Employment Insurance may mitigate impact of unemployment on food security: Analysis on a propensity-score matched sample from the Canadian Income Survey.

Food insecurity, the inadequate access to food due to financial constraints, affects one-sixth of Canadian households, with substantial health implications. We examine the impact of unemployment and the mitigating effect of Employment Insurance (EI) on household food insecurity in Canada. Using the Canadian Income Survey 2018-2019, we sampled 28,650 households with adult workers 18-64 years old. We used propensity score matching to pair the 4085 households with unemployed workers with 3390 households with only continuously employed workers on their propensity towards unemployment. Among unemployed households, we also matched 2195 EI recipients with 950 nonrecipients. We applied adjusted logistic regression to the two matched samples. Food insecurity affected 15.1% of the households without unemployed workers and 24.6% of their unemployed counterparts, including 22.2% of EI recipients and 27.5% of nonrecipients. Unemployment was associated with 48% (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.32-1.66; 5.67 percentage points) higher likelihood of food insecurity. This association was significant and similar across income levels, full-time and part-time workers, and household compositions. EI receipt was associated with 23% (aOR 0.77, 95% CI 0.66-0.90; 4.02 percentage points) lower likelihood of food insecurity, but this association was only significant among households with lower income, full-time workers, and children under 18. The findings suggest a broad impact of unemployment on working adults' food insecurity and a substantial mitigating effect by EI on select unemployed workers. Making EI more generous and accessible for part-time workers may help alleviate food insecurity.

Effect of Canada Child Benefit on Food Insecurity: A Propensity Score-Matched Analysis.

INTRODUCTION: Food insecurity-the inadequate access to food due to financial constraints-affects 1 in 6 households in Canada, with serious health implications. Family benefit programs supplementing income have shown potential in mitigating the risk of food insecurity, but there is little understanding of their protective effects. The authors aimed to estimate the impacts of the additional Canada Child Benefit provided to families with children aged <6 years on household food insecurity. METHODS: The authors sampled 28,435 households receiving Canada Child Benefit with children aged <8 years from the Canadian Income Survey 2018-2020 fielded in 2019-2021 and analyzed in 2022. Households without children aged <6 years were 1:1 propensity-score matched to those with children aged <6 years, who received up to $1,068 in additional Canada Child Benefit per child annually. The authors compared the 2 groups' 12-month food insecurity likelihood after matching. Subsample analyses were performed by household income, housing tenure, and household type. RESULTS: Receipt of the additional Canada Child Benefit ($724 on average) was associated with 2.89 (95% CI=1.35, 4.42) percentage points lower probability of experiencing food insecurity among recipients with children aged <6 years (from 24.30% to 21.42%). The association was similar across socioeconomic subgroups and significant among all but high-income earners and mortgage-free homeowners. CONCLUSIONS: The authors found plausibly causal evidence that the more generous Canada Child Benefit for Canadian families with young children reduces their probability of food insecurity. Increasing benefits for economically disadvantaged households, characterized by low incomes, single parenthood, and renting (versus owning), may improve the program's efficiency and equity in supporting families' food security.

Pain-driven emergency department visits and food insecurity: a cross-sectional study linking Canadian survey and health administrative data.

BACKGROUND: As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals' pain-driven emergency department visits. METHODS: We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest-throat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models. RESULTS: The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20-1.68), 1.64 (95% CI 1.37-1.96) and 1.99 (95% CI 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits. INTERPRETATION: Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization.

Classification Differences in Food Insecurity Measures between the United States and Canada: Practical Implications for Trend Monitoring and Health Research.

