Annurev Anthro 101819 110317

Annual Review of Anthropology
Food Insecurity, Nutritional

Inequality, and Maternal–Child
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Health: A Role for Biocultural

Scholarship in Filling
Annu. Rev. Anthropol. 2021.50:75-92. Downloaded from www.annualreviews.org
Knowledge Gaps
Barbara A. Piperata1 and Darna L. Dufour2
1
Department of Anthropology, The Ohio State University, Columbus, Ohio 43210, USA;
email: piperata.1@osu.edu
2
Department of Anthropology, University of Colorado Boulder, Boulder, Colorado 80309, USA;
email: Darna.Dufour@colorado.edu
Annu. Rev. Anthropol. 2021. 50:75–92 Keywords

The Annual Review of Anthropology is online at
diet, nutritional status, coping strategies, food choice, household food
anthro.annualreviews.org
distribution, child feeding
https://doi.org/10.1146/annurev-anthro-101819-
110317 Abstract
Copyright © 2021 by Annual Reviews.
Food insecurity, a significant contributor to nutritional inequality, dispro-
All rights reserved
portionately affects women and children in low- and middle-income coun-
tries. The magnitude of the problem has inspired research on its impacts on
health, especially on nutritional status and, more recently, mental well-being.
Current research is dominated by surveillance-type studies that emphasize
access, one of food security’s four dimensions. Findings are inconclusive re-
garding the association between food insecurity and women and children’s
nutritional status, but some evidence indicates that it is a key contributor to
mental distress in women. To understand these inconsistent findings, we em-
phasize the need for research on the strategies that people use to cope with
inadequate access to food. We contend that biocultural approaches that rec-
ognize the importance of local contexts and the role of broader political-
economic factors in shaping them are well suited for addressing current
knowledge gaps.
75
INTRODUCTION
Food is essential for survival, development, and function and has profound social and cultural sig-
nificance as it functions to establish and maintain social bonds, acts as a signal of social status, and
serves as an important component of one’s identity. The inability to obtain sufficient food, i.e.,
being food insecure, therefore, has far-reaching biological as well social consequences. Unfortu-
nately, the number of food-insecure people in the world is significant and has been increasing
since 2015, reversing the steady downward trend seen earlier this century (FAO et al. 2020). In
2019, an estimated 2 billion people—25% of the global population, or one in four people on the
planet—were food insecure (FAO et al. 2020). Although it is true that the majority (96%) of food-
insecure individuals live in low- and middle-income countries (LMICs) (FAO et al. 2020), food
insecurity is also a reality for citizens of high-income nations. In the United States, for example,
an estimated 14% of children live in food-insecure homes, and estimates for African American
(23%) and Hispanic (17%) children are significantly higher (Coleman-Jensen et al. 2020).
This review was written during the severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) pandemic. In the 12 months since the pandemic was declared in March 2020, it has am-
plified existing food insecurity by disrupting global and local food systems, as well as through the
loss of incomes (HLPE 2020). In Latin America alone, the pandemic almost tripled the number of
people requiring food assistance in the summer of 2020 (United Nations 2020). In fact, the FAO
et al. (2020) estimated that the pandemic would force an additional 83–132 million people into
the ranks of the food insecure and undernourished in 2020.
Food insecurity is highly correlated with poverty and is a key contributor to nutritional inequal-
ity, i.e., disparities in the ability to consume a diet that meets nutritional needs. The increasing
prevalence of food insecurity and related nutritional inequality is not the result of an insufficient
food supply (FAO et al. 2020) but, rather, unequal access to available food resulting from political-
economic systems and related policies that concentrate wealth and power over food production,
distribution, and consumption in the hands of the few (Patel 2012). The impact of the SARS-
CoV-2 pandemic on the inequities in these systems and policies, and thus long-term trends in
food insecurity, remains to be seen.
The sheer magnitude and global pervasiveness of food insecurity have inspired a growing body
of scholarship on the relationship between food insecurity and human health. Dominating this
research are surveillance-type surveys that provide valuable information on the prevalence of food
insecurity but offer inconclusive evidence of the linkages between food insecurity and health (e.g.,
Moradi et al. 2019). Anthropologists, however, are interested in understanding the strategies that
people use to cope with food insecurity and in identifying the proximal pathways that link food
insecurity and health while also recognizing that local dynamics are influenced by the broader
political-economic context (Hadley & Crooks 2012).
We have two goals in writing this review. The first is to provide a critical assessment of
our current state of knowledge regarding the food security–health relationship. The second is
to demonstrate the insights that biocultural approaches used by anthropologists and those in
related disciplines can contribute to our understanding of this relationship. We begin with a
brief overview of the concept of food security, including its four dimensions. We follow this with
a discussion of the tools used to measure food security in the health-oriented literature and a
critical review of our current state of knowledge regarding the association between food security
and health. We limit our review to studies conducted in LMICs, which are home to most of the
world’s food insecure (FAO et al. 2020). Within these countries, we focus on women as well as
children under five years of age, as both have been the target of most research owing to their
greater biological needs (Prentice et al. 1996, Torun et al. 1996) and, often, social vulnerabilities
(Ivers & Cullen 2011, Pelto 1987). In terms of health outcomes, we concentrate on measures of
76 Piperata • Dufour
women’s and children’s nutritional status as these are the focus of the current literature. However,
we also review the newer body of work that has focused on maternal mental health. In the final
section, we turn our attention to current gaps in knowledge and use case studies that emphasize
anthropological methods to demonstrate the potential of a biocultural approach for refining our
understanding of the food security–health relationship.
FOOD SECURITY: A MULTIDIMENSIONAL CONCEPT

