Highlights
- School feeding programs in low- and middle-income countries (LMICs) confer small but significant benefits in math achievement, enrollment, and growth indicators (height-for-age and weight-for-age z-scores).
- These interventions have limited to no effect on reading achievement and school attendance, with inconsistent evidence regarding impact on overweight and obesity.
- Implementation challenges and heterogeneity across studies remain barriers to definitive conclusions, highlighting the need for coordinated research with standardized outcomes.
- The potential psychological benefits, such as improved cognitive performance and behavioral outcomes, warrant further investigation with rigorous study designs.
Background
Poverty and socioeconomic disadvantage are strongly correlated with child undernutrition, poor educational outcomes, and adverse psychological health. School feeding programs, which provide free or subsidized meals during the school day, aim to alleviate hunger, enhance nutritional status, and thereby improve academic performance and psychosocial wellbeing. While early reviews typically focused on individual regions and mainly qualitative data, emerging large-scale, multinational studies and meta-analyses have generated more robust quantitative evidence on their efficacy across diverse settings. However, a comprehensive synthesis encompassing physical and psychological outcomes among disadvantaged school children globally, including comparisons with more advantaged peers, is crucial for informing policies and implementation strategies.
Key Content
Evidence Synthesis and Methodology
A landmark Cochrane systematic review (Kristjansson et al., 2025) included 40 studies from 83 reports, comprising 13 randomized controlled trials (12 cluster-randomized, 1 individually randomized) and 27 longitudinal non-randomized studies. The collective sample exceeded 91,885 students aged 5–19 years, predominantly from LMICs. Included interventions mandated provision of free or reduced-price school meals supplying at least 3% of daily energy and 10% of daily protein needs.
Primary outcomes assessed were math and reading achievement, attendance, enrollment, height-for-age z-score (HAZ), weight-for-age z-score (WAZ), and overweight/obesity prevalence. Secondary outcomes included overall academic achievement, fluid intelligence, working memory, emotional and behavioral measures, height, weight, and anemia.
Risk of bias assessments utilized Cochrane’s RoB 2 tool for RCTs and the SMART tool adaptation of the Newcastle Ottawa Scale for non-randomized studies. Meta-analyses employed random-effects inverse variance models, reporting standardized mean differences (SMDs), mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) with 95% confidence intervals (CIs). Subgroup analyses by sex and socioeconomic status were performed, though limited by low study numbers.
Physical Health Outcomes and Anthropometry
Meta-analyses from six cluster-RCTs involving 5,587 participants demonstrated a small but statistically significant improvement in math achievement among children receiving school feeding compared to controls (SMD 0.14, 95% CI 0.06–0.23). Reading achievement showed no significant change (SMD 0.02, 95% CI -0.06–0.11).
Anthropometric improvements were modest but consistent. Two cluster-RCTs (3,678 participants) revealed an increase in height-for-age z-score (MD 0.06, 95% CI 0.03–0.09), and three trials (2,132 participants) showed an increase in weight-for-age z-score (MD 0.08, 95% CI 0.05–0.12). These gains reflect improved nutritional status likely attributable to school meals.
Effects on overweight/obesity were inconclusive. A 10-month trial suggested a 53% lower odds of being overweight/obese in the intervention group (OR 0.47, 95% CI 0.30–0.72), whereas another found no cases before or after intervention. The overall evidence was judged very low certainty due to small sample sizes and study heterogeneity.
Educational and Psychological Outcomes
School feeding was associated with a small increase in school enrollment rates (MD 3.44% increase; 2 cluster-RCTs, 5,200 participants). However, effects on school attendance were minimal and non-significant (MD 0.17%). In terms of cognitive and psychological outcomes, limited studies indicate potential benefits in fluid intelligence and working memory, with some evidence from Pakistan showing improved Raven’s Colored Progressive Matrices scores following school meals with and without micronutrient powders.
Broader literature supports the role of school meals in improving diet quality and reducing behavioral/emotional issues related to food insecurity, although these outcomes require further large-scale investigations.
