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Food Insecurity in Adults with Mood Disorders:
Prevalence Estimates and Associations with
Nutritional and Psychological Health
Karen M. Davison
Kwantlen Polytechnic University

Bonnie J. Kaplan
University of Calgary, AB, Canada

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Original Publication Citation
Davison, K & Kaplan, B. (2015). Food insecurity in adults with mood disorders: prevalence estimates and associations with
nutritional and psychological health. Annals of General Psychiatry, 14(21), 1-7, doi: 10.1186/s12991-015-0059-x

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Davison and Kaplan. Ann Gen Psychiatry (2015) 14:21
DOI 10.1186/s12991-015-0059-x

PRIMARY RESEARCH

Open Access

Food insecurity in adults with mood
disorders: prevalence estimates and associations
with nutritional and psychological health
Karen M Davison1,2*† and Bonnie J Kaplan1,3,4†

Abstract
Background: Because little is known about food insecurity in people with mental health conditions, we investigated
relationships among food insecurity, nutrient intakes, and psychological functioning in adults with mood disorders.
Methods: Data from a study of adults randomly selected from the membership list of the Mood Disorder Association
of British Columbia (n = 97), Canada, were analyzed. Food insecurity status was based on validated screening questions asking if in the past 12 months did the participant, due to a lack of money, worry about or not have enough
food to eat. Nutrient intakes were derived from 3-day food records and compared to the Dietary Reference Intakes
(DRIs). Psychological functioning measures included Global Assessment of Functioning, Hamilton Depression scale,
and Young Mania Rating Scale. Using binomial tests of two proportions, Mann–Whitney U tests, and Poisson regression we examined: (1) food insecurity prevalence between the study respondents and a general population sample
from the British Columbia Nutrition Survey (BCNS; n = 1,823); (2) differences in nutrient intakes based on food insecurity status; and (3) associations of food insecurity and psychological functioning using bivariate and Poisson regression
statistics.
Results: In comparison to the general population (BCNS), food insecurity was significantly more prevalent in the
adults with mood disorders (7.3% in BCNS vs 36.1%; p < 0.001). Respondents who were food-insecure had lower
median intakes of carbohydrates and vitamin C (p < 0.05). In addition, a higher proportion of those reporting food
insecurity had protein, folate, and zinc intakes below the DRI benchmark of potential inadequacy (p < 0.05). There
was significant association between food insecurity and mania symptoms (adjusted prevalence ratio = 2.37, 95% CI
1.49–3.75, p < 0.05).
Conclusions: Food insecurity is associated with both nutritional and psychological health in adults with mood disorders. Investigation of interventions aimed at food security and income can help establish its role in enhancing mental
health.
Keywords: Food insecurity, Nutrient intakes, Mood disorders
Background
Among health researchers, policy makers, practitioners, and decision makers, there are concerns about the
growing global and ethical issue of food insecurity [1],
*Correspondence: karen.davison@kpu.ca
†
Karen M Davison and Bonnie J Kaplan have contributed equally to this
work
2
Department of Biology, Health Science Program, Kwantlen Polytechnic
University, 12666 72nd Avenue, Surrey, BC V3W 2M8, Canada
Full list of author information is available at the end of the article

defined as the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain
ability to acquire acceptable food in socially acceptable
ways [2]. The impact of food insecurity on mental health
is significant and may be attributed to its associations
with suboptimal diet [3–5], and psychological issues
such as depression, eating disorders, and impaired cognition [6–9]. Of the few investigations that have examined
food insecurity in populations with confirmed diagnosis
of a mental health condition, results have indicated an

© 2015 Davison and Kaplan. This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
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org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Davison and Kaplan. Ann Gen Psychiatry (2015) 14:21

association with food insufficiency [10] and that patients
in a psychiatric emergency unit who lacked food security
had higher levels of psychological distress compared to
food-secure individuals [11]. In a previous study of the
determinants of food intakes in a sample of adults with
confirmed mood disorders conducted by the authors
[12], a high prevalence of inadequate intakes of several
micronutrients (e.g., folate, vitamin B12, iron, zinc) was
found. As part of this investigation, the authors also
included food insecurity screening questions and measures of psychological symptoms, as it was speculated
that food access would be associated with both dietary
intake and mental function in this population. To further understanding of food insecurity in specific mental
health populations, we used data from the study of adults
with mood disorders to answer the following research
questions: (1) what is the prevalence of food insecurity
compared to a general population sample?; and (2) is
food insecurity associated with poorer nutrient intakes
and psychological function? It was hypothesized that in
this sample of adults with mood disorders, food insecurity would be: (1) significantly more prevalent than in the
general population; (2) associated with suboptimal nutrient intakes based on defined standards; and (3) associated with poorer psychological functioning.

