Discussion

This study investigated relationships between ACE and experiences of food insecurity in a population-based sample of emerging adults. Results of this study extend existing research on associations between ACE and childhood food insecurity by showing that all forms of ACE were related to an elevated prevalence of food insecurity in emerging adulthood, and these relationships were similar for young people from lower and middle SES households. The adverse experience of emotional abuse was most robustly linked to emerging adult food insecurity, with close to half of those who experienced emotional abuse indicating they were food insecure in the past year. Additionally, the results showed there was a stepwise increase in the prevalence of food insecurity among emerging adults as the number of ACE increased. This observation of a cumulative relationship between ACE and food insecurity adds to growing evidence that those with a history of ACE may be in particular need of food assistance programs. It seems likely that the individuals with ACE histories who experience food insecurity are less likely than others to have had access to supports to address the sequelae of ACE. Therefore, it could be beneficial for food assistance programs to develop resources for reaching emerging adults with ACE histories as one potential point connecting them to resources such as free or sliding-fee mental healthcare.

The results are consistent with the literature addressing specific associations between various forms of ACE and food insecurity. Two prior studies have examined these relationships among nationally representative samples of children and young adults, and similarly observed that most forms of ACE are related to an increased prevalence of food insecurity^{(Reference Testa and Jackson10,Reference Jackson, Chilton and Johnson37)} . For example, among a sample of 12 288 young adults, Testa and Jackson separately examined associations between food insecurity and the ACE of emotional abuse, physical abuse, sexual abuse, low parental warmth, physical neglect, community violence, substance abuse in the household, parental separation or divorce, suicide exposure and incarceration of a household member^{(Reference Testa and Jackson10)}. Testa and Jackson observed odds ratios for food insecurity ranging from 1·29 for community violence to 1·68 for parental incarceration in models that accounted for demographic factors and potential mediators (e.g. depressive symptoms); low parental warmth, physical neglect and suicide exposure were the only forms of ACE that were not associated with food insecurity^{(Reference Testa and Jackson10)}. The current study adds to these prior findings by demonstrating that associations between ACE and food insecurity are present even after adjusting for adolescent food insecurity as a potential confounder. Finally, by mutually adjusting for all different forms of ACE, we aimed to identify what ACE may be most important in predicting food insecurity and found a particularly strong association between childhood emotional abuse and future risk for food insecurity. Emotional abuse has been linked to higher levels of depression, but little is known about its relationship to other risk factors for experiencing food insecurity (e.g. below average school performance, perceptions of food adequacy)^{(Reference Christ, de Waal and Dekker38)}.

Findings of the current study also extend what is known about the consistency of observed relationships among young people of diverse, childhood SES backgrounds. Prior research has demonstrated that both ACE and childhood food insecurity are associated with future educational attainment, but few studies have examined whether parental education moderates the relationship between ACE and food insecurity^{(Reference Houtepen, Heron and Suderman39)}. Higher levels of parent education, which are linked to higher parent incomes, may reduce the risk of future food insecurity in young people by increasing child educational attainment and income potential. Further, higher parent education and the household resources that often come with it may help to buffer the impacts of ACE. For the current study, household SES was primarily determined by the educational attainment of parent(s) at the time when participants were first enrolled in school classrooms. The results provide limited evidence that high household SES in childhood may buffer the relationship between some forms of early life adversities and future food insecurity in emerging adulthood. Though notably, emotional abuse and a household member having a mental health problem were strongly related to food insecurity even in high-SES households. It is also important to acknowledge there was a relatively small number of participants who experienced childhood emotional abuse and were from high SES households (n 25), and therefore, the CI for the adjusted prevalence of adult food insecurity among this subsample is wide (35·8–77·5 %). However, the estimated prevalence of adult food insecurity among participants who experienced emotional abuse was very similar among those from low SES households (50·3 %) as compared with those from high SES households (56·6 %). The results are in line with related research among the Avon Longitudinal Study of Parents and Children that found associations of ACE with some educational and health outcomes (e.g. depression, drug use, and smoking) were not altered by adjustment for socio-economic factors^{(Reference Houtepen, Heron and Suderman39)}. Additional research will be needed to clarify the role of household SES; however, the results imply that interventions should not focus solely on ACE or solely on socio-economic deprivation, as both appear to be important predictors of future food insecurity. For example, it may be informative for qualitative research to explore the degree to which emerging adults with a history of childhood emotional abuse may benefit from the resources of their parental household and the role of challenges related to executive functioning^{(Reference Mark, Poltavski and Petros40)}. Similarly, future studies could help to address whether the resources of high SES households may be sufficient to overcome the potential impact of most other types of ACE on a young person’s ability to perform well in school and as an adult earn an adequate income for purchasing food.

