Following an international workshop on developing the evidence base for policy relating to school food held in London, UK, in January 2012, the objectives of the present paper were (i) to outline a rationale for school food research, monitoring and evaluation in relation to policy and (ii) to identify ways forward for future working.

The authors analysed presentations, summaries of evidence, and notes from discussions held at the international workshop in London in 2012 to distil common themes and make recommendations for the development of coherent research programmes relating to food and nutrition in schools.

International, with an emphasis on middle- and high-income countries.

Overviews of existing school food and nutrition programmes from the UK, Hungary, Sweden, the USA, Australia, Brazil, China, Mexico and other countries were presented, along with information on monitoring, evaluation and other research to demonstrate the impact of school feeding on health, attainment, food sourcing, procurement and finances, in the context of interactions between the evidence base and policy decisions. This provided the material which, together with summaries and notes of discussions, was used to develop recommendations for the development and dissemination of robust approaches to sustainable and effective school food and nutrition programmes in middle- and high-income countries, including policy guidelines, standards, cost-effectiveness measures and the terms of political engagement.

School food and nutrition can provide a cohesive core for health, education and agricultural improvement provided: (i) policy is appropriately framed and includes robust monitoring and evaluation; and (ii) all stakeholders are adequately engaged in the process. International exchange of information will be used to develop a comprehensive guide to the assessment of the impact of school food and nutrition policy and supporting infrastructure.

To outline the evolution of school food standards and their implementation and evaluation in each of the four countries of the UK since 2000.

Review of relevant policies, surveys and evaluations, including country-specific surveys and regional evaluations.

UK: England, Wales, Scotland and Northern Ireland.

Primary and secondary schools and schoolchildren.

By September 2013 standards will have been introduced in all primary and secondary schools in the UK. Evaluations have varied in their scope and timing, relating to government forward planning, appropriate baselines and funding. Where standards have been implemented, the quality and nutritional value of food provided have improved. Emerging evidence shows improved overall diet and nutrient intake by school-aged children as a result.

The re-introduction of school food standards in the UK has not been centrally coordinated, but by September 2013 will be compulsory across all four countries in the UK, except in England where academies are now exempt. Provision of improved school food has had a demonstrable impact on diet and nutrition beyond the school dining room and the school gate, benefiting children from all socio-economic groups. Improved school food and dining environments are associated with higher levels of school lunch take up. Implementation of school food standards requires investment. It is critical to policy development that the value of this investment is measured and protected using planned, appropriate, robust and timely evaluations. Where appropriate, evaluations should be carried out across government departments and between countries.

To provide an overview of school food and nutrition monitoring from 1980 to the Healthy Hunger-Free Kids Act of 2010 and data on school food availability in the USA.

A review of the history of school food and nutrition policy, monitoring and evaluation efforts in the USA over the past three decades.

USA.

School food service, school districts and schools nationwide.

The school food environment in the USA is governed by a patchwork of federal, state and local laws and policies. The federal government has primary authority over the school meal programmes and has recently issued updated regulations governing the food and nutrient requirements for meals sold or served through the National School Lunch and School Breakfast Programs. Competitive foods (i.e. foods and beverages sold/served outside the meal programmes) are governed primarily by state and district laws and policies, although new federal regulations are expected to set minimum standards in this area. The USA has a long history of data monitoring and evaluation funded by government and private foundations which has enabled decision makers to monitor progress and opportunities to improve the foods and beverages made available to students in school.

School food-related monitoring and evaluation research has been highly influential in influencing legislation and policy, leading to improvements in the foods and beverages available to children at school as part of planned meals and individual items sold outside the meal programmes. The lessons learned from the US experience provide insights that may be valuable for implementation, monitoring and evaluation of school food programmes in other countries.

The present paper analyses the advances and challenges of the school feeding programme in Brazil (PNAE), as part of the Brazilian experience building up an integrated food and nutrition security national system. It explores the role of policy and regulatory frameworks in constructing quality service delivery and intersectoral integration.

Review of PNAE and federal government technical documents and studies, legislation, minutes of meetings and official documents of the National Council of Food and Nutrition Security from 2003 to 2011.

Food insecurity has decreased significantly in Brazil in the last decade, indicating that appropriate choices were made in terms of public policies and institutional arrangements, which other countries can learn from.

Brazil food and nutrition security system; school feeding; school food.

