C Probart are with the Department of Nutritional Sciences, College of Health and Human
Development, The Pennsylvania State University, University Park, Pennsylvania, USA.
Correspondence: LH Jomaa, Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State
University, University Park, PA 16802, USA. E-mail: lamisjomaa@gmail.com.
Key words: children's health, cognitive functions, developing countries, dietary intake, education, growth, micronutrient status, school-aged
children, school feeding programs
Special Article
doi:10.1111/j.1753-4887.2010.00369.x
Nutrition Reviews Vol. 69(2):8398 83
world. One of the major reasons for this lag in progress
toward universal primary education is the persistence of
poverty, hunger, and malnutrition.
4
Infants and children
are among the most vulnerable population groups subject
to the adverse, and when very young, irreversible, short-
and long-term cognitive, physical, and psychosocial con-
sequences of hunger and undernourishment.
5,6
There is
also increased evidence that childhood undernutrition
imposes signicant economic costs on individuals and
nations, and that improving childrens diets and nutrition
can have positive eects on their academic performance
and behaviors at school as well as their long-term pro-
ductivity as adults.
7,8
School feeding programs (SFPs) have been continu-
ously gaining popularity in developing countries, mostly
among those aected severely by childhood hunger and
malnourishment. These programs aim to enhance the
concentration span and learning capacity of school chil-
dren by providing meals in schools to reduce short-term
hunger that may otherwise impair childrens perfor-
mance.
9
Currently, SFPs exist in 70 of the 108 low- and
lower-middle income countries, and most of them have
been initiated and funded by the WFP.
10
Some of these
SFPs have evolved and been adopted nationally while
others still rely on the assistance, funding, and/or exper-
tise of the WFP and its development partners in varying
degrees. The WFP and its development partners have
been promoting school feeding in its dierent modalities
for years as eective interventions that help alleviate
hunger and improve the cognitive and educational abili-
ties of children. When children are provided with food
at school, not only do parents receive an incentive to
send their children to school, particularly girls, children
are also encouraged to attend and complete a school
day. Thus, SFPs can help developing countries and their
development partners meet a number of MDGs, includ-
ing the eradication of hunger, achieving universal
primary education, and closing the gender gap by giving
boys and girls equal opportunities for completion of
primary schooling.
11,12
According to Belgeron and Del Rossos conceptual
framework for Food for Education (FFE),
13
also known
as SFPs, FFE programs provide food transfer to children
at school, income transfer to their families, and resource
transfer to the schools operating these programs. In 2009,
the World Bank and the WFP published a joint review
on SFPs
14
re-emphasizing the rationale and objectives of
these programs. The three main objectives identied were
to provide safety nets for families to absorb social and
economic shocks, improve the education and scholastic
performance of school-aged children, and enhance chil-
drens nutrition and health status. To parallel the three
main pillars or objectives of SFPs (safety nets, nutrition,
and education), a logical framework for SFPs was devel-
oped mapping the inputs, outputs, outcomes, and impacts
for each of the objectives and rationales of the pro-
grams.
15
Resources or inputs include micronutrient
fortied meals, snacks, and take-home rations, as well
as anthelmentic treatments; outputs include the numbers
of children fed, schools reached, and food rations/
deworming tablets distributed. If nutrition is the objective
of the program, the outcomes identied are the allevia-
tion of hunger and improvement of the micronutrient
status of school-aged children; the intended impacts
are to improve the nutrition and health of beneciary
children and improve their learning capacities. The main
impacts of SFPs with regard to meeting educational
objectives are to improve learning, increase lifetime earn-
ings of targeted children, and increase access to education
for girls, orphans, and vulnerable children. In addition,
educating families and future generations about family
planning, HIV/AIDs prevention, and other health topics
are among the intended impacts of SFPs.
Although the benets of school feeding are well-
documented, controversy remains over the eectiveness
of SFPs. According to Kristjansson et al.,
16
experts at
a School Feeding/Food for Education Stakeholders
meeting in 2000 concluded that there is little evidence for
nutritional benets of school feeding and that school
feeding only enhances learning when other improve-
ments in school quality are made (World Bank, n.d). The
present reviewwas conducted to summarize the nutrition
literature on the impact of school feeding, focusing
primarily on the relationship between school feeding
and changes in the nutritional and health outcomes
of targeted school-aged children and secondarily on
more established cognitive and educational outcomes.
The review sheds light on gaps in the literature regarding
school feeding in developing countries and other chal-
lenges faced by those implementing SFPs. Furthermore, it
highlights the need for theory-based impact evaluation
studies to strengthen the design and implementation of
existing and future SFPs.
