School nutrition programs help school-age children and adolescents grow physically, mentally, and emotionally, especially in low- and middle-income nations (LMICs). Despite the fact that school feeding programs are common in LMICs, it is unclear what advantages they really provide. This systematic review and meta-objective analysis’s is to assess how school nutrition programs affect children and adolescents in LMICs’ educational and health results.
The effects of school meals on the nutritional and health outcomes of kids and teens enrolled in primary or secondary education in LMICs will be the subject of meticulously planned interventional research. The Cochrane Library, MEDLINE, EMBASE, CINAHL, and governmental or organizational websites were utilized as information sources to find pertinent published or unpublished research. The Cochrane Risk of Bias tool and the ROBINS-I tool will be used, respectively, to evaluate the risk of bias in randomized and non-randomized trials. The selection of studies, data extraction, and evaluation of the risk of bias will all be done separately by two reviewers. All the included studies will be summarized in a narrative. When necessary, meta-analyses will be carried out. I2, subgroup analyses, and meta-regression will be used to evaluate the effects’ heterogeneity. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) technique will be used to evaluate each outcome’s degree of evidence.
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Understanding the advantages of such programs should serve as the foundation for designing and implementing school feeding programs in LMICs. This research will provide vital supporting data on the health and scholastic advantages of school meals for kids and teenagers in LMICs.
Regular review and registration
On November 18, 2019, this protocol was submitted to PROSPERO, the International Prospective Register of Systematic Reviews (registration number: pending).
The physical, mental, and psychological development of children and adolescents between the ages of 6 and 19 depends on nutrition throughout the school years. It is estimated that 66 million school-age children in the developing world attend school each day hungry, with 23 million of those children living in Africa. Children and teenagers who attend school when hungry are much less likely to learn, grow, and reach their full potential.
School feeding programs, often known as school meal programs, are initiatives that consistently provide children and adolescents attending school nourishing diets. The advantages of school meals for kids and teenagers include lowering hunger, cutting down on vitamin deficiencies and anemia, minimizing overweight and obesity, boosting academic and cognitive performance, and promoting gender parity in access to education [4,5,6,7,8]. Most nations have school nutrition programs in some shape or another and on some level [6, 8]. The demand for school feeding programs is highest in low- and middle-income countries (LMICs), where coverage is often insufficient due to hunger and poverty. School feeding programs are commonly accessible in high-income nations. Most sub-Saharan African nations limit their school feeding initiatives to the areas with the greatest food insecurity rather than providing them to all students. To optimize the advantages for kids and teenagers, school food programs must be made more widely available and their quality must be raised.
The effects of school feeding programs on certain scholastic and health outcomes for school-age children and adolescents in LMICs are little understood. The most recent Cochrane study on the possible impacts of school eating was released in 2007, therefore earlier evaluations don’t include all of the most recent research. Additionally, prior research had a narrower focus in terms of the age range or the results it looked at (for example, it only looked at anthropometric and nutritional outcomes, not educational or psychosocial outcomes, or the other way around). Additionally, earlier analyses tended to concentrate on the supply of school meals without specifically evaluating whether particular content (food kinds, quantities, and nutrients) of the school meals had the most positive effects on outcomes. In order to create and execute future programs, it is necessary to update and improve the evidence synthesis on school feeding interventions and a variety of educational and health outcomes for kids and teenagers.
This systematic review and meta-objective analysis’s is to assess the effects of school feeding programs on the academic and health outcomes of children and adolescents enrolled in primary or secondary education in LMICs who are aged 6 to 19 years old. We’ll highlight research from randomized controlled trials (RCTs). RCTs better take into consideration extraneous variables including baseline nutritional deficiency levels and contributions from schools and instructors [8, 12] that could skew the results of school feeding programs. We will also include other carefully constructed interventional studies, such as non-randomized controlled trials and controlled before-after studies (CBAs), which were able to account for baseline variations across intervention arms.
Design/methodology Research question
We want to assess how school food programs affect the health and educational results of kids and teenagers enrolled in primary or secondary education in LMICs. Additionally, we want to evaluate how distinct school feeding effects could alter depending on program parameters and food composition.
RCTs with the intervention randomly assigned either individually or in clusters will be included (classes or schools). Since CBAs are non-randomized studies with a somewhat rigorous design and make up a significant fraction of the relevant literature, we will also include them. As long as the baseline distinctions between the intervention arms were taken into account in the analysis, non-randomized controlled trials are likewise acceptable for inclusion.
When we have access to early results from current investigations, we will include ongoing studies as well as published publications, unpublished work, and grey literature.
studies carried out in LMICs, as the World Bank’s fiscal year 2020 is defined.
studies involving kids and teens (boys and females) in elementary or secondary schooling between the ages of 6 and 19 (i.e., primary, middle, or high school).
studies that looked at the effects of food distribution, including food given to the family and eaten outside of the school environment (take-home ration) as well as meals (breakfast, lunch, or supper) or snacks taken at school (in-school feeding). We’ll take into account offering solid meals or liquids (e.g., milk). Studies that looked at food stamps or food coupons given to participants at school to obtain food will also be included (in the market or food banks).
