Shireen: In this episode, Dr. Vivienne Hazzard will be talking about the relationship between disordered eating and chronic health conditions, as well as the groups that are impacted and affected by food insecurity, and lastly, what clinicians can do to screen for food insecurity.

Podcasting from Dallas, Texas, I am Shireen and this is the Yumlish podcast. Yumlish Is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Dr. Vivienne Hazzard is a registered dietitian with a PhD and MPH in nutrition from the University of Michigan School of Public Health. She is currently a postdoctoral research fellow at the University of Minnesota whose research aims to prevent disordered eating and eating disorders. Welcome Dr. Hazzard.

Hazzard:  Thank you so much for having me here today Shireen. 

Shireen: An absolute pleasure. So, Dr. Hazzard, can you talk a little bit about why you chose to do research in this space and then can you also help us understand the difference between disordered eating and eating disorders? 

Hazzard: Absolutely. So I, I first became interested in studying disordered eating and eating disorders when I was training to become a registered dietician. I rotated in a number of outpatient clinics for management of diabetes and cardiovascular disease. And I encountered several patients who struggled with disordered eating. A lot of those patients seem to struggle, particularly with binge eating, which when I say binge eating, I mean eating a lot of food in a certain amount of time and feeling out of control while they're eating it, feeling like they cannot stop eating. And I found that patients really didn't want to be engaging in those behaviors. So it caused them to stress and it also interfered with management of their conditions.

So that, that really led me to feel passionate about working to prevent those behaviors from developing in the first place so that patients wouldn't, wouldn't even need to worry about dealing with these behaviors. And in response to your the other piece of the question, the difference between disordered eating and eating disorders,

when I refer to disordered eating behaviors, I'm referring to behaviors like binge eating, which I just described as well as restrictive behaviors like fasting and skipping meals.  and also other unhealthy weight control behaviors like making one self sick or abusing laxatives. So those can occur like at any frequency.

They don't have to be occurring regularly for them to cause problems. But when they occur with a certain level of frequency and cause a certain level of impairment, they may make it so that someone meets criteria for a clinical eating disorder. And some of the most common eating disorders are Binge Eating Disorder, Bulimia Nervosa and Anorexia Nervosa.

And so those each involve some kind of combination of the disorder, eating behaviors that I mentioned, but again occur with a certain frequency such as every week and, and cause a certain level of impairment.

Shireen:  Thank you for helping us understand that. I wanna dive a little bit more into disordered eating.

How does disordered eating relate to chronic health conditions like diabetes? 

Hazzard:  That's a great question. I think that link is probably overlooked a lot more often than it should be. I would say there are three main ways that disordered eating and chronic health conditions tend to be related. One way is that disorder disordered eating seems to increase risk for chronic health conditions. The research evidence seems to most strongly support this for binge eating.

Research shows that binge eating increases risk for developing hypertension, dyslipidemia, and diabetes over time. So that's one piece of the puzzle. And another way that disordered eating is related to chronic health conditions stems from the dietary recommendations that are typically made by healthcare providers to help manage chronic health conditions.

So while those recommendations are really important for management of the conditions, Having a large focus on meal plans and dietary rules to manage those conditions can lead to sometimes an unhealthy obsession with food, diet and weight, which can actually trigger, disordered eating. And there's also a type of disordered eating that's unique to insulin dependent diabetes, it's colloquially referred to as Diabulimia.

And it's when someone intentionally restricts their insulin to lose weight.  And this, of course, results in high blood sugar. So it really interferes with diabetes management. And that leads me to the last major way that disorder of eating is related to chronic health conditions, which is that disorder of eating more broadly, not just restricting insulin use can interfere with management of these chronic conditions.

For example, binge eating can really spike blood sugar. So that's my long winded way of saying that there's definitely a strong link between disordered eating and chronic health conditions.

Shireen:  You mentioned looking at food insecurity. So what led you to your study to follow that relationship between food insecurity and disordered eating?

Hazzard:  Yeah. I studied disordered eating before I brought the food insecurity piece into my research.  So my experiences with those patients that I mentioned inspired me to study disordered eating, but it was a bit later on in my research career that I started looking into the role of food insecurity. Food insecurity, which when I say that I'm referring to inadequate access to enough safe and nutritious food, is something that I've been passionate about addressing for a long time.

