RESEARCH

Original Research

A Randomized Controlled Trial of Three School

Meals and Weekend Food Backpacks on Food
Security in Virginia
Michael Burke, PhD, MPH; Charlotte Cabili, MS, MPH; Danielle Berman, PhD; Sarah Forrestal, PhD; Philip Gleason, PhD

ARTICLE INFORMATION ABSTRACT

Article history: Background Food insecurity is a concern for the health and well-being of low-income
Submitted 13 January 2020 children in the United States. School-based nutrition assistance programs aim to reduce
Accepted 27 October 2020 food insecurity; however, there is limited evidence of their combined impact on food
insecurity among children (FI-C).
Keywords: Objective This study tested the impact of the Virginia 365 demonstration project on
Food security the food security status of children attending low-income schools.
National School Lunch Program
School Breakfast Program
Design A cluster-randomized trial was conducted from 2016 to 2017 with baseline and
Child and Adult Care Food Program follow-up surveys.
Food backpacks Participants/setting Households with children who attended a treatment (n ¼ 19) or
control (n ¼ 19) school in rural and urban Virginia were included.
2212-2672/Published by Elsevier Inc. on behalf of Intervention Treatment schools became food hubs where children had access to free
the Academy of Nutrition and Dietetics. This is an breakfast, lunch, and supper on school days, and a food backpack on weekends and
open access article under the CC BY-NC-ND license school breaks. Control schools implemented a similar, but less robust set of benefits.
(http://creativecommons.org/licenses/by-nc-nd/
4.0/).
Main outcome measures The primary outcome was the percentage of children clas-
https://doi.org/10.1016/j.jand.2020.10.026 sified as FI-C as measured by the US Department of Agriculture Household Food Security
Survey Module. Secondary outcomes included very low food security among children
and food security among households and adults.
Statistical analysis performed Logistic regression models tested the impact of the
demonstration on FI-C and secondary outcomes adjusting for baseline household and
individual characteristics.
Results At follow-up, 1,393 treatment households and 1,243 control households
completed a survey sufficiently to be included in the analysis. The rate of FI-C in
treatment households was higher at 25.9% compared with 23.9% in control households,
a difference of 2 percentage points (95% CI 0.1 to 3.9). The rate of very low food security
among children in treatment households was lower at 3.2% compared with 3.9% in
control households, a difference of 0.7 percentage points (95% CI 1.3 to 0.10).
Conclusions Although the distinction in nutrition assistance benefits between treat-
ment and control schools was less than planned, providing a suite of school-based
nutrition assistance programs targeted broadly to low-income households with chil-
dren has both positive and negative impacts on child and household food insecurity.
J Acad Nutr Diet. 2021;121(1 Suppl 1):S34-S45.

H
OUSEHOLD FOOD INSECURITY IS A CONCERN FOR
the health and well-being of low-income children
in the United States.1 Food insecurity occurs when
household members experience disruptions to the
quality and quantity of the household food supply due to a
lack of money or other resources.2 In 2018, 16.5% of low-
income households had food insecure children, meaning
children were directly exposed to food insecurity.2 This is a
nutrition and public health concern because food insecurity
is associated with lower fruit consumption, iron-deficient
anemia, learning and social development, and mental
health disorders among children.3-6 Given the prevalence of
food insecurity among children and its associations with
negative health and social outcomes, numerous nutrition
assistance programs seek to reduce and prevent it through
increased access to healthy food.
School meals are a cornerstone of nutrition and food se-
curity among low-income children. The National School
Lunch Program (NSLP) provides students access to a healthy
school lunch and is offered to low-income students either
free of charge or at a reduced price. In an average month in
fiscal year 2018, 29.7 million children participated in NSLP, of
which 74% received free or reduced-price (FRP) meals.7 The
School Breakfast Program (SBP) provides access to a healthy

Published by Elsevier Inc. on behalf of the Academy of Nutrition and Di-

etetics. This is an open access article under the CC BY-NC-ND license
S34 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS (http://creativecommons.org/licenses/by-nc-nd/4.0/).

