The New school food standards and nutrition of school children: Direct and Indirect Effect Analysis

School Meal Nutrition Standards Reduce Disparities Across Income and Race/Ethnicity

INTRODUCTION

Children's diets in the U.S. typically fail to meet dietary recommendations, contributing to associated adverse health outcomes. The Healthy, Hunger-Free Kids Act (HHFKA) of 2010 required the U.S. government to update nutrition standards for school meals to align with the Dietary Guidelines for Americans (DGAs). This study estimates the evolving impact of substituting school-prepared food for home-prepared food on overall daily diet quality and by subcomponents of diet quality. Subgroup analyses are performed by race/ethnicity and income.

METHODS

Two, nonconsecutive days of dietary recall data from the National Health and Nutrition Examination Survey (2005-March 2020) are used to calculate schoolchildren's Healthy Eating Index (HEI)-2020 scores. The study includes children with complete two-day dietary intakes who attend kindergarten through twelfth grade in a school offering lunch. An individual-level fixed effects regression is employed to examine the relationship of school food consumption on HEI-2020 scores before and after HHFKA-mandated changes in nutrition standards. Analyses were conducted on September 23, 2023.

RESULTS

Prior to changes in standards (2005-2008), school food did not impact diet quality within the overall group of children. In 2009-2012, positive associations between school food and diet quality emerged for low-income students and for non-Hispanic Black students. By 2013-2020, improvements were seen across all groups. The association between school food and diet quality was most attributable to more favorable consumption of dairy, fruit, whole grains, refined grains, added sugars and saturated fats.

CONCLUSIONS

HHFKA-based nutrition standards were associated with beneficial dietary changes and reduced dietary disparities for children across diverse backgrounds.

Universal Free School Meals and School and Student Outcomes: A Systematic Review

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.

Promoting Healthier Purchases: Ultraprocessed Food Taxes and Minimally Processed Foods Subsidies for the Low Income

INTRODUCTION

Fiscal policies can shift relative food prices to encourage the purchase and consumption of minimally processed foods while discouraging the purchase and consumption of unhealthy ultraprocessed foods, high in calories and nutrients of concern (sodium, sugar, and saturated fats), especially for low-income households.

METHODS

The 2017-2018 packaged food purchase data among U.S. households were used to derive household income- and composition-specific demand elasticities across 22 food and beverage categories. Policy simulations, conducted in 2022-2023, assessed the impact of national taxes on unhealthy ultraprocessed food and beverage purchases, both separately and alongside subsidies for minimally processed foods and beverages targeted to low-income households. Resultant nutritional implications are reported on the basis of changes in purchased calories and nutrients of concern. In addition, financial implications for both households and the federal government are projected.

RESULTS

A sugar-based tax on sugar-sweetened beverages would lower both volume and calories purchased with the largest impact on low-income households without children. Meanwhile, targeted subsidies would increase fruit, vegetable, and healthier drink purchases without substantially increasing calories. Under tax simulations, low-income households would make larger reductions in their absolute volume and calorie purchases of taxed foods and beverages than their higher-income counterparts, suggesting that these policies, if implemented, could help narrow nutritional disparities.

CONCLUSIONS

Levying national taxes on unhealthy ultraprocessed foods/beverages and offering targeted subsidies for minimally processed foods/beverages could promote healthier food choices among low-income households. Such policies have the potential to benefit low-income households financially and at a relatively low cost for the federal government annually.

School Nutrition Personnel Perceptions of School Salad Bars before and after COVID-19

Many schools have salad bars as a means to increase students' fruit and vegetable intake. School nutrition programs experienced drastic changes to the school food environment due to COVID-19. The aim of the current study was to understand cafeteria personnel's experiences related to salad bar implementation before the COVID-19 pandemic and in the current school environment to inform efforts to enhance salad bar sustainability. Seven elementary schools (N = 30 personnel) installed salad bars prior to COVID-19; three of these schools (n = 13 personnel) re-opened salad bars after COVID-19. Cafeteria personnel completed surveys assessing their experiences with salad bars at both time points. Satisfaction with salad bar implementation and training was high pre- and post-COVID-19. Most agreed that salad bars increased students' fruit and vegetable intake, yet had concerns about cleanliness and waste. Perceived job difficulty increased post-COVID-19 (p = 0.01), and satisfaction with student salad bar training decreased (p = 0.001). Additional staff support and greater student training were needed post-COVID-19. Overall, salad bars were viewed favorably; however, more challenges and lower satisfaction were reported following COVID-19. Increasing support for cafeteria personnel is needed for salad bar sustainability and improving the school food environment.

