Food Insecurity and Eating Disorders

Eating disorders are complex illnesses. Diverse and multifaceted, they are associated with biological, psychological, and social factors that themselves are complex and interact with one another in complex ways.

One factor often overlooked in conversations about eating disorder development, illness, and recovery is food insecurity. Research about the link between food insecurity and eating disorders has emerged in recent years, as food insecurity has likewise seeped into the public consciousness more generally.  

This article describes what we know about food insecurity and eating disorders to date, how to screen for food insecurity, and how to integrate food insecurity support into eating disorder treatment and recovery. By addressing food insecurity in patients with eating disorders (and eating disorders in patients experiencing food insecurity), providers can play a critical role in intervening and supporting those dually affected.

What is food insecurity?

Food insecurity, as defined by the USDA, is the “limited or uncertain availability of nutritionally adequate and safe food” or the “limited or uncertain ability to acquire acceptable foods in socially acceptable ways.” Assessed on a household level, food insecurity is influenced by multiple factors and occurs at different levels of severity.  

Food insecurity is multi-dimensional.

The four basic components of food security are food availability, access, stability, and utilization. A household is considered to be experiencing food insecurity when any one dimension is threatened or unmet.

1. Availability: Is there adequate food available? Does the household have a sufficient supply of food of an appropriate quality?
2. Access: Is food physically and economically accessible? Does the household have the resources to purchase or acquire food?
3. Stability: Is there a risk of losing access or availability over time?
4. Utilization: Can the food be used appropriately? Can the household prepare, consume, and store the food to meet its needs?

Food insecurity occurs at different levels of severity.

Though we tend to think of food insecurity at only its most severe level, it exists along a spectrum that ranges from food-secure situations to food-insecure ones. Within the range are multiple opportunities for identification and intervention.

The USDA outlines the following four ranges of food security:

1. High food security: Household reports no food access problems or limitations.
2. Marginal food security: Household reports problems or anxiety at times about accessing adequate food, but the quality, variety, and quantity of food were not substantially reduced.
3. Low food security: Household reports that the quality, variety, and desirability of their diets were reduced, but the quantity of food intake and normal eating patterns were not substantially disrupted.
4. Very low food security: Household reports that the eating patterns of one or more of its members were disrupted and food intake was reduced because the household lacked money or resources for food.

Food insecurity is increasing due to COVID-19.

Rates of food insecurity had been falling before 2020, but the pandemic and its associated economic fallout have significantly driven them up. The number of households experiencing food insecurity is increasing across the country, and COVID-19 has only worsened the problem in locations already experiencing high rates.

Food Insecurity and Eating Disorders

Growing research is revealing a link between food insecurity and eating disorders. The studies to date, though limited, show clear indications of overlapping experiences of food insecurity and disordered eating and eating disorders.

Food Insecurity and Disordered Eating Behaviors

Studies show significant eating disorder behaviors among adolescents and adults with food insecurity.

• People living with high levels of food insecurity report higher levels of binge eating, a higher likelihood of having any type of eating disorder, dietary restraint for any reason (e.g., avoiding a food group or types of food), weight self-stigma, and high levels of worry (Becker, Middlemass, Taylor, Johnson, & Gomez, 2017)
• Adult food pantry clients report higher eating disorder symptoms, including vomiting, laxative/diuretic use, fasting, and intense exercise (Becker, Middlemass, Taylor, Johnson, & Gomez, 2017; Becker, Middlemass, Gomez, & Martinez-Abrego, 2019)
• Adolescents in households experiencing food insecurity report higher rates of compensatory behaviors, including laxative/diuretic use, fasting, skipping meals to lose weight (Hooper, Telke, Larson, Mason, & Neumark-Sztainer, 2020).

Food Insecurity and Diagnosed Eating Disorders

The first studies to examine the association between food insecurity and diagnosed eating disorders also show a strong association.

• Food insecurity is associated with binge eating disorder (Rasmusson, Lydecker, Coffino, White, & Grilo, 2019) and bulimia (Lyndecker & Grillo, 2019).
• People with a history of childhood food neglect are more likely to have binge eating disorder, bulimia, or anorexia than those without childhood food neglect (Coffino, Grilo, & Udo, 2020)

These food insecurity studies align with what we know about eating disorders more generally. Limited food intake—for any reason—and fluctuating food availability are known to increase eating disorder pathology. As food intake decreases during periods of scarcity (or other periods of restriction or starvation), it is likely to increase drastically during periods of abundance or availability. Restriction often leads to overeating.   

