Students with Food Insecurity Are More Likely to Screen Positive for an Eating Disorder at a Large, Public University in the Midwest

Published:March 24, 2021DOI:



      College students experience a disproportionately high prevalence of both food insecurity and eating disorders. Food insecurity is associated with stress, irregular eating patterns, weight change, depression, and body dissatisfaction, making it a possible risk factor for the onset of eating disorders. However, the association between food insecurity and eating disorders among college students is not well understood.


      This study explored the relation between food insecurity and screening positive for an eating disorder among students attending a large, public Midwestern university.


      Cross-sectional data were collected using an online survey administered from March through June 2018.


      Participants were recruited from a random sample of 2,000 students, with oversampling from the following groups: racial/ethnic minorities, first-generation students, and students from lower-income households. Of those sampled, 851 students (43%) responded. The final analytic sample comprised 804 students after excluding those with missing data.

      Main outcome measure

      The validated 5-item Sick, Control, One stone, Fat, Food (SCOFF) questionnaire was used to screen for the presence of an eating disorder.

      Statistical analyses performed

      Poisson regression was used to model prevalence ratios for positive SCOFF screens (≥2 affirmative responses) by levels of food security (ie, high, marginal, low, or very low). Models were adjusted for sex, age, race/ethnicity, degree type, financial aid, and first-generation student status.


      Compared to students with high food security, a higher prevalence of positive SCOFF screens was found among students with marginal food security (prevalence ratio [PR], 1.83, 95% CI 1.26 to 2.65; P = 0.001), low food security (PR 1.72, 95% CI 1.16 to 2.54; P = 0.007), and very low food security (PR 2.83, 95% CI 2.01 to 3.97; P < .0001).


