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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
Food Sufficiency

Introduction

This toolkit summarizes content from the Food Sufficiency Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

From the MCH Block Grant Guidance. In 2021, 12.8% of children lived in food insecure households.1 Food insecurity had been decreasing since the Great Recession, but the number of children in food insecure households increased by 10% in 2020 due to the COVID-19 Pandemic. The percentage sharply declined by 20% in 2021, the lowest prevalence on record since 1998. There were several temporary measures taken as part of the Public Health Emergency response to expand benefits and access to programs such as SNAP, WIC, and the National School Lunch Program plus general economic relief.1,2 Large disparities exist by race/ethnicity, disability status, urbanicity, and family structure.3 Food insecurity among children is associated with poor health status, mental health problems, behavioral and socio-emotional problems, and poor educational performance and academic outcomes.4

Goal. To increase the percent of children whose households are always able to afford to eat good nutritious food.

Note. Access other related measures in this Population Domain through the Toolkits page.

New. Innovative Strategies to Improve Food Sufficiency in State Title V Programs: A Resource Guide to Enhance Food Access Through Title V. This resource guide lists some strategies that Title V programs in ten states and the District of Columbia are currently using to increase food sufficiency following the Individual plus Policy, System, and Environmental (I+PSE) Conceptual Framework.

Overview: Read a summary of the issue related to Title V

Food sufficiency, or the ability of a household to consistently afford and access nutritious foods,1 is the focus of this NPM, although there are many related concepts.* Food insufficiency and food insecurity both are due to insufficient resources to meet basic needs, but their meanings are different.2 Food insecurity is the limited or uncertain availability of safe and nutritionally adequate foods, or the limited or uncertain ability to acquire acceptable foods in socially acceptable ways (without using emergency food supplies, scavenging, or stealing).3 Low food security is reduced quality, variety, or desirability of diet, but with little or no indication of reduced food intake.3 Food insufficiency is considered a more severe form of food insecurity (“very low food security”) and measures whether a household generally has enough to eat.3

Food insufficiency can manifest in various ways, such as households lacking consistent access to enough food, skipped meals, or reliance on unhealthy food options. Access to sufficient nutritious food is critical for healthy development. Poor nutrition affects every demographic, but historically underserved communities bear the burden of diet-related disease, such as obesity and diabetes.4 Research has established an association between food scarcity and poor child health outcomes and diminished well-being.5 Food insecurity among children is associated with poor health status, mental health concerns, behavioral and socio-emotional issues, and poor educational performance and academic outcomes.6,7,8

Families experiencing food insufficiency may participate in programs such as the Supplemental Nutrition Assistance Program (SNAP) or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program to aid in making food more affordable. Participation in SNAP and WIC during childhood has long-term benefits helping to improve food security across the life course.9 Increased access to school meal programs among children at risk for food insufficiency can also help ensure adequate nutrition and mitigate health issues.10

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerator: Number of children, ages 0 through 11, whose households are reported by a parent to have always been able to afford to eat good nutritious food in the past year.

Denominator: Number of children, ages 0 through 11

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Nutrition and Weight Status Objective 01: Reduce household food insecurity and hunger (Baseline: 11.1% of households were food insecure in 2018, Target: 6.0%)

Related to Nutrition and Weight Status Objective 02: Eliminate very low food security in children (Baseline: 0.59% of households with children under 18 years had very low food security among children in 2018, Target: 0.0%)

DATA SOURCES

National Survey of Children’s Health (NSCH)

MCH POPULATION DOMAIN

Child Health

MEASURE DOMAIN

Social Determinants of Health

Data Sources: Learn more about the issue and access the data directly

This NPM is measured through data collected from the National Survey for Children’s Health (NSCH). In 2022, 69.6% of households with young children aged 0-5 could always afford to eat good nutritious meals while 26.4% of households could always afford enough to eat but not always the kinds of foods that were healthy.11 For households with children aged 6-11, 67.2% could always afford to eat good nutritious meals while 27.4% could always afford enough to eat but not always the kinds of foods that were healthy.11

