Abstract
Objective:
To determine the relationship between household food insecurity status over a 12-month period and adults’ use of publicly funded health care services in Ontario for mental health reasons during this period.
Methods:
Data for 80,942 Ontario residents, 18 to 64 years old, who participated in the Canadian Community Health Survey in 2005, 2007-2008, 2009-2010, or 2011-2012 were linked to administrative health care data to determine individuals’ hospitalizations, emergency department visits, and visits to psychiatrists and primary care physicians for mental health reasons. Household food insecurity over the past 12 months was assessed using the Household Food Security Survey Module. Logistic regression models were used to estimate the odds of mental health service utilization in the past 12 months by household food insecurity status, adjusting for sociodemographic factors and prior use of mental health services.
Results:
In our fully adjusted models, in comparison to food-secure individuals, the odds of any mental health care service utilization over the past 12 months were 1.15 (95% confidence interval [CI], 1.04 to 1.29) for marginally food-insecure individuals, 1.39 (95% CI, 1.19 to 1.42) for moderately food-insecure individuals, and 1.50 (95% CI, 1.35 to 1.68) for severely food-insecure individuals. A similar pattern persisted across individual types of services, with odds of utilization highest with severe food insecurity.
Conclusions:
Household food insecurity status is a robust predictor of mental health service utilization among working-age adults in Ontario. Policy interventions are required to address the underlying causes of food insecurity and the particular vulnerability of individuals with mental illness.
Keywords: food insecurity, mental health services, ontario
Abstract
Objectif:
Déterminer la relation entre l’état de l’insécurité alimentaire des ménages sur une période de 12 mois et l’utilisation par les adultes des services de santé financés par l’État en Ontario pour des raisons de santé mentale durant cette période.
Méthodes:
Les données de 80 942 résidents de l’Ontario, de 18 à 64 ans, qui ont participé à l’Enquête sur la santé dans les collectivités canadiennes en 2005, 2007-2008, 2009-2010, ou 2011-2012 ont été couplées aux données administratives de la santé pour déterminer les hospitalisations individuelles, les visites aux services d’urgence, et les visites aux psychiatres et aux médecins des soins de première ligne pour des raisons de santé mentale. L’insécurité alimentaire des ménages a été évaluée au cours des 12 derniers mois à l’aide du Module d’enquête sur la sécurité alimentaire des ménages. Des modèles de régression logistique multinomiale ont servi à estimer les probabilités de l’utilisation des services pour la santé mentale dans les 12 derniers mois au moyen de l’état d’insécurité alimentaire des ménages, en ajustant pour les facteurs sociodémographiques et l’utilisation antérieure des services de santé mentale.
Résultats:
Dans nos modèles pleinement ajustés, en comparaison avec les personnes ayant une sécurité alimentaire, les probabilités d’une utilisation des services de santé mentale au cours des 12 derniers mois étaient de 1,15 (IC à 95 % 1,04 à 1,29) pour les personnes ayant une insécurité alimentaire marginale, de 1,39 (IC à 95 % 1,19 à 1,42) pour les personnes ayant une insécurité alimentaire modérée, et de 1,50 (IC à 95 % 1,35 à 1,68) pour les personnes ayant une insécurité alimentaire grave. Un modèle semblable persistait dans les types de services individuels, les probabilités d’utilisation étant plus élevées pour l’insécurité alimentaire grave.
Conclusions:
L’état d’insécurité alimentaire des ménages est un prédicteur robuste de l’utilisation des services de santé mentale chez les adultes en âge de travailler en Ontario. Des interventions politiques sont nécessaires pour s’attaquer aux causes sous-jacentes de l’insécurité alimentaire et de la vulnérabilité particulière des personnes souffrant de maladie mentale.
