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  • Published: 16 March 2020

Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: protocol for a systematic review and meta-analysis

  • Dongqing Wang 1 &
  • Wafaie W. Fawzi 1 , 2 , 3  

Systematic Reviews volume  9 , Article number:  55 ( 2020 ) Cite this article

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School feeding programs are beneficial for the physical, mental, and psychosocial development of school-age children and adolescents, particularly those in low- and middle-income countries (LMICs). While school feeding programs are ubiquitous in LMICs, the specific benefits of school feeding programs are unclear. The aim of this systematic review and meta-analysis is to evaluate the impacts of school feeding programs on the educational and health outcomes of children and adolescents in LMICs.

Rigorously designed interventional studies on the impacts of school feeding on nutritional and health outcomes of children and adolescents receiving primary or secondary education in LMICs will be included. The following information sources were used to identify relevant published or unpublished studies: MEDLINE, EMBASE, CINAHL, the Cochrane Library, and governmental or organizational websites. The risk of bias of randomized and non-randomized studies will be assessed using the Cochrane Risk of Bias tool and the ROBINS-I tool, respectively. Two reviewers will independently conduct the selection of studies, data extraction, and assessment of the risk of bias. A narrative synthesis of all the included studies will be provided. Meta-analyses will be performed whenever appropriate. Heterogeneity of effects will be assessed by I 2 , subgroup analyses, and meta-regression. The certainty of evidence for each outcome will be assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

The design and implementation of school feeding programs in LMICs should be based on the understanding of the benefits of such programs. This work will provide a crucial evidence base for the educational and health benefits of school feeding on children and adolescents in LMICs.

Systematic review registration

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) on November 18, 2019 (registration number: pending).

Peer Review reports

Nutrition during the school years is crucial for the physical, mental, and psychosocial development of children and adolescents aged 6 to 19 years. It is estimated that, across the developing world, 66 million school-age children go to school every day hungry, with 23 million hungry children in Africa [ 1 ]. Attending classes hungry severely impacts children’s and adolescents’ abilities to learn, to thrive, and to realize their full potentials [ 2 ].

School feeding programs (sometimes referred to as school meal programs) are interventions that regularly provide nutritious foods to children and adolescents attending school [ 3 ]. Benefits of school feeding on children and adolescents include alleviating hunger, reducing micronutrient deficiency and anemia, preventing overweight and obesity, improving school enrollment and attendance, increasing cognitive and academic performance, and contributing to gender equity in access to education [ 4 , 5 , 6 , 7 , 8 ]. Most countries have some forms of school feeding programs in some way and at some scale [ 6 , 8 ]. School feeding programs are widely available in high-income countries but generally have incomplete coverages in low- and middle-income countries (LMICs), where the need is greatest in terms of hunger and poverty [ 5 ]. Most countries in sub-Saharan Africa only have school feeding interventions that are targeted toward the most food-insecure regions instead of being universally available [ 5 ]. It is imperative to expand the coverage of school feeding programs and to improve the quality of existing programs to maximize their benefits on children and adolescents.

Little is known about the impacts of school feeding programs on specific educational and health outcomes of school-age children and adolescents in LMICs. Previous reviews on the potential effects of school feeding are outdated, with the most recent Cochrane review published in 2007 [ 9 ], thus do not reflect all of the currently available evidence. Also, previous work has limited scopes in terms of the age range [ 10 ] or the outcomes examined (e.g., anthropometric and nutritional outcomes but not educational or psychosocial outcomes or vice versa) [ 11 ]. Further, prior reviews have focused on the provision of school meals and did not explicitly evaluate what specific content (types and amounts of foods and nutrients) of the school meals conferred the largest benefits on outcomes [ 9 ]. Therefore, an updated and refined synthesis of evidence on school feeding interventions and a wide range of educational and health outcomes of children and adolescents is warranted and will inform the design and implementation of future programs.

The aim of this systematic review and meta-analysis is to evaluate the impacts of school feeding programs on educational and health outcomes of children and adolescents aged 6 to 19 receiving primary or secondary education in LMICs. We will emphasize findings generated from randomized controlled trials (RCTs). RCTs better account for external factors that may confound the effect of school feeding programs, including background nutritional deficiency levels and inputs from schools and teachers [ 8 , 12 ]. We will also include other rigorously designed interventional studies, including controlled before-after studies (CBAs) and non-randomized controlled trials that were able to account for the baseline differences between intervention arms [ 9 ].

Methods/design

Research question.

We aim to evaluate the impacts of school feeding programs on educational and health outcomes of children and adolescents receiving primary or secondary education in LMICs. We also aim to assess the potentially different impacts of school feeding by characteristics of the program and by composition of the foods provided.

Eligibility criteria

Inclusion criteria.

We will include RCTs, with the intervention randomized individually or in clusters (classes or schools). We will also include CBAs as they are non-randomized studies with a relatively rigorous design and occupy a non-negligible proportion of the relevant literature [ 9 ]. Non-randomized controlled trials are also eligible for inclusion as long as the baseline differences between intervention arms were accounted for in the analysis.

We will include published articles as well as unpublished and grey literature and will include ongoing studies where preliminary findings are available to us.

Studies conducted in LMICs as defined by the World Bank 2020 fiscal year.

Studies involving children and adolescents (boys and girls) aged 6 to 19 who were receiving primary or secondary education (i.e., primary, middle, or high school).

Studies that examined the impacts of the provision of foods, including meals (breakfast, lunch, or dinner) or snacks consumed at school (in-school feeding), and foods distributed to the family and consumed outside of the school setting (take-home ration) [ 5 ]. We will consider the provision of solid foods or beverages (e.g., milk). We will also include studies that examined food stamps or food vouchers distributed at school for the participants to access foods (in the market or food banks).

The comparison (control) group in each included study can be participants who did not receive school feeding or any other interventions, or participants who received alternative interventions instead of school feeding. We will also consider the comparison of school feeding programs with different food compositions, such as the comparison between an updated program with an original one.

We will include educational, nutritional, anthropometric, cognitive, and morbidity outcomes of children and adolescents. Potential outcomes include height, weight, skinfold thickness, mid-upper arm circumference, micronutrient status, hemoglobin level, school enrollment, school attendance, dropout, school achievement (math, reading, spelling), on-task behavior, cognition, and morbidity (e.g., fever, cough, diarrhea, and vomiting). Studies with results for at least one outcome of interest will be included.

No restrictions will be placed on the year, language, sample size of the study, or the duration of the intervention.

Exclusion criteria

Non-randomized controlled trials that did not account for the baseline differences between intervention arms.

Interventional studies without a proper control group, such as uncontrolled before-after studies, uncontrolled interrupted time series studies, and uncontrolled difference-in-difference designs.

Observational studies (e.g., cohort, case-control, and cross-sectional studies).

Editorials, commentaries, opinions, and review articles (these will, however, be used to identify additional original studies).

Studies conducted among preschool children only. Feeding interventions among preschool children are important and of great interest but are beyond the scope of this work, which will focus on the school setting.

Studies that examined the impacts of micronutrient fortification, micronutrient supplementation, or nutrition education; however, if such interventions are complementary to otherwise eligible school feeding interventions, these studies will be included.

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.

Information sources

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 covered the three databases (i.e., MEDLINE, EMBASE, and the Cochrane Library) that are recommended by the Cochrane Handbook for Systematic Reviews of Interventions [ 13 ]. 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) for studies not identified from the database searching. We will conduct a manual search of references of retained articles and previous reviews. We will also consult with content experts on school feeding to identify any additional studies. Reports written in languages other than English will be translated by colleagues who are native speakers of the corresponding languages whenever possible. Studies that cannot be adequately translated will be excluded.

Search strategy

We consulted with a health science librarian to develop the PubMed search strategy, which is provided in Additional File 1 . The sensitivity of the search strategy was examined by confirming that several sentinel articles were identified. The PubMed strategy will be adapted to the syntax appropriate for other databases. The initial search took place in November 2019, and an updated search will be conducted in early April 2020.

Data management

EndNote X9 (Clarivate Analytics, PA, USA) will be used to store the records retrieved from searches of electronic databases. The records will also be imported into Covidence (Veritas Health Innovation, Melbourne, Australia), an internet-based program that facilitates the streamlined management of the systematic review. Duplicate records will be detected and removed first by EndNote and then by Covidence.

Selection of studies

The results of the searches will be independently assessed by two reviewers based on the inclusion and exclusion criteria. All titles and abstracts will be reviewed first to remove irrelevant studies. For potentially eligible studies and studies with unclear eligibility, the full texts will be obtained and reviewed to confirm eligibility using a form for full text screening, which will be pilot tested on five randomly selected full texts. Disagreements between reviewers will be resolved by discussion or by a third reviewer when necessary. Inter-rater agreement will be quantified by calculating the raw percentage of agreement and Cohen’s κ coefficient. Specific reasons for study exclusions will be documented and summarized using the flow diagram for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 14 ]. Neither of the reviewers will be blind to journal titles or the names of the authors.

Data extraction

Data of the retained studies will be extracted by two reviewers independently and entered into a data extraction form, which will be pilot tested on five randomly selected studies. Disagreements in the extracted information between reviewers will be resolved by discussion or by a third reviewer. When necessary, the corresponding authors of the studies will be contacted to obtain relevant information. We will extract the following information: title, authors (first author and corresponding author), contact information of corresponding author, journal (or source for unpublished reports), calendar year of publication, calendar year of intervention, country, source of funding, 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 co-interventions), measure of adherence, comparator/control, outcomes assessed, main findings with point estimates and measures of variance (standard errors, 95% confidence intervals, or p values), theory to explain success (if available), and theory to explain failure (if available). Multiple reports of a single study will be collated as additional results may be provided in different reports. Whenever there are inconsistent results across reports of a single study, we will contact the corresponding author to obtain more accurate results. The data extraction form is provided in Additional File 2 .

Assessment of risk of bias

The risk of bias will be independently assessed by two reviewers. Any disagreement on the risk of bias between reviewers will be resolved by discussion and by a third reviewer when necessary. The risk of bias assessments will be conducted for each outcome reported in each trial, rather than for the whole study. For RCTs, we will use version 2 of the Cochrane Risk of Bias tool (RoB 2) [ 15 ], which considers the following five domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported results. For cluster-randomized trials, we will additionally consider bias from the timing of identification and recruitment of individual participants in relation to timing of randomization [ 16 ]. Each domain will be judged as “low risk of bias,” “high risk of bias,” or “some concerns.” We will consider an RCT to be of low risk of bias if it is judged to have low risk of bias for all domains; we will consider an RCT to be of high risk of bias if it is judged to have high risk of bias in at least one domain or have some concerns for multiple domains (≥ 3) in a way that substantially lowers confidence in the result; we will consider an RCT to have some concerns if it raises some concerns in at least one domain but not to be at high risk of bias for any domain [ 15 ]. For CBAs and non-randomized controlled trials, we will use the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool [ 17 ], which considers biases from confounding, bias in selection of participants into the study, bias in classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in measurement of outcomes, and bias in selection of the reported results. Each domain will be judged as “low risk of bias,” “moderate risk of bias,” “serious risk of bias,” “critical risk of bias,” or “no information.” We will consider a non-randomized study to be of low risk of bias if it is judged to have low or moderate risk of bias for all domains; we will consider a non-randomized study to be of high risk of bias if it is judged to have serious or critical risk of bias in one or more domains; we will consider a non-randomized study to have some concerns if the assessment is unclear for one or more domains but low or moderate for all other domains. We will contact the corresponding authors of the reports to obtain more information when necessary. We will summarize the results of the assessment of the risk of bias in a table, in which the judgment for each domain will be presented with a justification [ 15 ].

