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

A New Approach To Guide Research And Policy At The Intersection Of Income, Food, Nutrition, And Health

Income distribution, food and nutrition insecurity, and poor diet quality contribute to diet-related disease, which is a major threat to population health and health equity. Based on our review and synthesis of the empirical evidence, we provide a new conceptual model for understanding the interrelationships among income, food security, nutrition security, diet quality, and health. We identify directions for future research and discuss the policy and program implications of the model. Overall, interventions that address income and food security can facilitate, but do not ensure, nutrition security and better diet quality, although they can improve health in other ways. Importantly, even people who are food and nutrition secure and have adequate income frequently have unhealthy diets. Addressing these challenges will require innovative policies to improve nutrition security, diet quality, and health. Such policies should include efforts to increase the availability and accessibility of Food Is Medicine interventions in health care. Health insurance coverage for evidence-based, clinically indicated Food Is Medicine programs is critical to the success of these efforts.

Food insecurity and risk of nutrition insecurity among Supplemental Nutrition Assistance Program participants in Rhode Island and Connecticut, USA

Objective

To 1) describe food insecurity and risk of nutrition insecurity (henceforth nutrition insecurity); 2) test the associations between perceived food access and neighborhood environment and food and nutrition insecurity, and differences in these associations; and 3) test the associations between food and nutrition insecurity and diet quality, among a sample of adults with low income.

Methods

Between May-September 2023, Supplemental Nutrition Assistance Program (SNAP) participants in Rhode Island and Connecticut, USA (n = 1234) completed a food frequency questionnaire, from which we calculated healthy eating index (HEI)-2015 scores. An online survey included questions on perceived food access barriers and the food environment, and food and nutrition security. We used separate adjusted regression models to estimate correlates associated with food and/or nutrition insecurity and their associations with diet quality.

Results

Individuals were 35 years old, on average, 92 % were women, 43 % identified as Hispanic, and 58 % and 30 % were food and nutrition insecure, respectively. The average HEI-2015 score was 64. Lack of money was associated with an 8-fold higher odds of experiencing food insecurity (95 % Confidence Interval [CI] = 5.76, 10.67). The largest magnitude of association with nutrition insecurity was having few or no full-service grocery stores nearby (Odds Ratio[OR] = 2.27; 95 % CI = 1.27, 4.06), followed by lack of money and limited transportation. Associations between food and nutrition insecurity and HEI-2015 were negative but not statistically significant.

Conclusions

The prevalence of food insecurity among SNAP participants was higher than Americans, on average. Perceived food access barriers were associated with food and nutrition insecurity.

SNAP Participation as a Moderator of Food and Nutrition Security and Combined Cardiometabolic Conditions: A Mixed Regression Approach

Objectives: To examine the relationships between food security, nutrition security, Supplemental Nutrition Assistance Program (SNAP) participation, and cardiometabolic outcomes, including hypertension, hyperlipidemia, or diabetes, among low-income U.S. individuals. Methods: A cross-sectional survey of 486 participants (April-June 2021) assessed food and nutrition security and cardiometabolic outcomes. Mixed-effects logistic regression models adjusted for covariates and included a random effect for state of residence. Moderation analyses evaluated SNAP participation's impact. Results: Very low food security was associated with higher odds of having at least one cardiometabolic condition, such as hypertension, hyperlipidemia, or diabetes (AOR = 1.96; 95% CI: 1.04-3.69; p = 0.04). SNAP moderated this relationship (p-interaction = 0.007), with non-participants experiencing significantly higher risk. Non-SNAP participants with very low food security had 3.17 (95% CI = 1.17-8.61) times higher odds of having a cardiometabolic condition. Among SNAP participants, very low food security was not significantly associated with having a cardiometabolic condition (OR = 1.62; 95% CI = 0.64-4.13). Higher nutrition security was associated with lower odds of having at least one cardiometabolic condition (AOR = 0.59; 95% CI: 0.41-0.83; p = 0.002). Conclusions: Nutrition security and SNAP participation mitigate cardiometabolic risks, underscoring their importance in public health interventions.

A Measure of Nutrition Security Using the National Health and Nutrition Examination Survey Dataset

Importance

Accurate and practical measures of nutrition security are needed to assess and monitor its prevalence and to identify its associated risk factors in the US.

Objective

To propose a nutrition security measure derived from combining self-assessed food security and diet quality indicators available in the National Health and Nutrition Examination Survey (NHANES) and to assess the prevalence and associated sociodemographic and health factors of nutrition security.

