key: cord-0950618-my133k74 authors: Ahuja, Manik; Sathiyaseelan, Thiveya; Wani, Rajvi J.; Fernandopulle, Praveen title: Obesity, food insecurity, and depression among females date: 2020-09-17 journal: Arch Public Health DOI: 10.1186/s13690-020-00463-6 sha: 4f1cb455c49fa8f6ac3b24939efcb9c27e29a5bd doc_id: 950618 cord_uid: my133k74 BACKGROUND: Nutritional psychiatry is an emerging field of research and it is currently exploring the impact of nutrition and obesity on brain function and mental illness. Prior studies links between obesity, nutrition and depression among women. However, less is known how food insecurity may moderate that relationship. METHODS: Data were employed from the Collaborative Psychiatric Epidemiology Surveys (CPES), 2001–2003. Two logistic regression models were Logistic regression was used to determine the association between obesity, gender, food insecurity, and past year Major Depressive Disorder (MDD). We then stratified by gender, and tested the association between obesity and past year MDD, and if food insecurity moderated the association. RESULTS: Obesity was associated with an increased risk for past year Major Depressive Disorder (MDD) among females (AOR = 1.35; 95% CI 1.17–1.55) and was not associated among males (AOR = 1.07; 95% CI, 0.86–1.32). Women who reported that reported both obesity and food insecurity reported higher odds of past year MDD episode (AOR = 3.16; 95% CI, 2.36–4.21, than women who did not report food insecurity (AOR = 1.08; 95% CI, 1.02–1.38). CONCLUSION: With rising rates of mental health problems, females should be closely monitored to understand how poor diets, food insecurity, and obesity play a role in mental health outcomes. It is recommended that clinicians and treatment providers consider the patient’s diet and access to nutritious foods when conducting their assessment. Nutritional psychiatry is an emerging field of research and it is currently exploring the impact of nutrition on brain function and mental illness. Nutrition has been vastly overlooked as a contributor to mental health problems [1] . The prevalence of obesity in the adult population is a global health challenge [2] , and is associated with adverse outcomes including chronic disease and mortality. Obesity is defined as Body Mass Index (BMI) of 30 or more, and known to highly prevalent among individuals who consume inexpensive, caloriedense foods and engage in lower levels of physical activity [3] [4] [5] [6] . Several studies have found associations between obesity and mental health problems [7] [8] [9] . Simon and his colleagues (2006) concluded that obesity is associated with approximately 25% increase in odds of mood and anxiety disorders [10] . A large cross-sectional study conducted by McMartin et al. [11] reported consistent inverse relationships between fruit and vegetable intake and major depressive disorder (MDD) [12] . The associations between dietary patterns and depression remains significant and strong epidemiological evidence suggests that poor diet can have a negative effect on mental health disorders. Implementing changes to the diet is gaining popularity in life sciences as it provides structural, functional, and biochemical roles of macro-and micronutrients in mental well-being [13] . Studies have revealed positive associations between obesity and depressive symptoms among women and either negative or no associations among men [8, 10, 14, 15] . Studies show there are significant gender disparities, as women are nearly twice as likely as men to suffer from mental illness [16, 17] . According to data from the National Health and Nutrition Examination Survey (NHANES), the rate of obesity for adult women is over 40% in the U.S. [18] , and is expected to continue to rise over the next 30 years [19] , placing even more women at risk. In addition, obesity and depression both carry an increased risk for other diseases such as cardiovascular disease [20] . There are still more gaps to fill when it comes to understanding obesity and mental health among women. The dietary intake in the female population in conjunction with the biochemical measurements of diet can aid in distinguishing the cause of MDD, whether it is caused by reduced intake, altered metabolism or enzymatic function [21] . For many there is limited access to nutritious food as it can be costly, therefore, individuals often consume poor diets. As food insecurity impacts 1 in 7 people in the United States and it can also be a contributor to the rising obesity rate [22] . Prior studies have found associations between food insecurity and poor mental health among females [23, 24] . To date, no studies have investigated how food insecurity moderates the effects of obesity and depression particularly among women. To current study addresses these gaps using a nationally representative, ethnically diverse sample