Food Insecurity, Dietary Quality, and Health Care Utilization in Lower-Income Adults: A Cross-Sectional Study



      Food insecurity and poor nutrition are prevalent in the United States and associated with chronic diseases. Understanding relationships among food insecurity, diet, and health care utilization can inform strategies to reduce health disparities.


      Our aim was to determine associations between food security status and inpatient and outpatient health care utilization and whether they differed by dietary quality in lower-income adults.


      This was a cross-sectional study of data from the 2009-2016 National Health and Nutrition Examination Survey.


      Participants were 13,956 lower-income (<300% federal poverty level) adults 18 years and older in the United States.

      Main outcome measures

      Self-reported health care utilization in the past 12 months included no usual source of care, any outpatient visit, any mental health service use, and any hospitalization.

      Statistical analyses

      Multiple logistic regression was used to study the association between food insecurity and health care utilization. Analyses were stratified by diet-related comorbidities to account for potential confounding and mediation of health care utilization, and by dietary quality.


      In a sample of lower-income adults <300% federal poverty level, 4,319 participants (27.4%) were food insecure, 2,208 (15.0%) were marginally food secure, and 7,429 (57.6%) were food secure. Food insecurity was associated with having no usual source of care (adjusted odds ratio [aOR] 1.30; 95% CI 1.11 to 1.52), any mental health service use (aOR 2.02; 95% CI 1.61 to 2.52), and any hospitalization (aOR 1.19; 95% CI 1.01 to 1.41). Food-insecure adults were more likely to report no outpatient visits if they had diet-related comorbidities (aOR 1.45; 95% CI 1.10 to 1.92) or the lowest dietary quality (aOR 1.53; 95% CI 1.06 to 2.23). Marginal food security was associated with having no usual source of care (aOR 1.22; 95% CI 1.04 to 1.44).


      Adults with food insecurity were more likely to be hospitalized, use mental health services, and have no usual source of care. Food-insecure participants with diet-related comorbidities or poor diet were less likely to have outpatient visits. Hospitalizations and mental health visits represent underused opportunities to identify and address food insecurity and dietary intake in lower-income patients.