Methods
Sample

The data were from a cross-sectional nutrition survey
of adults (>18 years) with clinically defined mood disorders (Structured Clinical Interview for DSM-IV-TR Axis
I Disorders or SCID; [13]) who lived in the lower mainland of British Columbia; 146 individuals were randomly
selected from the membership list of the Mood Disorder Association of British Columbia and invited to participate. Of the 146 randomly selected members, 26 were
deemed ineligible and 23 refused to participate. Eleven of
the 23 individuals who declined participation completed
a non-response questionnaire, and statistical comparisons showed no significant differences compared to the
respondents based on a variety of lifestyle habits (e.g.,
smoking, multivitamin use).
As part of the recruitment process, all individuals
received phone follow-up from research staff to determine their interest and eligibility. Full details of recruitment, data collection, quality control, and overall
nutrient intake results have been published previously
[12]. This study adhered to guidelines in the Declaration of Helsinki and was approved by the University of
Calgary’s Conjoint Health Research Ethics Board. Sufficiency of statistical power (minimum 80%) to conduct
the analysis was based on: (1) the hypothesis, food insecurity would be associated with lower nutrient intakes;

Page 2 of 7

(2) results from a Canadian study on food insecurity and
nutrient intakes reporting mean intakes of folate of 424
and 378 micrograms for food-secure and food-insecure
groups, respectively, with a common standard deviation
of 18.5 [14]; and (3) an alpha level of 0.05 [15].
Measurements
Dependent variable

Food insecurity Food insecurity status was determined
as having an affirmative response to at least one of the
two screening questions:
1. In the past 12 months did you worry that there would
not be enough to eat because of lack of money?
(Question description: Worry about food access).
2. In the past 12 months did you not have enough food
to eat because of lack of money? (Question description: Compromised diet).
These two screening questions, which have previously
been used in Statistics Canada national surveys [16], were
also used in the British Columbia Nutrition Survey and
allowed for direct comparisons of food insecurity between
the sample and the general population. In the Canadian
survey and in our study, a third question was also used: “In
the past 12 months, did you or anyone in your household
not have enough food to eat because of a lack of money?”.
All of our study respondents who responded affirmatively
to question two also indicated “yes” to the third question.
Due to this redundancy in responses, the third question
was not included in the analysis.
Independent variables

Psychological functioning and symptoms Psychological,
social, and occupational functioning was based on scores
of the Global Assessment of Functioning Scale (GAF) [17].
Current symptoms of depression and mania were measured based on the Hamilton Depression Scale (Ham-D)
[18], and Young Mania Rating Scale (YMRS) [19].
Diet Nutrient intakes were derived from 3-day food
records (two weekdays and one weekend day; non-consecutive) according to standard protocols [20]. The dietary variables included intakes of energy, macronutrients,
and selected micronutrients (i.e., vitamins B6, B9, B12, and
C, plus the trace minerals iron, and zinc) that function in
cognition, and were analyzed using Food Processor SQL
with the Canadian nutrient file [21].
Covariates

Covariates included in the analysis were body mass index
(BMI; kg/m2; continuous variable) measured according

Davison and Kaplan. Ann Gen Psychiatry (2015) 14:21

Page 3 of 7

to standard protocols used in national and provincial
nutrition surveys [20], diagnosis of depressive or bipolar
disorder based on the SCID (dichotomous), following a
therapeutic (diet for a medical condition) diet (dichotomous), sociodemographic factors including age (continuous), gender (male/female), in a relationship or not
(dichotomous), and income (dichotomized as low versus
adequate, based on Canadian government standards).
Data analysis

