RESEARCHREVIEW

CURRENT RESEARCH FOR FAMILY ADVOCACY PROGRAMS • VOL. 1, NO. 3 • FALL 2023

FOOD INSECURITY: EFFECTS ON HEALTH AND FAMILY STRESS
Food insecurity is a significant stressor to individuals and families, which commonly stems from financial
difficulties. It is further compounded when other circumstances, such as frequent transitions and family conflicts,
are present. In this edition of Research Review (RR), wedefine food insecurity and describe methods of measuring it, discuss the association between food insecurity
and family stress, and suggest how to provide assistanceto families who are struggling with securing adequate
food. This information will be helpful to the Army Family
Advocacy Program (FAP) in two ways: (1) by providing
information about food insecurity that can be integrated
into the assessment of a victim or family that has had aviolent incident and been referred to FAP, and (2) by integrating information about food insecurity and its effecton family stress into classes conducted for FAP personnel
to prevent family violence. The information presented
here may also be useful to health care providers in familypractice, pediatrics, and for other clinicians who treat
patients with illnesses and perform health and wellness
checks.
Definition of food security and insecurity. According to the U.S. Department of Agriculture (USDA), foodsecurity is defined as “access by all people at all times
to enough food for an active, healthy life” (EconomicResearch Service, 2021b). The USDA identifies four levelsof food security, with low and very low food security constituting being food insecure. (Of note, the Office of theSecretary of Defense (OSD) classifies food security into
three categories: food secure, low food security, and very
low food security.)• High food security—Households had no problems, oranxiety about, consistently accessing adequate food.
• Marginal food security—Households had problems
at times and anxiety about accessing adequate food,but the quality, variety, and quantity of their foodintake were not substantially reduced.
• Low food security—Households reduced the quality,variety, and desirability of their diets, but the quantityof food intake and normal eating patterns were notsubstantially disrupted.
• Very low food security—At times during the year,
eating patterns of one or more household members
were disrupted and food intake was reduced because
the household lacked money and other resources forfood. Self-reported food intake was below levels considered adequate.
The extent of food insecurity in the US and in themilitary. In 2021, 89.8% of U.S. households were continuously food secure throughout the year. However, 10.2%
of U.S. households reported being food insecure at sometimes during that year. Of the 10.2%, 6.4% had low foodsecurity and 3.8% had very low food security at sometime during 2021 (see ers.usda.gov for publications of avariety of topics related to food security). In a 2018 report, 25.8% of active duty military personnel were foodinsecure: and of those, 15.4% had low food security and10.3% had very low food security (Asch et al., 2023).
Stressors associated with food insecurity. Food
insecurity is associated with multiple forms of psychological distress including depression and anxiety, sleepimpairment (Myers, 2020). It has also been associatedwith children’s negative academic performance and cogni-tive distress (Gallegos, Eivers, Sondergeld, & Pattinson,2021). Food insecurity can result from financial stress,
the high cost of food, inadequate nutritional knowledge,
inadequate skills for food preparation, and preferences
for poor-quality food and cultural food habits (van derVelde et al., 2019). Food insecurity has been linked to illhealth in adults, as well as developmental, behavioral, andmental health problems in children and adolescents. It
has also been associated with risk for interpersonal andself-directed violence by adults such as suicidal behavior(attempted or completed), peer violence and bullying,
youth dating violence, and child maltreatment (Frank etal., 2023).
Very low food security in households with children.
In 2021, the USDA noted that 6.2% of households withchildren were affected by food insecurity: 5.5% of families
with children were low food secure, and 0.7% were very
low food secure. In most cases, when children are foodinsecure, so are adults. Parents often protect their children
from food insecurity even when they are struggling with
reduced dietary quality and intake (ers.usda).
Measures of food security/insecurity. The USDA
measures food insecurity using an 18-item survey with 10
items for adults and an additional eight items for families
with children (see Appendix). A shorter, six-item version of the longer USDA 18-item survey is also available(https://www.ers.usda.gov/media/8282/short2012.pdf).
A two-item version based on the USDA 18-item survey(Radandt et al., 2018) has also been used. These two latterforms have been employed in research and can be practi-For over 20 years, the Center’s Family Violence
and Trauma Project has published thenewsletters Joining Forces Joining Families(JFJF) and Research Review: Family Violence(RR) on child maltreatment and domestic
violence. The publications provide criticalinformation to professionals working in family
services, primary care, and mental healthas well as those in positions of community
leadership or policy development. Please
visit https://www.cstsonline.org/resources/
newsletters/ for links to these newsletters, andshare this information with your colleagues.

