Impact Of The 2010 US Healthy Hunger-Free Kids Act On School

Impact Of The 2010 Us Healthy Hunger Free Kidsact On School Breakfas

Impact of the 2010 US Healthy, Hunger-Free Kids Act on School Breakfast and Lunch Participation Rates Between 2008 and 2015 Nicole Vaudrin, MS, RD, Kristen Lloyd, MPH, Michael J. Yedidia, PhD, MPH, Michael Todd, PhD, and Punam Ohri-Vachaspati, PhD, RD Objectives. To evaluate National School Lunch Program (NSLP) and School Breakfast Program (SBP) participation over a 7-year period before and after the implementation of the 2010 Healthy, Hunger-Free Kids Act (HHFKA), which required healthier school lunch options beginning in school year (SY) 2012–2013 and healthier school breakfast options beginning in SY2013–2014. Methods. Data were gathered from low-income, high-minority public schools in 4 New Jersey cities.

We conducted longitudinal analyses of annual average daily participation (ADP) in school meals among enrolled students overall and among those eligible for free or reduced-price meals. We used linear mixed models to compare NSLP and SBP participation rates from SY2008–2009 to SY2014–2015. Results. NSLP participation rates among students overall differed little across years (from 70% to 72%). SBP rates among enrolled students were stable from the beginning of the study period to SY2013–2014 and then increased from 52% to 59%.

Among students eligible for free or reduced-price meals, the ADP was lowest in SY2012–2013 (when the HHFKA was implemented) before rebounding. Conclusions. The HHFKA did not have a negative impact on school meal participation over time. Public Health Implications. The HHFKA-strengthened nutrition standards have not affected school meal participation rates.

With time, students are likely to accept healthier options. (Am J Public Health. 2018;108:84–86. doi:10.2105/ AJPH.2017.304102) The 2010 Healthy, Hunger-Free Kids Act(Public Law ; HHFKA) aligned National School Lunch Program (NSLP) and School Breakfast Program (SBP) re- quirements with the Dietary Guidelines for Americans. New NSLP meal patterns, im- plemented in school year (SY) 2012–2013, included more fruits, vegetables, and whole grains and a gradual reduction in sodium content. Similar SBP standards were imple- mented during the following year (SY2013– 2014).1 Additional requirements came into effect in SY2014–2015, as well as smart snacks standards for food and beverages sold outside of school meal programs.2 Further changes in the requirements are ongoing.1 The acceptability of new meal offerings has been evaluated in short-term longitudinal and cross-sectional analyses.2–6 According to qualitative results, school administrators and food service workers perceive that, although students initially complained, consumption patterns have not changed significantly.3 In only 2 studies were participation data used to examine the HHFKA’s impact on school lunch par- ticipation, and neither of these inves- tigations assessed effects on the SBP,4,5 a program that has been historically underused.7 In a study conducted in middle and high schools in 11 Massachusetts school dis- tricts, Cohen et al. found no significant differences in NSLP participation rates 1 year before and 1 and 2 years after the imple- mentation of the HHFKA among students overall and among those receiving free meals.4 Using a small sample (n = 6) of Washington State schools from a single district, Johnson et al. evaluated NSLP participation via meal production records 16 months before and 15 months after implementation of the HHFKA and saw a 1% decrease in participation among mid- dle and high school students.5 The relatively narrow time frames of these studies may be inadequate to capture changes in re- sponse to the new regulations.6 It is likely that schools began making changes when the HHFKA passed (2010) or when the US Department of Agriculture’s pro- posed ruling was issued (2011), before the actual implementation of the standards.8 In this study, we used school meal par- ticipation data over a 7-year period from SY2008–2009 to SY2014– years before and 3 years after HHFKA imple- mentation) to analyze NSLP and SBP par- ticipation rates in low-income, high-minority kindergarten through grade 12 schools.

Our aim was to assess the impact of the legislation on changes in these rates. ABOUT THE AUTHORS Nicole Vaudrin and Punam Ohri-Vachaspati are with the School of Nutrition and Health Promotion, Arizona State University, Phoenix. Kristen Lloyd and Michael J. Yedidia are with the Rutgers Center for State Health Policy, New Brunswick, NJ. Michael Todd is with the College of Nursing and Health Innovation, Arizona State University.

Correspondence should be sent to Punam Ohri-Vachaspati, PhD, RD, School of Nutrition and Health Promotion, Arizona State University, 500 N 3rd St, Phoenix, AZ 85001 (e-mail: [email protected] ). Reprints can be ordered at by clicking the “Reprints†link. This article was accepted August 16, 2017. doi: 10.2105/AJPH.2017. Research Peer Reviewed Vaudrin et al. AJPH January 2018, Vol 108, No.

