Recent Research on Food Security and its Connection to Health and Well-Being from Food Research and Action Center and Children’s Healthwatch

Food insecurity exists when people do not have access, at all times, to enough nutritious food to support an active and healthy life.¹ In 2012, 14.5 percent of all households and 20 percent of households with children in the U.S. were food insecure.¹

As detailed in this brief, these alarming food insecurity rates have high individual and societal costs in terms of poor health and reduced well-being. This article looks particularly at research findings related to diabetes, HIV, and mental health as well as general health and well-being.

Food Security as a Crucial Factor in Understanding Health and Well-Being

Food insecurity negatively affects dietary intake and increases stress,^1,2 which can compromise health and well-being. Moreover, because of limited resources, people in food insecure households often are forced to choose between food and medication,^3,4 postpone preventive or needed medical care,^5,6 or forgo the foods needed for special medical diets (e.g., diabetic diets).⁷ Berkowitz and colleagues⁸ show that, in general, one out of three chronically ill adults is unable to afford medicine, food, or both. Such forced choices can exacerbate disease and compromise health, leading to increased expensive physician visits, emergency room visits, and hospitalizations.^5,9

Consequently, food insecurity is associated with a variety of negative health and well-being outcomes. For example, adults in food insecure households are more likely to have poor or fair health,¹⁰ reduced nutrient intake,¹¹ be overweight,^12,13 and have a lower quality of life.¹⁴ Children in food insecure households are more likely to have poor health,^15,16 behavior problems,¹⁷ frequent stomachaches and headaches,¹⁸ and worse developmental outcomes.¹⁹

Furthermore, food insecurity is associated with a number of costly chronic diseases, often directly, but also indirectly through stress- or diet-dependent pathways.^20,21 For example, food insecurity might cause a person to rely on foods that are less nutritious, which can increase his/her risk for heart disease.²² Or, food insecurity might cause increased stress, which can negatively impact mental health.² Recently, in particular, more attention has been placed on associations between food insecurity and, respectively, diabetes, HIV, and mental health. The following discussion summarizes the latest developments in research on the associations between food insecurity and these three chronic conditions.

Feast, Famine, or Nutrient Poor: How Food Insecurity and Diabetes are Related

A number of studies show those who are food insecure are more likely to have diabetes,^23,24 low blood sugar,²⁵ and a more difficult time keeping blood sugar levels in an acceptable range.²⁵ For instance, Ding and colleagues²⁶ found that men who were food insecure were more likely to have prediabetes compared to men who were food secure. It has been observed that food insecurity induces “feast and famine” cycles in which individuals eat more when food is abundant but then reduce intake when food supplies are depleted, which may negatively impact diabetes-related outcomes. Seligman and colleagues²⁷ provide evidence for this hypothesis: they found that hospital admissions for low blood sugar are higher at the end of the month for low-income individuals than high-income individuals, suggesting that people are more likely to have low blood sugar at the time that food resources, including SNAP and other benefits, are most likely to be depleted. Another hypothesis for poor outcomes is that people who are food insecure are more likely to purchase a low-cost diet that relies on energy-dense but nutrient-poor foods. While the specific mechanism requires further investigation, the association between food insecurity and diabetes and poor diabetes-related outcomes is apparent and an active area of research.

Tough Decisions: Treating HIV or Having Enough to Eat

A growing body of research demonstrates an association between food insecurity and incomplete viral suppression among adults that are HIV positive. For example, Mendoza and colleagues²⁸ found that children who were food insecure and HIV positive had incomplete viral suppression and decreased CD4 counts (a marker of immune response to HIV). Like many others with chronic diseases, those who are food insecure and HIV positive often have to make difficult decisions between taking their medicine or having enough to eat. Those who are food-insecure and HIV positive also may not be able to eat a healthy and nutritious diet that would support immune system health. While nationwide statistics are not available, those living with HIV likely have higher rates of food insecurity compared to the general population,^29,30 which is a concern as HIV positive individuals already face many negative outcomes for their health and well-being.

