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Food Insecurity is the first of three Social Determinants of Health domains the Gravity Project will address during Phase 1 work.  

Community Homework

TaskInstructions and Due Dates
Review and comment on the Diagnoses and Goals data concepts for the Food Insecurity Data Set End-to-End Review.  Download the Food Insecurity Screening Tool Summary.
  • Email all comments to by October 31, 2019.
  • For data elements currently ON the Summary List
    • include data element ID # and reason(s) you do not feel the element is appropriate for Food Insecurity
  • For data elements NOT ON the Summary List
    • Submit the data element type (Screening, Diagnosis, Goal, Intervention)
    • Include a description for the data element you propose
    • For a screening element, attach a copy or link to the screening tool
Review and comment on the Case Management CPT Codes that have been identified to represent the work of case/care management and care coordination.  Click here to download the Case Management CPT Codes.

Click here for food-related terminology, definitions and source materials. These are the definitions and descriptions we will be using to guide community discussions around food insecurity data elements.

Interventions Framework

This is an updated draft of the framework for intervention data element concepts. Thank you to everyone who submitted comments on the initial version!

Working Draft Data Elements

This is where we will post data items that have been submitted and adjudicated.  These data elements will be the focus of our community discussions.  If there are data elements you are aware of that are not included here, please click here to submit them as soon as possible.

Food Insecurity Master List

The Food Insecurity Master List is used to track all adjudicated data elements for the food insecurity domain.  The latest version will be posted here as it is updated.

Click here to download the current Food Insecurity Master

Adjudicated Data Element Submission Statistics

Below is a list of how many of each food insecurity data element type has been adjudicated as of the date listed.

DateScreening Tool/Questions



17Oct1956 tools / 203 questions6013147220
12Sept1956 tools / 191 questions6012146218
29Aug1941 tools / 126 questions4411103158
15Aug1936 tools / 95 questions429100151
01Aug1928 tools / 71 questions38987134
18Jul199 tools / 34 questions



Screening Tools

Screening Tool




The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) have made the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool to use in the AHC Model. This screening tool assesses 5 core domains:

  • Housing instability
  • Food insecurity
  • Transportation problems
  • Utility help needs
  • Interpersonal safety


FIES-SMThe Food Insecurity Experience Scale (FIES) Survey Module (FIES-SM) consists of eight questions regarding people's access to adequate food, and can be easily integrated into various types of population surveys.
Health Information National Trends Survey (HINTS)HINTS collects data about the use of cancer-related information by the American public. These data provide opportunities to understand and improve health communication.
Health LeadsThe Health Leads Social Needs Screening Toolkit is a comprehensive blueprint for health systems seeking to identify and screen patients for adverse social determinants of health.

HFIASHousehold Food Insecurity Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide provides a simple and user-friendly approach for measuring the impacts of development food aid programs on the access component of household food insecurity. The guide includes a standardized questionnaire and data collection and analysis instructions. The HFIAS is composed of a set of nine questions that have been used in several countries and appear to distinguish food insecure from food secure households across different cultural contexts. The information generated by the HFIAS can be used to assess the prevalence of household food insecurity (access component) and to detect changes in the food insecurity situation of a population over time.
Household Food Security Survey Module (HFSSM)

The HFSSM focuses on self-reports of uncertain, insufficient or inadequate food access, availability and utilization due to limited financial resources, and the compromised eating patterns and food consumption that may result.  The HFSSM contains 18 questions about the food security situation in the household over the previous 12 months. Each question specifies a lack of money or the ability to afford food as the reason for the condition or behaviour. The questions range in severity from worrying about running out of food, to children not eating for a whole day.

Note:  This is a Canadian survey adapted from the US Food Security Measurement Method.
Hunger Vital SignThe Hunger Vital SignTM (HVS) is a validated 2-question food insecurity screening tool that allows clinicians to accurately identify households at risk of food insecurity and address patient needs appropriately.
IHELPIHELP is a tool for collecting pediatric social histories. It includes both household needs (financial strain, insurance, hunger, domestic violence, housing stability and housing conditions) and several child-specific domains (child educational needs, child legal status, and power of attorney/guardianship).
Kaiser Permanente Your Current Life Situation (YCLS)Kaiser Permanente's Your Current Life Situation (YCLS) survey was developed to capture a range of social and economic needs, including living situation, housing, food, utilities, childcare, debts, medical needs, transportation, stress, and social isolation.
KleinmanDr. Arthur Kleinman determined that a person's own opinions and viewpoints can affect their health.  This set of open-ended questions has been used to explore how and why individuals believe what they do about illnesses and treatments to support shared decision making.

