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.
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.
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.
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:
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.
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.
Studies show significant eating disorder behaviors among adolescents and adults with food insecurity.
The first studies to examine the association between food insecurity and diagnosed eating disorders also show a strong association.
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.
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.
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:
A patient screens positive for food insecurity if the response is “often true” or “sometimes true” to either or both of the statements.
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.
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:
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.
Three primary federal resources include:
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).
Other assistance is available at the state, county, and/or city level. Look online and in your neighborhood for support via:
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.
Copyright © 2019 - Emily Program. All rights reserved.