Universal Free School Meals: Implementation of the Community Eligibility Provision and Impacts on Student Nutrition, Behavior and Academic Performance

Food insecurity, defined as limited or uncertain access to adequate food, affects more than 11 million U.S. children. Childhood food insecurity is associated with numerous negative physical and mental health consequences, as well as poor cognitive function and academic performance. Through the Community Eligibility Provision (CEP), high-poverty schools participating in the U.S. Department of Agriculture’s school meal programs are able to provide universal free breakfast and lunch. Rolled out over three years in ten states and the District of Columbia, CEP became available to eligible schools nationwide in 2014. Though emerging evidence suggests benefits of CEP for student health, learning, and behavior, one-third of eligible schools have not yet opted in. This dissertation explores implementation of CEP and its impacts on student nutrition, behavior, and academic performance. Findings are presented in three manuscripts. The first paper evaluates which school, district, and state characteristics were associated with CEP participation across U.S. public schools in School Year 2017-18. Odds of CEP participation were higher in higher in schools with more students directly certified for free meals, in Title I schools, in middle and high schools, in urban schools, in schools with lower enrollment and a lower proportion of Hispanic students, in very large districts, in districts and states without Republican elected officials, and in states where CEP had been available longer. Barriers to adoption may be addressed through federal or state policy change and through targeted technical support from advocates and state education agencies to schools in suburban and small districts. The second paper uses in-depth interviews with food service staff at schools participating in CEP in Maryland to explore perceived facilitators and barriers to implementation and benefits for students, staff, and food service operations. Perceived benefits of CEP include increased meal participation, reduced student stigma and financial stress among parents, and improved staff morale. Identified implementation barriers, including concerns about impacts of CEP on federal, state, and grant funding, may be addressed through policy intervention. Identified best practices for implementation, including strong communication with parents and creative strategies to boost student meal participation, can be adopted by participating schools and districts. The third paper uses a comparative interrupted time series design to estimate the relationship between CEP adoption and student meal participation, behavior, and academic performance outcomes in Maryland schools. The study compares outcomes in CEP-participating schools to schools that are eligible or near-eligible but not participating using data from five years pre-implementation and four years post-implementation. Results show that CEP participation is linked to increased breakfast and lunch participation in elementary and middle schools, and lunch participation in high schools. CEP is also associated with improvements in elementary school attendance, middle school disciplinary referrals, and elementary science test scores. Dissertation findings highlight barriers to CEP adoption, best practices for implementation, and benefits for students, families, and schools. Results point to opportunities to increase CEP uptake through state and federal policy change and targeted promotion by anti-hunger advocates and state education agencies. Future research should assess how state policies influence CEP adoption and how CEP impacts student stigma, food security, and school finances

Universal school meals and associations with student participation, attendance, academic performance, diet quality, food security, and Body Mass Index: A systematic review

The school environment plays an important role in children\u27s diets and overall health, and policies for universal free school meals have the potential to contribute to positive child health outcomes. This systematic review evaluates studies examining the association between universal free school meals and students\u27 school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published in economically developed countries published through December 2020 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters\u27 Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. A total of 47 studies were identified and the Newcastle-Ottawa Scale (NOS) was applied to assess bias. Nearly all studies examining universal free school meals found positive associations with school meal participation. Most studies examining universal free school meals that included free lunch found positive associations with diet quality, food security, and academic performance; however, the findings of studies examining only universal free breakfast were mixed. Research findings were similarly mixed when examining attendance as an outcome. Concerns about adverse outcomes on student BMI were not supported by the literature; in fact, several studies detected a potentially protective effect of universal free school meals on BMI. Research examining the impact of universal free meals on school finances was limited, but suggest that lower-income school districts in the U.S. may have positive financial outcomes from participation in universal free school meal provisions. Additionally, providing free meals to students may be associated with improved household incomes, particularly among lower-income families with children. Further research is needed to examine the financial implications of universal free meals for both school districts and families. Overall, universal free school meals may have multiple benefits for students and countries should consider universal free school meal provisions with strong nutrition guidelines. (PROSPERO registration: CRD42020221782)

Teachers as Healthy Beverage Role Models: Relationship of Student and Teacher Beverage Choices in Elementary Schools.

