Integrated Impact Assessment Universal Free School Meals

The Integrated Impact Assessment (IIA) process is a tool for identifying potential impacts associated with the Mayor’s expansion of universal free school meals (UFSM). The IIA includes ways to avoid and mitigate any adverse impacts, and enhance the benefits of the scheme. The purpose of the IIA is to promote better integration of social, environmental and economic considerations in the development of key policies and programmes. This IIA draws together the following assessments:

• an Equalities Impact Assessment (EqIA)
• an Economic Impact Assessment (EcIA)
• a Health Impact Assessment (HIA)
• an Environmental Assessment (EA).

The assessment findings have been brought together into one conclusion that highlights the positive impacts of the scheme; and areas for further consideration, mitigation, and enhancement. This has been organised under three themes:

• London’s people (incorporating the EqIA and HIA)
• London’s economy (incorporating the EcIA)
• London’s environment (incorporating the EA).

These will be used by the GLA to inform further policy development. The Theory of Change underpinning this policy (set out in Annex A) has also been used to help guide this assessment.

• The Mayor’s UFSM policy has been developed in response to the cost-of-living crisis. As such, the policy had to be developed quickly to ensure readiness for the academic term starting in September 2023.
• The UFSM policy was refined based on the EqIA report conducted by Arup and associated findings (set out in Annex B) and other assessments developed by Arup. 
• This final IIA report has been informed by: Arup’s initial IIA work, including the published EqIA; the Theory of Change; an evidence review; and stakeholder engagement.

The Mayor proposes a one-off £135m of emergency funding to provide all school children in state-funded primary schools (including alternative provision (AP) and special schools) in the capital in Key Stage 2 (KS2) years with universal free school meals  for the 2023‑24 academic year. This unprecedented funding is expected to help up to 287,000 more state primary school children, saving families upwards of £440 per child across the next year. The aim of the scheme is to help families with the spiralling cost of living. A further £5m has also been allocated as contingency funding for costs such as access requirements for children with special educational needs and disabilities (SEND), or with religious dietary requirements such as kosher food.

The Mayor will fund the price per meal of £2.65. This is above the standard government rate of £2.53 per meal, which was increased from £2.41 per meal in June 2023.

All schools will receive a grant based on an assumed 90 per cent uptake. However, boroughs that can evidence a higher uptake will receive further funding. Boroughs that currently fund UFSM will be allocated funding as if they were not currently providing the function. The Mayor hopes that these boroughs will use the offset funds to support families in financial hardship or to support other cost-of-living related measures.

City Hall has highlighted that the Mayor’s policy is consistent with the government’s existing funding of school meals, as outlined in Department for Education (DfE) guidance.[1] As with existing funding, the Mayor’s policy would cover state-funded primary schools, pupil referral units and special schools, including maintained schools, academies and free schools (including faith schools).

The GLA conducted further assessments around the feasibility of extending the policy’s scope beyond the national FSM scheme. These assessments informed the Mayoral Decision for the programme.[2] This assessment is set out in Annex C.

The Mayor continues to do all he can to support Londoners of all backgrounds affected by the cost-of-living crisis. The UFSM scheme is just one measure within a range of steps the Mayor is taking to help Londoners. GLA funding has recently been made available to support families with children during holiday periods. As part of this, the Mayor has made £3.1m available in emergency grant funding to the Felix Project and the Mayor’s Fund for London to deliver the equivalent of 7 million meals to families in need across school holidays. This will include consideration of those families with protected characteristics, such as faith groups.

Currently all state-funded school children at Key Stage 1 (KS1) (reception through to year 2) receive FSM as part of the government’s Universal Infant Free School Meal scheme. At KS2 (primary-school children in years 3-6), only those that meet specific eligibility criteria receive FSM.

A handful of London boroughs (LBs) provide an exception to this. These boroughs, which have already implemented UFSM for all primary-school pupils, include the following:

• LB Southwark has funded FSM to all primary-school children for the last 10 years. Southwark is now rolling out a pilot scheme for secondary-school pupils.
• LB Newham has funded FSM to all children in primary schools since 2009.
• LB Tower Hamlets has been providing FSM to all primary-school children since 2014. It is now rolling out a pilot scheme for secondary-school pupils up to year 11.
• LB Westminster, in January 2023, started providing free school lunches to all children attending primary school in Westminster City Council.
• LB Islington has been providing FSM to all primary-school children since 2011.

Currently, to qualify for Universal Credit (and thus, to be eligible for the national primary-school FSM offer), a household can earn no more than £7,400 per year (after tax and not including benefits). This is regardless of the number of children in the family.

Research by the Child Poverty Action Group (CPAG)[1] has shown that hundreds of thousands of school children live in poverty, but are not currently eligible for government FSM. In addition, although data on eligible school children is held at government level, the current process means that parents have to formally apply to their local authority (LA), or via their child’s academy school, to claim FSM. Government estimates on claim rates indicate that, in London, around 20 per cent of school children who are eligible for FSM have not taken up the offer.[2] Although there are limited studies looking at why this might be, a recent study identified that stigma, quality of school meals and a lack of knowledge around entitlement had contributed to lack of take-up.[3]

Historically, families who were undocumented due to their immigration status, and/or with no recourse to public funds (NRPF) (i.e. no entitlement to the majority of welfare benefits including income support, housing benefits, and a range of allowances and tax credits) were not entitled to FSM under the current eligibility criteria. However, a scheme to make FSM available to these families was introduced during COVID-19, and permanently extended to all households with NRPF in January 2023.

Expected outcomes from the Mayor’s scheme are as follows:

• London’s primary-age children in years 3-6, who attend state-funded schools (including special schools and AP) and are not currently entitled to FSM provided by the government, will have access to at least one nutritious meal a day during term-time. This will offer associated benefits to their health and educational performance.

• Some impacts of the cost-of-living crisis are mitigated. These include increased household food security, and thus improved mental health amongst parents; decreased indebtedness; and changes to household food purchasing behaviour, such as a reduction in purchasing (sometimes unhealthy) food for packed lunches.
• Improved awareness and encouragement to take up existing schemes to support Londoners during the cost-of-living crisis. These include the Mayor’s Fund for London and The Felix Project, which both provide free meals for families and their children during school holidays.
• FSM and poverty-related stigma and shame are reduced.

The IIA is a means by which different technical assessments are brought together in a holistic and integrated manner. The IIA tests the performance of the UFSM policy to identify the likely positive and negative effects. Where adverse effects are predicted, the IIA identifies the measures that can mitigate them.

The IIA brings together multiple assessments, each with their own legal requirements and/or guidance to adhere to and apply. The section below describes the methodologies for the component parts of the IIA based on relevant legislation, guidance and best practice.

The IIA methodology has been guided by the Environmental Assessment of Plans and Programmes Regulations 2004 (the Strategic Environmental Assessment (SEA) Regulations).

The EqIA was published in advance of the full IIA publication, and was accompanied by a supplementary analysis produced by the GLA to consider impacts on the London independent school sector (with a particular focus on faith schools). This supplementary analysis is set out in Annex C.

The IIA has also used the Theory of Change (set out in Annex A) for this policy to frame its review.

In developing the IIA a range of stakeholders were interviewed and involved in shaping some of the policy.

The IIA is supported by detailed technical reports including:

• the Theory of Change (Annex A)
• the EqIA (Annex B) and supplementary paper on non-state funded schools (Annex C)
• evidence review
• quantitative data.

The following assumptions and limitations have been made:

• The policy is aligned to the scope of the government’s current FSM scheme, as set out in the DfE guidance.[1] The government’s current FSM scheme does not extend to pupils within private or independent schools and it has been decided to adopt the same approach in the Mayor’s policy. The policy will cover state-funded primary schools, pupil referral units and special schools, including faith schools. Engagement and analysis highlighted a need to further investigate the potential impact and effects of the policy on schools across the whole education sector, including independent schools. This additional analysis has been conducted by the GLA and can be found as a supplementary paper to the EqIA. Both of these are set out in Annex B (EqIA) and Annex C (supplementary analysis). Following that analysis a decision was taken not to extend the Mayor’s policy to independent schools.
• With regard to the EqIA and faith, the assessment has focused on faiths for which census data on prevalence is available – namely the Christian, Buddhist, Hindu, Jewish, Muslim and Sikh faiths. However, there is an awareness that other faiths also exist, and members of these communities may also have specific dietary needs associated with their beliefs. These include, but are not limited to Rastafarians, members of the Church of Jesus Christ of Latter-Day Saints, and Seventh-day Adventists.
• It is assumed that all schools in London who are eligible will take up the funding offer.
• It is assumed that the cost-of-living crisis does not escalate further.
• There is no equivalent policy to this at such scale and scope to enable direct comparison. As such there are some unknowns with this policy.
• This IIA was developed alongside initial development of the policy.

