LEARNING OBJECTIVES

After reading this article you will be able to:

• • provide a balanced overview of food insecurity for people with severe mental illness

• • demonstrate the principles of assessing food insecurity in mental health practice

• • understand the complexity of food insecurity for adults with severe mental illness and the policy changes that are required in the UK.

Food insecurity can be defined as ‘a lack of the financial resources needed to ensure reliable access to food to meet dietary, nutritional, and social needs’ (Blake Reference Blake2019). The history of food insecurity in the UK indicates that it was first defined at the 1974 World Food Conference, where attending governments declared that everyone has the right ‘to be free from hunger and malnutrition in order to develop their physical and mental faculties’ (United Nations 1975). Almost 50 years after the World Food Conference's pledge to eradicate food insecurity within 10 years (World Food Summit Reference Wight1996), it remains a significant problem across the world. In January 2022, it was estimated that 8.8% of UK households (4.7 million adults) were experiencing food insecurity, compared with 7.3% in July 2021 (Food Foundation Reference Scott, Sutherland and Taylor2022). Furthermore, 3.6% of adults (1 million) have reported that someone in their household had to go a whole day in the past month without eating because they could not afford or access food; and people living with a disability are up to five times more likely to experience food insecurity than those without a disability (Food Foundation Reference Scott, Sutherland and Taylor2022).

Well before the COVID-19 pandemic, food insecurity was already a major concern in the UK. In 2014, the Children's Society presented evidence to an All-Party Parliamentary Group to raise awareness of food insecurity (Forsey Reference Finlay2014). Four years later, Special UN Rapporteur Sir Phillip Alston highlighted the increasing number of people depending on foodbanks in the UK (Alston Reference Alston2018). UK food banks provide emergency food parcels. They are predominantly run by volunteers. Food is donated by members of the public and a range of organisations, such as churches, supermarkets and local businesses. Despite these high-profile reviews of the evidence, it has taken the current pandemic and the persistent efforts of a professional footballer to bring the issue of food insecurity into the public and political spotlights (Child Food Poverty Task Force Reference Purdam2020).

In the final 2 weeks of March 2020, the start of the first national lockdown for COVID-19 in the UK, there was an 81% increase in the use of emergency food parcels from The Trussell Trust, a UK network of food banks (Trussell Trust Reference Thompson, Smith and Cummins2020) and food banks reported a 59% increase in need (Independent Food Aid Network 2020). More recently, the substantial rise in the cost of living has resulted in an increase in the number of households experiencing poverty. In the winter of 2021–2022, 62% of households reported having higher energy bills compared with the previous winter (Food Foundation Reference Scott, Sutherland and Taylor2022). This is predicted to increase even more owing to planned increases in the UK energy price cap, the first of which came into force on 1 April 2022. Furthermore, people living on Universal Credit (means-tested government benefits) are up to five times more likely to have experienced food insecurity (Food Foundation Reference Scott, Sutherland and Taylor2022).

Food insecurity among children has resulted in reports of children having shoplifted for food, scavenged for food from bins, eaten tissue paper to fend off hunger, bartered for food at school, sold drugs for food and mugged other children for money for food (Finlay 2019). However, the implications of food insecurity for other vulnerable groups have been seldom considered.

Foodbanks provide emergency food packages to individuals experiencing food insecurity. These usually consist of non-perishable food items, and often they do not constitute a nutritious balanced diet. There is stigma around the use of foodbanks, and they are often only used as a last resort (Elliott Reference Dimbleby2016). Foodbanks are therefore not a long-term solution to food insecurity.

Although it is unsurprising that there is a clear link between poverty and food insecurity (Wight 2014), a wider range of factors have been linked to the likelihood of a person experiencing food insecurity. These factors do not usually occur in isolation and, when combined, can produce highly complex and stressful situations that are hard to resolve. Household income is the most prominent factor, but this is compounded by a lack of food-related knowledge or skills and problems with physical access to food (Nzuza Reference McGlone2016). It is important to acknowledge that the definition of poverty in relation to food insecurity includes that of in-work poverty, which occurs when a working household's total net income is insufficient to meet its needs (Hick Reference Grisaru, Kaufman and Mirsky2017).

