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Two global conferences in the 1990s recognised the need for action to address undernutrition by reducing micronutrient deficiencies and improving child nutrition (Dalmiya and Schultink 2003) and the majority of the

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Millennium Development Goals, drawn up in 2000, were directly or indirectly related to nutrition (Tanumihardjo et al. 2007). As a result, programmatic health and nutrition interventions targeting maternal and child undernutrition have resulted in major reductions in undernutrition (Bhutta et al. 2008; Black et al. 2008).

The results of these interventions are significant, with an estimated 1 million child deaths prevented as a result of Vitamin A supplementation between 1998-2000 (Dalmiya and Schultink 2003). Stunting was reduced between 1990-2010 (M de Onis et al. 2011) and it is further estimated that existing interventions could reduce stunting at 36 months by 36%, mortality between birth and 36 months by about 25%, and disability-adjusted life years associated with stunting, severe wasting, intrauterine growth restriction and micronutrient deficiencies by about 25% (Bhutta et al. 2008).

Alongside micronutrient interventions, a significant intervention for addressing nutritional inadequacies in children is the provision of food in school. With an annual investment of between $US 47-75 billion, school food represents a major social programme and it is estimated that worldwide, 368 million school children are fed daily (World Food Programme 2013a). While the aims of school food programmes will differ by country and circumstances, generally, in both higher and lower income countries, the aims include improving nutritional status, growth, cognitive and academic performance and relieving short term hunger (Kristjansson et al. 2009). In low income countries, school food programmes support families in securing education for their children, especially girls who are often differentially excluded from education (Victora et al. 2008). Such programmes commonly provide a safety net to support the most vulnerable families and children, facilitating the transfer of resources to households to the value of the food distributed and more in the case of take home rations. Additionally, such programmes benefit local agricultural production and market development (Bundy et al. 2012; World Food Programme 2013b).

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Analysis of outcomes of school food provision has found positive significant effects on weight in lower income countries and mixed but generally positive effects in higher income countries. For height, results from lower income countries were mixed but in higher income countries, results were moderate and positive (Kristjansson et al. 2009). School food programmes have also been found to result in an increase in school attendance and enrolment (Bundy et al. 2012; World Food Programme 2013b) as well as having a significant positive effect on growth and cognitive performance (Greenhalgh et al. 2007; Kristjansson et al. 2009).

School food programmes are usually funded from government budgets and as a result, the scale of the school food programme will be associated with the income level of a country. Evidence indicates that countries with well- established government funding have more developed meal systems which are consolidated in national policy frameworks (Harper et al. 2008). While the aim of school food provision may be similar across countries, the form that provision takes will vary and in higher income countries, there is evidence of diversity in terms of the cost of the meal, the food provided, catering services, the dining environment and the level of take up of school food (Harper et al. 2008).

In terms of charging for a meal, generally, in low income countries there is no element of the cost recovery that is common in higher income countries (World Food Programme 2013b). Here the cost of a meal can vary, from 98p (USA) to £4.50 (France). Of the developed countries, only Sweden and Finland provide free meals to all pupils in compulsory education regardless of ability to pay, while in Brazil and Chile, deprived regions are targeted for free provision. In all other countries, with the exception of Australia, meals are provided free or at a reduced price for families who qualify (Harper et al. 2008).

In many countries such as the UK, Sweden and Finland, a full canteen service is provided but elsewhere, for example Ireland and Germany, provision is limited to sandwiches and soup. In Italy, France, Japan and

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Hong Kong the emphasis is on organic and locally sourced produce and meals cooked onsite (Harper et al. 2008).

In many countries such as Italy, Finland and Japan, the dining environment is considered important for the transmission of cultural and social lessons. In Japan, there is a philosophy in which the school lunch environment contributes to the formation of proper eating habits and promotes good social relationships and in Finland, teachers and pupils eat at the same time and the school lunch supports the learning of manners and Finnish customs. Similarly in Italy, teachers and pupils eat their lunch together and meal times are considered to be part of the children’s cultural education and the use of tablecloths, crockery and cutlery is encouraged (Harper et al. 2008).

Variation in the rate of uptake of the school food programme is also evident by country, for example in Canada and Australia uptake is very low (9% and 14% respectively) as the vast majority of children bring packed lunches. In Spain, where the majority of pupils go home for lunch, uptake is 14% and in England, Ireland and Chile (where secondary education is not compulsory) take up is around 40% with Scotland and Wales slightly over 40%. In comparison, take up is high in countries where the meal is free, Finland (95%), Sweden (85%) (Harper and Wells 2007).

The worldwide provision of food in schools reflects an acknowledgement that inadequacies in children’s diets occur in both developing and developed countries including the UK, where issues of food insecurity have been of increasing concern over recent years.