It is important to review the environmental, social and economic objectives contained within key legislation and strategies that are of relevance to the UFSM policy. This section provides a summary of the plans, programmes and strategies at a regional (London) scale that inform the IIA of the UFSM policy.

There are several strategies setting out the Mayor’s vision for specific topic areas, including:

• the London Food Strategy (2018)[1]
• the London Plan (2021),[2] which brings together the geographic and locational aspects of other strategies, and provides the policy framework for the Mayor's own decisions on strategic planning
• the London Health Inequalities Strategy (2018)[3]
• the Mayor’s Equality, Diversity and Inclusion Strategy (2018)[4] and the Mayor’s Equality Objectives (2022), objective 7, to “remove the barriers preventing children and young Londoners from realising their potential now and in later life”
• the London Environment Strategy (2018).[5]

Following a review of the following policies and strategies, the topics, sub-topics and key considerations have been identified (Table 1). These are also aligned to the Theory of Change.

Table 1: Key considerations identified in the review of relevant policies. 

EqIA

As aforementioned, the IIA process involved a thorough EqIA process that considered the potential for each action to result in disproportionate or differential equality effects. It explored the impacts of the policy on all the protected characteristics (not including marriage and civil partnership) and included socioeconomic status. The assessment also recognises the impacts of intersectional inequalities such as disability and ethnicity, which also intersect with socioeconomic status and other protected characteristics to form multiple layers of disadvantage.

The assessment includes recommendations for measures that should be put in place as the proposed policy evolves, to: reduce or remove potential adverse equality effects; strengthen potential positive equality effects; and ensure that, where possible, the proposed policy promotes equality of opportunity.

Following completion of the EqIA, a contingency funding pot has been set aside to support specific access requirements for some groups of children, in certain extraordinary and specific circumstances, in relation to the Mayor’s programme. It also is intended to address unforeseen implementation issues for schools and boroughs that may inhibit their participation in the policy.

A summary of the key findings is included here below:

• Age: Positive impacts on children aged 7-11 who will now benefit from FSM; and the benefits for nutrition, mental health and wellbeing, and academic learning and attainment that this will bring.
• Disability: FSM will be available to more children (i.e. those in years 3 to 6) in state schools, a proportion of which will be children with disabilities.
• Sex: The proposed policy is likely to bring financial, and health benefits to children from lone-parent, and thus lone-income, households that are statistically more likely to be headed by women.
• Sexual orientation and gender reassignment: LGBTQ+ parents or guardians, who are more likely to be economically constrained than heterosexual parents or guardians, may benefit from the financial relief provided by this proposed policy.
• Socioeconomic status: Reduced stigma around receipt of FSM, as all children can partake; and improved attendance. The data shows a correlation between levels of income deprivation within an LA area and school attendance.
• Race: Universal provision removes a potential barrier to uptake of FSM. Currently, FSM requires completion of forms, which may hinder uptake for those not fluent in English. There is potential to reduce the stigma around receipt of FSM. The data indicates that pupils from Black and minority ethnic groups are both more likely to receive FSM and to be living in poverty. The universal policy will therefore assist those already in receipt of FSM by reducing stigma– as well as ensuring those living in poverty, but unable to claim government FSM due to restrictive eligibility criteria, are able to access free meals.
• Religion/belief: UFSM will be available to all state-funded primary schools, including faith schools. The EqIA identified concerns around the price point of £2.65 per meal and whether this would be enough to cater for certain dietary needs in relation to faith groups i.e. kosher and halal meals. Several recommendations have been made in the EqIA as to how this issue might be addressed.
• Additional groups, such as those with caring responsibilities and lone parents, may disproportionately benefit from the financial relief provided by this proposed policy.

To review the full EqIA see Annex B.

The following table sets out the assessments of the UFSM scheme against three core strands: London’s people (incorporating the HIA and EqIA); London’s economy (incorporating the EcIA); and London’s environment (incorporating the SEA). It also identifies mitigation and/or enhancement measures that are either in place or recommended for consideration.

 

 

 

An Evidence-based Theory of Change

Appendix 1:

An Updated Systematic Review of the Literature Examining Universal Free School Meals in the United Kingdom and Internationally*

 

Prepared by Dr. Juliana F.W. Cohen^1,2 and Dr. Gabriella M. McLoughlin^3,4

 

¹ Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA

²Department of Nutrition and Public Health, Merrimack College, 315 Turnpike Street, North Andover, MA 01845, USA

³ College of Public Health, Temple University, Philadelphia, PA, USA

⁴Washington University Implementation Science Center for Cancer Control (ISC3), United States

*Update to the publication: Cohen, J.F., Hecht, A.A., McLoughlin, G.M., Turner, L. and Schwartz, M.B., 2021. Universal school meals and associations with student participation, attendance, academic performance, diet quality, food security, and body mass index: A systematic review. Nutrients, 13(3), p.911.

 

June 2023

Summary of Results

I. Participation: There is currently very strong evidence both from the UK and internationally that Universal Free School Meal (UFSM) policies are associated with increased school meal participation. While the greatest increase in participation is often among students not previously eligible for free school meals, there are also typically increases in participation among students from low-income households who were previously eligible for free school meals. Participation measures are still recommended for inclusion in future studies if (1) examining the impact of UFSM among diverse student populations; and/or (2) examining other outcomes (to support inferences among associations between UFSM and other outcomes).

II. Diet Quality and Food Insecurity:  Overall there is good evidence to suggest that UFSM is associated with improvements in students’ diets and food security in the presence of strong nutrition standards, but there is currently limited research with a low risk of bias that has been conducted in the UK.  Future studies should emphasize valid measures of students’ diets including plate waste (all ages) and 24-hour recalls (ages 10+), as well as strong study designs that limit the risk of bias.*   

III. Attendance:  Overall there is moderate evidence regarding UFSM and attendance, although there is currently a lack of evidence in the UK. As prior research has typically found the greatest benefits may be in sub-populations (i.e., children who are food insecure and/or from low-income households), future evaluations should ensure appropriate data are collected to measure the impact of UFSM on attendance both overall and specifically within these subpopulations.

 

IV.  Academic Performance:  Overall there is moderate evidence to suggest that UFSM is associated with improvements in students’ academic performance, although there is currently limited research with a low risk of bias that has been conducted in the UK.  Objective measures such as test scores in math and reading should be considered.  Additionally, as some research suggests potentially greater benefits among sub-populations, future evaluations should ensure appropriate data is collected to measure the impact on academic performance both overall and specifically within subpopulations.

V.  Body Mass Index:  Overall there is moderate evidence to suggest that UFSM is associated with no adverse impact on BMI or may potentially reduce the risk of overweight, although there is currently limited research with a low risk of bias that has been conducted in the UK.  Of note, changes in BMI typically are only seen over the course of multiple years and thus BMI is not recommended to be examined in short-term studies. 

VI.  School Meal Finances: Overall there is moderate evidence to suggest that UFSM is associated with improvements in school meal finances, although there is currently limited research with a low risk of bias that has been conducted in the UK. 

VII. Other findings related to implementation of USFM:  Other outcomes that were outside the scope of the review included the impact on household finances, as well as qualitative research examining the impact of UFSM on outcomes including stigma.  However, there is good evidence that UFSM reduces stigma for students and stress for households, although there is more limited research that has been conducted in the UK[1]. There is currently more limited evidence overall (and within the UK) examining the impact of UFSM on household finances [2, 3].

*Future studies should emphasize strong study designs which include: (1) representative samples of student populations; (2) sufficient sample sizes (e.g., >100 participants); (3) Appropriate comparison groups; (4) Controlling for confounding factors (e.g., age/grade, gender); (5) Valid/Objective measures of outcomes; and (6) Appropriate statistical tests (e.g., multi-level modeling to account for clustering within schools).

Methods

An updated systematic review of the literature was conducted to evaluate studies examining the association between universal free school meals and students’ school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published through April 2023 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters’ Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. Eligible studies were English, peer-reviewed quantitative research publications or official government reports within countries with developed economies (i.e., members of the Organization for Economic Co-Operation and Development [OECD]) [43], and conducted in primary (i.e., elementary) and secondary (i.e., middle, and/or high) schools during the academic year.    