Participants who did not receive school feeding or any other treatments, as well as those who got other interventions in place of school feeding, may be considered the comparison (control) group in any research that is included. Additionally, we will compare school feeding programs with various meal compositions, such as comparing an updated program to an initial program.
Children’s and teenagers’ educational, nutritional, anthropometric, cognitive, and morbidity outcomes will be included. Height, weight, skinfold thickness, mid-upper arm circumference, micronutrient status, hemoglobin level, enrollment in school, attendance there, dropout rates, academic success (math, reading, spelling), on-task behavior, cognition, and morbidity are some potential consequences (e.g., fever, cough, diarrhea, and vomiting). Studies that have findings for at least one relevant outcome will be included.
There won’t be any limitations on the study’s year, language, sample size, or length of the intervention.
Non-randomized controlled trials in which the baseline variations between the intervention arms were not taken into consideration.
Interventional investigations without a suitable control group, including uncontrolled difference-in-difference designs, uncontrolled interrupted time series studies, and uncontrolled before-after studies.
Observational research (e.g., cohort, case-control, and cross-sectional studies).
editorials, commentaries, reviews, and articles with opinions (these will, however, be used to identify additional original studies).
studies limited to young children in preschool. Although important and of great interest, feeding interventions for preschoolers are outside the purview of this study, which will concentrate on the school environment.
Studies that looked at the effects of micronutrient fortification, micronutrient supplementation, or nutrition education will be included if they complement other eligible school feeding interventions.
Clinical treatment programs targeted toward individuals with specific medical conditions, or programs toward underweight, overweight, or obese individuals.
Studies that only examined aggregate-level economical or agricultural outcomes.
Studies that described school feeding programs without linkage to specific outcomes.
The following databases were searched for eligible studies, from the inception of each database through November 2019: MEDLINE (via PubMed), EMBASE, CINAHL, and the Cochrane Library. The selection of the four electronic databases was made in consultation with a health science librarian with expertise in systematic searching. Our search included the Cochrane Handbook for Systematic Reviews of Interventions’ three recommended databases, MEDLINE, EMBASE, and the Cochrane Library. For studies that weren’t found through database searching, we also searched ClinicalTrials.gov and other governmental or organizational websites (World Food Programme (WFP), World Health Organization, Food and Agriculture Organization (FAO), and World Bank). We’ll manually search past reviews and the references of articles that were kept. To identify any additional studies, we will also speak with subject matter experts on school feeding. Reports written in languages other than English will, whenever possible, be translated by coworkers who are native speakers of those languages. Studies that cannot be translated correctly will not be considered.
In order to create the PubMed search strategy, which is presented in Additional File 1, we sought advice from a health science librarian. By confirming that several sentinel articles were found, the sensitivity of the search strategy was tested. The PubMed approach will be modified to use other databases’ specific syntax. A new search will be conducted in the early months of April 2020 after the initial one in November 2019 was completed.
management of data
The records gleaned through searches of electronic databases will be kept in EndNote X9 (Clarivate Analytics, PA, USA). Additionally, the data will be transferred into Covidence, an online tool developed by Veritas Health Innovation in Melbourne, Australia, to enable the systematic review’s efficient administration. EndNote and Covidence will each detect and get rid of duplicate records in turn.
choice of studies
Two reviewers will independently evaluate the search results based on the inclusion and exclusion criteria. First, all titles and abstracts will be scrutinized to weed out any pointless studies. The full texts of studies that may be eligible or whose eligibility is debatable will be acquired and reviewed to determine eligibility using a form for full text screening, which will be put through a pilot test on five randomly chosen full texts. Reviewer disagreements will be settled via discussion or, if required, by a third reviewer. By calculating the raw percentage of agreement and Cohen’s coefficient, inter-rater agreement will be quantified. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram will be used to record and summarize the specific justifications for study exclusions. Both reviewers will be aware of the authors’ names and the names of the journals they are reviewing.
extraction of data
Two reviewers will independently extract the data from the retained studies and input it into a data extraction form, which will then be pilot tested on five randomly chosen studies. Discussion or a third reviewer will be used to settle any differences in the retrieved material amongst the reviewers. To gather pertinent information, the respective authors of the research will be contacted as needed. We will gather the following data: Title, authors (first author and corresponding author), first author’s address, journal (or source for unpublished reports), publication year, intervention year, nation, funding source, study design, sample size (number of clusters for each group and number of participants in each group), sample characteristics (e.g., age, sex, and socioeconomic status), intervention (including timing, duration, food and nutritional content), and title (if available). As separate reports may include additional findings, several reports of a single research will be compiled. We shall get in touch with the appropriate author if there are discrepancies in the findings of different publications of the same research in order to get more precise results. The Additional File 2 contains the data extraction form.