Position of the American Dietetic Association: Food Insecurity and Hunger in the United States

from the association

ADA REPORTS

Position of the American Dietetic Association: Food Insecurity and Hunger in the United States ABSTRACT It is the position of the American Dietetic Association that systematic and sustained action is needed to bring an end to domestic food insecurity and hunger and to achieve food and nutrition security for all in the United States. The Association believes that immediate and long-range interventions are needed, including adequate funding for and increased utilization of food and nutrition assistance programs, the inclusion of food and nutrition education in all programs providing food and nutrition assistance, and innovative programs to promote and support the economic self-sufficiency of individuals and families, to end food insecurity and hunger in the United States. Food insecurity continues to exist in the United States, with over 38 million people experiencing it sometime in 2004. Negative nutritional and nonnutritional outcomes have been associated with food insecurity in adults, adolescents, and children, including poor dietary intake and nutritional status, poor health, increased risk for the development of chronic diseases, poor psychological and cognitive functioning, and substandard academic achievement. Dietetics professionals can play a key role in ending food insecurity and hunger and are uniquely positioned to make valuable contributions through provision of comprehensive food and nutrition education, competent and collaborative practice, innovative research related to accessing a safe and secure food supply, and advocacy efforts at the local, state, regional, and national levels. J Am Diet Assoc. 2006;106:446-458.

0002-8223/06/10603-0012$32.00/0 doi: 10.1016/j.jada.2006.01.016

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POSITION STATEMENT It is the position of the American Dietetic Association that systematic and sustained action is needed to bring an end to domestic food insecurity and hunger and to achieve food and nutrition security for all in the United States. The Association believes that immediate and long-range interventions are needed, including adequate funding for and increased utilization of food and nutrition assistance programs, the inclusion of food and nutrition education in all programs providing food and nutrition assistance, and innovative programs to promote and support the economic self-sufficiency of individuals and families, to end food insecurity and hunger in the United States.

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ood insecurity and hunger continue in millions of households across the nation (1), despite the agricultural bounty, wealth, and inexpensive food supply of the United States. Because the citizens and residents of the United States are its most valuable resource, from a human capital point of view, it is cruel, unwise, and short-sighted to allow food insecurity and hunger to continue to exist at their present levels, especially because they are avoidable. Possible consequences of food insecurity include hunger and malnutrition, as well as physical impairments, chronic disease, psychological suffering, and sociofamilial disturbances (24). Figure 1 summarizes terms relevant to this article. Although the safety and security of the United States and its food supply are of utmost importance, another position of the American Dietetic Association focuses on those issues (5). In the current position, food security relates to food availability and access and does not include food safety from a bioterrorism or natural disaster standpoint. Using a broad-based ap-

Journal of the AMERICAN DIETETIC ASSOCIATION

proach to systematically address food insecurity and hunger will ensure community food security and lead to nutrition security. Healthy People 2010 includes several nutrition-related objectives for the nation, such as increasing “food security [to 94%] among US households and in so doing reduce hunger” (6). Similarly, the US Department of Agriculture’s Community Food Security Initiative has the goal of cutting US food insecurity in half by 2015 (7). Nutrition and food security are essential conditions that are preventable threats to the health and wellbeing of US citizens and residents, and achieving nutrition and food security is consistent with the nation’s public health goals. Throughout this article, the term food insecurity will be used to refer to all aspects of food and nutrition insecurity and hunger. Since the publication of the previous position paper in 2002 (8), the food security status of the United States has been further documented, with the most recent estimates of food insecurity continuing to fall short of the Healthy People 2010 objective (1,6). In addition, several publications documenting the relationships of welfare reform, food assistance, and nutritional and nonnutritional outcomes to food insecurity have been released, continuing to underscore that food insecurity is of high priority for public health action. In 1996, Congress enacted the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). Commonly referred to as the welfare reform law, the PRWORA changed services to low-income families. In summary, the PRWORA: ● ●

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established Temporary Assistance for Needy Families; changed eligibility standards for Supplemental Security Income child disability benefits; required states to enforce a strong

© 2006 by the American Dietetic Association

ADA REPORTS Community Food Security: “A situation in which all community residents obtain a safe, culturally acceptable, nutritionally adequate diet through a sustainable food system that maximizes self-reliance and social justice (104),” without resorting to emergency food sources (105). Food Insecurity: “Limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways (2).” Food Insufficiency: An inadequate amount of food intake due to a lack of resources (106). Food Security: “Access by all people, at all times to sufficient food for an active and healthy life . . . [and] includes at a minimum: the ready availability of nutritionally adequate and safe foods, and an assured ability to acquire acceptable foods in socially acceptable ways (2).” Hunger: “The uneasy or painful sensation caused by a lack of food. The recurrent and involuntary lack of access to food . . . [which] may produce malnutrition over time (2).” Nutrition Security: “The provision of an environment that encourages and motivates society to make food choices consistent with shortand long-term good health (107).” US Department of Agriculture Food Security Classifications (31) ● Food secure: “Households show no or minimal evidence of food insecurity.” ● Food insecure without hunger: “Food insecurity is evident in household members’ concerns about adequacy of the household food supply and in adjustments to household food management, including reduced quality of food and increased unusual coping patterns. Little or no reduction in members’ food intake is reported” (31). ● Food insecure with hunger (moderate) a: “Food intake for adults in the household has been reduced to an extent that implies that adults have repeatedly experienced the physical sensation of hunger. In most (but not all) food-insecure households with children, such reductions are not observed at this stage for children” (31). ● Food insecure with hunger (severe) a: “At this level, all households with children have reduced the children’s food intake to an extent indicating that the children have experienced hunger. For some other households with children, this already has occurred at an earlier stage of severity. Adults in households with and without children have repeatedly experienced more extensive reductions in food intake” (31). ● Food insecure with hunger among children: “At least one child in the household (age 0-17) has been hungry during the year because of constrained household resources. [All children were not necessarily hungry. For example, only an older child experienced hunger, with younger children being shielded from hunger]” (31,108). Figure 1. Food insecurity and hunger-related terms. aSometimes combined into a single, broader category of food insecurity with hunger (31).