The concept of food security, as used today, first appeared in The State of Food and Agriculture
1973, the report where FAO Director General A.H. Boerma called attention to a deterioration
in “world food security” resulting from poor harvests and subsequent depletion of grain stocks
(FAO 1973). The following year, the World Food Conference report defined food security in
terms of availability and stability as “availability at all times of adequate world food supplies of
basic foodstuffs to sustain a steady expansion of food consumption and to offset fluctuations in
production and prices” (FAO 2003, p. 27). In 1983, owing in part to the influence of Amartya
Sen’s work, which drew attention to unequal access to available food ( Jones et al. 2013), the FAO
broadened the definition to include an access component: “ensur[ing] that all people at all times
have both physical and economic access to the basic food they need” (FAO 1983, section 26a). The
1996 Rome Declaration on World Food Security expanded the definition to encompass nutrition
and wellbeing: “Food security exists when all people, at all times, have physical and economic
access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for
an active and healthy life” (FAO 1996). This 1996 definition is the most often cited in the current
literature, but, as Jones et al. (2013) note, there are many others.
As conceptualized by the FAO et al. (2013), and used here, food security has four dimensions:
availability, access, utilization, and stability (Figure 1). The availability dimension is concerned
with food production, food stocks, and trade. The access dimension recognizes that while food may
be available, it may not be physically or economically accessible. The third dimension, utilization,
includes the strategies that people use to cope with inadequate access to food—such as food choice,
preparation, and intrahousehold food distribution—and culminates in biological utilization, the
literal physical and mental embodiment (Krieger 2001) of food in/security. The final dimension,
stability, adds a time element to the other three dimensions and refers to the constancy of food at
global, national, local, and household scales.
Linkages between the dimensions and the hierarchical relationships among availability, access,
and utilization are illustrated in analysis by Block et al. (2004) of the household-level consequences
of the 1997–1998 financial crisis and drought in central Java, Indonesia. The drought resulted in
poor harvests, limiting food availability and driving up prices, which were already rising rapidly
owing to the financial crisis. High food prices constrained household economic access to food.
In the utilization domain, constrained access was reflected in food choices that included fewer
higher-priced animal source foods and dark green leafy vegetables and resulted in a decline in
diet quality. The weight-for-age of young children remained stable, but maternal body weight
declined, leading the authors to suggest that mothers had modified intrahousehold food distri-
bution to buffer children during the crisis. Child micronutrient status deteriorated as assessed by
the increased prevalence of anemia, which the authors speculate was the result of a decline in the
consumption of higher-priced, nutrient-rich foods.
MEASURING FOOD SECURITY: ACCESS AND UTILIZATION

Jones et al. (2013) provide a useful overview of common tools used to measure the four dimen-
sions of food security, including their scale (e.g., national, regional, household) and recall period
www.annualreviews.org • Food Insecurity and Maternal–Child Health 77

AVAILABILITY
ACCESS (ECONOMIC/PHYSICAL)
UTILIZATION
Food choice Food preparation

Culture Meal composition
STABILITY
Economics Cooking
Safety
Dietary diversity
Nutritional value
Biological utilization Food distribution

Reproduction Intrahousehold allocation
Nutritional status Child feeding practices
Nutrient absorption
Mental health
Figure 1
The four dimensions of food security. The relationship between availability, access, and utilization is
hierarchical, and the stability dimension applies to all three. The components of the utilization dimension
represent the more proximal pathways that influence health outcomes across the life span.
(e.g., month, year), as well as specifics on data required and methods used to gather those data
(e.g., aggregated food supply data, focus groups, surveys). While all four dimensions play a role in
influencing health, access and utilization have been the foci of food security–health research.
Research in LMICs investigating the food security–health linkage emphasizes the access di-
mension and relies heavily on a core set of household-level questionnaires designed to measure the
experience of being food insecure. Most common is the Household Food Insecurity Assessment
Scale (HFIAS), a tool that became available in 2007 and was based on the US Household Food
Security Survey Module (HFSSM) developed in the 1990s (Supplemental Table 1). The newest
tool is the FAO’s Food Insecurity Experience Scale (FIES) intended for global use (Cafiero et al.
2018). All these tools include questions that probe respondents’ perceptions of having enough
to eat and the quality/quantity of food in the diet, and they use standard cutoff values to classify
households as food secure or mildly, moderately, or severely food insecure (Coates et al. 2007).
In the utilization dimension, the food-related components—food choice, preparation, and dis-
tribution (Figure 1)—capture the complex human behaviors that shape what people eat. All are
influenced by inadequate access to food. Thus, if the goal is to understand how food insecurity is
embodied, physically and mentally, then studying utilization is essential. Unfortunately, few stan-
dardized tools are available. The tool most often used is the dietary diversity score (DDS), a count
of the different food groups in the diet, e.g., cereals, leafy greens, white roots, and tubers (Kennedy
et al. 2010). Differences in the criteria for categorizing foods into groups, and for determining the
level of measurement (e.g., household, individual), complicate comparisons between studies. For
a helpful review of DDS as an indicator of food security, see Ruel (2003). There are currently no
standardized instruments for measuring the other food-related components of utilization such as
food preparation or intrahousehold distribution, and they remain understudied.
The biological component of the utilization dimension is ultimately reflected in the nutritional
status of individuals, that is, the biological status of individuals resulting from nutrient intake
and the body’s ability to digest, absorb, and utilize those nutrients for maintenance, growth, and
reproduction. Malnutrition is a general term referring to poor nutritional status that encompasses
under- and overnutrition. The tool of choice for assessing nutritional status is anthropometry.
Among children, the most common measure is height-for-age, where the height-for-age z-score
(HAZ) is used to define stunting (HAZ ≤ −2), a reflection of growth faltering over a sustained
period owing to inadequate nutrition and/or repeated infections (WHO 2006). Less common is
the weight-for-height measure, where a low weight-for-height z-score (WHZ ≤ −2) is used to
define wasting, a measure of thinness and generally indicative of recent nutritional deficiencies
(WHO 2006). The nutritional status of adult women is most often measured as body mass index
[BMI; weight (kg)/height (m2 )] and by applying the World Health Organization (WHO 1995)
cutoffs for underweight (BMI <18.5) and overweight/obesity (BMI ≥25).
Micronutrient deficiencies are also indicators of nutritional status but are rarely measured,
even though standardized tools are available. The most frequently assessed micronutrient is iron,
measured via blood hemoglobin. The adequacy of other micronutrients is sometimes inferred
from measures of dietary diversity. In studies exploring the relationship between food security and
mental health, questionnaires assessing mental distress, e.g., anxiety and depression, are commonly
employed.
FOOD SECURITY AND HEALTH