school breakfast and is offered before the school day and is
either free of charge or at a reduced price for low-income
students. In an average month in fiscal year 2018, 2.4
million children participated in SBP, of which 85% received
FRP meals.7 To increase access and participation in SBP,
alternative delivery models offer “grab ‘n’ go” breakfast and
breakfast in the classroom rather than in a cafeteria. Both
NSLP and SBP participation are associated with lower rates of
child and household food insecurity.8,9
Schools also have access to other federal and community
programs to provide students with meals outside of the
school day. The Child and Adult Care Food Program (CACFP)
provides at-risk children in afterschool programs a nutritious
meal or snack (commonly referred to as a supper). In an
average month in fiscal year 2018, 1.9 million meals were
served to children through CACFP.7 When CACFP suppers are
offered along with NSLP and SBP, children have access to a
breakfast, lunch, and a supper meal or snack on school days.
Some schools in low-income areas also offer food for week-
ends and school breaks through food backpack programs.
Schools typically partner with local food banks and faith-
based organizations to offer food packs to low-income stu-
dents and are not part of any federal or state programs. CACFP
is associated with lower rates of household food insecurity,10
but fewer researchers have examined the association be-
tween food backpacks and food insecurity.
The Commonwealth of Virginia was awarded a grant from
the Food and Nutrition Service of the US Department of
Agriculture to test the impact of providing low-income stu-
dents free breakfast, lunch, and CACFP suppers during the
school day, and food backpacks on weekends and school
breaks on food insecurity among children (FI-C). It was 1 of 5
demonstration projects that resulted from direction in the
2010 Child Nutrition Act11 and the only one to heavily involve
school-based nutrition assistance programs. The purpose of
this study was to test whether the project was successful in
reducing FI-C. A secondary purpose was to test whether the
project improved other measures of food insecurity,
including very low food security among children (VLFS-C)
and household and adult food insecurity. To achieve these
purposes, the Virginia 365 (VA 365) demonstration project
was implemented in 19 rural and urban schools in Virginia.
The project was evaluated using a cluster-randomized trial
design to test the impact of providing the free meals and food
backpacks in schools. We hypothesized that households with
students in schools receiving the project benefits would have
lower rates of FI-C, as well as lower rates of VLFS-C and
household and adult food insecurity. To test these hypothe-
ses, we used logistic regression models to examine differ-
ences in rates of food insecurity within households that did
and did not receive the project benefits.
METHODS
Overview
The VA 365 demonstration project took place between 2016
and 2018, with the primary evaluation period during the
2016-2017 school year (ClinicalTrials.gov number, NCT
04218747). A detailed description of the project, methods,
and additional results can be found elsewhere,12 but will be
summarized here. The evaluation used a cluster-randomized
trial design with a convenience sample of 38 schools in
January 2021 Volume 121 Number 1 Suppl 1
RESEARCH
RESEARCH SNAPSHOT
Research Question: Does providing low-income children
access to free school breakfast, lunch, and supper during the
school day, and a food backpack on weekends and school
breaks reduce food insecurity among children?
Key Findings: Although the distinction in nutrition assistance
benefits between treatment and control schools was less
than planned, a school-based demonstration project aimed
at reducing food insecurity in children in low-income
households through increased participation in school meal
programs and food backpacks decreased the most severe
form of food insecurity in children but increased less severe
forms in children, adults and households.
Virginia. Schools were the experimental unit and were
recruited to participate by the Virginia Department of Edu-
cation. School participation in the study was voluntary. The
sample included 30 elementary, 6 middle, and 2 high schools
located in the urban city of Richmond or in the rural south-
west. All schools had at least 50% of households eligible for
FRP lunches and low academic performance, defined by the
Virginia Department of Education as “accredited with warn-
ing” based on low scores on student assessments. This study
was approved by the New England Institutional Review
Board.
Random Assignment
Random assignment of schools occurred across several steps.
First, schools were stratified based on their location in a rural
or urban area. Next, schools were matched based on several
characteristics including county and city (if possible), per-
centage of FRP-eligible students when available, grades
served, and enrollment of students eligible for school meal
programs. Finally, schools in each pair were either arbitrarily
or randomly assigned into a treatment or control group. In
the case of arbitrary assignment, within each matched pair,
the school that was listed first alphabetically was assigned to
the treatment group and the other to the control group.
Sixteen schools were assigned in this way. Although not
technically random, it was not based on self-selection or
other meaningful observable characteristics that could bias
estimates. The arbitrary assignment of schools was
completed prior to the grant award.
The Consolidated Standards of Reporting Trials Flow Dia-
gram shows the derivation of the sample, from the initial
sample frame, random sample of eligible households,
through random assignment, and follow-up (Figure). Within
the 19 treatment and 19 control schools, a stratified random
sample of households with FRP students or students who
attended a Community Eligibility Provision (CEP) school were
selected to participate in the evaluation. Schools in low-
income areas can participate in CEP, which allows all chil-
dren access to free meals through NSLP and SBP regardless of
household income. Households were stratified by region of
Virginia (schools in urban Richmond or the rural southwest).
Selection of households occurred over several steps. Within
the 38 schools, 10,705 households met selection criteria and
were eligible for sampling. A random sample of 6,333
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS S35
RESEARCH

Household sample
Enrollment and consent
(n=4,750)

Prior to
randomization,
schools matched on
school and student
characteristics

Treatment Control

n=19 schools n=19 schools

Allocation n=2,487 households n=2,263 households
n=209 ineligibles n=183 ineligibles

Households with Households with

Baseline analysis baseline data baseline data
(n=1,380) (n=1,216)

Households with Households with

follow-up data follow-up data
(n=1,393) (n=1,243)
Follow-up analysis
Households missing Households missing
child food security child food security
measures (n=13 ) measures (n=10)
Figure. Flow diagram for the randomized controlled trial evaluation of the VA 365 Demonstration Project.

households were selected for participation in the evaluation.
Of these 6,333 households, a random sample of 4,750 were
selected for data collection. This second random sample was
taken as a reserve sample (ie, the difference of 1,583 house-
holds) in case of low response rates or other issues. Of the
4,750 households selected for data collection, 392 were
ineligible at baseline and an additional 3 were ineligible at
follow-up; therefore, 4,355 households comprised the eval-
uation sample and were contacted for data collection. At
follow-up, 1,393 treatment households and 1,243 control
households completed a survey sufficiently to be included in
the analysis. The weighted follow-up response rate was 63%
in the treatment group and 62% in the control group.
The VA 365 Demonstration Project
Treatment schools received 2 sets of benefits, and control
schools implemented a similar, but less robust set of benefits.
The first set of benefits expanded free school-based nutrition
assistance programs to all children in all treatment schools.
The second set of benefits loosened restrictions in CACFP and
strengthened school backpack programs. In regard to the first
set, all children in treatment schools were eligible to receive a
free breakfast, lunch, and supper each school day and a food
backpack on weekends and school breaks. Although 11 of the
19 treatment schools were already implementing universal
free breakfast and lunch and some Richmond schools were
implementing free snacks and/or suppers through CACFP, the
intervention expanded these benefits to all children in all
treatment schools. Note that data on the number of Rich-
mond treatment schools and afterschool program sites that
were already participating in the CACFP At-Risk Afterschool
Meals component were unavailable. Only 3 schools in
Southwest VA implemented CACFP and only for 2 months as
a test run for the intervention. In regard to the second set,
treatment schools received a waiver from Food and Nutrition
Service that allowed them to serve CACFP suppers during the
school day rather than after school, as federally required. This
is a considerable benefit because it ensured that many more
students would have access to the supper. The supper was
usually provided in the last class periods before the end of
the school day (ranging from 2:15 PM to 4:15 PM). In addition,
all children in treatment schools were offered a food back-
pack each weekend and on school breaks. Typically, children
took food backpacks home on Fridays and each backpack
included foods that would comprise 2 breakfasts, lunches,
and suppers. When children needed additional food to cover
long weekends and extended school breaks, schools would
distribute the additional food packs together with the regular

S36 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS January 2021 Volume 121 Number 1 Suppl 1
 RESEARCH

Table 1. Treatment and control child nutrition programs and operations during the Virginia 365 Project school year (n ¼ 38
schools)

