National School Lunch Program

Home , Food delivery, Special Milk Program

Chapter 5 National School Lunch Program

The National School Lunch Program (NSLP) is the who are not certified for meal benefits, elementary oldest and second-largest food and nutrition assistance school students are more likely to participate than sec- program (FANP) in the U.S. Department of Agriculture ondary school students, and males are more likely to (USDA) nutrition safety net. Targeted specifically to participate than females (Fox et al., 2001; Gleason, school-age children, the NSLP is the cornerstone of the 1996; Maurer, 1984; Akin, 1983a). largely school-based child nutrition programs, which also include the School Breakfast Program (SBP), the Since 1998, when the NSLP was expanded to include Child and Adult Care Food Program (CACFP), the after-school snacks, this component of the program has Summer Food Service Program (SFSP), and the been growing steadily. Between FY 2000 and FY Special Milk Program (SMP). 2002, the number of after-school snacks provided through the NSLP increased from 70 million to 123 Schools that participate in the NSLP receive Federal million (USDA/FNS, 2003a).78 reimbursement for each program meal served to students. USDA does not reimburse schools for adult The NSLP is administered by the Food and Nutrition meals, second meals, and a la carte items (including Service (FNS) and its regional offices. At the State extra servings of components of program meals). level, the program is administered by State agencies, Since 1998, the program has also covered snacks most often departments of education. State agencies served to children in after-school programs. Any child oversee Federal reimbursements, provide technical in a participating school is eligible to receive NSLP assistance, and monitor program performance. At the meals; in FY 2002, more than 28 million children par- local level, the program is operated by school food ticipated on an average school day. The program authorities (SFAs). Most SFAs are individual school served more than 4.7 billion lunches and 123 million districts; however, regional school unions and residen- after-school snacks, at a cost of $6.9 billion (USDA, tial childcare institutions also serve as SFAs. Food and Nutrition Service (FNS), 2003a). Federal Subsidies

Program Overview Participating SFAs receive two types of Federal assistance: cash reimbursements and commodities. Cash The NSLP was established in 1946 to “safeguard the reimbursements are based on the number of lunches health and well-being of the Nation’s children and to and after-school snacks served, established reimburse- encourage the domestic consumption of nutritious ment rates, and the poverty level of participating stu- agricultural commodities and other foods....”77 A major dents. A cash subsidy is provided for every program impetus for the program was the prevalence of nutrition- lunch and snack served. Additional cash subsidies are related health problems identified during the screening provided for meals and snacks served to children who of young men for military service in World War II. qualify for free or reduced-price meal benefits. Currently, students eligible for free lunches and snacks Today, almost 99 percent of public schools and 83 per- are those from families with incomes at or below 130 cent of all public and private schools combined partici- percent of the Federal poverty level. Students from pate in the NSLP. Nationally, the program is available families with incomes between 130 and 185 percent of to about 92 percent of all students (Burghardt et al., poverty are eligible to receive reduced-price lunches 1993; Burghardt and Devaney, 1995). On an average and snacks.79 school day, about 60 percent of children in schools that offer the NSLP participate in the program (Fox et al., 2001). Participation varies with household income, 78To be eligible to receive reimbursement for after-school snacks, school age, and gender. For example, studies have shown that districts must participate in the NSLP and must sponsor or operate an after- school program that provides children with regularly scheduled educational students certified to receive free or reduced-price or enrichment activities in a supervised environment (USDA/FNS, 2003b). lunches are more likely to participate than students 79Federal regulations allow schools that operate in high-poverty areas (areas where 50 percent or more of school-age children are eligible for free or reduced-price meals) to receive the “free” reimbursement rate for all 77National School Lunch Act of 1946, Public Law 79-396. after-school snacks, regardless of the students’ family incomes.

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 175 Basic cash reimbursement rates for the 2002-03 school The components of the traditional NSLP meal year were $2.14 for free lunches, $1.74 for reduced- pattern are: price lunches, and $0.20 for lunches served to children who purchased meals at the full price (referred to as • Meat or meat alternate: 1 serving per meal “paid meals”).80 Snacks were reimbursed at rates of $0.58, $0.29, and $0.05, respectively. • Vegetables, fruits, and/or full-strength juices: 2 or more servings per meal Children eligible for reduced-price lunches cannot be charged more than $0.40 per lunch. SFAs set their • Grains/breads: 1 or more servings per meal/8 serv- own prices for full-price/paid lunches, but must ings per week operate their school meal service program on a non- • Milk: 1 serving per meal. profit basis (USDA/FNS, 2003c). Of the 4.7 billion lunches served in FY 2002, 48 percent were served Over the years, research has shown that, with few excep- to children eligible for free meals and 9 percent tions, the meals offered in the NSLP provide students the to children eligible for reduced-price meals 81 opportunity to satisfy one-third of their daily needs for (USDA/FNS, 2003a). food energy and an array of essential vitamins and minerals (Burghardt et al., 1993; Wellisch et al., 1983). Schools receive agricultural commodities on an entitlement basis and may also receive bonus com- In the early 1990s, however, USDA’s first School modities. Entitlement commodity assistance is based Nutrition Dietary Assessment Study (SNDA-I) exam- on the number of reimbursable lunches served the ined the nutrient content of school lunches in compari- previous school year. For the 2002-03 school year, son with recommendations included in the Dietary the cash value of entitlement commodities was Guidelines for Americans (USDA and U.S. Department $0.1525 per meal (USDA/FNS, 2003c). Schools may of Health and Human Services, 1990) and the National elect to receive cash in lieu of commodity foods. In Research Council’s Diet and Health report (National addition to entitlement commodities, schools may Research Council, 1989). SNDA-I found that, in com- request bonus commodities—commodities that parison with these guidelines, NSLP meals were high become available through agricultural surplus—in in fat, saturated fat, and sodium, and low in carbohy- amounts that can be used without waste. The types drates (Burghardt et al., 1993). At the time the SNDA- and amounts of bonus commodities available vary I data were collected (the 1991-92 school year), from year to year depending on purchasing decisions schools were not required to offer meals that were made by USDA. consistent with these guidelines.

Nutrition Standards The School Meals Initiative To be eligible for Federal subsidies, NSLP meals must for Healthy Children meet defined nutrition standards. Program regulations In response to the SNDA-I findings, USDA made a have long stipulated that lunches should provide one- commitment to implement the Dietary Guidelines in third of the children’s Recommended Dietary the NSLP. The embodiment of this commitment is the Allowances (RDAs). To ensure that these standards are School Meals Initiative for Healthy Children (SMI). The met, program regulations have historically included SMI, launched in 1995, is designed to improve the food-based menu planning guidelines. These guide- nutritional quality of school meals by providing schools lines, originally known as the “Type A meal pattern,” with educational and technical resources that can be define specific types of food to be offered as well as used to (1) assist foodservice personnel in preparing minimum acceptable portion sizes. nutritious and appealing meals and (2) encourage children to eat more healthful meals. Key components of the SMI include revised nutrition standards for school 80Reimbursement rates for both lunches and snacks are higher in Hawaii meals, a major restructuring of menu planning require- and Alaska. In addition, lunch reimbursement rates are higher for schools ments, and a broad-based nutrition education program. that operate in high-poverty areas (60 percent or more of students eligible for free or reduced-price meals). The nutrition standards established under the SMI 81Information on the percentage of after-school snacks served to children eligible for free or reduced-price meal benefits is not available in pub- maintain the longstanding goal of providing one-third licly available summaries of administrative data. of students’ daily needs for food energy and nutrients. In

176 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program addition, the standards include goals for fat and saturated Related Program Changes fat content that are consistent with the Dietary The SMI has been supported by several parallel initia- Guidelines recommendations.82 The Healthy Meals for tives. For example, considerable effort has been devoted Healthy Americans Act (P.L. 103-448) formally required to improving the nutrient profile of the commodity that school meals be consistent with the Dietary foods provided to NSLP schools (Buzby and Guthrie, Guidelines and that schools begin complying with SMI 2002). In addition, under the Nutrition Title of the nutrition standards in the 1996-97 school year unless a 2002 Farm Act, USDA received $6 million for a pilot waiver was granted by the relevant State agency. The program to provide fresh and dried fruits and fresh regulatory requirement that school meals be consistent vegetables to children in elementary and secondary with the Dietary Guidelines has been incorporated into schools. The pilot program, which was implemented in the FNS strategic plan. The current goal is for all schools the 2002-03 school year, was very well received to satisfy these standards by 2005 (USDA/FNS, 2000a). (Buzby et al., 2003) and was expanded under the Child Under SMI and the Healthy Meals for Healthy Nutrition and WIC Reauthorization Act of 2004 (P.L. Americans Act, menu planning requirements were 108-265). restructured to offer schools several alternatives to the Most recently, policymakers have begun to focus on traditional food-based NSLP meal pattern. These the “school nutrition environment” (Ralston et al., include a computer-based menu planning approach 2003; American School Food Service Association known as Nutrient Standard Menu Planning (NSMP). (ASFSA), 2003; USDA/FNS, 2000b). A school’s NSMP focuses on the nutrient content of meals rather nutrition environment includes the nutritional quality than the specific types of food offered. School districts of reimbursable school meals, the availability and may implement NSMP on their own or may contract nutritional quality of competitive (non-NSLP) foods, with an outside agency. An enhanced food-based meal meal scheduling, physical characteristics of the cafete- pattern was also developed. This is similar to the tradi- ria, nutrition education and marketing activities, and tional pattern but requires more servings of breads and the school’s commitment to nutrition and physical grain products over the course of a week and larger activity. servings of fruits and vegetables. School districts may also use any other reasonable approach to menu plan- Major attention has been focused on the issue of ning, subject to State agency guidelines. Implementation “competitive foods” in school meal programs—foods of new menu planning systems has proved to be a other than those included in NSLP and SBP meals lengthy process. In the 1999-2000 school year, only 63 (USDA/FNCS, 2001). In 1998-99, USDA’s second percent of all SFAs reported that they had “fully imple- School Nutrition Dietary Assessment Study (SNDA-II) mented” the menu planning system of their choice found that more than half of all elementary schools had (Abraham et al., 2002). Eighty-five percent indicated a la carte programs that offered items other than milk, that their plans were at least three-quarters implemented. juice, and desserts (Fox et al., 2001). The same was true of roughly 90 percent of middle schools and high The nutrition education component of the SMI is the schools. Many schools had a la carte programs that Team Nutrition Initiative (TN) (see chapter 16). TN pro- made it possible for students to purchase complete vides technical assistance, educational resources, and meals on an a la carte basis. SNDA-II also demonstrat- training to school foodservice personnel, children, par- ed that revenue from a la carte sales was inversely ents, teachers, and school administrators. TN uses related to rates of student participation in the NSLP. behavior-oriented strategies to (1) assist school foodservice personnel in preparing and serving meals that The CDC-sponsored School Health Policies and meet the SMI nutrition standards without sacrificing Programs Study (SHPPS) found that more than a quar- taste or attractiveness, (2) promote healthful eating ter of elementary schools, 62 percent of middle/junior habits and regular physical activity among both children high schools, and 95 percent of senior high schools and parents, and (3) build a support base among school had vending machines (Wechsler et al., 2001). A sub- administrators and other school and community partners stantial number of schools also had school stores, can- for healthy patterns of eating and physical activity teens, or snack bars available to students during meal (USDA/FNS, 2002). time. Some school districts have entered into potentially lucrative “pouring rights” contracts that may lead to 82Goals for sodium and cholesterol content are not included in SMI nutrition standards. However, schools are encouraged to monitor levels of increased availability and marketing of soft drinks (Lin these dietary components. and Ralston, 2003; Nestle, 2000).

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 177 Chapter 5: National School Lunch Program

Although not part of the reimbursable NSLP meal, com- Consequently, even these relatively recent data may petitive foods contribute to students’ in-school dietary not provide an accurate picture of the nutrient content intake. Currently, there are no Federal nutrition-related of meals currently offered in the NSLP. standards governing competitive foods, and research has shown that foods offered through these alternative It is important to keep the changing nature of the NSLP sources tend to be high in fat, sodium, and/or sugar in mind when reviewing the summary of NSLP research (French et al., 2003; Kubik et al., 2003; Zive et al., 2002; that follows. The existing research provides information USDA/FNCS, 2001; Wechsler et al., 2001; Glengdahl on previous and potential impacts of the NSLP; howev- and Seaborn, 1999). Concerns about the negative impact er, new research is essential to understanding the impact of competitive foods has prompted calls for action at of the NSLP as it operates today (Guthrie, 2003). local, State, and Federal levels to limit their availability and/or to establish nutrition standards for them. Research Overview Implications for Interpreting The literature search identified a total of 26 studies Available Research that examined the impact of the NSLP on nutrition- The vast majority of the research reviewed in this chap- and health-related outcomes of participating children. ter is based on data that were collected before the SMI Among these are two USDA-sponsored national evalu- was launched or in the very early stages of its imple- ations that included student-level outcomes: the mentation. This includes all of the studies that were National Evaluation of School Nutrition Programs national in scope, those with the strongest designs and (NESNP) conducted in 1980-81 and the SNDA-I analysis methods, and all of the studies that looked at study, conducted in 1991-92. A third USDA-sponsored impacts on students’ dietary intakes over 24 hours. national evaluation, the SNDA-II study, conducted in the 1998-99 school year, is not included in this sum- Given the nature and extent of the changes associated mary because it did not collect student-level data. with the SMI—changes that specifically targeted the nutrient content of school lunches and students’ con- Most studies examined impacts on dietary intake at sumption of healthful lunches—it is important that lunch and/or over 24 hours. A smaller number consid- results of the available research be interpreted in the ered impacts of NSLP participation on other measures proper context. Existing research provides a compre- of nutrition and health status or on household food hensive picture of past and potential impacts of the expenditures. One study also looked at impacts on NSLP; however, because of the major changes that school attendance and cognitive performance. have been implemented under SMI and related ongo- The majority of the available research is quite dated. ing changes, it cannot be assumed that these findings Fifteen of the 26 studies used data that were collected apply to today’s NSLP. during or prior to the early 1980s. And, as noted, Indeed, there is evidence that the nutrient content of almost all studies used data that were collected prior to meals offered in the NSLP has changed since the imple- implementation of the SMI. mentation of the SMI. The SNDA-II study found that, Measures of Participation relative to lunches offered in 1991-92 (as reported in SNDA-I), lunches offered in 1998-99 were significantly Measures of program participation varied across studies lower in total fat, saturated fat, and sodium (although, (and sometimes within studies, depending on the out- on average, lunches continued to exceed Dietary come being evaluated). Most studies equated the pur- Guidelines and NRC recommendations for those nutri- chase or consumption of a school lunch on the day(s) ents). Moreover, SNDA-II demonstrated that reductions of dietary assessment with program participation. This in fat and saturated fat content could be achieved with- entails some risk that children who usually eat a school out sacrificing overall nutrient content. That is, although lunch did not do so on the day of the survey, or that lower in fat, NSLP lunches continued to meet the goal some who ate the school lunch on that day usually do of providing one-third of the RDAs for key nutrients. not participate. However, NESNP researchers evaluated the extent of this problem and concluded that defin- The SNDA-II data were collected relatively early in ing participation on the basis of one day’s behavior the implementation of the SMI and, since that time, gave an accurate picture of participation, at least with efforts to implement the SMI nutrition standards have the large sample available in that study and with data continued at the Federal, State, and local levels. collected on all 5 weekdays (Wellisch et al., 1983).

