Addressing Food Insecurity in the United States: A Systematic Review of Interventions from Randomized Controlled Trials

Background and Purpose: Food insecurity remains a persistent public health challenge in the United States, affecting over 13% of households, and disproportionately impacting non-white and low-income populations. Despite the implementation of numerous programs, including the Supplemental Nutrition Assistance Program (SNAP), food pantries, school meals, and educational programs, food insecurity levels have not substantially declined over the past two decades. To identify effective interventions, this systematic review examines randomized controlled trials (RCTs) that address food insecurity, evaluates their methodological strengths and limitations, and highlights implications for policy and future research.

Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Inclusion criteria were guided by the PICOS framework (population, intervention, comparison, outcome and study design) and included studies that: (1) were conducted in the United States; (2) utilized an RCT design with a no-intervention control group; and (3) measured food insecurity as an outcome. A systematic search of PubMed, Embase, Web of Science, and ProQuest Central yielded 6,243 articles. Articles were imported into EndNote for deduplication, then screened in Rayyan by two independent reviewers. Twenty-four studies met the inclusion criteria. Data on study characteristics, intervention details, and outcomes were extracted. Study quality was assessed using the Cochrane Risk of Bias Tool.

Results: The 24 included studies, conducted between 2003 and 2024, covered diverse geographic regions with sample sizes ranging from 30 to nearly 50,000 participants. Interventions varied widely, including increases in SNAP benefits, medically tailored food boxes, nutrition education, and food vouchers. Implementation settings ranged from healthcare facilities and schools to community organizations. Thirty-eight percent of studies reported significant improvements in food security following intervention, while 50% found no significant differences between intervention and control groups. Two studies reported mixed or conditional results. Notably, increases in SNAP benefits did not significantly improve food security, likely due to modest benefit increases. However, SNAP education programs demonstrated positive effects, suggesting their potential as a cost-effective intervention.

Conclusions and Implications: This review highlights the mixed effectiveness of RCT-tested interventions in addressing food insecurity. The inconsistent evidence underscores the need for further high-quality trials with longer follow-up periods to assess intervention sustainability. Educational interventions, particularly SNAP education, showed promise, but emphasis on individual behavior change alone overlooks broader structural and systematic factors that cause food insecurity. Future research should explore interventions tailored for vulnerable subpopulations, including children, older adults, and adults with chronic diseases. Crucially, subsequent studies should evaluate intervention sustainability beyond the study period, as household food insecurity is dynamic, strongly influenced by a family’s economic circumstances, and highly sensitive to policy changes and access to social safety nets. Future RCTs should also prioritize robust study designs that account for intervention utilization and participant adherence to better determine the necessary "dose" required for meaningful improvements. Ultimately, addressing food insecurity requires a multifaceted approach that combines direct food assistance, financial support, and education to create lasting impacts on food security in the United States.