Data synthesis

A systematic and narrative synthesis of all included studies will be presented in the text and also as a table. School feeding will be treated as a dichotomous exposure (i.e., intervention vs. control). Effect estimates for continuous outcomes will be expressed as mean differences (with 95% confidence intervals) comparing the intervention group with the control group; effect estimates for dichotomous outcomes will be expressed as risk ratios, rate ratios, hazard ratios, or odds ratios (all with 95% confidence intervals), comparing the intervention group with the control group. For RCTs, we will extract the results based on intention-to-treat analyses. When more than two intervention groups are present in a study, they will be treated as separate arms. However, when the interventions of the additional arms are not relevant to school feeding, they will not be taken into account. Ideally, cluster-randomized studies should report results from analyses that appropriately account for the study design, such as mixed-effects models or generalized estimating equations. Studies that ignored clustering are overprecise and will receive unduly high weights in the meta-analysis. When cluster-based studies did not use the proper statistical methods to account for clustering, we will extract or apply an intraclass correlation coefficient to modify the standard errors based on the approach described in the Cochrane Handbook for Systematic Reviews of Interventions [ 13 ].

If studies for a given outcome are sufficiently consistent in terms of intervention, comparator, and outcome definition, we will conduct a random-effects, inverse-variance-weighted meta-analysis for the outcome. The random-effects method will be used as the effect of school feeding is presumed to be heterogeneous across time and populations. Heterogeneity of effects across studies will be assessed by computing the I 2 statistic, which represents the percentage of the total variation in the effect estimates that is due to true heterogeneity rather than chance; I 2 > 50% will be considered as substantial heterogeneity [ 18 ].

We will assess the sources of heterogeneity by conducting subgroup analyses with the following prespecified characteristics: unit of allocation (individual, class, or school), modality of intervention (in-school meal, in-school snacks, take-home ration, food stamps/food vouchers), presence of co-interventions (by itself or combined with complementary interventions), timing of intervention (breakfast, lunch, dinner, or snack), duration of intervention (defined as the interval between the initialization of the school feeding intervention, and when the outcomes were assessed), year of study, country or region, level of food insecurity of the region, age group of participants (primary or secondary education), sex of participants, type of report (published or unpublished), and risk of bias (low, high, or some concerns). To assess the potentially differential impacts by the specific content of the meal, we will conduct exploratory subgroup analyses by the type and amount of the foods or nutrients entailed in the program, such as the presence of fruits, vegetables, and animal source foods, or the adequacy of micronutrients and macronutrients (defined in relation to the Recommended Dietary Allowances). To further explain heterogeneity, we will perform meta-regression using the predictors mentioned above. We will use contour-enhanced funnel plots to detect publication bias if there are 10 or more studies available for an outcome [ 19 ]. We will assess the robustness of the results by excluding studies judged to have a high risk of bias, and by repeating the analyses using fixed-effects models. We will compute for each outcome a 95% prediction interval, which provides a predicted range of the effect of the intervention when applied in an individual setting [ 20 ]. Statistical analyses will be conducted using STATA 16 (StataCorp, College Station, Texas). For outcomes with insufficient data or extreme heterogeneity that cannot be assessed in subgroup analyses or meta-regression, we will provide a narrative synthesis without a meta-analysis.

Assessment of certainty of evidence

The overall certainty of evidence for each included outcome will be assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach, which considers risk of bias, publication bias, imprecision, inconsistency, and indirectness [ 21 , 22 , 23 , 24 , 25 , 26 ]. The strength of the overall evidence will be judged as high, moderate, low, or very low [ 21 ].

Registration and reporting

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) on November 18, 2019. However, at the time of this proofing, the protocol has still not been reviewed or assigned a registration number. We reached out to PROSPERO for an update on the registration status and was told that the registration for non-U.K. studies would take a long time (4-5 months with a minimum of 140 days). In the event of protocol amendments, the date of each amendment will be accompanied by a description of each change and the rationale on PROSPERO. We prepared this protocol following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) [ 27 ]. The PRISMA-P checklist can be obtained from Additional File 3 . We will report this systematic review following the Cochrane Handbook for Systematic Reviews of Interventions [ 13 ] and the PRISMA guidelines [ 14 ].

School feeding programs have been and will continue to be essential for the provision of nutrients, improvement of academic performance, and the promotion of a healthy lifestyle in LMICs. Therefore, there is a strong political will to continue to fund new programs and to expand on existing programs [ 28 ]. The design and implementation of school feeding programs in LMICs should be based on the established benefits of such programs on specific educational and health outcomes of children and adolescents, for which an updated evidence base is needed.

The State of School Feeding Worldwide , published by the WFP, summarized the status of school feeding across the world and reported that school feeding programs are ubiquitously present. However, the quality of school feeding programs varies greatly across countries and with national income [ 6 ]. The report also highlighted a need to strengthen the evidence base on the potential benefits of school feeding. Drake et al. reviewed the design and implementation of 14 school feeding programs in LMICs [ 28 ]. They concluded that there is no one-size-fits-all model for school feeding programs, given that different countries approach school feeding programs with different objectives. However, they did identify some good practices that are likely applicable across countries, such as the inclusion of fruits and vegetables, the collaboration with local smallholder farmers, and the incorporation of school feeding programs as the component of a much broader curriculum of nutrition and health education. They noted that there was a lack of quantitative data on the impacts of school feeding, especially those from randomized controlled trials. A recently published report by the FAO-reviewed nutrition guidelines and standards for school meals from 33 LMICs through surveys targeted toward relevant stakeholders and found considerable variation between and within countries in terms of coordination, management, funding, objectives, and modalities of school feeding programs [ 3 ]. For example, the objectives of the identified school feeding programs include addressing short-term hunger, reducing nutrient deficiency, improving attendance and school performance, encouraging healthy eating habits, and supporting local agriculture and economy. Lunch is the most common timing for the identified programs, and the majority of the school lunch programs offer cooked meals that range from single dishes based on staples with added vegetables, legumes, and animal-source foods to menus with a main dish and a side dish; fruits are provided as part of the meal in some programs. Nutrition education and school gardens (often also for educational purposes) are the most common complementary interventions to the feeding programs. However, this report focused on government-owned programs and excluded any pilot projects or scalable programs coordinated by non-governmental entities. None of the reports mentioned above quantitatively linked school feeding programs to specific outcomes of children and adolescents.

Numerous systematic reviews have synthesized the impacts of school-based dietary interventions on various outcomes of children and adolescents [ 9 , 10 , 11 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. However, most of the reviews consist primarily of nutrition education programs that did not provide actual foods. To date, only a few reviews focused on or were able to draw conclusions regarding school feeding programs [ 9 , 10 , 11 , 44 , 45 ]. Kristjansson et al. conducted the first systematic review on this topic with 18 studies (nine from lower-income countries) among socio-economically disadvantaged children and adolescents across the world [ 9 ]. It was reported that, in RCTs from lower-income countries, participants who were fed at school gained an average of 0.39 kg more weight over 19 months and attended school more frequently (4 to 6 more days per year per participant) than those in control groups; school-fed participants in lower-income countries also had better performances in math and short-term cognitive tasks compared to controls. However, results for height and results from higher-income countries are mixed, suggesting that the benefit of school feeding varies by outcome and by socioeconomic status, with disadvantaged participants from lower-income countries likely to benefit more from school feeding. While comprehensive at the time, this first systematic review only included seven RCTs, five of which were conducted in lower-income countries. Jomaa et al. reviewed the impacts of school feeding programs on educational and health outcomes of primary-school-age children in developing countries. They reported relatively consistent positive associations between school feeding and energy intake, micronutrient status, school enrollment, and school attendance, but reported inconclusive results on growth, cognition, and academic achievement [ 10 ]. However, this review did not include children and adolescents at the secondary school level or studies conducted prior to 1990. Krishnaratne et al. reviewed rigorously designed studies among children and adolescents in LMICs. They found significant associations between school feeding and enrollment, dropout, progression, and nonsignificant associations with attendance and learning [ 44 ]. Snilstveit et al. systematically reviewed interventions for improving learning outcomes and access to education for children and adolescents in LMICs and reported positive associations between school feeding and enrollment, attendance, and various learning outcomes [ 45 ]. The reviews by Krishnaratne [ 44 ] and Snilstveit [ 45 ], however, did not specifically focus on school feeding, nor did they consider non-educational endpoints such as nutrition and health. Watkins et al. reviewed the impacts of school feeding on the nutritional status of primary-school-age children and preschool and adolescent girls in LMICs; they reported small and significant effects on weight gain and small and nonsignificant effects on height gain among school-age children [ 11 ]. Nevertheless, this review focused on anthropometric outcomes and nutritional status and had limited coverage on educational or psychosocial outcomes. None of the previous reviews examined in detail whether different content (e.g., types and amounts of foods and nutrients) of the provided meals had differential impacts on children and adolescents, which is crucial information for the design and improvement of future programs.

School years represent a critical period not only for physical and mental development but also for the formation of long-term dietary and lifestyle habits. This systematic review and meta-analysis will provide a comprehensive evidence base for the development and refinement of future school feeding programs targeted toward children and adolescents in LMICs.

Availability of data and materials

All data that will be generated and analyzed during this study will be included in the published article or its supplementary information files.

Abbreviations

Controlled before-after study

Food and Agriculture Organization

Grading of Recommendation, Assessment, Development, and Evaluation

Low- and middle-income country

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

International Prospective Register of Systematic Reviews

Randomized controlled trial

Risk of Bias in Non-randomized Studies of Interventions

World Food Programme

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Krishnaratne S, White H, Carpenter E. Quality education for all children? What works in education in developing countries, vol. 20. New Delhi: International Initiative for Impact Evaluation (3ie), Working Paper; 2013. p. 155.

Snilstveit B, Stevenson J, Phillips D, Vojtkova M, Gallagher E, Schmidt T, et al. Interventions for improving learning outcomes and access to education in low-and middle-income countries: a systematic review. Campbell Collaboration. 2015.

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Acknowledgements

We thank Jacqueline Cellini at Francis A. Countway Library of Medicine at Harvard University for conceptual consultation and assistance with developing the search strategy.

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PubMed search strategy.

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Wang, D., Fawzi, W.W. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: protocol for a systematic review and meta-analysis. Syst Rev 9 , 55 (2020). https://doi.org/10.1186/s13643-020-01317-6

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literature review on school feeding

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Sensitive to nutrition? A literature review of school feeding effects in the child development lifecycle

The purpose of this paper is to provide an up-to-date literature review on school feeding and the potential impact on nutrition, including school age children, pre-school and adolescent girls. The review is aimed at providing evidence-based guidance to national governments on school feeding and nutrition from a lifecycle approach. The review seeks to consolidate the existing evidence, analyse what this evidence translates into in terms of programming, and understand the potential of improving nutrition through school feeding programmes globally. Gaps in the evidence are also consolidated in a research agenda.

Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: A systematic review and meta-analysis

Affiliations.

  • 1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.
  • 2 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.
  • 3 Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.
  • PMID: 34552720
  • PMCID: PMC8442580
  • DOI: 10.7189/jogh.11.04051

Background: School feeding programs are ubiquitous in low- and middle-income countries (LMICs) and may have critical implications for the health and education of school-age children and adolescents. This systematic review aimed to assess the impacts of school feeding on educational and health outcomes of children and adolescents in LMICs.

Methods: Interventional studies on the effects of school feeding on nutritional and health outcomes of children and adolescents receiving primary or secondary education in LMICs were included. MEDLINE, EMBASE, CINAHL, the Cochrane Library, and grey literature were searched (through December 2019) to identify eligible studies. We included randomized controlled trials and controlled before-after studies on school feeding conducted in LMICs among children and adolescents aged 6 to 19 who received primary or secondary education. Two reviewers independently conducted study selection, data extraction, and risk of bias assessment. Meta-analyses were performed for outcomes available in three or more independent studies. Subgroup analyses were conducted by study design and school feeding modality whenever possible.

Results: Fifty-seven articles met the inclusion criteria for the review, including 44 randomized controlled trials and 13 controlled before-after studies; 19 articles were included in the meta-analysis. School feeding resulted in a significant increase in height (mean difference = 0.32 cm; confidence interval (CI) = 0.03, 0.61; P = 0.032) and weight (mean difference: 0.58 kg; 95% 95% CI = 0.22, 0.93; P = 0.001) over 12 months, compared to those in the control groups. School feeding also resulted in a significant increase in the percentage of school days attended (2.6%; 95% CI = 1.2%, 3.9%; P < 0.001).

Conclusions: School feeding is an important approach to improving the health and education outcomes of children and adolescents living in LMICs. More well-designed research is needed to establish further the effectiveness of school feeding for nutritional outcomes and academic achievement.

