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Spill MK, Trivedi R, Thoerig RC, Balalian AA, Schwartz MB, Gundersen C, Odoms-Young A, Racine EF, Foster MJ, Davis JS, MacFarlane AJ. Universal Free School Meals and School and Student Outcomes: A Systematic Review. JAMA Netw Open 2024; 7:e2424082. [PMID: 39120904 PMCID: PMC11316229 DOI: 10.1001/jamanetworkopen.2024.24082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/21/2024] [Indexed: 08/10/2024] Open
Abstract
Importance The White House National Strategy on Hunger, Nutrition, and Health included expanding free school meals to all students, regardless of income, which has sparked debate in the United States. Objective To assess the association between universal free school meals (UFSMs) and school and student outcomes in the United States. Evidence Review An expert panel-informed protocol was developed to evaluate intervention or cohort studies comparing UFSM programs, such as the Community Eligibility Provision (CEP), with non-UFSM programs in US schools from August 2012 (excluding 2020-2021 due to the COVID-19 pandemic) in peer-reviewed publications or government reports. Outcomes included meal participation rates, attendance, dietary intake and quality, food waste, economic impact, food insecurity, anthropometrics, disciplinary actions, stigma, and shaming. A search of Medline, Econlit, Business Source Ultimate, ERIC, Agricola, Cab Abstracts, and CINAHL was performed in April 2024. Two researchers screened articles for inclusion, extracted data, and assessed risk of bias, using the Risk of Bias in Nonrandomized Studies of Interventions tool, for each included study. Grading of Recommendations, Assessment, Development, and Evaluations was used to assess the certainty of evidence for each outcome. Findings The search identified 2784 records, with 6 studies included, representing more than 11 000 elementary, middle, and high schools. Nonrandomized intervention studies performed difference-in-difference or rate ratio analysis to investigate CEP participation rates, attendance, anthropometrics, and/or suspensions. CEP was associated with increased lunch (3 studies; moderate certainty) and breakfast (1 study; very low certainty) participation. School attendance was unchanged or improved in schools with CEP compared with schools without UFSM (2 studies; low certainty). CEP was associated with lower obesity prevalence (1 study; very low certainty) and fewer suspensions (1 study; very low certainty). Reasons for downgrading the certainty ratings included indirectness (data not fully representative of the United States) and inconsistency (small number of studies limiting ability to assess consistency). Despite the limitations, the evidence reflected well-designed longitudinal intervention studies appropriate for decision-making. Conclusions and Relevance In this systematic review, UFSMs were associated with increased meal participation, no or slight improvements in attendance, and decreased obesity prevalence and suspension rates; certainty of evidence was moderate for lunch participation and low or very low for other outcomes. Studies did not report several important outcomes, such as diet quality and food security, suggesting the need for more high-quality research encompassing policy-relevant indicators.
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Affiliation(s)
- Maureen K Spill
- Texas A&M Agriculture, Food & Nutrition Evidence Center, Fort Worth
| | - Rupal Trivedi
- Texas A&M Agriculture, Food & Nutrition Evidence Center, Fort Worth
| | - Rachel C Thoerig
- Texas A&M Agriculture, Food & Nutrition Evidence Center, Fort Worth
| | - Arin A Balalian
- Texas A&M Agriculture, Food & Nutrition Evidence Center, Fort Worth
| | - Marlene B Schwartz
- Department of Human Development and Family Science, College of Liberal Arts and Science, University of Connecticut, Storrs
| | - Craig Gundersen
- Department of Economics, Hankamer School of Business, Baylor University, Waco, Texas
| | - Angela Odoms-Young
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, New York
| | - Elizabeth F Racine
- Department of Nutrition, College of Agriculture and Life Sciences, Texas A&M University, College Station
| | - Margaret J Foster
- Center for Systematic Reviews and Research Syntheses, University Libraries, Texas A&M University, College Station
| | - Julie S Davis
- Texas A&M Agriculture, Food & Nutrition Evidence Center, Fort Worth
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Cabrera-Ledesma B, Abril-Ulloa V, Pinos-Vélez V, Carpio-Arias V. A Descriptive Qualitative Study of the Perceptions of Regulatory Authorities, Parents, and School Canteen Owners in the South of Ecuador about the Challenges and Facilities Related to Compliance with the National Regulation for School Canteens. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5313. [PMID: 37047929 PMCID: PMC10094177 DOI: 10.3390/ijerph20075313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/23/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
The prevalence of overweight and obesity in the Ecuadorian school population continues to increase. An important factor in children's nutrition is the food offered in school canteens. The objective of this study was to explore the perceptions of the challenges faced by and facilities of school canteens in the provinces of southern Ecuador in terms of complying with national regulations. For this qualitative descriptive study, semi-structured interviews were conducted in 2021 with six school canteen owners, six school directors, five health experts, and seven parents of children attending school from three provinces, Cañar, Azuay, and Morona Santiago, in Ecuador. The data were transcribed and subsequently analyzed in ATLAS ti. The participants indicated several challenges to comply with the regulations of school canteens, such as the expenses generated by them, the lack of control of street food vendors in the surroundings of the schools, and the lack of trained personnel. Regarding the facilities, they highlighted that the regulation for cleaning and hygiene are more easily fulfilled. Standards and control of the food stipend in school canteens are required to ensure a supply of healthy food for the children. Multiple challenges and strategies are proposed to improve the eating habits of the school population and to improve the nutrition of schoolchildren.
