Assessing and Monitoring Nutrition Security in the United States: A Narrative Review of Current Measures and Instruments.

PURPOSE OF REVIEW: Because nutrition plays a crucial role in the development of chronic diseases, ensuring nutrition security is important for promoting population health. Nutrition security is defined as having consistent and equitable access to healthy, safe, affordable foods essential to optimal health and well-being. Distinguished from food security, nutrition security consists of two constructs: healthy diets and nutritional status. The study aimed to identify population measures that reflect the important constructs of nutrition security (i.e., healthy diets and nutritional status) to inform U.S. nutrition security assessment and monitoring. RECENT FINDINGS: Through a narrative review conducted across multiple databases, associations between subconstructs of healthy diets and nutritional status were identified. Of the six subconstructs that constitute healthy diets, nutrient adequacy and moderation were most often used to assess and monitor healthfulness of U.S. population diets and were associated with health outcomes. There is little evidence of an association between health outcomes and macronutrient balance or diversity in the U.S. Thirteen instruments were identified as potentially suitable for measuring at least one subconstruct of healthy diet in the population. This review highlights the importance of nutrition security in addressing population health challenges. It emphasizes the potential use of multiple instruments and measures to comprehensively monitor population nutrition security and inform intervention strategies. Identifying feasible and practical measures for assessing and monitoring nutrition security is imperative for advancing population health and mitigating the burden of chronic diseases.

Assessing and Monitoring Nutrition Security to Promote Healthy Dietary Intake and Outcomes in the United States.

The US Department of Agriculture's Economic Research Service leads the federal government in data development and research on food security in US households. Nutrition security is an emerging concept that, although closely related, is distinct from food security. No standard conceptualization or measure of nutrition security currently exists. We review the existing research on nutrition security and how it is informed by the more robust literature on food security and diet quality. Based on this review, we propose a conceptual framework for understanding nutrition security and its relationship to food security. We identify two constructs (healthy diets and nutritional status) and multiple subconstructs that form the basis of nutrition security. The proposed framework and corresponding constructs are intended to provide (a) understanding of how nutrition security arises and how it differs from food security, (b) background on why assessment and monitoring of nutrition security is important, and (c) guidance for a research agenda that will further clarify the meaning of nutrition security and its measurement.

Development and Validation of a Physical Food Security Tool for Older Adults.

BACKGROUND: Current measures of food insecurity focus on economic access to food, but not on the physical aspect of food insecurity that captures the inability to access food or prepare meals. This is particularly relevant among the older adult population who are at a high risk of functional impairments. OBJECTIVES: To develop a short-form physical food security (PFS) tool among older adults using statistical methods based on the Item Response Theory (Rasch) model. METHODS: Pooled data from adults aged ≥60 y of the NHANES (2013-2018) (n = 5892) were used. The PFS tool was derived from the physical limitation questions included in the physical functioning questionnaire of NHANES. Item severity parameters, fit and reliability statistics, and residual correlation between items were estimated using the Rasch model. The construct validity of the tool was assessed by examining associations with the Healthy Eating Index (HEI)-2015 scores, self-reported health, self-reported diet quality, and economic food insecurity, using weighted multivariable linear regression analysis, controlling for potential confounders. RESULTS: A 6-item scale was developed, which had adequate fit statistics and high reliability (0.62). It was categorized based on raw score severity into high, marginal, low, and very low PFS. Very low PFS was associated with respondent's self-reported poor health (OR = 23.8; 95% CI: 15.3, 36.9; P < 0.0001), self-reported poor diet (OR = 3.9; 95% CI: 2.8, 5.5; P < 0.0001), low and very low economic food security (OR = 6.08; 95% CI: 4.23, 8.76; P < 0.0001), and with lower mean HEI-2015 index score, in comparison to older adults with high PFS (54.5 compared with 57.5, P = 0.022). CONCLUSIONS: The proposed 6-item PFS scale captures a new dimension of food insecurity that can inform on how older adults experience food insecurity. The tool will require further testing and evaluation in larger and different contexts to demonstrate its external validity.

SNAP Participation and Emergency Department Use.