Registration: PROSPERO ID: CRD42020159003.

Copyright © 2021 by the Journal of Global Health. All rights reserved.

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The Importance and Challenges of School Feeding: Literature Review

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To select in the literature the importance and challenges of food for the development and potential of the individual related to growth, promotion, and health. Method: This is an Integrative Literature Review and 188 articles were selected for analysis. After applying the defined inclusion and exclusion criteria, 15 studies were included in the research. The studies showed that dealing with the subject is essential, allowing children and adolescents access to healthy and quality food, guaranteeing their right to food as provided for in the Statute of Children and Adolescents. Most studies concluded that several schools do not offer adequate food to their users, despite the importance of this practice being evidenced by the works. Therefore, implementing and implementing the guidelines that the National School Feeding Program legislation offers is essential to change this scenario in the school context.

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School Feeding Program (SFP) is a targeted safety net program designed to provide educational and health benefits to vulnerable children. However, limited evidence exists regarding the effect of the intervention on the nutritional status and school attendance of children. The study is aimed at examining the effects of SFP on dietary diversity, nutritional status and class attendance of school children in Boricha district, Southern Ethiopia. The study was conducted based on a representative data collected from 290 students drawn from the district. A school-based comparative cross-sectional study was conducted on school children aged 10-14 years. Data were collected using structured pretested questionnaire. The effects of SFP on dietary diversity score (DDS), class attendance rate, body-mass-index for age (BAZ) and height-for-age (HAZ) Z-scores were assessed using multivariable linear regression model. The finding showed significantly higher mean (±SD) of DDS in SFP beneficiaries (5.8...

literature review on school feeding

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Importance of good nutrition for children Imagine a young child in a typical government school in India. This little girl is six years old and getting ready for school. Her mother is getting ready too because she must be in the field by 7 am. She has no time to make breakfast for the little girl or her brother. The little girl barely has time to wash her face and get into her school uniform. There is a bit of rice leftover from the night before, which the mother hurriedly divides between her two children – barely a mouthful each. Then, they run to school, just in time for the assembly. As they file into their classrooms for their first lesson, the little girl feels a familiar rumble in her stomach – she is hungry, and lunch is several hours away. It is going to be another long morning.

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Context Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children’s dietary intake may help address this double burden of malnutrition. Objective This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children’s health and nonhealth outcomes. Data sources, extraction, and analysis Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Eval...

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The CIE HIV/AIDS and Gender Unit approached CIE Education Services towards the end of 2004 and asked for assistance in processing the data they had collected in a survey of school feeding schemes. Research over a number of years in the area of school feeding schemes shows a number of benefits of these schemes: School feeding schemes address short-term hunger and improving cognition • Long distances that children walk to school can impact on nutrition • Providing breakfast to disadvantaged learners can improve test scores • School feeding programmes can improve short-term memory and increase problem-solving skills. School feeding schemes increase enrolments and improve attendance • Children in poor health start school late in life or not at all • Malnourished children complete fewer years at school than better nourished children • School feeding programmes are associated with increased school enrolment, regular attendance, lower repetition and dropout rates. School feeding schemes address micronutrient deficiencies and improve learning • Iron deficiency causes children to be listless, inattentive and uninterested • Addressing iron deficiencies can improve IQ scores. School feeding schemes promote community participation • Increase contact and communication between parents and teachers • Raise the value of education in the community • Community ownership can influence the success of the project. Data was collected in three main ways. A telephonic survey was carried out of all Catholic schools in the country and focus group interviews were conducted with children who benefit from feeding schemes. Children were also asked to draw pictures of what feeding schemes meant to them. 296 schools out of 342 Catholic schools responded to the telephonic questionnaire. 47,3% (140) of the schools surveyed have school feeding schemes operating in them. 52,7% (156) of the schools do not have school feeding schemes in place. There is overwhelming evidence that school feeding programmes improve attendance at school as well as the performance of disadvantaged learners. School feeding schemes can minimise the effects of malnutrition.

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This work is licensed under the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/legalcode), which permits unrestricted use, distribution, and reproduction, provided the original work is properly credited. Cette œuvre est mise à disposition selon les termes de la licence Creative Commons Attribution (https://creativecommons.org/licenses/by/4.0/legalcode), qui permet l’utilisation, la distribution et la reproduction sans restriction, pourvu que le mérite de la création originale soit adéquatement reconnu.

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Article Contents

Introduction, acknowledgments, supporting information, mapping the evidence of novel plant-based foods: a systematic review of nutritional, health, and environmental impacts in high-income countries.

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Sarah Nájera Espinosa, Genevieve Hadida, Anne Jelmar Sietsma, Carmelia Alae-Carew, Grace Turner, Rosemary Green, Silvia Pastorino, Roberto Picetti, Pauline Scheelbeek, Mapping the evidence of novel plant-based foods: a systematic review of nutritional, health, and environmental impacts in high-income countries, Nutrition Reviews , 2024;, nuae031, https://doi.org/10.1093/nutrit/nuae031

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Shifting from current dietary patterns to diets rich in plant-based (PB) foods and lower in animal-based foods (ABFs) is generally regarded as a suitable strategy to improve nutritional health and reduce environmental impacts. Despite the recent growth in supply of and demand for novel plant-based foods (NPBFs), a comprehensive overview is lacking.

This review provides a synthesis of available evidence, highlights challenges, and informs public health and environmental strategies for purposeful political decision-making by systematically searching, analyzing, and summarizing the available literature.

Five peer-reviewed databases and grey literature sources were rigorously searched for publications.

Study characteristics meeting the inclusion criteria regarding NPBF nutrient composition and health and environmental outcomes in high-income countries were extracted.

Fifty-seven peer-reviewed and 36 grey literature sources were identified; these were published in 2016–2022. NPBFs typically have substantially lower environmental impacts than ABFs, but the nutritional contents are complex and vary considerably across brands, product type, and main primary ingredient. In the limited evidence on the health impacts, shifts from ABFs to PB meats were associated with positive health outcomes. However, results were mixed for PB drinks, with links to micronutrient deficiencies.

If carefully selected, certain NPBFs have the potential to be healthier and nutrient-rich alternatives to ABFs and typically have smaller environmental footprints. More disaggregated categorization of various types of NPBFs would be a helpful step in guiding consumers and key stakeholders to make informed decisions. To enable informed policymaking on the inclusion of NPBFs in dietary transitions as part of a wider net-zero and health strategy, future priorities should include nutritional food standards, labelling, and subdivisions or categorizations of NPBFs, as well as short- and long-term health studies evaluating dietary shifts from ABFs to NPBFs and standardized environmental impact assessments, ideally from independent funders.

The fragile interconnection between food systems and the environment is increasingly evident. 1–3 While current agricultural practices are damaging the environment, environmental change is putting food supplies at risk of disruption if timely adaptation strategies are not used. 4–8 This relationship exists at a time when food systems are already struggling to provide healthy diets for all, with many populations experiencing a coexistence of undernutrition and obesity. 1 , 3

Structural changes in food systems are critical to both safeguard people’s health and accomplish the climate adaptation and mitigation commitments mentioned in The United Nations Framework Convention on Climate Change 9 and the United Nations’ Sustainable Development Goals. 10 While production-side strategies can contribute toward climate mitigation, substantial opportunities for further emission reductions and acceleration toward net-zero targets can be achieved through dietary changes and the resulting lower demand for foods with a large environmental footprint.

In food-secure and high-income settings, a shift from “conventional diets” (which typically contain high amounts of animal-based foods [ABFs]) to predominantly plant-based (PB) diets could improve population and planetary health. 2 , 11 Dietary change has many obstacles, with diets influenced by many factors 12 , 13 that act as barriers to increasing consumption of minimally processed PB foods (eg, legumes, vegetables). If common barriers are removed, such as the need for additional cooking skills, major changes in taste and appearance of commonly consumed dishes, and fear of social stigma, 14 , 15 novel plant-based foods (NPBFs), products designed to mimic and replace ABFs to allow easy incorporation into habitual diets (eg, vegan and vegetarian meat and dairy) (see Box 1 ), may offer an easier option to facilitate this shift.

In recent years, the NPBF landscape has expanded rapidly. Several new types of NPBFs (eg, PB drinks, yogurts, eggs, meats) were introduced to the market, and trends showed increasing sales, volume, and investment growth across many countries. 16–21 In 2023, data suggested a possible slowdown, especially for PB meats, with some consumers criticizing their cost and taste, 22 and some NPBF manufacturers reporting net losses. 23 , 24 However, sales of supermarkets’ own-label PB meat alternatives have seen growth, 23 alongside consistent increases in sales of PB dairy and eggs 25 (see Supplementary file 1, section 1.1, in the Supporting Information online for detailed information on costs).

According to a global survey focusing on individuals following vegan or vegetarian diets most or all of the time, 22.0% of consumers reported adhering to a meat-free diet, and there is growing interest in embracing PB eating, with approximately 42.0% of consumers anticipating that PB foods will replace most meat within a decade. 26 With consumption of NPBFs in the United Kingdom doubling between 2008 and 2019, particularly among women and younger generations, and the fact that in 2022, 60.0% of US households purchased at least 1 type of NPBF, verification of any health and sustainability claims in marketed products is of vital importance. 22 , 27 , 28 Currently, various NPBFs are advertised as potential dietary “game changers,” with claims that they would play an important and positive role in sustainability and health, 29 , 30 and, thus, could play a pivotal role in the so-called consumption corridors. 31 However, because of their novelty, some consumers question these positive claims. 32 Although NPBFs are generally regarded as a low-carbon alternative to ABFs, their nutrient and health profiles remain largely unknown and are often criticized. This is primarily related to concerns regarding micronutrient and protein content, along with higher content of saturated fats and sodium in comparison to ABFs, and level of processing. 33 , 34

Previous reviews have primarily focused on single aspects of NPBFs 17 , 19 , 22 , 25 , 29 , 34–46 or ingredients of NPBFs 39 , 47–50 ; a few recent reviews explored the positive health and environmental outcomes of consuming selected NPBFs. 51–53 However, research quantifying the potential impacts of NPBFs is still in its infancy, and an overview that is both systematic and comprehensive, comprising health, nutrient, and environmental outcomes from peer-reviewed and grey literature of different types of NPBFs, does not yet exist, to our knowledge. This lack makes it difficult for policy makers and consumers to assess the trade-offs between nutrient composition and the environmental and health impacts of NPBFs, and hinders the potential inclusion of NPBFs in sustainable and healthy dietary recommendations.

To synthesize available evidence, highlight challenges, inform public health and environmental strategies, and inform purposeful political decision-making, we aimed, in this study, to systematically search, analyze, and summarize the available grey and peer-reviewed literature on the nutrient composition, environmental footprints, and health effects of NPBFs sold and consumed in high-income countries, and to quantify and summarize their reported results.

The full-study protocol we followed is published elsewhere (see Nájera Espinosa et al 54 and Supplementary file 1, section 2, in the Supporting Information online for more details on the methods). Briefly, a systematic search was performed to identify peer-reviewed journal articles and grey literature that contained data on the nutrient composition, health impacts, and environmental impacts of NPBFs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. 55

Peer-reviewed literature

Five scientific databases were systematically searched (MEDLINE, Embase, Global Health, GreenFILE, and the Web of Science Core Collection) on August 29, 2021; we conducted an updated search on June 29, 2022. The search was limited to articles published and accepted after January 2016 until June 29, 2022, because of the substantial growth in supply and demand of NPBFs in the past 7 years. 16–19 In addition to database searching, citation lists from identified systematic literature reviews were handsearched (see Supplementary file 1, section 2.6, in the Supporting Information online for the full search strategy). After the quality criteria were applied (described in Supplementary file 1 , Table S1 in the Supporting Information online ), titles were manually and triple screened. Abstracts were manually double screened after application of a supervised machine-learning algorithm (ie, a support vector machine 56 ) through Scikit Learn 57 that ranked and highlighted likely relevant articles (ie, conducted priority screening). This approach is described elsewhere in detail (see Supplementary file 1, section 2.1, in the Supporting Information online ). 58 Full texts were manually screened by 2 authors and data were also double extracted.

