From the chapter ‘Health‘
Patrick Barwise, Emeritus Professor of Management and Marketing at London Business School
According to the World Health Organization (WHO), Britain is on course to be the most obese nation in Europe by the early 2030s.[i] There is also agreement across the political spectrum of the need to address large inequalities of opportunity within and between the different parts of the country. Both obesity and inequality have been reinforced by the COVID-19 pandemic, which has also impacted children’s education, especially for children in households without the technology for effective remote learning.
One measure that would help address these challenges is found in the Independent Review that published a (two-part) National Food Strategy recommendation to government between 2020 and 2022: expanding the eligibility of free school meals (FSMs) to every child up to 16 whose parent or guardian is receiving Universal Credit.[ii] But at the time of writing it remains unadopted (2023), even though the government has accepted some of its other recommendations.[iii]
Towards an evidence-based investment case for free school meals
Those of us who think the long-term benefits of FSMs greatly outweigh the short-term costs need to build a powerful evidence-based investment case. This essay summarises some of the existing evidence, its limitations and a three-step plan towards a stronger, evidence-based case. It focuses on FSMs in primary schools because, relative to secondary schools:
- They have far more control over what the children eat during school hours. FSMs are therefore likely to have more impact on children’s short-term health, learning and behaviour.
- Children’s diets at primary school are also likely to be a bigger influence on their long-term food habits, attitudes and preferences.
- The meals for primary school students are smaller and cost less per head.
Other things being equal, the return on investment is therefore likely to be higher than for FSMs in secondary schools. Of course, this does not mean that we should not also look for ways to improve, and reduce inequalities in, the diets of both preschool and secondary school children[iv] and pregnant women,[v] but these fall outside the scope of this essay.
The development and long-term impact of young children’s food habits, attitudes and preferences
The food habits, attitudes and preferences of ten-year-old children vary enormously between rich and poor areas and families. The most plausible explanation is that they grow up in very different environments, including in what they are given to eat – and see others eating[vi] – at home and at school in their first ten years.
Governments’ ability to influence what children eat at home is limited.[vii] However, they have significant control over meals at primary school and therefore, potentially, on under-tens’ food habits, attitudes and preferences.[viii] The food habits, attitudes and preferences children develop in their early years are likely to be a strong influence on what they will eat over the rest of their lives[ix] – and on what they will give their own children to eat.
The 2004–05 Jamie Oliver ‘Feed Me Better’ campaign in Greenwich
In 2004, celebrity chef Jamie Oliver launched a campaign to improve school meals in the UK. One inner-London borough, Greenwich, shifted from low-cost, highly-processed school meals to healthier options.[x] In 2011, a study by economists Michèle Belot and Jonathan James, using data for 2002–07 from the participating primary schools and a control group, showed that the healthier meals led to significant improvements in English, maths and science, and a 15 per cent reduction in absenteeism, especially those due to sickness.[xi]
The 2009–11 free school meals pilot
In 2009, the Labour government’s Department for Children, Schools and Families (DCSF) set up a two-year pilot study with FSMs for all children in Newham and Durham primary schools, while in Wolverhampton primary and secondary schools provided FSMs to families in receipt of Working Tax Credits and with an annual income of up to £16,040.[xii]
An independent evaluation of this pilot[xiii] found that the extended entitlement trial in Wolverhampton had little impact on children’s diet, eating habits or attainment, but Newham and Durham saw measurable increases in both the take-up of FSMs and pupil attainment (especially among those from poorer families and/or with lower prior attainment).
School meals in other countries
These two English examples mirror evidence from other countries, especially those with much lower rates of childhood obesity than the UK. Some of this is anecdotal,[xiv] but it suggests many some countries have healthier school meals than in UK state schools, and that in many cases these meals are free or heavily subsidised and available to more children than in the UK.
Anecdotal evidence is supported by a review led by Marija Oostander. This found healthy school meals ‘can have strong short-term influences on children’s consumption of calories and key nutrients’.[xv] However, they explain that the research to date is not powerful enough to establish the behavioural and health benefits of school meals beyond the short term.
Earlier studies find evidence of dietary improvements, especially in younger children.[xvi] The benefits of school meals depend on their nutritional quality. A 2018 study of meals provided in all California public (state) schools over a five-year period found that ‘students at schools that contract with a healthy school-meal vendor score higher on CA (California) state achievement tests. We do not find any evidence that healthier school meals lead to a decrease in obesity rates’.[xvii]
Towards a stronger evidence base: a three-step plan
What can the government do to build a stronger evidence base?
It could:
- systematically pull together the existing evidence from the UK and elsewhere on (i) the nature and impact of healthier school meals and (ii) how free or subsidised healthy school meals relate to different rates of childhood obesity;
- replicate the Jamie Oliver campaign with results evaluated over several years and supplemented by quantitative impact measures that consider food habits and preferences, learning, behaviour and health and fitness;
- implement a 12-month study of universal free school meals, including a range of healthy affordable meals children are happy to eat.