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child support program for collection of child support payments; restricted legal immigrants’ and other aliens’ eligibility for welfare and other public benefits; provided resources for foster care data systems and a national child welfare study; established a block grant to states to provide child care for working parents; altered eligibility criteria and benefits for child nutrition programs; and tightened national standards for food stamps and commodity distribution (9).

The most recent annual report to Congress regarding indicators of welfare dependence showed that dependence on welfare decreased from 1996 to 2000 (10), paralleling the decrease in the Food Stamp Program and Temporary Assistance for Needy Families caseloads. Although Temporary Assistance for Needy Families caseloads have decreased, it remains questionable whether most low-income households are better off. Over the past 4 years, poverty has increased. The most recent report showed that the

number of Americans living in poverty increased to 37 million (12.7% of the population) in 2004, compared with 35.9 million (12.5%) in 2003 (11). Median household income was unchanged. Food Stamp Program participation has also increased. Specifically, since July 2000, when the Food Stamp Program caseload was almost 16.9 million, the caseload has continued to increase to 25.5 million in 2004 (12). In fact, the average number of Food Stamp Program participants increased 12% in fiscal 2004, the largest percentage increase since 1992. However, participation in that year (about one in 12 Americans) remains below the greatest participation in Food Stamp Program (fiscal 1994), when about one in nine Americans participated (13). Conversely, the national Temporary Assistance for Needy Families caseload continued to decline in fiscal 2002 (14), even when combined participation was considered for Separate State Programs and modified eligibility criteria by some states to include more low-income families were instituted. Recent data indicate that the PRWORA may have negatively im-

pacted domestic food and nutrition security. Using a sample of multi-ethnic, urban, low-income and moderateincome adults living in upstate New York, Devine and colleagues (15) examined the relationship of workers’ jobs to their food choices before the PRWORA through a qualitative study. Work was perceived by some as having multiple barriers to meeting food choice ideals. Having lives with multiple jobs, inflexible hours, night work, and family demands were associated with limited food choices, lacking time and energy to prepare and share family meals, and having guilt about failing to eat according to personal and health ideals (15). Since the PRWORA, Fuller and colleagues (16) examined whether young children’s social development and behavior were related to maternal employment among women from California and Florida who entered welfareto-work programs in 1998. Household food security status consistently predicted frequency of reading to the child and maternal depression. Both parenting practices and maternal depression were related to behavior problems (aggressive behavior) and social development (inattentiveness)

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ADA REPORTS among both girls and boys. Although food security was not directly associated with social development and behavioral problems, it was mediated by reading to the child and maternal depression. These findings underscore that employment gains rarely affect child outcomes unless the mother’s income and broader economic security also improve (16). Cook and colleagues (17) examined the associations of loss or reduction of welfare benefits with household food security and health outcomes of young children seen at a sample of urban medical centers and emergency departments during August 1998 through December 2000. After controlling for confounding factors, children in households whose welfare benefits were terminated or reduced had greater odds of being food insecure and having poorer health (hospitalized since birth or admitted the day of an emergency department visit) compared with those without decreased benefits. In fact, receiving food stamps did not ease the effects of decreased welfare benefits on food insecurity or hospitalizations (17). Similarly, from January 2000 through December 2001, using the same multisite strategy, Casey and colleagues (18) examined maternal depression, changing public assistance, food security, and child health status in a sample of mothers whose young children were seen in general clinics or emergency departments. After controlling for confounding variables, a positive maternal depression screen was associated with loss of financial support and food stamps, household food insecurity, and poorer child health. This underscores the potential relationship of maternal depression to child health in the context of welfare reform. Finally, immigrants and their children seem especially vulnerable to food insecurity in the face of welfare reform (19,20), which warrants further exploration. In fact, Quandt and colleagues (21) showed that food insecurity was four times more prevalent among migrant and seasonal Latino farmers. As the impact of the PRWORA continues to be examined, its relationship to food insecurity will be clarified, as will its relationship to nutrition and other outcomes. Current trends of food insecurity and its relationship to nutritional and non-

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nutritional outcomes will be further discussed in the Key Point sections of this article. However, a significant development worth highlighting is a Spanish-language version of the United States Household Food Security Module (22). Hispanic households experience greater levels of food insecurity compared with the national average for the United States (1). Before the work by Harrison and colleagues (2003), during interviews, including those used for computing the national estimates of food security, interviewers free-translated the questions to those preferring to have the interview conducted in Spanish. The Spanish-language version as published by Harrison and colleagues (22) is recommended for use by the Economic Research Service and available online (23,24). KEY POINT: FOOD INSECURITY IS A PREVALENT NUTRITIONAL PROBLEM IN THE UNITED STATES According to the most recent national estimates (1), 88.1% of United States households were food secure throughout 2004. However, 11.9% of households (13.5 million) experienced food insecurity sometime during the year because of resource constraints, representing 38.2 million people (including 13.9 million children). Overall, 8% of households (9 million) were food insecure without hunger. These households used a variety of coping strategies to avoid hunger, including: ● ● ●

eating less-varied diets; participating in federal food-assistance programs; and getting emergency food from community food pantries, emergency kitchens, and shelters.

