Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alternatively contact researchonline@lshtm.ac.uk. Available under license: Copyright the author(s)Cochrane Database of Systematic Reviews School feeding for improving the physical and psychosocial health of disadvantaged students (Review) Kristjansson Citation: Kristjansson B, Petticrew M, MacDonald B, Krasevec J, Janzen L, Greenhalgh T, Wells GA, MacGowan J, Farmer AP, Shea B, Mayhew A, Tugwell P, Welch V. School feeding for improving the physical and psychosocial health of disadvantaged students. T A B L E O F C O N T E N T S

The main objective of this systematic review was to determine the effectiveness of school feeding programs in improving physical and psychosocial health for disadvantaged school pupils. A comprehensive search was conducted up to May 2006. We included 18 studies.School meals may have some small benefits for disadvantaged children. We recommend further well‐designed studies on the effectiveness of school meals be undertaken, that results should be reported according to socio‐economic status, and that researchers gather robust data on both processes and carefully chosen outcomes.AbstractBackgroundEarly malnutrition and/or micronutrient deficiencies can adversely affect physical, mental, and social aspects of child health. School feeding programs are designed to improve attendance, achievement, growth, and other health outcomes.ObjectivesThe main objective was to determine the effectiveness of school feeding programs in improving physical and psychosocial health for disadvantaged school pupils.Search strategyWe searched a number of databases including CENTRAL (2006 Issue 2), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), PsycINFO (1980 to May 2006) and CINAHL (1982 to May 2006). Grey literature sources were also searched. Reference lists of included studies and key journals were handsearched and we also contacted selected experts in the field.Selection criteriaData from randomized controlled trials (RCTs), non‐randomised controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series studies (ITSs) were included. Feeding had to be done in school; the majority of participants had to be socio‐economically disadvantaged.Data collection & analysisTwo reviewers assessed all searches and retrieved studies. Data extraction was done by one of four reviewers and reviewed by a second. Two reviewers independently rated quality. If sufficient data were available, they were synthesized using random effects meta‐analysis, adjusting for clustering if needed. Analyses were performed separately for RCTs and CBAs and for higher and lower income countries.Main resultsWe included 18 studies. For weight, in the RCTs and CBAs from Lower Income Countries, experimental group children gained an average of 0.39 kg (95% C.I: 0.11 to 0.67) over an average of 19 months and 0.71 kg (95% C.I.: 0.48 to 0.95) over 11.3 months respectively. Results for weight were mixed in higher income countries. For height, results were mixed; height gain was greater for younger children. Attendance in lower income countries was higher in experimental groups than in controls; our results show an average increase of 4 to 6 days a year. Math gains were consistently higher for experimental groups in lower income countries; in CBAs, the Standardized Mean Difference was 0.66 (95% C.I. = 0.13 to 1.18). In short‐term studies, small improvements in some cognitive tasks were found.Reviewers’ conclusionsSchool meals may have some small benefits for disadvantaged children. We recommend further well‐designed studies on the effectiveness of school meals be undertaken, that results should be reported according to socio‐economic status, and that researchers gather robust data on both processes and carefully chosen outcomes.

KEY MESSAGES • Offer collaborative and interactive self-management education and support. • Incorporate problem solving, goal setting and self-monitoring of health parameters for ongoing self-management of clinical and psychosocial aspects of care. • Design and implement person-centred learning to facilitate informed decision-making and achievement of individual goals. • Individualize self-management education interventions according to the type of diabetes and recommended therapy within the context of the individual's ability for learning and change, culture, health beliefs and preferences, literacy level, socioeconomic status and other health challenges.• Create and offer self-management support that reflects person-centred goals and needs.

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IntroductionOne-third of the world's population suffers from micronutrient deficiencies, due primarily to inadequate dietary intake. The World Health Organization (WHO) and the United Nations Food and Agriculture Organization (FAO) have identified food fortification, supplementation, nutrition education, and disease control measures as the four main strategies for improving dietary intakes [1]. Fortification-the addition of micronutrients to a processed food to improve the food's nutritional quality-is often regarded as the "easiest" of these four strategies to implement, for several reasons. First, by virtue of the fact that it piggybacks on an existing product market, fortification, to be successful, does not require changing food behaviors before it can have an impact. Second, it can have an impact in the short run. Third, once it is established, fortification affects people's micronutrient status without their having to make a conscious decision to "participate" in the program. Fourth, it is generally regarded as costeffective relative to the other three strategies [2]. Fifth, fortification is generally thought to be more sustainable Despite these appealing characteristics and the fact that there is considerable experience in implementation, progress in fortification, with the exception of salt iodization, has been slow. This has particularly been the case in middle-and lower-income countries,* due to a number of factors, including the following:** » Inadequate understanding and inadequate information about the significance of micronutrient deficiencies; » Private sector concerns about the public's acceptance of altered (i.e., fortified) food; » Inadequate understanding about what fortification will cost and who will pay (i.e., the incidence of the costs of fortification); » Uncertainty about the competitive impact of fortification-both within the same product market and on substitute products due to fortification-induced higher relative costs and prices; » The distinct and largely nontraditional types of activities that are required by governments to initiate, implement, monitor, and maintain a mass fortification program; » Little understanding of the potential coverage of such a program; » Lack of understanding of the impact of micronutrient deficiencies (hidden hunger) and the potential benefits-i.e., the public health impact-that a fortification program could be expected to produce. This study attempts to address several of these factors and thereby help to accelerate the rate of progress of introducing fortification and reducing micronutrient deficiencies. The paper presents an analysis of the feasibility, cost, and cost-effectiveness of fortifying four food vehicles-wheat flour, maize flour, vegetable oil, and sugar-in 48 high-priority countries and discusses how these results and other criteria might be used to devise a strategy for addressing the unfinished fortification agenda. Selection of countriesTo identify priority countries, a series of countryranking analyses was undertaken using six "need" c...