Design, Setting, and Participants

This cross-sectional study used data from 6 cycles of NHANES, which collects data on general health status and behaviors, dietary intake, physiological measurements, and sociodemographic characteristics, conducted from 2007 to 2018. All participants were adults aged 20 years or older. Statistical analysis was performed between October 2023 and April 2024.

Exposures

Sociodemographic and health characteristics, including age, sex, race and ethnicity, marital status, household size, presence of children in the household, educational level, poverty to income ratio (PIR), Supplemental Nutrition Assistance Program (SNAP) participation, weight status, chronic conditions, and health insurance coverage.

Main Outcomes and Measures

A nutrition security measure was derived from combining self-assessed food security, measured using the US Department of Agriculture Household Food Security Survey Module, and self-rated diet quality indicators. Four nutrition security status categories were created from dichotomized food security and diet quality measures: food secure with high diet quality (FSHD), food secure with low diet quality (FSLD), food insecure with high diet quality (FIHD), and food insecure with low diet quality (FILD). Only respondents classified as FSHD were considered to be nutrition secure.

Results

The unweighted analytic sample included 28 898 NHANES participants. The weighted mean [SD] age of participants was 47.3 [14.5] years; 51.9% (weighted) of the sample was female; 11.1% identified as Black, 13.6% as Hispanic, and 67.4% as White individuals; and 35.6% of those surveyed were classified by the proposed measure as nutrition insecure (ie, FSLD, FIHD, or FILD). Of these participants, 20.2% (95% CI, 19.4%-21.0%) were categorized as being nutrition insecure due to FSLD, 8.4% (95% CI, 7.8%-9.1%) due to FIHD, and 7.0% (95% CI, 6.4%-7.6%) due to FILD. The remaining 64.4% (95% CI, 63.2%-65.7%) were classified as FSHD (ie, nutrition secure). Younger age (20-44 years: average marginal effect [AME], -0.193; 95% CI, -0.217 to -0.168), low income (PIR <1.30: AME, -0.111; 95% CI, -0.136 to -0.085), lower educational level (≤high school diploma: AME, -0.135; 95% CI, -0.156 to -0.114), racial and ethnic minority status (Hispanic: AME, -0.054; 95% CI, -0.075 to -0.032), SNAP participation (AME, -0.073; 95% CI, -0.099 to -0.047), obesity (AME, -0.118; 95% CI, -0.138 to -0.097), and self-reported fair or poor general health (AME, -0.239; 95% CI, -0.260 to -0.217) were factors associated with nutrition insecurity.

Conclusions and Relevance

This cross-sectional study proposed a feasible and practical measure for assessing and monitoring nutrition security using validated measures in the NHANES. This study laid the groundwork for exploring other national datasets and performing regular data collection of key dimensions for nutrition security assessment and monitoring in the US.

Beyond Food Assistance: A Scoping Review Examining Associations of Nonfood Social Safety Net Programs in the United States With Food Insecurity and Nutrition Outcomes

OBJECTIVE

To conduct a scoping review to summarize the state of the evidence on associations between participation in nonfood social safety net programs (eg, income assistance, housing assistance) in the United States and food- and nutrition insecurity-related outcomes.

BACKGROUND

Food and nutrition insecurity are persistent public health challenges in the United States that increase chronic disease risk and exacerbate health disparities. Several food assistance programs enhance food and nutrition security. Nonfood social safety net programs, however, may also improve these outcomes by relieving households' financial strain. Understanding the scope of research on nonfood social safety net programs' associations with not only food insecurity but also nutrition insecurity is needed to understand their potential to reduce the burden of diet-related chronic disease.

METHODS

Six databases were systematically searched for peer-reviewed articles. Articles were included if they were published between 1995 and 2023; conducted in the United States; available in English; included a dependent variable of food- and/or nutrition insecurity-related measures; and included an independent variable of participation in a federally funded, nonfood social safety net program.

RESULTS

Included articles (n = 65) reported on studies that examined 10 unique social safety net programs; 8 studies examined program interactions. Twenty studies focused on COVID-19 pandemic-era programs. Fifty-eight studies used food insecurity, food insufficiency, or food hardship as outcomes, and 11 studies used nutrition insecurity-related outcomes. Overall, results suggest that participation in nonfood social safety net programs is associated with reductions in food insecurity. Current evidence for an association between program participation and nutrition insecurity-related outcomes is limited.

CONCLUSION

Further research is warranted on the association between nonfood social safety net programs and nutrition insecurity; potential interactions between social safety net programs; associations between the expiration of pandemic-era programs and food and nutrition insecurity; and how program impacts might differ among populations with persistent disparities in food and nutrition insecurity.