About one third of food-insecure households (4.4 million or 3.9% of United States households) were food insecure with hunger. However, in most households, children, especially younger children, were protected from hunger. In sum, 545,000 children lived in households classified as food insecure with hunger among children (0.7% of the children in the nation) (1). Households at risk for food insecurity during 2004, consistent with previous years’ estimates, included: ●

households with incomes below the income-to-poverty ratio (⬍1.00,

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36.8% of households; ⬍1.30, 34% of households; ⬍1.85, 29.8% of households); households with children and headed by a single woman (33% of households) or man (22.2% of households); households headed by a black nonHispanic* (23.7% of households) or Hispanic (21.7% of households); and households located in principal cities (15.4% of households), outside metropolitan (rural) areas (13.1% of households), the south census region of the United States (13.3% of households), or the west census region of the United States (12.8% of households) (1).

Food insecurity and hunger among older adults have also been reviewed (25,26). Although the households with older adults have rates of food insecurity less than the national average (6.5% for households with elderly; 7.3% for households with elderly living alone), all households with older adults present are not food secure (1). As the number of older adults increases in the United States, understanding food insecurity in this segment of the population is paramount. Quantitative, qualitative, psychological, and social factors characterize the experience of food insecurity among older adults, similar to the findings of other studies not focused on older adults (4,27); however, Wolfe and colleagues (28) reported that older adults are uniquely concerned with having the right food for health, which may relate to their awareness of the influence of diet on health and their incidence of diet-related health problems. Households receiving food from emergency food providers, including food pantries, soup kitchens, and shelters, seem to be particularly vulnerable to food insecurity and hunger. Data from America’s Second Harvest indicated that 71% of clients were food insecure, whereas 37% experienced food insecurity with hunger in 2001 (29). A sample of households us-

*The term Hispanic refers to people who trace their origin or descent to Mexico, Puerto Rico, Cuba, Central and South America, and other Spanish cultures.

ADA REPORTS ing food pantries in Ohio during summer 2004 indicated that 85.6% of households were food insecure, with 50.1% experiencing food insecurity with hunger during the previous 12 months (30). In that same study, households from rural counties were less food secure than those from nonrural counties, and those with children were less food secure than those without children. Finally, households with older adults present were more food secure than those without older adults (30). According to the most recent national estimates of food insecurity and hunger in the United States (1): ●

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food pantry and emergency kitchen usage was strongly associated with food insecurity, with food-insecure households being 17 times and 16 times more likely than their foodsecure counterparts to have obtained food from a food pantry or emergency kitchen, respectively; among food-insecure households, those experiencing hunger were approximately twice and four times as likely to have used a food pantry or emergency kitchen, respectively, than those without hunger; about 30% of households using pantries or emergency kitchens were food secure; however, of those, 55% had reported some concerns or problems in securing adequate food and could be categorized as at risk for food insecurity; and use of food pantries varied by household structure, race, and ethnicity, with food pantry usage being higher among households with higher rates of poverty, food insecurity, and hunger, including those with children, those being headed by a single woman with children, and those being non-Hispanic black or Hispanic.

Important caveats to interpreting food-security assessment measures used for the annual estimates include that questions are posed to respondents regarding the previous 12 months. Therefore, those experiencing food insecurity or hunger any time during the previous year are classified as food insecure or hungry. Consequently, the daily rates of food insecurity and hunger are far below the annual rates. On average, it is estimated that 0.5% to 0.8% of house-

holds (614,000 to 854,000 households) experience food insecurity and hunger (1). Food insecurity and hunger have been measured in the United States since 1995. Overall, the most recent estimate from 2004 (1) is at about the same level as when it was first measured in 1995. Its prevalence decreased until 1999, but it has trended upward since then. The prevalence of food insecurity with hunger among children, however, has remained unchanged over that period. The food security survey is conducted in early December of each year as a supplement to the Current Population Survey conducted by the US Census Bureau using standardized methods (1,31). Previously, a seasonal response effect may have affected food security prevalence estimates, because surveys were not conducted during the same month each year, so timing of food security surveys for the national estimates will remain constant (December annually) to avoid this effect (1). The causes of food insecurity must be understood before it can be eradicated. Unemployment and other employment-related problems, followed by low-paying jobs, high housing costs, poverty or lack of income, medical or health costs, substance abuse, high utility costs, mental health problems, homelessness, reduced public benefits, and high child-care costs have been cited as causes of hunger (32). Rose (33) noted that food insecurity is often triggered by an event that stresses the household budget—losing a job or assistance benefits, including food stamps, or gaining a household member. Consequently, households must often choose between buying food and other items. Among emergency food users, many must choose between food and health care/medication (30%), rent/mortgage (36%), or utilities (45%) (29). Choosing between medication and food has also been documented among emergency department patients (34). Immediate and long-range interventions targeting the causes of food insecurity will undoubtedly assist in the improvement and eradication of food insecurity. Adequate funding for and increased use of food and nutrition assistance programs, as well as innovative programs to promote and support economic self-sufficiency, is

paramount. Recommending to clients that they access existing programs providing food and nutrition assistance, social services, and job training is an immediate intervention that dietetics professionals can use and is consistent with stage one, initial food systems change, of a three-stage continuum (initial food systems change, food systems in transition, food systems redesign for sustainability) for a food systems approach to building community food security (35). KEY POINT: FOOD INSECURITY IS RELATED TO NUTRITIONAL AND NONNUTRITIONAL OUTCOMES AND IS A PREVENTABLE THREAT TO THE HEALTH OF THE US POPULATION Food insecurity can have grave consequences, including physical impairments related to insufficient food (illness, fatigue), psychological issues caused by lack of access to food (feelings of constraints to go against held norms and values; stress at home), and sociofamilial disturbances (modification of eating patterns and related ritual; distortion of the means of food acquisition and management) (4). Evidence continues to document the relationship of nutritional and nonnutritional outcomes to food insecurity and underscores food insecurity as a high priority for public health action, especially in view of its potential negative impact on the community from a public health and economic perspective. Dietary Intake Several studies have shown a relationship between food insecurity and food and nutrient intake, as well as risk for nutrient deficiencies among some life span groups. The implications for food insecurity among US children were reviewed by Kaiser and Townsend (36), who highlighted that although hunger among children is rare in the United States, evidence suggests that food insecurity or insufficiency may be associated with lower dietary quality in children, especially older children (and adults). Although food insufficiency does not influence dietary variety of US children (37) or the intake of energy and macronutrients (38), it does seem to be associated with decreased consumption of dark green and other