Health, wellbeing and nutritional impacts after 2 years of free school meals in New Zealand

In 2020, a government-funded healthy school lunch program was introduced in a quarter of New Zealand schools, selected due to high levels of socio-economic barriers. This study assesses the impact of the introduction of the school lunch program from family (whānau), student and school principal perspectives. Across four schools, we conducted five focus groups (two with secondary students and three with family members) and four school principal interviews. Participating schools represented a range of contexts: primary and secondary, schools with cooks in on-site kitchens and schools receiving meals delivered by external caterers. Thematic analysis was used to develop themes describing the health, wellbeing and nutritional impact of the program. Family participants were 82% Indigenous Māori and self-identified as having 'borderline' (73.5%) or no financial security (8.8%). Seven positive impact themes were identified: improved food security, enhanced equity, increased appreciation of healthy foods for students, enhanced mana (wellbeing) for all, reduced financial hardship/stress for families, opportunities for nutritional learning and recognition that appreciation and uptake happen over time. Four negative impact themes were identified: low uptake that created food waste, perception that healthy food is not palatable for students, lack of knowledge of the program and loss of agency for students. This is the largest intervention in nutrition and food security for children implemented in New Zealand since the 1930's. The first 2 years have offered wellbeing and financial benefits for students and families, particularly when school environments promote uptake. More involvement of students and family members in the program planning is essential.

Did mental and emotional health of SNAP families' children improve during the COVID-19 pandemic?

The onset of the COVID-19 pandemic disproportionately affected low-income households in the United States. As part of the government's response to the pandemic, households with children participating in the Supplemental Nutrition Assistance Program (SNAP) benefited from several temporary provisions. This study examines whether the mental/emotional well-being of children in SNAP families was influenced by the SNAP temporary provisions, overall and across subpopulations by race/ethnicity and school meal programs (SMP) participation status of children. Cross-sectional data from the 2016-2020 National Survey of Children Health (NSCH) were used to study the occurrence of mental, emotional, developmental, or behavioral (MEDB) health of children (6-17 years) in SNAP families. Difference-in-Differences (DID) analyses were conducted to assess the association between MEDB health of children in SNAP families and the implementation of the SNAP provisions. Overall, finding show that between 2016 and 2020, children in SNAP families were more likely to face adverse MEDB conditions than children in non-SNAP families (p < 0.05). DID analyses indicate that children's MEDB health was not statistically affected following the first year of SNAP temporary provisions (p > 0.1). Additionally, no differential results were found by race/ethnicity of children or SMP participation (p > 0.1). Results are robust to the use of different well-being measures. These results suggest that SNAP provisions may have been associated with the reduction of the adverse effects of the pandemic on children's well-being.

Implementation of Flexibilities to the National School Lunch and Breakfast Programs and Their Impact on Schools in Missouri

BACKGROUND

In 2018, the United States Department of Agriculture (USDA) issued flexibilities to the National School Lunch and Breakfast Programs, relaxing the nutrition standards for milk, whole grains, and sodium. This study examines the implementation decision-making among Missouri school food services and the impact of implementing these flexibilities on the meals served.

METHODS

We developed a survey using the Consolidated Framework of Implementation to determine schools' implementation of the flexibilities and factors related to implementation. To determine how the implementation of flexibilities affected participation, we merged the survey results with school-level meal county data from the Missouri Department of Elementary and Secondary Education. We used ordinary least squares regression to examine how flexibility adoption related to the number of meals served.

RESULTS

Most schools implemented the wheat, milk, and sodium flexibilities. Common reasons for implementation were increasing participation, meeting students' preferences, expanding menu variety, and saving money. The implementation of flexibilities was associated with more lunches and breakfasts being served per month, particularly among free and reduced-price meals.

CONCLUSIONS

Continued research is needed to determine how the increased uptake of school meals that do not fully meet dietary guidelines by low-income students results in inequities in health outcomes. The findings can inform the design and implementation of future policies, especially as new rules related to flexibility design are determined.

Association of the Healthy, Hunger-Free Kids Act of 2010 With Body Mass Trajectories of Children in Low-Income Families

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.

Would A National Sugar-Sweetened Beverage Tax In The United States Be Well Targeted?

Sugar-sweetened beverage (SSB) taxes have been proposed to discourage excessive sugar consumption, but it is unclear how high- vs. low-SSB purchasers respond to such taxes. We first examine heterogeneity in the purchase and financial effects of a national SSB tax across different types of households buying varying amounts of SSBs. We find high-SSB purchasers are less responsive to SSB price changes than low purchasers but make larger absolute reductions in SSB purchases in response to the tax, given their notably greater purchase levels prior to the tax. Nonetheless, the economic burden of the tax falls more heavily on high-SSB purchasers who are more likely comprised of lower-income households. We then investigate whether the income regressivity of the tax will be mitigated if low-income households are targeted by fruit and vegetable (FV) subsidies. We show that depending on the tax pass-through and subsidy rates, FV subsidies can fully offset high-SSB purchasers' tax burdens, and subsidy transfers are distributed relatively uniformly across the SSB purchase distribution of low-income households. Therefore, FV subsidy transfers would be financially more beneficial to low- and moderate-SSB purchasers because they bear smaller shares of the tax burden than high-SSB purchasers.