Scaling up measurement to confront food insecurity in the USA

Abstract

It is necessary to scale up measurement in order to confront the persisting problem of food insecurity in the United States (USA). The causes and consequences around food insecurity are briefly described in order to frame the complexity of the public health issue and demonstrate need for expanded measurement approaches. We assert that measurement of food security in the USA is currently based upon a core set of rigorous metrics and, moving forward, should also constitute a supplemental registry of measures to monitor and address variables that are associated with increased risk for food insecurity. Next, we depict dietary quality as a primary example of the power of measurement to make significant progress in our understanding and management of food insecurity. Finally, we discuss the translational implications in behavioral medicine required to make progress on achieving food security for all in the USA.

Implications

Practice: Scaling up the measurement of food security will promote a more nuanced understanding of the drivers of food insecurity to ultimately achieve a more targeted approach. Expanded and systematic measurement will result in the ability to tailor approaches in the adoption and implementation of policies and programs that improve food security.

Policy: A systematically administered supplemental registry of food security measures, in addition to the core set of metrics that already exist, will result in the ability to develop effective policies that address food insecurity alongside its related consequences.

Research: Collaborative research efforts with multidisciplinary stakeholders and practice-based partnerships are required in order to build a supplementary set of food security measures that help the field to rigorously evaluate and understand the role of factors that lead to food insecurity and policy, systems, and environmental supports that reduce related health disparities.

COMMENTARY

Food security, on the individual or household level, is commonly defined within the USA as “access by all people at all times to enough food for an active, healthy life [1].” Similarly, the Food Agriculture Organization (FAO) defines food security as “when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life [2].” The FAO definition expands the concept of food security by providing more specificity to the access component, further describing quality food, and endorsing individual needs and preferences.

While these statements provide public health stakeholders with a common goal to achieve, food insecurity in the USA persists. In the USA, 13.7 million individuals were food insecure during 2019 [3]. Over one third of these individuals experienced very low food security, with disrupted eating patterns due to the lack of ability to obtain food [3]. With the onset of COVID-19 and the rise in unemployment and poverty, the number of food-insecure individuals in America has increased substantially. Recent analyses from the COVID Impact Survey demonstrate that 28% of all respondents and 42% of those with children reported worry about food running out [4]. The worldwide pandemic highlights the fragility of the food system, revealing gaps in nutrition assistance in the USA and has the potential to produce negative economic impacts, including food insecurity, into the foreseeable future [5].

Surveillance measures in the USA assess the amount and extent of food security because it is of national interest to ensure that the American population is healthy and can contribute to society and economic growth [6–8]. In response to results from surveillance measures, pockets of policies and programs exist to confront the widespread problem, but there has been limited systematic progress at a larger scale [9]. Food insecurity has hovered between 10% and 15% over the past 20 years and is rapidly rising in 2020 [4,10].

In this paper, the causes and consequences around food insecurity are described in order to frame the complexity of the public health issue and demonstrate the need for expanded measurement approaches. We assert that the measurement of food security in the USA is currently based upon a core set of rigorous metrics and, moving forward, should also constitute a supplemental registry of measures to monitor and address variables that are associated with increased risk for food insecurity. Next, we depict dietary quality as a primary example of the power of measurement to make significant progress in our understanding and management of food insecurity. Finally, we discuss the translational implications in behavioral medicine required to make progress in achieving food security for all in the USA.

What are the causes of food insecurity in the USA?

Achieving food security is complex because the factors that lead to food insecurity are interconnected [11]. Food insecurity centers around poverty, with other linked contributors playing a role, including inadequate assets, human capital, and health [11,12]. The ability to afford sufficient nutritious food is essential to being food secure. In balance with the amount of money needed for housing, transportation, and health care, individuals who are unemployed, underemployed, or work at or around the minimum wage struggle to cover all of the costs with daily life [13]. Low-income households below 185% of the poverty threshold are most likely to be food insecure [3].