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ADA REPORTS vegetables and increased consumption of eggs. Lower meat consumption has been shown among Hispanic school-age children living in food-insecure households (39) and Hispanic preschool children living in hungry households, where milk intake and Food Guide Pyramid scores are also negatively impacted (40). In Hispanic households with preschool children, greater household food insecurity has been associated with lower variety of most foods, particularly fruits and vegetables (41). Among adolescents, lower intake of fruits and vegetables is associated with food insecurity (42). Using a sample of children and adults from the Third National Health and Nutrition Examination Survey, Bhattacharya and colleagues (43) examined the relationship between nutritional status, poverty, and food insufficiency. For children, poverty, rather than food insufficiency, was predictive of poor nutrition among preschool children (2 to 5 years old), with impoverished preschoolers having less healthful diets and being more likely to have lower serum values of nutrients. Neither poverty nor food insecurity were associated with nutritional outcomes of school-age children (6 to 11 years old). For adults (18 to 64 years old) and older adults (65 years old and older), however, both poverty and food security were predictive of poor nutrition. Specifically, adults from food-insecure homes had less healthful diets and were likely to have low serum nutrient values, supporting the relationship of food insecurity to poor nutritional outcomes (43). Food insecurity in women was reviewed by Olson (44), who highlighted that women’s roles in managing family feeding make them vulnerable to the consequences of food insecurity, with fruits and vegetables being sacrificed initially in the face of approaching hunger. Women living in rural food-insecure households in New York have been shown to be about half as likely to consume five servings of fruits and vegetables daily and more likely to consume zero to two servings daily than women in food-secure households, significantly lowering their intakes of potassium, fiber, and vitamin C (45). Continuing Survey of Food Intakes by Individuals (1989 to 1991) confirmed that adult women from food-insufficient house-

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holds were more likely to have low intakes of vitamins A and C than their food-sufficient counterparts, even after controlling for income and other pertinent variables (46). Food insufficiency was also significantly associated with low intakes of energy, vitamins E and B-6, thiamin, niacin, and magnesium. Similarly, women from hungry households receiving emergency food assistance in an urban area reported lower intakes of energy, vitamin A, folate, iron, and magnesium (47). One reason for women modifying their dietary intake may be to spare other family members, especially children, from experiencing nutrient deprivation. In fact, single mothers from low-income households have been shown to compromise their own diets to feed their children, preserving the adequacy of their children’s diets (48). Food-insufficient adults (ages 20 to 59 years), compared with their foodsufficient counterparts from Third National Health and Nutrition Examination Survey, had lower intakes of calcium and were more likely to have calcium and vitamin E intakes below 50% of the recommended amounts (3). They were also more likely to report less frequent consumption of milk/ milk products, fruits/fruit juices, and vegetables. The negative consequences of food insufficiency also included lower, yet within normal range, blood levels of vitamin A and three carotenoids. In addition to the work by Bhattacharya and others (43), several studies have examined dietary intake in relation to food insecurity and food insufficiency in older adults (3,46,49,50). Studies have shown that adults 65 years and older in food-insufficient households were more likely to have intakes below 50% of the recommended daily allowance for calcium, protein, vitamin A, vitamin B-6, phosphorous, thiamin, riboflavin, and niacin than their food-sufficient counterparts (46). Serum levels of a carotenoid and vitamin E were also lower in food-insufficient adults 60 years and older (3). In summary, these results show that individuals residing in households lacking access to food may consume diets deficient in particular food groups and nutrients, increasing the risk of poor health, chronic disease development, and other nonnutritional outcomes, if not immediately,

in the long term. Continuing to document dietary outcomes of food insecurity is paramount, as is provision of innovative food and nutrition education by dietetics practitioners, including collaborative, community-based education programs. For example, not having a garden has been associated with hunger among households with preschool children (51). One example of a potential education program is gardening education in collaboration with a master gardener to increase produce availability in the household. Adequate funding for and increased use of food and nutrition assistance programs, including those providing nutrition education, is particularly important to improve the dietary outcomes related to food insecurity. In addition, developing partnerships and networks that build local food systems are crucial. Examples would be partnerships with emergency food and feeding programs, farmers’ markets, community gardens, and farmto-school programs. In the short term, to improve community food security, maximizing access to and use of existing food and nutrition assistance programs is vital (35). Other Nutritional and Nonnutritional Outcomes Overweight and obesity, health status, chronic disease incidence and risk, school performance, and mental health are related to food insecurity. Several reviews have summarized work conducted in this aspect of nutrition (25,36,52,53), and numerous studies are currently underway. Collectively, the literature shows that food insecurity has negative nutritional and nonnutritional outcomes and underscores the potential negative implications of food insecurity on US health care costs. In addition to continuing to document these factors through collaborative research projects related to food access and outcomes across the life span, provision of innovative food and nutrition education by dietetics professionals and adequate funding for food and nutrition assistance programs is imperative. Overweight and Obesity. For children, evidence does not seem to support that food insecurity increases the risk of being overweight in childhood; in fact, severe lack of access to food

