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The Cost of Hunger Physical and Psychological Effects of Food Insecurity

mcdouble $1.00 360 calories

apple $ 0 .75 95 calories

The Cost of Hunger Physical and Psychological Effects of Food Insecurity




introduction 9








physical effects 19

Obesity Statistics


The Role of Energy Density and Energy Costs


Long Term Implications for Eating Patterns and Body Weight

psychological effects 39

Maternal Depression and Behavior Problems in Preschoolers


Attachment and Mental Proficiency in Toddlers


Mental Disorders in Teenagers

Conclusion 57

Summary and Implications


Introduction The phenomenon loosely labeled hunger in the 1980s is now being discussed as food security or insecurity. At a minimum it includes the following: The ready availability of nutritionally adequate and safe foods, and the assured ability to acquire personally acceptable foods in a socially acceptable way. The order of these qualifications reflects the current degree of consensus. The definition explicitly includes every person at all times; even though defining a situation that seems to be unattainable may seem counterproductive, a less inclusive definition cannot be justified on either ethical or nutritional bases. “Enough food for an active, healthy life” implies a diet with sufficient energy, nutritional quality and safety to prevent diet mediated malnutrition or limitations in activity levels. Food insecurity includes limited or uncertain access. “Socially acceptable ways” refer to conventional food sources such as grocery stores, restaurants and government food assistance programs “Personally acceptable” is included to reinforce the value our society places on freedom of choice; in practice, freedom of choice differentiates how cattle are fed from how humans acquire food.


Food insecurity is the inability to access enough food for a healthy and active lifestyle.


i n t r o d u cti on

Food Insecurity Statistics food security status in us households, 2011

9. 2% low food security 5 .7 % very low food security


f ood in s ec u rit y s tat is t ic s

percent of food insecure households in 2010

household composition with children < 6 yrs 2 1 .9 %

married-couple families 1 3 .9 % female head, no spouse 36 . 8 % male head, no spouse 24 . 8 %

race of households white 1 5 .5% african-american 29. 2%

hispanic 32 . 3%

household income-to-poverty ratio under 100% 45 . 2% under 130% 43 .5% under 185% 4 0 . 3% 185% and over 8 %

area of residence inside metropolitan area 20 . 3% in principal cities 24 . 2% not in principal cities 1 7.9 % outside metropolitan area 2 2%

geographic region northeast 1 8 .5% midwest 1 7. 3% south 2 1 .9 % west 2 3%



20 %

30 %



i n t r o d u cti on

Measuring Food Security Household food security is often measured with the 18-item USDA Household Food Security Scale (left). According to the USDA, households are classified as food insecure if they answer greater than three affirmative responses out of 18 total questions. Families endorsing more items are classified

We worried whether our food would run out before we got money to buy more.


Sometimes Never

The food that we bought just didn’t last and we didn’t have money to get more.


Sometimes Never

as low or very low food secure. Evidence has shown that participation in food assistance programs, such as the Special Supplemental Program for Women, Infants, and Children (WIC) or the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program) reduces the prevalence of food insecurity.

We couldn’t afford to eat balanced meals.


Sometimes Never

Did you or other adults in the household ever cut the size of your meals or skip meals because there wasn’t enough money for food? Yes No

How often did this happen? (If yes to previous question)

Almost every month

Some months but not every month

Only 1 or 2 months

Did you ever eat less than you felt you should because there wasn’t enough money for food?



Were you ever hungry, but didn’t eat, because there wasn’t enough money for food?




mea s u res

Did you lose weight because there wasn’t enough

Did you ever cut the size of any of the children’s meals

money for food?

because there wasn’t enough money for food?





Did you or other adults in your household ever not eat for

Were the children ever hungry but you just couldn’t

a whole day because there wasn’t enough money for food?

afford more food?





How often did this happen? (If yes to previous question)

Did any of the children ever skip a meal because there

Almost every month

wasn’t enough money for food?

Some months but not every month

Only 1 or 2 months



(Questions 11-18 were asked only if the household included

How often did this happen? (If yes to previous question)

children age 0-17)

Almost every month

Some months but not every month

Only 1 or 2 months

We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.

Did any of the children ever not eat for a whole day


because there wasn’t enough money for food?





We couldn’t feed our children a balanced meal, because we couldn’t afford that


Sometimes Never

The children were not eating enough because we just couldn’t afford enough food


Sometimes Never


The Effects of Food Insecurity


ef f ec t s

Household food insecurity is a major U.S. public health

a partnership in which they recognize and interpret both

problem. Based on data from the U.S. Department of

verbal and nonverbal communication signals from one

Agriculture (USDA), in 2010, 14.5 percent of U.S. households

another. This process forms a basis for the emotional

(17.2 million households) were food insecure, with rates

bonding or attachment between infants and caregivers

as high as 49.9 percent for low-income, female-headed

that is essential to healthy social functioning. Parental

households with children. Although food insecurity is

responsivity is thought to provide the emotional support

associated with poverty, approximately 85 percent of food

that children need to develop internal regulatory skills and

insecure households with children had an adult who was

an interest in exploration and ongoing social interactions,

employed, suggesting that employment opportunities and

thereby leading to advances in psychosocial, cognitive and

wages are important considerations in food insecurity.

language competence. Thus, the caregiving context plays a critical role in protecting and socializing children.

