Newswise — Whether eating out or buying food from the grocery store, Americans of all ages are, for the most part, eating poorly everywhere—except at school. The information comes from a new dietary trends study, which also reveals persistent or worsening disparities in meal quality from restaurants, grocery stores, and other sources—but not school—by race, ethnicity, and income.

Published today in JAMA Network Open and led by researchers at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University, the study analyzed all meals (including snacks and beverages) consumed by Americans over 16 years. By 2018, the most recent year for which national data is available, meals with the lowest nutritional quality came from restaurants, where 65% of adult meals and 80% of children’s meals were of poor quality. Entertainment venues and food trucks were next, with 44% of adult meals and 52% of children’s meals being of poor nutritional quality. At work sites, 51% of adult meals eaten were of poor dietary quality. 

Grocery stores were better sources of food, with 33% of adult meals eaten and 45% of children’s meals being of poor quality. Schools were best, where only 24% of meals consumed by children were of poor nutritional quality. 

“Schools are now the single healthiest place Americans are eating. This finding is particularly timely given widespread school closures over the last year from COVID-19, and current efforts to safely and fully reopen schools. Our results suggest substantial nutritional harms for millions of kids who have not been consistently receiving meals at school and must rely on other sources. These harms also disproportionately affect low-income, Black and Latinx children,” said Dariush Mozaffarian, dean of the Friedman School and senior author of the study. 

Analyzing the diets of about 40,000 adults and 21,000 children between 2003 and 2018, the research team found significant improvements in the nutritional quality of school food consumed over this period, almost all happening after the passage of the federal Healthy, Hunger-Free Kids Act in 2010, which mandated much stronger school and early child care nutrition standards. The findings represent food as actually consumed from different U.S. sources, not what is theoretically available to be purchased. 

In U.S. children from 2003 to 2018:

  • The proportion of poor nutritional quality food consumed from restaurants declined least, from 85% to 80%.
  • The proportion of poor nutritional quality food consumed from grocery stores declined modestly, from 53% to 45%.
  • The proportion of poor nutritional quality food consumed from schools was cut by more than half, from 57% to 24%.
  • Significant disparities were seen in improvements in food consumed from grocery stores, with greater improvements among whites than Blacks or Hispanics, and among children in households with greater family income or heads of household with higher educational attainment than with lower income or education. 
  • In contrast, improvements in food consumed from schools were equitable by race/ethnicity, education, and household income. 

“Our results underscore the fact that the nutritional quality of most meals, snacks, and drinks consumed in the U.S. remains poor, and with important differences by where the food is obtained,” said Mozaffarian. “Improvement in schools was especially striking, large, and equitable across population subgroups. This is clearly linked to the 2010 Healthy Hunger-Free Kids Act, a powerful lesson on how a single federal policy can improve both nutrition and equity for millions of Americans. These findings are especially timely with the new focus of the presidential administration, USDA, and Congress on nutrition security.” 

“The nutritional improvements in foods obtained at school came from kids eating more of what’s good for them, such as whole grains, total fruits, greens and beans, and less of what’s harmful, such as sugary drinks, refined grains, and foods with added sugar,” said first author Junxiu Liu, a postdoctoral scholar at the Friedman School at the time of the study, now assistant professor at the Icahn School of Medicine at Mount Sinai. “These were the specific targets of the Healthy Hunger-Free Kids Act.” 

Despite these improvements, Mozaffarian and Liu pointed out, school meals only provided 9% of calories for the average child over the course of an entire year, highlighting the importance of improving the nutritional quality of food choices from the other sources. 

Grocery stores accounted for 65% of calories for children and 67% for adults, followed by restaurants at 19% of calories for children and 22% of calories for adults. Other sources, such as gifts from others, food trucks, and entertainment venues, represented 8% of calories for children and 9% for adults. 

Additional results for U.S. adults from 2003 to 2018 include: 

  • The proportion of poor nutritional quality food consumed from restaurants remained relatively stable, at 65%.
  • The proportion of poor nutritional quality food consumed from workplaces declined modestly, from 56% to 51%.
  • The proportion of poor nutritional quality food consumed from grocery stores declined modestly, from 40% to 33%. 

“COVID-19 has changed the equation for where Americans are getting their food. Grocery stores were the main source before the pandemic, a trend which has only accelerated – including online. Restaurants that have survived the pandemic are now reopening. This is a perfect time to take stock of our food sources and choices as a nation and find policy solutions to put better nutrition on the table for all Americans,” Mozaffarian said. 


This new study is part of a series led by Friedman School researchers investigating patterns and trends in diet quality among U.S. adults and children. The team used data from the nationally representative National Health and Nutrition Examination Survey (NHANES) and assessed nutritional quality using the American Heart Association (AHA) diet score and the Healthy Eating Index (HEI)-2015, which provided similar results. The authors note that self-reported food recall is subject to error, and there is no single, agreed-upon measure of dietary quality.



Authors and Funding

This study is part of the Food Policy Review and Intervention Cost-Effectiveness initiative (Food-PRICE)a collaborative research effort at the Friedman School, funded by the National Institutes of Health’s National Heart, Lung and Blood Institute. Food-PRICE brings together scientists from across the United States and Europe to identify cost-effective nutritional strategies that can have the greatest impact on improving the health of Americans.

Additional authors are Renata Micha of the Friedman School, Colin Rehm of the Albert Einstein College of Medicine, and Yan Li of the Icahn School of Medicine at Mount Sinai. 

This work was supported by an award from the National Institutes of Health’s National Heart, Lung, and Blood Institute (R01HL130735) and a postdoctoral fellowship award to Dr. Liu from the American Heart Association. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Please see the study for conflicts of interest.

Journal Link: JAMA Network Open