There is sufficient evidence that food insecurity screening can result in increased connection to food insecurity resources.
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The findings below synthesize the results of the studies across three domains of measurement:
Note: There are few robust evaluations of screening outcomes. Most studies identified in this analysis focus on process measures (i.e., prevalence of screening), workflows, or qualitative analyses. In addition, some studies combined food insecurity screening with hands-on support in navigating resources such as through the assistance of community health workers (CHW). We reviewed studies that evaluated screening alone, screening and referral, and screening with the addition of hands-on navigation support. In an attempt to isolate the impact of screening, we excluded studies with hands-on navigation support in the above impact assessment, though you can still review the studies in the evidence table. Overall, the outcomes of screening combined with a navigation or supportive intervention did have stronger results than evaluations of screening and referral alone.
Food-related needs fall into three interrelated categories: food insecurity, nutrition insecurity, and dietary quality.
Food Insecurity
Food insecurity is defined as not having access to enough food. In 2021, 10.2% (13.5 million) of United States (U.S.) households reported being food insecure over the last year. Of families experiencing food insecurity, 6.4% (8.4 million) were identified as having low food security and 3.8% (5.1 million) were identified as having very low food security[1]. Food insecurity varies by race, ethnicity, household makeup, and income. Rates of food insecurity are higher than the national average (10.2%) for families that identify as Black (19.8%) or Hispanic/Latino (16.2%), for households with children (12.5%), and for households with income below 185% of the poverty line (26.5%)[2]. The majority of Medicaid enrollees fall in this low-income bracket. Additionally, food insecurity may be more common for those whose employment status, neighborhood of residence, and access to transportation further impact their food access[3],[4],[5].
Nutrition Insecurity
Nutrition security is the “consistent and equitable access to healthy, safe, affordable foods essential to optimal health and wellbeing[6].” While most food insecure households are also nutrition insecure, food secure households can also be nutrition insecure. As most screenings focus on food security rather than nutrition security, national data on the prevalence of nutrition insecurity is not yet available. The concept of nutrition insecurity has been adopted by the United States Department of Agriculture (USDA) and the Centers for Disease Control and Prevention (CDC) as a core goal for their food-related initiatives. Nutrition security, beyond just food insecurity, is necessary to reduce the chronic illnesses caused as a result of poor nutrition[7].
Dietary Quality
While food and nutrition insecurity are primary drivers of poor diet, other factors such as food availability (food deserts), personal preference, nutrition knowledge, and other psychosocial factors may contribute to dietary options and choices[8]. Analysis found that 45% of U.S. adults have a poor diet[9]. According to analysis of a representative sample of U.S. high school students, only “8.5% of high school students nationwide met [USDA] fruit recommendations and 2.1% met vegetable recommendations[10].” Research on adult dietary consumption has shown that income is a predictor for inadequate vegetable consumption (only 7% of adults below or close to the poverty level consume adequate vegetables) but even high income groups had inadequate vegetable consumption (only 11.4% of adults in the highest income categories consume adequate vegetables)[11]. Healthy People 2030 includes a number of specific nutrition objectives including increasing calcium, potassium, fruit, and vegetable (including dark green, red and orange, beans and peas) consumption in people over age two[12],[13],[14],[15],[16],[17],[18].
Health Impacts of Food and Nutrition Insecurity and Poor Diet
Having an unhealthy diet and poor nutrition is associated with a range of physical and behavioral health conditions that are disproportionately experienced by people of color. Poor diet is associated with both obesity and Type 2 diabetes, as well as other chronic health conditions such as cardiovascular disease and cancer. Individuals experiencing food and nutrition insecurity are uniquely at risk and have a much higher risk of long-term chronic health conditions including obesity, diabetes, and hypertension. Consuming unhealthy food and beverages, such as sugar-sweetened beverages and highly processed foods, puts people at higher risk of at least 13 types of cancer, including endometrial (uterine) cancer, breast cancer in postmenopausal women, and colorectal cancer.
The length of time a person is food insecure impacts the severity of the health impacts. A study examining food insecurity in children over four years of age found that children who experienced food insecurity for longer periods of time had worse health outcomes[26].
According to the CDC, among those ages 2 to 19 the prevalence of obesity was 19.7% and affected about 14.7 million. Childhood obesity is also more prevalent among certain racial and ethnic groups (26.2% among Hispanic/Latino children, 24.8% among non-Hispanic Black children). Obesity-related conditions include high blood pressure, high cholesterol, Type 2 diabetes, breathing problems such as asthma and sleep apnea, and joint problems[27].
