When Makailah Dowell was growing up, having food wasn’t always guaranteed.
Dowell was raised by her grandmother in Bonners Ferry, Idaho. During her childhood, Dowell and her grandmother experienced homelessness and when they found a place to live, they relied on food stamps. Living in a small town, said Dowell, their options for food through EBT were limited because of inflated prices.
When her grandmother got a job at a hotel, even though “it didn’t pay as much as she deserved to be paid,” Dowell was able to have more regular access to food.
“I would get so excited when my grandma would come home from work because that meant there was something to eat,” said Dowell.
At the same time, Dowell was dealing with an eating disorder.
Relationships with food
While food insecurity and eating disorders may not always be a part of the same conversation, research has demonstrated a link between the two. A 2020 review of existing research concluded that food insecurity was associated with higher instances of behavior associated with eating disorders in adults, such as binge eating and “compensatory behaviors” to control weight, such as using laxatives.
Katie Loth
“Your (food) intake, voluntarily or not, is the biggest risk factor for developing an eating disorder,” said Katie Loth, Ph.D., MPH, RD, LD, a dietician and researcher at the University of Minnesota whose research has focused on the relationships children and teenagers have with food. “We think of it as being voluntary. (If) I am a teenager who doesn’t wanna gain weight, I’m gonna skip eating. But it can also be I’m a teenager whose family is food insecure, so I’m not eating a couple of meals a day because we don’t have enough food, and my body doesn’t know the difference between those two types of restriction(s).”
Adriana Lindenfeld, a therapist at Equip Health, which provides multidisciplinary virtual treatment for those with eating disorders, describes people living with food insecurity as experiencing a “feast or famine” cycle, which leads to binge eating when food becomes available.
“(In the feast or famine cycle), food intake changes due to the fluctuation of food availability,” explained Lindenfeld. “For example, after receiving a paycheck, there (are) more means to be able to get food.”
Food, self-image and health consequences
There are, Lindenfeld further confirmed, disparities in eating disorders by racial identity.
“Black teens are 50% more likely to have bulimic and binge eating behaviors (and) the Latin community has the highest bulimia nervosa and binge eating disorder rates, which are the two eating disorders most linked to food insecurity,” said Lindenfeld.
“Let’s just talk about it,” said Dowell. “BIPOC folks are two to three times (more) likely than their white counterparts to have food insecurity.”
Dowell’s own eating disorder was also spurred on by bullying from her peers in a majority white area, where she was a visible minority.
Makailah Dowell
“I was bullied on race, I was bullied on the size of my body, I was bullied on everything,” said Dowell. “I straightened my hair every day at 5 a.m. before I went to school at 8 a.m. It took me three hours to straighten my hair every single day and show up to school in a different, presenting white way. We live in a society where the white ideal is pressed forward – being thin, having straight hair, having colored eyes. I wanted to change myself. I even bought colored contacts, which I could never wear ’cause I can’t put things in my eyes. I looked at every single way to change my body. So that’s where the bulimia came in for me. It was the diet culture. It was the bullying, it was the lack of representation in a northern Idaho town that is predominantly white.”
Another contributing factor to the development of eating disorders is societal stigma and fatphobia – where a slimmer body is assumed to be a healthier body.
“When people compliment folks on losing weight, we have no idea what’s behind that,” said Loth. “You don’t know if they’re losing weight because they’re restricting, because they’re food insecure, because they’re on a diet (or) because they’re sick. People will talk about feeling ashamed to go to a food shelf or to get food stamps because they feel like people are judging them, because of the way that they look. I think that is likely another trigger for people to wanna control their weight. People who are food insecure are not immune to the general societal milieu that is discussed around them.”
Eating disorders also have long term consequences for a person’s health, both physically and mentally.
“For kids and adults, (eating) disorders are highly related (or) comorbid with other mental health diagnoses (and) issues,” said Lindenfeld. “There are higher rates of depression (and) anxiety in people with eating disorders, (along with) mood disorders.”
Disordered eating can also lead to social isolation at school and work, which can be particularly harmful for the social development of children and teenagers.
“I like to use this metaphor for my patients of an eclipse,” said Lindenfeld. “The person being the sun, the eating disorder being the moon. The eating disorder coming and juxtapos(ing) on top of the person. We are unable to see the person. With treatment, the idea is for that eclipse to start to separate so we can see the full person.”
Adriana Lindenfeld
Physically, Lindenfeld added, purging or vomiting creates an imbalance in electrolytes, which leads to potential cardiac issues, including cardiac arrest and arrhythmia. People who get periods may also stop having periods altogether after disordered eating, a condition known as amenorrhea, which can lead to a decrease in bone density.
In Dowell’s case, purging when she was younger has put her at an increased risk of developing throat cancer. Consequently, she encourages those who have had an eating disorder to inform their medical providers about their history.
“There are scars from your eating disorder that are there and you should be talking to your doctor about,” said Dowell. “When you get a new provider, you should say ‘Hey, I had an eating disorder for this amount of years. What should I be getting screened for in my life? What should I be looking for?’”
