Food Insecurity and Mental Health: Understanding Their Interrelated Relationship in Adults in Salt Lake County

Food insecurity and mental health are two significant public health issues that can impact an individual's quality of life. There is little research about how these two phenomena intersect, and what does exist is mostly quantitative. This study explored the intersection of food insecurity and mental health by examining the lived experiences of adults aged 18-64 in Salt Lake County. This study was done through a qualitative lens using phenomenology. Data was collected through a workshop and semi-structured interviews with participants who have experienced food insecurity and who have a mental health diagnosis. The findings of this study illustrate the ways in which food insecurity and mental health intersect and the impact it can have on individuals' lives. The study also highlights the importance of access to resources and support systems for individuals affected by both food insecurity and a mental health diagnosis. This research has implications for community organizations, healthcare providers, policymakers, and anyone working to address these issues and improve the well-being of those experiencing food insecurity and who have a mental health diagnosis.

Food Insecurity and Mental Health Food Insecurity and Mental Health: Understanding their Interrelated Relationship in Adults in Salt Lake County Hollie Saatkamp Westminster College A thesis submitted in partial fulfillment of the requirement for the degree of Master of Arts in Community Leadership Westminster College Salt Lake City, Utah May 2023 Food Insecurity and Mental Health Abstract Food insecurity and mental health are two significant public health issues that can impact an individual's quality of life. There is little research about how these two phenomena intersect, and what does exist is mostly quantitative. This study explored the intersection of food insecurity and mental health by examining the lived experiences of adults aged 18-64 in Salt Lake County. This study was done through a qualitative lens using phenomenology. Data was collected through a workshop and semi-structured interviews with participants who have experienced food insecurity and who have a mental health diagnosis. The findings of this study illustrate the ways in which food insecurity and mental health intersect and the impact it can have on individuals' lives. The study also highlights the importance of access to resources and support systems for individuals affected by both food insecurity and a mental health diagnosis. This research has implications for community organizations, healthcare providers, policymakers, and anyone working to address these issues and improve the well-being of those experiencing food insecurity and who have a mental health diagnosis. Keywords: Food Insecurity, Mental Health, Mental Illness, Food Security, Food Access, Community Resources, Food Education Food Insecurity and Mental Health Dedication This thesis is dedicated to my friends and family who supported me during this process, to the great food that kept me nourished, and to Poppy and Oliver, two good dogs that were there for me to pet when I needed them. Food Insecurity and Mental Health Acknowledgements I would first like to thank my participants in this study. Without them, this thesis would not exist. Thank you for sitting down and talking with me and sharing a part of your story. Thank you for supporting me and encouraging me. Thank you for your optimism and example. I would also like to thank Crossroads Urban Center and Erika Gee for working with me and providing me with great insights and feedback. I appreciate your flexibility and willingness to meet with me. Thank you for helping me have a better understanding of the good work you do to help our community. I would like to thank my thesis advisor, Shelley Erickson, for providing me with valuable feedback and encouragement when I needed it. Your support has strengthened my resolve and lessened my stress, for which I am immensely grateful. I’m so glad I got to go through this process with you. Thank you to my cohort who commiserated and celebrated with me during this program. Knowing we were in a similar situation reassured me and helped me to keep going. I am so proud of all of us. Food Insecurity and Mental Health Table of Contents Chapter I ....................................................................................................................................... 1 Introduction .................................................................................................................................... 1 Problem Statement .......................................................................................................................... 1 Research Question .......................................................................................................................... 2 Root Causes .................................................................................................................................... 2 Conceptual Frameworks ................................................................................................................. 5 Study Context ................................................................................................................................. 6 Significance .................................................................................................................................... 7 Positionality Statement ................................................................................................................... 8 Community Organization ............................................................................................................. 10 Conclusion .................................................................................................................................... 10 Chapter II .................................................................................................................................... 11 Introduction ...................................................................................................................................11 Food Security and Food Insecurity ............................................................................................... 11 Food Security and Insecurity Defined .......................................................................................... 12 Root Causes .................................................................................................................................. 12 Resources and Support ................................................................................................................. 13 The Impact of Poverty ................................................................................................................... 14 Nutrition and How it Relates to Physical and Mental Health ........................................................ 16 The Relationship of Food Insecurity and Mental Health .............................................................. 17 Childhood Food Insecurity and Mental Health ............................................................................ 19 Conclusion .................................................................................................................................... 20 Chapter III .................................................................................................................................. 21 Introduction .................................................................................................................................. 21 Research Context .......................................................................................................................... 21 Participants ................................................................................................................................... 22 Access ........................................................................................................................................... 23 Research Design ........................................................................................................................... 23 Data Collection ............................................................................................................................. 23 Workshop Process ........................................................................................................................ 24 Interview Process ......................................................................................................................... 25 Data Analysis ................................................................................................................................ 25 Trustworthiness ............................................................................................................................ 26 Ethical Concerns ........................................................................................................................... 26 Data Storage ................................................................................................................................. 27 Potential Limitations .................................................................................................................... 27 Conclusion .................................................................................................................................... 28 Chapter IV ................................................................................................................................... 29 Introduction .................................................................................................................................. 29 Childhood Experiences Impacting Adulthood ............................................................................. 29 The Education Gap ....................................................................................................................... 35 Stable Housing .............................................................................................................................. 38 Food Insecurity and Mental Health Mental Health and Food Habits .....................................................................................................41 Resources and their Role .............................................................................................................. 44 Food Pantries ................................................................................................................................ 49 Conclusion .................................................................................................................................... 52 Chapter V .................................................................................................................................... 53 Introduction .................................................................................................................................. 53 Recommendations ........................................................................................................................ 53 Recommendations for Organizations Working with Food Insecure Adults ................................. 54 Community Organization and Similar Non-Profits ...................................................................... 54 Recommendations for Organizations Working with Adults with Mental Illness .......................... 55 Recommendations for Policy and Interested Organizations ......................................................... 56 Policy Recommendations .............................................................................................................. 57 Interested Organization Recommendations .................................................................................. 58 Future Research ............................................................................................................................ 59 Personal Reflection ....................................................................................................................... 59 References ................................................................................................................................... 61 Appendices .................................................................................................................................. 72 Appendix A: In-Person Recruitment Script for Workshop Participation ..................................... 72 Appendix B: In-Person Recruitment Script for Interview Participation ....................................... 73 Appendix C: Email Script to Send to Organizations ..................................................................... 74 Appendix D: Workshop Guide ...................................................................................................... 75 Appendix E: Interview Guide ....................................................................................................... 76 Appendix F: Informed Consent for Workshop .............................................................................. 78 Appendix G: Informed Consent for Interviews ............................................................................. 80 Appendix H: Resource List ........................................................................................................... 82 Appendix I: IRB Approval ............................................................................................................ 83 Appendix J: NIH Certificate ......................................................................................................... 84 Food Insecurity and Mental Health 1 Chapter I Introduction In this study, I explored the relationship between food insecurity and mental illness in adults in Salt Lake City. In this chapter, I explain the problems linked to both food insecurity and mental illness, my research question, the root causes of the problems, the conceptual frameworks that I used in this study, the study context, the significance of this study, and my own positionality on this topic. Problem Statement In our capitalist society, people are not able to obtain enough food for themselves and their families, and if they are, they often cannot control what food they get, whether it is a good diet for them, and how consistent and healthy the meals are (Long et al., 2020). Food security, as defined by the Food and Agricultural Organization of the United Nations is “when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life,” (FAO, par. 16, 2006). Some people may be able to feed themselves, but not in a way that meets their dietary or health needs, and so are still considered food insecure. In Salt Lake County, 10.7% of people were food insecure in 2019 (Healthy Salt Lake, 2021). This number likely increased during the COVID-19 pandemic, however not all of the data from that time frame has been published yet. In addition to food insecurity, “close to one in five Utah adults experience poor mental health,” (Summers et al., 2019, p. 1). While many people do experience mental illness in Utah, those in a lower socio-economic demographic experience mental illness at a higher rate (Utah Department Food Insecurity and Mental Health 2 of Health, 2022). The signs indicate that lower socio-economic status can impact one’s mental health. Those in lower income brackets also tend to experience more food insecurity. In addition, food insecurity has been linked to mental illness (Loftus et al., 2020; Pourmotabbed et al.; 2020, Stuff et al., 2004). Food insecurity can cause stress and contribute to anxiety and depression, and if food is obtained in ways that are not deemed socially acceptable, it can lead to feelings that may lead to depression, such as alienation, shame, and a sense of powerlessness, (Jones, 2017; Pourmotabbed et al., 2020). Food insecurity has been linked to poorer diet quality, nutritional deficiencies that affect mental health, and an added psychological burden on those trying to navigate government assistant programs, food banks, and other social systems (Bergmans et al., 2019). The connection has been found in previous studies, but the way the interrelated relationship between food insecurity and mental health affects the daily lives of those experiencing them has not been explored thoroughly in literature as of writing. Research Question(s) My research question was: How does the intersection of food insecurity and a mental health diagnosis affect the lived experience of adults aged 18-64 in Salt Lake County? I wanted to bring out people’s experiences surrounding this topic and their stories, in order to get a greater understanding of how food insecurity and mental illness affect people. Root Causes At first glance, food insecurity and mental illness might not seem to be wholly connected. However, after looking into it further, it is clear that a relationship is there. It is apparent after looking at the research that exists on