Qualitative data, mixed-methods, and/or survey-based (non-experimental) research, while outside the scope of the systematic review, was also examined and briefly summarized. Research published between 2012-2023 examining implementation determinants (i.e., supports, challenges, considerations) and outcomes (i.e., impacts) of UFSM were determined based on a backwards citation search of the systematic review (and therefore while not systematically evaluated, the majority of relevant publications were likely obtained).

Assessment of study quality and biases were based on an adapted Newcastle–Ottawa Scales (NOS) for cross-sectional and cohort studies, which are commonly used to assess nonrandomized research. Study quality and the risk of bias was based on multiple factors including the representativeness and size of the study populations, the quality of the measures used to assess outcomes, inclusion of baseline and post-implementation measures among the same population, appropriate analyses conducted, and adequate follow-up time to measure outcomes (i.e., at least one school year). Quality assessments were interpreted based on the following categories: very high risk of bias (0–3 points), high risk of bias (4–6 points), and low risk of bias (≥7 points).

Results

I. School Meal Participation

Background and Summary: A primary goal of universal free school meals is to increase school meal participation. Two peer-reviewed studies and two government reports examining universal free school meals in the United Kingdom (UK) found positive associations with school meal participation. Of the 17 peer-reviewed publications and four government reports conducted in the U.S. that examined school meal participation as an outcome (n=21 studies), 20 found a positive association between universal free school meals and National School Lunch Program (NSLP) or School Breakfast Program (SBP) participation and one found mixed results. Among the studies conducted using methodology with a low risk of bias, all 11 found positive associations between universal free school meals and school meal participation rates. To summarize, there is a large literature examining the relationship between offering universal free meals and student participation. Overall, the findings consistently show that student participation in school meal programs increases when meals are provided at no cost. Further, the increase in participation tends to be largest among students who previously did not qualify for free or reduced-price meals, while also increasing participation rates among students from low-income households who were previously eligible for free meals.

School Meal Participation Research in the UK: Among research conducted in the UK, a government report examining the pilot of Universal Infant Free School Meals (UIFSM) in England among primary school students in three local authorities found that universal free school meals were associated with approximately a 30% increase in the percent of students taking a school lunch at least once a week (i.e., roughly 90% of students had a school lunch at least once week in schools with universal free school meals compared with 60% of students in matched control schools) [4]. The greatest increases in participation were among students who were not previously eligible for school meals. Similarly, in another government report examining universal free school meals in Scotland, school lunch participation increased by 22 percentage points (from 53% to 75%), with the greatest increases among students not previously registered for free school meals (an increase of 28 percentage points) [5]. A study conducted in primary schools in Scotland with a low risk of bias examining universal free school meals also found the greatest increases in lunch participation were among students not previously eligible for free school meals (14.4 percentage point increase [p<0.001]) [6]. Lastly, a study with a low risk of bias examining UIFSM among children in England and Scotland both before and after implementation of this policy found that UIFSM was associated with a greater proportion of children consuming school meals [7]. 

School Meal Participation Research in Other Countries: In the United States, several studies have examined the impact of universal free school breakfast programs and SBP participation. Using nationally representative data, Andreyeva and colleagues found that UFSM (through the Community Eligibility Provision [CEP] was associated with the probability of children’s eating free school lunch by 9.3% (p < 0.01) [8].  In a study conducted by Leos-Ubel et al. in New York City among elementary and middle school students, access to universal free breakfast was positively associated with SBP participation, with rates varying by student socio-economic status (SES) [9]. Among students with the lowest household income levels who were already eligible for free school meals, there was an increase in participation by 5% (p<0.05). Among students previously eligible for reduced-price meals, there was a 21% increase in SBP participation ([p<0.01), and among students eligible for full- price meals previously, there was a 36% increase in participation (p<0.01). Similar results were observed in a study conducted by Ribar and colleagues in a school district in North Carolina where three elementary schools removed universal free breakfast while one school introduced it [10]. Overall, universal free breakfast was associated with 16.4% higher rates of SBP participation (p<0.05), with the greatest increase in participation rates among students from higher-income households who were not previously eligible for free or reduced-price meals (27.5%; p<0.05). Nearly identical results were observed in a government report examining the pilot of universal free breakfast in six school districts in six states, with schools within each district randomly assigned to universal free breakfast or control (means-tested based on eligibility for free or reduced-price meals); after one year, universal free breakfast was associated with a 16 percentage point increase in participation (p=0.01), again, with the largest increases observed among students not previously eligible for free or reduced-price meals [11]. In a second government report examining the extended impact of this pilot program, the increases in participation were maintained over three years [12]. Another study conducted by Soldavini and associates in North Carolina elementary, middle, and high schools found that providing universal free breakfasts was positively associated with significantly greater odds of breakfast participation at all grade levels, with the exception of high school students who were previously eligible for free or reduced-price meals [13]. A third study by Wahlstrom et al. examining six elementary schools in Minnesota also observed high SBP participation rates among schools with universal free breakfast, although no statistical analyses were conducted and this study was assessed to have a very high risk of bias [14]. In a cross-sectional study conducted by Khan and colleagues in a Vermont middle school serving universal free breakfast, food-insecure students were significantly less likely to eat breakfast at home compared with food-secure students, and nearly all (91.3%) of the food-insecure students reported eating free breakfast at school [15]. However, a cross-sectional study in Philadelphia, Pennsylvania conducted by Dykstra et al. found that students participated in the free SBP only 31% of the time (however, changes in participation rates were not measured) [16]. Although there were significantly higher participation rates among minority students compared with their white peers, there were no differences in participation by eligibility for free or reduced-price meals or by food-insecurity levels. 

Several studies have also examined universal free school meal provisions prior to the implementation of CEP in the U.S. One study in Texas conducted by Rivas examining a school district that implemented Provision 2 observed a 16% increase in overall school meal participation rates (although this was not analyzed for statistically significant differences and the study was considered to have a very high risk of bias) [17]. Similarly, in a study conducted by Schwartz et al. among middle schools in New York City, Provision 2 was positively associated with NSLP participation, with differences observed by student SES; on average there was an 11% increase in NSLP participation among students not previously eligible for school meals (p<0.05) and a 5.4% increase among students from lower-income households (p<0.01) [18]. A government report examining a no-fee school meal pilot program in several states found an increase in lunch participation by approximately 10 percentage points (although this study was deemed to have a very high risk of bias) [19]. Another government report evaluating an initiative to eliminate reduced-price fees for school meals observed similar changes, with an 11% increase in lunch participation and 9% increase in breakfast participation among students previously eligible for reduced-price meals (and this study also was assessed to have a very high risk of bias) [20].

The CEP was introduced in 2010, and several studies tested its impact using pre-post designs.  Pokorney et al. examined all CEP schools (n=654) before and after implementation compared with eligible non-CEP schools (i.e. schools that chose not to participate in CEP but met the eligibility criteria [n=1221]) in Pennsylvania and found that on average CEP was associated with an 8% increase in school lunch participation [21]. In sub-analyses examining participation by student SES, NSLP participation rates were higher among students not previously eligible for free or reduced-price meals, but slightly lower among lower-income students in CEP schools compared with non-CEP schools. Turner and colleagues also examined the introduction of CEP, as well as the use of Provisions 1, 2, and 3 in public schools in California, and found that universal free school meals were associated with a 5.8 percentage point increase in NSLP participation and 3.5 percentage point increase in SBP participation [22]. Lastly, Tan et al. used national data from K-8 schools to address this question and found that CEP was associated with an 11.7% higher likelihood of participating in the NSLP among near-cutoff students (i.e., students who were near the cutoff and had uncertain eligibility for free or reduced-price meals [p=0.023]) and a 19% higher likelihood of participation among students previously eligible for full-price meals (p<0.001) [23]. CEP was also associated with a 19.6% higher likelihood of participation in the SBP among students previously eligible for full-price meals in this study (p<0.05).

Research Gaps and Recommendations:  Currently strong evidence (i.e., multiple studies with a low risk of bias) exists to support the association between UFSM and school meal participation.  Future research should still consider including participation as an outcome, particularly if conducted in diverse school settings.

