Consider this evidence-based approach to tackling a critical health issue.
- An estimated 5.3 million children live in food insecure households in the United States, which increases the risk of neurodevelopmental disabilities, asthma, and depressive symptoms.
- Using an evidence-based framework, nurses can identify food insecurity in children and mitigate its effects.
- The 3A Framework (assess, address, advocate) supports a focused approach to identifying food insecurity and providing appropriate referrals.
The U.S. Department of Agriculture (USDA) defines food insecurity as a household condition characterized by limited or uncertain access to sufficient food, which includes running out of food or having inadequate amounts or poor-quality food. Child food insecurity refers to an individual child who lacks adequate food, whereas household food insecurity arises when one or more members of a household consistently face food shortages. (See Food insecurity: Troubling numbers.)
The impact of child and household food insecurity on children can vary, as adults may restrict their own food intake to ensure that their children receive enough food. Low-income households with young children who have special needs are particularly susceptible to experiencing food insecurity compared to their peers without such needs. Adverse health outcomes in children experiencing food insecurity include the risk of neurodevelopmental disabilities, asthma, depressive symptoms, and poor academic performance.
Addressing social determinants of health
A nurse’s guide to food banks, food pantries, and soup kitchens
Food insecurity: Troubling numbers
In 2019, according to the U.S. Department of Agriculture Food Economic Research Service, an estimated 35.2 million Americans lived in food-insecure households, including 5.3 million children.
- The prevalence of food insecurity nationwide stands at 10.5%. However, it varies based on household type, with rates of 13.6% for all households with children and 14.5% for households with children under age 6.
- Among households headed by single women with children, the prevalence jumps to 28.6%.
- The prevalence of food insecurity among Black, non-Hispanic households stands at 19.1% and 15.6% for Hispanic households.
- Black and Brown individuals in the United States experience food insecurity at higher rates, with non-Hispanic Black and Hispanic households being twice as likely to face food insecurity compared to non-Hispanic White households.
- The U.S. Census Bureau has been asking households about their food consumption for the past 3 years. The results indicate that the number of Americans facing food shortages has increased by 23%, to 19.2 million people.
- Poverty tends to exacerbate food insecurity. It affects 27.6% of households below 185% of the poverty threshold.
- Waxman and colleagues reported that in 2017–2018, 26.6% of caregivers with children under the age of 3 years reported experiencing food insecurity; among low-income families with children under 3, food insecurity prevalence exceeds 50.9%
- Burkhardt discovered that 31% of families with infants screened in urban clinics faced food insecurity, frequently resorting to stretching formula by diluting it as a strategy to save money.
As described by the Rural Health Information Hub, obtaining affordable and nutritious food presents a considerable challenge for individuals living in rural regions. Many of these areas have few food retailers and qualify as food deserts, leaving their residents with insufficient access to fresh and reasonably priced food. Paradoxically, some of these food deserts sit within regions where agriculture plays a pivotal role in the local economy.
Financial constraints and other impediments, such as transportation challenges, play a role in restricted access to food. Many rural residents find themselves compelled to opt for more expensive and less healthful food options, such as those found in gas station convenience stores, or endure lengthy journeys to neighboring towns where supermarkets or grocery stores offer a selection of fresh produce, milk, eggs, and other essential food items.
Awareness about food insecurity has gained momentum in the media and among the public. During the COVID-19 pandemic, families who had never experienced food insecurity needed assistance to feed their children. According to Feeding America, during the worst of the pandemic (2020 through 2021), 42 million to 45 million people and up to 15 million children experienced food insecurity, resulting in a surge in demand at food banks and long lines for food. These households frequently face difficult choices, such as prioritizing between food and essentials like diapers, medications, or rent. Consequently, food insecurity places significant stress on parents and caregivers.
