School Provision of Universal Free Meals and Blood Pressure Outcomes Among Youths

The Community Eligibility Provision is a federal universal free school meals policy for schools in low-income areas. Expanding access to school meals, which are children's most nutritious food source, may be a health-promoting policy.

To assess whether school-level adoption of the Community Eligibility Provision was associated with childhood blood pressure outcomes.

This cohort study used a difference-in-differences design for staggered policy adoption, observing low-income public and charter schools in 12 US states longitudinally from 2013 through 2019. The medical records for patients aged 4 to 18 years receiving care from community health organizations in the OCHIN health care network were matched to schools based on address. Data were analyzed from April 1 to July 5, 2024.

School participation in the Community Eligibility Provision.

The primary outcome was the annual school-level proportion of patients with a high blood pressure measurement (at or above the 90th percentile for age, sex, and height), and the secondary outcomes included a hypertensive measurement (at or above the 95th percentile) and mean systolic and diastolic blood pressure percentiles.

The sample included 1052 schools matched to 155 778 distinct patients. The mean (SD) proportions of patients based on race and ethnicity were as follows: 0.04 (0.08) Asian patients, 0.46 (0.33) Hispanic patients, 0.01 (0.03) patients of multiple races, 0.01 (0.02) Native Hawaiian or Other Pacific Islander patients, 0.13 (0.22) non-Hispanic Black patients, 0.25 (0.26) non-Hispanic White patients, and 0.09 (0.09) patients with unknown race and ethnicity. The majority of schools (n = 670 [63.7%]) were located in California or Oregon. School participation in the Community Eligibility Provision was associated with a -2.71 percentage point (95% CI, -5.10 to -0.31 percentage point; P = .03) net reduction in the proportion of patients with a high blood pressure measurement, corresponding to a -10.8% (95% CI, -20.4% to -1.2%) net decrease over 5 years. Participation was also negatively associated with the proportion of patients with a hypertensive measurement and with the mean diastolic blood pressure.

This cohort study of schools matched to child and adolescent patient medical records from a large network of community health organizations found that school participation in the Community Eligibility Provision was associated with a net reduction in blood pressure outcomes. These findings add to mounting evidence that universal free school meals may be associated with improved child health.