The Journal of Nutrition. First published ahead of print December 31, 2014 as doi: 10.3945/jn.114.199414. The Journal of Nutrition Community and International Nutrition
Household Food Insecurity Is Positively Associated with Depression among Low-Income Supplemental Nutrition Assistance Program Participants and Income-Eligible Nonparticipants1–3 Downloaded from jn.nutrition.org at UNIVERSITY OF CALIFORNIA SAN FRANCISCO on June 28, 2016
Cindy W Leung,4* Elissa S Epel,4,5 Walter C Willett,6,7 Eric B Rimm,6,7 and Barbara A Laraia8 4 Center for Health and Community, School of Medicine, and 5Department of Psychiatry, University of California, San Francisco, CA; 6Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA; 7Channing Division of Network Medicine, Department of Medicine, Brigham and WomenÕs Hospital and Harvard Medical School, Boston, MA; and 8School of Public Health, University of California, Berkeley, CA
Abstract Background: Food insecurity is associated with adverse mental health outcomes. Given that federal food assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), aim to alleviate food insecurity, there may be heterogeneity in the association between food insecurity and depression by SNAP participation status. Objective: With the use of data from the 2005–2010 NHANES, we examined the associations between household food security and depression and whether these differed by SNAP participation. Methods: The study population was restricted to 3518 adults with household incomes #130% of the federal poverty level. Food insecurity was assessed with the 18-item US Household Food Security Survey Module; a score of $3 was considered food insecure. Depression was assessed with the 9-item Patient Health Questionnaire and was defined as a score of $10. Multivariate logistic regression models examined the associations between food insecurity and depression, adjusting for sociodemographic and health characteristics. Results: The overall prevalence of depression was 9.3%, ranging from 6.7% among SNAP nonparticipants to 12.8% among SNAP participants. For every depressive symptom, there was a dose-response relation, such that a higher prevalence was observed with worsening food insecurity. After multivariate adjustment, food insecurity was positively associated with depression (P-trend < 0.0001), but SNAP participation modified this relation (P-interaction = 0.03). Among low-income, eligible nonparticipants, very low food security was significantly associated with higher odds of depression (OR: 5.10; 95% CI: 3.09, 8.41). Among SNAP participants, very low food security was also associated with higher odds of depression but at a lower magnitude (OR: 2.21; 95% CI: 1.54, 3.17). Conclusion: The complex relation between food insecurity and mental health may vary on the basis of SNAP participation status. Programmatic efforts to address the risk of depression among their beneficiaries may positively affect the mental health of low-income adults.
Keywords:
J Nutr doi: 10.3945/jn.114.199414.
depression, food insecurity, food stamps, Supplemental Nutrition Assistance Program, National
Health and Nutrition Examination Surveys
Introduction Food insecurity, defined as a lack of consistent access to food for all members of the household, has persisted at high levels in the 1 Supported by the University of California Multicampus Research Program and Initiatives (MRPI) proposal 142691 (CWL). 2 Author disclosures: CW Leung, ES Epel, WC Willett, EB Rimm, and BA Laraia, no conflicts of interest. 3 Supplemental Figure 1 is available from the ‘‘Online Supporting Material’’ link in the online posting of the article and from the same link the in the online table of contents at http://jn.nutrition.org * To whom correspondence should be addressed. E-mail:
[email protected].
United States throughout the past decade (1). In 2013, it was estimated that 14.3% of households, or ;1 in 7 Americans, experienced food insecurity at some point during the past year. Food insecurity is associated with poorer health consequences among adults, including obesity, systemic inflammation, and diabetes, and it is considered a serious public health challenge (2–8). Food insecurity is also associated with adverse mental health outcomes, particularly higher rates of anxiety and depressive symptoms among women (9–16). These associations are not
ã 2015 American Society for Nutrition. Manuscript received August 7, 2014. Initial review completed September 13, 2014. Revision accepted December 2, 2014. doi: 10.3945/jn.114.199414.
Copyright (C) 2014 by the American Society for Nutrition
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Methods Study population. NHANES is an ongoing, multistage cross-sectional survey administered by the National Center for Health Statistics. NHANES is designed to be representative of the civilian, noninstitutionalized US population and collects information on demographics, dietary intake, mental health, and health-related behaviors. This analysis combined data from the 2005–2010 surveys, representing 17,132 adults 20 y and older. The analytic sample was restricted to households whose incomes fell at or below 130% of the federal poverty level (FPL) to include individuals financially eligible to receive SNAP benefits. The analytic sample comprised adults aged 20–65 y with complete data on household food security (missing n = 136), SNAP participation (missing n = 137), and depression (missing n = 714) and excluded pregnant women (n = 185) and NHANES participants with a sampling weight of zero (n = 131). The final sample comprised 3518 adults. Depression. The 9-item Patient Health Questionnaire (PHQ-9) was added to the NHANES mobile examination centers beginning in 2005. 9
Abbreviations used: FPL, federal poverty level; PHQ-9, 9-item Patient Health Questionnaire; SNAP, Supplemental Nutrition Assistance Program.
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The PHQ-9 asks respondents to self-report the frequency of 9 DSM-IV signs for depression over the past 2 wk, ranging from ‘‘little interest or pleasure in doing things’’ to ‘‘thoughts that you would be better off dead or of hurting yourself in some way.’’ Responses were self-reported and scored from 0 (not at all) to 3 (nearly every day). The sum of the responses was calculated, and a score of $10 was used to identify individuals with depression (26). The PHQ-9 is validated as a tool to screen, measure, and diagnose the severity of depression in clinical and general populations (26, 27). Household food security and SNAP participation. Food insecurity was measured with the 18-item US Food Security Survey Module (28). Questions are ordered by severity and attribute-related experiences or behaviors to insufficient resources to buy food over the past 12 mo. A raw score was created by summing the affirmative responses of the 18 questions, with a higher score reflecting higher levels of food insecurity. Categories were then assigned on the basis of guidelines from the USDA: 0, full food security; 1–2, marginal food security; 3–5 (households without children) or 3–7 (households with children), low food security; and 6–10 (households without children) or 8–18 (households with children), very low food security. Food insecurity refers to households reporting low or very low food security. SNAP participation was assessed with the question, ‘‘In the last 12 mo, did you or any members of your household receive Food Stamp benefits?’’ Both food insecurity and SNAP participation are measured at the household level. Study covariates. Sociodemographic covariates included age (in 10-y increments), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other or multiple race/ethnicities), education level (
