Food Insecurity: Screening

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including healthcare delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

According to the U.S. Department of Agriculture (USDA) Economic Research Service’s Current Population Survey, 12.8% of households experienced food insecurity in 2022, with 7.7% of households experiencing low food security and 5.1% experiencing very-low food security.¹  Nearly one-third of households with incomes below the federal poverty threshold are food insecure. Food insecurity is one among a multitude of medical, psychological, and social conditions common among economically disadvantaged households. In both children and adults, experiencing food insecurity is associated with negative effects on health outcomes.^2,3

Interventions to address food insecurity include those taking place at the community level (i.e., food pantries or free school lunch programs); through local, state, or federal programs (e.g., Special Supplemental Nutrition Program [SNAP] or Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]); or those directly related to the healthcare setting (as addressed in this recommendation statement).

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for food insecurity on health outcomes in the primary care setting. There is limited evidence on the health outcome effect of screening for and interventions to address food insecurity in the primary care setting, and the balance of benefits and harms cannot be determined.

Refer to Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁴

Patient Population Under Consideration

This recommendation applies to children, adolescents, and adults, including pregnant and postpartum persons.

Definitions

Food insecurity is considered a social risk factor; it is a measurable and modifiable social and economic condition shaped by broader social and structural determinants of health, and measured at the household or individual level.³ The Centers for Medicare & Medicaid Services have identified five core social risk factors that community services can help with: food insecurity, housing instability, transportation problems, utility help needs, and interpersonal safety.⁵ Social risk factors often are interconnected. For example, food insecurity is associated with other factors such as housing instability and transportation issues. Social needs, such as food security, are social factors patients identify as issues for which they would like assistance.⁶

Food insecurity is generally defined as an economic and social condition of perceived limited or uncertain access to sufficient amounts of nutritious food needed for an active and healthy life.^7,8 Food insecurity can be long term, temporary, periodic (i.e., running out of money at the end of the month), or related to a specific event (i.e., loss of employment). It can also differ among household members, such as when parents or caregivers go without food to maintain their children’s diet. Food insecurity differs from hunger, which is generally defined as an individual-level physiological state related to insufficient caloric intake that may result from food insecurity.⁹

Individuals may respond to food insecurity by changing their preferred variety of foods, food sources (e.g., grocery stores, convenience stores, or food pantries), the amount of food they consume, or going without food.^10,11 The USDA divides food insecurity into two categories: “very low food security,” in which some household members reduce their food intake because of an inability to afford enough food, and “low food security,” where at some point during the year, households reduced the quality, variety, or desirability of their diets but maintained normal eating patterns.¹² Additionally, the USDA classifies food security into two categories: “marginal food security,” in which households had problems or anxiety accessing food at times, but did not substantially alter the quality, variety, or quantity of their intake, and “high food security,” in which households had no problems or anxiety about consistently accessing adequate food.¹²

Populations at Risk

Poverty, due to unemployment or other conditions, is the primary cause of food insecurity. Certain populations, such as households with children (particularly those with children younger than age 6 years); households headed by a single caregiver; households of those with incomes below 185% of the poverty level; lesbian, gay, bisexual, and transgender persons; older adults; individuals with disabilities; and veterans are at higher risk for food insecurity.³ Having a chronic medical condition is both a risk factor for and associated with food insecurity. Persons living in low-income neighborhoods are at increased risk of food insecurity for several reasons, including limited access to healthy foods, fewer full-service grocery stores, and limited public and private transportation options.^13-15

There are significant disparities in food insecurity by race and ethnicity. In 2022, 22% of non-Hispanic Black households and 20% of Hispanic households experienced food insecurity, compared with 9% of White households. Native American/Alaska Native households are more than twice as likely as White populations to experience food insecurity.^16,17

Screening Tests

There are limited data on how screening tools are used in clinical practice. Multiple social risk factors are often assessed via multidomain tools (e.g., Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education [WE CARE], Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) rather than screening for food insecurity alone.^3,18  The most frequently used and studied single-domain screening tool for food insecurity is the two-item Hunger Vital Sign tool. The first question asks respondents if during the past 12 months, they: 1) worried about running out of food and not having money to buy more, and 2) experienced running out of food and not having money to buy more.^19-21 It is derived from, and validated, against the USDA Household Food Security Survey.²¹

Treatment or Interventions

Interventions applicable to healthcare settings include food prescription programs, food boxes or pantries provided in, or linked to, clinics, and medically tailored meals.^22,23 Another common form of primary care–based intervention is care coordination linking patients with local or state benefits programs (e.g., onsite benefits coordinator to assist with enrollment in SNAP or WIC).