Household food insecurity has been hypothesized to operate through dual pathways:

As proposed by the family stress model, families with few

1. A nutritional pathway, characterized by deficits in the

economic resources may be forced to make difficult choices

among basic needs, such as food, housing, energy and health

quantity and quality of food

2. A caregiver stress pathway, characterized by depression

and anxiety related to the lack of food.

care, often resulting in frustration and emotional distress. Emotional distress, frequently manifested as symptoms of depression and anxiety, increases the number of stressors,

nutritional pathway With limited resources, food insecure families often resort to low-cost, low nutrient-dense food, as they sacrifice diet quality to ensure that they have enough food to avoid the physiological pangs of hunger. Low nutrient-dense diets may increase the risk for obesity or for micronutrient deficiencies, including iron deficiency. Dietary data have shown that

interferes with caregiving practices and adversely impacts children’s well-being. Household food insecurity has been associated with caregiver depression and anxiety and with the resulting poor caregiving practices that have been shown to lead to deficits in both mental development and attachment.

children from low-income food insecure households consume fewer calories, carbohydrates and fruits, and have higher cholesterol values than their food secure, higherincome peers. In addition food insecure-exposed children consume fewer fruits, dark green vegetables, grains, yogurt, nuts, seeds, and dried beans and peas, but more sugar and eggs than children from food-secure households, illustrating that the quality of children’s diets differ as a function of their food security status.

caregiver depression and anxiety pathway Most of the research on food insecurity has been crosssectional. However, several longitudinal investigations into the mechanisms linking household food insecurity with children’s health and development have used the Early Childhood Longitudinal Study, which includes the USDA Household Food Security Scale. Two studies found that food insecurity operates through maternal depression and parenting to negatively impact children’s mental development and attachment and to promote overweight by 24 months. Early in life, children and caregivers establish


Physical Effects Among women, food insecurity without hunger appears to be associated with obesity. Analyses of NHANES III data showed that women, but not men, in food-insufficient households were more likely to be overweight than were food-sufficient women (58% compared with 47%). In another study, food-insecure women were more than ten pounds heavier on average than was the comparison group. Whereas links between food insecurity and lower diet quality might be expected, the association between food insecurity and obesity was something of a paradox. Given that low-income families are the chief beneficiaries of food-assistance programs, exploration of the causal connections between food insecurity and obesity has major implications for food and nutrition policies in the United States.


Food insecurity and obesity appear to be linked.


p hys i ca l e ffe c ts

Obesity Statistics Estimated Percentage of US Adults by BMI

6 . 3% extremely obese

31 . 2% obese

35 .7 % overweight


adult bmi specifications normal

1 8 .5 –24 .9


25 –29.9


30 – 4 0

extremely obese

40 +

obes it y s tat is t ic s

obesity percentages in america by Poverty-to-income ratio (pir) pir more than 350%

pir 130%â&#x20AC;&#x201C;350%

pir less than 130%

44.5% 40% 40.8%



34.6% 32.2%


30.5% 29.9%

30.1% 28.5%



0% men





54.7% 51.6% 47.6% 45.5% 44.9%


40% 39%


39.2% 34.5%

29% 27.5%


0% women






The Role of Energy Density Costs


t he rol e of en ergy d en s it y c os t s

energy-density cost framework In 1992, Basiotis hypothesized and confirmed a behavioral model in which household members faced with diminishing incomes first consumed less expensive foods to maintain energy intakes at a lower cost. To multiple-choice questions about food sufficiency, these participants responded â&#x20AC;&#x153;enough but not the kinds of food we want to eat,â&#x20AC;? which implied adequate energy intakes but a limited range of food choices. Only when incomes diminished still further did households reduce dietary energy to intakes below daily requirements, which resulted in overt deprivation. Food restriction at home first occurs in adults because parents typically turn over their own food to children when resources are scarce. In the present framework, the association between poverty and obesity is mediated, at least in part, by the low cost of energy-dense foods, which may in turn promote overconsumption. The hypothesis is that energy density and energy costs are inversely linked, such that the selection of energy-dense foods by food-insecure or low-income consumers may represent a deliberate strategy to save money. Analogous to the findings of Basiotis, persons attempting to limit food costs will first select less expensive but more energy-dense foods to maintain dietary energy. The energy-cost curve linking food costs with dietary energy density and energy intakes is shown below. As food costs diminish further, dietary energy density rises, and total energy intakes may actually increase. Some of the evidence linking dietary energy density with higher energy intakes is outlined in the following pages.

Energy-density cost curve as food costs diminish further, dietary energy density rises, and total energy intakes may actually increase.

energy density

food energy food energy requirement $$$



p h y s i ca l e ffe c ts

energy density and cost of selected foods

high energy density means low energy costs

x axis represents energy cost (dollars per 2400 calories) y axis represents energy density (calories per gram)

Developments in agriculture and food technology have made energy-dense foods accessible to consumers at a very low cost. The relation between the energy density (MJ/kg) of selected foods and their energy cost (cents/10 MJ) is shown on the left. Energy density values were taken from food composition tables and from Rolls and Barnett, whereas energy costs were based on supermarket prices in Seattle collected in the winter of 2003. The energy cost of cookies

9. 6

or potato chips was about 1200 Calories per dollar, whereas


that of fresh carrots was about 250 Calories per dollar. The shortening

energy cost of soft drinks was, on average, 875 Calories per dollar, whereas that of orange juice from concentrate was 170 Calories per dollar. Fats and oils, sugar, refined grains, potatoes, and beans represented some of the lowest-cost options and provided dietary energy at minimal cost. As indicated by the logarithmic scale, the differential in energy


7. 2

costs between sugar and strawberries was in the order of


several thousand percent. The hierarchy of food prices is such that dry foods with a stable shelf life are generally less costly than are perishable chocolate

meats or fresh produce with a high water content. As a


rule, potato chips, chocolate, and locally bottled soft drinks provide dietary energy at a lower cost than do naturally hydrated lean meats, fish, and fresh vegetables and fruit. Energy-dense foods may contain a relatively high proportion 4.8

of refined grains, added sugars, and vegetable fats.