II. Diet Quality and Food Insecurity

Background and Summary: Another priority of universal free school meals is to improve the nutritional quality of children’s diets and reduce food insecurity. In the presence of strong nutrition standards, school meals may improve children’s diets directly by providing healthy foods (i.e., fruits, vegetables, whole grains, etc.) [24-29]. There may be indirect benefits as well; prior research has found that healthy school meal consumption is associated with decreased intake of less healthy foods outside of school, potentially attributable to increased satiety from nutrient dense, high fiber school meals [30]. Additionally, when school meals are provided at no cost, families are able to save those funds and increase their purchasing power for other foods, further reducing food insecurity.

Of the eight peer reviewed studies and one government report in the UK examining diet quality and/or food insecurity, 3 found improvements, 4 found no association, and one had mixed results. Of the seven peer-reviewed publications and one government report conducted in the U.S. that examined diet-related outcomes (n=7 studies), two found a positive association between universal free school meals and dietary quality and two found a positive association with food security. Three studies examined only universal free breakfast and found mixed results with diet quality. Among the 19 studies conducted in other OECD countries (18 peer-reviewed and one government report), including Denmark, Norway, Japan, Greece, and New Zealand, 13 found improvements in students’ dietary outcomes and three found no association. Of the three studies that examined food insecurity, two studies found improvements and one found no association. Of the studies examining dietary outcomes that were considered to have a low risk of bias, the majority (6 out of 7) found improvements in dietary outcomes. All three studies examining food insecurity had a low risk of bias.

Diet Quality and Food Insecurity Research in the UK: When examining just universal free breakfast, two studies in Wales with a high risk of bias examined the same dataset with slightly different analyses, and both found that free school breakfasts were associated with an increase in the number of healthy items eaten at breakfast [31, 32], with larger increases observed in lower-income schools [32]. Overall, there was no association between free breakfasts and breakfast skipping [31], but in sub-analyses, free breakfast was inversely associated with breakfast skipping among students from lower-income households and among students at schools serving higher proportions of students with household poverty [32]. Examining 24-hour recalls among a subsample of the students participating in the Welsh study, researchers found that among children receiving a free school breakfast, nearly half also had a breakfast at home prior to coming to school, but this was not associated with significant differences in calories consumed over a 24-hour period [33].

When examining school lunch initiatives, results were mixed among studies conducted in England. One study conducted by Spence et al. with a high risk of bias examining UIFSM in two primary schools found that free school lunches had lower consumption of non-milk extrinsic sugar (i.e., added sugar) and biscuits (i.e., shortbread cookies) at lunch, but higher intake of cakes/sweet puddings (i.e., desserts), which were offered daily with school lunches after the main meal was served [34]. The reductions in added sugar were also observed among the students’ overall diets (i.e., over the course of an entire day). Another government report by Kitchen and colleagues examining UIFSM found no association with student diets [4], and a third conducted by Gatenby and associates with a very high risk of bias examining a free lunch scheme similarly found no association with overall nutrients consumed throughout the day (although this study was deemed to have a very high risk of bias). Notably, students who received school lunches consumed less at lunch than students who brought their lunches from home, but then compensated by eating more foods outside of the lunch period [35]. One study with a low risk of bias conducted by Parnham and colleagues examined dietary data from the National Diet and Nutrition Survey before and after implementation of UIFSM found this policy was associated with reduced consumption of sodium, with the greatest effects observed among students from low-income households [7]. Similarly, greater milk and reduced crisp consumption was observed among students from low-income households.  No association was seen among food groups including fruit, vegetables, or sugar-sweetened beverages. Lastly, a study conducted by Carlisle et al. with a very high risk of bias examined a free lunch initiative in London among two secondary schools (one mainstream and one special education) compared with two control schools and found no association with hunger or food insecurity, although students at the control schools who were from low-income households (and thus at greatest risk for food insecurity) were also receiving free school meals [1]. 

Diet Quality and Food Insecurity Research in Other Countries: Among studies examining diet quality in the United States, four studies examined universal free breakfasts and two examined CEP. Crepinsek and colleagues examined a national sample of elementary schools participating in universal free breakfast versus matched control schools offering traditional (means-tested) breakfasts [36]. This study found that universal free breakfast was positively associated with the consumption of a nutritionally substantive breakfast, including more servings of fruit and dairy. However, there was no association with breakfast skipping or overall dietary intakes over a 24-hour period. Similarly, a government report examining the pilot implementation of universal free school breakfasts in six states found no association with nutrients consumed over the course of a day, but students with universal free breakfast were more likely to eat breakfast on all five school days (p<0.01) [11]. A study by Dykstra et al. using a national sample of schools also found that when universal free breakfast was provided, rates of breakfast skipping remained comparable between food-secure and food-insecure students [16]. A study in Boston conducted by Kleinman examined the diets of students and found that those with improved nutrient intakes had significant increases in SBP participation [37]. However, this was not observed among all students receiving school breakfasts (i.e., higher SBP participation was observed among the subsample of students with improved diets, but not all SBP participants had observed improvements in their diets). One cross-sectional study without a comparison group examining universal free school meals in six CEP elementary schools in Virginia found that participation in school meals was associated with consumption levels within recommendations by the Dietary Guidelines for Americans, with students consuming roughly 2.5% out of the recommended limit of 10% of daily calories for added sugars (although consumption was not compared with rates prior to implementing CEP) [38]. Two studies examining food insecurity in the U.S. found that CEP was associated with improvements in food security. Poblacion and colleagues used simulation modeling with national data and estimated that CEP would lead to a 3.73% increase in students becoming food secure and a 3.17% increase in food security among previously food-insecure households with children [39]. Similarly, a study by Gross et al. conducted in Maryland found that when compared with students at CEP schools, students attending schools in another district that opted not to participate in CEP had increased odds of being in a household that was food insecure (OR 2.85, 95% CI 1.67, 4.88) [40]. Using nationally representative data, Andreyeva and colleagues found that CEP was not associated with food security [8]. 

When examining just universal free breakfast, a study conducted in Norway among 10^th grade students found that free breakfast was associated with overall higher Healthy Eating Index (HEI) scores among male students, but no significant change was observed among female students (and this study was considered to have a very high risk of bias) [41]. When examining school lunch initiatives in Norway, a country where nutrition standards are voluntary, studies measuring students’ diets were mixed. One study by Ask et al. examining 9^th grade students participating in a pilot free lunch intervention for four months found no association with healthy food scores (although this study was considered to have a very high risk of bias) [42]. A study by IlløKken et al. assessed students ages 10-12 in an intervention school offering free school lunch (compared with a control group comprised of students at the same school and an additional control school) and found that free school lunch was positively associated with healthy food scores after six months of exposure, primarily due to increased consumption of fruits, vegetables, and fish spread [43]. In a separate report of results after following the same students for a year, Vik et al. found that healthy food scores remained significantly higher in the intervention group compared with the control group [44], but there were no significant changes in overall meal frequency (e.g., frequency of eating breakfast, lunch, or dinner on weekdays) [45].

In other countries, studies examining school meal programs have generally found positive results concerning dietary quality. One study in Japan examining the mandatory school lunches served in elementary and junior high schools found that consuming school lunches was positively associated with total diet quality [46]. Additionally, a study conducted in the greater Tokyo area among children ages 6-12 found that providing universal (mandatory) school lunches was associated with a reduction in SES-related dietary disparities, particularly regarding fruit and vegetable consumption [47]. A smaller study conducted in one kindergarten class in New Zealand found that offering free lunches to all students in the class was associated with significant reductions in snack food consumption while at school (although this study was assessed to have a very high risk of bias) [48]. In the OPUS School Meal study, which provided free lunches to all 3^rd and 4^th grade students in nine schools in Demark for three months (and the students ate packed lunches from home for three months) found significant improvements in students’ diets, including 16% higher vegetable intakes (p<0.0001) and 48% higher fish intakes (p<0.0001), as well as 30% lower intakes of saturated fats (p<0.0001) [49]. Lastly, a similar study conducted in Denmark among four schools that provided free school lunches for two months (compared with control schools with lunches packed from home only) also found that free meals were associated with improved dietary quality, including reductions in saturated fat and snacks and increases in vegetables and fish [50]. When the school meals were no longer provided at no cost after the two-month period, participation in school lunch became limited and there were no longer improvements in dietary quality observed.