No. of treatment schools (n [ 19) No. of control schools (n [ 19)

Virginia 365 demonstration benefitsa

Participated in SBPb 19 19
Offered free breakfast to all children 19 12
Participated in NSLPc 19 19
Offered free lunch to all children 19 12
Participated in the CACFPd at-risk afterschool meals 19 11
Offered the meal during the school daye 19 0
f
Participated in a backpack program 19 10
Offered the backpack to all children 19 0
g
Other school-based nutrition assistance programs
Participated in the FFVPh 2 11
Participated in the NSLP afterschool snack program 1 1
Used alternative school breakfast modeli 16 17
a
Virginia 365 benefits were a set that included universal free breakfast and lunch; universal free CACFP meal during the school day; and a universal free food backpack each weekend and
school break. As indicated, all 19 treatment schools participated in these programs. Because of unintended overlap, some control schools implemented exactly the same benefits (ie,
universal free breakfast and lunch) or similar, but less robust versions of benefits (ie, CACFP meals after the school day to participating students and a limited backpack program).
b
SBP ¼ School Breakfast Program.
c
NSLP ¼ National School Lunch Program.
d
CACFP ¼ Child and Adult Care Food Program.
e
Treatment schools received a waiver from the US Department of Agriculture, Food and Nutrition Service to serve the meal during the school day to all children rather than after the end of
the school day to participating children.
f
All children in treatment schools were offered a food backpack on weekends and school breaks. In control schools, the backpacks were only provided to selected children.
g
Benefits not part of the Virginia 365 demonstration but offered to students.
h
FFVP ¼ Fresh Fruit and Vegetable Program. Operated at least 2 days per week but often fewer than 5 days per week. Most treatment schools decided to stop participating in FFVP to avoid
too many eating occasions during the school day.
i
Includes models such as “grab ‘n’ go” and breakfast in the classroom.

delivery at the end of the school week or, to account for the
additional weight and volume, distribute the additional packs
on earlier school days leading up to the break. The backpack
program was made possible by a strong partnership with
local food banks and nonprofit groups. Treatment households
also received some other benefits, however, they were not
evaluated as part of this demonstration project, but are noted
here for completeness. During the summer months before
school started, students eligible for FRP school meals also
received an electronic benefits transfer card that could be
used on eligible foods at Supplemental Nutrition Assistance
Program authorized retailers. These benefits were provided
after baseline data collection and therefore could not influ-
ence responses to the baseline survey. They ended 5 to 9
months before follow-up data collection, making it unlikely
to influence responses to the food security measure, which
had a 30-day recall period. The summer electronic benefits
transfer benefits were not part of the evaluation because
similar projects had already been evaluated.13 Treatment
households also had access to free nutrition education clas-
ses, however, <1% of treatment households attended a class;
therefore, whether or not a household received nutrition
education is not included as part of this analysis.
Control schools implemented a similar set of benefits
(Table 1); however, these benefits were less robust compared
with what treatment schools received. For example, 11 con-
trol schools implemented CACFP At-Risk Afterschool Meals,
but could only deliver it to eligible children after the end of
the school day (ie, control schools did not receive a CACFP
waiver from Food and Nutrition Service). Ten control schools
also implemented a backpack program. Both CACFP and
backpack program benefits were targeted toward selected
children and were not universally available to all students.
Backpack programs did not have the same packing and de-
livery infrastructure or depth of partnerships compared with
treatment schools. Twelve of the 19 control schools served
school meals at no cost through the CEP and this was iden-
tical to what treatment schools received. Finally, treatment
schools were encouraged to participate in alternative break-
fast models—16 treatment schools participated in such a
model but 17 control schools did too. It is critical to note,
however, that project benefits in treatment schools were
available to all students and in control schools they were
available only to eligible students or in the case of NSLP and
SBP, those in CEP schools.
It was known from the beginning that there would be some
overlap between treatment and control schools in terms of
nutrition benefits, but the extent of the overlap was unin-
tended and not known until after it was too late to change the
research design. It was not possible to prevent the control