Taken together, the research findings provide a foundation for future research and highlight the need to address eating disorders and food insecurity as issues that can overlap. There is a clear need to screen for eating disorders in people experiencing food insecurity and to screen for food insecurity in people experiencing eating disorders.

Screening for Food Insecurity

The following two screening tools can be integrated into your clinical work to identify and intervene in situations where patients are experiencing food insecurity. Both are validated in multiple populations and can be used in conjunction with other general screening measures or provider-patient conversations about eating.

Hunger Vital Sign™

The Hunger Vital Sign™ is a simple two-question screener. For each statement below, a patient responds whether the statement was “often true,” “sometimes true,” or “never true” for their household in the last 12 months:

1. “Within the past 12 months, we worried whether our food would run out before we got money to buy more.”
2. “Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.”

A patient screens positive for food insecurity if the response is “often true” or “sometimes true” to either or both of the statements.

Radimer/Cornell Food Insecurity Measure

A longer, more multi-dimensional screening tool is the Radimer/Cornell measure of food insecurity. This tool can be used as an alternative to the Hunger Vital Sign™ or a follow-up to it to glean more insight into which areas of food insecurity are influencing your patient most.

1. Do you worry that your family may run out of food before you have money to buy again?
2. Do you worry that you may not be able to afford to buy adequate food?
3. Do you wish you could buy more food if you had more money?
4. Has your family ever run out of food because you do not have more money to buy food?
5. Has your family ever eaten the same type of food for several consecutive days because you do not have enough money to buy different food?
6. Have you ever eaten less than you want because you do not have enough money to buy food?
7. Have your children, according to you, not had enough to eat because you do not have enough money to buy food?
8. Do you have enough money to buy healthy and nutritious food for your children?
9. Sometimes a person’s body weight drops because of not eating enough. Has your body weight dropped in the last year because of the lack of food?

Food Insecurity Support

Given that many people experience shame and stigma associated with food insecurity, approach these conversations with sensitivity and empathy. When a patient screens positive for food insecurity, document it in the patient’s electronic health record (EHR) and be prepared to connect the patient to resources.

Case studies show that a two-prong approach to providing resources is most impactful:

1. Providing food or financial support at the moment of detection, AND
2. Providing a list of resources or programs to support the patient’s longer-term needs

At The Emily Program, we currently provide groceries and gift cards to clients experiencing food insecurity via our Food and Supplement Assistance program. This immediate support is paired with opportunities for seeking grant assistance, such as that provided by eating disorder foundations like WithAll, or for federal and local support.

Federal Resources

Three primary federal resources include:

• Supplemental Nutrition Assistance Program (SNAP): Monthly benefits for purchasing food using an EBT card
• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): Nutritionally tailored food packages for pregnant, breastfeeding, and postpartum women, infants, and children up to age five
• The Emergency Food Assistance Program (TEFAP): Emergency food distributed through local food pantries and organizations

Other programs cater to children in households experiencing food insecurity, including the National School Lunch Program (NSLP), Afterschool Nutrition Programs, Summer Nutrition Programs, and the Child and Adult Care Food Program (CACFP).

Local Resources

Other assistance is available at the state, county, and/or city level. Look online and in your neighborhood for support via:

• Food shelves and banks
• Community assistance programs
• Large hunger programs

Recovery Support

The support for patients experiencing food insecurity and eating disorders doesn’t end when your patient is provided a bag of groceries or gift card for purchasing food. At that point, the support shifts to helping the patient incorporate the food into their treatment and recovery.

How will they manage the triggers associated with a fluctuating food supply? What support do they need to handle food preparation and storage? How will they fit unfamiliar foods into their meal plans and family menus?

As part of a full eating disorder treatment team, a dietitian can help with meal planning and food preparation skills, as well as education about how a variety of foods can be used to meet the client’s needs in recovery.

If you are concerned about an eating disorder in a patient experiencing food insecurity or food insecurity in a patient experiencing an eating disorder, The Emily Program can help. Submit a referral online or by calling 1-888-364-5977 today.