both of these topics that systemic problems from capitalism Food Insecurity and Mental Health 3 and neoliberalism are some of the main root causes for both of these issues, (James, 2008; Long et al., 2020). Capitalism is the economic structure that exists in the United States and in Utah. Under this system, income inequality has increased over the last few decades, and the top 1% hold more wealth than they have before, widening the gap (Jackson & Victor, 2021; Milner, 2021). When it comes to food insecurity, this means that more people are food insecure because they cannot afford sufficient and nutritious food for themselves or their families. In addition, the problem is not that there isn’t enough food to go around, it’s that the way it is distributed does not work for the people. It’s not necessarily a lack of food, but a lack of good distribution that prevents access to healthy and nutritious food (Elkharouf & Pritchard, 2019; Halewood, 2011; Webster & Zumbansen, 2015). This is linked to capitalism, because the food farming and factory and supply chain companies value their profits over feeding people, and so will even waste food if it won’t make them a profit (Chakraborty, 2018). In addition to the distribution, the way foods are priced, paired with low wages, creates an economy that makes food security out of reach for many. Neoliberal policies tend to increase inequality in a capitalist system, which can make food access difficult for those affected (Long et al., 2020). Neoliberalism includes the ideas that it should be up to individuals to care for themselves, and the governments should not interfere with state relief programs, but preserve the systems in place for private organizations and free markets to rule themselves (Long et al., 2020). This contributes to the idea that individuals are responsible for their own so-called failures in the system, rather than the system itself. This is why, rather than government and economic policies existing to truly feed people, they rely on nonprofits such as food pantries to make up for their Food Insecurity and Mental Health 4 lack. Neoliberalism feeds into the view that asking for help should be frowned upon and viewed as a weakness, and so there is also a social stigma placed upon those who receive benefits such as SNAP benefits or those who utilize food pantries, which can lead to feelings of shame and depression (Zeira, 2021). This can lead to poor mental health outcomes for those experiencing food insecurity. Capitalism affects mental health outcomes in a few ways. Work and leisure are both seen as ways to generate consumption under this system, and so for those who need to make money, their hobbies often become unfulfilling and dissatisfying (Matthews, 2019). Due to the increasing inequality under capitalism, people often turn their hobbies and creative outlets into ways to generate money, which can place a burden of pressure on them and drain out any enjoyment they once had in said hobby or creative outlet. Matthews also pointed out that for humans to be more mentally healthy, their creative needs must be met, as humans have imagination and reason. Without an opportunity to do that, or with each opportunity turned into a struggle to make money and survive, mental health worsens. When it comes to neoliberalism and mental health, it’s been shown that English-speaking countries that have incorporated neoliberal capitalist policies in their governance have twice as many people that suffer from emotional distress than people in countries that did not incorporate those policies (James, 2008). These neoliberal policies, such as reduced social supports and benefits, increased taxes for certain things, and increased privatization and deregulation also created a shift in mainstream ideology that favors consumerism, competitiveness, and individualism, which can lead to depression and anxiety, because it doesn’t connect with humanity’s needs for community and socialization. The social stigma that can occur from people not being independent enough according to neoliberal ideology and utilizing food banks or Food Insecurity and Mental Health 5 SNAP benefits or other sources for help can also lead to poorer mental health outcomes (Zeira, 2021). Neoliberalism and capitalism affect food security and mental health in an interrelated way, and until the systems are changed, they will likely continue to do so. Conceptual Framework The frameworks I am using in this study are critical theory and intersectionality. Critical theory has no set definition, it pulls from the work of many, including Marxist theory and the Frankfurt School of Critical Social Theory. This theory is focused on ideological critique of the dominant culture, and it works to challenge the oppressive systems in place in society (Brookfield, 2005). This theory points out the hegemonic values people hold that keep the current systems in place. This theory posits that the current economic and social structures are problematic, and are the source of the crises we face, and that by understanding this and the theory, we will be prompted to change it (Brookfield, 2005). Critical theory is useful because it works to challenge the systems in place that many people have simply accepted, such as capitalism. Challenging our capitalist systems could lead to better food security and mental health outcomes for many people. Critical theory shows that the capitalist food system in place leaves many people without food, without access to healthy food, and without control over where they get their food. The main system of power in current society is one in which the rich and large agricultural corporations’ benefit while the workers are often not able to afford the food they grow (Halewood, 2011). It has led to neoliberal policies of global trade that leave many farmers and workers all over the world without much while the food they produce goes to people half a world away. Critical theorists envision a world where we can base our economies as one that is in Food Insecurity and Mental Health 6 service to nature and its resources, rather than the other way around (Capra & Jakobsen, 2017). This would help people feel more connected to nature and their food sources, as well as lessen the pressure of consumerism and individualism that often leads to poor mental health. Intersectionality is a term that is used to describe how different identities such as race, ethnicity, gender identification, sexual orientation, ability, and socio-economic status intersect and create different outcomes for people in terms of access and equality in our society (Center for Intersectional Justice, 2021). Intersectionality was introduced in the 1980’s by Kimberlé Crenshaw as a different lens to view the world with, and has been used in many research studies since as a way to better understand social justice causes through multiple lenses, (Cho et al., 2013; Crenshaw, 2017). Intersectionality is important to this study because mental illness and food insecurity are experienced differently for Black, Indigenous, People of Color (BIPOC), people with different gender identities, sexual orientations, disabilities, and other identifiers, than they are for a white cisgender, heterosexual male, and those differences are important to recognize. There are different factors leading to their food insecurity and/or mental illness that are necessary to acknowledge in the study. In addition, this study is looked at an intersection, with ability and socioeconomic status factoring in, as food security is affected by socioeconomic status, and mental illness is considered a disability that qualifies for benefits in the United States, (National Alliance on Mental Illness, 2014). Due to this, intersectionality was a useful framework to guide this study, along with critical theory. Study Context The research took place in Salt Lake City because it is a semi-urban population that I had access to, as it’s where I currently live. Utah also has the highest rate of mental illness in the Food Insecurity and Mental Health 7 U.S., which makes its capital city a great location to do research that studies people’s experience with mental illness (Chow, 2022). There are also several organizations and movements related to food security and to mental health in Salt Lake City, and so I had a good foundation to build off of and learn from. I focused on adults between the ages of 18 - 64 because it is a group that is largely affected by this issue, and one that I had access to. I had no gender, sexual orientation, or race exclusions, and I worked with people across genders, sexual orientations, and races within this age range. I required participants to have a mental health diagnosis, but they did not have to disclose what their diagnosis was, in order to protect their privacy. For access, I worked at a mental health organization with a population of people who were also experiencing food insecurity that I reached out to for participation if they were willing. This study was done as a qualitative research study, more specifically a phenomenology as referenced in Merriam and Tisdell (2016). Qualitative research studies are valuable because they add human voices to the story, and can show a deeper look into the issue from a more personal perspective. At the time of writing, there are very few qualitative research studies on this intersection, and so there was an opportunity for further understanding of this issue from a qualitative lens through this study. I did this through a workshop with participants to generate an interview guide, and then one-on-one interviews to bring out people’s individual stories and experiences. Significance While there have been many studies about food insecurity and mental health separately, the research about the two of them together and how they are connected is fairly new. Most Food Insecurity and Mental Health 8 studies about these two issues together are within five years old, with a few dating back 10-15 years, and not many more than that. In addition, most of the research has been quantitative, trying to find and establish a connection, rather than understand that connection, or they have been large scale overviews that don’t provide much insight into how the issue affects people’s daily lives (Bergmans et al., 2019; Liebe et al., 2022; Long et al., 2020; Pourmotabbed et al., 2020). My study is important as a qualitative study because it presents a different angle to this topic. It also shows how these phenomena affect people in their everyday lives, which sheds some light on food insecurity and mental illness in a unique way. In addition, this type of study has not been done in a localized area such as Salt Lake City, and Salt Lake is a good location due to being in Utah, which has the highest rate of mental illness in the United States (Chow, 2022). This study presents a great opportunity to understand the interrelated relationship between food insecurity and mental health. A greater understanding of these issues can lead to legislation or policies that can help people who are affected. It can also help inform organizations that work with food insecure populations and/or those with a mental health diagnosis about ways to better serve these people and direct them to resources that may benefit them. Positionality Statement I am a white, cisgendered woman, currently 26 years old. I am a part of the LGBTQ+ community, but I have experienced a life of relative privilege, especially with regards to food security. I grew up in a middle-class home in Ohio, and while my parents were not wealthy, they did make enough to keep me and my siblings comfortably fed. I grew up loving food and trying new things to eat, and I can remember from a young age feeling upset upon learning that not everyone had access to food, and that many within our own country often went hungry. The Food Insecurity and Mental Health 9 United States supposedly has so much wealth, and yet it cannot feed its people. I have long wanted to learn what can be done to help fix that. I recognize that food insecurity is often experienced differently for BIPOC, and people of other minority groups, and it can be more common for those groups, for a variety of reasons, many of which are systemic. The same can be said for mental illness. Keeping myself aware of that and educating myself more on the reasons were beneficial for my research. I am from a more privileged demographic; however, I do have some experience with these issues. I was diagnosed with depression and anxiety at 19, and experienced it earlier than that. It has affected my life in a few ways, such as bringing on periods of isolation, anxiety attacks, suicidal thoughts, and lack of motivation for daily tasks, including feeding myself. Many times, especially since living away from my parents, I have only been fed because I have a supportive social network that helps me to ensure I am meeting my needs. I know that mental health can impact many different aspects of one’s life from personal experience. If mental illness is added onto a precarious or unstable financial situation, and a small or nonexistent social network, food security can be something that is out of reach for many. I worked with adults with severe and persistent mental illness (SPMI) at my job. Many of these adults experienced food insecurity, which inspired my research direction. I care about people and envision a world where everyone has access to the care and nourishment they need. I have hope that through this study, I may be able to shed a light on this issue and find ways that can improve things for the people experiencing them. Food Insecurity and Mental Health 10 Community Organization The community organization that I worked with is Crossroads Urban Center, a nonprofit organization that helps low-income people in Salt Lake and has a couple food pantries. Many of their clients also have a diagnosed mental illness, and so this organization worked well with my study. My research can benefit the organization by providing insight and suggestions on how to better serve their clients and utilize their food pantries in order to accommodate those with a mental health diagnosis. Conclusion This study explored the relationship between food insecurity and mental illness in adults aged 18 – 64 in Salt Lake City. In this chapter, I explained that capitalism and neoliberalism are some of the main root causes for both food insecurity and mental illness, that critical theory and intersectionality are important frameworks to look at this issue through, and that doing this study in Salt Lake City as a qualitative research study is significant. I explained my positionality and the benefit this study can bring to my partner organization. In the next chapter, I will go into more detail on the literature that does exist on this topic, and how it relates to my research question. Food Insecurity and Mental Health 11 Chapter II Introduction The research question I explored in this study is how the intersection of food insecurity and a mental health diagnosis affect the lived experience of adults aged 18-64 in Salt Lake County. This topic was and continues to be important to me as someone who has a mental health diagnosis and who has long been interested in food security and ensuring more people are food secure. Literature in this field is still fairly new, with a large number of studies taking place within the last 5 to 10 years, and a few that are 10 years or older. Many studies point out the relationship between food insecurity and poverty, the relationship between nutritional diet quality and mental health, and some attempt to explain the links in more detail between food security and mental health. This chapter gives an overview of the existing literature on food insecurity, how poverty affects both food security and mental health, how nutrition affects physical and mental health, what is known about how food insecurity and mental health affect each other, and it will touch on childhood food insecurity and mental illness. Food Security and Food Insecurity This section explains what food security and insecurity are, some of their root causes, and some resources that exist to help offset food insecurity. These are significant because it is important to understand what food insecurity is in order to understand what the participants in this study are experiencing. The root causes play a role in what may have gotten the participants to where they are, and the resources they access are relevant to many of the participants’ experiences of handling their food insecurity while also living with mental illness. Food Insecurity and Mental Health 12 Food Security and Insecurity Defined Food systems throughout the world do not feed every person within them. Due to systemic problems from capitalism, neoliberal trade policies and colonialism, many people are food insecure (Chakraborty, 2018; Halewood, 2011; Jackson & Victor, 2021; Long et al., 2020). Food security, as mentioned in Chapter I, is when people have sufficient access to safe and nutritious food that meets their dietary needs and preferences for an active and healthy lifestyle, (FAO, 2006). Food insecurity is defined as “a