Development and validation of a 1-item very low food security screen

Introduction: The Centers for Medicare and Medicaid Services has made screening for health-related social needs (HRSNs) mandatory since 2024. Patients screening positive for HRSN food insecurity (FI) are connected with Supplemental Nutrition Services using 1115 Demonstration waivers. With a shift in funding, Massachusetts adopted a more stringent FI-level screening protocol (very low food security [VLFS]). To date, there is no screening tool that identifies VLFS alone; thus, we developed a sensitive, specific, and valid screen to determine risk for VLFS. Methods: Sensitivity, specificity, and positive- and negative-predictive values were used to test combinations of questions compared with the USDA Household Food Security Survey Module using the 2022 Current Population Survey. Results: The best VLFS screen was, "In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?" (yes/no). The screen was highly sensitive, specific, and valid for detecting VLFS risk in US households with and without children (sensitivity, 92.2% and 97.2%; specificity, 96.2% and 97.4%, respectively), and with diverse populations. Conclusion: The VLFS screen is recommended for use by states adopting a more stringent FI-level screening protocol.