Does “Food Insecurity” Promote Obesity?

The authors of a recent study conducted by a Yale University research team suggested that “food insecurity” may lead to binge eating and somehow promote obesity. What is “food insecurity"? It has been defined “as being characterized by a shortage of nutritionally adequate food and difficulty acquiring adequate food in socially acceptable ways.” Hunger America summarizes it, "Food insecurity refers to a lack of available financial resources for food at the level of the household."Certainly food insecurity in poor communities could contribute to binge eating but is that the same as binge eating disorders (BED) caused by calorie-restricted diets? Probably not. And does food insecurity per se lead to more obesity? The Yale researchers state: “Results highlight the need to devote resources towards policy revisions, preventative interventions, and psychiatric treatments aimed at decreasing the overall association of food insecurity with BED and obesity among low-income Americans.” They also suggest food insecurity increases the risk of weight-related health problems including diabetes, metabolic syndrome, and cardiovascular disease (1). However, the suggestion that having food less available from time to time leads to BED and obesity is questionable.Binging Is Not Necessarily an Eating DisorderBinging on food or eating a lot more food at a faster rate than usual when you are very hungry is pretty much normal psychological behavior and not indicative of an eating disorder. Indeed, such a tendency to binge eat was no doubt helpful for our ancient human ancestors who (for the most part) evolved in places in which food insecurity was par for the course for much of every year and sometimes for the whole year. Research shows that intermittent fasting (IF) in which people intentionally do not eat some days does not make it more likely for people to gain weight but may be more likely to lead to weight loss than to weight gain (2).While this reviewer has suggested that calorie-restricting diets are the primary promoter of serious eating disorders, the process is very different than what occurs with food insecurity. Who believes hunter-gatherer teenage girls were developing serious eating disorders because sometimes they had to go hungry because food was not available? Should we be blaming BED for psychological problems with food caused by food insecurity or the frustration and the internal psychological conflicts resulting from eating less than hunger demands? It matters psychologically whether the intense hunger results from intentionally restricting calorie intake or is the result of unintentional and transient calorie reduction due to not being able to access food in a socially acceptable way (a.k.a. food insecurity). Disordered thinking about food (or eating disorders) is caused by people pitting their own willpower against the biological drive to eat (hunger) in order to lose what is believed to be excess body fat or weight. Food insecurity does not lead to significant psychologically-diagnosed eating disorders and/or promote obesity. If eating disorders were caused by food insecurity (as opposed to intentionally trying to lose weight by restricting food intake) then we would expect to see far more anorexia nervosa (AN) in poor communities than more affluent ones where food insecurity is largely absent. In fact, bulimia and AN are far less common in places where food insecurity is common than more affluent places. Most researchers in the eating disorder field recognize that many patients with AN generally have a period in which they binge eat. However, in those who develop eating disorders, this binge eating is not being caused by food insecurity but by the individual’s determination to lose excess body fat to conform to some idealized societal norm.In poor communities, where food insecurity is common, the binging is due to external barriers limiting one's access to food. In these communities, food insecurity may lead to real hunger and then the strong hunger signals that lead to binging once they can access food again, but this is not an eating disorder. Binging and purging or bulimia nervosa (a.k.a. bulimia) is often the next step in the progression to the most pathological or deadly types of eating disorders such as AN. While bulimia is a pathological eating disorder that starts with binging, this binging generally occurs after a calorie-restricted diet and not due to lack of access to food. Binging when one is trying to lose weight can lead to nausea and guilt, but bulimia is rare in communities where food insecurity is common. Those who are the most determined to not eat in order to lose weight and keep it off are at the highest risk of seeing their bulimia to progress to AN. AN is very uncommon in places where food insecurity is most common.Binging in response to strong hunger is not a sign of psychopathology because the hunger was the result of external factors limiting access to food rather than a determination to eat less to lose and keep off what is perceived to be excess body fat. When strong hunger signals result from using willpower or conscious effort to limit food intake below what hunger demands (or calorie restricted dieting), this battle between the drive to eat more (hunger) and the desire to limit calorie intake (willpower) may lead first to binging and weight re-gain. In the more determined dieter, binging may lead to feelings of guilt, failure, or shame that cause the binge to be followed by purging so that bulimia may develop. Therefore, it appears that eating disorders are caused by an internal conflict between the drive to eat (hunger) and the desire to be thinner or less fat due largely to societal expectations or internalized social pressure. These societal pressures are largely absent in communities where food insecurities are most common.There is a fundamental psychological difference between the binging seen in areas where food insecurity and where food is intake limited by one’s goal to become thinner, healthier, more attractive to the opposite sex, or some other pressure that motivates one to lose weight. We see eating disorders in male athletes who are trying to "make weight." High school wrestlers may develop eating disorders such as bulimia and even anorexia nervosa and this is also true of male jockeys, who also are pressured to maintain weight lower than what eating until satiated would result in. Eating disorders were once far more common among flight attendants but have declined markedly since airlines did away with weight requirements. Eating disorders are not caused by food insecurity but rather by insecurity about conforming to externalized expectations for one to maintain a lower body weight and needing to battle hunger to do so.So why is obesity also more common in communities where food insecurity is more common than in those with little or no food insecurity? It is likely not because, as the authors of this recent article suggested, food insecurity leads to binging and binging leads to weight gain. Rather it is because the food available in those communities tends to have a low satiety/kcal or in simple terms tends to be calorie dense and nutrient poor. In poor communities, access to high satiety/per calorie foods such as whole fruits and vegetables is more limited than in more affluent areas. The result is the typical diet of people in these poor communities has a lower satiety per calorie content than the foods in more affluent areas. Having more access to healthier foods, and perhaps more emphasis on eating a healthier diet with a lower calorie density, fewer beverage calories, and more fiber from whole plant foods leads to consuming more of these high satiety/kcal foods and thus a lower risk of obesity in more affluent communities. Also, people on limited budgets are less likely to be able to afford quality whole fruits and vegetables even when they are available. Fruits and vegetables' cost per calorie is relatively high compared to the sugar-rich drinks and calorie-dense foods loaded with cheap refined carbohydrates and fats. The result of more limited access to healthier food choices in areas where "food insecurity" is most common is a gravitation towards cheaper sources of calories when money is limited. Binging on whole fruits and vegetables would be unlikely. Even for those who never experience food insecurity but ignore healthy food options for “desserts” tend to end up overweight or obese because their diet is largely composed of "fattening" foods and drinks than the average person in a more affluent communities where food insecurity is virtually absent.Bottom Line: The binge eating seen in people due to food insecurity is fundamentally different than the binging that arises in response to increased hunger resulting from one’s own effort to lose or control one’s weight. It is only the latter that is likely to lead to serious eating disorders. The association between obesity and food insecurity in poor communities is likely due in large part to the type of foods and drinks available in those communities, which have a lower satiety/kcal than the foods consumed in more affluent places.By James J. Kenney, PhD, FACNReferences:

1. Rasmusson G, Lydecker JA, Coffino JA, White MA, Grilo CM. Household food insecurity is associated with binge-eating disorder and obesity. Int J Eat Disord. 2018;1–8. https://doi.org/10.1002/eat.22990.
2. Hutchison AT, Liu B, Wood Re, et. al. Effects of Intermittent Versus Continuous Energy Intakes on Insulin Sensitivity and Metabolic Risk in Women with Overweight. Obesity 2019;27:50-8.

Further reading:Eatright.org position statement on disordered eatingDiscussion of food insecurity by Feeding America