Schools are a key setting for curbing student intake of sugar-sweetened beverages (SSBs). While studies suggest that restrictions on SSBs, increased access to healthier beverages, and education about the importance of drinking water instead of SSBs can promote healthier beverage patterns among students, there is little known about the impact that teachers' own beverage choices can have on those of their students. Data were drawn from cross-sectional surveys administered as part of a larger evaluation of a drinking water access and promotion intervention in public elementary schools in the San Francisco Bay Area region of California. Descriptive statistics were used to examine teacher (n = 56) and student (n = 1176) self-reported beverage consumption at school. Mixed-effects logistic regression was used to examine associations between teacher and student beverage intake adjusting for clustering of students by teacher. Teachers were also surveyed via open-ended questions about strategies to increase student water consumption at school. Nearly all teachers reported drinking water during the school day (95%), often in front of students. Teacher SSB intake was rare (9%). Students whose teachers drank water in front of their classes were significantly more likely to report drinking water during the school day. Teachers tend to select healthy beverages at work and may serve as role models to encourage student consumption of water instead of SSBs

Validation of a survey to examine drinking-water access, practices and policies in schools

ObjectiveEnsuring ready access to free drinking-water in schools is an important strategy for prevention of obesity and dental caries, and for improving student learning. Yet to date, there are no validated instruments to examine water access in schools. The present study aimed to develop and validate a survey of school administrators to examine school access to beverages, including water and sports drinks, and school and district-level water-related policies and practices.DesignSurvey validity was measured by comparing results of telephone surveys of school administrators with on-site observations of beverage access and reviews of school policy documents for any references to beverages. The semi-structured telephone survey included items about free drinking-water access (sixty-four items), commonly available competitive beverages (twenty-nine items) and water-related policies and practices (twenty-eight items). Agreement between administrator surveys and observation/document review was calculated using kappa statistics for categorical variables, and Pearson correlation coefficients and t tests for continuous variables.SettingPublic schools in the San Francisco Bay Area, California, USA.SubjectsSchool administrators (n 24).ResultsEighty-one per cent of questions related to school beverage access yielded κ values indicating substantial or almost perfect agreement (κ>0·60). However, only one of twenty-eight questions related to drinking-water practices and policies yielded a κ value representing substantial or almost perfect agreement.ConclusionsThis school administrator survey appears reasonably valid for questions related to beverage access, but less valid for questions on water-related practices and policies. This tool provides policy makers, researchers and advocates with a low-cost, efficient method to gather national data on school-level beverage access

Food Rescue Intervention Evaluations: A Systematic Review

Food rescue, the practice of gathering food that could otherwise be wasted and redirecting it for human consumption, represents a critical opportunity to improve food security and reduce waste. As global interest in reducing hunger and food waste grows, better insight is needed to assess and compare the effectiveness of different models of food rescue. We conducted a systematic review of peer-reviewed studies evaluating food rescue interventions with the aim of synthesizing findings and comparing methodologies. We searched PubMed, Academic Search Ultimate, and Science Citation Index for studies published worldwide, in English, through June 2019. Studies were included that: a) evaluated an existing or proposed food rescue intervention and, b) quantitatively or qualitatively measured the intervention impact. All nineteen included studies were observational and the intervention types ranged widely. The most commonly reported metric was the weight of food recovered. Few studies reported client outcome measures. The included studies suggested promising effects of food rescue interventions, including positive return on investment, decreased environmental burden, large quantities of food rescued and clients served, and high stakeholder satisfaction. Comparison across studies was challenging, however, due to inconsistent metrics and insufficiently detailed methodology. This review documents a need for additional evaluation of food rescue interventions and recommends a standardized methodology. Additional dialogue among key stakeholders is warranted to develop consistent, meaningful metrics to assess food rescue

Influence of Food and Beverage Companies on Retailer Marketing Strategies and Consumer Behavior