Introduction
Household food insecurity (inadequate or insecure access to food because of financial constraints) is a serious public health problem in many affluent nations, including Canada. In 2012, the most recent year for which national data are available, 12.6% of Canadian households experienced some food insecurity.1 Food insecurity is a potent marker of nutritional inequities in Canada,2–4 but the associations between food insecurity and health extend far beyond nutritional vulnerability. In Canada, experiences of hunger in childhood or youth have been linked to the subsequent development of a variety of chronic conditions, including asthma and depression.5–7 Among Canadian adults, measures of household food insufficiency and food insecurity have been associated with multiple indicators of chronic disease and poor health8–11 and increased health care utilization.2,12
The association between household food insecurity and mental illness is particularly strong, with analyses of Canadian population survey data revealing substantially higher odds of mood and anxiety disorders,13–15 signs and symptoms of depression,14 and suicidal ideation,14,16 among adults in food-insecure households, independent of other sociodemographic predictors of poor health. Similar associations have been reported in the United States,17–26 United Kingdom,27,28 Australia,29 New Zealand,30 and globally.31 Studies of specific patient populations (e.g., type 2 diabetes, HIV, hepatitis C) have also reported strong associations between depression and food insecurity.32–35 The relationship appears to be graded, with the probability of mental health problems rising with the severity of household food insecurity.11,14–16,23,34,36 For example, 9% of food-secure adults (18-64 years) in the 2007-2008 Canadian Community Health Survey (CCHS) reported diagnosis of a mood or anxiety disorder, but this rose to 16% with marginal food insecurity, 22% with moderate food insecurity, and 40% with severe food insecurity.11
While the existing research suggests that mental health problems are common among adults affected by household food insecurity, almost all of this evidence has been drawn from self-reports of mental health status. One exception is a recent UK study using primary care records to chart higher rates of common mental disorders among food-insecure women in the perinatal period.28 Objective measures of morbidity are needed to fully understand the burden of mental illness associated with household food insecurity in Canada. Using linked survey and administrative health care data from a large population-based sample of adults in Ontario, this study was undertaken to determine the relationship between household food insecurity status over a 12-month period and adults’ use of publicly funded health care services for mental health reasons during this period.
Methods
Data Sources
This study made use of data from 4 cycles of Statistics Canada’s CCHS, conducted in 2005, 2007-2008, 2009-2010, and 2011-2012.37 Statistics Canada conducts the CCHS to provide regular and timely estimates of health determinants, health status, and health system use for individuals, 12 years of age and older, living in private dwellings across Canada.
Data from CCHS were linked to administrative health care data that have been uniquely encoded and housed at the Institute for Clinical Evaluative Sciences in Toronto, Ontario, for all respondents who gave permission to have their survey data linked. This included 83% of respondents in the 4 cycles of CCHS used. We used the Canadian Institute for Health Information Discharge Abstract Database, Ontario Mental Health Reporting System, National Ambulatory Care Reporting System, and Ontario Health Insurance Plan claims. To identify health service utilization that was specifically for reasons of mental health, we used the diagnostic groupings developed for the Mental Health and Addictions Scorecard and Evaluation Framework Baseline Scorecard for inpatient and emergency department visits38 and the modified validated algorithm for outpatient visits,39 which includes indicators focused predominantly on care provided in outpatient physician and acute care settings. These data sets and the diagnostic codes applied to each data set to identify service utilization for mental health reasons are described in Table 1.
Table 1.
Summary of Administrative Health Care Databases Used to Identify Health Service Utilization for Mental Health Reasons.
| Database | Setting | Description | Diagnostic Codes for Mental Health Visits |
|---|---|---|---|
| Ontario Mental Health Reporting System (OMHRS) | Mental health inpatient hospitalizations | The OMHRS collects, ,analyzes and reports on information about individuals admitted to designated adult mental health beds in Ontario. Some mental health patients are still in inpatient acute beds (CIHI-DAD). | All main diagnoses except for DSM-IV 290.x. or 294.x (excludes dementia) |
| Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) | Acute inpatient hospitalizations | The CIHI-DAD is a national database that contains demographic, clinical, and administrative data for inpatient hospital admissions. | Main diagnosis using ICD-10-CA: F04 to F99 (excludes dementia) and using ICD-9: 291.x to 319.x, except 290.x. or 294.x (excludes dementia) |
| National Ambulatory Care Reporting System (NACRS) | Emergency department visits | The NACRS contains data for all emergency department visits. | Main diagnosis using ICD-10-CA: F04 to F99 (excludes dementia) and using ICD-9: 291.x to 319.x, except 290.x. or 294.x (excludes dementia), or secondary diagnosis of self-harm using ICD-10-CA: X60-X84, Y10-Y19, Y28, and using ICD-9: E95 |
| Ontario Health Insurance Plan (OHIP) | Outpatient and physician services | The OHIP data cover all services and procedures provided by health care providers who can claim under OHIP (e.g., physicians, laboratory services). | Any outpatient OHIP visit/consult to a psychiatrist Any outpatient OHIP visit/consult to a general practitioner with a mental health diagnostic code (295, 296, 297, 298, 300, 301, 302, 306, 309, 311, 303, 304, 897, 898, 899, 900, 901, 902, 904, 905, 906, 909) |
Population
Our initial linked sample comprised 87,387 individuals, 18 years and older, living in the province of Ontario and with a valid Ontario health insurance number during the 4 years prior to their CCHS interview. The exclusion of individuals without a valid health insurance number for the entire period (n = 2489) and those with missing data on food insecurity status or any sociodemographic covariate (n = 3956) resulted in a final analytic sample of 80,942 individuals. If an individual was a respondent in more than 1 cycle of CCHS (n = 937), only their first record was included in this study.