One study in New Zealand examined universal free breakfast and food insecurity. Mhurchu et al. conducted a study in 14 primary schools in New Zealand with universal free breakfast and found a significant decrease in children’s self-reported short-term hunger, but no association with overall food insecurity levels [51]. In contrast, two studies conducted in Greece (as part of the ‘DIATROFI’ program) with universal free lunches found significant reductions in food insecurity, with the greatest decreases among food-insecure households with hunger [52, 53].

Research Gaps and Recommendations:  While overall there is good evidence to suggest that UFSM is associated with improvements in students’ diets and food security in the presence of strong nutrition standards, there is currently limited research with a low risk of bias that has been conducted in the UK. 

III. Attendance

Background and Summary: Researchers have theorized that universal free school meals could increase students’ school attendance rates through two mechanisms. The first explanation is that students from low-income households may be motivated to attend school to access the food available. Secondly, improved nutrition from school meals may also decrease the incidence of illness, which could improve attendance. There have been no government reports or peer-reviewed publications in the UK examining attendance (of note, there is non-peer reviewed policy brief that did not meet inclusion criteria for this review written by Holford and Rabe that found UIFSM was associated with improved absence rates).

Of the eight peer-reviewed publications and two government reports conducted in the U.S. that examined attendance (n=9 studies), six found a positive association between universal free school meals and attendance (primarily among sub-populations) and four found no association. A limited number of studies (n=3 peer-reviewed publications) have been conducted in other OECD countries, which included Denmark and New Zealand; none found an association with overall attendance, and one found a positive association among students with higher school breakfast participation rates in sub-analyses. Among the studies considered to have a low risk of bias, half (5 out of 10) found positive associations with attendance.

Attendance Research in the UK: None (As noted above, one policy brief that did not meet the inclusion criteria did find improvements in absence rates)

Attendance Research in Other Countries: When examining studies only implementing universal free breakfast, Bartfeld et al. conducted a study in approximately 1,000 elementary schools in Wisconsin with varying breakfast models (including universal free and means-tested programs) and found that for lower-income students only, universal free breakfast was associated with an increase in the percent of days attended (0.24 percentage point increase; p=0.023) and a decrease in the percent of students with low attendance (3.5 percentage point decrease; p<0.001) [54]. Similarly, in the Kleinman et al. study in Boston (n=97 students), improvements in attendance were observed only among the students who improved their nutritional status (which was associated with participation in the SBP) [37]. Leos-Urbel and colleagues also observed improvements in attendance among subpopulations within New York City elementary and middle schools; universal free breakfast was associated with a small increase in attendance among low-income Black students and higher-income Asian students [9]. In the study conducted by Ribar et al. in North Carolina among elementary schools that stopped offering universal free breakfasts, no impact on attendance was observed [10]. Using nationally representative data, Andreyeva and colleagues found that CEP was associated with daily school attendance by 0.24 percentage points (p < 0.01) [8].  Lastly, two government reports examining the pilot of the universal free school breakfast program in six states found no association with attendance after either one year [11] or three years [12] of exposure.

Two studies examined universal free school meals and attendance. Gordanier et al. evaluated 3-8^th grade students throughout South Carolina and found CEP was inversely associated with absences (i.e., improved attendance) among elementary students but not middle school students [55]. Bartfeld and colleagues examined elementary schools throughout Wisconsin and found that after two years of exposure, there were no associations between CEP and overall attendance rates, but a 3.5 percentage point reduction was observed in the percent of low-income students with low attendance (p=0.045) [56]. It was also noteworthy that no associations with attendance were observed within the first year of implementation. Similarly, Schwartz et al. found no association between Provision 2 and overall attendance rates among middle school students in New York City [18].

Among other OECD countries, in the study conducted by Mhurchu et al. in the 14 schools with a free school breakfast program, as well as in the study by Munday and colleagues examining free lunches among a kindergarten classroom (both conducted in New Zealand), neither found an association with overall attendance rates (although the study by Munday et al. was considered to have a very high risk of bias) [48, 51]. However, in secondary analyses examining students with higher school breakfast participation (attendance at least 50% of the time at school breakfast), Mhurchu et al. found small but significant improvements in attendance (1.6% increase; p=0.016). Laursen and associates also found no association between a free school lunch program and overall attendance among 3^rd and 4^th grade students in Denmark [57]. However, most of the students in these studies had limited exposure to free meals (ranging from 2.5 to 10 months).

Research Gaps and Recommendations: Overall there is moderate evidence regarding UFSM and attendance, although there is a lack of evidence in the UK. Prior research suggests the greatest benefits may be in sub-populations (i.e., children who are food insecure and/or from low-income households), which should be accounted for in future evaluations.

IV.  Academic Performance

Background and Summary:  Academic performance may also be influenced by universal free school meals, both directly through potential improvements in nutrition, as well as indirectly through potential increases in school attendance rates [58-62]. In the UK, one government-funded project conducted in England found a positive association between universal free school meals and academic performance while two studies in Wales found no association. Among the 11 studies in the U.S. (n=9 peer-reviewed and n=2 government reports), all four examining CEP found positive associations with academic performance, while the six studies examining universal free breakfast were mixed. One study in New Zealand found no association when examining universal free breakfast. Specifically among the studies with a low risk of bias, 3 out of 7 found a positive association with academic performance.

Academic Performance Research in the UK: No association was found within primary schools in Wales between implementation of a free breakfast initiative and cognitive scores among two studies with a high risk of bias examining the same data using slightly different analyses [31, 32]. However, in a government report examining UIFSM, free lunch was associated with improved academic performance; students made on average 4-8 weeks more progress compared with similar students in control schools [4].

Academic Performance Research in Other Countries: Of the studies examining universal free breakfast, Kleinman et al.’s study in Boston found significant improvements in academic performance (i.e., math test scores), but only among students who improved their nutrient intakes [37]. Similarly, Walhstrom and colleagues observed positive trends in standardized achievement test scores within six elementary schools (compared with three control schools) in Minnesota after piloting universal free breakfasts, although no statistical analyses were conducted and this study was considered to have a very high risk of bias [14]. In Bartfeld et al.’s study in Wisconsin elementary schools, universal free breakfast was positively associated with math (0.07 SD higher, p=0.001) and reading (0.04 SD higher, p=0.035) test scores, but only among higher income students [54]. Contrasting with those studies, Leos-Ubel et al.’s study among elementary and middle school students in New York City [9], Ribar et al.’s study in North Carolina [10], and the two government report examining the pilot of universal free breakfast found no significant associations with test scores after one or three years of exposure [11, 12]. 

Among studies examining school meal provisions that include lunch in the U.S., Gordanier et al.’s study among 3-8^th grade students in South Carolina found that CEP was positively associated with math test scores (0.06 standard deviation increase) among elementary students, but did not have any significant associations with reading scores in elementary school, nor any test scores among middle school students [55]. Similarly, Schwartz et al. found a positive association between Provision 2 and academic performance among middle school students in New York City; math and English Language Arts standardized test scores were significantly higher, with the greatest improvements observed among higher-income students [18]. Using nationally representative data, Andreyeva and colleagues found that while CEP was not associated with academic performance overall, there was improved reading scores among Hispanic children by 0.055 standard deviations [8]. 

Lastly, in a study conducted by Taylor and colleagues in Vermont, CEP was associated with higher perceptions of improved academic performance and readiness to learn according to school staff surveys, although no direct, objective measurements of academic performance were collected (and the study was considered to have a very high risk of bias) [63]. In studies conducted in other OECD countries, Mhurchu et al. found no association between a free school breakfast program and academic performance in New Zealand primary schools [51].

Research Gaps and Recommendations:  Overall there is moderate evidence to suggest that UFSM is associated with improvements in students’ academic performance, although there is currently limited research with a low risk of bias that has been conducted in the UK. 

V.  Body Mass Index

Background and Summary: One concern about universal free school meals has been the potential adverse impact on children’s BMI, particularly if a child receives a breakfast at home and then receives a second breakfast and lunch at school [18, 64]. However, if healthier meals are provided by schools, they may reduce the risk of obesity to the extent that they replace less nutritionally balanced foods with higher quality school meals [65, 66]. The evidence that school meals are on average healthier than lunches brought from home supports this theory [27, 67]. Further, it may be that increased satiety from healthy lunch consumption leads to reduced consumption of less healthy foods after school [30].