1. Accelerate with Evidence—Start with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous

     

 

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Cutting Edge:

Emerging:

Promising:

 

Key Findings and Emerging Issues: Read more from the literature

The following are key findings emerging from the literature:

  1. Enhanced WIC and SNAP benefits and services have significantly reduced food insecurity rates by providing increased access to nutritious foods and essential resources for low-income families and individuals.26,27,28
  2. School meal programs play a vital role in providing nutritious meals to children. Evidence supporting an increase in participation rates, reduction of stigma associated with free and reduced-price meals, and expanding afterschool and summer meal programs have proven effective.29,30,31
  3. Collaborating with community-based organizations and grassroots initiatives can help reduce food insecurity including food banks, food rescue programs, community kitchens, and initiatives that foster local food production and distribution.32,33,34
  4. Engaging healthcare providers, such as pediatricians and family doctors, in screening for and addressing food insufficiency is an effective method to help identify at-risk families and connect them to appropriate resources and support.35,36,37

Research. Multiple strategies are emerging as potential approaches to advance this NPM, but haven’t been studied with enough rigor to be included in the evidence-based continuum. Additional research is needed to verify outcomes, but initial studies have shown promise of these strategies in MCH settings:

  • Implementing policies that address income inequality, and providing income support, to help reduce household food insecurity.38,39
  • Utilizing early childhood programs, such as Head Start, to help families develop increased knowledge and skills to support a healthy lifestyle.40
  • Identifying and addressing structural barriers that contribute to food insufficiency, such as lack of affordable housing, transportation challenges, and limited availability of healthy food options in certain neighborhoods, to help create more equitable food environments.41

Research Gaps: Learn where more study is needed

Topical Area Knowledge Gaps. Lack of studies on:

  • Evaluating the impact of nutritional education and awareness programs on household food choices and children's dietary intake. 
  • Exploring the effectiveness of community-based interventions in improving food security for children.

Specific Intervention Research Gaps. Lack of studies on:

  • Implementing policies that address income inequality, and providing income support, to help reduce household food insecurity.
  • Utilizing early childhood programs, such as Head Start, to help families develop increased knowledge and skills to support a healthy lifestyle.
  • Identifying and addressing structural barriers that contribute to food insufficiency.

Strategy Videos: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

Also, watch this video from the Association of State Pulbic Health Nutritionalists (ASPHN).

2. Think Upstream with Planning Tools—Lead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Title V agencies can help improve child food sufficiency by:

  • Conducting Needs Assessment and Data Collection to further understand the intersection of food insufficiency, SDOH, and health outcomes, and tailor interventions to address the specific needs of vulnerable populations.7,25
  • Supporting Outreach and Education by providing clear, relevant, and culturally appropriate nutrition education materials and making connections to resources for nutritious food to empower families to make informed choices.16,25
  • Building Partnerships and Collaborations with organizations and local health departments that utilize food banks, community gardens, healthcare providers, and social service agencies to help mitigate food hardships in communities.25
  • Educating Policymakers and Informing Policy Changes that address the SDOH and root causes of food insufficiency, such as poverty, income inequality, lack of education, and limited access to affordable housing.25

SDOH and Health Equity Considerations: Identify ways to advance health for all

Social Determinants of Health (SDOH)

SDOH, such as income, education, employment and community resources, play a major role in influencing a family’s ability to access and afford nutritious food. Healthy food may be hard to find or too expensive to afford. Households with lower incomes often face barriers to obtaining high-quality meals. Employment and income are potentially limiting financial resources that families can allocate towards a healthy diet.12

Strategies to address food sufficiency require an equity-focused, SDOH-based approach including:

