To the Editor — Food insecurity is one predictor of ill health. Is food insecurity a consequence of policy decisions? Yes, in a way. Food insecurity has been linked to low wages, adverse social and economic conditions, limited access to healthy foods, residential segregation, lack of affordable housing and multiple indices of neighbourhood disadvantage. Huge racial, ethnic, economic and even geographic disparities in food insecurity were revealed and underscored by the COVID-19 pandemic. This year, the US Congress has authorized the White House to call a conference on food, nutrition, hunger and health1 to spark a national discussion of the root causes and social determinants of food insecurity, and the deepening socioeconomic divisions in health.

As defined by the US Department of Agriculture (USDA)2, food security has two important components. Low food security is defined by reduced quality, variety or desirability of the diet. Not being able to afford balanced meals is one telling sign — but there is little indication of eating less. Very low food security, previously called ‘food insecurity with hunger’, is associated with limited food budgets, skipped meals and calorie-restricted diets. Going hungry or eating less because there wasn’t enough money for food are the telling signs. Very low food security is viewed as a more severe and debilitating condition than uncertain access to nutritious foods.

Food insecurity has root causes that are economic in nature. The USDA has estimated the national prevalence of food insecurity at 11.1% or approximately 1 in 9 households3. Approximately 1 in 25 households experienced very low food security. The same data pointed to social disparities, showing that food insecurity was higher in lower-income states, affected 1 in 4 female-headed households and 1 in every 3 households living below the federal poverty level. Our successive WAFOOD surveys in Washington state4,5,6 likewise pointed to multifold differences in food insecurity rates by education, income and race/ethnicity. The WAFOOD sample was mostly female, mostly lower income, and included many front-line workers in food industries and single parents with children. Based on the USDA six-item food security scale2, 13% of WAFOOD households reported low food security and a further 17% reported very low food security. The estimated 30% rate among this vulnerable group was much higher than the national average3. Consistent with national data, higher rates of food insecurity were seen among households living in poverty, single parents with children and communities of colour. Higher levels of food insecurity were seen among respondents in food-based services and those who had lost their jobs due to COVID-19. Rural counties were affected as well.

Reports of lived experience pointed to the causal nature of economic conditions. Paying for rent and food were the top financial concerns of food-insecure households6. High and rising food prices were the most frequently cited barriers to adopting healthier diets. Food-insecure households spent less on food, reporting poor and worsening diet quality and more limited access to meat, fresh vegetables and fresh fruit5. Food insecurity was linked to higher rates of obesity, diabetes, asthma and other chronic conditions. Food-insecure respondents reported more stress, anxiety and depression.

Housing insecurity may be another predictor of ill health. Still without a standard definition, housing insecurity is linked to high rent-to-income ratios, substandard housing, overcrowding and frequent moves7. Housing insecurity is also linked to residential segregation, disparities in home ownership and inequalities in wealth. Real estate values, which are increasingly used as a wealth metric in health studies8, can determine whether supermarkets and grocery stores remain in the neighbourhood or relocate elsewhere. Taken together with limited access to food sources, housing insecurity can affect body weight, diabetes and other health outcomes, mental health and general well-being. Decades of housing segregation represent another socioeconomic — and policy driven — determinant of health.

The White House conference is focusing on food and not on housing — for now. Two of its five pillars are to improve food access and affordability, and to empower all consumers to make healthy choices. The ultimate goal is to reduce racial, ethnic and other disparities, end hunger and reduce the risk of chronic disease. At this juncture, I feel that three points bear repeating.

First, the narrative of food access, often framed in terms of food deserts and physical distance to food stores, may not always be entirely correct9. For many people, access to healthy foods is driven by economics and is determined by food price. Although there have been arguments to the contrary10, healthier foods generally cost more. This was finally recognized by the 2021 revision of the USDA Thrifty Food Plan, the first one in many years, and by a substantial increase in food benefits under the USDA Supplemental Nutrition Assistance Program (SNAP)11. Food access is about more than the distance to the nearest supermarket.

Second, the very notion of food ‘choice’ does not apply equally across socioeconomic groups. For many people, the ability to make healthy food choices was removed long ago by stagnating wages, economic hardships and time poverty. Education may not help much. “The only label that we ever look at is the one that says 79 cents”, someone memorably told me years ago. The White House conference will include members of the general public who are affected by hunger and nutrition insecurity in the United States. Reports of lived experience, which are so rare at scientific meetings, can greatly enrich the usual academic perspectives and point to effective policy options. Community engagement is vital and listening sessions at regional, country and local levels are already being held.

Third, hunger is not the only consequence of reduced food expenditures. Many food-insecure households gravitate — and not by choice — towards lower-cost foods that offer ample calories, plenty of added sugars and fats, excess sodium and minimal nutritional value. In such cases, being forced to reduce food budgets is the first step on the pathway to being overweight. That concept is hard to reconcile with the notion that food insecurity and being overweight ought to be mutually exclusive — there are multiple reasons why they are not12. Food insecurity, cheap excess calories, and vitamin and mineral deficiencies can go hand in hand.

There are economic and policy remedies that will require multi-sector efforts. The White House conference will identify ways to provide opportunities for farmers and ranchers to meet the nutrient gaps. The packaged food industry will need to expand convenient access to healthy, safe and affordable food. The price of healthy foods needs to come down and lower-cost packaged foods will need to be reformulated to increase nutrient density and minimize nutrients of public-health concern.