In the UK, one government report found no association with BMI and another study in England found a greater likelihood of students being a healthy weight with UIFSM.  In the U.S., only three peer-reviewed studies and one government report in the U.S. have examined BMI and universal free school meals (n=4 studies), and five studies (n=4 peer-reviewed publications) have been conducted in other OECD countries including Norway, and the Netherlands. The majority (8 out of 9) found either no association with BMI or a reduced probability of developing overweight and obesity. Among the limited number of studies considered to have a low risk of bias, 2 out of 3 found universal free school meals were associated with lower BMIs among students.

BMI research in the UK:  A government report in England found no association between UIFSM and BMI [4]. Another study with a high risk of bias conducted in England found UIFSM was associated with a greater likelihood of students being a healthy weight.[2]

BMI research in Other Countries: In the U.S., Schwartz and colleagues found no association between free lunches offered through Provision 2 and BMI among middle school students in New York City [18]. In sub-analyses, Provision 2 was associated with a 2.5% reduced probability (p<0.01) of obesity among higher-income students. In a government report examining the pilot of universal free breakfast, there was no association with the prevalence of overweight after one year of exposure to free school breakfasts [11]. Using nationally representative data, Andreyeva and colleagues found that while CEP was not associated with BMI overall, there was a decreased probability of overweight by 3.1% among children from low-income families (p < 0.05)  [8].  Bullock and colleagues found no association with BMI and Universal Free Breakfast [68].

A study in the Netherlands conducted by Bartelink et al. found that providing children ages 4-12 with a free lunch (in additional to some structured physical activity after lunch) was inversely associated with BMI z-score after two years of follow-up (standardized effect size= −0.083, p=0.01) [69]. In a study conducted by Ask et al. among 10^th graders in Norway, providing free breakfasts also appeared to be protective against excess weight gain; BMI remained unchanged among students receiving free school breakfast, whereas there was a significant increase in the BMI of students in the control group over the span of four months (although this study was deemed to have a very high risk of bias) [41]. Another study by Ask et al. conducted in Norway among 9^th grade students found no association between a pilot free lunch program and BMI after four months of exposure, and this study also was considered to have a very high risk of bias [42]. These results contrast with a study conducted in Norway that found a free school lunch program was associated with higher BMI z-scores, compared with a decrease in BMI z-scores among the control students (F = 10.007, p = 0,002), despite the healthier food scores observed among the students with free lunch [44].

Research Gaps and Recommendations:  Overall there is moderate evidence to suggest that UFSM is associated with no adverse impact on BMI or potentially support reduced risk of overweight, although there is currently limited research with a low risk of bias that has been conducted in the UK.  Of note, changes in BMI typically are only seen over the course of multiple years and thus should not be examined in short-term studies. 

VI.  Finances

Background and Summary: Concerns have also been raised about the impact of universal free school meals on school finances, specifically due to the increase in costs from preparing and serving more meals [18, 64]. One study in Scotland estimated the overall costs of providing universal free lunches. Additionally, 6 out of the 7 peer-reviewed publications and government reports in the U.S. reported that increased food and labor costs were balanced by increased revenues from school meals served through federal reimbursements. Of note, these estimates of the cost of implementation do not include the increase in cost to the U.S. federal government. Among these studies, only one was considered to have a low risk of bias, and this study found positive outcomes for school finances with universal free school meals.

Finances Research in the UK: In Scotland, a government report examining school meals found that the costs of preparing meals varied (from £1.79 to £4.65 per meal). The cost per meal decreased as the number of meals served increased, likely due in part to economies of scale (e.g., buying in bulk or through contract negotiations) [5].

Finances Research in Other Countries: In the U.S., a national study conducted by Long et al. found that the full meal costs among medium and large size schools significantly lower for breakfast (-$0.58; p=0.025), but there were no statistically significant differences for lunch or for smaller schools overall [70]. In a study in Texas that examined a school district with Provision 2 found that implementation was associated with a 5% increase in annual revenue (statistical significance was not assessed and the study was assessed to have a very high risk of bias) [17]. Similarly, a government report examining the pilot of universal free school breakfasts found that there was an increase in labor costs, but these were more than offset by the increase in meals served (and thus an increase in federal reimbursements), resulting in an average savings of $0.11 per breakfast served for districts [11]. Another government report examining the USDA No-Fee School Meal Pilot Program in three states found that providing universal free school meals was associated with a 33% increase in federal reimbursement overall and reduced administrative costs [19]. In a third government report examining CEP, this provision was associated with increased federal meal reimbursements (increase of 5.6% for NSLP and 1.9% for SBP) [71]. Staff also spent significantly less time distributing and processing applications for free and reduced-price meals and/or verifying student eligibility, which resulted in an average savings of 68 minutes per student annually (translating to a labor-saving cost of approximately $29 per student per year). This time savings is partially offset by an average 30 minute/student increase in staff time annually to claim reimbursable meals (p<0.01). Overall, this government report found that federal funding via reimbursements per student increased by 13.5% (or $5.33 per student annually), resulting in potential net gains for school districts participating in CEP. Similarly, in a study conducted in Vermont, school staff (e.g., principals, food service staff, and business managers) perceptions were measured using an online survey, and roughly half of participants perceived that school finances had improved (52.4%), while only 44% perceived that the school meal program deficit was reduced [63]. No objective measurements of school finances were collected in this study. Conversely, a government report examining schools that eliminated reduced-price fees within 5 states found that federal reimbursements for the school meals served only partially offset the program costs with higher participation rates (although this report was deemed to have a very high risk of bias) [20].

Research Gaps and Recommendations:  Overall there is moderate evidence to suggest that UFSM is associated with improvements in school meal finances, although there is currently limited research with a low risk of bias that has been conducted in the UK. 

VII.  Other findings related to implementation of UFSM

Implementation outcomes were outside the scope of the review included the impact on household finances, as well as qualitative data examining the impact of UFSM on other outcomes, such as stigma.  In these studies, multiple themes were documented. First, a primary outcome of the qualitative research was that UFSM was associated with reductions in perceived stigma for students [72-75]. Additionally, reductions in stress for households, particularly due to less time and money spent preparing meals at home for students to eat at school [74], was documented although there is more limited research that has been conducted in the UK [1]. There is also currently more limited evidence overall (and within the UK) examining the impact of UFSM on household finances [2, 3]. The qualitative research also documented that schools potentially benefited from UFSM through reductions in perceived administrative burden, as this policy reduced paperwork and administrative load [72, 76].  Overall, the data indicate improvements in acceptability (i.e., stakeholders’ perceptions that a particular intervention/policy is credible), adoption (i.e., more schools adopting UFSM policies as a result of positive findings), and cost (i.e., lower administration costs).

When examining factors related to the school setting, prior research highlighted the need for sufficient reimbursement rates for school meals, particularly with rising inflation and costs of foods, as well as the need for infrastructure and resources (such as staff, equipment, and space), particularly for older school building and/or urban districts [72, 76, 77].  When examining factors related to engaging key stakeholders (i.e., students, caregivers), there were some barriers to participation documented, including student meal preferences and cultural appriopriateness of school foods, and research in the UK documented some concerns about meal quality during the COVID-19 pandemic resulting in potential reductions in school meal participation [78]. Overall, data suggest that these barriers could in part be addressed by engaging students as key stakeholders, promoting school meals within school systems (e.g., parent-facing newsletters and information, bringing meals into the classroom), and reducing sales of snacks and beverages during school hours (i.e. foods and drinks sold outside of the school meal program) [2, 76, 79-82]. Lastly, the qualitative literature suggested that potential concerns regarding food waste could be addressed through ensuring sufficient time to eat, as well as age-appropriate portion sizes, effective communication strategies, and accounting for student food preferences and cultural norms when planning meals [83, 84]. 

Research Gaps and Recommendations:  Research examining the implementation of UFSM, including determinants and processes, are currently limited.  Future research should examine this to support the ability to identify mechanisms that link implemetation determinants to outcomes, including at the child and school levels.  Understanding outcomes of implementation beyond compliance and fidelity to providing UFSM can help researchers to identify other areas of impact. The implementation outcomes framework [85] outlines an array of key impacts which can be considered when determining the success a UFSM policy. Lastly, a focus on measuring equitable implementation can help to determine if UFSM policies are benefitting students at greatest risk for food insecurity and health disparities more broadly.

Citations

1.             Carlisle, V.R., et al., A Mixed Methods, Quasi-Experimental Evaluation Exploring the Impact of a Secondary School Universal Free School Meals Intervention Pilot. International Journal of Environmental Research and Public Health, 2023. 20(6): p. 5216.