To minimize the loss of sample due to missing data on household income (a problem affecting 16.8% of respondents), data on neighborhood-level income quintiles were derived by linking 2006 census data to individuals’ residential postal code data. Statistics Canada has adjusted income for household size and community size such that each community would be expected to have 20% of its population in each income quintile. This ecological proxy methodology has been found to reliably estimate household income quintile.40
Measures
Household food security status and sociodemographic characteristics were derived from the CCHS. Household food insecurity over the past 12 months was assessed using the Household Food Security Survey Module, a validated, 18-item scale41 (Appendix A). The conditions assessed range from experiences of anxiety that food will run out before household members have money to buy more, to modifying the amount of food consumed, experiencing hunger, and going whole days without eating. We applied Health Canada’s classification scheme to define moderate and severe household food insecurity.41 Respondents with no affirmative responses were considered “food secure,” while those with 1 affirmative response were considered “marginally food insecure.” (Details of the classification scheme are presented in Appendix B.)
Outcomes included outpatient visits to psychiatrists and primary care physicians for a mental health reason and emergency department visits and hospital admissions for which the main diagnosis was a mental health problem (Table 1). Because the majority of the individuals in our sample made no use of health care services for mental health reasons over the past 12 months, service use was coded as a dichotomous variable, with use defined as 1 or more visits or hospital admissions.
Statistical Analyses
Sample characteristics were described using means and proportions. (See Supplementary Tables S1 and S2 for a comparison of characteristics of the analytic sample with respondents excluded due to missing data.) Linear trend and chi-square tests were performed to examine the association between each covariate and food insecurity status. Linear trend tests were conducted to determine the association between the number of adults with hospitalizations, emergency department visits, psychiatrist visits, and visits to primary care physicians for a mental health reason and household food insecurity status.
Binary logistic regression models were used to estimate the odds of mental health service utilization (considering any service utilization as well as the 4 specific types of service utilization described above) in the 12 months prior to the CCHS interview by household food insecurity status over this period. Models were adjusted for age, sex, and sociodemographic characteristics previously identified as significant predictors of household food insecurity status and mental health.11,42 These variables included respondent’s education, respondent’s immigration status (defined as Canadian born or not), household structure, number of adults and number of children younger than 18 years living in the household, household income (represented by neighborhood income quintile at the census tract level), main source of household income, homeownership, and urban versus rural residence.
To differentiate health care utilization for mental health reasons in the past 12 months that reflects continued care for chronic mental health problems from that which is indicative of heightened health care needs associated with household food insecurity in the current year, we reran the regression models described above, including binary variables to indicate service utilization for mental health reasons in each of the 3 prior years.
Because Canadian population studies have repeatedly documented substantially higher rates of mood and anxiety disorders among women than men in food-insecure households,11,13,15,36 we repeated the aforementioned logistic regression analyses of mental health care utilization, including an interaction term to test whether the observed associations between food insecurity and mental health care utilization differed by sex. No model yielded a statistically significant interaction (P > 0.05). To confirm that the relationship between food insecurity and mental health care utilization was similar for men and women, we repeated the logistic regression analysis of any health care utilization for mental health reasons, stratifying by sex.
An alpha level of P < 0.05 was used to test for significance, and all tests were 2-sided.
