Healthy, Hunger-Free Kids Act Research Articles

EXPRESS: Groceries or School Cafeterias: How Households Respond to School Nutrition Mandates

The Healthy, Hunger-Free Kids Act (HHFKA) placed strict nutritional mandates on meals served at U.S. public schools. This policy offers a unique opportunity to study household response to a large, exogenous change in healthiness of food available to their children. Did more healthy school meals lead households to substitute towards them, and away from grocery food purchases? Which households were more responsive to the nutritional mandates? And was there any spillover effect on the nutritional quality of their grocery food purchases? We document a meaningful decrease in the quantity of grocery food in response to the HHFKA, and a small decrease in quality. Consistent with substitution towards school meals, more of the quantity decrease is attributable to items likely to be purchased for children and categories traditionally associated with breakfast and lunch (the meals served at school). The HHFKA attracted even greater participation from financially and time constrained households for whom school meals were already important and were now coupled with the additional benefit of healthier food. These findings have important implications for policy makers and researchers, but also for food manufacturers and retailers.

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

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

Improvements in School Food Offerings over Time: Variation by School Characteristics.

The 2010 Healthy, Hunger-Free Kids Act (HHFKA) improved the nutritional quality of food served in schools. This longitudinal study examined school food offerings over time from school year 2010-11 to 2017-18 in public schools (n = 148) in four New Jersey cities. Six food indices were used to assess the number of healthy and unhealthy items offered as part of the National School Lunch Program (NSLP), in vending machines, and à la carte (i.e., competitive foods). Multilevel, multivariable linear regression with quadratic terms was used to model the trends over time. Interaction terms were added to examine whether the time trends varied by school-level factors, such as proportion of students eligible for free or reduced-price meals (FRPMs), race/ethnicity of enrolled students, and school level. Over the study period, healthy items offered in the NSLP increased (p < 0.001), while unhealthy items in the NSLP decreased (p < 0.001). Significantly different rates of declines in NSLP unhealthy offering were observed among schools at the two extremes of FRPM eligibility (p < 0.05). The trends for healthy and unhealthy foods offered in competitive foods showed significant non-linear trends, and differences were observed for school-level race/ethnicity, with worse outcomes for schools with majority Black student enrollment.

Farm to School Programs in Low-Income, High Minority K-12 Schools in New Jersey Before and After Implementation of the Healthy Hunger Free Kids Act

ABSTRACT We analyzed the prevalence of farm to school (FTS) programs in K-12 schools in four low-income, high-minority cities in New Jersey before and after implementation of the Healthy Hunger-Free Kids Act (HHFKA), between school years 2010–11 and 2017–18. Multivariable logistic regression was used to model FTS participation and the prevalence of FTS before versus after HHFKA initiation. Schools showed a significant positive trend in FTS participation (OR 1.18; p = .010) over the study period. Nonetheless, 20% of schools participated in FTS for 3+ years over the eight-year study period. Findings underscore the importance of federal legislation in supporting child nutrition initiatives.

School Garden Prevalence Before and After the Implementation of the Healthy Hunger-Free Kids Act.

The Healthy Hunger-Free Kids Act (HHFKA) of 2010 supported implementation of school gardens for promoting fruit and vegetable consumption. We examined school garden prevalence over time by school-level factors during the period before and after the implementation of HHFKA. Using data from the New Jersey Child Health Study, conducted in 4 low-income New Jersey cities, prevalence of school gardens among K-12 schools (n=148) was assessed between school year 2010-2011 and 2017-2018. Multivariable analysis estimated changes in garden prevalence over time adjusting for school-level factors. Overall, the sample included 97 elementary and 51 middle/high schools. Multivariable logistic regression showed that compared to 2010-2011 (19%) a higher proportion of schools reported having a garden in 2013-2014 (32%, p=0.025). Over the entire study period, schools with majority Hispanic student enrollment had approximately half the odds of having a garden compared to schools with majority Black students (p=0.036). School garden prevalence increased in the year immediately following the implementation of the HHFKA but this increase was not sustained over time. Future research should investigate the reasons for this decline and potential disparities by race/ethnicity.