lack of consistent access to enough food for every person in a household to live an active, healthy life,” (Feeding America, 2018, para. 1). Some people may be able to feed themselves, but not in a way that meets their dietary or health needs, and so are still considered food insecure. For those living below the federal poverty line, 32% were food insecure in the United States (USDA, 2018). In Utah, 8.9% of people lived below the poverty line in 2019, and 10% of the population was food insecure according to data from 2020 (Community Action Partnership of Utah, 2022; Utah Food Security Taskforce, 2021). This equates to about one in ten people who are not able to meet their own or their households needs for food and/or nutrition. Those percentages also indicate that some people experienced food insecurity while not living below the poverty line, and so it is a fairly widespread issue. With costs rising and wages staying mostly stagnant, it is likely that this number will rise. Root Causes Some of the main root causes of our problematic food systems are from capitalism and neoliberal trade policies. One aspect to our ineffective food systems is not that there isn’t enough food to go around, it’s that the way it is distributed does not work for the people. It’s not necessarily a lack of food, but a lack of good distribution that prevents access to healthy and Food Insecurity and Mental Health 13 nutritious food (Elkharouf & Pritchard, 2019; Halewood, 2011; Webster & Zumbansen, 2015). The globalized system we live in means that food gets shipped from all over the world, and oftentimes those who work in the fields cannot afford what they grow (Halewood, 2011). Webster and Zumbansen (2015) point out that because of the monopoly that many agribusinesses have on land and food production, they also are able to control prices and distribution. Because profit is the main goal of capitalism, many people go unfed even when there is sufficient food for them nearby, because of high costs and low wages. Food sovereignty, which is a term used to define putting the control of land and growing methods back into the hands of local peasants and indigenous peoples, is one way that capitalism is being challenged (Halewood, 2011). These movements are working to combat this and put the power of food production and distribution in the power of the local farmers and workers of an area, rather than the large corporations. Neoliberalism, another root cause of food insecurity, focuses on individual accomplishments or failures rather than governmental support. Its policies tend to favor private organizations and free market rule, rather than state aid and relief programs, (Long et al., 2020). This puts all the burden of success or failure on the individual, and the faulty systems in place avoid blame. This can lead to those who are experiencing food insecurity to feel isolated and ashamed for not being able to provide for themselves or their families, and for having to rely on government programs or food pantries and other food related nonprofits. Resources and Supports SNAP, or the Supplemental Nutrition Assistance Program can provide a small amount of support, but it is not sufficient. It requires an application process that can often be overwhelming for those already struggling. In addition, only certain foods can be purchased with SNAP, and Food Insecurity and Mental Health 14 hot foods cannot be bought with it, so those without reliable access to a kitchen may not be able to cook for themselves (Utah Department of Workforce Services, 2022). Furthermore, the benefits for one person on SNAP add up to less than $300 a month, and people are only eligible at a certain income level, which means that many are not eligible, even if they do experience food insecurity, and those that do obtain SNAP benefits still may not be able to provide for their needs on what they get, especially as prices continue to rise (Utahns Against Hunger, 2022). Food banks can also be insufficient because they rely on donations, which are not always consistent. They also give people what they have that may not be anything that can go together and make a meal, that may be required to cook, and some people don’t have kitchens, and food given away may be close to expiring or already expired. This is important, because many of the people in this study, those aged 18-64 in Salt Lake County experiencing food insecurity and who have a mental health diagnosis, are those who have used SNAP benefits and/or accessed food pantries. Their experiences with these resources can be a part of their stories of going through food insecurity while having a mental health diagnosis. The Impact of Poverty Poverty has been shown to impact both mental health and food insecurity rates. However, studies looking into this tend to be quantitative, and don’t shed much light on what participants’ experiences look like. One meta-analysis of several papers found that food insecurity and depression seemed to be most common in Asians 65 years or older, (Pourmotabbed et al., 2020), others found that aside from income level, most other demographic and socioeconomic indicators did not have enough evidence to be significant (Bergmans et al., 2019; Cook & Frank, 2008; Stuff et al., Food Insecurity and Mental Health 15 2004). Those latter studies did find evidence that there is a link between food security and poverty, especially in rural areas, and these indicators also coincided with poorer mental health outcomes than those with more income and food security. These studies did acknowledge that non-white respondents did tend to have lower income levels as well as increased food insecurity and poor mental health outcomes. This is likely due to systemic issues within the United States that make it more difficult for non-white people to access the services and care they need (Feeding America, 2018; Loftus et al., 2020; Utah Food Security Taskforce, 2021). The link between food insecurity and lower incomes makes sense, because it costs money to be able to provide oneself and their family with consistent, sufficient, and nutritious food. This is more likely in rural areas as well, because one must factor in the cost of travel and access. The lower the income, the higher the rates of both food insecurity and serious mental illness, at an increasing rate (Afulani et al., 2018; America's Health Rankings, 2022; Cook & Frank, 2008; Huddleston-Casas et al., 2009). Lower income usually means less access to sufficient and nutritious food, as well as mental health services, so it can exacerbate both food insecurity and mental health in an interrelated way for adults. This link was also pointed out in studies of food insecurity and mental health during the COVID-19 pandemic (Nagata et al., 2021; Polsky & Gilmour, 2020). The pandemic led to loss of jobs and lower income for many people, which increased food insecurity, reliance on SNAP assistance, and poor mental health. The causal and directional link is not certain, but evidence does indicate a strong relationship (Polsky & Gilmour, 2020). This is significant, because it means an increase in income and/or food security could lead to better mental health outcomes. This could be affected through this research through a better understanding for both, and potentially legislative or policy changes that would help increase food security in Utah. Food Insecurity and Mental Health 16 Nutrition and How it Relates to Physical and Mental Health In addition to the link between poverty and food insecurity and how they affect mental health, the lack of good diet and nutrition common with food insecure households can also affect mental health in addition to physical health (Bergmans et al., 2019; Cook & Frank, 2008; Pourmotabbed et al., 2020; Stuff et al., 2004). Lack of access or affordability to a nutritious and balanced diet is a factor in poor mental health. Poor nutrition can lead to high blood pressure and hormonal imbalances, an increase in disability, a reduction of proteins, up-regulation of stress and immune systems, and a deficiency in certain vitamins that have been shown to contribute to depressive illness (Davison et al., 2017; Huddleston-Casas et al., 2009; Stuff et al., 2004). Food insecurity and a lack of sufficient nutrition can also increase the risk for diabetes, hypertension, coronary heart disease, kidney disease, poor sleep, and other chronic illnesses in nonelderly adults (Gregory & Coleman-Jensen, 2017; Gundersen & Ziliak, 2015; Laraia, 2013). These illnesses can have long-term effects on people that may impact them their entire lifetime. This may lower the quality of a person’s life, which could in turn lead to poorer mental health, whether it be depression, anxiety, or another symptom or diagnosis. This is also shown in another way. In a study done in Flint, Michigan, it was found that the better-quality food in an area, and the greater access the fruit and vegetables, the less of an impact food insecurity had on mental health (Bergmans et al., 2019). As less nutritional value and quality in one’s diet seems to lead to poorer mental health, a more healthy and nutritional diet, even in those experiencing food insecurity, seems to lead to somewhat better mental health outcomes. However, accessing healthier and fresher ingredients can be difficult for those who are food insecure, because the food may be more expensive, and it may take more healthy food intake to fill someone up as opposed to the quicker and less nutritional options. In addition, in Food Insecurity and Mental Health 17 certain climates such as in northern Utah, fresh fruits and vegetables cannot be grown all year, which limits their availability in community gardens and food pantries (Bergmans et al., 2019; Davison et al., 2017). Some people also may not have access to a kitchen, and so they are not able to cook healthy meals for themselves even if they could obtain more fresh ingredients. This is because many people experiencing food insecurity may be unhoused or at shelters without kitchens, and some transitional housings do not have full kitchen set-ups in them (Loftus et al., 2020). This may affect people’s mental health as well, because they are not able to provide their body with sufficient nutrition or choose their meals for themselves, two things that are important to mental health. The Relationship of Food Insecurity and Mental Health There is evidence to suggest that there is a link between food insecurity and mental health (Afulani et al., 2018; Loftus et al., 2020; Pourmotabbed et al., 2020; Stuff et al., 2004). Food insecurity has been linked to poorer diet quality, nutritional deficiencies that affect mental health, and an added psychological burden on those trying to navigate government assistant programs, food banks, and other social systems, (Bergmans et al., 2019). These burdens can include navigating websites and multiple forms if the person has access to a computer, long wait times on the phone if they go that route, transportation access, especially in places without public transportation, and potential judgment from society and those around them. Food insecurity can cause stress and contribute to anxiety and depression, and if food is obtained in ways that are not deemed socially acceptable, such as stealing or even accessing food pantries, it can lead to feelings that may lead to depression, such as alienation, shame, and a sense of powerlessness, (Jones, 2017; Pourmotabbed et al., 2020). This is likely due to the individualistic and capitalist nature of our society, where people are seen as responsible for themselves, and receiving Food Insecurity and Mental Health 18 government health can be seen as a sign of individual rather than systemic failure (Long et al., 2020, Zeira, 2021). Because this field of study is still fairly new, especially for non-elderly adults, there is not much evidence to significantly determine the direction of the link between food insecurity and mental health. Many studies seemed to imply that the direction was one way, that food insecurity led to poor mental health, or they simply did not attempt to determine a specific causal direction (Cook & Frank, 2008; Jones, 2017; Pourmotabbed et al., 2020). Of the studies that did look into a directional aspect, several did reference one earlier study. This study stated that in a sample of rural, low-income women, there was evidence that the relationship between food insecurity and depression was recursive and simultaneously causal (Huddleston-Casas et al., 2009). This means that the relationships affected each other in a way that exacerbated it both ways, and that could continuously occur in a cycle. A few later studies also noted that the relationship may be bidirectional, meaning that while food insecurity may impact mental health, mental health may also play a role in one’s food security status (Afulani et al., 2018; Gundersen & Ziliak, 2015; Liebe et al., 2022). In one direction, it may be because when one is food insecure, their poor nutrition can lead to poorer mental health, as well as the economic factors they are experiencing, as well as social stigma. In the other direction, poor mental health may lead to loss of appetite or motivation to feed oneself, especially to cook healthy meals, and it may also mean that their mental illness affects their ability to work and earn an income sufficient for food security. While this may seem bleak, it also means that there are multiple ways to go about addressing these needs. More research, especially longitudinal research, is needed on this topic to truly determine the direction, correlation, and impacts. Furthermore, the studies listed above studies simply state that a relationship exists, and do not share the stories and experiences of Food Insecurity and Mental Health 19 those involved. This is because those studies are based on quantitative research, utilizing surveys and census data rather than individual meetings and experience sharing. My study attempts to fill that gap by bringing to light people’s personal experiences with food insecurity and mental health. In addition to looking into the direction of the link between food security and mental health, the type of mental health symptoms and diagnoses studied is important to note. Most studies used a self-diagnosis survey to assess mental health, using a scale to rate their mental health from options such as “poor” “fair” and “good” and more, or they used another similar scale (Bergmans et al., 2019; Davison et al., 2017; Huddleston-Casas et al., 2009; Stuff et al., 2004). This can be useful, but it can also mean that the types of symptoms captured tend to be more general and may not capture the effects of various mental health diagnoses, such as those with schizoaffective disorder or obsessive-compulsive personality disorder. Most studies used depression and anxiety symptoms as their reference for mental health indicators, which means there is a need for more research into the relationship between food security and mental health outside of depression and anxiety. Childhood Food Insecurity and Mental Illness While this study does focus on adults aged 18-64, it is important to acknowledge the effects that childhood food insecurity and mental illness can play a role into adulthood. Studies have shown that when children experience food insecurity, they also experience higher rates of mental illness (Burke et al., 2016; McLaughlin et al., 2012; Melchior et al., 2012; Poole-Di Salvo et al., 2016) This is often due to economic status and is impacted by capitalism (Burke et al., 2016; McLaughlin et al., 2012). It can also be impacted by family make up, such as foster care (Kinarsky, 2017; Lockwood et al., 2015). This is important to note because the experiences of Food Insecurity and Mental Health 20 children can follow them into adulthood and impact their futures. They may not be able to develop healthy coping skills and develop conditions such as complex post-traumatic stress disorder (Burke et al., 2016; Melchior et al., 2012; Starecheski, 2015). This was all relevant to my research because while interviewed adults, their experiences were influenced by their childhood, which will be explored more in cChapter IV. Conclusion Research on the link between food security and mental health in non-elderly adults is still a relatively new field. From what is out there already, a link has been found between the two, as well as a related link to low income and poor nutrition. The link seems to be bidirectional, although more research is needed to determine that. More research is also needed to understand the link between food security and other mental health outcomes besides depression and anxiety. There is still more that can be added to this field, especially in regard to the impact of the COVID-19 pandemic and the intricacies of the relationship between food security and mental health. This study will be a qualitative addition that shows how these two phenomena affect people’s lived experiences, something that has not been explored much in the current literature. Food Insecurity and Mental Health 21 Chapter III Introduction The literature in Chapter II shows that there is a link between