BACKGROUND: Food insecurity, inadequate access to food due to financial constraints, is a major public health issue in the United States and Canada, where the same 18-item questionnaire is used to monitor food insecurity. Researchers often assume that findings on food insecurity from the 2 countries are comparable with each other, but there are between-country differences in how food insecurity status is determined. OBJECTIVES: We aimed to compare the distribution of household food insecurity in the Canadian population applying the US and Canadian classification schemes. We also examined the extent to which associations between food insecurity and adults' health differ under the 2 schemes. METHODS: We used the population-representative Canadian Community Health Survey 2005-2017 linked to administrative health records. Food insecurity was measured by the Household Food Security Survey Module. Adults 18 y and older with valid food insecurity status were included from all jurisdictions except Quebec (n = 403,200). We cross-tabulated food insecurity status classified by the US and Canadian schemes. We also fitted logistic regressions on self-reported and objective health measures adjusting for confounders. RESULTS: Applying the Canadian classification scheme, 7.7% of households were food insecure; the number fell to 6.0% with the US scheme. Associations between food insecurity status and health measures were mostly similar across classification schemes, although the associations between food insecurity and self-reported health were slightly larger if the US scheme was applied. Marginal food security/insecurity was associated with worse health measures irrespective of the classification scheme. United States-Canada discordance in classification of marginal food security/insecurity had a limited effect on health prediction. CONCLUSIONS: United States-Canada differences in classification affected the apparent distribution of household food insecurity but not the associations between food insecurity and measures of adult health. Marginal food security/insecurity should be set apart from the food-secure group for trend monitoring and health research.

Examining the relationship between food insecurity and causes of injury in Canadian adults and adolescents.

BACKGROUND: Food insecurity, as an indicator of socioeconomic disadvantages and a determinant of health, may be associated with injury by increasing risk exposure and hampering risk mitigation. We examined the association between food insecurity and common causes of injury in the general population. METHODS: Linking the Canadian Community Health Survey 2005-2017 to National Ambulatory Care Reporting System 2003-2017, this retrospective cohort study estimated incidence of injury-related emergency department (ED) visits by food insecurity status among 212,300 individuals 12 years and above in the Canadian provinces of Ontario and Alberta, adjusting for prior ED visits, lifestyle, and sociodemographic characteristics including income. RESULTS: Compared to those in food-secure households, individuals from moderately and severely food-insecure households had 1.16 (95% confidence interval [CI] 1.07-1.25) and 1.35 (95% CI 1.24-1.48) times higher incidence rate of ED visits due to injury, respectively, after confounders adjustment. The association was observed across sex and age groups. Severe food insecurity was associated with intentional injuries (adjusted rate ratio [aRR] 1.81; 95% CI 1.29-2.53) including self-harm (aRR 1.87; 95% CI 1.03-3.40) and violence (aRR 1.79; 95% CI 1.19-2.67) as well as non-intentional injuries (aRR 1.34; 95% CI 1.22-1.46) including fall (aRR 1.43; 95% CI 1.24-1.65), medical complication (aRR 1.39; 95% CI 1.06-1.82), being struck by objects (aRR 1.43; 95% CI 1.07-1.91), overexertion (aRR 1.31; 95% CI 1.04-1.66), animal bite or sting (aRR 1.60; 95% CI 1.08-2.36), skin piercing (aRR 1.80; 95% CI 1.21-2.66), and poisoning (aRR 1.65; 95% CI 1.05-2.59). Moderate food insecurity was associated with more injuries from violence (aRR 1.56; 95% CI 1.09-2.21), falls (aRR 1.22; 95% CI 1.08-1.37), being struck (aRR 1.20; 95% CI 1.01-1.43), and overexertion (aRR 1.25; 95% CI 1.04-1.50). Moderate and severe food insecurity were associated with falls on stairs and being struck in non-sports settings but not with falls on same level or being struck during sports. Food insecurity was not related to transport injuries. CONCLUSIONS: Health inequity by food insecurity status extends beyond diseases into differential risk of injury, warranting policy intervention. Researchers and policymakers need to address food insecurity as a social determinant of injury to improve health equity.

The role of provincial social policies and economic environments in shaping food insecurity among Canadian families with children.