ground turkey 2.4


beans rice frozen fish

strawberries lettuce $1

$. 1 0 grains


fruits & vegetables


meat & protein

$1 0 fats & sweets

t he rol e of en ergy d en s it y c os t s

The current US diet derives close to 50% of energy from added sugars and fat. Data from the Economic Research Service of the USDA show that the per capita availability of caloric sweeteners and fats and oils each increased by about 20% between 1977 and 1997. Retail price increases during that time were much lower for sweets and fats than for vegetables and fruit. Other studies have shown that foods identified as accounting for the greatest increase in energy intake by Americans during that time were salty snacks, desserts, soft drinks, fruit drinks, hamburgers and cheeseburgers, Mexican food, and pizza. In 1977–1978, these foods combined accounted for 18.1% of the dietary energy consumed by Americans and for 27.7% of energy in 1994–1996. For the most part, many such foods are composed of refined grains, added sugars, and fats. Studies on dietary choices leading to obesity have focused overwhelmingly on the sugar and fat content of snacks, fast foods, beverages, and confectionery. Epidemiologic studies have linked diets composed of fats and sweets, potatoes, and refined grains with higher glycemic indexes and a higher risk of obesity and type 2 diabetes. Obese patients were accordingly advised to replace fats and sweets with a more prudent dietary pattern characterized by a high intake of fruit, vegetables, whole grains, poultry, and fish. Among public health measures for the prevention of obesity are the need to restrict the consumption of energy-dense snacks and sugar-sweetened soft drinks and to increase the consumption of whole grains and energy-dilute vegetables and fruit. The inverse relation between energy density and energy cost suggests that “obesity-promoting” foods are simply those that offer the most dietary energy at the lowest cost. Given the differential in energy costs between energy-dense and energy-dilute foods, the advice to replace fats and sweets with fresh vegetables and fruit may have unintended economic consequences for the consumer.


p hys i ca l e ffe c ts

the healthy eating index Prices and incomes affect food choices, dietary habits, and diet quality. The Healthy Eating Index (HEI)—a 12-component,

Health disparities among US population groups are related to inequalities in SES. Some of these disparities may be mediated by an unequal access to a healthy diet. Whereas “good” diets were associated with higher education and

100-point scale developed by the USDA—is a measure of the

incomes, “poor” diets were associated with overweight.

quality of the total diet. The first 8 components measure

In USDA studies, female CSFII respondents aged older than

the degree to which a given diet conforms to the food guide

19 years with “poor” diets had a BMI of 26.4 compared with

pyramid in the consumption of grains, vegetables, fruits,

24.8 for females whose diets were “good.” For males, “poor”

milk products, and meat. The next 4 components measure

diets were associated with a BMI of 26.8, as opposed to

fat, saturated fat, cholesterol, and sodium intakes as well

25.7 for “good” diets.

as the variety of foods in the diet. An HEI score of 80 implies a “good” diet, a score between 51 and 80 implies that a diet “needs improvement,” and a score less than 51 indicates a “poor” diet.

The effect of SES variables on diet quality has normally been ascribed to a higher educational level or to a greater awareness of health issues among higher-income respondents. However, nutrition knowledge alone does not

Income disparities had more of an effect on diet quality than

necessarily lead to a healthy diet. Another possibility is that

on total energy intakes. HEI scores improved with increasing

healthier diets cost more and are beyond the reach of many

age, education, and income. HEI scores were higher for the

low-income families.


wealthier and better-educated groups. Education had a stronger effect on diet quality than did incomes. Strong 66.5

associations between higher household incomes and higher quality diets were also obtained in studies conducted in Canada, France, the United Kingdom, and other countries of the European Union. Women reporting food insecurity had lower quality diets. Mean HEI scores in the 1988–1994 NHANES III data set were 58.8 for women in food-insecure households compared with 62.7 for women in food-sufficient households. Foodinsecure women had lower HEI component scores for fruit


(2.2 compared with 3.4), vegetables (5.1 compared with 5.8), milk (5.2 compared with 6.1), and food variety (6.4. compared with 7.3) and were less likely to comply with the cholesterol


guidelines (7.4 compared with 8.2). Women in food-insecure households consumed the same amount of energy as did women in food-sufficient households (1959 compared with 1868 kcal/d). Although the energy density of the diet was not calculated, energy-dense diets are those that contain the least fruit, vegetables, and milk. Limited economic resources appeared to have an adverse effect, not so much on dietary energy, but rather on the overall quality and, potentially, the energy density of the diet.

< 12 yrs

1 2–1 6

hei scores by education



> 16

t he rol e of en ergy d en s it y c os t s

Healthy Eating Index Components 1. Total fruit (includes 100% juice) 2. Whole fruit (not juice) 3. Total vegetables 4. Dark green and orange vegetables and legumes 5. Total grains 6. Whole grains 7. Milk 8. Meat and beans 9. Oils 10. Saturated fat 11. Sodium 12. Calories from solid fat, alcohol, and added sugar



64% 63.8

62.5 62% 61.8





56% 0–50

51–1 0 0

1 01–1 30

1 31–20 0


30 0

hei scores by % of pir


p hys i ca l e ffe c ts

Women in the healthiest diet group spent an additional $1,000 per year on food, with vegetables and fruit accounting for the largest amount of the cost. Yet almost 71% in the healthiest diet group and 60% in the least-healthy group did not agree that it was more expensive to eat a healthier diet, contrary to evidence obtained from the study itself.


t he rol e of en ergy d en s it y c os t s

do healthy diets cost more?

and other fruit; and carbonated sodas. The proportion of women consuming salads and fruit on a given day was

Data from the Bureau of Labor Statistics indicate that

double for the highest-income group relative to the

income disparities do affect diet quality. Food purchases

lower-income group.

made by high-income households differed markedly from those made by low-income households. In 1992, households

Observational data on the costs of freely chosen diets

in the top quintile by income spent $1997/person (2.6% of

are limited. The Consumer Expenditure Survey, conducted

total expenditures) for food, compared with $1249 (18.7%)

by the Bureau of Labor Statistics, collects household data

spent by those in the bottom quintile. Wealthier households

on food expenditures for the Consumer Price Index. The

bought higher-quality meats, more fish and seafood,

USDA CSFII provides data on individual food consumption

more fruit and vegetables, and more convenience foods.

and nutrient intakes. The Consumer Expenditure Survey does

Despite buying lower-cost items, poor households devoted

not report quantities of foods purchased, whereas the CSFII

a far greater share of their disposable income to food. Their

does not collect data on the cost of the foods consumed.