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RESEARCH
schools from offering some of the same benefits that treat-
ment schools offered, primarily because control schools were
legally allowed to participate in nutrition assistance pro-
grams available to them, and ethical concerns related to
denying control schools resources to feed children who were
in immediate need. Ultimately, although there was an overlap
in some benefits between treatment and control schools, we
believe considerable differences remained that the research
design was capable of detecting—primarily with universal
CACFP and backpack program benefits in treatment schools.
Indeed, even considering the overlap issue, not a single
school in the control group received the robust set of benefits
that all treatment schools received.
Participants and Data Collection
Data were collected from participating households via base-
line and follow-up telephone surveys. Survey respondents
received a $30 gift card. The baseline survey was conducted
before the start of the intervention and the follow-up survey
was conducted approximately 9 months after the start of the
demonstration. A knowledgeable adult in the household
completed the survey. A random subset of households that
did not respond to the telephone survey were selected for in-
field locating. For these households, a member of the study
team physically went to the person’s last known address and
attempted to conduct the survey in-person.
Measurement
The primary outcome of interest was FI-C. Secondary out-
comes of interest were VLFS-C and food insecurity and very
low food security among households and adults. Both the
primary and secondary outcomes were measured using the
US Department of Agriculture’s Household Food Security
Survey Module (HFSSM) with a 30-day recall period.2 The
module consists of 18 Likert-type items: 10 at the adult level
and 8 at the child level. Items are first scored then summed
together. Based on the number of affirmations, children,
adults, and households are classified as food secure or 1 of 2
sequentially more severe categories: food insecure or very
low food secure. The HFSSM is the reference standard for
measuring food insecurity in the United States.
The primary independent variable of interest was the
treatment or control status of the school that children
attended. Treatment or control status captures the overall
effect of the demonstration on food insecurity. To understand
how the intervention might have impacted food security, we
measured a number of other variables that were targeted by
the intervention. Specifically, we measured participation in
child nutrition programs, which included SBP, NSLP, and
CACFP suppers, as well as food backpack programs.
We measured variables that could confound the relation-
ship between food security status and the effects of the
intervention and were included as covariates in the regres-
sion models. Specifically, we included baseline measures of
child and adult food insecurity and very low food security;
the number of adults in the household; mean age of children
in the household; presence of teenager in household;
respondent age in years; total household income; respondent
employment status; respondent health status; respondent
race and ethnicity; language preference; baseline participa-
tion in Supplemental Nutrition Assistance Program, Special
S38 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
Supplemental Nutrition Program for Women, Infants, and
Children, or school-based meal programs; baseline use of
food pantries, emergency kitchens, and community pro-
grams; locality of household; and month of follow-up survey.
Households were excluded from the sample if they had
missing food security data. When possible, missing data on
the follow-up survey were replaced with information from
administrative data from participating schools (eg, race and
ethnicity and language preference). For these covariates, an
approach known as “dummy variable adjustment” was used
to address missing covariate data. In this approach, binary
indicators of the missing-value status of covariates were
included in the regression model.14 Aside from households
that did not respond to the baseline survey (about 20% of
those with valid outcome data), only a small share of
households had missing data on variables included in this
analysis, with income being imputed for 6.2% of households
and <3.0% for other covariates.
STATISTICAL ANALYSIS
Analyses were conducted using Stata software (version 15)
(Stata Corp, College Station, TX).15 All statistics incorporate
survey weights to be representative of all eligible households
in the demonstration. The sample weights also help ensure
that differential patterns of survey response do not lead to
systematic differences between the households included in
the treatment and control groups of the evaluation. An intent
to treat approach was used when analyzing the data. Stata
survey procedures were used to account for the complex
survey design and weights.
Descriptive statistics were used to examine socioeconomic
differences at baseline between treatment and control groups
and to infer whether the randomization was successful. To
test for statistically significant differences between treatment
and control groups, c2 tests were used for categorical vari-
ables and t tests were used for continuous variables. Logistic
regression was used to estimate the impact of the project on
food security status at the child, adult, and household levels.
Logistic regression was also used to estimate the impact of
the project on participation in SBP, SBP FRP meals NSLP, NSLP
FRP meals, supper program, backpack program, after school
snack program, receiving food at other centers (eg, Head
Start), or did not participate in any school-based nutrition
programs. Specifically, we estimated 2 sets of models for food
security outcomes at the child, adult, and household levels.
One set tested the impact of the intervention on the odds of
being either food secure vs food insecure; the second tested
the impact on the odds of being food secure or food insecure
vs being very low food secure. For the nutrition assistance
programs, we estimated the odds of participation in the
program vs no participation in the program.
Results are presented as predicted probabilities calculated
from the log-odds of the logistic regressions and are pre-
sented in the results tables. The predicted probability for the
control group is the weighted probability of food security in
the control group. This represents the counterfactual condi-
tion; that is, what level of food security we would expect if
the project had not occurred. The impact of the project,
which we present as the difference between treatment and
control conditions in the tables below, is calculated as the
average marginal effect (also known as the average partial
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Table 2. Characteristics of households that responded to the baseline survey for the evaluation of the Virginia 365 Project (n ¼
2,596)

Total sample Treatment Control P

Characteristic (n [ 2,596) (n [ 1,380)a (n [ 1,216)b valuec

ƒƒƒƒƒƒ
ƒ mean (standard error)ƒƒƒƒƒƒ
ƒ!
d
HH size
No. of HH members who share food 4.1 (0.03) 4.1 (0.03) 4.0 (0.05) 0.429
No. of children in household 2.3 (0.03) 2.3 (0.06) 2.3 (0.06) 0.510
Reported monthly HH out-of-pocket food expenditures ($)e 378 (5) 378 (22) 378 (25) 0.993
ƒƒƒƒƒmedian (standard error)ƒƒƒƒƒ!
HH income last month ($)f 1,582 (22) 1,562 (50) 1,600 (67) 0.844
e
Reported monthly HH out-of-pocket food expenditures ($) 308 (6) 310 (8) 300 (11) 0.459
ƒƒƒƒƒƒƒƒ% (standard error)ƒƒƒƒƒƒƒƒ!
Respondent age 0.895
Respondent is under 40 y 61.5 (1.27) 61.0 (4.68) 62.1 (4.63)
Respondent is 40 y or older 38.5 (1.27) 39.1 (4.68) 37.9 (4.63)
Age of children
Younger than 5 y 30.2 (1.13) 31.0 (3.35) 29.4 (2.95) 0.791
5 to 11 y 79.6 (0.86) 79.1 (7.30) 80.2 (6.76) 0.938
12 to 17 y 48.8 (0.96) 49.6 (6.89) 47.9 (7.41) 0.907
18 y (or older if still in school) 5.7 (0.55) 6.2 (1.62) 5.2 (1.31) 0.711
Single adult HH 37.6 (1.06) 37.0 (4.21) 38.2 (3.57) 0.881
Any HH adult employed in last 30 d 69.2 (1.20) 68.3 (1.64) 70.0 (2.64) 0.664
Race/ethnicity 0.957
Hispanic, all races 7.8 (1.35) 7.8 (1.64) 7.8 (2.79)
Black, non-Hispanic 46.1 (1.45) 45.7 (9.06) 46.6 (9.20)
White, non-Hispanic 41.9 (1.55) 41.9 (9.67) 41.8 (9.87)
Other, non-Hispanic 4.2 (0.42) 4.6 (0.75) 3.8 (0.56)
g
HH nutrition benefit program participation
Reported currently receiving SNAPh 47.2 (1.15) 48.3 (3.17) 46.1 (3.83) 0.743
i
Reported receiving WIC 13.2 (0.63) 13.1 (1.63) 13.3 (1.65) 0.954
Reported receiving food from pantry, emergency kitchen, or 11.2 (0.82) 12.7 (1.14) 9.7 (1.07) 0.089
community program
Reported receiving FRPj lunch 83.6 (0.74) 83.4 (3.78) 83.9 (4.22) 0.947
Reported receiving FRP breakfast 73.8 (1.17) 73.8 (73.78) 73.9 (73.78) 0.993
Reported receiving school suppers 13.6 (1.1) 13.2 (2.53) 14.0 (2.44) 0.862
Reported receiving food backpacks 16.9 (2.04) 18.4 (3.96) 15.3 (2.65) 0.560
Reported receiving any out of school services 44.7 (2.28) 46.1 (4.58) 43.2 (3.81) 0.685
HH food-security status
Insecure 34.7 (1.23) 33.4 (1.92) 36.0 (1.90) 0.401
Very low food security 15.6 (0.78) 15.9 (1.12) 15.3 (1.27) 0.739
Adult food-security status
Insecure 31.7 (1.14) 31.0 (2.09) 32.4 (1.79) 0.675
Very low food security 15.1 (0.79) 15.8 (1.15) 14.5 (1.19) 0.494
Child food-security status
(continued on next page)