  • Implementing policies focused on increasing income, such as raising the minimum wage, to directly impact a family’s ability to afford enough nutritious food.13
  • Ensuring families have access to safe and affordable housing to free up financial resources to afford enough nutrient-dense food.14
  • Promoting nutrition education and health literacy programs, such as SNAP-Ed, to empower families and support healthy eating.15,16
  • Ensuring benefits for food assistance programs are adequate to support healthy eating patterns, such as permanent increases to the purchasing power of SNAP benefits.16

Health Equity

Systemic racism in the U.S. significantly contributes to food hardships, disproportionately impacting communities of color.17 For example, Black children are nearly three times more likely to live in a household with low food security than White children.9 Efforts to promote health equity must ensure all who have been historically underserved, marginalized, and/or adversely affected by poverty and inequality achieve food sufficiency.18

Strategies to address food sufficiency and promote an equitable food system include:

  • Improving access to programs like SNAP and WIC to ensure broader coverage and support, and reducing barriers to participation by streamlining enrollment practices, having a single application, and expanding online shopping options.16,19   
  • Expanding the reach of the emergency food network in remote, rural, Tribal, and/or low-income areas to increase access to food.16
  • Supporting change in the food environment by reducing the price of healthy products and increasing access to healthy options, such as affordable, local, seasonal produce at farmers’ markets.20
  • Providing cultural competency training for healthcare professionals to help address the food needs of children and families from diverse backgrounds while tailoring dietary interventions to the specific cultural and linguistic needs of communities to overcome barriers to access.21

Special Considerations: Tease out ways to zoom in on populations of focus

Children with Special Health Care Needs (CSHCN)

The relationship between food sufficiency and CSHCN is of paramount importance, as proper nutrition plays a critical role in their overall well-being and development. In 2022, data from the NSCH revealed that 69.4% of non-CSHCN families and 58.4% of CSHCN families reported always being able to afford good nutritious meals.22 Ensuring food sufficiency for CSHCN requires a comprehensive approach that considers both the specific nutritional needs associated with their health conditions and the potential financial strains placed on families who may require additional resources to meet these needs.23

3. Work Together with Implementation Tools—Move from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Implementation Resources: Use these field-generated resources to affect change

Practice. The following tools can be used to translate evidence to action to advance this NPM:

Partnership. The following organizations focus efforts on advancing food sufficiency:

References

Introductory References: From the MCH Block Grant Guidance

1 Coleman-Jensen, Alisha, Matthew P. Rabbitt, Christian A. Gregory, Anita Singh, September 2022. Household Food Security in the United States in 2021, ERR-309, U.S. Department of Agriculture, Economic Research Service. https://www.ers.usda.gov/webdocs/publications/104656/err-309.pdf
2 U.S. Department of Agriculture. FNS Responds to COVID-19. (n.d.) https://www.fns.usda.gov/coronavirusotnote>
3 Ullmann H, Weeks JD, Madans JH. Children Living in Households That Experienced Food Insecurity: United States, 2019-2020. NCHS Data Brief. 2022;(432):1-8. https://www.cdc.gov/nchs/products/databriefs/db432.htm#:~:text=Summary-,In%202019%E2%80%932020%2C%2010.8%25%20of%20children%20aged%200%E2%80%93,or%20age%20of%20the%20child>
4 Food Research and Action Center (FRAC). The impact of poverty, food insecurity, and poor nutrition on health and well-being. 2017 December. https://frac.org/wp-content/uploads/hunger-health-impact-poverty-food-insecurity-health-well-being.pdf

Toolkit References: From the Evidence Accelerator

1 Health Resources & Services Administration. (2024). Title V Maternal and Child Health Services Block Grant to States Programs. Technical Assistance Resources.

2 Food Research & Action Center (FRAC). (2021) Defining Food Insecurity and Measuring it During COVID-19.

3 Association of State Public Health Nutritionists (ASPHN). (2023) Food and Nutrition Security Primer.

4 U.S. Department of Agriculture (USDA). (n.d.) Food and Nutrition Security | USDA

5 Gundersen C, Ziliak JP. Childhood food insecurity in the US: trends, causes, and policy options. Future Child 2014:1–19.