178 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program

Several studies defined program participation on the with intakes below a defined cutoff. Again, none used basis of usual NSLP participation practices, such as the approach recommended by the IOM, which calls whether a student usually ate a school lunch a mini- for use of data on usual intake in conjunction with mum number of times per week or the proportion of defined Estimated Average Requirements (EARs) potential lunches eaten during the study period. In (IOM, 2001). evaluating the impact of the NSLP on students’ linear growth, the NESNP used historical information on stu- Consequently, the available research presents an dents’ participation from grade 1 through the current imperfect picture of the substantive significance of dif- grade, and computed an average weekly NSLP partici- ferences observed in the dietary intakes of NSLP par- pation rate for each student (Wellisch et al., 1983). ticipants and nonparticipants. It provides information on whether NSLP participants consumed more or less Definition of nonparticipant comparison groups also energy and nutrients than nonparticipants. However, differed across studies. Most researchers used nonpar- this information cannot be used to draw conclusions ticipants in the same schools as NSLP participants. about whether NSLP participants were more or less Hoagland (1980) distinguished between students who likely than nonparticipants to have adequate intakes. did and did not have the NSLP available to them. The NESNP oversampled schools that did not offer the In addition, research has shown that assessing the NSLP. However, investigators ultimately concluded dietary intakes of children presents unique challenges that schools not offering the NSLP did not constitute (Medlin and Skinner, 1988; Baranowski and Simons- an appropriate comparison group, so they used nonpar- Morton, 1991) and that recall-based data collection ticipants in NSLP schools instead. methodologies do not necessarily work well with young children (Baxter, 2000 and 2003). As a result, The following two sections summarize major findings recall-based measures of the dietary intakes of NSLP from existing research on the impact of the NSLP on participants and nonparticipants are subject to nutrition- and health-related outcomes. The first sec- increased measurement error. tion summarizes studies that assessed impacts on students’ dietary intake. The second section discusses Research Overview studies that examined impacts on other nutrition and The literature search identified 19 studies that exam- health outcomes, including weight and height, nutri- ined the impact of NSLP participation on students’ tional biochemistries, household food expenditures, dietary intakes. Characteristics of these studies are and school performance. summarized in table 26. Most studies examined impacts on intake of food energy and nutrients. Impacts on Dietary Intake However, three studies (Devaney et al., 1993; Gleason and Suitor, 2001; Rainville, 2001) looked at impacts Estimates of NSLP impacts on dietary intake are sub- on food consumption as well as energy and nutrient ject to the limitations discussed in chapter 2. Most intake, and four studies (Cullen et al., 2000; Melnick studies used data for a single day or meal, and there- et al.,1998; Wolfe and Campbell, 1993; Yperman and fore provide weak estimates of individuals’ usual Vermeersh, 1979) looked only at impacts on food con- intake. Some studies used multiple days of data or sumption. Five studies focused exclusively on impacts other means (such as a food frequency checklist) to on dietary intake at lunch, seven studies looked at both better capture usual intake. However, none of the lunch and 24-hour intakes, and seven studies focused available studies used the approach to estimating usual exclusively on 24-hour intake. intake that was recently recommended by the Institute of Medicine (IOM, 2001).83 The available research can be divided into three groups. Group I includes the two national evaluations that exam- Similarly, in assessing intakes of food energy, vita- ined student-level outcomes: SNDA-I (1991-92 school mins, and minerals, researchers generally compared year) and NESNP (1980-81 school year). Group II mean intakes of participants and nonparticipants or includes five studies that are based on secondary compared the proportion of individuals in each group analysis of data from national cross-sectional surveys. Two of these studies (Gleason and Suitor, 2001 and 83Gleason and Suitor (2001) used these methods to describe dietary 2003) used data collected between 1994 and 1996. The intakes of U.S. children. However, in assessing differences in intakes of NSLP participants and nonparticipants, they used regression-adjusted mean other three studies in this group are based on data from intakes that were based on 1 or 2 days of data. the late 1970s or early 1990s. Group III consists of 11

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 179 Chapter 5: National School Lunch Program e n n n n od d h e t s model rients) s t t Continued— s for full s (foods) u bias- gressio gressio gressio w-incom j o d l a on- - te re te re te re n a a a ison of o ent (nu i s s Analysis met e r g e means Multivari with fixed-effec to control for selectio bias Multivari with selecti Multivari Compar r Bivariate t-test sample and sample adjustm Bivariate t-test h on h on h on h on h on Measure of participation y intakes Ate NSLP lunc recall day Ate NSLP lunc recall day Ate NSLP lunc recall day Ate NSLP lunc recall day Ate NSLP lunc recall day t vs. t vs. t vs. t vs. t vs. pant pant pant pant pant ents’ dietar n n n n n Design partici partici partici partici partici Participa non Participa Participa Participa Participa non non non non s 1 e ) ) e 4 n a 1 l day 6 , nts nts nts in nts in nts in Program on stud latio 1 18 with 18 with = n ( ,350) ,556) ,866) ,556) es 1-12 es 1-12 es 1-12 esce esce esce esce esce dren and dren and dren and dren and dren and 3 6 1 6 a Popu t (sample siz a Chil adol Chil adol grad (n~ Chil adol grad (n= Chil adol ages 6- 2 days of intak d Chil adol ages 6- or 2 schoo of intake dat (n= grad (n= e e v v lls lls uti uti al School Lunch hour hour hour on onsec onsec method e 24- e 24- e 24- our reca our reca Data collection Singl Singl recall recall recall 24-h 24-h Singl 2 nonc 2 nonc the Nati f P 1 N d pact o ools tative tative m ic an ic surveys n n ally ally ubl ubl 0-81) 1-92) 4-96 CSFII 4-96 CSFII 0-81 NES onal Data source Nation represe sample of students from 329 p Nation represe sample of students from 276 p schools (198 199 199 private sch (199 198 er at at is of nati e e ov take nd nd nd nd nd ours ours ours ours ours n urs Outcome(s) Nutrient i Nutrient intake at lunch a over 24 h Food intak lunch Nutrient intake at lunch a over 24 h Nutrient intake at lunch a over 24 h Nutrient intake at lunch a over 24 h Food intak lunch and 24 ho at lunch a over 24 h of table. udies that examined the i t 7) at end 03) 01) and and II: Secondary analys I: National evaluations n n 3) llisch et al. e See notes Table 26—S Study Group Devaney et al. (1993) (SNDA-I) W (198 (NESNP) Group Gleaso Suitor (20 Gleaso Suitor (20 Fraker (198

180 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program n laysis od h ance ance s Continued— s and ession; gressio vari vari usted an te re a g regr adj Analysis met Analysis of Bivariate t-test chi-square test Chow tests Multivari Switchin of covariance Analysis of Gender- inued t (vs. r of r of data h on h on h on h on nch y er of er of u a be be unc unc unc unc mb mb u u h) tion d a Measure of participation y intakes—Con observ sack lunc Ate school l recall day Ate school l days ate school lunch to n days of dietary days ate school lunch to n days ate any l Ratio of num Ratio of num Ate school l Ate school l recall day recall day 3 , 2 4 2 2 t vs. t vs. t vs. t vs. t vs. t vs. pant pant pant pant pant pant ents’ dietar n n n n n n Design partici partici partici partici partici partici Participa non Participa Participa non non Participa Participa Participa non non non ) 5 5 e n n n n nts nts nts Program on stud latio 18 18 21 ,397) ,797) ,554) ,554) ,155) es 2-4 es 2 and es 2 and esce esce esce dren i dren i dren i dren and dren and dren and 1 1 1 1 3 570) Popu (sample siz grad (n= Chil grad grad (n= (n= Chil Chil Chil adol ages 6- (n= Chil adol ages 6- (n= Chil adol ages 6- (n= rd rd n tion e) e) School Lunch plus plus o o o a ll ll al rec rec hour d d ntitativ ntitativ ste method a e 24- our reca our reca qua qua Data collection 24-h 24-h and w Visual observ of food selecti Single 24-hour recall (non Singl Single 24-hour recall (non 2-day foo 2-day foo recall the Nation f ty 8) 1 w 0 1 99 pact o ools rk Ci Ne o d m n n led nts in g New rge samples a astern an (1 in l 7-88) 9-90) omly ic an 7-78 NFCS 7-78 NFCS 1-74 Data source Michig York State, exclud York City (198 schools i southe schools i 197 197 197 NHANES-I Students in 1 All stude rand selected classrooms in 25 samp publ private sch in New Y Students in 5 (198 at studies with e e e ours ours ours ours Outcome(s) Nutrient intake over 24 h Nutrient intake over 24 h Nutrient intake over 24 h Nutrient intake at lunch Food intak lunch Food intak over 24 h Food intak at lunch of table. udies that examined the i ate and local t at end ll IIIA: St e e nd ill la 0) 1) 8) 3) 3a) 3b) lfe and o See notes Table 26—S Study Akin et al. (198 Akin et al. (198 Hoag Group Rainv (200 Melnick et al. (199 W Campb (199 (198

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 181 Chapter 5: National School Lunch Program nd n uls od h sts means means ance ance a an-Ke Continued— e gressio vari ewm te re of vari a ison of ison of d) d) Analysis met e test rang Compar (type of statistical test not reporte Analysis Analysis of Multivari Student-N Compar (no statistical t reporte Unmatched t-test inued t re o h) on ool y: y h (vs. h (vs. h (vs. d on s h) on ys ys study ne eek, week, week a al hi nc se d unc da da a unc ing n d d on h or o que i t unch or a bag l at least ly ate sch v ng mac d r Measure of participation e y intakes—Con s b offered dur perio lunch) on o Participati dummies b lunch 3 times/week 0-1 time per w 2-3 times per 4-5 times per Ate NSLP lunc home l snack bar l food recor Took 70% or m of school me Usual Ate NSLP lunc brown usual fre Ate NSLP lunc sack lunc vendi food recor 6 2 7 t vs. ts, t vs. t vs. t vs. t vs. pant pant pant pant pant ents’ dietar n n n n n n Design partici partici partici partici partici non Participa before vs. after Participa non non Participa Participa non non Participa Participa ) ) 6 8 e n 282 28) n n n nts nts in Program on stud 7 latio -16 0 ,495) es 1-4 es 5 and e 5 (n= es 7 and esce esce dren i dren i dren ages dren i dren and dren and 8 233) 512) 254) Popu (sample siz (n= grad grad (n= Chil Chil Chil 8-12 (n= Chil adol ages 1 (n= grad (n= Chil adol grad Chil end rd e n tion k School Lunch v o daily i o a t al s rec d hour calls, d utive ste method a e 24- Data collection 3-day foo Singl 3 nonconsecu Single 24-hour recall 24-hour re including 1 wee day recall and w of food selecti Visual observ food recor 5 consec the Nation f t 5 o e 0 ) n n i i es r 1 l l e n 71 ty o o i d pact o o o 1 le h h on m n ican- nts in nts in grad c c districts ons i w York i s s d) d eers small samples en from 1 e e l l 2) 1-73) 9) ama d d d d ashingt Data source i i State, Blacks and Mex Americans w W in 1 district rural Ne State (1970- Students in 1 m selected classrooms in 3 schools i district in Alab Students in 1 m All stude Students in schools/ in 8 reg All stude selecte Sample of childr States, plus volunt (197 oversamp (197 Texas (dates n reporte Salt Lake C (198 at studies with e nd ours ours ours Outcome(s) lunch Nutrient intake over 24 h Nutrient intake at lunch a over 24 h Food intak Nutrient intake at lunch Nutrient intake at lunch Nutrient intake over 24 h of table. udies that examined the i ate and local t at end t of e r n a f l on, IIIB: St e 8) 2) 0) 1) 4) W en et al. d See notes n Table 26—S Study Price et al. (197 Emmons et al. (197 U.S. Departme Health, Educati a (HEW) (10- State Nutrition Survey) Group Cull (200 Ho et al. (199 Perry et al. (198