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Table 2. Characteristics of households that responded to the baseline survey for the evaluation of the Virginia 365 Project (n ¼
2,596) (continued)

Total sample Treatment Control P

Characteristic (n [ 2,596) (n [ 1,380)a (n [ 1,216)b valuec

Insecure 21.8 (0.90) 20.7 (1.50) 23.0 (1.53) 0.374

Very low food security 2.5 (0.27) 2.3 (0.40) 2.6 (0.52) 0.699
Health status 0.218
Good or excellent 72.1 (1.18) 70.6 (1.81) 73.6 (1.42)
Fair or poor 27.9 (1.18) 29.4 (1.81) 26.4 (1.42)
Primary language 0.639
English 94.5 (1.34) 95.4 (1.72) 93.6 (2.78)
Spanish 5.5 (1.34) 4.6 (1.72) 6.4 (2.78)
School location 0.889
Nonurban 32.4 (5.43) 33.7 (11.39) 31.0 (10.47)
Urban 67.6 (5.43) 66.3 (11.39) 69.0 (10.47)
a
As described in the Methods section, treatment group predicted probabilities are calculated as the sum of the control group weighted, observed probability, and the average marginal
effect.
b
Control group values are the weighted average of observed values in the sample control group.
c
P values are obtained from 2-tailed t tests of statistically significant differences for continuous measures and from c2 tests of independence for binary measures.
d
HH ¼ household.
e
Reported out-of-pocket food expenditures at stores and restaurants in the last 30 days. Excludes purchases made with SNAP and WIC.
f
Includes all earnings, Social Security, pensions, veteran benefits, unemployment insurance, workers compensation benefits, child support, payments from roomers and borders, Temporary
Assistance for Needy Families, and Supplemental Security Income for all household members.
g
Calculations include eligible and ineligible households for a specific program listed.
h
SNAP ¼ Supplemental Nutrition Assistance Program.
i
WIC ¼ Special Supplemental Nutrition Program for Women, Infants, and Children.
j
FRP ¼ free or reduced-price.

effect) using the margins command in Stata. Specifically, we
use the margins command to estimate the difference, for
each observation in the full sample, between the predicted
probability of an outcome with the treatment variable set as
one and the predicted probability with the treatment variable
set to zero, and then calculate a weighted average of these
observation-level differences. This has the advantage of
making use of all sample members’ observable characteristics
when translating the estimated coefficient of the treatment
variable into a difference in predicted probabilities. The
predicted probability for the treatment group is the sum of
the control group probability and the average marginal effect
of the project (treatment), which is based on the calculations
described above. One sided z tests were used to test for sig-
nificance for food security outcomes because there was a
strong prior belief that the intervention would improve food
security status among treatment households and was part of
the original research and analysis plan. Given the results of
the study, however, we were incorrect to assume that the
intervention could only improve food security and we note
when impacts on food insecurity are significant with 2-tailed
tests. All other statistical tests other than food insecurity
outcomes used 2-sided tests exclusively. Results were
considered significant at an a of .05.
RESULTS
There were no significant differences in socioeconomic vari-
ables between treatment and control households among
households that completed the baseline survey (Table 2).
Overall, the mean household size was 4.1 with 2.3 children in
each household. The median household income in the pre-
vious month was $1,582 and 69% of households had at least 1
employed adult. The plurality of respondents were Black,
non-Hispanic (46%), followed by White, non-Hispanic (42%).
At baseline, 20.7% of treatment households had FI-C
compared with 23.0% of control households (P ¼ 0.374);
2.3% of treatment households were VLFS-C compared with
2.6% of control households (P ¼ 0.699). In addition, there
were no significant differences in socioeconomic variables
between treatment and control households among house-
holds that had follow-up survey data sufficient for inclusion
in the analysis (results not shown).
The demonstration project was unsuccessful in reducing FI-
C, and counter to our hypothesis, actually increased it. The
predicted probability of FI-C in treatment households was
25.9% compared with 23.9% in control households, a differ-
ence of 2 percentage points (95% CI 0.1 to 3.9) (Table 3). Using
our a priori hypothesis and a 1-tailed test, this difference is
not statistically significant (P ¼ 0.98). Using a 2-tailed test,
however, this difference is statistically significant (P ¼ 0.04).
The demonstration project was successful in reducing VLFS-C.
The predicted probability of VLFS-C in treatment households
was 3.2% compared with 3.9% in control households, an ab-
solute difference of 0.7 percentage points (95% CI 1.3
to 0.1) or a relative difference of 18% (P < 0.05, 1-tailed test).
Although individual items from the HFSSM are not typically
considered, given the nature of the results, we examined

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Table 3. Impact of the Virginia 365 Project on food insecurity among children, adults, and households (n ¼ 2,634)

