Nutrition security screening in clinical care: a feasibility and implementation evaluation in family medicine and subspecialty clinics.

BACKGROUND: Nutrition insecurity (NI), or limited access to nutritious foods that support health, is increasingly recognized as relevant to health and distinct from food insecurity (FI). However, its integration into clinical assessment remains largely untested. OBJECTIVES: Our objective was to evaluate the feasibility of implementing a 2-item Nutrition Security Screener (NSS) alongside the Hunger Vital Sign, an existing FI screener, within a large integrated health system. METHODS: The NSS and FI screener were embedded into both Epic (electronic health record) and MyChart (patient portal) in a family medicine clinic and heart failure clinic from November 2023-October 2025. Eligible patients were prompted to complete screeners electronically prior to visits or during rooming. We analyzed 24 months of screening data, including completion rates, screening modality, referral rates, FI/NI prevalence, associations with sociodemographic and clinical characteristics, and reported barriers to healthy eating. RESULTS: Among 8,218 eligible patients, 98.5% answered at least one question and 7,697 (93.6%) answered all questions; 71% completed screening via the patient portal. Overall, 11.3% screened positive for NI or FI (4.8% both; 3.6% NI only; 3.0% FI only). After adjusting for demographics and FI, NI independently associated with Medicaid (OR=1.74; 95% CI: 1.30, 2.32) and Medicare (OR=1.76; 95% CI: 1.22, 2.54), compared to commercial insurance; and with obesity (OR=1.48; 95% CI: 1.19, 1.84) and type 2 diabetes (OR=1.45; 95% CI: 1.08,-1.93). Among patients with NI (n=648), common barriers to healthy eating included cost, limited time to cook, and uncertainty about qualification for government assistance. Of eligible patients, 7.1% received a documented referral. CONCLUSIONS: Integrating NI screening into routine clinical care was feasible and acceptable, with strong uptake through the patient portal. Clinical correlates and reported barriers highlight the utility of NI assessment, complementary to FI screening, for informing tailored nutritional and social interventions.