Ever since I spent time as a Master of Public Health student and dietetic intern working in WIC clinics and local food banks in Detroit. But it wasn't until I started my current research fellowship a few years ago that I became interested in the link between food insecurity and disordered eating. At the time, there had only been a few studies on that topic. But the evidence from those studies was really compelling and led me to look at the relationship between food insecurity and clinical eating disorders in a sample of nearly 3000 adults in the U.S. that closely matched the demographic makeup of the country.

So we referred to that as a nationally representative sample. And in that study food insecurity over the past year was assessed with a validated tool and eating disorders over the past year were assessed with face to face diagnostic interviews. What we found was that participants who experienced food insecurity over the past year were about three and a half times more likely to have had binge eating disorder over that time and close to five times more likely to have had bulimia nervosa over that time.

That was a after accounting for factors like education level and income. And these statistics were really striking. It's pretty rare to see relationships that strong in research. For comparison, we also looked to see how food insecurity was related to mood disorders and anxiety disorders. And although we did find that there were links with those disorders as well, the relationships were not nearly as strong as they were for the eating disorders.

So I was really struck by how strongly food insecurity was linked with the eating disorders and right around the same time, an opportunity arose through my fellowship to get funding, to conduct a research project in a cohort of young adults who are diverse with respect to socioeconomic background and race and ethnicity. The project was supposed to fall within some designated persons.

So it was supposed to look at factors that disproportionately affect marginalized populations, which food insecurity does. And it was encouraged that the project used innovative assessment methods. Food insecurity doesn't tend to be stable over time. It can fluctuate over the long term. So someone may be food insecure one year and then their employment status or something may change.

And they may not be food insecure at the following year. It can also fluctuate though, over the short term, such as throughout the month. So I propose to use an innovative assessment method that involves kind of mini surveys that you send to participants multiple times per day, every day. And I proposed to do that for two weeks.

I was lucky enough to get my proposal funded. So I did get to carry out that project and my interest in the length between food and security and disordered eating just keeps getting stronger. The more research I conduct on the topic.

Shireen:  That is interesting. Anything else in your findings that you'd like to share? 

Hazzard:  Yeah, I guess one I haven't mentioned yet is that I've found food insecurity to predict increased likelihood of binge eating five years later, even when accounting for preexisting binge eating. Which suggests that it's not only that binge eating is more common in individuals experiencing food insecurity, but that food insecurity is actually a risk factor for the development of binge eating.

Another finding that I think is really important. And also surprising is that food insecurity is also strongly linked with self-induced vomiting to control weight, that is making oneself sick, to control their weight. And that's a finding that emerged in some of the first studies led by Dr. Carolyn Becker on food insecurity and disordered eating.

And it seems to keep replicating across different samples. Including a sample of over 60,000 participants across five countries that I looked at this question in recently, we found the participants experiencing very low food security, which involves reduced food intake, were nearly 15 times more likely to report regularly vomiting to control their weight.

And by regularly, I mean, at least one time a week over the last few months. So the length between food insecurity and vomiting for the purpose of weight control is really strong, but we definitely need more research to understand what's going on there.

Shireen:  I wanna talk a little bit about some of the groups that are impacted by this.

So food insecurity is more likely to affect not only lower socioeconomic groups. But also other marginalized groups. So we're talking about people of color people of diverse sexual orientations, gender identities. In general, do we tend to see higher risk for disordered eating in these marginalized groups and any thoughts on why that, that may be the case?

Hazzard:  It's a really great question. So historically disordered eating and eating disorders were actually thought to primarily only affect thin, white, affluent girls. And that myth, which has now definitely been disproven has unfortunately shaped a lot of the theoretical models and approaches to treatment and prevention for eating disorders.

Like I said, that myth has been disproven. So we now know that disordered eating affects people across all social strata. And in response to your question about whether we actually see higher risk for disorder eating in marginalized groups, we definitely do for certain groups. For example, we see higher risk for disordered eating in sexual and gender minorities, as well as in certain racial and ethnic groups.

Like we generally tend to see fairly high rates of disordered eating in Hispanic and Latinx populations. Why we see that? We don't know for sure yet. Part of it could be the fact that we see rates of food insecurity are higher in those groups. It could also have to do with the unique stressors that individuals in those groups experience related to being part of those marginalized groups.

Shireen:  Has your research offered any insights as to why food and security might increase for disordered eating? 

Hazzard:  It has, at least to some extent. There's still a lot more research we need to do to understand this relationship. But the study that I mentioned earlier, that I received funding for, which involved several really short surveys throughout the day for a two week period, has offered some insights.