Variable Treatment (n [ 1,392)a Control (n [ 1,242)b Differencec 95% CI P valued

Children
Secure 74.1 76.1 e2.0e e3.9 to e0.1 0.982
e
Insecure 25.9 23.9 2.0 0.1 to 3.9 0.982
Very low food security 3.2 3.9 e0.7 e1.3 to e0.1 0.011
Adults
Secure 64.0 68.4 e4.4e e6.7 to e2.0 >0.999
Insecure 36.0 31.6 4.4 e
2.0 to 6.7 >0.999
Very low food security 17.6 14.7 3.0e 1.3 to 4.6 >0.999
Households
Secure 61.0 65.8 e4.9e e7.4 to e2.3 >0.999
Insecure 39.0 34.2 4.9 e
2.3 to 7.4 >0.999
Very low food security 18.0 15.3 2.7e 1.0 to 4.5 0.999
a
As described in the Methods section, treatment group predicted probabilities are calculated as the sum of the control group weighted probability and the average marginal effect.
b
Control group values are the predicted weighted probability of the food security outcome among observations in the control group.
c
Differences are the average marginal effect, calculated as described in the Methods section of this article. The average marginal effect is calculated using estimates from logistic regressions
that adjusted for baseline measures of household income and employment status; the survey respondent’s age, race/ethnicity, health status, and preferred language; household size and
presence of a teenager; household participation in the program being analyzed at follow-up; and indicator variables for the month of follow-up survey response. Values may not reflect
exact differences due to rounding.
d
P values associated with each impact estimate are from a 1-tailed test of statistical significance.
e
Estimate would have been significant with a 2-tailed test.

responses to the 8 child-level items. Treatment households
were 3.8 percentage points more likely (P < 0.05) to report
relying on a few kinds of low-cost foods to feed their children
and 1.1 percentage points less likely (P ¼ 0.05) to report that
their children skipped meals. When treatment households
did report their children skipped a meal, they were 0.8 per-
centage points less likely (P < 0.05) to report it happened
more than 2 of the last 30 days. There were no other signif-
icant differences between treatment and control households
on the other child-level items.
The demonstration project increased both adult and
household food insecurity. Among treatment households, the
predicted probability of adult food insecurity was 36.0%
compared with 31.6% in the control group, a difference of 4.4
percentage points (95% CI 2.0 to 6.7). Using our a priori hy-
pothesis and a 1-tailed test, this difference is not statistically
significant (P > 0.99). Using a 2-tailed test, however, this
difference is statistically significant (P < 0.01). The predicted
probability of very low food security among adults was 17.6%
in treatment households compared with 14.7% in control
households, a difference of 3 percentage points (95% CI 1.3 to
4.6). Using our a priori hypothesis and a 1-tailed test, this
difference is not statistically significant (P > 0.99). Using a 2-
tailed test, however, this difference is statistically significant
(P < 0.01).
Among treatment households, the predicted probability of
household food insecurity was 39.0% compared with 34.2% in
the control group, a difference of 4.9 percentage points (95%
CI 2.3 to 7.4). Using our a priori hypothesis and a 1-tailed test,
this difference is not statistically significant (P > 0.99). Using
a 2-tailed test, however, this difference is statistically signif-
icant (P < 0.00). The predicted probability of household very
low food security was 18.0% in treatment households
compared with 15.3% in control households, a difference of
2.7 percentage points (95% CI 1.0 to 4.5). Using our a priori
hypothesis and a 1-tailed test, this difference is not statisti-
cally significant (P > 0.99). Using a 2-tailed test, however, this
difference is statistically significant (P < 0.01).
We examined responses to the 10 adult and household-
level items to understand these results. Compared with
control households, treatment households were significantly
more likely to affirm 7 of the 10 items. More specifically, they
were more likely to affirm (1) worry that food would run out
(P < 0.05); (2) food bought but did not last (P < 0.05); (3)
could not afford to eat balanced meals (P < 0.05); (4) adults
cut the size of meals or skipped meals (P < 0.05); (5) cut or
skipped meals in more than 2 of the last 30 days (P < 0.001);
(6) ate less than felt they should (P < 0.05); and (7) lost
weight because there was not enough money for food (P <
0.05).
There were significant differences in reported participation
rates in child nutrition programs targeted by the demon-
stration (Table 4). Treatmentecontrol differences in school
supper program and food backpack program participation
were notably larger than differences in NSLP and SBP
participation. Treatment households were 19.9 percentage
points more likely to report participation in a school supper
program compared with control households (predicted
probability of 45.9% vs 26.0%; P < 0.001). Similarly, treatment
households were 35.6 percentage points more likely to report
participation in a food backpack program compared with
control households (predicted probability of 58.1% vs 22.5%; P
< 0.001). Treatment households were 2.0 percentage points
more likely to report participation in the NSLP compared

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Table 4. Treatment and control predicted probabilities in child nutrition programs targeted by the Virginia 365 project (n ¼
2,636)

Child Nutrition Program (% of households that Treatment (n [ Control (n [ P

reported receipt) 1,393)a 1,243)b Differencec 95% CI valued

VA 365 Demonstration Benefitse

School Breakfast Program 81.9 79.6 2.4 0.0 to 4.7 0.042
Free or reduced-price breakfastf 78.8 73.6 5.2 2.3 to 8.1 <0.001
National School Lunch Program 91.3 89.3 2.0 0.4 to 3.5 0.007
Free or reduced-price lunchf 86.4 80.2 6.2 2.7 to 9.7 <0.001
Supper programg 45.9 26.0 19.9 15.5 to <0.001
24.3
Backpack program 58.1 22.5 35.6 30.6 to <0.001
40.7
Other School-Based Nutrition Assistance Programs
Food at after school program where snacks are 32.8 28.1 4.7 1.1 to 8.3 0.013
received
Food at another center, (eg, Head Start or daycare) 9.5 10.1 e0.6 e2.1 to 0.451
e0.9
None of the above 5.0 6.8 e1.8 e3.1 to 0.007
e0.5
a
As described in the Methods section, treatment group predicted probabilities are calculated as the sum of the control group weighted probability and the average marginal effect.
b
Control group values are the predicted weighted probability of program participation among observations in the control group.
c
Differences are the average marginal effect, calculated as described in the Methods section of this article. The average marginal effect is calculated using estimates from logistic regressions
that adjusted for baseline measures of household income and employment status; the survey respondent’s age, race/ethnicity, health status, and preferred language; household size and
presence of a teenager; household participation in the program being analyzed at follow-up; and indicator variables for the month of follow-up survey response. Values may not reflect
exact differences due to rounding.
d
P values are based on two-tailed tests of statistical significance.
e
VA 365 Benefits were a set that included universal free breakfast and lunch; universal free CACFP meal during the school day; and a universal free food backpack each weekend and school
break.
f
Parents were asked about their child’s participation in the School Breakfast Program and/or the National School Lunch Program. Within control schools, this includes children eligible for
free, reduced-price, and paid meals. In treatment schools, all children received free meals.
g
Includes CACFP meals served at school during the school day for treatment schools or after the end of the school day for control schools.

