Emergency Free School Meal Distribution During the COVID-19 Pandemic in High-Poverty Urban Settings

BACKGROUND

The coronavirus disease 2019 pandemic triggered nationwide school closures in March 2020, putting millions of children in the United States who were reliant on subsidized school meals at risk of experiencing hunger. In response, the US Department of Agriculture mobilized the Summer Food Service Program and Seamless Summer Option program to provide emergency free school meals. There is a need to investigate the effectiveness of these programs in covering underresourced communities during the pandemic.

OBJECTIVE

This study assessed associations between meal distribution and census tract demographics (ie, poverty level, race/ethnicity, and deprivation level based on social deprivation index score).

DESIGN

An observational study using longitudinal meal distribution data collected over an 18-month period following school closures (March 2020 to August 2021).

PARTICIPANTS AND SETTING

Monthly meal distribution data were collected for community sites serving 142 census tracts within 4 urban New Jersey cities predominantly populated by people with low incomes and from racial and ethnic minority groups.

MAIN OUTCOME MEASURES

Main outcome measures were the number of meals served monthly by Summer Food Service Program and Seamless Summer Option meal sites.

STATISTICAL ANALYSES PERFORMED

A 2-part multivariable regression approach was used to analyze the data.

RESULTS

In the first step, logistic regression models showed that high-deprivation tracts were more likely to serve meals during the observed period (odds ratio 3.43, 95% CI 1.001 to 11.77; P = 0.0499). In the second step, among tracts that served any meals during the observed period, mixed effects negative binomial regression models showed that high-poverty and high-deprivation tracts served comparatively more meals (incidence rate ratio [IRR] 2.83, 95% CI 2.29 to 3.51; P < 0.001 and IRR 1.94, 95% CI 1.65 to 2.28; P < 0.001, respectively).

CONCLUSIONS

Findings show that meal distribution during the pandemic was higher within census tracts with higher poverty and deprivation levels, indicating that underresourced communities with higher need had more free meals available during this unprecedented public health emergency.

It is time: free meals at schools for all

The link between school feeding programmes (SFP) and the promotion of healthy eating and health is being explored in studies performed in different countries. The coronavirus disease-19 pandemic has revealed flaws and weaknesses in contemporary food systems, with many school-age children experiencing food insecurity and hunger. There is intense debate among policymakers regarding whether government SFP should be universal or targeted. Countries such as Brazil and India, which have two of the most comprehensive universal free-of-charge programmes, have shown the benefits of SFP, including improved nutritional status, support for more sustainable food systems, attendance and academic performance. Evidence shows and supports actions advocating that it is time to offer healthy and free school meals for all students.

Meals, Education, and Gardens for In-School Adolescents: A Cluster Randomized Trial of an Adolescent Nutrition Intervention Package in Tanzania

PURPOSE

This study aimed to implement and evaluate integrated, school-based nutrition intervention packages for adolescents in Dodoma, Tanzania.

METHODS

A cluster randomized controlled trial was conducted among six secondary schools in Dodoma, Tanzania. Two schools received the full-intervention package of school meals, nutrition education, school gardens, and community workshops. Two schools received the partial-intervention package without the school meals component. Two schools served as the controls and did not receive any intervention. The intervention was implemented over one academic year. The analytical sample included 534 adolescents aged 14 to 17 at baseline and 286 parents. Outcomes included nutrition knowledge, food preferences, diet quality, food insecurity, physical activity, growth, and anemia. Linear models were used to estimate mean differences, and logistic regression models were used to estimate odds ratios (ORs).

RESULTS

Compared to the control, both the partial (OR: 0.59; 95% confidence interval [CI]: 0.35, 1.00) and full (OR: 0.49; 95% CI: 0.40, 0.59) interventions were associated with lower odds of poor diet quality among adolescents. Among the parents, both the partial (OR: 0.28; 95% CI: 0.20, 0.40) and full (OR: 0.28; 95% CI: 0.13, 0.58) interventions were associated with lower odds of poor diet quality. The partial (OR: 0.29; 95% CI: 0.18, 0.47) and full (OR: 0.47; 95% CI: 0.30, 0.72) interventions were associated with lower odds of adolescent overweight or obesity.

DISCUSSION

School-based nutritional intervention packages incorporating multiple actions may improve the diet quality of adolescents and their household members and reduce the double burden of adolescent malnutrition.

Daily Saturated Fat and Sodium Content of Elementary School Meals in a Large Sample of 128 Geographically Diverse School Systems in the United States

BACKGROUND

Despite federal regulations limiting saturated fat and sodium levels on a weekly average basis, daily nutrient content of school meals in the United States is not regulated, leading to potential large fluctuations and intake well in excess of dietary recommendations.

OBJECTIVE

To assess the daily prevalence of potential public elementary school meal combinations that were high in saturated fat and sodium (using cutoffs based on the US Department of Agriculture weekly average reimbursable meal thresholds), and to identify saturated fat and sodium thresholds for entrées to limit full meals exceeding those cutoffs.

DESIGN

Cross-sectional.

PARTICIPANTS AND SETTING

Four weeks of publicly available public elementary school (kindergarten through grade five) breakfast and lunch menus with associated nutrition data were collected from a national stratified random sample of 128 school districts during fall 2019.

MAIN OUTCOME MEASURES

Percent of meal combinations exceeding the saturated fat and Target 1 sodium thresholds were calculated, as well as thresholds for saturated fat and sodium levels in breakfast and lunch entrées.

STATISTICAL ANALYSES

Descriptive statistics and logistic regression were used to examine the odds of alignment with sodium and saturated fat US Department of Agriculture thresholds.

RESULTS

The prevalence of elementary breakfast and lunch meal combinations that were high in sodium was on average 11% and 12.4%, respectively, and for saturated fat was 10.6% and 34%, respectively. Entrées above certain thresholds (≥400 and ≥1,000 mg sodium and ≥4.5 and ≥6 g saturated fat for breakfast and lunch, respectively) had a higher odds of producing a reimbursable meal that was high in sodium and saturated fat.

CONCLUSIONS

There is widespread availability of high-saturated fat and sodium elementary school meal combinations on a daily basis. Daily thresholds, in addition to weekly nutrient thresholds, as well as limits on sodium and saturated fat for entrées, may therefore be needed to prevent daily excess intake of saturated fat and sodium among elementary students.

Willingness for more vegetarian meals in school canteens: Associations with family characteristics and parents' food choice motives in a French community

The school meal system could contribute to the transition towards more sustainable food system by promoting plant-based meals. Knowing whether parents want more vegetarian school meals for their children is a prerequisite for a successful implementation. The present study aimed to estimate the proportion of parents who would opt for more vegetarian school meals for their children and to study associations of willingness with family characteristics and food choice motives. An online survey was sent to parents whose children are registered for school canteen in Dijon (France). We collected child-level information, data on family sociodemographic characteristics, and data on dietary habits and food choice motives of the family. We examined family characteristics associated with the willingness to increase the frequency of vegetarian school meals from one meal per week to two or daily. Generalized linear models were performed. In total, 49% of parents were willing to opt for a second weekly vegetarian meal and 26% for a daily vegetarian meal for their children (n = 1261). Parents willing to opt for more vegetarian meal were more likely to have higher education, be flexitarian or vegetarian and to currently opt for pork-free meals for their children, and their children attended the school canteen less frequently. Environmental motives were positively associated with the willing to opt for a second weekly vegetarian meal; familiarity and sensory appeal motives were negatively associated. Health and animal welfare motives were positively associated with the willing to opt for a daily vegetarian meal and sensory appeal was negatively associated. Increasing the frequency of vegetarian school meals would satisfy a demand expressed by parents but must be accompanied by interventions enhancing pleasure of eating vegetarian meals.

Implementation and effectiveness of a school-based intervention to increase adherence to national school meal guidelines: a non-randomised controlled trial

OBJECTIVE

Implementation of school meal guidelines is often inadequate, and evidence for effective implementation strategies for school-based nutrition interventions is limited. The aim of the present study was to examine the implementation and effectiveness of a multi-strategy implementation intervention to increase adherence to the Norwegian national school meal guideline.

DESIGN

The study was a school-based hybrid implementation effectiveness trial with a pre-post non-equivalent control group design, testing three implementation strategies: internal facilitation, training and an educational meeting.

SETTING

Primary schools and after-school services in two counties in south-east Norway.

PARTICIPANTS

School principals, after-school leaders and class teachers from thirty-three schools in the intervention county and principals and after-school leaders from thirty-four schools in a comparison county.

RESULTS

There was a significant difference of 4 percentage points in change scores between the intervention and the comparison groups at follow-up, after adjusting for baseline adherence (B = 0·04, seB = 0·01, t = 3·10, P = 0·003). The intervention effect was not associated with the school's socio-economic profile. School-level fidelity was the implementation dimension that was most strongly correlated (r s = 0·48) with the change scores in the intervention group, indicating that principals' support is important for gaining the largest intervention effects.

CONCLUSIONS

A school-based intervention with low intensity, based on trained teachers as internal facilitators, can increase adherence to the national school meal guideline among Norwegian primary schools, irrespective of local socio-economic conditions. Implementation fidelity, at an organisational level, may be a useful predictor for intervention outcomes in schools.