OBJECTIVES: To examine whether Supplemental Nutrition Assistance Program (SNAP) participation is associated with emergency department use among low-income children and whether any such association is mediated by household food hardship and child health status and/or moderated by special health care needs (SHCN) status. We hypothesized SNAP to be associated with reduced likelihoods of emergency department use, with greater effect sizes for children with SHCN and mediation by food hardship and health status. METHODS: In this secondary analysis, we estimated a bivariate probit model (with state-level SNAP administrative policies as instruments) within a structural equation modeling framework using pooled cross-sectional samples of children in low-income households from the 2016 to 2019 iterations of the National Survey of Children's Health (n = 24 990). RESULTS: Among children with and without SHCN, respectively, SNAP was associated with: 22.0 percentage points (pp) (95% confidence interval [CI] 12.2-31.8pp) and 17.1pp (95% CI 7.2-27.0pp) reductions in the likelihood of household food hardship exposure (4.8pp difference-in-differences, 95% CI 2.3-7.4pp), 9.7pp (95% CI 3.9-15.5pp) and 7.9pp (95% CI 2.2-13.6) increases in the likelihood of excellent health status (1.9pp difference-in-differences, 95% CI 0.7-3.0pp), and 7.7pp (95% CI 2.9-12.5pp) and 4.3pp (95% CI 1.0-7.6pp) reductions in the likelihood of emergency department use (3.4pp difference-in-differences, 95% CI 1.8-5.1pp). CONCLUSIONS: We found SNAP participation was associated with lower likelihoods of emergency department use, that better food hardship and health statuses mediated this association, and that effect sizes were larger among children with SHCN. Food hardship relief may improve outcomes for vulnerable children and the health systems serving them.

Household food insufficiency, health status and emergency healthcare utilisation among children with and without special healthcare needs.

OBJECTIVE: To compare exposure to household food insufficiency and the relationship between household food insufficiency and both health status and emergency healthcare utilisation among children with and without special healthcare needs (SHCN). DESIGN: Analysing pooled data from the 2016-2017 iterations of the National Survey of Children's Health, we conducted multivariate logistic regressions on household food insufficiency, health status and emergency healthcare utilisation. We assessed interactions between household food insufficiency and children's SHCN status in our models of health status and utilisation. SETTING: United States. PARTICIPANTS: Parents of a nationally representative sample of non-institutionalised children (aged 0-17 years). RESULTS: Children with SHCN were more likely to experience household food insufficiency (70 v. 56 %), non-excellent health status (67 v. 28 %) and emergency healthcare utilisation (32 v. 18 %) than other children. Household food insufficiency was associated with 37 % (children with SHCN) and 19 % (children without SHCN) reductions in the likelihood of having excellent health. Household food insufficiency was associated with a roughly equal (16-19 %) increase in the likelihood of emergency department utilisation across groups. CONCLUSIONS: Compared with other children, children with SHCN have an elevated risk of exposure to household food insufficiency and experiencing greater reductions in health status when exposed.

U.S food insecurity and population trends with a focus on adults with disabilities.

Food insecurity is a key indicator of well-being. This article provides an overview of food security measurement and population trends with a focus on adults with disabilities and their risk for food insecurity. Food-insecure households had difficulty providing enough food for all their members due to a lack of resources. Disabilities have been shown to be a strong risk factor for food insecurity. This finding has held true across multiple datasets and while examining different types of disability. Work-limiting disabilities and disabling mental health conditions appear to be particularly detrimental to food insecurity. However, less is known about the mechanisms through which disabilities affect food insecurity. More research in this area can help point toward policy solutions to improve the food security of those with disabilities.

Food insecurity, acculturation and diagnosis of CHD and related health outcomes among immigrant adults in the USA.

OBJECTIVE: To deepen understanding of the relationship between food insecurity, acculturation, and diagnosis of CHD and related health outcomes among immigrant adults. DESIGN: Using cross-sectional, nationally representative data from the National Health Interview Survey 2011 to 2015, we address two research questions. First, what is the relationship of household food insecurity and acculturation with: CHD, angina pectoris, heart attack, self-rated poor health and obesity? Second, what is the association of food insecurity with these health outcomes over years of living in the USA? We estimate multivariate logistic regressions without (question 1) and with (question 2) an interaction term between food insecurity and acculturation for CHD and related health outcomes. SETTING: USA. PARTICIPANTS: Low-income immigrant adults. RESULTS: Food insecurity and acculturation are both associated with diagnosis of CHD and related health outcomes among immigrant adults. Food insecurity and acculturation are associated with the health of female immigrants more than males. Also, the differences by food security status in the probability of having several poor health outcomes (self-rated heath, obesity, women's angina pectoris) are largest for those in the USA for less than 5 years, decrease for those who have lived in the USA for 5-14 years, and are larger again for those in the USA for 15 or more years. CONCLUSIONS: Recent and long-term food-insecure immigrants are more vulnerable to CHD and related health outcomes than those in the USA for 5-14 years. Further research is needed to understand why.

Food Insecurity Is More Strongly Associated with Poor Subjective Well-Being in More-Developed Countries than in Less-Developed Countries.

