A School Meals Program Implemented at Scale in Ghana Increases Height-for-Age during Midchildhood in Girls and in Children from Poor Households: A Cluster Randomized Trial.

BACKGROUND: Attention to nutrition during all phases of child and adolescent development is necessary to ensure healthy physical growth and to protect investments made earlier in life. Leveraging school meals programs as platforms to scale-up nutrition interventions is relevant as programs function in nearly every country in the world. OBJECTIVE: The aim of this study was to evaluate the impact of a large-scale school meals program in Ghana on school-age children's anthropometry indicators. METHODS: A longitudinal cluster randomized control trial was implemented across the 10 regions of Ghana, covering 2869 school-age children (aged 5-15 y). Communities were randomly assigned to 1) control group without intervention or 2) treatment group providing the reformed national school feeding program, providing 1 hot meal/d in public primary schools. Primary outcomes included height-for-age (HAZ) and BMI-for-age (BAZ) z scores. The analysis followed an intention-to-treat approach as per the published protocol for the study population and subgroup analysis by age (i.e., midchildhood for children 5-8 y and early adolescence for children 9-15 y), gender, poverty, and region of residence. We used single-difference ANCOVA with mixed-effect regression models to assess program impacts. RESULTS: School meals had no effect on HAZ and BAZ in children aged 5-15 y. However, in per-protocol subgroup analysis, the school feeding intervention improved HAZ in 5- to 8-y-old children (effect size: 0.12 SDs), in girls (effect size: 0.12 SDs)-particularly girls aged 5-8 y living in the northern regions, and in children aged 5-8 y in households living below the poverty line (effect size: 0.22 SDs). There was also evidence that the intervention influenced food allocation and sharing at the household level. CONCLUSION: School meals can provide a platform to scale-up nutrition interventions in the early primary school years, with important benefits accruing for more disadvantaged children. This trial was registered at www.isrctn.com as ISRCTN66918874.

The nutrition transition and adolescents' diets in low- and middle-income countries: a cross-cohort comparison.

OBJECTIVE: To investigate changes in dietary diversity and dietary composition among adolescents in four developing countries. DESIGN: We analysed dietary diversity and consumption of seven food groups and foods with added sugars as reported by adolescents from two cohorts growing up 8 years apart, when they were aged about 12 years. SETTING: Ethiopia, India (Andhra Pradesh), Peru and Vietnam in 2006 and 2013. SUBJECTS: Adolescents (n 3659) from the older cohort (OC) born in 1995/96 and adolescents (n 7422) from the younger cohort (YC) born in 2001/02 (N 11 081). RESULTS: Controlling for other factors, dietary diversity increased in Peru (OC=4·89, YC=5·34, P<0·001) and Ethiopia (OC=3·52, YC=3·94, P=0·001). Dietary diversity was stable in India (OC=4·28, YC=4·29, P=0·982) and Vietnam (OC=4·71, YC=4·73, P=0·814); however, changes in dietary composition were observed. YC adolescents were more likely to consume eggs (India: +32 %, P=0·038; Vietnam: +50 %, P<0·001) and milk and dairy (India: +12 %, P=0·029; Vietnam: +46 %, P<0·001). Other notable shifts included meat consumption in Peru (+72 %, P<0·001) and consumption of fruit and vegetables in Ethiopia (+36 %, P<0·001). Compared with OC, the prevalence of added sugar consumption was greater among the YC in Ethiopia (+35 %, P=0·001) and Vietnam (+44 % P<0·001). Between 2006 and 2013, disparities in dietary diversity associated with household wealth and place of residence declined, although this varied by country. No marked gender disparities in dietary diversity were evident. CONCLUSIONS: We found significant changes over time in dietary diversity among adolescents in four countries consistent with the hypothesis of the nutrition transition.

Establishing Global School Feeding Program Targets: How Many Poor Children Globally Should Be Prioritized, and What Would Be the Cost of Implementation?

The creation of Human Capital is dependent upon good health and education throughout the first 8,000 days of life, but there is currently under-investment in health and nutrition after the first 1,000 days. Working with governments and partners, the UN World Food Program is leading a global scale up of investment in school health, and has undertaken a strategic analysis to explore the scale and cost of meeting the needs of the most disadvantaged school age children and adolescents in low and middle-income countries globally. Of the 663 million school children enrolled in school, 328 million live where the current coverage of school meals is inadequate (<80%), of these, 251 million live in countries where there are significant nutrition deficits (>20% anemia and stunting), and of these an estimated 73 million children in 60 countries are also living in extreme poverty (

The Evolution of School Health and Nutrition in the Education Sector 2000-2015 in sub-Saharan Africa.

