This is the first study to our knowledge to examine the nutritional needs of the unhoused from their own perspective in a Chicago, Illinois sample. Based on the responses of twenty unhoused individuals, we identified key barriers and resources that may be leveraged to optimize their nutrition, while increasing our understanding of their goals. Because our study sample and data collection took place outside on the streets of Chicago, this study uniquely captures individuals who may otherwise not be readily surveyed within traditional brick-and-mortar institutions such as medical centers, clinics, or community-based organizations.

One of the most salient takeaways from our study population is that the unhoused were motivated to select nutritious food options, yet often had to rely on donations to eat. With no participant consuming adequate amounts of each food group, it may be inferred that the donated food options the unhoused receive are nutritiously inadequate. It is also important to note that many individuals in the United States do not eat sufficient servings of each food group. Data reported by the United States Department of Agriculture’s Economic Research Service from the 2015–2018 National Health and Nutrition Examination Survey reported that all age groups were deficient in all food groups except protein and grains [23]. In particular, approximately two-thirds of adults ages 20 years of age or older consumed any amount of fruit per day and ninety-five percent consumed any amount of vegetable [24]. Overall, this trend of consuming more proteins and less fruits, vegetables, and dairy that is seen in the general United States population was similar among our unhoused sample.

From the perspective of charitable organizations and programs who serve the unhoused, there are constraints on the nutritional quality they can offer, most prominently, perishability, cost, and lack of awareness [25]. For street medicine organizations, this is compounded by limitations in what can be carried on foot, along with necessary medical supplies. From the perspective of the unhoused, several factors that affect food consumption have been elucidated, most striking are constraints due to limited ability to store, refrigerate, or prepare food, as well as dentition needs, chronic health concerns. Our findings contribute to the growing body of research describing the barriers to nutrition experienced by the houseless, including the mixed methods study by Sprake and colleagues which found that major nutritional barriers included the lack of access to refrigerators, areas to prepare meals, and storage areas for food [16]. Our findings that oral health is of great importance to the unhoused is consistent with prior data from a 2014 Australian study by Ford and colleagues which found that the houseless experienced more frequent and more severe oral health concerns than the general public [26]. Regarding chronic health conditions, diet has demonstrated to be a key modifiable risk factor in preventing or decreasing the burden of cardiovascular disease, hypertension, and diabetes [27,28,29]. Thus, it is of great importance for community organizations, including street medicine programs, to be mindful of the food options we provide to the unhoused. Table 3 summarizes these needs, as well as our recommendations for how organizations can be mindful of them when offering food.

We have also synthesized our personal recommendations for selecting specific food items to offer the unhoused, especially from the street medicine perspective where transportability to the individual is needed (Table 4). Importantly, for each food recommended, single, individually packaged servings exist—whether it is in individual pouches (applesauce, peanut butter, oatmeal), cups (vegetable cups, guacamole) or cans (chicken salad, tuna). When possible, we recommend opting for pull-top cans instead of those which require use of a can opener. For perishable items such as cheeses or yogurt, consider freezing the foods before distributing to increase their longevity once distributed. While hot meals were sought after by those experiencing houselessness in our study, there are limitations in street medicine organizations’ ability to deliver hot meals on foot. Warm meal ideas that street medicine programs may be able to offer include burritos, hot sandwiches, burgers, and quesadillas.

These recommendations may be considered when purchasing food as an organization, but also when requesting donations from the public. Often, organizations feel they can only provide as nutritious of food as their donators provide them with [25, 30]. Further, they can be used to screen for the acceptability of food donations from the public [30]. Developing partnerships with community gardens, or starting your own community garden, may be a mechanism for organizations to access fresh fruits and vegetables on a budget [31]. Another way to support those experiencing houselessness nutritionally is to offer can openers for them to keep. Further, increasing access to microwaves and stoves as methods for heating or preparing food, as well as increasing access to kitchen facilities will increase the variety of food they could consume. Organizations with brick-and-mortar locations may best be suited to pursue this, such as drop-in centers and shelters.

Initial studies have investigated the nutritional quality of food provided by charitable organizations, including an analysis by Albrecht, which found that homeless shelter directors across 17 Illinois counties reported no involvement of registered dieticians in any of their meal planning. The same shelter directors reported significant barriers to providing nutritious meals including, limited time, financial resources, and relying on volunteers to cook [25]. Similar findings have been found by Pelham-Burn and colleagues, which evaluated a single United Kingdom brick-and-mortar charitable meal organization, reported similar difficulties to providing nutritious foods to the unhoused including having a limited budget, limited food availability that relies on outside donations, desiring to maintain traditional flavor palates, and having misconceptions about what is nutritious [32]. The same authors reported that a minority of the meals served met suggested micro or macronutrients [32]. More work in this area of exploring how well organizations are providing nutritious food options continues to be ongoing [19].

Lastly, our work demonstrates the utility that medical students have in the advancement of social programming. As reported by King and colleagues, the houseless believe medical students can best support them through listening, combating the stigma of homelessness, participating in a multitude of clinical experiences, and advocating for improvements at the institutional level [33]. Based on the collective findings of our cross-sectional study, we advocate that programs and organizations which provision food to the unhoused should be aware of the dietary insufficiencies and nutritional barriers the unhoused experience.

In terms of limitations, this pilot study’s modest sample size limits the generalizability of our findings. Further, this study captures the experiences and attitudes of those experiencing houselessness on the streets of downtown Chicago, Illinois. Thus, the participants may not capture differences in nutritional profiles based on location or more specific types of dwelling. The study is limited by the scope of the survey questions utilized, which may not account for all nuanced factors affecting nutrition. Importantly, the scope of the survey questions did not include demographic information, preventing our ability to determine factors that may correlate with the findings we describe and further prohibits the generalizability of this study.