Abstracts of presentations (as of 2nd May 2006)
Dr. Elizabeth KristjanssonAssociate Professor at the University of Ottawa / Cochrane Review of School Meals
abstract
Background
This review, focussing specifically on equity, is the first formal systematic review of the topic of school feeding, and will be the first in a series of school feeding/supplementation reviews.
Why school feeding? Worldwide, 852 million people suffered from under nourishment in the period between 2000 and 2002. In 2004, in developing countries, more than 135 million children under five years of age were underweight and 162 million were stunted. Early malnutrition and/or micronutrient deficiencies have been related to poor cognitive functioning and low academic achievement. Hunger may also affect attention and thus educational attainment. The goals of school feeding programs may differ, but often include: reduction of short-term hunger, increasing school attendance and enrolment, improving nutritional and micronutrient status, improving cognition, and improving academic performance. However, there is some controversy over their effectiveness. This review is designed to study the effectiveness of school meal programs and to examine their potential for reducing health disparities.
Objectives
1. To assess the effectiveness of school feeding programs for improving physical and psycho-social health outcomes for socio-economically disadvantaged elementary and high school children.
2. To study and explore the potential of school feeding programs for reducing socio-economic inequalities in health.
3. To illuminate the process by which school feeding programs achieve (or fail to achieve) an impact on growth, cognitive development, and school performance.
Search strategy
The search strategy was carefully developed by our librarian and involved both published and grey literature databases. We hand searched reference lists of included studies and key journals. Experts in the field were contacted to see if we had missed any relevant studies.
Selection criteria
Data from Randomized Controlled Trials (RCTs), Non-Randomised Controlled Clinical Trials (CCTs), Controlled Before and After Studies (CBAs), and Interrupted Time Series studies (ITS) were included. Primary studies were included if feeding was done in the school setting, and if participants comprised mainly economically/socially disadvantaged elementary and high school students from any country of the world. Disadvantage was broadly defined, and was based on the description of the students or of the area in which they lived.
Data collection & analysis
Our data extraction form was carefully developed and pilot-tested a priori. Data from primary studies were extracted by one of 4 people including 2 research assistants (DF and CW) and two reviewers (BK, VR). All extractions were reviewed by a second person. Two reviewers (BK, BS) independently rated the quality of each study; differences in ratings were then discussed. Experts on the study team; nutritionists: JK, BM, AF; clinical psychologist: LJ; internist: PT) helped to assess the reliability of outcome measures. AF and LJ also helped to judge adequacy of baseline measurements. One of two nutritionists (BM, JK) reviewed each study and assessed the intensity of the nutrition programme, and its impact on nutritional status. A clinical psychologist (LJ) reviewed the data in terms of impact on cognitive functioning. A thorough realist review was performed by TG. The data were synthesized, and, where possible, meta-analyzed.
For analysis, studies were first classified according to whether or not they were in Lower and Lower-Middle Income countries (LLMIC) or Higher-Income countries and then by study design.
Main results
After initial screening, we retrieved 363 potentially useful studies. Seventeen were included in this review and 335 were not included; 9 of these are awaiting assessment. The 17 included studies comprised 6 RCTs, 9 CBAS, and 2 Interrupted time Series (ITS). Of these, 9 were from Lower and Lower-Middle Income countries (5 of the 6 RCTs and 4 of the 8 CBAs). 8 of the seventeen studies were performed in higher-income countries; only one of these was an RCT while 5 were CBAs and 2 were Interrupted Time Series. The children in our included studies ranged in age from 5 to 19 years; most studies included elementary school children.