with control households (predicted probability of 91.3% vs
89.3%; P ¼ 0.007). Similarly, treatment households were 2.4
percentage points more likely to report participation in the
SBP compared with control households (predicted probabil-
ity of 81.9% vs 79.6%; P ¼ 0.042). These results suggest that
the school supper and food backpack programs were driving
the results of the evaluation, given the much higher partici-
pation rates in treatment households compared with control
households.
DISCUSSION
Although there are important limitations to consider, such as
some control schools offering similar, but less robust benefits
as treatment schools, the VA 365 demonstration evaluation
provides rigorous evidence on the effect of a suite of school-
based child nutrition programs on food insecurity. Although
the demonstration did not meet its primary goal of reducing
FI-C, it nonetheless provides important information for
policy-makers, nutrition practitioners, and others to consider
when using schools as food hubs to address food insecurity in
low-income households with children. It also raises
important questions about the assumption that providing
food to households that are at risk or are experiencing food
insecurity can do no harm.
The demonstration was unsuccessful in reducing FI-C in
treatment households, and actually increased it by 2.0 per-
centage points compared with control households. This result
was unexpected and it is not clear why it occurred. It is often
assumed that providing food directly to households will
reduce food insecurity.16 Although this might be true in some
circumstances, it is possible that the nature of the treatment
benefits engendered unexpected responses to items in the
HFSSM. For example, we found that treatment households
were more likely to affirm the item related to relying on low-
cost foods to feed their children, making it more likely that
they would be classified as FI-C. This result is understandable
if we assume that the extra food treatment households
received through the demonstration was viewed as low cost.
That is, the additional food treatment households received
could have worsened food insecurity by creating a perception
that the food was low cost and they were unable to afford
more. There were no significant differences between treat-
ment and control households on other child-level items

