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

摘要 儿童肥胖症非常普遍，很难治疗和预防，而且是主要的健康和经济问题。 后果。低收入儿童和黑人、拉丁裔和美国原住民的儿童 与收入较高的白人或亚裔儿童相比，肥胖带来的负担不成比例。 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，是种族的基础。 以及肥胖症的收入差距。这些结构性因素通常被认为是 肥胖症和肥胖症差距；然而，人们也认识到，它们很难干预。政策 干预是影响这些潜在根本原因的变化的一种选择。使用自然实验 方法，我们有机会利用最近的政策变化-社区资格条款(CEP) 2010年《健康无饥饿儿童法案》的执行情况--评估向所有儿童提供免费膳食的程度 贫困程度高的学校影响肥胖症的流行。CEP于2010年通过，允许高中学校- 贫困学区向所有在校儿童提供普遍免费餐食(早餐和午餐)，而不是 要求个人签约参加免费和减价午餐计划。其目标是增加对 减少学校用餐，最终减少粮食不安全和肥胖。该计划针对的是较低收入和 中低收入儿童，其中许多人没有得到免费和降价午餐，尽管 符合条件的。因为CEP针对的是高度贫困的学校，所以重点关注一个社会决定因素(收入 限制)，并且是非代理政策(即儿童及其家庭不需要做任何额外的事情即可获得 好处)，这项政策有很高的理论潜力来减少肥胖，甚至可能减少肥胖 差距。CEP可以通过促使个人用更健康的代用品来影响儿童的体重 不健康的食物，以及免费提供一天两餐，从而间接影响儿童BMI 增加家庭可支配收入的途径。可支配收入的增加可能会导致 减少粮食不安全，减少父母的压力，和/或可能被用于促进健康 行为，如在家庭中进行体力活动或购买更健康的食物，每一种行为都是 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 但关于CEP对健康影响的科学文献很少。拟议的研究旨在 通过使用稳健的数据和方法全面评估CEP对肥胖结果的影响 因果推断以评估：1)CEP对肥胖的影响2)CEP对潜在中介的影响 机制3)按种族/民族和收入对肥胖的影响的异质性4)对人口的影响- 肥胖症水平差异。

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.