METHODOLOGY AND CRITERIA FOR SELECTION OF
EMPIRICAL EVIDENCE INCLUDED IN THE REVIEW
Articles and manuscripts included in this review were
identied using primarily PubMed and Web of Science
databases, as well as the World Food Program headquar-
ters online database and library. Research articles
addressing this topic and published in peer-reviewed
journals in the past 20 years (19902009) were screened
and those that did not meet the inclusion criteria of our
review were excluded (see Table 1). Variations of terms
were used in the search process to nd studies of dierent
designs and interventions conducted in developing
countries. Randomized controlled trials (RCTs), which
Nutrition Reviews Vol. 69(2):8398 84
are experiments in which investigators allocate eligible
people randomly into treatment and control groups to
receive or not to receive one or more of the interventions
being compared, are regarded as the gold standard of
research. However, non-randomized trials are seen as
important complimentary studies when randomization
or blinding is inappropriate, unethical, or sometimes not
feasible. Thus, our review included RCTs, intervention/
control studies, crossover design studies, and eective-
ness reports of existing SFPs. Table 2 includes a
summarized description of the studies included in the
review, outlining their research designs, study partici-
pants, duration of observations/interventions, outcomes
measured, and the main ndings.
IMPACT OF SCHOOL FEEDING ON NUTRITION AND
HEALTH OF SCHOOL-AGED CHILDREN
Growth and body composition
Evidence of the impact of SFPs on childrens growth
and body composition remains inconclusive due to the
mixed results reported from dierent studies. A few
studies found a positive eect of school feeding on chil-
drens growth and anthropometric indices, while others
showed no eect. In 2006, Kristjansson et al.
16
conducted
the rst systematic review and meta-analysis to explore
the impact of school feeding on a number of physical and
psychosocial variables in school-aged children. A total of
18 studies were included in the review, nine of which
were conducted in developing/lower income countries
(Kenya, Jamaica, India, Indonesia, and China), ve of
which were RCTs, and four of which were controlled
before and after (CBA) trials. The meta-analysis showed
an overall small, non-signicant change in height
between children who did or did not receive meals
at school in RCTs,
1719
whereas a signicant increase
in height was observed in CBA trials.
16,2022
On average,
school-fed children gained 1.43 cm in height more than
controls. The meta-analysis of two RCTs within the same
review showed a small, yet signicant eect of school
feeding on height-for-age (z-score change = 0.04 [95%CI:
0.020.06]). However, authors found a stronger and more
consistent eect of school feeding on weight gain from
the three RCTs and three CBA trials that were analyzed; a
gain that ranged between 0.25 to 0.75 kg a year.
Similar positive eects of school feeding were
reported by Powell et al.
18
Researchers reported positive
nutritional outcomes from their RCT in which they
provided 395 primary school-aged children (2
nd
to 5
th
graders), from 16 rural Jamaican schools, breakfast meals
every day for one school year (8 months). Children in the
control group (n = 396 children) were given one-quarter
of an orange as a placebo. Researchers found that children
in the breakfast group gained signicantly more weight
(b = 0.42), height (b = 0.25), and BMI (b = 0.16) than
children in the control group (P < 0.05). A slight substi-
tution eect was observed among breakfast consumers
over lunchtime, as they consumed 54 calories less on
average than the control group. Substitution is a reduc-
tion in home diet for students who are receiving food at
school. However, the decrease in energy intake did not
oset the total energy consumed from the school break-
fast meal and a net increase in dietary (energy) intake was
observed among breakfast consumers. Children receiving
breakfast gained, on average, an additional 0.25 cm
during the 8-month intervention, a gain which, when
extrapolated by researchers, was found to be equivalent
to 0.4 cm increase in height per year or approximately 1
Table 1 Inclusion and exclusion criteria for studies and publications
included in this review.
Study
characterstic
Inclusion criteria Exclusion criteria
Setting Developing countries Developed countries
Sample Primary school-aged children Children < 5 years (infants,
toddlers, preschoolers)
Children at secondary school
level
Intervention Eect of in-school meals,
fortied/supplemented
meals and/or snacks, and
take-home food rations
(THRs)
Complimentary health/
nutrition interventions (ex.
De-worming)
Eect of micronutrient
supplements, not part of a
school feeding program or
study
Publication
timeframe
1990 and later Prior to 1990
Nutrition Reviews Vol. 69(2):8398 85
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.
Nutrition Reviews Vol. 69(2):8398 89
month of growth in the National Center for Health Sta-
tistics (NCHS) reference population. The increase in
weight among intervention group members was found to
be even greater than the increase in height, an equivalent
of 23 months of weight gain in the reference population.
Analyzing the eect of breakfast based on the nutritional
status of children, researchers observed more signicant
gains in height and BMI among adequately nourished
children compared to undernourished children, b = 0.77
and b = 0.18 (P < 0.005), respectively.
18
The signicantly
greater increase in the height and BMI of adequately
nourished children compared to undernourished chil-
dren was somewhat unexpected. Powell et al.
18
argued
that the undernourished group of children recruited in
this study was only moderately undernourished, whereas
children in previous studies were more severely under-
nourished. The undernourished children may have
greater dietary needs than their well-nourished counter-
parts and these dietary requirements were either not met
through the school breakfast meals or were oset by
reduced dietary intakes at home. This study had some
limitations as it lacked data on the micronutrient status of
children and their health conditions and possible infec-
tions that may interfere with the absorption of nutrients
from school meals. In addition, the sample of undernour-
ished children may have been suering from subclinical
infections that could have impeded their absorption of
nutrients, such as iron and zinc, that are needed for
adequate growth and development. It is also possible that
energy and nutrient utilization were better in the
adequately nourished group of children compared to the
malnourished children.