ADA REPORTS seems to be associated with lower body weight in young children (3638,40,54-58). As summarized by Kaiser and Townsend (36), prolonged undernutrition in early life may trigger accumulation of body fat in adolescence and adulthood, as evidenced by Martins and colleagues (59). The “fetal origins hypothesis” or “thrifty phenotype” introduced by Hales and Barker (60), which highlights the theory that environmental influences, namely nutrient deficiencies, in fetal and early life are primarily responsible for the relationship of low birth weight to metabolic disorders in adult life, may explain food-insecurity–related outcomes. Adult women in food-insecure households are particularly at risk for overweight and obesity (61-69). Possible causes of this phenomenon have been asserted, including a binge-like eating pattern or overeating when food is available (44) and consumption of empty-calorie, high-fat and high-sugar foods (70,71). However, additional research is needed for both adults and children to further clarify the relationship of overweight and obesity to food insecurity and hunger. Adult Health and Chronic Disease. Food insecurity/insufficiency is associated with the risk and incidence of chronic diseases (3,34,72), as well as with poor diabetes and chronic disease management (34,73,74) and overall poor health status (74-78). Other conditions have come to the forefront as also being associated with food insecurity, including human immunodeficiency virus (HIV) infection (79) and depression (18). The position of the American Dietetic Association and Dietitians of Canada on nutrition intervention related to nutritional care of those with HIV infection (80) highlighted that achieving food and nutrition security is challenging for those with HIV. Food insecurity and hunger seem to be prevalent for both men and women with HIV (79). Depression may also be keenly associated with women in food-insecure households. As previously noted, maternal depression was associated with food insecurity among mothers of young children (18). Other studies have also shown food insecurity/insufficiency to be related to depression (16,76,81).

Child/Adolescent Health and Academic Achievement. Risks of poor health, as well as decreased cognitive performance and academic achievement, are related to food insecurity. After controlling for confounding factors, including poverty, Alaimo and colleagues (54) showed that children from food-insufficient households had poorer health status and experienced more frequent stomachaches and headaches than children from foodsufficient households, although preschool children from food-insufficient households had colds more frequently. Casey and others (82) found that children 3 to 8 years of age in food-insecure households had lower physical function, although children 12 to 17 years old reported lower total health-related quality of life. Behavioral and psychosocial problems, including getting along with others and/or seeing a psychologist, have also been associated with food insecurity and hunger in children, either directly or mediated through other factors (16,83-85). Connell and others (86) published information elucidating the effects of food insecurity on the social and emotional wellbeing of children. For teens and adolescents (83,87), food insufficiency was associated with: (a) counseling by a psychologist, (b) suspension from school, (c) difficulty getting along with other teenagers, and (d) an increased risk of suicide. Regarding cognitive and academic performance, children from food-insufficient households, even after adjusting for confounding factors, had significantly lower arithmetic scores and were more likely to have repeated a grade, compared with those from food-sufficient households (83). School performance and academic achievement among children were negatively associated with the number of years a child had lived in a food-insecure household (88). KEY POINT: FOOD INSECURITY AND HUNGER IN THE UNITED STATES CAN BE ALLEVIATED THROUGH A VARIETY OF IMMEDIATE AND LONG-RANGE INTERVENTIONS A variety of strategies are used by households when faced with resource constraints. Federal food-assistance and nutrition education programs, along with community-based nongovernmental programs, have been

shown to improve food and nutrition security. Because households undoubtedly experience job transitions, layoffs, and family disruptions, regardless of the economy, robust safety net programs are vital to helping US citizens and residents achieve food and nutrition security (89). As stressed in the position statement, adequate funding for food and nutrition assistance programs is vital to maintain the integrity of the US nutrition safety net. However, systematic, sustainable actions are also needed to achieve domestic food and nutrition security. Overall, a longterm, systematic, broad-based approach, as described by McCullum and colleagues (35), seems appropriate to effectively sustain our economic social systems to preserve our most vital resource, the citizens and residents of the United States. Federal and Nonfederal Programs Several federal and nonfederal programs address a variety of aspects of food security. Figure 2 is a selective list of food-assistance programs and Web site addresses, as well as informational resources and names of organizations, that may be helpful to dietetics professionals. In addition to these organizations, state food security and hunger centers or coalitions, several federal agencies, professional organizations, and foundations fund hunger- and food-security–related programs and research. Generally, the most recent national estimates support that those with greater difficulty accessing food participate in food-assistance programs (1). It would be expected, because food-assistance programs provide food and other resources, that households would be more food secure after receiving the benefits. However, those seeking assistance from programs are typically those with greater levels of food insecurity. This is a self-selection effect and has been called self-targeting (1). Essentially, self-targeting is choosing to seek food and nutrition assistance based on the perception that you need that assistance. Many households choose to obtain assistance in the form of emergency food and meals from emergency food providers in their communities. As previously noted, households using these programs seem to be particu-

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ADA REPORTS Program

Web site

America’s Second Harvest

www.secondharvest.org

Bread for the World

www.bread.org

Child and Adult Care Food Program

www.fns.usda.gov/cnd/Care/CACFP/cacfphome.htm

Center on Hunger and Poverty

www.centeronhunger.org

Community Food Security Coalition

www.foodsecurity.org

Community Food Security Initiative

http://attra.ncat.org/guide/a_m/cfsi.html

Congressional Hunger Center

www.hungercenter.org

Elderly Nutrition Program

www.aoa.gov/press/fact/alpha/fact_elderly_nutrition.asp

Expanded Food and Nutrition Education Program

www.csrees.usda.gov/nea/food/efnep/efnep.html

Food Distribution Programs: ● Commodity Supplemental Food Program ● Department of Defense Fresh Fruit and Vegetable Program ● Food Distribution Disaster Assistance ● Food Distribution Program on Indian Reservations ● National Processing Agreement Demonstration Program ● Nutrition Services Incentive Program ● Schools/Child Nutrition Commodity Programs ● State Processing Program ● The Emergency Food Assistance Program

