Nutrition

Strengthening US Food Policies and Programs to Promote Equity in Nutrition Security: A Policy Statement From the American Heart Association

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Nutritionally inadequate dietary intake is a leading contributor to the development of chronic cardiometabolic diseases.1,2 Food insecurity, a common cause of inadequate nutrition, is defined by the US Department of Agriculture (USDA) as a “household-level economic and social condition of limited or uncertain access to adequate food,”3 and it contributes to disparities in chronic disease outcomes, especially for cardiovascular diseases.4,5 Food insecurity has affected at least 1 in 10 US households since the 1990s.6 Although national data showed that the overall prevalence of food insecurity was stable during the COVID-19 (coronavirus disease 2019) pandemic in 2020 (10.5%) compared with 2019 (10.5%), households with children and Black households experienced statistically significant increases in food insecurity during 2020.7 In the United States, food security is measured using the USDA food security survey modules that assess a household’s ability to afford and access sufficient calories, but these measures do not robustly assess a household’s ability to afford and access sufficient nutritious food and consume a diet consistent with the US Dietary Guidelines for Americans.8–10 There is growing consensus that US food policies and programs should transition away from the current, somewhat narrow, term “food security” and toward the broader term “nutrition security” that includes having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease.10

A focus on nutrition security is critical for addressing socioeconomic and racial and ethnic disparities in nutrition and chronic disease.4,5 There is strong evidence that food insecurity is associated with obesity, diabetes, cardiovascular disease, and cancer.11–15 Worsening socioeconomic disparities in diet quality are increasingly recognized as drivers of chronic disease disparities.4,16 These associations are potentially mediated by chronic stress that results from experiencing food insecurity or other adverse social determinants of health and by poor dietary quality related to low consumption of nutritious food and overconsumption of energy-dense, nutrient-poor food.17

US national data on the prevalence of food insecurity fail to capture the number of Americans who are lacking in adequate nutrition because of low resources or who are nutrition insecure and at risk for nutrition-related chronic disease.18–20 Shifting from using the term food security to the term nutrition security would emphasize factors beyond availability, access, and affordability of food. Specifically, the United Nations Committee on Food Security identified 4 pillars of food security and nutrition to include not only availability and access (including affordability), but also utilization and stability of nutritious food over time.21

In this policy statement, we provide the scientific rationale for strengthening US food policies and programs to promote equity in nutrition security and reduce nutrition-related chronic disease disparities. We advocate for equitable and stable availability, access, affordability, and utilization of nutritious food for Americans who are at risk for or who are experiencing food insecurity. The Figure demonstrates the components needed to advance from food sufficiency and security to nutrition security that can help reduce disparities in chronic disease. Table 1 defines the food and nutrition terms used frequently throughout the policy statement. In this policy statement, we summarize and review the scientific evidence for current policies and programs designed to improve food security, and we conclude by proposing new or expanded policies and programs that will not only improve food security but will increase equity in nutrition security in the United States. Last, we recommend expanding the USDA measure of food security to include the metrics of nutrition security: availability, access, affordability, utilization, and stability of nutritious food.

Table 1. Definitions of Food and Nutrition Terms
Term Definition
Dietary quality A healthy overall dietary pattern of total foods and beverages consumed, including both adequacy and moderation, as outlined in the US Dietary Guidelines for Americans.9 Several metrics have been developed and validated to assess the overall quality of a dietary pattern in terms of nutritious food consumed (eg, Healthy Eating Index, Alternative Healthy Eating Index).
Food insecurity3 A household-level economic and social condition of limited or uncertain access to adequate food. Food insecurity includes the US Department of Agriculture definitions of low food security (report of reduced quality, variety, or desirability of diet with little or no reduced food intake) and very low food security (report of disrupted eating patterns and reduced food intake).
Food security3 Access by all members of a household at all times to enough food for an active, healthy life, which, at a minimum, includes availability of nutritionally adequate and safe foods. Food security includes the US Department of Agriculture definitions of high food security (no reported indications of food access problems or limitations) and marginal food security (anxiety over food sufficiency or shortage of food in the household but little or no indication of changes in diets or food intake).
Food sufficiency The minimum level of energy and nutrient intake necessary to support the basic functions of human life in the immediate time frame.
Hunger3 Individual-level physiological discomfort that may result from food insecurity.
Nutrient Nutrients include macronutrients (carbohydrates, fats, proteins, and their subtypes), micronutrients (vitamins and minerals), and dietary fiber.
Nutrition The interaction of nutrients and other components in food and beverages as they relate to growth, maintenance, reproduction, health, and disease; includes consumption, absorption, assimilation, metabolism, and excretion.
Nutrition security10 Having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease.
Nutritious food Food and beverages that provide adequate amounts of beneficial nutrients and minimal potentially harmful dietary components, in the context of avoiding excessive energy (calorie) intake.9 Nutritious foods include fruits, vegetables, whole grains, legumes and nuts, seafood, liquid plant-based oils, and low-fat dairy products. Foods should be minimally processed and low in added sugars, saturated fat, and sodium.9,22
Figure.

Figure. Moving from food sufficiency to nutrition security in the United States.