food insecurity and mental illness (Loftus et al., 2020; Pourmotabbed et al., 2020; Stuff et al., 2004). In Salt Lake County, 10.7% of people were food insecure in 2019 (Healthy Salt Lake, 2021). In addition to food insecurity, poor mental health is experienced by nearly one in five adults in Utah (Summers et al., 2019). In addition, people experience mental illness at a higher rate when they are in a lower socio-economic demographic (Utah Department of Health, 2022). In this study, I asked the question, How does the intersection of food insecurity and a mental health diagnosis affect the lived experience of adults aged 18-64 in Salt Lake County? This chapter will outline the research context of the study, the participants I recruited and how I accessed them, the research methodology and design I framed this study by, and the data collection and analysis methods I used. It also explores the trustworthiness, ethical concerns, and potential limitations that are relevant to this study. Research Context The research took place in Salt Lake County, which is a semi-urban population that I had access to, as it’s where I currently live. In the past few years, the COVID-19 pandemic has affected the food security of many Utah citizens. At the beginning of the pandemic, some protections were in place to help people get by and purchase food, such as stimulus checks and SNAP benefits. However, while the pandemic is still ongoing, many protections are gone or are on their way to ending. This has made food access harder for many Utah residents. Food Insecurity and Mental Health 22 Utah also has a large population that have a mental health diagnosis, in fact, it has the highest rate of mental illness in the U.S. (Chow, 2022). This means that the Salt Lake area provided me with a good opportunity to study how the intersection for food insecurity and mental health affects the lived experience of adults living there. Participants I focused on adults between the ages of 18 - 64 because it is a group that is largely affected by this issue. This age range also has the maturity to understand and consent to the study and to an interview. They also have a range of life experience from which to pull from when sharing their experiences. This group is also usually responsible for looking after themselves, when it comes to food access and their mental health. I had no gender, sexual orientation, or race exclusions, and I worked with people across genders, sexual orientations, and races within this age range in order to have a broader and more diverse understanding of this intersection. The participants were required to have a mental health diagnosis, but were not required to disclose their diagnosis in order to protect their privacy. There are several organizations and movements related to food security and to mental health in Salt Lake County that serve people who experience both. Valley Behavioral Health and Alliance House are a few organizations that work with adults with mental health diagnoses. The Utah Food Bank and Crossroads Urban Center are organizations that work with people who are experiencing food insecurity. Many of the people served by these organizations overlap. I interviewed people who are clients of or benefit from these organizations, because they are the people experiencing this intersection. I also did a workshop with seven participants in order to generate the interview questions. I then interviewed five adults who were currently or who had experienced food insecurity while also having a mental health diagnosis. The particular diagnosis Food Insecurity and Mental Health 23 was not as important than that they had one, and the participants were not required to disclose their specific diagnosis. Access I gained access to participants for interviews through my former place of work, a local mental health organization. I asked for volunteers to interview with me about this topic (see Appendix C). The director of the organization was aware of this and allowed for the members to choose for themselves whether they desired to be interviewed or not. I did not treat anyone differently at work whether they decided to participate in this study or not. Research Design The research is a qualitative research study, and studied it as a phenomenology, as referenced in Merriam and Tisdell (2016). A phenomenology is a form of qualitative research, and it is the study of phenomena through lived experience, and how that experience can be transformed into consciousness. This study is a phenomenology because I was interested in the lived experience of people who have a mental health diagnosis and are food insecure, and how those affect each other in that person’s life. Data Collection I collected my data in this study through a workshop and interviews. Interviews were a useful means of collection for me because I wanted to understand the lived experiences of people, and get to know their personal perspectives. One-on-one interviews could draw those perspectives out without outside interference. Food Insecurity and Mental Health 24 While this study is not an ethnography, I did pull from Spradley’s (1979) work on The Ethnographic Interview as a guideline, including building rapport and asking some of the different types of questions included, such as grand tour and experience questions. This was because those questions provided a good guideline for an overview of understanding one’s experience, and they helped me understand the participant and their experience deeper. Rapport refers to the relationship between the interviewer and the participant, and it indicates one with good feelings and harmony. I built this by getting to know the person better and starting off the interview with light ice-breaker type questions. The interviews themselves were semi-structured so as to have a general direction, but allow for people to share their experiences in whichever way felt right to them. Workshop Process The interview guide was partially developed through a workshop with participants. I verbally recruited people for the workshop and had them sign an informed consent form for the workshop as well, (see Appendix A and F). During the workshop, I asked a few prompting questions as mentioned in Appendix D and then wrote down and recorded responses. We had paper to write on and brainstorm with, and it was an open discussion to generate questions that could be asked during the interviews. I did this workshop because the participants had a greater idea than I might have when it came to questions to ask around the topics of food insecurity and mental health, since they are the people experiencing them. This workshop to lasted a little under an hour, and it took place in an empty conference room at a mutually convenient location. Food Insecurity and Mental Health 25 Interview Process I interviewed 5five people about my research question, and conduced these interviews for about 30 minutes to an hour. The interviews were based off the guide generated from the workshop (see Appendix E). If the participant did not wish to continue for the full time, I did not require that they did so, and let them know they were free to leave anytime. I also ensured that there was time after the interview to extend if they wished to do so. The interviews were done in the evenings or on weekends according to the way our schedules matched up. I asked the participants if they had a quiet place they preferred to be interviewed at, and if they did not, we went to a coffee shop. All participants signed an Informed Consent form (see Appendix G) before the interview after reading through it, hearing my explanation about it, and indicating that they understood it. I let them know I was available anytime over text or email or at a scheduled time over the phone to answer questions or concerns that may have arisen about anything in the process. The interviews were recorded with consent through Otter.ai for future reference. Data Analysis Immediately after the interviews, I wrote down notes about impressions and connections I made during the process. All interviews were transcribed from the recordings following the interview. The transcriptions were done using the site Otter.ai, and the Microsoft Word dictation and transcription tools, and I listened to and edited them accordingly as a backup. I began data analysis by first going through the initial interview and developing a potential list of codes through a process known as emergent coding (Saldaña, 2009). With each subsequent interview, I continued to revise and refine this list of codes until all data was gathered. Once data collection was finalized, I coded the data set with the finalized coding framework, which consists of process codes, descriptive codes, and in vivo codes that capture the essence of participants’ Food Insecurity and Mental Health 26 iterations. Through this process of coding, I was able to identify patterns and themes that arose from the data, and ensure that the assertions I made were fully warranted. Trustworthiness One of the ways I demonstrated the trustworthiness of my study is through member checking (Merriam & Tisdell, 2016). I did this by presenting my preliminary findings and analysis to some of the people I interviewed and checking in with them to see if it is an accurate understanding of their experience and the phenomena. This helped to prevent my biases from getting into the analysis and it also ensured that the participants could better capture their experiences. Another way that I validated the research was to work with a few of the participants in a workshop as mentioned earlier in the data collection section to help create some of the interview questions (Creswell & Miller, 2000). While I do have a mental health diagnosis, I have not experienced food insecurity, and so I do not have a full grasp on this intersection and experience. By including some participants in creating interview questions, I could ensure that the interviews were more fully able to capture people’s experience and can go in a direction that would better align with participant’s perspectives. Ethical Concerns There were a few ethical concerns to consider. When interviewing people individually, there is always the risk of making people uncomfortable or bringing up something that is harmful to their mental state, especially when specifically touching on mental health topics. I let people know that what they shared was up to them and they didn’t have to say anything they didn’t feel comfortable sharing. I also provided a list of resources for mental health services and food access Food Insecurity and Mental Health 27 for participants (see Appendix H). A few days after the interview I checked in with them to see if they were doing okay. Also, when gathering participants, it was important that they knew what the research was for, and they didn’t feel coerced or bribed into it, which is why I asked for volunteers without financial reward. I had them sign and understand a consent form, and let them know that they could opt out at any time with no consequences. I didn’t have them sign the form until I ensured they understood it, by asking questions about their understanding, and listening to and responding to what questions they had, including clarifying terms and process. Their privacy was protected by giving them and any organizations mentioned unconnected pseudonyms in my reporting, using one that they chose if they decided to do so. In addition, I obtained IRB approval before conducting my research (see Appendice I and J). Data Storage All data was stored on a password protected computer that could only be accessed by me, and any hardcopies were stored in a locked and secure storage container in my home office. Limitations There were some limitations to this study that came up during the process. I did not get as many participants as I was hoping to get. I also wanted to have participants from different genders, sexual orientation, ages, races and other backgrounds, including Native Americans and immigrants, and while I did have some diversity, it wasn’t as much as I had hoped. It was a bit difficult to work with people’s schedules and my own, and so I tried to ensure that I remained patient and flexible. My positionality as a white person who doesn’t struggle too much for food, even though I do have some experience with mental illness, may have meant that some people didn’t want to open up to me as much. Building rapport helped with that, and it was important to Food Insecurity and Mental Health 28 listen to and respond to everyone sincerely. There were some challenges with finding places to interview people who wished to meet in person. We were able to work that out through discussion and patience, however. In addition, speaking about the topics of mental health and food security could have been potentially triggering to some participants, and so I ensured I had a list of resources available for them. Conclusion This chapter has explored how the methods and the research designs in this study helped me answer my research question about how the intersection between food insecurity and a mental health diagnosis affects the lived experience of adults aged 18-64 in Salt Lake County. I have also explored the context of the study, the participants I recruited and how I accessed them. I outlined the efforts I made to ensure the trustworthiness of the study, and I considered the ethical concerns and potential limitations that were relevant to this study and how I solved or worked around these concerns. Food insecurity and mental illness affect many people living in Salt Lake County, and there has previously not been much of an opportunity for them to share their experiences about how their lives have been affected by the intersection of these issues. This study provided an opportunity for them to do that through the methods outlined throughout this chapter. Chapter IV will highlight the experiences of the participants and discuss just how the relationship of these two phenomena affect people’s lives. Food Insecurity and Mental Health 29 Chapter IV Introduction Chapter III explained how I gathered my research, the scope of my study, and the participants I included. I am researching how the intersection of food insecurity and a mental health diagnosis affect the lived experience of adults aged 18-64 in Salt Lake County. After conducting a workshop and one on one interviews, I have compiled the significant findings in this chapter. Themes that have appeared are those touching on childhood experiences, education, housing stability, mental health and food habits, and resources, including food pantries. This chapter will discuss participants’ thoughts and experiences with these subjects and how they relate to food insecurity and mental health. It will also relate back to the literature that does exist on these subjects to show the participants’ experience in greater context. Childhood Experiences Impacting Adulthood Childhood experiences with food and mental health can impact the relationships people have with them as they become adults. The habits built when young can be difficult to overcome once older, especially when mental health is poor (Kinarsky, 2017; Lockwood et al., 2015). Many participants reflected on their mental health and relationships with food when they were growing up. Frank, a Native American adoptee who uses she/her pronouns talked about her experience growing up not learning much about healthy eating, in part impacted by her mother’s mental health: My mom would spend hundreds of dollars on prepackaged nutritional meals, and that stuff is all chemicals, it’s not nutrition at all, but it was a mental health issue for her, a Food Insecurity and Mental Health 30 self-esteem issue where, I want to get healthy, I'm gonna spend a shit ton on Jenny Craig. Yeah, so it's like getting away from mental illness and getting away from those ideas of what they thought was healthy or what they thought was beneficial and finding my own way. Through friends, through experiences. Frank’s statement demonstrated her observations of her mother’s relationship to food, and how mental health affected that. She grew up with certain ideas about food that she later realized she needed to get away from. She continued: What can I make out of the healthy shit I have? Because it's also education. I didn't know about healthy food until my friend taught me last year. And it was like breaking all of the bad education that I learned from my mom that taught me. Frank’s understanding and relationship with food was limited, because she never got any education about healthy eating. Her mother didn’t have a full understanding of healthy eating, and relied on some fad diets of the time, due to her mental health. Frank realized she needed to unlearn this, but couldn’t do so without support. Her friend taught her because she didn’t learn as a child. Her experience shows that her parents influence on her relationship to food did impact her relationship to it into adulthood, and that mental illness may make it difficult to unlearn unhealthy habits and associations without support. Randall, a participant of Mexican descent who mostly grew up in