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Identifying food insecurity: Two-question screening tool has 97% sensitivity :

October 22, 2015

“Within the past 12 months, we worried whether our food would run out before we got money to buy more. Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.” Yes or no?

Answering yes to either of these questions indicates that a family is struggling with food insecurity, according to a new AAP policy statement titled Promoting Food Security for All Children.

The U.S. Department of Agriculture (USDA) defines a food-insecure household as one in which “access to adequate food is limited by a lack of money or other resources.”

Pediatricians can use the two-item tool to screen children for food insecurity and refer those who screen positively to resources that support access to adequate healthy food, according to the policy, which is available at and will appear in the November issue of Pediatrics.

Dr. SchwarzenbergDr. Schwarzenberg

“It is important for pediatricians to be aware of the fact that food insecurity can occur in any population,” said Sarah Jane Schwarzenberg, M.D., FAAP, a lead author of the statement and a member of the AAP Committee on Nutrition. “I think sometimes people believe food insecurity affects only inner-city, impoverished people, but in fact, after the recession, we saw people in the suburbs and nontraditional areas experiencing food insecurity as well.”

Widespread, complex problem

Sixteen million U.S. children — 21% of the nation’s children — live in food-insecure households.

Although 60% of all food-insecure families have incomes below the income eligibility cutoff for many child nutrition programs, 30% of food-insecure households have incomes above this level, confirming that food insecurity is not always linked to poverty. Other key factors contributing to food insecurity include unemployment, underemployment, immigration, large family size, households headed by single women, lower education and parent separation or divorce.

Impacts on child health

Food insecurity can negatively affect behavior and development and have a lifelong impact on health. According to the policy statement, children living in food-insecure households are more likely to experience:

  • stress, contributing to depression and anxiety;
  • worse overall health and more hospitalizations when they are 3 years old or younger;
  • iron deficiency;
  • lower bone density in preadolescent boys;
  • obesity due to lack of access to healthy foods;
  • lower cognitive skills;
  • dysregulated behavior;
  • developmental problems affecting school performance; and
  • malnutrition that can lead to diabetes, hyperlipidemia and cardiovascular disease later in life.

Pediatricians’ role

A resolution titled “Universal Screening for Hunger/Food Insecurity During Office Visits” was ranked No. 7 by attendees of the 2015 AAP Annual Leadership Forum.


Dr. FlanaganDr. Flanagan“It can be embarrassing for families to say they are struggling, but I think the onus is on us as pediatricians to make families feel comfortable by explaining that food security correlates with children’s health and that lack of access to food can severely impact health and the opportunity to learn,” said Patricia J. Flanagan, M.D., FAAP, a co-author of the policy statement and vice chair of the AAP Council on Community Pediatrics Executive Committee.


The policy statement reports that answering yes to either of the two screening questions, which come from the 18-item Household Food Security Scale used by the USDA, identifies food insecurity with a sensitivity of 97% and a specificity of 83% compared to the full scale.

Food entitlement programs are important resources for food-insecure families. Among those detailed in the policy statement, the Supplemental Nutrition Assistance Program aids 47 million Americans — 72% of whom are children — and has demonstrated that it helps to reduce food insecurity and negative health and developmental outcomes.


  • Use the two-question screening tool at health maintenance visits or sooner, if needed.
  • Become familiar with and refer food-insecure families to community resources.
  • Become educated about the nutritional content of food offered in supplemental programs.
  • Learn about food insecurity-related factors that contribute to obesity and burden food-insecure families.
  • Incorporate education about food insecurity into medical school and residency programs.
  • Advocate for food assistance programs at the local, state and national levels, including protecting and increasing access to and funding for these programs, as well as ensuring that these programs include nutritious foods.
  • Support research into food insecurity and its association with stress and adverse health outcomes, as well as ways to improve access to quality, nutritious foods.
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