Systemic Review on the Associations of Universal Free School Meals and School and Student Outcomes

Objectives: The White House National Strategy on Hunger, Nutrition, and Health included expanding free school meals to all students. This systematic review (SR) was conducted to assess the relationship between universal free school meals (UFSM) and nutrition, health and other outcomes in US schools. Methods: An expert panel informed the development of the protocol (PROSPERO CRD42023464854) to evaluate intervention or cohort studies comparing UFSM programs like the Community Eligibility Provision (CEP) to non-UFSM programs in US schools from August 2012 to October 2023, 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, or shaming. Two researchers screened articles for inclusion, extracted data, and assessed risk of bias (ROB) for each included study. GRADE was used to assess the certainty of evidence for each outcome. Results: The search resulted in 2658 records; four studies were included. All were quasi-experimental studies investigating CEP and participation rates and/or attendance. Three studies from 5452 schools in Pennsylvania, South Carolina, and Texas suggest that CEP at lunch is associated with increased meal participation (low certainty) and CEP at breakfast is associated with increased meal participation (very low certainty). Two studies from 925 schools in Wisconsin and Pennsylvania, found no change or improved attendance in schools with CEP compared to schools without UFSM (very low certainty). Certainty ratings of low or very low resulted from ROB (non-random design, not all key confounders accounted for), directness (data not fully representative of the US), and consistency (small number of studies limits ability to assess consistency). Despite the limitations, evidence reflects well-designed longitudinal intervention studies appropriate for decision making. Conclusions: UFSMs were associated with increased breakfast and lunch participation, and no to slight improvement in attendance. No studies reported several important outcomes, suggesting the need for more high-quality research. Funding Sources: Texas A&M Agriculture, Food, and Nutrition Evidence Center.