In the 10 years since the federal government , studies have suggested the policy has wide-ranging benefits. Students in participating schools , are and .

Now, as cuts to food assistance programs threaten to slash access to universal school meals, a new study led by the 91̽�� finds another potential benefit to the programs: Students in participating schools were less likely to have high blood pressure, suggesting that universal free meals might be a powerful tool for improving public health. 

“High blood pressure is an important public health problem that isn’t studied as much on a population level as obesity,” said , a 91̽��postdoctoral researcher of health systems and population health and lead author of the study. “We have evidence that CEP increases participation in school meals, and we also have evidence that school meals are more nutritious than meals that kids obtain elsewhere. This is a public health policy that is delivering nutritious meals to children who may not have previously had access.”

For the study, , researchers linked two datasets that rarely interact. They obtained medical records of patients ages 4-18 from community health organizations, and used patients’ addresses to identify the school they attended. The data encompassed 155,778 young people attending 1,052 schools, mostly in California and Oregon.

Researchers estimated the percentage of students with high blood pressure before and after schools opted into universal free meals, and compared those results against eligible schools that had not yet participated in the program. They also tracked students’ average systolic and diastolic blood pressure readings. All data were aggregated at the school level. 

They found that school participation in the CEP was associated with a 2.71% decrease in the proportion of students with high blood pressure, corresponding to a 10.8% net drop over five years. School participation in CEP was also associated with a decrease in students’ average diastolic blood pressure. 

“In previous work on the health impacts of universal free school meals, our team found that adoption of free meals is associated with decreases in and , which are closely linked to risk of high blood pressure,” said , a professor of health, society and behavior at the University of California Irvine’s Joe C. Wen School of Population & Public Health and senior author of the study. Jones-Smith conducted much of this research while on faculty at the 91̽��School of Public Health. “So in addition to directly affecting blood pressure through provision of healthier meals, a second pathway by which providing universal free meals might impact blood pressure is through their impact on lowering risk for high BMI.” 

Improved nutrition of school meals may have helped drive the decrease, researchers said. The 2010 law that established the CEP also created stronger nutritional requirements for school meals. As a result, those meals now more closely resemble the , which to be an effective tool for managing hypertension. 

Despite the evidence supporting the DASH diet’s effectiveness, public health officials previously lacked an effective mechanism to encourage people with high blood pressure to follow its recommendations. “We know there are a lot of barriers to people eating this diet,” Localio said, but the combination of universal free meals and increased nutritional standards likely helped students overcome those barriers.

The study also contradicts the common misperception that universal free meals mostly benefit wealthier students, because students from low-income families would already receive free meals. The study sample consists primarily of low-income patients, with 85% of included students enrolled in public health insurance such as Medicaid.

“There is a perception that providing universally free school meals will only improve outcomes for students of relatively higher-income families, but our findings suggest that there are benefits for lower-income children as well,” Jones-Smith said. “Potential mechanisms for this include decreasing the income-related stigma around eating school lunch by providing it free to all students and eliminating the time and paperwork burden of individually applying, thus decreasing barriers to participation in school meals.”

These findings come at an uncertain time for universal free meals. A school is eligible to participate in the CEP if . In this way, recent cuts to the Supplemental Nutrition Assistance Program (SNAP), the nation’s largest food assistance program, may affect schools’ access to the program.

“We’re in a contentious time for public health, but it seems like there’s bipartisan support for healthy school meals,” Localio said. “There’s legislation being considered in a number of states to expand universal free meals, and these findings could inform that decision-making. Cutting funding to school meals would not promote children’s health.” 

Co-authors on the study include , research professor emeritus of health systems and population health at the UW; , teaching professor of economics at the UW; Wyatt Benksen and Aileen Ochoa of OCHIN; and , associate professor of nursing at the UW. This study was funded by the Eunice Kennedy Shriver National Institute of Child Health & Human Development. 

For more information or to contact the researchers, email Alden Woods at acwoods@uw.edu.

New research from the 91̽�� shows that the program can improve fruit and vegetable intake and food security among low-income populations by providing financial support for buying healthy food.

The Fresh Bucks program works with local partners to help Seattle residents access healthy food. The program accepts applications from Seattle households with income less than 80% of the area median — $110,950 for a family of four in 2024. Recipients can use the $40 per month benefit to purchase fruits and vegetables at more than 40 retail locations throughout Seattle, including farmers markets, Safeway stores and independently owned grocery stores.

The study, , shows that Fresh Bucks households experience a 31% higher rate of food security and consume at least three daily servings of fruits and vegetables 37% more often than those assigned to a program waitlist.

“I would classify both of those numbers as pretty large,” said , co-author, 91̽��affiliate professor of health systems and population health and of epidemiology and University of California, Irvine professor of health, society and behavior. “We don’t routinely see interventions that work that well. It’s a pretty big impact on diet in terms of what we can do from a policy perspective and expect to make a difference in food insecurity.”

