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

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Nutritionally inadequate dietary intake is a leading contributor to chronic cardiometabolic diseases. Differences in dietary quality contribute to socioeconomic and racial and ethnic health disparities. Food insecurity, a household-level social or economic condition of limited access to sufficient food, is a common cause of inadequate dietary intake. Although US food assistance policies and programs are designed to improve food security, there is growing consensus that they should have a broader focus on nutrition security. In this policy statement, we define nutrition security as an individual or household condition of having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease. Despite existing policies and programs, significant gaps remain for achieving equity in nutrition security across the life span. We provide recommendations for expanding and improving current food assistance policies and programs to achieve nutrition security. These recommendations are guided by several overarching principles: emphasizing nutritional quality, improving reach, ensuring optimal utilization, improving coordination across programs, ensuring stability of access to programs across the life course, and ensuring equity and dignity for access and utilization. We suggest a critical next step will be to develop and implement national measures of nutrition security that can be added to the current US food security measures. Achieving equity in nutrition security will require coordinated and sustained efforts at the federal, state, and local levels. Future advocacy, innovation, and research will be needed to expand existing food assistance policies and programs and to develop and implement new policies and programs that will improve cardiovascular health and reduce disparities in chronic disease.
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
Figure. Moving from food sufficiency to nutrition security in the United States.
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
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
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
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
CACFP indicates Child and Adult Care Food Program; CMS, Centers for Medicare & Medicaid Services; CMS CMMI, Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation; CNR, Child Nutrition Reauthorization; COVID-19‚ coronavirus disease 2019; CSFP, Commodity Supplemental Food Program; DGA, Dietary Guidelines for Americans; DRI, Dietary Reference Intake; EBT, Electronic Benefit Transfer; EFNEP, Expanded Food and Nutrition Education Program; FDPIR, Food Distribution Program on Indian Reservations; FFVP‚ Fresh Fruit and Vegetable Program; FINI, Food Insecurity Nutrition Incentive; FPL, Federal Poverty Level; GusNIP, Gus Schumacher Nutrition Incentive Program; HER, Healthy Eating Research; NIFA, USDA National Institute of Food and Agriculture; NSLP, National School Lunch Program; OAA, Older Americans Act; SBP, School Breakfast Program; SFMNP, Senior Farmers’ Market Nutrition Program; SFSP, Summer Food Service Program; SNAP, Supplemental Nutrition Assistance Program; SNAP-Ed, SNAP-Education; SSO, Seamless Summer Option; TEFAP, The Emergency Food Assistance Program; USDA FNS, US Department of Agriculture, Food and Nutrition Service; and WIC, Special Supplemental Nutrition Program for Women, Infants and Children.
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
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
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.
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
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
USDA indicates US Department of Agriculture.
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.
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.
Writing Group Disclosures
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
* Modest.
† Significant.
Reviewer Disclosures
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
* Significant.
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.
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.”
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

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