Free school meals tied to improved child health

A US cohort study of schools matched to child and adolescent patient medical records from a network of community health organizations found an association between school participation in the Community Eligibility Provision (CEP) programme and a net reduction in blood pressure (BP) outcomes.

“The CEP 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,” said the investigators.

To evaluate the association between school-level adoption of the CEP and childhood BP outcomes, the study used a difference-in-differences design for staggered policy adoption to longitudinally observe low-income public and charter schools in 12 US states from 2013 to 2019. The sample included 1,052 schools matched to 155,778 distinct patients (mean age 10.9 years). About two-thirds of the schools (63.7 percent) were in California or Oregon. [JAMA Network Open 2025;8:e2533186]

School participation in the CEP was associated with a net reduction of -2.71 percentage points (p=0.03) in the proportion of patients with a high BP measurement, corresponding to an 11-percent net reduction over 5 years.

CEP participation was also tied to significant net reductions in the percentage of patients with a hypertensive measurement (-2.48 percentage points; p=0.03) and in the mean diastolic BP percentile (-2.21 percentage points; p=0.01), as well as a numerical net reduction in the mean systolic BP percentile (-0.50 percentage points; p=0.68).

When obesity prevalence was added as a covariate, the associations, though slightly diminished, remained negative, suggesting that CEP may independently affect BP. This finding aligns with evidence showing a correlation between CEP and relative reductions in obesity. [Pediatrics 2024;153:e2023063749; Health Aff Sch 2025;3:qxaf144]

Improved health at population level

Paediatric hypertension increases the risk of hypertension in early adulthood and disproportionately burdens children from low-income and racially and ethnically minoritized cohorts. [JAMA Netw Open 2021;4:e213917; Prev Chronic Dis 2021;18:E88]

The CEP is a universal free-meals policy that allows schools with a high percentage of students from low-income households to provide free breakfast and lunch to students. It increases school meal participation and may improve diet quality by substituting some meal components with healthier alternatives. [Nutrients 2021;13:911]

“CEP became available nationwide in 2014; since then, more schools have adopted the policy each year,” said the researchers. In 2024, with over 47,000 schools participating, the programme has reached more than 23 million children. [https://frac.org/cep-report-2024, accessed October 23, 2025]

“Given the popularity of such policies, understanding their health effects is critical. CEP has the potential to improve population health, as supported by emerging evidence showing associations with obesity reduction,” the researchers pointed out. “CEP may reduce high BP, not only through improved nutrition and obesity reduction, but also through reduced household income constraints and food insecurity.”

Evidence suggests that enhanced school meal nutrition standards are associated with reduced BMI and obesity risk in children from low-income families. [JAMA Pediatr 2023;177:401-409; Health Aff (Millwood) 2020;39:1122-1129] According to the researchers, these enhanced standards may have contributed to the study findings.

“These findings add to mounting evidence that universal free school meal policies such as the CEP represent promising strategies for improving population-level health,” the researchers concluded.

Although the data were not nationally representative, patients from health clinics in low-income and racially/ethnically diverse regions represent priority groups for such interventions. “We do not assume these findings to be representative for children from higher-income families; future research should assess this association in other settings and populations,” they said.