Road to treatment and combating food insecurity
While on public assistance, Dowell was only able to see a doctor around once a year. During these appointments, she was open about what was happening – that she was focused on losing weight and was forcing herself to vomit. She asked her doctor if that was normal, but her doctor didn’t follow up with any discussions or diagnosis.
Instead, it was Dowell’s dentist who let her know that something wasn’t right. Her teeth were decaying in front of him, he told her, something that shouldn’t be happening at her age. At the time, Dowell was 16 years old.
“I broke down and was like ‘Yeah, I’ve been forcing myself to throw up in the shower every morning,” recalled Dowell. After the dentist heard her, he brought in her grandmother and told her that Dowell had an eating disorder.
During that time, however, Dowell found out that she was losing her hearing in her left ear. At this point, she was already deaf in her right ear and needed surgery.
“With public assistance, there’s a certain amount of money for each person in that state,” said Dowell. “So for me, getting that surgery and getting that support meant that I had to lax up on my mental health support and coverage. So I decided – which wasn’t a fair decision (for) a 16-year-old (to have to make) – that I would rather have my hearing aids and my cochlear implant and I would just take the free therapy support (instead of specialized eating disorder treatment).”
Now, as lead peer mentor at Equip Health, Dowell’s role involves sharing her own experiences and letting people who are in similar situations as she was know that certain experiences are normal in that context.
“If folks came to me and were food insecure, I would normalize the experience of eating out of the trash,” said Dowell, who noted that when she was looking things up as a teenager, eating out of the trash was something that she wasn’t able to recognize as a symptom of disordered eating in her behavior. “I would normalize the experience of being in a single parent household and not having all the cool things that the other kids have (and) of getting free lunches.”
In treatment for eating disorders, said Lindenfeld, the first step is reaching medical stability. What happens next at Equip Health, however, can differ from person to person.
“Sometimes at Equip, the cause (of an eating disorder) is important,” said Lindenfeld. “We also at times take an agnostic stance – there’s multiple factors, we cannot pinpoint that one thing that caused the eating disorder. For adults, we utilize cognitive behavioral therapy. When it is for kids, we use family-based treatment. Eating disorders do not happen in isolation. The idea with any case is understanding the maintaining mechanisms. Food insecurity can be a maintaining mechanism.”
Clients at Equip Health have a care team consisting of a therapist specializing in eating disorder treatment, a registered dietician and a medical provider, along with family and peer mentors. Those involved in treating the disorders, said Lindenfeld, must also think beyond the treatment space and into the wider context.
“How can we connect them with resources such as food banks? How can we navigate the gaps that exist in society (related to) seeking and finding (these) resources?” said Lindenfeld. “Our main goal is to make effective, personalized treatment that is accessible (and) actionable for those in need.”
Food insecurity in Minnesota
In 2022, Feeding America estimated 14.2% of children under 18 in Minnesota were facing food insecurity. Of these children, 34% were estimated to be ineligible for federal nutrition programs.
Additionally, according to Second Harvest Heartland, a hunger relief organization operating in Minnesota and west Wisconsin, there are racial disparities in food insecurity in Minnesota. In 2022, 29% of Black Minnesotans and 23% of Hispanic Minnesotans were food insecure.
Rachel Holmes
“Food insecurity in Minnesota has definitely increased since the pandemic,” said Rachel Holmes, director of advocacy and community engagement at The Food Group. “We’ve seen food shelf visits increase by about 2 million each year since 2020. Last year, we had a record 7.5 million visits made to food shelves.”
The Food Group is combating food insecurity in a variety of ways. It works with food shelves in the state by supplying them with food, as well as providing grants in partnership with the Minnesota Department of Children and Families to support food shelf operations.The organization also runs the Market Bucks program, where more than a hundred participating farmer’s markets in Minnesota allow those using SNAP benefits to purchase food to triple their budget while shopping.
“(For) every $1 they spend on SNAP, they get two additional dollars for free that are market bucks that they can use. So if you spend $10, you could have a $30 budget to spend at that market that day,” Holmes explained.
To better help people get connected with support, The Food Group also runs the Minnesota Food Helpline, where people can call to receive assistance in getting connected to healthy food in the state, whether through the SNAP program or through any of The Food Group’s own programs. The helpline’s number is (888) 711-1151, and those seeking resources are able to call or text, with interpretation available for those more comfortable speaking non-English languages.
“When stories (about food insecurity) come (out), you never know who’s reading them,” said Holmes on the importance of sharing information about the helpline. “There might be someone that needs help themselves.”
“Get help as soon as possible and if you can’t get the help, find some group support, find some free support to at least start having the conversations around what your own recovery could look like, even if that means harm reduction, (and) especially if you don’t have access (to treatment), because we know that’s a privilege. ” said Dowell. “Waiting is going to result in a life of – regret isn’t the word – but a lifetime of sadness (about) what happened to you and the scars that were put onto your body. It’s easy for us to talk about the folks who get to come through the virtual door, the folks who get to come to treatment. We (also) have to talk about the folks who are still out there, who aren’t getting the help they deserve, because they deserve this conversation just as much.”