Feeding for a brighter future: The long-term labor market consequences of school meals in rural China

This study examines the impacts of childhood exposure to the Nutrition Improvement Program (NIP), which provides free school meals to eligible students in rural China, on adult labor market outcomes. Using data from the China Family Panel Studies, we employ a cohort difference-in-differences (DID) design to identify the NIP's long-term effects. The results show that early-life exposure to the NIP has increased adulthood employment probability by 6.5 percentage points. Childhood exposure to the NIP has also resulted in an average increase of 12.4% in adult hourly wages and 10.3% in annual income. These findings remain robust to a battery of validity checks. Our heterogeneous analysis demonstrates that these effects are more pronounced among those who are females and from households with low socioeconomic status. Further, we find that exposure to the NIP yields lasting beneficial effects on adult education attainment, cognitive and non-cognitive skills, as well as health and health behaviors. This suggests that improvements in human capital accumulation and health behaviors are potential mechanisms contributing to the long-term labor market consequences of the NIP. Our study sheds light on the enduring impacts of school-based nutrition intervention on individuals' economic well-being in developing countries.

Phthalates, adipates, BPA, and pesticides in school meals

BACKGROUND

Exposure to phthalates, adipates, bisphenol-A (BPA), and pesticides may have important health consequences for children, but little is known regarding their presence in school meals, a major food source for children. The aims of this study were to determine the presence of phthalates, adipates, BPA, and pesticides in school meals.

METHODS

Using a cross-sectional design, n = 50 school meal components were collected from four school districts in New England (n = 8 elementary/K-8 schools) differing preparation methods (on-site scratch cooking and pre-packaged heat and serve meals with plastic films) between 2019 and 2021. Meal components were tested for the presence of phthalates, adipates, BPA, and pesticides by an independent laboratory.

RESULTS

One adipate, DEHA, was detected in 42% of samples (range 0.08 mg/kg - 50.39 mg/kg). Among the prepackaged foods, DEHA was detected in 86% of samples, which also contained the highest average concentrations among all the samples tested. The phthalate Diisononyl phthalate (DINP) was detected in only one sample, and BPA was not detected in any of the samples tested. Pesticides were detected in 64% of produce and 27% of entrées, but most had levels that were lower than the average levels detected by the USDA's Pesticide Data Program and only one sample had levels that exceeded those detected by the USDA (Cyfluthrin levels in one sample of apples were 0.038 mg/kg compared with an USDA average range of 0.004-0.032 mg/kg).

CONCLUSIONS

Overall pesticides and phthalate levels in school meals are low and BPA was not detected. However, this study suggests that manufacturers may be changing to less studied plasticizers such as DEHA. More studies should examine the impact of DEHA on human health, particularly among children. As schools transition back from the COVID-19 pandemic, foods packaged in plastic should be minimized where possible. Overall, school meals remain one of the healthiest options for children and policies that support on site cooking can further strengthen the quality of school meals.

Private school canteens: an analysis of the economic and financial aspects of the traditional and the healthy models

BACKGROUND

One of the reasons for the more prominent resistance of canteen managers to implementing healthy canteens is based on the belief in the economic infeasibility of these models. The research aimed to verify the economic and financial viability of traditional and healthy models of school canteens in a Brazilian metropolis.

METHODS

The case study was carried out with 36 companies in the school canteen sector in a Brazilian metropolis. The classification of items sold in canteens considered the extent and purpose of food processing according to the NOVA Classification. The characterization and definition of traditional canteens and healthy canteens were proposed considering the amount of in natura or minimally processed foods and culinary preparations without the presence of ultra-processed foods; the percentage of ultra-processed foods or processed foods or culinary preparations with the presence of ultra-processed foods; and the existence of prohibited foods. The economic and financial analysis was carried out mainly through the evaluation of profitability. Data were collected through an electronic self-administered questionnaire sent to canteen managers. The Mann-Whitney test was used to compare medians and the Chi-Square/Fisher's Exact Test to compare proportions.

RESULTS

The study included six companies, responsible for 36 canteen units in private schools, 30 classified in the traditional model (83.3%), and six in the healthy model (16.7%). The median percentage of natural, minimally processed foods and commercialized culinary preparations was higher among the healthy model canteens (87.9% vs. 60.0%, p < 0.001). While the median percentage of ultra-processed, processed, or preparations with the presence of ultra-processed (40.0% vs. 12.1%, p < 0.001) and prohibited foods (10.0% vs. 0%, p < 0.001) sold was higher in the traditional model canteens. The results indicated that the profitability in the healthy canteens was higher (p < 0.001) than in the traditional ones.

CONCLUSIONS

Healthy school canteens showed better financial and economic results compared to traditional canteens with emphasis on greater profitability and a shorter recovery time of the initial investment.

Parent perceptions of changes in eating behavior during COVID-19 of school-aged children from Supplemental Assistance Program Education (SNAP-Ed) eligible households in California

This cross-sectional study examined the associations between parent-reported, perceptions of changes in school-aged children's (ages 5-18) school meal participation, household cooking, fast food consumption, dietary intake, and weight during the COVID-19 pandemic. Respondents with low-income and school-aged children (n = 1040) were enrolled using quota sampling to approximate the distribution of low-income households and race/ethnicity among California residents who completed an on-line questionnaire developed by the authors. Adjusted multinomial models examined associations between parent-reported changes in school meal participation and time spent cooking, with parent-reported changes in child diet and body weight during COVID-19 (from before March 2020 to January-March 2021). During the pandemic, decreased school meal participation was associated with decreased child's fast food intake (OR[95 %CI] = 1.47[1.04-2.07]); conversely, increased school meal participation was associated with increased child's fast food intake (OR[95 %CI] = 1.71[1.09-2.68]). Decreased cooking at home was associated with decreased fruit and vegetable intake (OR[95 %CI] = 2.71[1.62-4.53]), increased sugar-sweetened beverage intake (OR[95 %CI] = 3.83[2.16-6.81]), and increased fast food intake (OR[95 %CI] = 4.09[2.45-6.84]); while increased cooking at home was associated with increased fruit and vegetable (OR[95 %CI] = 2.26[1.59-3.20]), sugar-sweetened beverage (OR[95 %CI] = 1.88[1.20-2.94]), sweets (OR[95 %CI] = 1.46[1.02-2.10]), and salty snack food intake (OR[95 %CI] = 1.87[1.29-2.71]). These parent-reported perceived changes in meal sources during the pandemic for children from low-income California households, and the mixed results in their associations with changes in parent-reported child dietary intake, suggest the need for strengthening policies and programs to support both access to, and healthfulness of, meals from school and home during prolonged school closures.

Contribution of school meals to the recommended nutrient and energy intake of children enrolled in the National Homegrown School Feeding Program in Zaria, Nigeria

BACKGROUND

A poor nutritional status in children results in reduced physical and mental health and poor academic performance. The National Homegrown School Feeding Program (NHSFP) was introduced in Nigeria in 2016 to ameliorate short-term hunger and improve the nutritional status of school-aged children (SAC). At least 33% of the recommended nutrient intake (RNI) for the enrolled students should be met by the school meals. However, to our knowledge, the contribution of school meals served through the NHSFP to the RNI of SAC in Zaria, Nigeria, remains to be explored.

METHODS

We conducted a school-based cross-sectional study among 276 eligible SAC recruited from public primary schools in the Zaria Local Government Area. Portion sizes of the meals served through the NHSFP were determined using an electronic scale, meal samples were collected for nutrient analysis, and the average daily nutrient intake of the participants from the meals was calculated. The average daily intake of nutrients and energy of the participants was compared with the age- and sex-specific RNI to estimate the percentage contribution of the meals.

RESULTS

The portion sizes recorded were 199.3 ± 20.6 g, 263.9 ± 11.5 g, 242.1 ± 16.8 g, 311 ± 17.3 g, and 160.3 ± 1.9 mL, respectively, for moi-moi, jollof rice and beans, bean porridge, jollof rice and boiled egg, and yoghurt. In addition, the meals contained moisture (30.13-66.11%), ash (0.73-7.08%), crude fat (9-32.61%), crude protein (7.25-24.5%), crude fiber (0-2.45%), and total carbohydrate (2.19-29.74%) with an energy content ranging from 183.6 to 330.57 kcal. Similarly, the meals contained calcium (82.58-711 mg), potassium (133-797 mg), sodium (340-1720 mg), iron (0.078-8.60 mg), zinc (1.84-13.4 mg), vitamin A (2.38-100.56 RAE), and vitamin C (0.04-1.57 mg) per 100 g of the school meals. The meals contributed 18.2-19.1%, 102.8-183.7%, 13.04-13.6%, and 26.1%-35.8% of the RNI for carbohydrates, proteins, fiber, and energy, respectively. Furthermore, they contributed 137-175%, 314.3-502.2%, 87.6-142.1%, 21.5-25.1%, 279.2-348.5%, 3.3-5.9%, 24.7-48.8%, and 3.3-5.9% of the RNI for iron, zinc, calcium, potassium, sodium, vitamin A, and vitamin C, respectively.

CONCLUSION

The meals served through the NHSFP contributed at least 33% of the RNI for energy, protein, iron, calcium, sodium, vitamin A, and zinc. However, they could not meet the 33% of the RNI for carbohydrates, fiber, potassium, and vitamin C. Increasing the portion sizes and the diversity of the meals can address the suboptimal contribution of the meals to the RNI for carbohydrates, fiber, potassium, and vitamin C.