level of satisfaction with the perceived quality of the diet

Neither database can provide information about diet quality

was not reported.

in relation to diet costs. The USDA Food Stamp Survey does report food use and food price data but it is limited to

To achieve a healthy diet it may be necessary to spend

food-assistance recipients. Further studies on diet quality

more money. The UK Women’s Cohort Study is one of the

in relation to diet costs represent a major research need.

few observational studies to have explored food costs,

As yet, there are no data that would allow us to link all of

perceived and actual, in a study cohort of 15,191 women

the dietary and economic variables into a causal chain.

aged 35–69 years. Women in the healthiest diet group spent an additional 617 pounds sterling (≈$1000) per year on food

In the absence of large-scale community studies, few

relative to the least-healthy diet group, with vegetables

intervention studies purport to show that healthful diets

and fruit accounting for the largest amount of the cost.

are not more expensive than are less healthful diets. One

Yet almost 71% in the healthiest diet group and 60% in the

study, based on only 20 families with an obese 8–12-year-old

least-healthy group did not agree that it was more expensive

child undergoing treatment, and a high attrition rate (20/31)

to eat a healthier diet, contrary to evidence obtained from

showed that a decrease in family energy intakes from 1881

the study itself. Cade et al concluded that the individual

to 1338 kcal/person was indeed associated with a decrease in

assessment of diet costs was, to a large extent, a matter

diet costs from $6.77 to $5.04. However, energy costs per 1000

of subjective perception rather than of objective facts.

kcal actually increased by more than 10% (from $3.69 to $4.11). Nonetheless, the authors concluded that a more healthful

There is substantial evidence that food purchases are

diet was not more expensive than the typical American diet.

influenced by food costs. Several studies have mentioned diet costs as a barrier to dietary change, especially among low-income respondents. Dietary variety and the consumption of fresh produce were generally associated with higher food costs. In USDA studies, total energy intakes or percentage of energy from fat varied little with incomes or participation in the Food Stamp Program . In contrast, a greater dietary variety and higher consumption of vegetables and fruit were associated with higher education and higher income levels. Recent USDA/Economic Research Service analyses of food and nutrient intakes by income, defined in relation to poverty status, showed the same link between incomes and diet quality. Although there was not much difference in energy or macronutrient intakes by income and no difference in the consumption of basic commodities (milk, meat, and grains), there were major income-related differences in the consumption of (among other foods) lettuce and lettuce-based salads; melons, berries,


Long-Term Implications for Eating Patterns and Body Weight


l on g- t erm imp l ic at ion s f or eat in g pat t ern s a n d body w eight



Socioeconomic disadvantage in childhood is positively

This study aimed to understand how poverty-associated

associated with increased risk of obesity in adulthood.

food deprivation in childhood contributes to the well-known

In the Dunedin Multidisciplinary Health and Development

relationship between low socioeconomic status (SES)

Study, Poulton et al. showed that as childhood SES, body

in childhood and obesity in the adult years.

mass index (BMI) and waist-to-hip ratio at age 26 years decreased. These associations remained significant after controlling for infant health and after adding statistical controls for adult SES. Upward mobility did not eliminate the effect of low SES in childhood on adult BMI, but did modify its effect on waist-to-hip ratio. Poulton et al. state, ‘‘Research now needs to identify the key mechanisms that bring about this longitudinal association’’ between low SES in childhood and adult obesity. Our group has conducted research on food insecurity as it is experienced in food-rich countries such as the US and its relation to obesity in adult women. Food insecurity is defined as occurring ‘‘whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain.” Several teams of investigators have found a significant association between food insecurity and increased risk of overweight and obesity in women in cross-sectional studies. In the one longitudinal study covering the time period from early pregnancy until 2 years postpartum, food insecurity at the beginning of pregnancy was positively associated with major weight gain at 2 years postpartum but only in the women who were initially obese. This finding could be interpreted as suggesting that both food insecurity and obesity are influenced by a common factor. We speculated that this common factor was the experience of poverty associated food insecurity in early childhood and the eating practices and attitudes resulting from food insecurity. In a recent study of 25 overweight and obese poor white women, eating in childhood as a way to keep your mind off of your problems was mentioned as a factor contributing to weight problems in the adult years.


p h y s i ca l e ffe c ts

methods Thirty low-income, rural women with at least one child were followed for over three years with annual semi-structured interviews collecting quantitative and qualitative data. For the quantitative portion, the measures of interest were body mass index (BMI), food insecurity, eating patterns, and SES. For the qualitative portion, text from the interviews was analyzed using the constant comparative method.

grew up with low SES

grew up with low SES

those who grew up in a poor home were more likely to have bad eating habits, indicated by low hei scores.

those who grew up in a poor home were also more likely to be food insecure.




l on g t erm imp l ic at ion s f or eat in g pat t ern s a n d body w eight

results Growing up in a poor household was associated with increased risk of overweight and obesity in adulthood. Experiences of poverty-associated food deprivation in childhood appeared to super-motivate some women to actively avoid food insecurity in adulthood. It also influenced the womenâ&#x20AC;&#x2122;s current food preferences. Tremendous excitement accompanied the availability of food after periods of deprivation in both the women and their children. Some women had used food to meet emotional needs in childhood and overeating had become a generalized response to negative emotional states in the adult years.


low hei score

those who were food insecure were more likely to have bad eating habits.

participants who had bad eating habits were more likely to be overweight or obese.


72.7% OBESE


p hys i ca l e ffe c ts

a case study of the influence of early experiences on current eating patterns For some women, contemporary eating patterns associated with childhood food deprivation, particularly overeating, may evolve over time to become a more generalized response to negative emotional states. Emeline related that as a child,

“When I get nervous I’ll eat a lot, I’ll eat a lot. And then when I’m not nervous and I’m calm, I’m just, I’m so stuffed from eating so much that I don’t want to eat.”