Association between School Meal Participation and BMI Z-Scores Before and After the Federal Healthy Hunger-Free Kids Act

ObjectivesEvaluate differences in the association between school meal participation and BMI z-scores before and after the federal Healthy Hunger-Free Kids Act (HHFKA) among Black and Latinx children using nationally representative survey data.MethodsData from the 2007–2018 National Health and Nutrition Examination Survey waves were used along with linear regression models to examine associations between self-reported participation in school breakfast or lunch (0, vs 1–2, 3 + days per week) and BMI z-scores, among Black and Latinx children ages 5–17 who were eligible for free or reduced-price meals. The models were constructed separately for Black and Latinx children and adjusted for age, sex, nativity, education of the main caregiver and family income. To evaluate whether the associations differed before and after HHFKA, the adjusted models included an interaction between school meal participation (lunch or breakfast) and the survey wave indicating the period after (2015–2018) versus before (2007–2010) the 2010 HHFKA's standards for school meals took effect.ResultsWe found differential associations between lunch and breakfast participation and BMI z-scores in the period after versus before HHFKA among Black (p < 0.05), but not Latinx children. Among Black children, breakfast participation 1–2 and 3 + days (vs 0 days) was associated with lower BMI z-scores after HHFKA (−0.68 and −0.27 respectively, though significant only among the former). Further, lunch participation between 1–2 days was significantly associated with lower BMI z-scores (−0.64), whereas participation for 3 + days (vs 0 days) was non-significantly related to higher BMI z-scores (0.03).ConclusionsParticipation in school breakfast and lunch was generally associated with lower BMI z-scores after HHFKA among Black, but not among Latinx children. Longitudinal research is needed to assess dietary and obesity effects of large-scale school nutrition policies among children with the highest obesity prevalence and children who are more likely to be exposed to these policies.Funding SourcesThe National Heart, Lung, and Blood Institute of the National Institutes of Health and The Robert Wood Johnson Foundation.

Breath Stable Isotope Analysis Serves as a Non-invasive Analytical Tool to Demonstrate Dietary Changes in Adolescent Students Over Time.

Concern about adolescent diets, obesity, and the associated health risks have been growing in the United States. This inspired former First Lady Michelle Obama to spearhead the Healthy Hunger-Free Kids Act (HHFKA), which made changes to the national school lunch program by increasing servings of whole grains, fruits, and vegetables. Our study examined the variability of student carbohydrate sources throughout the day and before and after the implementation of HHFKA using a stable isotope dietary biomarker. This method uses carbon stable isotope values of exhaled CO2 breath (δ13Cbreath) and provides a quantitative, non-invasive measure. δ13Cbreath samples were collected throughout the day from students (n = 31) that attended a public high school in Salt Lake City, UT. δ13Cbreath measurements reflected the short-term carbohydrate inputs from the previous meal. Carbohydrate sources were not consistent throughout the day; most students had their lowest inputs of corn/sugar-based carbohydrates after lunch. We compared our results with an earlier study that had been conducted pre-HHFKA. After-lunch δ13Cbreath values decreased significantly between the two time points, suggesting an increase in whole grain, fruit, and vegetable carbohydrates in the lunch program. Our results demonstrated that δ13Cbreath measurements provide a valuable tool to examine carbohydrate sources in an individual's diet throughout the day. We believe that this tool could be beneficial to studies examining the relationship between sugar sweetened beverages, added sugars, and refined carbohydrates and health outcomes like diabetes and obesity in both adolescent and adult populations.

Strategies to Improve School Meal Consumption: A Systematic Review.

School meals can play an integral role in improving children’s diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students’ access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., “Smarter Lunchroom”) techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students’ access to flavored milk. Several studies found increases in students’ meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).