To test the first hypothesis, prevalence estimates of food
insecurity (i.e., affirmative response to at least one of the
two food insecurity screening questions) and low income
were compared (using binomial tests of two proportions)
to regional data available from the 1999 British Columbia Nutrition Survey (BCNS; n = 1,823) that contained
the same income and food insecurity measures [20]. The
BCNS was conducted by the British Columbia Ministry
of Health Services, Health Canada, and the University of
British Columbia. It randomly sampled British Columbians aged from 19 to 84 years. Most of the BCNS participants were married (65.2%), did not hold a university
degree (85.5%), and had income levels above the poverty
cut-off (74.8%).
To examine the second hypothesis, differences in nutrient intakes between respondents who were either foodinsecure or secure were compared using Mann–Whitney
U tests or binomial tests of two proportions based on
the Dietary Reference Intakes [22]. Specifically, the proportion of the sample above and below the Estimated
Average Requirements (EAR; to estimate prevalence of
possible nutrient inadequacy) or within and above the
Adequate Macronutrient Distribution Ranges (AMDR;
to estimate suboptimal or excess macronutrient intake)
were analyzed.
To test the third hypothesis, bivariate relationships
between food insecurity and the psychological measures were analyzed using the Mann–Whitney U test and
crude prevalence ratios. Cut-offs used to categorize the
mental health measures included scores of 7 or less for
the Ham-D [18] and 12 or less for the YMRS [19] which

indicate that symptoms are currently absent. A cut-off of
60 for the GAF was used; scores less than this indicate
more severe mental illness [23].
The final steps of the analysis involved conducting
Poisson regression with robust variance to examine
relationships between food insecurity and psychological functioning while adjusting for age, sex, relationship
status, and income. This particular method was chosen
as it is considered the most viable model option when
analyzing cross-sectional data [24]. It provides adjusted
prevalence ratios that are interpreted as the ratio of the
proportion of the persons with the outcome (e.g., low
GAF scores) over the proportion with the exposure (e.g.,
food insecurity). To test whether the Poisson model form
fit the data, the goodness-of-fit Chi-squared test was
applied. All data analyses were performed using Stata
10.0 [25].

Results
Description of sample

Similar to the general population sample studied in
the BCNS, most respondents (n = 97) were females
(n = 69; 71.1%). Unlike the BCNS, most did not have
a university degree (n = 76; 78.4%) and were not in a
relationship (61.9%). Approximately half of the sample (49.0%) had government defined low-income levels
(Statistics Canada, 2013). Most (67.0%) had body mass
indices greater than 24.9 kg/m2 and 19.0% indicated
they were following a specific diet for medical reasons.
Based on the SCID, 58 (59.8%) met criteria for bipolar
disorder and 39 (40.2%) for depressive disorder. More
than 85% of the participants were taking psychiatric
medications.
Comparison of prevalence estimates of food insecurity

As hypothesized, the sample of adults with mood disorders had a higher proportion of individuals (36%) experiencing food insecurity (p < 0.001) compared to the
general population sample (BCNS) (Table 1). The proportion of individuals reporting low-income status was
also higher in adults with mood disorders (p < 0.05).

Table 1 Indicators of low income and food insecurity compared to regional survey data
Characteristic

Low-income status
Study
(n = 97)

BCNS
(n = 1,823)

Worry about food accessa

Compromised dietb

Study
(n = 97)

BCNS
(n = 1,823)

Study
(n = 97)

BCNS
(n = 1,823)

7.3 (6.1–8.6)

19.6 (12.2–28.9)**

3.4 (2.6–4.3)

Prevalence estimates (%) with 95% confidence intervals for income and food insecurity
Income and food insecurity

40.2 (30.4–50.7)*

25.2 (23.2–27.3)

36.1 (26.6 to 46.5)**

* p < 0.05, ** p < 0.0001.
a

Question: in the past 12 months did you worry that there would not be enough to eat because of lack of money?

b

Question: in the past 12 months did you not have enough food to eat because of lack of money?