An investigation of diet quality across racial groups in the United Kingdom and United States considering nutritional adequacy, disease risk, and environmental sustainability: a secondary analysis of NDNS and NHANES datasets

Diet indices are quantitative assessments of the quality of population intake. Understanding diet quality is crucial to support health and well-being; however, knowledge of diet quality across racial groups is limited. To examine diet quality of acial groups 'White', 'Black', 'Asian', and 'Other' in the United Kingdom (U.K.) and United States (U.S.), U.K. and U.S. national survey data were used to calculate Alternative Healthy Eating Index (AHEI-2010), Diet Quality Index-International (DQI-I), and EAT-Lancet scores. ANCOVA tests compared median total quality scores across racial groups adjusting for covariates. Kruskal-Wallis tests examined differences in individual component scores. Spearman correlations identified association of diet quality scores across indices. Highest diet quality scores were reported for U.K. and U.S. Asian groups. Most noticeable differences were apparent between U.S. Asian and White/Black groups (62% Asians within highest tertile of AHEI-2010 score vs. 29% Whites; P < 0.001). All racial groups demonstrated poor diet quality in terms of sustainability; EAT-Lancet scores were <40% of maximum total score for U.S. White, Black, and Other groups. AHEI-2010 diet quality scores were moderately associated with EAT-Lancet scores, evident across all groups (r = 0.53-0.65; P < 0.001). There is a need for all groups to increase intake of wholegrains, especially Black groups (mean Wholegrain score for U.S. Black group within DQI-I was 0.60 (maximum score of 5)) as demonstrated within AHEI-2010, DQI-I, and EAT-Lancet component scores. Additionally, increased intake of vegetables and legumes and decreased intake of processed and red meat would improve the adequacy, healthiness, and sustainability of U.K. and U.S. racial diets.

Food retailer actions toward the National Strategy on Hunger, Nutrition, and Health to promote nutrition security: Applicability of the Business Impact Assessment-Obesity as a monitoring tool

The White House National Strategy on Hunger, Nutrition, and Health (National Strategy) encourages actions across government and society to promote nutrition security. Nutrition security includes adequate food, diet quality, and equity, and food retail settings can promote these major concepts. Of all National Strategy whole-of-society calls to action, food retailers can contribute to 15 calls as key actors. However, there is currently no standardized monitoring tool to track food retailers' commitments and actions toward the National Strategy to promote nutrition security. The Business Impact Assessment-Obesity and population-level nutrition (BIA-Obesity), a tool originally developed for corporate accountability monitoring, can be tailored for the National Strategy and nutrition security, given its standardized indicators and process to assess food company policies and commitments across six domains. We discuss the fit of the BIA-Obesity indicators for tracking food retailers' commitments and actions across four pillars of the National Strategy. Existing indicators are appropriate to monitor components of Pillar 1: Improve Food Access and Affordability; Pillar 2: Integrate Nutrition and Health; Pillar 3: Empower All Consumers to Make and Have Access to Healthy Choices; and Pillar 5: Enhance Nutrition and Food Security Research. We suggest expanding current indicators to include equity, local foods, the digital food environment, and food waste reduction to improve alignment of the BIA-Obesity with the National Strategy. Application of the BIA-Obesity as an existing tool can facilitate data cohesion and more rapid assessment of the food retailer landscape to mutually meet nutrition security goals by 2030.

Cross-context equivalence and agreement of healthy diet metrics for national and global monitoring: a multicountry analysis of cross-sectional quantitative 24-hour dietary intake studies

BACKGROUND

Despite national and global commitments to improve nutrition, there are no universally accepted indicators for at-scale monitoring of diets. Several metrics have been proposed and used, but they vary in their comprehensiveness and validity in capturing the properties of healthy diets and, potentially, their interpretability across contexts.

OBJECTIVE

The objective of this study was to assess the cross-context equivalence and agreement of healthy diet metrics.

DESIGN

Quantitative 24-h dietary intake data from 57,456 nonpregnant females (15-49 y) in 21 countries were used to construct the food group diversity score (FGDS) and Minimum Dietary Diversity for Women indicator; the Global Diet Quality Score (GDQS) and its submetrics: GDQS+ and GDQS-; the Global Dietary Recommendations (GDR) score and its submetrics: noncommunicable disease (NCD)-Protect and NCD-Risk scores; and the All-5 indicator. Associations between (standardized) measures and indicators were quantified by fitting linear and logistic mixed-effect models across World Bank country income classifications, respectively. The levels of agreement between measures were assessed using Bland-Altman plots of z-scores, whereas rank correlations were assessed using Spearman's ρ.

