Research Article| Volume 52, ISSUE 3, P249-258, March 2020

Post–Healthy, Hunger-Free Kids Act Adherence to Select School Nutrition Standards by Region and Poverty Level: The Healthy Communities Study

Published:November 26, 2019DOI:



      This study determined the extent to which schools adhered to select nutrition and wellness provisions of the 2010 Healthy, Hunger-Free Kids Act and examined differences by US region and school poverty level.


      Comparison of cross-sectional observational data from the Healthy Communities Study (2013–2015) by region and school poverty level.


      A total of 401 US elementary and middle schools.

      Main Outcome Measures

      Adherence with federal nutrition standards for meals and competitive foods; extent of implementation of select aspects of school wellness policies.


      Descriptive statistics and multivariate regression were used. Differences were examined by school poverty level and region, adjusting for other school- and community-level covariates.


      Most schools reported meeting reimbursable school meal nutrition standards (74%); more schools in the West met nutrition standards (82%) than in the Midwest (64%). Most grains offered at lunch were whole grain–rich (82%), and most competitive foods complied with standards (78%) before they were required. Most schools had a wellness coordinator (80%). Lowest levels of adherence were reported for guidelines for classroom or school event foods. No differences were observed by school poverty level.

      Conclusions and Implications

      Findings suggest that Healthy Hunger-Free Kids Act provisions were feasible across a wide variety of schools, and schools successfully implemented reimbursable school meal nutrition standards regardless of school poverty level.

      Key Words

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      1. Institute of Medicine. Accelerating progress in obesity prevention: solving the weight of the nation. 2012. Accessed November 19, 2019.

        • Story M
        • Nanney MS
        • Schwartz MB
        Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity.
        Milbank Q. 2009; 87: 71-100
        • Gordon AR
        • Cohen R
        • Crepinsek MK
        • Fox MK
        • Hall J
        • Zeidman E
        The third School Nutrition Dietary Assessment Study: background and study design.
        J Am Diet Assoc. 2009; 109: S20-S30
        • Oliveira V
        The Food Assistance Landscape: FY 2018 Annual Report.
        US Department of Agriculture, Economic Research Service, Washington, DC2019
        • Au LE
        • Crawford PB
        • Woodward-Lopez G
        • et al.
        School wellness committees are associated with lower body mass index Z-scores and improved dietary intakes in US children: the healthy communities study.
        J Sch Health. 2018; 88: 627-635
        • Story M
        • Kaphingst KM
        • Robinson-O'Brien R
        • Glanz K
        Creating healthy food and eating environments: policy and environmental approaches.
        Annu Rev Public Health. 2008; 29: 253-272
        • US Department of Agriculture, Food and Nutrition Service
        Nutrition standards in the National School Lunch and School Breakfast Programs. Final rule.
        Fed Regist. 2012; 77: 4088-4167
        • US Department of Agriculture, Food and Nutrition Service
        National School Lunch Program and School Breakfast Program: nutrition standards for all foods sold in school as required by the Healthy, Hunger-Free Kids Act of 2010. Final rule and interim final rule.
        Fed Regist. 2016; 81: 50131-50151
      2. US Department of Agriculture. School meals: Healthy Hunger-Free Kids Act. 2014. Accessed November 19, 2019.

        • US Department of Agriculture, Food and Nutrition Service
        Local School Wellness Policy Implementation under the Healthy, Hunger-Free Kids Act of 2010. Final rule.
        Fed Regist. 2016; 81: 50151-50170
      3. US Department of Agriculture. School nutrition and meal coststudy. 2019. Accessed May 8, 2019.