P42 A Longitudinal Analysis of School Garden Prevalence Across 4 New Jersey Cities

<h3>Background</h3> School gardens are a popular strategy to increase preference and consumption of fruits and vegetables (FV). The Healthy Hunger Free Kids Act (HHFKA) of 2010 supported implementation of school gardens for promoting FV consumption. Current research lacks longitudinal assessments of changes in prevalence of school gardens over time. <h3>Objective</h3> In this study, we examine the prevalence of school gardens over time by school level factors before and after the implementation of the Healthy Hunger Free Kids Act (HHFKA). <h3>Study Design</h3> We used data from the New Jersey Child Health Study (NJCHS) conducted in 4 low-income NJ cities. Information on school garden prevalence was collected from all schools (n = 148) in the 4 study cities for school years between 2010-11 and 2017-18. <h3>Analysis</h3> Prevalence of school gardens was calculated for each school year over the study period. Multivariable analysis estimated changes in prevalence of school gardens over time adjusting for school-level factors including, school level (elementary vs middle/high), enrolled students' race/ethnicity, and enrolled students' eligibility for free and reduced-price meals (FRPM). <h3>Results</h3> There were 97 elementary and 51 middle/high schools in the sample. In 2010-11, 19% of all K-12 schools participated in school gardens. Multivariate analysis showed that after adjusting for school-level factors, compared to 2010-11, a higher proportion of schools reported having a garden in 2013-14 (29%, <i>P</i> = 0.055), 2014-15 (31%, <i>P</i> = 0.018), and in 2016-17 (31%, <i>P</i> = 0.051). Schools with majority Hispanic student enrollment had less than half the odds of having a garden compared to schools with majority Black students (<i>P</i> = 0.045). There were no differences in garden prevalence between elementary and middle/high schools or FRPM eligibility. <h3>Conclusion</h3> School garden presence showed patterns of increasing prevalence over time, especially in the years following the HHFKA. Future research should examine the reasons for differences in prevalence of gardens in schools with racially and ethnically diverse student populations over multiple time points.

P46 Farm to School Program Prevalence: Do School Characteristics Matter?

<h3>Background</h3> Farm to School programs (FTSP) have been promoted as part of the Healthy, Hunger-Free Kids Act (HHFKA) to improve school children's access of nutritious, local food. <h3>Objective</h3> We investigate the prevalence of FTSP in K-12 schools before and after the implementation of the HHFKA. We also examine differences in prevalence of FTSP by school-level (elementary vs middle/high school), proportion of students enrolled from various race/ethnicity groups and proportion of students eligible for free or reduced-price meals (FRPM). <h3>Study Design, Setting, Participants</h3> A secondary analysis of data collected between 2010–2017 from 148 schools participating in the New Jersey Child Health Study (NJCHS) was analyzed. Schools were located in 4 low-income high minority cities in NJ: Camden, New Brunswick, Newark, and Trenton. <h3>Measurable Outcome/Analysis</h3> Schools' personnel answered surveys at 3 time points between 2010-2017 and reported on their schools' participation in the FTSP for the year of the survey and the previous year. Bivariate and multivariate analyses were conducted to examine FTSP prevalence rates for each year of data collection and for time periods categorized as before and after the implementation of the HHFKA. Differences in prevalence rates were compared by school characteristics. <h3>Results</h3> Across all years, on average significantly (<i>P</i> < 0.001) more elementary schools (21%) participated in the FTSP compared to middle/high schools (8%). Based on multivariate logistic regression analysis, compared to 2010, the odds of FTSP participation were 4-5 times higher in 2016 (<i>P</i> = 0.008) and 2017 (<i>P</i> = 0.003). Adjusted estimates show that across K-12 schools, participation increased from 7% in 2010 to 26% and 27% in 2016 and 2017, respectively. No differences were observed in FTSP participation by other school demographics. <h3>Conclusion</h3> Elementary schools are more likely to participate in FTSP and rates of participation in the program across K-12 schools have increased significantly in recent years.

Better Diet Quality in the Healthy Hunger-Free Kids Act and WIC Package Reduced Childhood Obesity.

