Social Determinants of Health: Healthy School Meals for All

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.

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).

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)

A systematic review of economic evidence has not been conducted.

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.

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 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.

Effectiveness Review

• Logic Model – Effectiveness Review [PDF (Print Only) – 174 KB]
• Text Description – Effectiveness Review [PDF – 93 KB]

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

• Summary Evidence Table – Effectiveness Review [PDF – 336 KB]

The number of studies and publications do not always correspond (e.g., a publication may include several studies, or one study may be explained in several publications).

Effectiveness Review

Andreyeva T, Sun X. Universal school meals in the US: what can we learn from the Community Eligibility Provision? Nutrients 2021;13(8).

Bartfeld JS, Berger L, Men F. Universal access to free school meals through the Community Eligibility Provision is associated with better attendance for low-income elementary school students in Wisconsin. Journal of the Academy of Nutrition and Dietetics 2020;120(2):210-18.

Bartfeld JS, Berger L, Men F, et al. Access to the School Breakfast Program is associated with higher attendance and test scores among elementary school students. Journal of Nutrition 2019;149(2):336-43.

Bernstein LS, McLaughlin JE, Crepinsek MK, et al. Evaluation of the School Breakfast Program Pilot Project: final report, Nutrition Assistance Program Report Series, No. CN-04-SBP, Project Officer: Anita Singh. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation; 2004.

Gordanier J, Ozturk O, Williams B, et al. Free lunch for all! The effect of the Community Eligibility Provision on academic outcomes. Economics of Education Review 2020;77:101999.

Leos-Urbel J, Schwartz AE, Weinstein M, et al. Not just for poor kids: the impact of universal free school breakfast on meal participation and student outcomes. Economics of Education Review 2013;36:88-107.

Logan CW, Patty C, Harvill EL, et al. Community Eligibility Provision Evaluation. Project Officer: John R. Endahl. Prepared by Abt Associates for the U.S. Department of Agriculture, Food and Nutrition Service, 2014.

Pokorney PE, Chandran A, Long MW. Impact of the Community Eligibility Provision on meal counts and participation in Pennsylvania and Maryland National School Lunch Programs. Public Health Nutrition 2019;22(17):3281-7.

Ribar DC, Haldeman LA. Changes in meal participation, attendance, and test scores associated with the availability of Universal Free School Breakfasts. Social Service Review 2013;87(2):354-85.

Ruffini K. Universal access to free school meals and student achievement evidence from the Community Eligibility Provision. Journal of Human Resources 2022;57(3):776-820.

Schneider KR, Oslund J, Liu T. Impact of the Community Eligibility Provision program on school meal participation in Texas. Public Health Nutrition 2021;24(18):6534-42.

Schwartz AE, Rothbart MW. Let them eat lunch: the impact of universal free meals on student performance. Journal of Policy Analysis and Management 2020;39(2):376-410.

Tan ML, Laraia B, Madsen KA, et al. Community Eligibility Provision and school meal participation among student subgroups. Journal of School Health 2020;90(10):802-11.

Turner L, Guthrie JF, Ralston K. Community eligibility and other provisions for universal free meals at school: impact on student breakfast and lunch participation in California public schools. Translational Behavioral Medicine 2019;9(5):931-41.

Papers Providing Additional Information for Already Included Studies

Crepinsek MK, Singh A, Bernstein LS, et al. Dietary effects of universal-free school breakfast: findings from the evaluation of the school breakfast program pilot project. Journal of the American Dietetic Association 2006;106(11):1796-803.

McLaughlin JE, Bernstein LS, Crepinsek MK, et al. Evaluation of the School Breakfast Program Pilot Project: findings from the first year of implementation. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation; 2002.

Implementation Resource

Rural Health Information Hub, Social Determinants of Health in Rural Communities Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of programs to address social determinants of health in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Approaches to Addressing Food Insecurity in School Settings

Effectiveness Review

The CPSTF recommendation is based on a systematic review of 14 studies (published through 2021). The review combined 11 studies of Healthy School Meals for All from a published systematic review (Cohen et al. 2021; search period through December 2020) with 3 studies identified in an updated search that used the same search terms (search period January to December 2021).