Stressed Out: Food Insecurity and its Relation to Mental Health

Food insecurity is associated with distress which can cause or exacerbate existing mental illnesses. For example, Tarasuk and colleagues³¹ show that those classified as experiencing “severe” food insecurity are over three times as likely to have a mood or anxiety disorder. This is consistent with other work that shows adolescents living in a food insecure household are more likely to have a mood or anxiety disorder.³² Another recent study found that mothers who were depressed and experienced intimate partner violence (IPV) were more likely to be food insecure over time compared to those who were not depressed and did not experience IPV.³³ Finally, more research is focusing on understanding how stress, mental illness, and food insecurity all act in association with many of the observed negative outcomes related to food insecurity, such as behavioral problems in children, overweight, and poor academic achievement.³⁴

Improving Food Security to Protect Health and Well-Being

As summarized above, new research links food insecurity to a greater incidence of a range of chronic diseases such as diabetes, HIV, and poor mental health. These are expensive conditions in terms of health care costs, lost wages and productivity, and poor quality of life. While the impacts of food insecurity on health and well-being are both well-known and documented, there has not been an adequate response in the U.S. to eliminate food insecurity and its consequences. While the federal nutrition programs, most notably the Supplemental Nutrition Assistance Program (SNAP), have been crucial in improving food security during the Great Recession among low-income populations, there is an ongoing threat of worsening food insecurity if appropriate measures are not taken. And just last year, the Institute of Medicine declared SNAP benefits were too low to support a healthy and active life.³⁵

Increasing SNAP benefits and access to the program are critical to the nation’s success in eliminating food insecurity and its consequences.³⁶ But so too are a variety of other strategies,³⁷ such as increasing access to child nutrition programs, and expanding the Earned Income Tax Credit. Given all that is known about the wide-ranging effects of food insecurity, such approaches to help achieve food security for all in the U.S. will also, by extension, help improve the health and well-being of low-income populations, reduce health care spending, and increase worker productivity.