2.             Holford, A. and B. Rabe, Going universal. The impact of free school lunches on child body weight outcomes. Journal of Public Economics Plus, 2022. 3: p. 100016.

3.             Marcus, M. and K.G. Yewell, The Effect of Free School Meals on Household Food Purchases: Evidence from the Community Eligibility Provision. Journal of Health Economics, 2022. 84: p. 102646.

4.             Kitchen, S., et al., Evaluation of the free school meals pilot. 2013, London: Department for Education.

5.             MacLardie, J., et al., Evaluation of the free school meals trial for P1 to P3 pupils.  Edinburgh, Scottish Government Social Research. 2008.

6.             Holford, A., Take‐up of Free School Meals: Price Effects and Peer Effects. Economica, 2015. 82(328): p. 976-993.

7.             Parnham, J.C., et al., The impact of the Universal Infant Free School Meal policy on dietary quality in English and Scottish primary school children: evaluation of a natural experiment. Nutrients, 2022. 14(8): p. 1602.

8.             Andreyeva, T. and X. Sun, Universal school meals in the US: what can we learn from the Community Eligibility Provision? Nutrients, 2021. 13(8): p. 2634.

9.             Leos-Urbel, J., et al., Not just for poor kids: The impact of universal free school breakfast on meal participation and student outcomes. Economics of education review, 2013. 36: p. 88-107.

10.          Ribar, D.C. and L.A. Haldeman, Changes in meal participation, attendance, and test scores associated with the availability of universal free school breakfasts. Social Service Review, 2013. 87(2): p. 354-385.

11.          McLaughlin, J.E., et al., Evaluation of the School Breakfast Program Pilot Project: Findings from the First Year of Implementation. Nutrition Assistance Program Report Series. 2002.

12.          Bernstein, L.S., et al., Evaluation of the School Breakfast Program Pilot Project: Final Report. Special Nutrition Programs. Report Number CN-04-SBP. Nutrition Assistance Program Report Series. US Department of Agriculture, 2004.

13.          Soldavini, J. and A.S. Ammerman, Serving breakfast free to all students and type of breakfast serving model are associated with participation in the School Breakfast Program. Journal of the Academy of Nutrition and Dietetics, 2019. 119(7): p. 1142-1149.

14.          Wahlstrom, K.L. and M.S. Begalle, More than test scores: results of the Universal School Breakfast Pilot in Minnesota. Topics in clinical nutrition, 1999. 15(1): p. 17-29.

15.          Khan, S., et al., Prevalence of food insecurity and utilization of food assistance program: an exploratory survey of a Vermont middle school. Journal of School Health, 2011. 81(1): p. 15-20.

16.          Dykstra, H., et al., Breakfast-skipping and selecting low-nutritional-quality foods for breakfast are common among low-income urban children, regardless of food security status. The Journal of nutrition, 2016. 146(3): p. 630-636.

17.          Rivas, D., Everyone Eats for Free--Piloting Provision 2. School Business Affairs, 1994. 61(2).

18.          Schwartz, A.E. and M.W. Rothbart, Let them eat lunch: The impact of universal free meals on student performance. Journal of Policy Analysis and Management, 2020. 39(2): p. 376-410.

19.          Robinson, R.A., Food Assistance: Early Results of USDA's No-Fee School Meal Pilot Program. Report to U.S. Government Accountability Office (GAO). 1994.

20.          Brown, K., School Meal Programs: Experiences of the States and Districts That Eliminated Reduced-Price Fees. Report to the Chairman, Committee on Education and Labor, House of Representatives. GAO-09-584. US Government Accountability Office, 2009.

21.          Pokorney, P.E., A. Chandran, and M.W. Long, Impact of the Community Eligibility Provision on meal counts and participation in Pennsylvania and Maryland National School Lunch Programs. Public health nutrition, 2019. 22(17): p. 3281-3287.

22.          Turner, L., J.F. Guthrie, and K. Ralston, Community eligibility and other provisions for universal free meals at school: impact on student breakfast and lunch participation in California public schools. Translational behavioral medicine, 2019. 9(5): p. 931-941.

23.          Tan, M.L., et al., Community Eligibility Provision and School Meal Participation among Student Subgroups. Journal of School Health, 2020. 90(10): p. 802-811.

24.          Cohen, J.F., et al., Impact of the new US Department of Agriculture school meal standards on food selection, consumption, and waste. American Journal of Preventive Medicine, 2014. 46(4): p. 388-394.

25.          Cullen, K.W. and T.-A. Chen, The contribution of the USDA school breakfast and lunch program meals to student daily dietary intake. Preventive Medicine Reports, 2017. 5: p. 82-85.

26.          Gearan, E., et al., School Nutrition and Meal Cost Study Final Report Volume 2: Nutritional Characteristics of School Meals. Mathematica Policy Research, 2019.

27.          Fox, M.K., et al., School Nutrition and Meal Cost Study Final Report Volume 4: Student Participation, Satisfaction, Plate Waste, and Dietary Intakes. Mathematica Policy Research, 2019.

28.          Au, L.E., et al., Eating school lunch is associated with higher diet quality among elementary school students. Journal of the Academy of Nutrition and Dietetics, 2016. 116(11): p. 1817-1824.

29.          Au, L.E., et al., Eating school meals daily is associated with healthier dietary intakes: the Healthy Communities Study. Journal of the Academy of Nutrition and Dietetics, 2018. 118(8): p. 1474-1481. e1.

30.          Cohen, J.F., et al., The impact of 1 year of healthier school food policies on students’ diets during and outside of the school day. Journal of the Academy of Nutrition and Dietetics, 2018. 118(12): p. 2296-2301.

31.          Murphy, S., et al., Free healthy breakfasts in primary schools: a cluster randomised controlled trial of a policy intervention in Wales, UK. Public health nutrition, 2011. 14(2): p. 219-226.

32.          Moore, G.F., et al., Impacts of the Primary School Free Breakfast Initiative on socio-economic inequalities in breakfast consumption among 9–11-year-old schoolchildren in Wales. Public Health Nutrition, 2014. 17(6): p. 1280-1289.

33.          Jenkins, K.T., et al., A cross-sectional observational study of the nutritional intake of UK primary school children from deprived and non-deprived backgrounds: implications for school breakfast schemes. International Journal of Behavioral Nutrition and Physical Activity, 2015. 12(1): p. 86.

34.          Spence, S., et al., Implementation of Universal Infant Free School Meals: a pilot study in NE England exploring the impact on Key Stage 1 pupil’s dietary intake. Public Health Nutrition, 2020: p. 1-22.

35.          Gatenby, L., Children's nutritional intake as part of the Eat Well Do Well scheme in Kingston‐upon‐Hull–a pilot study. Nutrition Bulletin, 2011. 36(1): p. 87-94.

36.          Crepinsek, M.K., et al., Dietary effects of universal-free school breakfast: findings from the evaluation of the school breakfast program pilot project. Journal of the American Dietetic Association, 2006. 106(11): p. 1796-1803.

37.          Kleinman, R.E., et al., Diet, breakfast, and academic performance in children. Annals of Nutrition and Metabolism, 2002. 46(Suppl. 1): p. 24-30.

38.          Adams, E.L., et al., Using digital imagery to quantify students’ added sugar intake at lunch in Title I schools with universal free meals. Preventive Medicine Reports, 2020. 20: p. 101253.

39.          Poblacion, A., et al., Can food insecurity be reduced in the United States by improving SNAP, WIC, and the community eligibility provision? World Medical & Health Policy, 2017. 9(4): p. 435-455.

40.          Gross, S.M., et al., Household Food Security Status of Families with Children Attending Schools that Participate in the Community Eligibility Provision (CEP) and Those with Children Attending Schools that are CEP-Eligible, but Not Participating. Journal of Hunger & Environmental Nutrition, 2019: p. 1-16.

41.          Ask, A.S., et al., Changes in dietary pattern in 15 year old adolescents following a 4 month dietary intervention with school breakfast–a pilot study. Nutrition Journal, 2006. 5(1): p. 33.

42.          Ask, A.S., et al., Serving of free school lunch to secondary-school pupils–a pilot study with health implications. Public health nutrition, 2010. 13(2): p. 238-244.

43.          IlløKken, K.E., et al., Intervention study on school meal habits in Norwegian 10–12-year-old children. Scandinavian Journal of Public Health, 2017. 45(5): p. 485-491.