Insights into parents' and teachers' support for policies promoting increased plant-based eating in schools

Global environmental and public health challenges related to current food systems call for large-scale shifts towards increasingly plant-based diets, especially in Western meat-centric societies. School meal systems can play a role in these changes due to their widespread prevalence and multi-sectoral impact. However, there is a lack of evidence about how adults involved in the school meals system perceive school-based pro-environmental food policies, which limits the ability to align those policies with the needs and expectations of the school community. This study aimed to address this knowledge gap by exploring parents' (n = 104) and teachers' (n = 252) support for policies to promote increased plant-based eating in public schools in a highly meat-centric EU country (Portugal). Overall, teachers seemed to be slightly more supportive of such policies and displayed more favorable (injunctive and dynamic) norms toward plant-based eating, more negative appraisals of meals with meat (i.e., perceived healthiness, naturalness, and sustainability), and lower attachment to meat consumption. Furthermore, injunctive norms in favor of plant-based meals were linked with higher support for measures promoting plant-based meals in schools, in both samples (parents, teachers). Lower meat attachment and favorable perceived meal attributes (e.g., perceptions about plant-based and fish meals) were associated with teachers' support for measures promoting plant-based meals in schools. These findings suggest that future efforts and research with parents and teachers to enable less meat-centric and more flexitarian food practices in schools should consider social and motivation variables relevant to plant-forward transitions.

Caregiver perceptions of England's universal infant school meal provision during the COVID-19 pandemic

The United Nations (UN) recognises free school meals as critical, yet widely disrupted by COVID-19. We investigate caregiver perceptions and responses to interruptions to the universal infant free school meal programme (UIFSM) in Cambridgeshire, England, using an opt-in online survey. From 586 responses, we find 21 per cent of respondents' schools did not provide UIFSM after lockdown or advised caregivers to prepare packed lunches. Where provided, caregivers perceived a substantial decline in quality and variety of meals, influencing uptake. Direction to bring packed lunches, which caregivers reported to have contained ultra-processed foods of lower nutritional quality, influenced caregiver behaviour rather than safety concerns as claimed by industry. The quality and variety of meals, and school and government policy, had greater impact than concerns for safety. In the UK and at the international level, policymakers, local governments, and schools must act to reverse the trend of ultra-processed foods in packed lunches, while improving the perceived quality of meals provided at schools.

School Menu Review Programme (PReME): evaluation of compliance with dietary recommendations during the period 2006-2020 in Catalonia

BACKGROUND

The School Menu Review Programme (PReME) has been offering complimentary revisions of meal plans to all schools in Catalonia since 2006. This study aims to assess the evolution of compliance with PReME's recommendations in the meals provided by school cafeterias in Catalonia during the period 2006-2020.

METHODS

Pre-post study with a sample of 6,387 meal plans from 2221 schools assessed during the period. The information was collected mainly by public health specialists within the annual technical and sanitary inspection of school kitchens and cafeterias. Meal plans were evaluated by Dietitian-Nutritionists team according to the criteria of the National Health System's "Consensus document on nutrition in schools" and the Public Health Agency of Catalonia's current guide "Healthy eating at school". Reports were sent to each participating school. A few months later, a new meal plan and another questionnaire were collected and evaluated in comparison with the first meal plan. Compliance with the recommendations was analysed based on the type of canteen management and the school category.

RESULTS

Compliance improved during the study period. The percentage of schools that complied with dietary recommendations in relation to the five PReME indicators (fresh fruit, pulses, daily vegetables, fresh food and olive oil for dressing) has steadily increased since PReME began, (over 70% in all indictors; p =  < 0.001), with variations depending on school category and cafeteria management. Furthermore, an improvement in the levels of compliance with de recommended food frequencies was observed. with statistically significant differences for all items (p < 0.001), except for pulses whose compliance had been high since the beginning of the study (p = 0.216).

CONCLUSIONS

The positive evolution in compliance with PReME's recommendations provides evidence of the programme's effectiveness, with an improvement in the quality of school meals delivered in Catalonia.

Impact of school meals on educational outcomes in Addis Ababa, Ethiopia

OBJECTIVE

This study evaluated the impact of the Addis Ababa School Feeding Program (SFP) on educational outcomes.

DESIGN

Single-group repeated measurement/longitudinal study design and multistage stratified sampling design were followed. Effect sizes estimates, repeated measures ANOVA, Chi-square, Generalised Additive Mixed Model and mixed effects negative binomial regression were used. Academic scores, attendance and dropout and height and weight of schoolchildren were collected.

SETTING

School Feeding Programs in Addis Ababa, Ethiopia.

PARTICIPANTS

Schoolchildren in primary schools and school directors and teachers in fifteen randomly selected schools for Key Informant Interview (KII).

RESULTS

Anthropometric measurements of 4500 schoolchildren were taken from 50 schools. Academic scores of 3924 schoolchildren from 46 schools, class attendance records of 1584 schoolchildren from 18 schools and annual enrolment records of 50 schools were gathered. School meals achieved a minimum to large scale effects on educational outcomes with effect sizes (η²) of academic scores (boys = 0·023, girls = 0·04), enrolment (girls = 0·001, boys = 0·05) and attendance (Cramer's V = 0·2). The average scores of girls were significantly higher than that of boys (P < 0·0001). Height-for-age in all schoolchildren (P < 0·01) and BMI-for-age Z-scores in adolescent girls of 15-19 years (P < 0·0001) never had a significant positive relationship with average scores. Significant relation was observed between nutritional status and attendance (P = 0·021). KII showed that SFP created convenient teaching-learning environment and reduced hunger in schools, while boosting enrolment, attendance and academic performance among the schoolchildren.

CONCLUSION

The Addis Ababa SFP has positively contributed to educational outcomes. Strengthening the program would enhance nutritional outcomes and diminish educational inequalities.

Children's experiences of meals after obesity treatment: a qualitative follow-up four years after a randomized controlled trial

Background

The practice of eating together, commensality, is rarely explored in the context of childhood obesity treatment. This is noteworthy given long-standing debates about the physical, psychosocial, and societal benefits of meals, especially family meals. Moreover, as children with obesity experience weight bias and stigma both within and outside the home, it is important to examine meals as a locus of social exchange around food and the body. Our study is based on the premises that eating together (i) matters and (ii) occurs in different environments with diverse social organization, where food-related interactions create varying arrangements of individuals, groups, their statuses, and their actions.

Method

The study explores children’s experiences of meals in different social contexts. Thirty-two children (age 8–10 years) living in Sweden were interviewed, 4 years after they entered an obesity intervention trial. Thematic analysis was applied to the data.

Results

We thematized three meal types, with each meal type having two subthemes: (i) “The family meal”, with “Shared routines, rituals, and rules” and “Individual solutions and choices”; (ii) “The school meal”, with “Rules and norms of the school” and “Strategies of the child”; and (iii) “The friend meal”, with “Handling food that was disliked” and “Enjoyment of food”. These three different meal types carried different experiences of and knowledge about how they were socially organized.

Conclusions

While the children spoke about the family and school meals as meaningful, the friend meal stood out as particularly positive. Contrary to our expectations, the children did not express experiences of weight bias or obesity stigma around meals, nor did they speak negatively about parental control of their food intake. Our findings, especially regarding the friend meal, have implications for further research into commensality and social influences on eating among children with obesity, from early childhood into adolescence.

Dietary quality of school meals and packed lunches: a national study of primary and secondary schoolchildren in the UK

OBJECTIVE

School lunches represent a key opportunity to improve diets and health of schoolchildren. No recent nationally representative studies have examined the nutritional differences between school meals and packed lunches in the UK. This study aimed to characterise and compare the nutritional quality of school meals and packed lunches among primary and secondary school-age children.

DESIGN

A pooled cross-sectional analysis of the UK's National Diet and Nutrition Survey (2008-2017).

SETTING

United Kingdom.

PARTICIPANTS

3001 children (aged 4-16 years) who completed a 3/4-d food diary which recorded meal type (school meal/packed lunch). Multivariable logistic regression models assessed associations of meeting food and nutrient recommendations by meal type. Analyses were stratified by academic key stages (KS).

RESULTS

KS-1 (4-7 years) and 2 (8-11 years) children consuming school meals were more likely to meet minimum recommendations for vegetables, protein-rich foods and fibre, and not exceed maximum recommendations for salt, savoury and sweet snacks compared with pupils consuming packed lunches. However, in KS-3 (12-14 years) and 4 (14-16 years), these effects were reduced. As children aged, the median weight of fruits, vegetables, protein-rich foods and dairy products consumed typically decreased for both school meals and packed lunches, and generally an increasing proportion of school meals contained sweet and savoury snacks.

CONCLUSION

These findings suggest school meals are nutritionally superior to packed lunches but are not yet optimal. Quality declined at higher KS. Actions to improve lunches of primary and secondary schoolchildren across the UK are needed, with attention to KS-3 and 4 in secondary schools.

Number of meal components, nutritional guidelines, vegetarian meals, avoiding ruminant meat: what is the best trade-off for improving school meal sustainability?

PURPOSE

School meals have the potential to promote more sustainable diets. Our aim was to identify the best trade-off between nutrition and the environment by applying four levers to school meals: (i) reducing the number of meal components, (ii) complying with the French school nutritional guidelines, (iii) increasing the number of vegetarian meals, and/or (iv) avoiding ruminant meat.

METHODS

Levers were analyzed alone or in combination in 17 scenarios. For each scenario, 100 series of 20 meals were generated from a database of 2316 school dishes using mathematical optimization. The nutritional quality of the series was assessed through the mean adequacy ratio (MAR/2000 kcal). Seven environmental impacts were considered such as greenhouse gas emissions (GHGE). One scenario, close to series usually served in French schools (containing four vegetarian meals, at least four ruminant meat-based meals, and at least four fish-based meals) was considered as the reference scenario.