When food became available again after a period of food scarcity, Emeline would eat till “I had such a big stomachache. And then I would sleep. I remember that.” Over the course of her interviews Emeline realized that her current pattern of food binges bore some similarity to her childhood eating behavior. In childhood, a pattern of eating had been imposed upon her: she had at times been forced to go without food because her family had been food insecure; she had gorged herself when food became available. In adulthood, Emeline had endured additional food-insecure periods. Although by the third wave of data collection, Emeline was food secure, she had been food insecure at the beginning of the study. In adulthood, there were again fluctuations in her eating, with the current ebb and flow of her food intake relating to her emotional state. Emeline recognized that, “When my sister and I were growing up there were times we went to bed with nothing. And it wasn’t my mother’s fault. She worked hard.”


l on g t erm imp l ic at ion s f or eat in g pat t ern s a n d body w eight

Her mother’s recent illness had triggered a period of both nervousness and eating. Emeline continued:

“Eating, eating. Oh, yeah! ...I just know I got addicted to cheesecake and all that stuff. I did. It, oh, it was so bad!

When my mom was sick and, oh, that was, I mean I craved

cheesecake. I’m glad I got out of that one. So now I’m tryin’

to eat balanced, you know, the balanced meals and [sighs].

I just, when you get nervous you don’t think, you just wanna [she imitates eating] rrr, rrr, rrr!”

Emeline’s eating pattern from earlier in her life persisted, even though she was not currently food insecure. Her periodic overeating, now presumably for emotional comfort, echoed her overeating till I had such a big stomachache that had comforted her in childhood. “I’ll eat everything that I can, that’s not good for me. Junk food. Not can-, not candy. Like potato chips, dip, soda. I’ll go downstairs and buy a bunch of soda. Regular soda. And then I’ll cook and I’ll eat, and, you know, it’s not, it’s not healthy. I mean, so many people, what’s the name of it? Binge. Food binges. I know that I’ve had a problem with that for a long time. I have an eating, I do have an eating disorder, so. But I don’t, you know, in order to lose weight I don’t go in the bathroom and make myself sick, you know? I really try to cut back and exercise. I have them [food binges] a lot now. I, I think it’s because I get so nervous. At least two times a week. And then the rest of the time I’ll eat either, you know, a little bit or less than what I should eat for a meal. Because I’m not hungry.”


p hys i ca l e ffe c ts

Food deprivation in childhood and associated attitudes and behaviors towards food are one possible mechanism for explaining the association between childhood poverty and adult obesity.


l on g t erm imp l ic at ion s f or eat in g pat t ern s a n d body w eight

conclusions Several measures of growing up in disadvantaged socioeconomic circumstances were significantly associated with increased likelihood of being overweight or obese in adulthood. Further, the women who were categorized as growing up in low SES families described their povertyassociated experiences with food deprivation in early life. Some explicitly made the link between their past experiences and contemporary attitudes and behavior toward food. Second, the findings or hypotheses that emerged from the qualitative analyses provide insight into potential foodrelated mechanisms between childhood food deprivation and adult obesity. Current food shopping, preparation, and eating practices were influenced by childhood experiences of food deprivation among the women in this sample. Some women were highly motivated and made great effort to have an adequate household food supply in adult life because of their earlier experiences of food deprivation. Women also described repercussions of their earlier experiences that we interpreted as somewhat negative from a nutritional perspective, including eliminating economical and nutritious foods from their current diets and an emotional attachment to food and food availability. Emotional attachments and extreme excitement about having enough of the preferred foods available in the home led to overeating among some in the sample and increased their risk of overweight and obesity. Polivy (1996) notes the link between the experiences of food deprivation and overeating when food becomes available is well established.â&#x20AC;&#x192;


Psychological Effects Stressful social circumstances, particularly constrained economic resources, have been linked to behavioral problems in young children and to symptoms of depression and anxiety in mothers. Reducing the risk of these mental health problems in families might be possible if specific stressors that could feasibly be addressed by social policy were identified. Qualitative research has shown that food insecurity, defined as a limited or uncertain availability of nutritionally adequate and safe food resulting from constraints in economic resources is a particular form of material deprivation that can stress mothers and their children. Food insecurity is also a stress that may potentially be relieved by existing federal food assistance programs such as the Food Stamp Program or the Special Supplemental Nutrition Program for Women, Infants, and Children, but the impact of such programs is difficult to study.


Food insecurity has been shown to cause stress in mothers and their children.


Maternal Depression and Behavior Problems in Preschoolers


mat erna l d ep res s ion a n d behav ior p robl ems in p res c hool ers

intro In epidemiologic studies, food insecurity has been associated

Epidemiology is the study of causes,

with childhood behavior problems such as aggression,

distribution, and prevalence.

anxiety, depression, hyperactivity, and not getting along with peers. However, some of these studies did not control for other socioeconomic stressors, and each of these studies, expect for one, involved only low-income families living in 1 or 2 cities. The single study with a more diverse sample of US families did not use standardized measures of children's behavior problems and did not assess preschool-aged children, who may be particularly vulnerable to the stress arising from food insecurity. Furthermore, none of these studies measured food insecurity using the US Household Food Security Survey Module, now considered the standard for assessing household food security. Although there have been large studies examining the relationship between food security and mental health in mothers, none have included data on children's mental health. Using data on urban, 3-year-old children and their mothers from a recent US birth-cohort study, we examined the association of maternal food insecurity with depression and anxiety in mothers and with behavior problems in their preschool-aged children. In addition, we determined whether maternal depression and anxiety explained any of the association between maternal food insecurity and child behavior problems.

objectives We sought to determine if the prevalence of depression and anxiety in mothers and the prevalence of behavior problems in preschool-aged children are more common when mothers report being food insecure.


p s ycho logi c al e ffe c ts

prevalence of maternal mental health conditions mothers who are food insecure are more likely to have a major depressive episode and generalized anxiety disorder.

fully food secure 15.7%

4.1% 20.2%

marginally food secure




food insecure generalized anxiety disorder major depressive episode

prevalence of behavior problems among three-year-olds three-year-olds who are food insecure are more likely to have behavior problems such as aggression, anxiety or depression, and inattention/hyperactivity

