in progress

Final Research Plan

Food Insecurity: Preventive Services

July 28, 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 whether identifying food insecurity improves 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).

* For consideration of variation by population and intervention characteristics, see the “Approach to Assessing Health Equity and Variation in Evidence Across Populations” section.
† Intermediate outcomes include behavioral, physiologic, decision making, patient participation, and healthcare utilization outcomes.

  1. Does identifying food insecurity in healthcare improve 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, 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 identify food insecurity? What are the benefits and limitations of these tools (e.g., ease of administration)?
  2. What factors inform the appropriate reassessment interval for food insecurity?
  3. What are important moderators that affect the effectiveness or harms of food insecurity assessment and healthcare-related interventions?
  4. What is the acceptability (e.g., satisfaction) of food insecurity assessment and healthcare-related interventions to patients and providers?
  5. What is the uptake of services (e.g., rate of adoption or receipt of benefits) after food insecurity is identified?
  6. What are the patient, provider, and health system facilitators and barriers to implementing assessment for food insecurity?
  7. What are the patient, provider, health system, and community facilitators and barriers to implementing interventions to address food insecurity?

To the extent possible, we plan to describe the population, screening, and intervention characteristics of the included studies. Data on population characteristics will help us explore the degree to which the findings are representative of persons at risk for food insecurity as well as investigate differences in benefit and harms by different population groups. These groups include, but are not limited to, categorizations by age; racial, ethnic, and cultural identity; socioeconomic and insurance status; presence of other social needs; and type of chronic condition. In addition, we will consider contextual questions through a health equity lens with attention to differences across populations. Heterogeneity around assessment and screening may include temporality of food insecurity, level of food insecurity, screening for nutrition insecurity in addition to food insecurity, stand-alone screening for food insecurity vs. screening bundled with other social risk factor assessment, and details around implementation of screening (e.g., use of electronic health records, training of assessor, or mode of assessment). Heterogeneity around interventions may include setting of intervention (healthcare vs. community), type of intervention, and components in intervention (e.g., addresses nutrition or food access). Additional contextual questions will address moderators that affect the effectiveness or harms of food insecurity assessment and healthcare-related interventions (Contextual Question 3), facilitators and barriers to implementation of food insecurity assessment (Contextual Question 6), and healthcare interventions (Contextual Question 7).

The 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 Food insecurity
  • Water insecurity
  • Other social risk factors (e.g., unemployment, financial strain, housing instability) in the absence of food insecurity
Populations*
  • 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)
  • Persons with acute medical or psychiatric conditions
  • Persons undergoing treatment for cancer
  • Persons with severe 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 (anthropometric, biochemical, clinical, or dietary 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 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:
  • Interventions focused on adherence to dietary recommendations for management of chronic conditions
  • Public health/community-level policies
Comparators KQs 1, 4: Control group (can include historical control, 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 and nutrition security outcomes
  • Access to food
  • Behavioral outcomes (e.g., dietary intake, substance use)
  • Physiologic outcomes (e.g., blood pressure, hemoglobin A1c, healthy weight gain in pregnancy)
  • Healthcare-related decision making outcomes
  • Healthcare-related patient participation outcomes (e.g., medication compliance, attendance at medical appointments)
  • 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)
  • Community-level outcomes (e.g., number of food pantries)
  • Cost outcomes
KQ 2: Test positivity or test yield only
Settings All KQs
  • 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
  • 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, quasiexperimental 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 quasiexperimental 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.
§ Does not apply to pre-post study design.

Abbreviation: KQ=key question.

A draft Research Plan was posted on the USPSTF website for public comment from February 22 to March 21, 2022. In response to public comment, the USPSTF added a few additional outcomes to KQs 1 and 4, including food access, clinical decision making, and patient adherence. The USPSTF also added moderators of benefits and harms of assessment/screening (in addition to interventions) to CQ3 and added “facilitators” in addition to barriers for CQ6 and CQ7. A few commenters asked for inclusion of interventions to address food insecurity beyond the scope of the USPSTF. The USPSTF added a section, “Approach to Assessing Health Equity and Variation in Evidence Across Populations,” that addresses how the review would address health equity, heterogeneity by population, as well as heterogeneity of screening or interventions for food insecurity. Last, the USPSTF made minor clarifying changes to the questions and inclusion criteria.