The rate of cardiovascular disease in the Black population is disproportionately high and is a primary cause of differences in life expectancy between Black and White individuals[28]. Black Americans are disproportionately affected by colorectal cancer, with Black people being 20% more likely to develop colorectal cancer and 40% more likely to die from it than White people[29].
The impacts of food insecurity extend beyond diet-related diseases. Children who experience food insecurity have been shown to have a higher risk of iron deficiency anemia, lower non-cognitive performance, asthma, depression, suicide ideation, and tooth decay[30]. Food insecurity has been shown to be a major stressor in early childhood with implications for cognitive, language, motor, and socio-emotional skills[31]. Individuals experiencing food insecurity are more likely to go to the ER, less likely to have a usual source of care, and have higher healthcare costs[32],[33],[34],[35].
Screening for food insecurity has a unique opportunity for impact because of the prevalence of food-related community resources and the underutilization of government benefits including the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). SNAP, formally known as the Food Stamp Program, is a federally funded program, administered by states, that provides nutritional benefits (via vouchers or debit cards for certain food purchases) to eligible low-income individuals and families to reduce food insecurity and hunger[36]. A 2018 estimate of SNAP participation rates indicates that 18% of those eligible do not participate. WIC is a federal grant program to states to provide supplemental foods and nutrition education to pregnant and postpartum women, infants, and children up to age five who are found to be at nutritional risk[37]. There is significant opportunity to increase enrollment in WIC—36% of eligible one year-olds and 75% of eligible four-year-olds are not enrolled[38]. Evidence suggests that enrollment in SNAP and WIC reduces healthcare costs and improves health outcomes[39].
Studies of participants’ perceptions of social needs screening in clinical settings have found that they generally think social needs screening is appropriate because they recognize the connection between overall health and social risks. Providers report that screening increases awareness of social needs—identifying social needs can change care plans and improve provider interactions. The estimated costs of social needs screening vary widely from upfront costs of $6,644 to $49,087 and per individual per screening costs between $9.76 and $47.90[43].
While there has been an increasing recognition of the importance of nutrition security, most screening tools are still more focused on the concept of food insecurity rather than broader nutritional insecurity. This focus on food insecurity rather than nutrition insecurity likely results in an underrepresentation of the number of people whose eating habits are influenced by cost. For example, one study found that of people identified as food or nutrition insecure, 42% were both food and nutrition insecure, 14% were only food insecure and 43% were only nutrition insecure. To achieve the desired health impacts, screenings may need to shift to better address food and nutrition insecurity[44].
Families from three communities across two states.
A learning collaborative of five Developmental Understanding and Legal Collaboration for Everyone (DULCE) teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, and pediatric and behavioral health clinicians) to screen for and address Health Related Social Needs (HRSNs). More than 95% of families were screened for each HRSN: maternal depression (95.9%), intimate partner violence (96.3%), food insecurity (97.2%), employment and financial needs (98.6%), utilities (96.8%), and housing instability (97.2%). 92% of families were screened for all seven HRSNs, and three sites demonstrated shifts in screening rates from 72% to 79%, 92% to 100%, and 95% to 100.
Quality improvement intervention.
The study enrolled 311 participants. The main outcome was the percent of infants that received all well-child visits (WCVs) on time.
Healthcare Cost, Utilization & Value: the percentage of six-month-old infants that completed all five recommended WCVs on time, improved from 45.5% to 64.6%.
English speaking adults receiving medical care at a Federally Qualified Health Center (FQHC) primary care clinic.
Implementation of a social determinants of health (SDOH) screening tool and service referral. The research team administered the Core 5 SDOH screening tool and, if desired, referred participants with an identified need for SDOH services.
Quasi-experimental.
Pre-post emergency department visits were assessed three months after the intervention from electronic health records.
Healthcare Cost, Utilization & Value: 43% of patients reported a SDOH need, with food insecurity being most prevalent (62.2%).
The number of ED visits was significantly lower three months post-intervention compared to the three months prior for the 125 participants who wanted and received the SDOH service referral (IRR = 0.64, 95% CI = 0.41, 0.99) and for the 35 participants who reported receiving some/all of the needed services at the two-week follow-up (IRR = 0.36, 95% CI = 0.17, 0.76).
