Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science

Nutrition plays a vital role in health promotion and chronic disease prevention throughout the life course. Although dietary behaviors are influenced by many factors, where we live and how much money we make can affect our ability to access or afford healthy foods. Research has shown that socioeconomic status, food insecurity, and neighborhood food environments can be linked to diet quality and a variety of nutrition-related health outcomes, including cardiovascular disease, obesity, diabetes mellitus, and certain types of cancer. Specific to cardiovascular disease, food insecurity is adversely associated with key cardiovascular risk factors including hypertension and dyslipidemia. A 2021 systematic review found reduced food security increased the likelihood of reporting CVD-related outcomes such as coronary heart disease, angina, heart attack, peripheral arterial disease, and hypertension (Liu & Eicher-Miller, 2021). Food environments, such as lack of access to grocery stores and the presence of fast food restaurants at the neighborhood level, have also been shown to be associated with hypertension and increased cardiovascular risk (Malambo, et al., 2016). Elucidating the role of these social and environmental conditions on diet and nutritional status could help to prevent and manage diet-related health disparities and promote health equity.

On Sept. 21–23, 2021, the National Institutes of Health (NIH) in coordination with the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Agriculture (USDA) convened a virtual three-day workshop: Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science. The workshop was led by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with the NIH Office of Nutrition Research (ONR), and jointly sponsored by the following NIH Institutes and Offices: National Cancer Institute (NCI), National Institute on Minority Health and Health Disparities (NIMHD), National Institute of Nursing Research (NINR), and NIH Office of Disease Prevention (ODP). The workshop was also a key activity by the ONR Nutrition and Health Disparities Implementation Working Group following the release of the 2020–2030 Strategic Plan for NIH Nutrition Research.

More than 3,600 people registered worldwide and the online platform continues to be available for viewing through September 2022.

This workshop brought together a diverse group of scientists and researchers with expertise in nutrition, the built food environment, health and social policy, and behavioral and social sciences. Participants explored evidence-based approaches to addressing food insecurity and diet-related health disparities in the food environment. Each day of the agenda covered a broad theme.

Workshop Areas of Focus

State of the Science: Food Insecurity, Its Impact on Health, and Interventions

The first day focused on understanding the relationships among food insecurity, diet, and health, examining potential knowledge gaps, and exploring future opportunities for research. The session began by defining food insecurity/security, explaining how it is measured in the United States, and how data from population-based surveys are collected [for example: Current Population Survey Food Security Supplement (CPS-FSS), National Health and Nutrition Examination Survey (NHANES)]. Speakers shared information about current U.S. food insecurity rates, emerging definitions of nutrition security, and people who are disproportionally at risk. Also discussed was research on potential proposed pathways (for example: mental health, immune activation, and health behaviors) that link food insecurity and health outcomes, and implemented interventions being tested within community-based and health care settings.

Speakers provided their perspectives on research opportunities to close knowledge gaps related to food insecurity, as well as strategies to address those gaps. Some of these opportunities for consideration are summarized below.

Research Gaps and Opportunities

Research to Improve Understanding of Food Insecurity and Its Role in Health

• Conduct research to examine overlooked groups affected by food insecurity. Despite literature reports showing that the general prevalence of food insecurity in the general population is high, some of the groups with limited information include: American Indians, Black persons in the Upper Midwest, young adults not in college, 50- to 59-year-olds, and people with disabilities.
• Identify and better understand the biological mechanisms linking food insecurity to various health outcomes. Research has shown that food insecurity impairs cardiometabolic pathways, interacts in a vicious cycle that may aggravate the adverse consequences of obesity, and disproportionately affects minority populations.
• Consider research that aims to understand how policies (for example: Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infant and Children (WIC), other government programs, and nonprofit programs) impact food insecurity throughout the life course and the intergenerational implications of food insecurity.
• Develop longitudinal studies on the long-term impacts of food insecurity across the life course.

Intervention and Natural Experiment Research to Address Food Insecurity

• Consider research to evaluate program implementation, health outcomes, and ways to improve the effectiveness of governmental programs, such as SNAP and nonprofit sector programs. One such example is the Gus Schumacher Nutrition Incentive Program (or GusNIP) which aims to broaden the reach of healthful food incentive programs to other communities.
• Examine the possible association between local and state variation in policies, such as minimum wage, that may influence food insecurity. One example of this is the WAGE$ study.
• Conduct research to test interventions with broad frameworks, such as culturally informed interventions.
• Develop nontraditional or novel interventions to address the root drivers of food insecurity, such as poverty (for example: Building Wealth and Health Network).
• Consider research to evaluate nutrition education programs that provide incentives or supplemental funding for food and nutrition education to encourage healthy food choices.
• Study the impact of tailored interventions based on the experiences and needs of underserved populations within the context of their environment and address the stigma attached to food insecurity.
• Develop research to assess the impact of interventions targeting key health indicators (for example: obesity and cardiometabolic) by improving food insecurity and simultaneously addressing multiple health challenges.
• Continue approaches to expand scientific workforce diversity and support for researchers from diverse backgrounds in the nutrition and health disparities research pipeline.

State of the Science: Neighborhood Food Environments, Impact on Health, and Interventions

On the second day, speakers reviewed the current research on neighborhood food environments—including the retail, restaurant, and food service environments. They also explored the association between food environments and poor dietary behaviors, chronic disease, and health disparities. A panel highlighted available measures of the community and consumer neighborhood food environments, including geographic information system (GIS) technologies and technology-aided measurements. Speakers also discussed gaps in knowledge and research opportunities, including possible interventions which might improve the retail food environment and health outcomes. Exemplars included placing new grocery stores in existing food deserts, providing choice pantries, and improving access to healthier food choices in small retail food sources (e.g., corner stores, bodegas, convenience stores).

