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Tracy Hampton, PhD

JAMA. 2007;298:1851-1853.

Nutrition is paramount to health and survival, yet many individuals and families struggle to maintain a healthy diet, especially those with low incomes. Nearly 12.6 million households (11%) in the United States were "food insecure" at times during 2005, meaning they were without the resources to feed themselves enough or were unable for economic reasons to purchase healthful foods, according to the US Department of Agriculture (USDA).

Most, but not all, of the world's undernourished people live outside the United States, in poor countries. According to a report by the Food and Agricultural Organization of the United Nations, in 2001 to 2003, 820 million of the 854 million undernourished people worldwide were in developing countries, 25 million in the transitional countries, and 9 million in the industrialized countries (http://www.fao.org/docrep/009/a0750e/a0750e00.htm). In the United States, food insecurity tends to be higher among households with incomes near or below the federal poverty line, households headed by single women with children, and black and Hispanic households.

Although most of the world's undernourished people live in poor countries, food insecurity—lacking the resources to buy enough food or to purchase the appropriate foods for a healthful diet—is also a problem for some low-income families in the United States. (Photo credit: Tom Hahn/iStockphoto.com)

Experts are working to decrease the rates of food insecurity and to improve the health of individuals who do not have access to nutritious foods.

HEALTH EFFECTS
Food insecurity can affect health in a variety of ways. For example, an individual whose diet is lacking can experience malnutrition. Medication adherence may not be a high priority for patients who must focus their resources on obtaining access to an adequate food supply. And, as research is beginning to explain, access to food can affect the development and prevention of medical conditions and diseases.

These effects can be especially profound in children. When children live in food-insecure households, their health status may be impaired, making them less able to resist illness and more likely to become hospitalized (Casey PH et al. J Nutr. 2004;134[6]:1432-1438). Also, poverty and its associated poor nutrition can increase risks of stunting, inadequate cognitive stimulation, iodine deficiency, and iron deficiency anemia (Walker SP et al. Lancet. 2007;369[9556]:145-157).

In adults, food insecurity has been associated with type 2 diabetes (Seligman HK et al. J Gen Intern Med. 2007;22[7]:1018-1023). "Patients with diabetes require special diets, and yet the ability to be consistent with those special diets was compromised by food insecurity," said Mark Nord, PhD, of the Food Assistance Branch at the Economic Research Service of the USDA.

Food insecurity also has been linked to overweight and obesity, particularly among women (Townsend MS et al. J Nutr. 2001;131[6]:1738-1745; Wilde PE and Peterman JN. J Nutr. 2006;136[5]:1395-1400). This apparent paradox may be explained by the fact that high-calorie, processed foods often are less expensive than fresh, perishable foods such as fruits, vegetables, and low-fat dairy products.

"One of the first food groups that's cut out of an impoverished person's diet is produce," explained David H. Holben, PhD, RD, of the School of Human and Consumer Sciences, at Ohio University, in Athens. "Generally speaking, they often choose high-fat, high-sugar, low-cost foods that taste good," he added. Re searchers have found that marketing can also influence consumers, who are bombarded with advertising for unhealthful food and receive inadequate nutritional information, especially in restaurants (Hayne CL et al. J Public Health Policy. 2004;25[3-4]:391-407).

Food insecurity can also set up a scenario in which access to food is inconsistent, leading to periods of underconsumption followed by compensatory overconsumption. "There's good evidence that yo-yo dieting is associated with a higher risk of overweight and obesity, and it leads people to wonder if involuntary boom and bust cycles in food intake could also be associated," said Parke Wilde, PhD, of the Friedman School of Nutrition Science and Policy at Tufts University, in Boston.

FOOD AID PROGRAMS
Food insecurity in the United States is being addressed by a number of ongoing efforts, including federal food assistance programs such as the National School Lunch Program; the Food Stamp Program; and the Special Supplemental Nutrition Program for Women, Infants, and Children. While these programs have made great strides in improving diet quality, they are not able to reach all individuals in need.

"A little over half of food-insecure households get help from at least one of those programs," said Nord. The American Dietetic Association has called for a number of interventions, including providing adequate funding for the programs and increasing their use, making nutrition education a part of the programs, and promoting and supporting the economic self-sufficiency of individuals and families in the programs (Holben DH and the American Dietetic Association. J Am Diet Assoc. 2006;106[3]:446-458).

Wilde would like to see if delivering food stamps more frequently might have an impact—for example, twice monthly instead of once monthly. "I’d also like to see the food stamp benefit targeted towards specific categories of foods, such as fruits and vegetables and whole-grain foods," he added.