2 • RESEARCH REVIEW

cally incorporated into the clinical setting and introduced in a class providing information on food insecurity as a form of family stress.
The six-item survey consists of the following statements. Response options include “often, sometimes,never or don’t know/refused” or “yes/no”.
1. “The food that we bought just didn’t last and wedidn’t have money to get more.” (often, sometimes,never or don’t know/refused”)
2. “We couldn’t afford to eat balanced meals.” (often,sometimes, never or don’t know/refused”)
3. In the last 12 months, did you or other adults in thehousehold ever cut the size of your meals or skip
meals because there wasn’t enough money for food?
(Yes/No)
4. (If yes to question 3) How often did this happen—
almost every month, some months but not every
month, or in only 1 or 2 months?
5. In the last 12 months, did you ever eat less than you
felt you should because there wasn’t enough moneyfor food? (Yes/No)
6. In the last 12 months, were you ever hungry, but
didn’t eat, because there wasn’t enough money forfood? (Yes/No)
Scoring of the six-item module is based on therespondent’s positive endorsement of each item byRESEARCH REVIEW
EditorTasanee R. Walsh, PhD, MPH, MSW
Senior Scientist; Research Assistant Professor
Department of Psychiatry, USU
e-mail to tasanee.walsh.ctr@usuhs.edu
Research Review is a publication of the CSTS Family Violenceand Trauma Project and and the Army Deputy Chief of Staff,
G-9, Family Advocacy Program, Washington, DC
Editorial Consultants
Stephen J. Cozza, MD, COL, U.S. Army Retired
Professor of Psychiatry and Pediatrics, USU
James E. McCarroll, PhD, MPH, COL, US. Army Retired
Research Professor, Department of Psychiatry, USU

Fall 2023

indicating either “often” or “sometimes,” or “yes”. High or
marginal food security is assessed by an endorsement of0-1 items; 2-4 suggests low food security; and 5-6 suggests very low food security (see U.S. Household Food
Security Survey Module: Six-Item Short Form). Note thatthese classifications may differ from the 18-item surveythat includes items relevant to households with children,
whereas the six-item survey does not (see the Appendix
for the full 18-item questionnaire).
A two-item survey was developed for pediatricpractice (Hager et al., 2010) and has been used in dental
practice (Radandt et al., 2018). These items are:
1. “Within the past 12 months we worried whether ourfood would run out before we got money to buy more”
2. “Within the past 12 months the food we bought justdidn’t last and we didn’t have money to get more.”
These can be endorsed as ”often true”, “sometimestrue”, or “never true” in the last 12 months. A positiveendorsement (i.e., “sometimes true” or “often true”) on
either question is considered positive for food insecurity .
While most families in the Army are food secure, foodinsecurity is an important issue for the FAP and medical
communities to be aware of because it is a significant family stressor, and can also be associated with other stressors, such as financial stress and mental health. In thissection, we suggest some methods of inquiry that could
be used in a FAP assessment of clients and as a topic forteaching FAP personnel about the issues.
Inquiring about food insecurity in a FAP setting. In
the context of a FAP assessment, an inquiry could determine if a service member or service member’s family
has experienced food insecurity and if it occurred in thecontext of other family stressors.
The inquiry could be started with “I need to ask you
about some family stressors that might have affected yourrelationships. Have there been financial pressures thathave affected whether you have been able to buy enoughfood to feed your family in the way you like?” If the answer is “Yes”, the follow-up question could be “How often
did/does this occur? Is it often or just sometimes?”
Discussing food insecurity. Food insecurity is an important topic to discuss in a variety of venues. For example, FAP personnel should be made aware of the potential
for food insecurity to negatively affect family functioning.
Food insecurity can also be an indicator that a family is
struggling in multiple domains. The goal would be to provide the audience with a broad understanding of the topic

http://www.CSTSonline.org

and how it can be assessed. When there is food insecurity
in a household, this is most likely associated with otherfamily stressors. Thus it is an indicator of a family at risk
for other stressors.
Barriers to accessing food assistance in the military.
Stigma about asking for assistance is a common barrier for Service members. They may be afraid that asking for assistance will negatively impact their career andbe concerned that their command may assume they arefinancially irresponsible. Additional barriers include themilitary culture of self-sufficiency and the lack of knowledge of resources available to assist with finances andobtaining food assistance (Asch et al., 2023).
Resources for military families. There are many federal, state, and local programs to assist families. Federal
programs are listed at (https://www.feedingamerica.org/take-action/advocate/federal-hunger-relief-programs).
These include Supplemental Nutrition Assistance Program (SNAP), the National School Lunch Program(NSLP), the Women, Infants, and Children (WIC)
program and others. The Army Community Services canprovide a list of food assistance programs that is specificfor the installation. There is also the Military OneSource
Army Economic Security Toolkit (https://www.militaryonesource.mil/leaders-service-providers.)