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Affiliation(s)
| | - Victoria Abril-Ulloa
- Faculty of Medical Sciences, University of Cuenca, Cuenca 010201, Ecuador
- Research Group: “Public Health, Food and Physical Activity in the Life Cycle” Career of Nutrition and Dietetic, Medical Sciences Faculty, University of Cuenca, Cuenca 010201, Ecuador
| | | | - Valeria Carpio-Arias
- Research Group GIANH, School of Nutrition and Dietetics, Faculty of Public Health, Escuela Superior Politécnica de Chimborazo, Riobamba 060155, Ecuador
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Richardson AS, Weden MM, Cabreros I, Datar A. Association of the Healthy, Hunger-Free Kids Act of 2010 With Body Mass Trajectories of Children in Low-Income Families. JAMA Netw Open 2022; 5:e2210480. [PMID: 35511177 PMCID: PMC9073566 DOI: 10.1001/jamanetworkopen.2022.10480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/18/2022] [Indexed: 01/13/2023] Open
Abstract
Importance Implemented in 2012, the Healthy, Hunger-Free Kids Act of 2010 (HHFKA) increased nutritional requirements of the National School Lunch Program (NSLP) to reverse the potential role of the NSLP in childhood obesity. Objective To evaluate whether associations between the free or reduced-price NSLP and body mass growth differed after implementation of the HHFKA. Design, Setting, and Participants This cohort study used data from 2 nationally representative cohorts of US kindergarteners sampled in 1998 to 1999 and 2010 to 2011 and followed up for 6 years, through grade 5, in the Early Childhood Longitudinal Study Kindergarten Class of 1998-1999 (ECLS-K:1999, in 2003-2004) and Kindergarten Class of 2010-2011 (ECLS-K:2011, in 2015-2016). In total, 5958 children were selected for analysis from low-income families eligible for the free or reduced-price NSLP (household income <185% of the federal poverty level) who attended public schools and had no missing data on free or reduced-price NSLP participation or on body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) at kindergarten or grades 1 and 5. Data were analyzed from January 1 to September 7, 2021. Exposures Cross-cohort comparison of before vs after implementation of the HHFKA for free or reduced-price NSLP participation at kindergarten and grades 1 and 5. Main Outcomes and Measures Body mass index difference (BMID) from obesity threshold was the difference in BMI units from the age- and sex-specific obesity thresholds (95th percentile) and is sensitive to change at high BMI. Multigroup models by cohort included weights to balance the distribution of the 2 cohorts across a wide range of covariates. A Wald test was used to assess whether associations differed between the cohorts. Results In the final analysis, 3388 children in ECLS-K:1999 (1696 girls [50.1%]; mean [SD] age at baseline, 74.6 [4.3] months) and 2570 children in ECLS-K:2011 (1348 males [52.5%]; mean [SD] age at baseline, 73.6 [4.2] months) were included. The best fitting model for BMID change by free or reduced-price NSLP participation across the cohorts included fixed and time-varying associations. Before HHFKA implementation, grade 5 free or reduced-price NSLP participants had higher BMID, adjusted for their prior BMID trajectory, than nonparticipants (β = 0.54; 95% CI, 0.27-0.81). After HHFKA implementation, this association was attenuated (β = -0.07; 95% CI, -0.58 to 0.45), and grade 5 associations were different across cohorts (χ21 = 4.29, P = .04). Conclusions and Relevance In this cohort study using cross-cohort comparisons, children from low-income families who participated in the free or reduced-price NSLP had a higher likelihood of progression to high BMI that was no longer observed after HHFKA implementation. This finding suggests that the HHFKA may have attenuated the previous association of the NSLP with child obesity disparities.