The role of healthcare professionals
A study by Barnidge and colleagues revealed that a significant proportion of healthcare providers recognize the issue of food insecurity as a challenge for certain patients, with approximately 88% acknowledging its presence. However, only 15% of these providers reported actively screening for food insecurity. A much higher percentage (80%) expressed willingness to conduct such screenings. Many voiced concern regarding the appropriate course of action when encountering a positive screening result. In response to some of these challenges, the American Academy of Pediatrics has issued a recommendation to screen for food insecurity during health supervision visits in pediatric primary care settings. In addition, many hospitals and schools have incorporated food insecurity screening into their intake processes; some hospitals conduct screenings prior to discharge.
Because nutrition plays an important role in brain development, with particular significance between birth and 3 years of age, early intervention requires that providers understand the issue and have the skills to identify and address it. The 3A Framework (Assess, Address, Advocate), when incorporated into food insecurity screening during early childhood pediatric visits, can support nurses’ vital role in early intervention. In conjunction with the Hunger Vital Sign (HVS), this concise two-question screening tool aids the assessment of food insecurity.
Food insecurity and early childhood development
Food insecurity has serious consequences for young children, particularly infants and toddlers. Smaller brains mean more cognitive risk, and lack of optimal nutrition can adversely affect brain development and growth. Household and child food insecurity are associated with increased developmental risk at various ages, including 3 months through 24 months.
In a systematic review, Shankar and colleagues found that household food insecurity, even at very low levels, can have significant effects on young children’s behavior and emotional well-being. Zaslow and colleagues reported that food insecurity disrupts children’s development even in very early life (by age 9 months) with higher levels of food insecurity indirectly influencing cognitive development, particularly in the presence of maternal depression. (See Behavior and emotional well-being.)
Behavior and emotional well-being
Food insecurity can have the following effects on young children:
- Aggression and irritability. Hunger and inadequate nutrition can lead to heightened levels of irritability and even aggression in young children. Physical discomfort may interfere with their ability to regulate their emotions.
- Anxiety and worry. Children who experience food insecurity may develop anxiety about when they’ll have their next meal. The uncertainty surrounding food availability can lead to constant worry and stress.
- Depression and low mood. Chronic hunger and the associated stress and worry contribute to feelings of sadness and hopelessness. Over time, these emotions can develop into more severe symptoms of depression.
- Difficulty concentrating. Hunger and malnutrition can affect cognitive function, making it difficult for children to concentrate, focus, and engage in learning activities. Ultimately, this can impact their academic performance and overall development.
- Food hoarding or obsession. Some children who’ve experienced food insecurity develop a preoccupation with food and exhibit behaviors such as hoarding food or obsessing over it, even when they have enough to eat.
- Physical health issues. Inadequate nutrition as a result of food insecurity can lead to physical health problems such as stunted growth, a weakened immune system, and developmental delays.
- Risk of disordered eating. Although not all children who experience food insecurity will develop disordered eating patterns, some might have a strained relationship with food, which can lead to overeating when food is available and restricted eating when it’s not.
- Sleep disturbances. The stress and anxiety associated with food insecurity can disrupt sleep patterns, including difficulties falling asleep, staying asleep, or experiencing restful sleep.
A study by Hernandez and Jacknowitz showed that 24-month-old toddlers whose mothers experienced food insecurity scored 1.5 points lower in cognitive testing than toddlers whose families had adequate food. The study further demonstrated that toddlers living with adults who face temporary food insecurity, compared to those living with adults who never experienced food insecurity, exhibited slight but immediate adverse effects in cognitive development. A more recent study by Gallegos and colleagues supports these findings, noting that food insecurity prevents children from reaching their full physical, cognitive, and psychosocial potential. The study also indicates that transitioning between food security and food insecurity has a significant and lasting effect on academic/cognitive function, including maladaptive behavior such as externalizing (directing emotions at one’s environment).