Poverty is intertwined with systemic inequities. For example, individuals living in rural areas face higher poverty, unemployment, and food insecurity rates than in urban areas [14]. In other studies, discrimination is linked to food insecurity among racial/ethnic minority populations due to structural barriers that exist [15–18]. After controlling for economic factors, some household characteristics further increase the risk of experiencing food insecurity. Single women with children, non-Hispanic Black, Hispanic, households with grandchildren present, households with a disabled parent or child [19,20], households with someone who is currently or previously incarcerated [21], households with an adult smoker [22], and rural populations are most likely to be food insecure in the USA [3]. At its core, food insecurity is connected to poverty across socioeconomic status, sociodemographics, and geographies [23–25].

A myriad of system-level factors influences the risk of food insecurity [26,27]. Policies decrease or further exacerbate systematic inequities present in access to healthy food [9]. For instance, bolstering federal food assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), can stabilize the economy by reducing food insecurity and poverty, but these supports are politicized [28]. The pressing environmental issue of climate change, which disproportionately affects poorer groups in marginalized environments, can change food prices and access to food [29,30]. Since these factors are vast but connected with food security, it has been argued that system-level thinking and durable policy change are needed for more long-term solutions for food insecurity to move beyond stop-gap solutions [31].

What are the consequences of food insecurity in the USA?

Among children, food insecurity is associated with increased risks of some birth defects, anemia, lower nutrient intakes, higher risks of being hospitalized, having asthma, behavioral problems (e.g., cognitive problems, aggression, depression, and anxiety), and worse oral health [32,33]. For adults, studies have shown that food insecurity is associated with energy-rich and nutrient-poor intakes, increased rates of mental health problems (e.g., depression and stress), increased risk for chronic disease (e.g., Type 2 diabetes, hypertension, and hyperlipidemia), worse outcomes on health exams, self-reported poor or fair health status, and deprived sleep [34]. Deficient health for food-insecure Americans also comes with a cost to life and livelihood. In multivariable analyses, those with food insecurity had significantly greater estimated mean annualized health care expenditures, resulting in an estimated additional $77.5 billion in health care expenditure annually [35]. The deleterious consequences of food insecurity establish the urgency of the issue as a public health priority.

Current measures of food security in the USA

The U.S. Department of Agriculture’s (USDA’s) Household Food Security Survey Module (HFSSM) is the primary tool used to assess food insecurity in the USA [36]. Since the 1980s and 1990s, the food security field has shifted to experience-based measurement approaches [37,38], which typically use surveys, such as the HFSSM, that ask participants to answer questions about their subjective experience with food insecurity. Since the late 1990s, academics and researchers in the USA have rallied around this rigorous tool because this shared measurement across studies has led to a rapid increase in our understanding of disparities in food insecurity rates and severity [39].

The HFSSM was developed by the U.S. Food Security Measurement Project given a 10 year charge under the National Nutrition Monitoring and Related Research Act of 1990 to develop and validate a standardized instrument for measuring the prevalence of food insecurity [36]. Through an iterative process, the survey was developed, validated, applied, revised, and validated again to become the HFSSM, which is applied annually in the Current Population Survey with 40,000 households and in many other surveys [36].

Like all measurement tools, the HFSSM has strengths and weaknesses. The HFSSM offers a standardized, yet adaptable, approach to assessing food insecurity, with 6- to 18-item versions and the ability to be used as a screener, a household-level measure, and to assess both adult- and parent-reported child-level food insecurity, depending on the needs of the study [36]. Other researchers have adapted a two-item screener [40]. Unlike many other food security measures, the HFSSM has been psychometrically tested [41]. Although shortcomings in measurement with the tool exist as exemplified, food security ratings among parents have been found to be significantly different, with the majority of fathers reporting higher food security scores than their female partners [42].

The scoring outputs of the HFSSM produce an easy to interpret categorization of food insecurity severity—food secure, marginally food secure, low food security, and very low food security [36]. While knowing that the severity classification is useful for monitoring or assessing risk, it is not as ideal, in-and-of-itself, for informing intervention approaches. A major drawback from an intervention implementer or program evaluator perspective is that the HFSSM primarily focuses on food hardship as a result of the lack of financial resources (i.e., money)—thus leading to a lack of understanding of other facets of food insecurity. Psychosocial aspects of food insecurity (e.g., self-efficacy), duration and transience of food insecurity, and many hunger-coping and trade-off behaviors are not specifically addressed in the HFSSM.

