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According to Metallinos-Katsaras, Must, and Gorman (2012), food insecurity can be defined as “the lack of access to enough food for an active healthy life that results from limited or uncertain access to nutritionally adequate and safe foods in socially acceptable ways” (p. 1950). The United States Department of Agriculture (USDA) has created four different categories describing food security status—the designation of high food security denotes that “all household members have access at all times to enough food for an active, healthy life” (“Food Insecurity,” 2010, p. 2). Marginal food security signifies that “households members are, at times, uncertain of having enough foods because they have insufficient money and other resources for food. However, these households rarely need to reduce the quality, variety or quantity of their food intake” (“Food Insecurity,” 2010, p. 2). Low food security refers to a household in which “members are, at times, unable to acquire enough food because they insufficient money and other resources for food. These households report reducing the quality or variety of their diet, but rarely need to reduce their food intake” (“Food Insecurity,” 2010, p. 2). Finally, very low food security refers to when “the eating patterns of one or more household members are, at times, disrupted and their food intake reduced because they couldn’t afford enough food” (“Food Insecurity,” 2010, p. 2).
Food insecurity impacts nearly 15 percent of households in the US, but that impact is disproportionately felt by those of low income and racial/ethnic minorities (“Food Insecurity,” 2010, p. 2).  According to Metallinos-Katsaras, et al. (2012), 25.1% of black households and 26.2% of Hispanic households experience food insecurity, while only 10.7% of non-Hispanic white households experience food insecurity (p. 1950). However, income is an even greater risk factor for food insecurity than race/ethnicity—in addition to the challenges posed by low income, income shocks also create an increased risk for food insecurity (“Current and Prospective Scope of Hunger,” 2014, p. 5-1). Furthermore, and perhaps most importantly for the purposes of this review, households at the greatest risk for obesity are also at an increased risk for food insecurity (Rutten, Yaroch, Patrick, and Story, 2012, p. 2).
The Food Research & Action Center identifies six risks factors for obesity that are also associated with food insecurity—limited resources and lack of access to healthy, affordable foods; cycles of food deprivation and overeating; high levels of stress, anxiety, and depression; fewer opportunities for physical activity; greater exposure to market of obesity-promoting products; and limited access to health care (“Understanding the Connections,” 2015, p. 3-5). Research since 1995 has provided mixed conclusions about the relationship between food insecurity and childhood and adolescent obesity (Rutten, et al., 2012, p. 2). Rutten, et al. (2012) find that recent syntheses of currently existing research report that for households with incomes below the poverty line, headed by a single adult, or headed by black or Hispanic persons, there is a relationship between food insecurity and obesity (p. 2). In one study, Metallinos-Katsaras, et al. (2012) report “persistent household food insecurity without hunger was associated with 22% greater odds of obesity… compared with those who were persistently food secure” (p. 1952). In addition to this finding, the same study found that the association between the two varied depending on the weight status of the mother, suggesting a potential relationship between maternal weight status and childhood obesity (Metallinos-Katsaras, et al., 2012, p. 1953). Other studies indicate that the prevalence of obesity is higher among children in food-insecure households than among those children in food-secure households” (Eisenmann, Gundersen, Lohman, Garasky and Stewart, 2011, p. e79). Still other studies indicate that there is no relationship between food insecurity and childhood obesity or even that there is a relationship between food insecurity and childhood underweight (CITATION).
Given the wide breadth and depth of factors related to the low-income status associated with a risk for childhood obesity, it is difficult to assess and control for confounding variables. Income is one of the most significant confounding variables and review of currently existing literature indicates that even well-designed longitudinal studies are limited because “samples were drawn from the general population rather than low-income populations, thus reducing the ability to detect associations between food insecurity and health outcomes given the low incidence of food insecurity among populations at higher income levels and unavoidable confounding by income” (Metallinos-Katsaras, et al., 2012, p. 1950). Given that food insecurity is determined by surveys completed by heads of households, data may be mismeasured or inconsistent for a number of reasons—self-reporting allows for the possibility of inaccurate responses due to shame felt for heading a household in which children experience food insecurity or due to fear that sounding food secure might jeopardize eligibility for assistance programs like SNAP (Gunderson and Kreider, 2009, p. 972). Gunderson (2009) concluded, “In the absence of strong (and untestable) assumptions on counterfactual outcomes and the reporting error process, we cannot fully identify the impact of food security on health” (Gunderson, et al., 2009, p. 972).
