Importance: An estimated 12.8% of US households experienced food insecurity in 2022.

Objective: To review the evidence on benefits and harms of screening and interventions for food insecurity in health care settings.

Data Sources: MEDLINE, CINAHL, and the Cochrane Central Registry of Controlled Trials through October 11, 2022; references of existing reviews; surveillance through January 24, 2025.

Study Selection: English-language randomized clinical trials (RCTs), nonrandomized studies of interventions, and pre-post studies conducted in US health care settings that examine the impact of screening or interventions for food insecurity; instrument accuracy studies of brief screening tools.

Data Extraction and Synthesis: Single extraction, verified by a second reviewer. Results were narratively summarized.

Main Outcomes and Measures: Food insecurity; dietary, physiologic, quality of life, health outcomes; sensitivity and specificity of screening tools.

Results: One RCT (n = 789) examined the impact of screening for food insecurity and found no difference in food insecurity after 6 months (29.6% in the intervention group vs 29.8% with usual care). Ten accuracy studies (n = 123,886) compared 1-, 2-, and 6-item subsets of the US Department of Agriculture Household Food Security Survey (HFSS) with the full HFSS. Sensitivity was typically above 95% and specificity above 82%, although most studies did not administer the screener separately from the reference standard, potentially overstating the accuracy. Twenty-nine studies (n = 74,292) examined interventions to address food insecurity, but 27 were rated as poor quality for the outcomes of interest for this review. Of the 2 fair-quality studies, 1 randomized crossover study (n = 44) found that home delivery of medically tailored meals was associated with reduced food insecurity (41.9% while “on meals” vs 61.5% while “off meals,” P = .05). The other fair-quality propensity-matched cohort study found a smaller increase in body mass index among children whose families participated in a mobile food bank than those who did not after 6 months (mean difference in change, −0.68 [95% CI, −1.2 to −0.2]). The remaining studies found wide-ranging effect sizes for change in food security status but generally trended in the direction of benefit.

Conclusions and Relevance: Brief screening tools likely have sufficient sensitivity to identify people with food insecurity in health care settings, but most studies of interventions to improve food insecurity had high risk of bias, limiting the ability to draw firm conclusions.

Food insecurity is generally defined as a household-level economic and social condition of limited or uncertain access to adequate safe, nutritious food needed for an active and healthy life.^1,2 According to the US Department of Agriculture Economic Research Service’s Current Population Survey, 12.8% (17.0 million) of households were food insecure in 2022, with 7.7% of households experiencing low food security and 5.1% of households experiencing very low food security.³ There are differences by race and ethnicity; in 2022, 22.4% of Black non-Hispanic households and 20.8% of Hispanic households experienced food insecurity, compared with 9.3% of White households.³ American Indian/Alaska Native groups are also more than twice as likely as White populations to experience food insecurity.⁴ Food insecurity may lead to disrupted meal patterns and/or skipped meals, which can contribute to inadequate dietary intake, malnutrition, nutritional deficiency, or poor dietary quality.^5,6 Food insecurity is associated with a wide range of health issues in both children^7-9 and adults.^7,10-12

This review was commissioned to support the US Preventive Services Task Force (USPSTF) in considering a recommendation on preventive services for food insecurity in primary care settings.

Scope of Review

Figure 1 shows the analytic framework and key questions (KQs) that guided the systematic review. This report is a summary of a full evidence review,¹⁴ which includes additional methodologic details, results for additional outcomes, and the full findings for 7 contextual questions intended to provide additional background information.

Data Sources and Searches

This review builds on the work of 2 foundational reviews: a 2021 technical brief conducted for the USPSTF¹⁵ on screening and interventions for social risk factors and a 2019 scoping review by De Marchis and colleagues¹⁶ addressing screening for food insecurity in health care settings. Studies included in these reports were evaluated for inclusion in the current review. Bridge searches were conducted to capture any new studies published after the searches of the 2 foundational reviews by searching MEDLINE via Ovid, CINAHL via EBSCO, and the Cochrane Central Registry of Controlled Trials for relevant studies published beginning January 1, 2017 (for screening studies, bridging from the study by De Marchis et al¹⁶), and June 1, 2018 (for intervention studies, bridging from the technical brief¹⁵), and ending on August 21, 2023. A research librarian developed and executed the search, which was peer-reviewed by a second research librarian (eMethods in the Supplement). These searches were supplemented by examination of reference lists of other previously published reviews. Additionally, ongoing surveillance was conducted through January 24, 2025, using targeted searches to identify major studies that might affect the review conclusions.¹³ One new study was identified;¹⁷ however, it did not substantially change the review’s interpretation or findings or conclusions and is not discussed further.

Study Selection

Two independent reviewers screened titles, abstracts, and full-text articles using a priori eligibility criteria (eTable 1 in the Supplement). Studies were restricted to English-language studies conducted in the US, with no age restriction on participants. Studies of screening for food insecurity or interventions to address food insecurity were included if they were conducted in general populations, pregnant women, or among people with chronic medical conditions such as diabetes and hypertension. Studies were excluded if 50% or more of participants were undergoing cancer treatment, had other acute medical or psychiatric conditions, or had severe malnutrition or known nutritional deficiencies. For all KQs other than KQ2 (performance of screening tools), randomized clinical trials (RCTs), nonrandomized studies of interventions, and pre-post studies were included as long as some part of the study occurred in a health care setting (eg, case-finding, recruitment, referral, intervention). The health care tie-in could include, for example, screening conducted in a clinical setting, recruitment through a health care delivery or payment system, and interventions or programs integrated into, associated with, or referred from health care. For studies of screening or intervention benefit (KQ1, KQ4), a minimum of 12 weeks postbaseline follow-up was required, but no minimum follow-up was required for studies reporting harms (KQ3, KQ5).