The retail food environment plays an important role in shaping dietary habits that contribute to obesity and other chronic diseases. Food and beverage manufacturers use trade promotion—incentives paid to retailers—to influence how products are placed, priced, and promoted in stores. This review aims to: (1) catalogue trade promotion practices that manufacturers use to influence retailer marketing strategies, and (2) describe how these retailer marketing strategies affect consumer purchasing behavior and attitudes. Researchers searched five databases, Academic Search Ultimate, Business Source Ultimate, PsycINFO, PubMed, and Web of Science, to identify literature from industry and academic sources published in English through November 2019. Twenty articles describing manufacturer trade promotion practices were synthesized and provided insight into four types of trade promotion practices: category management, slotting allowances, price discounts, and cooperative advertising. Fifty-four articles describing the impact of retailer marketing on consumers were synthesized and graded for quality of evidence. While comparison across studies is challenging, findings suggest that retailer marketing strategies, such as price promotions and prominent placement, lead to increased sales. Results can guide efforts by policymakers, public health practitioners, and food retailers to design retail environments that improve healthy eating while maintaining retailer financial interests. Additional research should measure the impact of retailer marketing strategies on consumer diet quality and retailer outcomes (e.g., return-on-investment)

Perceived Barriers to Fruit and Vegetable Gardens in Early Years Settings in England: Results from a Cross-Sectional Survey of Nurseries.

Garden-based interventions may increase child intake of fruits and vegetables and offset food costs, but few have been conducted in early care and education (ECE). This study assessed whether nurseries were interested in and perceived any barriers to growing fruits and vegetables. Surveys were mailed to a cross-sectional sample of nurseries in 2012-2013 throughout England. Nurseries were stratified based on socioeconomic status as most, middle, or least deprived areas. We fit logistic regression models to assess the odds of nurseries interested in growing fruits and vegetables and perceiving any barriers, by deprivation tertile. A total of 851 surveys were returned (54% response). Most nurseries (81%) were interested in growing fruits and vegetables. After adjustment, there was no difference in interest in the middle (OR 1.55; CI 0.84, 2.78; p = 0.16) or most (OR 1.05; CI 0.62, 1.78; p = 0.87) deprived areas, compared to the least deprived. Nurseries reported barriers to growing fruits and vegetables, including space (42%), expertise (26%), and time (16%). Those in the most deprived areas were more likely to report space as a barrier (OR 2.02; 95% CI 1.12, 3.66; p = 0.02). Nurseries in the most deprived areas may need creative solutions for growing fruits and vegetables in small spaces.This work was undertaken by the Centre for Diet and Activity Research (CEDAR), a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. The funders had no role in the design, execution, interpretation, or writing of the study

Perceived Barriers to Fruit and Vegetable Gardens in Early Years Settings in England: Results from a Cross-Sectional Survey of Nurseries

Garden-based interventions may increase child intake of fruits and vegetables and offset food costs, but few have been conducted in early care and education (ECE). This study assessed whether nurseries were interested in and perceived any barriers to growing fruits and vegetables. Surveys were mailed to a cross-sectional sample of nurseries in 2012–2013 throughout England. Nurseries were stratified based on socioeconomic status as most, middle, or least deprived areas. We fit logistic regression models to assess the odds of nurseries interested in growing fruits and vegetables and perceiving any barriers, by deprivation tertile. A total of 851 surveys were returned (54% response). Most nurseries (81%) were interested in growing fruits and vegetables. After adjustment, there was no difference in interest in the middle (OR 1.55; CI 0.84, 2.78; p = 0.16) or most (OR 1.05; CI 0.62, 1.78; p = 0.87) deprived areas, compared to the least deprived. Nurseries reported barriers to growing fruits and vegetables, including space (42%), expertise (26%), and time (16%). Those in the most deprived areas were more likely to report space as a barrier (OR 2.02; 95% CI 1.12, 3.66; p = 0.02). Nurseries in the most deprived areas may need creative solutions for growing fruits and vegetables in small spaces