RESULTS

Reducing the number of meal components induced an important decrease of the energy content but the environmental impact was little altered. Complying with school-specific nutritional guidelines ensured nutritional quality but slightly increased GHGE. Increasing the number of vegetarian meals decreased GHGE (from 11.7 to 61.2%) but decreased nutritional quality, especially when all meals were vegetarian (MAR = 88.1% against 95.3% in the reference scenario). Compared to the reference scenario, series with 12 vegetarian meals, 4 meals containing fish and 4 meals containing pork or poultry reduced GHGE by 50% while maintaining good nutritional quality (MAR = 94.0%).

CONCLUSION

Updating French school nutritional guidelines by increasing the number of vegetarian meals up to 12 over 20 and serving non-ruminant meats and fish with the other meals would be the best trade-off for decreasing the environmental impacts of meals without altering their nutritional quality.

Impact of introducing a farm to school program on the number of school lunches served

Farm to school (FTS) programs are becoming more prevalent throughout the United States. Yet, their impacts on students' behaviors are still not well understood. This study analyzes the impacts of introducing the local procurement aspect of a FTS program in a Florida school district on the number of National School Lunch Program (NSLP) meals served and the selection of salad meals prepared with FTS products using daily school-level point of sale (POS) data, product procurement records, NSLP menu data and linear panel regression analyses. The study district implemented the FTS program in 15 of its 22 elementary schools between mid-October of 2015 and mid-January of 2016. Weighted difference in differences regressions that account for the non-random assignment of the district's elementary schools into the FTS program and variation in the timing of implementation across schools indicate that the introduction of the FTS program did not affect the number of NSLP meals served or type of meals served at schools with FTS programs. We find some evidence that students selected more NSLP salad offerings on days when these meals were prepared with FTS products; however, these findings were no longer significant when school-level fixed effects were included in the model.

The contribution of school meals to food security among households with children and adolescents in Brazil

OBJECTIVES

This study aimed to analyze the relationship between food insecurity and school meal consumption, adjusted for sociodemographic variables.

METHODS

This cross-sectional study investigated households with children and adolescents living in Brazilian municipalities. A semistructured survey was administered to parents/guardians at a parent-teacher meeting to assess their socioeconomic conditions and access to food, using the Brazilian Food Insecurity Scale to classify households as having food security or mild, moderate, or severe food insecurity. Parents and students were asked about the frequency of their consumption of school meals offered by the Brazilian School Food Program, which is one of the largest public policies in Brazil and offers free meals to all students in all public schools. Multinomial regression was performed to assess the relationship between food security and frequency of school meal consumption.

RESULTS

A total of 1705 students participated in the study, most of whom displayed some degree of food insecurity (56.5%) per the Brazilian Food Insecurity Scale. Regular consumption of school meals (>3 times/wk) was reported by 78.5% of students. Regarding the frequency of school meal consumption adjusted by sociodemographic variables, students from households with food insecurity (moderate or severe) were more likely to regularly consume school meals. The prevalence of households with moderate or severe food insecurity was twice as high as for those who lived in households with food security after adjusting for sociodemographic variables (odds ratio: 2.35; 95% confidence interval 1.53-3.61).

CONCLUSIONS

The Brazilian School Food Program has contributed greatly to food security. Although the guarantee of universality is essential for the program to reach all school children who are experiencing food insecurity, the program should also aim for greater equity.

Impact of the community eligibility provision program on school meal participation in Texas

OBJECTIVE

To estimate the impact of opting into the community eligibility provision (CEP) on school meal participation among students in Texas.

DESIGN

A quasi-experimental design using a two-way fixed effects panel difference-in-difference model and the variation in adoption timing to estimate the impact of opting into CEP on student breakfast and lunch participation in eligible, ever-adopting schools.

SETTING

All public and charter K-12 schools in Texas participating in national school meals (breakfast and/or lunch) from 2013 to 2019 who are eligible for the CEP program in at least 1 year and choose to opt into the program in at least 1 year (n 2797 unique schools and 16 103 school-years).

PARTICIPANTS

School-level administrative data from the Texas Department of Agriculture on meal counts, enrollment and summary characteristics of students merged with district-level educational and socio-demographic data from the Texas Education Authority.

RESULTS

We find opting into CEP increased school breakfast participation by 4·59 percentage points (P < 0·001) and lunch participation by 4·32 percentage points (P < 0·001), on average. The effect is slightly larger (4·64 and 4·61, respectively) and still statistically significant when excluding summer months.

CONCLUSION

Our findings suggest that opting into CEP modestly increases school meal participation in Texas, with a similar impact on breakfast and lunch.

Factors Associated with Universal Free School Meal Provision Adoption among US Public Schools

BACKGROUND

The Community Eligibility Provision (CEP) allows high-poverty schools participating in US Department of Agriculture meal programs to offer universal free school meals. Emerging evidence suggests benefits of CEP for student meal participation, behavior, and academic performance. Although CEP became available nationwide in 2014, in school year 2019-2020, one third of eligible schools were not participating.

OBJECTIVE

This study evaluates which school, district, and state factors are associated with CEP participation.

DESIGN

Cross-sectional study comparing CEP-participating with eligible nonparticipating schools to assess the relationship between CEP participation and school, district, and state factors.

PARTICIPANTS

US public schools eligible for CEP in school year 2017-2018 (n = 42,813).

MAIN OUTCOME MEASURES

CEP participation.

STATISTICAL ANALYSES PERFORMED

Penalized regression variable selection methods to determine which factors contribute information to the model. Generalized logistic regression to predict odds of CEP participation unadjusted and adjusted for each factor in the full sample and in stratified analyses by whether a state was part of the CEP phase-in period (early vs late implementing states).

RESULTS

In the full sample, adjusted odds of CEP participation were greater in states where CEP had been available longer (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.34, 1.67). In late implementing states, adjusted odds of CEP participation were higher in schools with more students directly certified for free meals (OR in schools with 80%-89% vs 30%-39% directly certified: 19.32; 95% CI, 12.98, 28.76), Title I schools (OR, 1.85; 95% CI, 1.55, 2.21), and urban schools (OR suburban vs urban, 0.46; 95% CI, 0.36, 0.59). Differences by school level, enrollment, district size, student race/ethnicity, and geographic region also existed.

CONCLUSIONS

Findings may help advocates, state agencies, and policymakers understand potential barriers to adoption and guide research exploring effective strategies to promote uptake. Future research should use qualitative and longitudinal designs to explore barriers to adoption, including cost and state and local policies.

Mitigating childhood food insecurity during COVID-19: a qualitative study of how school districts in California's San Joaquin Valley responded to growing needs

OBJECTIVES

To explore best practices and challenges in providing school meals during COVID-19 in a low-income, predominantly Latino, urban-rural region.

DESIGN

Semi-structured interviews with school district stakeholders and focus groups with parents were conducted to explore school meal provision during COVID-19 from June to August 2020. Data were coded and themes were identified to guide analysis. Community organisations were involved in all aspects of study design, recruitment, data collection and analysis.

SETTING

Six school districts in California's San Joaquin Valley.

PARTICIPANTS

School district stakeholders (n 11) included food service directors, school superintendents and community partners (e.g. funders, food cooperative). Focus groups (n 6) were comprised of parents (n 29) of children participating in school meal programmes.

RESULTS

COVID-19-related challenges for districts included developing safe meal distribution systems, boosting low participation, covering COVID-19-related costs and staying informed of policy changes. Barriers for families included transportation difficulties, safety concerns and a lack of fresh foods. Innovative strategies to address obstacles included pandemic-electronic benefits transfer (EBT), bus-stop delivery, community pick-up locations, batched meals and leveraging partner resources.

CONCLUSIONS

A focus on fresher, more appealing meals and greater communication between school officials and parents could boost participation. Districts that leveraged external partnerships were better equipped to provide meals during pandemic conditions. In addition, policies increasing access to fresh foods and capitalising on United States Department of Agriculture waivers could boost school meal participation. Finally, partnering with community organisations and acting upon parent feedback could improve school meal systems, and in combination with pandemic-EBT, address childhood food insecurity.

Hiring Requirements and Qualifications of School Food Authority Directors Changed in Some Districts After Implementation of US Department of Agriculture Professional Standards

BACKGROUND

In 2015, the US Department of Agriculture set minimum education and training requirements (ie, professional standards) to ensure that school nutrition professionals have the knowledge and experience to operate school meal programs. No study to date has examined whether hiring requirements and qualifications of school food authority (SFA) directors have changed since 2015.

OBJECTIVE

To assess changes in hiring requirements and qualifications of SFA directors since the US Department of Agriculture professional standards were established, overall and by district size.

DESIGN

Cross-sectional analysis of nationally representative district-level data from the 2012 and 2016 cycles of the School Health Policies and Practices Study.

PARTICIPANTS/SETTING

In 2012, 660 sampled districts completed the School Health Policies and Practices Study Nutrition Services questionnaire. In 2016, 599 sampled districts completed the questionnaire.

MAIN OUTCOME MEASURES

Hiring requirements for newly hired SFA directors and reported qualifications of SFA directors.

STATISTICAL ANALYSES PERFORMED

Differences in prevalence estimates from 2012 to 2016 for all districts and by district size were assessed with χ2 tests.