References
¹Coleman-Jensen A, Nord M, Singh A. Household Food Security in the United States in 2012. U.S Department of Agriculture, Economic Research Service, 2013;(155).
²Siefert K, Heflin CM, Corcoran ME, Williams DR. Food insufficiency and physical and mental health in a longitudinal survey of welfare recipients. J Heal Soc Behav Soc Behav. 2004;45(2):171–186.
³Biros MH, Hoffman PL, Resch K. The prevalence and perceived health consequences of hunger in emergency department patient populations. Acad Emerg Med. 2005;12(4):310–317.
⁴Sullivan AF, Clark S, Pallin DJ, Camargo CA. Food security, health, and medication expenditures of emergency department patients. J Emerg Med. 2010;38(4):524–528..
⁵Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21(1):71–77.
⁶Ma CT, Gee L, Kushel MB. Associations between housing instability and food insecurity with health care access in low-income children. Ambul Pediatr. 2008;8(1):50–7.
⁷Seligman HK, Jacobs EA, López A, Tschann J, Fernandez A. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care. 2012;35(2):233–238.
⁸Berkowitz SA, Seligman HK, Choudhry NK. Treat or Eat: Food insecurity, cost-related medication underuse and unmet needs. Am J Med. 2014;127(4):303–310.
⁹Nelson K, Cunningham W, Andersen R, Harrison G, Gelberg L. Is food insufficiency associated with health status and health care utilization among adults with diabetes? J Gen Intern Med. 2001;16(6):404–411.
¹⁰Stuff JE, Casey PH, Szeto KL, et al. Household food insecurity is associated with adult health status. J Nutr. 2004;134(9):2330–2335.
¹¹Rose D. Economic determinants and dietary consequences of food insecurity in the United States. J Nutr. 1999;129(2S Suppl):517S–520S.
¹²Adams EJ, Grummer-Strawn L, Chavez G. Food insecurity is associated with increased risk of obesity in California women. J Nutr. 2003;133(4):1070–1074.
¹³Townsend MS, Peerson J, Love B, Achterberg C, Murphy SP. Food insecurity is positively related to overweight in women. J Nutr. 2001;131(6):1738–1745.
¹⁴Vailas LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. J Am Diet Assoc. 1998;98(5):548–553.
¹⁵Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134(6):1432–1438.
¹⁶Weinreb L, Wehler C, Perloff J, et al. Hunger: its impact on children’s health and mental health. Pediatrics. 2002;110(4):e41. doi:10.1542/peds.110.4.e41.
¹⁷Slack KS, Yoo J. Food hardship and child behavior problems among low-income children. Soc Serv Rev. 2013;79(3):511–536.
¹⁸Alaimo K, Olson C. M, Frongillo EA, Briefel RR. Food insufficiency, family income, and health in US preschool and school-aged children. Am J Public Health. 2001;91(5):781–786.
¹⁹Jyoti DF, Frongillo EA, Jones SJ. Food insecurity affects school children’s academic performance, weight gain, and social skills. J Nutr. 2005;135(12):2831–2839.
²⁰Miller GE, Chen E, Parker KJ. Psychological stress in childhood and susceptibility to the chronic diseases of aging: moving toward a model of behavioral and biological mechanisms. Psychol Bull. 2011;137(6):959–997.
²¹McCullough ML, Feskanich D, Stampfer MJ, et al. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr. 2002;76(6):1261–1271.
²²Ford ES. Food security and cardiovascular disease risk among adults in the United States: Findings from the national health and nutrition examination survey, 2003-2008. Prev Chronic Dis. 2013;10(11):E202.
²³Laraia BA, Siega-Riz AM, Gundersen C. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain, and pregnancy complications. J Am Diet Assoc. 2010;110(5):692–701.
²⁴Seligman HK, Bindman AB, Vittinghoff E, Kanaya AM, Kushel MB. Food insecurity is associated with diabetes mellitus: Results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999-2002. J Gen Intern Med. 2007;22(7):1018–1023.
²⁵Seligman HK, Davis TC, Schillinger D, Wolf MS. Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. J Health Care Poor Underserved. 2010;21(4):1227–1233.
²⁶Ding M, Wilson N, Garza B, Zizza A. Undiagnosed prediabetes among food insecure adults. Am J Health Behav. 2014;38(2):225–233.
²⁷Seligman HK, Bolger AF, Guzman D, López A, Bibbins-Domingo K. Exhaustion of food budgets at month’s end and hospital admissions for hypoglycemia. Health Aff. 2014;33(1):116–123.
²⁸Mendoza J a, Paul ME, Schwarzwald H, et al. Food insecurity, CD4 counts, and incomplete viral suppression among HIV+ patients from Texas Children’s Hospital: a pilot study. AIDS Behav. 2013;17(5):1683–7.
²⁹Weiser SD, Fernandes KA, Brandson EK, et al. The association between food insecurity and mortality among HIV-infected individuals on HAART. J Acquir Immune Defic Syndr. 2009;52(3):342–349.
³⁰Kalichman SC, Cherry C, Amaral C, et al. Health and treatment implications of food insufficiency among people living with HIV/AIDS, Atlanta, Georgia. J Urban Heal Bull New York Acad Med. 2010;87(4):631–641.
³¹Tarasuk V, Mitchell A, McLaren L, McIntyre L. Chronic physical and mental health conditions among adults may increase vulnerability to household food insecurity. J Nutr. 2013;143(11):1785–1793.
³²McLaughlin KA, Green JG, Alegría M, et al. Food insecurity and mental disorders in a national sample of U.S. adolescents. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1293–303.
³³Hernandez DC, Marshall A, Mineo C. Maternal depression mediates the association between intimate partner violence and food insecurity. J Women’s Heal. 2013;23(1):29–37.
³⁴Nord M. What have we learned from two decades of research on household food security? Public Health Nutr. 2013;17(01):2–4.
³⁵Institute of Medicine. Supplemental Nutrition Assistance Program Examining the Evidence to Define Benefit Adequacy. (Caswell JA, Yaktine AL, eds.). Washington, DC: Institute of Medicine and the National Research Council, Committee on National Statistics, Food and Nutrition Board; 2013.
³⁶Hartline-Grafton H. SNAP and Public Health: The Role of the Supplemental Nutrition Assistance Program in Improving the Health and Well-Being of Americans. Washington, DC: Food Research and Action Center; 2013:1–12.
³⁷Food Research and Action Center. Ending Childhood Hunger by 2015: The Essential Strategies for Achieving the President’s Goal. Washington, DC: Food Research and Action Center; 2009:1–8.