Components of Nutrition Security

Availability, Accessibility, and Affordability

The foundation of nutrition security is ensuring that nutritious foods are consistently available, accessible, and affordable (Figure).1,9,23 Availability means that every community must have sufficient quantity (calories) and appropriate quality (nutrients) of food. Accessibility means that nutritious foods are obtainable by individuals of all physical and mental conditions and in all geographic locations and that nutritious foods are acceptable and align with individuals’ cultural, social, or other dietary preferences.9,24 Affordability means that individuals have sufficient resources to acquire nutritious foods and that nutritious foods are available at a cost that can be purchased by all individuals.

The availability, accessibility, and affordability of nutritious foods is inequitable in the United States. Compared with those with a higher income, Americans with a lower income tend to have lower dietary quality and consume fewer vegetables, fruit, and whole grains and more refined grains, saturated fats, and added sugars.4,25 These differences are related to several individual, socioeconomic, environmental, and structural barriers, including individual knowledge, preferences, and skills; the higher cost of eating a nutritious diet;26 and variation in the built environment between communities.25–28 In 2015, 12.8% of the US population had both lower income and limited access to a grocery store, supermarket, or supercenter.27 Furthermore, individuals who lack access to nutritious foods tend to be from underrepresented racial and ethnic groups (eg, Black and Hispanic) and to be geographically centralized in specific parts of the United States (eg, the South).28–31 Communities of color are more likely than predominantly White communities to have a higher number of fast-food outlets and convenience stores and fewer grocery stores and supermarkets,32 and this is a strong predictor of obesity.33 Last, lack of transportation contributes to low access to grocery stores and supermarkets among people with low food security.34

Many current US policies and programs are designed to improve the availability of and access to affordable nutritious food. For example, the National School Lunch Program, School Breakfast Program, and Summer Food Service Program provide meals at low or no cost to millions of school-aged children throughout the year. However, other US policies impede the availability and access to affordable nutritious food, such as agricultural subsidies that contribute to a system of production, distribution, marketing, and demand that leads to lower cost of less nutritious food relative to more nutritious food.35,36 Changes to agricultural subsidies alone will be unlikely to produce significant changes in US population food availability or dietary intake. A sustained future effort to implement subsidies combined with other economic incentives and to expand commodity food programs will be needed to increase production, marketing, and delivery of nutritious foods and have a positive long-term effect on nutrition security.35,37

Utilization

To achieve nutrition security, food must not only be available, accessible, and affordable, but people must also be able to utilize the food. Utilization includes all steps that occur between the time of access to food to the time when the nutrients from food are available to be used by the body. One of the common domains is physiological utilization. Maximizing physiological utilization of nutrients consumed requires adequate health for chewing, digesting, absorbing, and distributing nutrients.38–42 However, there are many steps that occur before consumption that affect successful utilization. These include proper food storage, preparation, and distribution within the household. Regarding food storage, many perishable foods require refrigeration, but others require dry spaces and containers for preventing exposure to moisture, contaminants, or pests. Regarding preparation, individuals who do not have access to proper food preparation tools and kitchen equipment, who have low nutrition knowledge or culinary literacy and skills, or who have limited time because of work or other responsibilities, are more likely to have compromised utilization and lower nutrition security.38,39,41,43–46 Although there is an abundance of pre-prepared foods available in the United States that offer time-saving convenience, many are ultra-processed and provide little nutrition. Many foods with high nutritional value, such as vegetables, grains, and legumes, usually require some preparation by using basic kitchen tools (eg, cutting knives and boards, pots and pans, measuring cups and spoons, can opener) and kitchen equipment (eg, stove, oven)47; pre-preparation of healthy foods (eg, precut vegetables) could improve utilization if access to basic tools and equipment is limited, but this would further increase their price. Other important factors affecting food utilization are differences in intrahousehold distribution that can result in inadequate utilization of food by one or more members of the household.39,40 Among older adults, social isolation, lack of social support, and decreased mobility can have an adverse effect on the utilization and intake of healthy food.48–50 Social stigma related to poverty, race, and ethnicity can also affect the utilization of food assistance programs and consumption of a nutritious diet by influencing individual and structural factors, such as program participation, discrimination, and targeted marketing practices.51,52

Stability

Nutrition security requires stability of a nutritious diet across the life course, ensuring that all people have availability, accessibility, affordability, and utilization of nutritious food at all ages. The 2020 to 2025 US Dietary Guidelines recognizes the importance of stability by emphasizing continuity in healthy eating patterns at every stage of life.9 Although current US food policies and programs help to ensure stable access to nutritious food for many individuals, numerous gaps exist within and between these programs that create barriers to nutrition stability. For example, access to federal nutrition assistance programs can vary by time (eg, month, season) and eligibility limitations. In the Supplemental Nutrition Assistance Program (SNAP), the largest US federal food assistance program, states are required to issue benefits to eligible households once a month. There is evidence that many families spend most of their benefits in the first week of receipt, running out of SNAP benefits at the end of the month.53 Other research has shown that losing access to SNAP benefits in the past year was associated with higher odds of having very low food security, suggesting that many families are not able to access the longer-term SNAP benefits they need.54

There are also gaps in children’s access to food assistance programs that reduce their nutrition stability. Rates of food insecurity among children are higher in the summer, a time when children do not have access to the National School Lunch Program and School Breakfast Program.55 Although the Summer Food Service Program and Seamless Summer Option aim to close this nutrition gap, lack of transportation and complex program rules can be barriers to participation.56 Last, age-eligibility rules for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) create a gap in food and nutrition programs for some children when they turn 5 years old and become age-ineligible for WIC but have not yet entered kindergarten and gained access to free or reduced-priced school meals.57 Although immigrant families are eligible for WIC,58 they are often ineligible for SNAP,59 thus creating a larger gap in access to food and nutrition programs for these families. Hence, achieving nutrition stability for all Americans will require more coordinated efforts across federal, state, community, and private sector programs.53