foster care, explained how that impacted his development when it came to food-related responsibilities: My mom taught my sister kind of how to cook eggs. But she didn't teach us how to cook. We grew up with my mom until we were 10 years old. Then, at 10 years old, they threw us into foster care. And from 10 to 18, we grew up in foster homes where they just, like Food Insecurity and Mental Health 31 about 80% of the time, we had whatever we wanted, and a lot of it was just junk food. So, they didn't really teach us at foster homes. Budgeting or shopping or any of that stuff. Randall’s experiences demonstrate some of the gaps in the foster care system, especially when it comes to food education. Randall did not have a stable home life, and those he lived with in the foster care system did not teach him about healthy eating, budgeting, shopping, or cooking. Studies have shown that people that grew up in foster care have less food security and higher rates of mental illness (Kinarsky, 2017; Lockwood et al., 2015) This certainly impacted Randall, as after he left foster care, he had a period of time where he was unhoused as well. This affected his food security and mental health, as will be explored later in this chapter. Tyler, a young man in his 20’s, talked about how his single father’s mental illness impacted their situation while he was growing up, “I think not knowing his mental illness, him not being able to like work with it... It had to like, kind of lead him to impulsive buying and things, like not buying the necessities.” Tyler’s father’s shopping habits were affected by his mental health, and this worsened the financial situation in their home. He later reflected, “I'm assuming the nutrients, like not enough nutrients definitely affected my brain. But in addition, like always being like the poor one in my friend group and everything. I think that affected me too.” From a young age, Tyler recognized his family’s financial state, and that added to his mental stress, on top of not getting the nutrients he would have needed as a child to fully develop a healthy mind and body. Capitalism is one of the root causes of both food insecurity and mental health, and it can lead to poorer mental health and higher rates of food insecurity (James, 2008; Long et al., 2020). In addition, neoliberal policies under capitalism can lead to people feeling shame for needing help and not being able to take care of themselves (Zeira, 2021). This affected Tyler as a child Food Insecurity and Mental Health 32 among his friends, his experience shows how experiencing food insecurity can impact mental health for young children, as it may create a sense of shame or inferiority among peers. Frank talked about how food insecurity and mental illness all compounded together when she said: Even though I was adopted, I can still see the generational mental illness and it's not necessarily oh, I want to provide the best for my kids, like I'm providing for my kids, period, even if it's the shittiest food. Which given that and also growing up poor you only have certain options. So, it's like you don't have nutritious shit, you have what's available at the lowest penny. And so, it's like, they're checking off one box, okay, my kids are fed but like nutritionally, no. Without money to afford much food, and with poor mental health, many people will choose quick, convenient options. Frank observed this growing up with her parents, and it also impacted her views on food later in life. The lack of good nutrition can affect a child’s growth and development (Chilton et al., 2007; Cook et al., 2006). It may lead to health problems that can affect them later in life, and has also been shown to affect mental health (Burke et al., 2016; Cook et al., 2006; Melchior et al., 2012). Tex, a participant in his mid 40’s, was raised in a home with an unstable mother. He reflected, “My birth mom was a bad drug addict and a prostitute. [She would] send in the fiveyear-old and see how much he could come out with.” He grew up using food banks, and said that “We were homeless a lot. The idea of eating out was to go to the shelter.” Tex grew up with a heavy sense of responsibility for his younger siblings, and said that “I was always the parent, for everyone including my mom.” When I asked about how that may have affected his mental Food Insecurity and Mental Health 33 health, he said “I was diagnosed bipolar when I was eight.” It is evident that his childhood food insecurity impacted his mental health, which followed him into adulthood. In addition, Tex learned to cook out of necessity and responsibility, but he did not have time to focus on his mental health. He didn’t receive support for his mental health until he was 25 or 26, according to him. His experience reveals how vital it is to ensure that children and families have access to sufficient safe, healthy and nutritious food, as that can play a large role on their growth and development and mental health. Participants also spoke about how their own and their family’s mental health affected them growing up. Randall did not have a great understanding of mental health as a child. He explained: Yeah, when we grew up, there was no such thing as mental health. It was, you're just acting stupid or whatever. You just need to control yourself and you'll be fine. So mental illness was like, not even real... at least from what I got from my mom. Growing up, it was not real, it’s just, you're just faking it or whatever. Randall’s mental illness went undiagnosed for a long time, which meant he did not have access to resources or help. Children with mental illness may become adults with worse symptoms (Copeland et al., 2015; Harrington, 1990). Those symptoms led to Randall to not understanding his mind or body, and not accessing the help he needed until later in life. Guido shared his experience with mental health as well. He said, “I was always a depressed child. But back then, I didn't know why I was so depressed until I went to the hospital and was diagnosed with depression. I kept trying to harm myself and others.” I asked “When you were younger, did your depression affect your relationship with food at all?” He replied: Food Insecurity and Mental Health 34 Yeah, yes, it did... I stopped eating more. I wasn't getting involved with my family as much as I used to with, ‘round you know, holidays, and that's why the holidays are hard for me sometimes. There's the bad memories too. Yeah, but I try to look for the good memories. The time I did want to help my grandmother cook because like I said I was a picky eater when I was a kid. For Guido, mental illness was something that affected his relationship with his family. It affected his appetite, and created some bad memories. However, he turned to food and cooking as a way to help his mental health, and he had good memories of cooking as a child. Still, he also shared how what he ate brought on social judgment from his peers growing up. He said: When I was little like people used to tease me at lunch. Cause I’d bring my homemade food. Yeah, I never really bought lunch. I’d always bring this Star Wars tin. Star Wars with Count Chocula and yeah, hot chocolate. And they’d always say what are you eating today? That’s gross, your mother, you know. While free and reduced school lunches did exist when Guido was in school, not all kids had access to the program. Many kids’ families could not afford the school lunches, and so the children had to bring in food from home. This led to teasing for Guido, and other similar stories have been shared about how children tend to tease each other over cultural foods and differences in opinions about school lunches (Ludvigsen & Scott, 2009; Salazar, 2007). This teasing may bring about more feelings of shame and inferiority around food for children, which can impact their mental health. The way people grow up and their childhood relationship to food and mental health makes an impact on them once they are adults. What they see from their parents also has an Food Insecurity and Mental Health 35 impact. (Chilton et al., 2007; Cook & Frank, 2008; Poole-Di Salvo et al., 2016). This is important because these childhood experiences played a role in the participants’ experiences as adults. The Education Gap Many participants expressed that they did not get an education about cooking, shopping, budgeting, and healthy eating as children. Due to this, they mentioned it could be difficult to learn and educate themselves as adults while also dealing with mental illness. Bo, a man in his early 30’s, said There were times when the only thing I had was the food bank food or a little bit of money to buy food, but since I felt so discombobulated when I would go to the grocery store, I didn't know what to get. I didn't have healthy habits. So, I would get like junk food or things that weren't very economical. For Bo, going to the grocery store was overwhelming, in part due to his mental illness, and so he got things that may not have been the best for him, or financially worthwhile. He never learned healthy habits, and found it hard to learn them. He had been used to being given food from food banks, so when he could buy things himself, he didn’t know what to get. Mental health can impact people’s food purchasing and eating habits, and people may not feel that they can learn how to improve things for themselves without guidance. Randall touched on this when he said: The Food and Drug Administration should give out some cool free videos on how to cook some of our basic foods, like how to cook oatmeal. Because oatmeal’s cheap, but if Food Insecurity and Mental Health 36 you don't know how to cook it right you would just do it once, you quit and you'll buy pizza every weekend. Randall felt that without understanding how to cook, people may end up eating unhealthy, convenient foods, because it takes less mental effort. This can be detrimental for people because the lack of nutrition can affect people’s mental health (Cook & Frank, 2008; Davison et al., 2017; Gregory & Coleman-Jensen, 2017; Loftus et al., 2020). He suggested that videos can be made to help people learn. While some people could look at videos and help online to learn how to cook and shop, not everyone has access to a computer. In addition, some people may not have the energy or mental capacity to do the research they would need to do. Tyler put it this way, when he stated: It's just having like a skeleton or framework. Of like, how to eat food, cook food, and also how to save money, and like balancing those factors. Doing it on your own is just guesswork. And maybe not everyone has the means for that, mentally. Food insecurity can affect people in different ways, and those who have a mental health diagnosis may find it hard to learn skills needed to feed themselves well and on a budget. Tyler acknowledged that there is a lot to figure out, and some people may not be in a place where they can mentally focus on learning it all. Yet without help and support, many people are guessing about what’s best for them. Tyler expanded on this and pointed out that education was important when he said: Food Insecurity and Mental Health 37 I wish there's like a way to show, how do you keep a budget with your food, and how to like, make recipes and everything. I mean, it's kind of more yeah, they have it, but more education. (...) It’s hard to figure out yourself when you have a mental illness. As Tyler showed, mental illness can affect people living with food insecurity by making it difficult for them to learn skills such as cooking and budgeting. In addition, some places may offer classes, but people may not know where to find these classes, or their mental illness may limit their ability to attend or participate, like if they are dealing with social anxiety. Randall mentioned a few things that he learned that he wished more people could learn as well. He said: I think if people with disabilities were taught, just simply to look at the ingredients on every food. And understand that the first main ingredient on the ingredients section on the back, on the food, is the main ingredient. It's what's in there the most, and then the second ingredient and then so on, with the last being the very least that there is inside that food. And I feel if they were educated in that, they can either make a decision to do it themselves or not. And then how to read the price per item, or the price per pound. That was very hard for me the longest. But if people were taught that, they could save a little bit more money. Randall’s comment also connects to something that a lot of participants in these quotes have touched on: saving money. Money is a major concern for those experiencing food insecurity, and it is also a concern for those with mental illness (Community Action Partnership of Utah, 2022; Huddleston-Casas et al., 2009; Matthews, 2019). This is due in large part to capitalism and the way it affects both food security and mental health. People experiencing both food insecurity and Food Insecurity and Mental Health 38 mental illness may be in a position where they have to choose between paying for therapy, appointments, and medication, or food for themselves. The next section shows what the participants in this study tended to prioritize. Stable Housing As mentioned earlier, capitalism plays a large role in people’s food security and mental health. Participants struggled to improve either without stable housing and living situations. Once they got more stable, they tended to prioritize their mental health first over their food security. They were then able to notice their eating habits and try to make changes and seek out better education. Frank talked about how she was working on improving her situation. “I'm prioritizing. For me, it's, I’d rather take care of my mental health and make sure that that's on track. Rather than the food.” She saw her food insecurity as a lesser issue to her mental health. When mental health is poor, it may be difficult to build new habits and make lifestyle changes. For Frank, she wanted to improve her mind before her food security. This might look like going to appointments and staying on top of medication rather than paying for certain foods and keeping a consistent eating schedule. Randall explained how having stable housing has changed things for him: Well, stability brought me some more of thinking ability, and thinking ability brought me research, with research brought me to ‘am I eating the right things?’ (...) Just, being stable has helped me to accumulate things little by little. And I'm branching out by looking on like YouTube videos. Just barely. A little bit. But I will branch out more. I just need to stay more stable. Food Insecurity and Mental Health 39 When he talked about thinking ability, Randall showed that before he was stable, he wasn’t able to think as much, due to his mental health. Stability enabled him to get out of survival mode, and that has gradually allowed him the time and mental ability to analyze his habits and work toward improving them. Stable housing can play a large role in improving both food insecurity and mental health, (Benston, 2015; Loftus et al., 2020). In his experience, he needed to get his mind in the right spot after obtaining housing before he could start to make more long-term changes in his food habits. Randall also talked about what things were like for him before he was stable. He experienced a period of homelessness and during that time, he did not focus on his mental health or food insecurity, but on survival. He said: I was just like, where am I gonna sleep at or where am I going to go tonight where people won’t bother me, but that's kind of somewhere close to like, a store or somewhere. (...) I would like, I would go to places like McDonald's usually, because they always have seats where you can sit down, sometimes charge your phone, and I would just hang out there for a couple hours and then I would move on to like the next fast-food place. And I would buy like one item and a cup of water. Just to like, hang out there for another two hours. Yeah, until I kept on until the day passed and it was time for me to find a place to sleep outside somewhere. I always feel I gotta buy something. Or else they’ll kick me out or something. Randall was focused on where he was going to sleep, not about his physical or mental health. What he mentioned also touches on how capitalism puts pressure on people to buy and consume something in order to take up space. In order to be inside somewhere for a while, he felt he had to buy something, which can be a common feeling under neoliberal capitalism (Zeira, 2021). Food Insecurity and Mental Health 40 Access to daily necessities such as bathrooms, chargers, and food all came with a cost for Randall, which made him feel nervous and guilty just to occupy space and fulfill his needs, which was not good for his mental health. Even with housing, and some stability, some participants still found it difficult to meet their food needs. Tex talked about his situation, saying: Well right now, I'm living off a lot of junk food and stuff. Because there's not a lot of space for food at my sister's. And yeah, that