Food insecurity, inadequate access to food due to financial constraints, affects 17.3% of Canadian children, with serious health repercussions. Capitalizing on the geo-temporal variation in social policies and economic environments across Canadian provinces between 2005 and 2018, we examined the association between provincial policies and economic environments and likelihood of experiencing food insecurity among households with children. Drawn from 13 years of the Canadian Community Health Survey, our sample comprised 123,300 households with below-median income with children under 18 in the ten provinces. We applied generalized ordered logit models on the overall sample and subsamples stratified by Low-Income Measure (LIM). Higher minimum wage, lower income tax, and lower unemployment rate were associated with lower odds of food insecurity in the overall sample. A hypothetical one-dollar increase in minimum wage was associated with 0.8 to 1.0-percentage-point decrease in probability of food insecurity. The probability of food security increased by 1.2 to 1.6 percentage points following a one-percentage-point drop in bottom-bracket income tax rate. One-percentage-point lower unemployment rate corresponded to 0.6 to 0.8-percentage-point higher probability of food security. Higher welfare income and lower housing price predicted lower likelihood of severe food insecurity in the below-LIM subsample. Higher sales tax and median wage predicted higher likelihood of food insecurity among above-LIM households. Income support policies, favorable labor market conditions, and affordable living costs were all related to reduced food insecurity among Canadian households with children. Policies that increase minimum wage, reduce taxes, and create jobs may help alleviate food insecurity.

Food insecurity, chronic pain, and use of prescription opioids.

Chronic pain has been on the rise in recent decades in Canada. Accordingly, the use of prescription opioids (PO) in Canada increased drastically between 2005 and 2014, only starting to decrease in 2015. Both pain and PO use have serious public health repercussions, disproporionately affecting select socially disadvantaged populations. Food insecurity is a strong risk factor for mental disorders and suicidal outcomes, yet its relationship to chronic pain and PO use is largely unknown. Using two recent cycles from the population representative Canadian Community Health Survey (CCHS), we examined the association of household food insecurity status with chronic pain and PO use among Canadians 12 years and older, adjusting for health and sociodemographic characteristics. Compared to food-secure individuals, marginally, moderately, and severely food-insecure individuals had 1.31 (95% confidence interval [CI] 1.15-1.48), 1.89 (95% CI 1.71-2.08), and 3.29 (95% CI 2.90-3.74) times higher odds of experiencing chronic pain and 1.55 (95% CI 1.30-1.85), 1.77 (95% CI 1.54-2.04), and 2.65 (95% CI 2.27-3.09) times higher odds of using PO in the past year, respectively. The graded association with food insecurity severity was also found in severe pain experience and pain-induced activity limitations among chronic pain patients and, less consistently, in intensive, excess, and alternative use of PO and its acquisition through means other than medical prescription among past-year PO users. Food insecurity was a much more powerful predictor of chronic pain and PO use than other well-established social determinants of health like income and education. Policies reducing food insecurity may lower incidence of chronic pain and help contain the opioid crisis.

Food insecurity is associated with mental health problems among Canadian youth.

BACKGROUND: Research has linked food insecurity to mental health problems, though little is known about this relationship among Canadian youth. We investigate the association between food insecurity severity and mental illnesses in a nationally representative youth sample. METHODS: We sampled 55 700 youth 12-24 years from recent cycles of Canadian Community Health Survey. Household food insecurity was measured using a standard 18-item questionnaire. We fitted Poisson regressions on self-rated mental health and diagnosed mood and anxiety disorders, controlling for sociodemographic confounders. Clinical assessments of emotional distress, major depression and suicidal ideation were examined in subsamples with available data. We stratified the sample by gender, age and survey cycle to test potential demographic heterogeneity. RESULTS: One in seven youth lived in marginal (5.30%), moderate (8.08%) or severe (1.44%) food insecurity. Results showed that food insecurity was associated with higher likelihood of every mental health problem examined. The association was graded, with more severe food insecurity linked to progressively worse mental health. Notably, marginal, moderate and severe food insecurity were associated with 1.77, 2.44 and 6.49 times higher risk of suicidal thoughts, respectively. The corresponding relative risk for mood disorders were 1.57, 2.00 and 2.89; those for anxiety disorders were 1.41, 1.65 and 2.58. Moderate food insecurity was more closely associated with mental health problems in 18-24 year olds than in 12-17 year olds. CONCLUSIONS: Food insecurity severity was associated with poorer mental health among Canadian youth independent of household income and other socioeconomic differences. Targeted policy intervention alleviating food insecurity may improve youth mental health.