Nutrition stability also depends on maximizing the utilization of nutritious foods across the life course, which can be supported by nutrition education, and policy, systems, and environmental approaches, as well.60 Although nutrition is important at every stage of life, early childhood is especially important because it provides an opportunity for developing long-term healthy eating habits that track into adulthood.61 Two of the leading federally funded programs focusing on nutrition education among families, WIC and Head Start, provide health education to families with young children, but families are no longer eligible for these programs when children turn 5 years old.62,63 For older children, the proportion of schools providing education on nutrition and dietary behaviors decreased from 84.6% to 74.1% between 2000 and 2014.64 The Expanded Food and Nutrition Education Program and the SNAP Education program are federally funded, community-based programs that provide education about nutrition topics, including dietary practice and management, food resource management, and food security. SNAP Education funding can also be used to implement policy, systems, and environmental approaches.60 A systematic review of the effect of these programs on nutrition-related outcomes found that they were effective for improving immediate behavior change to improve consumption of nutritious food but that maintenance of these behaviors over time was poor.65 Population-based educational approaches, such as nutrition labeling and media campaigns, are effective for improving healthy food choices and could potentially expand the reach of nutrition education beyond intensive individual-based programs.35

Policies and Programs to Achieve Nutrition Security in the United States

US nutrition-related policies and programs are critical to ensuring nutrition security in the United States, but gaps remain. Future efforts are needed to improve the reach and sustainability of federal, state, and community policies and programs, while maintaining equity and dignity of participants. Table 2 provides descriptions of some of the US nutrition policies and programs with the largest reach, their potential effect on nutrition security, and recommendations based on existing evidence and expert consensus of the authors for strategies that could increase their impact on nutrition security.