      Students with food insecurity at any level were more likely to screen positive for an eating disorder via the SCOFF questionnaire. Prospective studies are needed to determine whether food insecurity is a risk factor for the onset of eating disorders among college students.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bruening M.
        • Argo K.
        • Payne-Sturges D.
        • Laska M.N.
        The struggle is real: a systematic review of food insecurity on postsecondary education campuses.
        J Acad Nutr Diet. 2017; 117: 1767-1791
        • Anderson S.A.
        Core indicators of nutritional state for difficult-to-sample populations.
        J Nutr. 1990; 120: 1559-1600
        • Baker-Smith C.
        • Coca V.
        • Goldrick-Rab S.
        • Looker E.
        • Richardson B.
        • Williams T.
        #RealCollege 2020: Five Years of Evidence on Campus Basic Needs Insecurity.
        The Hope Center for College, Community, and Justice of Temple University, Philadelphia, PA2020
        • Coleman-Jensen A.
        • Rabbitt M.P.
        • Gregory C.A.
        • Singh A.
        Household Food Security in the United States in 2018, ERR-270.
        US Department of Agriculture, Economic Research Service, Washington, DC2019
        • Hudson J.I.
        • Hiripi E.
        • Pope H.G.
        • Kessler R.C.
        The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.
        Biol Psychiatry. 2007; 61: 348-358
        • Lipson S.K.
        • Sonneville K.R.
        Eating disorder symptoms among undergraduate and graduate students at 12 U.S. colleges and universities.
        Eat Behav. 2017; 24: 81-88
        • Robinson L.
        • Aldridge V.
        • Clark E.M.
        • Misra M.
        • Micali N.
        A systematic review and meta-analysis of the association between eating disorders and bone density.
        Osteoporos Int. 2016; 27: 1953-1966
        • Kisely S.
        • Baghaie H.
        • Lalloo R.
        • Johnson N.W.
        Association between poor oral health and eating disorders: systematic review and meta-analysis.
        Br J Psychiatry. 2015; 207: 299-305
        • Mantel Ä.
        • Hirschberg A.L.
        • Stephansson O.
        Association of maternal eating disorders with pregnancy and neonatal outcomes.
        JAMA Psychiatry. 2019; 77: 285-293
        • Linna M.S.
        • Raevuori A.
        • Haukka J.
        • Suvisaari J.M.
        • Suokas J.T.
        • Gissler M.
        Reproductive health outcomes in eating disorders.
        Int J Eat Disord. 2013; 46: 826-833
        • Micali N.
        • Solmi F.
        • Horton N.J.
        • et al.
        Adolescent eating disorders predict psychiatric, high-risk behaviors and weight outcomes in young adulthood.
        J Am Acad Child Adolesc Psychiatry. 2015; 54: 652-659.e1
        • Riedlinger C.
        • Schmidt G.
        • Weiland A.
        • et al.
        Which symptoms, complaints and complications of the gastrointestinal tract occur in patients with eating disorders? A systematic review and quantitative analysis.
        Front Psychiatry. 2020; 11: 195
        • Hudson J.I.
        • Lalonde J.K.
        • Coit C.E.
        • et al.
        Longitudinal study of the diagnosis of components of the metabolic syndrome in individuals with binge-eating disorder.
        Am J Clin Nutr. 2010; 91: 1568-1573
        • Montagnese C.
        • Scalfi L.
        • Signorini A.
        • De Filippo E.
        • Pasanisi F.
        • Contaldo F.
        Cholinesterase and other serum liver enzymes in underweight outpatients with eating disorders.
        Int J Eat Disord. 2007; 40: 746-750
        • Green M.
        • Rogers J.
        • Nguyen C.
        • et al.
        Cardiac risk and disordered eating: decreased R wave amplitude in women with bulimia nervosa and women with subclinical binge/purge symptoms.
        Eur Eat Disord Rev. 2016; 24: 455-459
        • Oflaz S.
        • Yucel B.
        • Oz F.
        • et al.
        Assessment of myocardial damage by cardiac MRI in patients with anorexia nervosa.
        Int J Eat Disord. 2013; 46: 862-866
        • Crow S.J.
        • Peterson C.B.
        • Swanson S.A.
        • et al.
        Increased mortality in bulimia nervosa and other eating disorders.
        Am J Psychiatry. 2009; 166: 1342-1346
        • Kärkkäinen U.
        • Mustelin L.
        • Raevuori A.
        • Kaprio J.
        • Keski-Rahkonen A.
        Do disordered eating behaviours have long-term health-related consequences?.
        Eur Eat Disord Rev. 2018; 26: 22-28
        • Lipson S.K.
        • Sonneville K.R.
        Understanding suicide risk and eating disorders in college student populations: results from a National Study.
        Int J Eat Disord. 2020; 53: 229-238
        • Laraia B.
        • Vinikoor-Imler L.C.
        • Siega-Riz A.M.
        Food insecurity during pregnancy leads to stress, disordered eating, and greater postpartum weight among overweight women.