Databases searched for the Cohen et al. 2021 review included PubMed, Education Resources Information Center (ERIC), Thomson Reuters Web of Science, and Academic Search Ultimate. The databases for the updated search included PubMed, ERIC, Scopus, and Academic Search Complete.

PubMed

((((((((((((universal school meals[Title/Abstract]) OR (“community eligibility provision”[Title/Abstract])) OR (“universal free meal*”[Title/Abstract])) OR (“universal free breakfast”[Title/Abstract])) OR (“universal free school breakfast program”[Title/Abstract])) OR (“free lunch”[Title/Abstract])) OR (“free breakfast”)) OR (“meal reimbursement”[Title/Abstract])) OR (“meal programs”[Title/Abstract])) OR (“school meal programs”[Title/Abstract])) OR (reduced[Title/Abstract] AND price[Title/Abstract] AND “co pay”[Title/Abstract])) OR (“Meals”[Majr])) AND (Students OR Schools) OR (access[Title/Abstract] OR poverty[Title/Abstract] OR hunger)[Title/Abstract] AND (lunch[Title/Abstract] OR breakfast)[Title/Abstract] AND (school*[Title/Abstract] OR student*)[Title/Abstract]

Scopus

(TITLE-ABS-KEY (“universal school meals” OR “community eligibility provision” OR “universal free meal*” OR “universal free lunch” OR “universal free breakfast” OR “universal free breakfast program” OR “school meal provision” OR “free lunch*” OR “free breakfast” OR “meal reimbursement” OR “reduced-price co-pay” OR “reduced-price copay” OR “school meal reimbursement” OR “healthy school meals for all” ) ) AND ( TITLE-ABS-KEY ( student* OR school* ) ) AND PUBYEAR > 2020

ERIC

noft(“universal school meals” OR “community eligibility provision” OR “universal free meal*” OR “universal free lunch” OR “universal free breakfast” OR “universal free breakfast program” OR “school meal provision” OR “free lunch*” OR “free breakfast” OR “meal reimbursement” OR “reduced-price co-pay” OR “reduced-price copay” OR “school meal reimbursement” OR “healthy school meals for all” ) AND noft((student* OR school*))

Peer reviewed

Limits: 2021

Academic Search Complete

S1 TI ( (“universal school meals” OR “community eligibility provision” OR “universal free meal*” OR “universal free lunch” OR “universal free breakfast” OR “universal free breakfast program” OR “school meal provision” OR “free lunch*” OR “free breakfast” OR “meal reimbursement” OR “reduced-price co-pay” OR “reduced-price copay” OR “school meal reimbursement” OR “healthy school meals for all”) ) AND AB ( (“universal school meals” OR “community eligibility provision” OR “universal free meal*” OR “universal free lunch” OR “universal free breakfast” OR “universal free breakfast program” OR “school meal provision” OR “free lunch*” OR “free breakfast” OR “meal reimbursement” OR “reduced-price co-pay” OR “reduced-price copay” OR “school meal reimbursement” OR “healthy school meals for all”) )

S2 TI ( student* OR school* ) OR AB ( student* OR school* )

S3 S1 AND S2

S4 S1 AND S2 Limiters – Scholarly (Peer Reviewed) Journals

S5 S1 AND S2 Limiters – Scholarly (Peer Reviewed) Journals; Published Date: 20210101-20211231

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.

Bernstein LS, JE McLaughlin, MK Crepinsek, et al. Evaluation of the School Breakfast Program pilot project: final report. U.S. Department of Agriculture. Published 2004. Accessed June 22, 2022. https://files.eric.ed.gov/fulltext/ED486532.pdf.

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.

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.

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.

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 2021a;13:911.