182 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program ct n stri od h of gressio cond di te re a nalysis the se e utritionally adequate, Analysis met stics: n 2-way a varianc Multivari ri inued e t aract ut the analysis of ate 5 s h on n y a h o r to data o unc Measure of participation y intakes—Con d on baseline ch n the analysis, b se Number of d school l days pri Ate NSLP lunc recall day collection ely i at s ba roup separ t vs. t vs. pant pant ents’ dietar n n ered t subg id Design s partici partici con Participa non Participa non differen r were ) e n ricts d for fou 104) n Program on stud rte latio (n= 1 repo escents in es 10 es 1-3 dren i 307) e two dist Popu (sample siz grad (n= Chil Adol grad and 1 daily. red. Th Results were re offe y School Lunch te NSLP al enc hour st we . y fa method h program. udents a e 24- c eak r income. st - Data collection Food frequ Singl checklist recall ee lun the Nation r f d free b ination Surve m 1 viduals. nd not low . pact o l in 60 percent of ms. y unch an lic Indi h), a ction of a f y s; c m n ra nts in 2 hoo nia s b omly s. prog e in 2 n pub h free l nd lunch meals. student Data source ption Surve Rand selected students in 1 urba All stude classrooms per grad schools i Califor high sc Kansas and Nutrition Exa d Intake ast a m u s her lunch er than participant Foo where bot and after introdu eakf gible for free lun r i e nd ours ours s rath rs. of b s he with non c s before come (el skippe ide Food Con ng Survey of cond district Outcome(s) Nutrient intake at lunch a over 24 h Food intak over 24 h nch was lun iate NLSP and ot a se d intake skippers s y, low-in udies that examined the i contribution t s: pare for lu 0) ce d rate r n and nd CSFII = Continui NHANES-I = First National Health NFCS = Nationw n (198 9) Data sou Did not different Included lunch Accounte Study included Study com Unit of analysi 1 2 3 4 5 6 7 Table 26—S Study Howe a Vade Yperma Vermeersch (197 did not sepa nutritionally need

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 183 Chapter 5: National School Lunch Program

State and local studies. Six of these studies (Group III- to many relevant variables and their findings, including A) included relatively large numbers of children (more differences between selection-adjusted and unadjusted than 500) from multiple sites—schools, SFAs, or results, make intuitive sense. Others reviewing the same States. The remaining five studies (Group III-B) had literature (see, for example, Rossi, 1998 and Devaney substantially smaller samples and generally weaker et al., 1997) have reached the same conclusion. designs. With the exception of studies by Rainville (2001) and Cullen et al. (2000), all of the Group III A more recent study by Gleason and Suitor (2003) studies are based on data collected before the imple- used data from the 1994-96 wave of the CSFII. This mentation of the SMI. Six are based on data from the study improved upon the SNDA-I analysis by using a mid-1980s or earlier. fixed-effects model to control for selection bias. The analysis included 1,614 children who (1) attended The strongest evidence about the impact of the NSLP schools where the NSLP was offered and (2) had 2 on the dietary intake of participating students comes days of intake data, at least one of which was a school from the SNDA-I study (Devaney et al., 1993) and an day. The fixed-effects model was estimated in a analysis by Gleason and Suitor (2003) that used data paired-differences form, where differences between the from the 1994-96 Continuing Survey of Food Intakes 2 days of intake data were regressed on corresponding by Individuals (CSFII). SNDA-I is the most recent, differences in student characteristics, including NSLP comprehensive, and state-of-the-art study designed participation status. Thus, the estimation of NSLP specifically to study the NSLP. It included nationally impacts was based on variation in NSLP participation representative samples of public and private schools status of specific individual students rather than on and of students attending those schools. Information, variation in participation status of different groups of including a single 24-hour recall, was collected for students. This ensured that the estimate was not influ- 3,350 school-age children in 329 schools. enced by unmeasured differences that may have exist- ed between different groups of students. SNDA-I used a participant vs. nonparticipant design. However, Devaney and her colleagues used an instru- The analysis included both students who reported mental variables approach to control for selection bias. intake for 2 school days and those who reported intake The authors confirmed the robustness of their results for 1 school day and 1 non-school day. To control for using a variety of specifications. The model used to the possibility that students’ intakes varied on school estimate impacts on dietary intake at lunch controlled and non-school days for reasons other than the NSLP, for the price charged for a full-price lunch; student sta- the model included a dummy variable that indicated tus with regard to free and reduced-price meal bene- whether the intake day was a school day. The model fits; interaction terms for the price of a full-price lunch also attempted to control for potential unobserved dif- and benefit eligibility categories; availability of offer- ferences that may have had varying influences on chil- vs.-serve;84 ability to leave school for lunch; availabil- dren’s consumption behaviors on the 2 days. For ity of low-, moderate-, and high-fat lunches;, and serv- example, it included the day of the week, the number ing capacity of the lunch room. In estimating impacts of hours of television watched on the intake day, two on 24-hour nutrient intake, researchers adjusted for variables that indicated frequency of exercise, and self-selection into the NSLP but not into the SBP variables that indicated whether reported intakes were because they concluded, based on exploratory analy- heavier or lighter than usual. ses, that there was no selection bias in breakfast intakes. An earlier study by Gleason and Suitor (2001) also used the 1994-96 CSFII. However, that study did not Selection-bias adjustments are not without problems and attempt to control for selection bias. The authors raised frequently produce implausible results (see discussion appropriate concerns about likely selection bias and in chapter 4). SNDA-I analysts, however, had access cautioned that estimates of differences between NSLP participants and nonparticipants observed in that analysis should not be interpreted as valid estimates of 84Offer vs. serve (OVS) is a NSLP policy that allows students to refuse NSLP impacts. some of the foods offered to them in reimbursable school lunches. At the time the SNDA-I data were collected, OVS was mandatory for secondary Although SNDA-I (Devaney et al., 1993) and the most schools and was optional, at the discretion of local authorities, for elementary schools. Under OVS, students could refuse two of the three meal components recent study by Gleason and Suitor (2003) provide the in the traditional food-based meal pattern that was in effect at the time. strongest available data on NSLP impacts, both studies

184 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program are based on data collected prior to the SMI. The liter- and Suitor (2003) are based on fixed-effects models. ature search identified only two studies that compared For the most part, findings from the two studies are dietary intakes of NSLP participants and nonpartici- consistent. Where findings diverge, Gleason and pants using data collected sometime after the SMI was Suitor’s results are considered stronger because of the implemented (Rainville, 2001; Cullen et al., 2000).85 improved methods used to control for selection bias. Rainville looked at both food and nutrient consumption at lunch, comparing intakes of students who ate SNDA-I researchers stressed the importance of look- NSLP lunches and students who ate lunches from ing separately at NSLP effects by both age and gender. home. The study by Cullen et al. looked only at con- They pointed out, for example, that lunch options are sumption of fruits and vegetables at lunch, comparing usually more varied for older students and that these contributions of NSLP lunches and snack-bar lunches. students typically make their own decisions about Both of these studies were local in scope and both what to eat for lunch. Younger students, on the other have substantial methodological limitations relative to hand, generally have fewer options and decisions SNDA-I and Gleason and Suitor (2003), particularly about their lunches are often made by parents. with regard to generalizability and selection bias. Moreover, research has shown that adolescent females However, when viewed in concert with findings from are more likely than males or younger children to con- SNDA-II, these more recent studies provide suggestive sume diets low in nutrients relative to the RDAs. evidence of post-SMI impacts of the NSLP. In SNDA-I, selection-bias adjustments made little dif- Impacts on Intake of Food Energy ference in conclusions about NSLP effects on younger and Nutrients at Lunch children, but substantially affected the conclusions about older students, particularly females. SNDA-I Nine studies examined the impact of NSLP participation conducted subgroup analysis by age and gender (6- to on students’ intake of food energy and nutrients at lunch. 10-year-olds, 11- to 18-year-old males, 11- to 18-year- Results of these studies are summarized in table 27. old females) and by income (low-income and non-low- The table is divided into four sections: food energy income (income greater than 185 percent of poverty)). and macronutrients, vitamins, minerals, and other In table 27, results of SNDA-I subgroup analyses are dietary components. The text follows this general reported when estimates for one or more subgroups organization, but combines findings for vitamins and differed from results of the overall analysis and when minerals in one section. the result of one of the analyses—the overall analysis or the subgroup analysis—revealed a statistically sig- In the interest of providing a comprehensive picture of nificant difference. the body of research, both significant and nonsignificant results are reported in table 27 and in all other Food Energy and Macronutrients “findings” tables. As noted in chapter 1, a consistent pattern of nonsignificant findings may indicate a true Findings from SNDA-I (Devaney et al., 1993) and underlying effect, even though no single study’s results Gleason and Suitor (2003) suggest that, prior to the would be interpreted in that way. Readers are cau- implementation of the SMI, NSLP participants and tioned, however, to avoid the practice of “vote count- nonparticipants consumed roughly equivalent amounts ing,” or adding up all the studies with particular of food energy at lunch. (Note that results are reported results. Because of differences in research design and in table 27 using only the senior author’s name and other considerations, findings from some studies merit that SNDA-I results are reported as Devaney (1993).) more consideration than others. The text discusses Neither study found a significant difference in the methodological limitations and emphasizes findings energy intakes of NSLP participants and nonpartici- from the strongest studies. In this case, emphasis is pants at lunch. Interestingly, however, both sets of given to findings from SNDA-I (Devaney et al., 1993) researchers found that impact estimates that were not and from the most recent Gleason and Suitor (2003) adjusted for selection bias showed that NSLP partici- study, for the reasons discussed previously. All find- pants consumed significantly more food energy than ings reported for SDNA-I are based on selection-bias- nonparticipants (data not shown). Devaney and her adjusted models, and all findings reported for Gleason colleagues attributed the difference between the two results to differences in unobserved characteristics that may affect participation, such as differences in 85Studies that examined the nutrient content of NSLP and non-NSLP meals as offered or served, but did not assess food and/or nutrient intakes appetite, food preferences, and food energy needs. These of NSLP participants and nonparticipants, were not included in this review. factors are controlled for in the selection-bias-adjusted

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 185 Chapter 5: National School Lunch Program } } d ] less l d l] l] d a ct n a o Continued— i nch nal] nal] t a n nsume ups note up note [ [nationa [nationa ) ) ) ro ro ant imp } 3 1 3 g g 0 9 ts co es at lu 7) [natio 7) [natio 9 n 1 ( (200 (200 y Signific n n e n a y intak v Participa {except sub {males, 5-1 {except sub e Fraker (198 Fraker (198 Gleaso Gleaso D dietar nts’ less ] ] l l d a a n n o o i i nal] nal] nal] t t a a nsume n n [ [ } [10 schools] [10 schools] [10 schools] ) ) 0 ) ) ) 3 3 1 1 1 21} 21} ts co 9 9 7) [natio 7) [natio 7) [natio n 9 9 4) [3 schools] 1 1 ( ( y y h Program on stude e (200 e (200 e (200 e e ill ill ill n n a a v v Participa {males, 15- {11-18; females} {males, 15- {females, 5-1 e e t impact Rainv Fraker (198 Fraker (198 Fraker (198 Perry (198 Rainv Rainv D D n ifica d } } } d d ] ] l l d l] No sign a a n n tional School Lunc } o o i i 1 nsume nal] nal] nal] t t e a a m co } n n ups note ups note up note [ [ o 1 e Na [10 schools] [nationa c ) ) ts 2 ) ) ro ro ro n 3 3 n i 1 3 g g g - 9 9 7) [natio 7) [natio 7) [natio 9 9 w more/same 1 1 o l ( ( (200 ; y y e (200 n 8 91) [1 school] e e 1 ill n n Participa - a a 1 v v 1 { {except sub {except sub {females, 15- {except sub e e Fraker (198 Fraker (198 D Ho (19 Perry (1984) [1 site] D Rainv Gleaso Howe (1980) [1 site] Fraker (198 e impact of th } } d ] ] ] l l l d l] l] l] l] l] l] l] l] l] a a a ct examined th n n n l] a t o o o i i i 2 nal] nal] t t t a a a } n n n tha ups note up note [ [ [ me} 4 s [10 schools] [nationa [nationa [nationa [nationa [nationa [nationa [nationa o ) ) ) 1 ) ) ) ) ) ) ) ) ) [nationa ) [nationa ro ro ant imp 3 3 3 1 1 1 1 3 3 3 1 g g 9 9 9 7) [natio 7) [natio 9 9 9 983 983 0) [1 schoo 1 1 1 w-inc ( ( ( studie 98 (200 (200 (200 (200 (200 (200 (200 y y y e (200 Signific n n n n n n n 91) [1 school] 91) [1 school] 91) [1 school] 91) [1 school] e e e ill n n n a a a llisch (1 llisch (1 v v v e e {6-10; lo {except sub {except sub {females, 11- Participants consumed more e e e Gleaso Gleaso Ho (19 Ho (19 Ho (19 Fraker (198 W Howe (1 Gleaso Ho (19 W Fraker (198 D Gleaso Rainv D Gleaso D Gleaso Gleaso of table. s Findings from e t at end a r d ergy y h energy and macronutrients o b r See notes a Table 27— Outcome Food Food en Protein C Fat Saturated fat

