What screening tools are available to identify food insecurity in clinical practice?

Food Insecurity Screening Tools and Clinical Implementation

The 2-item Hunger Vital Sign (HVS) is the most validated and widely recommended screening tool for food insecurity in clinical practice, and should be implemented systematically with established referral pathways to community resources. 1

Primary Screening Tool: The 2-Item Hunger Vital Sign

The Hunger Vital Sign consists of two questions asking patients about the past 12 months: 1

1. "Did you worry about running out of food and not having money to buy more?"
2. "Did you experience running out of food and not having money to buy more?"

• This tool is derived from and validated against the USDA Household Food Security Survey, which is the gold standard for food insecurity assessment 1
• The HVS has been validated across multiple clinical settings including primary care, emergency departments, and dental clinics 1
• Multiple professional societies endorse this tool specifically, including the American Academy of Nutrition and Dietetics, American Academy of Pediatrics, and American Diabetes Association 1

Alternative and Complementary Screening Approaches

Multi-Domain Screening Tools

When screening for multiple social determinants simultaneously, consider: 1

• WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) - validated in pediatric settings
• PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) - comprehensive social risk assessment

Enhanced Nutrition Screening

Consider adding the one-item Brief Nutrition Security Screener (BNSS) alongside the HVS to identify patients at highest risk for diet-related health complications 2. Patients who screen positive on both tools have significantly increased odds of:

• Self-reported "fair" or "poor" general health (OR 2.91) 2
• At least one chronic condition (OR 2.03) 2
• Low fruit and vegetable intake (OR 2.42) 2

Clinical Implementation Strategy

Screening Logistics

Administer screening in written format when possible, as 75% of patients prefer this method over verbal questioning 3. The screening requires approximately 5 minutes to complete 3.

Screen at regular intervals, ideally every 6 months rather than annually, as one study demonstrated greater improvements in social needs with biannual screening during the COVID-19 pandemic 1.

High-Risk Populations Requiring Prioritized Screening

Target screening efforts toward populations with documented higher prevalence: 1

• Households with children, particularly those under 6 years of age
• Single-caregiver households
• Households with incomes below 185% of poverty level
• Older adults and individuals with disabilities
• Veterans
• Patients with chronic medical conditions (bidirectional relationship with food insecurity)
• Racial/ethnic minorities: 22% of non-Hispanic Black households, 20% of Hispanic households, and 20-30% of Native American/Alaska Native populations experience food insecurity 1

In emergency department settings, food insecurity is associated with African American or Black race (OR 5.21), Hispanic ethnicity (OR 3.47), public insurance (OR 5.74), and increasing patient age 3.

Intervention Pathways Following Positive Screens

Establish concrete referral systems before implementing screening, as screening without actionable interventions may cause harm through stigma and privacy concerns 1. Healthcare-based interventions include: 1

1. Food prescription programs - formal prescriptions for healthy foods
2. On-site or linked food pantries/food boxes
3. Medically tailored meals for patients with specific dietary needs
4. Care coordination and referrals to:
   • SNAP (Supplemental Nutrition Assistance Program)
   • WIC (Special Supplemental Nutrition Program for Women, Infants, and Children)
   • Local food pantries
   • Free lunch programs

Implementation Realities and Pitfalls

Be aware that resource utilization remains suboptimal even with co-located services. In one ED study, 60% of patients screened positive and 98% accepted food vouchers, but only 38% redeemed them at a co-located food market 4. This highlights that screening and resource availability alone are insufficient—active care coordination and follow-up are essential 4.

Successful food delivery programs demonstrate feasibility and potential impact. A healthcare-food bank partnership achieved 89.9% successful home food deliveries and showed reductions in ED visits (-41.5% vs -25.3% in controls) and hospitalizations (-55.9% vs -17.6% in controls) over 12 months 5.

However, connection rates to referred services remain modest. In one cancer screening program, only 33% of patients referred to SNAP or home delivery services successfully received those services, despite 87% responding to follow-up calls 6.

Critical Clinical Context

Food insecurity screening serves dual purposes beyond direct food provision: 1

1. Identifying barriers to managing existing conditions - particularly crucial for diabetes, hypertension, and cardiovascular disease management
2. Enabling patients to access other preventive care services - food insecurity may prevent attendance at follow-up appointments or medication adherence

Food insecurity in childhood has long-term health consequences, including associations with obesity, asthma, mental health conditions, worse oral health, and poor health outcomes later in life 1. In adults, food insecurity is associated with obesity, diabetes, hypertension, and cardiovascular disease 1.

Potential Harms and Mitigation

No studies have reported direct harms from screening itself 1, but potential concerns include:

• Stigma associated with disclosure
• Fear of legal/justice system involvement, particularly Child Protective Services for families
• Privacy concerns regarding sensitive social information

Mitigate these risks by: ensuring confidential screening processes, establishing trust through clear communication about how information will be used, and having robust referral systems in place before screening implementation 1.

Practical Screening Frequency

While optimal screening intervals remain understudied, evidence suggests screening every 6 months is superior to annual screening for improving social needs outcomes 1. Most screening tools do not assess duration or periodicity of food insecurity, so repeated screening is necessary to capture changes over time 1.