Table 2. US Nutrition Policies and Programs and Recommendations to Increase Impact on Nutrition Security
Nutrition program Funding source and administration66 Population Program description and effect on nutrition security Recommendations to increase effect on nutrition security
Adults, families, and children
  SNAP Federal funding through the Farm Bill
Administered by USDA FNS		 Households with low income without substantial assets (eg, monthly cash income <130% of the FPL)
Puerto Rico, American Samoa, and the Commonwealth of the Northern Mariana Islands receive block grant programs to operate programs similar to SNAP.		 Program description: Monthly cash value on EBT card that can be exchanged for any food (except prepared foods intended for on-site consumption) at SNAP-authorized retailers.
Impact on nutrition security: Expansion of household food budget increases quality of food purchases overall.		 Incentivize nutritious food purchases (eg, subsidize fruit and vegetable purchases) and disincentivize sugary beverages and other foods, such as junk food and processed meats.67–71 Strengthen requirements for SNAP-authorized retailers to stock and market healthy foods.53 Maintain benefit levels to help cover the cost of a nutritious diet, such as the October 2021 changes to the Thrifty Food Plan.72 Make permanent the recent expansion during the COVID-19 pandemic of online SNAP purchasing.
  SNAP-Ed Federal funding through the Farm Bill
Administered by USDA FNS		 Households participating in the SNAP program
Low-income communities
Low-income individuals eligible for SNAP benefits or other federal programs, such as Medicaid or Temporary Assistance for Needy Families		 Program description: Offers SNAP participants support in shopping and cooking healthy food on a budget. Provides some communities with the opportunity to implement policy, systems, and environmental approaches for healthier food choices and consumption.73 Impact on nutrition security: Provides SNAP participants and communities with tools to improve nutritional knowledge and skills that contribute to increased use and stability of healthy food.74 Expand opportunities for communities to implement policy, systems, and environmental approaches to support healthier shopping and cooking.
Increase funding to improve reach.
  FDPIR Federal funding legislated through the Farm Bill
Administered by USDA FNS and Tribal governments		 Households with low income living on American Indian reservations and Tribal households living near reservations; eligibility restricted to households not enrolled in SNAP
Eligibility requirements are similar to SNAP.		 Program description: Monthly food package with both fresh and frozen meat, fruits and vegetables, grains, and other foods, including some selected traditional foods; includes perishable and nonperishable items.
Impact on nutrition security: Continued efforts to improve the quality of included foods will better support nutrition security.75		 Expand inclusion of more traditional foods and Native-produced foods.
Expand opportunities for Tribal self-government administration and decisions about procurement, especially from Native food producers.75 Allow Native households to use both FDPIR and SNAP in the same month.
  TEFAP Federal funding legislated through the Farm Bill
Administered by USDA FNS and food banks		 Households with low income that meet state eligibility criteria Program description: Provides commodity foods for distribution through the state and local charitable food systems.
Impact on nutrition security: Recent efforts to increase the nutritious foods provided by TEFAP may increase nutrition security.		 Assess and communicate the nutritional value of TEFAP foods to charitable food partners using appropriate standards, such as the HER Nutrition Guidelines for the Charitable Food System.76 Expand options to include more culturally appropriate foods.
 Charitable Food System Federal, state, and local funding. Federal resources provided through TEFAP and the CSFP
Administered by community-based nonprofit organizations
Private monetary and food donations and grant funding administered by food banks and other community-based organizations		 Adults and children experiencing food insecurity Program description: Food banks and community agencies (eg, food pantries, meal programs) obtain and distribute food to people experiencing food insecurity.
Impact on nutrition security: Efforts to improve the nutritional quality of the food that moves throughout the system may increase nutrition security.		 Provide federal support to assess and communicate the nutritional value of food as it travels from donor to client using appropriate standards, such as the HER Nutrition Guidelines for the Charitable Food System.76 Provide federal support to implement programs to treat chronic disease (eg, type 2 diabetes), such as medically tailored food boxes.77
  CACFP Federal funding through CNR provided by grants to states
Administered by USDA FNS and state agencies; operated by childcare, afterschool, adult care, and emergency shelters		 Children participating in childcare and afterschool programs; adults ≥60 y of age, or persons living with chronic disabilities Program description: Provides reimbursement for meals and snacks in early care and education facilities (centers and homes), afterschool programs, adult care, and emergency shelters. In 2017, the USDA updated CACFP meal pattern standards.78 Impact on nutrition security: Participation in CACFP may improve the dietary quality of meals and snacks served.79–82 Simplify the application process and reduce the administrative burden for sponsors and sites.
Increase the value of reimbursements.
Incentivize regulatory authorities and state agencies to identify and reduce barriers to sites’ participation in the program.
Provide technical assistance, additional funding, and ongoing assessment to ensure that the implementation of the CACFP nutrition standards results in meals aligned with the DGA for children and adults.83
  EFNEP Federal funding through the Farm Bill
Administered by USDA NIFA to land grant institutions		 Low-income adults and children Program description: Nutrition education provided to adults through a series of lessons or to children as part of afterschool, camp, or community-based programs.84 Impact on nutrition security: Improvement in dietary intake and knowledge of food preparation, resource management, and safety.85,86 Expand the program to increase reach of nutrition education to more adults and children.
Provide longer-term programs to improve stability of nutrition behaviors over time.65
  GusNIP (Formerly known as FINI) Federal grants legislated through the Farm Bill
Administered by NIFA to nonprofit organizations		 Low-income adults and their families
Nutrition incentive programs are for SNAP participants
Produce prescription programs are for individuals with low income and food insecurity and often for those with diet-related chronic disease (type 2 diabetes)		 Program description: Provides competitive grants for programs that incentivize purchase of fruits and vegetables at the point of purchase.
Impact on nutrition security: Funded projects aim to increase purchases and intake of fruits and vegetables.87–90		 Provide sustained funding for the program in the next Farm Bill.
Decrease or eliminate match requirement for Nutrition Incentive grants in next Farm Bill.
Augment and coordinate federal funding with state, local, or private funding.
Adapt program rules based on research findings.
 Medicaid Federal regulatory processes and state 1115 waivers
Administered by state Medicaid programs		 Medicaid participants Program description: Some states with waivers have used Medicaid funding for programs to reduce food insecurity.
Impact on nutrition security: Medically tailored meals could improve nutrition security of specific patient populations.91,92		 Provide CMS funding to improve nutrition through specific interventions (eg, medically tailored meals or groceries, produce prescriptions) to prevent and treat chronic disease.77,92,93 Expand reach by integrating funding into standard Medicaid services rather than requiring a waiver.
Children and pregnant or postpartum women
  WIC Federal funding through CNR
Administered by states through block grants from USDA FNS		 Pregnant, postpartum, and breastfeeding women, infants, and children up to 5 y of age living in a household with income at or below 185% of the FPL Program description: EBT card allows for purchases of specific food items in specific quantities that align with the DGA (eg, cereal with ≤6 g sugar per dry ounce). The program also provides nutrition education, breastfeeding support, and health care referrals.