www.fns.usda.gov/fdd/

Food Recovery (A Citizen’s Guide to Food Recovery)

www.usda.gov/news/pubs/gleaning/content.htm

Food Research and Action Center

www.frac.org

Food Security in the US Briefing Room

www.ers.usda.gov/briefing/foodsecurity

Food Stamp Program

www.fns.usda.gov/fsp/

Mazon: A Jewish Response to Hunger

www.mazon.org

Meals on Wheels Association of America

www.mowaa.org

National School Lunch Program

www.fns.usda.gov/cnd/Lunch/Default.htm

Nutrition Assistance Program for Puerto Rico, American Samoa, and the Northern Marianas

www.fns.usda.gov/fns/menu/programs.htm

School Breakfast Program

www.fns.usda.gov/cnd/Breakfast/Default.htm

Senior Farmers’ Market Nutrition Program

www.fns.usda.gov/wic/SeniorFMNP/SFMNPmenu.htm

Share Our Strength

www.strength.org

Special Milk Program

www.fns.usda.gov/cnd/Milk/Default.htm

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

www.fns.usda.gov/wic/

Summer Food Service Program

www.summerfood.usda.gov

WIC Farmers’ Market Nutrition Program

www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm

World Hunger Year (WHY)

www.worldhungeryear.org

Figure 2. Selected programs, organizations, and resources that address food insecurity and hunger in the United States. larly vulnerable to food insecurity and hunger. However, these data undoubtedly understate the number of households that actually use these programs, according to the most recent national estimates of food inse-

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curity and hunger in the United States (1): ●

about 3.9 million US households (3.5%) obtained emergency food from pantries at least once during

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the 12-month period before December 2004, representing 6.9 million adults and 4.2 million children; about 539,000 US households (0.5%) had members who ate at least one meal at an emergency kitchen; and

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frequency of pantry usage during the year, for those using a pantry, was 1 or 2 months, 47%; some months but not every month, 29%; and almost every month, 24%.

In addition to the aforementioned community-based emergency food-assistance programs, many households choose to participate in a federal program. Generally, the most recent national estimates support that those with greater difficulty accessing food participate in food-assistance programs (1): ●

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Households with incomes less than 130% of federal poverty level: Œ Of those receiving food stamps in the previous 30 days, 49.4% were food insecure, with 18.6% experiencing hunger. Œ Of those not receiving food stamps, only 28.7% were food insecure, with 10.1% experiencing hunger. Households with incomes less than 185% of federal poverty level: Œ Free or reduced-price National School Lunch Program (NSLP): ● For those with school-age children and receiving NSLP in the previous 30 days, 47.8% were food insecure, with 13.1% experiencing hunger. ● Of similar households not receiving NLSP benefits, 24.6% experienced food insecurity, with 6.8% reporting hunger. Œ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): ● For those with children under age 5 years and receiving WIC benefits in the previous month, 42.3% were food insecure, with 10.5% experiencing hunger. ● Of those not receiving WIC benefits, 32.1% were classified as food insecure, with 7% experiencing hunger.

Although the statistics may be biased downward because of underreporting by respondents and ineligibility of households for the programs, overall, 55.2% of food-insecure households participated in WIC, the NLSP, or the Food Stamp Program during the month before the administration of the Current Population Survey Food Security Survey Supplement. Looking at it another way, the NSLP,

the Food Stamp Program, and WIC reach 36%, 29.7%, and 13.6%, respectively, of food-insecure families (1). Participation by households experiencing food insecurity with hunger was 28%, 32.6%, and 9.6% for the NLSP, the Food Stamp Program, and WIC, respectively. Despite their importance for households with limited incomes and resource constraints, little is known about the impact of these programs on participant food security status; however, several studies are emerging. Participation in WIC, as previously noted, improved the dietary variety of younger preschoolers in participating households (37), as well as the overall dietary quality of households with at least one participant in the program (90). Herman and colleagues (91) also reported that WIC made a significant contribution to reducing food insecurity among first-time participants. Although food insecurity and hunger were not the focus, several studies have also reported on the benefits of the WIC and Senior Farmers’ Market Nutrition Programs (92-94). Participation in the Expanded Food and Nutrition Education Program, which educates low-income families on food selection and resource management skills, seems to improve the food security status of households (95,96), with a dose-response relationship between the number of lessons received and decreases in food insecurity (95). Further research is needed to clarify the nutritional and nonnutritional outcomes, including overweight and obesity (97), of food and nutrition assistance programs, as well as means of identifying and eliminating barriers to participation. Community-Based Systematic Actions Long-term interventions are needed to achieve food and nutrition security in the United States. In a community, the norms and networks that facilitate collective action are called social capital (98), whereas at the household level, social capital is the perceived sense of social trust and community reciprocity (99). Community-level social capital seems especially important for achieving food and nutrition security in the United States because it has been shown to decrease the odds of

experiencing hunger (99). As part of the US Department of Agriculture’s Community Food Security Initiative efforts to cut US hunger in half by 2015, a variety of methods are planned (7): ●

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improving coordination between existing federal programs and related federal, state, and community initiatives; increasing public awareness of the causes and consequences of food insecurity; and highlighting innovative community solutions to hunger.

Creating multisector partnerships and networks, including government and public health agencies, educational institutions, nonprofit organizations, and the volunteer sector, will be vital for developing the infrastructure needed to achieve food and nutrition security (35). The US Department of Agriculture spends billions of dollars each year on food-assistance programs that protect against food insecurity. Communitybased programs can boost the effectiveness of Federal programs in a variety of ways (100,101). Examples of the benefits of community food security programs for both farmers and community residents include (101): ●

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food stamp outreach programs help to increase the number of eligible participating households in a community, decreasing reliance on emergency food programs; farmers’ markets boost incomes of local farmers, while increasing community access to fresh produce; community gardens help residents in public housing and other low-income households to supplement their diet with fresh produce; food buying cooperatives save households money by pooling resources; community-supported agriculture programs help to stabilize small farmers economically, while providing high-quality, below-retail-cost produce to consumers; farm-to-school initiatives assist local farmers in selling fresh produce directly to school meal programs; and food recovery programs rescue wholesome food from being thrown away and provide food to groups serving those in need.