Simeons review of a study conducted in a rural
school in Jamaica did not show remarkable changes in
the weight gain of children following consumption of a
morning meal each school day for two semesters.
23
A
total of 115 students in grade 7 (1213 years old) were
recruited; one class (n = 44 students) received the school
meal (100 mL milk and either a slice of cake or a meat-
lled pastry providing a total of 500 kcal on average)
and two classes served as controls. Weight for age was
measured before the school feeding intervention started
(1
st
semester) and at the beginning and end of the second
semester (during which intervention took place). Stu-
dents in both the intervention and the control groups
gained weight after the 2
nd
semester; however, there was
no signicant dierence in weight gain between both
groups. The lack of impact of school feeding on the
weight gain of these children may be attributed to several
limitations of this study. Data on the height of children
at baseline was not collected due to time constraints;
thus, researchers could not measure the change in
height after the intervention was completed and observe
whether there were signicant dierences in height
change between the intervention and control groups. In
addition, total dietary intake of participants was not
assessed to learn if the school meal provided additional
calories and nutrients to the childs dietary intake or if
it was compensated for with diminished energy and food
consumption outside of school hours.
A large study that was conducted in Bangladesh
by Ahmed Akhter and the International Food Policy
Research Institute provided evidence regarding the posi-
tive impact of SFPs on dietary intakes and educational
outcomes of school-aged children. The SFP was imple-
mentedby theWFPandthe Government of Bangladeshin
approximately 6,000 primary schools located in highly
food-insecure rural areas and four slum areas in Dhaka
city, Bangladesh. Ahmed
24
reported that the BMI of chil-
dren receiving a midmorning snack at school increased by
4.3% compared to children in control schools who were
not receiving these snacks. The midmorning snack con-
sisted of a packet of fortied wheat biscuits providing a
total of 300 calories and 75% of the recommended daily
allowances of vitamins and minerals for school-aged
children; it was given to students for each day of school
attendance. The average energy intakes of participants
were 11% and 19% higher in rural and urban slum areas,
respectively, than the energy intakes of sex- and age-
matched students in control schools who did not partici-
pate in the SFP. Energy intake consumed from biscuits
was 97%additional tothe childs normal diet; thus, the SFP
improved net food consumption of the participating chil-
dren, and the extra energy from the biscuits was not com-
pensated for by a decrease in food consumption at home.
Using household food consumption surveys, researchers
observed that the majority of students receiving SF shared
fortied biscuits with other members of their families on a
regular or intermittent basis. These spillover eects of SF
biscuits on food consumption of the participants siblings
(ages 25 years) led to a 7% increase in total calories
consumed, on average, by these preschoolers.
In terms of body composition, studies have also
shown promising results. Grillenberger et al.
25,26
con-
ducted an RCT in 12 primary schools from a rural
malaria-endemic area in Kenya (Embu District). Schools
were assigned to one of three food supplement groups: 1)
energy, 2) milk, or 3) meat supplement. In larger schools
with more than one grade 1, classes were randomly
assigned to one of the three isocaloric supplement
groups. A total of 544 students participated in the study
and, depending on the group to which their school or
classroom was assigned, they were further randomly
assigned to a food supplement group (treatment) or no
supplement group (control). The number of children in
each group was relatively equal, approximately 140 chil-
dren per group. Children in the treatment groups (receiv-
ing food supplements) were fed Githeri, a local vegetable
Nutrition Reviews Vol. 69(2):8398 90
stew, with meat, milk, or extra oil added, depending
on the treatment group to which they were assigned, i.e.,
meat, milk, or energy. The control groups did not receive
food. Researchers observed that children in each of the
supplementation groups gained approximately 0.4 kg
(10%) more weight than children in the control groups.
In addition, children in the three treatment groups
showed increases in mean upper-arm area circumference
(MUAC), a measure that is usually used as an indicator
of protein-energy malnutrition. They also gained more
mid-upper arm muscle circumference (MUAMC), which
is a ne indicator for the total body muscle mass, than the
control groups; this was mainly observed in members
of the meat group, whose gain reached up to 90%. The
signicant gain in MUAMC among children in the meat
group highlights the importance of providing children
with a good source of high-quality protein that is also
rich in multiple micronutrients and can increase the bio-
availability of iron and zinc. This is important, especially
among children living in rural communities where the
staple plant-based foods are low in iron and zinc content
and people are susceptible to micronutrient deciencies.
The overall eects of supplementation on height, height
for age, weight for height z-scores, and measures of body
fat were insignicant in this study; however, researchers
observed a positive eect of milk supplements on height
gain in a subgroup of children (stunted children with
height for age z scores
-
1.4).