Food Insecurity amid the COVID-19 Pandemic: Food Charity, Government Assistance, and Employment.

To mitigate the effects of the coronavirus disease 2019 (COVID-19) pandemic, the federal government has implemented several financial assistance programs, including unprecedented funding to food charities. Using the Canadian Perspectives Survey Series 2, we examine the demographic, employment, and behavioural characteristics associated with food insecurity in April-May 2020. We find that one-quarter of job-insecure individuals experienced food insecurity that was strongly associated with pandemic-related disruptions to employment income, major financial hardship, and use of food charity, yet the vast majority of food-insecure households did not report receiving any charitable food assistance. Increased financial support for low-income households would reduce food insecurity and mitigate negative repercussions of the pandemic.

Pour atténuer les conséquences de la pandémie de COVID­19 (la maladie à coronavirus 2019), le gouvernement fédéral a mis en place plusieurs programmes d'aide financière, accordant notamment des ressources financières sans précédent aux organismes de bienfaisance en alimentation. À l'aide des données de l'enquête 2 de la série d'enquêtes sur les perspectives canadiennes, nous étudions les caractéristiques liées à la démographie, à l'emploi et au comportement qui peuvent être associées à l'insécurité alimentaire en avril-mai 2020. Nous constatons qu'un quart des personnes en situation de précarité d'emploi ont vécu de l'insécurité alimentaire, condition liée de près aux perturbations du revenu d'emploi, aux graves difficultés financières et au recours aux organismes de bienfaisance en alimentation attribuables à la pandémie. Pourtant, la grande majorité des ménages touchés par l'insécurité alimentaire n'ont pas déclaré recevoir d'aide alimentaire caritative de quelque nature. Un soutien financier accru pour les ménages à faible revenu réduirait l'insécurité alimentaire et atténuerait les répercussions négatives de la pandémie.

Severe food insecurity associated with mortality among lower-income Canadian adults approaching eligibility for public pensions: a population cohort study.

BACKGROUND: The prevalence of food insecurity among adults over 65 in Canada is less than half of that among adults approaching 65, possibly due in part to the public pension universally disbursed from the age of 65. Given research associating food insecurity with higher risk of premature mortality, our objective was to determine the likelihood that food-insecure adults with incomes below the national median would live past 65 to collect the public pension. METHODS: We linked respondents of the Canadian Community Health Survey 2005-15 to the death records from the Canadian Vital Statistics Database 2005-17. We assessed household food insecurity status through a validated 18-item questionnaire for 50,780 adults aged 52-64 at interview and with household income below the national median. We traced their vital status up to the age of 65. We fitted Cox proportional hazard models to compare hazard of all-cause mortality before 65 by food insecurity status while adjusting for individual demographic attributes, baseline health, and household socioeconomic characteristics. We also stratified the sample by income and analyzed the subsamples with income above and below the Low Income Measure separately. RESULTS: Marginal, moderate, and severe food insecurity were experienced by 4.1, 7.3, and 4.5% of the sampled adults, respectively. The crude mortality rate was 49 per 10,000 person-years for food-secure adults and 86, 98, and 150 per 10,000 person-years for their marginally, moderately, and severely food-insecure counterparts, respectively. For the full sample and low-income subsample, respectively, severe food insecurity was associated with 1.24 (95% CI: 1.06, 1.45) and 1.28 (95% CI: 1.07, 1.52) times higher hazard of dying before 65 relative to food security. No association was found between food insecurity and mortality in the higher-income subsample. CONCLUSIONS: Severely food-insecure adults approaching retirement age were more likely to die before collecting public pensions that might attenuate their food insecurity. Policymakers need to acknowledge the challenges to food security and health faced by working-age adults and provide them with adequate assistance to ensure healthy ageing into retirement.

Food Insecurity Is Associated With Higher Health Care Use And Costs Among Canadian Adults.

