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Department of Public Health, University of Helsinki, 00014 Helsinki, Finland
2To whom correspondence should be addressed. E-mail: sirpa.sarlio-lahteenkorva{at}helsinki.fi
ABSTRACT
Fears and experiences of food restriction influence eating behavior but the association between past and present economic disadvantage, food insecurity and body size is poorly understood. Therefore, we examined these associations in a nationwide, representative sample of 25- to 64-y-old Finnish men and women (n = 6506). The respondents were classified by their body mass index (BMI) into four groups: thin, normal, overweight and obese. Economic disadvantage was assessed by three indicators including low household income, unemployment during past 5 y and long-term economic problems in childhood. Food insecurity was assessed by five separate items concerning economic fears and experiences related to sufficient supply of food during the past 12 mo, and a combined scale in which those with affirmative responses to four to five items were classified as hungry. Multivariable logistic regression analyses were conducted using both the BMI grouping and indicators of economic disadvantage as independent variables to predict food insecurity, controlling simultaneously for age, educational attainment and sex. The results showed that low household income, recent unemployment and economic problems in childhood were all predictors of food insecurity. Thin people were most likely to be hungry and showed most food insecurity in five separate items. In addition, obese people reported more buying cheaper food due to economic problems and fears or experiences of running out of money to buy food than did normal weight subjects. In conclusion, both past and present economic disadvantage is associated with various aspects of food insecurity. The association between food insecurity and BMI is curvilinear.
KEY WORDS: • food insecurity • economic disadvantage • body mass index
In affluent societies people are constantly surrounded by food and
problems associated with excess energy intake are increasing. Adult
obesity is becoming a more serious problem than undernutrition even in
many developing countries (1
). It is tempting to believe
that the availability of food or experience of hunger are not widely
experienced serious problems in affluent societies (2
),
especially because thinness is more common among those with high
socioeconomic status and an inverse relationship between body weight
and socioeconomic status is often found (3
).
Nevertheless, economic constraints are likely to limit the available
dietary options in affluent societies. A recent study shows that 
8%
of U.S. households were food insecure without hunger, that is, they
were concerned about adequate food supply, substituted foods with
cheaper ones, and reduced the quality and variety of their diets.
Moreover, 4% of the households showed a reduction in food intake
during the study (4
). Although hunger rates decline with
raising income, food insufficiency is not limited to very low income
persons and households. Events that jeopardize household budgets, such
as losing a job or gaining a new household member, may be associated
with food insufficiency (5
). Over one-half of
food-insufficient individuals have been found to live in employed
families (6
).
Fears and experiences of food restriction are likely to affect the
quality of diet and eating behavior in many ways. Healthy diets tend to
cost more than energy-dense food (7
–9
), and this may
influence dietary intake and eating patterns. Lower intake of energy
and nutrients has been found among women using emergency food
assistance and reporting experiences of hunger (10
), and
elderly individuals and women from food-insufficient households
(11
). People with limited resources may decrease their
intake of vegetables and fruits and show disordered eating patterns
(12
). They may also skip meals (13
), but
choose more energy-dense foods to prevent hunger (14
)
and consume food in excess when money is again available. Previous
studies suggest that both voluntary and involuntary food deprivation
result in a variety of cognitive and behavioral changes, such as
preoccupation with food and eating (15
). In addition to
the quantitative and qualitative aspects, hunger or food insecurity
also has psychological and social components. Although hunger is
managed differently by various households, there tends to be a general
sequencing of the experience of hunger. Food anxiety is often
experienced first, and the quality of food is generally affected before
the intake quantity (16
).
The association between body size, economic disadvantage and food
insecurity is poorly understood, however. Chronic lack of economic
resources may lead to food insufficiency that can result in
malnutrition and underweight. In contrast, many studies show that
socioeconomic disadvantage during childhood (17
–20
),
living in a deprived area (21
), low income
(22
, 23
) or decrease in household income (24
),
and experiencing unemployment (25
, 26
) increase the risk of
weight gain in some population groups, probably mostly due to untoward
behavioral changes. Fears of future economic problems may additionally
affect body size. According to a recent study, white-collar
employees with threatened job security gained weight. This trend could
not be explained by changes in smoking, drinking or exercise habits
(27
). Unfortunately, changes in dietary habits were not
evaluated in this study. It is possible that experiences and fears of
economic problems lead to food insecurity, which, in turn, may lead to
dietary patterns that favor weight gain.
Indeed, some studies suggest that economic problems resulting in food
insecurity may contribute to obesity. Cyclical or episodic periods of
food insecurity due to economic problems seem to alter eating behavior
and promote weight gain in children (14
), and a study of
rural women of child-bearing age and having children at home showed
that food insecurity in the household is related to obesity
(28
). A recent study by Townsend et al. (29
)
confirmed that food insecurity, especially adjustments for the quality
of food eaten in the household, is positively related to overweight in
women in the United States. However, otherwise, we lack studies that
address these issues at the population level.
We examined whether economic disadvantage and body size are associated with food insecurity, using a nationwide representative sample of working-aged adults from Finland. We hypothesized that both past and present economic disadvantage are associated with food insecurity. Additionally, we hypothesized that less severe forms of food insecurity, such as food anxiety or impaired quality of diet, may contribute to obesity, whereas more severe forms, when the quantity of food is reduced, are more likely to be associated with thinness.
MATERIALS AND METHODS
The data were from a Finnish "Survey on Living Conditions"
collected in 1994 by the government statistical authorities, Statistics
Finland. The sample satisfactorily represents the noninstitutional
population 15 y of age or older. The data were collected by
personal face-to-face interviews (n = 8650) with a 73%
response rate (30
, 31
). We included only
working-aged, i.e., 25- to 64-y-old subjects (n
= 6506) in our study. Income data for 1993 were linked from the
taxation register, and completed education from the national register
of educational degrees at Statistics Finland. Completed educational
attainment was categorized into three groups: higher (
13 y),
secondary (10–12 y), and basic (
9 y). Age was categorized into 5-y
age groups.
Body mass index (BMI)3 .
BMI was calculated using self-reported information on body height
and weight. The subjects were classified according to BMI into four
groups: thin (BMI < 20 kg/m2), normal weight (BMI
= 20–24.9 kg/m2), overweight (BMI = 25–29.9 kg/m2) and obese (BMI 30
kg/m2). This classification is widely used and recommended
in Finland and other Scandinavian countries (32
), and,
except for the higher cut-point between normal weight and thinness
than that used by the World Health Organization (18.5
kg/m2), it is in agreement with the one recommended by the
World Health Organization (1
).
Indicators of economic disadvantage.
Three indicators of economic disadvantage were used. Early economic
disadvantage was assessed by asking the respondents to report whether
they had had long-term economic problems in their childhood family.
Economic insecurity in the recent past was assessed by asking the
respondents whether they had experienced unemployment within past
5 y. Current economic situation was assessed by register-based
data on household disposable income per consumption unit, calculated
with the formula of the Organisation for Economic Co-operation
and Development (33
). Those belonging to the
lowest quintile of household income were classified as having low
household income per consumption unit. All three indicators of economic
disadvantage were used as dichotomous variables (yes = 1, no
= 0) in the logistic regression analyses.
Indicators of food insecurity.
We used five separate questions about fears and experiences of food
insecurity during the past 12 mo due to economic problems. These items
were from the Edmonton Food Policy Council’s survey among residents
with low incomes. Our set of questions is based on the adult hunger
scale (34
) and it included the following items:
1) "Have you had fears of running out of food before you have money to buy more?"
2) "Have you run out of money to buy food?"
3) "Have you had too little food due to economic problems?"
4) "Have you bought cheaper food than you normally buy?"
5) "Have you been without food at least a day due to economic problems?"
Responses to these questions were used as separate dichotomous
variables (yes = 1, no or don’t know = 0) in the analysis.
In addition, we combined these five items into a summary scale (0–5),
where zero indicates negative or don’t know responses to all items and
scores of five indicate affirmative responses. The internal consistency
of the scale was assessed by using the Cronbach’s 
coefficient. All
items correlated positively, and the was 0.72. To detect the most
severe form of food insecurity, when the quantity of food is reduced,
we further identified those with at least four affirmative responses
and studied them as a separate hungry group in the logistic regression
analysis (scores 4–5 = 1, scores 0–3 = 0).
Multivariable logistic regression analyses were conducted using all three indicators of economic disadvantage and the BMI grouping as independent variables to predict food insecurity, using each of these single items and the summary scale of severe food insecurity as outcome variables. All analysis controlled simultaneously for age, educational attainment and sex. Statistical analysis was completed with SPSS, Version 9.01 (SPSS, Chicago, IL).
This study was based on secondary analysis of data collected by governmental statistical authorities, Statistics Finland. Ethical considerations were taken into account by the authorities when the data were collected. Individuals cannot be identified in the data analyzed in this study.
RESULTS
Descriptive unadjusted data show that buying cheaper food due to
economic problems is fairly common, because one-quarter of the
studied population reported doing so during the past 12 mo. Nine
percent reported fears of running out of food due to economic problems,
11% had experiences of running out of money to buy food and 3% had
had too little food due to lack of money. The most serious single form
of food insecurity according to the summary scale, i.e., being without
food for at least a day, was reported by 2% of the sample. The most
severe form of food insecurity, that is, affirmative responses to four
to five questions were reported by 2.7% of the population. Both past
and present indicators of economic disadvantage were significantly
associated with all indicators of food insecurity (P < 0.0001). In addition, our data suggest that deviant body weight is
associated with food insecurity. The thinnest group seemed to be most
likely to experience hunger and to report food insecurity by all of our
indicators, usually followed by the obese (Table 1
).
|
).
|
DISCUSSION
Food insecurity is a complex and multidimensional phenomenon.
According to Life Sciences Research Office, food insecurity exists
whenever the availability of nutritionally adequate and safe foods or
the ability to acquire acceptable foods in socially acceptable ways is
limited or uncertain (35
). In addition to material quality
and quantity, food insecurity includes psychological and sociocultural
dimensions (2
, 16
). Food insecurity is not limited to those
who have inadequate nutrient and energy supplies. Food insecurity
exists when people lack choice, fear running out of food, or are forced
to make major changes in their preferred eating habits due to economic
constraints. The results of this study are consistent with this broad
scope of food insecurity.
Our results show that economic disadvantage, even in the distant past,
is associated with food insecurity, and both thin and obese people are
more likely to report experiences and fears of food insecurity. There
are several potential explanations for this finding but the current
evidence for physiological explanations is likely to be quite limited.
Chronic episodes of food insufficiency may lead to weight loss
(36
), but the majority of current studies do not support
an adverse effect of weight loss or weight cycling on metabolism
(37
). In addition, the evidence linking early
undernutrition to future risk of obesity is limited and contradictory
(38
). Therefore, explanations for our findings should be
searched among key social and behavioral factors.
As can be expected, current economic disadvantage, in our study,
belonging to the lowest quintile of the household income distribution,
was associated with food insecurity. Moreover, both experiencing
economic problems in childhood and unemployment within the past 5 y were independently associated with all indicators of food insecurity.
In keeping with previous studies (18
, 39
), these findings
stress the importance of the life-course perspective and the
influence of childhood circumstances on adult life, although pathways
underlying these observations are not fully understood. It is known
that behavioral models and dietary tastes are established very early
(8
), and restricting access to palatable foods may affect
children’s behavioral response to food (40
). In addition,
if households turn to cheaper foods with inferior nutritional quality
when money is tight (2
), then this may result in eating
patterns that contribute to childhood obesity (14
) and may
teach children to use similar behavioral patterns in adulthood.
Moreover, sustained economic hardship during adult life increases the
risk of having difficulties with daily activities, such as cooking,
shopping and managing money (39
).
In addition, experiences of food deprivation may affect social and
psychological security throughout life. Food deprivation may further
result in a variety of behavioral and cognitive changes, including
preoccupation with food and eating (15
). Long-term
unemployment is likely to cause special problems even when food is
available, because people have to live with chronic economic
difficulties (41
). There is also some evidence that low
socioeconomic status leads to psychosocial stress, promoting central
obesity through psychoneuroendocrinological pathways (42
).
Although thinness is often found to be associated with higher
socioeconomic status (3
), thin people in this study were
most likely to give affirmative responses to all separate food
insecurity items and, furthermore, showed increased risk for hunger.
Our results suggest that even in developed welfare states, such as
Finland, some people are hit by circumstances in which they are forced
to reduce their intake of food due to economic problems. Previous
studies have shown that food insecurity and hunger may be common among
some special vulnerable groups, such as immigrants (43
).
However, our data do not allow us to examine whether these people would
be overrepresented in our group of thin people. The data were collected
during a period of deep economic recession including very high
unemployment and increasing long-term unemployment
(44
). Consequently, economic and social problems increased
in Finland. Under such conditions, special vulnerable groups may be
borne in which serious weight- and food-related problems, such as
thinness due to lack of food, are enhanced (45
).
Nevertheless, although thin people were most likely to report food
insecurity, thinness was quite rare. Only 5% of our sample could be
classified as thin, whereas 12% were obese.
Obese people were more likely to report buying cheaper food and having
fears or experiences of running out of money to buy food, indicating
food anxiety and reduced quality of the diet. It is possible that
economic problems enhance food insecurity, which, in turn, may lead to
eating patterns that favor the intake of fat-rich food to prevent
hunger (14
). It is further possible that eating patterns
change so that foods are consumed in excess when money is available
again.
There are a number of potential caveats in this study. The data are
cross-sectional and do not allow causal judgments, and BMI was
calculated from self-reported data. Moreover, although there is a
substantial amount of research on the validation of
questionnaire-based measures of food insecurity
(46
–49
), the validity of our questions on food insecurity
is unknown. The five items included in our study were adapted, without
direct validity testing, from a Canadian survey (34
).
Nevertheless, except for questions that focus on reduced food intake
among children, these items cover all other key areas presented in the
extensively tested core module of the U.S. Census Bureau’s Food
Security Supplement in Current Population Survey (46
).
Cognitive tests of these food insecurity questions would be vital, as
suggested by Alaimo et al. (50
). Unfortunately, we lack
such tests in the Finnish setting and it remains unclear what the
questionnaire items are strictly measuring from the perspective of the
respondents. Furthermore, although previous studies report that food
insecurity is associated with decreased nutrient intake
(10
–12
), it is not known how well our items of food
insecurity are associated with nutrient intake or the nutritional
status. Although hunger and food insecurity were associated with
thinness, we do not have information about potential malnutrition in a
clinical sense. This study used population survey data, and this method
may not capture the most severely disadvantaged people.
In conclusion, our study suggests that past and present economic disadvantage may give rise to food insecurity, which is likely to be related to abnormally low and high body weight. To further confirm this finding, we need focused, longitudinal, in-depth studies on the social, behavioral and physiological pathways through which serious food insecurity is produced.
FOOTNOTES
1 Supported by the Academy of Finland, Research
Council for Health (Projects 52277, 48553 and 37800). 
3 Abbreviation used: BMI, body mass index.
Manuscript received 11 April 2001. Initial review completed 14 May 2001. Revision accepted 22 August 2001.
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 L. L Kaiser, M. S Townsend, H. R Melgar-Quinonez, M. L Fujii, and P. B Crawford Choice of instrument influences relations between food insecurity and obesity in Latino women Am. J. Clinical Nutrition, November 1, 2004; 80(5): 1372 - 1378. [Abstract] [Full Text] [PDF]
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D. Gibson Long-Term Food Stamp Program Participation is Differentially Related to Overweight in Young Girls and Boys J. Nutr., February 1, 2004; 134(2): 372 - 379. [Abstract] [Full Text] [PDF]
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R. E Mazur, G. S Marquis, and H. H Jensen Diet and food insufficiency among Hispanic youths: acculturation and socioeconomic factors in the third National Health and Nutrition Examination Survey Am. J. Clinical Nutrition, December 1, 2003; 78(6): 1120 - 1127. [Abstract] [Full Text] [PDF]
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 M. C Gulliford, D. Mahabir, and B. Rocke Food insecurity, food choices, and body mass index in adults: nutrition transition in Trinidad and Tobago Int. J. Epidemiol., August 1, 2003; 32(4): 508 - 516. [Abstract] [Full Text] [PDF]
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E. A. Frongillo Understanding Obesity and Program Participation in the Context of Poverty and Food Insecurity J. Nutr., July 1, 2003; 133(7): 2117 - 2118. [Full Text] [PDF]
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D. Gibson Food Stamp Program Participation is Positively Related to Obesity in Low Income Women J. Nutr., July 1, 2003; 133(7): 2225 - 2231. [Abstract] [Full Text] [PDF]
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N. T. Vozoris and V. S. Tarasuk Household Food Insufficiency Is Associated with Poorer Health J. Nutr., January 1, 2003; 133(1): 120 - 126. [Abstract] [Full Text] [PDF]
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