Grey literature

To capture grey literature in a systematic way, a manual search was conducted on Google (see Supplementary file 1, section 2.3 , and Table S3 in the Supporting Information online ). Text from the webpages was then scraped and a state-of-the-art, pretrained language model from Hugging Face 59 was used to create a summary of each web link. Results were exported into a comma-separated value, or CSV, file. Additionally, a manual search in Google of relevant websites from the top NPBF producers in the United Kingdom and United States was conducted. 60–63 And literature from relevant websites that promote NPBFs, such as the Good Food Institute and Green Queen, were searched and screened manually (see Supplementary file 1, section 2.3 , and Tables S4 and S5 in the Supporting Information online ).

Data analysis, categorization, and key definitions: nutrient, health, and environmental outcomes

The PICO (population, intervention, comparison, and outcome) criteria are defined in Table 1 (see Supplementary file 1, Table S1 in the Supporting Information online for a detailed list of the inclusion and exclusion criteria). Main study characteristics and nutrient, health, and environmental outcomes were extracted (see Supplementary files 1 and 3 in the Supporting Information online for more details).

PICO criteria for inclusion of studies

PB drinks and milk reported in 100 ml of product.

NPBFs and their ABF counterparts were categorized into food groups on the basis of their primary ingredient ( Table 2 ). See Supplementary file 1, sections 2.4 and 2.5, in the Supporting Information online for more details on the selection of nutrients, data analysis assumptions, and ABF baseline comparators). The following terms for each NPBF type are used in this review:

Food groups for novel plant-based foods and animal-based foods and their respective reported main primary ingredient

For the purposes of this review, peanuts were included in the Nuts and Seeds group because they are typically consumed as such.

Blended or mixed products, if reported, the first ingredient was taken as the primary ingredient. For example, soy & almond PB drinks were labelled as legumes.

If a product did not report any ingredients, they were categorised as unknown.

PB meat products or alternatives: include different types of PB meats (eg, PB chicken, sausages, mincemeat), categories (eg, mycoprotein, legumes), and brands

PB drink products or alternatives: include different PB drink categories (eg, legumes, nuts, seeds) and brands

PB yogurt products or alternatives: include different PB yogurt categories (eg, legumes, coconut) and brands

PB cheese products or alternatives: include different types of PB cheese categories (eg, coconut, nuts, seeds) and brands

PB egg products or alternatives: include different types of PB egg categories and brands

Mention of PB products (without further specification) refers to all the listed product subcategories mentioned, except for PB eggs.

Assessment of robustness and relevance

A modified version of the Critical Appraisal Skills Program checklist for randomized controlled trials 64 was adapted to assess robustness and relevance of the studies in the full-text reviewing stage. The modifications involved the exclusion of the randomization, blinding, and cost-effectiveness criteria on the Critical Appraisal Skills Program checklist, and funding source was added as a criterion. Studies were assessed by 4 reviewers (G.H., R.P., S.P., and S.N.E.). Studies were assessed as follows: (1) clear description of the study design, (2) appropriate comparison group, (3) clear description of the methods, (4) rigorous and clearly described analysis, (5) funding source, and (6) precision of measure of effect. Studies with a minimum score of 1 were included, and sensitivity analysis was performed by funding source (see Supplementary file 1, section 2.2, in the Supporting Information online for more details).

Fruit, vegetable, legume, and nut content in novel plant-based foods

In addition to the review component, a cross-sectional analysis was conducted to examine the total fruit, vegetable, legume, and nut content (percentage estimate) of each type of NPBF sold in the United Kingdom. For this, a time-stamped data set of observations from UK supermarkets generated by FoodDB in October 2021 was used. Details are described elsewhere 65 and in Supplementary file 1, section 2.7, in the Supporting Information online . Detailed data at the global level are not available to date; hence, this part of the analysis is limited to the United Kingdom only.

Sensitivity analysis

A common concern about studies on the health impacts and environmental sustainability of NPBFs is that they can be funded by the industry that produces them; hence, we conducted a sensitivity analysis by funding source. Furthermore, given that relative improvements in health and environmental sustainability depend on the baseline comparator used ( Supplementary file 1, section 2.2, in the Supporting Information online ), the sensitivity analysis based on the main primary ingredient of a given NPBF and its respective ABF comparator was also performed. The Wilcoxon test for sensitivity analysis with a significance level set at P  ≤ 0.05 was used.

Systematic search results

A total of 49 563 peer-reviewed and 891 grey literature records were identified from the initial search. After unique literature sources were screened, 57 peer-reviewed articles and 36 grey literature studies met the inclusion criteria ( Figure 1 ). Supplementary 1, section 2, in the Supporting Information online provides further details on the screening process. The study characteristics that were extracted included basic study details (eg, authors, year, type of study, country, number of participants, follow-up period), relevant macro- and micronutrient content (eg, those related to common deficiencies, such as iron, calcium, vitamin B 12 ), health and health proxy data (eg, obesity, micronutrient status, risk factors related to noncommunicable diseases), and environmental variables (eg, carbon, water, and land-use data).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of systematic review process reporting nutrient composition, and environmental and health outcomes of novel plant-based products in high-income countries. Abbreviations: IPCC, Intergovernmental Panel on Climate Change.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of systematic review process reporting nutrient composition, and environmental and health outcomes of novel plant-based products in high-income countries . Abbreviations : IPCC, Intergovernmental Panel on Climate Change.

Nutrient composition of novel plant-based foods

The nutrient content of NPBFs was the most frequently studied outcome (n = 56 studies). Nutrient data were typically collected through supermarket cross-sectional surveys or manufacturers’ websites. PB meat alternatives (n = 35) and PB drink alternatives (n = 19) were most frequently reported; fewer studies researched PB cheese (n = 5) and yogurt alternatives (n = 4). No studies were found that assessed PB egg alternatives. The nutritional profile of NPBFs varied greatly by manufacturing process, including the main base ingredient (eg, soy, almond); the processing techniques, time, and temperature applied; and the type of product manufactured (ie, PB drinks, PB meats). 39 , 40 , 66 , 67

Energy density, saturated fat, fiber, sugar, sodium, and micronutrient content of plant-based meat alternatives

The 35 publications evaluating PB meat alternatives reported on 508 PB meat products with 66 ABF comparators. Where the median values for meat comparators were reported to be 221.0 kcal/100 g (interquartile range [IQR], 186.6–246.7), 5.7 g/100 g saturated fat (IQR, 3.2–7.1), and very low fiber (<0.1 g/100 g; IQR, 0.0–0.5), most meat-alternative groups were reported to have lower energy density, lower saturated-fat content, and more fiber ( Figure 2 and Supplementary file 2: Table S1 for detailed macronutrient information disaggregated by main ingredient). Mycoprotein-based meat alternatives were reported to be the least energy dense, with a median energy value of 123.0 kcal/100 g (IQR, 94.0–198.5; with ABFs, P value of difference [ P d ] < 0.001), whereas meat alternatives based on cereals and grain had the highest energy density of all PB meats (226.0 kcal/100 g [IQR, 189.8–268.5]; P d < 0.360), with values very similar to those of meat and poultry. Mycoprotein-based meats were also reported to be lowest in saturated fat (0.8 g/100 g [IQR, 0.5–1.3]; P d < 0.001), whereas nut- and seed-based meats had the highest saturated fat content (1.4 g/100 g [IQR, 1.1–1.7]; P d = 0.003) of all PB meats, which still was significantly lower than saturated fat content in meat and poultry. Finally, mycoprotein-based meat was reported to contain the highest fiber content (median, 6.0 g/100 g [IQR, 5.2–7.1]; P d  < 0.001), whereas cereal- and grain-based meats had the lowest fiber content of all PB meats (3.1 g/100 g [IQR, 2.3–3.9]; P d < 0.001), which still was significantly higher than in meat and poultry.

Macronutrient, sodium, and energy content in plant-based meat and drink alternatives in their respective food group based on main primary ingredient  (ie, predominant or core food item on the ingredient list) compared with meat and poultry, and dairy, respectively. Data were limited to raw products only. Abbreviation: M, median of each category.

Macronutrient, sodium, and energy content in plant-based meat and drink alternatives in their respective food group based on main primary ingredient   (ie, predominant or core food item on the ingredient list) compared with meat and poultry, and dairy, respectively . Data were limited to raw products only. Abbreviation : M, median of each category.

Meat and poultry contained a median of 0.5 g/100 g total sugar (IQR, 0.0–0.9) and 426.7 mg/100 g sodium content (IQR, 101.0–672.8). All PB meats contained more total sugar but had similar levels of sodium in comparison with meat and poultry. Mycoprotein-based meats had the lowest total sugar content of all PB meats (median, 0.8 g/100 g [IQR: 0.5–1.8]; P d < 0.001], and nut- and seed-based meats contained the highest total sugar amount (median, 4.2 g/100 g [IQR, 2.3–6.6]; P d = 0.002); both showed strong evidence of being higher in total sugar content than meat and poultry. This is equivalent to 0.4 g and 3.4 g of total sugar/80.0 g serving size, or, if these sugars are considered free, 1.6% and 13.4% of the maximum recommended approximately 25.0 g average daily sugar intake. 68 Finally, the median sodium values for all PB meat groups did not show strong evidence of a difference from meat and poultry, except for legume-based meats (median, 520.0 mg/100 g [IQR, 400.0–636.0]; P d = 0.011). This is equivalent to 416.0 mg of sodium (or 1.0 g of salt) per 80.0 g serving size, or 20.8% of the maximum recommended 5.0 g average daily salt intake. Moreover, there were extreme outliers, with some PB meats reported to contain more than 1400.00 mg sodium (equivalent to 2.8 g salt) per 80.0 g; thus, consumption of 1 portion of this PB meat alternatives is more than half the recommended maximum daily intake of salt. 69

Only a few studies (n = 9) evaluated micronutrient data; these reported on 250 PB meat products and 24 ABF comparators. Micronutrient content ranged vastly across all groups: whereas some products would provide substantial contributions to average daily requirements, others were much less nutritious ( Table 3 and Supplementary file 2: Table S2 ). 69–83 For example, the median iron content for cereal- and grain-based PB meats (5.4 mg/100 g [IQR, 4.2–5.4]) was higher than the median of meat and poultry (1.3 mg/100 g [IQR, 1.1–1.6]). On the contrary, vitamin B 12 levels were lower for PB meat alternatives (medians ranged from 0.1 μg/100 g [IQR: 0.0–0.9] to 0.3 μg/100 g [IQR: 0.3–0.3]) as compared with 1.2 μg/100 g (IQR: 0.6–1.6) in meat and poultry. However, certain individual products had a comparable or higher vitamin B 12 content than their ABF comparator.

Summarized micronutrient values for PB meat and drinks and animal-based foods a

Values are compared with global average daily requirements (see Supplementary file 2 in the Supporting Information online for detailed information containing all disaggregated numbers by main ingredient of each novel plant-based food and animal-based foods). The table only reports micronutrients commonly found in meat and dairy. PB products also provided other micronutrients not commonly found in meat and dairy (ie, calcium in PB meats).

Abbreviations : ADR, average daily requirement; max, maximum; min, minimum; IQR, interquartile range; PB, plant-based.

No studies reported nutrient data from organic products. Although protein levels were not the main focus of this study, protein results are reported in Supplementary file 1: Figure S2 and Supplementary file 2: Table S1 , and show that, particularly, legume- and mycoprotein-based PB meats typically match meat and poultry in protein content.