School meals had a small but statistically significant effect on weight gain in Lower and Lower-Middle Income countries. Meta-analysis of the RCTs showed an average gain of .47 kg over periods ranging from 7 months to 2 years while meta-analysis of the CBAs showed an average gain of .67 over periods of a year. Results from higher-income countries were mixed, but generally positive. Meta-analyses of effects on height in LLMIC showed null results from RCTs and small positive results in the CBAs. Results for height from higher income countries were mixed, but generally positive. Small but consistent improvements in attendance were noted in LLMIC; extrapolating to a school year would mean an average increase of 4 to 8 days a year for students who were given school meals. School meals also resulted in small improvements in the short-term in a few cognitive tasks and in 'on-task behaviour’; the short-term effects on cognitive tasks were evident only for those subjects who the authors described as undernourished. Significant, but very small improvements in four longer-term studies were also seen in tests relating to math achievement, and in two studies, on fluid intelligence. We found limited data relating to socio-economic inequalities in health, but were able to report some data on differences in effectiveness by baseline nutritional status and to qualitatively compare results from LLMIC to those from high income countries.
Reviewers' conclusions
We conclude that school meals can have some small benefits for disadvantaged children. The benefits realized seem to be related to the provision of sufficient energy, conditions for learning in the classroom, substitution at home, and on participation and compliance. We recommend that further well-designed studies on the effectiveness of school meals be undertaken, and that results should be stratified by socio-economic status. Attention should be paid to the nutritional quality and palatability of meals provided. We recommend that researchers gather quality data on outcomes that directly demonstrate effects on physical, social, and psychological health.
1
Ms Albaneide Maria Lima Peixinho CamposNational Coordinator of Programa Nacional de Alimentação Escolar (PNAE)
Dr. Andrea Polo Galante
Professor at the Sao Camilio University (Brazil) / Nutritional impact of School Feeding
in Brazil
albaneide Peixinho abstract
The National School Feeding Program of Brazil (PNAE) started in 1955 and is managed bythe NationalDevelopment of Educational Fund (FNDE). It is considered one of the biggest school feeding programs in the world with an emphasis on access to food as a basic human right. It takes care of about 36 million registered Brazilian students in day-care centres, daily pay-schools, basic education schools, as well as the aboriginal schools and “quilombolas” of the country. Program objectives are as follows:
· Address nutritional needs of the pupils in relations to growth, development and learning capacity;
· Provide supplementary school income; and:
· Develop healthy eating habits amongst school children.
The guiding principles of the program are universality, equality, continuity, decentralization and social participation. PNAE, as a central government agency, allocates financial resources to the Federal States and Municipalities to supplement their school feeding programmes. The financial contribution is destined to purchase commodities under strict regulations and supervision.
Development of indicators to measure the nutritional content and meal quality is required to evaluate the effectiveness of the programmes. Some research has been carried out on the school feeding programme, mainly in the Southern and Southeast region of the country. Four research studies (one in the Northeast region, two in the South-eastern region and one in the Southern region) and an anthropometric study have been carried out. Nutritional indicators such as weight and height measurement and food consumption have been used in the studies. The results of these studies demonstrate that not all the studied children have height deficit; overweight is more frequent than the low weight. Part of the nutrients is supplied by the school feeding programmes, which are in charge of the regional feeding habits. In 2001, an anthropometric study was carried out in three regions (North, Northeast and Centre-west) with approximately 150,000 pupils of 6 to 14 years of age. The results show that the majority of the analyzed children met the medium band of height for each period ofage.
andrea galante abstract
A Municipal Program of Health Care for public school students has been established by a Municipal Law (no. 13.780) and confirmed by the Decree no. 45.986 in June 2005. The main objective of the Health Promotion programme is to reflect upon the meaning of “Health” and “Quality of Life”, and to identify causes / possible solutions for the problems that affect the schools and the neighborhood communities. Amongst the several actions that can be taken to prevent/control illness, this report only focuses on possible solutions for inadequate nutrition.
The programme started in April 2005 by evaluating the nutritional status of a non representative sample of elementary school students. 3,450 students between 7 and 10 years old have been tested; from the enquiry it emerged that the 8.3 percent of the sample is overweight, that the 7.6 percent is obese and that the 6.3 percent has a low height. 683 students under 7 years old have been also examined; 28 percent of them showed anemia, and their percentage increased up to 54.4 percent among the children under 2 years old.
In order to improve the current nutritional status, it has been suggested i) to train the school teachers on nutritional education, ii) to reconsider the need of food intake and fortify food at the schools.
