Reducing childhood obesity and related illness has garnered tremendous attention over the last 2 decades, particularly in schools, afterschool programs, and child care centers.1,2 Less attention has been given to where children spend their summer.3 Emerging research indicates weight gain accelerates in the summer, particularly among certain racial/ethnic populations and children who are overweight.4 The summer has other understudied impacts on children's developmental trajectories and well-being that likely disproportionately affect high-risk children.5 Recently, a National Academies of Sciences, Engineering and Medicine Ad Hoc Committee on Summertime Experiences put forth a range of recommendations aimed at improving planning, administration, and coordination of summertime programs and services for children and youth; improving availability, access, and equity of summertime programs; and advancing data collection and research.6 Although work is needed to understand and address accelerated summer weight gain, structured environments-such as federally assisted summer meal programs-could be a critical building block for school-aged children's health.4,7-11 That is, summer meals can provide (1) supplemental nutrition assistance to high-risk families to help address food insecurity during the summer months when there are no school meals; (2) healthy meals in structured settings that might help reduce obesity risk; and (3) support to other programs that offer education, physical activity, or job training. This article provides an overview of the US Department of Agriculture (USDA) Summer Meals Program (SMP) and highlights opportunities to strengthen SMP's public health impacts. We also discuss initial SMP implications of 2 relevant policy provisions of the Families First Coronavirus Response Act (P.L. 116-127), signed into law on March 18, 2020.
Call out: Federally assisted summer meal programs are a critical building block for school-aged children's health.
WHAT IS THE USDA SUMMER MEALS PROGRAM?
Since 1968, the USDA Food and Nutrition Service (FNS) works to provide free, nutritious meals to children when school is not in session during the summer with state education agencies, the state health or social service departments, or a designated FNS regional office (Table 1).12-14 Units of local government, camps, schools, housing projects, and private nonprofit organizations such as community centers, hospitals, and churches can sponsor the USDA Summer Food Service Program (SFSP) and be approved as open, enrolled, or camp sites.15 Summer Food Service Program is also known as the SMP; for our purposes, SMP refers to both SFSP and the Seamless Summer Option.12 At most sites, children 18 years or younger are generally able to receive either 1 or 2 reimbursable meals each day; exceptions include sites serving persons with disabilities older than 18 years who participate in USDA breakfast or lunch programs or migrant children. The Seamless Summer Option is available for schools that participate in the USDA school meal programs, allowing streamlined continuation of the same meal service rules and claims procedures used during the regular school year.16 For all types of SMP, children must consume meals and snacks on-site, which is known as the "congregate feeding" requirement.17
In July 2018, during the peak month for summer meals, SFSP provided meals to 2.7 million children each day at 49 795 sites.18 But, the SFSP reaches only 16% of children who receive federal food and nutrition assistance during the regular school year or less than one-sixth of children who receive free or reduced-price meals during the school year. Participation varies across states. For example, 0.2% of the eligible population participated in SFSP in Arizona, whereas 4.2% participated in the District of Columbia. In a study examining the geographic availability of the SFSP and Seamless Summer Option in California, urban counties were more likely than rural counties to have higher participation rates and many rural counties did not have programs in July.19 This is unfortunate because USDA school meals program participation helps to protect households from food insecurity during the school year.20,21
Nevertheless, the USDA's estimates for SMP participation lack reliability. A recent Government Accountability Office report found estimates of SFSP participation were calculated inconsistently from state to state and from year to year.22,23 The Government Accountability Office recommended that the FNS administrator (1) improve program participation estimates, particularly by focusing on variations in the number of operating days of meal sites and in the months in which the greatest number of meals are served; (2) communicate with SFSP stakeholders regarding flexibility with the on-site requirement in areas that have experienced crime and violence; (3) evaluate and annually report to Congress its use of waivers and demonstration projects to grant states and sponsors flexibility with requiring children to consume meals on-site in areas experiencing crime or violence; and (4) disseminate information about existing flexibilities available to streamline administrative requirements for sponsors.