44.          Vik, F.N., W. Van Lippevelde, and N.C. Øverby, Free school meals as an approach to reduce health inequalities among 10–12-year-old Norwegian children. BMC public health, 2019. 19(1): p. 951.

45.          Vik, F.N., et al., Possible effects of a free, healthy school meal on overall meal frequency among 10–12-year-olds in Norway: the School Meal Project. BMC Research Notes, 2019. 12(1): p. 382.

46.          Asakura, K. and S. Sasaki, School lunches in Japan: their contribution to healthier nutrient intake among elementary-school and junior high-school children. Public health nutrition, 2017. 20(9): p. 1523-1533.

47.          Yamaguchi, M., N. Kondo, and H. Hashimoto, Universal school lunch programme closes a socioeconomic gap in fruit and vegetable intakes among school children in Japan. The European Journal of Public Health, 2018. 28(4): p. 636-641.

48.          Munday, K. and M. Wilson, Implementing a health and wellbeing programme for children in early childhood: A preliminary study. Nutrients, 2017. 9(9): p. 1031.

49.          Andersen, R., et al., Dietary effects of introducing school meals based on the New Nordic Diet–a randomised controlled trial in Danish children. The OPUS School Meal Study. British journal of nutrition, 2014. 111(11): p. 1967-1976.

50.          Sabinsky, M.S., et al., Effect of implementing school meals compared with packed lunches on quality of dietary intake among children aged 7–13 years. Journal of nutritional science, 2019. 8.

51.          Mhurchu, C.N., et al., Effects of a free school breakfast programme on children's attendance, academic achievement and short-term hunger: results from a stepped-wedge, cluster randomised controlled trial. Journal of Epidemiology & Community Health, 2013. 67(3): p. 257-264.

52.          Dalma, A., et al., Effectiveness of a school food aid programme in improving household food insecurity; a cluster randomized trial. European Journal of Public Health, 2020. 30(1): p. 171-178.

53.          Petralias, A., et al., The impact of a school food aid program on household food insecurity. The European Journal of Public Health, 2016. 26(2): p. 290-296.

54.          Bartfeld, J.S., et al., Access to the school breakfast program is associated with higher attendance and test scores among elementary school students. The Journal of nutrition, 2019. 149(2): p. 336-343.

55.          Gordanier, J., et al., Free Lunch for All! The Effect of the Community Eligibility Provision on Academic Outcomes. Economics of Education Review, 2020. 77: p. 101999.

56.          Bartfeld, J.S., L. Berger, and F. Men, Universal Access to Free School Meals through the Community Eligibility Provision Is Associated with Better Attendance for Low-Income Elementary School Students in Wisconsin. Journal of the Academy of Nutrition and Dietetics, 2020. 120(2): p. 210-218.

57.          Laursen, R.P., et al., Do healthy school meals affect illness, allergies and school attendance in 8-to 11-year-old children? A cluster-randomised controlled study. European Journal of Clinical Nutrition, 2015. 69(5): p. 626-631.

58.          Cohen, J.F., et al., The effect of healthy dietary consumption on executive cognitive functioning in children and adolescents: a systematic review. British Journal of Nutrition, 2016. 116(6): p. 989-1000.

59.          Popkin, B.M. and M. Lim-Ybanez, Nutrition and school achievement. Social Science & Medicine, 1982. 16(1): p. 53-61.

60.          Moonie, S., et al., The relationship between school absence, academic performance, and asthma status. Journal of school health, 2008. 78(3): p. 140-148.

61.          Singh, K., M. Granville, and S. Dika, Mathematics and science achievement: Effects of motivation, interest, and academic engagement. The journal of educational research, 2002. 95(6): p. 323-332.

62.          Smerillo, N.E., et al., Chronic absence, eighth-grade achievement, and high school attainment in the Chicago Longitudinal Study. Journal of school psychology, 2018. 67: p. 163-178.

63.          Taylor, J., et al., Universal Free School Meal Programs in Vermont Show Multi-domain Benefits. Journal of Hunger & Environmental Nutrition, 2020: p. 1-14.

64.          Altindag, D.T., et al., Free lunch for all? The impact of universal school lunch on student misbehavior. Economics of Education Review, 2020. 74: p. 101945.

65.          Kenney, E.L., et al., Impact Of The Healthy, Hunger-Free Kids Act On Obesity Trends: Study examines impact of the Healthy, Hunger-Free Kids Act of 2010 on childhood obesity trends. Health Affairs, 2020. 39(7): p. 1122-1129.

66.          Vericker, T.C., M.E. Gearing, and S.D. Kim, Updated Nutrition Standards for School Meals Associated With Improved Weight Outcomes for Boys in Elementary School. Journal of School Health, 2019. 89(11): p. 907-915.

67.          Farris, A.R., et al., Nutritional comparison of packed and school lunches in pre-kindergarten and kindergarten children following the implementation of the 2012–2013 national school lunch program standards. Journal of nutrition education and behavior, 2014. 46(6): p. 621-626.

68.          Bullock, S.L., et al., Associations between a Universal Free Breakfast Policy and School Breakfast Program Participation, School Attendance, and Weight Status: A District-Wide Analysis. International Journal of Environmental Research and Public Health, 2022. 19(7): p. 3749.

69.          Bartelink, N.H., et al., Can the Healthy Primary School of the Future offer perspective in the ongoing obesity epidemic in young children? A Dutch quasi-experimental study. BMJ open, 2019. 9(10).

70.          Long, M.W., K. Marple, and T. Andreyeva, Universal free meals associated with lower meal costs while maintaining nutritional quality. Nutrients, 2021. 13(2): p. 670.

71.          Logan, C.W., Community eligibility provision evaluation. 2014: United States Department of Agriculture, Food and Nutrition Service, Office ….

72.          Cohen, J.F.W., et al., Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine. Nutrients, 2022. 14(19): p. 4031.

73.          Zuercher, M.D., et al., Providing School Meals to All Students Free of Charge during the COVID-19 Pandemic and Beyond: Challenges and Benefits Reported by School Foodservice Professionals in California. Nutrients, 2022. 14(18): p. 3855.

74.          Martinelli, S., et al., Healthy School Meals for All in Arizona: A Comprehensive Assessment of Benefits, Cost Scenarios, and Community Perspectives. 2023, Arizona State University: Phoenix, Arizona.

75.          Jessiman, P.E., et al., A qualitative process evaluation of universal free school meal provision in two London secondary schools. BMC Public Health, 2023. 23(1): p. 300.

76.          Hecht, A., et al., Universal free schools meals through the Community Eligibility Provision: Maryland food service provider perspectives. Journal of Agriculture, Food Systems, and Community Development, 2021: p. 1-22.

77.          Chambers, S., et al., Learning from the implementation of Universal Free School Meals in Scotland using Normalisation Process Theory: Lessons for policymakers to engage multiple stakeholders. Food Policy, 2020. 95: p. 101936.

78.          Davies, E., M. Vannoni, and S. Steele, Caregiver perceptions of England’s universal infant school meal provision during the COVID-19 pandemic. Journal of Public Health Policy, 2023. 44(1): p. 47-58.

79.          Bailey-Davis, L., et al., Middle school student and parent perceptions of government-sponsored free school breakfast and consumption: A qualitative inquiry in an urban setting. Journal of the Academy of Nutrition & Dietetics, 2013. 113: p. 251-257.

80.          Mauer, S., L.E. Torheim, and L. Terragni, Children's Participation in Free School Meals: A Qualitative Study among Pupils, Parents, and Teachers. Nutrients, 2022. 14(6).

81.          Addis, D.S. and P.S. Murphy, Free school meals: Socio-ecological influences on school level take up of entitlement. British Journal of School Nursing, 2018. 13(8): p. 394-402.

82.          Galli, F., et al., Co-Producing Sustainability: Involving Parents and Civil Society in the Governance of School Meal Services. A Case Study from Pisa, Italy. Sustainability, 2014. 6(4): p. 1643-1666.

83.          Blondin, S.A., et al., 'It's just so much waste.' A qualitative investigation of food waste in a universal free School Breakfast Program. Public Health Nutrition, 2015. 18(9): p. 1565-1577.

84.          Askelson, N.M., et al., Understanding Perceptions of School Administrators Related to School Breakfast in a Low School Breakfast Participation State. Journal of School Health, 2017. 87(6): p. 427-434.

85.          Proctor, E., et al., Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Administration and Policy in Mental Health and Mental Health Services Research, 2011. 38(2): p. 65-76.