Universal free school meals improve student health and participation

By Dr. Priyom Bose, Ph.D.Reviewed by Benedette Cuffari, M.Sc.Aug 14 2024

A recent JAMA Network Open study examines the impact of universal free school meal (UFSM) programs on student and school outcomes in the United States.

Study: Universal Free School Meals and School and Student Outcomes: A Systematic Review. Image Credit: Robert Kneschke / Shutterstock.com

The UFSM program in the United States

In 2022, the White House National Strategy on Hunger, Nutrition, and Health was launched with the goal of improving healthy eating patterns, increasing physical activity levels, and ending hunger in America by 2030.

Since 2013, the Community Eligibility Provision (CEP) has reimbursed eligible schools to serve free meals to their students. In the 2022-2023 school year, 19.9 million children had access to UFSMs through the implementation of CEP in 82% of eligible schools. The following school year, California, Colorado, Maine, Massachusetts, Michigan, Minnesota, New Mexico, Nevada, and Vermont began to offer UFSMs to all schools, regardless of their CEP eligibility.  

The expansion of UFSMs to all students, regardless of income status, remains contentious among politicians due to the increased costs associated with this program. Thus, a high-quality systematic review (SR) is needed to examine the association between UFSMs and various student- and school-level outcomes.

About the study

Previous SRs on UFSMs have considered available international and cross-sectional evidence. Comparatively, the present SR evaluates longitudinal evidence on the associations between UFSMs in the U.S. and student- and school-level outcomes. The variables initially considered in this analysis included dietary intake, diet quality, meal participation rates, food waste, stigma, shaming, and economic impacts, such as attendance, anthropometrics, and disciplinary actions.

Key confounding factors and Population, Intervention, Comparator, Outcome (PICO) elements were considered. Two independent reviewers assessed the risk of bias in each study using the Non-randomized Studies of Interventions (ROBINS-I) tool, which identifies common sources of bias across non-randomized studies. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method was also used to provide a certainty of evidence rating.

Study findings

Six non-randomized intervention studies, representing over 11,000 schools in the U.S., were included in the SR. Three studies reported a positive association between the provision of UFSMs and increased meal participation.

Two studies did not identify any differences in attendance scores between schools with and without CEP. However, the overall evidence on attendance was mixed, as one study reported a significant decline in absenteeism in schools with CEP.

One study assessed the association between the prevalence of obesity and the implementation of CEP using a difference-in-difference analysis. In schools that implemented CEP interventions, the prevalence of obesity was reduced by 0.60 percentage points, whereas normal weight increased by 0.58 percentage points compared to CEP-eligible schools that did not participate in the program.

One study reported a reduced number of suspensions by 0.7 percentage points in schools that offered USFMs. These results were only significant for low-income students, where lunch eligibility was considered a proxy for income.

Five of the six studies appropriately controlled for confounding factors through difference-in-difference analyses and, as a result, were considered to have a low risk of bias. Only one study was rated to have a high risk of bias due to several key confounders that were not considered in the analysis.

The GRADE approach determined a moderate association to exist between CEP implementation and meal participation. Comparatively, a low association was observed between lunch and breakfast participation and attendance. The certainty was also very low for the association between USFMs and anthropometrics or disciplinary actions.

Conclusions

UFSMs are associated with higher meal participation and attendance rates, a reduced prevalence of obesity, and school suspensions among U.S. students. These associations could also influence other student outcomes, like academic performance; however, more studies are needed to evaluate this relationship.

The strengths of the current SR include the analyzed studies' large sample sizes and the data sources' validity. The current study also aimed to inform policy decisions, as only U.S. studies were included, whereas studies that did not provide causal estimates were excluded.

Although a few studies were included in the review, these studies were associated with lower bias and higher certainty than some studies included in similar reviews. Rigorous methods were also used to assess the risk of bias and certainty of evidence.

One fundamental limitation of the current study is the small number of articles and outcome variables considered in the analysis. The selected studies did not provide evidence of other priority outcomes, such as food waste, stigma, and shaming.