1 AJPH RESEARCH mailto: [email protected] METHODS A longitudinal analysis of annual average daily participation (ADP) in school meals was conducted as part of the New Jersey Child Health Study. Public schools located in 4 urban, low-income, high-minority New Jersey cities (Camden, New Brunswick, Newark, and Trenton) were evaluated. Each of the cities has one public school district. Data were gathered from the National Center for Education Statistics and the New Jersey Department of Agriculture. Schools were excluded if they were missing either de- mographic or school meal participation data (exclusions made up less than 5% of the original sample during each year).

Numbers of schools included varied across years as a result of closings, openings, and reconfi- gurations; 139 were included in SY2008– 2009, 137 in SY2009–2010, 134 in SY2010–2011, 131 in SY2011–2012, 127 in SY2012–2013 (one of these schools did not report SBP participation rates), 127 in SY2013–2014, and 119 in SY2014–2015. We divided ADP counts according to payment type (full price, reduced price, free, and total), obtained from the New Jersey Department of Agriculture, by total school enrollments to calculate NSLP and SBP participation rates. We calculated participa- tion rates among students eligible for free or reduced-price meals, students paying full price, and all enrolled students. Annual school demographic data obtained from the National Center for Education Sta- tistics included percentages of students of different races, percentages eligible for free or reduced-price meals, and school grade levels.

ADP rates were square transformed to reduce skewness. We used linear mixed models in SPSS version 23 (SPSS Inc, Chicago, IL) to compare repeated observations of meal par- ticipation rates clustered within schools (that were in turn clustered within cities) and ex- amine pairwise between-year differences in school meal participation rates after adjustment for school level (elementary, middle, or high). Models were run for all payment categories. We back transformed estimated mean partic- ipation rates (calculated from models in- corporating square-transformed ADP rates) by taking the square roots of the estimates. RESULTS Most of the schools were elementary schools (75%), and students were primarily of minority (52% Black and 43% Hispanic) and low-income (81% eligible for free or reduced-price meals) backgrounds.

Across the study period, ADP rates for the NSLP and the SBP were 71% and 54%, respectively. Comparisons of each study year with SY2008–2009 (the base year) showed that there were no significant differences in model-adjusted NSLP participation rates among all enrolled students overall (Figure 1). Although there were statistically significant differences when the various study years were compared with one another, mean partici- pation rates differed only slightly, ranging from 70% to 72%. The lowest NSLP participation rate (69%) among students eligible for free or reduced- price meals was in SY2012–2013, the school year the HHFKA lunch standards were implemented; after model adjustment, this rate was significantly (P

Participation rates in all of the other –––––––2015 A n n ual A ve ra g e D ai ly Pa rt ic ip at io n R at e, % School Year ............................................................... ............ Implementation of the HHFKA NSLP SBP 64% 73% 69% 71% 72% 77% 70% 82% 71% 73% 71% 60% 59% 47% 52% 55% 52% 56% 50%49% 52% 49% 52% 73% 71% 70% 59% 71% NSLP all students NSLP free & reduced SBP all students SBP free & reduced P

Models included school level (elementary, middle, and high) as a fixed effect. FIGURE 1—Annual Average Adjusted National School Lunch Program (NSLP) and School Breakfast Program (SBP) Daily Participation Rates: 4 New Jersey Cities, School Years 2008–2009 to 2014–2015 AJPH RESEARCH January 2018, Vol 108, No. 1 AJPH Vaudrin et al. Peer Reviewed Research 85 study years (73% in SY2009–2010, 82% in SY2010–2011, 77% in SY2011–2012, and 73% in both SY2013–2014 and SY2014– 2015) were significantly higher (P

Rates climbed to 59% in SY2013–2014 and 60% in SY2014– 2015 (P

There were no meaningful changes in NSLP participation rates among students overall. Among students eligible for free or reduced- price meals, NSLP participation rates were high during the recession (2008–2012) and then dropped to their lowest levels when the HHFKA was first implemented in SY2012–2013 before rebounding in subsequent years. National data also show increased NSLP participation among students eligible for free or reduced-price meals during the recession.9 As noted, 2 studies examining school meal participation, one focusing on participation rates4 and the other on production records as a proxy for meal participation,5 did not reveal any significant differences among students overall4,5 or among students receiving free meals.4 The SY2012–2013 drop in our data may suggest an initial lack of acceptance of the new meal standards, particularly among students eligible for free or reduced-price meals.

However, with continued student exposure to healthy meals, the rates rebounded in SY2013–2014 and continued to increase in SY2014–2015. Also, as shown in previous research, the implementation of smart snacks standards in SY2014–2015 may have affected NSLP participation rates.10 The higher NSLP participation rates observed in our study relative to previous research may be accounted for by the higher percentage of students eligible for free or reduced-price meals (81%) than in those studies (32% and 52%). Nationally, meal participation rates are higher among students eligible for free or reduced-price meals than among noneligible students.11 SBP participation rates among students overall remained relatively unchanged until SY2013–2014, when they increased by 7 percentage points.