Individuals with diabetes receiving medical care at a FQHC in a large Midwest city.
The Food for Health program screened all individuals receiving care within the FQHC network for food insecurity. Electronic health records alerted providers to those who screened positive for food insecurity. Those who screened positive received nutrition education and care teams made referrals to local food pantries, mobile produce trucks, and other community food resources. Benefits specialists at the health centers provided enrollment assistance to those who were financially qualified for SNAP.
Longitudinal, single group repeated-measures design.
The study enrolled 933 participants with diabetes; n= 398 (42.66%) completed follow-up that included hemoglobin A1c (HbA1c) results.
Health: There was a decrease in mean HbA1c (Δ = −0.22, P = 0.01) over the study period.
Among participants with poor glycemic control (33.12%), food secure participants exhibited significantly greater levels of HbA1c improvement than food insecure participants (Δ = −0.55, P = 0.04). Among participants with good glycemic control, changes in HbA1c were not significantly different between food secure and food insecure participants (Δ = 0.23, P = 0.21).
Caregivers of three to 10-year-old children presenting for well-child visits.
Food insecurity screening incorporating a menu offering food-assistance referrals including 1) finding a food pantry, 2) getting hot meals, 3) applying for SNAP, and 4) applying for WIC. Referrals were offered independent of food insecurity status or eligibility.
Multiple logistic regression.
n= 340 caregivers
Social 106 (31.2%) screened positive for food insecurity:
At follow-up, of the 107 caregivers who selected one or more referrals:
Families of children receiving pediatric (0-26 months of age) clinical services in Pittsburgh, PA.
A clinical-community direct referral model to enroll eligible households in SNAP. Families were screened for food insecurity in their primary care setting. Eligible families were invited to participate in a direct referral to a local organization assisting with SNAP applications. A food stamp specialist telephoned participants to determine SNAP eligibility, assist with the application, and/or provide other supports.
Research brief. Descriptive.
Referrals, eligibility determination, enrollment, and estimated benefits were tracked.
n= 486 families
Social: A total of 486 families were referred to the community partner
Low-income older adults in an urban setting in the southern United States.
Recruitment occurred at four sites, corresponding to buildings housing older adults who were eligible to participate in the program.
Individuals were screened for food insecurity and social isolation. A partnership with the food bank and a farm-based organization provided a weekly congregate or home-delivered meal, pilot a cooking class, and offer a mobile market selling fresh vegetables at discounted prices to those screened eligible.
Descriptive analysis.
n=339
Social: 339 participants enrolled:
Among the 230 food-insecure participants:
The mobile market served 75 participants weekly and 15 individuals took part in cooking classes.
Individuals from two clinics referred to a social risk screening and navigation program.
Enrollment in a clinic-based social needs program - Hopkins Community Connection (HCC) program (formerly Health Leads©)
Retrospective cohort study.
Health care utilization was compared over the subsequent 12 months for those who completed a full intake and received resource navigation (enrolled) to those referred (not enrolled). Logistic regression was used to assess the association between enrollment with well-child visit attendance and emergency department visits.
n=761 enrolled
Healthcare Cost, Utilization & Value: At both sites, the majority of enrolled patients had high well-child visit attendance post-intervention (Site A: 81.6%, Site B: 71.4%). Well-child visit attendance for non-enrolled but referred patients was significantly lower (Site A: 52.7%, Site B: 35.0%). Enrolled participants were significantly more likely to have high well-child visit attendance than non-enrolled patients, adjusting for pre-intervention utilization (Site A adjusted odds ratio [aOR]: 5.83, Site B aOR: 4.20). There were no significant differences in ED use at either clinic.
Individuals at Coastal Family Medicine, in Wilmington, North Carolina.
A screening process for social determinants of health revealing a 26.3% prevalence of social needs.
Quality improvement. Descriptive statistics.
n=400 patient encounters
Social: Interventions for positive screenings included provision of a website link (90%), health navigator referral (45%), and the provision of pediatric food boxes (57%).
Individuals screened for food insecurity across seven community-based organizations (CBOs) and three clinics.
CBOs and clinics screened for food insecurity and provided SNAP application assistance to their clients and patients found eligible.
Observational, two-year intervention.
Of the 15,296 individuals screened, 5,724 (37.4%) reported food insecurity.
Social: 35% of the participants who completed the entire intervention enrolled in SNAP.