NC Safe Environment for Every Kid (SEEK)SEEK is an evidence-based, practical model for improving primary healthcare for children and their families. SEEK helps primary healthcare professionals (PCPs) address common psychosocial problems, such as parental depression and substance use. The SEEK Parent Questionnaire-R (PQ-R) screens for the targeted psychosocial problems.

Medicare Total Health Assessment (THA)The Medicare Total Health Assessment (MTHA) is a survey used to assess several things, including food insecurity, in the elderly. The survey is offered to Medicare Advantage members in advance of Annual Wellness Visits that are a CMS-mandated benefit offering.
PRAPAREThe Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health.

SWYCThe Survey of Well-being of Young Children (SWYC)™ is a freely-available, comprehensive screening instrument for children under 5 years of age.
US Household Food Security 6 ItemSix-Item Short Form of the Food Security Survey Module
For surveys that cannot implement the 18-item or 10-item measures, this "Short Form" 6-item scale provides a reasonably reliable substitute. It uses a subset of the standard 18 items. This is the same six-item questionnaire that is in the Guide.

US Household Food Security 10 ItemU.S. Adult Food Security Survey Module
(10 items) Three-stage design with screeners. Screening keeps respondent burden to the minimum needed to get reliable data. Most households in a general population survey are asked only three questions. The questionnaire has been modified very slightly from that specified for households without children in the Guide.

US Household Food Security 18 ItemU.S. Household Food Security Survey Module
(18-items) Three-stage design with screeners. Screening keeps respondent burden to the minimum needed to get reliable data. Most households in a general population survey are asked only three questions (five if there are children in the household). The questionnaire has been modified slightly from that in the Guide, and the questions have been re-ordered to group the child-referenced questions after the adult-referenced questions.

We CareWE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a clinic-based screening and referral system developed for pediatric settings. The 12-question WE CARE screening tool assesses needs in 6 domains: parental educational attainment, employment, child care, risk of homelessness, food security, and household heat and electricity.

Terminology, Definitions and Resources


Definition or Description


Food access

There are many ways to measure food store access for individuals and for neighborhoods, and many ways to define which areas are food deserts—neighborhoods that lack healthy food sources. Most measures and definitions take into account at least some of the following indicators of access:

  • Accessibility to sources of healthy food, as measured by distance to a store or by the number of stores in an area.
  • Individual-level resources that may affect accessibility, such as family income or vehicle availability.
  • Neighborhood-level indicators of resources, such as the average income of the neighborhood and the availability of public transportation.

Food desert

The Food Access Research Atlas maps census tracts that are both low income (li) and low access (la), as measured by the different distance demarcations. This tool provides researchers and other users multiple ways to understand the characteristics that can contribute to food deserts, including income level, distance to supermarkets, and vehicle access.

Food security

Access by all people at all times to enough food for an active, healthy life.
Food security range:  high food securityNo reported indications of food-access problems or limitations.
Food security range:  marginal food securityOne or two reported indications—typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication of changes in diets or food intake.
Food insecurityLimited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.

Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide To Measuring Household Food Security, Revised 2000. Alexandria, VA: US Department of Agriculture, Food and Nutrition Service; 2000.

Food insecurity range: low food security

Reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake.
Food insecurity range:  very low food securityReports of multiple indications of disrupted eating patterns and reduced food intake.
HungerTerm should refer to a potential consequence of food insecurity that, because of prolonged, involuntary lack of food, results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation.

Data Element Concept Leads




Value Set Subject Matter Expert

Linda Hyde

EMI Advisors, LLC
Value Set Subject Matter ExpertLisa NelsonEMI Advisors, LLC
Food Insecurity Subject Matter ExpertSarah DeSilveyLarner College of Medicine at the University of Vermont
Food Insecurity Subject Matter Expert

Donna Partel

Academy of Nutrition and Dietetics
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