Food security status operates on a spectrum to describe quality and quantity of household food supply, which is subsequently categorized as high, marginal, low, and very low food security; the latter two conditions are classified as food insecure (Figure 1).² The health and nutrition-related consequences of food insecurity on household members are often cumulative as food insecurity severity increases. Household food insecurity is linked to many nutrition-related outcomes due to its effects on dietary quality and quantity,⁵ associations with mental and physical health,⁶ and impacts disease self-management capabilities of affected members.⁷ These outcomes may contribute to disability, which can further reduce household resources due to health care costs and adult unemployment, leading to a vicious cycle of compromised food supply.⁸ A brief overview of select nutrition implications for adult- and child-household members affected by household food insecurity is presented below.

Dietary patterns of adults experiencing household food insecurity reflect low consumption of fruits and vegetables, dairy products, iron, zinc, vitamin E, and vitamin B₆,⁹, with common serum deficiencies including iron, vitamin B₁₂, calcium, magnesium, vitamin A, vitamin C, carotenoids, and folate.¹⁰ These deficiencies can result in anemia, low bone density, and general poor health. Food insecurity is inconsistently associated with obesity among women, which may result from the metabolic consequences of cyclical food restriction and consumption of energy-dense foods as a strategy to lower food costs.^11–13 Food insecurity may contribute to the development of metabolic syndrome¹⁴ and is associated with many chronic diseases,¹⁵ such as type 2 diabetes and hypertension.¹⁶ Household food insecurity can also compromise disease self-management abilities, including glycemic control among diabetics.^7,17

Iron deficiency disproportionately affects children living in food insecure households, which can impair motor skill, language and cognitive development, socioemotional state, attentiveness, and school performance.¹⁸ Household food insecurity is associated with greater odds of child hospitalization and fair to poor health status.¹⁹ Children who live in households with very low food security at any point between birth and toddler years, especially if they are born at a low birth weight, have greater odds of obesity before kindergarten than their food secure peers.²⁰ Furthermore, repeated episodes of hunger in childhood may affect future chronic disease development.¹⁸ Similar to adult household members, teenagers may sometimes restrict or go without food to protect younger siblings.²¹ Without proper nutrition intake, food insecurity undermines adolescent physical and emotional growth, stamina, academic achievement and job performance.²¹

Nutrition screening identifies patients who may need special interventions and should be informed by the risk characteristics of the population being screened.²² While screening is most often implemented by individuals outside of the nutrition services team, dietetics practitioners should provide input on the selection of screening questions and referral procedures.²² Food insecurity screening considerations for at-risk populations are summarized in Table 1.

Researchers typically use the 10-item U.S. Adult Food Security Survey Module that can include an additional 8 items for assessing households with children;² however, shorter screening options are available for clinical and community practice settings. The American Academy of Pediatrics²³ and the American Association of Retired Persons²⁴ endorse a two-question screening tool with ≥97% sensitivity and ≥74% specificity for household food insecurity. Answering “often true” or “sometimes true” to either question below indicates potential household food insecurity:²⁵

When potential household food insecurity is identified, screening protocols should include follow-up procedures for client linkage to food assistance programs and an additional referral to a qualified dietetics practitioner when household food insecurity may be contributing to nutrition-related health status. The dietetics practitioner can then proceed with assessing nutritional risk in the context of food insecurity as the first step of the NCP, followed by diagnosis, intervention, and monitoring/evaluation.⁴ Critical thinking questions and considerations related to the delivery of care for food insecure clients for each step of the NCP are detailed in Table 2.

Nutrition assessment is an ongoing process of collecting and analyzing client data in order to inform the nutrition diagnosis.⁴ When the dietetics practitioner identifies a client who is at risk for food insecurity through positive screening results, the practitioner can apply their knowledge of food insecurity’s possible psychosocial, behavioral, nutritional and physical health consequences to inform data collection during the five domains of nutrition assessment (Table 2). To guide critical thinking, the dietetics practitioner should first determine the severity of household food insecurity to then consider how the degree of compromised food supply may be affecting food intake (Figure 1). Probing questions during the patient interview can be used to assess how food insecurity is affecting level of food intake, meal patterns, or other eating behaviors. If the dietetics practitioner suspects the intake domain is being affected, he or she can then explore remaining assessment domains to determine if data are clustering to reflect food insecurity as an underlying cause for nutrition problem(s).