makes me more tired, more grumpy. The fridge is only so big and it’s four adults there. Right now, the freezer is so full you open it and stuff falls out. The frustration of sharing space with others can affect one’s mental health. For Tex, living in a small space with several adults led to a change in his eating habits, which also affected his mental health. He didn’t feel in control of his diet, and therefore, of his life. This illustrates just how complex the relationship between food insecurity and mental health can be, because there may be other factors at play as well. Frank talked about how space affected her situation as well: For me, it's the space. I need like furniture because I have a lot of appliances, that I know that I can cook, I know I can do a lot, but I need more furniture, more space to do that. And so, I am just doing more healthier, quicker, convenient meals rather than cooking all day and it's just it's because I guess, like, space for me. Food Insecurity and Mental Health 41 Frank didn’t feel she had the room to cook, and so she tended to eat quicker, more convenient meals. Frank lives in housing that is owned by a mental health organization. Many people who live in mental or behavioral health housing do not get much control over their space, and some places do not have full kitchens or cooking appliances. This can limit people’s ability to feed themselves, and it can also affect their mental health in a negative way, (Benston, 2015; Henwood et al., 2014; Wright & Kloos, 2007). Mental Health and Food Habits With or without stability, mental health can still have an impact on people’s food security. Participants talked about how their mental health affects their eating and cooking habits. They tend to eat less, and eat unhealthier food when their mental health is not doing as well. Food can be a way to cover up negative emotions. Symptoms can also affect how people perceive their food. Tyler explained how he finds it hard to cook because of his mental health symptoms. “It's hard finding the time to cook, so I think that that's like the biggest thing. Like ADHD, I don’t know, I just like, bounce around a lot. So, it's like getting myself to discipline myself.” Tyler and many people with mental illness find that their mental health symptoms make it hard for them to care for themselves. His experience shows that it can be isolating to feel in charge of one’s own nourishment and that it is up to them to “discipline” themselves. Supports and accommodations are not always visible or made available to people with mental illness to enable them to work with their symptoms in order to accomplish tasks such as cooking (Arbesman & Logsdon, 2011; Smith et al., 2015). This can be especially difficult if one doesn’t have community to help them as well. Food Insecurity and Mental Health 42 Randall explained how his mental health affected him when he said: Sometimes when I'm feeling somewhat depressed, which is maybe like once a month or once every other week, I eat a little bit more. But because I'm already buying like, healthy cereals and stuff, I just eat an extra cereal bowl of cereal (...) I feel like I need to fill up with something to cover that sadness. So, I just have an extra bowl of cereal. Randall had started to learn and develop healthier shopping and eating habits, but he noticed that his eating habits did get affected when his mental health symptoms were worse. For him, that looked like eating more food as a way to cover up negative emotions. For others, this may look differently. Guido explained how his mental health has affected his eating habits when he said “I went through a period where I wasn't eating. I'm still working on that. I'm getting better.” I asked “Do you know what might be causing that?” He replied “They said it's psychological.” He went on to say “If you're not getting enough nutrition after you eat, it affects your body, and if you're like me, affects my mind and everything, you know.” For Guido, his mental health symptoms lead to him eating less, something his doctors have discussed with him. He has noticed that when he eats less, it has an effect on his body and mind, and it may even worsen his mental health symptoms. He noticed that he feels better when he does eat. He described this when he said: Today, when I went shopping, I had to grab something to eat because I hadn’t eaten all day. I didn't eat lunch. So, I grabbed some hot wings. Just kind of munched on them. I noticed, putting my groceries away at home, I was feeling a little better. Food Insecurity and Mental Health 43 This is likely a familiar experience, but for those experiencing food insecurity and mental illness like Guido, it can be a very common occurrence. Long periods of not eating and worsening symptoms, and then feeling better after eating even something small. Frank also recognized this in herself. She said: If I'm having a bad mental health day, I don't really care about my body as much, so I probably eat shittier food. Versus a good mental health day, I want to take care of my body and you know, drink more water. Mental health affects the food intake and nutrition that people like Frank eat. As shown earlier, nutrition can affect many things in the body. Mental illness can make it difficult for the body to get what it needs, which can make symptoms and health deteriorate in a cyclical way (Cook & Frank, 2008; Davison et al., 2017; Jones, 2017; Pourmotabbed et al., 2020). If this becomes a habit, one’s mental health may become worse over time. In addition, food can trigger this mental health deterioration in another way. Guido talked about how his symptoms can increase around food: Say I’m at the basketball game and walking through the corridor and they've got all these like burger places and pizza places and nacho stands, and I’ll walk by and look. Just look, see what they got. And I see what’s eye-pealing. And sometimes it's not eye-pealing and sometimes you want a Chick fil A, there’s Chick fil A, then you see somebody get one and you're like, nah. That's when my mental health messes with me. My voices just start messing with me. They're telling me yeah; you don't want one of those. It’ll kill you. Heart attack waiting to happen. One of those, you get a coronary for sure. All kinds ofjust all kinds. Food Insecurity and Mental Health 44 For Guido, food can be a trigger into worse mental health symptoms. His experience with food and mental illness is complicated. Food has brought both good and bad memories and associations to him. It both helped and worsened his mental health symptoms in different ways. This dynamic shows that the relationship between food insecurity and mental health is complex. Improving one may not necessarily improve the other, because they can be very intertwined for people, and some things may be out of their control. Lucy, a woman in her early 30’s, talked about how food insecurity can affect people dealing with eating disorders. She said “If you struggle with disordered eating or like an actual eating disorder, food insecurity makes that so much worse. (...) You don't have food for a long time so then you tend to binge once you finally have food.” Lucy showed one way that food insecurity can negatively affect someone’s health, is through disordered eating, which is closely linked with poor mental health symptoms, (Herpertz-Dahlmann et al., 2008; Neumark-Sztainer et al., 2006). Resources and Their Role There are resources available in the community for people who are experiencing food insecurity and who have a mental health diagnosis. Participants talked about how they got access to the food and mental health resources that they now access. I asked Randall about how he got access to mental health resources, and he told his story: When I was homeless, and around the second year, two and a half years. I was sitting at a homeless day center. And somebody, some lady just yelled out, ‘does anybody want to apply for disability? Apply for disability?’ And I kind of talked to the lady because, actually let me roll back. I applied for a reduced bus pass. But the city I was in, Oregon, I Food Insecurity and Mental Health 45 think, they specifically told us we cannot just get a reduced bus pass. We needed to see some type of psychiatrist lady. And I went to go see the psychiatrist lady. And she talked to me for about five to 10 minutes. After those minutes, she gave me a piece of paper and I looked through it, and they said something about like, mental illness and that I had mental illness and I kind of brushed it off. I was like, whatever she's, she's crazy. So, I got my reduced bus pass. But anyways, a few months later, that's when I was at a homeless state center. And I was around like, 24 years old. Yeah, about 24-25 years old. And I said, Yeah, sure. I’ll see if this is for me, is it even possible? I don't know. I've been homeless for two years already. So, I was like, something's got to be, something's going on. So, I don't know what it is. But I just want to find out. Little by little, I figured out I had mental illness. And I was willing to accept that. Randall had grown up among people with the attitude that mental illness wasn’t real, and it wasn’t until he was homeless that he was able to learn about his own mental illness. Accessing those mental health resources led him to access other supports that helped him find greater stability. Unfortunately, as his experience shows, many people slip through the cracks and are not able to get the help they need until later in life. His undiagnosed mental illness likely impacted his living situation and therefore food security, and neither could improved until he finally got help through state and community resources. Bo also got access to other resources through his mental health supports. He explained: If I didn't seek out a therapist, I might not have gotten Medicaid, because they were the ones to suggest it and say hey, these are the resources available to you, and it was almost like through the mental health services that I got access to the other to the food services. I mean, they were accessible. I just didn't know about them. Food Insecurity and Mental Health 46 Bo’s experience is significant because it shows that without support, many people may not be accessing resources that are available to them. Mental illness and food insecurity occur together, so it is important for mental health resources and organizations to be able to learn about and access the other supports available to them so that they can get all the help that they may need. Some resources may not be beneficial to everyone, however. Tex had a negative experience with a local mental health organization. I asked him about how mental health resources may have helped him when it comes to food insecurity and food-related resources or skills. He said: I know, when I was going to Lakeside and stuff, they never taught anything about it. Lakeside Mental Health is just a bad program. A lot of it is just, they have a day program... It’s this stupid hangout place. There's no real classes, no real support. [Organization names have been changed] For Tex, he had a negative experience with this organization, and they did not help him access other resources or skills. His experience reveals that some resources seem to be insufficient to meet the needs of people experiencing food insecurity and mental illness. This became apparent as participants talked about the struggles they faced when navigating the systems in place to help them. They mentioned that there were still barriers in place to receiving help from food pantries and getting food boxes. The help they receive from Social Security and other services did not seem to be sufficient enough to help them meet their needs. The time needed to go to food pantries, cook, and shop was at times overwhelming, especially for those with mental illness. Going to the grocery store could be overstimulating and stressful for some participants. Food Insecurity and Mental Health 47 Tex talked about how grocery shopping used to be a negative experience for him. He said: I do have social anxiety so it’s hard for me to go anywhere sometimes (...) I've gotten somewhat better but still, like in my 20s [it] was hard for me to go to the grocery store. [I would] have panic attacks. Tex’s mental health impacted his ability to shop for himself. This affected his food security and ability to get stable for a while as well. I asked Guido if he had any difficulties when it came to shopping for groceries. He replied: Yeah, like today I was running around trying to find- had to ask where some certain items were. (...) I was running around all over the store and passed it twice. Didn't even know it. It’s stressful because then I feel belit- like stupid. Like stupid. I gotta ask. God, I feel so stupid. Guido and Tex’s experiences show that things that many people take for granted may not be an easy experience for all. There are not really any accommodations for people with mental illness at grocery stores, and so the act of shopping for and then feeding themselves may become a great challenge with negative associations. Besides the difficulties that may come with just going to the grocery store, figuring out food stamps and SNAP benefits can be another challenge for those with mental illness. Tex explained some of the problems he had faced saying “One of the big ones is when you lose your food stamps, you don't turn in the paperwork and you lose your food stamps, or Workforce Food Insecurity and Mental Health 48 Services screws up and you lose your food stamps out of the blue.” He said this can happen because “they don't tell me I need to turn in paperwork.” For those with mental illness, figuring out things like paperwork can be difficult, and it may be hard to keep track of deadlines. Losing food stamps and assistance can be a major setback to many people, and for others, even having them is not sufficient. Guido mentioned that his Social Security was not meeting his needs properly. He said: I realized I needed to get a job. Because I was on Social Security and that just wasn't bringing in enough groceries. I can maybe get a week's worth of groceries and that was it. I had to fend for myself for the rest of the month. So that was some of the necessities I was able to get to access, but not a lot. Like I needed to, you know. And it kind of stunted my growth. Guido noticed that his needs were not being met with Social Security assistance. Luckily for him, he was able to get a job and improve his situation. Some people, however, cannot work because their mental illness may keep them from holding a job (Bilder & Mechanic, 2003; Boardman, 2003; Henry & Lucca, 2004). In cases where people are not able to work or make up for the lack in other ways, their situation may look more like Tex’s, as he shared “Well, you know how like with food stamps and stuff you only get paid once a month? So, the end before you get paid? Lots of times you have no food and that gets very stressful.” The once-a-month payments mean that people, especially those with mental illness who did not get an education on shopping and budgeting, spend most of their money at once, and are left dry for the rest of the month. The money they receive may also not be sufficient for a month’s worth of groceries as well (Hoefer & Curry, Food Insecurity and Mental Health 49 2012; Tarasuk et al., 2014). This will likely be exacerbated soon as SNAP benefits are reduced as COVID-19 protections end. Food Pantries In addition to resources such as mental health organizations and government benefits, food pantries are available for many people who experience food insecurity. However, for those with a mental health diagnosis and others, these supports may not be sufficient either. Danny, a community advocate who has had his own struggles with food insecurity and mental illness commented on some of the gaps: For people that are getting you know, low income, and have to work three jobs, they don’t have time to cook a really good meal so they're just doing like fast food and quick things. And I feel like a lot of times when you get like food boxes and like free things, it's like just raw vegetables and things that you have to have time to cook and you can’t. So, a lot of times those aren't really that beneficial. Food pantries do not always get to control what they are given, and that then trickles down to the people they give to. For Danny, who has a busy schedule, this means that a lot of the food he receives does not work for his lifestyle. Getting food without choosing it was a major sticking point for many people when talking about accessing food pantries. Guido talked about this as well, when he shared: When I was first living on my own, it was tough, I had to go to a food bank. Yeah, it wasn't getting what I liked, what I grew up on. It wasn’t my lifestyle. They're just giving Food Insecurity and Mental Health 50 me like other cultures like rice and beans, but, but I still made the best I could with what I got. Receiving food that was not aligned with his culture was a learning process for Guido. Food pantries may not be all be culturally sensitive as well, like for people from