How does food insecurity affect people's lives?

What about people with severe mental illness?

Individuals with mental ill health are a marginalised population in terms of preventable physical illnesses. People with severe mental illness (SMI), including schizophrenia and bipolar affective disorder, are particularly vulnerable in terms of their physical health, resulting in a life expectancy that is 15–20 years shorter compared with people without SMI (Brown Reference Brown2010). Additionally, it is widely reported that obesity is more prevalent in people with SMI than in the general population (Working Group for Improving the Physical Health of People with SMI 2016). Contributing factors include the illness itself, medication side-effects and social/environmental barriers to eating healthily and being active (Muralidharan Reference McGeechan, Ells and Giles2020).

Adults with SMI are disproportionately affected by food insecurity. A recent systematic review (Teasdale Reference Nzuza and Duval2021) showed that 40% of people with SMI experience food insecurity. People with SMI were also found to be 2.71 times more likely to report food insecurity than non-psychiatric controls/the general population. The odds of food insecurity in SMI were higher in high- and high-middle-income countries compared with low- and low-middle-income countries, probably owing to the high overall food insecurity rates in the general population of lower-income countries.

People with mental ill health face a significant income gap compared with those without such conditions: one UK study estimated that the majority earn almost one-third less and that just 11% of people with psychosis were in employment in 2014 (Bond Reference Bond and D'Arcy2020). The Trussell Trust notes that mental ill health is a concern reported by food banks, with an estimated 38% of people accessing them having a mental health condition (Hadfield-Spoor Reference Forsey2018).

People living with SMI report that food insecurity is increasingly prevalent. In a UK study on obesity in SMI commissioned by the Health and Wellbeing Alliance (Wilton Reference Puddephatt2020) interviewees reported:

The syndemic nature of having an SMI in conjunction with food insecurity remains an under-researched area worldwide (Swinburn 2019). This potentially leads to food insecurity being unrecognised across health and social care systems.

How is food insecurity currently managed in SMI clinical practice?

At present, mental health practitioners may not prioritise asking about food insecurity. There are many potential explanations for this. We have already identified a lack of evidence regarding the prevalence of food insecurity in adults with SMI in the UK. The evidence we do have is predominantly anecdotal reports from people with mental ill health as part of other work, for example the above-mentioned study on obesity in SMI (Wilton Reference Puddephatt2020). It is therefore important to raise awareness of food insecurity for clinicians working with people with SMI.

Furthermore, many people accessing food banks report a sense of social stigma and shame, being seen as ‘failures’. This includes being reliant on others for their survival, being seen by other people in their local area as lacking in the choice of food they could eat and not being able to provide for their families (Purdam Reference Purdam2016). It may therefore be particularly difficult for people presenting to mental health services to raise the issue of food insecurity with their clinician owing to the stigma attached to it.

The lead author (J.S.) undertook some ‘patient and public involvement’ (PPI) work as part of a recent grant application on food insecurity in SMI. The patient representatives spoke about their experiences of food insecurity and gave examples of people wanting to remain in a psychiatric hospital for longer than required to have access to hot meals. The work uncovered that, although it is a sensitive subject, patients would welcome an opportunity to talk to mental health practitioners about food insecurity if this would result in some support to access services.

How can psychiatrists support patients with SMI who are experiencing food insecurity?

Psychiatrists working in teams that support people with SMI might champion the issue of food insecurity in this population, leading by example to address the wider determinants of health and provide more holistic mental health services. For example, a psychiatrist could raise awareness in their own multidisciplinary team (MDT) of the prevalence and experiences of individuals with SMI in relation to food insecurity by sharing this article or providing an update at a team meeting. They could work with their MDT to familiarise themselves with the local services that are available to support individuals who are experiencing food insecurity and establish links with these organisations. It is vital that healthcare practitioners working in mental health assess for food insecurity routinely as part of the care they provide. When food insecurity is identified, practitioners should work with the individual to identify the support that they require to access food. As identified in the clinical vignettes in Boxes 1 and 2, this is often a complex matter and needs to be person-centred and tailored to individual circumstances and needs.