Impact on nutrition security: Benefits can only be used to purchase nutritious foods, and nutrition education and breastfeeding support may also improve nutrition security.62		 Extend eligibility for children through 6 y of age to address the gap in nutrition assistance before entering kindergarten.57 Permit states the option to certify infants for 2 y instead of 1 y.94 Extend eligibility for postpartum women to 2 y.94 Make permanent the increase in cash value voucher for fruits and vegetables from $9 per mo for kids and $11 per mo for adults to $35 per mo for each child and adult.94 Include more options for traditional and first foods for Native American participants.95
 Head Start program Many programs supported by federal funding through the US Department of Health and Human Services
Administered by the Office of Administration for Children and Families		 Children from birth to 5 y of age living in a household at or below 100% of the FPL
Program offered in American Indian and Alaska Native communities and to migrant families engaged in agricultural labor		 Program description: Comprehensive program to support children’s early learning and development and health and families’ well-being.
Impact on nutrition security: Provides nutrition assessments, education, and counseling to children and their families; provides meals and snacks to Head Start classes.96,97		 Increase funding so that Head Start is available to all eligible children.
  NSLP Federal funding through CNR; some states provide additional funding
Administered by USDA FNS, state agencies, and local school food authorities		 All students in participating schools who meet eligibility thresholds can participate in NSLP
Children with household income <130% of the FPL are eligible for free lunch
Children with household income between 130% and 185% of the FPL are eligible for reduced-priced lunch
Schools with ≥40% of students eligible for free meals can offer free meals to all students		 Program description: Provides fully or partially subsidized lunch for children at school (kindergarten through 12th grade, including preschool children if the program is offered in a school).
Impact on nutrition security: Because school lunches must meet federal nutrition standards and the average school meal is more nutritious and less caloric than the average meal packed from home,98 the NSLP likely improves nutrition security.99,100		 Protect and strengthen nutrition standards for foods sold as part of the school lunch (eg, return to the 100% whole-grain rich standard for grains; establish a sodium reduction schedule and add a new sodium target to align with the DRI; remove 1% flavored milk; and establish added sugars standards).
Strengthen the nutrition standards for Smart Snacks (ie, foods and beverages sold outside the school meal programs)‚ including the addition of an added sugars standard.
Increase federal reimbursement rates.
Provide technical assistance, additional funding, and ongoing assessment to ensure that the implementation of the NSLP nutrition standards results in meals aligned with the DGA for children.
Expand access to all children through universal free meals (ie, as passed in California and Maine).101,102
  SBP Federal funding through CNR
Administered by the USDA FNS, state agencies, and local school food authorities		 Similar to NSLP Program description: Provides fully or partially subsidized breakfast for children at school (kindergarten through 12th grade, including preschool children if the program is offered in a school).
Impact on nutrition security: Because school breakfasts must meet federal nutrition standards, SBP likely improves nutrition security.103		 Increase federal reimbursement rates.
Protect and strengthen the nutrition standards, including the addition of an added sugars standard.
Provide technical assistance, additional funding, and ongoing assessment to ensure that the implementation of the SBP nutrition standards results in meals aligned with the DGA for children.
Expand access to all children through universal free meals (ie, as passed in California and Maine).101,102 Support strategies to increase participation (eg, breakfast after the bell, grab and go).104
 SFSP Federal funding through CNR
Administered by USDA FNS, states, local food service authorities, and local private and nonprofit service institutions		 Children ≤18 y of age and certain individuals with disabilities >18 y of age in communities, activities, or camps where at least half of children are from households with incomes <185% of the FPL Program description: Provides free meals and snacks to low-income children and some adults with disabilities when school is closed.
Impact on nutrition security: SFSP likely improves nutrition stability because it is offered to children who rely on the NSLP and SBP during the school year.105–107		 Simplify the application process to reduce the administrative burden for sponsors and sites.
Align nutrition standards with the DGA to be consistent with the SBP and NSLP.
Supplement the SFSP by expanding the Summer-EBT pilot and making the program permanent.
Expand access to all children through universal free meals.
Study whether the pandemic waivers should be maintained to improve participation (eg, noncongregate meals, distributing multiple meals at once).
  SSO Federal funding through CNR. Some states provide additional funding
Administered by USDA FNS, state agencies, and local school food authorities		 Same as NSLP/SBP Program description: Provides free meals and snacks to low-income children when school is closed. Allows schools that offer NSLP and SBP to continue meal service over the summer without a gap.
Impact on nutrition security: SSO offers stability to children who rely on school meals during the school year, and it uses the same nutrition standards as NSLP and SBP with additional flexibility granted in some circumstances.106,107		 Increase reimbursement rate to align with SFSP.
  FFVP Federal funding through CNR. Some states provide additional funding
Administered by USDA FNS, state agencies, and local school food authorities		 Elementary school children attending schools with the highest percentage of students with free and reduced-priced benefits, participate in the NSLP, and complete an application for the FFVP. Program description: Provides children with access to free fresh fruits and vegetables outside of meals.
Impact on nutrition security: Increases consumption of fruits and vegetables by children in participating schools.108		 Expand funding for the program to support serving fruits and vegetables more frequently.
Expand the program to more schools and age groups.
Older adults
  CSFP Federal funding legislated through the Farm Bill
Administered by the charitable food system		 Adults ≥60 y of age with incomes <130% of the FPL Program description: Provides monthly box of commodity foods for pickup at a local food bank (or food bank distribution site), or sometimes for home delivery.
Impact on nutrition security: Because of recent efforts to increase the nutrient quality of CSFP foods, this program likely improves nutrition security.		 Assess and communicate the nutritional value of CSFP foods to partners using appropriate standards such as the HER Nutrition Guidelines for the Charitable Food System.67 Expand options to include more culturally appropriate foods.
Expand access to the program to reduce lengthy waitlists.
 Meals on Wheels Federal funding through the OAA and state and local sources, private donations from foundations, corporations and individuals, and federal block grants
Administered through state and local agencies		 Adults ≥60 y of age, their spouses and caregivers, and adults <60 y of age who are homebound; recipients are unable to prepare or afford nutritious meals
Eligibility may vary by county or program		 Program description: Home delivery of daily nutritious meals
Impact on nutrition security: Provides stable and affordable access to nutritious meals.109		 Increase federal funding for the program through OAA to expand access to all eligible older adults by reducing lengthy waitlists and eliminating meal costs.
Expand options to include more culturally appropriate food.
  SFMNP Federal funding legislated through the Farm Bill
Administered through USDA FNS and state and Indian Tribal Organization agencies		 Older adults who are at least 60 y of age and have household incomes ≤185% of the FPL
In some states, older adults ≥60 y of age who participate in CSFP or SNAP		 Program description: Monthly coupons that can be exchanged for eligible foods at farmers’ markets, roadside stands, and community- supported agriculture programs.
Impact on nutrition security: Increases access to and consumption of fruits and vegetables among older adults.110		 Expand funding for the program in the next Farm Bill.
Simplify the application and authorization process to reduce administrative burden on state agencies.

