A School Meals Program Implemented at Scale in Ghana Increases Height-for-Age during Midchildhood in Girls and in Children from Poor Households: A Cluster Randomized Trial

Background: Attention to nutrition during all phases of child and adolescent development is necessary to ensure healthy physical growth and to protect investments made earlier in life. Leveraging school meals programs as platforms to scale-up nutrition interventions is relevant as programs function in nearly every country in the world. Objective: The aim of this study was to evaluate the impact of a large-scale school meals program in Ghana on school-age children's anthropometry indicators. Methods: A longitudinal cluster randomized control trial was implemented across the 10 regions of Ghana, covering 2869 school-age children (aged 5-15 y). Communities were randomly assigned to 1) control group without intervention or 2) treatment group providing the reformed national school feeding program, providing 1 hot meal/d in public primary schools. Primary outcomes included height-for-age (HAZ) and BMI-for-age (BAZ) z scores. The analysis followed an intention-to-treat approach as per the published protocol for the study population and subgroup analysis by age (i.e., midchildhood for children 5-8 y and early adolescence for children 9-15 y), gender, poverty, and region of residence. We used single-difference ANCOVA with mixed-effect regression models to assess program impacts. Results: School meals had no effect on HAZ and BAZ in children aged 5-15 y. However, in per-protocol subgroup analysis, the school feeding intervention improved HAZ in 5- to 8-y-old children (effect size: 0.12 SDs), in girls (effect size: 0.12 SDs)-particularly girls aged 5-8 y living in the northern regions, and in children aged 5-8 y in households living below the poverty line (effect size: 0.22 SDs). There was also evidence that the intervention influenced food allocation and sharing at the household level. Conclusion: School meals can provide a platform to scale-up nutrition interventions in the early primary school years, with important benefits accruing for more disadvantaged children.