cultures who don’t eat pork or beef. This can make it difficult for them to improve their food security, because their choices become more limited (De Souza, 2019; Remley et al., 2010; Wright et al., 2019). The lack of choice is also detrimental to people’s mental health. Lucy explained how this affected her, stating that “When you get things from like most food banks, especially like during COVID, some of them that you choose, but you don't get to necessarily choose what you're getting. And it's kind of, it almost feels dehumanizing.” For Lucy, the inability to choose had her feeling less than human, and that had an impact on her mental health. This also affected Guido in a similar way. He shared: I just felt lesser than others. You know, unfortunate than others. You know, what other people can afford I couldn't. I had to go to the food bank and just get what I was given. I didn’t have a choice. I couldn’t go, it made me feel belittled (...) It kind of affected my mood and it affected my mental health and I started hearing voices and they're telling me I'm no good. It's hard. For Guido, experiencing food insecurity and needing to access food banks worsened his mental health symptoms. He felt judged by society, and that his worth was less because he needed to access supports. This is unfortunately not an uncommon feeling for people accessing resources and supports (Loftus et al., 2020; Long et al., 2020; Zeira, 2021) Food Insecurity and Mental Health 51 A lack of choice can be difficult for those accessing food pantries, especially those with a mental health diagnosis. There are some food pantries that do offer a choice. However, there are still difficulties people face when accessing these. Tex explained this when he said: There's a place called Mountainside and they let you pick. You go there twice a month. They give you a big box. Oh, [there’s] one over by where my sister lives that lets you pick. They give you like a month supply practically. But unfortunately, you need a car. There’s no way to carry it home. I mean, it's literally a month's supply of food. (...) That's another problem I had, is I used go there with my second wife a lot, and there's no way I could carry it all home. So, I had to leave half of it. Nothing else I could do except carry it. It won’t all fit on the bus. [Name of the organization has been changed] Transportation and accessibility can be difficult for those needing to access food pantries. Tex’s experience is not uncommon. People may be able to get to food pantries, but cannot bring everything home without transportation (Dave et al., 2017; Grier-Welch et al., 2020). Danny also shared similar concerns, talking about some food banks. He said “They won't deliver unless you're homebound. Yeah, but I'm not homebound, but I still don’t have a car to go and pick up five boxes of food from the food bank.” Different food pantries have different rules and requirements, and for Danny, some of them make them difficult for him to utilize. With a home but no transportation, he was limited with his choices when it came to food pantry access. Others may have been limited by their lack of a home as well. There is a large crossover between those experiencing homelessness and mental illness. Randall experienced a period of homelessness, and he did not access food pantries at the time, because he did not have a place to keep the food. He explained “You get a box. And that box will like you know last you a few Food Insecurity and Mental Health 52 days. I don't want to carry all that around me.” For him, his lack of a home meant he had nowhere to store the food he would have gotten. This discouraged him from accessing them, which would have worsened his food insecurity. Conclusion My research question was how does the intersection of food insecurity and a mental health diagnosis affect the lived experience of adults aged 18-64 in Salt Lake County. The themes that emerged through my interviews and a workshop are those of the impact of childhood experiences into adulthood, the education gap, the importance of stable housing, mental health and food habits, and resources and their role. This chapter showed participants’ thoughts and experiences with these subjects and how they related to food insecurity and mental health. It also referenced the literature that exists on these subjects to show the participants’ experience in greater context. From what has been shown, food insecurity and mental health are intertwined in a somewhat cyclical way that affects people in many different ways and aspects of their lives. It is clear from the experiences of the participants that this relationship is complex and multifaceted. Improving food insecurity may not necessarily improve mental health outcomes, and vice versa, but some good can be done through efforts to improve both for people. Much of the problems arising with food insecurity and mental illness are due to the capitalist system that we currently live in. Until that is altered, improving the resources available to people and the knowledge of people in power about this relationship would be a valuable way to bring about positive change. Food Insecurity and Mental Health 53 In the next chapter, I will discuss recommendations that participants brought up, and that have come up through this research process, that can be of help to different organizations that work with those who experience food insecurity and who have a mental health diagnosis. Food Insecurity and Mental Health 54 Chapter V Introduction For my thesis, I researched how the intersection of food insecurity and a mental health diagnosis affect the lived experience of adults aged 18-64 in Salt Lake County. Through a workshop and one-on-one interviews, I have learned from people’s personal experience about what experiencing both of these phenomena simultaneously is like for them. Through this research, it is clear that there are improvements that could be instituted in organizations that serve those living with food insecurity and those living with mental illness. There are also some policies that could be made through the state legislature that could improve things for this group of people. In addition, other interested organizations could participate in improving the state of things in a few ways. There is also still a need for future research on this topic, as the research is still fairly new and mostly done through a quantitative lens. Recommendations There are several different recommendations in this paper. For those working with food insecure adults, that includes food pantries such as the community organization I worked with. For mental health organizations, the recommendations include more training and teaching for clients and staff alike. There are also policy recommendations for the local legislature, as well as general recommendations for any person or organization that may want to get involved in facilitating solutions. Food Insecurity and Mental Health 55 Recommendations for Organizations Working with Food Insecure Adults Many of the participants I interviewed and met with expressed their frustrations with some of the food pantries and other resources that they accessed. Some places don’t give them an option to choose what food they are given, and so they may be left with items that do not go together, that may require knowledge of cooking and access to a kitchen, and that may be expired or close to expiring. In addition, many food pantries don’t have a delivery option, and so people must carry everything they get home with them, which can be difficult without access to reliable transportation, especially if the place gives them a large amount, such as a month’s worth, of food. In meeting with my community partner, a local food pantry, I was informed that they get their food from a larger food bank in the area, and so do not have as much control about what food they can give to their clients. They also said that they didn’t provide recipes with their food because they believed that people could access recipes online. This study has demonstrated that sometimes people do not have the mental bandwidth to find recipes and take the extra steps to look something up, even if they do have reliable access to the internet. Community Organization and Similar Nonprofits. The following are suggestions and recommendations for organizations working with food insecure adults, such as the community partner I was working with. These recommendations have also come up through participant’s responses in this study. One suggestion is to print out recipe cards to put with food given at a food pantry where choice may be limited. This way, people can have ideas about what to make with what they’ve been given, without having to expend their perhaps limited mental energy on figuring it out. Another recommendation is to allow for choice whenever possible. If there is a way to allow people to come in and choose their food products, allow for that. If not, but perhaps Food Insecurity and Mental Health 56 they could make switches, then let that be an option. Allowing for choice and independence in whatever way possible will help clients feel more human and valued, which can improve their mental health. Since some food may be close to expiring or be expired, instead of putting it with the food bags or boxes that people get, those ones could be laid out for people to choose, and the food further from expiring could be put in the bags or boxes given to clients. This could incorporate the element of choice and help people get food that will last them longer overall. Transportation is a more difficult issue. Not everyone has access to a car, but it would be expensive on the food pantry’s end to pay people to deliver food all over. They may also be short of staff as well. Some recommendations may be to have a designated place that people can leave their food for the day and come back and get in multiple trips over the day. However, not everyone would have the time or money to make several trips. Perhaps an organization could look into partnering with a local rideshare company to offer discounted transportation from their location to where the client lives or would like to be dropped off. This may be expensive as well, however. Transportation and access is something that requires more research and work to find a solution that works for more people. Recommendations for Organizations Working with Adults with Mental Illness. The participants in this research all were accessing mental health resources and working with organizations in the community. Many expressed that some organizations did not help them enough to learn important skills such as cooking and shopping. Independent living skills can build confidence and improve one’s mental health (Arbesman & Logsdon, 2011; Benston, 2015; Boardman, 2003; Henwood et al., 2014). These mental health organizations mainly provided some therapy and medical help, and not much else, according to participants, such as Tex. Food Insecurity and Mental Health 57 Some recommendations for these organizations are as follows. It is important to recognize that mental illness and its symptoms can increase with a lack of housing, food, and other forms of stability, as well as the stress of living in our capitalist society. Some people may not have the energy to learn, and they will not have developed good habits due to their childhoods. One recommendation would be to have regular trainings for employees on understanding these circumstances and ensure clients are being treated with empathy and respect. In addition, mental health organizations could offer classes about budgeting, cooking, shopping, and healthy eating for their clients. If possible, these classes could offer real-world practice. The Clubhouse International model has been received by participants well, and many said that it helped them greatly. These recommendations could help those who are working with mental health organization also improve their food security and skills, which may improve their mental health as well. Recommendations for Policy and Interested Organizations In addition to the recommendations for organizations working with food insecure adults and adults with mental illness, there are also other opportunities for interventions and solutions to be made that can help people living in Utah. Policy recommendations could generate a greater scale of benefit within and beyond Salt Lake County. In addition, there are opportunities for other organizations such as grocery stores or community gardens to get involved with creating positive change. Policy Recommendations. Some changes could be made on a legislative level in order to improve things for people living with mental illness and experiencing food insecurity. Community kitchens could be made available, if cities allowed for it, so that those without Food Insecurity and Mental Health 58 access to one could still cook and learn skills and feed themselves. There is a Utah Food Security Task Force that will be based out of Utah State University. This task force was created by the Utah State Government. This task force could have a requirement that its members also have trainings on mental health and how it can impact people’s experiences with food insecurity. In addition, because childhood experiences impact people as they become adults, expanding free school lunch programs and access to nutritious meals for kids could become a focus for the Food Insecurity Task Force. The state could also lower the tax rates on food. A Mental Health and Wellness Task Force could be created, as Utah is the number one state for mental illness. Ensuring that schools have a sufficient number of counselors and mental health professionals is also one recommendation to help the children in the state as well. Interested Organization Recommendations. There are other ways that any interested organization could get involved in order to help improve this situation in Salt Lake City. Grocery stores could create a near expiration section to offer foods for discounted prices. They could also look into creating guides for their stores or other accommodations, as well as training for their employees so that they can help those that get overwhelmed or anxious in their stores due to mental illness. Community gardens could have therapists or wellness speakers come to talk about mental health while people learn gardening skills. Organizations or individuals could offer classes as well, on cooking budgeting, shopping, and healthy eating, especially to those with mental illness, and they could partner with other local mental health organizations to run these classes and bring clients in. Food Insecurity and Mental Health 59 Future Research The research that exists is relatively new and mostly quantitative. This study is qualitative and added to this new field of research, showing the lived experience of people who live with mental illness and food insecurity. There is a rich world of possibility to continue the research of this intersection. Some may want to simply replicate this study in a different city or with a different sample size. Another possibility is to look into how different ethnic and cultural backgrounds may impact things as well. It would be interesting to research how gender and gender identity plays a role, and for those who live with families versus independently. Someone could look into how gardening can impact both food insecurity and mental health. In addition, looking into transportation and access is a way to expand on this research, as mentioned earlier in this chapter. Different types of qualitative research could be done, such as story circles or ethnographies. More research into the way this intersection can affect people in a cyclical way would be beneficial to the field. There are many possibilities to researching this intersection in the future, beyond those that I listed above. This is an important topic, and further research and understanding could benefit many people who experience both food insecurity and mental illness with the positive changes that could come from this understanding. Personal Reflection I have always found it important that people are fed, because it I feel it should be a right for humans to be able to meet their basic needs. I have been lucky to not experience much food insecurity in my own life, but I have dealt with mental illness. My mental illness has made Food Insecurity and Mental Health 60 motivation and basic tasks difficult for me, and mine is not as severe as others may experience. I realized that when one is already struggling to feed oneself, having a mental health diagnosis on top of that could make things much harder. I wanted to do this research to see how these both truly affected each other, and hear about others’ experiences. By doing this research, I was able to learn a lot about other people’s walks of life and how they have navigated life while experiencing both food insecurity and mental illness. The participants have given me a sense of appreciation at their perseverance and ability to work with and overcome the challenges they have faced. Unfortunately, the conditions that brought many of them to experience their food insecurity and mental health symptoms are still prevalent in society, and in some cases getting worse. My hope is that this research, and additional research in the future can shed a greater light on these issues and that more people are able to become food secure and manage their mental health symptoms. Food Insecurity and Mental Health 61 References Afulani, P. A., Coleman-Jensen, A., & Herman, D. (2018). Food insecurity, mental health, and use of mental health services among nonelderly adults in the United States. Journal of Hunger & Environmental Nutrition, 15(1), 29–50. https://doi.org/10.1080/19320248.2018.1537868 America's Health Rankings. (2022). Explore food insecurity in Utah | 2021 health of women and children report. America’s Health Rankings. https://www.americashealthrankings.org/explore/health-of-women-andchildren/measure/food_insecurity_household/state/UT Arbesman, M., & Logsdon, D. W. 