Federal Food Assistance and Competitive Funding

The Agricultural Improvement Act of 2018 (known colloquially as the Farm Bill) included $428 billion in federal funding over 5 years.111 About three-quarters of this money was targeted for federal food and nutrition assistance programs. SNAP, WIC, and the Food Distribution Program on Indian Reservations provide essential financial resources to assist households with the quantity of food purchased but, with the exception of WIC, do not focus on the nutritional quality of food purchased. Federal school-based programs (eg, National School Lunch Program and School Breakfast Program) provide free or low-cost meals for children from lower-income families. Approximately 30 million school-aged children participated in National School Lunch Program and >14 million participated in School Breakfast Program in 2019.112,113 The Child and Acute Care Food Program provides reimbursement for meals and snacks in early care and education facilities (centers and homes), afterschool programs, adult care, and emergency shelters.78 Improved nutrition standards in recent years, such as the Healthy Hunger Free Kids Act, have contributed to better nutrition security for children.99,100,114 Programs for older adults include the Commodity Supplemental Food Program, Meals on Wheels, and the Senior Farmers’ Market Nutrition Program. Nutrition education programs supported by federal funding, such as WIC, SNAP Education, and Head Start, provide important resources for developing nutrition knowledge and skills, but the reach of these programs is limited by age restrictions and low participation rates.115 Thus, food assistance programs vary in their capacity to meet the nutritional needs of the people who rely on them. Each of them, however, provides an important opportunity to support nutrition security for a large number of Americans at all stages throughout the life course.

In 2008, federal legislation through the Farm Bill began authorizing funds for projects to explore the use of financial incentives to increase the purchase and consumption of nutritious food. The most common are SNAP incentive programs that provide financial incentives for choosing fruits and vegetables at the point of purchase (eg, farmers markets, grocery stores). The first incentive program to be evaluated was the USDA-funded Healthy Incentives Pilot (HIP)‚ a randomized controlled trial conducted in Hamden County, Massachusetts, that compared SNAP participants receiving HIP incentives with those not receiving incentives. Participants who received HIP incentives purchased and consumed more fruits and vegetables than the participants who did not receive HIP incentives.67 Other studies enrolling low-income adults have demonstrated the effectiveness of supermarket fruit and vegetable incentives,69,70 and one demonstrated the benefit of adding a sugar-sweetened beverage disincentive.68

The success of the HIP program led to the Food Insecurity Nutrition Incentive, authorized through the 2014 Farm Bill, which included $100 million over 5 years for competitive grants for SNAP incentives, but required 1:1 nonfederal match funding. In the 2018 Farm Bill, Food Insecurity Nutrition Incentive was renamed the Gus Schumacher Nutrition Incentive Program and allocated $250 million over 5 years for 2 incentive types of programs: nutrition incentives (requiring 1:1 nonfederal match) for SNAP participants and produce prescriptions (which do not require match) and are not specific to SNAP participants. Preliminary research suggests that these programs increase consumption of fruit and vegetables and improve food security in both children and adults.88–90

Charitable Food System

The charitable food system in the United States comprises food banks (organizations with large warehouses that source and distribute food to community agencies), food pantries (community sites where clients acquire groceries at no cost to prepare meals at home), and meal programs (dining rooms that provide prepared meals at no cost).116 More than 200 food banks and 60 000 partnering community agencies are affiliated with the nationwide network Feeding America.117 The food distributed through this network comes from several sources. Approximately 25% of food is purchased with federal funding and given to states to distribute through The Emergency Food Assistance Program and the Commodity Supplemental Food Program. More than 60% of food is donated by food growers, distributors, retailers, and community food drives, and the remaining food is purchased by food banks with donated funds or grants.

Until recently, incentives for food banks and food pantries to address nutrition have been limited by their primary metric of success: number of pounds of food distributed.118 This system rewards the distribution of inexpensive, energy-dense, nutrient-poor calories. However, with evidence that the charitable food system has become a regular source of food for chronically food-insecure households,119 and with feedback from clients that they prefer healthier foods,120 some organizations have shifted from exclusive metrics of food quantity to include metrics of food quality.121 In response, many stakeholders, including Feeding America, have engaged in efforts to realign incentives to support nutrition security and promote nutrition-focused food banking.122

Recently, Robert Wood Johnson Foundation’s Healthy Eating Research Program convened an expert panel and released a nutrition-ranking system tailored to the unique context of the charitable food network.76 This system categorizes foods as green (choose often), yellow (choose sometimes), and red (choose rarely), and there are multiple opportunities to use this information to support nutrition security. For example, the USDA could incorporate these standards when establishing the specifications for the foods they purchase for The Emergency Food Assistance Program and the Commodity Supplemental Food Program, and retail food donors could use them to select which foods to donate. Food banks can use nutrition ranking to guide purchasing decisions and may choose to formalize this process through a nutrition policy. Research suggests that when food pantry directors see the nutrition rankings at the food bank, they select healthier options123; when food pantries implement nutrition ranking, their inventory improves over time124; and when food pantry clients see nutrition rankings, they select healthier foods.125 A range of behavioral economic interventions in food pantries can promote nutritious food choices,126,127 and for specific high-risk populations, such as people with type 2 diabetes, food boxes in pantries can be tailored to meet their nutritional needs.128