In reviewing the current state of knowledge on food security and the health of children 0–5 years
of age and women of reproductive age, we focused on studies that directly tested the relationship
between food security and health by measuring both food security and specific health outcomes
of interest, namely, measures of nutritional status and maternal mental distress. Details on search
criteria are included in Supplemental Tables 2 and 3.
Child Nutritional Status: Stunting and Wasting

Stunting and wasting are indicative of suboptimal growth and development, and both increase the
risk of morbidity and mortality from infectious diseases such as diarrhea, pneumonia, and measles
(Black et al. 2013). In addition, stunting, especially in children under age 3, is a well-known risk
factor for poor motor and cognitive development (Grantham-McGregor et al. 2007). In the studies
we reviewed, stunting was the most common measure of nutritional status and hence health. All
studies emphasized the access dimension of food security, with the HFIAS being the most common
instrument employed. A few included data on dietary diversity, an indicator of utilization.
National-level studies. The national-level studies reviewed utilized cross-sectional data from
nationally representative surveys to assess the relationship between household food security and
children’s nutritional status (Supplemental Table 2). The findings are mixed; four studies re-
ported a significant relationship, and three did not. Differences in analytical approaches make
direct comparisons difficult. That said, two studies deserve further comment. The studies from

Malawi ( Jones 2015) and Nepal (Dorsey et al. 2018) use robust models that control for confound-
ing variables, and neither identified a significant association between household food security and
children’s nutritional status. Both also included data on dietary diversity and aimed to determine if
dietary diversity moderated the relationship between household food access and child outcomes;
it did not. The study by Habib et al. (2016) was the only one that assessed micronutrient status.
While they reported a significant association between food insecurity and anemia, they did not
include dietary data.
Regional studies. The regional studies (Supplemental Table 2) focused on resource-poor sub-
populations in specific districts known, or suspected, to have a high prevalence of child under-
nutrition. Studies in rural areas of Africa and Asia predominated, and findings are inconsistent.
All reported high levels of household food insecurity, and most reported high levels of stunting.
However, half of the studies found a positive association between food insecurity and stunting; half
did not. The reasons for the disparate results between studies are not apparent, but variation in
local environmental and household contexts is likely responsible, at least in part. For example, the
work of M’Kaibi et al. (2016) with small-scale Kenyan farmers considered two factors significant
to rural agricultural communities: seasonality and district-level differences in agricultural produc-
tivity. They found that household food insecurity was associated with stunting in the preharvest
season (season of scarcity) in both agricultural districts, but not in the postharvest and not when
both seasons were combined. This finding highlights the need for longitudinal studies, especially
in agricultural communities in seasonal environments.
Studies in urban settings in Africa and Asia are scarce. Unlike in rural zones, food produc-
tion in urban settlements is minimal to nonexistent. Hence, access to food is income dependent,
and the poor are at greatest risk of food insecurity. An elegant study by Mutisya et al. (2015)
looked specifically at the potentially modifying effect of household wealth on the relationship be-
tween food security and child stunting in low-income urban households in Kenya. After stratifying
households into wealth tertiles, the authors observed that within each tertile, increasing food in-
security tended to increase the risk of stunting. However, the association was significant only for
the middle wealth tertile. This finding is contrary to the expectation that the relationship would
be strongest in the poorest homes and suggests that the effect of wealth on the food security–
stunting relationship may not be as straightforward as expected. Of the regional studies, only a
few included dietary data, and only the study in India by Chandrasekhar et al. (2017) reported a
significant association between dietary diversity and the likelihood of stunting.
Summary. The current literature does not consistently support the idea that inadequate access
to food at the household level results in child undernutrition. In the 25 studies reviewed, only 13
found a positive relationship. The reasons for these mixed results can be attributed to differences