In another study conducted in South Africa,
27
the fortication of soup powders with iron and vitamin
C, when combined with deworming within a SFP, led to
signicant improvements in height, height-for-age, and
weight-for-height z scores of primary school children
aged 68 years; the improvements were mainly among
those with low baseline iron stores. Furthermore, com-
bined food fortication and deworming led to improve-
ments in weight and weight for age z scores of children
who had adequate iron stores at baseline. One important
nding of this study is that the combined positive eects
of iron fortication and deworming on childrens anthro-
pometric status surpassed the individual eects of each
treatment alone.
Dietary and micronutrient status
The nutritional benets of school breakfast programs
were further documented in studies conducted in
Peru.
28,29
In 1993, the government of Peru launched a
school breakfast program in one of the poorest provinces
of the country, the Andes region. An evaluation of the
school breakfast program implemented in the outskirts
of two Peruvian cities (Matahuasi and Huaraz) showed
signicant improvements in the energy, protein, and
micronutrient intakes of a subsample of children receiv-
ing the school breakfast. A total of 120 children were
recruited from the 3
rd
and 4
th
grades and were divided
equally between the experimental and control groups.
After implementation of the school breakfast program,
signicant dierences were seen between the experimen-
tal group and the control group with respect to total
energy intake (2,182 versus 1,731 kcal/day), protein
intake (56.1 versus 43.6 g/day), and iron intake (21.6
versus 12.5 mg), P < 0.001.
28
The energy intake of chil-
dren receiving the school breakfast increased by 15.2%,
their protein intake increased by 16.1%, and their dietary
iron intake increased by 60%. One of the strengths of this
study is that the observed increase in the dietary intake
of children within the experimental group was not
compensated for by lower food consumption at home.
Instead, children consuming a breakfast meal at school
had signicantly higher overall dietary intakes compared
to their control counterparts. In addition, the study con-
trolled for a number of variables, including childrens
stature (height-for-age) and nutritional status (weight-
for-age) in their regression analyses in an attempt to
measure the independent eect of school breakfast con-
sumption on dietary intake and a number of educational
and cognitive markers. Using data from a nationally man-
dated school meal program in India, Afridi
30
conducted
an empirical analysis of 24-hour food consumption
recalls for children (age range, 414 years; n = 976) on
school and non-school days to estimate the extent to
which children benet from the targeted school meal
program. Afridis study showed that the meal program
provided children with a signicant proportion of their
daily intake of ve nutrients (energy/calories, proteins,
carbohydrates, calcium, and iron). Furthermore, 49100%
of the food transfers were reected in the total daily
intakes of children, indicating that the program suc-
ceeded in improving dietary intake for the ve essential
nutrients for which the diets of children in India were
found to be highly decient.
In Bogota, Colombia, Arsenault et al.
31
conducted
a longitudinal observation of 3,202 children aged 512
years in public schools to examine whether a state-
launched snack program (initiated in 2004 in all public
primary schools) had any impact on the nutritional status
of children. The snack consisted of a beverage, a cereal
and/or a protein component, was well as a sweet com-
ponent that included peanuts and Petit Suisse cheese,
as well as fruits on most days. The snack was designed to
provide children with a certain percentage of recom-
mended daily intakes (30% of energy, 50% of iron, and
40% of calcium). Only 3 months after the program was
pilot-tested, researchers observed greater increases in
serum vitamin B
12
levels among children receiving the
snacks compared to the controls. However, signicant
changes were not observed in the hemoglobin, serum
Nutrition Reviews Vol. 69(2):8398 91
ferritin, or folate levels of children. This can be explained
by the low prevalence of iron deciency at baseline and
the fact that children in both the schools receiving the
snack and the controls were receiving iron supplements
prior to this programs initiation.
Food fortication with micronutrients or the supple-
mentation of children with multiple nutrients are among
the strategies used in certain SFPs to reduce multiple
micronutrient deciencies and improve the nutritional
status and cognitive and learning capacities of school-
aged children. Van Stuijvenberg et al.
32
were interested in
determining the eects of providing schoolchildren with
mineral-fortied biscuits on their micronutrient status.
The researchers conducted their study in a rural school in
South Africa located in an area with a high prevalence of
micronutrient deciencies. They recruited 115 children
(611 years old) to serve as the treatment group and 113
children served as controls. The treatment group received
biscuits fortied with iron, beta-carotene, and iodine (at
50% of the RDA) whereas the control group consumed
non-fortied biscuits. Signicant improvements were
observed in the vitamin A, iron, and iodine status of
children who received the fortied biscuits. In addition,
anemia, vitamin A, and iodine deciencies were reduced
by 13%, 28%, and 67%, respectively, in this sample.
However, improvements seen in the vitamin A and iron
status of childrenwere not sustained after consumptionof
the fortied biscuits was interrupted during the schools
summer break. The researchers concluded that since the
biscuits provided only 50% of the RDA for vitamin A in
the form of carotene, this may have been only sucient to
maintainthe day-to-day vitaminAlevels but not sucient
for replenishing very low or depleted vitamin A stores.