Brazil's integrated food and nutrition security policy approach promoted intersectorality in the food system, articulating actions to guarantee access to healthy food and to strengthen family farming. The quality of school meals has progressively improved; in particular, the availability of fruits and vegetables increased. However, national standards regarding menu composition have not yet been met. Regulations were an important factor, along with the policy approach linking food production, nutrition, health and education. Challenges are related to conflict of interests and to farmers’ insufficient capacity to meet supply requirements and comply with technical procedures.

Local food production, school meals and nutrition education can be linked through integrated programmes and policies, improving access to healthier foods. Government leadership, strong legislation, civil society participation and intersectoral decision making are determinant.

To provide an overview of the status of monitoring and evaluation (M&E) of school feeding across sub-Saharan Africa and to reflect on the experience on strengthening M&E systems to influence policy making in low-income countries.

Literature review on the M&E of school feeding programmes as well as data from World Food Programme surveys.

Sub-Saharan Africa.

Countries implementing school feeding.

Only two randomized controlled impact evaluations have been implemented in sub-Saharan Africa. Where M&E data collection is underway, the focus is on process and service delivery and not on child outcomes. M&E systems generally operate under the Ministry of Education, with other Ministries represented within technical steering groups supporting implementation. There is no internationally accepted standardized framework for the M&E of school feeding. There have been examples where evidence of programme performance has influenced policy: considering the popularity of school feeding these cases though are anecdotal, highlighting the opportunity for systemic changes.

There is strong buy-in on school feeding from governments in sub-Saharan Africa. In response to this demand, development partners have been harmonizing their support to strengthen national programmes, with a focus on M&E. However, policy processes are complex and can be influenced by a number of factors. A comprehensive but simple approach is needed where the first step is to ensure a valid mandate to intervene, legitimizing the interaction with key stakeholders, involving them in the problem definition and problem solving. This process has been facilitated through the provision of technical assistance and exposure to successful experiences through South–South cooperation and knowledge exchange.

An increasing focus on legislation, policy and guidance on the nutritional content of school food has in part been in response to the limited impact of more behavioural or educational approaches. However, there is a risk that a sole focus on policy-level action may lead to neglect of the important contribution that more behavioural approaches can make as components of effective, coordinated, multilevel action to improve the dietary intake of schoolchildren. The current paper aims to highlight the potential importance of viewing alternative approaches as complementary or synergistic, rather than competing.

The socio-ecological and RE-AIM frameworks are used to provide a theoretical rationale and demonstrate the importance of explicitly identifying the interdependence of policies, interventions and contextual structures and processes. School food case study evidence is used to exemplify how understanding and exploiting these interdependencies can maximise impact on dietary outcomes.

Case studies of trials in schools in the UK (South West England and Wales) and Australia (Victoria).

Schoolchildren.

The case studies provide examples to support the hypothesis that the reach, effectiveness, adoption, implementation and maintenance of school food policies and interventions can be maximised by understanding and exploiting the interdependence between levels in the socio-ecological framework.

Rather than being seen as competing alternatives, diverse approaches to improving the diets of schoolchildren should be considered in terms of their potential to be complementary and synergistic, acting at multiple levels to improve acceptability, fidelity, effectiveness and sustainability.

To estimate the costs per relevant unit (pupils and meals) associated with improvements to school food and the potential economic and health gains that may result.

Calculation of costs per relevant unit (pupils and meals) based on (i) Department for Education expenditure to support improvements in school food, 2005–2011 and (ii) measures of the changes in the number of pupils taking school lunch and the number of meals served over the same time period; plus examples of the use of linked data to predict longer-term economic and health outcomes of healthier eating at school.

England.

Local authorities, government departments and non-departmental public bodies.

Analysis of investment over a 6-year period indicates that costs of setting up and maintaining a change organization such as the School Food Trust were low in relation to short-term benefits in nutrition and behaviour. Models that predict long-terms gains to the exchequer and to quality-adjusted life years need further elaboration.

Modest levels of government investment in the delivery and promotion of healthier school food is likely to yield both short-term and long-term benefits in relation to nutrition, learning, economics and health.

An analysis undertaken jointly in 2009 by the UN World Food Programme, The Partnership for Child Development and the World Bank was published as Rethinking School Feeding to provide guidance on how to develop and implement effective school feeding programmes as a productive safety net and as part of the efforts to achieve Education for All. The present paper reflects on how understanding of school feeding has changed since that analysis.

