Journal of Urban Health

, Volume 89, Issue 6, pp 952–964 | Cite as

The Hunger–Obesity Paradox: Obesity in the Homeless

  • Katherine A. KohEmail author
  • Jessica S. Hoy
  • James J. O’Connell
  • Paul Montgomery


Despite stereotypes of the homeless population as underweight, the literature lacks a rigorous analysis of weight status in homeless adults. The purpose of this study is to present the body mass index (BMI) distribution in a large adult homeless population and to compare this distribution to the non-homeless population in the United States. Demographic, BMI, and socioeconomic variables from patients seen in 2007–2008 were collected from the Boston Health Care for the Homeless Program (BHCHP). This population was compared to non-homeless adults from the National Health and Nutrition Examination Survey (NHANES). Among 5,632 homeless adults, the mean BMI was 28.4 kg/m2 and the prevalence of obesity was 32.3 %. Only 1.6 % of homeless adults were underweight. Compared to mean BMI in NHANES (28.6 kg/m2), the difference was not significant in unadjusted analysis (p = 0.14). Adjusted analyses predicting BMI or likelihood of obesity also showed that the homeless had a weight distribution not statistically different from the general population. Although underweight has been traditionally associated with homelessness, this study suggests that obesity may be the new malnutrition of the homeless in the United States.


Homeless Obesity Body mass index Malnutrition 


  1. 1.
    Kusmer KL. Down and out, on the road: the homeless in American history. New York: Oxford University Press; 2002: 3.Google Scholar
  2. 2.
    Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health. 2010; 100(7): 1326–1333.PubMedCrossRefGoogle Scholar
  3. 3.
    Wright JD, Weber E. Homelessness and health. New York: McGraw-Hill; 1987: 114.Google Scholar
  4. 4.
    Gelberg L, Stein JA, Neumann CG. Determinants of undernutrition among homeless adults. Public Health Rep. 1995; 110(4): 448–454.PubMedGoogle Scholar
  5. 5.
    Rodriguez RM, Fortman J, Chee C, Ng V, Poon D. Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department. Ann Emerg Med. 2009; 53(5): 598–602.PubMedCrossRefGoogle Scholar
  6. 6.
    Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006; 21(1): 71–77.PubMedCrossRefGoogle Scholar
  7. 7.
    Baggett TP, Singer DE, Rao SR, O'Connell JJ, Bharel M, Rigotti NA. Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med. 2011; 26(6): 627–634.PubMedCrossRefGoogle Scholar
  8. 8.
    Luder E, Ceysens-Okada E, Koren-Roth A, Martinez-Weber C. Health and nutrition survey in a group of urban homeless adults. J Am Diet Assoc. 1990; 90(10): 1387–1392.PubMedGoogle Scholar
  9. 9.
    Vredevoe DL, Brecht ML, Shuler P, Woo M. Risk factors for disease in a homeless population. Public Health Nurs. 1992; 9(4): 263–269.PubMedCrossRefGoogle Scholar
  10. 10.
    Luder E, Boey E, Buchalter B, Martinez-Weber C. Assessment of the nutritional status of urban homeless adults. Public Health Rep. 1989; 104(5): 451–457.PubMedGoogle Scholar
  11. 11.
    Drake MA. The nutritional status and dietary adequacy of single homeless women and their children in shelters. Public Health Rep. 1992; 107(3): 312–319.PubMedGoogle Scholar
  12. 12.
    National Health Care for the Homeless. Demographic and Other Client Data. 2003. Available at: Accessed May 15, 2010.
  13. 13.
    O'Connell JJ, Oppenheimer SC, Judge CM, Taube RL, Blanchfield BB, Swain SE, Koh HK. The Boston Health Care for the Homeless Program: a public health framework. Am J Public Health. 2010; 100(8): 1400–1408.PubMedCrossRefGoogle Scholar
  14. 14.
    National Alliance to End Homelessness. Homelessness counts: state by state data on homelessness. Available at: Accessed March 1, 2010.
  15. 15.
    Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010; 303(3): 235–241.PubMedCrossRefGoogle Scholar
  16. 16.
    Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev. 2007; 29: 1–5.PubMedCrossRefGoogle Scholar
  17. 17.
    Wang Y, Beydoun MA. The obesity epidemic in the United States—sex, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007; 29: 6–28.PubMedCrossRefGoogle Scholar
  18. 18.
    Scheier LM. What is the hunger–obesity paradox? J Am Diet Assoc. 2005; 105(6): 83–84. 86.CrossRefGoogle Scholar
  19. 19.
    Caballero B. A nutrition paradox—underweight and obesity in developing countries. N Engl J Med. 2005; 352(15): 1514–1516.PubMedCrossRefGoogle Scholar
  20. 20.
    Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004; 79(1): 6–16.PubMedGoogle Scholar
  21. 21.
    Center on Hunger and Poverty. The Paradox of Hunger and Obesity in America. 2003. Available at: Accessed June 15, 2010.
  22. 22.
    Randers MB, Petersen J, Andersen LJ, Krustrup BR, Hornstrup T, Nielsen JJ, Nordentoft M, Krustrup P. Short-term street soccer improves fitness and cardiovascular health status of homeless men. Eur J Appl Physiol. [Published online ahead of print Sep 29 2011]. Accessed December 4, 2011.
  23. 23.
    Larson NI, Story MT. Food insecurity and weight status among U.S. children and families: a review of the literature. Am J Prev Med. 2011; 40(2): 166–173.PubMedCrossRefGoogle Scholar
  24. 24.
    Breakey WR, Fischer PJ, Kramer M, Nestadt G, Romanoski AJ, Ross A, Royall RM, Stine OC. Health and mental health problems of homeless men and women in Baltimore. JAMA. 1989; 262: 1352–1357.PubMedCrossRefGoogle Scholar
  25. 25.
    Yun S, Zhu BP, Black W, Brownson RC. A comparison of national estimates of obesity prevalence from the behavioral risk factor surveillance system and the National Health and Nutrition Examination Survey. Int J Obes (Lond). 2006; 30(1): 164–170.CrossRefGoogle Scholar
  26. 26.
    Schwarz KB, Garrett B, Hampsey J, Thompson D. High prevalence of overweight and obesity in homeless Baltimore children and their caregivers: a pilot study. MedGenMed. 2007; 9(1): 48.PubMedGoogle Scholar
  27. 27.
    Lewis KK. Overweight and obesity in Massachusetts: epidemic, hype or policy opportunity? Policy Brief: The Massachusetts Health Policy Forum. 2007: 1–7.Google Scholar
  28. 28.
    Office of the Law Revision Counsel, U.S. House of Representatives. The Public Health and Welfare: Definitions. United States Code. 2010 Feb 1. 42 USC Sec. 11360. Available at: Accessed July 30, 2011.

Copyright information

© The New York Academy of Medicine 2012

Authors and Affiliations

  • Katherine A. Koh
    • 1
    • 2
    Email author
  • Jessica S. Hoy
    • 1
  • James J. O’Connell
    • 1
  • Paul Montgomery
    • 3
  1. 1.Harvard Medical SchoolBostonUSA
  2. 2.University of OxfordOxfordUK
  3. 3.The Center for Evidence-Based InterventionUniversity of OxfordOxfordUK

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