CBOs assisted a greater proportion of food-insecure individuals (55%) than clinics (22%).
Males, adults 40 years or older, rural residents, and African Americans were more likely to be interested in receiving assistance, and adults 40 years or older, rural residents, and American Indians/Alaska Natives were more likely to enroll in SNAP.
Low-income families at a pediatric resident continuity clinic.
Pediatric residents were trained to screen for, assess, and provide initial management of food insecurity.
All participants completed a single food insecurity question (part of a larger questionnaire); a subset of participants completed the USDA Food Security Scale (“gold standard”), upon recruitment and six months later.
Food insecurity interventions included providing information on how to apply for SNAP benefits and other federal food assistance programs and providing information about local food resources such as food pantries.
Randomized controlled trial.
Social: Intervention families had a larger increase in screening rates than control families (24% vs. 4.1%, p<0.01). Intervention families were more likely to maintain SNAP enrollment (97% vs. 81%, p=0.05). Food insecurity rates remained stable at approximately 30% for both groups.
English-speaking caregivers of children 0-36 months on the general pediatrics services of a large urban children’s hospital. Caregivers were from diverse socio-demographic/socioeconomic backgrounds.
The WE CARE Houston social needs intervention included systematically screening and referring hospitalized pediatric patients’ families to publicly available resources to meet social needs such as food, employment, housing, and caregiver education.
Randomized controlled trial.
n = 413 caregivers from
Social: 5% of study participants had ≥1 social risk (median 2, range 0–9). WE CARE Houston identified caregiver employment, health insurance, primary care physician, depression, childcare, smoking, and food resources as the most prevalent social needs. Among these, caregivers were most receptive to resources for childcare, mental health, health insurance, and primary care (PCP). The most common resources enrolled were food (such as SNAP, WIC, or a food pantry), health insurance, PCP, and childcare.
Health: There were no differences in caregiver-reported health indicators including well-child check, ED visits, hospitalizations, immunizations, and perceived child health by study arm.
Patients at a Federally Qualified Health Center in New Haven, Connecticut.
Two-item food insecurity screening tool.
Those identified as food-insecure received resources on how to obtain food and supplemental nutrition.
Mixed methods.
n= 1,272 individuals screened
Social: There was a 97.9% completion rate of the screening tool; 534 of 1,272 (41.9%) respondents were at risk for food insecurity.
Male respondents had higher prevalence than females (46.3% vs 38.9%, p = 0.009), and Hispanic people (34.4%) less than White (54.4%) and Black people (53.8%) (p < 0.001).
Adults (18+), seen for a medical visit at sites of the University of California San Diego (UCSD) Student-run Free Clinic Project.
Screened using the 6-item United States Department of Agriculture (USDA) Food Security Survey.
Those screened eligible were:
Cross-sectional study. Descriptive analysis.
n= 463
Social:
The total screening rate was 92.5% (430 of 463)
201 participants received monthly boxes of food onsite, 66 used an off-site food pantry, and 64 were enrolled in SNAP.
Families with a neonate admitted to the neonatal intensive care (NICU).
Development of screening for food insecurity. Families with a positive food insecurity screening were referred to programs such as SNAP, WIC, and food pantries local to the families’ residence.
Quality Improvement project.
Social: In the first few weeks of the screening, 91% of the eligible population were screened, with an increase to 95% that was sustained for the rest of the project duration. Over the project duration, 6.75% of the screened families reported food insecurity with approximately 91% referred for resources.
Healthcare entities that screen those 50 years and older for food insecurity.
Clinical-community partnerships across the U.S., involving health care entity-based programs that screen patients for food insecurity and connects them with food resources.
Landscape assessment using the Systematic Screening and Assessment Method.
A network of food insecurity researchers, experts, and practitioners identified 57 programs, 22 of which met the inclusion criteria of being health care entities that 1) screen patients for food insecurity, 2) link patients to food resources, and 3) target patients including adults aged 50 years or older.
Most programs (n = 13) focus on patients with chronic disease, and most (n = 12) partner with food banks. Common interventions include referrals to or a list of food resources (n = 19) such as SNAP and WIC, case managers who navigate patients to resources (n = 15), assistance with federal benefit applications (n = 14) such as SNAP, WIC, Medicaid, and Medicare, patient education and skill building (n = 13), and distribution of fruit and vegetable vouchers redeemable at farmers markets (n = 8). Most programs (n = 14) routinely screen all patients.
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