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Affiliation(s)
- Andrea S. Richardson
- Department of Behavioral and Policy Sciences, RAND Corporation, Pittsburgh, Pennsylvania
| | - Margaret M. Weden
- Department of Economics, Sociology, and Statistics, RAND Corporation, Santa Monica, California
| | - Irineo Cabreros
- Department of Economics, Sociology, and Statistics, RAND Corporation, Boston, Massachusetts
| | - Ashlesha Datar
- Center for Economic and Social Research, University of Southern California, Los Angeles
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Harshman SG, Castro I, Perkins M, Luo M, Mueller KB, Cena H, Portale S, Raspini B, Taveras E, Fiechtner L. Pediatric weight management interventions improve prevalence of overeating behaviors. Int J Obes (Lond) 2022; 46:630-636. [PMID: 34862470 PMCID: PMC8883500 DOI: 10.1038/s41366-021-00989-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 09/20/2021] [Accepted: 10/06/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine changes in prevalence of overeating behaviors in a comparative effectiveness study of two pediatric weight management interventions. METHODS Four-hundred and seven children, ages 6-12 years, with a BMI ≥ 85th percentile were enrolled in a comparative effectiveness trial of two pediatric weight management interventions. Prevalence of "sneaking, hiding or hoarding food", and 'eating in the absence of hunger' was evaluated at baseline and 12 months. Statistical methods included McNemar's test and longitudinal logistic regression. RESULTS Prevalence of "sneak, hide, or hoard food" significantly decreased in all participants from 29.1% to 20.7% at 12 months. The prevalence of "eating in the absence of hunger" decreased in all participants from 46.7% to 22.4% at 12 months. Use of SNAP benefits, free/reduced meals at school, parental stress, housing, and food insecurity at baseline were associated with an increased likelihood of endorsing overeating behaviors at 12 months. Conversely, those who engaged in at least one session of the pediatric weight management intervention were significantly less likely to endorse "eating in the absence of hunger" at 12 months. CONCLUSIONS Participation in pediatric weight management interventions improves the prevalence of overeating behaviors and is associated with participant engagement and social determinants of health, specifically food security status. Efforts to engage populations impacted by food insecurity and other social determinants of health risk factors will be critical for success of weight management interventions. CLINICAL TRIAL REGISTRATION This trial has been registered at ClinicalTrials.gov (identifier: NCT03012126).
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Affiliation(s)
- Stephanie G. Harshman
- Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts;,Eating Disorders Clinical and Research Program, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts
| | - Ines Castro
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, Massachusetts
| | - Meghan Perkins
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, Massachusetts
| | - Man Luo
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, Massachusetts
| | - Katelee B. Mueller
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, Massachusetts
| | - Hellas Cena
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.,Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, Pavia, Italy
| | - Sandra Portale
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Benedetta Raspini
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Elsie Taveras
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, Massachusetts
| | - Lauren Fiechtner
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, Massachusetts;,Department of Gastroenterology and Nutrition, MassGeneral Hospital for Children, 175 Cambridge St, Boston, Massachusetts,,Greater Boston Food Bank, 70 S. Bay Avenue, Boston, MA 02118
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Abstract
PURPOSE OF REVIEW This review examines the current evidence about the ways in which food insecurity relates to obesity in children and adolescents, examining diet and diet-related behaviors, and taking into consideration the role of stress. RECENT FINDINGS While living with food insecurity impacts stress and diet-related behaviors in children and adolescents, it is not clear whether food insecurity is associated with obesity above and beyond the influence of poverty. However, strategies to mitigate food insecurity and obesity are inherently connected, and recent examples from clinical practice (e.g., screening for food insecurity among patients) and advocacy (e.g., policy considerations regarding federal food programs such as the Supplemental Nutrition Assistance Program, or SNAP) are discussed. Food insecurity and obesity coexist in low-income children and adolescents in the USA. The COVID-19 pandemic exerts disproportionate burden on low-income children and families, magnifying their vulnerability to both food insecurity and pediatric obesity.
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Affiliation(s)
- June M Tester
- Division of Pediatric Endocrinology, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, Oakland, 94609, CA, USA.
- Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, 550 16th Street, 4th Floor Box 0110, San Francisco, CA, USA.
| | - Lisa G Rosas
- Epidemiology and Population Health, Stanford University, School of Medicine, Stanford, CA, USA
| | - Cindy W Leung
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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