from the United States. The current study used secondary data from the National Co-Morbidity Survey Replication (NCS-R), National Survey of American Life (NSAL), and National Latino and Asian American Study (NLAAS), as these were presented in the Collaborative Psychiatric Epidemiology Surveys (CPES), 2001-2003. CPES was designed to collect representative samples of majority and minority adult populations in the U.S., with oversampling of race/ ethnic minorities [25] . The study employed probability sampling techniques to identify 252 geographic areas across the U.S., where adults were selected from each eligible household [25] . For specific study design see [26] [27] [28] . The final sample included 20,013 respondents (aged > = 18), who self-identified as female (n = 11,463; 57.3%), male (n = 8550; 42.7%), non-Hispanic white (n = 7.587; 37.9%), black (n = 6.281; 31.1%), Latino (n = 3.620; 18.1%), and Asian (n = 2.284; 11.4%). The CPES data were obtained from the Inter-university Consortium for Political and Social Research (Ann Arbor, MI). All procedures that involved human subjects, including consent from all participants 18 years of age and older, were approved by the Institutional Review Board at the University of Michigan [29] . The current study used data from the National Co-Morbidity Survey Replication (NCS-R), National Survey of American Life (NSAL), and National Latino and Asian American Study (NLAAS), as these were presented in the Collaborative Psychiatric Epidemiology Surveys (CPES), 2001-2003. The final sample included 20,013 respondents (with complete information on all variables in the analyses) who self-identified as female (n = 11,463; 57.3%) and male (n = 8550; 42.7%), non-Hispanic white (n = 7.587; 37.9%), Black (n = 6.281; 31.1%), Latino (n = 3.620; 18.1%), and Asian (n = 2.284; 11.4%). The primary outcome of interest in the current study is report of past year Major Depressive Disorder (MDD) episode. Past year episode of MDD was assessed based on lifetime report of MDD, as measured by the diagnostic interview of World Mental Health Initiative version of the composite International Diagnostic Interviews, which is based on DSM-IV criteria (APA [30] ). Obesity was coded binary, with participants who reported a BMI level ≥ 30 kg/meter squared as 1, and BMI level < 30 as 0. BMI was determined participant from self-reports of height and weight. This coding of this measure is consistent with prior studies on obesity and depression (Gavin et al. [31] ). Respondents were classified as either obese (BMI ≥30 kg/meter squared [kg/m 2 ]) or non-obese (BMI 18.5-29.9 kg/m 2 ) both for consistency with previous research and a lack of evidence suggesting that overweight status is statistically associated with depression. Food insecurity was based on the following question 'In past yr-how often not enough money to buy food?', and coded binary with 1 representing any report of food insecurity in the past year. This variable 'food insecurity' was selected based on its definition of having inconsistent access to adequate food because of limited financial and other resources [32] , and has been applied in prior studies [33] [34] [35] . We adjusted for income, education, age, and race. Income was coded as 1 representing low income of <$30, 000, and 0 representing income > = $30,000. Education was coded as =30, overall (n = 1543; 7.7%) participants reported past year MDD, and (n = 1942; 9.7%) reported past year food insecurity. In Table 2 , we examined the association between obesity and 12-month MDD. In our fully adjusted model examining the main effects, obesity (AOR = 1.26; 95% CI 1.12-1.41), male gender (AOR = 0.57; 95% CI 0.51-0.64), and food insecurity (AOR = 3.29; 95% CI 2.82-3.83) were associated with past year MDD. We tested for interactions for gender and obesity, and found that females who reported obesity (AOR = 1.35; 95% CI 1.17-1.55) reported higher odds of past year MDD than males (AOR = 1.07; 95% CI, 0.86-1.32). In Table 3 , we used logistic regression to examine the effect of food insecurity as a moderating variable with obesity and MDD among females. We found that obese participants that reported food insecurity (AOR = 3.16; 95% CI, 2.36-4.21) had significant higher odds than participants who did not report food insecurity (AOR = 1.08; 95% CI, 1.02-1.38). This study reveals the association between obesity and depression and the moderating role of food insecurity that exists among women using a nationally representative sample from the United States. The study found an association between obesity and past year episode of MDD among women, but not men, which is consistent with prior research [8, 36, 37] . Depression may be associated with obesity due to factors such as negative body image, and low self-esteem [38, 39] , which is more prevalent among women [40] . There are many potential