Developmental risk in young children refers to factors or circumstances that can potentially hinder or negatively impact a child’s physical, cognitive, emotional, social, and behavioral development. For example, these children may experience communication and language disorders; challenges with learning letters, numbers, shapes, and colors; awkward or uncoordinated movements; frequent aggressive behavior; difficulty with age-appropriate tasks associated with reading, writing, math, and other learning areas; and chronic health conditions, such as diabetes, cardiovascular disease, anemia, osteoporosis, and GI disorders.
A systematic review by de Oliveira and colleagues found an association between food insecurity and poor early child development outcomes among children under age 5 years in high- and low-middle-income countries. Meta-analysis displayed a link between food insecurity and developmental risk and cognitive outcomes related to vocabulary and math skills, potentially resulting in impaired brain function and behavioral problems.
Screening for food insecurity
Many screening tools exist to help healthcare professionals identify food insecurity. Porter and colleagues noted several tools, including the USDA Household Food Security Survey (18-item full form and 6-item short form), Community Childhood Hunger Identification Project, WE CARE screening, and WellRx survey. Some of these tools offer the convenience of web-based self-administration, which allows caregivers, healthcare providers, and others to complete the screening at any time.
HVS, one of the easier tools to use, asks for responses to two statements: “Within the past 12 months, we worried whether our food would run out before we got money to buy more” and “Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.” Responding “Often true” or “Sometimes true” to either statement indicates food insecurity.
The HVS, derived from the USDA 18-item Household Food Security Survey, uses a sample of urban caregivers (n=30,098 families) of children younger than age 3. It has a sensitivity of 97% and a specificity of 83%. Sensitivity refers to the tool’s ability to identify all households experiencing food insecurity correctly. Specificity measures the tool’s accuracy in identifying food-secure households.
Determining food insecurity considers the quantity of food available but not necessarily the health aspects of available food. Some communities lack local options to shop for healthy foods (food deserts), and some communities are besieged with fast food restaurants (food swamps). These typically are found in urban areas with predominantly Black and Brown residents. The global aim of food insecurity screening is to connect families and children with the necessary resources.
For example, the Supplemental Nutrition Assistance Program (SNAP) provides benefits to increase the food budget of low-income families so they can purchase more healthy food. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves children up to age 5 at nutrition risk and pregnant and breastfeeding women. WIC aims to support the health of its beneficiaries by providing nutritious foods to promote healthy eating as well as healthcare recommendations. Intended for low-income families, WIC eligibility varies with state guidelines.
The 3A framework and food insecurity reduction
The 3A framework allows for a more focused approach to aid identification of individuals at risk for food insecurity and make appropriate referrals.
Assess through screening
In the context of food insecurity, assessment helps identify, via screening, those experiencing limited or uncertain access to adequate food and allows for the provision of appropriate interventions and support. Based on findings by Shankar, providers (physicians, nurse practitioners, and nurses working in schools, parishes, community health, and acute care) who care for young children should incorporate food insecurity screening into their practices and intervene when possible.
Children facing food insecurity are less likely to receive appropriate developmental screening, surveillance, and timely referral to early intervention and other early childhood development and education services. Screening should occur at each patient encounter as households may not always be food insecure. Providers should consider conducting a food insecurity screening at a first meeting and at regular intervals during subsequent visits.
To reduce the embarrassment and stigma associated with food insecurity, providers can give parents the screening tool to complete on their own. They can then bring it back with them at a follow-up visit or submit it online. However, staff should be available to assist with form completion as requested.
Knowles and colleagues put the HVS tool into practice at three pediatric clinics, which served 7,284 families with children under age 5. Among the participants, 1,133 (15.6%) reported food insecurity; the clinics connected 630 of these (55.6%) with community resources. These findings highlight the significance of incorporating screening and helping families access support.
Address via referral and support
When providers address food insecurity, they actively respond to the challenges and needs associated with inadequate access to sufficient, healthy food. This response can involve implementing interventions to alleviate food insecurity, such as providing food assistance and promoting access to nutritious food.
