Assessing the Implementation of U.S. Programs and Policies for the Prevention of Food Insecurity and Obesity in School Settings

Abstract

Five million children in the U.S. live in households experiencing food insecurity and may face numerous structural and environmental barriers to health that elevate the risks of physical, developmental and emotional harm, as well as diet-related disease later in life. Given the limited public health dollars available for chronic disease prevention, alignment of anti-hunger and obesity interventions in schools through evidence-based nutrition standards and program practices could increase program impact on nutrition outcomes, ensure equitable adoption of programs and policies, and make good use of financial resources. The following three papers aim to identify best practices for program implementation in terms of what interventions might offer the best value for impact, how existing programs may be strengthened, and what supports could be useful for helping schools adopt nutrition policies.

The first paper features a cost-effectiveness analysis of school-based body mass index (BMI) ‘report cards,’ where student BMI is reported to parents/guardians by letter with nutrition and physical activity resources. Many states implement BMI report cards despite the lack of evidence for effectiveness on BMI outcomes, and thus, may be a candidate for de-implementation. We employed a microsimulation model to estimate the societal costs and impacts on childhood obesity if BMI report cards were implemented in U.S. public schools for students in grades 3 to 7 in the 15 states that only measure student BMI over 10 years (2023-2032). This hypothetical implementation was projected to reach more than 8 million children (95% uncertainty interval [UI]: 7.7-8.9 million) but would not prevent any cases of childhood obesity. Implementation and health care costs would total $210 million (95% UI: $30.5-$408 million). De-implementation of school-based BMI report cards could free up resources for interventions with evidence for effectiveness on childhood obesity.

The second paper features a cross-sectional assessment of program implementation factors associated with more nutritious offerings among school-based weekend backpack programs which supply students with food on Fridays to take home for alleviating weekend hunger. Our study aimed to fill research gaps for the national prevalence of weekend backpack programs, implementation characteristics, and whether the food being offered helps to advance nutrition security. Among our stratified, random sample of U.S. public schools, more than half (53.7%, 95% CI: 46.8%, 60.7%) of the 413 school respondents reported participating in a weekend backpack program during spring of 2022. A sub-sample of 49 schools with programs had an average Healthy Eating Index (HEI) 2015 total score of 58.4 (sd: 12.3) for backpack contents, similar to the national average for a child’s daily diet (score of 54). Key implementation characteristics (affiliation with an anti-hunger organization and having consulted a dietitian) were not associated with more nutritious backpack offerings, but there was a slight association between food costs and HEI-2015 scores. Contrary to our hypothesis, those who reported spending more than $0.50 per food item had slightly lower HEI-2015 scores (difference of 6.8 points, p.05). Weekend backpack programs reach many children, but more studies on program implementation and efforts to support nutrition security are needed.

The third paper features a cross-sectional assessment of the relationship between school participation in implementation supports and the nutritional quality of school lunches served. Schools participating in the National School Lunch Program were required to adopt the nutrition standards of the Healthy, Hunger-Free Kids Act of 2010 by the 2012-2013 school year. We utilized data from the USDA School Nutrition and Meal Costs Study’s nationally representative sample of U.S. public school food authorities (2014-2015) to explore whether reported participation in training/technical assistance or the purchase of new equipment to meet the nutrition standards was associated with HEI-2010 scores. Nearly 80% of school food authorities reported participating in training/technical assistance, and one third reported purchasing new equipment between the 2012-2013 and 2014-2015 school years. These implementation supports were not associated with SFA average HEI-2010 scores for lunches served; however, it appears that SFAs that reported the adequacy of training/TA as more than adequate, compared to inadequate, were associated with slightly higher HEI-2010 scores for lunches served (difference of 3.2 points, 95% CI: 0.6, 5.8, p.05). Further study of implementation supports is warranted to understand how best to assist schools in adopting nutrition standards for healthier school meals.

U.S. public schools have implemented a variety of nutrition program and policy interventions aimed at helping children grow and thrive. Our findings highlight opportunities for further inquiry, innovation, and partnerships among public health practitioners, policymakers, and researchers to improve food security and nutrition outcomes for children nationwide.