Nutrition diagnosis identifies the nutrition problem to be addressed by the dietetics practitioner through nutrition intervention and is organized into a statement with the following structure: “Problem” [related to] “Etiology” [as evidenced by] “Signs/Symptoms” (PES).⁴ By gathering information during the client interview to assess how the degree of household food insecurity is affecting dietary intake or clinical domain nutrition problems, the dietetics practitioner can effectively identify how food insecurity is functioning as a cause or contributing risk factor of the nutrition problem in the “etiology” statement. An example food insecurity-informed nutrition diagnosis from the intake domain is as follows:

If no intake or clinical domain nutrition problem is identified, yet food insecurity is suspected to be contributing to nutritional risk, then a nutrition problem from to the “food safety and access domain” can be used. For example:

Example food insecurity-related diagnoses from each of the three diagnosis domains are listed in Table 2.

A nutrition intervention is designed “to resolve or improve the nutrition diagnosis or nutrition problem” and its selection should be informed by the etiology of the problem, whenever possible.⁴ Since food insecurity results from poor food access among other factors, interventions usually include coordination of nutrition care to facilitate linkage to food assistance or other financial resources, but can also span food and nutrient delivery, nutrition education, and nutrition counseling (Table 2). Planning interventions in a multi-staged design by first prioritizing stabilization of household food supply and limiting nutrition education to survival information, followed by the subsequent establishment of long-term behavior change goals, will likely help improve the client’s ability to adhere to nutrition recommendations.

Nutrition monitoring and evaluation aims to quantify client progress toward resolving the nutrition diagnosis through the achievement of intervention-related goals.⁴ Thus, outcomes for monitoring and evaluation are chosen based on the nutrition diagnosis and intervention.⁴ Example outcomes for food insecure clients may include food assistance program participation and satisfaction, improvement in quality and quantity of food intake according to nutrition prescription, improvements in body composition, and improvements in laboratory values related to nutritional status and disease management. Special considerations for food insecure populations during monitoring and evaluation are described in Table 2.

Tulsa CARES is a non-profit organization in Tulsa, Oklahoma, delivering social services, including mental health, housing, health care navigation, care coordination, and nutrition, to people affected by HIV/AIDS.²⁶ Staffed by a registered dietitian nutritionist (RDN), nutrition and dietetic technician, registered (NDTR), and certified dietary manager, the Tulsa CARES nutrition program provides disease-appropriate groceries, prepared meals, and nutrition education to over 300 clients annually. Approximately two-thirds (67%) of clients served annually are food insecure. Conversations with Tulsa CARES dietitian, Melissa Cejda, MHA, RDN/LD, CDE (March 2017), informed this program spotlight.

As the program’s RDN, Cejda partners with local HIV healthcare providers to accept external MNT referrals based on food insecurity or other nutrition concerns. Tulsa CARES also internally screens all existing clients for food insecurity during new client intake and annual reassessment appointments using a self-administered version of the 6-item Short Form Food Security Survey Module.¹ Positive screenings result in a referral to the RDN or NDTR, which initiates the NCP for a more thorough assessment of client food needs.

Cejda notes that many clients living in food insecure households have other social and medical problems, such as mental health co-morbidities, substance use, diabetes, or HIV-associated wasting, all of which inform her data collection priorities during nutrition assessment. All patients receive a Nutrition-Focused Physical Exam to assess for malnutrition and lipodystrophy, including muscle mass or body fat depletion, which Cejda notes can occur as a result of HIV infection and be exacerbated by food insecurity. After completing her nutrition assessment, Cejda commonly identifies nutrition diagnoses of inadequate protein intake, excessive carbohydrate intake, and limited access to food.