Energy density, saturated fat, fiber, sugar, sodium, and micronutrient content of plant-based drinks

The 19 studies evaluating PB drinks reported on 397 PB drinks (unflavored and unsweetened) and 52 dairy milk products. Where dairy milk comparators were reported to contain median values of 50.1 kcal/100 mL energy density (IQR, 39.3–63.0), 1.1 g/100 mL saturated fat (IQR, 0.9–2.2), and no fiber (0.0 g/100 mL; IQR, 0.0–0.0), most PB drink groups were reported to have lower energy density, lower saturated fat content, and more fiber ( Figure 2 and Supplementary file 2: Table S1 ). Coconut-based drinks were reported to be the least energy dense (median energy value, 20.0 kcal/100 g [IQR: 19.0–33.7]; P d < 0.001), whereas drinks based on cereals and grains had the highest energy density of all PB drinks (median, 59.0 kcal/100 mL [IQR: 43.0–57.0]; P d = 0.566) but not significantly higher than dairy milks. PB drinks made of cereals and grains, fruits and vegetables, and nuts and seeds were reported to be lowest in saturated fat (median, 0.2 g/100 mL; IQRs, 0.1–0.2, 0.2–0.2, and 0.1–0.3, respectively; P d < 0.001), whereas coconut-based drinks had the highest saturated fat content (median, 1.1 g/100 mL; IQR, 0.9–1.7; P d = 0.952) of all PB drinks, but this was not significantly different than dairy milks. All PB drinks contained more fiber than dairy milks; however, only the drinks based on cereals and grains, legumes, and nuts and seeds were significantly higher in fiber when compared with dairy milks (for cereals and grains, and for legumes: median, 0.5 g/100 mL [IQRs, 0.2–0.8 and 0.2–0.6, respectively]; and for nuts and seeds, 0.3 g/100 mL [IQR, 0.3–0.5]; P d < 0.001).

Dairy milks contained a median of 4.7 g/100 mL total sugar (IQR, 4.3–5.0) and 39.1 mg/100 mL sodium (IQR, 33.6–43.3). Most PB drinks contained less total sugar than did dairy milks, but they had similar levels of sodium. However, the total sugar content was only significantly lower for coconut (median, 1.9 g/100 mL; IQR, 1.5–2.5), legumes (median, 1.9 g/100 mL; IQR, 0.5–2.6), and nut- and seed-based drinks (median, 2.4 g/100 mL; IQR, 0.2–3.3) when compared with dairy milks ( P d < 0.001). This is equivalent to 3.8 g and 4.8 g of total sugar/200.0 mL serving size, or, if these sugars are considered free, 15.2% and 19.2% of the maximum recommended 25.0 g average daily sugar intake. 68 The only PB drink group that was statistically different in sodium content compared with dairy milks was the group based on nuts and seeds (median, 47.2 mg/100 mL [IQR, 34.0–60.0]; P d = 0.032). This is equivalent to 94.4 mg of sodium (0.2 g of salt) per 200.0 mL serving size, or 4.0% of the maximum recommended 5.0 g average daily salt intake. 69 However, there were also some extreme outliers, some of which reported containing more than 3 times this amount of sodium per 200.0 mL, the equivalent of approximately 12.0% of the daily World Health Organization recommendation. 69

A few studies (n = 16) evaluated micronutrient data of PB drinks, reporting on 249 PB alternative products and 37 ABF comparators. Iodine was only reported in PB drinks, not in other types of PB products. Like PB meat alternatives, micronutrient content ranged vastly across all groups: some products contributed to the average daily requirement, whereas others were much less nutritious ( Table 3 and Supplementary file 2: Table S2 ). For example, the median calcium content for all PB drink categories was 120.0 mg/100 mL (IQRs as follows: cereals and grains, 120.0–120.0; coconut, 120.0–120.0; fruits and vegetables, 120.0–120.0; legumes, 120.0–120.0; nuts and seeds, 114.5–120.0) as compared with 116.7 mg/100 mL (IQR, 109.3–124.0) for dairy milks. However, none of the PB products (median, 0.0 μg/100 mL; IQR, 0.0–1.4) matched the iodine content of dairy milks (median, 24.9 μg/100 mL; IQR, 20.0–36.5).

Only 4 studies (evaluating 29 PB drinks and 11 dairy milk products) reported nutrient data from organic PB products. All evaluated different nutrients, hence no further pooling of results was possible for organic products as a subgroup. Protein results are reported in Supplementary file 1: Figure S2 and Supplementary file 2: Table S1 in the Supporting Information online, which show that, particularly, legume-based PB drinks typically match dairy milk in protein content.

Energy density, saturated fat, fiber, sugar, sodium and micronutrient content of plant-based yogurt alternatives

The 4 studies on PB yogurt alternatives evaluated 191 PB yogurt products with 90 dairy-based comparator products (unflavored and unsweetened). The overall nutritional composition of PB yogurts appears to show some variation by main primary ingredient (see Supplementary file 2 in the Supporting Information online ); however, formal disaggregated assessment of PB yogurts by primary ingredient was not possible, because that information was often not reported by authors. At an aggregate level, PB yogurts typically contained less saturated fat and sodium but had a higher energy density and higher total sugar and fiber content.

Only 2 studies evaluated micronutrient data of PB yogurts (excluding sodium) and, therefore, no further pooling of results was possible. No studies reported nutrient data from organic PB yogurts. Protein results are reported in Supplementary file 2: Table S1 in the Supporting Information online . Only the sample of a legume-based PB yogurts came close to matching dairy yogurt in protein content.

Energy density, saturated fat, fiber, sugar, sodium and micronutrient content of plant-based cheese alternatives

The 5 studies evaluating PB cheese alternatives reported on 163 PB cheese products with 143 dairy-based comparator products. PB cheese alternatives were the least nutritionally diverse foods. Where the primary ingredient of PB cheeses was known, this was mostly coconut oil ( Supplementary file 2 in the Supporting Information online ); however, like PB yogurts, the main ingredient was often not reported by authors.

The cheese comparators were reported to contain median values of 284.0 kcal/100 g energy density (IQR, 108.0–330.1), 14.0 g/100 g saturated fat (IQR, 11.0–17.3), and no fiber (0.0 g/100 g; IQR, 0.0–0.0). Most PB cheese subgroups were reported to have higher energy densities and higher saturated fat and fiber content. PB cheese based on nuts and seeds had the highest energy density (328.0 kcal/100 g [IQR, 306.0–328.0]; P d = 0.334]), whereas coconut oil-based cheese had the highest saturated fat content (21.0 g/100 g [IQR, 19.7–22.0]; P d < 0.001]), a significant difference, with 50.0% more than dairy cheese. Unlike PB drinks, PB meat, and PB yogurt alternatives, not all PB cheese contained fiber. Nut- and seed-based cheese had the highest fiber content (median, 2.5 g/100 g [IQR, 2.4–2.7]; P d < 0.001). Although the median fiber content of PB cheese made from coconut oil was 0.0 g/100 g (IQR, 0.0–1.7; P d = 0.011), some products did contain up to 5.9 g/100 g and, therefore, strong evidence was found that both PB cheese based on nuts and seeds and on coconut oil had significantly higher fiber content than did dairy cheese.

Most PB cheese contained less sugar and sodium than did dairy cheese, which had a median of 2.0 g/100 g (IQR, 0.5–5.0) and 720.0 mg/100 g (IQR, 560.0–1000.0), respectively, across the identified studies. In general, PB cheese alternatives had either no or minimal total sugar content. Finally, coconut oil–based cheese had the highest sodium content across all PB cheese (median, 714.0 mg/100 g [IQR, 600.0–880.0]; P d = 0.897), but this was similar to dairy cheese. PB cheese made of nuts and seeds had the lowest median sodium content (240.0 mg/100 g [IQR, 200.0–240.0]; P d = 0.001), which would equal 48.0 mg of sodium (0.1 g of salt) per 20.0 g serving size, or 2.0% of the recommended maximum daily salt intake 69 ; hence, this type of PB cheese had a large reduction in sodium compared with dairy cheese.

The micronutrient content of PB cheese was evaluated by only 2 studies. Only 1 product made of nuts and seeds was fortified with calcium, whereas coconut-based PB cheese was typically fortified with vitamin B 12 (median, 2.5 μg/100 g; IQR, 2.5–2.5). For dairy cheeses, these medians were 815.0 mg/100 g (IQR, 463.0–930.0) for calcium and 2.5 μg/100 g (IQR, 1.8–2.5) for vitamin B 12 .

No studies reported nutrient data from organic products. Protein results are reported in Supplementary file 2: Table S1 in the Supporting Information online. Nut- and seed-based cheese typically had the highest protein content, though it did not match the protein content of dairy cheese.

Health impacts and risk factors of novel plant-based foods

Eleven peer-reviewed studies were included in this review, 9 of which evaluated PB meat alternatives and 3 evaluated PB drinks ( Table 4 ) 84–94 (see Supplementary file 1, section 3.3, in the Supporting Information online for further details on the health outcomes). No health studies were found that evaluated consumption of PB cheese, yogurt, or egg alternatives; links between NPBFs and mental health outcomes; nor any grey literature evaluating any health outcomes.

Summary of the evidence on the health impacts and risks of novel plant-based foods

Health impacts and risk factors of plant-based meat alternatives

Studies of PB meats (n = 9) showed positive health outcomes when individuals switched from consuming ABFs. Three studies on mycoprotein consumption by both healthy and overweight adults found a positive association with lower glycemic markers, 84 reduced energy intake, 84 , 85 and insulin release. 85 Moreover, mycoprotein consumption was hypothesized to have a beneficial impact on the plasma lipidome. 86

Four studies with healthy adults evaluated PB meat alternatives consumption (other than mycoprotein). When considering the same caloric intake, consumption of PB meats was associated with a lower risk of cardiovascular disease than was consumption of ABFs, mostly by reducing fasting serum levels of trimethylamine- N -oxide, and low-density lipoprotein cholesterol concentrations, compared with ABF consumption. 87 Furthermore, consumption of PB meats was associated with a reduction in body weight as compared with meat consumers. 87 , 88 Lysine-enriched PB meat as a substitute for ABFs was reported to increase muscle protein synthesis rates, which is a biological process of building new protein cells via amino acids. 89 Last, the replacement of 4 meat-containing meals per week with PB meat alternatives elicited positive changes in the gut microbiome, with changes in the presence of butyrate-producing pathways and increased taxa. 90

Health impacts and risk factors of plant-based drinks

Studies assessing PB drinks (n = 3) only focused on almond and soy drinks. The main focus and health outcomes of these studies varied. Sun et al 91 researched the reduction in glycemic response in young adults consuming soy drink or bovine milk together with white bread. These authors found that both products had a similar glycemic response through different biological pathways. Dineva et al 92 assessed micronutrient content in PB drinks and found significantly lower iodine intake and urinary iodine concentration in people consuming only PB drinks, 93 highlighting the need for appropriate fortification as more people transition to eat more NPBFs. Finally, Shen et al 93 evaluated the impact of PB drinks on dental health and found that a soy drink with added sugar caused enamel demineralization, compared with dairy milk, which promoted remineralization.

Environmental impacts of novel plant-based foods

A total of 53 studies evaluated at least 1 environmental outcome, using the life cycle assessment method, evaluating 209 PB products and 91 ABFs as comparators. Most studies used life cycle assessment inventories, and some relied on data providers (n = 32) to calculate environmental footprints. System boundaries varied across studies, with the majority evaluating category impacts from cradle-to-retail (see Supplementary file 3 in the Supporting Information online ). Studies mainly assessed the effect of substituting ABFs with NPBFs on greenhouse gas emissions (GHGE) (n = 50), followed by blue-water footprint (WF) (n = 39) and land use (LU) (n = 17) ( Figure 3 and Supplementary file 1: Table S11 in the Supporting Information online ). Although methods, assumptions, and inventory data varied from 1 study to another, most studies consistently reported percentage reductions in GHGE and LU for the production of NPBFs as compared with ABFs. Wider differences were observed in blue WF.

Reduction of environmental impacts by respective funding source. Calculated as a percentage difference between each novel plant-based (PB) product (by product type and food group based on main primary ingredient [ie, predominant or core food item on the ingredient list]) in comparison with their respective reported baseline (eg, dairy milk and cheese, meat and poultry). See Supplementary file 3 in the Supporting Information online for detailed information on the baseline used for each reference. Data were limited to raw products only. Studies reporting data on cooked PB products also found reductions in environmental impacts.

Reduction of environmental impacts by respective funding source . Calculated as a percentage difference between each novel plant-based (PB) product (by product type and food group based on main primary ingredient [ie, predominant or core food item on the ingredient list]) in comparison with their respective reported baseline (eg, dairy milk and cheese, meat and poultry). See Supplementary file 3 in the Supporting Information online for detailed information on the baseline used for each reference. Data were limited to raw products only. Studies reporting data on cooked PB products also found reductions in environmental impacts.