186 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program } ] less l d l] d a ct n a o Continued— i 2 t a n nsume up note [ [10 schools] ) ) ) [nationa ro ant imp 3 1 g 9 ts co 9 n 983 1 ( y e (200 Signific 91) [1 school] e ill n a llisch (1 v Participa e {except sub e Rainv Ho (19 D W less ] ] ] ] l l l l d l] l] l] l] l] a a a a n n n n o o o o i i i i t t t t a a a a nsume n n n n [ [ [ [ [nationa [nationa [nationa [nationa [nationa me} ) ) ) ) ) ) ) ) ) 3 3 3 3 3 1 3 3 3 co ts co 9 9 9 9 n n 9 9 9 9 1 1 1 1 ( ( ( ( (200 (200 (200 (200 (200 } y y y y h Program on n n n n n low-i 8 e e e e 1 n n n n - a a a a 1 v v v v Participa 1 {non- { e e e e t impact Gleaso D Gleaso D Gleaso Gleaso D D Gleaso n ifica d } ] ] ] ] l l l l d l] l] l] l] No sign a a a a n n n n l] tional School Lunc o o o o i i i i 1 nsume t t t t a a a a } } ; ; n n n n up note [ [ [ [ e e 8 8 [nationa [nationa [nationa [nationa me} ) ) ) ) ts co 1 1 ) ) ) ) ro m m 3 3 3 3 n 3 1 3 1 g o o co 9 9 9 9 c c n 9 9 9 9 n n 0) [1 schoo more/same 4) [3 schools] i i 1 1 1 1 - - ( ( ( ( 98 (200 (200 (200 (200 w w y y y y n n n n low-i o o 91) [1 school] e e e e l l - - n n n n Participa n n a a a a o o v v v v {non- {females, 11- n {females, 11- n {except sub impact of the Na e e e e Ho (19 Gleaso D D D Gleaso Perry (198 Gleaso Gleaso Howe (1 D e } } } d d ] ] ] l l l d l] l] l] l] l] l] l] l] l] l] l] a a a ct examined th n n n l] l] l] a t o o o Continued i i i t t t a a a n n n tha ups note ups note up note [ [ [ s [10 schools] [10 schools] [10 schools] [10 schools] [10 schools] [10 schools] [10 schools] [nationa [nationa [nationa [nationa [nationa [nationa [nationa ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) [nationa ) [nationa ) [nationa ) [nationa ro ro ro ant imp 3 3 3 1 1 1 1 1 1 1 1 1 1 3 1 1 3 g g g 9 9 9 9 9 9 983 983 983 983 0) [1 schoo 0) [1 schoo 0) [1 schoo 4) [3 schools] 4) [3 schools] 1 1 1 ( ( ( studie 98 98 98 (200 (200 (200 (200 (200 (200 (200 y y y e (200 e (200 e (200 e (200 e (200 e (200 e (200 Signific n n n n n n n e e e ill ill ill ill ill ill ill n n n a a a llisch (1 llisch (1 llisch (1 llisch (1 v v v e e e e {except sub {except sub {except sub Participants consumed more e e e Gleaso Rainv Howe (1 Gleaso Gleaso W Perry (198 Howe (1 W Perry (198 Howe (1 Rainv D Gleaso Gleaso Rainv Gleaso Gleaso Rainv Rainv Rainv W W D D Rainv y intakes at lunch— of table. Findings from at end 6 12 vin a ents’ dietar n See notes Table 27— stud Outcome Vitamins Vitamin A Vitamin B Vitamin B Vitamin C Vitamin D Vitamin E Folate Niaci Ribofl

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 187 Chapter 5: National School Lunch Program less l] d ct a Continued— nsume ) [nationa ant imp ts co n 983 Signific llisch (1 Participa e {older} W less ] ] l l d a a n n o o i i t t a a } nsume ; n n [ [ e 8 ) ) 1 m 3 3 o ts co 9 9 c n 9 9 n i 1 1 - ( ( w y y h Program on o e e l - n n n a a o v v Participa {females, 11- n e e t impact D D n 3 ifica } me o d } ] ] ] ] ] l l l l l d l] l] No sign a a a a a n n n n n w-inc tional School Lunc o o o o o i i i i i 1 nsume t t t t t a a a a a co } n n n n n up note [ [ [ [ [ on-lo 8 w -income} w -income} [nationa [nationa ) ) ) ) ) ts 1 ) ) ro o o 3 3 3 3 3 n 3 3 g 9 9 9 9 9 18; n 9 9 9 9 9 more/same 4) [3 schools] 1 1 1 1 1 ( ( ( ( ( (200 (200 ; non-l ; non-l y y y y y n n 8 8 91) [1 school] e e e e e n n n n n Participa a a a a a v v v v v {11-1 {11-1 {females, 11- {6-10; 11- {except sub impact of the Na e e e e e Ho (19 D D D D Gleaso Perry (198 D Gleaso e 3 } } } } d d d ] ] ] ] ] l l l l d l] l] l] l l] l] l] l] l] l] l] l] l] l] l] a a a a ct a examined th n n n n l] l] l] a n t o o o o Continued o i i i i i t t t t t a a a a a n n n n tha n ups note ups note ups note up note [ [ [ [ [ s [10 schools] [10 schools] [10 schools] [10 schools] [nationa [nationa [nationa [nationa [nationa [nationa [nationa [nationa [nationa ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) [nationa ) [nationa ) [nationa ) [nationa ) [nationa ro ro ro ro ant imp 3 3 3 3 1 1 1 1 3 1 1 1 3 3 1 1 3 1 g g g g 9 9 9 9 0 9 9 9 9 0 983 983 983 983 983 0) [1 schoo 0) [1 schoo 0) [1 schoo 4) [3 schools] 4) [3 schools] 1 1 1 1 2 ( ( ( ( ( studie 98 98 98 (200 (200 (200 (200 (200 (200 (200 (200 (200 y y y y ger} e (200 e (200 e (200 e (200 Signific n n n n n n n n n n e e e e o ill ill ill ill n n n n s a a a a a llisch (1 llisch (1 llisch (1 llisch (1 llisch (1 v v v v e e e e e e {except sub {except sub {except sub {except sub {youn l Participants consumed more e e e e Gleaso Gleaso G Gleaso W Perry (198 Rainv Gleaso W Perry (198 Howe (1 W Gleaso Rainv Howe (1 W D Gleaso D Rainv W Howe (1 D Gleaso Rainv D Gleaso Gleaso y intakes at lunch— of table. Findings from at end horus m esium ents’ dietar u i c l See notes a Table 27— stud Outcome Thiamin Minerals C Iron Magn Phosp Zinc

188 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program y less ses l] l] d s ct a ific nal] c ne of the nsume more spe } [10 schools] [nationa [nationa ext discu 0 ) adding up all the a ) ) ant imp 1 3 1 ts co 7) [natio n The t significant findings ma at least o (200 (200 ting,” or e (200 Signific n n ts. ill and tain only to e l ed significantly Participa p {females, 5-1 per m m han others. u Fraker (198 Gleaso Gleaso Rainv studen a s e s attern of non “vote coun l l con a r e v tice of o ideration t c istent p r s s o f s } rticipants Where findings con t l less d ] ong low-incom l nt. u d re con s . a m t e n 1, a n r fica r oid the pra o i v nal] t m nly a a schools). o NSLP pa nsume } n 3 ups note [ 8 hapte merit mo ) d to a 1 ro 3 g ts co 9 7) [natio al vs. n 9 d in c ted that 1 cally significa tistically signi ( studies differed fr s significant o y cautione h Program on sta note e ult s re atisti n s indica some a v Participa we s st ple, nation s not {females, 11- {except sub s e t impact ers are D Fraker (198 n when res exam articipant r ly ifica research. A ings from n but wa n and wa fference i y. Read s. d on y of kets}. ctio ctio wa , find d } c s d ] ] n l l study (fo , the d ente l] l] No sign and nonp r a a s e n n v tional School Lunc o o {in bra i i 1 nsume nal] t t a a ted in that co } e of the n n are pre ups note [ [ 1 nsideratio ; howe [nationa [nationa rticipants ) ) ts 2 s ) ) ro es bgroup cture of the bod 3 3 co n 3 3 g s scop r 9 9 was in same dire was in same dire 7) [natio 9 9 bias-adjusted model more/same aly - 1 1 ( ( een pa nalyse (200 (200 sive pi y y n n 91) [1 school] e e n n Participa a a e betw v v c prehen ate, and the selection {except sub {females, 15- bgroup an ign and othe impact of the Na e e ended lunch ended lunch st studies. s u m lts would be interpre v v Fraker (198 Gleaso D D Gleaso Ho (19 s e identifies the su e subgroup a ) com on d nge a stro 1993 y’s resu earch d s ll entry also et al., the publicati y ] f providing een NSLP and een NSLP and l l] l] l] l] observed in all ll findings are fro es in re a ct s from the ne c examined th s n single stud a a t o Continued i 2 t ct. A name, a s rn wa n tha finding ction-bias-adjusted differen [ gh no ome} differen s [10 schools] [10 schools] [10 schools] s [nationa [nationa [nationa [nationa ulation, the ce ) ) ) ) ) ) ) ) ant imp 3 1 1 1 1 3 1 1 9 cant effe 9 author’ e, sele r SNDA-I (Dev 1 Difference betw Difference betw w -inc d in the interest o en thou ( phasize v This patte studie (200 (200 (200 (200 udy pop y of e (200 e (200 e (200 Signific n n n n signifi 91) [1 school] 91) [1 school] st e s s. senio ill ill ill n porte ct, e ult a s. Because of v ck lunch. ck lunch. {6-10; lo e re Participants consumed more e tically erall sampl r res , s sa sa v Gleaso Gleaso Gleaso Ho (19 Rainv Rainv Gleaso Rainv D Ho (19 y intakes at lunch— vs. vs. ability sults a P P derlying effe nonparticipant han the entire re cular result d a stati e n un Findings from rs r NSL r NSL her t a report Cell entries show the with parti s ents’ dietar d sug esterol um Results fo Results fo In main analysis for o Notes: Nonsignificant To maintain read 1 2 3 Table 27— stud Outcome Other dietary components Adde Chol Fiber Sodi subgroup rat indicate a true studies methodological limitations and em analyse magnesium tha

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 189 Chapter 5: National School Lunch Program results. This may explain the significant differences in and saturated fat, on average, than lunches offered in energy intake reported by other researchers whose secondary schools (the statistical significance of these analyses did not account for selection bias. differences was not tested). In addition, the schools included in Rainville’s study, and the lunches they The available studies are largely consistent in finding offered, may not be representative of lunches offered that NSLP participants consumed significantly more pro- nationwide. The two volunteer school districts that par- tein at lunch than nonparticipants. SNDA-I did not find ticipated in Rainville’s study were relatively affluent— this effect in the overall analysis. However, subgroup with 18 percent and 25 percent of students approved analyses revealed a significant NSLP impact among 6- for free and reduced-price meals, respectively—and to 10-year-olds and among low-income children. the reimbursable lunches offered in these districts provided even less fat (29.4 percent of total food energy) SNDA-I and Gleason and Suitor (2003) both found than required under the SMI (no more than 30 percent). that lunches consumed by NSLP participants prior to By comparison, SNDA-II found that lunches offered in the SMI were significantly lower in carbohydrates, as elementary schools provided an average of 33.5 per- a percentage of total food energy, than lunches con- cent of total food energy from fat. sumed by nonparticipants. SNDA-I subgroup analyses revealed that this pattern did not hold for females ages Vitamins and Minerals 11-18. Gleason and Suitor (2003) found that the differ- Data from SNDA-I (Devaney et al., 1993) and ence in carbohydrate consumption was due to Gleason and Suitor (2003) suggest that prior to imple- decreased consumption of added sugars among NSLP mentation of the SMI, NSLP participants had signifi- participants. Consumption of other forms of carbohy- cantly greater lunch intakes of vitamin B , riboflavin, drates was essentially equivalent for the two groups. 12 calcium, magnesium, phosphorus, and zinc than non- Findings from SNDA-I and Gleason and Suitor (2003) participants. Subgroup analyses conducted by Devaney are also consistent with regard to intakes of total fat and and her colleagues revealed substantial variation in saturated fat. The data indicate that, prior to implementa- these results across subgroups. Most often, significant tion of the SMI, lunches consumed by NSLP participants differences were concentrated among 6- to 10-year- provided significantly more fat and saturated fat, as a olds and low-income students. percentage of total energy intake, than lunches con- Findings from SNDA-I and Gleason and Suitor differ for sumed by nonparticipants. SNDA-I subgroup analyses vitamins A and C. SNDA-I found that NSLP participants revealed that the difference in intake of total fat was consumed significantly more vitamin A and signifi- concentrated among 6- to 10-year-old and non-low- cantly less vitamin C at lunch than nonparticipants.86 income students. Gleason and Suitor observed comparable trends in Findings from Rainville (2001), the only study in this intake, but found that differences between NSLP par- group based on data collected after implementation of ticipants and nonparticipants were not statistically sig- the SMI, paint a notably different picture. Rainville nificant. As noted above, results from Gleason and found no significant differences in the mean carbohy- Suitor are considered stronger because of the improved drates, fat, and saturated fat content of NSLP lunches approach to selection-bias adjustment in their analysis. and sack lunches consumed by elementary school stu- For all other vitamins and minerals, neither SNDA-I dents. These results suggest that the carbohydrate con- nor Gleason and Suitor (2003) found significant differ- tent of NSLP lunches has increased since the imple- ences between lunch intakes of NSLP participants and mentation of the SMI, while the fat and saturated fat nonparticipants. It is likely that the significant effects content has decreased. This is consistent with the trend reported in other studies are at least partially attributa- observed in SNDA-II (Fox et al., 2001). ble to selection bias. Both SNDA-I researchers and However, Rainville’s analysis did not adjust for selection Gleason and Suitor (2003) found significant effects for bias, and factors other than selection bias may have con- thiamin, vitamin B6, folate, and iron in regression tributed to their more positive findings. For example, models that did not adjust for selection bias (data not Rainville included only 2nd, 3rd, and 4th graders, while both SNDA-I and Gleason and Suitor (2003) included 86Although participants consumed significantly less vitamin C at lunch students in grades 1 through 12. SNDA-II found that than nonparticipants, intakes of both groups far exceeded the one-third lunches offered in elementary schools were lower in fat RDA standard defined for NSLP meals.