Dr. Akhter AhmedSenior Research Fellow - International Food Policy Research Institute (IFPRI) / FFE Benefits for Education in Bangladesh: Comparing the Effects of Food versus Cash for Education, and Assessing the Impact of the School Feeding Program
abstract
Food for Education (FFE) programs have been implemented in two basic forms: children are fed in school (School Feeding Programs) or families are given food if their children attend school (Food for Schooling Programs). Both programs combine educational opportunity with food-based incentives. FFE programs provide immediate sustenance for the hungry, but perhaps more importantly, they empower future generations by educating today’s children.
Bangladesh possesses a wealth of institutional diversity and experiences in implementing both food for schooling and school feeding programs for primary school children, as well as cash-based education incentive programs. For over a decade IFPRI has been working with the government of Bangladesh and donors to evaluate these programs. This presentation will highlight the educational benefits of these programs.
From 1993 to 2002, the Food for Schooling (FFS) program provided a free monthly ration of rice or wheat to poor families in rural Bangladesh if their children attended primary school.[1] The family could consume the grain, thus reducing its cash outlay for food, or it could sell the grain and use cash to meet other expenses. IFPRI evaluations of the Bangladesh’s FFS program found that the program fulfilled its objectives of increasing school enrollment, promoting school attendance, and preventing dropouts. The enrollment increase was greater for girls than for boys. However, because Bangladesh did not invest in school resources at the same rate at which enrollment increased, class sizes increased in FFS schools. Consequently, there have been concerns about the deterioration of the quality of education in FFS schools. To investigate the possible negative impact of the FFS program on learning, IFPRI collected student achievement test data in schools and analyzed the data in a carefully designed multivariate framework. The results reveal that the class size had no statistically significant effect on student academic achievement. This finding negated the assertion that the increased number of students in FFS school classrooms reduced learning.
The government of Bangladesh terminated the FFS program in 2002 and initiated the Primary Education Stipend (PES) program. The PES program provides cash assistance to poor families if they send their children to primary school. Based on longitudinal panel data, IFPRI compared the outcomes of the FFS and PES programs. The results suggest that both programs encourage poor families to enroll their children in primary school. The rate of increase in enrollment was greater for FFS (19%) than for PES (14%).The difference can likely be attributed to the larger incentive (income transfer) that FFS provided. The increased attendance due to FFS was maintained during the 4-9 months between the end of FFS and the launch of PES. In both programs, net enrollment rates are higher for girls than boys. The higher opportunity costs of attending primary school for boys than girls may explain this discrepancy. For those parents whose children participated in FFS and then switched to PES, about 80% of them prefer PES cash stipend to FFS food ration, because cash can be used directly to meet education and other household expenses.
In 2002, the government of Bangladesh and the WFP launched the School Feeding Program (SFP) in highly food-insecure areas of the country. The SFP provides a mid-morning snack consisting of 8 fortified wheat biscuits. The biscuits provide 300 kilocalories and 75% of the recommended daily allowance of vitamins and minerals, at a cost of U.S. 6 cents per pack of eight biscuits (one snack). SFP provides incentives directly to primary-school children themselves, as opposed to food or cash to parents to send their children to school. The findings of IFPRI evaluation of the SFP show that the program has raised school enrollment by 14.2% and increased school attendance by 1.3 days a month. It has reduced the probability of dropping out of school by 7.5%. Participation in the SFP increased achievement test scores by 15.7%. Participating students did especially well in mathematics.
Mr Ramón Cristián Martínez AhumadaNational Director of JUNAEB (Chile)
Mr Gerardo Munoz
Junta Nacional de Auxilio Escolar y Becas (JUNAEB) (Chile) / Evaluation of school feeding educational outcomes and cost/benefit of school feeding in Chile
abstract
Background
The main objectives of the Programa Alimentacion Escolar (PAE) in Chile are to contribute to a reduction of school dropout and absenteeism rates and to improve the nutritional status of the students.
Objectives
The study attempted to measure the effects produced by the PAE in terms of the degree to which it reaches it objectives. The main indicators for this study are PAE targeting, the extent to which PAE acts as a feeding complement and how PAE prevents school absenteeism and dropout.