Impact of Universal Free Meals on Childhood Obesity Risk and Obesity Disparities

摘要 儿童肥胖症是一种高度流行的疾病，难以治疗和预防，并对健康和经济造成重大影响。 后果低收入儿童以及黑人、拉丁裔和美洲土著种族/族裔的儿童 与高收入和白色或亚洲儿童相比，儿童的肥胖负担不成比例。 有证据表明，经济和环境因素，其中许多是由结构性种族主义驱动的，是种族歧视的基础。 和收入差距。这些结构性因素往往被认为是造成这些问题的潜在根源。 肥胖和肥胖的差异;然而，他们也被认为是难以干预。政策 干预措施是改变这些潜在根源的一种选择。用一个自然实验 我们有机会利用最近的政策变化-社区资格条款（CEP） 2010年《健康无饥饿儿童法》-评估向所有儿童提供免费膳食的程度 在高度贫困的学校影响肥胖的流行。CEP于2010年通过，允许高中- 贫困学区向所有在校儿童提供普遍免费的膳食（早餐和午餐）， 要求个人报名参加免费和减少午餐计划。目标是增加参与 学校供餐，并最终减少粮食不安全和肥胖。该计划的目标是低-和 中低收入家庭的儿童，其中许多人没有得到免费和减价的午餐，尽管他们是 合资格的.由于CEP针对的是高度贫困的学校，因此侧重于社会决定因素（收入 限制），并且是一项非代理政策（即儿童及其家庭不需要做任何额外的事情来获得 的好处），这一政策具有很高的理论潜力，以减少肥胖，并可能减少肥胖 差距。CEP可能会通过促使个人以更健康的方式替代健康食品来影响儿童体重。 不健康的食物，每天免费提供两餐，从而通过间接影响儿童BMI 增加家庭可支配收入的途径。可支配收入的增加可能导致 减少粮食不安全，减少父母压力，和/或可能用于促进健康 行为，如体力活动或购买更健康的食物在家庭中，其中每一个已经 与肥胖有关。CEP代表着学校政策的重大变化和社会安全的扩大 网，但缺乏科学文献存在的CEP的健康影响。拟议的研究旨在 通过使用可靠的数据和方法，全面评估CEP对肥胖结局的影响， 因果推理，以评估：1）CEP对肥胖的影响2）CEP对潜在介导的影响 机制3）种族/民族和收入对肥胖影响的异质性4）对人口的影响- 肥胖水平差异。

ABSTRACT Childhood obesity is highly prevalent, difficult to treat and prevent, and of major health and economic consequence. Lower income children and children of Black, Latinx, and Native American race/ethnicity experience a disproportionate burden of obesity as compared to higher income and White or Asian children. Evidence suggests that economic and environmental factors, many driven by structural racism, underlie racial and income disparities in obesity. These structural factors are often acknowledged as potential root causes of obesity and obesity disparities; however, they are also recognized as difficult to intervene upon. Policy interventions are one option for affecting change upon these potential root causes. Using a natural experiment approach, we have an opportunity to leverage a recent policy change—the Community Eligibility Provision (CEP) of the Healthy Hunger-Free Kids Act of 2010—to assess the degree to which providing free meals to all children in high poverty schools affects obesity prevalence. The CEP was passed in 2010 and allows schools in high- poverty school districts to provide universal free meals (breakfast and lunch) to all children in the school without requiring individuals to sign up for the free and reduced lunch program. The goal is to increase participation in school meals and ultimately reduce both food insecurity and obesity. The program is targeted at lower- and lower-middle income children, many of whom were not receiving free- and reduced-price lunches despite being eligible. Because the CEP is targeted to high-poverty schools, focuses on a social determinant (income constraints) and is a non-agentic policy (i.e. children and their families do not need to do anything extra to receive the benefits), this policy has high theoretical potential to decrease obesity and possibly decrease obesity disparities. CEP could be expected to impact child body weight by prompting individuals to substitute healthier foods for unhealthier food and by providing two meals a day at no cost, thus affecting child BMI through indirect pathways of increased disposable household income. This increase in disposable income could lead to decreased food insecurity, decrease parental stress, and/or could potentially be used for health promoting behaviors, such physical activity or purchasing of healthier foods in the household, each of which has been associated with obesity. CEP represents a significant change in school policy and an expansion of social safety nets, but scant scientific literature exists on the health impacts of CEP. The proposed study aims to comprehensively assess the impacts of CEP on obesity outcomes through using robust data and methods for causal inference in order to assess: 1) the impact of CEP on obesity 2) impact of CEP on potential mediating mechanisms 3) heterogeneities in impacts on obesity by race/ethnicity and income 4) impacts on population- level obesity disparities.