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Public Health
April 12, 2021

Disparities in Diet Quality in School-Age Children—Opportunities and Challenges

Author Affiliations
  • 1Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park
JAMA Netw Open. 2021;4(4):e215358. doi:10.1001/jamanetworkopen.2021.5358

Liu et al1 analyzed data collected in 8 cross-sectional cycles of the National Health and Nutrition Examination Survey between 2003 to 2004 and 2017 to 2018 and examined the trends of diet quality by major food sources in children and adults. The largest improvement in diet quality was seen in foods consumed in school settings, with the proportion of children consuming poor diet quality more than halved, from 55.6% to 24.4%.1 The improvement was primarily seen after 2010 and was equitable across subgroups of populations by race/ethnicity, parental education, and household income. Food consumed from other sources, including grocery stores, restaurants, and worksites, showed small to modest improvement in diet quality, but with population disparities. The analysis used 2 validated indices to assess diet quality, the American Heart Association diet score (range, 0-80) and the Healthy Eating Index–2015 (range, 0-100), and the findings were similar for both indices.

The significant improvement in diet quality from schools is striking and promising. The findings reported by Liu et al1 support that policies that have aimed to improve nutrition in school settings have been effective. Among other efforts, the evolvement of the local school wellness policies has coincided well with the promising change discovered in this new publication. Established in 2004 through the Child Nutrition and Special Supplemental Nutrition Program for Women, Infants, and Children Reauthorization Act, the wellness policies were required in all schools that participated in federally reimbursable meal programs. The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) further strengthened the wellness policy by providing new specific requirements related to the implementation, evaluation, and reporting on progress. In 2016, the final rule for wellness policies was published and further strengthened the requirements on public involvement, transparency, implementation, and evaluation.2 The final rule includes standards and nutrition guidelines for all foods and beverages sold to students on campus, including foods sold for the breakfast and lunch programs (school meals nutrition standards) and competitive foods sold outside meal programs (Smart Snack in School nutrition standards). Changes in the nutrition standards for school meals, comparing the 2004 wellness polices with the 2010 HHFKA, include specific requirement of whole grain intake (from no specification to that at least half of the grains must be whole grains), a specific target for sodium reduction (from no target to a specific target by child age in the 2014-2015 school year and a further restricted target in the 2017-2018 school year), increased fruit and vegetable amount (from ½ to ¾ cup combined per day to ¾ to 1 cup of vegetables, plus 1 cup of fruit per day), and elimination of trans fat (from no limit to 0 g per serving). As of the 2014 to 2015 school year, Smart Snacks in School nutrition standards require all snack foods sold on campus to meet the minimum limits on fat, sugar, sodium, and calorie content. These important changes are in line with some of the dietary components that were thought to be associated with the observed diet quality change, such as increased intake of whole grains and reduced intake of sugar-sweetened beverages and sodium. This study by Liu et al1 and evidence from other intervention and longitudinal studies3 support the positive impact of the wellness policies and HHFKA legislative guidelines on students’ diet quality.

Increasing access to healthy foods at school settings does provide an opportunity to promote diet quality in school-age children. However, there is still much room for improvement. For food consumed at schools in 2017 to 2018, the mean American Heart Association score was 39.5 (out of a maximum of 80), and the mean Healthy Eating Index–2015 score was 51.6 (out of a maximum of 100).1 Only a tiny fraction of school food quality meets the ideal criteria defined by American Heart Association. Dietary component scores for fruits, vegetables, nuts, seeds, legumes, and seafood and plant protein are still far away from optimal. Another concern is added sugar. The Smart Snack in Schools standards include the rule that “acceptable food items must have ≤35% of weight from total sugar as served.”2 The current standards do not include a focus on added sugars, which should be limited to less than 10% of calorie intake starting at age 2 years, according to the newly released Dietary Guidelines for Americans 2020 to 2025.4 As of January 1, 2021, the updated nutrition facts label that includes added sugar as a separate line of information should appear on all food packages, except for the single-ingredient sugars (manufacturers have until July 1, 2021, to make the changes). Guidelines regarding added sugar standard for meals and snacks consumed in school settings are expected to be updated.

Outside school settings, there are challenges. In 2017 to 2018, grocery stores were the major source of calories for children (64.6% of the total calories), followed by restaurants (20.3% of calories) and then schools (6.9% of calories).1 Despite the modest improvement made in the past, nearly one-half of the children (45.1%) consumed poor-quality foods from grocery stores.1 The proportion was 79.6% for foods eaten from restaurants.1 In addition, significant disparity exists, for example, by income level. A recent review5 described several barriers to a healthy diet in underserved populations, including the unfavorable nutrition environment, which leads to poor physical access to healthy affordable foods, and economic barriers associated with lack of resources, which lead to food insecurity and compromised diet. The food environment in the communities is hard to change. Single point-of-purchase interventions, such as grocery store environment changes without economic incentives6 and calorie labeling in restaurants,7 have yielded mixed results. These findings suggest that multifaceted interventions are needed to improve healthy food availability, economic food access, and nutrition literacy to promote improved diet quality in the underserved population.

The current COVID-19 pandemic further complicates the diet inequality situation in socioeconomically vulnerable populations. Food insecurity rates have increased and continue to disproportionately affect low-income children and children of color. Nationwide, policies have been put in effect during the pandemic to reduce hunger in children, including the Pandemic Electronic Benefits Transfer program, the emergency SNAP benefits, the stimulus check for low-income families, and the flexible National School Lunch Program and School Breakfast Program to offer meals to school-age children.8 Whether the consistent benefit of school meals will extend to the COVID-19 era and beyond requires to be evaluated. Although schools were given flexibility in terms of school meal delivery during school closures and remote learning, low-income families may not have the transportation to pick up the food and/or the ability to safely store the food that sometimes comes in bulk. Understanding how children are eating from other sources during and after the pandemic also requires further investigation.

The study by Liu et al1 has highlighted the promising trend of improved diet quality in school settings. Policy and programming efforts should continue to improve child diet toward the optimal level while children are eating at schools. The stagnant trends of poor diet quality and substantial disparity in diet quality from grocery stores and restaurants are worrisome. The study’s findings call for policy commitment and multifaceted interventions in settings outside school to start making the positive changes in these settings.

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Article Information

Published: April 12, 2021. doi:10.1001/jamanetworkopen.2021.5358

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Na M. JAMA Network Open.

Corresponding Author: Muzi Na, PhD, MHS, Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, 108C Chandlee Laboratory, University Park, PA 16802 (muzi.na@psu.edu).

Conflict of Interest Disclosures: None reported.

Liu  J, Micha  R, Li  Y, Mozaffarian  D.  Trends in food sources and diet quality among US children and adults, 2003-2018.   JAMA Netw Open. 2021;4(4):e215262. doi:10.1001/jamanetworkopen.2021.5262Google Scholar
US Food and Nutrition Service; US Department of Agriculture. 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. Published July 29, 2016. Accessed March 11, 2021. https://www.fns.usda.gov/cn/fr-072916d
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US Department of Agriculture; US Department of Health and Human Services. Dietary guidelines for Americans, 2020-2025, 9th ed. Published December 2020. Accessed March 15, 2021. https://dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf
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