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Association of Universal Free School Meals With School and Student Outcomes
TAKE-HOME MESSAGE
- This review evaluated the effect of universal free school meals on student outcomes. Schools with universal free school meals had increased breakfast and lunch participation, no change or modest improvement in attendance, lower obesity prevalence, and fewer suspensions. Most results were rated as having low or very low certainty of evidence, with one study having a moderate certainty of evidence.
- Clinicians should advocate for the implementation of such programs to improve certain health outcomes. Further research is needed to increase the certainty of evidence on this topic.
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
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.
Additional Info
Disclosure statements are available on the authors' profiles:
Universal Free School Meals and School and Student Outcomes: A Systematic Review
JAMA Netw Open 2024 Aug 01;7(8)e2424082, MK Spill, R Trivedi, RC Thoerig, AA Balalian, MB Schwartz, C Gundersen, A Odoms-Young, EF Racine, MJ Foster, JS Davis, AJ MacFarlaneFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
A frequent subject of policy debate is government-run nutrition programs. These can include general supplemental nutrition programs (such as SNAP or WIC), but often include programs like school meals. One element of school meal programs has been increasing federal support for universal free school meals (UFSM). Although opponents argue that this program ends up providing free lunch for children whose families can easily afford it, proponents note that it reduces paperwork barriers, lowers administrative costs (as one does not need to verify eligibility), and can reduce “lunch shaming” where a paperwork issue may result in a child not being able to receive lunch at the point of receiving one.
Although the argument is that we should universally be against any child being hungry, the deeper question is whether it makes a difference — are children better off when UFSMs are provided? This systematic review of 6 studies covering over 11,000 schools examined this question.
On a basic level, there was an increase in school meal participation — which is perhaps an exercise in the obvious — but it does seem to indicate that UFSM did result in more children using the program, even if we don’t know why they didn’t previously. Attendance was improved in a couple of studies, obesity prevalence was reduced in one study, and suspensions dropped in one study.
Underwhelming? I agree, and so did the authors who reported that there was only moderate certainty of evidence for meal participation and low or very low certainty of evidence for the other outcomes. As the authors note, there were several outcomes that were simply not reported, such as quality of diet or general assessments of food security. While it is typical for systematic reviews to begin with a large number of records from the database and end up with not that many included, starting from 2784 and ending up with a mere 6 highlights how poor the evidence base is for this type of work. While school nutrition programs produce a lot of data that can be reviewed, they don’t necessarily investigate other questions wholesomely.
Clinically, what does this mean? Not much that would change our thinking at this time. I will say that the paper is worth reading for the excellent discussion of all the nuances of school nutrition programs and where they may or may not affect child outcomes. I advise that while we await better evidence, we should follow a policy-level “first, do no harm” approach by coming back to basic principles: we shouldn’t need a study to prove that a hungry child is not better off than one who is adequately fed.