Cohen JFW, Hecht AA, Hager ER, et al. Strategies to improve meal consumption: a systematic review. Nutrients 2021b;13(10):3520.

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.

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.

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.

Fleischhacker S, Campbell E. Ensuring equitable access to school meals. J Acad Nutr Diet, 2020;120(5):893-7.

Forrestal S, Potamites E, Guthrie J, et al. Associations among food security, school meal participation, and students’ diet quality in the first school nutrition and meal cost study. Nutrients 2021;13(307).

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.

Kenney EL, Barrett JL, Bleich SN, et al. Impact of the Healthy, Hunger-Free Kids Act on obesity trends. Health Affairs 2020;39(7):1122-9.

Larson N, Wang Q, Grannon K, et al. A low-cost, grab-and-go breakfast Intervention for rural high school Students: changes in School Breakfast Program participation among at risk students in Minnesota. Journal of Nutrition Education and Behavior 2018;50(2):125-32.e1.

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.

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.

Milfort R, Taylor J, May L, et al. Third Access, Participation, Eligibility, and Certification Study (APEC-III) Final Report, Volume 1. Published 2021. Accessed July 12, 2022. https://fns-prod.azureedge.us/sites/default/files/resource-files/APECIII-Vol1.pdf.

Mozaffarian D, Fleischhacker S, Andrés JR. Prioritizing nutrition security in the US. Journal of the American Medical Association 2021;325(16): 1605-6.

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).

National Center for Education Statistics. Digest of education statistics: 2020. Number and percentage of public school students eligible for free or reduced-price lunch, by state: selected years, 2000-01 through 2018-19. Published 2021. Accessed July 12, 2022. https://nces.ed.gov/programs/digest/d20/tables/dt20_204.10.asp.

National Center for Education Statistics. Concentration of public school students eligible for free or reduced-price lunch. Published 2022. Accessed June 22, 2022. https://nces.ed.gov/programs/coe/indicator/clb.

Newman C. U.S. The income volatility see-saw: implications for school lunch. Department of Agriculture Economic Research Service. Published 2006. Accessed June 22, 2022. www.ers.usda.gov/publications/pub-details/?pubid=45597.

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, EIB-174. Published 2017. Accessed June 22, 2022. www.ers.usda.gov/publications/pub-details/?pubid=84002.

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.

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.

USDA. Ensuring access to free and reduced-price school meals for low-income students. Published 2016a. Accessed June 22, 2022. www.fns.usda.gov/cn/ensuring-access-free-and-reduced-price-school-meals-low-income-students.

USDA. Meaningful access for persons with limited English proficiency in the school meal programs: guidance and Q&As. Published 2016b. Accessed April 26, 2022. www.fns.usda.gov/cn/meaningful-access-persons-lep-school-meal-guidance-and-qas.

USDA. Community Eligibility Provision alternative breakfast models. Published 2016c. Accessed June 22, 2022. https://fns-prod.azureedge.us/sites/default/files/cn/cep_increasingbfast.pdf.

USDA. The School Breakfast Program. Published 2021. Accessed June 22, 2022. www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/school-breakfast-program.

USDA. The National School Lunch Program. Published 2022a. Accessed June 22, 2022. www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/national-school-lunch-program.

USDA. Child nutrition tables. Published 2022b Accessed June 22, 2022. www.fns.usda.gov/pd/child-nutrition-tables.

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion.

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:

• Updated Title I Guidance for Schools Electing Community Eligibility
• Updated E-rate Guidance for Schools Electing Community Eligibility

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:

• USDA Community Eligibility Provision Resource Center
• USDA Community Eligibility Provision Planning and Implementation Guidance
• Community Eligibility Provision: Alternative Breakfast Models [PDF – 161 KB]

Healthy People 2030

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

• Increase the proportion of students participating in the School Breakfast Program — AH-04
• Increase the proportion of eligible students participating in the Summer Food Service Program — AH-R03
• Reduce household food insecurity and hunger — NWS-01
• Eliminate very low food security in children — NWS-02