in study methods and design but are more likely related to the fact that household food security
is only one of the determinants of child nutritional status. For example, nonfood factors such
as the impact of infection on child nutritional status are well known but rarely controlled for
(Black et al. 2013). The mixed findings may also be explained by variation in the actual foods
in the diet, their preparation and distribution among household members, and the nuances of
child feeding practices across studies (i.e., utilization domain). Unfortunately, these data are largely
missing in the current literature. Finally, the assumption that the period of inadequate access to
food corresponds to the timeframe when a child crosses the threshold between nourished and
undernourished may not be warranted, an issue that Galvin (1988) points to in her work among
the Turkana.
Women’s Nutritional Status and Mental Distress
The linkages between household food insecurity and women’s health in resource-poor settings in
LMICs have received little attention compared with the research on children. The two main con-
cerns have been undernutrition in mothers, especially as it relates to reproduction, and maternal
mental distress. A recent concern has been on overweight mothers (BMI ≥25) with stunted chil-
dren, a phenomenon referred to as the dual burden of malnutrition (Wells et al. 2020). It occurs in
a small percentage of households (Dieffenbach & Stein 2012, Jehn & Brewis 2009), particularly in
places experiencing the nutrition transition (Popkin et al. 2012), and is thought to be due, in part,
to the intergenerational cycle of malnutrition, where fetal undernutrition and early childhood
undernutrition place individuals at an increased risk of overweight/obesity in adulthood in these
contexts ( Jehn & Brewis 2009, Wells et al. 2020). In the literature reviewed, we distinguish, where
relevant, income levels within LMICs (i.e., low income, low-middle income, and upper-middle in-
come) to highlight differences in food insecurity and health outcomes (Supplemental Table 3).
Nutritional status. Underweight (BMI <18.5) in women is most often a manifestation of chronic
dietary energy deficiency and is prevalent in LMICs, especially in Africa and Asia (Black et al.
2013). Underweight in women is associated with higher morbidity and mortality, lower levels of
physical activity, and an increased risk of birthing a low-birth-weight infant (Kurpad et al. 2005).
Overweight, by comparison, reflects chronic positive energy balance. It is increasingly prevalent
in upper-middle-income countries experiencing economic growth and dietary transitions and is
associated with the risk of chronic, diet-related diseases (Popkin et al. 2012). BMI cutoffs for
underweight (BMI <18.5) and overweight (BMI ≥25) are the same for all populations, although
a lower cutoff for overweight is sometimes used for Asian populations (WHO Expert Consult.
2004).
The association between food insecurity and women’s BMI is different in low-income in com-
parison with upper-middle-income countries. In rural settings in low-income countries, the preva-
lence of underweight is high (15–40%), and regional studies consistently report that food inse-
curity is associated with underweight (Abdu et al. 2018, Abraham et al. 2015, Bekele et al. 2020,
McDonald et al. 2015). In contrast, in both rural and urban settings in upper-middle-income
countries, the prevalence of underweight tends to be low and the BMI distribution is shifted to
the right. Findings from regional studies in these settings are inconsistent, but positive associa-
tions between food insecurity and higher BMI are common ( Jomaa et al. 2017, Pei et al. 2018).
Similarly, nationally representative studies from the upper-middle-income countries of Mexico
and Brazil have found that mild food insecurity is associated with higher BMIs ( Jones et al. 2017,
Velásquez-Melendez et al. 2011).
The most common indicator of micronutrient deficiencies in women is anemia, a symptom of
iron deficiency, the most prevalent micronutrient deficiency in the world (de Benoist et al. 2008).
Anemia is associated with a number of adverse health consequences, including reduced work ca-
pacity (Haas & Brownlie 2001), poor iron transfer from mothers to infants, and preterm and low-
birth-weight infants (Balarajan et al. 2011). Although anemia has multiple causes (Balarajan et al.
2011), it is often assumed to be the result of inadequate dietary iron intake. Hence, intuitively we
would expect anemia to be associated with food insecurity. Available studies support this assump-
tion for the low-income countries of Bangladesh and Cambodia (Ghose et al. 2016, McDonald
et al. 2015) and the upper-middle-income countries of Mexico and Ecuador ( Jones et al. 2017,
Weigel et al. 2016).
In summary, we found limited data on the association between food insecurity and women’s nu-
tritional status. In low-income countries, food insecurity is associated with underweight, whereas