Ultimately, the HFSSM produces results that are helpful for answering research questions related to food insecurity rates and severity but are not inherently actionable because it does not examine causes or present a full examination of the lived food insecurity experience. However, our understanding of the complex factors associated with food insecurity and, ultimately, the solutions is lagging. One reason, within the USA, may lie partially in our approach to food security measurement. Assessing relevant factors for food security along with the HFSSM may ultimately assist the public health practice in addressing the precursors of food insecurity and related barriers to food security.

Expanded measures of food security

While food security measurement in the USA has primarily focused on economic access to enough food, an expanded conceptualization of food security may be warranted [43–45]. Specifically, the state of food security is portrayed with four “pillars,” including availability, access, utilization, and stability, and also a “nutritional dimension” that is integral to more fully defining food security [46]. The availability pillar refers to the physical presence of reliable and consistent sources of enough food for an active and healthy life that can be acquired in socially acceptable ways [43,47,48]. Access refers to economic and physical resources in order to gain access to the available food that meets dietary needs and food preferences [43,47,48]. Utilization is the ability to use, prepare, store, and absorb nutrients from the food that is available and accessible [44,47,48]. Stability is refers to the constancy of food security over time acknowledging food insecurity can be an intermittent or chronic [44,47,48]. In recent years, nutrition security has been the suggested terminology to underscore the importance of a wide range of essential nutrients to address malnutrition and undernutrition [46]. There are no standardized tools that address all four food security pillars [47].

While the HFFSM has been the primary tool used in the USA for the past two-plus decades, there has been innovation internationally. Many different experience-based tools are used outside of the USA, such as the Coping Strategies Index [49], Food Insecurity Experience Scale [50], Household Dietary Diversity Score [51], the Household Food Insecurity Access Scale [52], and others that measure different aspects of food insecurity experience [53]. In the USA, the recently developed Four-Dimensional Food Insecurity Scale assesses four dimensions of food insecurity (quantitative, qualitative, psychological, and social), is in preliminary agreement with the HFSSM, identifies underserved populations in community contexts who may be overlooked with a traditional measure, and connects people with available resources to mitigate food insecurity [54]. There have been calls to extract key elements of these tools to produce a complementary measure or set of measures that comprehensively reach the drivers of food insecurity [55,56].

Furthermore, recent research has shed light on the multitude of socioecological factors across the life course (e.g., racial and ethnic disparities) that shape the food insecurity experience but are not currently considered by a standardized food security tool. These include, but are not limited to, culture and family dynamics [57–59], experience of racial discrimination [15], social cohesion and social capital [60–62], resilience [63,64], intramonth variation [65], rural versus urban differences [66,67], and charitable food utilization [68].

There is clearly an opportunity in the USA to learn from the recent literature and utilize innovation to complement existing measurement approaches without losing the strengths and history that the HFSSM provides. A registry of standardized measures would complement the HFSSM to coordinate the understanding of evidence-informed surveillance and intervention evaluation across food insecurity research. Food security is a public health priority that requires alignment in our understanding of the antecedents to food insecurity in order to build practices and policies that support individuals toward food security.

Toward measurement of dietary quality as a dimension of food security in the USA

Dietary quality is a primary opportunity in which to leverage measurement to make significant progress in confronting food security. Strong evidence points to an association between food insecurity and poor dietary quality [34,69,70]. As broached in both the USDA and FAO definitions of food insecurity and exemplified in conceptual models, such as those presented by Gross et al. [43] and Jones et al. [71], dietary quality and understanding disruptions in dietary quality are essential to measuring the effects food insecurity has on households. Despite the clear negative impact food insecurity has on nutritional intake, current measures merely touch on dietary quality. The HFSSM scoring outputs categorize food insecurity as disruptions in quantity, quality, variety, or desirability of food for the household or individual [72]. Although “balanced meals” are mentioned in the HFSSM, access to quality (nutritionally healthful) foods is not emphasized in the measurement tool.