190 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program shown); however, these effects disappeared in models NSLP participants consumed significantly more cho- that controlled for selection bias. lesterol than nonparticipants.89

Every study that examined intakes of riboflavin, calci- Gleason and Suitor (2003) also studied fiber intake. um, and phosphorus found that NSLP participants con- They found that lunches consumed by NSLP participants sumed significantly larger amounts of these nutrients contributed significantly more fiber than those con- at lunch than nonparticipants (although SNDA-I found sumed by nonparticipants. that results varied for some subgroups of children). It is generally accepted that this pattern is due to Impacts on Total Daily Intake of increased consumption of milk, a concentrated source Food Energy and Nutrients of all these nutrients, by NSLP students (Lin and To have a meaningful influence on students’ nutrition Ralston; 2003, Devaney et al., 1993; Radzikowski and or health status, NSLP impacts on dietary intake must Gale, 1984). (Impacts on food consumption patterns be sustained over the course of the day. It is possible are discussed in more detail in a subsequent section.) for effects on lunch intakes to be offset by other meals and snacks consumed throughout the day. Therefore, Moreover, analyses completed by both SNDA-I and for a more complete appreciation of how the NSLP NESNP (Wellisch et al., 1983) researchers suggested affects students’ dietary intake, it is important to exam- that differences in the vitamin and mineral intakes of ine the program’s effect on the total diet. In the avail- NSLP participants and nonparticipants at lunch are due able literature, this was generally assessed as impacts to the types of food consumed, rather than the quanti- on 24-hour intake. ties. Both SNDA-I and NESNP examined the nutrient density of lunches and found it to be higher in lunches Fourteen studies examined the impact of NSLP partici- eaten by NSLP participants than those eaten by non- 87 pation on 24-hour intake of food energy and nutrients. participants. Although only the NESNP results were (Seven of these studies also assessed lunch intake and tested for statistical significance, both groups of inves- were included in the preceding section.) Findings are tigators concluded that the NSLP increased intakes of summarized in table 28 and discussed below. All the selected nutrients by providing lunches that were studies that assessed impacts on 24-hour intake were more dense in those nutrients, rather than by provid- completed before implementation of the SMI. In addi- ing more food. tion, SNDA-I did not include subgroup analyses for the 24-hour intake data. Consequently, little is known Results of the SNDA-II study, which found that reduc- about differential impacts on 24-hour intake for vari- tions in the fat and saturated fat content of NSLP meals ous subgroups of students. A few of the early NSLP were achieved without reducing vitamin and mineral studies did look at impacts among selected subgroups content, suggest that impacts on intake of key vitamins (Akin, 1983a and b; Hoagland, 1980; U.S. Department and minerals are likely to persist in post-SMI meals. In of Health Education and Welfare, 1972; Emmons et fact, SNDA-II found that the average vitamin and min- al., 1972). However, findings from these studies are eral content of the lower fat lunches offered in the quite dated, most of the studies used simple bivariate 1998-99 school year was significantly greater than the comparisons, and none attempted to control for selec- vitamin and mineral content of higher fat lunches tion bias. offered in 1992-93 (SNDA-I) (Fox et al., 2001).88 Food Energy and Macronutrients Other Dietary Components With emphasis given to findings from SNDA-I Both SNDA-I (Devaney et al., 1993) and Gleason and (Devaney et al., 1993) and Gleason and Suitor (2003), Suitor (2003) found that pre-SMI lunches consumed the available data indicate that before implementation by NSLP participants and nonparticipants provided of the SMI, NSLP participants and nonparticipants comparable amounts of cholesterol and sodium. consumed similar amounts of food energy and protein However, the SNDA-I subgroup analysis revealed that over 24 hours. among 6- to10-year-olds and low-income students, SNDA-I and Gleason and Suitor (2003) both found that, in comparison with nonparticipants, 24-hour 87Nutrient density measures nutrient intake relative to energy intake: % RDA for nutrient ‘X’ % RDA for energy. 88SNDA-II looked only at vitamin A, vitamin C, calcium, and iron—the 89Overall mean cholesterol intakes at lunch were less than one-third of nutrients that are specifically addressed in SMI standards. the recommended daily maximum of 300 milligrams (NRC, 1989b).

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 191 Chapter 5: National School Lunch Program } ours d ] less l l] l] d a ct n a 24 h o Continued— i nal] nal] t a n nsume ups note [ } [nationa [nationa ) 0 ) ) ro ant imp 3 1 3 g 9 ts co es over 7) [natio 7) [natio 9 n 1 ( (200 (200 y Signific n n e n a y intak v Participa {females, 5-1 {except sub e Fraker (198 Gleaso Gleaso Fraker (198 D dietar nts’ } 1 ] ] less l l d ] l d a a a n n n l] o o i i o t t i nal] nal] nal] t a a a n n nsume [ [ n ups note [ week} , 15-21} ) ) ) 0 0 State] 0 ro 3 8 8 g 21} ts co 9 9 9 7) [natio 7) [natio 7) [natio n 9 1 1 0) [1 schoo ( ( 1 ( 78) [1 d 98 d y h Program on stude n n e a a l l n g g a a a v Participa {2-3 times per {except sub {females, 5-1 {males, 15- o o e t impact H Howe (1 Price (19 D Fraker (198 Fraker (198 H Fraker (198 n ifica d 1 ] ] } l l ] l d l] a a No sign a n n n l] o o i i tional School Lunc o ate} ate} t t i nsume nal] nal] nal] nal] t a a a n n co } [ [ n equ equ up note [ 1 ) ) e Na [nationa ) ts 2 0 0 ) ro } 3 n 8 8 3 g 4 21} 9 ly ad ly ad 9 9 7) [natio 7) [natio 7) [natio 7) [natio 9 1 1 0) [1 schoo more/same ( ( 1 ( nal nal d 98 d (200 y n n n e a a l l n Participa g g a a a v {females, 15- {except sub {nutritio {males, 5-1 {males, 15- {nutritio o o e Fraker (198 H H Fraker (198 Emmons (1972) [1 district] Gleaso Fraker (198 Fraker (198 D Howe (1 Emmons (1972) [1 district] e impact of th } } } d ] ] l l d d l] l] l] l] l] l] l] l] l] l] a a ct examined th n n a t l] o o i i a nal] nal] t t a a } n n tha ups note up note up note [ [ 4 s [nationa [nationa [nationa [nationa [nationa [nationa [nationa ation [nationa ) ) 1 0 States] 0 States] State] ) ) ) ) ) ) ) ) [nationa ) [nationa ro ro ro ant imp 3 3 1 1 1 3 3 1 3 g g g 9 9 7) [natio 7) [natio 9 9 983 983 1 1 ( ( 78) [1 studie (200 (200 (200 (200 (200 (200 (200 83a) [n 83a, b) y y Signific n n n n n n n e e (1972) [1 (1972) [1 n n a a llisch (1 llisch (1 v v e e {females, 11- {except sub {except sub {except sub Participants consumed more e e Gleaso Gleaso Fraker (198 W Akin (19 Emmons (1972) [1 district] HEW Gleaso Fraker (198 W Akin (19 Gleaso Price (19 Gleaso D Emmons (1972) [1 district] D HEW Gleaso Gleaso of table. Findings from te at end a ergy energy and macronutrients See notes Table 28— Outcome Food Food en Protein Carbohydr Fat Saturated fat

192 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program ] less l d a ct n a o Continued— ate} i t a n equ nsume [ ) ant imp 3 9 ly ad ts co 9 n 1 ( nal y Signific e n a v Participa {nutritio e D Emmons (1972) [1 district] ] less } l ] ] ] l l l d d l] l] a l] a a a n n n n l] l] l] o i o o o ate} t i i i t t t a a a a n nsume [ n n n equ up note [ [ [ ) [nationa [nationa ) ) ) ) 0 ) ) [nationa ro 3 3 3 8 1 1 g ts co 9 9 9 ly ad 9 n 9 9 9 1 983 0) [1 schoo 0) [1 schoo 0) [1 schoo ( 1 1 1 ( ( ( nal 98 98 98 d (200 (200 y y y h Program on n n n e e e a l n n n g a a a llisch (1 a v v v Participa e {nutritio {except sub o e e e t impact H Howe (1 Gleaso Emmons (1972) [1 district] W Howe (1 D D D Howe (1 Gleaso Emmons (1972) [1 district] n ifica d } ] } l d ] } l d l] l] l] l] l] l] l] l] l] a No sign a n n o l] l] l] l] i tional School Lunc o ate; t i a a a a nsume t a a n co [ n equ ups note up note [ ) w income [nationa [nationa [nationa [nationa [nationa [nationa [nationa [nationa [nationa ation ation ation ation ) ts ) 0 ) ) ) ) ) ) ) ) ro ro 3 n 8 1 1 1 3 3 3 3 3 3 g g 9 ly ad 9 9 1 more/same ( 1 ( nal d (200 (200 (200 (200 (200 (200 (200 (200 (200 years} years} 83b) [n 83a) [n 83a) [n 83b) [n ears; lo y come} n n n n n n n n n n 8 8 e n a l n Participa g a a v low-i {12-1 {12-1 {except sub {except sub {nutritio {6-11y impact of the Na o e d Akin (19 Gleaso Gleaso Gleaso Akin (19 Gleaso Gleaso Gleaso Gleaso Gleaso Akin (19 Emmons (1972) [1 district] Emmons (1972) [1 district] H D Gleaso Akin (19 e e } ontinu C } 1 ] l d come l] l] l] l] a l] l] l] l] n ct n rs— examined th a o t l] l] l] l] l] l] i t a a a a a a a n [ tha edy; edy} } n-low i ups note ) [nationa s e [nationa [nationa [nationa ation ation ation ation ation ation [nationa ) 0 States] 0 States] 0 States] 0 State] ) ) ) ) [nationa ) [nationa ) [nationa ro ant imp 3 m 8 1 3 1 g 9 o ly ne ly ne 9 c 1 983 983 983 ( n ars; no ars} ars} i nal nal 78) [1 - studie d (200 (200 (200 83a) [n 83a) [n 83b) [n 83b) [n 83a) [n 83a) [n 83a, b) over 24 hou y (19 w Signific n n n n s e o a l l (1972) [1 (1972) [1 (1972) [1 e t g llisch (1 llisch (1 llisch (1 o a e e e {except sub {6-11 ye {6-11 ye {6-11 ye {nutritio {nutritio n Participants consumed more o W Akin (19 H W Akin (19 Akin (19 Gleaso Akin (19 Gleaso Akin (19 Emmons (1972) [1 district] HEW Akin (19 Emmons (1972) [1 district] HEW W Gleaso Akin (19 Price (19 HEW Devan y intak of table. Findings from at end 6 12 ents’ dietar n See notes Table 28— stud Outcome Vitamins Vitamin A Vitamin B Vitamin B Vitamin C Vitamin E Folate Niaci

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 193 Chapter 5: National School Lunch Program less d ct a Continued— nsume week} State] ant imp ts co n 78) [1 Signific Participa {2-3 times per Price (19 ] ] less l l ] ] l l d a a a a n n n n o o i i o o ate} ate} ate} t t i i t t a a a a n n nsume [ [ n n equ equ equ [ [ ) ) ) ) 0 0 3 3 8 8 ts co 9 9 ly ad ly ad ly ad 9 9 n 9 9 1 1 ( ( 1 1 ( ( nal nal nal d d y y h Program on n n e e a a l l n n g g a a a a v v Participa {nutritio {nutritio {nutritio o o e e t impact H Emmons (1972) [1 district] H Emmons (1972) [1 district] D D Emmons (1972) [1 district] n ifica d } } ] ] l l d d ] ] ] l l l l] l] l] a a l] l] No sign a a a n n n n n l] l] l] o o l] i i tional School Lunc o o o ate} t t i i i a nsume t t t a a a a a n n co [ [ n n n equ ups note ups note [ [ [ ) ) [nationa [nationa [nationa ation ) ) ) ts ) 0 0 ) ) ) [nationa ) [nationa ro ro 3 3 3 } n 8 8 1 3 3 g g 9 9 9 ly ad 9 9 9 9 9 1 1 983 983 0) [1 schoo 0) [1 schoo 0) [1 schoo more/same ( ( 1 1 1 ( ( ( nal 98 98 98 d d (200 (200 (200 years} 83a) [n y y y ncome n n n n n 8 e e e a a l l n n n Participa g g a a a llisch (1 llisch (1 a a v v v e e {low-i {except sub {12-1 {nutritio {except sub impact of the Na o o e e e d H H Gleaso Gleaso W Howe (1 D Howe (1 D Emmons (1972) [1 district] Emmons (1972) [1 district] Gleaso W Akin (19 Howe (1 Emmons (1972) [1 district] D Emmons (1972) [1 district] e e ontinu C } ] d l l] l] l] l] l] l] l] l] l] l] ct a rs— examined th l] a n t l] l] l] o a a a i t a tha edy; edy} edy} } eek} n up note [ s e [nationa [nationa [nationa [nationa [nationa [nationa ation ation ation [nationa 0 States] 0 States] 0 States] 0 States] State] State] State] ) ) ) ) ) ) ) ) [nationa ) [nationa ) [nationa ro ant imp m 3 3 3 1 1 1 1 g o ly ne ly ne ly ne 0 c 0 983 983 983 0) [1 schoo n ars} 2 i nal nal nal 78) [1 78) [1 78) [1 ( - studie 98 (200 (200 (200 (200 (200 (200 83a) [n 83a) [n 83a) [n 83a, b) over 24 hou w Signific n n n n n n n s o o l (1972) [1 (1972) [1 (1972) [1 (1972) [1 e s t a llisch (1 llisch (1 llisch (1 o e e e e {0-1 time per w {nutritio n {6-11 ye {except sub {nutritio {nutritio l Participants consumed more Gleaso Gleaso G Gleaso Price (19 Gleaso Gleaso Price (19 Emmons (1972) [1 district] HEW W Akin (19 W Akin (19 Emmons (1972) [1 district] Emmons (1972) [1 district] HEW HEW Gleaso W Akin (19 Howe (1 Price (19 Emmons (1972) [1 district] HEW Akin (19 y intak of table. Findings from at end vin m a esium ents’ dietar u i c l See notes a Table 28— stud Outcome Ribofl Thiamin Minerals C Iron Magn