RESULTS

The consumption of healthy food groups was positively associated with concurrent intakes of unhealthy food groups, in particular in high-income countries. Hence, metrics constructed using both healthy and unhealthy food groups (i.e., GDR score and GDQS) showed relatively less discriminatory capacity across country income classifications than their respective submetrics or FGDS. Standardized metrics of healthy (e.g., FGDS and GDQS+) and unhealthy food group consumption (i.e., NCD-Risk and GDQS-) exhibited strong agreement and correlations.

CONCLUSION

Composite metrics weighting both healthy and unhealthy food groups have limited cross-context equivalence, because a wide range of diets can theoretically return similar scores. Healthy food group (sub)metrics performed comparably, likely indicating strong underlying construct validity (i.e., dietary diversity and nutrient adequacy). For national and global monitoring, refinement and validation of unhealthy food group metrics (i.e., moderation) is recommended to complement healthy food group metrics.

Social Determinants of Cardiovascular Health in Asian Americans: A Scientific Statement From the American Heart Association

To achieve cardiovascular health (CVH) equity in the United States, an understanding of the social and structural factors that contribute to differences and disparities in health is necessary. The Asian American population is the fastest-growing racial group in the United States but remains persistently underrepresented in health research. There is heterogeneity in how individual Asian American ethnic groups experience CVH and cardiovascular disease outcomes, with certain ethnic groups experiencing a higher burden of adverse social conditions, disproportionately high burden of suboptimal CVH, or excess adverse cardiovascular disease outcomes. In this scientific statement, upstream structural and social determinants that influence CVH in the Asian American population are highlighted, with particular emphasis on the role of social determinants of health across disaggregated Asian American ethnic groups. Key social determinants that operate in Asian American communities include socioeconomic position, immigration and nativity, social and physical environments, food and nutrition access, and health system-level factors. The role of underlying structural factors such as health, social, and economic policies and structural racism is also discussed in the context of CVH in Asian Americans. To improve individual-, community-, and population-level CVH and to reduce CVH disparities in Asian American ethnic subgroups, multilevel interventions that address adverse structural and social determinants are critical to achieve CVH equity for the Asian American population. Critical research gaps for the Asian American population are given, along with recommendations for strategic approaches to investigate social determinants of health and intervene to reduce health disparities in these communities.

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.

Evaluation of daily eating patterns on overall diet quality using decision tree analyses

BACKGROUND

Preliminary evidence suggests that meal timing is associated with higher quality diets. Less is known about whether types of food consumed during specific eating episodes (i.e., day-level eating patterns) predict diet quality.

OBJECTIVES

We investigated the association between day-level eating patterns and diet quality.

METHODS

Decision tree models were built using 24-h dietary recall data from the National Health and Nutrition Examination Survey 2015 and 2017 cycles in a cross-sectional study. Sixteen food groups and 12 eating episodes (e.g., breakfast, lunch) were included as input parameters. Diet quality was scored using the Healthy Eating Index-2020 and categorized as higher or lower quality diets based on the median score. Mean decrease in impurity (MDI) ± standard deviation determined the relative contribution that day-level eating patterns had on diet quality; higher values represented greater contributions.

RESULTS

We analyzed 12,597 dietary recalls from 9347 United States adults who were aged 18 y and older with ≥1 complete recall. Meals (breakfast, lunch, dinner) and respective snacking episodes had the greatest variety of dietary groups that contributed to the Healthy Eating Index-2020 score. Any whole-grain intake at breakfast predicted a higher quality diet (MDI = 0.08 ± 0.00), followed by lower solid fat intake (<8.94 g; MDI = 0.07 ± 0.00) and any plant protein intake at dinner (MDI = 0.05 ± 0.00).

CONCLUSIONS

Day-level eating patterns were associated with diet quality, emphasizing the relevance of both food type and timing in relation to a high-quality diet. Future interventions should investigate the potential impact of targeting food type and timing to improve diet quality.

Exploring Multidimensional and Within-Food Group Diversity for Diet Quality and Long-Term Health in High-Income Countries