Davison and Kaplan. Ann Gen Psychiatry (2015) 14:21

Page 4 of 7

Food insecurity and nutrient intakes

The respondents who reported food insecurity had lower
median carbohydrate and vitamin C intakes (Table 2).
The assessment of nutrient intakes based on the EARs
indicated that those reporting food insecurity had higher
proportions of inadequate protein, folate and zinc intakes
(p < 0.05). The food-insecure group also had a higher
proportion of participants with excess total fat intakes as
measured by the AMDR (p < 0.05).
Food insecurity and psychological functioning

Based on the bivariate analysis, some associations were
found between food insecurity and psychological functioning when measured as continuous variables (Table 3).
Ham-D and YMRS scores were significantly higher
(p < 0.05) in participants with compromised diet (i.e.,
answered affirmatively to the food insecurity screening
question “In the past 12 months did you not have enough
food to eat because of lack of money”). In addition,
higher depression scores were found in those reporting
low income (p < 0.05).

Crude prevalence ratios (PRs) of food insecurity and
the psychological measures (dichotomized based on their
defined cut-off scores) showed significant association
between food insecurity and mania symptoms (Table 4).
When Poisson regression was applied, the ratio of the
proportion of respondents with high YMRS scores over
the proportion with food insecurity was 2.37 (95% CI
1.49–3.75, p < 0.001). Low income was also consistently
associated with worse scores on all psychological measures (adjusted PRs ranged from 2.68 to 2.88, p < 0.05).
The variables in the final three Poisson regression models
included the psychological measures (i.e., GAF, YMRS,
Ham-D, respectively) age, sex, and income. The goodness-of-fit Chi-squared test results were not significant
for all models (goodness-of-fit 51.34 to 55.01, p’s > χ2
(92) = 1.00) suggesting that the Poisson model form fit
the data.

Discussion
The results of this study indicated that food insecurity
was more prevalent in adults with mood disorders when

Table 2 Comparisons of nutrient intakes by food security status
Measurement

Nutrient intakes according to food insecurity statusa Nutrient intakes compared to Dietary Reference
(median, IQRb)
Intakesc and by food insecurity statusa
Food insecure (n = 36)

Food secure (n = 61)

Food insecure (n = 36)

Food secure (n = 61)

d

Energy and macronutrients

% > AMDR (95% CI)

Energy (kilocalories)

2,406 (1,907; 2,875)

2,541 (1,802; 3,182)

–

–

Protein (% of calories)

14.0 (10.1; 18.4)

13.7 (9.4; 20.1)

5.5 (0.7–18.7)

0

Carbohydrates (% of calories)

47.8 (41.3; 57.3)*

52.9 (48.5; 59.8)

0.2 (0.1–19.5)*

11.4 (4.7–22.2)

Fibre (g)

21.5 (13.7; 29.4)

24.3 (15.3; 30.2)

–

–

Fats (% of calories)

35.4 (29.2; 45.0)*

34.2 (25.9; 38.9)

55.6 (38.1–72.1)*

29.5 (18.5–42.6)

% < EARe (95% CI)
Protein (g/kg)

–

–

19.4 (6.5–32.4)*

4.9 (0.5–10.3)

Vitamins
Vitamin B6 or pyridoxine (mg)

1.5 (1.0; 2.0)

1.5 (1.2; 2.2)

30.6 (16.3–48.1)

21.3 (11.9–33.7)

Vitamin B9 or folate (dietary folate
equivalents)f

74.2 (39.7; 204.4)

114.5 (55.0; 225.4)

83.3 (67.2–93.6)*

52.5 (39.3–65.4)

Vitamin B12 or cobalamin (μg)

3.3 (1.9; 4.6)

3.5 (1.9; 5.1)

27.8 (14.2–45.2)

26.2 (15.8–39.1)

Vitamin C (mg)

80.5 (51.8; 180.7)*

128.8 (70.2; 216.7)

27.8 (14.2–45.2)

21.3 (11.9–33.7)

Iron (mg)

14.4 (10.2; 18.3)

16.0 (12.0; 23.8)

13.9 (4.7–29.5)

6.6 (1.8–15.9)

Zinc (mg)

8.9 (5.8; 11.8)

8.8 (6.4; 12.8)

52.8 (35.5–69.6)*

31.1 (19.9–42.3)