Addressing food insecurity aims to mitigate its impact and work toward ensuring that individuals and households have reliable and consistent access to nutritious food. Bottino and colleagues found that including a “referral menu” with local resources on the screening form helped to increase the identification of families with food insecurity by 15% (compared to screening alone). The referral menu asked, “Would you like help with any of the following? Please check all that apply.” Options included finding a food pantry, getting hot meals, applying for SNAP benefits, applying for WIC or help with the WIC office (they also could choose “none of these”). Over half of the caregivers who selected any referral asked for help finding a food pantry.
Posting resources on healthcare organization websites, placing them on bulletin boards, and providing them in pamphlets empowers individuals and households that may not feel comfortable disclosing their food insecurity directly to their providers. Essel and colleagues reported that, regardless of how well screening tests perform, follow-up with referrals to food sources remains a vital factor in care. When providers understand available resources, they can help connect families to federal nutrition programs, emergency food resources, and financial support to sustainably assist them through times of food hardship.
Advocate for food insecurity reduction policies
Advocacy related to food insecurity can involve activities such as lobbying for policy changes, educating the public, mobilizing communities, and collaborating with stakeholders. Advocacy aims to promote positive social, economic, and political changes that lead to more equitable and food-secure communities.
Sharing families’ stories of food insecurity with policymakers can serve as a powerful advocacy approach. The link between food insecurity and economic stability as a social determinant of health requires advocating for policies that address poverty.
Advocacy for food security remains an ongoing and multifaceted effort that requires collaboration, persistence, and a deep understanding of the complex factors at play. By addressing the root causes and implementing effective strategies, advocates can make a significant impact.
Nurses can make a difference
Food insecurity leads to adverse health outcomes among children, especially during early childhood neurodevelopment. Routine screening, referrals to local resources, and advocacy all play a role in mitigating the impact of food insecurity and promoting positive health outcomes for children. Nurses can incorporate valid and reliable tools to screen for food insecurity during routine visits in primary care settings or add this screening to nursing admission assessments in acute care, school, and community/public health settings.
Schools serve as invaluable support for families facing financial difficulties. Collaborating with food banks and schools ensures that children have access to free or affordable meals and that families can find essential groceries. When children have access to nutritious quality food, they gain the vitality and concentration necessary for their educational and personal development. In the hospital setting, nurses can offer a referral for nutritional evaluation by a dietician. This ensures the assessment of a child’s food security even in emergency situations.
Nurses can request a social service consultation to help families navigate assistance programs and provide family education about healthy food choices. Nurses also can connect families with and advocate for local resources or governmental assistance programs as well as local community organizations that address the root causes of food insecurity.
When nurses implement screening, referrals, and advocacy, they help mitigate the impact of food insecurity and promote positive health outcomes for infants and young children.
Acknowledgment
Dr. Sallie Porter passed away unexpectedly on April 28, 2023. We acknowledge her contributions to this article as well as her dedication to her students at all levels of nursing education, and importantly to the field of pediatric nursing, particularly the social determinants of pediatric healthcare.
This paper received partial support from the Caplan Foundation for Early Childhood (S.Porter, PI, R.Qureshi, co-PI). #17-0008 RUF
Rubab Qureshi is an associate professor in the division of nursing science at Rutgers University School of Nursing in New Brunswick, New Jersey. Cheryl Holly is a professor in the division of nursingscience and co-director of the Northeast Institute for Evidence Synthesis and Translation at Rutgers University School of Nursing. Mercedes Echevarria is an associate professor and associate dean in the DNP Program at the George Washington University School of Nursing in Washington, DC. Ganga Mahat is a clinical professor in the division of entry to practice at Rutgers University School of Nursing. Sallie Porter was an associate professor in the division of advanced practice at Rutgers University School of Nursing.
American Nurse Journal. 2025; 20(1). Doi: 10.51256/ANJ012514
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Key words: food insecurity, child food insecurity, pediatric care, food deserts
