Relative to high-FI states, low-FI states had more sociopolitical indicators with intended positive public health impacts. Notably, low-FI states had both proximal sociopolitical indicators aimed to improve food access and distal factors influencing inequalities and substance use, which may have had beneficial spillover effects on FI. Thus, findings suggest that FI mitigation efforts should apply a systems perspective^(45,46) and consider population-level strategies to increase financial resources, reduce disparities and regulate substance use in addition to strengthening food access. These insights may have implications not only for the USA but globally, as well.

FI mitigation efforts should consider which factors (i.e. proximal, inequality or substance use-related regulations) amplify or reduce FI and the magnitudes of their effects, individually and in the context of other factors. These considerations may explain unexpected findings; for instance, low-FI states like SD or VA have some sociopolitical indicators with low scores for their intended positive public health impacts (such as for SNAP participation rates, wage gap and tobacco regulations). Relatedly, it is important to understand how multiple indicators within the same category may impact FI. For instance, although OK and LA have high SNAP participation rates among eligible participants, they have high FI. It is possible that, despite SNAP participation, poor food environments (which relate to income and healthy food proximity) are more powerful determinants of FI rates in these states. Such differences may also suggest potentially unmeasured or interacting indicators that might influence FI. Thus, future research investigating the magnitude of the impact of these intersecting indicators on FI is warranted.

Notably, findings suggest that non-food-related sociopolitical indicators (that are not traditionally targeted by FI-related policies) may be important in addressing FI, underscoring the increasingly urgent need to prioritise cross-sector policy initiatives. This research reinforces the importance of a Health in All Policies⁽⁴⁷⁾ approach, an integrated policymaking framework that considers health implications across all sectors to improve population outcomes⁽⁴⁸⁾. Thus, as FI rates continue to rise, sustainable FI mitigation efforts are crucial and must prioritise coordinated action across multiple government agencies and sectors to advance relevant policy initiatives. These may include enhancing healthy food access, expanding SNAP budgets, minimum wages and Medicaid coverage, promoting health equity and strengthening public health protections like substance-related regulations^(47,49).

Some aspects of this study warrant careful consideration. Study limitations include an ecological analysis of a small subset (n 25) of US states. Thus, findings may not generalise to other states, levels (e.g. individual, local) or international settings. Furthermore, due to the small sample size, we relied on bivariate analyses and did not account for unmeasured heterogeneity across states or potential confounders, for example, other state-level sociopolitical factors (e.g. substance use recovery programme accessibility or SNAP implementation features). Additionally, this study’s cross-sectional, exploratory nature precludes causal inference. Finally, despite use of robust data sources, some sociopolitical indicators may not fully or accurately reflect each state’s complex policy landscapes. Considering these limitations, patterns identified between sociopolitical environment and FI must be interpreted with caution.