However, that does not mean that food insecurity is not worth examining as a means of understanding childhood obesity. Eisenmann, et al. (2011) suggested, “regardless of whether food insecurity and obesity are related after controlling for other factors, all of the studies to date have definitely shown that food insecurity and overweight/obesity co-exist. Thus, even though the paradoxical relationship may not exist at the population level, the paradoxical food-insecure-obesity phenotype exists at the individual level” (p. e82). It appears that in the absence of a causal relationship, both stem from related factors of socioeconomic deprivation. Food insecurity is associated with a variety of negative health outcomes, including “poor general health and health limitations; increased hospitalization and psychological visitation, clinical levels of psychosocial dysfunction, including anxiety and depression; and academic problems” (Eisenmann, et al., 2011, p. e73-e74).  These negative health outcomes result in part from food insecurity’s impact on the quality of food more than the quantity—“This trade-off between quality and quantity among food-insecure households can lead to increased consumption of lower-quality foods that are typically higher in refined grains, fat, and sugar, and are less satiating and more likely to lead to weight gain” (Metallinos-Katsaras, et al., 2012, p. 1954). Perhaps, then, given that adequate nutrition is a key influence on biological growth and child development, one potential negative health outcome is increased risk of childhood obesity.
Risk of childhood obesity may be further influenced by the effect that food security has on mothers. Numerous studies have documented that women experiencing food insecurity are more likely to be obese than food secure women, and Metallinos-Katsaras, et al. (2012) documented an association between maternal weight status and risk for childhood obesity in food insecure homes, suggesting that food insecurity creates conditions or coincides with other factors that in turn lead to increased risk for childhood obesity (“Food Insecurity,” 2010, p. 1; p. 1953). That risk may become especially great during specific periods during childhood—Laraia (2013) notes that maternal food insecurity creates a significant stressor early in a child’s life and, “experienced for a relatively short duration but at a critical developmental stage for offspring,” creates an increased risk of obesity and metabolic syndrome for the child later in life (p. 206). In addition, Eisenmann, et al. (2011) point to the interaction of food insecurity and maternal stressors as resulting in an increase in the probability of childhood overweight and obesity (p. e79). Maternal stressors have not been documented as having a significant impact on childhood obesity in households that are food secure (Lohman, Stewart, Gunderson, Garasky, and Eisenmann, 2009, p. 233). That maternal stressors and food insecurity are related to childhood obesity is not particularly surprising—“household production theories posit that families ‘produce’ children’s health outcomes, such as obesity, through the allocation of parental resources or lack thereof” (Lohman, et al., 2009, p. 231). Thus, stressors, when transmitted to children and adolescents, may lead to increased stress; biologically, that stress may be manifest in higher cortisol levels (Lohman, et al., 2009, p. 231). Chronically high cortisol levels may increase the risk of obesity, and the stress itself may result in poor behavioral responses (e.g., reduced physical activity) associated with obesity (Lohman, et al., 2009, p. 231). Maternal stressors, too, may play a role in diminished parenting and adverse coping strategies for food insecurity that increase risk for childhood obesity. Lohman, et al. (2009) point to evidence that, “in response to limited food resources, parents may purchase cheaper, energy-dense foods, overeat when food is more plentiful, and overprotect their children by giving them more food than needed when food is available. Each of these factors may be exacerbated in households headed by stressed mothers” (p. 233-234). In addition to an increased likelihood for dependence on energy-dense foods, food insecure households frequently exhibit a cyclical pattern of having enough food at the beginning of a month and not enough at the end of the month; if these two patterns interact for significant periods of time, it is possible that they might alter metabolism and “result in a positive energy balance,” creating increased risk for obesity (Laraia, 2013, p. 203).
Studies of food security with macaques confirm that food scarcity alters food intake and creates a preference for high-fat, high-sugar foods; activates the hypothalamic-pituitary-adrenal axis, releasing cortisol and altering metabolic processes; and teaches animals that high-fat, high-sugar foods alleviate the stress response, creating a propensity to turn to those foods again, even when the stress is much less (Laraia, 2013, p. 204). Furthermore, the findings of these animal models “suggest that the rapid changes in the availability of food, even when calories were not restricted, led to dramatic behavior changes and disruptions in maternal-offspring interactions” (Laraia, 2013, p. 206). The impact of these disruptions may not be immediately felt. It is possible that food insecurity at one point in time can create poor health outcomes at a much later point in time, and the severity and duration of insecurity, as well as the period during which it occurs, are important factors to take into consideration as well (Laraia, 2013, p. 210). The potential results of food insecurity may be further compounded in those who are “prone to store energy as weight or who are highly reactive” (Laraia, 2013, p. 210).
Given these noted interactions between food insecurity and factors that create an increased risk for childhood obesity, addressing food insecurity is potentially a key method for addressing this poor health outcome and the later health outcomes associated with childhood obesity.