in upper-middle-income countries it is associated with overweight. In both low- and upper-
middle-income countries, food insecurity is associated with anemia. The limited research available
and the lack of information on dietary intake limit our ability to understand the pathways between
food insecurity and the health outcomes measured.
Mental health. For many reasons, we should expect food insecurity to undermine mental well-
being. Most studies suggest that nonnutritional pathways related to the management of inade-
quate access to food drive this association (Weaver & Hadley 2009). We found the relationship
between food insecurity and mental well-being to be the most consistent of any of the health
outcomes reviewed (Supplemental Table 3). While studies varied geographically, in sample size,
and in women’s age and reproductive status, as well as in the instruments used to measure the two
principal variables, all studies have found food insecurity to be a predictor of mental distress. We
highlight two particularly insightful studies to support this association.
The first is a study by Hadley & Patil (2008) among Sukuma agropastoralists and Pimbwe hor-
ticulturists in Tanzania. The authors demonstrated that a decline in food security across seasons
was associated with a decline in mental well-being, with the Pimbwe disproportionately affected.
Their ethnographic data suggested that group differences may be related to the fact that the lean
season among the Pimbwe, unlike the Sukuma who rely on animals for labor, coincides with in-
creased physical labor. Hadley & Patil (2008) provide a unique longitudinal study that captured
changes in food security over time and directly addressed the question of directionality, i.e., does
food insecurity lead to poor mental health, or does poor mental health lead to food insecurity?
The second study, by Sparling et al. (2020), addressed the relative role of micronutrient defi-
ciencies versus social pathways linking food security and mental health. It is one of the few studies
to include data on food access (HFIAS), dietary diversity, and micronutrient levels (anemia sta-
tus). The authors found that both more severe food insecurity and lower dietary diversity predicted
mental distress among women in rural Bangladesh. A lack of data on women’s micronutrient status
as it relates to dietary diversity is a limitation. Also lacking are data on the social meaning of the
foods women consume, which should be considered when exploring the relative importance of
biological and social pathways linking food security and mental health.
Although the literature offers consensus regarding the food security–mental distress relation-
ship, as with the studies focused on nutritional status, most studies lack contextual data and fail to
investigate how food insecurity undermines mental well-being, which would include the mental
strain of managing inadequate access to food.
THE POTENTIAL OF BIOCULTURAL APPROACHES

The current literature is dominated by studies relating one dimension of food security—access—
with health outcomes. This limited scope is likely due to the development of the HFIAS instru-
ment, which is easy to administer and has been validated for use in many different countries. The
focus on access bypasses the utilization domain (Figure 1), obscuring the strategies that people
use to manage food insecurity and, thus, the proximal pathways by which inadequate access to
food is ultimately embodied. These strategies play out within the household, which, as pointed
out 30 years ago by Gittelsohn (1991), remains a black box. Household-level strategies are, of
course, embedded in broader sociocultural, political-economic, and environmental contexts, and
we suggest that using biocultural approaches to investigate household coping strategies can help
explain how food insecurity affects health.
While the term biocultural remains loosely defined in the anthropological literature (Wiley &
Cullin 2016), a goal of biocultural scholarship has been to trace the pathways by which everyday
lived experiences shape health (Leatherman & Goodman 2020). To do so, scholars advocate for
a deep understanding of the local context to identify and operationalize the cultural variables
relevant to the biological outcome(s) of interest (Dufour 2006, 2009), while also recognizing that
the broader political economy shapes local contexts and influences human agency (Goodman
& Leatherman 1998, Hicks & Leonard 2014, Himmelgreen et al. 2013). Here we highlight
research that delves into the black box to explore how people manage inadequate access to food to
demonstrate how biocultural scholarship can advance understanding of the food security–health
relationship. We organize our discussion around the components of the utilization domain: food
choice, food preparation, and intrahousehold food distribution. These components have a hier-
archical relationship; e.g., food choice precedes preparation and prepared foods are distributed
among household members, which together ultimately determine the nutritional intakes of
individuals. In the final section of this review, we turn to a neglected topic encapsulated within the
utilization domain: physical activity levels. Because a reduction in physical activity is a response
to inadequate dietary intake, with significant implications for people’s ability to manage food
insecurity, we see this topic as essential for future research.
Food Choice
Food choice is most often measured using a DDS, i.e., a count of food groups consumed by a
household or individual (Ruel 2003). In terms of food security, investigators have generally hy-
pothesized that poor access results in a low DDS, which increases the risk of nutrient inadequacy
and hence undernutrition (Arimond & Ruel 2004, Rah et al. 2010). However, as illustrated in this
review, data on food choice are often lacking in the food security–health literature, and, when
they are included, findings are inconclusive (Supplemental Table 2). If a key question is how
inadequate access to food affects food choice and, consequently, people’s health, then DDS is a
blunt instrument because it tells us little about the actual foods consumed and nothing about their
meaning to those who select and consume them. For example, farmers in Lao People’s Demo-
cratic Republic, who rely on glutinous rice as a base for meals, will mix rice with less expensive
and less socially valued cassava roots during periods of seasonal food stress (Van Esterik 2006).
This practice increases the DDS score but obscures the fact that the increased DDS is a coping
strategy.
The longitudinal study by Dufour et al. (1997) among urban Colombian women illustrates the
power of a biocultural approach for understanding food choices under conditions of inadequate
access. The women in the study lived in a state of chronic income uncertainty owing to a reliance
on work in the informal economy, and when money was in short supply, they altered meal com-
position. A common strategy was to substitute eggs for more valued meat and to omit vegetables;
these choices altered their DDS but did not necessarily affect the protein or energy content of
the diet. Another choice was to substitute chicken feet for meat, which did not alter DDS but did
reduce protein intake. For most women, these meal alterations were intermittent, not chronic, and
were not associated with nutritional status. However, ethnographic data on the social meaning of
foods revealed that these strategies invoked feelings of shame.
The mental health consequences of altering food choice in response to inadequate access have
been explored in greater depth by Hadley, Weaver, and colleagues in their work in Brazil and
Ethiopia (Hadley et al. 2016, 2019; Weaver et al. 2019). These studies confirm that within a cul-
tural group, people agree on the prestige value of foods and, when access is inadequate, are forced
to consume less prestigious foods and a lower variety of foods. Piperata et al. (2016, 2020) report
similar findings in Nicaragua. In all three settings, changes in the types and variety of foods un-
dermined mental health owing to their association with poverty and low social status. In some