        Obesity (Silver Spring). 2015; 23: 1303-1311
        • Whittle H.J.
        • Sheira L.A.
        • Wolfe W.R.
        • et al.
        Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States.
        J Nutr. 2019; 149: 1393-1403
        • El Zein A.
        • Shelnutt K.P.
        • Colby S.
        • et al.
        Prevalence and correlates of food insecurity among U.S. college students: a multi-institutional study.
        BMC Public Health. 2019; 19: 660
        • Darling K.E.
        • Fahrenkamp A.J.
        • Wilson S.M.
        • D’Auria A.L.
        • Sato A.F.
        Physical and mental health outcomes associated with prior food insecurity among young adults.
        J Health Psychol. 2017; 22: 572-581
        • Bruening M.
        • van Woerden I.
        • Todd M.
        • Laska M.N.
        Hungry to learn: the prevalence and effects of food insecurity on health behaviors and outcomes over time among a diverse sample of university freshmen.
        Int J Behav Nutr Phys Act. 2018; 15: 9
        • Bruening M.
        • MacLehose R.
        • Loth K.
        • Story M.
        • Neumark-Sztainer D.
        Feeding a family in a recession: food insecurity among Minnesota parents.
        Am J Public Health. 2012; 102: 520-526
        • Bruening M.
        • Brennhofer S.
        • van Woerden I.
        • Todd M.
        • Laska M.
        Factors related to the high rates of food insecurity among diverse, urban college freshmen.
        J Acad Nutr Diet. 2016; 116: 1450-1457
        • Hooper L.
        • Telke S.
        • Larson N.
        • Mason S.M.
        • Neumark-Sztainer D.
        Household food insecurity: associations with disordered eating behaviours and overweight in a population-based sample of adolescents.
        Public Health Nutr. 2020; 23: 3126-3135
        • Cheung H.C.
        • Shen A.
        • Oo S.
        • Tilahun H.
        • Cohen M.J.
        • Berkowitz S.A.
        Food insecurity and body mass index: a longitudinal mixed methods study, Chelsea, Massachusetts, 2009–2013.
        Prev Chronic Dis. 2015; 12: E125
        • Leung C.W.
        • Epel E.S.
        • Willett W.C.
        • Rimm E.B.
        • Laraia B.A.
        Household food insecurity is positively associated with depression among low-income supplemental nutrition assistance program participants and income-eligible nonparticipants.
        J Nutr. 2015; 145: 622-627
        • Becker C.B.
        • Middlemass K.M.
        • Gomez F.
        • Martinez-Abrego A.
        Eating disorder pathology among individuals living with food insecurity: a replication study.
        Clin Psychol Sci. 2019; 7: 1144-1158
        • Altman E.A.
        • Ritchie L.D.
        • Frongillo E.A.
        • Madsen K.A.
        Food insecurity is associated with body dissatisfaction among children in California.
        J Acad Nutr Diet. 2019; 119: 1732-1737
        • Shankar-Krishnan N.
        • Fornieles Deu A.
        • Sánchez-Carracedo D.
        Associations between food insecurity and psychological wellbeing, body image, disordered eating and dietary habits: evidence from Spanish adolescents.
        Child Indic Res. 2021; 14: 163-183
        • Liechty J.M.
        • Lee M.J.
        Longitudinal predictors of dieting and disordered eating among young adults in the U.S.
        Int J Eat Disord. 2013; 46: 790-800
        • Middlemass K.M.
        • Cruz J.
        • Gamboa A.
        • et al.
        Food insecurity & dietary restraint in a diverse urban population.
        Eat Disord. March 4, 2020; ([Epub ahed of print]. doi:10.1080/10640266.2020.1723343)
        • West C.E.
        • Goldschmidt A.B.
        • Mason S.M.
        • Neumark-Sztainer D.
        Differences in risk factors for binge eating by socioeconomic status in a community-based sample of adolescents: findings from Project EAT.
        Int J Eat Disord. 2019; 52: 659-668
        • Zickgraf H.F.
        • Stefano E.
        • Price J.
        • Veldheer S.
        • Rogers A.
        • Rigby A.
        The relationship between food insecurity and binge and night eating symptoms in prebariatric surgery patients is mediated by depressive symptoms.
        Surg Obes Relat Dis. 2019; 15: 1374-1379
        • Becker C.B.
        • Middlemass K.
        • Taylor B.
        • Johnson C.
        • Gomez F.
        Food insecurity and eating disorder pathology.
        Int J Eat Disord. 2017; 50: 1031-1040
        • Stinson E.J.
        • Votruba S.B.
        • Venti C.
        • Perez M.
        • Krakoff J.
        • Gluck M.E.
        Food insecurity is associated with maladaptive eating behaviors and objectively measured overeating.
        Obesity (Silver Spring). 2018; 26: 1841-1848
        • Rasmusson G.
        • Lydecker J.A.
        • Coffino J.A.
        • White M.A.
        • Grilo C.M.
        Household food insecurity is associated with binge-eating disorder and obesity.
        Int J Eat Disord. December 19, 2018; ([Epub ahead of print]. doi:10.1002/eat.22990)