There are a number of key programs and initiatives aimed at addressing food insecurity administered by federal, state, and local governments. First and foremost, the Supplemental Nutrition Assistance Program (SNAP) distributes benefits in the form of an Electronic Benefit Transfer (EBT) card for the purchase of food at authorized retailers (Gunderson, et al., 2011, p. 11). Benefits are apportioned according to family size and income level, and states determine eligibility for SNAP based on income and, in some cases, assets tests (Gunderson, et al., 2011, p. 11). Second, the National School Lunch Program (NSLP) operates in schools and childcare facilities to provide meals to children at reduced or no cost; in 2010, more than 31 million students participated in the program (Gunderson, et al., 2011, p. 13). Other programs, set up by the Child Nutrition Act of 1966 and successive legislation, create nutritional “safety nets” via School Breakfast programs, the Child and Adult Care Food program, the Summer Food Service program, the Special Milk program, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (“Current and Prospective Scope of Hunger,” 2014, p. 4-2). Furthermore, other government programs targeted at providing housing, medical, energy, or other assistance can help reduce the financial stress associated with food insecurity and “make household-level resources available for food purchases” (“Current and Prospective Scope of Hunger,” 2014, p. 4-2).
In addition to these publicly administered programs, the private sector houses a network of emergency and nonemergency programs to assist needy households, which includes food pantries, soup kitchens, shelters, mobile distribution facilities, and programs targeted at seniors and children (“Current and Prospective Scope of Hunger,” 2014, p.4-2). Many of these programs are administered by the Feeding America national network, and although they are primarily donation-based programs, many are supported by The Emergency Food Assistance Program (TEFAP) of the USDA through the provision of food donations and funding (“Current and Prospective Scope of Hunger,” 2014, p. 4-2, 5-5).
Outside the realm of programs designed to directly alleviate the stress of food insecurity through the provision of food and financial assistance, efforts have also been made by both public and private organizations to address the food environment in which many food insecure families find themselves. These efforts include conducting community assessments to determine the characteristics of the food environment at hand, promoting community supported agriculture, and addressing the placement of supermarkets in low-income communities. Rutten, et al. (2012) note the efforts of the USDA Community Food Projects Competitive Grants Program in “supporting communities in local efforts to improve local food systems,” which has historically funded projects that share common aims—“they focus on the food needs of low-income populations; they aim to connect local food producers and consumers; they strive to increase the local food production and self-reliance; and they attempt to develop integrated solutions to agriculture, food, and nutrition-related problems” (p. 5).
WHO PARTICIPATES
	These programs are critical at creating a safety net for food insecure households by increasing the stability of food supply, thus alleviating food insecurity and, potentially, related poor health outcomes. Studies of these programs have indicated a significant degree of success in reducing food insecurity. Increasing SNAP participation has been shown to improve food insecurity, and increasing SNAP benefit amounts have been shown to do the same—a comprehensive examination of food insecurity in the US indicates, “a $10 per person increase in SNAP benefits was associated with a 12 percent reduction in the odds of a household being food insecure” (“Current and Prospective Scope of Hunger,” 2014, p. 4-7). In addition, the NSLP has been estimated by Gunderson, et al. (2011) to decrease the prevalence of food insecurity among participants from anywhere between 2.3 to 15.8 percentage points (p. 15). However, little research exists exploring the degree of success these programs have in reducing childhood obesity. Eisenmann, et al. (2011) note, “food assistance programmes [sic] may play a protective role for risk of overweight in low-income children,” but the extent of that role has yet to be determined (p. e81). Additional efforts must be made to integrate obesity prevention into food insecurity programs and to integrate addressing food insecurity into currently existing obesity prevention programs.
	Research by Martin and Ferris (2007) suggests that key risk factors in need of further address in obesity prevention programs include food insecurity among adults and gender among children (p. 36). In particular, greater attention and resources are needed for two possible areas—“early intervention programs, particularly for girls with overweight parents, may provide the greatest long-term success for reducing childhood overweight. At the same time, programs that effectively reduce food insecurity among adults may in turn help prevent obesity” (Martin, et al., 2007, p. 36).
	Thus, strengthening the wide variety of already existing programs is critical. Both public and private programs require continued funding and administration, as well as expansion before new programs and efforts can be created to fill gaps in addressing food insecurity. A review of current research regarding food security in the US identifies nine key ways to strengthen federal food and nutrition assistance programs:
Maintain support and funding for SNAP;
Ensure SNAP benefits are adequate and provide recipients with enough resources;
Avoid SNAP eligibility restrictions that penalize the unemployed;
Increase the availability of summer meal programs for children;
Use SNAP to provide assistance in the summer to children who quality for free meals during the school year;
Expand the use of the federal government’s Community Eligibility Option to help provide free meals for all students in qualifying schools;
Expand the School Breakfast Program
Expand WIC to assist a greater number of women and children;
Expand the Child and Adult Feeding Program in order to provide more food and nutrition interventions in childcare centers (“Current and Prospective Scope of Hunger,” 2014, p. 5-3, 5-4).
Any modifications to currently existing programs should take care to investigate the potential unintended consequences of such changes. For example, changes to SNAP have been proposed with the intention of enhancing nutrition among participants by changes the types of foods available for purchase; however, these proposed changes might decrease the effectiveness of the program if additional restrictions on food options discourage participation and lead to greater prevalence of food insecurity (Gunderson, et al., 2011, p. 15).