Dietary quality can focus on broad-based measures of eating behavior, such as the assessment of dietary patterns (e.g., Healthy Eating Index) [73], food groups (e.g., fruit and vegetable intake), ingredients (e.g., sugar), or specific micronutrient or macronutrient intake (e.g., calcium) [74]. These measures of dietary quality consider aspects of adequacy (foods or nutrients to consume), moderation (foods or nutrients to limit), and balance and variety (within and across foods and nutrients) [74].

Using broad-based measures that are applied to understand dietary quality across populations, it is recognized that when compared to food-secure adults, food-insecure adults typically underconsume vegetables, fruits, dairy, and foods containing vitamins A, B, C, D, calcium, iron, magnesium, and zinc [75–77]. Studies point to the overconsumption of nutrients that come from less healthful foods, including ultraprocessed foods and beverages containing added sugars, saturated fats, and empty calories [75–78].

Measures of dietary quality should measure the unique ways in which food-insecure household’s diets are disrupted. It is known that food-insecure households struggle with meeting dietary recommendations [79] due to general reliance on foods with lower nutritional quality and cost to meet caloric needs (e.g., energy dense and/or ultraprocessed), decreased food autonomy (e.g., inability to ensure diet meets preferences, cultural, and health needs), limited dietary diversity, cyclical (e.g., intramonth) food nutritional quality, and sociodemographic and economic inequalities [78,80–84]. Much research rests on the hypothesis that food insecurity leads to the displacement of nutrient-dense foods with less-expensive energy-dense foods. Higher consumption of sugar-sweetened beverages, salty snacks, and high-fat dairy among food-insecure versus food-secure individuals has been documented [75–78]. There is conflicting evidence about energy intake, with some food-insecure individuals not consuming sufficient calories, while other food-insecure individuals consume calories in excess [76]. These results are aligned with the various circumstances that food-insecure individuals face, including not consuming enough food, worry about not consuming enough food (yet still consuming enough foods), and over-consuming energy-dense and nutrient-poor foods [75–77]. New or modified measures should consider such disruptions as fundamental to addressing the nutritional quality of diets among food-insecure populations [69,85].

Practical limitations in dietary quality measurement must be considered in the context of food-insecure populations. For instance, more comprehensive dietary assessment methods, such as 24 hr recalls and long food frequency questionnaires, are not appropriate for many settings or populations associated with food-insecure participants. While comparatively accurate and comprehensive, they often require repeated follow-up, considerable time and expertise to administer, and/or can require high literacy or numeracy skills [86]. Therefore, it can be more practical to use brief dietary assessment methods (e.g., dietary screeners). Such dietary indicators are usually simple to administer, rapid to complete, and straightforward to calculate a score [87]. However, current dietary screeners do not assess many of the dietary complications that food-insecure households encounter.

Taken together, there is a need to comprehensively understand predictors of dietary quality among food-insecure populations in order to set priorities for policies and programs that will better serve the impacted populations. A new or modified tool would ideally be applicable across settings and populations, balance measuring dietary quality, include key metrics that are specifically correlated with dietary quality among food-insecure populations (e.g., food autonomy, cyclical patterns, socioeconomic, and sociodemographic variables), account for the severity of food insecurity, and consider the lived food insecurity experience. A nuanced understanding of dietary quality among food-insecure individuals through a tailored measurement tool will provide evidence for developing and delivering systematic and large-scale interventions that improve dietary intake and public health among food-insecure populations.

Expanding measurement among food-insecure populations in the context of nutrition assistance

A comprehensive set of food insecurity measures on a national level may lead to a stronger understanding of the actions that can be taken to align policy and program actions. Currently, a labyrinth of nutrition assistance programs exists on the federal level (e.g., SNAP, The Special Supplemental Nutrition Program for Women, Infants, and Children [WIC], and The Child and Adult Care Food Program [CACFP]) and through the emergency food system (e.g., food pantries and food banks) to provide food for food-insecure families.