STUDY OBJECTIVES: To document the progression of school health and nutrition and its integration within the education sector in sub-Saharan Africa between 2000 and 2015. BACKGROUND: School health and nutrition programs have contributed to "Education for All" objectives by helping ensure that children benefit from quality education and reach their educational potential. METHODS: Analysis of education sector plans (ESPs) in terms of the Focusing Resources on Effective School Health (FRESH) framework and the World Bank Systems Approach for Better Education Results (SABER) School Health survey from a set of countries in sub-Saharan Africa. RESULTS: Between 2000 and 2015, the presence and scope of school health and nutrition as reflected in the four FRESH pillars grew substantially in ESPs. Three of these pillars have large, upfront costs. The fourth pillar requires recurring annual budgetary allotments. CONCLUSION: Governments clearly recognize that evidence-based, contextually designed school health and nutrition programs can contribute to education sector goals. Moving into the post-2015 era, these programs can also help draw the last 10% of children into school and enhance their readiness to learn.

Evaluation of alternative school feeding models on nutrition, education, agriculture and other social outcomes in Ghana: rationale, randomised design and baseline data.

BACKGROUND: 'Home-grown' school feeding programmes are complex interventions with the potential to link the increased demand for school feeding goods and services to community-based stakeholders, including smallholder farmers and women's groups. There is limited rigorous evidence, however, that this is the case in practice. This evaluation will examine explicitly, and from a holistic perspective, the simultaneous impact of a national school meals programme on micronutrient status, alongside outcomes in nutrition, education and agriculture domains. The 3-year study involves a cluster-randomised control trial designed around the scale-up of the national school feeding programme, including 116 primary schools in 58 districts in Ghana. The randomly assigned interventions are: 1) a school feeding programme group, including schools and communities where the standard government programme is implemented; 2) 'home-grown' school feeding, including schools and communities where the standard programme is implemented alongside an innovative pilot project aimed at enhancing nutrition and agriculture; and 3) a control group, including schools and households from communities where the intervention will be delayed by at least 3 years, preferably without informing schools and households. Primary outcomes include child health and nutritional status, school participation and learning, and smallholder farmer income. Intermediate outcomes along the agriculture and nutrition pathways will also be measured. The evaluation will follow a mixed-method approach, including child-, household-, school- and community-level surveys as well as focus group discussions with project stakeholders. The baseline survey was completed in August 2013 and the endline survey is planned for November 2015. RESULTS: The tests of balance show significant differences in the means of a number of outcome and control variables across the intervention groups. Important differences across groups include marketed surplus, livestock income, per capita food consumption and intake, school attendance, and anthropometric status in the 2-5 and 5-15 years age groups. In addition, approximately 19 % of children in the target age group received some form of free school meals at baseline. CONCLUSION: Designing and implementing the evaluation of complex interventions is in itself a complex undertaking, involving a multi-disciplinary research team working in close collaboration with programme- and policy-level stakeholders. Managing the complexity from an analytical and operational perspective is an important challenge. The analysis of the baseline data indicates that the random allocation process did not achieve statistically comparable treatment groups. Differences in outcomes and control variables across groups will be controlled for when estimating treatment effects. TRIAL REGISTRATION NUMBER: ISRCTN66918874 (registered on 5 March 2015).

Food-package assignments and breastfeeding initiation before and after a change in the Special Supplemental Nutrition Program for Women, Infants, and Children.

BACKGROUND: In 2009, the USDA implemented an interim rule that changed the prescribed foods in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Options for mother and infant dyads include a full breastfeeding package with no infant formula, a partial breastfeeding package with some infant formula, and a full formula package with a smaller postpartum food package for the mother. The changes were designed to encourage WIC mothers to choose breastfeeding for their infants. OBJECTIVE: The purpose of this study was to measure changes in the following 3 outcomes: WIC food-package assignments, WIC infant formula amounts, and breastfeeding initiation. DESIGN: We compared outcomes before and after implementation of the interim rule in a national random sample of 17 local WIC agencies (LWAs). The data source was administrative records for 206,092 dyads with an infant aged 0-5 mo in the sampled LWAs. RESULTS: There were changes in WIC food-package assignments and infant formula amounts but no change in breastfeeding initiation. For dyads in whom the infant was in his or her birth month, the percentage of mothers who received the partial breastfeeding package fell from 24.7% (preimplementation) to 13.8% (postimplementation), the percentage of mothers who received the full breastfeeding package rose from 9.8% (preimplementation) to 17.1% (postimplementation), and the percentage of mothers who received the full formula package rose from 20.5% (preimplementation) to 28.5% (postimplementation). CONCLUSIONS: After the change, fewer WIC mothers of new infants received the partial breastfeeding package. More WIC mothers received the full breastfeeding package, but more mothers also received the full formula package.