Dietary diversity is a crucial component of healthy eating patterns because it ensures nutritional adequacy. Yet, concerns have been raised about the potential risks of its increase, which may reflect excessive consumption of unhealthy foods and higher obesity or cardiometabolic risk, particularly in high-income countries. However, the links between dietary diversity and different health outcomes remain inconclusive because of methodological differences in assessing dietary diversity. Numerous studies, mostly cross-sectional, have assessed dietary diversity using different indicators usually based only on the number of foods or food groups consumed. In this perspective, we emphasize that dietary diversity is a multidimensional concept encompassing the number of foods in the diet (food coverage) but also their relative proportions (food evenness) and the nutritional dissimilarity of foods consumed over time (food complementarity). Consequently, a comprehensive assessment of dietary diversity reflecting all its dimensions, both between and within-food groups, is needed to determine the optimal level of complementarity between and within-food groups required to improve health and diet quality. Moreover, given the prevailing context of abundant highly processed and energy-dense foods in high-income countries, promoting dietary diversity should prioritize nutrient-dense food groups. Until recently, within-food group diversity has received limited attention in research and public health recommendations. Still, it may play a role in improving diet quality and long-term health. This perspective aims to clarify the concept of dietary diversity and suggest research avenues that should be explored to better understand its associations with nutritional adequacy and health among adults in high-income countries.

Food and Nutrition Insecurity: Experiences That Differ for Some and Independently Predict Diet-Related Disease, Los Angeles County, 2022

BACKGROUND

National surveillance shows that food insecurity affects ∼1 in 10 Americans each year. Recently, experts have advocated for surveillance of nutrition insecurity alongside food insecurity. Nutrition security refers to the nutritional adequacy of accessible food and factors that impact one's ability to meet food preferences.

OBJECTIVES

This study presents representative estimates of food insecurity and nutrition insecurity for Los Angeles County, CA, United States; compares predictors of these constructs; and examines whether they independently predict diet-related health outcomes.

METHODS

In December 2022, a representative sample of Los Angeles County adults participating in the Understanding America Study (N = 1071) was surveyed about household food insecurity and nutrition insecurity over the past 12 months. Data were analyzed in 2023.

RESULTS

Reported rates were similar for food insecurity (24%) and nutrition insecurity (25%), but the overlap of these subgroups was less than 60%. Logistic regression models indicated that non-Hispanic Asian individuals had higher odds of nutrition insecurity but not food insecurity. Moreover, nutrition insecurity was a stronger predictor of diabetes compared with food insecurity, and both constructs independently predicted poor mental health.

CONCLUSIONS

Food and nutrition insecurity affect somewhat different populations. Both constructs are valuable predictors of diet-related health outcomes. Monitoring nutrition insecurity in addition to food insecurity can provide new information about populations with barriers to healthy diets.

Food Insecurity Associated with Higher Stress, Depressive Symptoms, and Lower Diet Quality among Women Caregivers in North Carolina

BACKGROUND

Research suggests a bidirectional relationship between food insecurity and stress, but few studies have examined associations of food insecurity with stress and other indicators of cardiometabolic health, including depression, diet quality, and body weight, among lower-income women in the U.S.

METHODS

This cross-sectional study analyzed data from lower-income women caregivers living in North Carolina (n = 100): 42% Black/African American, 25% Hispanic/Latina, and 33% White women. Multivariable linear regression models were used to determine associations of food insecurity status with perceived stress, depressive symptoms, diet quality, and body mass index (BMI). Multivariable logistic regression models were used to determine associations of food insecurity with clinical depression and BMI ≥ 30 kg/m2. Associations were examined with and without adjustment for perceived stress.

RESULTS

Forty-two percent of the sample were experiencing food insecurity. Compared to food secure caregivers, food-insecure caregivers had significantly higher perceived stress (β: +7.51; 95%CI: 4.19, 10.84) and depressive symptoms (β: +3.55; 95%CI: 0.54, 6.56) and lower diet quality (β: -9.10; 95%CI: -15.81, -2.40). Associations with BMI outcomes were not statistically significant.

CONCLUSION

Findings support removing stigma in nutrition assistance programs and clinical interactions, motivate future longitudinal studies, and inform the development of destigmatizing interventions for health promotion or disease prevention.

Benefits of using both the Hunger Vital Sign and brief nutrition security screener in health-related social needs screening

Food security is a commonly screened for health-related social need at hospitals and community settings, and until recently, there were no tools to additionally screen for nutrition security. The purpose of this study was to assess the potential advantage of including a one-item brief nutrition security screener (BNSS) alongside the commonly used two-item Hunger Vital Sign (HVS) food security screener for identifying individuals with diet-related health risks. Cross-sectional survey data were collected from April to June 2021. Generalized linear mixed models were used to assess associations between screening status and dietary and health variables. Recruitment was done across five states (California, Florida, Maryland, North Carolina, and Washington) from community-based organizations. Participants (n = 435) were, on average, 44.7 years old (SD = 14.5), predominantly women (77%), and racially/ethnically diverse. In adjusted analyses, being in the food insecure and nutrition insecure group (but not the food insecure and nutrition secure or food secure and nutrition insecure groups) was associated with significantly increased odds for self-reported "fair" or "poor" general health [OR = 2.914 (95% CI = 1.521-5.581)], reporting at least one chronic condition [2.028 (1.024-4.018)], and "low" fruit and vegetable intake [2.421 (1.258-4.660)], compared with the food secure and nutrition secure group. These findings support using both the HVS and BNSS simultaneously in health-related social needs screening to identify participants at the highest risk for poor dietary and health outcomes and warrant further investigation into applying these screeners to clinical and community settings.

