In this stepped-wedge, cluster randomised controlled trial, a free SBP did not have a significant effect on children's school attendance, academic achievement, self-reported grades, sense of belonging at school, behaviour or food security. However, the programme had significant positive effects on children's short-term hunger ratings. Although most schools offered the breakfast programme 5 days per week, recorded weekly student attendance ranged from 4% to 38% of days. Sensitivity analyses conducted with children who attended the programme more frequently (at least 50% of the time it was available) demonstrated a significant effect of the breakfast programme on school attendance among this subgroup.
The strengths of this trial include its large sample size, high follow-up rates (88% of randomised children), use of objective measures of school attendance and academic achievement, and pragmatic design, which allowed evaluation of the effects of a breakfast programme as implemented in routine practice.21
The population was diverse, drawn from low socioeconomic resource areas and included substantially higher proportions of Māori (34%) and Pacific (42%) children than would be expected on the basis of their representation in the population (24% and 12%, respectively).22
Study limitations include potential selection bias, whereby the children who entered the trial may have been different in important ways from average deciles 1–4 school populations. While our study population was not substantially different from overall school rolls in terms of age, gender and ethnicity, they may have differed in other unmeasured socio-demographic factors, for example, household income or parental education level. It is possible that the programme could produce more positive effects among children at greater need of a school feeding programme not enrolled in the trial.
Variable breakfast composition (cereal and milk in some schools and cereal, bread, milk and chocolate flavoured drinks in others) and reduced availability of the breakfast programme in some schools (fewer than 5 days/week) may also have limited the impact of the intervention. Data on breakfast programme attendance rates were missing for four schools in term 4. These schools did not complete breakfast rolls because they reported that the number of registered study participants attending the programme was low (less than five registered students per day per school). However, this was a pragmatic trial and the main trial effects observed likely reflect those of a real-life breakfast programme.
Finally, the relatively low attendance rates by study participants at the breakfast programme and the likelihood that many, rather than increasing breakfast consumption, simply replaced breakfast at home with breakfast at school almost certainly influenced the absence of effect on study outcomes. In combination, these factors could explain the lack of observed effect of the breakfast programme on the range of outcomes assessed; both have previously been identified as reasons why school feeding programmes may not be effective.23
Our sensitivity analysis supports the hypothesis that breakfast programme attendance rates influenced study outcomes because there was a significant positive effect on school attendance for children who attended the programme more regularly. Low attendance at the breakfast programme most likely reflects the typical ‘healthy volunteer’ selection bias seen in many trials. Families who consented to participate in the study and completed questionnaires are likely to have been those least in need of a free breakfast programme.
In the UK, government-funded school feeding programmes date back to the early 20th century.24
Recently, an interesting natural experiment took place when British chef, Jamie Oliver, undertook a campaign to improve nutritional standards in schools. Evaluation of the campaign found that educational outcomes improved significantly in intervention schools and school absences fell by 14%.25
Although the evaluation was conducted with careful matching of control schools, it was not a prospective randomised controlled trial and, as such, confounding cannot be ruled out. An alternative explanation, however, may relate to frequency of consumption of school meals. About 45% of British schoolchildren eat school dinners every day,25
whereas children in our trial, only attended the breakfast programme 4%–38% of the time it was open. Thus, it is possible that frequent regular
consumption of healthy school meals is necessary to impact on attendance and academic achievement.
In 2004, a large, cluster randomised controlled trial was undertaken of a Welsh government-funded free breakfast programme for primary schools.26
Primary outcomes were breakfast skipping, episodic memory and breakfast diet.27
Attendance at the Welsh breakfast programme was relatively low, and there was no evidence of an effect on breakfast skipping, episodic memory or class behaviour, although students reported consuming significantly higher numbers of healthy food items at breakfast.27
Similar to our trial, there was a move from home to school-based breakfast eating among children.
The US Department of Agriculture subsidises the SBP.28
While a number of evaluations indicate that the SBP contributes to improved nutrition among programme participants,29
few have examined effects on aspects of school performance. A small study (n=133 children) suggested higher rates of participation in the SBP were associated with improved psychosocial and academic functioning.31
However, there was no comparative control group. Another non-randomised study found evidence of improved academic performance in children participating in the SBP but was also small (n=97 students) and findings were based on subgroup analysis.18
Thus, most research on the impact of SBPs on children's health and educational outcomes in high-income countries has taken the form of evaluations and cannot exclude the effects of confounding. Robust randomised controlled trials have not found an effect of SBPs on school attendance, academic achievement, memory or behaviour.27
However, relatively low breakfast programme attendance and moves from home to school-based breakfast consumption may account for lack of observed effects.
This research demonstrated that a non-standardised free SBP in New Zealand alleviated children's short-term hunger but did not impact on children's school attendance, academic achievement or behaviour. More frequent programme attendance may be required to influence school attendance and academic achievement.
What is already known on this subject
School feeding programmes are intended to alleviate short-term hunger, improve nutrition and educational attainment of children, and transfer income to families. There is evidence that such programmes have positive effects on children's nutrition, health and school attendance for disadvantaged children and those in developing countries. However, the evidence is less conclusive regarding impact on academic achievement, particularly in high-income countries.
What this study adds
A free SBP did not have a significant effect on New Zealand children's school attendance, academic achievement, self-reported grades, sense of belonging at school, behaviour or food security. However, the programme had significant positive effects on children's short-term hunger ratings. More frequent programme attendance may be required to influence school attendance and academic achievement.