Another issue is SFSP administration. The USDA Office of the Inspector General recently examined the administration of SFSP.24 The Office of the Inspector General recommended FNS strengthen its SFSP monitoring and oversight by a variety of strategies, such as (1) modifying the management evaluation review guidance; (2) improving the SFSP waiver process to ensure the financial and operational integrity of sponsor and site operations by obtaining formal written legal opinion from the USDA Office of the General Counsel as to whether FNS has the legal authority to create nationwide waivers of SFSP regulations through policy memoranda in the absence of a State agency or sponsor written request and other requirements; and (3) enhancing the processes for assessing SFSP's risk for improper payments.
STRENGTHENING SMP'S PUBLIC HEALTH IMPACTS
Congress could make meaningful improvements to the SMP through the Child Nutrition Reauthorization (CNR) process across a variety of domains including access, dietary quality, engagement, enrichment, teen job training programs, food security, health, and poverty alleviation (Tables 2 and 3). Over the last 5 decades, a variety of legislative efforts have taken place during or outside of the CNR process aiming to expand access to summer meals (Table 1). This reauthorization process usually occurs every 5 years or so and allows Congress to make any modifications to the permanent statutes that authorize the USDA child nutrition programs and the related policies; specifically, the Richard B. Russell National School Lunch Act of 1946, the Child Nutrition Act of 1966 (P.L. 111-296) and, in a few cases, Section 32 of the Act of August 24, 1935 (P.L. 74-320). Most of the funding for SFSP requires annual appropriated mandatory spending based on criteria such as per-meal reimbursements set forth in authorization legislation. Therefore, this summer is a critical time for food, nutrition, and health professionals to contact their respective congressional members and arrange opportunities to see SMP in action and to hear from SMP participants and parents about what is working and address barriers to access. The following are key potential legislative actions to highlight.
Summer Electronic Benefit Transfer for Children (SEBTC) is a promising approach to address food security during the summer and is being utilized as emergency EBT during the COVID-19 response.
Ensuring Access to Summer Meals
One of the most promising recent congressional actions to address summer food insecurity is the authorization and appropriations to support the Summer Electronic Benefits Transfer for Children (SEBTC).25 This innovative but limited demonstration project distributes a monthly benefit during the summer on USDA Supplemental Nutrition Assistance Program (SNAP) or the Special Supplemental Nutrition Program for Women, Infants, and Children electronic benefit transfer (EBT) cards to children eligible for free or reduced-price school meals. In the 2010 Agriculture Appropriations Act (P.L. 111-80), Congress authorized and provided funding for the USDA to implement and rigorously evaluate this program from summers 2011 to 2019.26-28 In summer 2011, 11 400 children were served through SEBTC; by 2016, more than 209 000 children in 9 states and 2 tribal nations were served. Rigorous research found the benefit of $60 per month per child reduced the most severe category of food insecurity among children during the summer by one-third and the $30 benefit was as effective. Households redeemed benefits at similar rates in the $30 versus $60 monthly benefit categories. Children in households receiving the $60 benefit ate slightly more nutritious foods (fruits and vegetables, whole grains, dairy foods, and less added sugars) than children in the $30 group, and both had positive nutrition outcomes compared with children with no benefit.29 The Families First Coronavirus Response Act (P.L. 116-127) allows the USDA to approve state plans to provide emergency SNAP assistance to households with children who would otherwise receive free or reduced-price meals at school (if not for their schools being closed due to the COVID-19 emergency), through EBT. To be eligible, the child's school must be closed for at least 5 consecutive days. Thus, there is a natural experiment occurring regarding the expansion of this program, and it might extend through the summer, pending the progress of this current pandemic.