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ADA REPORTS Education and Practice ● Continue to incorporate food security foundation knowledge and skills and competencies, as well as creative pedagogy, into dietetics education programs (109,110). ● Continue to learn about food insecurity and its consequences on individuals, households and communities, and communicate this information to other professionals, legislators, policy makers, and community members to increase awareness about food insecurity and its effects on health and well-being. ● Food insecurity may make purchasing food difficult for the client and prevent compliance to a prescribed diet, consider food securityrelated issues when assessing clients, including: 䡩 money for dietary prescription and/or medication; 䡩 availability of a refrigerator/freezer, utilities, and transportation; 䡩 participation in food assistance programs; 䡩 gardening practices; 䡩 other means of acquiring foods (hunting/fishing); 䡩 unintentional weight loss; 䡩 quality of the diet; 䡩 nutrition education need regarding meal planning and purchasing, label reading, and food safety (53,111); and 䡩 understanding the culture of the local community, which will help determine appropriate questions and/or information to include about food and nutrition security during the nutritional care process. ● Screen clients for resource-constrained, lack of access to food using a single-item food sufficiency question, “Which of the following statements best describes the food eaten in your household: 1) Enough of the kinds of food we want to eat; 2) Enough but not always the kinds of food we want to eat; 3) Sometimes not enough to eat; or 4) Often not enough to eat” (36). ● Network with organizations and programs addressing food insecurity in the local community, including food and nutrition assistance programs, emergency food and meal programs, food recovery groups, farmers markets, community-supported agriculture farms, community gardens, anti-hunger advocacy organizations, and food cooperatives. ● Develop a database and/or website of food and nutrition assistance organizations for providing information related to community food security assistance programs, food assistance client referrals, client history, food donation, and nutrition education may be useful (112). ● Educate eligible clients on the availability and benefits of Federal and non-Federal resources available in the community and make referrals or recommend participation. ● Develop innovative programs that provide nutrition education and build skills in order to improve the food security of individuals, households, and communities, including programs highlighting the benefits of local, seasonal, and sustainably grown foods, focusing on the development of effective household management strategies and food preparation, and creating food-based projects that foster economic development. Research ● In view of the nine research priorities of the American Dietetic Association, including “access to a safe and secure food supply” (103), conduct or collaborate on food insecurity and hunger-related research, including projects that map community processes, document the nutritional value of emergency foods, investigate the causes of food insecurity and its effects on health, nutritional status and wellbeing of special, at-risk population groups, and the impact of food system issues, such as seasonal variation in food availability, on food insecurity in the community. ● Cost-benefit analyses to determine the effectiveness of food recovery and other programs are also needed. ● Participate in evaluating innovative, community-based programs designed to address food insecurity. Advocacy and Public Policy ● Support legislative and regulatory processes that promote uniform, adequately funded food and nutrition assistance programs, nutrition education, and programs that support the economic self-sufficiency of individuals and families. ● Serve as advocates for the nutritionally vulnerable and those groups at increased risk for food insecurity. ● Assist in efforts to improve food access and acquisition by individuals and reduce edible food loss through food recovery and gleaning. ● Partner with local and State antihunger advocacy organizations. ● Serve on a local food policy council, which examines local food systems and provides recommendations for social and public policy changes. Figure 3. Contributions that dietetics professionals can make to improve food insecurity and hunger in the United States. ROLES AND RESPONSIBILITIES OF DIETETICS PROFESSIONALS The American Dietetic Association is committed to helping people enjoy more healthful lives (102). One of the five critical areas facing all Americans is a safe, sustainable, and nutritious food supply (103). Dietetics professionals are uniquely positioned to play

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leadership roles in developing, implementing, and evaluating strategies to achieve US food and nutrition security. The dietetics practitioner understands the effects of inadequate dietary intake and food insecurity on health and wellbeing, and is trained in food systems, management, negotiation, decisionmaking, and marketing/promotion. Di-

etetics professionals are uniquely positioned to play key leadership roles and to collaborate with policy makers, government and community leaders, health departments, extension programs, anti-hunger organizations, and community-based organizations, including emergency food providers, to eliminate food insecurity in the United

ADA REPORTS States and to establish food-secure communities. As summarized in Figure 3, dietetics professionals are uniquely positioned to make valuable contributions in education, practice, research, advocacy, and public policy, especially through community-based involvement. References 1. Nord M, Andrews M, Carlson S. Household Food Security in the United States, 2004 (ERR-11). Alexandria, VA: US Department of Agriculture, Economic Research Services; 2005. 2. Anderson S. Core indicators of nutritional state for difficult to sample populations. J Nutr. 1990;102:1559-1660. 3. Dixon LB, Winkleby M, Radimer K. Dietary intakes and serum nutrients differ between adults from food-insufficient and foodsufficient families: Third National Health and Nutrition Examination Survey, 1988-1994. J Nutr. 2001;131:1232-1246. 4. Hamelin A-M, Habicht J-P, Beaudry M. Food insecurity: Consequences for the household and broader social implications. J Nutr. 1999;129(suppl):S525S528. 5. American Dietetic Association. Position of the American Dietetic Association: Food and water safety. J Am Diet Assoc. 2003;103:1203-1218. 6. Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. Healthy People 2010. Available at: http://www.health.gov/ healthypeople. Accessed June 28, 2005. 7. National Center for Appropriate Technology. Community Food Security Initiative (CFSI). Available at: http://attra.ncat.org/guide/ a_m/cfsi.html. Accessed July 30, 2005. 8. American Dietetic Association. Position of the American Dietetic Association: Domestic food and nutrition security. J Am Diet Assoc. 2002;102:1840-1847. 9. Economic Research Service. Food and Nutrition Assistance Programs: Welfare Reform and Food Assistance. Available at: http://www.ers.usda.gov/Briefing/