Data on school feeding programme outcomes were collected through a literature review. Regression models were used to analyse relationships between school feeding costs (from data that were collected), the per capita costs of primary education and Gross Domestic Product per capita. Data on the transition to national ownership, supply chains and country examples were collected through country case studies.

School feeding programmes increase school attendance, cognition and educational achievement, as well as provide a transfer of resources to households with possible benefits to local agricultural production and local market development. Low-income countries exhibit large variations in school feeding costs, with concomitant opportunities for cost containment. Countries are increasingly looking to transition from externally supported projects to national programmes.

School feeding is now clearly evident as a major social programme in most countries with a global turnover in excess of $US 100 billion. This argues for a continuing focus on the evidence base with a view to helping countries ensure that their programmes are as cost-effective as possible. Clear policy advice has never been more important.

To develop a feasible, valid, reliable web-based instrument to objectively evaluate school meal quality in Swedish primary schools.

The construct ‘school meal quality’ was operationalized by an expert panel into six domains, one of which was nutritional quality. An instrument was drafted and pilot-tested. Face validity was evaluated by the panel. Feasibility was established via a large national study. Food-based criteria to predict the nutritional adequacy of school meals in terms of fat quality, iron, vitamin D and fibre content were developed. Predictive validity was evaluated by comparing the nutritional adequacy of school menus based on these criteria with the results from a nutritional analysis. Inter-rater reliability was also assessed.

The instrument was developed between 2010 and 2012. It is designed for use in all primary schools by school catering and/or management representatives.

A pilot-test of eighty schools in Stockholm (autumn 2010) and a further test of feasibility in 191 schools nationally (spring 2011).

The four nutrient-specific food-based criteria predicted nutritional adequacy with sensitivity ranging from 0·85 to 1·0, specificity from 0·45 to 1·0 and accuracy from 0·67 to 1·0. The sample in the national study was statistically representative and the majority of users rated the questionnaire positively, suggesting the instrument is feasible. The inter-rater reliability was fair to almost perfect for continuous variables and agreement was ≥67 % for categorical variables.

An innovative web-based system to comprehensively monitor school meal quality across several domains, with validated questions in the nutritional domain, is available in Sweden for the first time.

To compare food choices and nutrient intakes of pupils taking a school lunch or a packed lunch in eighty secondary schools in England, following the introduction of the food-based and nutrient-based standards for school food.

Cross-sectional data collected between October 2010 and April 2011. Pupils’ lunchtime food choices were recorded over five consecutive days.

Secondary schools, England.

A random selection of 5925 pupils having school lunches and 1805 pupils having a packed lunch in a nationally representative sample of eighty secondary schools in England.

The differences in the specific types of food and drink consumed by the two groups of pupils are typical of differences between a hot and cold meal. On average, school lunches as eaten contained significantly more energy, carbohydrate, protein, fibre, vitamin A, folate, Fe and Zn than packed lunches, and 8 % less Na.

Although neither school lunches nor packed lunches provided the balance of nutrients required to meet the nutrient-based standards (based on about one-third of daily energy and nutrient requirements), school lunches generally had a healthier nutrient profile, with lower Na and percentage of energy from fat, and higher fibre and micronutrient content. These differences were greater than those reported prior to the introduction of compulsory standards for school lunches. In order to ensure more pupils have a healthy lunch, schools could introduce and enforce a packed lunch policy or make school meals the only option at lunchtime.

Results of the WHO European Childhood Obesity Surveillance Initiative indicated that on average one out of four primary-school children is overweight or obese. Portugal presented one of the highest prevalences of obesity. Childhood obesity prevention and treatment should be a top priority. The aim of the present study was to evaluate the effectiveness of Program Obesity Zero (POZ), a multi-component, community-, family- and school-based childhood obesity intervention.

Parents and children attended four individual nutrition and physical activity counselling sessions, a one-day healthy cooking workshop and two school extracurricular sessions of nutrition education. Waist circumference, BMI, physical activity level, sedentary behaviours, and nutrition and physical activity knowledge, attitudes and behaviour were assessed at baseline and after 6 months. Diet was assessed using two 24 h recalls, at baseline and at 6 months.

Five Portuguese municipalities and local communities.