Food insecurity, or the lack of access to nutritionally adequate foods, is linked to lower-income households and is often associated with poor nutrient intake, diabetes and hypertension. Diet quality, including fruit and vegetable intake, impacts the risk for premature disability and death from cardiometabolic disease, cancer and other causes. But fresh fruits and vegetables tend to be less available in lower-income neighborhoods and more expensive than processed foods.

“The UW’s study helps us understand how the City of Seattle’s Fresh Bucks program shows up in the day-to-day decisions of our enrolled households,” said Robyn Kumar, Fresh Bucks program manager at the City of Seattle Office of Sustainability. “Findings show that the healthy food access program makes a tangible difference for customers, significantly increasing food security and fruit and vegetable intake. We know these lifestyle changes have long-lasting benefits, and Fresh Bucks is helping to ensure that our most overburdened community members have equitable access to healthy foods and increased quality of life.”

In October 2021, 6,900 new applicants and existing beneficiaries applied to receive benefits in 2022. The total number of applicants exceeded program funding, so 4,200 households were randomly chosen to receive benefits. The remaining applicants were placed on a waitlist. The City of Seattle then mailed a follow-up survey to all 6,900 applicants in July 2022. The sample for this study consists of the 1,973 households who completed and returned the survey.

Researchers compared new applicants who received the benefit and new applicants assigned to the waitlist. They also considered the impact of losing Fresh Bucks by comparing returning applicants who were placed on the waitlist with those who continued receiving benefits. Losing the benefit reduced food security by 29% and resulted in households being 26% less likely to eat fruits and vegetables at least three times a day.

“The results were quite symmetric,” said , lead author and 91̽��teaching professor of economics. “The people who gained the program saw nearly the same benefit as what was lost by the people who lost the program. So, it seems like there are two things going on: One is that the program is helping people, and the other is these effects don’t magically sustain themselves without funding.”

Because of the health risks associated with poor diet, insurers have recently shown increased interest and investment in “food is medicine,” or FIM, programs, which include produce prescriptions and programs that provide free, healthy food for patients. Before FIM programs, federal grants funded “nutrition incentive programs” to increase healthy food access and food security.

But Fresh Bucks differs from other healthy food benefit programs in several ways, including focused enrollment within households disproportionately impacted by food insecurity and diet-related chronic disease, divesting enrollment from SNAP participation, enabling participants to redeem benefits at a large chain food retailer and smaller local stores and no required match spending — where participants receive additional benefits based on how much of their own money they spend.

“We clearly see that once this program goes away, people can no longer afford to eat these foods, as evidenced by the increase in fruits and vegetables when people are receiving the benefit, but the near symmetric decrease when benefits are lost,” Jones-Smith said. “I think that really drives home the fact that money or material resources are necessary for enacting this kind of dietary change.”

Other co-authors from the 91̽��include , recently graduated doctoral student of health systems and population health; , associate professor of health systems and population health; and , community research coordinator. The study was funded by the National Heart, Lung and Blood Institute of the National Institutes of Health.

For more information, contact Knox at knoxm@uw.edu.

Eight cities in the United States have implemented , which contribute to health issues including obesity and Type 2 diabetes.

New research from the 91̽�� investigated responses to sweetened beverage taxes using the purchasing behavior of approximately 400 households in Seattle, San Francisco, Oakland and Philadelphia – all of which recently introduced beverage taxes. was published online Sept. 30 in Health Economics.

Researchers found that after the tax was introduced, lower-income households decreased their purchases of sweetened beverages by nearly 50%, while higher-income households reduced purchases by 18%. Since previous studies have shown that lower-income individuals consume sweetened beverages at a higher-than-average rate, these results suggest the taxes could help reduce health disparities and promote population health.

“If households reduce their sugar intake, they will experience health benefits,” said , co-author and 91̽��associate teaching professor of economics. “Sweetened beverages are one of the largest sources of sugar in the American diet. They have all kinds of health consequences and don’t really provide any nutrition. The idea with the tax is that lower-income people, because they reduce their intake more, receive greater health benefits than the higher-income households.”

Using , researchers followed the households for a year before and after the tax was implemented in their city. Consumers were given a handheld scanner to report their purchases.

The results showed that households experienced price increases for taxed beverages, with the difference persisting for at least one year post-tax. Price increases were largest for lower-income households – a 22% increase in sweetened beverage prices versus 11% for higher-income households. After the tax was implemented, lower-income households saw a 47% decline in purchases of sweetened beverages. Researchers didn’t observe a post-tax increase in cross-border shopping.

“We also looked at untaxed beverages and found that lower-income households are substituting with untaxed beverages,” Knox said. “They’re using some of their money to go buy a different beverage, rather than buying a candy bar instead of buying a Coke.”

