Changes in association between school foods and child and adolescent dietary quality during implementation of the Healthy, Hunger-Free Kids Act of 2010

Purpose: The purposes of the study were to estimate the effect of Healthy, Hunger-Free Kids Act of 2010 (HHFKA) implementation on dietary quality of all U.S. school-aged children and adolescents and examine whether those effects differed by the demographic group. Methods: We used survey regression on 2007–2016 National Health and Nutrition Examination Survey data to estimate the proportion of energy intake from school foods and the association between school food intake and dietary quality, before and after the HHFKA passage/implementation. To account for demographic changes in the U.S. population over time, inverse probability weighting was used. The product of the proportion of energy from school foods and the association between school food intake and dietary quality estimated the effect of the HHFKA implementation on dietary quality. Results: School food intake quantity remained stable during the study period. The HHFKA implementation improved students’ dietary quality by 4.3 Healthy Eating Index-2010 points (95% confidence interval: 2.5, 6.1) on days when school foods were eaten and by 1.3 Healthy Eating Index-2010 points (95% confidence interval: 0.73, 1.8) averaged over all days annually. Conclusions: The HHFKA implementation improved the total dietary quality of U.S. school students. U.S. students would benefit from eating school meals in the post-HHFKA era, and HHFKA regulations should not be relaxed.