Two hundred and sixty-six overweight children (BMI ≥ 85th percentile) aged 6–10 years, from low-income families in five Portuguese municipalities, were assigned to the intervention.

Children showed reductions in waist circumference (−2·0 cm; P < 0·0001), mean BMI (−0·7 kg/m2; P < 0·0001) and BMI-for-age percentile (−1·7; P < 0·0001) at 6 months. Overall, children's intake of fruit and vegetables was <400 g/d throughout the intervention. After 6 months, higher fibre consumption and an apparent decrease in sugary soft drinks intake to a quarter of that observed at baseline (mean intake: 198 ml/d at baseline), with improvements in physical activity levels and screen time <2 h/d, were also observed.

The findings suggested that POZ is a promising intervention programme, at municipality level, to tackle childhood overweight and obesity.

To assess lunchtime provision of food and drink in English secondary schools and the choices and consumption of food and drink by pupils having school lunches, and to compare provision in 2011 with that in 2004.

Cross-sectional data collected between October 2010 and April 2011. In each school, food and drink provision, including portion weights and number of portions of each item served at lunchtime, were recorded over five consecutive days. Caterers provided recipe information.

England.

A random selection of 5969 pupils having school lunches in a nationally representative sample of eighty secondary schools in England.

Compared with 2004, significantly more schools in 2011 provided main dishes, vegetables and salads, water, fruit juice and other drinks on 4 or 5 d/week (P < 0·005). The number of schools offering items not permitted under the food-based standards for school food on 4 or 5 d/week fell significantly over time (P < 0·005), while the number not offering these items on any day increased significantly (P < 0·005). Meals eaten by pupils were well-balanced in relation to macronutrients.

Lunchtime food provision and consumption in secondary schools have improved considerably since 2004, following the introduction of new compulsory standards for school food in 2009. To maximise their energy and nutrient intake at lunchtime, pupils should be encouraged to select a full meal, and to take and eat more fruit and vegetables. Schools also need continued support to increase the micronutrient content of menus and recipes.

Although previous research has shown that the Food Dudes programme increases children's fruit and vegetable consumption at school, there has been limited evaluation of the extent to which changes are maintained in the long term. Furthermore, despite knowledge that the nutritional content of home-supplied meals is lower than that of school-supplied meals, little consideration has been given to the programme's impact on meals provided from home. The present study therefore assessed the long-term effectiveness of the Food Dudes programme for both school- and home-supplied lunches.

Two cohorts of children participated, one receiving the Food Dudes intervention and a matched control group who did not receive any intervention. Consumption of fruit and vegetables was assessed pre-intervention, then at 3 and 12 months post-intervention. Consumption was measured across five consecutive days in each school using weighed intake (school-provided meals) and digital photography (home-provided meals).

Fifteen primary schools, six intervention (n 1282) and seven control schools (n 1151).

Participants were children aged 4–11 years.

A significant increase in the consumption of fruit and vegetables was found at 3 months for children in the intervention schools, but only for those eating school-supplied lunches. However, increases were not maintained at 12 months.

The Food Dudes programme has a limited effect in producing even short-term changes in children's fruit and vegetable consumption at lunchtime. Further development work is required to ensure the short- and long-term effectiveness of interventions promoting fruit and vegetable consumption in children such as the Food Dudes programme.

The present study aimed to determine whether a multi-component school-based intervention can maintain children's fruit and vegetable intake post eligibility for free school fruit and vegetables.

A random sample of fifty-four English primary schools was randomised to receive the 10-month intervention Project Tomato, a multi-component theory-based intervention, or the control. Each group consisted of twenty-seven schools.

Children's intake of fruit and vegetables is below recommendations. The English School Fruit and Vegetable Scheme has a short-term impact on intake while children are eligible for the scheme.

Dietary measurements were collected from 658 Year 2 pupils aged 7–8 years at baseline and at follow-up 20 months later.

Following an intention to treat analysis, the intervention as delivered compared with the control had no impact on the intake of fruit and vegetables (2 g/d, 95 % CI −23, 26 g/d) or on the number of portions of fruit (0·0 portions, 95 % CI −0·3, 0·3) or vegetables (0·0 portions, 95 % CI −0·2, 0·3) consumed daily by children. Intake of fruit and vegetables at school and home dropped by ∼100 g/d and 50 g/d, respectively, between baseline and follow-up in both the intervention and control groups.

