Findings corroborate results from previous reviews, adding support for a possible, protective role for breakfast consumption in preventing excess adiposity during childhood and adolescence. However, drawing a causal conclusion from the collective evidence is curtailed by methodological limitations and inconsistencies, including study design, follow-up duration and frequency, exposure and outcome assessment, as well as limited consideration of confounding, mediating and effect-modifying variables. More rigorous study designs employing valid and standardized measurement of relevant variables are needed.

Findings add to the evidence that BIC can increase school breakfast participation substantially and suggest that it has the potential to improve overall school attendance rates. Additional research is needed to explore the generalizability of these findings and the potential impacts on achievement for longer periods and on additional outcomes, such as weight status.

Objective: To understand stakeholders' perspectives on food waste in a universal free School Breakfast Program implementing a Breakfast in the Classroom model. Design: Semi-structured focus groups and interviews were conducted with school district stakeholders. Inductive methods were used to code resulting transcripts, from which themes were identified. The analysis provides a thematic analysis of stakeholders' perspectives on food waste in the School Breakfast Program. Setting: Ten elementary schools in a large urban school district implementing a universal free Breakfast in the Classroom model of the US national School Breakfast Program. Subjects: Elementary-school students (n 85), parents (n 86), teachers (n 44), cafeteria managers (n 10) and school principals (n 10). Results: Stakeholders perceived food waste as a problem and expressed concern regarding the amount of food wasted. Explanations reported for food waste included food-related (palatability and accessibility), child-related (taste preferences and satiation) and programme-related (duration, food service policies, and coordination) factors. Milk and fruit were perceived as foods particularly susceptible to waste. Several food waste mitigation strategies were identified by participants: saving food for later, actively encouraging children's consumption, assisting children with foods during mealtime, increasing staff support, serving smaller portion sizes, and composting and donating uneaten food. Conclusions: Stakeholders recognized food waste as a problem, reported myriad contributing factors, and have considered and employed multiple and diverse mitigation strategies. Changes to the menu and/or implementation logistics, as well as efforts to use leftover food productively, may be possible strategies of reducing waste and improving the School Breakfast Program's economic, environmental and nutritional impact. Keywords Food waste National School Breakfast ProgramBreakfast in the Classroom Elementary school Students

Objective: To understand perspectives of stakeholders during initial district-wide implementation of a Breakfast in the Classroom (BIC) model of the School Breakfast Program. Design: Qualitative data were collected from twenty-nine focus groups and twenty interviews with stakeholders in a school district early in the process of implementing a BIC model of the School Breakfast Program. Setting: Ten elementary schools within a large, urban school district in the USA that served predominantly low-income, racial/ethnic minority students. Subjects: Purposively selected stakeholders in elementary schools that had implemented BIC for 3-6 months: students (n 85), parents/guardians (n 86), classroom teachers (n 44), cafeteria managers (n 10) and principals (n 10). Results: Four primary themes emerged, which were interpreted based on the Diffusion of Innovations model. School staff had changed their perceptions of both the relative disadvantages and costs related to time and effort of BIC over time; the majority of each stakeholder group expressed an appreciation for BIC; student breakfast consumption varied from day to day, related to compatibility of foods with child preferences; and stakeholders held mixed and various impressions of BIC's potential impacts. Conclusions: The study underscores the importance of engaging school staff and parents in discussions of BIC programming prior to its initiation to pre-emptively address concerns related to cost, relative disadvantages and compatibility with child preferences and school routines/workflow. Effectively communicating with stakeholders about positive impacts and nutritional value of the meals may improve support for BIC. These findings provide new information to policy makers, districts and practitioners that can be used to improve implementation efforts, model delivery and outcomes.