Other experts are working to raise awareness about the circumstances many food-insecure individuals face so that policy makers will be better equipped to make decisions about improvements to food assistance programs. For example, 2 groups in Washington, DC, the Hatcher Group, a public affairs firm that connects nonprofits and foundations to policy makers and the media, and the nonprofit Food Research and Action Center, developed a "Food Stamp Challenge" to highlight what it is like to eat on the average food stamp benefit—approximately $1 per meal. Members of Congress, governors, state officials, and other community leaders have taken the challenge and have learned firsthand how difficult it is to make ends meet on the average food stamp benefit.

"They realize how economically fragile families who qualify for the Food Stamp Program and are living on this amount of money are," said Lynn Parker, of the Food Research and Action Center. Parker noted that while the food stamp benefit should be increased, the ultimate goal is to boost individuals' funds so they no longer depend on such programs. Individuals with low incomes tend to spend a greater percentage of their income on food, suggesting that a small increase in income could have a great effect on the ability to obtain a nutritionally adequate diet (Nelson K et al. JAMA. 1998;279[15]:1211-1214).

Local food pantries, emergency kitchens, and various state initiatives are also improving access to healthful foods. In New York, families in Harlem can use food stamps to purchase shares in upstate farmers' crops and receive weekly deliveries of fresh, seasonal foods. And in West Virginia, foods that would otherwise be discarded by local grocers are given to participants in a food stamp nutrition education program (http://www.nga.org/files/pdf/0608creatinghealthystatesnutrition.pdf).

CLINICAL EFFORTS
Physicians, nurses, dieticians, and other health care workers can also help address food insecurity issues. For example, they could educate patients on how to choose nutrient-dense foods in a cost-effective way. Holben has suggested that clinicians ask patients questions such as those related to money for food, participation in food assistance programs, meal habits, quality of diet, food label reading, and food safety (Tscholl E and Holben DH. J Am Acad Nurse Pract. 2006;18[7]:335-342; Holben DH and Myles W. Am Fam Physician. 2004;69[5]:1058-1060). A number of researchers are working to develop simple screening tools that could be implemented in a clinician's office to determine whether economic access to enough food is a problem for patients.

"In addition, partnering with and referring patients to community-based agencies that administer food assistance could dramatically improve the food access and well-being of individuals and families," said Holben. He and others also advocate that clinicians and scientists devote more research to studying the long-term effects of food insecurity on all aspects of health. "Exploring food insecurity's connection to diabetes, cardiovascular disease, bone and dental health, cancer, and other [diseases] is warranted," said Holben.

Experts say that the health effects of food insecurity must be addressed to reach the goal of Healthy People 2010, the Department of Health and Human Services' disease prevention and health promotion objectives for the United States (http://www.healthypeople.gov/). The program aims to help individuals increase life expectancy and improve their quality of life and to eliminate health disparities. "Having a better understanding of the connections between food insecurity and health and disease is paramount to reaching those goals," said Holben.

Food Insecurity In Latin America Recent efforts are beginning to shed light on the status of food insecurity in regions outside the United States. "Assessment of household-level food insecurity in other countries is a burgeoning industry right now," said Mark Nord, PhD, of the US Department of Agriculture. Efforts are particularly robust in Latin America. "In Brazil, the data from 2004 show a prevalence just under 35% overall, but in the rural areas, the prevalence is over 43%," said Hugo Melgar-Quiñonez, MD, PhD, of the department of human nutrition at Ohio State University, in Columbus. In Columbia, the national prevalence was 40.8% in 2005, he said. "That's at least 3 to 4 times higher than in the United States." Melgar-Quiñonez and others are currently designing tools to standardize the measurement of food insecurity across Latin America from year to year. More research should reveal the trends in food insecurity in other nations as well as the potential causes. Globalization may play a role—investigators say it could be encouraging the uneven development of new dietary habits between rich and poor. Individuals of low socioeconomic status may be more likely to purchase imported, cheap, nutrient-poor foods while the more affluent and educated choose more expensive, healthful foods (Hawes C. Global Health. 2006;2:4). A number of countries are seeing increases in obesity and chronic diseases related to increased access to "Western-type" diets. Experts believe that efforts to improve income and education and change individuals' behavior in terms of diet and physical activity will be important for the health of nations in the years to come (Kain J et al. Cad Saude Publica. 2003;19[Suppl 1]:S77-S86).—T.H.

Food Security Resources The US Department of Agriculture's Food and Nutrition Service administers a range of nutrition assistance programs throughout the United States (http://www.fns.usda.gov/fsec/). The Food Research and Action Center, a national nonprofit organization, is working to improve public policies and public-private partnerships to eradicate hunger and undernutrition in the United States (http://www.frac.org/index.html). The United Nations' World Food Programme includes among its missions saving lives during refugee crises, improving nutrition and quality of life of the world's most vulnerable people, and enabling development (http://www.wfp.org/). The World Bank is a source of financial and technical assistance to developing countries with the goal of reducing global poverty and improving living standards (http://www.worldbank.org/). The International Food Policy Research Institute provides policy solutions that reduce hunger and malnutrition throughout the world (http://www.ifpri.org/).