RESULTS

Significant increases were found for 3 hiring requirements: degree in nutrition or related field, registered dietitian credential, and food safety certification. Significant changes in 4 of the 5 reported qualifications were found including an increase in the percentage of district directors with a degree in nutrition or a related field and decreases in the percentage of directors with a School Nutrition Specialist credential from the School Nutrition Association, School Nutrition Association certifications, and certified dietary managers. Changes were found in small and medium districts, but not large districts.

CONCLUSIONS

District hiring requirements and SFA director qualifications have changed since the implementation of the US Department of Agriculture professional standards, including some differences by district size. Future research could identify challenges facing districts in hiring directors who have a degree in nutrition or related fields or who have specialized nutrition credentials or certificates (eg, registered dietitians).

Tracking the environmental footprints of institutional restaurant service in nursery schools

When dietary habits are analyzed in the framework of school catering services, nutritional indicators are essential criteria in the definition of menus, but attention should also be paid to the associated environmental impacts. It is especially relevant to assess food patterns in nursery schools when consumption habits are most strongly implemented, and they must be healthy and sustainable. With the aim of evaluating the main environmental indicators: Carbon and water footprints (CF and WF), ten menus consisting of lunch and afternoon snack were evaluated, which comprise a wide range of food categories (fruits and vegetables, starch-based products, milk and milk products, non-dairy sources of protein, and others). The CF of the menus varied considerably according to their composition, with beef-rich menus having the worst profile (up to 2.24 kg CO₂/menu and 0.39 kg CO₂/100 kcal). Regarding the WF, meals rich on animal-based products also entailed water implications and mainly associated with the consumption of beef. Green WF and blue WF are responsible for 88% of the contributions to this indicator, on average. The WF indicator reaches up to 1271 L·menu^-1 and 223 L/100 kcal for a menu containing beef meat. This study confirms the effect on CF and WF from animal-based products, specifically beef meat and dairy products. The findings of the study can be useful to make recommendations not only to consumers on reducing the environmental impacts from food production and consumption, but also to design balanced menus with better environmental scores based on the combination of low and high footprint food products, always providing the necessary energy and nutrients, an unquestionable issue in toddlers and pre-school children whose need to follow balanced and healthy diets, being meat an important foodstuff.

A systematic review of school meal nudge interventions to improve youth food behaviors

Background

School meal programs have a large reach and thus are ideal environments in which to implement interventions targeting improved youth eating behaviors and reduced food waste. This systematic review summarizes the evidence on the effectiveness of school meal nudge interventions on influencing children’s eating and waste behaviors.

Methods

Inclusion criteria required studies have participants in primary or secondary school (grades K-12) with interventions that occurred during school lunch or breakfast in the cafeteria and included at least one of the following outcomes: selection, consumption, waste, or school meal participation. Analyses of intervention outcomes were restricted to studies of strong and moderate quality.

Results

Twenty-nine studies were included in the quality assessment. Included interventions fell into three categories: 1) placement/convenience, 2) marketing/promotion, or 3) variety/portions. The 20 strong and moderate quality studies included in outcome analyses generally used strong data collection methods and study designs, but were limited by an overall lack of intervention fidelity checks. Multi-component interventions often did not use methods that allowed for separate analyses of outcomes for different intervention components.

Conclusions

School meal nudge interventions were positively associated with food selection, and had an inconsistent relationship with food consumption. There were few studies evaluating the impact of nudge interventions on meal participation or food waste. The limited evidence available links nudges to improved meal participation, as well as undesirable increases in food waste. Future research in this area should use methods that incorporate implementation metrics, attend to systems factors, and allow the outcomes of individual intervention components to be isolated.

Cross-sectional associations between lunch-type consumed on a school day and British adolescents' overall diet quality

Diet quality of children consuming school meals tends to be better than that of children consuming packed lunches (from home) or food bought outside school. This study investigates the association between different types of lunch consumed in a school day and diet quality of UK adolescents. A total of 2118 British adolescents were included from the National Diet and Nutrition Survey (Years 1-8; between 2008 and 2016). All participants attended school and were aged 11-18 years with valid 3 or 4-day diary records and the analyses were stratified by age group (11-14 and 15-18 years). The Diet Quality Index for Adolescents (DQI-A) tool consisting of three components; diet quality, diversity and equilibrium, was used to assess adherence to dietary recommendations. Overall DQI-A scores range from -33 to 100%. Overall mean DQI-A score for all adolescents was low at 21.1%. Fewer (17.4%) adolescents reported buying lunches from cafés and shops, compared to adolescents consuming cooked school meals and packed lunches (28.3% and 36.6%, respectively), and they had the lowest DQI-A% score of 14.8%. Adolescents having cooked school meals (reference group) had a higher overall DQI-A% of 21.8%. Diet quality scores of older adolescents having packed lunches and shop/café-bought lunches were 5.5% higher (CI 2.7 to 8.4%; p < 0.01) and 5.0% lower (CI 8.1 to 2.0%; p < 0.01) than cooked school meals respectively, after adjusting for gender, region, energy under-reporting and equivalised household income. For younger adolescents the results were attenuated particularly among packed lunch consumers. UK adolescents generally consume a poor quality diet and adolescents purchasing lunches from outside the school gates have the lowest quality diets. Unlike with older children there is little difference between school meals and packed lunches for younger children. Regulation policies on food outlets around secondary schools as well as improving food choices within school premises are needed.

The importance of school lunches to the overall dietary intake of children in Sweden: a nationally representative study

Objective:

School lunches have potential to foster healthy diets in all children, but data on their importance are relatively scarce. The current study aimed to describe the dietary intake from school lunches by sex and school grade, and to assess how the daily intake, school lunch intake and the daily intake provided by lunch differ by sex and parental education.

Design:

Cross-sectional. All foods and drinks consumed for 1–3 weekdays were self-reported. Energy, absolute and energy-adjusted intakes of nutrients and food groups were calculated per weekday and per school lunch. Mixed-effects linear models assessed sociodemographic differences in dietary intakes. Nutrient and energy density at lunch and during the rest of the day were compared.

Setting:

Seventy-nine Swedish primary schools.

Participants:

Pupils in grades 5 and 8 (N 2002), nationally representative.

Results:

Lunch provided around half of daily vegetable intake and two-thirds of daily fish intake. Nutrient density was higher and energy density lower at lunch compared with the rest of the day (P < 0·001). Boys had greater energy-adjusted intakes of red/processed meat and lower intakes of vegetables and dietary fibre compared with girls (P < 0·001), overall and at lunch. Daily energy-adjusted intakes of most nutrients/food groups were lower for pupils of lower-educated parents compared with pupils of parents with higher education, but at lunch, only Fe and fibre intakes were significantly lower in this group.

Conclusions:

School lunches are making a positive contribution to the diets of Swedish children and may mitigate well-established sex differences and social inequalities in dietary intake.

Improving the overall sustainability of the school meal chain: the role of portion sizes

PURPOSE

This work analyses the meal supply in primary schools in Italy to highlight new areas of inefficiency upstream of the food chain, regarding the size of the food portions specified in public tenders. A lack of conformity of food portions can potentially lead to a double negative externality affecting the sustainability of school meals: overweight children and food waste.

METHOD

Based on the data contained in the contract between municipalities and school catering services, the analysis was performed on the portion sizes (in grams) of the main food products included in the school menu for each regional capital (RC) in Italy. Data analysis regarded two main aspects: consistency of food portions within regions and adherence to national standards for childrens.

RESULTS

The results revealed great discrepancies amongst regions and in several cases, portion sizes significantly larger than the reference values of standard portions for school catering. The study also profiles RC on the basis of portion sizes, school meal attendance, and childhood obesity rates.

CONCLUSIONS

School meals have the potential to educate the next generation regarding healthy eating habits, and thus play a leading role in obesity prevention in children. Similarly, the educational role of eating at school can contribute to raising children's awareness about one of the most urgent environmental challenges-food waste-by introducing the best strategies for waste reduction, reuse, and recycling. Results have economic, social, health, and environmental implications and highlight the need to revisit policies to introduce new solutions for more sustainable and healthy school canteens in Italy.

LEVEL OF EVIDENCE

Level V, descriptive studies.

Universal Access to Free School Meals through the Community Eligibility Provision Is Associated with Better Attendance for Low-Income Elementary School Students in Wisconsin

BACKGROUND

Beginning in 2014-2015, schools nationwide have had the option of offering free meals to all students in qualifying schools through the Community Eligibility Provision (CEP). The CEP has been linked to greater likelihood of eating school meals, but little is known about its impact on broader outcomes.

OBJECTIVE

The purpose of this study was to estimate the association between the CEP and school attendance among elementary school students (grades 1 to 5).

DESIGN

This was a quasi-experimental study in which students' attendance records were observed over 1 baseline and 2 follow-up years in a sample of CEP and eligible non-CEP schools.

PARTICIPANTS/SETTING

The participants were elementary school students in Wisconsin during three consecutive school years beginning 2013-2014. The main sample included 92,126 observation-years for students in 37 CEP and 108 eligible non-CEP elementary schools.

INTERVENTION

CEP-participating schools offered breakfast and lunch free to all students through the School Breakfast Program and the National School Lunch Program beginning in 2014-2015.

MAIN OUTCOME MEASURES

The outcome measures were the attendance rate (defined as the percentage of school days attended) and low attendance (defined as attending fewer than 95% of available days) during the first and second implementation years.