Also, the dietary intake of vitamin A from meals con-
sumed at home during the summer months, were assessed
to be approximately 10% of the RDA per day; thus, during
the period inwhich the fortied biscuit were not oered to
students, retinol values reverted to the baseline level. All
these ndings indicate that the diets of these children
contained very low amounts of micronutrients and the
childrens body stores were depleted rapidly during the
summer months. According to the same authors, resolv-
ing iron deciency through food fortication can be very
challenging due to the low bioavailability and high reac-
tivity of the iron compounds used in food fortication.
33
However, the provision of vitamin C-fortied drinks (rich
in ascorbic acid) along with fortied food has been shown
to improve iron status and is thus encouraged in SFPs
targeting children with high levels of iron deciency and
iron-deciency anemia, when feasible.
34
Only iodine did
not return to the levels measured prior to the interven-
tion, and that was probably because iodization of salt was
mandated in SouthAfrica 6 months after the intervention
was in place.
This study provides promising results in terms of
food fortication and its impact on childrens micronu-
trient status. The fortication of food proved successful in
alleviating highly prevalent micronutrient deciencies,
such as iron and vitamin A, which can lead to serious
consequences for the health and cognition of children.
However, the amount and duration of fortication were
insucient to maintain these changes. Thus, the challenge
remains for researchers and policy planners to design
SFPs that not only provide the targeted children with
adequate types and amounts of micronutrients, depend-
ing on their deciencies, but also ensure that the duration
of fortication or micronutrient supplementation is
sucient to replenish depleted body stores.
In another intervention-control study conducted
in South Africa by Kruger et al.,
27
the fortication of soup
powder with iron and vitamin C, when combined with
the use of anthelmintic treatment (deworming) as part of
a school feeding scheme, resulted in signicant, positive
changes in the hemoglobin, mean corpuscular volume
(MCV), and serum ferritin levels of children receiving
fortied soups compared to controls. These positive
eects were observed mainly among children with low
baseline iron stores. Furthermore, fortication of biscuits
with bovine-hemoglobin as part of a nationwide SFP in
Chile led to signicant improvements in the iron status
of children (aged 611 years) who received fortied
biscuits compared to children consuming non-fortied
biscuits.
35
These positive ndings were observed despite
the low rates of iron-deciency anemia found among
the recruited samples of school children. In addition,
increases in hemoglobin concentrations and iron stores
(serumferritin) were observed among boys across all ages
and among girls, mainly after menarche. These ndings
highlight the importance of providing micronutrients to
school-aged children, particularly during growth phases
with high micronutrient demands.
The use of food supplements to overcome multiple
micronutrient deciencies among school-aged children
in developing countries is another area of interest to some
researchers and program planners. Neumann et al.
17
assessed the micronutrient status of children before inter-
vention using 24-hour recalls and biochemical measures.
They found that children had low micronutrient intakes
of vitamins A, B
12
, B
2
, zinc, and iron. Furthermore, at
baseline, approximately 30% of children were found to
be stunted and underweight. The same research group
later analyzed the eect of providing three dierent food
supplements (meat, milk, and energy) on the micronutri-
ent status of these primary school children. In their 1-year
intervention, researchers succeeded in reducing the
prevalence of vitamin B
12
deciency by 17% for the meat
supplement group and by 27% for the milk group. The
fact that a similar eect was not observed in the energy
Nutrition Reviews Vol. 69(2):8398 92
group can be explained by the higher level of vitamin B
12
in animal-source foods such as meats and dairy prod-
ucts.
36
The prevalence of infection among children par-
ticipating in this study decreased after 1 year of receiving
school food supplementations (lower prevalence of
elevated C-reactive protein levels and enlarged spleens
with a decrease in plasma ferritin and copper levels).
However, the researchers did not observe any signicant
improvements in the levels of other micronutrients, such
as iron, zinc, copper, or vitamin A and could not nd
any diet-related explanation for the lack of signicant
eects of meat and milk supplementation on these micro-
nutrients. Researchers attributed the lack of signicant
increases in vitamin A, iron, zinc, and copper levels to the
confounding eect of malaria and the high rate of infec-
tion among this population. In a follow-up study, Murphy
et al.
37
reported changes in the childrens micronutrient
intakes after comparing three 24-hour recalls collected
before school feeding started with three 24-hour recalls
collected after feeding was initiated. The researchers
observed that the intakes of vitamin B
12
, vitamin A, ribo-
avin, and calcium of children in the milk group were
greater than those of children in the control group. Also,
children in the meat group had higher intakes of vitamin
B
12
, vitamin A, and available iron and zinc than the
control group. The total energy intake of children in
the meat group was also higher than that found in either
the milk or the energy groups. Although the energy intake
of children at home decreased upon consuming one
of the fortied snacks, the decrease in energy intake was
lowest in the meat group. Thus, consumption of the meat
snacks in this study improved the dietary quality (micro-
nutrient status) and dietary quantity (total energy intake)
of participant children, whereas the milk snacks had a
positive impact solely on dietary quality.