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related to ability to afford balanced meals; children not eating
enough; cutting the size of meals; children being hungry; and
children not eating all day. These items are more severe than
the items about relying on low-cost meals, so it is possible
that the intervention benefits were insufficient to affect these
domains. Finally, based on assumptions made by the Rasch
model, which is a statistical model that underlies food se-
curity status classification,17 it should be theoretically
impossible for an intervention to positively affect FI-C but
negatively affect VLFS-C, like our study found. Although we
discuss possible reasons for this unexpected finding, it raises
important questions about the suitability of the HFSSM as
measurement tool in certain evaluation settings. Future
research should consider how targeted nutrition assistance
interventions might change the likelihood of affirming items
on the HFSSM and the implications this could have for
measuring changes in food security status and the underlying
assumptions of the Rash model.
The demonstration was successful in reducing VLFS-C by
0.7 percentage points in treatment households compared
with control households. This is a considerable reduction
given that VLFS-C is severe condition and reducing its prev-
alence is of policy and public health importance.18 Children
who are very low food secure experience considerable dis-
ruptions in the quality and quantity of the foods they
consume. Treatment households were significantly less likely
to affirm the 2 child-level items related to skipping meals
compared with control households, but not the more severe
items related to children going hungry and not eating for a
whole day. This result can be explained by the treatment
group receiving an extra meal each day through CACFP and a
food backpack that was meant to cover breakfast and lunch
on weekends and school breaks. It is unclear why these extra
meals would not affect the rate at which children were
hungry or did not eat for a whole day, but it is possible that
although children in treatment households were less likely to
skip meals, that did not translate to complete removal of
hunger or not eating for whole day, especially the latter,
which is a rare occurrence (<1% in the treatment and control
groups) and could represent extreme circumstances that the
intervention could not address. For these households, sub-
stantially reducing food insecurity might require solutions in
addition to providing more food. Future research should
consider how schools can best identify and then target
nutrition assistance to the households in most need, and the
most effective method of assistance to prevent and reduce FI-
C and VLFS-C as the solutions can differ.
The demonstration was unsuccessful in reducing adult or
household food insecurity, and actually increased it. Similar
to the results for FI-C, this was unexpected and it is unclear
why it occurred. One possibility is that the extra food pro-
vided to households in the treatment condition—particularly
the CACFP suppers and food backpacks—altered perceptions
of household food insecurity. Both programs might have been
viewed as “extra” benefits by participants because they are
much less commonly used than NSLP and SBP. These extra
benefits might have created a sense of relative deprivation19
in adults responding to the HFSSM. That is, the extra benefits
created a situation where increased access to food for their
children actually made adults feel worse about their own
food security because it highlighted that the food was needed
in the first place. Another possibility is that adults in
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RESEARCH
treatment households reduced their own food consumption
in response to their children being better fed and this nega-
tively affected their own food security. Treatment households
had median out-of-pocket food expenditures that were $11
less compared with control households (analysis not shown),
and it is possible that this translated to less food consumed
for adults in treatment households. Ultimately, this impact
analysis cannot answer why food insecurity increased in
treatment households, but it does raise important questions
that could be answered through future research.
Finally, although the demonstration successfully increased
participation in NSLP, SBP, CACFP, and food backpacks in
treatment schools relative to control schools, the results
should be interpreted with caution and within the context of
a control-group that offered a similar, but less robust set of
benefits. This weakened the originally planned contrast be-
tween treatment and control schools and complicates inter-
pretation of the findings because the contrast between the
treatment and control group is lessened and inconsistent.
Although the contrast is less than ideal, we believe that there
is still sufficient distinction between the treatment and
control groups. Not a single control school received the
robust set of benefits that all treatment schools received nor
did a single control school make the benefits available to all
students, which all treatment schools did. The other con-
cerning issue is that there was variation in the type of ben-
efits made available to students in the control group, such
that not all control schools uniformly delivered the same set
of benefits. This complicates the interpretation of the findings
because it makes it less clear what the treatment group is
being compared with and therefore difficult to have complete
faith in the counterfactual. We view this as a considerable
issue, however, because we consider average differences in
food security and other outcomes between treatment and
control groups, we believe that the comparison is worthwhile
as it represents a policy-relevant and real-world scenario.
That is, where some schools offer a robust set of nutrition
assistance compared with other schools that offer a limited
set. Furthermore, our original research and analysis plan held
us accountable to this analysis approach and reporting.
Strengths and Limitations
This study had several strengths. First, it used a randomized
controlled trial design to test the causal impact of the VA 365
demonstration on food security status. The use of randomi-
zation largely eliminates sources of confounding and bias.
Furthermore, there were no outliers in measured variables or
schools that were driving the results; the data were well
balanced. Second, food security status was assessed using the
reliable and valid HFSSM, which is the reference standard
measure. Third, intensive project management, technical
assistance, and local partners resulted in the demonstration
being delivered as intended. Finally, the use of baseline and
follow-up surveys allowed adjustment of baseline variables,
strengthening our inferences.
This study also had several limitations. First and foremost,
and as discussed previously, the study design was moderately
compromised because the control group delivered a similar,
but less robust set of benefits than what the treatment group
delivered. This likely weakened the planned for counterfac-
tual that is ideally achieved through randomization. We
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS S43
RESEARCH
believe in this case, however, that there were still sufficient
differences between the treatment and control groups to
justify and support the analysis, results, and conclusions.
Second, there was attrition between randomization, the
baseline survey, and the follow-up survey. Although we used
statistical weights that account for this attrition, it is possible
that residual differences could affect our inferences in un-
known ways. Although, the nonresponse rate was similar
between treatment and control households, there were no
significant difference in demographic variables or other
measured characteristics at follow-up, and results did not
change if covariates were excluded from modeling (analyses
not shown), which strengthens our confidence in the internal
validity of the evaluation. Third, the demonstration took
place in low-income rural and urban areas of Virginia. Our
findings might not generalize to other geographic areas or
schools with different student body characteristics. Fourth,
although all treatment schools delivered all demonstration
services as intended, there was variation in certain aspects of
the delivery. For example, the timing of CACFP suppers varied
and so did methods of backpack distribution (eg, some placed
food directly into student backpacks and others let children
choose to pick food backpacks up from a distribution table).
Fifth, because schools operating under CEP were included in
the sample, some higher-income households at low-risk of
food insecurity were included in the analysis. Although likely
a relatively small share of households, their inclusion was
unavoidable because income verification before randomiza-
tion was not possible through school administrative records
as schools operating under CEP do not collect household-
level income. Finally, the HFSSM might not be the best
measurement of interventions that target individual children
away from home, as it was designed to capture overall food
experiences at the household level. A more focused measure
sensitive to children’s experiences might have better
captured the interventions impacts on FI-C.
CONCLUSIONS
A demonstration aimed at reducing food insecurity through
increased participation in a suite of school-based nutrition
assistance programs decreased the most severe form of
food insecurity in children but also increased less severe
forms in children, adults, and households. Although the
distinction in nutrition assistance benefits between treat-
ment and control schools was less than planned, these
results suggest that providing a suite of nutrition assistance
programs targeted broadly to low-income households with
children can both positively and negatively affect food
insecurity compared with schools that provide a similar but
less robust suite of nutrition assistance programs. Future
work should address how to best target food insecure
households with resources to produce the best outcomes
for with FI-C vs VLFS-C in school-based settings, and the
S44 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
complex manner in which food security status is perceived
and reported by respondents when receiving additional
nutrition assistance.
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AUTHOR INFORMATION
M. Burke is a social science research analyst, US Department of Agriculture, Food and Nutrition Service, Alexandria, VA. C. Cabili is a researcher,
Mathematica, Washington, DC. D. Berman is a special nutrition evaluation branch chief, US Department of Agriculture, Food and Nutrition
Service, Alexandria, VA. S. G. Forrestal is a senior survey researcher, Mathematica, Chicago, IL. P. M. Gleason is an associate director, Human
Services Research and Senior Fellow, Mathematica, Washington, DC.
Address correspondence to: Michael Burke, PhD, MPH, US Department of Agriculture, Food and Nutrition Service, 1320 Braddock Pl, 5th Floor,
Alexandria, VA 22314. E-mail: Michael.Burke@usda.gov
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
This article is published as part of a supplement supported by the U.S. Department of Agriculture, Food and Nutrition Service. This work was
funded by the US Department of Agriculture, Food and Nutrition Service under contract no. AG-3198-C-14-0019. The findings and conclusions in
this publication are those of the authors and should not be construed to represent any US Department of Agriculture office or US Government
determination or policy.
ACKNOWLEDGEMENTS
The authors thank Ronette Briefel, DrPH, RD, who directed the Virginia demonstration project and all other demonstration projects in the
Evaluation of Demonstrations to End Childhood Hunger. We thank study team members who contributed to the data collection and analyses,
including the coauthors of the Virginia 365 final evaluation report (Pia Caronongan, PhD Gregory Chojnacki, MPP, MA, Nicholas Redel, MA, and
Breanna Wakar, MA) and programmers who helped prepare the data tables (Natalie Larkin, BA Kelley Monzella, BA, and Liz Potamites, PhD). The
authors thank the US Department of Agriculture Food and Nutrition Service for review of a previous version of the manuscript. Everyone named
provided permission to be acknowledged. The findings and conclusions in this publication are those of the authors and should not be construed
to represent any office US Department of Agriculture or US Government determination or policy.
AUTHOR CONTRIBUTIONS
The Virginia Department of Education designed the intervention. M. Burke provided oversight for all aspects of the evaluation. M. Burke wrote
the manuscript and had primary responsibility for final content. C. Cabili served as the evaluation liaison to the Virginia Department of Education,
conducted the implementation analysis, and led the impact evaluation report. D. Berman provided oversight for the evaluation. S. Forrestal
directed the survey operations. P. Gleason designed the evaluation and had oversight of the analysis. All coauthors contributed to analyses,
reviewed the draft manuscript, and approved the final manuscript.

January 2021 Volume 121 Number 1 Suppl 1 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS S45