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The workshop will be about an hour to two hours, at a conference room at Alliance House or SLCC according to availability, and it will take place at 5 pm on a weeknight. If any of you would be interested in participating in the workshop, please write down your email or phone number so that I can contact you about scheduling the workshop and answer any questions you may have. Thanks so much!” Food Insecurity and Mental Health 73 Appendix B In-Person Recruitment script for interview participation (at local organizations): “Hello, my name is Hollie Saatkamp, I am a student at Westminster College in the Masters of Arts in Community Leadership program. As a part of my thesis, I will be asking for participants to interview with me about their experiences with food insecurity and mental illness. These interviews will be one-on-one, will last about an hour, and will take place in a public location of your choosing. If any of you would be interested in interviewing with me about your experiences, please write down your email or phone number so that I can contact you about scheduling the workshop and answer any questions you may have. Thanks so much!” Food Insecurity and Mental Health 74 Appendix C Email script to send to organizations: Hello, my name is Hollie Saatkamp, I am a student at Westminster College in the Masters of Arts in Community Leadership program. As a part of my thesis, I will be asking for participants to interview with me about their experiences with food insecurity and mental illness. Because your organization works with a population that is likely to experience both food insecurity and mental illness, I would like to interview people who access your organization. Would I be able to schedule a time with you to come and introduce myself and my research project to your clients and potentially recruit people for interviews? Please let me know if you have any questions for me. Thank You! Hollie Saatkamp Food Insecurity and Mental Health 75 Appendix D WorkshopWelcome: “Hello everyone, thank you so much for agreeing to participate in this workshop. The first thing we will do is go over the informed consent forms. Please take some time to read them and ask me any questions you may have. (Allow about 5 minutes) If you are clear on everything, please sign it and hand it to me. And remember that you are free to withdraw at anytime for any reason. Just as a reminder, this workshop’s purpose is to generate questions for an interview guide, and to discuss what may come up during the interview process that would be good for me to be aware of. Before we get jump into that, however, I’d like to start with an icebreaker question. Could we go around and have everyone introduce yourself by what you would like to be called, your pronouns if you feel comfortable doing so, and then tell us what you would hoard if you were a dragon and why? :)” Workshop Question Prompts: Warm-up – What comes to mind first when you think of food security and mental health? What questions could I ask to learn more about people’s experiences with food insecurity? I will ask that verbally while having a large paper or whiteboard with “Food Insecurity Questions” written on it, that I can write potential questions on below. What questions could I ask to learn more about people’s experiences with living with a mental health diagnosis? I will ask that verbally while having a large paper or whiteboard with “Mental Health Related Question” written on it, that I can write potential questions on below. What questions could I ask to learn more about people’s experiences with how food insecurity and mental illness affect each other in their lives? I will ask that verbally while having a large paper or whiteboard with “Food Insecurity and Mental Health Questions” written on it, that I can write potential questions on below. Are there any other related questions I should ask or things that I have missed? I will ask that verbally while having a large paper or whiteboard with “Other Questions” written on it, that I can write potential questions on below. Food Insecurity and Mental Health 76 Appendix E Interview Guide Background Information: Can you tell me about how you grew up and what yours and your family’s relationship to food was? What was the geographical area you grew up in? Rural, urban, suburbs? What about money for your family growing up? How did that affect things? Was mental illness something you or your family dealt with growing up? How did your family make-up affect things for you? Did you learn how to shop and cook growing up? Food Related: What would be your definition of food insecurity? Why do you think people experience food insecurity? Do you think you are educated enough about food and nutrition? What about cooking? How does time play a role in your food habits? How would you say experiencing food insecurity affects your mental health? Mental Health: How would you say mental health affects your food insecurity? Are eating disorders something you’ve had to deal with? If so, what is your experience with that? Does your relationship to food differ when your mental health symptoms increase? Decrease? How might it differ? Are there any difficulties when it comes to shopping and cooking when your mental health is not doing well? Do you feel there is pressure from society to eat a certain way? Does that affect your mental health? Resources: How did you find out about any services you use? For food or mental health? How well do the resources you access address your needs? What should food pantries/other resources know about mental illness? Food Insecurity and Mental Health What should mental health resources know about food insecurity? I let participants know that if they have any questions about definitions, terms, or processes during the interview, that they can ask me at any time. I also allowed for them to take the interview in their own direction based off of the topic. 77 Food Insecurity and Mental Health 78 Appendix F Informed Consent Form: Thank you for agreeing to participate in this study, which will take place from November, 2022 to May, 2023. This form details the purpose of this study, a description of the involvement required and your rights as a participant. The purpose of this study is: • to gain insight into how food insecurity and mental illness affect each other in adults living in Salt Lake County. The benefits of the research will be: • To better understand the intersection of mental health and food insecurity and how they affect each other. • To add to the research on this topic and bring in new insights from a qualitative lens. Potential risks of this study are: • Negative emotions and psychological harm due to discussing potentially traumatic experiences. • Financial costs that come when accessing some community resources. • There will be a list of resources provided for participants to access mental health and food assistance. The methods that will be used to meet this purpose include: • • A workshop with participants One-on-one interviews This consent form is for participation in the workshop. You may also check a box below if you would like to agree to participate in an interview later in the study. You are encouraged to ask questions or raise concerns at any time about the nature of the study or the methods I am using. Please contact me at any time at my email address [e-mail] or at the phone number 513-238-0033. Our discussions will be audio recorded to help me accurately capture your insights in your own words. The tapes will only be heard by me for the purpose of this study. If you feel uncomfortable with the recorder, you may ask that it be turned off at any time. There may also be photos taken and physical documents stored by me. If you wish to not have your photo taken, do not check the box indicating your consent. You also have the right to withdraw from the study at any time. In the event you choose to withdraw from the study all information you provide (including any recordings) will be destroyed and omitted from the thesis. If you have any questions about this study or wish to withdraw, please contact: Investigator: Shelley Erickson Email: [e-mail] Co Investigator: Hollie Saatkamp Email: [e-mail] If you have any questions regarding your rights as a research participant, please contact: Food Insecurity and Mental Health Chair of IRB: Sheryl Steadman 79 Email: [e-mail] Insights gathered by you and other participants will be used in writing a qualitative research report, which will be read by my professor and presented to the MACL 689 Capstone Project Class. Though direct quotes from you may be used in the paper, your name and other identifying information will be kept confidential. By signing this consent form I certify that I ____________________________ (Print Full Name Here) agree to the participate in the workshop. ☐ I agree to have photos of me taken, understanding that they will only be used for the research and will be destroyed after. ☐ I do not agree for photos of me to be taken. ☐ I also agree to participate in a one-on-one interview. (Participant Signature) _______________________________ (Researcher’s Signature) (Date) ________________ (Date) Food Insecurity and Mental Health 80 Appendix G Informed Consent Form: Thank you for agreeing to participate in this study, which will take place from November, 2022 to May, 2023. This form details the purpose of this study, a description of the involvement required and your rights as a participant. The purpose of this study is: • to gain insight into how food insecurity and mental illness affect each other in adults living in Salt Lake County. The benefits of the research will be: • To better understand the intersection of mental health and food insecurity and how they affect each other. • To add to the research on this topic and bring in new insights from a qualitative lens. Potential risks of this study are: • Negative emotions and psychological harm due to discussing potentially traumatic experiences. • Financial costs that come when accessing some community resources. • There will be a list of resources provided for participants to access mental health and food assistance. The methods that will be used to meet this purpose include: • • A workshop with participants One-on-one interviews This consent form is for participation in a one-on-one interview. You are encouraged to ask questions or raise concerns at any time about the nature of the study or the methods I am using. Please contact me at any time at my email address [e-mail] or at the phone number 513-238-0033. Our interview will be audio recorded to help me accurately capture your insights in your own words. The tapes will only be heard by me for the purpose of this study. If you feel uncomfortable with the recorder, you may ask that it be turned off at any time. You also have the right to withdraw from the study at any time. In the event you choose to withdraw from the study all information you provide (including any recordings) will be destroyed and omitted from the thesis. If you have any questions about this study or wish to withdraw, please contact: Investigator: Shelley Erickson Email: [e-mail] Co Investigator: Hollie Saatkamp Email: [e-mail] If you have any questions regarding your rights as a research participant, please contact: Chair of IRB: Sheryl Steadman Email: [e-mail] Food Insecurity and Mental Health 81 Insights gathered by you and other participants will be used in writing a qualitative research report, which will be read by my professor and presented to the MACL 689 Capstone Project Class. Though direct quotes from you may be used in the paper, your name and other identifying information will be kept confidential. By signing this consent form I certify that I ____________________________ (Print Full Name Here) agree to the participate in an interview. (Participant Signature) _______________________________ (Researcher’s Signature) (Date) ________________ (Date) Food Insecurity and Mental Health 82 Appendix H Resources List (This list will grow as time goes on in the study) Food-Related Resources: Utah Food Bank https://www.utahfoodbank.org/ 3150 South 900 West, SLC, UT 84119 [phone] Website has information about Food Pantries all over SLC and Utah MOSAIC Interfaith Ministries - Free http://www.lssu.org/ 4392 South 900 East, SLC, Utah 84124 801-588-0139 Monday – Thursday; 8:00 AM to 3:00 PM [e-mail] Crossroads Urban Center - Free https://www.crossroadsurbancenter.org/ Emergency Food Panty 347 South 400 East, SLC, UT 84111 801-364-7765 Monday – Friday, 9:00 AM – 5:00 PM Crossroads Westside Food Pantry 1358 W Indiana Avenue, SLC, UT, 84104 801-935-4079 Monday, Tuesday, Thursday, Friday 9:00AM - 5:00PM (closed Wednesday) Hildegard’s Food Pantry - Free https://stmarksutah.org/foodpantry 231 E 100 S, SLC, UT 84111 801-328-2303 Tuesday, Wednesday and Friday, from 11:00-1:30 and Thursday from 5:00-6:30. [e-mail] Mental Health Resources: Valley Behavioral Health – Accepts Medicaid and Medicare, and other insurances https://valleycares.com/ [phone] [phone] Alliance House - Free https://www.alliancehouse.org/ 1724 South Main Street Salt Lake City, Utah 84115 801-486-5012 [e-mail] Cornerstone Counseling – Accepts Medicaid and other insurances https://www.voaut.org/cornerstone 447 West Bearcat Drive, SLC, UT 84115 801-355-2846 Hours: Mon - Thurs 8-6 PM /Friday 8-4 PM Salt Lake Behavioral Health – No cost for assessments, accepts Medicare and other insurances https://saltlakebehavioralhealth.com/ 3802 South 700 East, Salt Lake City, UT 84106 801-264-6000 Free Crisis Hotlines: 1-800-273-8255 1-800-784-2433 988 211 SafeUT - Free 833-372-3388 or download the app. Food Insecurity and Mental Health 83 Appendix I Westminster College Institutional Review Board (IRB) For the Protection of Human Subjects Form F IRB Approval Notification Form (applicant fills out the top portion) Principal Investigator: Shelley Erickson Co-Investigators: Hollie Saatkamp Title: Food insecurity and mental health: Understanding their interrelated relationships in adults in Salt Lake City. ✓ Approved Approved with conditions Disapproved Comments: 1. You are required to immediately report any adverse reactions or complications of the project to the Institutional Review Board. 2. There may be no change or addition to the project, or changes of the investigators involved, without prior approval of the Institutional Review Board. 3. If applicable, the attached consent statement has been approved by the IRB. Please copy this document and use for all subjects entered into this study. 11/14/2022 Chairperson, Institutional Review Board IRB Approval Valid: 11/14/2022 to 11/13/2023 Date IORG #: 0004878 FWA #: 00024317 Proposal # 2023011 Food Insecurity and Mental Health 84 Appendix J NIH Certificate – April 2021 Saatkamp_Hollie_approval.pdf APPROVAL of a thesis/project submitted by Author(s): Hollie Saatkamp School Department: School of Education Title of Thesis: Food Insecurity and Mental Health: Understanding their Interrelated Relationship in Adults in Salt Lake County Chairperson, Supervisory Committee: Shelley Erickson Approved on 04-27-2023 Dean of School of Education: Lance Newman Approved on 04-27-2023 Saatkamp_Hollie_permission.pdf STATEMENT OF PERMISSION TO DEPOSIT & DISPLAY THESIS IN THE INSTITUTIONAL REPOSITORY Name of Author: Hollie Saatkamp Additional Authors: | | | School Department: School of Education Title of Thesis: Food Insecurity and Mental Health: Understanding their Interrelated Relationship in Adults in Salt Lake County With permission from the author(s), the staff of the Giovale Library of Westminster College has the right to deposit and display an electronic copy of the above named thesis in its Institutional Repository for educational purposes only. I hereby give my permission to the staff of the Giovale Library of Westminster College to deposit and display as described the above named thesis. I retain ownership rights to my work, including the right to use it in future works such as articles or a book. Submitted by the Author(s) on 4/26/2023 2:39pm The above duplication and deposit rights may be terminated by the author(s) at any time by notifying the Director of the Giovale Library in writing that permission is withdrawn.