Health Care Integration

It is widely recognized that the United States, compared with other developed nations, spends more money on health care and relatively less money on social services.129 There are opportunities, however, to incentivize and support health care systems and insurers to engage in efforts to address the social determinants of health with the goals of more effective primary prevention (prevention of chronic disease among those at high risk) and secondary prevention (prevention of complications among those with chronic disease). Nutrition security is a key social determinant of health for cardiovascular disease risk and chronic disease prevention.4,15

Conceptually, health care integration is based on the supposition that patients experiencing food insecurity can be identified in the clinical setting by using a screening test (eg, the Hunger Vital Sign) and then referred to a program supporting improved access to nutritious food, and that the resulting improvements in dietary intake and food security will have the downstream effect of improved clinical satisfaction and improved health outcomes.130 In response, numerous new programs, policies, and initiatives seeking to engage the health care system in efforts to bring more nutritious foods to specific patient populations, often referred to as food as medicine, have been implemented.131 For example, the Gus Schumacher Nutrition Incentive Program produce prescription projects allow clinicians to write prescriptions for fresh fruits and vegetables (or benefits redeemable for fresh fruits and vegetables).87 The patient populations targeted in these interventions are heterogeneous, spanning primary prevention (eg, patients at high risk of developing type 2 diabetes) to secondary prevention (eg, patients with diabetes). In all cases, these interventions give clinicians in the health care system tools to advance nutrition security, in addition to more traditional approaches using medications and behavioral counseling.

The Centers for Medicaid & Medicare Services and many health care organizations have started piloting programs to integrate the provision of food assistance and medically tailored meals into clinical care. Medicaid has supported state innovation and experimentation in addressing food insecurity through regulatory processes and waivers based on Section 1115 of the Social Security Act that allow states to implement pilot and demonstration projects designed to promote the goals of Medicaid.132 For example, in some states, health systems can support Medicaid participants experiencing food insecurity to connect with community-based organizations (such as home-delivered medically tailored meals) or federal programs (such as SNAP). The Accountable Health Communities model also sought to connect Medicare and Medicaid patients experiencing unmet social needs, including food insecurity, to community and federal resources.133,134 Since implementation of the Affordable Care Act, community nutrition programs have been eligible for community benefit grants from local nonprofit hospitals that seek federal tax–exempt status. To the extent that these programs increase access to nutritious foods, not just access to calories, they can simultaneously support nutrition security.

Community-based organizations, including medically tailored meal providers, food banks, and fruits and vegetable voucher programs, have sought to demonstrate the positive impact of their programs on dietary intake, health outcomes, and health care costs.135 These efforts have been driven by a desire for increased financial support from the health care sector and recognition of the potential financial benefits of a healthier and more nutrition-secure population. There is a limited body of evidence demonstrating that targeted health care interventions to address food insecurity improve dietary quality and some health outcomes,77,91,92,136 but more research is needed to understand the long-term effect of these programs on health and medical spending.

Nutrition Policies and the Covid-19 Pandemic

The sharp rise in food insecurity during the first several months of the COVID-19 pandemic exposed both strengths and weaknesses in existing US nutrition-related policies and programs. Starting in April 2020, many families experienced food insecurity for the first time, joining the millions of other households that had been food insecure before the pandemic, and these effects were largest in underrepresented racial and ethnic groups.137 In response to the crisis, the federal government quickly pivoted to increase benefits and reduce barriers to the SNAP and WIC programs and to implement the Pandemic Electronic Benefits program for states to provide additional funds to families with children to compensate for the loss of school meals.138,139 USDA also authorized waivers and flexibilities to make sure school meals were safe and available, including allowing schools to serve free meals to respond to the changing nature of the COVID pandemic. The charitable food system mobilized emergency food distribution sites, working with communities and schools to meet the needs of families.137

During a crisis such as a pandemic, equitable access to any food (ie, food sufficiency) is prioritized. However, as the crisis abates and emergency programs may be discontinued, it remains important to continue focusing on expansion and innovation of current and new policies and programs that will provide consistent and equitable availability, access, affordability, and utilization of nutritious food. In October 2021, the Thrifty Food Plan, which is used to determine the amount of SNAP benefits, was changed to more realistically estimate the cost of a nutritious meal.140 This resulted in an ≈20% change in benefit levels for SNAP recipients, an important step toward achieving equity in nutrition security. Furthermore, 46 states and the District of Columbia were approved to participate in the SNAP Online Purchasing Pilot expansion in October 2020 to improve access to online grocery shopping and delivery among SNAP participants.141

Overarching Principles and Specific Policy Recommendations to Improve Nutrition Security

Our recommendations for improving nutrition security in the United States were guided by several overarching principles for food assistance programs and policies (Table 3). These principles focus on emphasizing nutritional quality, improving reach, ensuring optimal utilization, improving coordination across different programs,53 ensuring stability of access to food assistance programs across the life course, and ensuring equity and dignity for access and utilization. For example, these principles could be applied in the charitable food system to improve nutrition security by having food pantries coordinate with job-training programs and other social services, providing healthy food choices, and allowing clients to select their own food to create a more dignified and equitable experience.118

Table 3. Overarching Principles for US Food Assistance Policies and Programs to Achieve Nutrition Security for All Americans
Principles for food assistance programs to achieve nutrition security
Ensure nutritional quality by emphasizing nutrition standards.
Improve reach by increasing outreach and simplifying enrollment and certification procedures.
Ensure optimal utilization by all participants.
Improve coordination across different programs.53,118
Ensure stability of access to programs across the life course, avoiding gaps in coverage for age groups.
Ensure equity for stable availability, access, affordability, and utilization, including the provision of acceptable foods aligned with cultural, social, and dietary preferences.
Ensure dignity by reducing stigma associated with participation.51
Develop and implement a national measure of nutrition security, expanding the USDA food security screening tool.