Diabetes mellitus-Progress and opportunities in the evolving epidemic

Diabetes, a complex multisystem metabolic disorder characterized by hyperglycemia, leads to complications that reduce quality of life and increase mortality. Diabetes pathophysiology includes dysfunction of beta cells, adipose tissue, skeletal muscle, and liver. Type 1 diabetes (T1D) results from immune-mediated beta cell destruction. The more prevalent type 2 diabetes (T2D) is a heterogeneous disorder characterized by varying degrees of beta cell dysfunction in concert with insulin resistance. The strong association between obesity and T2D involves pathways regulated by the central nervous system governing food intake and energy expenditure, integrating inputs from peripheral organs and the environment. The risk of developing diabetes or its complications represents interactions between genetic susceptibility and environmental factors, including the availability of nutritious food and other social determinants of health. This perspective reviews recent advances in understanding the pathophysiology and treatment of diabetes and its complications, which could alter the course of this prevalent disorder.

Food (in)security in relation to nutrition (in)security in a national cross-sectional sample of Supplemental Nutrition Assistance Program participants: considerations of an emerging construct

BACKGROUND

Food insecurity, lack of access to sufficient food for an active, healthy life, is a persistent problem in the United States. Recently, nutrition security has emerged as a new concept. However, limited research exists examining how nutrition security relates to the established concept of food security.

OBJECTIVES

This study assessed a recent metric of nutrition security and explored how well it describes the underlying construct among a sample of Supplemental Nutrition Assistance Program (SNAP) participants. We examined the correlation between food and nutrition security and demographic predictors of joint food and nutrition security status.

METHODS

We conducted a national, web-based survey (Qualtrics; 30 September-19 October, 2022) in English and Spanish of adults aged ≥18 y (n = 1454) who reported receiving SNAP benefits in the past 12 mo. We measured food security using the US Department of Agriculture 6-item Food Security Survey and assessed nutrition security using the Gretchen Swanson Center for Nutrition Household Nutrition Security measure. We used multinominal logistic regression to examine demographic predictors of food and nutrition security.

RESULTS

The majority (80.4%) of SNAP participants experienced food insecurity, and 59.1% reported experiencing nutrition insecurity. Food and nutrition security were moderately correlated (0.41); 55.6% of SNAP participants were both food and nutrition insecure, 3.5% were food secure but nutrition insecure, 24.8% were food insecure but nutrition secure, and 16.1% were both food and nutrition secure. Of SNAP participants, 24.8% reported experiencing food insecurity but not nutrition insecurity. Hispanic ethnicity and Southern residence were associated with joint food and nutrition insecurity.

CONCLUSIONS

These findings raise questions about how nutrition security is conceptualized and measured and its added value beyond existing food security measurement scales. Further research is needed to understand differences in food and nutrition security experiences and risk factors and determine a validated definition and measure of nutrition security for future policy solutions.

Relationship between Food Security, Nutrition Security, and Diabetes: The Role of Supplemental Nutrition Assistance Program Participation

Background

Inadequate nutrition and poor diet quality are associated with a heightened risk of diabetes. The connection between food insecurity measures and diabetes has been established, with evidence indicating that Supplemental Nutrition Assistance Program (SNAP) participation contributes to reductions in food insecurity. Recently developed nutrition security measures, defined as the ability to acquire healthful foods to prevent diseases, and their association with diabetes and SNAP participation are not yet understood.

Objectives

This study aimed to assess the relationship between food security and nutrition security in relation to diabetes overall and by SNAP participation and nutrition security as potential modifiers.

Methods

Secondary data analysis of cross-sectional pilot study data collected from adults in 5 US states (N = 517). Logistic regression mixed models included moderation analysis and clustering effects by state to address site-level confounding.