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18. Casey P, Goolsby S, Berkowitz C, Frank D, Cook J, Cutts D, Black MM, Zaldivar N, Levenson S, Heeren T, Meyers A, Children’s Sentinel Nutritional Assessment Program Study Group. Maternal depression, changing public assistance, food security, and child health status. Pediatrics. 2004;113:298-304. 19. Capps R, Ku L, Fix M. How are immigrants faring after welfare reform? Preliminary evidence from Los Angeles and New York City. Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services. March 4, 2002. Available at: http:// aspe.hhs.gov/hsp/immigrantsfaring02/. Accessed January 4, 2006. 20. Van Hook J, Balistreri KS. Ineligible parents, eligible children: Food stamps receipt, allotments, and food insecurity among children of immigrants. Soc Sci Res. 2006;35:228-251. 21. Quandt SA, Arcury TA, Early J, Tapia J, Davis JD. Household food security among migrant and seasonal Latino farmworkers in North Carolina. Public Health Rep. 2004;119:568-576. 22. Harrison GG, Stormer A, Herman DR, Winham DM. Development of a Spanish-language version of the US Household Food Security Survey Module. J Nutr. 2003;133:1192-1197. 23. Economic Research Service. Food Security in the United States: Household Survey Tools. Available at: http://www.ers. usda.gov/Briefing/FoodSecurity/ surveytools/. Accessed June 29, 2005. 24. Journal of Nutrition. US Food Security Survey Instrument, Spanish Version. Available at: http://www.nutrition.org/cgi/ content/full/133/4/1192#SEC4. Accessed June 29, 2005. 25. Hall B, Brown JL. Food security among older adults in the United States. Top Clin Nutr. 2005;20:329-338. 26. Frongillo EA, Horan CM. Hunger and aging. Generations. Fall 2004:28-33. 27. Radimer KL, Olson CM, Greene JC, Campbell CC, Habicht JP. Understanding hunger and de-

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71. Drewnowski A, Darmon N. The economics of obesity: Dietary energy density and energy cost. Am J Clin Nutr. 2005;82(suppl): S265-S273. 72. Rainville B, Brink S. Food insecurity in Canada, 1998-1999. Ottawa: Human Resources Development Canada, Applied Research Branch of Strategic Policy; 2001. Available at: http:// www11.hrsdc.gc.ca/en/cs/sp/ hrsdc/arb/publications/research/ 2001-000066/page00.shtml. Accessed July 4, 2005. 73. Nelson K, Brown ME, Lurie N. Hunger in an adult patient population. JAMA. 1998;279:12111214. 74. Nelson K, Cunningham W, Andersen R, Harrison G, Gelberg L. Is food insufficiency associated with health status and health care utilization among adults with diabetes? J Gen Intern Med. 2001;16:404-411. 75. Pheley AM, Holben DH, Graham AS, Simpson C. Food security and perceptions of health status: A preliminary study in rural Appalachia. J Rural Health. 2002;18:447-454. 76. Siefert K, Heflin CM, Corcoran ME, Williams DR. Food insufficiency and the physical and mental health of low-income women. Women & Health. 2001; 32:159-177. 77. Stuff JE, Casey PH, Szeto KL, Gossett JM, Robbins JM, Simpson PM, Connell C, Bogle ML. Household food insecurity is associated with adult health status. J Nutr. 2004;134:23302335. 78. Vozoris NT, Tarasuk VS. Household food insufficiency is associated with poorer health. J Nutr. 2003;133:120-126. 79. Normén L, Chan K, Braitstein P, Anema A, Bondy G, Montaner JSG, Hogg RS. Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada. J Nutr. 2005;135:820-825. 80. American Dietetic Association. Position of the American Dietetic Association and Dietitians of Canada: Nutrition intervention in the care of persons with human immunodeficiency virus

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ADA position adopted by the House of Delegates on April 22, 1990, and reaffirmed on September 4, 1994; June 22, 2000; and May 24, 2004. This position will be in effect until December 31, 2009. The ADA authorizes republication of the position statement/support paper, in its entirety, provided full and proper credit is given. Requests to use portions of the position must be directed to ADA Headquarters at 800/877-1600, ext 4835 or [email protected]. Author: David H. Holben, PhD, RD (Ohio University, Athens, OH). Reviewers: Mary Ellen Druyan, PhD, MPH, RD (Vita Products, Inc, Chicago, IL); Christine McCullum-Gomez, PhD, RD (University of Texas Health Science Center at Houston, Houston, TX); Mary L. Meck Higgins, PhD, RD (Kansas State University, Extension Human Nutrition, Manhattan, KS); Carol E. O’Neil, PhD, MPH, RD (Louisiana State University Baton Rouge, LA); Public Health and Community Nutrition dietetic practice group (Rachel Hayes-Bohn, MPH, RD, USDA Food and Nutrition Service, Alexandria, VA); Jennifer A. Weber, MPH, RD (ADA Government Relations, Washington, DC); Weight Management dietetic practice group (Vangie Ramos-Tate, MS, RD, Whiteriver Service Unit, Whiteriver, AZ; and Karen K. Wilson, MA, RD, Greater Philadelphia Coalition Against Hunger, Philadelphia, PA). Association Positions Committee Workgroup: M. Patricia Fuhrman, MS, RD, FADA (chair); Naomi Trostler, PhD, RD; Angie Tagtow, MS, RD (content advisor).