Cejda’s approach to nutrition intervention typically involves a combination of food direct assistance, nutrition education, and nutrition counseling. Tulsa CARES’ on-site food pantry allows Cejda to assist clients with selecting foods that reinforce nutrition intervention goals, such as meeting protein needs or balancing macronutrient intake. The food pantry is intentionally stocked with nutrient-dense foods, such as low-sodium canned vegetables and beans, frozen fruits and vegetables, lean meats, low-fat dairy and alternatives, dried beans, and whole grain products to better meet the nutrition intervention needs of clients. Nutrition supplement assistance for individuals with identified micronutrient deficiencies or muscle wasting are also available. When working with clients affected by food insecurity, Cejda observes that, “Your nutrition intervention is often going to be simpler, and you may need to work with the client to prioritize one realistic, achievable goal at a time, as opposed to multiple goals at once. Some of my interventions and recommendations will be changed based on the degree of a client’s access to food, which can limit their readiness or ability to make dramatic eating changes compared to someone who is food secure.” For HIV-positive patients dealing with multiple diagnoses, such as diabetes, Cejda also includes interventions that set realistic goals to improve comorbidities. “[For diabetic clients], I often emphasize for patients to eat consistent meals at consistent times to prevent hypoglycemia and take their medicine on time. Education on food sources of carbohydrate and economic ways to balance these foods with lean protein and healthy fat is also essential.”

Cejda and her team monitor and evaluate clients over time for food security status and health outcome improvements, such as BMI, body composition, blood pressure, and updated lab work received through partnerships with healthcare providers. On a personal level, Cejda defines client success through subjective measures as well, such as “improved quality of life, feeling better, and less daily worry”.

Public health and community dietetics practitioners are often charged with planning nutrition programs for priority populations, a process that can be guided by the NCP.²⁷ One example is New York State’s Just Say Yes (JSY) to Fruits and Vegetables program, a Supplemental Nutrition Assisance Program (SNAP) Educational Initiative (SNAP-Ed).²⁸ As a SNAP-Ed funded initiative, JSY is an obesity prevention program designed to promote healthy diets and active lifestyles to SNAP recipients and eligible families through the provision of behaviorally-focused nutrition education and obesity prevention strategies.²⁸ Its initiatives include the development and adoption of policies and systems that facilitate and support environmental changes to improve healthy food access and consumption. Conversations with Paula Brewer, MS, RDN, CDN (March 2017), JSY Program Director, informed this program spotlight.

The assessment step for JSY involved collecting aggregate data.²⁷ Brewer and her team gathered state-wide and national data from sources including the United States Department of Agriculture, Feeding America, and U.S. studies of food insecurity to identify obesity, diabetes, high blood pressure, and suboptimal dietary patterns²⁹ as key disparities affecting the target population. Program planners then progressed to the second step of the NCP: diagnosing the community problem. They emphasized a prevention approach and prioritized goals for fruit and vegetable consumption and general healthful eating, since diets high in fruits and vegetables may help prevent obesity and hypertension³⁰, while green, leafy vegetables are particularly helpful in the prevention of type 2 diabetes.³¹

According to Brewer, the intervention step included development of a two-pronged, evidence-based intervention: “Education so that people have the knowledge, the confidence, and the skill to improve their dietary intake, [and] working on the emergency food environment to increase access to healthier food.” To implement this intervention, JSY partnered with New York’s emergency food network. At partner food pantries, JSY RDNs or other trained nutrition educators deliver 45-minute, healthy eating workshops for food pantry clients. JSY partners with local food banks to help establish nutrition policies that improve the quality of food offered. Further, JSY operates a healthy pantry demonstration initiative in which pilot food pantries are strategically designed to encourage shoppers to take healthful products.

Brewer mentioned that expanding program monitoring and evaluation is a priority. Program administrators currently evaluate client intention to change behavior. Future evaluation plans include measures of fruit and vegetable intake and self-efficacy. JSY assesses their healthy pantry initiative using a process evaluation following the RE-AIM model.³²

Through the implementation of general healthful eating programs and initiatives in direct collaboration with food banks, JSY illustrates how the NCP can be applied to address nutrition problems at the community level for populations affected by food insecurity.