6 Food Research and Action Center (FRAC). (2017 December) The impact of poverty, food insecurity, and poor nutrition on health and well-being.

7 US Department of Health and Human Services, Office of Disease Prevention and Health Promotion (Healthy People 2030). Food Insecurity.

8 Pourmotabbed, A., Moradi, S., Babaei, A., Ghavami, A., Mohammadi, H., Jalili, C., ... & Miraghajani, M. (2020). Food insecurity and mental health: a systematic review and meta-analysis. Public health nutrition, 23(10), 1778-1790.

9 Insolera N, Cohen A, Wolfson JA. SNAP and WIC Participation During Childhood and Food Security in Adulthood, 1984-2019. Am J Public Health. 2022 Oct;112(10):1498-1506.

10 Huang, J., & Barnidge, E. (2016). Low-income Children's participation in the National School Lunch Program and household food insufficiency. Social science & medicine (1982), 150, 8–14.

11 Child and Adolescent Health Measurement Initiative. 2022 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). NSCH 2022: Food insufficiency, Nationwide, Age in 3 groups (childhealthdata.org)

12 Banks, AR, Bell, BA, Ngendahimana, D, Embaye, M, Freedman, DA, & Chisolm, DJ. (2021). Identification of factors related to food insecurity and the implications for social determinants of health screenings. BMC Public Health, 21, 1-8.

13 Drexel University Center for Hunger-Free Communities (2021, December). Minimum Wage is Not Enough: A True Living Wage is Necessary to Reduce Poverty and Improve Health.

14 Campanera, M., Gasull, M., & Gracia-Arnaiz, M. (2023). Food security as a social determinant of health: Tackling inequalities in primary health care in Spain. Health and Human Rights, 25(1), 9.

15 Silva P, Araújo R, Lopes F, Ray S. Nutrition and Food Literacy: Framing the Challenges to Health Communication. Nutrients. 2023; 15(22):4708.

16 U.S. Department of Agriculture (USDA). (2022 March). USDA Actions on Nutrition Security.

17 Raskind, I. G. (2020). Hunger does discriminate: addressing structural racism and economic inequality in food insecurity research. American Journal of Public Health, 110(9), 1264.

18 Thorndike, A. N., Gardner, C. D., Kendrick, K. B., Seligman, H. K., Yaroch, A. L., Gomes, A. V., ... & American Heart Association Advocacy Coordinating Committee. (2022). Strengthening US food policies and programs to promote equity in nutrition security: a policy statement from the American Heart Association. Circulation, 145(24), e1077-e1093.

19 Expanding SNAP Online Purchasing Options | Food and Nutrition Service (usda.gov)

20 Ziso, D., Chun, O. K., & Puglisi, M. J. (2022). Increasing Access to Healthy Foods through Improving Food Environment: A Review of Mixed Methods Intervention Studies with Residents of Low-Income Communities. Nutrients, 14(11), 2278. (nih.gov)

21 Di Noia, J., Furst, G., Park, K., & Byrd-Bredbenner, C. (2013). Designing culturally sensitive dietary interventions for African Americans: review and recommendations. Nutrition reviews, 71(4), 224-238.

22 Child and Adolescent Health Measurement Initiative. 2022 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). NSCH 2022: Food insufficiency, Nationwide, Special health care needs status (childhealthdata.org)

23 Balistreri, K. S. (2019). Food insufficiency and children with special healthcare needs. Public Health, 167, 55-61.

24 Holley, C. E., & Mason, C. (2019). A systematic review of the evaluation of interventions to tackle children’s food insecurity. Current Nutrition Reports, 8, 11-27.

25 US Department of Health and Human Services (2022, September). Current Federal Programming and Coordination efforts Related to Food and Nutrition Insecurity and Diet-Related Diseases.