* Abbreviations: HEI 2010 — : Healthy Eating Index 2010 HHFKA — : Healthy, Hunger-Free Kids Act WIC — : Special Supplemental Nutrition Program for Women, Infants, and Children The reductions in the prevalence of childhood obesity achieved by the Healthy, Hunger-Free Kids Act (HHFKA) and the changes in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package have not been widely recognized. Both the HHFKA and the regulatory updates to the WIC package substantially changed the quality of the foods provided. Both changes improved diets and led to reductions in the prevalence of obesity in the most vulnerable youth served by these programs. The HHFKA was passed by Congress in 2010, and its implementation was required in schools by 2012. In the Act, Congress set age-appropriate caloric ranges, required that at least 51% of grains be whole grains, required students to take at least one-half cup serving of fruits or vegetables with every school breakfast or lunch, and required that schools offer 1 cup of flavored or unflavored fat-free milk or 1% milk. Despite concerns, the changes were not associated with an increase in plate waste.1 In several studies, researchers have confirmed an increase in the quality of school meals and in improved consumption. For example, dietary quality was assessed before and after implementation of the new HHFKA standards by using the Healthy Eating Index 2010 (HEI 2010) and food consumption data from the nationally representative NHANES.2 The HEI 2010 score reflected the degree to which dietary intake was consistent with the 2010 Dietary Guidelines for Americans. The HEI 2010 scores among students aged 5 to 18 years were stratified by low-income, low-middle–income, and middle-high–income students and compared to those among non–school lunch participants in the same income categories. The HEI 2010 scores increased from 42.7 to 54.6 among school lunch participants compared to a decrease from 34.8 to 34.1 among nonparticipants. The differences in comparison with non–school lunch participants were 12.6, … Address correspondence to William H. Dietz, MD, PhD, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University, 214 11th St NE, Washington, DC 20002. E-mail: dietzwcd4{at}gmail.com

Analyzing the Association between Student Weight Status and School Meal Participation: Evidence from the School Nutrition and Meal Cost Study.

Childhood obesity remains a pressing public health concern. Children consume a substantial amount of their caloric intake while in school, making the passage of the Healthy Hunger-Free Kids Act (HHFKA) in 2010 and the subsequent improvements to the school meal standards a key policy change. Using data from the School Nutrition and Meal Cost Study, this paper seeks to re-examine the association between students’ (N = 1963) weight status and participation in the National School Lunch Program (NSLP) and School Breakfast Program (SBP) since the implementation of these policy changes to determine whether, and how, this relationship has changed. After controlling for a wide array of student characteristics and school-level fixed effects, findings from the multivariate regression analyses indicate that usual participation in the school meal programs has no clear association with students’ weight status, which contradicts findings from earlier studies conducted prior to the passage of the HHFKA. These findings are discussed in relation to changes in the demographic composition of usual NSLP participants over time.

The Need for Investment in Rigorous Interventions to Improve Child Food Security

The Need for Investment in Rigorous Interventions to Improve Child Food Security

The Development, Implementation, and Evaluation of Innovative Strategies to Reduce Food Insecurity among Children in the United States

The Development, Implementation, and Evaluation of Innovative Strategies to Reduce Food Insecurity among Children in the United States

Did the New School Meal Standards Improve the Overall Quality of Children's Diets?

AbstractSchool meal programs represent the second largest form of food assistance in the United States. Schools receive federal reimbursements, totaling $17 billion in 2018, provided they meet certain nutritional standards. The Healthy Hunger‐Free Kids Act (HHFKA) updated these standards beginning with 2012–2013 school year. We document the impact of consuming school‐prepared food, rather than home‐prepared food, on diet quality pre‐ and postpolicy reform. Pre‐HHFKA, school food increased dietary quality for relatively disadvantaged children, with null‐to‐negative effects among all other students. Post‐HHFKA, significant improvements are observed across the entire distribution of dietary quality, mainly driven by older, higher‐income students.

Variability in Dietary Quality of Elementary School Lunch Menus with Changes in National School Lunch Program Nutrition Standards.

ABSTRACTNational School Lunch Program (NSLP) standards recently changed significantly. The Healthy, Hunger-Free Kids Act (HHFKA) presumably improved the dietary quality (DQ) of meals, whereas Child Nutrition Program (CNP) Flexibilities appear to decrease DQ. This variability has not been quantified. Our objective was to determine differences in DQ between elementary school lunch menus meeting NSLP standards: School Meal Initiative (SMI), HHFKA, CNP Flexibilities, and evidence-based best practices (BP). A base menu was portioned per NSLP standards and analyzed for nutrient content and DQ. Statistical analyses included 1-factor ANOVA, Kruskal–Wallis, and Dunnett's test. The BP menu had higher whole fruit and whole grain Healthy Eating Index scores than SMI (Ps < 0.0083). The BP and HHFKA menus had higher refined grain and added sugars scores than SMI (Ps < 0.0083). The SMI menu had lower total vegetable and saturated fat scores than all menus (Ps < 0.0083). This study informs policy toward improving standards, positively affecting child health and academic performance through higher-DQ lunches.