Our findings from that study showed that instances of greater food availability predict more binge eating symptoms later in the day, among young adults who are experiencing food insecurity. This supports the Feast or Famine Cycle theory. I'll back up a little bit, so food availability might fluctuate over the course of the month in the context of food insecurity, depending on when paychecks and public assistance benefits come in.

So what the feast or famine cycle theory proposes is that people experiencing food insecurity may restrict their food intake during periods of the month with less food available, and they may binge eat during periods of the month when more food is available, like after receiving a paycheck or food assistance benefits.

And so the findings from our study did seem to at least in part support that theory, if someone is having trouble affording enough food, what can they do to avoid developing disordered eating patterns or reduce these patterns? If they're already experiencing them. This is a really important question.

Based on the findings I just talked about with the feast or famine cycle, it seems like maintaining a relatively stable level of food availability throughout the month is pretty important. There can be a lot of shame and stigma surrounding using public food assistance programs like SNAP and WIC and around visiting food pantries or food shelves.

But those resources are there for a reason. And I would encourage people who are having trouble affording enough food to use as many resources as they can to try to have enough food all throughout the month. And regarding any shame or stigma that people may feel around using those resources. I think it's really important for people to remember that the fact they're having trouble affording food is not a reflection on them, but it's a reflection on our society and the ways that society has failed them.

Shireen:  Speaking of, of society in general, I think of the immediate community that one is surrounded bit with. Can you elaborate on how clinics, clinician teams can really do more to help by implementing the appropriate screening programs.

Hazzard:  Yeah, so there's a really quick and easy screening tool for food insecurity called the hunger vital sign.

You can easily Google it it'll come up. It's only two items. And if clinicians work in a healthcare system that uses an Epic based electronic health record system, I believe the hunger vital sign is actually already built into that system. So it should be fairly easy to incorporate into a clinic setting.

I think it's also really important to train providers, to have conversations around food insecurity. So if a patient screens positive for food insecurity, The provider needs to have a, a conversation with the patient about, about how food insecurity is impacting their treatment and what they can do about that.

And these conversations can be difficult, especially for someone who doesn't have any training around approaching sensitive conversations like this. So I think that that kind of training is really important. And then also of course, having resources to refer patients to so talking with the patient about whether or not, they are currently using some of those resources like SNAP and WIC, if they're eligible. If they know about local food banks, food pantries, they can visit. And if they don't working to connect them with those resources, 

Shireen:  So, what does research look like for you next, Dr. Hazzard? Where, where are you going from here?

Hazzard:  Good question. I definitely wanna continue my work in this area. I really wanna do some what we call qualitative research. So I, a lot of the research I've talked about today with you here has been looking at numbers. So I've, you know, reported some statistics. And that, that tells us. That there's a strong link between food insecurity and eating, but it doesn't tell us why.

So what I really wanna do is conduct interviews with people who are experiencing food insecurity or who have experienced food insecurity in the past, and also experienced eating to try and understand. Why food insecurity may increase, increase that risk for disorder eating.

Shireen:  Lovely. So with that we are toward the end of the episode.

I, I find it remarkable. The research that you're doing is much needed research. There's so many questions still left to answer, but I'm, I'm so glad to see that you're working in this space to, to chip away at this problem, will really help us understand and get to some of the root causes of why these these circumstances, unfortunate circumstances exist.

As we are to toward the end of the episode at this point, we like for listeners to know how they can connect with you, and then just learn more about your work. 

Hazzard:  Yeah, absolutely. So you can find me on Twitter. My handle is @the_hazzard_, h a z z a r d underscore. You can also look up my name on PubMed or Google Scholar to see some of my research articles.

Shireen:  Thank you so much for spending this time with us, Dr. Hazzard, and to our listeners, as we wrap up this episode, head over to our social media, our Facebook, our Instagram, and tell us why we should think about food insecurity and health. What does it mean to you? Again, head over to our Facebook at Yumlish or Instagram at yumlish_  and answer this quick question.

And with that Dr. Hazzard, thank you so much again for your time.

Hazzard:  Thank you so much again for having me, it's been a pleasure.

Shireen:  Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website, Yumlish.com for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

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PubMed Articles

Articles Mentioned: 

https://www.sph.umn.edu/news/severe-food-insecurity-linked-with-disordered-eating-behaviors-in-young-people-including-binge-eating-five-years-later/