194 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program d r y sse less -hou ses l] l] sse d s ct a y a ific c s and 24 nsume spe . Stud [nationa [nationa ext discu ke s adding up all the a ) ) ant imp a e 3 1 c ts co n The t e int significant findings ma m (200 (200 ting,” or Signific n n differen tain only to Participa per -hour han others. Gleaso Gleaso 4 es in at-ho c attern of non “vote coun an 2 tice of istent p differen ideration t c s s con } Where findings less d a d or smaller th re con oked at oid the pra rent v rs lo nal] schools). nsume 3 ups note hapter 1, diffe merit mo d to a ro g ts co 7) [natio al vs. n d in C week. studies gram. Autho cautione h Program on er note s h pro some c Participa ple, nation {except sub s were either not t impact ers are Fraker (198 n exam 4-5 times p r ifica research. A P ings from of free lun e intake y. Read y of kets}. wa -21} , find d c 1 5 ction s ] ] l l ] ] ] ] t-hom n l l l l study (fo l] l] l] a a No sign a a a a n n n n n n o o i i tional School Lunc o o o o {in bra t t i i i i nsume nal] t t t t a a a a a a n n ted in that co [ [ e of the n n n n rticipated in NSL del. [ [ [ [ nsideratio ) ) [nationa [nationa [nationa after introdu ) ) ) ) ts ferent but a 0 0 ) ) ) ; females, 1 bgroup cture of the bod 3 3 3 3 co n 8 8 1 3 3 scop 0 r 9 9 9 9 9 9 7) [natio 9 9 9 9 1 1 more/same ted mo re dif ( ( 1 1 1 1 ually pa e and s ( ( ( ( r s d d (200 (200 (200 sive pi y y y y n n n n n e e e e s we a a l l n n n n Participa g g a a a a s befo a a v v v v prehen n who u ate, and the .10. {males, 5-1 ign and othe impact of the Na o o e e e e st studies. s 0 ake d lts would be interpre Gleaso Fraker (198 H Gleaso D H Gleaso D D D r intake e identifies the su e d e com on d nge a hou childre - r stro o y’s resu selection-bias-adju earch d s e 24 ison of int r r ontinu ll entry also C the publicati 8) are f . f providing sed on l] l] l] l] l] l] l l] e whe significant at p es in re compa s ct s from the a rs— c examined th s single stud rted a n t l] e ba o a on i t name, al. (197 a s repo tha finding n sed gh no [ orted a differen s a s [nationa [nationa [nationa [nationa [nationa [nationa ation ulation, the ce State] ) ) ) ) ) ) ) ) [nationa ant imp 3 3 1 1 1 3 1 0 author’ 983 0 r r Price et sted/not al., 1993) ar 2 d in the interest o ere rep en thou 78) [1 ( 2) are b fo phasize v studie (200 (200 (200 (200 (200 (200 83a) [n ble 26). udy pop over 24 hou te significant are tho Signific n n n n n n n ) w st s y et o senio s porte e ct, e s (197 not sults s a llisch (1 s. Because of ane e e v l e re Participants consumed more r rted a s (see ta Gleaso Gleaso G Gleaso Gleaso Gleaso Akin (19 Price (19 W Gleaso y intak -I (De A noted, re sults a et al. (1983b difference mons et al. es repo derlying effe han the entire re cular result c subgroup un Findings from r rs her t a Cell entries show the Differen with parti horus m ents’ dietar d sug esterol u i d Significance of Notes: Nonsignificant Findings for SND Findings for Akin Unless otherwise Findings for Em 1 o Table 28— stud Outcome Phosp Zinc Other dietary components Adde Chol Fiber S subgroup rat indicate a true studies methodological limitations and em intakes. impacts in fou

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 195 Chapter 5: National School Lunch Program intakes of NSLP participants were lower in carbohy- eating occasions other than lunch. Gleason and drates and higher in total fat and saturated fat as a per- Suitor’s model was based on differences within indi- centage of total energy intake. Gleason and Suitor vidual students rather than between groups of students, (2003) also found that 24-hour intakes of NSLP partic- and the model included covariates that controlled for ipants were significantly lower in added sugars than several potentially relevant variables, including Body the intakes of nonparticipants. All these findings are Mass Index (BMI),90 frequency of exercise, hours of consistent with findings from the analysis of lunch television watched, and whether reported intakes were intakes, indicating that pre-SMI impacts on intakes of heavier or lighter than usual. carbohydrate, fat, and saturated fat persisted over the course of the day. Other Dietary Components Both SNDA-I (Devaney et al., 1993) and Gleason and Vitamins and Minerals Suitor (2003) found that NSLP participation did not Findings from SNDA-I (Devaney et al., 1993) and affect students’ 24-hour intakes of cholesterol or sodi- Gleason and Suitor (2003) are divergent for 24-hour um. This is consistent with findings from their respec- intakes of most vitamins and minerals. SNDA-I found tive analyses of lunch intakes (using results for the that most of the increases in vitamin and mineral overall SNDA-I sample). intakes observed at lunch diminished over the course of the day. In SNDA-I, the only significant NSLP In addition, Gleason and Suitor (2003) found that impacts that persisted over 24 hours were an increase NSLP participants consumed significantly more fiber in vitamin A intake and a decrease in vitamin C intake. over 24 hours than nonparticipants. This is consistent (Overall mean vitamin C intakes of both groups were with the finding from the analysis of lunch intakes and more than 250 percent of the RDA.) NSLP partici- suggests that the NSLP’s impact on fiber intake per- sists over the course of the day. pants’ 24-hour intakes of vitamin B12, calcium, phosphorus, magnesium, and zinc continued to be greater than those of nonparticipants, but the differences were Impacts on Food Consumption Patterns not statistically significant. Examining the food consumption patterns of NSLP participants and nonparticipants can prove helpful in In contrast, Gleason and Suitor (2003) found that all of understanding the effects the NSLP has on students’ the impacts on vitamin and mineral intakes observed at nutrient intake. Several researchers looked at food lunch persisted over 24 hours. Specifically, they found consumption patterns, using a number of approaches. that, relative to nonparticipants, NSLP participants had SNDA-I researchers examined the percentage of stu- significantly greater 24-hour intakes of vitamin B12, dents consuming specific foods and food groups at riboflavin, calcium, magnesium, phosphorus, and zinc. lunch (Devaney et al., 1993). Simple weighted tabula- In keeping with findings from their analysis of lunch tions were reported, without adjustment for observed intakes, Gleason and Suitor (2003) found no signifi- differences in characteristics of the two groups or for cant impact on 24-hour intakes of vitamins A or C. selection bias. In their first analysis of the CSFII data, Gleason and Suitor (2001) computed the number of As noted, findings from Gleason and Suitor (2003) are Food Guide Pyramid servings consumed by each child considered stronger than findings from SNDA-I. and compared regression-adjusted means. Their analy- Indeed, Devaney and colleagues cautioned that sis looked at both lunch and 24-hour consumption. SNDA-I’s estimates of NSLP impacts over 24 hours were less precise than their estimates of NSLP impacts Cullen et al. (2000) also looked at Food Guide Pyramid at lunch. This is true because estimates of 24-hour servings, but their analysis was limited to lunch and to impacts are influenced by differences in unmeasured fruits and vegetables. Rainville (2001) and Wolfe and characteristics and measurement error associated with Campbell (1993) compared cumulative counts of food other eating occasions, in addition to differences in items within Food Guide Pyramid groups (expressed unmeasured characteristics and measurement error as categorical variables). Finally, Melnick et al. (1998) associated with lunch. The same is true of Gleason and and Yperman and Vermeersh (1979) used index scores Suitor’s (2003) estimates of NSLP impacts over 24 to reflect 24-hour food consumption. Melnick and his hours, of course; however, the fixed-effects model esti- colleagues computed a Food Guide Pyramid score and mated by Gleason and Suitor (2003) did a better job than the SNDA-I model of controlling for unmeasured 90BMI is the accepted standard for defining overweight and obesity. characteristics that may have affected consumption at BMI is equal to [weight in kilograms] ) [height in meters]2.

196 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program a 5-A-Day score for each student and also tabulated Gleason and Suitor (2001) reported that NSLP impacts the number of servings of fats, oils, and sweets con- on consumption of milk, vegetables, and meat were sumed. Yperman and Vermeersch constructed a meas- maintained over 24 hours. However, the decreased ure similar to the Food Guide Pyramid score, using consumption of grain products at lunch noted among data from a food frequency checklist. NSLP participants did not persist over 24 hours, nor did the decreased consumption of sweetened beverages. Because none of the studies that examined impacts on food consumption controlled for selection bias, con- Melnick et al. (1998) found that NSLP participants clusions about impacts on these outcomes are more consumed fewer servings of fats, sweets, and oils over tentative than those about impacts on intake of energy 24 hours than nonparticipants. These researchers also and nutrients. Results of the available studies, summa- found that NSLP participants scored higher than non- rized in table 29, are largely consistent. Only the stud- participants on a composite measure that evaluated ies by Rainville and Cullen are based on data that were servings from the Food Guide Pyramid (5th graders), collected sometime after the implementation of the SMI. as well as on a 5-A-Day score that looked specifically at fruit and vegetable consumption. Food Consumption at Lunch The available data suggest that NSLP participants con- The study by Yperman and Vermeersch (1979), which sumed more milk and vegetables at lunch and fewer found that the NSLP had a significant negative impact sweets and snack foods than nonparticipants. Findings on students’ “dietary complexity,” stands in stark con- for other food groups are equivocal. SNDA-I found trast to the positive or neutral findings of other studies. that a significantly greater proportion of NSLP partici- This result can be heavily discounted, however, because pants than nonparticipants consumed grain products at the study is dated and methods used to collect and ana- lunch. In contrast, Gleason and Suitor (2001) found lyze food group data do not meet current standards. that, on average, NSLP participants consumed significantly fewer servings of grains at lunch than nonpartic- Impacts on Other Nutrition- and ipants. In both cases, between-group differences were Health-Related Outcomes relatively small. The literature search identified 10 studies that looked The Gleason and Suitor (2001) finding deserves more at impacts of the NSLP beyond food and nutrient weight than the SNDA-I finding because the former intake. Table 30 describes these studies, three of which analysis looked at the actual number of servings con- are also included in the preceding section on dietary sumed (rather than the percentage of children eating at intake (Wellisch et al., 1983; Hoagland et al., 1980; least one item within the food group) and adjusted for and Emmons et al., 1972). Six studies looked at chil- differences in observed characteristics of students. dren’s weight and/or height. Four studies looked at Rainville (2001) reported results similar to Gleason and biochemical measures, specifically iron status or Suitor and found that the increase in the number of grain serum cholesterol levels, and three looked at impacts items consumed by nonparticipants was attributable to a on household food expenditures. Findings from these high prevalence of sandwiches in lunches from home. studies are summarized in table 31. One study (Gretzen and Vermeersch, 1980) also looked at school Gleason and Suitor (2001) found no difference attendance and cognitive performance. That study, between NSLP participants and nonparticipants in con- which is dated and has serious limitations as a test of sumption of fruits and juices at lunch. However, most the NSLP, found no effects of participation in a free of the other studies reported that NSLP participants school lunch program on any of these measures.91 consumed more fruit and juices than nonparticipants. Weight and Height Food Consumption Over 24 Hours Few studies have looked at the relationship between Data on food consumption patterns of NSLP partici- NSLP participation and children’s weight status or lin- pants and nonparticipants over 24 hours are more lim- ear growth, and none of them offers definitive evidence. ited. (SNDA-I (Devaney et al., 1993), Rainville The NESNP (Wellisch et al., 1983) measured students’ (2001), and Cullen (2000) did not evaluate 24-hour height, weight, and triceps skinfold (a measure of body consumption.) The available data suggest that some NSLP impacts on food consumption at lunch main- 91The study analyzed 8 years of school records in an attempt to determine tained over 24 hours, while others faded. the impact of free school lunch, alone and in combination with Head Start.

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 197 Chapter 5: National School Lunch Program s n r ] less l l] l] e d a ls] ls] ct n o o a o Continued— i t a n nsume [ [10 schools] [10 schools] [10 schools] [nationa [nationa ) ) ) ) ) ) ant imp 3 1 1 1 1 1 9 ption patt ts co 9 n 3) [51 scho 3) [51 scho 1 ( (200 (200 y e (200 e (200 e (200 Signific n n e ill ill ill n a lfe (199 lfe (199 v Participa o o e Rainv W Gleaso D Gleaso Rainv Rainv W nts’ food consum less ] l d a n o i t a nsume n [ ) 3 ts co 9 n 9 1 ( y h Program on stude e n a v Participa e t impact D n ifica d l] No sign ls] tional School Lunc nsume co schoo e Na [nationa ts 5 ) n 1 more/same 000) [ (200 n Participa en (2 Cull Gleaso e impact of th 1 1 ] ] ] ] l] l l l l l] l] l] a a a a ls] ls] ls] ct ls] examined th n n n n o o o a t o o o o i i i i t t t t a a a a n n n n tha [ [ [ [ schoo [nationa s [10 schools] [10 schools] [10 schools] [nationa [nationa [nationa ) ) ) ) ) ) ) ) 5 ) ) ) ant imp 3 3 3 3 3 1 1 1 1 1 1 9 9 9 9 9 9 9 9 9 3) [51 scho 3) [51 scho 3) [51 scho 1 1 1 1 ( ( ( ( 000) [ studie (200 (200 (200 y (19 y y y y e (200 e (200 e (200 Signific n n n e e e e e ill ill ill n n n n a a a a en (2 lfe (199 lfe (199 lfe (199 v v v v o o o Participants consumed more e e e e Gleaso W W W Rainv Gleaso Gleaso Rainv D D Rainv D Cull D Devan of table. ption s m ed ts, Findings from ng lk at end e 2 nsu ducts les at b eeten ages ucts See notes Table 29— Measure Lunch co Fruits and fruit juices Grain pro Meat, poultry, fish, and me substitutes Milk and mi prod Vegeta Fats, oils, and salad dressi Snack foods Sugar, swe and sw bever

198 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program less d ls] ct o a Continued— nsume ant imp 8) [25 schools] ts co n 3) [51 scho 99 Signific lfe (199 Participa o Melnick (1 W nts’ less d l] l] nsume [nationa [nationa ) ) 1 1 ts co n (200 (200 h Program on stude n n Participa t impact Gleaso Gleaso n ifica d l] No sign tional School Lunc nsume co [nationa ts ) n 1 more/same (200 n act of the Na Participa Gleaso e imp l] l] l] ls] ls] ls] ls] ct examined th o o o o a t tinued tha s [10 schools] [nationa [nationa [nationa on ) ) ) ) ant imp 1 1 1 1 C 3) [51 scho 3) [51 scho 3) [51 scho 3) [51 scho studie (200 (200 (200 e (200 Signific n n n ill lfe (199 lfe (199 lfe (199 lfe (199 o o o o Participants consumed more Gleaso W Rainv W Gleaso Gleaso W W of table. ption patterns— m Findings from u r of lk at end s e rsity/ ducts e les at ned b ils ages ucts See notes Table 29— food con Measure Food div total numb food items 24 hours Fruit and fruit juices Grain pro Meat, poultry, fish, and me substitutes Milk and mi prod Vegeta Fats, sweets, and o Snack foods Sweete bever