Policy makers are particularly interested in the response of lower-income consumers due to their higher consumption on average of sweetened beverages and concerns that the taxes are regressive.

Previous research from the UW found that lower-income and higher-income households paid about the same amount toward the tax, which means lower-income households spent a higher proportion of their income. But the study also showed more dollars went toward funding programs that benefit lower-income communities than those households paid in taxes. The annual net benefit to lower-income communities ranged from $5.3 million to $16.4 million per year across three U.S. cities.

More found the tax was also associated with declines in childhood body mass index among children in Seattle compared to a well-matched comparison group.

“Together, this body of work suggests the tax is having the intended health benefits and this new evidence gives reason to believe health benefits could be larger for households with lower incomes,” said , co-author and 91̽��professor of health systems and population health.

The research was funded by the UW’s Royalty Research Fund and the Robert Wood Johnson Foundation. Partial support was provided by a Eunice Kennedy Shriver National Institute of Child Health and Human Development research infrastructure grant.

For more information, contact Knox at knoxm@uw.edu and Jones-Smith at jjoness@uw.edu.

Sugar-sweetened beverages are a known contributor to several health issues, including poor diet quality, weight gain and diabetes. While several studies have shown that taxing sweetened beverages significantly reduces purchasing, questions have been raised about whether the taxes place a greater economic burden on lower-income households.

New research from the 91̽��, , addressed the issue by examining the economic equity impacts of sweetened beverage taxes in three cities: Seattle, San Francisco and Philadelphia.

“Sugar-sweetened beverages are the new tobacco,” said , senior author and clinical professor of health systems and population health in the 91̽��School of Public Health. “Public health researchers and others have been working for some time to reduce sales of these beverages. Taxes worked well to reduce tobacco purchases, and they’ve been applied and appear to work equally well in sugary drinks.”

The study showed the tax paid by households accounted for a larger proportion of income for lower-income households, but still only 0.01% to 0.05%. The annual per capita dollar amount that households paid toward the tax, between $5.50 and $31, didn’t differ by income level.

The researchers also found that sweetened beverage taxes redistributed dollars from higher- to lower-income households. More dollars went toward funding programs that benefit lower-income communities than those households paid in taxes. The annual net benefit to lower-income communities ranged from $5.3 to $16.4 million per year across the three U.S. cities.

“Cities have prioritized funding programs that benefit lower-income populations, which makes sweetened beverage tax policies more economically equitable,” Krieger said.

For example, revenue raised by has been used to fund programs and services that increase access to healthy food and support child health and learning in early childhood. In 2020, sweetened beverage tax revenue was also used to provide support to communities disproportionately impacted by the COVID-19 pandemic.

The researchers studied the volume of beverage purchases made in stores by 1,141 households in the three U.S. cities to estimate taxes paid by households during the first year after tax implementation. They then used city population data to calculate the per capita amount of sweetened beverage tax paid by income level.

The authors also reviewed public documents and contacted city representatives to find the dollar amount of annual tax revenue and the amount invested in programs serving lower-income communities.

“There aren’t a lot of studies right now that look at actual household purchases of these taxed beverages,” said co-lead author , 91̽��associate teaching professor of economics. “They mostly look at retail-level data. But you don’t know what people are doing at a household level. They could be going to another city to buy their sweetened beverages and bringing them back to Seattle. This study catches all of that. We’re just looking at households that live in these cities and the totality of everything they report having purchased.”

The study shows that sweetened beverage taxes “can be an economically progressive policy,” Krieger said. Seven local jurisdictions in the United States, the Navajo Nation and at least 45 other nations have implemented sweetened beverage taxes.

“These taxes selectively and specifically benefit people with lower incomes to a greater extent than people with higher incomes, because the money that’s raised by taxes goes toward programs serving lower-income communities,” Krieger said. “That’s from the economic point of view.

“The taxes also benefit people with lower incomes because they drive down consumption more and sales more for that population. People will consume less of an unhealthy product and they’ll be healthier because of that. It’s a win for health, it’s a win for the pocketbook and it’s a win for their communities.”

, 91̽��associate professor of health systems and population health and of epidemiology, was a corresponding author and co-principal investigator.

Other co-authors from the 91̽��were , clinical instructor of health systems and population health; , senior research scientist in the Center for Studies in Demography and Ecology, , affiliate associate professor of urban design and planning; and , who recently graduated with a master’s degree in epidemiology. , associate professor at the University of Pennsylvania Perelman School of Medicine, was also a co-author.

The study was funded by the Robert Wood Johnson Foundation’s with partial support from an NICHD grant to the at the 91̽��.

For more information, contact James Krieger at jkrieger@hfamerica.org and Melissa Knox at knoxm@uw.edu.

Correction on 7/13: A previous version of this story said that the annual net benefit to lower-income communities ranged from $5.3 to $19.1 million per year across the three U.S. cities. The latter number is actually $16.4 million.