Trace minerals

* p < 0.05.
a

Food-insecure or secure based on respondents who answered yes to either of the following questions: (1) in the past 12 months did you worry that there would not
be enough to eat because of lack of money; or (2) in the past 12 months did you not have enough food to eat because of lack of; food-secure based on respondents
who answered no to both questions.

b

Interquartile range.

c

Reference values that are quantitative estimates of nutrient intakes to be used for planning and assessing diets for healthy people.

d

Adequate macronutrient distribution ranges.

e

Estimated average requirement.

f

Dietary folate equivalents (DFE): values that adjust for the differences in absorption of food folate and synthetic folic acid; 1 mcg of DFE = 0.6 mcg of folic acid from
fortified food or as a supplement taken with a meal = 1 mcg food folate; 0.5 mcg of folic acid from a supplement taken on an empty stomach.

Davison and Kaplan. Ann Gen Psychiatry (2015) 14:21

Page 5 of 7

Table 3 Indicators of low income and food insecurity by psychological measures in adults with mood disorders (n = 97)
Psychological measure

Median and interquartile range
Low-income status

Worry about food accessa

Compromised dietb

Yes (n = 39)

No (n = 58)

Yes (n = 35)

No (n = 62)

Yes (n = 19)

No (n = 78)

Global Assessment of Functioning

60 (51; 70)

65 (55; 75)

10 (3; 16)

9 (4; 14)

3 (1; 5)

3 (1; 4)

Hamilton Depression Scale

60 (51; 65)*

65 (60; 75)

9 (4; 16)

9 (4; 14)

3 (2; 7)*

2 (1; 4)

Young Mania Rating Scale

58 (43; 68)

65 (55; 75)

10 (3; 19)

9 (4; 14)

4 (2; 7)*

2 (1; 4)

* p < 0.05.
a

Question: in the past 12 months did you worry that there would not be enough to eat because of lack of money?

b

Question: in the past 12 months did you not have enough food to eat because of lack of money?

Table 4 Crude and adjusted prevalence ratios of food insecuritya, psychological, and income measures
Psychological measure

GAF (<60)
YMRS (>12)
Ham-D (>7)
a

Crude prevalence ratio

Adjusted prevalence ratiob (95% confidence interval, p value)
Food insecurity

Low income

1.49 (0.97–2.31, p = 0.072)

1.42 (0.88–2.28, p = 0.148)

2.68 (1.53–4.71, p = 0.001)

1.02 (0.71–1.48, p = 0.880)

0.94 (0.59–1.49, p = 0.783)

2.88 (1.64–5.06, p = 0.000)

4.72 (1.36–16.24, p = 0.006)

2.37 (1.49–3.75, p = 0.000)

2.71 (1.59–4.63, p = 0.000)

Answered yes to question 1 or 2: Question 1: In the past 12 months did you worry that there would not be enough to eat because of lack of money?; and Question 2:
In the past 12 months did you not have enough food to eat because of lack of money?

b

Prevalence ratios from final models that included food insecurity, age, sex, and income; income is included in table as the adjusted prevalence ratios were
significant.

compared to a general population. Sample respondents
who reported food insecurity had significantly lower
intakes of carbohydrates and vitamin C. A higher proportion of the adults with mood disorders had potentially
inadequate intakes of protein, folate, and zinc. Finally,
food insecurity was consistently associated with worsened mania symptoms in adults with mood disorders.
This is the first study to report the relationships
between food insecurity and selected nutrients in adults
with mood disorders. As shown in other studies of food
insecurity in different populations [14, 26–28], there
is higher risk of inadequate intakes of essential nutrients which can have profound effects on mental health.
Research conducted in this sample of adults with mood
disorders has shown positive correlations between nutrient intakes and psychological function [29].
There are multiple interconnected ways in which food
insecurity could contribute to poorer nutritional and psychological health, including through nutrient deficiencies
and/or the body’s physiological response to the immense
stress from not having the resources to feed oneself
and/or one’s family [30–32]. When people experience
food insecurity, they may be forced to consume food in
socially unacceptable ways [33] which may affect psychological function directly or indirectly by altering nutrient intakes and metabolism. For example, reduced blood