of these settings, additional pathways linked food choice to poor mental health. For example, in
Ethiopia, food choice alterations precluded households from participating in important social ac-
tivities and, for Nicaraguan mothers, undermined their ability to meet the cultural definition of a
good mother.
Food Preparation
Food preparation methods are also opportunities for managing inadequate access to food. One is
food stretching. Hampshire et al. (2009) describe the stretching of the dietary staple, boule, during
the 2004–2005 food crisis in Niger. Boule, a porridge of millet, water, sugar, and curdled milk, was
stretched by increasing the water-to-millet ratio as food insecurity worsened and simplified by
eliminating the sugar and milk. Piperata et al. (2020) report that Nicaraguan mothers altered the
staple dish, gallo pinto (rice, beans, fried onion), by increasing the ratio of rice to beans when money
was inadequate. The nutritional implications of these strategies for coping with inadequate access
to food would be invisible if dietary data were lacking or limited to a DDS.

That most food preparation requires water argues for biocultural research to investigate the
synergistic effects of food and water insecurity on health (Brewis et al. 2020, Wutich 2020, Wutich
& Brewis 2014). We know, for example, that boiling improves the digestibility of carbohydrate sta-
ples such as roots and grains (Wang & Copeland 2013) and that water is essential for detoxifying
staple crops such as manioc (Dufour 1995), but few data are available to demonstrate how inad-
equate access to water can exacerbate food insecurity via food choice and preparation. A recent
qualitative study indicates that water insecurity impacted infant feeding practices by altering the
foods that mothers chose and delaying the timing of feeding (Schuster et al. 2020). This area
deserves further inquiry.
Intrahousehold Food Distribution and Child Feeding Practices

A third component of the utilization dimension is the distribution of food within the household.
Cultural beliefs and values influence who eats what and how much (Berti 2012, Haddad et al.
1996). A common assumption is that adults, particularly mothers, buffer children from food in-
security, an idea that is grounded in ethnographic research (Coates et al. 2006, Radimer et al.
1992). However, few studies include the quantitative data required to measure it or frame it as a
response to food insecurity (Berti 2012). Gittelsohn and colleagues’ work in Nepal (Gittelsohn
1991, Gittelsohn et al. 1997) illustrates the power of a biocultural approach for understanding
intrahousehold food distribution and its effects on intakes. To generate locally salient hypotheses
regarding potential nutritional inequalities among household members, the authors began with
systematic direct observations of family meals (e.g., serving order, amounts served), which they
then tested with quantitative data on dietary intakes of individuals. They found no differences in
the distribution of carbohydrate staples or dietary energy adequacy among family members. How-
ever, meat and vegetables, foods rich in important micronutrients, were preferentially allocated to
adult men and young children of both genders.
Another example is Leonard’s (1991) study in highland Peru, where he documents adults nutri-
tionally buffering children in the preharvest food scarcity season and its positive association with
children’s nutritional status. Piperata et al. (2013), in their study of mother–child pairs in rural
Amazonian communities, demonstrate that children’s energy and protein intakes were more ad-
equate (intake/need) than those of their mothers and that younger children were buffered more
than older children. The authors also show that buffering was most evident when households had
some food but not enough to meet the needs of all members. In contrast, when food stocks were
extremely low (severe food insecurity) or adequate (food secure), buffering was less pronounced or
absent. In both studies, ethnographic data, including detailed field observations, help explain the
quantitative findings. In Peru, seasonal nutritional buffering allowed children to maintain activity
levels necessary to accomplish important subsistence chores year-round. In the Amazon, buffering
was related to maternal perceptions of child vulnerability and the inability to reason with young
children when food supplies were low, which led mothers to acquiesce to children’s demands.
These biocultural studies illustrate how quantitative data on individual intakes can reveal how
food insecurity is differentially experienced by members of the same household and can explain
how adult perceptions of household food access might not align with children’s nutritional status.
Although intrahousehold food distribution is clearly important, it is also worth noting that in
many parts of the world, food exchange between households is likely a critical strategy for coping.
Some of the most informative work on this topic has been conducted among First Nations people
living in the Canadian Arctic (e.g., Collings et al. 2016, Harder & Wenzel 2012). As made clear in
a recent review (Nosratabadi et al. 2020), this strategy deserves more attention in the food security
literature.
The coping strategies discussed above shape the intakes of household members. In terms of
children, the period of complementary feeding (6–24 months) is critical because growth and devel-
opment are most rapid and the decline in HAZ leading to stunting progresses most precipitously
during this time (Victora et al. 2010). It is also a critical window for the development of the gut mi-
crobiome, which is shaped in large part by diet (Dominguez-Bello et al. 2011). The WHO (2003)
and extensive work by Pelto and colleagues (e.g., Pelto et al. 2013) assert that complementary
feeding is as much about the foods (e.g., types, special preparation) as it is the context of feeding
and care (e.g., timing of initiation, frequency, and assistance with eating). Furthermore, Panter-
Brick (1992) reminds us that the context of feeding is shaped by mothers’ work patterns and the
broader household economy. Thus, a critical question is how inadequate access to food influences
complementary feeding and hence children’s health.
While the influence of inadequate food access on feeding and health is addressed in the food
security–health literature (e.g., Janmohamed et al. 2020, Osei et al. 2010, Saha et al. 2008), data are
limited to DDS and, in some cases, minimal meal frequency, which are crude measures of intake.
In contrast, biocultural studies reveal variation in the quality of the diet among populations and
offer insights into how the local context shapes feeding practices in food-insecure environments
(e.g., Dettwyler 1986, Gray 1996, Panter-Brick 1992). For example, the complementary diet of
Ngisonyoka pastoralists in Kenya (Gray 1996), which includes milk and butterfat, would have
a low DDS but is likely more nutrient dense than that of children in Mali and Nepal, whose
diets include a greater variety of foods but are dominated by bulky staples (i.e., foods with low
nutrient density) (Dettwyler 1986, Panter-Brick 1992). These detailed biocultural studies also
reveal substantial variation in feeding practices. Ngisonyoka infants are fed frequently and force-
feeding was observed. In Mali and Nepal, feeding was infrequent (3–4 times per day), and, in Mali,
young children were expected to initiate their own feeding (Dettwyler 1986).
Across contexts, maternal work demands influenced complementary food choices and feeding
frequencies. For example, Panter-Brick (1992) attributes better intakes among low-caste Kami
(blacksmith) children compared with higher-caste Tamang (agropastoral) children to differences
in seasonal maternal work patterns. Among the Tamang, younger children ate more frequently
and had higher intakes during the monsoon season, owing in part to consuming snacks while
accompanying their mothers in agricultural work. Older children, left behind during the day, had
poorer intakes. Future biocultural research on this topic could adopt many of the methods used
in these studies, as well as the ethnographic tool developed by Pelto et al. (2013). Considering the
central role of women in provisioning children, studies should also consider how maternal health

