While food insecurity is a leading public health issue, nutrition security may be a better target for disease prevention strategies, research shows. The American Heart Association (AHA) released a policy statement on recommendations for expanding and improving food assistance policies and programs with a broader focus on nutrition security — providing equitable and stable availability, access, affordability, and use of food with sufficient nutritional quality — rather than a narrower focus on food security, or providing food with sufficient calories.1
The goal of the focus on nutrition security is to prevent diet-related chronic diseases such as cardiovascular disease, diabetes, obesity, and cancer. Communities of color, families with children, and people in rural areas are disproportionally affected by diet-related chronic diseases.2
“Healthy dietary quality is an important part of cardiometabolic health, but we need to recognize that achieving a healthy diet is not equitable for all people in the US,” said Anne Thorndike, MD, MPH, chair of the policy statement writing group and chair of the AHA nutrition committee. “If we are counseling our patients about diet and don’t have background information about their ability to purchase or acquire food, we can’t offer effective counseling,” said Dr Thorndike, who is also associate professor of medicine at Harvard Medical School and a physician at Massachusetts General Hospital in Boston.
The USDA also supported this focus on nutrition security in its recently released USDA Actions on Nutrition Security.2 The average American diet does not align with the Dietary Guidelines for Americans (DGA), with the overall Health Eating Index score being 59 out of 100 points, according to the USDA.
The COVID-19 pandemic highlighted the issue of food insecurity in this country in 2 ways, Dr Thorndike said. First, a large spike in food insecurity rates was seen at the onset of the pandemic; these rates evened out once programs were adapted to help address this need. Second, an estimated two-thirds of patients hospitalized with COVID-19 in the US had diet-related diseases. Thus, health care providers learned that poor diet is not only a risk factor for chronic cardiometabolic disorders but also for an acute infectious disease.
How is Nutrition Security Assessed?
Currently, no standard measure of nutrition security exists. Traditional measures of dietary quality such as 24-hour dietary recall and food frequency questionnaires may be burdensome to use routinely in daily practice, as noted in the AHA statement. Briefer tools are less specific and their validity and reliability may be questionable. The association called for research to develop validated questions to assess nutrition security for use in daily practice and national surveys.
As we wait for improved assessment tools, Dr Thorndike suggested using the 2-question Hunger Vital Sign tool and asking patients what they ate in the past 24 hours as a way to ease into the conversation (Table).3
Table. Hunger Vital Sign
|1. Within the past 12 months, we worried whether our food would run out before we got money to buy more||2. Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more|
This information gives clinicians the ability to hone in on simple cost-neutral changes to improve patients’ diet such as switching from sweetened beverages to water, whole-fat to low-fat dairy products, white potatoes or fries to baked sweet potatoes, and salt to low-cost spices such as garlic, cumin, and black pepper, Dr Thorndike said.
“Clinicians can’t do this alone, it has to be in partnership with their health systems or their practices and requires structure around screening for food security,” Dr Thorndike said.
Clinicians should partner with health systems to develop strategies for connecting patients with community resources. In Massachusetts, the Medicaid program is conducting a pilot study called the Flexible Services Program in which the accountable care organizations are given funds to connect people with food resources, including medically tailored meals, healthy food vouchers, or fruit and vegetables, Dr Thorndike explained.
Use and Stability of Nutritious Food
Use and stability of nutritious food over time are newer elements to consider in food-related policies and programs. Americans without access to proper food preparation tools, kitchen equipment, or time to prepare foods may rely on ultra-processed convenient foods that offer little nutrition, as noted in the AHA statement. Proper food storage is also an issue as many healthy foods are perishable and require refrigeration; others require dry spaces and containers to prevent spoilage from moisture, pests, and other contaminants.
Regarding stability, access to federal nutrition assistance programs such as Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) can vary by time and eligibility criteria, creating gaps in access to food assistance programs.
The AHA outlined recommendations to increase the impact of current US nutrition policies and programs on nutritional security and help reduce socioeconomic and racial/ethnic disparities in chronic disease rates. The AHA commended the USDA for evaluating the Thrifty Food Plan, which serves as the basis for calculating SNAP benefits, and initiating a 20% increase in benefit levels for SNAP recipients in October 2021 to more accurately reflect the cost of nutritious meals.
Principles for Food Assistance Programs to Achieve Nutrition Security
“We need programs and policies in place to make sure that we are equitable in our ability to achieve a healthy dietary quality for everyone,” Dr Thorndike said. Coordination across all programs and policies from the federal to community level as well as within the health care system is needed to address nutrition security, Dr Thorndike explained.
The AHA recommended the following principles for emphasizing nutritional quality, improving reach and optimal use, and improving coordination across US food assistance policies and programs:
- Emphasize nutrition standards
- Increase outreach and simplify enrollment and certification procedures
- Ensure optimal use by participants
- Improve coordination across programs
- Avoid gaps in coverage for age groups
- Ensure equity for stable availability, accessibility, affordability, and use (eg, provide foods aligned with cultural, social, and dietary preferences)
- Reduce stigma associated with participation
“As a physician, I am hoping that health care providers will increasingly recognize the importance of diet consumption on our health and that we should prioritize it for ourselves and our patients,” Dr Thorndike said.
1. Thorndike AN, Gardner CD, Kendrick KB, et al. Strengthening US food policies and programs to promote equity in nutrition security: a policy statement from the American Heart Association. Circulation. 2022 May 10:101161CIR0000000000001072. doi:10.1161/CIR.0000000000001072
2. US Department of Agriculture. USDA actions on nutrition security. March 17, 2022. Accessed May 9, 2022. https://www.ncbi.nlm.nih.gov/books/NBK209359/
3. 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):e26-32. doi:10.1542/peds.2009-3146