12.6% 11% 23.4% 19%





aggression 18.1% 14.6%



mat erna l d ep res s ion a n d behav ior p robl ems in p res c hool ers

methods A cross-sectional survey of 2,870 mothers of 3-year-old

Major Depressive Episode Criteria

children was conducted in 2001â&#x20AC;&#x201C;2003 in 18 large US cities. On the basis of the adult food-security scale calculated

Must have a total of 5 symptoms for at least 2 weeks.

from the US Household Food Security Survey Module,

One of the symptoms must be depressed mood or loss

mothers were categorized into 3 levels: fully food secure,

of interest.

marginally food secure, and food insecure. The 12-month

1. Depressed mood

prevalence in mothers of a major depressive episode (MDE)

2. Diminished interest of pleasure in all or

and generalized anxiety disorder (GAD) was assessed by

the Composite International Diagnostic Interview-Short

3. Significant weight loss or gain, or increase or decrease

almost all activities

Form. A child behavior problem in more than 1 of 3 domains

(aggressive, anxious/depressed, or inattention/hyperactivity)

4. Insomnia or hypersomnia (excessive sleeping)

was based on the Child Behavior Checklist.

5. Psychomotor agitation or retardation


7. Feelings of worthlessness or inappropriate guilt

in appetite

6. Fatigue or loss of energy

Seventy-one percent of the respondents were fully food secure, 17% were marginally food secure, and 12% were food insecure. After adjustment for socio-demographic factors plus maternal physical health, alcohol use, drug use, prenatal smoking, and prenatal physical domestic violence, the percentage of mothers with either major depressive episode or generalized anxiety disorder increased with increasing food insecurity: 16.9%, 21.0%, and 30.3% across the 3 levels. Among children, after further adjustment for maternal major depressive episode and generalized anxiety disorder, the percentage with a behavior problem also increased with increasing food insecurity: 22.7%, 31.1%, and 36.7%.

8. Diminished concentration or indecisiveness 9. Recurrent thoughts of death or suicide Generalized Anxiety Disorder Criteria Excessive anxiety and worry, occurring more days than not for at least 6 months. Difficulty controlling the worry The anxiety and worry are associated with at least three of the following six symptoms. Only one item is required in children. The symptoms cause impairment in social, occupational, or other important areas of functioning. 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance


p s ycho l o gi c al e ffe c ts

Mental health problems in mothers and children are more common when mothers are food insecure, a stressor that can potentially be addressed by social policy.


mat erna l d ep res s ion a n d behav ior p robl ems in p res c hool ers

conclusions Using a recent birth-cohort sample drawn from 18 large US cities, we have shown that the prevalence of behavior problems among 3-year-old children increases with the level of maternal food insecurity, as does the 12-month prevalence in mothers of an MDE and GAD. This study is unique in its examination of the relationship between food security and the mental health of both mothers and children in a large, population-based sample of families from multiple US cities. It has the further strengths of using well-validated measures of both food security and mental health and controlling for multiple covariates. Certain stresses early in life, such as emotional, physical, or sexual abuse, increase the risk of later mental health problems, possibly by altering brain neurochemistry and morphology Food insecurity may be a form of early life stress that can also have long-term health implications. Studies of variable foraging demand suggest that the stress associated with food insecurity might express itself through neural circuits involving corticotropin-releasing factor. These are the same neural mechanisms by which other early life stresses are hypothesized to result in a distinct biological subtype of adult depression. Future studies should examine whether household food insecurity increases a child's susceptibility to later mental health problems. Social policy can address food insecurity more directly than it can address many other early-life stresses, and doing so can enhance the well being of both mothers and children.


Attachment and Mental Proficiency in Toddlers


at ta c hmen t a n d men ta l p rof ic ien c y in t od d l ers

intro We lack research in which a fully articulated model is examined asking whether there are direct as well as indirect pathways between food security and child outcomes. We need a model that empirically tests the linkages across all of the components simultaneously while controlling for a range of potentially confounding variables. This is the purpose of the current analyses.

hypotheses Food insecurity during infancy will be directly associated with less positive social and emotional and cognitive outcomes for children during toddlerhood. There will be indirect effects of food insecurity during infancy on social, emotional, and cognitive outcomes during toddlerhood. We hypothesize that food insecurity may increase maternal depression, and this will in turn influence parenting behaviors and cognitively stimulating activities in the home, which will subsequently influence child outcomes.

objectives This study examined the associations between household food security during infancy and attachment and mental proficiency in toddlerhood.


p s ycho l o gi c al e ffe c ts

Methods Data from a longitudinal nationally representative sample of infants and toddlers from the Early Childhood Longitudinal Study—9-month (2001–2002) and 24-month (2003–2004) surveys were used. At 9 months, 10,688 parent interviews and 10,221 child assessments were completed. Data from the 9-month wave (including retrospective data from the previous calendar year) were used to categorize children in households according to their levels of food security. The 9-month study was also used to examine the pathways through which food insecurity influences social and emotional and cognitive development. Longitudinal analyses help to increase confidence that the relationships examined are causal in nature. Therefore, the child outcomes that are examined are derived from the 24-month data collection wave. Structural equation modeling was used to examine the direct and indirect associations between food insecurity at 9 months, and attachment and mental proficiency at 24 months. The outcome variables measured were social and emotional well-being, and cognitive and mental proficiency. The primary predictor was household food security. The mediators were cognitively stimulating activities, maternal depression, and parenting practices. The control variables included mother and father’s individual characteristics, household level characteristics, child characteristics, and child care characteristics.


at ta c hmen t a n d men ta l p rof ic ien c y in t od d l ers

Results Food insecurity worked indirectly through depression and parenting practices to influence security of attachment and mental proficiency in toddlerhood.

associations between food insecurity, emotional development, and cognitive development

food insecurity

maternal depression

positive parenting practices

cognitively stimulating activities

insecure attachment

mental proficiency


p s ycho l o gi c al e ffe c ts

The results underscore the importance of programs and policies seeking to assure that families with infants have sufficient nutrition, available predictably. Such efforts have the potential to affect two generations: both mothersâ&#x20AC;&#x2122; psychological well-being and positive behaviors with their infants, and the childrenâ&#x20AC;&#x2122;s development over the first two years.