IMPACT OF SCHOOL FEEDING ON EDUCATION
AND LEARNING
In addition to the promising nutritional outcomes,
studies highlight the importance and benets of oering
school-aged children school meals and/or snacks to
improve certain cognitive functions and scholastic
achievement, especially among disadvantaged malnour-
ished children. Thus, school feeding is once again of par-
ticular signicance in developing countries with the
highest percentages of malnourished children, low school
enrollment, and high dropout rates. Almost all types of
SFPs reported in the literature demonstrate a positive
impact on school enrollment and attendance.
23,24,28,32,38,39
The impact of school feeding on academic achievement
shows consistent positive eects on arithmetic tests,
but lower eects on reading, writing, and spelling
tests.
16,18,23,24,26
School feeding helps improve school
progress by reducing the dropout rate. This applies to
both school meals and take-home rations, with greater
benets to girls, in particular, when both modalities of
school feedings are oered together at school.
38
EVALUATING THE EVIDENCE
Findings from the nutrition literature may be mixed
and equivocal at times, thus weakening the evidence on
how eective SFPs are for improving various markers of
nutrition status, growth, and health. Mixed ndings may
be attributed to a multitude of factors, mainly dierences
in the objectives and methodologies used in SFPs. Dier-
ences lie in the design of household and school surveys,
the quality and quantity of food served to children, avail-
able school resources, durations of the interventions
(ranging from 1-month to 2- or 3-year interventions),
and the modalities of school feeding (school meals, forti-
ed snacks, take-home rations) in various settings and
studies. In addition, ndings from various studies and
national programs are dicult to compare as outcome
variables and indicators vary, and the age groups, degree
of malnourishment, and severity of worm infections and
illnesses in targeted school-aged children dier from one
program to another. Since study designs, sample popula-
tions, and outcome variables vary considerably, meta-
analyses of studies become more dicult to perform.
Despite the somewhat mixed results, the present review
demonstrates that SFPs have promising, positive impacts
on the nutrition and health status of school-aged chil-
dren. Providing food to children in the form of school
meals, snacks, or take-home rations can help alleviate
hunger, address the nutrition needs of children, improve
childrens micronutrient status (if food is fortied with
essential micronutrients or if micronutrient supplements
are provided), and reduce the susceptibility of children
to infectious diseases and illnesses (as summarized in
Table 3). However, the school feeding studies and pro-
grams in developing countries published to date lack an
in-depth investigation of whether children are receiving
culturally and developmentally appropriate nutrition
and health education lessons to complement the nutri-
tious foods and snacks being oered during a regular
school day. According to Powell et al.,
18
in order for the
achievement levels of children to improve and for chil-
dren in developing countries to fully benet from the
school feeding and supplemental services oered at their
schools, integrated interventions that include nutrition,
health, and educational components are needed. Success-
ful school nutrition and feeding programs in developed
countries have learned the importance of integrating
nutrition education into these programs.
40,41
A meta-analysis that explores school feeding and its
impact on the nutrition and cognition of school-aged
Nutrition Reviews Vol. 69(2):8398 93
children showed mixed, yet promising, results on changes
in the nutritional status of school-fed children compared
to non-school-fed children in developing countries.
16
Numerous studies in the nutrition literature, which were
discussed in this review, show that school feeding can
enhance childrens diets by increasing the total energy
intake of children consuming meals and/or snacks at
school. Although a substitution eect does occur, studies
have shown that the increase in total dietary intake from
school feeding osets any diminished intake at home. The
substitution eect varies depending on the modality
of school feeding (e.g., snacks/biscuits result in lower
substitution eects than meals), as well as the timing
and composition of meals (e.g., breakfast or mid-
morning meals result in lower substitution eects than
lunches).
16,4244
A growing body of literature supports micronutrient
fortication (fortifying commonly eaten foods) and
supplementation (providing nutrients through micronu-
trient pills or suspensions) as part of the SFPs in commu-
nities with high levels of micronutrient deciencies.
Studies highlight the importance of school deworming
(anthelmintic treatments) in regions where high rates of
worm infections prevail. As a result, the WFP has been
strongly recommending that multiple nutrient fortica-
tion and meal supplementation, as well as deworming, be
complementary services to school feeding and included
in the essential package.
45
In addition, research shows
that the eect of school feeding on the dietary intake and
growth of school-aged children is greater among those
that are malnourished compared to adequately nourished
children.
25,27
Furthermore, greater benets are observed
among younger school-aged children.
16
These ndings
have very important implications regarding the design
and targeting criteria that are set for SFPs. Thus, program
designers and planners are encouraged to target children
from highly food-insecure areas with high infection rates
in their populations in order to provide food to those who
are most susceptible to hunger and malnutrition and to
overcome the burdens of illness and diseases that may
otherwise impair the childrens growth and nutrition.
Evidence on the positive impact of school feeding
on education outcomes seems to be even stronger than
that observed and reported with nutritional outcomes.
The present review of the literature shows that SFPs have
a positive impact on childrens school enrollment and
attendance.
23,24,28,32,38,39
The impact of school feeding on
school-aged childrens academic achievement is consis-
tently positive for arithmetic tests, yet inconclusive for
reading, writing, and spelling tests.