Environmental footprints of plant-based meat alternatives replacing meat and poultry

The 34 publications evaluating PB meat alternatives reported on 135 PB meat products with 53 ABF comparators. The percentage difference showed reductions of more than 70% in GHGE, LU, and WF for most products when shifting from ABFs to PB meat alternatives. GHGE reductions across PB meat groups, based on primary ingredients, were similar, with the largest reduction in GHGE seen for nut- and seed-based meats, with a median value of –94.2% (IQR, –94.4 to –93.4), whereas PB meats based on legumes had the smallest reduction (–86.1%; IQR, –88.6 to –77.5). Only 2 of 134 PB products had higher levels of GHGE than their ABF comparator. For LU, mycoprotein (median, 89.0%; IQR, –92.3 to –76.5) and nut- and seed-based meats (median, 89.5%; IQR, –90.0 to –89.0) had the largest reduction. Alternatively, legume-based meats had the smallest LU reductions (median, –71.2%; IQR, –84.7 to –47.6). Only 3 of 55 products had higher LU than their ABF comparator. Finally, the largest reduction of WF was observed in PB meats made of cereals and grains (median, –92.6%; IQR, –94.1 to –92.0), and the smallest was observed with products made of mycoprotein (median, –73.7%; IQR, –84.4 to –55.2). Nine of 51 products had a higher WF than their respective ABF counterparts. Specifically, when certain individual legume- and mycoprotein-based meats were compared with chicken, PB meat alternatives reported requiring between 2.7% and 339.0% more water, with the largest difference observed in a Swedish chicken comparator to mycoprotein-based meats. This variation was attributed to differences between feed types, rearing systems, and farm efficiency across countries. 74 Comparisons were also made between the upper limit footprint of mycoprotein-based items and the average or lower limit footprint of the ABF. Moreover, there were extreme outliers, with some PB meats reporting a water percentage difference of 8006.9%. The authors attributed this to soybeans’ substantial water demand during processing and lower yield per soybean. 74

Environmental footprints of plant-based drinks alternatives replacing dairy milk

The 21 publications evaluating PB drinks reported on 51 PB drink products with 13 ABF comparators. PB drinks also were associated with reductions in GHGE and LU when shifting from dairy milk to PB drinks. Fruit- and vegetable-based drinks had the largest reduction of GHGE (median, –90.2%; IQR, –90.8 to –90.2]), whereas PB drinks based on cereals and grains had the smallest reduction (median, –76.9%; IQR, –88.8 to –56.0). Only 2 products of 36 had an increase of GHGE when comparing soy- (40.0%) and almond-based (18.9%) drinks with dairy milk (equivalent to 0.3, 0.4, and 0.3 kg CO 2 eq/100 g, respectively). 95 Wider differences were observed on the LU percentage difference; however, reductions were found for all products (n = 13 PB drinks).

Cereal- and grain-based drinks had the largest reduction (median, –86.4%; IQR, –92.7 to –76.0), whereas legume-based drinks had the smallest LU reductions (median, –56.6%; IQR, –75.5 to –38.8). The magnitude of change in the percentage difference for WF varied considerably, although, these data were less frequently reported by authors (n = 11 PB drinks). Cereal- and grain-based drinks had the largest reduction (median, –85.0%; IQR, –88.7 to –71.0), whereas legume-based drinks had the smallest WF reductions (median, –67.6%; IQR, –73.9 to –42.2). Nut- and seed-based drinks presented contradictory evidence. For example, Grant and Hicks 95 observed that almond drinks (9241.9%) required considerably more water than soy (–35.6%) and dairy milks (equivalent to 109.3, 0.8, and 1.2 L/100 g, respectively); whereas Ritchie 96 found that an almond drink required half the amount of water (–40.87%) than dairy milk (equivalent to 37.2 and 62.8 L/100 g, respectively). Data were limited to these 2 products; hence, no further pooling of results was possible.

Environmental footprints of plant-based yogurt alternatives replacing dairy yogurt

The 2 publications evaluating 2 PB yogurt alternatives compared to 2 dairy yogurts. They reported GHGE reductions ranging between –64.7% and –52.9%. Analysis of LU and WF was not possible due to lack of a baseline, differences in methods, and system boundaries.

Environmental footprints of plant-based cheese alternatives replacing dairy cheese

The 2 publications evaluating PB cheese alternatives reported on 21 PB cheese products with 23 ABF comparators. Data on the environmental impacts were particularly from coconut oil–based cheese alternatives (n = 20). All coconut oil–based cheese alternatives had a large reduction in amounts of GHGE and LU (GHGE: median, –75.4% [IQR, –77.4 to –59.3]; LU: median, –83.1% [IQR, –83.8 to –80.6]). A smaller reduction was observed in WF (median, –45.1%; IQR, –52.0 to 38.5), with a higher WF being reported than for the ABF comparator for only 3 products.

Health effects and environmental impacts of novel plant-based foods

Studies that simultaneously assessed both health and environmental outcomes and/or nutrient profiles of NPBFs were pooled ( Figure 4 ). Only 1 study reported environmental outcomes together with diet-related health effects of PB meat alternatives, and this study found that free access to NPBFs was associated with greater weight loss and reduced dietary carbon and LU, as compared with a control arm. 88 From 93 references, 20 studies assessed the environmental outcome and nutrient content of NPBFs; only 6 studies evaluated the health effects and nutrient content of NPBFs (see Supplementary file 1: Table S9 in the Supporting Information online ).

Reduction of environmental outcomes and their associated nutrient outcomes of novel plant-based foods (NPBFs) compared with baseline (eg, dairy milk and cheese, meat and poultry), expressed in percentage difference. The y-axis shows the increase or decrease of the nutrient content (energy, fiber, sodium, and saturated fat) in comparison with baseline; and the x-axis shows the reduction (or increase) of the environmental categories. Three environmental categories are reported: greenhouse gas emissions (circles), land use (triangles), and blue-water use (squares). Three NPBFs are reported: plant-based (PB) cheese alternatives (brown), PB meat alternatives (purple), and PB drinks (orange). PB yogurts were not included due to the limited amount of data. See Supplementary file 2 in the Supporting Information online for detailed information on the baseline used for each reference. Data were limited to raw products only.

Reduction of environmental outcomes and their associated nutrient outcomes of novel plant-based foods (NPBFs) compared with baseline (eg, dairy milk and cheese, meat and poultry), expressed in percentage difference . The y -axis shows the increase or decrease of the nutrient content (energy, fiber, sodium, and saturated fat) in comparison with baseline; and the x -axis shows the reduction (or increase) of the environmental categories. Three environmental categories are reported: greenhouse gas emissions (circles), land use (triangles), and blue-water use (squares). Three NPBFs are reported: plant-based (PB) cheese alternatives (brown), PB meat alternatives (purple), and PB drinks (orange). PB yogurts were not included due to the limited amount of data. See Supplementary file 2 in the Supporting Information online for detailed information on the baseline used for each reference. Data were limited to raw products only.

When compared with ABF counterparts, data suggest NPBFs are overwhelmingly associated with smaller environmental footprints. Data on nutritional profiles of NPBF were mixed: nutritional profiles for some NPBF groups were better aligned with healthy diets, but not for others. Clear co-benefits were observed for fiber intake from NPBFs. However, for the other nutrients, the picture was much more mixed due to the variability in content arising from differences in the main primary ingredients and the type of NPBFs.

Fruit, vegetable, legume, and nut content of novel plant-based foods

The percentage of fruit, vegetable, legume, and nut content in each NPBF in the United Kingdom was estimated as a case study ( Figure 5 ). Most NPBFs had at least 1 fruit, vegetable, legume, or nut, ranging from 0.0% to 100.0% of their weight. Overall, median content was low, with a few exceptions. PB meat alternatives had the highest content of vegetables and legumes, and PB cheese alternatives had the lowest content ( Supplementary file 1: Figure S5 and Supplementary file 2: Table S5 in the Supporting Information online ).

Estimated fruit, vegetable, legume, and nut content (%) in each novel plant-based foods product from time-stamped data from UK supermarkets. Panels show (a) plant-based (PB) drink alternatives; (b) PB meat alternatives; (c) PB cheese alternatives; and (d) PB yogurt alternatives.

Estimated fruit, vegetable, legume, and nut content (%) in each novel plant-based foods product from time-stamped data from UK supermarkets . Panels show (a) plant-based (PB) drink alternatives; (b) PB meat alternatives; (c) PB cheese alternatives; and (d) PB yogurt alternatives.

Assessment of robustness and relevance of the included studies

For results on the assessment of robustness and relevance of the included studies see Supplementary file 1 : Table S12 in the Supporting Information online in section 3.6 .

Sensitivity analysis of funding sources of nutrient composition studies

Almost half of the nutrition studies included (n = 26; 46.4%) were funded by academic funders; 44.6% (n = 25) were fully funded or partially funded by industry; and 10.0% (n = 5) did not state their funding source. NPBF manufacturers were the support for the majority of industry-funded studies (n = 21; 37.5%), followed by the livestock industry (n = 3; 5.4%), and both (n = 1; 1.8%). The sensitivity analysis of the percentage difference for all the nutrients associated with the burden of disease, except total sugar, revealed that studies funded by industry were more likely to find differences than those funded by academia, with the former typically reporting more positive results on lower energy and saturated fat ( Table 5 and see Supplementary file 1: Table S13 in the Supporting Information online for sensitivity analysis on studies partially funded by the industry). However, the direction across all studies was the same: reductions in energy and saturated fat content, and increases in fiber, total sugar, and sodium content.

Sensitivity analysis, based on funding source, of the percentage difference between novel plant-based foods vs animal-based foods in nutrient content and environmental impacts a

The funding source of 6 articles were unknown, so they were excluded from this analysis. The superscript b and c indicate the direction and dimension of the association.

Industry-funded studies show a more positive impact on health and environmental outcomes of their PB products (vs animal sourced foods) as compared with academically funded studies.

Industry-funded studies show a less positive impact on health and environmental outcomes of their PB products (vs animal-sourced foods) as compared with academically funded studies.

Abbreviations : ABF, animal-based food; IQR, interquartile range; NPBF, novel plant-based food.

Sensitivity analysis of funding sources of health studies

Only 2 health studies were funded by academia; the rest of the studies were either partially or wholly funded by industry (n = 9). Most industry-funded studies were from NPBF manufacturers (n = 8); 1 study was partially funded by Dairy Australia.

Sensitivity analysis of funding sources of environmental studies

Compared with nutritional studies, a greater percentage of environmental studies were by industry researchers, particularly from NPBF manufacturers (67.9%). Approximately 71.7% of studies (n = 38) were fully funded or partially funded by industry; 26.4% (n = 14) were supported by academic funders; and 1.9% (n = 1) did not state their funding source. Of the industry-funded studies, only 2 (3.8%) were funded by the livestock industry. The sensitivity analysis revealed that the percentage differences were significantly larger between academic and industry funders in terms of GHGE and LU. Studies funded by industry typically reported more positive results on LU than did studies funded by academic funders, and the opposite was observed for GHGE. Like nutrient studies, the direction (decreases in GHGE, LU, and WF) was the same regardless of the funding source ( Table 5 , and see Supplementary file 1: Table S13 in the Supporting Information online for the sensitivity analysis of studies partially funded by the industry).

Research findings

We reviewed evidence from high-income countries that was published in peer-reviewed and grey literature within the past 7 years on nutrient content, and environmental and health outcomes of consuming NPBFs. Most NPBFs typically have much lower environmental impacts compared with ABFs, particularly with respect to GHGE and, to a lesser extent, to LU and WF. The nutrient content of NPBFs is highly variable in comparison to the nutrient profiles of ABFs. Although several individual NPBFs had positive health and environmental outcomes, co-benefits identified were not universal across all NPBFs and several trade-offs were identified. The main primary ingredient, type of product, processing techniques, and brand were all important determinants of health, and nutritional and environmental outcomes, findings that show the need for further subcategorization of NPBFs to better educate consumers and enable them to take informed decisions regarding the healthiness and sustainability of their diets and (potential) dietary changes.