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        • Coleman-Jensen A.
        • Rabbitt M.P.
        • Gregory C.A.
        • Singh A.
        Household food security in the United States in 2019.
        (Published 2020. Accessed December 27, 2020)
        • Bauer L.
        The COVID-19 crisis has already left too many children hungry in America. The Hamilton Project 2020.
        (Accessed June 3, 2020)
        • Hake M.
        • Dewey A.
        • Engelhard E.
        • et al.
        The impact of the coronavirus on food insecurity in 2020 & 2021. Publishe 2020.
        (Accessed December 18, 2020)
        • Definitions of Food Security
        US Department of Agriculture, Economic Research Service.
        (Accessed December 15, 2020. Published 2020)
        • Gregory C.A.
        • Coleman-Jensen A.
        Food insecurity, chronic disease, and health among working-age adults.
        (Published 2017. Accessed June 6, 2020)
        • Dean E.B.
        • French M.T.
        • Mortensen K.
        Food insecurity, health care utilization, and health care expenditures.
        Health Serv Res. 2020; 55: 883-893
        • Kushel M.B.
        • Gupta R.
        • Gee L.
        • Haas J.S.
        Housing instability and food insecurity as barriers to health care among low-income Americans.
        J Gen Intern Med. 2006; 21: 71-77
        • Berkowitz S.A.
        • Seligman H.K.
        • Meigs J.B.
        • Basu S.
        Food insecurity, healthcare utilization, and high cost: A longitudinal cohort study.
        Am J Manag Care. 2018; 24: 399-404
        • Palakshappa D.
        • Khan S.
        • Feudtner C.
        • Fiks A.G.
        Acute health care utilization among food-insecure children in primary care practices.
        J Health Care Poor Underserved. 2016; 27: 1143-1158
        • Bhargava V.
        • Lee J.S.
        Food insecurity and health care utilization among older adults.
        J Appl Gerontol. 2017; 36: 1415-1432
        • Weiser S.D.
        • Hatcher A.
        • Frongillo E.A.
        • et al.
        Food insecurity is associated with greater acute care utilization among HIV-Infected homeless and marginally housed individuals in San Francisco.
        J Gen Intern Med. 2013; 28: 91-98
        • Becerra M.B.
        • Allen N.L.
        • Becerra B.J.
        Food insecurity and low self-efficacy are associated with increased healthcare utilization among adults with type II diabetes mellitus.
        J Diabetes Complications. 2016; 30: 1488-1493
        • Seligman H.K.
        • Schillinger D.
        Hunger and socioeconomic disparities in chronic disease.
        N Engl J Med. 2010; 363: 6-9
        • Rehm C.D.
        • Monsivais P.
        • Drewnowski A.
        Relation between diet cost and Healthy Eating Index 2010 scores among adults in the United States 2007-2010.
        Prev Med. 2015; 73: 70-75
        • Berkowitz S.A.
        • Seligman H.K.
        • Choudhry N.K.
        Treat or eat: Food insecurity, cost-related medication underuse, and unmet needs.
        Am J Med. 2014; 127: 303-310.e303
        • Spees C.K.
        • Clark J.E.
        • Hooker N.H.
        • Watowicz R.P.
        • Taylor C.A.
        Dietary intake contributions of food and beverages by source and food security status in US adults.
        J Nutr Educ Behav. 2017; 49: 667-673.e661
        • Morales M.E.
        • Berkowitz S.A.
        The relationship between food insecurity, dietary patterns, and obesity.
        Curr Nutr Rep. 2016; 5: 54-60
        • Zipf G.
        • Chiappa M.
        • Porter K.S.
        • Ostchega Y.
        • Lewis B.G.
        • Dostal J.
        National Health and Nutrition Examination Survey: Plan and operations, 1999–2010.
        (Published 2013. Accessed June 3, 2020)
      1. Poverty Guidelines. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.
        (Published 2020. Accessed June 30, 2020)
        • Nord M.
        • Brent C.P.
        Food insecurity in higher income households.
        (Accessed April 7, 2021. Published 2002)
        • Leung C.W.
        • Epel E.S.
        • Ritchie L.D.
        • Crawford P.B.
        • Laraia B.A.
        Food insecurity is inversely associated with diet quality of lower-income adults.
        J Acad Nutr Diet. 2014; 114: 1943-1953.e1942
        • Seligman H.K.
        • Bindman A.B.
        • Vittinghoff E.
        • Kanaya A.M.
        • Kushel M.B.
        Food insecurity is associated with diabetes mellitus: Results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999-2002.
        J Gen Intern Med. 2007; 22: 1018-1023
        • US Household Food Security Survey Module
        US Department of Agriculture, Economic Research Service.
        (Published 2012. Accessed December 27, 2020)
        • Fullerton C.A.
        • Witt W.P.
        • Chow C.M.
        • et al.
        Impact of a usual source of care on health care use, spending, and quality among adults with mental health conditions.
        Adm Policy Ment Health. 2018; 45: 462-471
      2. AMPM-USDA Automated Multiple-Pass Method. Food Surveys Research Group.
        (Published 2020. Accessed July 28, 2020)
        • Krebs-Smith S.M.