Results

Higher nutrition security scores among adults, after adjusting for confounders, were significantly associated with lower odds of diabetes risk (adjusted odds ratio = 0.59; 95% confidence interval: 0.40, 0.87; P value = 0.008). Statistically significant interaction effect of differences according to SNAP participation was observed for nutrition security (Phomogeneity/interaction = 0.021), adjusting for age, gender, race/ethnicity, education, employment, National School Lunch Program, Special Supplemental Nutrition Program for Women, Infants, and Children, food pantry use, household with children, survey mode, and food security. The association between food security and diabetes was not statistically significant overall. However, statistically significant interaction effect of differences according to SNAP participation was observed for food security (Phomogeneity/interaction = 0.047). Further, no interaction effect of differences in nutrition security was found between food security and self-reported diabetes/prediabetes (Phomogeneity/interaction = 0.250).

Conclusions

This study sheds light on the early exploration of the intricate relationship between nutrition security and diabetes. The findings suggest that a higher nutrition security score, after adjusting for confounders, was significantly associated with lower odds of diabetes risk. Notably, there were statistically significant interaction effects in these associations based on SNAP participation.

Pathways and policy options for food and nutrition gaps in arid agricultural farming systems in the Tigray Region, north Ethiopia

Food and nutrition security is a major global challenge especially indeveloping countries.Agriculture is main means of livelihoods and hunger is drastically increasing from time to time especially due to effects of climate change, conflict and other manmade and natural calamities in these countries. Similarly, the Tigray Region is one of the Ethiopia's most food and nutrition insecure regions with agriculture serving as the main source of income and employment. This study was therefore conducted to fill the gap in understanding the socioeconomic situation, bio-physical environment, institutional setting and policy landscape by analysing the existing circumstances in Tigray Region. This research employed quantitative data sets collected from 300 randomely selected Productive Saftey Net Program (PSNP) beneficiarieries and Non-PSNP households using probability proportional to size. The Household Dietary Diversity Score (HDDS) used as a proxy measure to nutrition security as our data is 24 h recall and food gap months as proxy to food security. Besides, Principal Component Analysis (PCA) method is used to construct household asset index. The results of the study revealed that there are clear and significant differences of the PSNP and Non-PSNP households, and gender in land holding (p<0.01%), asset ownership(p<0.01%), food gap months(p<0.01%), dietary diversity(p<0.01%), exposure to hazards and risks, copping strategies, yield, access to agricultural extension services, access to improved varieties (varietal diversification). The male headed households, and Non-PSNP households are better off than the female headed and PSNP households' counterparts. Thus, provision of practical training, conducting farmer's participatory research, field days, promoting and creating access to farmers' preferred high yielding improved varieties and management practices available in the research and extension consortium, support in research and development that develops and disseminate appropriate technologies to help farmers to lower their food gap months is highly important. In addition, sustainable intensification, off-farm employment alternatives, and engaging in agribusiness activities that create resilient livelihood options to those resource poor farm households, strengthening the formal and informal seed system would help to reduce food gap months, improve HDDS, build resilience of the food and nutrition insecure households. Therefore, customized extension services and packages are important for addressing the food and nutrition security gaps by setting goal, outcome and output indicators for future interventions in the research and development arena in filling food gap months, dietary diversity and household asset building through collaboration among relevant stakeholders in the food system.

Development and validation of an occurrence-based healthy dietary diversity (ORCHID) score easy to operationalise in dietary prevention interventions in older adults: a French study

Healthy diet and dietary diversity have been associated with healthy ageing. Several scores have been developed to assess dietary diversity or healthy diets in epidemiological studies, but they are not adapted to be used in the context of preventive nutrition interventions. This study aimed to develop an occurrence-based healthy dietary diversity (ORCHID) score easy to implement in the field and to validate it using dietary data from older participants in the latest French food consumption survey (INCA3). The ORCHID score was made of several components representing the consumption occurrences of twenty food groups, in line with French dietary guidelines. The score was then validated using dietary data (namely three 24-h recalls and a food propensity questionnaire) from 696 participants aged 60 years and over in the INCA3 survey. Score validity was evaluated by describing the association of the score with its components, as well as with energy intakes, solid energy density (SED) and the probability of adequate nutrient intakes (assessed by the PANDiet). Higher scores were associated with more points in healthy components such as 'fruits' and 'vegetables' (r = 0·51, and r = 0·54, respectively). The score was positively associated with the PANDiet (r = 0·43) and inversely associated with SED (r = -0·37), while no significant association was found with energy intakes. The ORCHID score was validated as a good proxy of the nutritional quality of French older adults' diets. It could therefore be a useful tool for both public health research and nutrition interventions.

Properties of the Household Food Security Survey Module Scale in Young Adults with Diabetes

BACKGROUND

The Household Food Security Survey Module (HFSSM) was not tailored to people with chronic diseases or young adults (YAs).

OBJECTIVES

We aim to evaluate whether the 18-item HFSSM meets assumptions underlying the scale among YAs with diabetes.