STATISTICAL ANALYSES PERFORMED

Difference-in-difference regression models with student fixed effects were estimated, with separate impacts for the first and second CEP years. Models adjusted for time-varying school and student characteristics.

RESULTS

Implementing the CEP had no association with attendance in the initial year. The second year of CEP was associated with a 3.5 percentage point reduction in the percentage of students with low attendance (P=0.045). An association between CEP and attendance was only found for economically disadvantaged students.

CONCLUSIONS

Offering meals free to all students through the CEP may modestly reduce the risk of low attendance among economically disadvantaged students in participating schools.

Serving Breakfast Free to All Students and Type of Breakfast Serving Model Are Associated with Participation in the School Breakfast Program

BACKGROUND

Many students experience challenges participating in the School Breakfast Program (SBP) when breakfast is served before school in the cafeteria. Serving breakfast free to all students or offering innovative breakfast serving models, such as breakfast in the classroom (BIC), grab n' go, or second chance breakfast, may encourage higher SBP participation rates.

OBJECTIVE

To examine the association between offering breakfast free to all students as well as breakfast serving model with student participation in the SBP in October 2017 among public schools in North Carolina.

DESIGN

Cross-sectional study using data from the North Carolina Department of Public Instruction.

PARTICIPANTS/SETTING

This study included data from 2,285 North Carolina public schools who served breakfast in October 2017 with 1,445,287 students.

MAIN OUTCOME MEASURES

The main outcome measures are the odds of a student participating in the SBP among students overall, students eligible for free or reduced-price (FRP) meals, and students not eligible for FRP meals.

STATISTICAL ANALYSES PERFORMED

Multiple logistic regression assessed the association between offering breakfast free to all students and breakfast serving model with the probability of participating in the SBP (number of students participating out of number of students enrolled) for students overall, eligible for FRP meals, and not eligible for FRP meals. Statistical models were stratified by school type (elementary, middle, and high schools).

RESULTS

Breakfast serving models positively associated with SBP participation were BIC and BIC plus grab n' go for elementary and high school students and grab n' go and second chance for middle and high school students (P<0.05). Serving breakfast free to all students was positively associated with SBP participation alone and in combination with BIC, second chance, and BIC plus grab n' go (P<0.05).

CONCLUSIONS

Serving breakfast free to all students and breakfast serving model were associated with SBP participation, and different relationships existed for different school levels.

The effect of introducing a free breakfast club on eating habits among students at vocational schools

Background

Unhealthy eating habits are a major problem among adolescents. The objective of the study was to assess the effect of a free breakfast club intervention on dietary habits among students at vocational schools.

Methods

The study included students (n = 318) from four vocational schools in Denmark. Food frequency questionnaires were used to measure eating habits at baseline, first, and second follow-up, after 7 and 14 weeks respectively, in a clustered randomized controlled intervention of four months. The effect of the intervention was evaluated through self-reported frequencies of breakfast intake, intake of whole grain products for breakfast and intake of unhealthy snacking in the morning. The outcome measures were daily breakfast intake (yes/no), daily intake of whole grain for breakfast (yes/no), and unhealthy snacking on school day mornings (yes/no).

Results

The proportion of students who had breakfast every school day increased significantly in the intervention schools from baseline to the first follow-up compared to the control group (OR: 3.77; P = 0.0149). The effect was attenuated at the second follow-up. The intake of whole grain products for breakfast increased significantly more among students in intervention schools compared to students in control schools both at first (OR: 4.13; P = 0.0079) and second follow-up (OR: 3.27; P = 0.0317). No significant change in unhealthy snacking was found.

Conclusion

Provision of free breakfast at vocational schools can improve the dietary quality of breakfast and decrease breakfast skipping. However, the sustainability of the intervention is a critical issue that needs to be further studied and addressed.

Trial registration

ISRCTN11265280. Registered 20 November 2018 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6701-9) contains supplementary material, which is available to authorized users.

Dietary Taurine Supplementation in School Meals Has Positive Effect on School Attitude Assessment in Korean High School Students

This study was conducted to evaluate the effect of supplementation with taurine-rich foods on school attitude assessment (SAA) in high school students. A total of 134 subjects were divided into a taurine-rich food supplemented (TS) group (68 subjects) and control group (66 subjects). For the TS group, school dinners supplemented with taurine-rich foods were provided for 5 days and average dietary amount of taurine supplementation was 466.2 mg/school dinner. Control group ate dinner at home or at restaurant ad libitum. The school attitude assessment survey-revised and 24-h recall method were used for SAA and dietary assessment, respectively. There were no significant differences in scores of dietary attitudes between the TS and control groups by gender. Average dietary taurine intake of the TS group (649.8 mg/day in males, 634.5 mg/day in females) was significantly higher compared to the control group (392.4 mg/day in males, 334.4 mg/day in females) (p < 0.01 in males and p < 0.001 in females, respectively). Total SAA scores in the TS group were significantly higher compared to the control group (p < 0.01) for attitudes toward teachers, goal valuation, and motivation/self-regulation (p < 0.01). Dietary taurine intake was showed positive correlations with scores for academic self-perception (p < 0.05), attitudes towards teachers (p < 0.001), goal valuation (p < 0.01), motivation/self-regulation (p < 0.05), and total scores (p < 0.01). According to the results, dietary taurine supplementation in school meals for 5 days had a positive effect on SAA in high school students. Therefore, dietary taurine supplementation in school and home meals may be necessary for improving SAA of high school students.

Evaluation of an intervention to improve the management of allergens in school food services in the city of Barcelona

BACKGROUND

An intervention to promote the development of an allergen control plan (ACP) and preventive measures for the management of allergens in school food services was implemented in all schools of Barcelona city over a three-year period (2013-2015) by the public health services. The present study aimed to assess changes regarding the management of food allergens in school food services in Barcelona after an intervention conducted by the public health services of the city.

METHODS

School meal operators of a random sample of 117 schools were assessed before and after the intervention using a structured questionnaire. The questionnaire collected general information on the students and their demand for special menus, and included 17 closed questions regarding the implementation of specific preventive measures for the management of allergens. Based on these 17 questions, a food safety score was calculated for each school. The improvement in these scores was evaluated.

RESULTS

The results showed positive increments in the percentage of implementation of 12 of the 17 preventive measures assessed. The percentage of school food services with an implemented ACP increased by 49%. Schools with external and internal food supplies increased their scores by 16.5% and 19.6%, respectively. The greatest improvements were observed in smaller food services and in schools located in districts with low gross household incomes.

CONCLUSIONS

The intervention was effective in improving school food services' management of allergens and in reducing the differences found among food services in the pre-intervention survey. We must also focus efforts on reducing socio-economic inequalities linked to the management of allergens.

Nutritional value of school meals and their contributions to energy and nutrient intakes of rural school children in Enugu and Anambra States, Nigeria

Background

Nutritional deficiencies among school children may hinge on inadequate nutrient intake. School meals should improve nutrient intakes by providing a third of recommended daily energy and nutrient intakes (RNI). The study aimed at evaluating school meals served in three rural schools to determine if they met one third of the RNI of the children. This will enhance meal planning.

Methods

Food samples (20 g) that constituted the school meals were collected for five consecutive days from three schools where school lunch programme was implemented. These were put in labelled small air tight plastic containers and stored in deep freezers in the Department of Home Science, Nutrition and Dietetics, University of Nigeria, Nsukka. The samples were analysed chemically using standard methods. Portion sizes of foods were obtained and the contributions made by these meals to the children's RNI were calculated. Results were presented in percentages and means ± standard deviations.

Results

The results showed that energy value of the meals ranged from 32.27 - 243.4 Kcal/100 g. The school meals contained carbohydrate (0.7 - 48.4 g), protein (0.69 - 12.6 g), vitamin C (0.7 - 8.22 mg), vitamin A (3.0 - 255.5 RE), iron (0.05 - 1.7 mg), calcium (3.0 -120 mg) and zinc (0.14 - 3.0 mg) per 100 g of food consumed. They contributed 16.4 - 25.5% energy, 53.4 - 116.9% protein, 66.0 - 159.5% vitamin A, 37.3 - 45.7% vitamin C, 13.2 - 28.5% calcium, 5.9 - 20.6% iron and 35.1 - 92.9% zinc to the children's daily requirements.

Conclusion

The school meals provided over one third of the RNI for protein, vitamins A and C, and zinc but did not meet a third of the RNI for energy, calcium and iron.

Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children´s diet and food consumption? A cross-national comparative perspective

There is little agreement among governments, institutions, scientists and food activists as to how to best tackle the challenging issues of health and sustainability in the food sector. This essay discusses the potential of school meals as a platform to promote healthy and sustainable food behavior. School meal programs are of particular interest for improving public diet because they reach children at a population scale across socio-economic classes and for over a decade of their lives, and because food habits of children are more malleable than those of adults. Current research on the history and health implications of school meal programs is reviewed in a cross-national comparative framework, and arguments explored that speak for the need of a new developmental phase of school meals as an integrative learning platform for healthy and sustainable food behavior. Nutritional, social, practical, educational, economical, political, and cultural perspectives and challenges linked to the implementation of healthy and sustainable school meals are discussed. Finally, the need for long-term interventions and evaluations is highlighted and new research directions are proposed.