BACKGROUND: Food insecurity is strongly associated with subjective well-being. People compare their well-being to a subjective reference that adjusts over time, which is called hedonic adaptation. OBJECTIVE: We aimed to deepen understanding of the relation between food insecurity and subjective well-being among countries from the perspective of possible hedonic adaptation between food insecurity and subjective well-being. METHODS: Global data from the Gallup World Poll 2014 were collected from 152,206 individuals in 147 countries. Telephone and face-to-face surveys were conducted in 37 and 111 countries, respectively, collecting data on law and order; food and shelter; institutions and infrastructure; job climate; and financial, social, physical, and evaluative well-being, including the Food Insecurity Experience Scale. Data were aggregated to country level and merged with economic and social measures from World Bank and United Nations sources: infant mortality, gross domestic product, economic inequality, agricultural value added, fertility, maternal mortality, female schooling, and female participation in the labor force. Multilevel linear regression was used to examine associations between well-being and food insecurity. RESULTS: Experiencing moderate or severe food insecurity was prevalent among countries, with a mean probability of 0.273 ± 0.220. Countries that were less developed economically and socially had a higher probability of experiencing food insecurity, lower subjective well-being as measured by the daily experience index, and less negative slopes for the relation between daily experience index and food insecurity. Food insecurity was the strongest predictor of daily experience from among the measures of economic and social development. CONCLUSIONS: The prevalence of food insecurity was strongly and negatively associated with subjective well-being across 147 countries. The association between food insecurity and poor subjective well-being within countries was stronger for more-developed countries, providing evidence of hedonic adaptation between food insecurity and subjective well-being. Food insecurity explained substantial variation in subjective well-being both among and within countries.

Food Insecurity Is Associated with Subjective Well-Being among Individuals from 138 Countries in the 2014 Gallup World Poll.

Background: Food insecurity is an aspect of living conditions that is particularly important for quality of life, health, and subjective well-being. The implementation of the 8-item Food Insecurity Experience Scale in 147 countries in the 2014 Gallup World Poll provided an unprecedented opportunity to understand the association of food insecurity with subjective well-being.Objective: We examined how food insecurity relates with measures of living conditions and how food insecurity and other living conditions relate with physical health and, in turn, subjective well-being.Methods: Data were collected from individuals aged ≥15 y by telephone in 38 countries and via face-to-face interviews in 111 others. The available sample was 132,618 (138 countries) and 122,137 (137 countries) for the daily experience and life evaluation indexes of subjective well-being, respectively. Daily experience was a continuous measure and life evaluation was categorized into thriving, struggling, and suffering. We estimated 6 linear or logistic regression models for each index controlling for country as a fixed effect.Results: Food insecurity was associated with the other 3 measures of living conditions: household income, shelter and housing, and employment. Food insecurity explained poor physical health and lower subjective well-being beyond other measures of living conditions. Instrumental and emotional support was associated with higher subjective well-being. The associations of food insecurity with subjective well-being were larger than with other explanatory variables. Food insecurity was associated with subjective well-being within each of the 4 World Bank income classes of countries, with a larger magnitude of differences for the higher-income classes.Conclusions: Food insecurity was strongly and negatively associated with subjective well-being in a large global sample of individuals aged ≥15 y. These results demonstrate the consistency of goal 2 of the Sustainable Development Goals, which has targeted 2030 to ensure food security for all people, year-round, with other goals to reduce food insecurity.

Food Insecurity and Health Outcomes Among Older Adults: The Role of Cost-Related Medication Underuse.

The purpose of this study is to examine the relationship between food security and cost-related medication underuse among older adults (persons aged 65 years and older) in the United States; and to determine if this relationship differs by sex, chronic disease status, and type of health insurance. Data are from a combined sample of older adults in the 2011 and 2012 National Health Interview Survey (N = 10,401). Both bivariate and multivariate analyses show a dose-response relationship between food insecurity and cost-related medication underuse among the elderly--increasing likelihood of cost-related medication underuse with increasing severity of food insecurity (P < 0.001). This association is not conditional on sex, chronic disease status, or type of health insurance. However, females and those with a chronic condition are more likely to report cost-related medication underuse than males and those without a chronic condition respectively; and older adults with Medicare and Medicaid or other public insurance are less likely to report cost-related medication underuse than older adults with only Medicare.

Food Insecurity and Cost-Related Medication Underuse Among Nonelderly Adults in a Nationally Representative Sample.

OBJECTIVES: We investigated whether nonelderly US adults (aged 18-64 years) in food-insecure households are more likely to report cost-related medication underuse than the food-secure, and whether the relationship between food insecurity and cost-related medication underuse differs by gender, chronic disease, and health insurance status. METHODS: We analyzed data from the 2011 and 2012 National Health Interview Survey (n = 67 539). We examined the relationship between food insecurity and cost-related medication underuse with the χ(2) test and multivariate logistic regression with interaction terms. RESULTS: Bivariate and multivariate analyses showed a dose-response relationship between food insecurity and cost-related medication underuse, with an increasing likelihood of cost-related medication underuse with increasing severity of food insecurity (P < .001). This association was conditional on health insurance status, but not substantially different by gender or chronic disease status. Being female, low-income, having no or partial health insurance, chronic conditions, functional limitations, or severe mental illness were positively associated with cost-related medication underuse. CONCLUSIONS: Using food insecurity as a risk factor to assess cost-related medication underuse could help increase identification of individuals who may need assistance purchasing medications and improve health for those in food-insecure households.