16,18,23,24,26
Although
there is reasonable evidence for school feeding and its
positive eects on short-term cognitive functions and
Table 3 Summary of the scientic evidence on the impact of school feeding activities and provisions on intended
nutrition, health, and educational outcomes in school-aged children and their households.
School feeding provisions and activities Positive intended outcomes
In-school meals (breakfast, lunch, or mid-day), snacks, and
take-home rations
Energy and micronutrient content of school meals, snacks,
and/or take-home rations
School-aged children (participants):
Energy intake*
Nutritional status*
School enrollment*
School attendance*
Growth (weight and height)

Cognition (memory, complex mental abilities) and

classroom behavior (attention and participation)

Educational achievement (arithmetic and literacy tests)

Household:
Energy intake of siblings and other family members
(in-school meals and take-home rations)

Deworming
Frequency and dosage of anthelmentic treatment
Decreased morbidities and illnesses*
Improved micronutrient/nutritional status of school-aged
children if deworming is coupled with micronutrient
fortication of school meals/snacks

Health and nutrition education curricula

Age, developmentally and culturally appropriate nutrition
and health education lesson plans
School-aged children:
Nutrition and health knowledge, attitudes, and behaviors

Household:
(c) Nutrition and health knowledge and attitudes of
household members, and allocation of food and health
resources

* Conclusive: consistent ndings that support the link between SFP provisions and intended outcomes.

Inconclusive: mixed results from the literature, weaker evidence on link between SFP provisions and intended outcomes.

Unexplored: no empirical evidence to explore the relationship between SFP provisions and intended outcomes.
Nutrition Reviews Vol. 69(2):8398 94
various dimensions of childrens school performance,
randomized controlled trials and well-designed evalua-
tion studies are needed to demonstrate the long-term
impact of these programs on childrens school comple-
tion and productivity as adults. Table 3 includes a
summary of the scientic evidence that justies the link
between school feeding provisions and activities and
intended positive outcomes on the nutrition, health, and
academic performance of school-aged children. The evi-
dence was considered conclusive if consistent ndings
were reported across studies reviewed in this paper; they
were considered inconclusive if ndings were mixed, and
unexplored if there is a lack of scientic measurement
of the link between the SFP provision or activity and the
intended outcome.
RESEARCH AND EVALUATION GAPS
The school feeding literature is rich with well-designed
trials and country reports; however, rigorous theory-
based impact evaluations are required in this area. Experi-
mental and quasi-experimental studies on the nutritional
benets of school feeding may target and evaluate specic
outcomes and biomarkers of childrens nutrition and
health status; however, these studies mostly fall short of
identifying the causal chain or theory behind the imple-
mented programs. Furthermore, many of these studies
lack a detailed description of the political, social, and
economic context of a SFP, thereby limiting the possibility
of replicating the program in similar contexts or the
generalizability of the ndings.
The International Initiative for Impact Evaluation
(3ie)
46
highlights the importance of theory-based
impact evaluations of programs in developing countries
designed to improve the livelihood of populations.
Numerous principles are needed for a theory-based
impact evaluation including the existence of a program
theory (causal chain), understanding the context of the
program, anticipating heterogeneity, conducting rigorous
factual analysis, and using mixed methods to validate
the outcomes and impact of a program.
47
In the case of
school feeding, there are insucient rigorous theory-
based evaluations of the nutritional and health impact of
these programs on school-aged children in developing
countries. The theory and context of SFPs that are funded
and managed by the WFP or transitioning to become
nationally owned are well-dened. However, the design of
these programs falls short from fullling other principles
needed for theory-based impact evaluations, including
the use or reporting of mixed methods (qualitative and
quantitative data), and the availability of factual and
counterfactual analyses (experimental versus control
or pre- and post-intervention results) in some of these
programs. On the other hand, experimental and quasi-
experimental studies assessing school feeding, such as
those reviewed in this paper, meet the scientic caliber
needed in impact evaluations yet often lack a clear de-
nition of the logical framework of the SFP being imple-
mented; moreover, their inconclusive ndings, at times,
limit them from validating the links between resources,
outputs, and outcomes within a causal chain of a school
feeding framework.
Furthermore, several questions were raised from the
literature on school feeding and should be addressed
when future programs and trials are designed to test the
eectiveness of SFPs. Some of these research gaps were
pointed out throughout this review, while others are sum-
marized as follows. 1) Studies on the SFPs vary in design
and some lack scientic rigor. Thus, eorts need to be
exerted to provide guidance to researchers on what stan-
dardized methods, designs, and outcomes would be best
implemented and measured to improve the quality of
evidence on school feeding. 2) The benets of school
feeding on nutrition, health, and education of school-
aged children are identied in the literature; however,
the scale of these benets requires further exploration.