Food insecurity predicts poorer health, yet how it relates to health care use and costs in Canada remains understudied. Linking data from the Canadian Community Health Survey to hospital records and health care expenditure data, we examined the association of food insecurity with acute care hospitalization, same-day surgery, and acute care costs among Canadian adults, adjusting for sociodemographic characteristics. Compared with fully food-secure adults, marginally, moderately, and severely food-insecure adults presented 26 percent, 41 percent, and 69 percent higher odds of acute care admission and 15 percent, 15 percent, and 24 percent higher odds of having same-day surgery, respectively. Conditional on acute care admission, food-insecure adults stayed from 1.48 to 2.08 more days in the hospital and incurred $400-$565 more per person-year in acute care costs than their food-secure counterparts, with this excess cost representing 4.4 percent of total acute care costs. Programs reducing food insecurity, such as child benefits and public pensions, and policies enhancing access to outpatient care may lower health care use and costs.

Association between household food insecurity and mortality in Canada: a population-based retrospective cohort study.

BACKGROUND: Food insecurity affects 1 in 8 households in Canada, with serious health consequences. We investigated the association between household food insecurity and all-cause and cause-specific mortality. METHODS: We assessed the food insecurity status of Canadian adults using the Canadian Community Health Survey 2005-2017 and identified premature deaths among the survey respondents using the Canadian Vital Statistics Database 2005-2017. Applying Cox survival analyses to the linked data sets, we compared adults' all-cause and cause-specific mortality hazard by their household food insecurity status. RESULTS: Of the 510 010 adults sampled (3 390 500 person-years), 25 460 died prematurely by 2017. Death rates of food-secure adults and their counterparts experiencing marginal, moderate and severe food insecurity were 736, 752, 834 and 1124 per 100 000 person-years, respectively. The adjusted hazard ratios (HRs) of all-cause premature mortality for marginal, moderate and severe food insecurity were 1.10 (95% confidence interval [CI] 1.03-1.18), 1.11 (95% CI 1.05-1.18) and 1.37 (95% CI 1.27-1.47), respectively. Among adults who died prematurely, those experiencing severe food insecurity died on average 9 years earlier than their food-secure counterparts (age 59.5 v. 68.9 yr). Severe food insecurity was consistently associated with higher mortality across all causes of death except cancers; the association was particularly pronounced for infectious-parasitic diseases (adjusted HR 2.24, 95% CI 1.42-3.55), unintentional injuries (adjusted HR 2.69, 95% CI 2.04-3.56) and suicides (adjusted HR 2.21, 95% CI 1.50-3.24). INTERPRETATION: Canadian adults from food-insecure households were more likely to die prematurely than their food-secure counterparts. Efforts to reduce premature mortality should consider food insecurity as a relevant social determinant.

Universal Access to Free School Meals through the Community Eligibility Provision Is Associated with Better Attendance for Low-Income Elementary School Students in Wisconsin.

BACKGROUND: Beginning in 2014-2015, schools nationwide have had the option of offering free meals to all students in qualifying schools through the Community Eligibility Provision (CEP). The CEP has been linked to greater likelihood of eating school meals, but little is known about its impact on broader outcomes. OBJECTIVE: The purpose of this study was to estimate the association between the CEP and school attendance among elementary school students (grades 1 to 5). DESIGN: This was a quasi-experimental study in which students' attendance records were observed over 1 baseline and 2 follow-up years in a sample of CEP and eligible non-CEP schools. PARTICIPANTS/SETTING: The participants were elementary school students in Wisconsin during three consecutive school years beginning 2013-2014. The main sample included 92,126 observation-years for students in 37 CEP and 108 eligible non-CEP elementary schools. INTERVENTION: CEP-participating schools offered breakfast and lunch free to all students through the School Breakfast Program and the National School Lunch Program beginning in 2014-2015. MAIN OUTCOME MEASURES: The outcome measures were the attendance rate (defined as the percentage of school days attended) and low attendance (defined as attending fewer than 95% of available days) during the first and second implementation years. STATISTICAL ANALYSES PERFORMED: Difference-in-difference regression models with student fixed effects were estimated, with separate impacts for the first and second CEP years. Models adjusted for time-varying school and student characteristics. RESULTS: Implementing the CEP had no association with attendance in the initial year. The second year of CEP was associated with a 3.5 percentage point reduction in the percentage of students with low attendance (P=0.045). An association between CEP and attendance was only found for economically disadvantaged students. CONCLUSIONS: Offering meals free to all students through the CEP may modestly reduce the risk of low attendance among economically disadvantaged students in participating schools.