folate levels (that may be a result of compromised dietary
folate intake due to food insecurity) may impair one-carbon metabolism, which has been implicated in the pathogenesis of psychiatric symptoms [34]. While previous
studies have shown links between food insecurity and
psychological symptoms such as depression, anxiety, and
suicide ideation [6, 7, 28, 35, 36], our results are the first
to show association with mania symptoms. One mechanism underlying this relationship may be due to suboptimal blood levels of vitamin C caused by either lower
intakes and/or increased breakdown due to stress. With
lower blood levels of vitamin C, disequilibrium between
ascorbic acid and vanadium metabolism may occur and
result in mania symptoms [37].
The consistent association between low-income status
and worse scores on the psychological measures is not
surprising as other studies have shown links with depression and low income [38]. However, to our knowledge,
this study is the first to report associations with YMRS
and GAF scores. While food insecurity is an independent determinant of health [39], cross-sectional surveys
have also shown it is strongly linked with another health
determinant, inadequate income [16, 40–42]. Unfortunately, the cross-sectional nature of these investigations
and our study cannot determine the temporality of the
relationships among food insecurity, low income, and

Davison and Kaplan. Ann Gen Psychiatry (2015) 14:21

mental health. However, longitudinal studies have shown
that associations between food insecurity and depression
are bidirectional [30, 43].
For several reasons, the results of this study should be
interpreted with caution. Limitations include the modest sample size and that the food insecurity screening
questions may not discriminate varying degrees of food
access. However, previous studies indicate that short
form measurement tools are appropriate to determine
the subjective experiences of food insufficiency [44].
Measurement error between food insecurity and psychological functioning may be present as the two may be
correlated (e.g., people in depressed mood states might
report increased food insecurity regardless of their true
status) and thereby yield a spuriously stronger positive
association. However, the multivariate analysis did not
show an association between food insecurity and Ham-D
scores. Finally, most of the sample was taking psychiatric
medications which may impact on food-related behaviours (e.g., increase appetite) [45] and therefore, increase
food insecurity.

Conclusions
Food insecurity is an important determinant of health
and significant public health and social issue [39, 40].
This study extends the current body of food insecurity knowledge by providing prevalence estimates and
reported associations with poorer nutrient intakes and
psychological functioning in a sample of adults with
mood disorders. While program and policy developments that strengthen food security would reduce health
and social inequities [41, 42], it may also be speculated
that such interventions may enhance the nutritional
and psychological well-being of those with mood disorders. Future investigations should focus on interventions
aimed at improving food security to establish its role in
enhancing mental health.
Abbreviations
AMDR: Adequate Macronutrient Distribution Ranges; BCNS: British Columbia
Nutrition Survey; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; EAR: Estimated Average Requirement; Ham-D: Hamilton
Depression scale; YMRS: Young Mania Rating Scale; GAF: Global Assessment of
Functioning scale.
Authors’ contributions
KMD conducted the study as part of her doctoral studies and was supervised
by BJK. KMD drafted the manuscript and BJK helped with revisions of the
manuscript. Both authors read and approved the final manuscript.
Author details
1
Department of Community Health Sciences, University of Calgary,
Calgary, AB, Canada. 2 Department of Biology, Health Science Program,
Kwantlen Polytechnic University, 12666 72nd Avenue, Surrey, BC V3W 2M8,
Canada. 3 Department of Pediatrics, University of Calgary, Calgary, AB,
Canada. 4 The Alberta Children’s Hospital Research Institute, Calgary, AB,
Canada.

Page 6 of 7

Acknowledgements
The authors thank their funding source, The Danone Research Institute. The
second author also thanks the Alberta Children’s Hospital Research Institute
for ongoing support. We also acknowledge the assistance of the Mood Disorders Association of British Columbia for providing support staff, office space
and assistance with recruitment.
Funding
Financial support for this project was obtained from The Danone Research
Institute, which played no role in carrying out the study, analyzing the results,
or influencing publication.
Compliance with ethical guidelines
Competing interests
The authors declare that they have no competing interests.
Informed consent
All procedures followed were in accordance with the ethical standards of the
responsible committee on human experimentation (institutional and national)
and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants included in the study.
Received: 7 February 2015 Accepted: 8 July 2015

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