3) Independent and combined eects of SFPs with
supplemental health and educational interventions,
including school-based health and nutrition education,
on the nutritional knowledge and eating behavior of
targeted children and their households are areas of
needed study. 4) Studies that explore or control for the
substitution eect of SFPs based on various factors
including modality, timing, and composition of snacks or
meals, age of child, and other household characteristics
are still limited, yet necessary. 5) Long-term studies and
program evaluations are needed to track the impact of
school feeding on nutritional/health status, educational
attainment, and productivity of children as they reach
adulthood. 6) Research on the cost-drivers, cost-
eectiveness, and benet-to-cost ratio of various feeding
programs, including cross-sectional and randomized
trials, is needed to better advise governments on how to
best allocate their limited resources
CHALLENGES AND FUTURE DIRECTIONS
School feeding programs face numerous and continuous
challenges, some of which are context-specic; however
others are more universal and apply to all SFPs imple-
mented in developing countries. The sustainability of
these programs, procurement of food in light of food
price uctuations and environmental and agricultural
changes, as well as questions of a programs cost-
eectiveness are common challenges faced by SFP plan-
ners and designers. Despite their importance, these issues
are beyond the scope of this review and were discussed in
Nutrition Reviews Vol. 69(2):8398 95
depth in the most recent joint WB and WFP publication
on school feeding.
48,49
Based on the most recent transition process theo-
ries and modules developed by the WFP and the WB with
the collaboration of national governments, the trend for
SFPs is to become government-driven and owned, more
cost-contained and cost-ecient, and linked with wider
school health and nutrition services such as water sanita-
tion, supplementation, and deworming, among other
services. The aim is for these SFPs to become embedded
into national policies and frameworks. Questions remain
about the feasibility and eectiveness of nationally
owned, funded, and managed SFPs. Thus, a working data-
base of success stories, country and program evaluation
reports that can be publicly accessible and updated not
only by the international agencies and funders but also
by national governments can help advance research in
this area. This would be an invaluable database and a
reference document that could be used by various stake-
holders involved in designing, funding, implementing,
and evaluating SFPs.
Local procurement of food is yet another area that
seems to be the focus of international non-governmental
and governmental organizations and that will be expand-
ing to provide full coverage to the growing number of
SFPs, especially in response to the nancial and food
crises. In addition, home-grown school feeding (HGSF) is
a new framework that is suggested to link school feeding
with local agricultural production.
50
HGSF seems to be
the next revolution in school feeding. Therefore, more
interest and funding might be channeled to expand on
this new framework. Furthermore, SFPs that oer more
nutritious food fortied or supplemented with required
micronutrients will also be sought in order to increase the
eectiveness of SFPs and their impact on the nutrition,
cognition, and health of children.
Researchers design rigorous randomized controlled
trials to examine the ecacy of SFPs and to establish
cause and eect relationships, when possible, between
school feeding in its dierent modalities and positive
nutrition and educational outcomes. However, ethical
issues arise as researchers deny or delay the provision of
foods and complimentary services, such as anthelmentic
treatment and micronutrient supplements, to children
in control groups that may otherwise benet from the
treatment.
CONCLUSION
Global eorts were exerted to set the MDGs, yet we are
still far from achieving those highly aspired goals. Mil-
lions of children are still deprived of some of their basic
human rights to be fed and taken care of, to receive the
necessary medical and health care, to go to school and get
a formal education that prepares the child for a produc-
tive adult life. The present review of the literature shows a
relatively consistent positive eect of SFPs on the energy
intake and micronutrient status of school-aged children,
and a decline in infections and morbidities, particularly in
programs in which micronutrient fortication and de-
worming are provided to school-aged children in regions
with multiple micronutrient deciencies and heavy loads
of worm infections. Mixed ndings were reported from
various studies in terms of the impact of school feeding
on weight, height, and BMI gains among school-aged
children. Long-term studies that assess the benets of
school meals, snacks, and take-home rations on childrens
growth and household food consumption patterns are
still lacking. Furthermore, as SFPs shift from emergency
and post-crisis strategies to stable and long-term devel-
opment projects and safety nets, complementary nutri-
tion and health education curricula will need to be
further emphasized with provision of school meals and
food rations to address long-term sustainable improve-
ments in nutrition.
In conclusion, the success and almost universality of
SFPs highlights the important yet challenging task of sus-
taining these programs and ensuring that they expand
and benet a larger target population of school-aged chil-
dren, preschoolers, and their households. Collaborative
eorts are required to ensure that SFPs not only expand,
but become increasingly cost-eective and ecient and
achieve intended outcomes in the short and long terms.
Health professionals, educators, researchers, and commu-
nity workers need to work together when developing
national and regional SFPs and designing trials to evalu-
ate their impact on various intended outcomes.
Acknowledgments
This review was conducted in part at the World Food
Programme (WFP) headquarters in Rome, Italy. The
authors thank Mr. Andreas Psoroulas, the head of the
WFP library, Ms. Nancy Walter, the Chief of the School
Feeding Policy at the WFP, and Ms. Carmen Burbano,
co-author of the joint WFP and WB publication
Rethinking School Feeding: Social Safety Net, Child
Development, and the Education Sector, as well as all
members of the School Feeding Division for providing
helpful information and sharing their expertise in this
area.
Declaration of interest. The authors have no relevant
interests to declare.
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