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Social Determinants of Health: Healthy School Meals for All

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This is a brief summary of the CPSTF finding and systematic review evidence for Social Determinants of Health: Healthy School Meals for All. Read a complete summary of the systematic review and CPSTF finding.

This information is also availble in a PDF version pdf icon [PDF - 223 KB].

Summary of Community Preventive Services Task Force Recommendation

The Community Preventive Services Task Force (CPSTF) recommends Healthy School Meals for All to increase student participation in the U.S. National School Lunch Program (NSLP) and School Breakfast Program (SBP) and reduce school absenteeism. Participation in these programs is associated with reduced food insecurity, improved nutritional quality of students’ diets, and improved academic outcomes.1-4 Healthy School Meals for All are expected to advance health equity by removing barriers to consistent access to free and healthy foods for students from households with lower incomes.

Major Findings

The CPSTF recommendation is based on evidence from a systematic review of 14 studies from a published review5 and updated search (January to December 2021).

Compared to the traditional model of NSLP and SBP that requires students to apply and meet certain household income-based eligibility requirements to receive free or reduced-price meals, Healthy School Meals for All led to the following outcomes:

  • 4.5 percentage point increase in NSLP and SBP participation
  • Reductions in school absenteeism

What are Healthy School Meals for All Interventions?

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 uses household income-based requirements to determine eligibility for free and reduced-price meals. The intervention aims to do the following:

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

Policy Context

Healthy School Meals for All is implemented through policies at federal, state, and local levels. Congress authorizes federal policies administered by the U.S. Department of Agriculture.6-8 The Community Eligibility Provision, the most widely used federal policy, allows schools and school districts to offer Healthy School Meals for All if at least 40% of enrolled students are directly certified for free meals based on their participation in other means-tested programs, such as the Supplemental Assistance Program, Temporary Assistance for Needy Families, or Food Distribution Program on Indian Reservations.7,9,10

Why is This Important?

  • Food and nutrition security is an established social determinant of health.11,12 Children experiencing food insecurity are at higher risk of poor physical and mental health, obesity, increased hospitalizations, poor academic performance, and behavioral problems.13-16
  • In 2020, 14.8% of households with children in the United States experienced food insecurity.17 Families from historically disadvantaged racial and ethnic populations and populations with lower incomes are more likely to experience food insecurity17 and often lack access to affordable nutritious foods.18
  • The NSLP and SBP reduce food insecurity4 and improve the nutritional quality of students’ diets.2 Traditional household income-based eligibility requirements for receiving free or reduced-price meals may, however, limit participation among students from households with lower incomes.

Learn More

U.S. Department of Agriculture, National School Lunch Program External Web Site Icon

U.S. Department of Agriculture, National School Breakfast Program External Web Site Icon

CDC Nutrition External Web Site Icon

CDC Healthy Schools External Web Site Icon


1 County Health Rankings & Roadmaps. School breakfast programs. Published 2019. Accessed June 22, 2022. www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/school-breakfast-programs.

2 Fox MK, Gearan E. School nutrition and meal cost study: summary of findings. Published 2019. Accessed June 22, 2022. https://fns-prod.azureedge.us/sites/default/files/resource-files/SNMCS_Summary-Findings.pdf.

3 Liu J, Micha R, Li Y, et al. Trends in food sources and diet quality among US children and adults, 2003-2018. JAMA Netw Open 2021;4(4): e215262.

4 Ralston K, Treen K, Coleman-Jenson A, et al. Children’s food security and USDA child nutrition programs. U.S. Department of Agriculture Economic Research Service; 2017, EIB-174. Accessed June 22, 2022. www.ers.usda.gov/publications/pub-details/?pubid=84002.

5 Cohen JFW, Hecht AA, McLoughlin GM, et al. Universal school meals and associations with student participation, attendance, academic performance, diet quality, food security, and body mass index: a systematic review. Nutrients 2021;13:911.

6 USDA. National School Lunch Program: Provisions 1, 2, and 3. Published 2014. Accessed June 22, 2022. www.fns.usda.gov/cn/provisions-1-2-and-3.

7 USDA. Community Eligibility Provision. Published 2019. Accessed June 22, 2022. www.fns.usda.gov/cn/community-eligibility-provision.

8 USDA. Child Nutrition COVID-19 Waivers. Published 2022b. Accessed July 12, 2022. www.fns.usda.gov/fns-disaster-assistance/fns-responds-covid-19/child-nutrition-covid-19-waivers.

9 Billings KC, Carter JA. Serving free school meals through the Community Eligibility Provision (CEP): background and participation. Congressional Research Service. Published 2020. Accessed June 22, 2022. https://crsreports.congress.gov/product/pdf/R/R46371.

10 National Archives. Code of Federal Regulations. Published 2022. Accessed July 12, 2022. www.ecfr.gov/current/title-7/subtitle-B/chapter-II/subchapter-A/part-245/section-245.9#p-245.9(f)(3)(i).

11 CDC, National Center for Chronic Disease Prevention and Health Promotion. Social determinants of health. Published 2022. Accessed June 22, 2022. www.cdc.gov/chronicdisease/programs-impact/sdoh.htm.

12 Serchen BA, Atiq O, Hilden D. Strengthening food and nutrition security to promote public health in the United States: a position paper from the American College of Physicians. Annals of Internal Medicine 2022 Jun 28; doi.org/10.7326/M22-0390.

13 Au LE, Zhu SM, Nhan LA, et al. Household food insecurity is associated with higher adiposity among US schoolchildren ages 10–15 Years: The Healthy Communities Study. Journal of Nutrition 2019;149(9):1642-50.

14 Cook JT, Frank DA, Levenson SM, et al. Child food insecurity increases risks posed by household food insecurity to young children's health. Journal of Nutrition 2006;136(4):1073–6.

15 McIntyre L, Williams JV, Lavorato DH, et al. Depression and suicide ideation in late adolescence and early adulthood are an outcome of child hunger. Journal of Affective Behaviors 2013;150(1):123-9.

16 Shankar P, Chung R, Frank DA. Association of food insecurity with children's behavioral, emotional, and academic outcomes: a systematic review. Journal of Developmental & Behavioral Pediatrics 2017;38(2): 135–50.

17 Coleman-Jensen A, Rabbitt MP, Gregory CA, et al. Household food security in the United States in 2020. Published 2021. Accessed June 22, 2022. www.ers.usda.gov/publications/pub-details/?pubid=102075.

18 Centers for Disease Control and Prevention (CDC). Healthy food environments: improving access to healthier food. Published 2020. Accessed June 22, 2022. www.cdc.gov/nutrition/healthy-food-environments/improving-access-to-healthier-food.html.

Established in 1996 by the U.S. Department of Health and Human Services, the Community Preventive Services Task Force (CPSTF) is an independent, nonfederal panel of public health and prevention experts whose members are appointed by the director of CDC. CPSTF provides information for a wide range of decision makers on programs, services, and other interventions aimed at improving population health. Although CDC provides administrative, scientific, and technical support for CPSTF, the recommendations developed are those of CPSTF and do not undergo review or approval by CDC. Find more information at www.thecommunityguide.org.