A critical next step to guide future US food policies and programs will be to develop and implement national measures of nutrition security. New modules could be added to the USDA food security screening tool to include questions about a household’s ability to utilize and consistently access nutritious food, such as fruits and vegetables, among all age groups. No standard measures of nutrition security currently exist, but a combined assessment of food insecurity and dietary quality appears to be a straightforward approach. However, assessing dietary quality has a myriad of challenges. For instance, gold standard measures (eg, 24-hour dietary recalls, food frequency questionnaires) tend to be burdensome and expensive, whereas briefer measures (eg, dietary screeners) are less specific and tend to be less rigorous, especially regarding validity and reliability.142 Research to develop and validate questions to assess nutrition security is needed. In the future, these questions could be integrated into national surveys, such as the Centers for Disease Control and Prevention’s National Health and Nutrition Survey, to monitor progress in achieving equity in nutrition security.

Conclusion

This policy statement highlights opportunities in current and future food assistance policies and programs to improve equity in nutrition security in the United States. Shifting from a narrower focus on providing food with sufficient calories to a broader focus on providing equitable and stable availability, access, affordability, and utilization of food with sufficient nutritional quality, consistent with the US Dietary Guidelines for Americans, over the life course, will ensure that all Americans have the opportunity to consume food that will prevent chronic disease. Moving in this direction will require coordinated and sustained efforts at the federal, state, and local levels. Future advocacy, innovation, and research will be needed to expand and strengthen existing policies and programs and to develop and implement new policies and programs that improve nutrition and health and reduce socioeconomic and racial and ethnic disparities in chronic disease.

Disclosures

Writing Group Disclosures
Writing group member Employment Research grant Other research support Speakers’ bureau/
honoraria		 Expert witness Ownership interest Consultant/advisory board Other
Anne N. Thorndike Massachusetts General Hospital NIH/NIDDK†; Greater Boston Food Bank*; NIH/NCI† None None None None None None
Christopher D. Gardner Stanford University None None None None None None None
Katherine Bishop Kendrick American Heart Association None None None None None None None
Caree Jackson Cotwright University of Georgia RWJF Healthy Eating Research† None None NIH/NHBLI* None Hand, Heart, Soul Project*; UNC Chapel Hill Child Weight Laboratory* None
Aldrin V. Gomes University of California, Davis None None None None None None None
Kendra N. Ivy Morehouse School of Medicine None None None None None None None
Stephanie Scarmo American Heart Association None None None None None None None
Marlene B. Schwartz University of Connecticut None None None None None None None
Hilary K. Seligman University of California San Francisco NIH†; CDC†; USDA through Gretchen Swanson Center for Nutrition†; multiple other grants† None None None None None Feeding America†
Amy L. Yaroch Gretchen Swanson Center for Nutrition None None None None None None None

Reviewer Disclosures
Reviewer Employment Research grant Other research support Speakers’ bureau/honoraria Expert witness Ownership interest Consultant/advisory board Other
Leah E. Cahill Dalhousie University (Canada) None None None None None None None
Shufa Du The University of North Carolina at Chapel Hill None None None None None None None
Kim Gans University of Connecticut None None None None None None None
Lorrene D. Ritchie University of California, Division of Agriculture and Natural Resources Child and Adult Care Food Program Roundtable (Purpose of project is to evaluate barriers to CACFP participation by independent childcare centers and inform the CDSS as CACFP administration transitions from the CA Dept. of Education)*; David and Lucile Packard Foundation (Purpose of the project is to evaluate participant perceptions of WIC services in 12 states during the COVID-19 pandemic to support efforts to increase participation and support retention on WIC)†; Westat/USDA (Purpose of the project is to determine prospectively the ongoing impact of WIC participation early in life on subsequent child nutrition and weight status)*; PHFE-WIC/CA Dept of Public Health (Conduct a qualitative study of WIC participants in Central and Northern California to inform improvements to WIC during and after COVID)* None None None None None None
Maurizio Trevisan The City College of New York None None None None None None None

Article Information

Acknowledgment

We would like to thank Mr Colby Duren for contributing to an early draft of this manuscript when he was serving at the Intertribal Agriculture Council as director of Policy and Government Relations.

Footnotes

Circulation is available at www.ahajournals.org/journal/circ

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Advocacy Coordinating Committee on February 25, 2022, and the American Heart Association Executive Committee on February 25, 2022. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email .

The American Heart Association requests that this document be cited as follows: Thorndike AN, Gardner CD, Bishop Kendrick K, Seligman HK, Yaroch AL, Gomes AV, Ivy KN, Scarmo S, Cotwright CJ, Schwartz MB; on behalf of the American Heart Association Advocacy Coordinating Committee. Strengthening US food policies and programs to promote equity in nutrition security: a policy statement from the American Heart Association. Circulation. 2022;145:e1077–e1093. doi: 10.1161/CIR.0000000000001072

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”

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