APPENDIX: SURVEY QUESTIONS USEDBY USDA TO ASSESS HOUSEHOLD FOOD
SECURITY (18-ITEM)

1. “We worried whether our food would run out
before we got money to buy more.” Was that often,
sometimes, or never true for you in the last 12months?
2. “The food that we bought just didn’t last and we didn’t
have money to get more.” Was that often, sometimes,
or never true for you in the last 12 months?
3. “We couldn’t afford to eat balanced meals.” Was that
often, sometimes, or never true for you in the last 12months?
4. In the last 12 months, did you or other adults in thehousehold ever cut the size of your meals or skip
meals because there wasn’t enough money for food?
(Yes/No)
5. (If yes to question 4) How often did this happen—
almost every month, some months but not every
month, or in only 1 or 2 months?

RESEARCH REVIEW • 3

6. In the last 12 months, did you ever eat less than you
felt you should because there wasn’t enough money forfood? (Yes/No)
7. In the last 12 months, were you ever hungry, but didn’teat, because there wasn’t enough money for food?
(Yes/No)
8. In the last 12 months, did you lose weight because
there wasn’t enough money for food? (Yes/No)
9. In the last 12 months did you or other adults in yourhousehold ever not eat for a whole day because there
wasn’t enough money for food? (Yes/No)
10. (If yes to question 9) How often did this happen—
almost every month, some months but not every
month, or in only 1 or 2 months?
(Questions 11–18 were asked only if the household
included children age 0-17)
11. “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.” Was that often, sometimes, or never true
for you in the last 12 months?
12. “We couldn’t feed our children a balanced meal,because we couldn’t afford that.” Was that often,
sometimes, or never true for you in the last 12months?
13. “The children were not eating enough because wejust couldn’t afford enough food.” Was that often,
sometimes, or never true for you in the last 12months?
14. In the last 12 months, did you ever cut the size of anyof the children’s meals because there wasn’t enoughmoney for food? (Yes/No)
15. In the last 12 months, were the children ever hungry
but you just couldn’t afford more food? (Yes/No)
16. In the last 12 months, did any of the children ever skipa meal because there wasn’t enough money for food?
(Yes/No)
17. (If yes to question 16) How often did this happen—
almost every month, some months but not every
month, or in only 1 or 2 months?
18. In the last 12 months did any of the children evernot eat for a whole day because there wasn’t enoughmoney for food? (Yes/No)

REFERENCES

Asch, B. J., Rennane, S., Trail, T. E., Berdie, L., Ward, J.
M., Troyanker, D., … Kemph, J. (2023). Food Insecurity
Among Members of the Armed Forces and Their Families. Retrieved from Santa Monica, CA:

4 • RESEARCH REVIEWFrank, M., Daniel, L., Hays, C. N., Shanahan, M. E.,Naumann, R. B., McNaughton Reyes, H. L., & Austin, A. E. (2023). Association of food insecurity withmultiple forms of interpersonal and self-directed violence: A systematic review. Trauma, Violence, & Abuse,
15248380231165689. doi:10.1177/15248380231165689
Gallegos, D., Eivers, A., Sondergeld, P., & Pattison, C.
(2021). Food insecurity and child development: A
state-of-the-art review. Int. J. Environ. Res. Public
Health., 18, 8990.doi:10.3390/ijerph18178990
Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M.,
Heeren, T., Rose-Jacobs, R., … Frank, D. A. (2010).
Development and validity of a 2-item screen to identify
families at risk for food insecurity. Pediatrics, 126(1),e26-32. doi:10.1542/peds.2009-3146
Myers, C. (2020). Food insecurity and psychological distress: A review of the recent literature. Curr. Nutr. Rep.,
9, 107-118. doi:10.1007/s13668-020-00309-1
Radandt, N. E., Corbridge, T., Johnson, D. B., Kim, A. S.,
Scott, J. M., & Coldwell, S. E. (2018). Validation of a
two-item food security screening tool in a dental setting. Journal of Dentistry for Children, 85(3), 114-119.
van der Velde, L. A., Schuilenburg, L. A., Thrivikraman,J. K., Numans, M. E., & Kiefte-de Jong, J. C. (2019).
Needs and perceptions regarding healthy eating amongpeople at risk of food insecurity: a qualitative analysis.
Int J Equity Health, 18(1), 184. doi:10.1186/s12939-0191077-0
Economic Research Service, “U.S. Household Food
Security Survey Module: Six-Item Short Form,” U.S.
Department of Agriculture, 2012.
Economic Research Service, “Documentation Overviewof Surveys,” U.S. Department of Agriculture, webpage,
September 8, 2021a. https://www.ers.usda.gov/dataproducts/food-security-in-the-united-states/documentation.aspx
Economic Research Service, “Food Security in the U.S.:
Measurement,” webpage, September 8, 2021b. https://www.ers.usda.gov/topics/food-nutrition-assistance/
food-security-in-the-u-s/measurement/
Economic Research Service, “Survey Tools,” U.S. Department of Agriculture, webpage,
September 8, 2021c. https://www.ers.usda.gov/topics/
food-nutrition-assistance/food-security-in-the-us/
survey-tools/

Fall 2023