in progress

Draft Research Plan

Food Insecurity: Preventive Services

February 24, 2022

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Figure 1 is the analytic framework that depicts the five Key Questions (KQs) to be addressed in the systematic review. The figure addresses the effect of identifying food insecurity on health outcomes (KQ1), the performance of risk assessment or screening to identify food insecurity (KQ2), and harms of assessment for food insecurity (KQ3). The figure also displays the effect of interventions on food security status, intermediate outcomes, and health outcomes (KQ4), the effect of improvements in food security outcomes on intermediate and health outcomes (4a), and the effect of improvements in intermediate outcomes on health outcomes (4b), as well as the harms or unintended consequences of these interventions (KQ5).

*Intermediate outcomes include behavioral, physiologic, and healthcare utilization outcomes.

  1. What is the effect of identifying food insecurity in primary care on health outcomes?
  2. What is the performance of risk assessment or screening tools to identify food insecurity?
  3. What are the harms or unintended consequences of assessment for food insecurity?
  4. What is the effect of healthcare-related interventions to address food insecurity on food security, intermediate outcomes (i.e., behavioral, physiologic, and healthcare utilization outcomes), or health outcomes?
    1. What are the effects of improvements in food security outcomes on intermediate and health outcomes?
    2. What are the effects of improvements in intermediate outcomes on health outcomes?
  5. What are the harms or unintended consequences of healthcare-related interventions to address food insecurity?

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.

  1. What risk assessment or screening tools are commonly used in clinical practice to address food insecurity? What are the benefits and limitations of these commonly used tools?
  2. What factors inform the appropriate reassessment interval for food insecurity?
  3. What are important moderators that affect the effectiveness or harms of interventions to address food insecurity?
  4. What is the acceptability of food insecurity assessment and interventions to patients and providers?
  5. What is the uptake of interventions after food security is identified as a social need?
  6. What are the patient, provider, and health system barriers to implementing assessment for food insecurity?
  7. What are the patient, provider, health system, and community barriers to implementing interventions to address food insecurity?

The proposed Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions.

Category Include Exclude
Condition KQs 1–5: Food insecurity with or without nutrition insecurity KQs 1–5:
  • Nutrition insecurity in food secure populations
  • Water insecurity
  • Other social risk factors (e.g., unemployment, financial strain, housing instability) in the absence of food insecurity
Populations* KQs 1–5: All ages
  • Children and their caregivers
  • Adolescents
  • Adults
  • Perinatal, pregnant, and postpartum persons
  • Older adults and their caregivers
  • Persons with stable common chronic conditions (e.g., diabetes, hypertension)
 KQs 1–5:
  • Persons with acute medical or psychiatric conditions
  • Persons with cancer
  • Persons with malnutrition or nutritional deficiencies
Assessment KQs 1–3: Risk assessment or screening for food with or without nutrition insecurity using tool that addresses food insecurity with other social risk factors or food insecurity alone KQs 1–3:
  • Nutrition assessment
  • Risk assessment or screening tools for social risk factors that do not explicitly address food insecurity
Interventions KQs 4, 5: Healthcare-related interventions† targeting food with or without nutrition insecurity
  • Individual level (e.g., referral to social services, provision of information about resources)
  • Healthcare system–level (e.g., policies, programs, staff training, primary care collaboration with community services)
 KQs 4, 5: Public health/community-level policies
Comparators KQs 1, 4: Control group (can include active control/comparator)

KQ 2: Any reference standard

KQs 3, 5: No comparator required if explicitly addresses harms

 KQs 1, 4: No control/comparator

KQ 2: No reference standard
Outcomes KQs 1, 4:
  • Food security outcomes
  • Behavioral outcomes (e.g., fruit and vegetable intake)
  • Physiologic outcomes (e.g., blood pressure, hemoglobin A1c, healthy weight gain in pregnancy)
  • Healthcare utilization (e.g., emergency department visits, hospitalization)
  • Health or surrogate health outcomes (e.g., low birth weight, developmental outcomes in children, incident diabetes, mental health, cardiovascular events, quality of life)

KQ 2: Test accuracy, predictive validity, and discrimination

KQs 3, 5: Any harms or unintended consequences		 KQs 1, 4:
  • Knowledge, skills, and self-efficacy outcomes
  • Provider-level outcomes (e.g., confidence in screening, awareness of resources)
  • Cost outcomes
KQ 2: Test positivity or test yield only
Settings KQs 1–5:
  • Any setting linked with healthcare system (e.g., primary care, specialty care, emergency department)
  • Conducted in the United States

KQs 1–3: Screening conducted in clinical setting or identified through healthcare delivery or payment system (e.g., health plan data)

KQs 4, 5: Interventions or programs integrated into, associated with, or referred from healthcare		 KQs 1–5:
  • No link with healthcare system
  • Conducted outside the United States
Study designs KQs 1, 4:
  • Randomized or clinically controlled trials, nonrandomized studies with a contemporaneous control or comparison, quasi-experimental studies (e.g., pre-post studies)
  • Minimum 12-week followup

KQ 2: Diagnostic test accuracy or risk assessment studies

KQs 3, 5: Randomized or clinically controlled trials, nonrandomized studies, and quasi-experimental studies		 KQs 1, 4: Randomized or clinically controlled trials, nonrandomized studies with less than 12- week followup

KQ 2: Test performance studies without reference standard

KQs 3, 5: Case series, case reports, or editorials
Study quality Fair to good Poor

* For all KQs, populations of interest include persons at higher risk for food insecurity (e.g., by age, race and ethnicity, health status, or other social risk factors).
† Healthcare-related interventions are those in which the patient’s food insecurity was identified through healthcare and/or the intervention itself is provided directly via a healthcare system, based within a healthcare system, or delivered in partnership with a healthcare system.

Abbreviation: KQ=key question.