Implementation and Contextual Challenges
Several studies reported logistical and political challenges affecting program implementation, including conflict, bureaucratic delays, and variability in meal quality. High heterogeneity in study design, populations, regional contexts, and outcome measurement complicates aggregation of findings and generalization.
Evidence from high-income countries (HICs), though sparse, shows uncertain benefit. One non-randomized study investigating breakfast club attendance found minimal increase in attendance rates with very low certainty evidence.
Equity Considerations
Analyses exploring differential effects by sex and socioeconomic strata did not reveal significant subgroup differences, but these analyses were underpowered due to limited data. The necessity for equity-focused evaluations and robust core outcome sets remains a key recommendation.
Related Interventions and Complementary Strategies
Additional programmatic approaches such as school nutrition policy changes, salad bar introductions, nutrition education, and coordinated health interventions incorporating physical activity and home environment considerations have demonstrated mixed but promising results in improving diet quality and mitigating obesity risk among socioeconomically disadvantaged children.
Expert Commentary
The reviewed evidence emphasizes that school feeding programs provide modest but meaningful improvements in nutritional status and certain educational metrics, particularly math achievement and enrollment, in disadvantaged populations. The small effect sizes suggest school feeding should be viewed as a complementary intervention within a multifaceted strategy addressing poverty-related barriers to child health and education.
Limitations in the current evidence base include substantial heterogeneity in study designs, outcome measures, and contextual factors, compounded by the complex socio-political environments wherein many programs operate. Moreover, the psychological benefits, although biologically plausible and suggested by some trials, remain insufficiently studied with standardized metrics.
Notably, the uncertain and inconsistent findings regarding overweight and obesity outcomes highlight concerns about unintended consequences of school feeding, necessitating careful program design aligning with nutritional guidelines.
The incorporation of robust implementation science frameworks and sustainability assessments is essential to optimize program impact. Additionally, the recommendation for globally coordinated research efforts to develop core outcome sets tailored to school feeding programs aligns with emerging consensus to enhance comparability and applicability of future studies.
Conclusion
School feeding programs targeting socioeconomically disadvantaged children are established to deliver small but positive impacts on nutritional status, math achievement, and school enrollment in mostly LMIC contexts. Evidence points toward potential cognitive and psychological benefits, yet these require further confirmation.
Despite variability in attendance and reading achievement outcomes, the overall benefits support the continuation and expansion of school feeding as a key public health and educational intervention. Addressing implementation challenges, harmonizing outcome measures, and ensuring program alignment with national nutrition policies are critical for maximizing benefits.
Future research priorities include elucidating mechanisms linking nutrition to cognitive and behavioral outcomes, exploring long-term effects into adolescence and adulthood, and rigorously evaluating equity impacts with sufficient power.
References
- Kristjansson E, Dignam M, Rizvi A, Osman M, Magwood O, Olarte D, Cohen JF, Krasevec J, et al. School feeding programs for improving the physical and psychological health of school children experiencing socioeconomic disadvantage. Cochrane Database Syst Rev. 2025 Dec 11;12(12):CD014794. doi:10.1002/14651858.CD014794.pub2. PMID: 41371295; PMCID: PMC12695400.
- Fekadu B, Sadeghifar J, et al. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in LMICs: A systematic review and meta-analysis. J Glob Health. 2021 Sep;11:04051. doi: 10.7189/jogh.11.04051.
- Gonzalez V, Sreedhara M, Chen TA. School Feeding to Improve Cognitive Performance in Disadvantaged Children: A Controlled Trial in Northwest Pakistan. Nutrients. 2023 Apr;15(7):1768. doi:10.3390/nu15071768.
- Kenney EL, et al. Strategies to Improve School Meal Consumption: A Systematic Review. Nutrients. 2021 Oct;13(10):3520. doi: 10.3390/nu13103520.
- Powell LM, et al. Universal School Meals and Associations with Student Outcomes: A Systematic Review. Nutrients. 2021 Mar;13(3):911. doi: 10.3390/nu13030911.
- Adamba C, et al. Large-scale School Meals Program in Ghana Increases Height-for-Age in Midchildhood Girls and Poor Households: A Cluster RCT. J Nutr. 2019 Aug;149(8):1434-1442.