at ta c hmen t a n d men ta l p rof ic ien c y in t od d l ers

conclusions The results of this study support the perspective that food security affects children’s development very early. More specifically, greater food insecurity, measured at nine months in a nationally representative sample of families with infants, predicted insecure child attachment and less advanced mental proficiency at 24 months, operating not directly but through food insecurity’s influence on maternal depression and in turn on parenting practices. These results add to the earlier findings of the present research group indicating that food security also has implications for the overall health and weight of toddlers. Together, these results provide substantial support for the view that food security begins to influence children’s development at very young ages.

policy implications Work such as the present study can help direct policy and program efforts, for example, potentially pointing to the need to address not only the sufficiency of food resources, but also maternal depression and parenting behavior. The present study indicates that food insecurity is present in over 10% of US households with infants. In addition, our findings indicate that food insecurity affects children’s development very early in life. Together with our earlier results, the present study indicates that the effects of food insecurity, operating through maternal mental health and parenting behaviors, predict child outcomes in the two major domains examined: social and emotional development and cognitive development. The findings raise the possibility that in families that have already been experiencing food insecurity, it may be beneficial to address not only the adequacy and reliability of food resources, but also maternal depression and less positive parenting behavior that may have developed in response to concerns about the adequacy of food.


Mental Disorders in Teenagers


men ta l d is ord ers in t eena gers

intro More than one in five U.S. youth younger than 18 years lived in a family with an income below the federal poverty line in 2010. Poverty is defined by the federal government as inadequate income relative to estimated need based on family size, and is consistently associated with increases in internalizing and externalizing problems in children and adolescents. However, little research has examined whether poverty specifically increases risk for youth psychopathology or whether other dimensions of socioeconomic status (SES) explain this relation. On the one hand, poverty might influence mental health as a result of deprivation in resources needed to sustain health, including food and shelter. This sort of material deprivation typically occurs in the context of extreme poverty and may be associated with psychopathology risk. On the other hand, prior research has found a linear association between family income and youth psychopathology, with lower levels of income related to a higher risk of anxiety, depression, and behavior disorders across the entire income distribution. Food insecurity, the inability to purchase adequate amounts of food to meet basic needs is one marker that may better capture severe material deprivation. In the United States, food insecurity is most commonly experienced by families living in poverty and those that have experienced recent economic stressors such as unemployment or loss of food stamps. Food insecurity is associated with adverse health outcomes in children and adolescents, including vitamin and nutrient deficiency, developmental delay, hospitalization, and overweight status, even after adjustment for family income. Food insecurity is also associated with symptoms of anxiety and depression and externalizing problems in children, although the authors are unaware of previous research examining the relation between food insecurity and youth mental disorders.

objectives To examine whether food insecurity is associated with pastyear DSM-IV mental disorders after controlling for standard indicators of family socioeconomic status (SES) in a U.S. national sample of adolescents.


p s ycho l o gi c al e ffe c ts

The associations between food insecurity and adolescent mental disorders were not reduced when controlling for extremely poverty, suggesting that food insecurity has more harmful consequences than simply living in an extremely poor family.


men ta l d is ord ers in t eena gers

method Data were drawn from 6,483 adolescentâ&#x20AC;&#x201C;parent pairs who

Clinical Guidance

participated in the National Comorbidity Survey Replication Adolescent Supplement, a national survey of adolescents

Food insecurity is associated with mood, anxiety, behavior,

13 to 17 years old. Frequency and severity of food insecurity

and substance disorders above and beyond the effects of

were assessed with questions based on the U.S. Department

other measures of SES in adolescents, suggesting that it

of Agricultureâ&#x20AC;&#x2122;s Food Security Scale (standardized to a mean

may be clinically useful to routinely inquire about hunger

of 0, variance of 1). DSM-IV mental disorders were assessed

in child and adolescent patients.

with the World Health Organization Composite International Diagnostic Interview. Associations of food insecurity with

Identifying children and adolescents in clinical care who

DSM-IV/Composite International Diagnostic Interview

experience recurrent hunger can be accomplished with

diagnoses were estimated with logistic regression models

a brief verbal assessment at each session.

controlling for family SES (parental education, household income, relative deprivation, community-level inequality,

Routinely assessing whether children and adolescents

and subjective social status).

in care are experiencing food insecurity provides the


at alleviating hunger and facilitating consistent access

opportunity to link families to social services aimed

Food insecurity was highest in adolescents with the

to food.

lowest SES. Controlling simultaneously for other aspects of SES, standardized food insecurity was associated with an increased odds of past-year mood, anxiety, behavior, and substance disorders. A 1-standard deviation increase in food insecurity was associated with a 14% increase in the odds of past-year mental disorder, even after controlling for extreme poverty. The association between food insecurity and mood disorders was strongest in adolescents living in families with a low household income and high relative deprivation.


p s ycho l o gi c al e ffe c ts

Food insecurity is associated with a wide range of adolescent mental disorders independently of other aspects of SES. Expansion of social programs aimed at decreasing family economic strain might be one useful policy approach for improving youth mental health.


men ta l d is ord ers in t eena gers


The inability to reliably access adequate amounts of food

Children and adolescents are at greater risk of experiencing

adolescent mental disorders. Given the dramatic increases

to meet basic needs is associated with a wide range of

poverty than any other segment of the U.S. population,

in child poverty in the past decade, these findings argue

and the dramatic increase in youth poverty over the past

for expanding programs aimed at alleviating hunger

decade raises concerns about the implications of this trend

in children and economic strain in families. Consistent

for child health and development. Deprivation in resources

evidence has suggested that the Food Stamp Program, the

needed to sustain health, including food, shelter, clothing,

Special Supplemental Food Program for Women, Infants,

and access to health care, is one of the primary pathways

and Children, and school nutrition programs are successful

through which poverty may have an adverse impact on

at improving access to food and nutritional outcomes

health. The present findings suggest that, indeed, the

for children, although numerous barriers impede the use

lack of access to reliable and sufficient amounts of food is

of these benefits by eligible families. The present study

associated with increases in adolescent mental disorders.