Research in context

If carefully selected, certain NPBFs (particularly certain PB drinks and meat alternatives) could be an effective part of interventions to achieve net-zero and health targets in high-income countries. By applying a combination of strategies, enhanced uptake of these foods could improve the nutritional quality of diets, improve health, and contribute to tackling climate change impacts.

At the macronutrient level, NPBFs are generally the healthier option, given their higher fiber content and typically lower saturated fat and calorie contents, which could be advantageous in high-income (often obesogenic) settings. Certain types of NPBFs, particularly mycoprotein and legume-based meats, often also contain a substantial amount of fruit, vegetables, legumes, and/or nuts, which are food groups that are typically underconsumed in high-income settings. Composition of legume and fruit and vegetable-based drinks, were also typically consistent with healthier diets in high-income food secure settings, including low energy density, low total sugar, high fiber and low saturated fat content. Caution is recommended in the selection of these products if they were to be part of dietary recommendations, or standard institutional procurement for example, as certain NPBFs can also have higher levels of total sugar, sodium, and saturated fats in comparison to their respective ABF. This is particularly true for certain cereal and grain-based drinks, and coconut-based cheese and yogurts. Although the specific type of oil used in each NPBF product was not analyzed, coconut oil, which is high in saturated fatty acids, is often the ingredient that increases saturated fat levels in NPBFs to levels similar to its ABF counterparts. 51 , 75 Indeed, coconut oil-based cheese had approximately 50% more saturated fat than dairy cheese, and typically contained the least amount of fruit, vegetables, legumes or nuts, with the majority being absent.

In line with other evidence, 39 , 97 , 98 fortified NPBFs, in some cases, can be nutritionally comparable to their respective ABFs. Some individual NPBFs contained even higher concentrations of iron, vitamin B 12 , and calcium, whereas others did not. However, micronutrient assessment was difficult because not all included studies reported micronutrients. This could be because either NPBFs were unfortified or the information simply was not reported. Especially when nutrient information is gathered from supermarket websites for individual studies, micronutrient data are generally not reported.

The highly varying nutrient content across and within all PB products and categories may cause consumer confusion when individuals are looking for healthy and environmentally friendly alternatives to ABFs. Clearer front-of-package labelling of certain nutrients and information campaigns could reduce such confusion and better enable the consumer to make informed decisions about food purchases. 99 Potential development of rules and regulations on the food standards of NPBFs could also be a step forward in having a larger range of “healthy” NPBFs, because such regulations could potentially encourage reformulation of NPBFs, including the reduction of sodium, total sugar, and saturated fat content, and increased micronutrients. From a technological perspective, this is certainly possible. For example, new biotechnological techniques have been developed that enable companies to reduce sugar content and improve palatability, nutrient profile, and digestibility of PB drinks. 67 , 100–103 Some processing techniques can also decrease levels of anti-nutrients and polyphenols, which commonly are associated with low mineral and vitamin bioavailability, 35 , 98 , 101 , 104–107 and increase protein yield. 101 Given that specific raw materials, isolated proteins, processing levels, and fortification methods, often used in NPBFs, as compared with ABF nutrient profiles, are still debated in the scientific community, further research on the nutrient content and health risks related to bioavailability, bioaccessibility, and byproduct formation during industrial processes will reveal whether there are differences in terms of health impacts of “natural” vs more “isolated” nutrients. 30 , 108 , 109 More research into the metabolic profiles of NPBFs is imperative, particularly in light of a recent study identifying differences in the abundance of profiled metabolites between beef and PB burgers, despite their labelled nutritional similarities. 110 Instead of continuing the debate between the superiority of ABFs vs NPBFs, or vice versa, acknowledging and embracing their complementary differences can contribute to a less polarized dietary transition. This is especially relevant because emerging evidence has suggested that people who consume NPBFs also tend to purchase ABFs. 111

From the limited evidence on health, the inclusion of NPBFs into diets appears to typically have beneficial health effects, particularly the consumption of PB meat alternatives. The positive health effects mostly relate to better weight management and associated reduced risk of noncommunicable diseases in high-income (and often obesogenic) countries. This is aligned with a recently published meta-analysis that found positive outcomes on total cholesterol, low-density lipoprotein cholesterol and triglycerides when consuming PB meat alternatives as replacements for meat. 51 Furthermore, a few older studies also found positive health outcomes when assessing consumption of mycoprotein-based foods (eg, drinks, cookies, milkshakes, crisps) 112–115 and soy protein with isoflavones, 50 compared with consumption of dairy milk and/or meat products.

Previous evidence revealed that NPBFs are often regarded as healthier alternatives to ABFs 116 ; hence, it could be hypothesized that people may consume NPBFs in larger quantities than they would otherwise have done when eating ABFs. This may have negative health implications, especially if consumed regularly. Establishing a clear division in PB foods classifications, including ultraprocessed and less processed PB alternative foods, could enable better assessment of short- and long-term health impacts of NPBFs if they were to be consumed at an even larger scale. 116

Ultraprocessed foods have been associated with many diet-related diseases because these foods are generally energy dense and hyperpalatable. 117 , 118 Almost all NPBFs fall, technically, within this category; however, in this review, we found that the nutritional composition of some NPBFs aligns well with healthy dietary recommendations, such as having a high fiber content, low energy density, and low saturated fat content. Additionally, 1 of the included studies 90 also found positive associations with the gut microbiome when substituting meat in certain meals with PB meat alternatives. To get a better overview of the overall effect of NPBFs on health, more information and detailed analyses are needed regarding level of processing and gastrointestinal fate.

Consistent evidence was found regarding environmental outcomes, similar to previous research. 52 , 53 , 108 , 119–121 Most NPBFs had smaller environmental footprints than their ABF counterparts, with median reductions reported of up to 94.3%, 89.5%, and 92.6% for GHGE, LU, and WF, respectively. Nevertheless, some PB products had greater environmental impacts than their ABF counterparts, with some extreme outliers particularly in terms of WF. Although evidence was rather consistent, and the direction of effect appears to be clear, care should be taken not to overinterpret the exact numerical results: environmental impact calculations are notoriously context dependent and sensitive to methodological and data choices. This makes it impossible to come up with a summary figure that is representative for all products, produced in all countries; generally, however, there is a broad body of evidence demonstrating a reduction in GHGE, LU, and WF for a wide range of PB products in a wide variety of contexts compared with their ABF equivalents.

To improve the strategic use of NPBFs to achieve more sustainable food systems, life cycle assessments of these products should incorporate the full range of environmental impact categories, as well as sociocultural, economic, and health impacts with harmonized methods and assumptions across studies.

This study revealed an evidence gap for health impacts of NPBFs, including mental and dental health, and other risks associated with micronutrient deficiencies. There is also a lack of health studies on PB yogurts, PB cheese, and PB egg alternatives. Research on the health effects of PB drinks has been conducted with only certain products, “generally soy and almond drinks,” but there is a gap in knowledge about other PB drinks, such as those made from oat, potato, and hazelnut, among others. Furthermore, some concerns have been raised about the carbohydrate content in some PB drinks. A study by Jeske et al 122 revealed that the presence of β-glucan in many oat-based drinks causes a moderate glycemic index, despite the high carbohydrate content. In fact, Dhankhar 104 associated the consumption of oat drinks with high β-glucan levels with a reduction in cholesterol levels in study participants. However, this evidence needs to be updated to reflect the potential benefits of different types of PB drinks and current market brands. Although dairy products contain naturally occurring sugars from lactose, it is difficult to determine the breakdown of “natural” vs added sugars in NPBFs from the available literature. More research is also required on dental health to assess the potential risks of increased dental cavities due to lower calcium bioavailability, and the effects of free sugar content, pH levels, and buffering capacity in NPBFs.

Additional research is needed to provide more nutrient environmental and health evidence for PB yogurts, cheese, and egg alternatives. Last, although this review assessment focused on 3 environmental outcomes, evidence on other environmental impacts, including biodiversity loss and socioeconomic implications, is scarce. Across the 3 themes assessed in this review, better standardization and clear reporting of results in NPBF studies in the future would facilitate updates of this review.

Relevance for policy and practice

Minimally processed PB foods are still considered the gold standard for healthier and more sustainable diets. However, shifts from ABFs to PB whole foods remain problematic because, despite all the scientific knowledge about healthy eating, dietary change toward minimally processed PB foods has not been achieved. This review revealed that NPBFs can be healthier and more environmentally friendly alternatives to ABF consumption, if carefully selected. Although behavioral aspects are embedded in this transition, NPBFs could offer a convenient, novel, and potentially more realistic option to facilitate dietary transitions at large scale, diversifying diets, and increasing consumption of fruits, vegetables, legumes, and nuts without the need for significant individual dietary habits.

For potential promotion of the inclusion of NPBFs as part of public procurement or embedding them into food-based dietary guidelines, some of the consideration regarding varying healthiness of specific types of NPBFs and the need for further subclassifications needs to be carefully addressed. Furthermore, affordability is a concern because NPBFs often are more expensive than their ABF counterparts. Although comprehensively synthesizing price data was outside of the scope of this study, in the United Kingdom, the Food Foundation found that PB drinks are, on average, 50.0% more expensive than dairy milk. 71

Active promotion of NPBFs would require more detailed analysis of consumer behavior: current consumption of NPBFs is generally higher among younger generations, women, White populations, and those with higher education and incomes. 28 Better understanding of main drivers and barriers of consumption of NPBFs would allow targeted promotion to widen this consumer group. 71 NPBFs could play an additional role in reducing the prevalence of micronutrient deficiencies, especially given their reformulation and fortification potential. For example, in Finland, a mass fortification strategy of vitamin D across dairy and nondairy products has shown positive health outcomes over the past decade. 123 Finally, formalization, standardization, and accountability of environmental labelling could help consumers making informed decisions and avoid misinformation.

Strengths and limitations

To our knowledge, this is the first systematic review assessing the published peer-reviewed and grey literature evidence from studies that evaluated nutrient, and health and environmental impacts or benefits of NPBFs. A strict and comprehensive search string was developed to assess the full breadth of studies and reports, and machine-learning models were used to filter the large number of studies and systematically present all the available evidence on various NPBFs.

This study only covered the past 7 years to assess the current evidence, and an exhaustive cross-check of references was not performed, which possibly introduces reporting bias for missed relevant studies from previous years. However, it was assumed that only a small amount of additional findings had been missed, given the recent emergence of the variety and types of these novel products. Second, only 3 environmental impact categories were examined: carbon footprint, LU, and blue-water consumption. However, the heterogeneity of study designs, from system boundaries to geographical location, agricultural inputs, and methods used to calculate environmental footprints, made the review process too time consuming to expand on other environmental impacts in this particular study. Reliable reporting of environmental impacts of novel ingredients used in NPBFs, including added minerals and vitamins for fortification purposes, are generally missing in many studies. All the data reported by authors were collected and each study was compared individually against its own baseline (ie, the ABF comparator provided by author). Given the large spectrum of methods to determine environmental footprints, this could have introduced some bias; however, the alternative (using a standardized comparator) would equally have its limitations (eg, this would not be representative for all farming systems and products). Third, products and nutrients were assessed individually. Although the nutrient content gives some guidance on probable health risks, in reality, people consume diets in which individual compounds interact, influencing unknown biological pathways. Fourth, several studies that did not specifically report on the proportion and type of NPBF in (self-)reported PB diets had to be excluded. For those studies, it was impossible, therefore, to assess the effect on health and environment of NBPFs alone vs all PB foods together (ie, whole foods, NPBFs, other PB foods such as tofu and tempeh) and complicated any efforts to calculate dietary shifts. Finally, most studies did not report the precision of measures of effect (n = 68), making it difficult to pool and synthesize results across the 3 themes assessed in this review.