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Living in a household with food insecurity as a child is associated with obesity asthma, cognitive problems, mental health conditions, and worse oral health.^2,24 Experiences of hunger during childhood have also been associated with poor health later in life.^25-27 In adults, food insecurity is associated with an increased risk of several health conditions, including obesity, diabetes, hypertension, cardiovascular disease, asthma, chronic obstructive pulmonary disease, arthritis, and kidney disease. Adults experiencing food insecurity are also more likely to experience poor mental health, including psychological distress, depression, and anxiety. The exact reasons for these connections are unclear, but some evidence suggests stress, challenges managing existing health conditions, dietary changes towards less healthy options, and changes in gut bacteria could all play a role.³

Potential Harms

No studies reported harms of screening.^28,29 Potential harms include stigma, fear of involvement in the legal/justice system (e.g., disclosing food insecurity may prompt Child Protective Services involvement), and other privacy concerns. There may also be unintended consequences from interventions. For example, patients who receive food-related benefits may see other benefits reduced or cut off if their income increases. This could lead to financial strain, making it difficult for them to afford other necessities.³⁰

Current Practice

Several studies indicate that providers and patients believe that social risks and/or needs, including food insecurity, should be addressed in healthcare settings. However, estimates of screening for food insecurity vary considerably across providers (between 25% and 100%).³¹ The screening tool, setting, type of visit, format/mode of delivery, and timing of screening varies across practice settings.³² Additionally, some healthcare systems use screening tools to measure prevalence and better understand the needs of their population, while others screen and follow with referrals, clinical care, and additional services.²²

While it is known that food and nutritional security change over time, there is limited research on the appropriate screening interval for food insecurity. Most screening tools do not assess the duration of food insecurity, and therefore cannot assess whether it is temporary.³³ One study examining food insecurity over the first years of the COVID-19 pandemic found that children of caregivers who received general social needs screenings and relevant referrals every 6 months had greater improvements in social needs than those who received annual well-child screenings and referrals.³⁴

Other Related USPSTF Recommendations

The USPSTF has recommendation statements related to social determinants of health, including screening for intimate partner violence, elder abuse, and abuse of vulnerable adults and the primary prevention of child maltreatment.^35,36 The USPSTF has also published commentaries on incorporating social determinants/social risk factors into its clinical preventive recommendations.^37,38

Additional Tools and Resources

The Community Preventive Services Task Force has recommendations for population-health interventions related to addressing social determinants of health.³⁹

Scope of Review 

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for food insecurity in the healthcare setting. To be included in the review, studies had to have occurred in a healthcare setting and include screening conducted in a clinical setting or identified through a healthcare delivery or payment system and interventions or programs integrated into, associated with, or referred from healthcare.³ Studies limited to participants who were undergoing cancer treatment, had other acute medical or psychiatric conditions, or had severe malnutrition or known nutritional deficiencies were excluded from the review.³ 

Accuracy of Screening Tests and Risk Assessment 

Ten fair-quality studies with a total of 123,886 participants assessed one-item (1 study), two-item (8 studies), or six-item (1 study) screening tools for performance.³ All were derived from the USDA's 18-item Household Food Security Survey. Study settings included primary care (4 studies), primary care plus emergency department (2 studies), emergency department (1 study), and dental clinic (1 study).³ The remaining two studies analyzed U.S. Census data. Five studies included only adult participants, four studied families with children, and one studied teenagers and young adults (ages 15 to 25 years). Eight studies only administered the reference standard and then assessed agreement between item subsets and the full version.³ 

For the two-item screening tool, the sensitivity was typically above 95% and specificity was above 82% when the screening tool was fully embedded in the reference standard (in most cases, the 18 or six-item version of the Household Food Security Survey) or administered within the same larger questionnaire.³ However, the lack of independent administration of the screening tool likely overestimated the performance of the screening tool under usual clinical use.³ The one-item screening tool had the lowest accuracy, with a sensitivity of 59% and specificity of 87%, but it was also the only study of the screening tool in which it was administered independently from the reference standard.³ 

Benefits of Screening and Interventions 

The USPSTF identified one fair-quality randomized, controlled trial (n=789) examining the benefits of screening for food insecurity in families with children younger than age 6 years.³ Parents in the intervention group were screened for child maltreatment risk factors (intimate partner violence, parent depression, substance abuse, and use of corporal punishment), which included food insecurity. Families screening positive for food insecurity were given information on how to access federal and local food-related assistance. It found no difference in the percentage reporting food insecurity after 6 months between the intervention group (29.6% with food insecurity) and usual care (29.8% with food insecurity).⁴⁰ 

The USPSTF reviewed two fair-quality studies (n=220) examining the benefits of healthcare-related interventions on food security, intermediate outcomes, and health outcomes.³ The first was a randomized crossover trial (n=44) that included home delivery of medically tailored meals to patients with diabetes for 12 weeks.⁴¹ At the end of the study period (24 weeks), the intervention was associated with reduced food insecurity (41.9% with food insecurity while on meals vs. 61.5% while off meals; p=0.05), improved mental health quality of life (4.7-point change from baseline while on meals vs. 0.8-point change while off meals), and improved diet quality (e.g., the 100-point total Healthy Eating Index score improved by 14.1 points while on meals compared to baseline but declined by 17.3 points while off meals). However, there was no impact on other quality of life measures; physiologic measures of blood pressure, lipid levels, or glucose levels; or cost-related medication underuse.^3,41 

The second fair-quality study (n=176) was a nonrandomized study of interventions comparing 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.⁴² At 6 months, the study found a smaller increase in body mass index among those who participated in the mobile food pantry. It did not report between-group differences in food insecurity but reported a 1-point reduction (4.3 to 3.3) on a 6-point food insecurity scale among those in the intervention group. 

Several other studies (27 studies) were found that did not contribute to the USPSTF assessment of the evidence because they were of poor quality due to a high risk of bias for the outcomes of interest. Many were pre-post studies or were designed for other purposes (e.g., primary interest in other outcomes or comparative effectiveness).³ 

Harms of Screening and Treatment 

The USPTF found no eligible studies on the harms of screening.³ Only one study of interventions, the trial of home-delivered meals (n=44), provided data on intervention harms. Harm was observed for only one participant who experienced gastrointestinal distress.⁴¹

The USPSTF recognizes the important connection between a person’s social and economic condition and their health, and continues to explore how to best incorporate social needs into its recommendation process. Given the potential evidence base and the feasibility of primary care–based interventions, screening for food insecurity was chosen as an initial recommendation statement focusing on a social risk factor. In order to assess the balance of benefits and harms, the USPSTF needs evidence that screening for food insecurity leads to health benefits. In the absence of this type of direct evidence, the USPSTF looks for evidence linking studies that show screening tests are accurate with evidence showing that interventions reduce food insecurity and improve health outcomes. However, as the USPSTF reviewed this topic, there were several aspects specific to screening for social risk that complicated its assessment of the balance of benefits and harms.

First, there are limitations to food insecurity interventions that can be provided or referred from the primary care setting. As a social condition, food insecurity requires direct intervention on the social circumstances (i.e., poverty) that cause it. Primary care–based and primary care–referrable interventions generally offer only limited “treatment” of food insecurity through interventions that provide access to community resources, or limited access to food without changing a person’s social circumstance (e.g., income). Community-based interventions, like those reviewed and recommended by the Community Preventive Services Task Force, may be a more effective way to address food insecurity.³⁹ Additionally, the most direct interventions to address social conditions that result in food security may occur with changes in policies at the local, state, and national levels.  