Strengths and limitations of the current study should be considered as part of interpreting the findings. Key strengths include the large, population-based sample of sociodemographically diverse participants, the ability to adjust for adolescent food security status as a potential confounder and the broad range of variables that were used to investigate the potential influence of different types of ACE on risk for experiencing food insecurity. The diversity of participants and large sample size allowed the study to conduct analyses adjusting for gender, ethnicity/race, markers of SES and living situation. Two main limitations warrant consideration. First, both ACE and food insecurity were assessed by survey self-report and were kept brief to limit participant burden. Food insecurity associated with food access problems is most reliably assessed among U.S. adult populations with the full Household Food Security Survey Module and accordingly our findings may have been weakened by measurement error associated with including only a small portion of items from this tool on the EAT 2018 survey⁽³³⁾. The adolescent survey at baseline included different measures of food insecurity that were drawn from a validated tool and similar to measures included in the Child Food Security Survey Module, but were not validated for use in young people this age^{(Reference Connell, Nord and Lofton41)}. Both measures of food insecurity were focused on food access problems, and thus, it is possible the assessment underestimated food insecurity and our study accordingly underestimated the true association between ACE and food insecurity stemming from challenges unrelated to food access. Retrospective self-reports of ACE may suffer from recall bias; however, retrospective recall is often the only feasible way to assess abuse and neglect in large epidemiologic cohorts. Further, it is not clear the extent to which retrospective report is less accurate than prospective assessments, which also suffer from underreporting and measurement error. Second, there was substantial attrition of the sample over longitudinal follow-up. If attrition is correlated with both ACE and food insecurity, then our findings may be affected by selection bias. IPW was designed to reduce this bias by weighting the sample to represent the original baseline, population-based sample.

There are several implications of the current study findings within the context of the growing evidence for developing trauma-informed policies and services to prevent food insecurity and the many adversities that young people have experienced during the COVID-19 pandemic. Primary prevention efforts to protect young people from ACE are of paramount importance along with efforts to address the potential consequences of adversity for outcomes that impact access to adequate food (e.g. low wages). For example, interventions designed to support young people with ACE to improve their academic performance and job skills could help them to earn adequate money for food. The results described here emphasise the great significance of providing supports for young people navigating the transition to adulthood during and in the aftermath of the COVID-19 pandemic. There is some evidence that young people with a history of ACE have experienced increased risk for financial difficulties during the COVID-19 pandemic^{(Reference Salmon, Taillieu and Stewart-Tufescu42)}. Health care providers and community-based nutrition professionals are well-positioned to collaborate with social work professionals to screen emerging adults for experiences of adversity so that supports can be provided for accessing food assistance, training programs, and mental health services; accordingly there are several opportunities to improve the implementation of best practices for providing referrals. It is noteworthy that emotional abuse was the most consistent and strongest risk factor for food insecurity in our study, yet this form of ACE is often hidden. A history of experiencing this ACE may not be recognised unless sensitive screening is implemented by health care providers. In the next phases and aftermath of the COVID-19 pandemic, it will be particularly important for health care providers to attend to abuse and other ACE (e.g. coercive control, mental health challenges resulting from stress associated with the pandemic) that may have increased or been hidden as a result of stay-at-home orders and societal trends in virtual work and school arrangements^{(Reference Archer-Kuhn, Hughes and Saini43)}. Importantly, any screening that occurs must be accompanied by evidence-based strategies for how to support individuals who reveal an ACE history. For example, there may be opportunities for health care providers to support young people with ACE histories by teaching positive coping strategies, identifying risks for depression and other mental health problems and/or making referrals to supports and resources (mental healthcare providers, safety net programs) that can reduce the risk for food insecurity.