        • Johnson DB
        • Podrabsky M
        • Rocha A
        • Otten JJ
        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; 170e153918
        • Cohen JF
        • Richardson S
        • Parker E
        • Catalano PJ
        • Rimm EB
        Impact of the new US Department of Agriculture school meal standards on food selection, consumption, and waste.
        Am J Prev Med. 2014; 46: 388-394
        • Schwartz MB
        • Henderson KE
        • Read M
        • Danna N
        • Ickovics JR
        New school meal regulations increase fruit consumption and do not increase total plate waste.
        Child Obes. 2015; 11: 242-247
        • Au LE
        • Gurzo K
        • Gosliner W
        • Webb KL
        • Crawford PB
        • Ritchie LD
        Eating school meals daily is associated with healthier dietary intakes: the healthy communities study.
        J Acad Nutr Diet. 2018; 118 (1474–1481.e1)
        • Cohen JFW
        • Gorski-Findling MT
        • Rosenfeld L
        • Smith L
        • Rimm EB
        • Hoffman JA
        The impact of 1 year of healthier school food policies on students’ diets during and outside of the school day.
        J Acad Nutr Diet. 2018; 118: 2296-2301
        • Chriqui JF
        • Pickel M
        • Story M
        Influence of school competitive food and beverage policies on obesity, consumption, and availability: a systematic review.
        JAMA Pediatr. 2014; 168: 279-286
        • Micha R
        • Karageorgou D
        • Bakogianni I
        • et al.
        Effectiveness of school food environment policies on children's dietary behaviors: a systematic review and meta-analysis.
        PLoS One. 2018; 13e0194555
        • Jahn JL
        • Cohen JF
        • Gorski-Findling MT
        • et al.
        Product reformulation and nutritional improvements after new competitive food standards in schools.
        Public Health Nutr. 2018; 21: 1011-1018
        • Ogden CL
        • Carroll MD
        • Fakhouri TH
        • et al.
        Prevalence of obesity among youths by household income and education level of head of household - United States 2011–2014.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 186-189
        • Taber DR
        • Chriqui JF
        • Chaloupka FJ
        Geographic disparities in state and district policies targeting youth obesity.
        Am J Prev Med. 2011; 41: 407-414
        • Piekarz-Porter E
        • Schermbeck RM
        • Leider J
        • Young SK
        • Chriqui JF
        Working on Wellness: How Aligned Are District Wellness Policies With the Soon-To-Be Implemented Federal Wellness Policy Requirements?.
        National Wellness Policy Study, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL2017
        • John LV
        • Gregoriou M
        • Pate RR
        • et al.
        Operational implementation of the Healthy Communities Study: how communities shape children's health.
        Am J Prev Med. 2015; 49: 631-635
        • Arteaga S
        • Loria C
        • Crawford P
        • et al.
        The Healthy Communities Study: its rationale, aims, and approach.
        Am J Prev Med. 2015; 49: 615-623
        • Strauss WJ
        • Sroka CJ
        • Frongillo EA
        • et al.
        Statistical design features of the Healthy Communities Study.
        Am J Prev Med. 2015; 49: 624-630
        • Ritchie LD
        • Wakimoto P
        • Woodward-Lopez G
        • et al.
        The Healthy Communities Study nutrition assessments: child diet and the school nutrition environment.
        Am J Prev Med. 2015; 49: 647-652
      4. US Department of Agriculture, Food and Nutrition Service. School nutrition dietary assessment (SNDA) Study III, pre-visit questionnaire and menu survey – reimbursable meals form. Princeton, NJ: Mathematica Policy Research, Inc.; 2004. Accessed November 19, 2019.

      5. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. School Health Policies and Practices Study (SHPPS). 2019. Accessed November 19, 2019.

      6. US Department of Agriculture, Economic Research Service. Rural-urban commuting area codes. 2014. Accessed November 19, 2019.

      7. National Center for Education Statistics. Concentration of public school students eligible for free or reduced-price lunch. 2018. Accessed November 19, 2019.

        • Patel AI
        • Hampton KE
        Encouraging consumption of water in school and child care settings: access, challenges, and strategies for improvement.
        Am J Public Health. 2011; 101: 1370-1379
        • Kant AK
        • Graubard BI
        Contributors of water intake in US children and adolescents: associations with dietary and meal characteristics—National Health and Nutrition Examination survey 2005–2006.
        Am J Clin Nutr. 2010; 92: 887-896
      8. US Department of Agriculture, Agricultural Research Service. Data tables: food and nutrient intakes by region, 1994–1996. Beltsville, MD: US Department of Agriculture; 1998. Accessed November 19, 2019.

        • Moore LV
        • Dodd KW
        • Thompson FE
        • Grimm KA
        • Kim SA
        • Scanlon KS
        Using behavioral risk factor surveillance system data to estimate the percentage of the population meeting US Department of Agriculture food patterns fruit and vegetable intake recommendations.
        Am J Epidemiol. 2015; 181: 979-988
        • Obisesan TO
        • Vargas CM
        • Gillum RF
        Geographic variation in stroke risk in the United States. Region, urbanization, and hypertension in the third National Health and Nutrition Examination Survey.
        Stroke. 2000; 31: 19-25
        • Cushman M
        • Cantrell RA
        • McClure LA
        • et al.
        Estimated 10-year stroke risk by region and race in the United States: geographic and racial differences in stroke risk.
        Ann Neurol. 2008; 64: 507-513
        • Singh GK
        • Kogan MD
        • van Dyck PC
        A multilevel analysis of state and regional disparities in childhood and adolescent obesity in the United States.
        J Commun Health. 2008; 33: 90-102
      9. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th edition. Washington, DC: US Department of Agriculture; 2015.

      10. US Department of Agriculture, Food and Nutrition Service. Child nutrition programs: flexibilities for milk, whole grains, and sodium requirements. 2017. Accessed November 19, 2019.

        • US Department of Agriculture, Food and Nutrition Service
        Child Nutrition Programs: flexibilities for Milk, Whole Grains, and Sodium Requirements. Final rule.
        Fed Regist. 2018; 83: 63775-63791
      11. National Center for Education Statistics. Number and percentage of public school students eligible for free or reduced-price lunch, by state: selected years; 2000–01 through 2014-15. 2017. Accessed November 19, 2019.