factors that contribute to higher rates of depression among women, and both obesity and food insecurity are important factors to consider. We looked at differences within women and found that women with high BMI levels (> = 30) and who reported food insecurity were at a significantly higher risk for depression than women who did not report food insecurity. Food insecurity is an important factor of health and nutrition outcomes [41] . Food insecurity may refer to individuals who are micronutrient deficient, or undernourished [42] . Food insecurity is also the uncertainty of acquiring nutritious food in a safe and socially acceptable manner Food insecurity has been found to be associated with obesity and unhealthy dietary patterns, both of which have negative health outcomes [43] . Given the increasing number of female-headed households, and the lower wages of women compared to men, women need special consideration in discussions of food insecurity and their effect on health [44] . Food insecurity is known to disproportionally affect women. A crosssectional study using data from the nationally representative Continuing Survey of Food Intakes by Individuals, found that food insecurity was associated to overweight status in women in the United States, but not men [45] . In another study using data from a nationally representative sample, Hanson et al. [43] found that low food security was associated with being obese among women [46] . The findings of the study reveal that there are severe implications associated with food insecurity, particularly with mental health among women. Targeted interventions to increase awareness about safe, nutritious foods among women should be considered. Nutrition education plays an important role in food security [43] . For example, one study found that nutrition education was shown to improve the food security of low-income individuals who participated in the Expanded Food and Nutrition Education Programs in two states [46] . Food-insecure women have lower intakes of healthy foods such as fruits and vegetables and other nutrients compared with food-secure women [47, 48] , It is important that women be given special consideration, and policy measures to improve access to safe, nutritious foods for women should be considered. These include public assistance programs, and other subsidies offered to women, which may prevent or reduce their risk of feeling food insecure. Given the current economic state, and the COVID-19 pandemic, women as well as children could feel the majority of the negative effects of food insecurity [49] . The results from this study should not be interpreted without considering the limitations. Firstly, the causeeffect relationships cannot be established in this study, given cross-sectional data were used. Second, was that surveys from non-English speaking Latinos and Asians were not collected in the NCS-R data. Third, depression diagnosis was based on DSM-IV criteria, as DSM-5 is currently implemented. There have been changes to diagnostic criteria, including the dropping of the Global Assessment of Functioning (GAF) scale, which was used in DSM-IV. This may pose a challenge among clinicians, who are using DSM-5 diagnosis to treat depression. However, the changes from DSM-IV to DSM-5 are not likely to significantly impact prevalence rates, and not affect the characteristics of diagnoses [50] . Fourth, BMI was calculated using self-reported height and weight by each participant. Prior studies have found that it is common for individuals to inaccurately report their height and weight, that include both over and underreporting measurements [51] . There are known discrepancies in these measurements when they are taken by a trained professional [51] . The impact of nutrition and obesity on mental health and overall fitness is being reported and documented. To fill the gap in the current knowledge and literature base, this study demonstrates an association between obesity and mental health outcomes by gender while evaluating the effect of food insecurity. It is recommended that clinicians allocate time in discussing vital nutrients when formulating a treatment plan, as diet can augment the medications used to treat and prevent various chronic diseases. It is also vital for health providers to also consider food insecurity in their assessment as it makes it difficult for patients to adhere to a diet that supports their diagnosis. Assessment of dietary habits and nutritional status of depressive patients, depending on place of residence Evolution not revolution: nutrition and obesity Poverty and obesity: the role of energy density and energy costs Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis Fast food, race/ethnicity, and income: a geographic analysis Obesity relationships with community design, physical activity, and time spent in cars Depression and