Changes are made periodically within nutrition assistance programs to improve aspects of food security. For example, historically, food security initiatives have focused on ensuring access to any food without an emphasis on dietary quality. SNAP is an example of this philosophy as it puts only minimal requirements on the types of foods that can be purchased using SNAP monthly benefits [88]. In more recent years, there has been greater emphasis placed on building systems that support access to quality food, in addition to quantity for food-insecure populations, such as nutrition incentive programs that aim to increase the purchase of fruits and vegetables among low-income consumers participating in SNAP by providing incentives at the point-of-purchase (e.g., the Food Insecurity Nutrition Incentive or FINI program, now referred to as the GusNIP program, administered out of USDA National Institute of Food and Agriculture) [89]. In the emergency food system, several strategies have been implemented to ensure a food supply that is less reliant on heavily processed, shelf-stable foods and provides balanced and nourishing ingredients [90–93]. Importantly, the effectiveness of such initiatives for improving dietary quality related to food insecurity cannot be comprehensively understood or improved without specific and sensitive measurements.

Measuring the impact of changes within these policy- and programmatic-driven entities that specifically target food-insecure households, so far, is patchwork. The HFSSM has been the only systematic measure applied, along with a host of diverse metrics, to understand the implications of these shifts for food security. Organizing a registry of measurement tools will assist the field in methodologically analyzing the effects of policy and program shifts and fine-tune as necessary to address food security.

Translation of food security into behavioral medicine

The immediate need to address populations impacted by food insecurity has spurred collaboration across practitioners and researchers in nutrition, agriculture, social services, public administration, public policy, economics, and other fields. These multidisciplinary and stakeholder-engaged approaches help bridge the “chasm” of discrepancies between evidence-based, efficacious interventions and what actually occurs in practice [94,95]. Moving forward, these existing partnerships should be capitalized upon to address food insecurity measurement. Such existing synergies can ground approaches in the measurement of a conceptual framework that considers the experience of food insecurity within the social context; predisposing factors, mechanisms, and consequences may cultivate greater insight to inform practitioners [96]. To take this one step further, dissemination and implementation frameworks applied throughout intervention development paired with a comprehensive evaluation of food insecurity intervention work can help systematically facilitate the “speed of translation” to have a greater public health impact [97].

CONCLUSION

This commentary underscores that there are benefits to a long history of research and surveillance utilizing the HFSSM to measure food insecurity in the USA. Nevertheless, there are inherent gaps in this measurement approach, given the emphasis on economic factors contributing to the experience of food insecurity. A recent systematic literature review focused on multi-item tools that measure food insecurity. This review identified that the current tools available are often limited in scope, with a majority assessing only one pillar of food insecurity, and should assess all dimensions of food insecurity [47].

Limited systematic measurement of food insecurity leads to an incomplete understanding of the complex factors, precursors, and barriers influencing food insecurity and a subsequent absence of multilevel evidence-based interventions to address food insecurity. In an important example, this paper demonstrated that the population-specific measurement of dietary quality in the context of food insecurity is lacking. The coexistence of low dietary quality, health concerns, and food insecurity have been partially attributed to the reliance on low-cost foods, which are often energy dense and low in nutrients. However, the mechanisms of this relationship are not comprehensively understood, and further research with coordinated measurement is needed.

Scaling up the systematic measurement of food insecurity can inform tailored approaches to better address the realities of Americans living in poverty and experiencing food insecurity. In order to garner evidence that can be addressed in the implementation of policy and programmatic change, there is a need for pragmatic and multifaceted measures of food insecurity that are brief, sensitive to change, actionable for multiple stakeholders, and feasible in low-resource settings [98,99]. Such an effort will enhance public health’s ability to scale up measurement to confront food insecurity in the USA.

Acknowledgments

Funding: This work was supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number 5P20GM104417. The content presented here is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflicts of Interest: The authors declare that they have no conflicts of interest.

Author Contributions: CBS presented manuscript idea and EEC, CAP, ALY contributed to the conceptualization thereafter. All authors contributed to the initial drafts, revisions, and the final manuscript.

Ethical Approval: This article does not contain any studies with human participants performed by any of the authors. This article does not contain any studies with animals performed by any of the authors.

Informed Consent: This study does not involve human participants and informed consent was, therefore, not required.