METHODS

Data from 1887 YAs with youth-onset type 1 diabetes or type 2 diabetes were used from the SEARCH for Diabetes in Youth Study, 2016-2019, and on 925 who returned for the SEARCH Food Security Cohort Study, 2018-2021, all of whom had completed the HFSSM. Guttman scaling properties (affirmation of preceding less severe items) and Rasch model properties (probability to answer an item based on difficulty level) were assessed.

RESULTS

Items 3 (balanced meals) and 6 (eating less than one should) were affirmed more frequently than expected (nonmonotonic response pattern). At 1.2%-3.5%, item nonresponse was rare among type 1 diabetes but higher among type 2 diabetes (range: 3.1%-10.6%). Items 9 (not eating the whole day) and 3 did not meet the Guttman scaling properties. Rasch modeling revealed that item 3 had the smallest difficulty parameter. INFIT indices suggested that some responses to item 3 did not match the pattern in the rest of the sample. Classifying household food insecurity (HFI) based on items 1 and 2 compared with other 2-item combinations, including item 3, revealed a substantial undercount of HFI ranging from 5% to 8% points.

CONCLUSIONS

Use of the HFSSM among YAs with diabetes could potentially result in biased HFI reporting and affect estimates of HFI prevalence in this population.

Direct and Indirect Effects of Food and Nutrition Security on Dietary Choice and Healthfulness of Food Choice: Causal Mediation Analysis

Background

Links between diet and food security are well established, but less is known about how food and nutrition security affect a household's ability to decide what to consume.

Objectives

This study's purpose was to quantify and compare causal pathways from 1) food and nutrition security to perceived dietary choice and 2) food and nutrition security to perceived healthfulness of food choice while testing for mediation by perceived limited availability of foods and utilization barriers to healthful meals.

Methods

Causal mediation analysis was conducted using an observational data set. Exposures included food insecurity and nutrition insecurity; mediators included perceived limited availability and utilization barriers; outcomes included perceived dietary choice and healthfulness choice; covariates included income and education.

Results

Dietary choice (range 0-4) was 0.9 to 1.1 points lower for participants with food/nutrition insecurity compared with participants with food/nutrition security (direct effects). Neither mediation nor moderation by perceived limited availability were present. Seventeen percent and 11 %, respectively, of the effects of food and nutrition security on dietary choice could be contributed to utilization barriers (mediation). Moderation by utilization barriers was present only for nutrition security (differences in dietary choice only present when barriers were low). Healthfulness choice (range 0-4) was 0.6 to 0.7 points lower for participants with food/nutrition insecurity compared with participants with food/nutrition security (direct effects). Mediation by perceived limited availability and utilization barriers was not present. Moderation was present only for nutrition security (differences in healthfulness choice only present when perceived limited availability was low; differences in healthfulness choice only present when barriers were low).

Conclusions

Food and nutrition security affect food choices, with utilization barriers acting as an intermediary step. When environmental and household utilization barriers to healthful food purchasing and preparation are high, the ability to decide what to consume does not differ between households with nutrition security and those with nutrition insecurity.

Defining a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity Among Pregnant Adolescent Girls and Women: A Secondary Analysis of Quantitative 24-h Recalls from Rural Settings in Bangladesh, Burkina Faso, India, and Nepal

Background

The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements.

Objective

This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs.

Methods

We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60.

Results

In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%).

Conclusions

The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status.

The Nutritional Content of Meal Images in Free-Living Conditions-Automatic Assessment with goFOODTM

A healthy diet can help to prevent or manage many important conditions and diseases, particularly obesity, malnutrition, and diabetes. Recent advancements in artificial intelligence and smartphone technologies have enabled applications to conduct automatic nutritional assessment from meal images, providing a convenient, efficient, and accurate method for continuous diet evaluation. We now extend the goFOODTM automatic system to perform food segmentation, recognition, volume, as well as calorie and macro-nutrient estimation from single images that are captured by a smartphone. In order to assess our system's performance, we conducted a feasibility study with 50 participants from Switzerland. We recorded their meals for one day and then dietitians carried out a 24 h recall. We retrospectively analysed the collected images to assess the nutritional content of the meals. By comparing our results with the dietitians' estimations, we demonstrated that the newly introduced system has comparable energy and macronutrient estimation performance with the previous method; however, it only requires a single image instead of two. The system can be applied in a real-life scenarios, and it can be easily used to assess dietary intake. This system could help individuals gain a better understanding of their dietary consumption. Additionally, it could serve as a valuable resource for dietitians, and could contribute to nutritional research.