        • Lydecker J.A.
        • Grilo C.M.
        Food insecurity and bulimia nervosa in the United States.
        Int J Eat Disord. 2019; 52: 735-739
        • Poll K.L.
        • Holben D.H.
        • Valliant M.
        • Joung H.D.
        Food insecurity is associated with disordered eating behaviors in NCAA division 1 male collegiate athletes.
        J Am Coll Health. 2020; 68: 105-109
        • Jung N.M.
        • de Bairros F.S.
        • Pattussi M.P.
        • Pauli S.
        • Neutzling M.B.
        Gender differences in the prevalence of household food insecurity: a systematic review and meta-analysis.
        Public Health Nutr. 2017; 20: 902-916
        • Leung C.W.
        • Wolfson J.A.
        • Lahne J.
        • Barry M.R.
        • Kasper N.
        • Cohen A.J.
        Associations between food security status and diet-related outcomes among students at a large, public midwestern university.
        J Acad Nutr Diet. 2019; 119: 1623-1631
        • U.S. Adult Food Security Survey Module
        Three-Stage Design, with Screeners.
        US Department of Agriculture, Economic Research Service, Washington, DC2012
        • Morgan J.F.
        • Reid F.
        • Lacey J.H.
        The SCOFF questionnaire: assessment of a new screening tool for eating disorders.
        BMJ. 1999; 319: 1467-1468
        • Sanchez-Armass O.
        • Raffaelli M.
        • Andrade F.C.D.
        • et al.
        Validation of the SCOFF questionnaire for screening of eating disorders among Mexican university students.
        Eat Weight Disord. 2017; 22: 153-160
        • Parker S.C.
        • Lyons J.
        • Bonner J.
        Eating disorders in graduate students: exploring the SCOFF questionnaire as a simple screening tool.
        J Am Coll Health. 2005; 54: 103-107
        • Wan Wahida W.M.Z.
        • Lai P.S.M.
        • Abdul Hadi H.
        Validity and reliability of the English version of the sick, control, one stone, fat, food (SCOFF) in Malaysia.
        Clin Nutr ESPEN. 2017; 18: 55-58
        • Garcia F.D.
        • Grigioni S.
        • Chelali S.
        • Meyrignac G.
        • Thibaut F.
        • Dechelotte P.
        Validation of the French version of SCOFF questionnaire for screening of eating disorders among adults.
        World J Biol Psychiatry. 2010; 11: 888-893
        • Kutz A.M.
        • Marsh A.G.
        • Gunderson C.G.
        • Maguen S.
        • Masheb R.M.
        Eating disorder screening: a systematic review and meta-analysis of diagnostic test characteristics of the SCOFF.
        J Gen Intern Med. 2020; 35: 885-893
      1. SAS [computer program]. SAS Institute, Carey, NC2013
        Version: Version 9.4
        • Keys A.
        • Brožek J.
        • Henschel A.
        • Mickelson O.
        • Taylor H.L.
        The Biology of Human Starvation.
        University of Minnesota Press, Minneapolis, MN1950
        • Neumark-Sztainer D.
        • Wall M.
        • Larson N.I.
        • Eisenberg M.E.
        • Loth K.
        Dieting and disordered eating behaviors from adolescence to young adulthood: findings from a 10-year longitudinal study.
        J Am Diet Assoc. 2011; 111: 1004-1011
        • Hernandez D.C.
        • Reesor L.M.
        • Murillo R.
        Food insecurity and adult overweight/obesity: gender and race/ethnic disparities.
        Appetite. 2017; 117: 373-378
        • Hernandez D.C.
        • Reesor L.
        • Murillo R.
        Gender disparities in the food insecurity–overweight and food insecurity–obesity paradox among low-income older adults.
        J Acad Nutr Diet. 2017; 117: 1087-1096
        • Hanson K.L.
        • Sobal J.
        • Frongillo E.A.
        Gender and marital status clarify associations between food insecurity and body weight.
        J Nutr. 2007; 137: 1460-1465
      2. Definitions of food security.
        • Taylor E.A.
        • Foster J.S.
        • Mobley A.R.
        A qualitative investigation of body weight and weight loss-related attitudes of mothers and fathers in the context of food insecurity.
        Eat Weight Disord. 2020; 25: 1663-1669
        • Leung C.W.
        • Stewart A.L.
        • Portela-Parra E.T.
        • Adler N.E.
        • Laraia B.A.
        • Epel E.S.
        Understanding the psychological distress of food insecurity: a qualitative study of children’s experiences and related coping strategies.
        J Acad Nutr Diet. 2020; 120: 395-403
        • Goldrick-Rab S.
        • Richardson J.
        • Kinsley P.
        Guide to Assessing Basic Needs Insecurity in Higher Education.
        Wisconsin HOPE Lab, Madison, WI2018


      M. R. Barry is a doctoral student, Department of Nutritional Sciences and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor.


      K. R. Sonneville is an assistant professor, Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor.


      C. W. Leung is an assistant professor, Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arb