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 199 Chapter 5: National School Lunch Program y a and wer s ses o s ct a n

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cluded r e h t tice of nts’ ideration t c o istent p s s n a

s es and in Where findings con a g wer ney et al. (1993)

r Wolfe and Cam o re con e ra consumption an c eva u 1, a ve r oid the pra a v s meat schools). sults fo 3 s for D hapte in merit mo d to a s ts scored l n eetened be al vs. d in c or tomato Result rence studies . s up, and re d cautione h Program on stude at sw note s atoe h gro some Participa c ple, nation nsume t impact ers are n in ea exam r than pot looked only r ifica e research. A ings from exception of diffe rvings co y. Read se h items y of kets}. wa c , find c s les oth n b study (fo No sign son et al. of lun tional School Lunc {in bra s number of ted in that e of the p. Glea d vegeta n ts scored ount ed that, with the nsideratio n c rt an er/same e bgroup cture of the bod co scop 8) [25 schools] r on mea high 99 ruits”) sive pi mulativ s as a grou Participa u act of the Na grade} ion but repo nd rage pt e based under “f prehen ate, and the r {2 ign and othe ve m st studies. a s lts would be interpre Melnick (1 u e identifies the su e imp s com on d ased on c nge r selection bias. a con ed here stro ened be y’s resu earch d our ) are b s cord ll entry also er the publicati d sweet adjusted fo p (re f providing gh ed. or 24-h i es in re f s from the ct rt hours. c examined th ille (2001 d for Cullen (2000) single stud a t v s, an name, repo are not tinued nding s er 24 one grou tha fi v gh no differen s ent data sweet s on ulation, the ce or Rain s ant imp f C ts scored h 8) [25 schools] 8) [25 schools] n author’ al. (2001) an r ults bles as 99 99 al., 1993) d in the interest o ot pre en thou sugar, er of items phasize ta v es studie udy pop ersisted o Signific st y et senio porte umb ct, e grade} son et ed at th up. R k s. Because of Participa ane v {5 e re r Glea and vege Melnick (1 Melnick (1 umption p s s sed on n e -I (De r A ts for sults a bell (1993) did n u ba ption patterns— s derlying effe han the entire s re cular result h con sul a e c m r un e Findings from u her t m s e

). y et al. (1993) loo y s onsuming food gro looked at fruits Cell entries show the r xity Score c with parti a e rical sco m m Study Devane Notes: Nonsignificant Food group re Findings for SND Wolfe and Camp 1 2 u hildren Table 29— food con Measure S 5-A-Day Index Score Food Guid Pyramid Index Score Dietary Compl subgroup rat indicate a true studies methodological limitations and em c catego observed in lun vegetable fruit drinks/flavored drinks.

200 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program n n n n od h means ance; on Continued— gressio gressio gressio gressio of means d) d) essi te re te re te re te re of vari a a a a ison ison of ate t-tests Analysis met ar regr Multivari Multivari Analysis Multivari Line bivari Multivari (type of statistical test not reporte Compar (type of statistical test not reporte Compar d d gh re of h” riod o h at least h on ffered c grade 1 g free ation ek e -term in g rt that “chil rt that chil unc unc h in d l lun o o rticip arly throu eals o a unc e lon Measure of participation gul n receiv g study p e 8 on and health outcomes Parent rep Bega “participates” school l and re Ate school l Averag grad 3 times per we recall day Parent rep eats schoo weekly p Ate school l Took 70% or m school m durin Not reporte triti l) o (iron, before otein) 5 t vs. t vs. t vs. t vs. t vs. t vs. ts, before vs. ts, before pant, pant pant pant pant pant Design n n n n n n n n rol, pr 4 e partici partici partici partici partici partici Program on other nu Participa non Participa non Participa after (cholester cholest non Participa Participa non Participa Participa non vs. after and after Participa non d h 772) wit = ) e ,556) n ,155) 6 3 mes es 6-21 332) des 1, 2, des 1-4 des 2 an = scents o School Lunch le latio al d 42) gra gra gra n 7 n n n nts in nts in ado nts ag a ld inc -15 (n= Popu n 1 ,797) (sample siz e 1 r eho ,155) es 1-8 (n= es 1-12 (n esce esce esce dren i dren i dren/ dren i dren ages 5-12 dren and dren and d l 3 844) i h 185% of poverty (n d hous grad Chil Chil adol Chil ages 1 Chil Chil 5 (n= Chil grad and 6 (n= (n= Chil adol (n= adol C the Nation f n e n d n I pact o 1 - S m hool i hools i on rict in York City E schools i State c c esentativ SFA in e, ools ograms s N 1 pr A 1 n H pari ent nt 3 N nts in selecte ic sch nts in 2 g New w York tion pr of students from 4 n in ally re nia Data source 7 opm ubl leme - na es in 1 dist 7-88) 0-81) 0-71) 7 PSID, Child 1 7 9 199 All stude Students in 5 1 Students in 4 s India programs i Califor Students in 1 s grad rural Ne (197 New York Stat exclud (198 Baltimore, MD Devel Supp Nation All stude interve and 2 com sample 276 p (198 2) 2 3) of table. hemistries ) 198 c 94) height udies that examined the i 0 980) t 003) 1) 8 9 00 at end 1 2) d/or ( nd d n a l iah a e (197 g lfe et al. (19 llisch et al. ( a o e See notes o Table 30—S Study Weight an Jones et al. (2 W W (NESNP) Gretzen and Vermeersch (1 Emmons et al. (197 Paig Nutritional bio Kand Peterson (2 H

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 201 Chapter 5: National School Lunch Program . n n n od h ls for means cond bias e gressio gressio gressio of means inued t 6 on- d) d) te re te re te re the se a a a ison ison of ent ate mod Analysis met ritionally adequate, Multivari with selecti adjustm Compar (type of statistical test not reporte (type of statistical test not reporte Multivari Multivari Separ Blacks, Whites, Mexican- Americans. Compar eristics: nut ut the analysis of t c 4 ara re per riod o ffered NSLP member s ng a NSLP at e old llar d ekly ek eh eals o e duri tes in n the analysis, b a Measure of baseline ch s (do participation e g study p e of free school on and health outcomes—Con ely i at ed on s typical we least onc Took 70% or m Any hous particip Not reporte Valu lunch school m durin Current we participation month) triti separ s ba ered group id s sub before , con n) were . t vs. ts vs. t vs. t vs. ts, before vs. pants pant pant pant Design n n n n n ricts our different tures r f partici partici partici partici Program on other nu pendi after (iron) Participa non Participa Participa non and after (iro Participa non Participa non rted fo e two dist Lunch es es red. Th ce. d SBP in ex ) e n Results repo rman des 1, 2, des 1-4 re offe latio al School 78) 56) 42) gra gra ,7 ,5 7 n n st we . nts in grad nts in grad and 5 6 y fa plement. Popu (sample siz uded NSLP an h program. l demic perfo c esce esce eak dren i dren i dren ages 8-12 dren and dren r 844) 992) a n income. - c inc s. s. 1-12 (n= Chil Chil adol 1-12 (n= and 6 (n= (n= Chil (n= Chil adol Chil ee lu the Nation ure; r f s and a d free b ination Surve d e m n nd not low evelopment Sup n pact o 1 ms. 2-73) ture mea unch an ndance, h), a ction of a f c m ra hools i and lunch meal rict in P State e c t gions i esentativ ools hools/ r s N pendi Nutrition Program e pr prog x h free l d (197 kfa e hool atte le 3 on State; s ea ic sch nts in 2 selecte r w York of students in a and Nutrition Exa namics, Child D ally re y Data source School ubl D es in 1 dist 0-81) 0-71) 0-81 NES her lunch shingt week where bot and after introdu gible for free lun a i ons of b res Students in sc All stude Students in 4 s grad rural Ne (197 Baltimore, MD W Blacks and Mexican- Americans w Nation districts in 8 re oversamp sample 276 p (198 198 come u ame s s before come (el not contributi al Evaluation of cond district 2) ure 3) ined physical fitness, sc iate NLSP and ot a se d intake m 198 (1976) y, low-in parate udies that examined the i a od expendit t x s: o se pare ce 2) r 1) ipation meas NESNP = Nation NHANES-I = First National Health PSID = Panel Study of In e (197 g (199 llisch et al. ( st and Price Data sou Study also e Study included Study com Did not different Partic e e 1 2 3 4 5 6 Table 30—S Study Emmons et al. (197 Paig Household f Lon W (NESNP) W district did not nutritionally need

202 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program s 6 1,2 e ] l ct m a ls] 3 a n o wer Continued— o i nal} t a ts lo n females} [ n e ) ant imp natio 3 th outc l 8 9 2) [4 schoo 4) [1 State] 1 secur ( 003) [

n Signific h Participa c s e (197 i l l lfe (199 e o {food-i {grade 1} W Paig W Jones (2 ion and hea t tri nd 6 ls] ls] wer nal} ts lo n males} males a e 6} e 6} [4 schools] e natio 0) re fe 2) [4 schoo 2) [4 schoo u secur 003) [ 2, grad 1, grad n Participa h Program on other nu e e e (197 e (197 {males} {grad {grad food-sec {food-i t impact Paig Gretzen (198 Paig Jones (2 n ifica e 1 ] l No sign l] a /sam ls] ls] 7 6 n tional School Lunc o i nal} t gher les} a edy; a n [ e Na

[4 schools] [4 schools] [4 schools] ) ) [nationa natio ts hi 3 0) 0) 0) n re m ly ne 8 u 983 9 2) [4 schoo 2) [4 schoo 4) [1 State] me} 1 nal ( o 003) [

h c s e (197 e (197 i Participa l llisch (1 lfe (199 l e o e {females} {grade 1} {grade 2} {food-sec low inc {nutritio W Gretzen (198 Emmons (1972) [1 district] Paig Paig Gretzen (198 Jones (2 W Emmons (1972) [2 districts] Gretzen (198 W e impact of th l] l] ct examined th a t gher

} tha ts hi r

n e ) [nationa ) [nationa ) ant imp d l 3 o 8 { 9 983 983

4) [1 State] 4) [1 State] ] l 1 ( a studie

5 n Signific h Participa o c i t s i l a l lfe (199 llisch (1 llisch (1 lfe (199 n e e e o o [ {older} {older} W W W W W

of table. t 4 x ight h e e g i Findings from e at end dy fat h d h

r ht/ ight o f ig

t t bility of bility of h h ht g g erwe i i e e See notes Table 31— Outcome Weight an Heig Proba und W W Body Mass Ind Percent bo Proba overwe overfatness

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 203 Chapter 5: National School Lunch Program y ses s ct a wer ific c ts lo spe n ext discu adding up all the a ) ) ant imp 1 1 0 0 0 0 The t 2 2 significant findings ma ( (

ting,” or Signific Participa h h a a i i tain only to d d n n per a a han others. K K attern of non “vote coun found. tice of ideration t c istent p s s

Where findings es were con ] ] c l l a a re con n n ren ls] 1, a wer o o r i i oid the pra t t v a a schools). n n ts lo [ [ 6

n hapte ) ) merit mo d to a 0 0 8 8 9 9 al vs. d in c 1 1 2) [4 schoo ( (

studies d d Participa cautione h Program on other n n note No significant diffe s a a l l e (197 g g e. some c a a ple, nation o o t impact ers are H H Paig n exam r ifica research. A ings from erforman y. Read y of e kets}. 8 8 wa , find ] c

s ] s l t n study (fo No sign a c i ademic p n /sam r weight.” ls] t o i tional School Lunc s {in bra t i a d

gher n over ted in that [ e of the 2

[ nsideratio )

, and ac ntile in NHANES I and II. (Wolfe et al., 1994). ) 0 ts hi bgroup cture of the bod 2 co sk of 8 scop rce n r 7 nce 9 9 1 2) [4 schoo 1 ( area

(

d sive pi r. s n n a l o pact of the Na e (197 Participa g m a ition for “at ri all). prehen ate, and the ign and othe . ea > 90th pe or arm fat o younge m r st studies. g BMI. s ) lts would be interpre Emmons (1972) [2 districts] Paig H E e identifies the su sm school attenda e im in nd com defin s on d nge a centile too s stro y’s resu per earch d CDS’s s et al., 1983 cal fitness, ll entry also arts. the publicati (sample . f providing ales age 10 a ile and arm fat a NCHS t hysi ch ot significant u th es in re p s from the ct inued c examined th single stud rted a t t gher centile name, owth r nding s sults n repo percen tha Con th ts hi fi r and fem per gh no differen s s n ulation, the ce not ant imp skinfold (Wellisch CDC g author’ s r n sted/ p younge d in the interest o NCHS also examined en thou BMI >90 e th phasize v rcentile; re studie ) : udy pop te c s nd Signific Participa st senio pe d triceps fatfold > 75 porte th ct, e not ure s s (1980 s. Because of s of tri e re r percentile o th

85 l = t for height <25 t for age an sults a two mea ales age 11 a urement hemistries o th at area <10 difference r s derlying effe health outcomes— c han the entire l re cular result w e o d t un r s Findings from e e t her t l n nd Vermeersch i d using s o b e l ite gro h Cell entries show the o l c o sse with parti

g h zen a on status c o m u L m r Included only m Based on weigh Based on arm f Based on mea Based on weigh Based on BMI > Asse Significance of Notes: Nonsignificant Gret 1 2 3 4 5 6 7 8 e e D Table 31— nutrition an Outcome Nutritional bio H Hematocrit Compos and ir variable S L subgroup rat indicate a true studies methodological limitations and em