A free lunch or a walk back home? The school food environment and dietary behaviours among children and adolescents in Ghana

Food environments can play an important roles in shaping nutrition and health outcomes. One such environment that has potential to affect youth is the school food environment. In contrast to higher-income countries, however, there is a critical evidence gap on the role of school food environments on children and adolescents in low- and middle-income countries. This mixed-methods study contributes to filling this gap by investigating the role of school food environments on dietary behaviours of children and adolescents in Ghana. It draws on data from household and school questionnaires as well as focus group discussions collected as part of the baseline for an impact evaluation of the Ghana School Feeding Programme (GSFP). Multi-level regression models were fitted with random intercepts at the individual, household and community levels. Excerpts from the focus group discussions provided a deeper understanding of quantitative findings. Children and adolescents who received free school meals provided by the GSFP or who lived further away from school were less likely to go home for lunch. More than half of sampled schools reported offering foods for sale by independent vendors, the most common being meals followed by confectionery, fruit and sugar-sweetened beverages. Predictors of bringing money to school to buy food included non-receipt of free school meals, adolescence, greater commuting distance from home, household asset score, and urban location. Policy efforts focusing on the school food environment may contribute to healthy dietary behaviours for children and adolescents with positive impacts over the lifecourse.

[Purchase of local foods for school meals in Andalusia, the Canary Islands and the Principality of Asturias (Spain)]

OBJECTIVE

To explore and compare the characteristics of Primary Education Centres (PEC) in Andalusia, the Canary Islands and the Principality of Asturias depending on whether or not they make local food purchases (LFP) for school meals and to explore the opinion of cafeteria managers about the benefits and challenges of this type of purchase.

METHOD

Information on the characteristics of 186 PECs and opinions of cafeteria managers about the benefits/challenges of LFP was collected through an electronic questionnaire. Data were stratified according to how the products were purchased (LFP: yes/no), and the chi square test was applied.

RESULTS

38.2% of the PECs studied make LFP. This is more frequent in rural areas (51.0 with self-managed cafeterias (80.0%), and their own kitchen (65.5%). These centres have less expensive menus than their peers (69.8%), participate more frequently in healthy eating programmes (81.5%) and purchase more organic food products (65.8%). According to the majority of the participants whose centres engage in LFP, the benefits include: supporting the local economy (97.2%), the offer of fresh foods (97.2%) and environmental sustainability (93.0%). The challenges include: productive capacity of the region (50.7%), the seasonal variation in food production (71.8%), and the lack of support (42.3%) and information from the government (46.5%).

CONCLUSION

The location of the centres, the management of the cafeteria and the availability of a kitchen on site can influence the development of LFP in schools. Government support could help to integrate LFP in schools, improving school meals at a lower economic and environmental cost.

The rural school meal as a site for learning about food

The aim of the article is to contribute to the understanding of the school meal as a site for learning about food, nutrition and the wider determinants of health in three small rural schools of Ecuador. Based on a year-long qualitative fieldwork, the multiple case study associates Vygotsky's sociocultural theory of learning with Noddings' theory of care to analyze the findings. In the study, elements of care in the relationships between children and adults seemed to promote dialogue and, in this way, adults were able to model what is required to care for others and oneself. This entails that a focus solely on food or limitations on social interaction during the school meal may reduce its learning opportunities. The study concurs with the research that the food is better received when it is more aligned with the students' expectations. In addition, the findings support the view that rural school meal programs should address the views of parents and teachers because of their influence on how the meal is prepared and provided. The article proposes that schools work within a flexible framework emphasizing attention to the caring aspects of the meal, as a means to develop this dimension of the school meal. The study also contends that a collaborative reshaping of conditions formally set by school food policy is consistent with a critical approach to food and nutrition. In connection with this, the study concludes by highlighting the value of revisiting Noddings' perspective of care as deriving from the practice of opening up and meeting the other.

The public's opinions on a new school meals policy for childhood obesity prevention in the U.S.: A social media analytics approach

OBJECTIVES

This study investigates the public's opinions on a new school meals policy for childhood obesity prevention, discovers aspects concerning those opinions, and identifies possible gender and regional differences in the U.S.

METHODS

We collected 14,317 relevant tweets from 11,715 users since the national policy enactment on Feb 9, 2010 through Dec 31, 2015. We applied opinion mining techniques to classify tweets into positive, negative, and neutral categories, and conducted content analysis to gain insights into aspects of opinions in terms of target, holder, source, and function.

RESULTS

There were more negative tweets about the school meals policy than positive ones (16.8% vs. 12.9%), in addition to neutral tweets (70.3%). The main targets for negative opinions were campaign and food, and those for positive opinions were policy and health benefits. The opinion holders represent a wide range of policy stakeholders. The first-hand source dominated the opinions. Statement accounted for the function of most opinions. Females (62.5%) were more involved than males (37.5%), and people in the South and the West regions (64.2%) engaged themselves more than people in the Northeast and the Midwest (35.8%) of the U.S.

CONCLUSIONS

Negative opinions about the school meals policy consistently outnumbered positive ones. The findings discovered the public's opinions for policy improvement, contributed to the evidence base of health benefits for policy promotion and community collaboration, and revealed interesting gender and regional differences in the opinions. The social media analytics offers significant methodological implications for discovering the public opinions on food policies.

Fourth-grade children's dietary reporting accuracy by meal component: Results from a validation study that manipulated retention interval and prompts

We examined reporting accuracy by meal component (beverage, bread, breakfast meat, combination entrée, condiment, dessert, entrée, fruit, vegetable) with validation-study data on 455 fourth-grade children (mean age = 9.92 ± 0.41 years) observed eating school meals and randomized to one of eight dietary recall conditions (two retention intervals [short, long] crossed with four prompts [forward, meal-name, open, reverse]). Accuracy category (match [observed and reported], omission [observed but unreported], intrusion [unobserved but reported]) was a polytomous nominal item response variable. We fit a multilevel cumulative logit model with item variables meal component and serving period (breakfast, lunch) and child variables retention interval, prompt and sex. Significant accuracy category predictors were meal component (p < 0.0003), retention interval (p < 0.0003), meal-component × serving-period (p < 0.0003) and meal-component × retention-interval (p = 0.001). The relationship of meal component and accuracy category was much stronger for lunch than breakfast. For lunch, beverages were matches more often, omissions much less often and intrusions more often than expected under independence; fruits and desserts were omissions more often. For the meal-component × retention-interval interaction, for the short retention interval, beverages were intrusions much more often but combination entrées and condiments were intrusions less often; for the long retention interval, beverages were matches more often and omissions less often but fruits were matches less often. Accuracy for each meal component appeared better with the short than long retention interval. For lunch and for the short retention interval, children's reporting was most accurate for entrée and combination entrée meal components, whereas it was least accurate for vegetable and fruit meal components. Results have implications for conclusions of studies and interventions assessed with dietary recalls obtained from children.

Energy and nutrient intakes of Swedish children in relation to consumption of and habits associated with school lunch

AIMS

School lunches are provided free in Sweden, although some children choose not to eat school lunch. The aim of this study was to analyse Swedish children's total energy and nutrient intakes on weekdays by the frequency of school lunch consumption and to analyse energy and nutrient intakes from school lunches by sex. Factors associated with children's school lunch habits were also studied.

METHODS

Children in grades 2 and 5 ( n=1905) completed a food diary (school lunch data available for 1840 children) and the mean energy and nutrient intakes per day and per school lunch were calculated. The children also completed questions on the frequency of school lunch consumption and school lunch habits. Logistic regression was used to assess factors associated with school lunch habits.

RESULTS

Children who reported eating school lunch every day had significantly higher energy and absolute nutrient intakes than children reporting eating school lunch less than five times a week, but not standardized for energy. Boys had significantly higher energy and absolute nutrient intakes from school lunches than girls, but not standardized for energy. Younger children and children who liked school lunches had higher odds of eating school lunch every day. Children in grade 5, those with a foreign background and those disliking school lunches had higher odds of omitting the main lunch component.

CONCLUSIONS

Regular school lunch consumption was associated with a higher total intake for most nutrients, but not a better nutrient density. School lunch habits were associated with age, ethnic background and liking school lunches.

Fourth-Grade Children's Reporting Accuracy for Amounts Eaten at School-Provided Meals: Insight from a Reporting-Error-Sensitive Analytic Approach Applied to Validation Study Data

BACKGROUND

Validation studies that have directly assessed reporting accuracy for amounts eaten have provided results in various ways.

OBJECTIVE

To analyze amount categories of a reporting-error-sensitive approach for insight concerning reporting accuracy for amounts eaten.

DESIGN

For a cross-sectional validation study, children were observed eating school-provided breakfast and lunch, and randomized to one of eight 24-hour recall conditions (two retention intervals [short and long] crossed with four prompts [forward, meal name, open, and reverse]).

PARTICIPANTS/SETTING

Data collected during 3 school years (2011-2012 to 2013-2014) on 455 children from 10 schools (four districts) in a southern US state.

MAIN OUTCOME MEASURES

Items were classified as matches (observed and reported), omissions (observed but unreported), or intrusions (unobserved but reported). Within amount categories (matches [corresponding, overreported, and underreported], intrusions [overreported], and omissions [underreported]), item amounts were converted to kilocalories.

STATISTICAL ANALYSES PERFORMED

A multilevel model was fit with food-level explanatory variables (amount category and meal) and child-level explanatory variables (retention interval, prompt, sex, and race/ethnicity). To investigate inaccuracy differences, t tests on three contrasts were performed.