        • Pannucci T.E.
        • Subar A.F.
        • et al.
        Update of the Healthy Eating Index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
        • Reedy J.
        • Lerman J.L.
        • Krebs-Smith S.M.
        • et al.
        Evaluation of the Healthy Eating Index-2015.
        J Acad Nutr Diet. 2018; 118: 1622-1633
      3. The Healthy Eating Index: SAS code. Division of Cancer Control and Population Sciences, National Cancer Institute.
        (Published 2019. Accessed December 20, 2019)
      4. 2015–2020 Dietary Guidelines for Americans. 8th Edition. US Department of Health and Human Services and US Department of Agriculture.
        (Published December 2015. Accessed July 10, 2020)
      5. HEI scores for Americans. US Department of Agriculture, Food and Nutrition Service.
        (Published 2019. Accessed July 10, 2020)
        • Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases
        Diet, Nutrition and the Prevention of Chronic Diseases.
        World Health Organization, 2003
        • Fardet A.
        • Boirie Y.
        Associations between food and beverage groups and major diet-related chronic diseases: An exhaustive review of pooled/meta-analyses and systematic reviews.
        Nutr Rev. 2014; 72: 741-762
        • Nelson R.H.
        Hyperlipidemia as a risk factor for cardiovascular disease.
        Prim Care. 2013; 40: 195-211
        • Chess D.J.
        • Stanley W.C.
        Role of diet and fuel overabundance in the development and progression of heart failure.
        Cardiovasc Res. 2008; 79: 269-278
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.W.
        The PHQ-9: Validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
      6. Module 3: Weighting. Continuous NHANES Tutorials. National Center for Health Statistics.
        (Published 2019. Accessed February 25, 2020)
      7. SAS 9.4 for Windows [computer program]. Version 9.4. SAS Institute, 2017
        • Liu Y.
        • Njai R.S.
        • Greenlund K.J.
        • Chapman D.P.
        • Croft J.B.
        Relationships between housing and food insecurity, frequent mental distress, and insufficient sleep among adults in 12 US States, 2009.
        Prev Chronic Dis. 2014; 11 (E37-E37)
        • Tsuchiya K.
        • Leung C.W.
        • Jones A.D.
        • Caldwell C.H.
        Multiple financial stressors and serious psychological distress among adults in the USA.
        Int J Public Health. 2020; 65: 335-344
        • Tarasuk V.
        • Cheng J.
        • Gundersen C.
        • de Oliveira C.
        • Kurdyak P.
        The relation between food insecurity and mental health care service utilization in Ontario.
        Can J Psychiatry. 2018; 63: 557-569
      8. Scientific report of the 2020 Dietary Guidelines Advisory Committee: Advisory report to the Secretary of Agriculture and the Secretary of Health and Human Services. Dietary Guidelines Advisory Committee.
        (Published 2020. Accessed July 29, 2020)
        • Alley D.E.
        • Asomugha C.N.
        • Conway P.H.
        • Sanghavi D.M.
        Accountable Health Communities—Addressing social needs through Medicare and Medicaid.
        N Engl J Med. 2016; 374: 8-11
        • Greenthal E.
        • Jia J.
        • Poblacion A.
        • James T.
        Patient experiences and provider perspectives on a hospital-based food pantry: A mixed methods evaluation study.
        Public Health Nutr. 2019; 22: 3261-3269
        • Feinberg A.T.
        • Hess A.
        • Passaretti M.
        • Coolbaugh S.
        • Lee T.H.
        Prescribing food as a specialty drug. NEJM Catalyst.
        (Published April 10, 2018. Accessed June 11, 2021)
        • Stenmark S.H.
        • Steiner J.F.
        • Marpadga S.
        • Debor M.
        • Underhill K.
        • Seligman H.
        Lessons learned from implementation of the food insecurity screening and referral program at Kaiser Permanente Colorado.
        Perm J. 2018; 22: 18-093
        • Chorniy A.
        • Currie J.
        • Sonchak L.
        Does prenatal WIC participation improve child outcomes?.
        Am J Health Econ. 2020; 6: 169-198
        • Gregory C.A.
        • Deb P.
        Does SNAP improve your health?.
        Food Policy. 2015; 50: 11-19
        • Berkowitz S.A.
        • Seligman H.K.
        • Rigdon J.
        • Meigs J.B.
        • Basu S.
        Supplemental Nutrition Assistance Program (SNAP) participation and health care expenditures among low-income adults.
        JAMA Intern Med. 2017; 177: 1642-1649
        • Damon A.L.
        • King R.P.
        • Leibtag E.
        First of the month effect: Does it apply across food retail channels?.
        Food Policy. 2013; 41: 18-27


      J. Jia is a clinical and research fellow, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.


      V. Fung is an assistant professor of medicine, Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA.


      J. B. Meigs is a professor of medicine, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.


      A. N. Thorndike is an associate professor of medicine, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, and Harvard Medical School, Harvard University, Boston, MA.