Besides SEBTC, other innovative legislative approaches could improve access to SMP sites, which poses a hurdle when children and/or parents do not know how to find a program or cannot get there even if they do find one.30 The USDA Summer Meal Site Finder helps children identify local sites offering USDA-supported meals and snacks.31 Parent, guardian, or youth awareness of a possible local site helps. However, a study in Texas found limited SMP site coverage and site density in rural, urban, and suburban areas and transportation accessibility are a key determinant for SMP site success.32 The USDA reported only 18% of SFSP sites offered transportation, although the majority of children did not use these services even if it was offered.33 A study in California reported geographic accessibility was associated with a significantly lower probability of very low food security, particularly among households with younger children and those living in less urban areas.34
Effective strategies to promote summer nutrition include expanding (1) the number of summer meals sites, (2) the number of meals served at sites, and (3) sites' hours of operation. A 2010 exploratory study examining SFSP among rural communities found lack of transportation and long distance to SFSP sites to be primary barriers to participation in addition to children's lack of interest in leaving home to participate or the parents' desire or need for children to stay home.35 Public libraries might be well positioned to provide summer meals and enrichment.36 Using a mixed-methods approach and supported by both public and private funding, a study examined the role of 10 public libraries in serving meals to children and adults for 6 to 8 weeks in low-income communities in Silicon Valley, California, during summer 2015. The surveyed adults in the program were primarily Latino (71%) and Asian (23%) and shared how they appreciated the libraries' enrichment programs, resources, and open and welcoming atmosphere. The adults participating in the program reported the following barriers to summer meals participation: lack of awareness, misinformation about the programs, structural barriers such as transportation, immigration fears, and stigma. Moreover, the CNR process should work to ensure sufficient support and oversight are in place to improve the reliability of the estimates for the USDA's SMP participation identified as problematic in the recent Government Accountability Office report, which will help better identify underserved areas, as well as better-performing sites.22
Improving SMP Meal Pattern Requirements
Summer Food Service Program has meal pattern requirements that sponsors must follow to receive reimbursement, which should align with the latest dietary guidelines (P.L. 101-445). Sponsors receive cash reimbursements for each meal and snack served, and federal-donated commodity foods are also offered.27 The SFSP requirements are less stringent than the USDA National School Lunch Program (NSLP) and do not meet the latest edition of the Dietary Guidelines for Americans (Table 4).14 Requiring SFSP participants to consume all their food on site and not be allowed to take components off-site might also encourage overconsumption for some participants. The USDA recently proposed a rule change (FNS-2019-0034) that will likely result in further weakened nutrition standards. Currently, sites using the Seamless Summer Option may use the NSLP and School Breakfast Program meal patterns. A 2015 review examined the nutrition standards of the USDA child meal programs and recommended the SFSP nutrition standards be updated to match those of the NSLP and the School Breakfast Program.37 The review explained how the last time SFSP underwent modifications was in 2000 and noted few studies have examined the nutritional adequacy of SFSP meals or the dietary intakes and health outcomes of SFSP participants. More rigorous studies of SFSP's impact on dietary intakes and health outcomes are needed. A 2017 cross-sectional study examined foods and beverages served to and consumed by children in 5 Boston summer day camps that provided meals and also looked at the extra foods and beverages brought into the summer camp. The researchers concluded the average total calories served for breakfast and lunch were consistent with national recommendations, but the average total calories for snacks served was more than double the recommended targets. Nonetheless, children consumed relatively little in this setting, especially fluids, and often consumed less-healthy options when bringing in outside foods and beverages.
Future research could focus on improving the healthfulness and appeal of meals served to children in the summer; efforts to promote water consumption should be considered as well. More research is needed to examine how to strengthen the nutrition standards of SFSP, recognizing the increasingly important role summer months have on student weight status and that many SFSP sites do not have the kitchen equipment or technical capacity of the USDA school meal programs. Given the SFSP nutrition standards are currently permitted as an option for the NSLP during the COVID-19 response, there is a natural experiment taking place, along with increased attention to the challenges (eg, logistical, financial) and opportunities (eg, product innovation) to strengthen the SFSP nutrition standards (P.L. 116-127, Sec. 202).
Incentivizing Innovative Partnerships
To strengthen SMP participation and public health impacts, each site should be encouraged to develop meaningful partnerships to promote other child development goals, such as education, physical activity, and job training. A critical partnership that the CNR could strengthen is between the USDA and the US Department of Education, which through innovative authorities and appropriations could collaborate to identify and scale up the most promising ways to maximize educational facilities, staff, and programs during the summer to effectively integrate healthy meals with learning.38 Building on the results of a study funded by the National Institutes of Health examining year-round schooling, the USDA and Department of Education could explore innovative data sharing agreements and joint funding mechanisms to expand understanding of the educational and health outcomes of year-round schools. Another partnership the CNR process could foster is between the USDA and the US Department of Labor to explore ways to optimize summer teen job training programs and professional development opportunities aligned with the development, promotion, and evaluation of the SMP. Other departmental partnerships with the USDA such as with the US Department of Housing and Urban Development and with the US Department of Transportation could be strengthened during CNR. As one example, in Maryland, a public-private partnership that included National Institutes of Health support developed and evaluated an integrative health intervention known as "Mission Thrive Summer."39 Among African American high school students in Baltimore, participants experienced statistically significant improvements in self-reported physical activity and dietary behaviors and enjoyed the various components of the program including cooking, farming, mindfulness, and employment. More work is needed to understand the impacts of youth development and job training programs on SMP participation and ultimately participant health and academic outcomes.