In the commercial world, as in the world of public policy, leaders make decisions using a combination of evidence and judgement. The longer term the costs and benefits, the more they have to rely on judgement. This means both exploiting the evidence already available and constantly trying to generate more through a structured test-and-learn approach. Those of us advocating FSMs now need to do the same.
Notes
[i] Kat, L. (2020) ‘Takeaway Britain on course to be the most obese nation in Europe, WHO warns’, The Times, 3 May.
[ii] National Food Strategy (2020) The Plan, Part One, www.nationalfoodstrategy.org, p 9.
[iii] National Food Strategy (2020) The Plan, Part One, www.nationalfoodstrategy.org, p 9.
[iv] Korkalo, L., Nissinen, K., Skaffari, E., et al (2019) ‘The contribution of preschool meals to the diet of Finnish preschoolers’, Nutrients, 11(7), 1531;
Mikkilä, V., Räsänen, L., Raitakari, O., Pietienen, P. and Viikari, J. (2005) ‘Consistent diary patterns identified from childhood to adulthood: The cardiovascular risk in Young Finns Study’, The British Journal of Nutrition, 93: 923–31.
[v] Fitzgerald, E., Hor, K. and Drake, A.J. (2020) ‘Maternal influences on fetal brain development: The role of nutrition, infection and stress, and the potential for intergenerational consequences’, Early Human Development, 150, 105190: 1–5.
[vi] My hunch is that the eating habits of the same-sex parent (that is, a boy’s father or girl’s mother) and same-sex older siblings are especially influential, but there seems to be little research on this and other factors driving the divergence in the development of young children’s food habits, attitudes and preferences. If so, it represents an important research gap and opportunity.
[vii] Boseley, S. (2019) ‘Leeds becomes first UK city to lower its childhood obesity rate’, The Guardian, 1 May, www.theguardian.com/world/2019/may/01/leeds-becomes-first-uk-city-to-lower-its-childhood-obesity-rate; Rudolf, M., Perera, R., Swanston, D., Burberry, J., Roberts, K. and Jebb, S. (2019) ‘Observational analysis of disparities in obesity in children in the UK: Has Leeds bucked the trend?’, Pediatric Obesity, 14(9): e12529, https://doi.org/10.1111/ijpo.12529
[viii] However, what children eat, and see eaten, at home is still likely to be a more powerful influence, so they may reject healthier school meals if these are too far from what they are used to. In the pilot phase of the 2004–05 Greenwich experiment discussed shortly, the children in one (secondary) school were given a choice between healthier and less healthy options, and mostly chose the latter. The resistance to the healthier meals was strongest among white working-class children. In the main experiment, only the healthier options were offered.
[ix] Craigie, A.M., Lake, A.A., Kelly, S.A., Adamson, A.J. and Mathers, J.C. (2011) ‘Tracking of obesity-related behaviours from childhood to adulthood: A systematic review’, Maturitas, 70(3): 266–84, https://pubmed.ncbi.nlm.nih.gov/21920682
[x] The scheme was rolled out five schools at a time, starting in September 2004. By September 2005, 81 of the borough’s 88 primary and secondary schools had switched to healthier meals. The other seven schools were unable to participate due to lack of kitchen facilities.
[xi] Belot, M. and James, J. (2011) ‘Healthy school meals and educational outcomes’, Journal of Health Economics, 30: 489–504.
[xii] This was increased to £16,191 in 2010–11. Families with an income up to these levels and receiving means-tested out-of-work benefits and/or Child Tax Credit were already eligible for FSMs. The Wolverhampton pilot made FSMs also available to those receiving Working Tax Credit.
[xiii] Kitchen, S., Tanner, E., Brown, V., et al (2012) Evaluation of the Free School Meals Pilot: Impact Report, Research Report DFE-RR227, London: Department for Education, www.gov.uk/government/publications/evaluation-of-the-free-school-meals-pilot-impact-report
[xiv] Karen Le Billon, K. (no date) ‘School lunch in France’, https://karenlebillon.com/french-school-lunch-menus
[xv] Oostindjer, M., Aschemann-Witzel, J., Wang, Q., et al (2017) ‘Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children’s diet and food consumption? A cross-national comparative perspective’, Critical Reviews in Food Science and Nutrition, 57(18): 3942–58, p 3953.
[xvi] Oostindjer, M., Aschemann-Witzel, J., Wang, Q., et al (2017) ‘Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children’s diet and food consumption? A cross-national comparative perspective’, Critical Reviews in Food Science and Nutrition, 57(18): 3942–58, p 2945.
[xvii] Anderson, M.L., Gallagher, J. and Ramirez Ritchie, E. (2018) ‘School meal quality and academic performance’, Journal of Public Economics, 168: 81–93.