Malnutrition is associated with reduced learning aptitude and growth during childhood. We examined the impact of providing two school lunch variants, a standard school meal (school feeding, n = 70), or the standard meal with additional micronutrients (school feeding + micronutrient powder (MNP), n = 70), in children attending two schools in northwest Pakistan. A third local government school, where no lunch was provided (no school feeding, n = 70), served as the control. The primary outcome, cognitive function, was assessed using the Raven\'s Coloured Progressive Matrices (RCPM) test, alongside haemoglobin, at three-time points: T1 (baseline, before the initiation of the school lunch programme), T2 and T3 (5 and 12 months, respectively, after the introduction of the school lunch). Data were analysed using linear mixed-effects models to contrast between trial groups, the changes from T1 to T2 and T3. Adjusted for T1 and other co-variates, improvements in the RCPM scores were significantly greater in the school feeding group at T2 (b = 1.61, (95% CI = 0.71-2.52), t = 3.52, p = 0.001) and T3 (b = 1.28, (95% CI = 0.22-2.35), t = 2.38, p = 0.019) compared with no school feeding. In addition, at T2 (b = 1.63, (95% CI = -0.10-3.37), t = 1.86, p = 0.065), there were no significant differences between school feeding + MNP and no school feeding groups. However, improvements in the RCPM scores were significantly greater in the school feeding + MNP group at T3 (b = 2.35, (95% CI = 0.51-4.20), t = 2.53, p = 0.013) compared with no school feeding. The findings indicate an improvement in cognitive performance in children who received a school meal with and without MNP, over a 12-month period. Currently there is no operational school feeding programme at the national or provincial level in Pakistan. Our findings, therefore, highlight the need for school feeding programmes to improve learning opportunities for children from underprivileged communities.

Ethiopia recently scaled up the implementation of a school feeding programme (SFP). Yet, evidence on the impact of such programmes on academic outcomes remains inconclusive. We evaluated the effect of the SFP on class absenteeism and academic performance of primary school students (grade 5-8) in Sidama zone, Southern Ethiopia.
This prospective cohort study enrolled SFP-beneficiary (n 240) and non-beneficiary (n 240) children 10-14 years of age from sixteen public schools and followed them for an academic year. School absenteeism was measured as the number of days children were absent from school in the year. Academic performance was defined based on the average academic score of the students for ten subjects they attended in the year. Data were analysed using multivariable mixed effects negative binomial and linear regression models.
Food insecure districts in Sidama zone, Southern Ethiopia.
SFP-beneficiary and non-beneficiary children 10-14 years of age.
The mean (sd) number of days children were absent from school was 4·0 (sd 1·5) and 9·3 (sd 6·0), among SFP beneficiaries and non-beneficiaries, respectively. Students not covered by the SFP were two times more likely to miss classes (adjusted rate ratio = 2·30; 95 % CI 2·03, 2·61). Pertaining to academic performance, a significant but small 2·40 (95 % CI 0·69, 4·12) percentage point mean difference was observed in favour of SFP beneficiaries. Likewise, the risk of school dropout was six times higher among non-beneficiaries (adjusted rate ratio = 6·04; 95 % CI 1·61, 22·68).
SFP promotes multiple academic outcomes among socio-economically disadvantaged children.