The current study also extends evidence in support of implementing trauma-informed policies and program models to provide food assistance for young people who have experienced adversity. A framework for developing trauma-informed policy has been developed and its core principles can be used to guide future efforts to address food insecurity^{(Reference Bowen and Murshid44)}. Many innovative policy responses to food insecurity were implemented during the COVID-19 pandemic, and there is now an opportunity for health care providers and community-based nutrition professionals to advocate for the continuation of effective policies. Temporary policies of relevance to emerging adult populations provided for an increase in Supplemental Nutrition Assistance Program (SNAP) benefit levels; expansion of eligibility for SNAP as a result of suspending the time limit for able-bodied adults without dependents; waiving or extending paperwork deadlines and interview requirements for SNAP; expansion of the fruit and vegetable benefit allotted by the Special Supplemental Nutrition Program for Women, Infants, and Children; the flexibility for SNAP benefits to be redeemed online and the creation of the Farmers to Families Food Box Program^{(Reference Otten, Averill and Spiker45)}. There is some evidence that these program modifications worked synergistically to prevent a steep rise in food insecurity during the pandemic^{(Reference Caspi, Seligman and Berge46)}; however, as these temporary policies expire it is timely to attend to the many barriers that emerging adults experience in accessing food assistance and programmatic strategies for addressing safety, trustworthiness and transparency, collaboration, empowerment and choice^{(Reference Bowen and Murshid44)}. To improve on existing policies, it could be important to address barriers to eligibility for food assistance benefits and attend to the stigma associated with accessing various forms of assistance. For example, most emerging adults who are enrolled in college or university studies are not currently eligible to receive SNAP benefits,^{(Reference Laska, Fleischhacker and Petsoulis47)} and the modification of eligibility requirements could be of great benefit to young people who are successfully admitted to a postsecondary institution. There is also a great need for the development of other policies to reach populations outside of college and university settings. Emerging adults further report experiencing stigma when accessing emergency food resources and therefore may particularly benefit from trauma-informed programs that attend to the principles of ensuring safety, empowerment, choice and collaboration (e.g. inviting recipients to assist with cooking and serving)^{(Reference Bowen and Irish48)}.

In summary, the results of this study indicate that food insecurity is more prevalent among young people who have a history of ACE. Additional research addressing how these types of traumatic and developmentally disruptive experiences may inhibit consistent access to the safe, healthy and affordable foods that are essential for optimal health and well-being would be beneficial to better guide interventions. It will be particularly important for future studies to comprehensively investigate linkages between ACE and markers of nutrition security. Nutrition security is a broader concept than food security and addresses having equitable and stable availability, access, affordability and utilisation of foods and beverages that promote well-being and prevent and treat disease^{(Reference Mozaffarian, Fleischhacker and Andrés49)}. Research addressing nutrition security is critical to build understanding of barriers relating to consumption of a nutritionally adequate diet. Measures of nutrition security have recently been developed and validated in U.S. samples^{(Reference Calloway, Carpenter and Gargano50)}, and therefore it will be feasible for future research to explore this construct of relevance to address the elevated rates of overweight, obesity and chronic disease among persons with a history of ACE^{(Reference Egger, Binns and Morgan3,Reference Petruccelli, Davis and Berman5)} . To directly inform the development of trauma-informed programming, studies could also attend to whether persons who have experienced ACE are able to access food assistance when they need it or whether an ACE history also impedes successful navigation of our complex safety net system. It will be imperative for future studies to more comprehensively assess food insecurity by attending to problems other than those related to food access (e.g. problems relating to food management, difficulty in accessing culturally familiar foods).