What changes are needed in the future?

Psychiatrists and their MDTs are well placed to champion the problem of food insecurity and promote the need for local and national policy change by lobbying for more equitable access to food in the UK. Since food insecurity was first recognised in the 1970s, a wide range of initiatives have attempted to address this health inequality. Although there are many emergency sources of support for people experiencing food insecurity, such as food banks, sustainable social supermarkets, food parcels and cooked meal provision, these are mainly reactive and temporary solutions. We need policy reform at local and national levels to prevent people falling into a food insecurity crisis and going hungry. The government programmes to address health inequalities encourage local initiatives such as food co-ops, community cafés, ‘cook and eat’ sessions, and partnerships between retailers, local authorities and communities. Research into local food projects has shown that social gains for individuals and communities are intrinsic to projects achieving nutritional and health benefits (McGlone Reference Keenan, Christiansen and Hardman1999).

To date, much of the policy reform has focused on childhood food insecurity, with other vulnerable groups often being excluded (including people with SMI). Although the Feeding Britain report A Hunger Free UK focuses mainly on food insecurity for children and families (Feeding Britain 2018), it does include a section regarding older adults, with recommendations such as finding innovative ways to fund social care and preventive measures to stop older people becoming malnourished, such as means-tested winter fuel payments and protecting ‘meals on wheels’ services. However, vulnerable adults aged 18 to 64 years who are experiencing food insecurity are not considered. We have discussed here the problems faced by people with SMI who are living alone, but it is important to acknowledge that some have families and children. For these people, food insecurity may interrelate with additional family pressures. The recommendations of this article therefore need to be considered in the context of each individual's circumstances.

To address this stark health inequality for adults living with SMI, policy makers initially need to understand the barriers these individual face accessing existing interventions to address food insecurity. It is vital that any new interventions or policies for adults with SMI are co-produced so that they are feasible and acceptable for this population. Public health interventions are often delivered to, rather than with, the target communities, which can raise questions about their acceptability in real-world practice (McGeechan Reference Jones2019). It is important that new interventions and/or policies adopt a value-driven approach, built on the principle that those who are affected by a service are best placed to design it.

Although it is important to address current levels of food insecurity for adults with SMI, it is vital that this population are fully considered in upstream policy changes aimed at preventing food insecurity. One of the reasons why hunger has not been moved higher up the political agenda is that the worst consequences of hunger among the poorest people in society are alleviated by the voluntary sector and communities (Feeding Britain 2018). The National Food Strategy focuses mainly on ensuring that the UK has sufficient access to food supplies by recommending that the government trials a ‘Community Eatwell’ programme providing targeted healthy eating support for people on low incomes (Dimbleby 2021). This would include identifying people who require dietary support and making a referral to a link worker (a non-clinical staff member with specialist training to support healthy eating). The link worker would design a programme to support the person to engage with community services. We would question whether this goes far enough in addressing the complex issues that surround the causes and consequences of food insecurity for people with SMI. The National Food Strategy fails to address the complex causes of food insecurity in vulnerable groups, such as fuel poverty and a benefits system that is not fit for purpose. Without addressing these upstream problems, people with SMI are likely to be living with food insecurity for the foreseeable future.

Take-home message

Psychiatrists need to routinely assess and monitor food insecurity in people with SMI. They need to work with people with mental ill health to co-produce interventions that are acceptable, accessible and can be tailored to individual circumstances. Urgent policy reform is required to ensure that adults with SMI are included in upstream policy changes that address food insecurity (Box 4).

Author contributions

J.S., C.H., E.P. and S.G. conceived the idea for this paper. S.K. and D.A. consulted on the content. J.S. led on the overall design and write-up, supported by C.H. S.G. approached the editor with the idea for the paper. All authors contributed to the writing of this paper.