suggests that if a lack of access to food is specifically

These findings are concerning because recent estimates have

associated with adolescent mental disorders, then these

suggested that more than 20% of U.S. families with children

programs may also have a meaningful impact on youth

experience at least some degree of food insecurity.

mental health, underscoring the importance of increasing

Food insecurity was associated with adolescent mood,

provide adequate food for their children.

their reach and uptake to assist families struggling to anxiety, behavior, and substance disorders after controlling for numerous other indicators of SES, such that a one standard deviation increase in food insecurity was associated with 14% greater odds of past-year mental disorder in adolescents. Importantly, food insecurity was more strongly related to adolescent mental disorders than traditional SES measurements, including parental education and income. The associations between food insecurity and adolescent mental disorders were not attenuated even when extreme poverty was controlled, suggesting that this aspect of material deprivation reflects a form of economic strain that has more pernicious consequences for adolescent mental health than simply living in a family with a very low income. Prior research has indicated that difficulty paying for the necessities of living is associated with poor physical health over and above the effects of income. Food insecurity was associated with mood disorders more strongly in adolescents living in families with low household income and high relative deprivation, consistent with prior research reporting the strongest associations between food insecurity and adverse physical health in low-income families. Together these findings suggest that extreme material deprivation not only is associated with behavioral problems in children, but also may be a determinant of mental disorders. The authors cannot determine in this study whether inadequate access to food specifically is related to mental disorders or whether these findings simply reflect an association of deprivation in access to basic necessities more broadly with adolescent psychopathology. This issue warrants further investigation in future research.


Conclusion Food insecurity, the inability to provide enough food for a healthy and active lifestyle, is a complicated and serious problem. Its effects extend beyond hunger to the physical and psychological aspects of individuals who experience food insecurity. Those who are food insecure are more likely to be obese, due to the high energy density of inexpensive foods. Dealing with food insecurity can also lead to a range of psychological effects, including attitude toward food, parental depression, child development, and behavior problems. Since the issue of food insecurity extends far beyond simply having enough food to eat, it is important that those who have the means to help are aware of the situation. Clearly understanding the problem and its effects is the first step to helping the impoverished. Now we need to implement programs that provide inexpensive and nutritious food to people of low income, and educate them about the importance of eating healthy.


The effects of food insecurity extend beyond hunger to physical and psychological aspcets of life.


Works Cited

Black, Maureen. “Household Food Insecurities: Threats to Children’s Well-being.” The SES Indicator 6.1 (2012). Web.

Campbell, Cathy C. “Food Insecurity: A Nutritional Outcome or a Predictor Variable?” Journal of Nutrition 121 (1991). Web. 3 Jan. 2013.

Coleman-Jensen, Alisha, Mark Nord, Margaret Andrews, and Steven Carlson. “Household Food Security in the United States in 2011.” U.S. Department of Agriculture Economic Research Service. Web.

Drewnowski, Adam, and SE Specter. “Poverty and Obesity: The Role of Energy Density and Energy Costs.” The American Journal of Clinical Nutrition 79.1 6-16 (2004). Web.

Ervin, R. Bethene, Ph.D. “Healthy Eating Index–2005 Total and Component Scores for Adults Aged 20 and Over: National Health and Nutrition Examination Survey, 2003-2004.” National Health Statistics Reports 44. Web.

McLaughlin, Katie A., Ph.D., Jennifer Greif Green, Ph.D., Margarita Alegría, Ph.D., E. Jane Costello, Ph.D., Jichael J. Gruber, M.S., Nancy A. Sampson, B.A., and Ronald C. Kessler, Ph.D. “Food Insecurity and Mental Disorders in a National Sample of U.S. Adolescents.” Journal of the American Academy of Child & Adolescent Psychiatry 51.12 (2012): 1293-303. Science Direct. Web.

Ogden, Cynthia, Ph.D., M.R.P. “Overweight and Obesity Statistics.” Ed. Cheryl Fryar, M.S.P.H. National Institute of Health 04-4158. Weight-Control Information Network. National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health, 2012. Web.

Ogden CL, Lamb MM, Carroll MD, Flegal KM. “Obesity and socioeconomic status in adults: United States 1988–1994 and 2005–2008”. NCHS data brief no 50. Hyattsville, MD: National Center for Health Statistics. 2010.

Olson, Christine M., Caron F. Bove, and Emily O. Miller. “Growing up Poor: Long-Term Implications for Eating Patterns and Body Weight.” Appetite 49.1 (2007): 198-207. Science Direct. Web.

Whitaker, R. C., S. M. Phillips, and S. M. Orzol. “Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in Their Preschool-Aged Children.” Pediatrics 118.3 (2006): E859-868. Web.

Zaslow, Martha, Jacinta Bronte-Tinkew, Randolph Capps, Allison Horowitz, Kristin A. Moore, and Debra Weinstein. “Food Security During Infancy: Implications for Attachment and Mental Proficiency in Toddlerhood.” Maternal and Child Health Journal 13.1 (2009): 66-80. 4 Mar. 2008. Web.


This book was designed and edited by Maria Burke for the thesis project at Washington University in St. Louisâ&#x20AC;&#x2122; Sam Fox School of Design & Visual Arts in the Spring of 2013. Typefaces used are Vista Slab OT and VistaSans. No part of this book may be used, copied, or reproduced without the designerâ&#x20AC;&#x2122;s permission. Thanks to all my teachers in the Communication Design progam, espically Sarah Birdsall, who have instructed and guided me for the past two years. Thanks also to all my wonderful studiomates, who make all the late hours in studio bearable. Finally, thanks to my parents and all my friends, for their incredible support!


The Cost of Hunger  

The Physical and Psychological Effects of Food Insecurity. For more detailed information, please visit

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