# Multi-Level Health Outcomes of Local Food Procurement in United States Farm-to-School Programs: a Systematic Review

## TL;DR

This study reviews how farm-to-school programs in the U.S. affect health outcomes at multiple levels, finding that local food procurement is linked to increased vegetable intake in children.

## Contribution

The paper provides the first systematic review of multi-level health outcomes associated with local food procurement in U.S. farm-to-school programs.

## Key findings

- Local food procurement in farm-to-school programs is associated with increased vegetable intake in children, especially those with low initial intake.
- Evidence is insufficient to determine health impacts beyond individual-level outcomes like fruit and vegetable consumption.
- Barriers to local food procurement include financial and operational limitations faced by schools.

## Abstract

Approximately 74% of schools in the United States participated in at least 1 farm-to-school (F2S) activity during the 2022 to 2023 school year. Relationships between specific F2S activities, particularly local food procurement, and health outcomes across multiple levels (individual, family, community, and population) have not been systematically reviewed and reported. We conducted a systematic review of peer-reviewed and gray literature to examine relationships between local food procurement within F2S programs and child, family, producer, and community health outcomes (PROSPERO# CRD420250624067). Secondarily, we cataloged reported economic impacts and barriers and facilitators to local food procurement in F2S programs. Systematic literature searches identified 520 unique records. After title and abstract and full-text screening, 7 peer-reviewed articles and 2 gray literature sources met inclusion criteria, representing 3 cross-sectional, 1 prospective cohort, and 5 quasi-experimental studies. All studies presented individual-level health outcomes and most focused on children’s fruit and vegetable intake. Results suggest local food procurement in F2S programs is associated with increases in children’s vegetable intake, particularly in those with low intake and more intensive F2S exposure, but is not associated with positive changes in fruit intake. Evidence was insufficient to draw conclusions for any other health outcome evaluated at any level. Local food procurement facilitators reported by study authors were program champions, culturally-relevant activities and foods, and family and community engagement. Schools also faced significant barriers related to their ability, capacity, and financial means to source local food. Local food procurement, one of the most common F2S activities in K-12 settings in the United States, is associated with higher vegetable intake among students, but additional rigorous research is needed to determine comprehensive multi-level impacts on student, family, producer, and community health.