Prescription medication nonadherence associated with food insecurity: a population-based cross-sectional study.

BACKGROUND: Food insecurity, defined as inadequate access to food owing to financial constraints, has been associated with poor disease management. Because cost-related nonadherence to prescription drugs is a possible explanation for such association, we examined the link between food insecurity and cost-related medication nonadherence in Canada. METHODS: Drawing on data for adult respondents (age ≥ 18 yr) who participated in the Canadian Community Health Survey 2016 Rapid Response module on prescription medication use, we assessed the association between household food insecurity and cost-related nonadherence to prescription drugs in the previous 12 months. We further examined the self-perceived health consequences of cost-related nonadherence among nonadherents. We applied Poisson models with bootstrap weights adjusting for sociodemographic characteristics. RESULTS: Of the 11 172 respondents in our sample, 930 (8.3%) reported cost-related nonadherence. Food insecurity affected 10.5% (95% confidence interval [CI] 9.1% to 11.8%) of adherents and 47.9% (95% CI 38.1% to 57.7%) of nonadherents. After adjustment for confounders, moderate and severe food insecurity were associated with 3.83 (95% CI 2.44 to 6.03) and 5.05 (95% CI 3.27 to 7.81) times higher prevalence of cost-related nonadherence, respectively, relative to food security. Despite being associated with lower probability of cost-related nonadherence, having drug insurance did not change the relation between food insecurity and cost-related nonadherence (p > 0.1 for all interactions). Severe food insecurity was correlated with higher prevalence of health deterioration and greater use of health care services as perceived consequences of cost-related nonadherence (p < 0.01 for both). INTERPRETATION: Food-insecure adults in Canada have a higher likelihood of cost-related nonadherence to prescription medications than their food-secure counterparts, which may constitute a burden on their health and lead to greater use of health care services.

Access to the School Breakfast Program Is Associated with Higher Attendance and Test Scores among Elementary School Students.

BACKGROUND: The School Breakfast Program (SBP) has grown and evolved substantially since its inception, yet relatively little is known about its impact on school engagement and academic outcomes. OBJECTIVES: The purpose of this study is to estimate the impact of the SBP on school attendance and standardized test scores, as well as how impacts differ among student subpopulations and between traditional and nontraditional program models. METHODS: The study uses administrative data from ∼1000 Wisconsin elementary schools during 2009-2014, including almost all public elementary schools in the state except those in Milwaukee Public School District. Over the 5-y period, 168 schools in our sample introduced a new SBP and/or changed the location of breakfast (classroom or cafeteria) or the payment structure. The impact of breakfast availability and type was evaluated using multivariable regression models with school fixed effects and extensive demographic controls, leveraging within-school changes in SBP availability and type. RESULTS: Implementing the SBP was associated with a 3.5-percentage-point reduction in the percentage of students with low attendance and an increase of 0.08 SD in normalized reading scores among likely-participant boys (P = 0.015), with no impact among girls. When breakfast was offered free to all students, the probability of low attendance was 3.5 percentage points lower than with traditional SBP for a broad cross-section of students (P < 0.001), and math and reading scores were 0.07 and 0.04 SD higher among the higher-income sample, respectively (P = 0.001 and P = 0.035, respectively). When breakfast was offered in the classroom, neither attendance nor reading scores differed relative to cafeteria-based SBP, whereas math scores among likely-participant boys were 0.05 SD lower (P = 0.045). CONCLUSIONS: Offering breakfast at school can modestly improve educational engagement and performance, but benefits differ across children and by program structure. Universally free breakfast appears particularly beneficial to both attendance and test scores.