Food systems and diets need to change to meet environmental and health targets. This comprehensive systematic review presents a holistic approach to summarize the evidence on the nutrient, health, and environmental impacts of NPBF consumption. Although PB whole foods remain the preferred option on health grounds, some NPBFs have potential for being a useful steppingstone in the process of food system and dietary transformation, functioning as a healthy and environmentally friendly alternative to ABFs, if carefully selected. Reformulation and fortification could further enhance NPBFs as a viable and effective food group that could accelerate the dietary transition toward sustainable and healthy diets. However, given the great variability in nutritional composition of individual NPBFs, widespread promotion of such products should be introduced and addressed with caution. Given that NPBFs are already important in the food system and consumption is expected to continue to increase, a few steps are urgently required to guide consumers and enable them to make informed decisions regarding their diets. These include a further subdivision or categorization of NPBFs, which currently fall mainly in the ultraprocessed (hence, “unhealthy”) food category. Furthermore, standardized and verifiable environmental assessments of NPBFs are needed to compare foods with regard to their environmental footprints. Finally, more research on the short- and longer-term health effects of NPBFs is urgently required to facilitate informed decision-making on the inclusion of NPBFs as part of a wider net-zero and health strategy.

Gratitude is extended to the authors who responded to inquiries and generously shared their individual data. Additionally, sincere appreciation is expressed to the FoodDB team for sharing their time-stamped data set of observations from UK supermarkets to estimate the total fruit, vegetable, legume, and nut content of foods.

Author contributions. S.N.E. contributed to conceptualization of the study, methodology, investigation, data curation, formal analysis, coding and analysis of machine learning, and writing the original draft of the article. G.H. contributed to the formal analysis (screening process), data validation, and review and editing of the manuscript. A.J.S. led the coding and analysis of machine learning, and reviewed and edited the manuscript. C.A.-C. and G.T. contributed to the literature screening process, and reviewed and edited the manuscript. R.G. reviewed and edited the manuscript. S.P. and R.P. contributed to data validation, and reviewed and edited the manuscript. P.S. contributed to conceptualization of the study, methodology, reviewed and edited the manuscript, supervised the work, acquired funding, and contributed to project administration.

Funding. This work was supported by a research grant from the National Institute for Health Research, Health Protection Research Unit PhD Studentship in Environmental Change and Health (grant NIHR200909) and the af Jochnick Foundation.

The funders had no role in the conception, design, performance, and approval of this work.

Declaration of interest. The authors have no relevant interests to declare.

Data availability. Source code for this work is available online (DOI: 10.5281/zenodo.7116157).

The following supporting information is available through the online version of this article at the publisher’s website:

Supplementary file 1 .

Supplementary file 2 .

Supplementary file 3 .

Box 1 Key Definitions

Novel plant-based foods (NPBFs): Acknowledging differences in terminology for NPBFs, for the purpose of this review, the term novel plant-based foods is used to describe plant-based (PB) drinks and PB meat, cheese, eggs, and yogurt alternatives that are of plant or fungal origin and designed to directly replace or mimic animal-based foods. This definition includes fungi-based foods (ie, mycoprotein) that biologically do not belong to the plant kingdom but are typically “designed” similarly to NPBFs as a direct replacement for animal-based foods. Here, the term excludes tofu, tempeh, and seitan because although these might be novel to some high-income settings, they have been part of traditional Asian diets for centuries and, hence, are not subject to the same challenges and evidence gap as NPBFs.

Ultraprocessed: Foods that have undergone a series of industrial techniques and processes

Minimally processed plant-based foods: Plant-based whole foods such as nuts, seeds, cereals, and legumes

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IMAGES

  1. The Importance and Challenges of School Feeding: Literature Review

    literature review on school feeding

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  1. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: A systematic review and meta-analysis

    As more studies become available, updated evidence synthesis on a wide range of outcomes based on systematic literature review is critical. School meals may provide nutritional benefits for children and adolescents. The benefits of school feeding on anthropometry and school attendance in our review are consistent with those reported in previous ...

  2. Impacts of school feeding on educational and health outcomes of school

    School feeding programs are beneficial for the physical, mental, and psychosocial development of school-age children and adolescents, particularly those in low- and middle-income countries (LMICs). While school feeding programs are ubiquitous in LMICs, the specific benefits of school feeding programs are unclear. The aim of this systematic review and meta-analysis is to evaluate the impacts of ...

  3. School Feeding Programs: What Happens Globally?

    To complement the school-based feeding program database, a literature review was carried out in the following databases: PUBMED, LILACS, Scielo, Google academic, and Science Direct. The following descriptors were used to search for articles: "School feeding program", "public policy", "guideline" and "world" and their combination.

  4. (PDF) The Impact of School Meal Programs on Educational ...

    Article PDF Available Literature Review. ... More research on school feeding programs is needed concerning the preschool age group (2-5 years), as there is a limited amount of information in ...

  5. School feeding programs in developing countries: impacts on children's

    The present review of the literature shows that SFPs have a positive impact on children's school enrollment and attendance. 23, - 39 The impact of school feeding on school-aged children's academic achievement is consistently positive for arithmetic tests, yet inconclusive for reading, writing, and spelling tests. 16, - 26 Although there is ...

  6. Sensitive to nutrition? A literature review of school feeding effects

    The purpose of this paper is to provide an up-to-date literature review on school feeding and the potential impact on nutrition, including school age children, pre-school and adolescent girls. The review is aimed at providing evidence-based guidance to national governments on school feeding and nutrition from a lifecycle approach.

  7. Impacts of school feeding on educational and health outcomes of school

    Background: School feeding programs are ubiquitous in low- and middle-income countries (LMICs) and may have critical implications for the health and education of school-age children and adolescents. This systematic review aimed to assess the impacts of school feeding on educational and health outcomes of children and adolescents in LMICs.

  8. School Feeding Programs in Middle Childhood and Adolescence

    Reviews the evidence about how school feeding meets multiple objectives—including social safety nets, education, nutrition, health, and local agriculture—and provides some indication of costs in relation to benefits. School feeding remains common across low-, middle-, and high-income countries, but significant variation exists, driven by context. School feeding can serve to protect earlier ...

  9. Sensitive to nutrition? A literature review of school feeding effects

    School feeding programmes are complex, involving a broad range of stakeholders across different sectors and implementation levels, and designing effective programmes requires managing trade-offs among targeting approaches, feeding modalities, and costs. The burdens of hunger, malnutrition and ill-health on school-age children are major constraints in achieving the Education for All and the ...

  10. The Importance and Challenges of School Feeding: Literature Review

    Evaluation of the National School Feeding Program: literature review. [8] Nadinne D,F; Melo L,S; Silva F,A. Scielo/2018 The article highlights the importance of the National School Feeding Program (PNAE), which began in the 1950s with the objective of significantly contributing to the development and potential of the individual, ensuring ...

  11. PDF Developing a School Feeding Program

    a comprehensive literature review of best practices for school feeding programs. The Global Child Nutrition Foundation The Global Child Nutrition Foundation works with a committed community of governments, civil society, and the private sector to ensure that hunger is not a barrier to learning for any child. Together we advocate

  12. The impact of the school feeding programme on the education and health

    Literature review. The current literature was selected from the mainstream international journals and reported South African studies and analysed based on their relevance to explaining the impact of the SFP on education and health outcomes. ... For example, the school feeding programme reduced illness by 12.3 per cent for boys and 9.2 per cent ...

  13. Integrating Family Farming into School Feeding: A Systematic Review of

    Family farming is strengthening its strategic role in school nutrition, but coordinating between school feeding programs and the agricultural sector has proven to be challenging. The goal of this review was to identify the problems that school feeding programs face in acquiring food from family farms. We selected studies from Web of Science, Medline/PubMed, and Scopus and evaluated their ...

  14. Impacts of school feeding on educational and health outcomes of school

    The State of School Feeding Worldwide, published by the WFP, summarized the status of school feeding across the world and reported that school feeding programs are ubiquitously present. However, the quality of school feeding programs varies greatly across countries and with national income . The report also highlighted a need to strengthen the ...

  15. Effect of school feeding program on academic performance of primary

    1. Introduction. Globally, every day, more than 66 million school children attend classes hungry, while 23 million hungry children reside in Africa [1].The Food and Agriculture Organization (FAO) reported hungry children started school lately, drop out sooner, learn less, and are more likely to have higher school absenteeism [2].Attending classes hungry severely impacts children's and ...

  16. The Impact of School Meal Programs on Educational Outcomes in African

    Findings from the nine studies included in this review suggest a positive correlation between school feeding programs and educational outcomes. Although mealtime may reduce classroom time, the benefits of providing a meal outweigh the potential loss of learning time because hungry children may not learn as effectively.

  17. Sustainability Recommendations and Practices in School Feeding ...

    Considering the importance of schools for sustainable food offers and the formation of conscientious citizens on sustainability, this systematic review aimed to verify the recommendations on sustainability in school feeding policies and the sustainability practices adopted in schools. The research question that guided this study is "what are the recommendations on sustainability in school ...

  18. School feeding programs for improving the physical and psychological

    This current review will not only update the previous review but will also involve a new and broader search of all the literature to ensure that we do not miss any relevant studies. This systematic review may contribute to the discourse surrounding the importance of school feeding programs in enhancing food security in LMIC and upper‐middle ...

  19. [PDF] Impact of School Feeding Programs on Student Attendance and

    Purpose: The aim of the study was to investigate the impact of school feeding programs on student attendance and performance in Ghana.Methodology: This study adopted a desk methodology. A desk study research design is commonly known as secondary data collection. This is basically collecting data from existing resources preferably because of its low cost advantage as compared to a field research.

  20. PDF Rwanda School Feeding Operational Guidelines Summary

    school feeding, the World Food Programme, for technical and financial support in advancing a high-quality universal school feeding programme in Rwanda since 2002 and particularly in the development, review and validation process of these School Feeding Operational Guidelines.

  21. Mapping the evidence of novel plant-based foods: a systematic review of

    G.H. contributed to the formal analysis (screening process), data validation, and review and editing of the manuscript. A.J.S. led the coding and analysis of machine learning, and reviewed and edited the manuscript. C.A.-C. and G.T. contributed to the literature screening process, and reviewed and edited the manuscript.

  22. A systematic literature review of research examining the impact of

    This literature review was undertaken as part of a collaboration between the Association for Citizenship Teaching (ACT) and Middlesex University, to inform the development of a programme of work to promote active citizenship in schools. ... Literature Review: Covell, K. (2010). School engagement and rights-respecting schools. Cambridge Journal ...

  23. PDF The Importance and Challenges of School Feeding: Literature Review

    Keywords— School food, School health, Healthy eating, Nutritional education, School feeding. Abstract— To select in the literature the importance and challenges of food for the development and potential of the individual related to growth, promotion, and health. Method: This is an Integrative Literature Review

  24. PDF The Impact of School Meal Programs on Educational Outcomes in African

    This review serves as an identification and analysis of current literature to prepare for future school meal program implementation. 2. Materials and Methods 2.1. Background This review was conducted to synthesize and analyze the research relating to the impact of school meal intervention programs on educational outcomes among children

  25. 2024 AP Exam Dates

    Spanish Literature and Culture. Art and Design: Friday, May 10, 2024 (8 p.m. ET), is the deadline for AP Art and Design students to submit their three portfolio components as final in the AP Digital Portfolio. ... All students who participate in late testing at a given school must take these alternate exams on the scheduled late-testing dates ...

  26. JCM

    Background: Chewing gum, considered a form of sham feeding, has been shown to improve intestinal motor and secretory function in various types of abdominal surgery. We conducted this systematic review to evaluate the effects of postoperative gum chewing on the recovery of gastrointestinal function after laparoscopic gynecologic surgery. Methods: We performed a comprehensive literature review ...

  27. Impact of Homegrown School Feeding Program on Smallholders' Farmer

    School feeding programs (SFPs) serve as an important safety net program to ensure that every child has access to quality education, health, and nutrition. ... Section 2 introduces the theoretical background and the review of the literature. The later section presents the methodological approach. Results are presented in Section 4, which is ...

  28. Supplemental Effluent Limitations Guidelines and Standards for the

    Printed version: PDF Publication Date: 05/09/2024 Agency: Environmental Protection Agency Dates: This final rule is effective on July 8, 2024. In accordance with 40 CFR part 23, this regulation shall be considered issued for purposes of judicial review at 1 p.m. Eastern time on May 23, 2024.Under section 509(b)(1) of the Clean Water Act (CWA), judicial review of this regulation can be had only ...

  29. Crushed Tablet Administration for Patients with Dysphagia and Enteral

    This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices.