1. Introduction

Food Insecurity in the United States

Food security in the US can be divided into 4 categories: high food security, marginal food security, low food security, and very low food security. The latter 3 categories (marginal, low, and very low) are classified as food insecure. Food insecurity can range from anxiety surrounding where the next meal will come from (marginal food security) to regularly missing meals due to lack of funds (very low food security)^[1][2]. While lack of financial support is a major reason for food insecurity, a second, commonly overlooked reason is food insecurity due to lack of access. Individuals experiencing food insecurity are more likely to live in areas with decreased access to nutritious foods, resulting in unhealthy options sometimes being the only option(s). To further explore this, Powell et al, analyzed census data to determine food availability and neighborhood characteristics in the United States. More specifically, 28,050 zip codes were analyzed, and it was observed that low-income neighborhoods included significantly less chain supermarkets. In fact, low income areas housed 75% of the number of markets compared to middle income neighborhoods. After data were adjusted for income and other confounding factors, African American neighborhoods had only 52% of markets of that in predominantly White neighborhoods. The observed availability decreased again in urban areas. African American neighborhoods also had higher numbers of non-chain supermarkets and grocery stores. This constitutes an interesting finding since chain supermarkets tend to have more food, overall, as well as better quality, more diversity in products, and lower prices. Minority (regardless of income level) and low-income neighborhoods face disproportionally higher food prices solely due to lack of access^[3] It is therefore probable that low income neighborhoods are more likely to choose cheaper and unhealthier options because grocery stores in their areas may be too expensive.

To explore whether or not this was indeed the case, Dimitri et al, studied the effect of incentives at farmers markets on fresh produce purchase/consumption. The researchers studied low income households in five different areas which were provided incentives to shop at farmers markets ($10 allowance). The incentives applied had to be matched with either cash or a federal nutrition benefit expenditure. Individuals were then asked at the end of a 12-16-week period if they believed this increased their vegetable consumption. While not all individuals reported increasing their fresh produce consumption, nutrition incentives did help increase willingness to utilize farmers markets, implying that access to fresh produce rather than cost mediation was the incentives’ attractive quality^[4]. These observations support further the notion that individuals who tend to be food insecure would increase their intake of higher quality healthier food if an access path was offered to them.

 2. Food Insecurity, Obesity, and T2DM

Particularly germane to this investigation, food insecure households actually exhibit higher rates of obesity. This correlation between obesity and food insecurity was evaluated in women in California. More specifically, 8,169 women over the age of 18 were interviewed on food security, using an adapted version of the US Household Food Security Module. It was found that 13.9% of these women experienced food insecurity without hunger, and 4.3% experienced food insecurity with hunger. Interestingly, 18.8% of these women were considered obese, per BMI classification, while their majority was deemed food insecure. It was determined that food insecure women not experiencing hunger were 47% more likely to be obese. In fact, women experiencing hunger were 2.8 times more likely to be obese than their food secure counterparts also^[5].

While it may seem contradictory that food insecurity promotes obesity, it is likely that this relationship is influenced by what is available in certain areas, and the level of financial resources available towards access to a wider variety of food. Obesity has been closely linked to the onset of several diseases, one such being T2DM. In fact, T2DM has been directly linked to food insecurity in several cases. In a comprehensive analysis by Gucciardi et al., household food insecurity was found higher in households which have at least one member with diabetes. With each earlier year of diagnosis, the likelihood of food insecurity increases by 4%, which may be due to the increased costs of T2DM treatment and management^[6].

In similar studies investigating T2DM and food insecurity, 4,423 adults over 20 years old were grouped as either food secure, mildly food insecure, or severely food insecure using the NHANES food security module. T2DM prevalence was also recorded, either by self- reporting or through a fasting serum glucose test, where a C-peptide level >0.50 nmol/L identified T2DM. The correlation between food insecurity and T2DM was then analyzed and was found that 11.7% of the food secure individuals, 10.0% of the mildly insecure individuals, and 16.1% of the severely food insecure individuals had T2DM. Comprehensively, this equated to overall odds ratio for diabetes of 1.2 for mild food insecurity and 2.1 for severe, as compared to the food secure individuals after adjusting for gender, age, race/ethnicity, family history of diabetes, education, and physical activity^[7]. These findings argue in favor of a link between food insecurity and T2DM in a twofold manner:

• Food insecure individuals may not have the income to purchase all of the nutrients they need, leading to the purchasing of canned or pre-made foods which tend to be high in salt and fat^[7]. These individuals may also not have the ability to purchase fresh produce and more expensive yet healthier items.
• Diabetic individuals experience additional costs associated with disease management, such as medication costs, monitoring and supply costs. This places an additional financial stress on household budgets, further increasing the likelihood of food insecurity and further exacerbating a vicious cycle^[6].

 3. Wasted Food; a Potential Solution?

Approximately 30-40% of all of the food generated in the US, constitutes waste each year, with 31% of the total waste occurring at the retail and consumer level^[8]. Most of the food that is wasted, especially at the consumer level, is due to misinformation and issues with appearance/acceptability. Relevant research demonstrates that consumers have certain idealistic expectations in terms of appearance as per the food purchased, and subsequently reject food, which is not “perfect” in appearance, even though the food may be nutritious and perfectly edible^[9]. According to some estimates, as much as 15% of the wasted food in the US could feed 25 million people annually in the US. In spite of such otherwise abundance, 11.1% of American households experienced food insecurity in some form in 2018^[9], termed as uncertainty at some point in time on the adequate meal provision for the household.

There is a variety of proposals for decreasing food waste in conjunction with reduction of food insecurity. One idea is through gleaning, or collection of leftover crops from fields that would otherwise go to waste^[10]. Gleaning is an ancient practice that was actually mentioned in the Old Testament, Leviticus 23:22, “When you reap the harvest of your land, moreover, you shall not reap to the very corners of your field nor gather the gleaning of your harvest; you are to leave them for the needy and the alien.” While gleaning dipped in popularity over the years it has recently been suggested as a potential method to decrease food waste gaining momentum. It now typically involves volunteers to collect the produce from local farms and produce growers which is then transported to food banks for distribution^[4]. While gleaning may not be enough, it can extend a positive impact on decreasing food wasted. In 2010, gleaning programs rescued 3.6 million tons of fresh produce in New York State alone, and similar numbers have been reported for California and Arizona^[4].

Most places involved with the production and/or preparation of food typically generate waste in some way, yet with a large portion of this waste being edible food. One such area is cafeterias, particularly in school settings, whereby large amounts of edible food is wasted daily. In a study in Florida, 3 schools were selected to participate in a waste study. All waste generated in cafeterias was collected and sorted into several groups, including food, milk, cardboard, paper, plastic, and Styrofoam. It was found that a majority of waste was food waste, which was defined as “plate waste from school-provided meals and meals bought from home, [and] food preparation waste”. It is also important to note that this collection moreover included breakfast, whenever applicable. On average, food waste alone accounted for 50.2 g/student/day of waste and averaged approximately 50% of waste for all three schools (range: 47.1%-57.8%). These results are interesting as in schools A and B, 50-60% of students were eligible for free or reduced lunch, nevertheless a significant amount of food still resulted to waste. It is likely that the observed numbers are biased on the high end, because students feel urged to take advantage of the offered food thus tend to over-order food. Also, significant amounts of waste were generated by schools’ A and B kitchens (school C was private and did not provide lunch)^[11]. It is likely that some of the food waste could have been repurposed, and that not all of the food eventually wasted was at the end of its lifecycle. Therefore, based on the large amount of waste produced in school cafeterias and given the fact that some students depend on school lunches for a guaranteed meal, it is worth investigating ways to repurpose excess food to decrease food insecurity particularly in children.

Similarly, the recently introduced School Food Recovery Act (January 2020) aims to establish a USDA grant program to allow schools to collect food waste data and implement programs to educate students. It was also reported that through hands-on food education, children eat three times as much food and vegetables compared to what they otherwise would^[12], meaning that their overall health can be improved through food waste education. While the exact details of this are not available at this time yet, it is a promising bill that may spark change within schools.

Many cities have programs available at the restaurant level as well, where leftover food can be picked up and distributed to those in need at little or no cost. However, these programs are not well documented, and it is difficult to determine their impact on food insecurity. More research is needed in this area to determine the direct relationship, but intuitively, it makes sense that these types of programs can increase access to healthier food^[13].

The relationship between food insecurity and obesity is well established. Also well-established is the relationship between obesity and T2DM. Less established, however, are the solutions to these issues. The wasted food from many sources may help to incrementally decrease food insecurity and thereby decrease the risk of obesity and T2DM.