26 Di Noia, J., Monica, D., Sikorskii, A., & Nelson, J. (2021). Pilot study of a farm-to-special supplemental nutrition program for women, infants, and children (WIC) intervention promoting vegetable consumption. Journal of the Academy of Nutrition and Dietetics, 121(10), 2035-2045.

27 Morris, E. J., Quinn, E. L., Rose, C. M., Spiker, M., O’Leary, J., & Otten, J. J. (2022). Insights from Washington State’s COVID-19 response: A mixed-methods evaluation of WIC remote services and expanded food options using the RE-AIM framework. Journal of the Academy of Nutrition and Dietetics, 122(12), 2228-2242.

28 Ridberg, R. A., Levi, R., et al. (2022). Additional fruit and vegetable vouchers for pregnant WIC clients: an equity-focused strategy to improve food security and diet quality. Nutrients, 14(11), 2328.

29 Burke, M., Cabili, C., et al. (2021). A randomized controlled trial of three school meals and weekend food backpacks on food security in Virginia. Journal of the Academy of Nutrition and Dietetics, 121(1), S34-S45.

30 Marcus, M., & Yewell, K. G. (2022). The effect of free school meals on household food purchases: evidence from the community eligibility provision. Journal of Health Economics, 84, 102646.

31 Collins, A. M., Klerman, J. A., Briefel, R., Rowe, G., Gordon, A. R., Logan, C. W., ... & Bell, S. H. (2018). A summer nutrition benefit pilot program and low-income children’s food security. Pediatrics, 141(4).

32 Cullen, D., Blauch, A., Mirth, M., & Fein, J. (2019). Complete eats: summer meals offered by the emergency department for food insecurity. Pediatrics, 144(4).

33 Kersten, M., Carrazco, L., Rosing, H., Swenski, T., Russell, D., Idrovo, J., & Lofton, S. (2023). Evaluation of the grow your groceries home gardening program in Chicago, Illinois. Journal of Community Health, 48(2), 179-188.

34 Taniguchi, T., Haslam, A., Sun, W., Sisk, M., Hayman, J., & Jernigan, V. B. B. (2022). Impact of a farm-to-school nutrition and gardening intervention for Native American Families from the FRESH study: a randomized wait-list controlled trial. Nutrients, 14(13), 2601.

35 Hickey, E., Phan, M., Beck, A. F., Burkhardt, M. C., & Klein, M. D. (2020). A mixed-methods evaluation of a novel food pantry in a pediatric primary care center. Clinical Pediatrics, 59(3), 278-284.

36 Saxe-Custack, A., LaChance, J., Jess, J., & Hanna-Attisha, M. (2021). Influence of a pediatric fruit and vegetable prescription program on child dietary patterns and food security. Nutrients, 13(8), 2619.

37 Knowles, M., Khan, S., Palakshappa, D., Cahill, R., Kruger, E., Poserina, B. G., ... & Chilton, M. (2018). Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings. Journal of health care for the poor and underserved, 29(1), 181-191.

38 Seligman, H. K., & Berkowitz, S. A. (2019). Aligning programs and policies to support food security and public health goals in the United States. Annual review of public health, 40, 319-337.

39 Dailey, A., Davidson, K., Gaskin, K., Cooper, L., Schell, B., Gagliardi, Y., & Glahn, K. (2022). Responding to food insecurity and community crises through food policy council partnerships in a rural setting. Progress in Community Health Partnerships: Research, Education, and Action, 16(2), 39-44.

40 Bonnet, K. R., Adams, L. E., Popescu, F., Mahoney, M. R., & Barkin, S. L. (2023). Head Start’s Role in Addressing Food and Nutrition Insecurity: Focus Group Findings. Journal of Nutrition Education and Behavior, 55(8), 612-620.

41 Hawkins, M., & Panzera, A. (2021). Food insecurity: a key determinant of health. Archives of Psychiatric Nursing, 35(1), 113-117.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.