RESULTS

Inaccuracy differed by amount category (P<0.001; in order from largest to smallest: omission, intrusion, underreported match, and overreported match), meal (P=0.01; larger for breakfast), retention interval (P=0.003; larger for long), sex (P=0.004; larger for boys), race/ethnicity (P=0.045; largest for non-Hispanic whites), and amount category×meal interaction (P=0.046). Overreported amounts were larger for intrusions than overreported matches (P<0.0001). Underreported amounts were larger for omissions than underreported matches (P<0.0001). Overall underreported amounts (from omissions and underreported matches) exceeded overall overreported amounts (from intrusions and overreported matches) (P<0.003).

CONCLUSIONS

Amount categories provide a standard way to analyze validation study data on reporting accuracy for amounts eaten, and compare results across studies. Multilevel analytic models reflecting the data structure are recommended for inference. To enhance reporting accuracy for amounts eaten, focus on increasing reports of correct items, thereby yielding more matches with fewer intrusions and omissions.

Implementing Smarter Lunchrooms Makeovers in New York state middle schools: an initial process evaluation

BACKGROUND

This paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6-8, typically children ages 10-14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers.

METHODS

Under research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013-2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery.

RESULTS

Approximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended.

CONCLUSIONS

RE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.

The School Food Environment and Obesity Prevention: Progress Over the Last Decade

The school food environment-including when and where children obtain food and the types of options available during the school day-plays an important role in children's consumption patterns. Thus, childhood obesity prevention efforts often focus on altering the school food environment as a mechanism for improving student dietary intake. This review examines the role school food programs and policies play in improving children's diet, weight, and health. Overall, research suggests that significant improvements have been made in school nutrition policies and programs. Due to the recent program changes made as a result of the 2010 Healthy, Hunger-Free Kids Act, an emphasis was placed on research conducted over the past decade and especially on the evaluation of foods and beverages served and sold since implementation of this national law. This review also examines remaining gaps in the literature and opportunities for further improvements in school food programs and policies.

Evaluation of a student participatory, low-intensity program to improve school wellness environment and students' eating and activity behaviors

Background

Most schools have not fully implemented wellness policies, and those that have rarely incorporate meaningful student participation. The aim of the Fuel Up to Play 60 (FUTP60) program is to help schools implement wellness policies by engaging students in activities to improve access to healthful, good tasting food and drinks, and increase the number and type of opportunities for students to be physically active. The aim of this paper is to present initial student-level results from an implementation of FUTP60 in 72 schools, grades 6–9.

Methods

The study used a non-controlled pretest/posttest with serial cross-sectional data. School process data and student-level data were collected in fall 2009 (pre-intervention) and spring 2010 (post-intervention). School wellness practices were captured during a baseline needs assessment survey. Validated self-administered questionnaires assessing dietary and physical activity (PA) behaviors were administered to students in grades 6–9 in the 72 pilot schools. Mixed-effects logistic regression controlling for clustering of schools and demographics was used to calculate odds ratios and confidence intervals to evaluate changes pre- and post- intervention.

Results

All 72 schools implemented FUTP60 during the 2009–2010 school year. Action strategies most frequently chosen by the schools included increasing breakfast participation and new activities before and after school. Positive and significant changes in students’ behaviors (n = 32,482 at pretest and 29,839 at post-test) were noted for dairy, whole grains, fruit, and vegetable consumption and PA levels pre- and post-intervention (OR 1.05 to 1.27). Students aware of the program at post-test were significantly more likely to report healthier eating and PA behaviors than students unaware of the program (OR 1.1 to 1.34).

Conclusions

FUTP60 pilot findings indicate that a low intensity program focused on wellness policy implementation is associated with small positive changes in student behaviors, especially when students were aware of the program. Although these initial results are promising, a more rigorous controlled study is warranted as a next step.

Lunch-time food choices in preschoolers: Relationships between absolute and relative intakes of different food categories, and appetitive characteristics and weight

Children's appetitive characteristics measured by parent-report questionnaires are reliably associated with body weight, as well as behavioral tests of appetite, but relatively little is known about relationships with food choice. As part of a larger preloading study, we served 4-5year olds from primary school classes five school lunches at which they were presented with the same standardized multi-item meal. Parents completed Child Eating Behavior Questionnaire (CEBQ) sub-scales assessing satiety responsiveness (CEBQ-SR), food responsiveness (CEBQ-FR) and enjoyment of food (CEBQ-EF), and children were weighed and measured. Despite differing preload conditions, children showed remarkable consistency of intake patterns across all five meals with day-to-day intra-class correlations in absolute and percentage intake of each food category ranging from 0.78 to 0.91. Higher CEBQ-SR was associated with lower mean intake of all food categories across all five meals, with the weakest association apparent for snack foods. Higher CEBQ-FR was associated with higher intake of white bread and fruits and vegetables, and higher CEBQ-EF was associated with greater intake of all categories, with the strongest association apparent for white bread. Analyses of intake of each food group as a percentage of total intake, treated here as an index of the child's choice to consume relatively more or relatively less of each different food category when composing their total lunch-time meal, further suggested that children who were higher in CEBQ-SR ate relatively more snack foods and relatively less fruits and vegetables, while children with higher CEBQ-EF ate relatively less snack foods and relatively more white bread. Higher absolute intakes of white bread and snack foods were associated with higher BMI z score. CEBQ sub-scale associations with food intake variables were largely unchanged by controlling for daily metabolic needs. However, descriptive comparisons of lunch intakes with expected amounts based on metabolic needs suggested that overweight/obese boys were at particularly high risk of overeating. Parents' reports of children's appetitive characteristics on the CEBQ are associated with differential patterns of food choice as indexed by absolute and relative intake of various food categories assessed on multiple occasions in a naturalistic, school-based setting, without parents present.

Effects of school meals with weekly fish servings on vitamin D status in Danish children: secondary outcomes from the OPUS (Optimal well-being, development and health for Danish children through a healthy New Nordic Diet) School Meal Study

Children's vitamin D intake and status can be optimised to meet recommendations. We investigated if nutritionally balanced school meals with weekly fish servings affected serum 25-hydroxyvitamin D (25(OH)D) and markers related to bone in 8- to 11-year-old Danish children. We conducted an explorative secondary outcome analysis on data from 784 children from the OPUS School Meal Study, a cluster-randomised cross-over trial where children received school meals for 3 months and habitual lunch for 3 months. At baseline, and at the end of each dietary period, 25(OH)D, parathyroid hormone (PTH), osteocalcin (OC), insulin-like growth factor-1 (IGF-1), bone mineral content (BMC), bone area (BA), bone mineral density (BMD), dietary intake and physical activity were assessed. School meals increased vitamin D intake by 0·9 (95 % CI 0·7, 1·1) μg/d. No consistent effects were found on 25(OH)D, BMC, BA, BMD, IGF-1 or OC. However, season-modified effects were observed with 25(OH)D, i.e. children completing the school meal period in January/February had higher 25(OH)D status (5·5 (95 % CI 1·8, 9·2) nmol/l; P = 0·004) than children completing the control period in these months. A similar tendency was indicated in November/December (4·1 (95 % CI –0·12, 8·3) nmol/l; P = 0·057). However, the effect was opposite in March/April (–4·0 (95 % CI –7·0, –0·9) nmol/l; P = 0·010), and no difference was found in May/June (P = 0·214). Unexpectedly, the school meals slightly increased PTH (0·18 (95 % CI 0·07, 0·29) pmol/l) compared with habitual lunch. Small increases in dietary vitamin D might hold potential to mitigate the winter nadir in Danish children's 25(OH)D status while higher increases appear necessary to affect status throughout the year. More trials on effects of vitamin D intake from natural foods are needed.

Diet-induced changes in iron and n-3 fatty acid status and associations with cognitive performance in 8-11-year-old Danish children: secondary analyses of the Optimal Well-Being, Development and Health for Danish Children through a Healthy New Nordic Diet School Meal Study

Fe and n-3 long-chain PUFA (n-3 LCPUFA) have both been associated with cognition, but evidence remains inconclusive in well-nourished school-aged children. In the Optimal Well-Being, Development and Health for Danish Children through a Healthy New Nordic Diet (OPUS) School Meal Study, the 3-month intervention increased reading performance, inattention, impulsivity and dietary intake of fish and Fe. This study investigated whether the intervention influenced n-3 LCPUFA and Fe status and, if so, explored how these changes correlated with the changes in cognitive performance. The study was a cluster-randomised cross-over trial comparing school meals with packed lunch (control). At baseline and after each treatment, we measured serum ferritin, whole-blood n-3 LCPUFA and Hb, and performance in reading, mathematics and d2-test of attention. Data were analysed using mixed models (n 726) and principal component analysis of test performances (n 644), which showed two main patterns: 'school performance' and 'reading comprehension'. The latter indicated that children with good reading comprehension were also more inattentive and impulsive (i.e. higher d2-test error%). The intervention improved 'school performance' (P=0·015), 'reading comprehension' (P=0·043) and EPA+DHA status 0·21 (95% CI 0·15, 0·27) w/w % (P<0·001), but it did not affect serum ferritin or Hb. At baseline, having small Fe stores was associated with poorer 'school performance' in girls, but with better 'reading comprehension' in both boys and girls. Both baseline EPA+DHA status and the intervention-induced increase in EPA+DHA status was positively associated with 'school performance', suggesting that n-3 LCPUFA could potentially explain approximately 20 % of the intervention effect. These exploratory associations indicate that increased fish intake might explain some of the increase in reading performance and inattention in the study.