Effect of the Healthy Hunger-Free Kids Act on the Nutritional Quality of Meals Selected by Students and School Lunch Participation Rates

JAMA Pediatr. 2016 Jan;170(1):e153918. doi: 10.1001/jamapediatrics.2015.3918. Epub 2016 Jan 4.


Importance: Effective policies have potential to improve diet and reduce obesity. School food policies reach most children in the United States.

Objective: To assess the nutritional quality of foods chosen by students and meal participation rates before and after the implementation of new school meal standards authorized through the Healthy Hunger-Free Kids Act.

Design, setting, and participants: This descriptive, longitudinal study examined changes in the nutritional quality of 1,741,630 school meals at 3 middle schools and 3 high schools in an urban school district in Washington state. Seventy two hundred students are enrolled in the district; 54% are eligible for free and reduced-price meals. Student food selection data were collected daily from January 2011 through January 2014 during the 16 months prior to and the 15 months after implementation of the Healthy Hunger-Free Kids Act.

Exposure: The Healthy Hunger-Free Kids Act.

Main outcomes and measures: Nutritional quality was assessed by calculating monthly mean adequacy ratio and energy density of the foods selected by students each day. Six nutrients were included in the mean adequacy ratio calculations: calcium, vitamin C, vitamin A, iron, fiber, and protein. Monthly school meal participation was calculated as the mean number of daily meals served divided by student enrollment. Mean monthly values of mean adequacy ratio, energy density, and participation were compared before and after policy implementation.

Results: After implementation of the Healthy Hunger-Free Kids Act, change was associated with significant improvement in the nutritional quality of foods chosen by students, as measured by increased mean adequacy ratio from a mean of 58.7 (range, 49.6-63.1) prior to policy implementation to 75.6 (range, 68.7-81.8) after policy implementation and decreased energy density from a mean of 1.65 (range, 1.53-1.82) to 1.44 (range, 1.29-1.61), respectively. There was negligible difference in student meal participation following implementation of the new meal standards with 47% meal participation (range, 40.4%-49.5%) meal participation prior to the implemented policy and 46% participation (range, 39.1%-48.2%) afterward.

Conclusions and relevance: Food policy in the form of improved nutrition standards was associated with the selection of foods that are higher in nutrients that are of importance in adolescence and lower in energy density. Implementation of the new meal standards was not associated with a negative effect on student meal participation. In this district, meal standards effectively changed the quality of foods selected by children.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Ascorbic Acid / administration & dosage
  • Calcium / administration & dosage
  • Child
  • Dietary Fiber / administration & dosage
  • Dietary Proteins / administration & dosage
  • Female
  • Food Preferences*
  • Food Services / standards
  • Health Promotion / methods
  • Humans
  • Hunger
  • Iron / administration & dosage
  • Longitudinal Studies
  • Lunch*
  • Male
  • Nutrition Policy / legislation & jurisprudence*
  • Nutritive Value*
  • Pediatric Obesity / prevention & control*
  • Schools
  • Students / statistics & numerical data*
  • United States
  • Vitamin A / administration & dosage
  • Vitamins / administration & dosage
  • Washington


  • Dietary Fiber
  • Dietary Proteins
  • Vitamins
  • Vitamin A
  • Iron
  • Ascorbic Acid
  • Calcium