and the time and energy demands involved in coping with food insecurity influence child feeding
practices.
Biological Utilization
The biological component of the utilization domain captures the outcomes of inadequate access
to food at the individual level. Nutritional status has been the primary outcome measure of in-
adequate dietary intakes, although other biological measures could also be used. These include
intestinal absorption, state of the microbiome, infant birth weight, and physical activity. The last
measure, physical activity, includes reductions in total energy expenditure that are physiologically
driven and hence are not under conscious control, as well changes in behavior that alter the types
of activities undertaken. These activity changes are strategies for coping with inadequate dietary
energy intake, which biocultural approaches can help illuminate.
Experiments have demonstrated the effect of changes in dietary energy intake on physical ac-
tivity. The most known is the Minnesota experiment in which adult males spent more time at
rest as energy intake was systematically reduced (Keys et al. 1950). In contrast, supplementation
studies among marginally nourished Indonesian and Mexican children showed that higher energy
intakes resulted in increased physical activity (Chavez et al. 1995, Jahari et al. 2000).
Studies of objectively measured physical activity in free-living populations suffering energy
stress are scarce. We focus here on studies of adult women because of their central role in house-
hold food procurement, preparation, and provisioning, all of which require physical work. For
example, Ferro-Luzzi et al. (1992) report that underweight Ethiopian women devoted more time
to rest and less to work activities than did women with normal BMIs. The study does not clarify,
however, the significance of these findings in terms of women’s strategies for coping with food
insecurity.
In comparison, Jenike’s (1996) study of Lese agriculturalists in Zaire provides insights into the
changes in physical activities that women used to manage food insecurity. He found that women
increased the time devoted to some work activities, specifically those with immediate payoffs in
terms of food, and the water and fuel needed to prepare it, but reduced time in activities that
were less essential to immediate survival. This observation is a good example of how changes in
physical activity may interact with other aspects of food security such as food preparation and the
provisioning of children.
In sum, making changes to physical activity is one of the ways that individuals accommodate
inadequate access to food. Biocultural studies can provide insight into how these accommodations
affect women’s capacity to manage household food insecurity.
CONCLUSION
Food security is a complex, multidimensional concept that is challenging to operationalize. As a
result, research on the topic typically focuses on a single dimension. In the food security–health
literature, the focus has been on the access dimension. This review has revealed an inconsistent
relationship between food access and health outcomes. The strongest relationship is between food
access and women’s mental health, which is logical considering that food security questionnaires
measure women’s perceptions of their ability to successfully procure food and provision those in
their care. The relationship between food access and the nutritional status of women and children,
however, is less direct, which may explain the inconsistent findings. The proximal pathways linking
access to actual dietary intakes, which include food choice, preparation, and intrahousehold distri-
bution, are shaped by the local context and, therefore, are expected to vary. All these pathways fall
under the utilization domain and remain underexplored. We maintain that biocultural approaches
are well suited to illuminate these pathways and thus to clarify how food insecurity is ultimately
embodied. Anthropologists are theoretically and methodologically well equipped to conduct this
needed research. Finally, as the number of food-insecure people continues to rise, anthropologists
working in affected communities worldwide are witness to the impacts on individuals and house-
holds and are thus positioned to draw attention to the inequities faced by those whose bodies get
counted but whose voices remain largely unheard and for whom sustained relief remains elusive.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.