Screening studies (KQ1, KQ3) were required to include an unscreened or usual care control group in which participants were not systematically screened. Intervention studies (KQ4, KQ5) were required to have elements specifically designed to reduce food insecurity, such as directly providing food or food vouchers, referrals to local food resources, or assistance with enrolling in government or other food assistance programs. Studies that addressed other social needs in addition to food insecurity were included as long as either more than 50% of the sample reported food insecurity at baseline or the results were reported separately for those with food insecurity at baseline. Evidence for KQ4a and KQ4b was limited to studies included in KQ4.

For KQ2 (performance of screening tools), studies that compared a brief screener or risk assessment tool with a longer, more detailed assessment of food insecurity were included if they were either conducted in a health care setting or included very large samples that were representative of the general US population.

Data Extraction and Quality Assessment

Two reviewers independently rated each study as “good,” “fair,” or “poor” using design-specific criteria (eTable 2 in the Supplement).¹³ Discordant ratings were resolved by consensus. One reviewer extracted data into standardized evidence tables, and a second reviewer checked the tables for accuracy.

Data Synthesis and Analysis

To synthesize findings on screening tool accuracy, sensitivity and specificity were calculated based on the 2 × 2 contingency table of true positives, false positives, true negatives, and false negatives if the sensitivity and specificity were not reported. Most studies examined agreement between the full US Household Food Security Survey 18-item assessment tool and a subset of the items embedded in this tool, without separate administration of the screener and reference standard. We used the terms sensitivity and specificity but acknowledge the departure from the preferred method of independent administration.

For KQ4, we grouped interventions into 3 broad categories:

• Food security only: intervention focused only on food security (eg, providing food or vouchers for food, referrals to local organizations that provide food, assistance with food-related benefits such as the Supplemental Nutrition Assistance Program [SNAP] and Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]) and did not address other social needs.
• Food security+nutrition education: combined food security components with nutrition and food preparation education (beyond minimal approaches such as inserts in food boxes or demonstrations at food box pickups).
• Multidomain: interventions that assessed and addressed other social needs in addition to food insecurity, as needed.

For studies of food security plus nutrition education and multidomain interventions, this report included only the food security–related outcomes. This is because intervention components addressing nutrition, medical needs or disease management, or other social needs could affect health and intermediate outcomes; therefore, outcomes could not be specifically attributed to the food insecurity components of the intervention. The highest-level food security components were identified and categorized as (1) food (eg, food boxes, delivery of prepared meals), (2) vouchers (exchanged for food, or subsidies to increase purchasing power), (3) application support (eg, patient navigation or help with identifying relevant resources and completing applications), and (4) referral only (information about local and federal food resources, with no further support).

For the outcome of percentage of individuals with food insecurity, risk ratios and 95% confidence intervals were calculated comparing the intervention and control groups (for traditional RCTs and nonrandomized studies of interventions), “on meal” and “off meal” (for a randomized crossover trial of meal provision), and postintervention vs preintervention values (for pre-post studies). Risk ratios are shown in a forest plot but not pooled due to the heterogeneity in study design, intervention, population, and other important features. All significance testing was 2-sided, and results were considered statistically significant if P ≤ .05. Strength of evidence was graded for each KQ, based on number, quality, consistency, precision, and risk of reporting bias.¹⁸

A total of 9435 abstracts and 413 full-text articles were screened for inclusion (Figure 2). Thirty-nine studies were identified (n = 198,762) as meeting inclusion criteria for this review: 1 examined the benefits of screening for food insecurity (KQ1);¹⁹ 10 examined the accuracy of screening tools (KQ2), including the 1 study also included for KQ1^19-28; 29 examined the impact of interventions to reduce food insecurity (KQ4)^29-57; and 1 reported on harms of interventions (KQ5), which was also included for KQ4.²⁹

Assessment Benefits

Key Question 1. Does identifying food insecurity in health care improve health outcomes?

One fair-quality RCT (n = 789) examined the impact of screening for food insecurity, using questions embedded in the Parent Screening Questionnaire, among parents with a child younger than 6 years (eTables 3 and 4 in the Supplement).¹⁹ Families screening positive for food insecurity were given information on how to access federal and local food-related assistance. At the 6-month followup, there was no difference in food insecurity between groups (29.6% in the intervention group [from 32.7% at baseline] vs 29.8% in the usual care group [from 31.1% at baseline], P = .90). This finding occurred despite the fact that a larger proportion of the intervention participants had maintained SNAP enrollment at the 6-month follow-up (97% of intervention participants were still enrolled after 6 months, vs 81% of control participants; P = .05) (eTable 5 in the Supplement).

Accuracy of Screening Instruments

Key Question 2. What is the performance of risk assessment or screening tools to identify food insecurity?

Ten studies (n = 123,886) examined the accuracy of a brief screening instrument to identify individuals or families with food insecurity (eTable 6 in the Supplement).^19-28 These studies examined 1-item, 2-item, or 6-item screeners (eTable 7 in the Supplement), all derived from the US Household Food Security Survey 18-item assessment tool.⁵⁸ The screening and reference tests were administered separately in only 1 study.¹⁹ One other study administered both the screening and reference tests in separate sections of a single questionnaire.²⁸ All of the remaining studies administered only the reference standard, with or without additional items, and examined the agreement of subsets of items with the full reference standard (referred to as “embedded” administrations). Sensitivity was typically above 95% and specificity was above 82% for all 2-item screeners when the screener was fully embedded in the reference standard or administered within the same larger questionnaire (Figure 3; eTable 8 in the Supplement). The lack of independent administration of the screener is likely to overestimate the performance of the screener under usual clinical use. The 1-item screener had the lowest accuracy, with sensitivity of 0.59 and specificity of 0.87 (95% CIs not reported) but was also the only instance of the screener being administered independently from the reference standard.¹⁹

Assessment Harms

Key Question 3. What are the harms or unintended consequences of assessment for food insecurity?

No studies reported harms of assessment for food insecurity.

Intervention Benefits

Key Question 4. What is the effect of health care–related interventions to address food insecurity on food security, intermediate outcomes, or health outcomes?

KQ4a. What are the effects of improvements in food security outcomes on intermediate and health outcomes?

KQ4b. What are the effects of improvements in intermediate outcomes on health outcomes?

Twenty-nine studies (n = 74,292) examined interventions to address food insecurity,^29-57 and all but 2 were rated as poor quality (Table 1; eTables 9-14 in the Supplement). Six of the studies recruited families with children,^{38,40,41,43,45,54} and the remainder focused on adult populations. The 23 studies among adults covered a range of populations, including broad-based or low-income adult populations,^{29,33,34,36,42,44,46,49} pregnant women,³¹ adults with chronic conditions or deemed at risk for chronic conditions (eg, meeting criteria for obesity, prediabetes, diabetes, hypertension, or dyslipidemia),^{29,30,32,35,37-39,47,50-53,56,57} or adults with a prespecified level of emergency department use.^48,55 Across all KQ4 studies that reported race and ethnicity, 30% of the included participants were Black, 18% were Hispanic, and 41% were White. One study was limited to people of the Navajo Nation, but otherwise there was minimal other representation of Native American individuals and also very minimal representation of people of Asian descent. Fourteen of the interventions addressed only food insecurity, 6 addressed food insecurity supplemented by nutrition counseling, and 9 provided interventions covering multiple domains or risk factors. Nineteen of the 20 studies targeting only food insecurity (with or without nutrition counseling) provided food or vouchers to the intervention participants, whereas 7 of the 9 multidomain studies did not provide food or vouchers but instead provided referrals, with or without additional navigation or application support.

Of the 2 studies rated as fair quality, 1 was a randomized crossover trial (n = 44) that included home delivery of medically tailored meals to patients with diabetes for 12 weeks.²⁹ At the end of the 24-week study period, the intervention was associated with reduced food insecurity (13/31 [41.9%] while on meals vs 24/39 [61.5%] while off meals, P = .05) (Figure 4; eTable 15 in the Supplement), improved mental health quality of life (4.7-point change from baseline while on meals vs 0.8-point change while off meals) (eTable 16 in the Supplement), and improved diet quality (eg, the 100-point total Healthy Eating Index score improved by 14.1 points while on meals compared with baseline but declined by 17.3 points while off meals [eTable 17 in the Supplement]). However, there was no apparent impact on other quality-of-life measures; physiologic measures of blood pressure, lipid levels, or glucose levels (eTable 18 in the Supplement) or cost-related medication underuse (eTable 19 in the Supplement). The other study (n = 176) rated as fair quality compared children in families who participated in a mobile food pantry with a propensity score–matched cohort of pediatric patients from the same neighborhood as the mobile pantry participants or from nearby neighborhoods not offering a mobile pantry program after 6 months.⁵⁴ This study found a smaller increase in body mass index among children of families who participated in the mobile food pantry (eTable 20 in the Supplement). This study did not report between-group differences in food insecurity but reported a reduction from 4.3 to 3.3 on a 6-point food insecurity scale among those in the intervention group (eTable 15 in the Supplement).

Nineteen additional studies (n = 70,537) reported a food security outcome but were rated as poor quality for the specific outcomes of interest for this review; improvements in food security were rarely reported to be statistically significant.^{30,32-35,37,38,40-44,48-50,52,55-57} Effect sizes were wide ranging, typically reported after 6 months or less, and trended in the direction of benefit in all studies but 1.³⁰ Eight studies (n = 3535) did not report a food security outcome; all of these included the provision of food or food vouchers but had other study aims, such as healthier diets or physiologic outcomes specific to the study population.^{31,36,39,44-46,51,53} The consumption of fruits and vegetables generally increased after participation in interventions that included either food boxes or vouchers. For other outcomes, 1 prepost study reported improvements in depression and self-rated health (eg, 69% rated their health as excellent or very good after receiving 23 weekly food boxes, compared with 52% at baseline [P = .04]).⁴² There was minimal impact on physiologic outcomes (blood pressure, lipids, glucose levels) or acute health care utilization, although none of these outcomes were reported by more than 3 studies. Detailed results for all outcomes and all studies are available in eTables 15, 16, 18, 19, and 21 in the Supplement.

Intervention Harms

Key Question 5. What are the harms or unintended consequences of health care–related interventions to address food insecurity?

One fair-quality study included for KQ4 reported that 1 person experienced gastrointestinal symptoms during the on-meal phase.²⁹ None of the other studies reported on harms of their interventions.

Evidence Summary

Evidence to support preventive interventions for food insecurity in primary care was very limited. The evidence on the benefits of screening was rated as insufficient; only 1 study examined the impact of a screening for food insecurity and found no improvement in food security. The strongest evidence was for accuracy of screening tools, finding that 2- and 6-item subsets of a longer 18-item food security assessment instrument had good agreement with the full 18-item questionnaire (moderate strength of evidence) (Table 2).

Evidence on the effectiveness of interventions to improve food security was hampered by methodologic limitations, particularly the fact that most were pre-post studies with only a single measurement at baseline and follow-up. As a result, confidence was very limited that changes in food security were due to the intervention. Setting aside these limitations, the evidence on interventions to reduce food insecurity was generally favorable. One very small (n = 44), fair-quality randomized crossover study did report lower levels of food insecurity when on meals vs off meals in a 24-week study (42% vs 62%),²⁹ and most of the poor-quality studies that focused on the provision of food or food vouchers generally found improved food security at follow-up, although many results were not statistically significant. The evidence was more mixed among studies that provided only application support or referrals, although some findings were favorable. Due to the limitations of the data, there was only low certainty that interventions can improve food security in the short term (1 year or less), particularly those that provide food or vouchers. Findings are consistent with those of other recently published systematic reviews of screening and intervention for food security, finding that much of the evidence is limited to study designs at higher risk of bias and focused on process (eg, receipt of referral) or food-insecurity status outcomes, rather than patient health outcomes.^59,60

Social Risk Factors vs Social Needs

Food insecurity is considered a key social risk factor—a measurable, intervenable, individual-level social and economic condition shaped by broader social and structural determinants of health such as house costs,wages, and the cost of higher education.^15,61-63 The Centers for Medicare & Medicaid Services has identified 5 core social risk factors that community services can help with: food insecurity, housing instability, transportation needs, utility help needs, and interpersonal safety.⁶⁴ These social risk factors are interconnected. For instance, a low income and unemployment are often directly connected to other risk factors, such as food insecurity, housing instability, and transportation issues.

Social needs are social risk factors that individuals prioritize as something they believe is important to address and would like assistance with.⁶¹ Not all households with food insecurity identify it as a pressing need,⁶⁵ and recent commentators have noted that exploring the patients’ social needs demonstrates respect by recognizing individuals’ autonomy and acknowledging that they are the best judge of their own needs.⁶⁶

Implementation

The difference between screening for social risk factors and social needs demonstrates one potential challenge in implementation, but there are other considerations as well. Simply implementing a risk screeningtool in an electronic health record system is unlikely to lead to widespread adoption.⁶⁷ Sufficient resources are needed, including appropriate staffing (eg, community health workers, translation services), training, and funding.^68-70

Specifically, some authors have suggested the need to ensure that staff who administer social risk screening display empathy and are sensitive to patient’s lived experience and social needs.⁶⁶ It is also important to involve community members and social service agencies in codesigning social support programs, support partnerships with existing community organizations, gather data on implementation to understand gaps in the process, identify unintended consequences, and help ensure equitable delivery of screening and interventions,⁷¹ because some evidence suggests differences in screening for social risk factors by patient race or ethnicity and preferred language.⁷² Although the acceptability of screening for food insecurity is generally rated good among patients,¹⁶ it may also evoke feelings of stigma, shame, fear of consequences, or mistrust.^15,73 Further, 1 study found that those with food insecurity had higher levels of mistrust in medical professionals, suggesting the need for sensitive handling of discussions related to social needs.⁷⁴ Also, patients with limited health literacy or language barriers may struggle to understand the purpose and importance of food insecurity assessments, impeding their participation.⁷³

Limitations

There were several limitations related to the scope and methods of this review. First, schools and community settings may provide important points of entry for addressing social needs for families with children but were not included because they are outside the scope of health care systems.

Second, although it was specified in the apriori research plan that only studies conducted in US health care settings would be considered for all KQs, the review included 2 studies examining the accuracy of screening tools (KQ2) that were not conducted in US health care settings. These were studies using data from the US Census Bureau, including very large samples that are representative of the US population. It was felt that instrument accuracy might be less vulnerable to variation across settings than screening and intervention studies and therefore that these studies would add potentially valuable information, given their large size and carefully constructed samples to be broadly representative of the US population.

Third, only screening and interventions to ameliorate food insecurity were addressed, yet people often experience more than 1 social risk factor, and it may not make sense to evaluate only food insecurity without considering other social risk factors such as financial or housing insecurity.

Last, because food security is a basic need as opposed to a medical condition, it may not fit well within the traditional USPSTF review. It would not be ethical to conduct a study that ignores identified food need (ie, includes a control group), and most long-term solutions to food insecurity are related to social and environmental factors that the health care system cannot change. The most important research questions, which are beyond the typical scope of the USPSTF review, may include what role the health care system can play with respect to food insecurity; patient preferences for how food insecurity is discussed to minimize feelings of shame and stigma; and identifying specific strategies and implementation approaches or components that are most effective and have the least risk of harm. In addition, there are critical limitations of the evidence. First and most concerning, there were only 3 eligible studies (combined n = 1009) on the benefits of screening or interventions for food insecurity that were rated as having at least fair-quality methods for the outcomes relevant to this review, the largest of which (n = 789) showed no benefit of screening. There were additional studies included that were rated as “poor” quality for the outcomes relevant to this review but did not lead to clear conclusions due to the high risk of bias in these studies; these studies were generally reports of pragmatic programs in which the primary aim was to implement the intervention rather than providing robust research findings. Therefore, the studies included yielded little information on whether interventions to improve food security led to improvements in health. In addition, none of the studies conducted analyses showing whether individuals who showed greater improvement in food security also showed greater improvements in health.

Second, the lack of reporting of the assessment windows (eg, 30-day or 12-month look back) used to assess food insecurity further limits the strength of the conclusions from the pre-post studies, which constituted 24 of the 29 studies of interventions.

Third, for interventions addressing food security along with other intervention components (eg, nutrition counseling, medical management, addressing other social needs), the impact of the other components could not be separated from the impact of the food security components; improvements in health outcomes could be due to medical management or improved diet quality, for example, rather than the receipt of food aid. Therefore, these outcomes were not included in this review. Relatedly, it also is possible that the other components affected the food security outcomes, limiting confidence that the food security elements of the intervention would have the same impact in the absence of the co-interventions. Fourth, the included studies assessed for social risk factors but rarely described how or whether social needs were determined after risk factors were identified. Future studies should carefully develop and describe the shared decision-making process once social risk factors have been identified.

Brief screening tools likely have sufficient sensitivity to identify people with food insecurity in health care settings, but most studies of interventions to improve food insecurity had high risk of bias, limiting firm conclusions.

Source: This article was published online in JAMA on March 11, 2025 (JAMA. doi:10.1001/jama.2024.22805).

Conflict of Interest Disclosures: Ms Martin reported that she is an author on one of the studies included for the analysis but that she recused herself from the quality rating process of included studies to avoid undue influence.

Funding/Support: This research was funded under contract 75Q80120D00004, Task Order 75Q80122F32006, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight; reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript finding

Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Justin Mills, MD, MPH (AHRQ); current and former members of the USPSTF who contributed to topic deliberations; and current and former Evidence-based Practice Center staff members Melinda Davies, MAIS; Rachel Thomas, MPH; Leslie Perdue, MPH; Katherine Essick; and Debra Burch for technical and editorial assistance at the Kaiser Permanente Center for Health Research. USPSTF members, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of this evidence report underwent external peer review from 4 content experts (Andrew Beck, MD, MPH [University of Cincinnati]; Emilia De Marchis, MD [University of California]; David Mosen, PhD, MPH [Kaiser Permanente Center for Health Research]; and Wendy Lane, MD, MPH [University of Maryland School of Medicine]) and 4 individuals at USPSTF federal partner agencies (National Heart, Lung, and Blood Institute; Office of Disease Prevention; Office of Research on Women’s Health; Eunice Kennedy Shriver National Institute of Child Health and Human Development). Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.

1. Coleman-Jensen A, Rabbitt M, Gregory C, Singh A. Household Food Security in the United States in 2020, ERR-298. US Department of Agriculture. Accessed January 10, 2025. https://www.ers.usda.gov/publications/pub-details/?pubid=102075
2. Food and Agriculture Organization of the United Nations, International Fund for Agricultural Development, World Food Programme. The state of food insecurity in the world. Published 2015. Accessed January 10, 2025. https://www.fao.org/3/i4646e/i4646e.pdf
3. Rabbitt MP, Hales LJ, Burke MP, Coleman-Jensen A. Household food security in the United States in 2022. Published 2023. Accessed October 30, 2023. https://www.ers.usda.gov/webdocs/publications/107703/err-325.pdf?v=5285
4. Jernigan VBB, Huyser K, Valdes J, Watts Simonds V. Food insecurity among American Indians and Alaska Natives: a national profile using the Current Population Survey-Food Security Supplement. J Hunger Environ Nutr. 2017;12(1):1-10. doi:10.1080/19320248.2016.1227750
5. Loopstra R. Interventions to address household food insecurity in high-income countries. Proc Nutr Soc. 2018;77(3):270-281. doi:10.1017/S002966511800006X
6. Anderson S. Core indicators of nutritional state for difficult-to-sample populations. J Nutr. 1990;120(suppl 11):1559-1600. doi:10.1093/jn/120.suppl_11.1555
7. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff (Millwood). 2015;34(11):1830-1839. doi:10.1377/hlthaff.2015.0645
8. Rose-Jacobs R, Black MM, Casey PH, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121(1):65-72. doi:10.1542/peds.2006-3717
9. Ryu JH, Bartfeld JS. Household food insecurity during childhood and subsequent health status: the early childhood longitudinal study—kindergarten cohort. Am J Public Health. 2012;102(11):e50-e55. doi:10.2105/AJPH.2012.300971
10. Leung CW, Kullgren JT, Malani PN, et al. Food insecurity is associated with multiple chronic conditions and physical health status among older US adults. Prev Med Rep. 2020;20:101211. doi:10.1016/j.pmedr.2020.101211
11. Venci BJ, Lee SY. Functional limitation and chronic diseases are associated with food insecurity among U.S. adults. Ann Epidemiol. 2018;28(3):182-188. doi:10.1016/j.annepidem.2018.01.005
12. Muldoon KA, Duff PK, Fielden S, Anema A. Food insufficiency is associated with psychiatric morbidity in a nationally representative study of mental illness among food insecure Canadians. Soc Psychiatry Psychiatr Epidemiol. 2013;48(5):795-803. doi:10.1007/s00127-012-0597-3
13. US Preventive Services Task Force. US Preventive Services Task Force Procedure Manual. Accessed January 10, 2025. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
14. O’Connor EA,Webber EM, Martin A, Henninger ML, Eder M, Lin JS. Preventive Services for Food Insecurity: A Systematic Review for the US Preventive Services Task Force. Evidence Synthesis No. 240. Agency for Healthcare Research and Quality; 2025. AHRQ publication 24-05314-EF-1.
15. Eder M, Henninger M, Durbin S, et al. Screening and interventions for social risk factors: technical brief to support the US Preventive Services Task Force. JAMA. 2021;326(14):1416-1428. doi:10.1001/jama.2021.12825
16. De Marchis EH, Torres JM, Fichtenberg C, Gottlieb LM. Identifying food insecurity in health care settings: a systematic scoping review of the evidence. Fam Community Health. 2019;42(1):20-29. doi:10.1097/FCH.0000000000000208
17. Poblacion A, Ettinger de Cuba S, Frank DA, et al. Development and validation of an abbreviated child and adult food security scale for use in clinical and research settings in the United States. J Acad Nutr Diet. 2023;123(10 suppl):S89-S102.e4. doi:10.1016/j.jand.2023.02.004
18. Berkman ND, Lohr KN, Ansari MT, et al. Grading the strength of a body of evidence when assessing health care interventions: an EPC update. J Clin Epidemiol. 2015;68(11):1312-1324. doi:10.1016/j.jclinepi.2014.11.023
19. Lane WG, Dubowitz H, Feigelman S, Poole G. The effectiveness of food insecurity screening in pediatric primary care. Int J Child Health Nutr. 2014;3(3):130-138. doi:10.6000/1929-4247.2014.03.03.3
20. Baer TE, Scherer EA, Fleegler EW, Hassan A. Food insecurity and the burden of health-related social problems in an urban youth population. J Adolesc Health. 2015;57(6):601-607. doi:10.1016/j.jadohealth.2015.08.013
21. Blumberg SJ, Bialostosky K, Hamilton WL, Briefel RR. The effectiveness of a short form of the Household Food Security Scale. Am J Public Health. 1999;89(8):1231-1234. doi:10.2105/AJPH.89.8.1231
22. Gattu RK, Paik G, Wang Y, Ray P, Lichenstein R, Black MM. The hunger vital sign identifies household food insecurity among children in emergency departments and primary care. Children (Basel). 2019;6(10):107. doi:10.3390/children6100107
23. Gundersen C, Engelhard EE, Crumbaugh AS, Seligman HK. Brief assessment of food insecurity accurately identifies high-risk US adults. Public Health Nutr. 2017;20(8):1367-1371. doi:10.1017/S1368980017000180
24. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26-e32. doi:10.1542/peds.2009-3146
25. Harrison C, Goldstein JN, Gbadebo A, Papas M. Validation of a 2-item food insecurity screen among adult general medicine outpatients. Popul Health Manag. 2021;24(4):509-514. doi:10.1089/pop.2020.0183
26. Makelarski JA, Abramsohn E, Benjamin JH, Du S, Tessler Lindau S. Diagnostic accuracy of two food insecurity screeners recommended for use in health care settings. Am J Public Health. 2017;107(11):1812-1817. doi:10.2105/AJPH.2017.304033
27. Radandt NE, Corbridge T, Johnson DB, Kim AS, Scott JM, Coldwell SE. Validation of a two-item food security screening tool in a dental setting. J Dent Child (Chic). 2018;85(3):114-119.
28. Harle CA, Wu W, Vest JR. Accuracy of electronic health record food insecurity, housing instability, and financial strain screening in adult primary care. JAMA. 2023;329(5):423-424. doi:10.1001/jama.2022.23631
29. Berkowitz SA, Delahanty LM, Terranova J, et al. Medically tailored meal delivery for diabetes patients with food insecurity: a randomized cross-over trial. J Gen Intern Med. 2019;34(3):396-404. doi:10.1007/s11606-018-4716-z
30. Wu AW, Weston CM, Ibe CA, et al. The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) cluster RCT. Am J Prev Med. 2019;57(2):e31-e41. doi:10.1016/j.amepre.2019.03.013
31. Morales ME, Epstein MH, Marable DE, Oo SA, Berkowitz SA. Food insecurity and cardiovascular health in pregnant women: results from the Food for Families Program, Chelsea, Massachusetts, 2013-2015. Prev Chronic Dis. 2016;13:E152. doi:10.5888/pcd13.160212
32. Slagel N, Newman T, Sanville L, et al. Effects of a fruit and vegetable prescription program with expanded education for low-income adults. Health Educ Behav. 2022;49(5):10901981221091926. doi:10.1177/10901981221091926
33. Aiyer JN, Raber M, Bello RS, et al. A pilot food prescription program promotes produce intake and decreases food insecurity. Transl Behav Med. 2019;9(5):922-930. doi:10.1093/tbm/ibz112
34. Berkowitz SA, Hulberg AC, Placzek H, et al. Mechanisms associated with clinical improvement in interventions that address health-related social needs: a mixed-methods analysis. Popul Health Manag. 2019;22(5):399-405. doi:10.1089/pop.2018.0162
35. Byker Shanks C, Vanderwood K, Grocke M, et al. The UnProcessed Pantry Project (UP3): a community-based intervention aimed to reduce ultra-processed food intake among food pantry clients. Fam Community Health. 2022;45(1):23-33. doi:10.1097/FCH.0000000000000310
36. Cohen AJ, Richardson CR, Heisler M, et al. Increasing use of a healthy food incentive: a waiting room intervention among low-income patients. Am J Prev Med. 2017;52(2):154-162. doi:10.1016/j.amepre.2016.11.008
37. Cook M,Ward R, Newman T, et al. Food security and clinical outcomes of the 2017 Georgia Fruit and Vegetable Prescription Program. J Nutr Educ Behav. 2021;53(9):770-778. doi:10.1016/j.jneb.2021.06.010
38. Fischer L, Bodrick N, Mackey ER, et al. Feasibility of a home-delivery produce prescription program to address food insecurity and diet quality in adults and children. Nutrients. 2022;14(10):10. doi:10.3390/nu14102006
39. Freedman DA, Choi SK, Hurley T, Anadu E, Hébert JR. A farmers’ market at a federally qualified health center improves fruit and vegetable intake among low-income diabetics. Prev Med. 2013;56(5):288-292. doi:10.1016/j.ypmed.2013.01.018
40. Gottlieb L, Hessler D, Long D, et al. Are acute care settings amenable to addressing patient social needs: a sub-group analysis. Am J Emerg Med. 2018;36(11):2108-2109. doi:10.1016/j.ajem.2018.03.034
41. Gottlieb LM, Adler NE, Wing H, et al. Effects of in-person assistance vs personalized written resources about social services on household social risks and child and caregiver health. JAMA Netw Open. 2020;3(3):e200701. doi:10.1001/jamanetworkopen.2020.0701
42. Izumi BT, Martin A, Garvin T, et al. CSA Partnerships for Health: outcome evaluation results from a subsidized community-supported agriculture program to connect safety-net clinic patients with farms to improve dietary behaviors, food security, and overall health. Transl Behav Med. 2020;10(6):1277-1285.
43. Jones LJ, VanWassenhove-Paetzold J, Thomas K, et al. Impact of a fruit and vegetable prescription program on health outcomes and behaviors in young Navajo children. Curr Dev Nutr. 2020;4(8):nzaa109. doi:10.1093/cdn/nzaa109
44. Orsega-Smith ESN, Cotugna N. Local pediatricians partner with food bank to provide produce prescription program. J Hunger Environ Nutr. 2020;15(3):353-359. doi:10.1080/19320248.2019.1592051
45. Saxe-Custack A, LaChance J, Hanna-Attisha M. Child consumption of whole fruit and fruit juice following six months of exposure to a pediatric fruit and vegetable prescription program. Nutrients. 2019;12(1):25. doi:10.3390/nu12010025
46. Scher K, Sohaki A, Tang A, Plum A, Taylor M, Joseph C. A community partnership to evaluate the feasibility of addressing food insecurity among adult patients in an urban healthcare system. Pilot Feasibility Stud. 2022;8(1):59. doi:10.1186/s40814-022-01013-3
47. Seligman HK, Lyles C, Marshall MB, et al. A pilot food bank intervention featuring diabetes-appropriate food improved glycemic control among clients in three states. Health Aff (Millwood). 2015;34(11):1956-1963. doi:10.1377/hlthaff.2015.0641
48. Shankar KN, Dugas JN, Flacks J, et al. High touch, high trust: using community health advocates and lawyers to address ED high utilizers. Am J Emerg Med. 2022;60:171-176. doi:10.1016/j.ajem.2022.07.049
49. Singer C, Porta C. Improving patient well-being in the United States through care coordination interventions informed by social determinants of health. Health Soc Care Community. 2022;30(6):2270-2281. doi:10.1111/hsc.13776
50. Wetherill MS, Chancellor McIntosh H, Beachy C, Shadid O. Design and implementation of a clinic-based food pharmacy for food insecure, uninsured patients to support chronic disease self-management. J Nutr Educ Behav. 2018;50(9):947-949. doi:10.1016/j.jneb.2018.05.014
51. Xie J, Price A, Curran N, Østbye T. The impact of a produce prescription programme on healthy food purchasing and diabetes-related health outcomes. Public Health Nutr. 2021;24(12):3945-3955. doi:10.1017/S1368980021001828
52. Kempainen S, Cutts DB, Robinson-O’Brien R, De Kesel Lofthus A, Gilbertson DT, Mino R. A collaborative pilot to support patients with diabetes through tailored food box home delivery. Health Promot Pract. 2023;24(5):963-968. doi:10.1177/15248399221100792
53. Ranjit N, Aiyer JN, Toups JD, et al. Clinical outcomes of a large-scale, partnership-based regional food prescription program: results of a quasi-experimental study. BMC Res Notes. 2023;16(1):13. doi:10.1186/s13104-023-06280-8
54. Woo Baidal JA, Duong N, Goldsmith J, et al. Association of a primary care-based mobile food pantry with child body mass index: a propensity score matched cohort study. Pediatr Obes. 2023;18(6):e13023. doi:10.1111/ijpo.13023
55. Renaud J, McClellan SR, DePriest K, et al. Addressing health-related social needs via community resources: lessons from accountable health communities. Health Aff (Millwood). 2023;42(6):832-840. doi:10.1377/hlthaff.2022.01507
56. Rivera RL, Adams M, Dawkins E, et al. Delivering Food Resources and Kitchen Skills (FoRKS) to adults with food insecurity and hypertension: a pilot study. Nutrients. 2023;15(6):17. doi:10.3390/nu15061452
57. Hager K, Du M, Li Z, et al. Impact of produce prescriptions on diet, food security, and cardiometabolic health outcomes: a multisite evaluation of 9 produce prescription programs in the United States. Circ Cardiovasc Qual Outcomes. 2023;16(9):e009520. doi:10.1161/CIRCOUTCOMES.122.009520
58. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food Security in the United States in 2021. US Department of Agriculture, Economic Research Service. Published 2022. https://www.ers.usda.gov/publications/pub-details/?pubid=104655
59. Oronce CIA, Miaki-Lye IM, Begashaw MM, Booth M, Shrank WH, Shekelle PG. Interventions to address food insecurity among adults in Canada and the US: a systematic review and meta-analysis. JAMA Health Forum. 2021;2(8):e212001-e212001. doi:10.1001/jamahealthforum.2021.2001
60. De Marchis EH, Torres JM, Benesch T, et al. Interventions addressing food insecurity in health care settings: a systematic review. Ann Fam Med. 2019;17(5):436-447. doi:10.1370/afm.2412
61. Alderwick H, Gottlieb LM. Meanings and misunderstandings: a social determinants of health lexicon for health care systems. Milbank Q. 2019;97(2):407-419. doi:10.1111/1468-0009.12390
62. Green K, Zook M. When talking about social determinants, precision matters. Health Affairs. Published October 29, 2019. Accessed January 10, 2025. https://www.healthaffairs.org/content/forefront/talking-social-determinants-precision-matters
63. Castrucci B, Auerbach J. Meeting individual social needs falls short of addressing social determinants of health. Health Affairs. Published January 16, 2019. Accessed November 10, 2021. https://www.healthaffairs.org/content/forefront/meeting-individual-social-needs-falls-short-addressing-social-determinants-health
64. Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. National Academies Press; 2017.
65. Gruß I, Varga A, Brooks N, Gold R, Banegas MP.Patient interest in receiving assistance with self-reported social risks. J Am Board Fam Med. 2021;34(5):914-924. doi:10.3122/jabfm.2021.05.210069
66. Garg A, LeBlanc A, Raphael JL. Inadequacy of current screening measures for health-related social needs. JAMA. 2023;330(10):915-916. doi:10.1001/jama.2023.13948
67. Cottrell EK, Dambrun K, Cowburn S, et al. Variation in electronic health record documentation of social determinants of health across a national network of community health centers. Am J Prev Med. 2019;57(6)(suppl 1):S65-S73. doi:10.1016/j.amepre.2019.07.014
68. Yaun JA, Rogers LW, Marshall A, McCullers JA, Madubuonwu S. Whole child well-child visits:implementing ACEs and SDOH screenings in primary care. Clin Pediatr (Phila). 2022;61(8):542-550. doi:10.1177/00099228221093279
69. Canavan CR, D’cruze T, Kennedy MA, et al. Missed opportunities to improve food security for pregnant people: a qualitative study of prenatal care settings in Northern New England during the COVID-19 pandemic. BMC Nutr. 2022;8(1):8. doi:10.1186/s40795-022-00499-7
70. Nederveld AL, Duarte KF, Rice JD, Richie A, Broaddus-Shea ET. IMAGINE: a trial of messaging strategies for social needs screening and referral. Am J Prev Med. 2022;63(3)(suppl 2):S164-S172. doi:10.1016/j.amepre.2022.04.025
71. Ridberg RA, Yaroch AL, Nugent NB, Byker Shanks C, Seligman H. A case for using electronic health record data in the evaluation of produce prescription programs. J Prim Care Community Health. 2022;13:21501319221101849. doi:10.1177/21501319221101849
72. De Marchis EH, Aceves B, Razon N, Chang Weir R, Jester M, Gottlieb LM. “Wanting the best for our folks”—a mixed methods analysis of community health center social risk screening initiatives. J Am Board Fam Med. 2023;36(5):817-831. doi:10.3122/jabfm.2023.230099R1
73. Selvaraj K, Korpics J, Osta AD, Hirshfield LE, Crowley-Matoka M, Bayldon BW. Parent perspectives on adverse childhood experiences & unmet social needs screening in the medical home: a qualitative study. Acad Pediatr. 2022;22(8):1309-1317. doi:10.1016/j.acap.2022.08.002
74. Thomas MK, Amstutz C, Orr-Roderick D, Horter J, Holben DH. Medical mistrust among food insecure individuals in Appalachia. Fam Community Health. 2023;46(3):192-202. doi:10.1097/FCH.0000000000000362