204 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program fat). Participation was defined on the basis of chil- (CDC, 2003). As used by Jones et al. (2003), it also dren’s average weekly participation from first grade includes children who are considered to be overweight through the current school year. The analysis, which (BMI at or above the 95th percentile) (CDC, 2003). did not control for selection bias, found that older par- Weights were reported by primary caregivers and ticipants weighed more and had greater mean triceps heights were measured by field interviewers. The skinfold measurements than comparably aged nonpar- authors indicate that approximately 86 percent of the ticipants. These findings are difficult to interpret, how- children had been weighed within the preceding month ever, because the authors did not provide information and that 16 percent of caregivers had to estimate on whether program participants were closer to age- weight because they had no recent reference point. standardized norms than nonparticipants (Rush, 1984). Thus, it is not clear whether the findings suggest a The analysis assessed the likelihood of being at risk of health benefit or risk. If, for example, children tended becoming overweight among children living in food- to be underweight for their age or stature, greater secure and food-insecure households, while controlling weight and fatness among participants could be con- for participation in a number of FANPs and other rele- sidered a benefit. On the other hand, if children tended vant characteristics. Results showed that NSLP partici- to be overweight for age or stature, these findings pation did not affect the likelihood that males would would not be considered beneficial. be at risk of becoming overweight, regardless of whether they lived in food-secure or food-insecure A more recent study by Wolfe et al. (1994) obtained households. The likelihood of being at risk of becom- similar results and reported them in a more easily inter- ing overweight was also unaffected by NSLP partici- preted manner. The authors assessed the prevalence of pation status among females in food-secure house- overweight in elementary school children in New York holds. Among females in food-insecure households, State, using BMI and measures of triceps skinfold and however, those who participated in the NSLP had 71- arm fat area. Data were compared with national refer- percent reduced odds of being at risk of becoming ence data for 1974 and 1980. NSLP participants were overweight, compared with those who did not partici- defined on the basis of a parent report that the child “eats pate. The authors offer no explanation for the apparent school lunch.” The authors concluded that overweight protective effect of NSLP participation among food- was a problem among elementary school students in insecure females and suggest that more research is New York State, and that students who ate the school needed to understand the relationship between income, lunch tended to be fatter than those who did not. food security, FANP participation, and weight status.

Wolfe and her colleagues made no attempt to assess or It is doubtful that cross-sectional studies can adequately control for selection bias, a critical consideration in address questions about program impacts on children’s estimating the impact of a feeding program on weight weight and height. Indeed, researchers who attempted status. Thus, these results indicate that NSLP partici- to assess the impact of the WIC program on these out- pants in New York State were more overweight than comes concluded that a longitudinal study with serial nonparticipants. They do not, however, indicate that measurements was essential (Puma et al., 1991). these differences are the result of NSLP participation. It is possible, for example, that overweight children Nutritional Biochemistries chose to participate in the NSLP more often than Four of the studies identified in the literature search nonoverweight children. examined impacts of the NSLP on nutritional biochemistries. Researchers examined measures of iron A recent study by Jones et al. (2003) looked at the rela- status (hemoglobin and/or hematocrit) and/or choles- tionship between food security, participation in FANPs, terol levels. Only Hoagland (1980) used a national including the NSLP, and the risk of overweight. The dataset in assessing these outcomes. The three smaller, authors used data from the 1997 Panel Study of local studies used the “participants, before vs. after” Income Dynamics (PSID) Child Development design (essentially a longitudinal design with a single Supplement to examine the risk of overweight among followup measurement), which is preferable to the children ages 5-12 in low-income households (income “participant vs. nonparticipant” design for assessing <185 percent of poverty). Risk of overweight was impacts on biological variables. With the exception of defined as BMI at or above the 85th percentile. This the recent study by Kandiah and Peterson (2001), stud- cutoff is routinely used to identify children who are ies are based on data from the 1970s. None of the considered to be “at risk” of becoming overweight studies reported a significant NSLP effect.

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 205 Chapter 5: National School Lunch Program

Iron will be an addition to total household food expenditures. However, its value may be partly offset if the Analyzing children’s hemoglobin and hematocrit val- household reduces some food expenditures because of ues from NHANES-I, Hoagland (1980) found no sig- the availability of the subsidized lunch—if, for exam- nificant differences between NSLP participants and ple, money that would have been spent to purchase nonparticipants. Working with a sample of children lunch for the student is applied to nonfood uses. from four schools in Baltimore, Paige (1972) found no effects on hematocrit levels or on a composite variable Two of the three studies that examined impacts on that reflected both growth status and iron status. household food expenditures were based on data collect- Emmons and colleagues (1972) found so few students ed for the NESNP. Wellisch and her colleagues (1983) with low iron status that they did not test the signifi- reported a dollar-for-dollar increase in the value of food cance of differences between groups. available to participating households as a result of partic- Cholesterol ipation in the NSLP. Long (1991) reanalyzed the NESNP data, using only the sample of students who Hoagland (1980) also used NHANES-I data to assess attended schools that offered the NSLP and adjusting for children’s cholesterol levels. He found no significant selection bias, and obtained somewhat different results. difference between NSLP participants and nonpartici- She found that the overall impact of NSLP participa- pants. In the same analysis, Hoagland attempted to tion was to increase household food expenditures, but look for differences in biochemical indicators of pro- she estimated that each additional NSLP benefit dollar tein-calorie malnutrition. Finding no abnormal levels reduced other food expenditures by about $0.61, for a of serum albumin in the sample, however, he conclud- net addition of $0.39 to the value of food expenditures ed that these measures were not useful for assessing on behalf of the household. Long’s results were compa- NSLP health impacts. rable to those of West and Price (1976), who evaluated the impact of free school lunches on household food Kandiah and Peterson (2001) examined total choles- expenditures for a sample of children ages 8-12 in terol and LDL cholesterol levels in a group of 30 chil- Washington State. dren and adolescents ages 11-15. The sample was limited to students who ate NSLP meals at least three West and Price (1976) and Wellisch et al. (1983) both times per week. Baseline levels were compared with found somewhat larger supplementation effects for followup levels measured 4 months later. Results Black than White households. Supplementation was also showed that both total cholesterol and LDL cholesterol somewhat greater for Hispanic households, but the effect levels decreased significantly over the 4-month period. was not statistically significant. Long’s reanalysis of the This was true for students who ate NSLP lunches as NESNP data did not include subgroup analyses. well as those who ate both breakfast and lunch. Rather than attribute these changes to a positive impact of the NSLP, the authors concluded that changes in choles- Summary terol levels over time were due to hormonal fluctua- The body of research reviewed in this chapter indi- tions associated with puberty. No information was pro- cates that, prior to implementation of the SMI, the vided on the protocol used in collecting students’ NSLP had a significant impact on the dietary intake of blood samples (for example, whether students were school-age children and adolescents. There is strong fasting when bloods were drawn and for what period evidence that the program increased children’s intakes of time) or on the reliability of the measures obtained. of selected vitamins and minerals at lunch (vitamin B , riboflavin, calcium, phosphorus, magnesium, and Household Food Expenditures 12 zinc), and the strongest available evidence suggests Assessment of household food expenditures can pro- that these effects persisted over 24 hours. Because of vide information on the extent to which receipt of limitations in the dietary assessment methodologies NSLP meal benefits increases the value of food avail- used, it is not possible to determine whether NSLP able to families.92 Potentially, the NSLP meal benefit participants were more likely than nonparticipants to have adequate intakes of these vitamins and minerals. 92Food expenditure data have also been used to evaluate the success of the NSLP in meeting its second objective: encouraging the consumption of There is also convincing evidence that, prior to the domestic agricultural products. The program is considered efficient in meeting its agricultural support goals if most of the NSLP subsidy is spent on food and SMI, NSLP participants consumed less carbohydrate little is diverted to nonfood expenditures (Radzikowski and Gale, 1984). and more fat and saturated fat (as a percentage of total

206 Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 Economic Research Service/USDA Chapter 5: National School Lunch Program food energy) than nonparticipants, both at lunch and impacts on vitamin and mineral intakes. However, evi- over 24 hours. The strongest available evidence sug- dence from SNDA-II suggests that changes in the gests that the difference in carbohydrate intake was macronutrient profile of school lunches has been due to decreased consumption of added sugars among achieved without compromising overall vitamin and NSLP participants. mineral content. In fact, lunches offered in 1998-99 provided significantly greater amounts of vitamin A, Finally, the available evidence indicates that, prior to vitamin C, calcium, and iron than lunches offered in the SMI, NSLP participation had no significant effect 1991-92. on intake of sodium or cholesterol. NSLP participation was associated, however, with a significantly greater With the exception of impacts on household food intake of dietary fiber, both at lunch and over 24 hours. expenditures, the existing evidence is too limited to support conclusions about whether NSLP participation Evidence from the SNDA-II study demonstrates that, affects other nutrition- and health-related outcomes. even in the early stages of the SMI, schools had made There is limited, but reasonably strong, evidence that significant progress in decreasing the fat and saturated NSLP participation increases total household food fat content of school lunches and in increasing the car- expenditures. However, the available data are quite bohydrate content. Since SNDA-II data were collected dated (the most recent were collected in the early (the 1998-99 school year), efforts have continued at 1980s). the Federal, State, and local levels to make school lunches consistent with SMI standards for these nutri- Clearly, there is a critical need for an updated study of ents. In addition, there has been increased emphasis on the NSLP and its impacts on children. To provide a nutrition education for school-age children to promote comprehensive picture of how the NSLP influences acceptance and consumption of healthier school meals. children’s food and nutrient intakes, future studies will need to differentiate between the multiple sources of Consequently, the current impact of the NSLP on stu- foods and beverages available at school (reimbursable dents’ intakes of total fat, saturated fat, and carbohy- meals, a la carte purchases, vending machines, snack drates is unknown and can only be answered with new bars, etc.). research. The same can be said of the program’s

Economic Research Service/USDA Effects of Food Assistance and Nutrition Programs on Nutrition and Health / FANRR-19-3 207 Chapter 5: National School Lunch Program

References Centers for Disease Control and Prevention. 2003. “CDC Growth Chart Training Modules.” Available: Abraham, S., M. Chattopadhyay, M. Montgomery, et al. http://www.cdc.gov/nccdphp/dnpa. Accessed May 2002. The School Meals Initiative Implementation Study: 2003. Third Year Report. USDA, Food and Nutrition Service. Cullen, K.W., J. Egan, T. Baranowski, et al. 2000. Akin, J.S., D.K. Guilkey, P.S. Haines, et al. 1983a. “Effect of a la Carte and Snack Bar Foods at School “Impact of the School Lunch Program on Nutrient on Children’s Lunchtime Intake of Fruits and Intakes of School Children,” School Food Service Vegetables,” Journal of the American Dietetic Research Review 7(1):13-18. Association 100(12):1482-86.

Akin, J.S., D.K. Guilkey, and B.M. Popkin. 1983b. Devaney, B.L., M.R. Ellwood, and J.M. Love. 1997. “The School Lunch Program and Nutrient Intake: a “Programs That Mitigate the Effects of Poverty on Switching Regression Analysis,” American Journal Children,” Future Child 7(2):88-112. of Agricultural Economics 65(3):477-85. Devaney, B.L., A.R. Gordon, and J.A. Burghardt. 1993. American School Food Service Association. 2003. The School Nutrition Dietary Assessment Study: Dietary “Legislative Update: Focus on Child Nutrition Intakes of Program Participants and Nonparticipants. Continues.” Available: http://www.asfsa.org/newsroom/ USDA, Food and Nutrition Service. sfsnews/legupdate0803.asp. Accessed August 2003. Emmons, L., M. Hayes, and D.L. Call. 1972. “A Study Baranowski, T., and B.G. Simons-Morton. 1991. of School Feeding Programs. I. Economic Elgibility “Dietary and Physical Activity Assessment in School- and Nutritional Need. II. Effects on Children with age Children: Measurement Issues,” Journal of School Different Economic and Nutritional Needs,” Journal of Health 61:195-97. the American Dietetic Association 61(9):262-75.

Baxter, S.D., W.O. Thompson, A.F. Smith, et al. 2003. Fox, M.K., M.K. Crepinsek, P. Connor, et al. 2001. “Reverse Versus Forward Order Reporting and the Second School Nutrition Dietary Assessment Study Accuracy of Fourth-graders’ Recalls of School Breakfast (SNDA-II): Final Report. USDA, Food and Nutrition and School Lunch,” Journal of the American Dietetic Service. Association 100(8):911-18. Fraker, T. 1987. Final Report: The Sodium and Macro- Baxter, S.D., W.O. Thompson, and H.C. Davis. 2000. nutrient Content of USDA School Lunches. USDA, “Prompting Methods Affect the Accuracy of Children's Food and Nutrition Service. School Lunch Recalls,” Journal of the American Dietetic Association 100(8):911-18. French, S.A., M. Story, J.A. Fulkerson, and A.F. Gerlach. 2003. “Food Environment in Secondary Burghardt, J., A. Gordon, N. Chapman, et al. 1993. The Schools: a la Carte, Vending Machines, and Food School Nutrition Dietary Assessment Study: School Food Policies and Prac-tices,” American Journal of Public Service, Meals Offered, and Dietary Intakes. USDA, Health 93(7):1161-67. Food and Nutrition Service. Gleason, P., and C. Suitor. 2003. “Eating at School: Burghardt, J.A. and B.L. Devaney (eds.) 1995. How the National School Lunch Program Affects “Background of the School Nutrition Dietary Children’s Diets,” American Journal of Agricultural Assessment Study,” American Journal of Clinical Economics 85(4):1047-61. Nutrition 61(1, Supplement):178S-181S. Gleason, P., and C. Suitor. 2001. Children’s Diets in Buzby, J.C., and J.F. Guthrie. 2002. Plate Waste in the Mid-1990’s: Dietary Intake and Its Relationship School Nutrition Programs: Final Report to Congress. with School Meal Participation. USDA, Food and E-FAN-02-009. USDA, Economic Research Service. Nutrition Service.

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