ACKNOWLEDGMENTS
We thank Kayla Porco for help with the literature search and Gretel Pelto for key references on
complementary feeding.
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Annual Review of
Anthropology
Contents Volume 50, 2021
Perspectives
Doing Fieldwork Without Knowing It

Renato Rosaldo p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Archaeology
Transgressing Time: Archaeological Evidence in/of the Anthropocene
Matt Edgeworth p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p93
Rethinking the Landscape: Emerging Approaches to Archaeological
Remote Sensing
Jesse Casana p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 167
Peirce and Archaeology: Recent Approaches
Joanne P. Baron p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 187
Recent Research on the Archaeology of War and Violence
Andrew K. Scherer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 403
Biological Anthropology
Food Insecurity, Nutritional Inequality, and Maternal–Child Health:
A Role for Biocultural Scholarship in Filling Knowledge Gaps
Barbara A. Piperata and Darna L. Dufour p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p75
The Earliest South African Hominids
Ronald J. Clarke, Travis Rayne Pickering, Jason L. Heaton, and Kathleen Kuman p p p p p 125
Human Evolution in Asia: Taking Stock and Looking Forward
Sang-Hee Lee and Autumn Hudock p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 145
The Human Sleep Paradox: The Unexpected Sleeping Habits of
Homo sapiens
David R. Samson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 259
Archaeoprimatology: The Longue Durée Interface Between Humans
and Nonhuman Primates
Bernardo Urbani p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 379
vii
The Evolution of Human Infancy: Why It Helps to Be Helpless

Karen R. Rosenberg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 423
Anthropology of Language and Communicative Practices

Music, Language, Aurality: Latin American and Caribbean
Resoundings
Amanda Minks and Ana María Ochoa Gautier p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p23
Touch and Social Interaction
Asta Cekaite and Marjorie H. Goodwin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 203
Conversation and Culture

Simeon Floyd p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 219
Language and the Military: Necropolitical Legitimation, Embodied

Semiotics, and Ineffable Suffering
Janet McIntosh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 241
Postcolonial Semiotics
Angela Reyes p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 291
Constructed Languages
Christine Schreyer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 327
Pidgins and Creoles: Debates and Issues
Christine Jourdan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 363
Sociocultural Anthropology
Slippage: An Anthropology of Shamanism
Bruce Grant p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 9
Syndemics: A Cross-Disciplinary Approach to Complex Epidemic
Events Like COVID-19
Merrill Singer, Nicola Bulled, Bayla Ostrach, and Shir Lerman Ginzburg p p p p p p p p p p p p p p p p41
Desiring Bureaucracy
Tess Lea p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p59
Political Theology/Theopolitics: The Thresholds and Vulnerabilities
of Sovereignty
Carlota McAllister and Valentina Napolitano p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 109
Intersectional Ecologies: Reimagining Anthropology and Environment
Sarah E. Vaughn, Bridget Guarasci, and Amelia Moore p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 275
The Political Economy of Attention
Morten Axel Pedersen, Kristoffer Albris, and Nick Seaver p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 309
viii Contents
Feminism in the House of Anthropology

Lilith Mahmud p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345
Indexes
Cumulative Index of Contributing Authors, Volumes 41–50 p p p p p p p p p p p p p p p p p p p p p p p p p p p 441

Cumulative Index of Article Titles, Volumes 41–50 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 445
Errata
An online log of corrections to Annual Review of Anthropology articles may be found at

http://www.annualreviews.org/errata/anthro
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Annual Review of Anthropology

Food Insecurity, Nutritional

Health: A Role for Biocultural

Annu. Rev. Anthropol. 2021. 50:75–92 Keywords

FOOD SECURITY: A MULTIDIMENSIONAL CONCEPT

MEASURING FOOD SECURITY: ACCESS AND UTILIZATION

www.annualreviews.org • Food Insecurity and Maternal–Child Health 77

Food choice Food preparation

Biological utilization Food distribution

FOOD SECURITY AND HEALTH

Child Nutritional Status: Stunting and Wasting

www.annualreviews.org • Food Insecurity and Maternal–Child Health 79

www.annualreviews.org • Food Insecurity and Maternal–Child Health 81

THE POTENTIAL OF BIOCULTURAL APPROACHES

insecurity, we see this topic as essential for future research.

www.annualreviews.org • Food Insecurity and Maternal–Child Health 83

to food would be invisible if dietary data were lacking or limited to a DDS.

Intrahousehold Food Distribution and Child Feeding Practices

www.annualreviews.org • Food Insecurity and Maternal–Child Health 85

might be perceived as affecting the objectivity of this review.

www.annualreviews.org • Food Insecurity and Maternal–Child Health 87

data 2011–2012. PLOS ONE 11(5):e0155051

www.annualreviews.org • Food Insecurity and Maternal–Child Health 89

www.annualreviews.org • Food Insecurity and Maternal–Child Health 91

Contents Volume 50, 2021

Doing Fieldwork Without Knowing It

The Evolution of Human Infancy: Why It Helps to Be Helpless

Anthropology of Language and Communicative Practices

Conversation and Culture

Language and the Military: Necropolitical Legitimation, Embodied

Feminism in the House of Anthropology

Cumulative Index of Contributing Authors, Volumes 41–50 p p p p p p p p p p p p p p p p p p p p p p p p p p p 441

An online log of corrections to Annual Review of Anthropology articles may be found at

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