Second, addressing social risk factors in primary care may not have the same direct relationship with health outcomes that is seen with health-focused screenings or interventions. Social risk factors such as food insecurity rarely exist in isolation, and screening for or intervening in one social determinant may not completely address the impact on health outcomes. Social determinants may also shape a patient’s situation in a manner that affects their ability to effectively receive other clinical preventive or primary care services, indirectly impacting a variety of health outcomes. For example, a patient’s food insecurity status may be important to identify to provide primary care management of diabetes, separately from providing resources for food insecurity directly. Identifying and addressing a social risk such as food insecurity in the primary care setting may also be necessary to help a patient attend to other preventive care needs.

Third, social needs (factors with which patients would like assistance), as opposed to social risks identified by screening, may complicate the direct benefit of screening. For example, a clinician may identify a patient with food insecurity, but if the patient prioritizes other concerns, the effect of screening and subsequent interventions may be limited.⁶

Finally, the USPSTF’s determination was partly based on the small number of acceptable studies on the benefits and harms of food insecurity interventions in the primary care setting. It is reasonable, however, to assume that providing adequate food and nutrition to those without consistent access to it due to poverty is a crucial component of overall health. Given these points, the USPSTF is further exploring how its established methods for assessing the benefits and harms of a preventive intervention can be most effectively used for food insecurity and perhaps other social determinants of health topics as well.

Several organizations provide guidance on screening and interventions for food insecurity. The American Academy of Family Physicians recommends that family physicians use a social risk screening instrument that includes food insecurity.⁴³ The American Academy of Nutrition and Dietetics,⁴⁴ the American Academy of Pediatrics,⁴⁵ and the American Diabetes Association⁴⁶ suggest using the two-item Hunger Vital Sign screening tool to assess the possibility of food insecurity. The American College of Cardiology/American Heart Association,⁴⁷ American College of Physicians,⁴⁸ and the American College of Obstetricians and Gynecologists⁴⁹ recommend screening but do not endorse a specific screening tool. AARP has developed a resource guide and toolkit for implementing food insecurity screening and referral for older patients in primary care.⁵⁰

The Community Preventive Services Task Force does not have a recommendation on screening but has recommendations addressing social risk factors, including food insecurity. It recommends universal free school meals (Healthy School Meals for All), finding that these programs reduced food insecurity, improved the nutritional quality of students’ diets, as well as improved academic outcomes and reduced school absenteeism.⁵¹ It recommends fruit and vegetable incentive programs for households with lower incomes, finding that these programs reduced household food insecurity and increased household fruit and vegetable consumption.⁵² It also recommends home-delivered and congregate meal services for older adults. It found that these services reduce hunger, food insecurity, and malnutrition, as well as enhance socialization and promote health and well-being.⁵³

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41. 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.

42. 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.

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50. Pooler J, Levin M, Hoffman V, Karva F, Lewin-Zwerdling A. Implementing Food Security Screening and Referral for Older Patients in Primary Care: A Resource Guide and Toolkit. Published November 2016. Accessed June 12, 2024. http://www.advancingstates.org/sites/nasuad/files/FINAL%20Resource%20Guide%20HI%20Res_0.pdf

51. Community Preventive Services Task Force. Social Determinants of Health: Healthy School Meals for All. Accessed June 12, 2024. https://www.thecommunityguide.org/findings/social-determinants-health-healthy-school-meals-all.html

52. Community Preventive Services Task Force. Social Determinants of Health: Fruit and Vegetable Incentive Programs. Accessed June 12, 2024. https://www.thecommunityguide.org/findings/social-determinants-health-fruit-vegetable-incentive-programs.html

53. Community Preventive Services Task Force. Nutrition: Home-Delivered and Congregate Meal Services for Older Adults. Accessed June 12, 2024. https://www.thecommunityguide.org/pages/tffrs-nutrition-home-delivered-and-congregate-meal-services-older-adults.html

Abbreviation: USPSTF=U.S. Preventive Services Task Force.