Implementation of the intervention was low, with associated lack of impact on fruit and vegetable consumption in children. Alternatives to the delivery of an intervention by teachers and parents are needed to improve the dietary intake of primary-school children.

To evaluate implementation and effectiveness of nutrition promotion programmes using the health-promoting schools (HPS) approach, to indicate areas where further research is needed and to make recommendations for practice in this field.

The searched electronic databases included: CINAHL, Cochrane Library, Health Reference Center, Informit Search, MEDLINE, ProQuest, PsycINFO, PubMed, ScienceDirect, Scopus, Social Services Abstracts and Web of Science. Inclusion criteria were: (i) controlled or before-and-after studies evaluating a nutrition intervention and involving the HPS approach, either fully or in part; (ii) provision of information about components and delivery of the intervention; and (iii) report on all evaluated outcomes.

Schools.

Students, parents and school staff.

All included studies described intervention delivery and six reported on process evaluation. In intervention schools school environment and ethos were more supportive, appropriate curriculum was delivered and parents and/or the community were more engaged and involved. Students participated in interventions at differing levels, but the majority was satisfied with the intervention. The evidence indicates that nutrition promotion programmes using the HPS approach can increase participants’ consumption of high-fibre foods, healthier snacks, water, milk, fruit and vegetables. It can also reduce participants’ ‘breakfast skipping’, as well as reduce intakes of red food, low-nutrient dense foods, fatty and cream foods, sweet drinks consumption and eating disorders. It can help to develop hygienic habits and improved food safety behaviours.

More professional training for teachers in the HPS approach, further qualitative studies, longer intervention periods, improved follow-up evaluations and adequate funding are required for future school-based nutrition promotion programmes.

To develop and apply a socio-ecological model (SEM) for healthy eating in school students, to better understand the association between factors at different levels of the SEM and pupils’ dietary choices.

Student-level data, collected through anonymised questionnaires, included reported dietary choices and correlates to these; data on school approaches to food were collected through postal surveys. We used multilevel analysis to study the association of each level of the SEM on student dietary choice while controlling for factors found at other levels.

Data were collected from secondary schools in Wales that were a part of the 2005/2006 Health Behaviour in School-aged Children (HBSC) study.

The final sample for analysis included data from 6693 students aged 11–16 years and 289 teachers from sixty-four secondary schools in Wales.

Student interpersonal factors, an individual's social environment, had a greater association with the dietary choices students made for lunch than student intrapersonal characteristics, those that reside within the person, which were found to have a greater association with the dietary choices made outside school. School organisational factors, such as rules and policies, had a greater association with whether students ate unhealthy foods, whereas the community nature of the school had a greater association with the choosing of healthy foods.

Using the SEM and multilevel analysis allowed us to study how factors were associated with the choice of different foods at different times of the day by students. Interventions can use an SEM to target specific correlates and change health outcomes in the school.

To determine whether an association exists between different clusters of fruit- and vegetable-specific family-environmental factors and children's daily fruit and vegetable intake, and whether these associations differ between countries with different school lunch policies.

Cross-sectional data from four European countries participating in the Pro Greens project in 2009. These countries have different school food policies: two serve free school lunches and two do not. Self-administered data were used. Food frequency questions served to assess fruit and vegetable intakes. The study assessed sixteen children-perceived family-environmental factors, which were clustered based on principal component analysis into five sum variables: fruit and vegetable encouragement; vegetable modelling, family routine and demand; fruit modelling; fruit and vegetable snacking practices; and fruit and vegetable allowing.

Schools in Finland, Germany, Sweden and the Netherlands.

Schoolchildren aged 11 years (n 3317).

Multilevel logistic regression analyses revealed positive associations between nearly all clustered family-environmental factors and daily fruit and vegetable intake. The study tested a moderation effect between family-environmental factors and school lunch policy. In five out of twenty models significant interactions occurred. In the stratified analyses, most of the associations between family-environmental factors and raw and cooked vegetable intake were stronger in Germany and the Netherlands, neither of which provided free school lunches.

Children reporting more fruit- and vegetable-promoting family-environmental factors had a more frequent intake of fruits and vegetables; the associations were stronger for vegetable intakes in countries providing no free school lunches, suggesting that parental involvement is crucial when schools offer no vegetables.