Social Determinants of Health: Healthy School Meals for All

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends Healthy School Meals for All to increase student participation in the U.S. Department of Agriculture’s National School Lunch Program (NSLP) and School Breakfast Program (SBP) and reduce school absenteeism. Participation in NSLP and SBP is associated with reduced food insecurity, improved nutritional quality of students’ diets, and improved academic outcomes (County Health Rankings & Roadmaps 2019, Fox et al. 2019, Liu et al. 2021, Ralston et al. 2017).

Healthy School Meals for All is expected to advance health equity in the United States by removing barriers to consistent access to free and healthy foods for students from households with lower incomes. Healthy School Meals for All is often implemented in schools in which a large proportion of enrolled students are from households with lower incomes (Billings et al. 2020, National Archives 2022, USDA 2019).

The full CPSTF Finding and Rationale Statement and supporting documents for Social Determinants of Health: Healthy School Meals for All are available in The Community Guide Collection on CDC Stacks.

Intervention

Healthy School Meals for All offers free, nutritious meals (i.e., breakfast, lunch, or both) to all students in a qualifying school, regardless of household income. It augments the traditional model of the NSLP and SBP which use household income to determine whether students are eligible for free or reduced-price meals. Interventions aim to do the following:

Improve access to NSLP and SBP for students from households with lower incomes by removing economic, administrative, language, and social barriers that may limit their participation
Increase participation in NSLP and SBP overall to improve diet quality and promote health and well-being for all students

About The Systematic Review

The CPSTF findings are 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).

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 sex and reported a similar distribution of females and males.
The 13 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.

Summary of Results

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 sex, race and ethnicity, or household income level.

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?

Implementation Considerations and Resources

Strategies to improve school meal consumption and reduce plate waste

A published systematic review of 96 studies (Cohen et al. 2021b) found the following strategies improved school meal consumption and reduced plate waste:

Offering more menu choices
Adapting recipes to improve the taste and more closely match students’ cultural preferences
Providing pre-sliced fruits
Rewarding students who try fruits and vegetables
Enabling sufficient time to eat by extending the lunch period
Limiting access to competitive foods during the school day

Strategies to improve participation in school breakfast programs

Participation in school breakfast programs tends to be lower than in school lunch programs (USDA 2022b). Implementing alternative breakfast models may boost participation (Bernstein et al. 2004; Larson et al. 2018). One study included in the review found breakfast participation was substantially higher when breakfast was served in the classroom rather than the school cafeteria (Bernstein et al. 2004). Other examples of alternative models include grab-and-go breakfast, second chance breakfast (e.g., breakfast offered during morning break or recess), and breakfast on the bus (USDA 2016c).

Strategies to address schools’ loss of free and reduced-price meals data

When schools implement Healthy School Meals for All, they stop collecting household income data to assess students’ eligibility for free and reduced-price meals. Schools have historically used these data to justify eligibility for other needs-based educational initiatives such as Title I funding. Schools may use alternative data sources to assess the income level of enrolled students to qualify for these initiatives. The following guidance is available for schools electing the Community Eligibility Provision to support Healthy School Meals for All:

Implementation resources

The following site provides information about the benefits of U.S. school meal programs and a resource list:

CDC Healthy Schools: School Meals

The following resources provide guidance and tools for implementation of Healthy School Meals for All using the Community Eligibility Provision:

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.