Speakers provided their perspectives on research opportunities to close knowledge gaps related to neighborhood food environments, as well as strategies to address those gaps. These potential research opportunities are summarized below.

Research Gaps and Opportunities

Research Methods to Improve Understanding of Neighborhood Food Environments and Role in Health

• Develop research to better characterize current food retail environment and consumer behavior through enhanced methodologies and alternative measures. For example, crowdsourced data can complement direct observation data, add variables of interest, fill content gaps, and classify food stores by category and price of products for sale. Direct observation studies using Global Positioning System (GPS) and GIS data can predict food environment interactions and inform intervention development.
• Investigate online shopping habits and patterns to understand their role in influencing diet and diet quality, given the increased use of the online food retail space.
• Integrate rigorous dietary outcomes and other measures beyond in research study designs. Additional neighborhood characteristics are factors that may influence the effects of interventions, and these relationships and pathways are part of the process in understanding the link between neighborhood food environments and health. Using store sales outcomes data to estimate diet may be a useful approach.

Interventions to Address Neighborhood Food Environments

• Develop multilevel, multicomponent interventions to improve the healthy food choices, including for small retail food stores. 
• Investigate the impact of interventions, and policies to attain healthier retail food environments and impact dietary intake. For example, examining the national impact of the Healthy Food Financing Initiative (HFFI) on dietary intake and to compare effects by community characteristics. Aligned with this goal is the establishment of a central HFFI research hub.
• Consider research in rural settings using community-engaged research methods and by integrating health care services and multilevel interventions.
• Develop interventions targeting the food environment that explicitly consider health equity and integrate other social determinants of health. This includes considerations of expanding the use of equity-oriented measures and outcomes in interventions.
• Use study designs which are methodically strongest for addressing biases and unmeasured confounders including novel trial designs (for example: randomized control trials, quasi-experimental studies). Earlier studies have shown mixed results on whether diet changes after a neighborhood intervention such as a new full-service grocery store.

Implementation Science, Policy, and Community-Based Research

Day 3 of the workshop explored implementation and community-based research approaches to address food insecurity and improve neighborhood food environments, including understanding where, in what circumstances interventions have been applied and how approaches can be improved. A presentation by NHLBI Center for Translation Research and Implementation Science (CTRIS) Director George Mensah, M.D., emphasized that implementation science focuses on the study of methods to promote the integration of research findings and evidence into policy and practice.

Panelists described several federal funded community-based programs, such as the Centers for Disease Control and Prevention funded State Physical Activity and Nutrition Program (SPAN), High Obesity Program 1809 (HOP), and Building Resiliency Inclusive Communities (BRIC). Experts also highlighted models of success, including Feeding America®, the Supporting Wellness at Pantries (SWAP) Initiative, SuperShelf, and Project Bread. Discussions led to the conclusion that food insecurity and neighborhood food environments are complex and speak to the need for person-centered and community-centered measurement and intervention approaches to distinguish between the environment, policy, and the individual behaviors and the importance of engaging stakeholders to ensure that measures are culturally responsive and grounded in communities’ lived experience.

Research Gaps and Opportunities

• Consider research to determine if strengthening the messaging about the strong connection between hunger and health through programs, policies, and best practices would improve the health of those experiencing food insecurity.
• Develop valid measures for the term nutrition security for use in the charitable food system.
• Examine the effectiveness of innovative approaches developed for food pantries to address hunger and health equity.
• Consider studies that examine the impact of food obtained outside of the charitable food sector.
• Investigate the impact of increases in healthy food purchases on unhealthy food purchases.
• Develop interventions in the emerging online sales environment to reduce food insecurity. Multi-component strategies should examine the added effect of each additional component.

Crosscutting Themes of the Workshop

Cross-cutting themes included using data and technology to better understand the impact of food insecurity and the role of community partnerships to provide the opportunity to leverage and study innovative community-based models.

Data and Technology

• Collect new data to better understand the intergenerational impacts of food insecurity and its effect on individuals in the same household. Design studies and collect data investigating the effects of food insecurity in relation to other life events and leverage existing efforts.
• Consider use of GPS and GIS data in research focused on assessment of the neighborhood food environment. 
• Disaggregate data, while protecting individual and community privacy, to better identify populations most impacted by food insecurity, hunger, and nutrition insecurity.
• Implement culturally and community-responsive technologies and methodologies for promoting nutrition and health. An example is the pilot study of a mobile application [Baltimore Urban Food Distribution (BUD)] that connects corner stores with local producers and wholesalers to improve access to healthier foods. Data scientists have also designed a participatory technology, mobile mapping, and SMS platform (Streetwyze) to link equitable food systems and community-powered health interventions.

Partnerships

• Promote efforts to increase community data capacity beyond federal grants, and increase training in data science. The Social Innovation and Universal Opportunity Lab (SOUL) is one model of such an effort.
• Foster new partnerships, which are key to achieving health equity related to food security and neighborhood food environments in the United States.
• Leverage existing local, regional, and federal efforts, such as Project Bread or Racial and Ethnic Approaches to Community Health (REACH) to reduce food insecurity and address neighborhood food environments.