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Social Determinants of Health: Healthy School Meals for All

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from 14 studies. Studies were identified from a published systematic review (Cohen et al. 2021a, 11 studies from 13 publications, search period through December 2020) and an updated search that used the same search terms (3 studies, search period January to December 2021).

The systematic review was conducted on behalf of CPSTF by a team of specialists in systematic review methods, social determinants of health, and in research, practice, and policy related to nutrition and food security.

Context

Food and nutrition security is an established social determinant of health (CDC 2022, Serchen et al. 2022). It exists when people have consistent physical, social, and economic access to affordable foods and beverages that promote health and prevent adverse health outcomes (CDC 2022, Mozaffarian et al. 2021). Families from historically disadvantaged racial and ethnic populations and populations with lower incomes often lack access to affordable nutritious foods (CDC 2020) and experience higher rates of food insecurity (Coleman-Jensen et al. 2021). Children experiencing food insecurity are at higher risk of poor physical and mental health, obesity, increased hospitalizations, poor academic performance, and behavioral problems (Au et al. 2019, Cook et al. 2006, McIntyre et al. 2013, Shankar et al. 2017).

Studies have shown that the NSLP and SBP — two key U.S. Department of Agriculture (USDA) meal programs — reduce food insecurity (Ralston et al. 2017). Children from households experiencing food insecurity receive significantly more of their daily energy from school meals than children from households that are not experiencing food insecurity (Forrestal et al. 2021). School meals also provide the best diet quality of major U.S. food sources among children and improve the nutritional quality of students’ diets (Fox et al. 2019, Liu et al. 2021). School meals are not linked with increases in obesity and have been associated with decreases in obesity among children from households with lower incomes (Kenney et al. 2020). Studies have also shown a favorable association between SBP and school attendance and academic performance (County Health Rankings & Roadmaps 2019).

NSLP and SBP have the potential to benefit millions of students in the United States, many of them from households with lower incomes (National Center for Education Statistics 2021, 2022). Estimates indicate more than half of students in U.S. public schools are eligible for free or reduced-price lunches (NCES 2021). In schools that offer NSLP and SBP, however, it is estimated that only 79% of students from households experiencing food insecurity participate in NSLP and only 38% participate in SBP (Forrestal et al. 2021).

The traditional payment model under which NSLP and SBP operate requires students to apply and meet certain income-based eligibility requirements to receive free or reduced-price meals. (USDA 2021, 2022a). This model presents economic, administrative, and language barriers that may make it more difficult for students from households with lower incomes to participate. Families with low to moderate monthly incomes undergo income fluctuations that cross the eligibility threshold for reduced-price lunches an average of five times a year (Newman 2006). The free and reduced-price meal certification process also presents barriers, as errors on applications or in administrative procedures may lead to eligible students being denied benefits. In the 2017-18 school year, an estimated 34 percent of students who were denied free and reduced-price meals were actually eligible to receive them (Milfort et al. 2021). Another issue is families with limited English proficiency may be unaware of the availability of free or reduced-price meals and may have difficulties with the application process if there are not translation services or forms available in their primary language (USDA 2016a, 2016b).

The traditional payment model also presents social barriers to participation. Students who are unable to pay for school meals may be denied nutritious meals and face stigmatization due to what is commonly referred to as “lunch shaming” practices. (Fleischhacker et al. 2020).

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 14 studies that compared Healthy School Meal for All to traditional NSLP and SBP models that use household income-based requirements to determine eligibility for free and reduced-price meals.

  • Meal Participation
    • Overall participation in the NSLP and SBP increased by 4.5 percentage points (9 studies)
    • Participation in the SBP increased by 4.6 percentage points (6 studies)
    • Participation in the NSLP increased by 4.3 percentage points (7 studies)
  • Absenteeism
    • Students missed fewer days of school (3 studies)

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

Based on results from this systematic review, the CPSTF finding should be applicable to all students in elementary, middle, and high schools that implement the NSLP or SBP, regardless of gender, race and ethnicity, or household income level.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

CPSTF identified the following questions as priorities for research and evaluation:

  • What is the impact of Healthy School Meals for All on dietary intake and household food security?
  • What are the barriers to participation in Healthy School Meals for All for students from households with lower incomes? Which strategies effectively address these barriers?

Remaining questions for research and evaluation identified in this review include the following:

  • How does the effectiveness of Healthy School Meals for All vary between high schools and elementary and middle schools?
  • How did the USDA nationwide waivers issued during the COVID-19 pandemic affect meal participation and academic outcomes? From 2020-2022, Congress granted the USDA authority to establish nationwide waivers to support Healthy School Meals for All schools operating NSLP and SBP.
  • What is the impact of Healthy School Meals for All on plate waste?

Study Characteristics

  • Study designs included pre-post with concurrent comparison groups (11 studies), randomized control trials (1 study), a retrospective cohort (1 study), and a single group pre-post (1 study).
  • All of the included studies were conducted in the United States.
  • Studies were implemented in elementary schools (5 studies), middle schools (1 study), a combination of elementary and middle schools (4 studies), or a combination of elementary, middle, and high schools (4 studies).
  • Studies were conducted in urban (3 studies) or a mix of urban, suburban, and rural (11 studies) areas.
  • Seven studies provided data on gender and reported a similar distribution of females and males.
  • The thirteen studies that reported race and ethnicity of participants had a higher percentage of students who self-identified as Hispanic or Latino or as Black or African American compared with U.S. population estimates.
  • Most of the studies included in the systematic review evaluated outcomes from schools in which a large proportion of enrolled students are from households with lower incomes.
  • Most of the data came from students from households with lower incomes. Across thirteen studies, a median of 63.3% of students came from households that either had incomes below 185% of the federal poverty level or were eligible for free or reduced-price school meals or other federal assistance programs.