Nationally, SBP participation among students eligible for free or reduced-price meals increased after the HHFKA’s school breakfast provisions were implemented, and the increase in New Jersey schools was among the highest.7 A key feature of the HHFKA, the community eligibility provision, allows schools with high poverty rates to offer free meals to all students.12 None of the schools in our sample participated in universal free meals before SY2014–2015, when 27 schools reported providing only free meals to all students. Participation in the community eligibility provision and alternative breakfast promotion projects (e.g., breakfast after the bell programs), which have been used in all 4 of the study cities since at least SY2013–2014, may have contributed to the increase in SBP participation rates.

Overall, our results are consistent with those of previous studies indicating that, contrary to controversial media reports on reactions to the new standards, the effects of the HHFKA on school meal acceptance and participation are minimal. With time, students are likely to accept healthier options. CONTRIBUTORS N. Vaudrin conducted the analysis and wrote the first draft. K.

Lloyd contributed to the analysis and to the development of the article. M. J. Yedidia conceptualized the study and contributed to the interpretation of the findings and the development of the article. M.

Todd contributed to the data analysis and to the development of the article. P. Ohri-Vachaspati conceptualized the study, procured the data, and contributed to the analysis and the development of the article. ACKNOWLEDGMENTS Funding for this project was provided by a grant from the Robert Wood Johnson Foundation and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1R01HDA1). HUMAN PARTICIPANT PROTECTION This study was approved bythe institutional review boards of Arizona State University and Rutgers University.

REFERENCES 1. US Department of Agriculture, Food and Nutrition Service. Healthy, Hunger-Free Kids Act. Available at: CNR_2010.htm. Accessed September 4, 2017.

2. US Department of Agriculture. Tools for schools: focusing on smart snacks. Available at: usda.gov/healthierschoolday/tools-schools-focusing- smart-snacks. Accessed September 4, 2017.

3. Turner L, Chaloupka FJ. Perceived reactions of ele- mentary school students to changes in school lunches after implementation of the United States Department of Agriculture’s New Meals Standards: minimal backlash, but rural and socioeconomic disparities exist. Child Obes. 2014;10(4):349–356.

4. Cohen JF, Gorski MT, Hoffman JA, et al. Healthier standards for school meals and snacks: impact on school food revenues and lunch participation rates. Am J Prev Med. 2016;51(4):485–492.

5. Johnson DB, Podrabsky M, Rocha A, Otten JJ. Effect of the Healthy Hunger-Free Kids Act on the nutritional quality of meals selected by students and school lunch participation rates. JAMA Pediatr. 2016;170(1):e153918.

6. Concanno K. Nutrition standards in the National School Lunch and School Breakfast Programs: proposed rule. Available at: /pdf/.pdf. Accessed September 4, 2017.

7. Food Research and Action Center. School breakfast scorecard: 2013–2014 school year. Available at: http:// frac.org/wp-content/uploads/School_Breakfast_ Scorecard_SY_2013_2014.pdf. Accessed September 4, 2017.

8. Ohri-Vachaspati P, Turner L,Adams MA, Bruening M, Chaloupka FJ. School resources and engagement in technical assistance programs is associated with higher prevalence of salad bars in elementary school lunches in the United States. J Acad Nutr Diet. 2016;116(3):417–426.

9. Food Research and Action Center. National School Lunch Program: trends and factors affecting student participation. Available at: uploads/national_school_lunch_report_2015.pdf. Accessed September 4, 2017.

10. Long MW, Luedicke J, Dorsey M, Fiore SS, Henderson KE. Impact of Connecticut legislation in- centivizing elimination of unhealthy competitive foods on National School Lunch Program participation. Am J Public Health. 2013;103(7):e59–e66.

11. Fox MK, Condon E. School Nutrition Dietary As- sessment Study IV: summary of findings. Available at: IV_Findings_0.pdf. Accessed September 4, 2017.

12. Logan CW, Connor P, Harvill EL, et al. Community eligibility provision evaluation. Available at: https:// pdf. Accessed September 4, 2017.

References

• US Department of Agriculture, Food and Nutrition Service. (2010). Healthy, Hunger-Free Kids Act. Available at: https://www.fns.usda.gov/cn/healthy-hunger-free-kids-act. Accessed September 4, 2017.
• US Department of Agriculture. (n.d.). Tools for schools: focusing on smart snacks. Available at: https://www.fns.usda.gov/healthierschoolday/tools-schools-focusing-smart-snacks. Accessed September 4, 2017.
• Turner, L., & Chaloupka, F. J. (2014). Perceived reactions of elementary school students to changes in school lunches after implementation of the United States Department of Agriculture’s New Meals Standards: minimal backlash, but rural and socioeconomic