Development and validation of a brief Nutrition Security Screener (NSS) for clinical and public health settings

Nutrition security encompasses access, availability, and affordability of foods that support well-being and prevent and manage diet-related conditions. Although food security is widely studied, validated nutrition security measures are not yet widespread, highlighting a critical gap in clinical and public health research and practice.

This study aims to validate a brief Nutrition Security Screener (NSS) in the United States.

The NSS was refined in pilot studies and implemented in 5 diverse populations, totaling 20,523 adults. Two items assessed the presence and severity of nutrition insecurity (NI) and 13 corresponding barriers. Multivariable logistic regression models and pooled analyses examined distributions and associations of NI with food insecurity (FI), sociodemographic characteristics, and health.

Across county, state, and national levels, NI prevalence ranged 18%-44% and varied by sociodemographic characteristics. About 60% of young adults reported NI, compared with 13% of older adults. NI was most prevalent among Hispanic/Latinx (26%-62%) compared with White (10%-40%) adults and those with the lowest (49%-65%) compared with the highest (3%-13%) income. NI only moderately correlated with FI measured by The Hunger Vital Sign (r = 0.55-0.63) and 6-item United States Department of Agriculture Module (r = 0.38-0.46), with discordance in 10%-28% of respondents. Adjusting for sociodemographic characteristics and FI, NI was independently associated with diabetes {odds ratio (OR) = 1.46 [95% confidence interval (CI): 1.19, 1.79]}, obesity [OR = 1.42 (1.19, 1.70)], hypertension [OR = 1.34 (1.13, 1.59)], hypercholesterolemia [OR = 1.34 (1.11, 1.61)], heart disease [OR = 1.39 (1.05, 1.85)], and stroke [OR = 2.03 (1.08, 3.83)], but not cancer [OR = 0.98 (0.62, 1.54)]. Common barriers were expense (75%-81%), cultural or traditional foods being unhealthy (47%-75%), and limited access to healthy choices (47%-53%). Affirming more barriers was associated with higher odds of all health outcomes except cancer.

A brief NSS enables assessment of NI prevalence and barriers to healthy eating in diverse populations, and is independently associated with diet-related disease, informing clinical, public health, and policy efforts to screen for and address NI.