Encouraging Tribal, State, and Local Innovation
Tribal governments play important roles in ensuring the health and well-being of their members and further legislative attention (eg, H.R. 2494 and S.1307) should be given in the form of pilot programs, research, and oversight hearings on the main opportunities and barriers to allowing tribal governments to administer SMP, among other child nutrition programs. Food, nutrition, and health professionals can help tribal governments assess their member's SMP usage, strengthen connections between tribal leaders and SMP nearby sites, and help build the tribe's capacity to administer SMP.
States could improve health and lower healthcare costs by expanding access to and improving the nutrition standards for summer meals.
States can also play key roles in developing policies, programs, and partnerships to support healthy eating and activity for children during summer.40 Without question, states have foundational roles in improving SMP participation and ensuring site compliance with SMP regulations. They can develop innovative departmental connections across social services, housing, transportation, and health sectors to identify high-risk families and optimize regular SMP participation. Similar to state efforts to strengthen NSLP nutrition standards, states can require or incentivize summer feeding sites to provide meals and snacks that meet higher nutrition standards than required by the USDA. That is, states could seek USDA waivers to test innovative SMP strategies, for example, expanding the emergency EBT option being used for the COVID-19 response for broader use during summer months. Mobilizing support from the SNAP-Education Program and Expanded Food and Nutrition Education Program, states can help build Healthy Kids During the Summer Time Coalitions, which can share best practices. These coalitions could be a subcomponent of a State Nutrition Action Council, which were established more than a decade ago by the USDA FNS regions to maximize nutrition education efforts and coordination and cooperation among state agencies, FNS nutrition assistance programs, public health agencies, and the Expanded Food and Nutrition Education Program.41 In addition, these summer food-focused coalitions can develop working groups to create and/or tailor model joint-use/shared-use agreements for local entities to adopt to utilize sites such as indoor and outdoor physical activity facilities at schools, nongovernment organizations, or parks and recreational centers, among others. State child nutrition leaders could also meet with congressional leaders to highlight what is working with SMP and where legislative changes, enhancements, or innovations are needed to accelerate the role of SMP in supporting children's health during these vulnerable summer months. Food, nutrition, and health professionals can be instrumental in contacting their respective state elected and agency leaders and arranging opportunities to see SMP in action and hear from SMP participants and their parents.
Ultimately, SMPs are local programs, where government and entities such as schools, public housing, faith-based organizations, parks, and recreational centers play a critical role. Local farms and businesses are essential as they most often provide the foods and beverages. The quality of meals served-and, in many cases, the adult supervision and the programming these sites offer-is invaluable in ensuring children eat the foods and beverages served and that they keep coming back. The literature is scarce on understanding why children come to an SMP site and what keeps them coming back. More attention should be given to securing funding and other supports from government agencies, nongovernment organizations, and the private sector to rigorously evaluate what makes a successful and sustainable SMP site. Similar to local efforts to improve the dietary quality of school meals, cities, towns, and counties can require or incentivize summer feeding sites to provide meals and snacks that meet higher nutrition standards than required by the USDA. Food, nutrition, and health professionals also can play key roles by improving the foods and beverages offered, integrating nutrition education and promotion, and contributing to the evidence base by evaluating SMP's impacts.42
CONCLUSIONS
Summer Meals Program participation may promote food security and nutrition, particularly for youths living below the federal poverty line. More attention is needed in research, policy, and practice to better understand the role these programs play in children's development and where improvements on both the summer meal and enrichment offerings are needed so we can best ensure our children's short- and long-term success. The upcoming CNR could potentially strengthen SMP's public health impacts by improving access to the program, strengthening meal pattern nutrition standards, and supporting innovative pilot programs, as well as rigorous research and evaluation studies. Food, nutrition, and health professionals can also work with tribal, state, and local decision makers to identify further ways to strengthen SMP's public health impacts.
REFERENCES