Disparities in the Healthfulness of School Food Environments and the Nutritional Quality of School Lunches.

The Healthy, Hunger-Free Kids Act (HHFKA), a public law in the United States passed in 2010, sought to improve the healthfulness of the school food environment by requiring updated nutrition standards for school meals and competitive foods. Studies conducted since the passage of the HHFKA indicate improvements in the food environment overall, but few studies have examined whether these improvements varied by the socioeconomic and racial/ethnic composition of students in schools. To better understand the extent of disparities in the school food environment after HHFKA, this paper examined differences in the healthfulness of school food environments and the nutritional quality of school lunches by the school poverty level and racial/ethnic composition of students using data from the School Nutrition and Meal Cost Study. Results from chi-square analyses showed lower proportions of high poverty, majority black, and majority Hispanic schools had access to competitive foods, while higher proportions of these schools had a school wellness policy in addition to a district wellness policy. The overall nutritional quality of school lunches, as measured by total Healthy Eating Index (HEI)-2010 scores, did not vary significantly across school types, although some HEI component scores did. From these findings, we concluded that there were disparities in the school food environment based on the socioeconomic and racial/ethnic composition of students in schools, but no significant disparities in the overall nutritional quality of school lunches were found.

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

The Healthy, Hunger-Free Kids Act (HHFKA) of 2010 made sweeping changes to school nutritional standards. We estimate the impacts of shifts in school nutritional standards on dietary quality as well as dietary quantity of children’s food intakes from school and away-from-school food sources. We find the average effect of consuming school food, rather than away-from-school food, on children’s overall dietary quality significantly increased from the pre- to post-HHFKA implementation period. This effect was solely driven by substantial improvements in the dietary quality of foods acquired at school, mainly among older and higher-income children. Our indirect effect analysis indicated that children shifted towards consuming lower-quality diets at home in the post-HHFKA period, thereby partially offsetting the positive effects of the HHFKA on their overall dietary quality. Indirect impacts were primarily driven by a subset of children consuming more than a third of their daily calories from school food. Additionally, we find suggestive evidence of a modest decrease in daily calorie intake, particularly among older and higher-income children. Together, our findings imply that the HHFKA, despite its unintended negative indirect effects, led children to consume more-nutritious, less-energy-dense diets.

Parental Perceptions of the Nutritional Quality of School Meals and Student Meal Participation: Before and After the Healthy Hunger-Free Kids Act

To examine (1) parental perceptions of school meals and (2) student meal participation before and after the implementation of the Healthy Hunger-Free Kids Act (HHFKA). Data were collected from telephone surveys of 2 independent cross-sectional panels in New Jersey (2009-2010 and 2016-2017). Households with children aged 7-18 years (pre-HHFKA: n = 1,027; post-HHFKA: n = 324). Parental perception of school meals and parental reports of student participation in school meals. Multivariable logistic regression models were developed to examine outcome variables. For school meal participation, nested models were analyzed first controlling for sociodemographic variables, followed by parental perception, and then the interaction between perception and time. Parental perceptions of school meals did not change significantly after the HHFKA. At both time points, school meal participation rates were significantly higher for children of parents who perceived school meals as healthy compared with children whose parents perceived meals to be unhealthy (pre-HHFKA: 89.9% vs 75.1%, P < 0.001; post-HHFKA: 87.3% vs 64.9%, P = 0.02). Because higher perception of school meal quality is associated with higher participation, it is important for school food programs to inform parents about the improved nutritional quality of school meals.

Did the New School Meal Standards Improve the Overall Quality of Children’s Diets?

School meal programs represent the second largest form of food assistance in the United States. Schools receive federal reimbursements, totaling $17 billion in 2018, provided they meet certain nutritional standards. We document the impact of consuming school food, rather than home-prepared food, on diet quality as standards changed under the Healthy Hunger-Free Kids Act (HHFKA). Pre-HHFKA, school food increased dietary quality for relatively disadvantaged children, with null-to-negative effects among all other students. Post-HHFKA, we find large improvements across the board, mainly driven by older, higher-income students although younger, lower-income students also experienced non-trivial gains.