obesity Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study Are mood disorders and obesity related? A review for the mental health professional Association between obesity and psychiatric disorders in the US adult population The association between fruit and vegetable consumption and mental health disorders: evidence from five waves of a national survey of Canadians Association of western and traditional diets with depression and anxiety in women Assessment of dietary factors, dietary practices and exercise on mental distress in young adults versus matured adults: a cross-sectional study Depressive symptoms in overweight and obese older adults: a test of the 'jolly fat' hypothesis Is obesity associated with major depression? Results from the third National Health and nutrition examination survey Uncovering the hidden impacts of inequality on mental health: a global study Depression in women: implications for health care research Trends in obesity among adults in the United States The rising prevalence of obesity Depression and cardiac mortality: results from a community-based longitudinal study Nutrition and depression: implications for improving mental health among childbearing-aged women Household food security in the United States in 2017, ERR-256. United States Dept Agric Food insecurity and mental health among females in highincome countries Food insecurity and mental health status: a global analysis of 149 countries Racial/ethnic differences in access to substance abuse treatment Considering context, place and culture: the National Latino and Asian American Study Sample designs and sampling methods for the collaborative psychiatric epidemiololgy studies (CPES) The National Survey of American life: a study of racial, ethnic and cultural influences on mental disorders and mental health The development and implementation of the National Comorbidity Survey Replication, the National Survey of American Life, and the National Latino and Asian American Survey American Psychiatric Association. Diagnostic and statistical manual of mental disorders source information Racial/ethnic differences in the association between obesity and major depressive disorder: findings from the comprehensive psychiatric epidemiology surveys Household food security in the United States in 2014 Food insecurity and health outcomes Food insecurity research in the United States: where we have been and where we need to go Understanding hunger and developing indicators to assess it in women and children The relationship between obesity and depression Body weight and psychological distress in NHANES I Childhood obesity and self-esteem Social marginalization of overweight children Gender differences in self-esteem, unvarnished selfevaluation, future orientation, self-enhancement and self-derogation in a U Food security: definition and measurement Food insecurity: special considerations for women The relationship between food insecurity, dietary patterns, and obesity Food insecurity is positively related to overweight in women Gender and marital status clarify associations between food insecurity and body weight The impact of nutrition education on food insecurity among low-income participants in EFNEP Improving the nutritional status of food-insecure women: first, let them eat what they like Household food insecurity with hunger is associated with women's food intakes, health and household circumstances Food insecurity will be the sting in the tail of COVID-19 Substance Abuse and Mental Health Services Administration. DSM-5 changes: implications for child serious emotional disturbance Self-reported vs. measured height, weight, and BMI in young adults Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Abbreviations BMI: Body mass index; DHA: Docosahexaenoic acid; MDD: Major Depressive Disorder; PUFA: Polyunsaturated fatty acids; WHO: World Health Organization No primary data collection was conducted.Authors' contributions MA designed the study, performed data analysis and interpretation, and prepared the manuscript. TS designed the study, conducted a literature search, and interpretation of findings in the drafted manuscript. RW participated in the design of the study, assisted and revised the draft manuscript. PF participated in the design of the study, assisted and revised the draft manuscript. All authors approved the final manuscript. The author(s) received no financial support for the research, authorship, and/ or publication of this article. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.Ethics approval and consent to participate Secondary analysis was conducted from the publicly available Collaborative Psychiatric Epidemiology Surveys (CPES), 2001-2003 dataset. Data has no identifying information. https://www.icpsr.umich.edu/icpsrweb/ICPSR/ studies/20240 The authors declare that they have no conflict of interest.