by Vivienne Hazzard, PhD, MPH, RD, postdoctoral research fellow, University of Minnesota Department of Psychiatry & Behavioral Sciences
This article originally appeared in the Minnesota Family Physician magazine.
Growing evidence indicates that binge eating (i.e., eating an unusually large amount of food while feeling a sense of loss of control over one’s eating) is more common among individuals experiencing food insecurity than among those who are food secure (1). This link between food insecurity and binge eating is thought to be related to a resource-imposed “feast-or-famine” cycle in which food intake decreases during periods of food scarcity and increases during periods of relative food abundance (e.g., after receiving a paycheck or food assistance benefits).
Considering that restricting one’s food intake—regardless of whether the restriction is voluntary or involuntary—can lead to a greater tendency to binge eat when presented with an opportunity to do so (2), influxes of food after receiving the requisite financial means may promote binge eating among individuals who have been restricting food due to limited food availability.
This possibility was investigated in a recent University of Minnesota study, led by myself, Vivienne Hazzard, PhD, MPH, RD, postdoctoral research fellow. In this study, 75 food-insecure young adults recruited from the Minneapolis-St. Paul metropolitan area were surveyed several times every day for two weeks.
The researchers found that symptoms of binge eating significantly increased in the days after food-insecure young adults received earnings (e.g., from a paycheck) or benefits (e.g., from a government food assistance program), suggesting that the “feast-or-famine” cycle may indeed help explain binge eating in the context of food insecurity. Irrespective of whether or not young adults had received earnings or benefits during the two-week study period, the study team also found that significantly more binge eating symptoms occurred in the hours following instances of increased food availability among these food-insecure young adults.
These findings highlight the importance of identifying approaches to ensure greater stability of socially acceptable ways to access adequate, nutrient-dense food.
THE ROLE OF FOOD ASSISTANCE PROGRAMS
It has been proposed that the “feast-or-famine” cycle may be amplified by some approaches used to mitigate food insecurity (3). For example, while the U.S. Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are critical for improving food security, they may inadvertently exacerbate the “feast-or-famine” cycle by providing benefits only once per month. Some food pantries and food shelve—particularly those with restrictions on how often clients may visit—may similarly exacerbate this cycle.
Supporting these ideas, the researchers conducting the University of Minnesota study of food-insecure young adults found that instances of increased food availability predicted more binge eating symptoms only among young adults participating in government-funded food assistance programs (i.e., SNAP/WIC) and/or using charitable food assistance programs (i.e., food pantries/food shelves). These results suggest that current approaches used to mitigate food insecurity may in fact contribute to binge eating among food-insecure individuals, which have important implications for family medicine providers working with food-insecure patients.
IMPLICATIONS FOR FAMILY MEDICINE
Given that food insecurity has affected over 1 in 10 U.S. households—and over 1 in 7 U.S. households with children—in recent years (4), all family medicine providers should expect that some of their patients face food insecurity. The link between food insecurity and binge eating is especially relevant not only for patients presenting with disordered eating or eating disorders, but also for patients with weight or mood management goals, as binge eating may hinder clinical progress in these realms (5,6). Moreover, food insecurity may further impede such progress if patients cannot afford nutritious food or must choose between paying for food and paying for medication.
Before a provider can offer to connect a patient with resources to alleviate food insecurity or discuss how food insecurity may influence that patient’s ability to adhere to the provider’s recommendations, the provider must be aware that the patient is experiencing food insecurity. Universal screening for food insecurity is, therefore, a critical first step, one that patients experiencing food insecurity report deeply valuing because it prompts an important discussion with their provider that they do not feel comfortable initiating themselves (7).
The two-item Hunger Vital Sign (8) is a validated food insecurity screening tool that is already built into the Epic Foundation System (under “Hunger Screening”).
As food insecurity is a sensitive topic, providers should be trained on how to approach conversations with patients screening positive for food insecurity. Such training can be done using simulation cases with standardized patients, which has been shown to increase provider comfort with discussing food insecurity in a clinical setting (9).
Additionally, information on both federal nutrition programs and local emergency food resources should be readily available for providers to refer patients to. In light of the findings from the recent University of Minnesota study described in this article, providers should encourage patients to use as many different forms of food assistance as needed to maintain a relatively stable level of food availability over the course of each month.
Food insecurity is a key social determinant of health linked not only with binge eating, but also with a wide range of adverse physical and mental health outcomes (10,11). Food assistance programs such as SNAP, WIC, and food pantries/food shelves play an integral role in mitigating food insecurity, yet the ways in which they are currently structured (e.g., SNAP and WIC providing benefits only once per month) may contribute to binge eating among food-insecure individuals.
Family medicine clinics should consider screening patients for food insecurity, and providers should be equipped to discuss food insecurity with patients, provide food resource referrals and talk with patients about how to utilize food resources to best maintain stability throughout the month.
- Hazzard VM, Loth KA, Hooper L, Becker CB. Food insecurity and eating disorders: A review of emerging evidence. Curr Psychiatry Rep. 2020;22(12). doi:10.1007/s11920-020-01200-0
- Polivy J. Psychological consequences of food restriction. J Am Diet Assoc. 1996;96(6):589-592. doi:10.1016/S0002-8223(96)00161-7
- Dinour LM, Bergen D, Yeh MC. The food insecurity-obesity paradox: A review of the literature and the role food stamps may play. J Am Diet Assoc. 2007;107(11):1952-1961. doi:10.1016/j.jada.2007.08.006
- Coleman-Jensen A, Rabbitt MP, Gregory C, Singh A. Household Food Security in the United States in 2020. ERR-298, U.S. Department of Agriculture, Economic Research Service; 2021.
- Kantilafti M, Chrysostomou S, Yannakoulia M, Giannakou K. The association between binge eating disorder and weight management in overweight and obese adults: A systematic literature review. Nutr Health. Published online November 24, 2021. doi:10.1177/02601060211032101
- Sonneville KR, Horton NJ, Micali N, et al. Longitudinal associations between binge eating and overeating and adverse outcomes among adolescents and young adults: Does loss of control matter? JAMA Pediatr. 2013;167(2):149-155. doi:10.1001/2013.jamapediatrics.12
- Kress C, Durvasula J, Knievel A, et al. Patient perspectives: Valuable food insecurity interventions. PRiMER. 2021;5:40. doi:10.22454/primer.2021.233359
- Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1).
- Morrison JM, Marsicek SM, Hopkins AM, Dudas RA, Collins KR. Using simulation to increase resident comfort discussing social determinants of health. BMC Med Educ. 2021;21(1):1-10. doi:10.1186/s12909-021-03044-5
- 1Weaver LJ, Fasel CB. A systematic review of the literature on the relationships between chronic diseases and food insecurity. Food Nutr Sci. 2018;9(5):519-541. doi:10.4236/fns.2018.95040
- Arenas DJ, Thomas A, Wang JC, DeLisser HM. A systematic review and meta-analysis of depression, anxiety, and sleep disorders in US adults with food insecurity. J Gen Intern Med. 2019;34(12):2874-2882. doi:10.1007/s11606-019-05202-4