In a study led by researchers at the Food is Medicine Institute at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, a new screening tool has been developed and validated to assess Americans’ access to healthy food. Designed to complement measures of food security, which focuses on people’s experiences not having enough resources for food, the new tool—the Nutrition Security Screener (NSS)—zeroes in on whether people can regularly get and eat nourishing foods that support health and prevent disease.
Developed in partnership with Kaiser Permanente and the Los Angeles County Department of Public Health and aligning with the U.S. Department of Agriculture (USDA) definition of nutrition security, the two-item NSS was implemented in five large surveys from 2022-2023 involving over 20,000 adults from diverse backgrounds and regions across the United States. Starting with a preamble that helps people understand what is meant by ‘healthy’ foods, the first item asks how hard it is to regularly obtain and eat healthy foods. Critically, the second item then identifies specific barriers to doing so, ranging from cost, cooking equipment, food storage, and transportation, to nutrition knowledge, cooking skills, family traditions, and more.
“Although the United States food supply provides plenty of calories, most Americans do not eat enough nutritious foods.” said last author Dariush Mozaffarian, director of the Food is Medicine Institute at the Friedman School. “Diet-related diseases are a leading cause of suffering, death, and preventable health care and costs—we need to understand the specific challenges different people and communities face to achieving a healthy diet.”
Noting that poor diets and nutrition do not affect populations evenly, the researchers emphasize the importance of sustaining and expanding measurement efforts. Their results come at a pivotal time. For over 30 years, the USDA’s Household Food Security Reports served as a national benchmark for understanding and tracking household food hardship in the U.S. The recent discontinuation of these reports represents a loss for research and policy evaluation as well as program planning aimed at addressing food security.
Food security screening is still often performed by health care and community organizations, and validated tools like the NSS complement these efforts by offering additional insight into the specific barriers people face when it comes to healthy eating. Together, these measures can guide strategies across health care, government, and community sectors to reduce barriers to healthy diets.
The results, published in The American Journal of Clinical Nutrition, validated the utility of the NSS in several ways. First, nutrition insecurity only moderately overlapped with food insecurity, suggesting that many people including those who do and do not screen as food secure still struggle to regularly access healthy foods and eat well.
Importantly, the study found that nutrition insecurity was independently associated with a range of chronic health conditions—even after accounting for food insecurity and demographic differences. People who screened as nutrition insecure had significantly higher risk of having diabetes, obesity, hypertension, high cholesterol, heart disease, stroke, and worse self-reported physical and mental health.
The reported barriers to nutrition security were striking. While the most common was healthy foods being too expensive (reported by up to 81% of respondents), many other barriers were reported often, including lack of knowledge about which foods are healthy or how to cook healthy foods; time constraints to shop, or to cook; traditional foods being difficult to make healthy; and limited availability of nutritious options where people shop.
“These results highlight that for many Americans, the barriers to healthy eating are complex and extend beyond affordability alone,” said first author Hope Craig, a doctoral candidate at the Friedman School.
The results suggested that food and nutrition security screening were complementary and together provide a more complete picture of food access. For example, people screening positive for both food and nutrition insecurity had the highest rates of diet-related chronic diseases.
“By identifying who has difficulty accessing healthy food and why, the NSS equips health care providers, public health officials, and policymakers with the information needed to better tailor interventions that seek to address the pathways connecting food and nutrition to health and close gaps in health disparities in the U.S.,” said Mozaffarian.
For instance, someone who struggles with the cost of healthy food might benefit from federal nutrition programs or “food is medicine” produce prescriptions, someone who lacks cooking skills might be better served by culinary education programs, and someone with physical limitations or lacking cooking equipment may need other support.
“We hope validation of this screening tool can help strengthen efforts to address the conditions that make healthy eating difficult,” said Craig.
The study’s authors encourage integrating nutrition security considerations alongside food security efforts to improve public health. As chronic diseases linked to poor diets continue to rise, tools like the NSS offer a way to identify at-risk populations and guide effective, targeted solutions for improving nutrition and health across the country.
Citation and Disclaimer
Citation: This work was supported by the National Institutes of Health (grant 2R01HL115189-10, PI: Mozaffarian), the National Science Foundation (S&CC-IRG Award 2125616, PI: de la Haye), the Kaiser Permanente East Bay Community Fund, the Kaiser Permanente National Social Health Practice Office, the Bia-Echo Foundation, the HAND Foundation, and the Seeding the Future Foundation. Complete information on authors, funders, methodology and conflicts of interest is available in the published paper.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.