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address in order to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line depicts a health outcome that follows an intermediate outcome. For more details, see the USPSTF Procedure Manual.^13
a Intermediate outcomes include behavioral, physiologic, decision-making, patient participation, and health care utilization outcomes.
^b Health outcomes include (but are not limited to): low birth weight, developmental outcomes in children, incident diabetes, mental health, cardiovascular events, quality of life.

KQ indicates key question.
^a Reasons for exclusion: Study aim: Study aim was not relevant. Setting: Study was not conducted in a country relevant to US practice or not conducted in, recruited from, or feasible for primary care or a health system. Population: Study was not conducted in an included population. Design: Study did not use an included design. Intervention: Study did not use an included intervention. Comparator: Study did not use an included comparator. Outcomes: Study did not report relevant outcomes. Quality: Study did not meet quality standards. Language: Study publication was not available in English. Publication type: Publication was a conference abstract only.

Shaded areas indicate range of 0.70-1.0, the arbitrary range in this review for good/acceptable accuracy. AAP indicates American Academy of Pediatrics; HFSS, Household Food Security Survey; HVS, Hunger Vital Sign; KQ, key question; NR, not reported; USDA-FSS, US Department of Agriculture Food Security Survey.

The size of data markers indicates the weight of each study, based on the inverse of the variance of the estimate. Appl support indicates application support (eg, applications for Supplemental Nutrition Assistance Program or Supplemental Nutrition Program forWomen, Infants, and Children); CG, control group; FS, food security; IG, intervention group; KQ, key question; multi, assessed and addressed multiple social domains; nutr ed, nutritional education.
^a Randomized crossover trial.
^b Nonrandomized study of interventions.
^c Cluster randomized clinical trial.

Abbreviations: FQHC, Federally Qualified Health Center; IG, intervention group; NRSI, nonrandomized studies of interventions; RCT, randomized clinical trial; SNAP, Supplemental Nutritional Assistance Program.
^a Quality rating was applied only to the outcomes and related analyses relevant to this review, which may differ from the primary aim of the study. Thus, studies could have fair or good quality methods for their primary aim, which would not be reflected in the rating. For quality rating criteria, see eTable 2 in the JAMA Supplement.
^b Participants were screened for food insecurity as part of the study enrollment process (and may have also been screened for other social needs).
^c Relevant outcomes only available on the subgroups of participants with diabetes.

Abbreviations: KQ, key question; NA, not applicable; NRSI, nonrandomized studies of interventions; RCT, randomized clinical trial.