Results
The mean age of participants was 42.7 years, and 53.7% were female (Table 2). The prevalence of household food insecurity in the study sample was 12.1%, with 3.7% marginally food insecure, 5.2% moderately food insecure, and 3.1% severely food insecure. When stratified by household food insecurity status, participants differed significantly in age, sex, household composition, education, home ownership, income, main income source, and urban versus rural area of residence. Adults in food-insecure households were much more likely to rent rather than own their dwellings, to be reliant on social assistance, and to be either unattached and living alone or to be lone parents.
Table 2.
Sample Characteristics.
| All | Household Food Insecurity Status | |||||
|---|---|---|---|---|---|---|
| Secure | Marginal Food Insecurity | Moderate Food Insecurity | Severe Food Insecurity | P Valuea | ||
| n | 80,942 | 71,254 | 3000 | 4214 | 2474 | |
| Survey cycle, n (%) | ||||||
| 2005 | 21,315 (26.3) | 18,609 (26.1) | 852 (28.4) | 1196 (28.4) | 658 (26.6) | |
| 2007-2008 | 21,418 (26.5) | 18,927 (26.6) | 806 (26.9) | 1029 (24.4) | 656 (26.5) | |
| 2009-2010 | 19,856 (24.5) | 17,521 (24.6) | 658 (21.9) | 1027 (24.4) | 650 (26.3) | |
| 2011-2012 | 18,353 (22.7) | 16,197 (22.7) | 684 (22.8) | 962 (22.8) | 510 (20.6) | |
| Sex | ||||||
| Male | 37,474 (46.3) | 33,645 (47.2) | 1257 (41.9) | 1640 (38.9) | 932 (37.7) | <0.0001 |
| Female | 43,468 (53.7) | 37,609 (52.8) | 1743 (58.1) | 2574 (61.1) | 1542 (62.3) | |
| Age at interview, years, mean (SD) | 42.7 (13.6) | 43.0 (13.6) | 38.8 (13.2) | 40.3 (13.2) | 41.9 (12.7) | 0.0360 |
| Respondent’s education, n (%) | ||||||
| <Secondary school graduate | 8774 (10.8) | 6779 (9.5) | 480 (16.0) | 893 (21.2) | 622 (25.1) | <0.0001 |
| Secondary school completion | 15,987 (19.8) | 13,876 (19.5) | 677 (22.6) | 947 (22.5) | 487 (19.7) | <0.0001 |
| Some postsecondary | 6229 (7.7) | 5224 (7.4) | 319 (10.6) | 407 (9.7) | 259 (10.5) | <0.0001 |
| Postsecondary graduate | 49,952 (61.7) | 45,355 (63.7) | 1524 (50.8) | 1967 (46.7) | 1106 (44.7) | <0.0001 |
| Housing tenure, n (%) | ||||||
| Does not own dwelling | 17,373 (21.5) | 11,972 (16.8) | 1247 (41.6) | 2383 (56.5) | 1771 (71.6) | <0.0001 |
| Owns dwelling | 63,569 (78.5) | 59,282 (83.2) | 1753 (58.4) | 1831 (43.5) | 703 (28.4) | |
| Main source of income, n (%) | ||||||
| Wages, salaries or self employed | 66,725 (82.4) | 60,733 (85.2) | 2284 (76.1) | 2640 (62.6) | 1068 (43.2) | <.0001 |
| Seniors income, dividends, interest | 8507 (10.5) | 7627 (10.7) | 235 (7.8) | 391 (9.3) | 254 (10.3) | 0.0007 |
| Employment Insurance, workers’ compensation | 1107 (1.4) | 731 (1.0) | 93 (3.1) | 162 (3.8) | 121 (4.9) | <0.0001 |
| Social assistance | 2674 (3.3) | 909 (1.3) | 248 (8.3) | 691 (16.4) | 826 (33.4) | <0.0001 |
| Other or none | 1929 (2.4) | 1254 (1.8) | 140 (4.7) | 330 (7.8) | 205 (8.3) | <0.0001 |
| Living arrangement, n (%) | ||||||
| Unattached, living alone | 16,722 (20.7) | 13,530 (19.0) | 689 (23.0) | 1316 (31.2) | 1187 (48.0) | <0.0001 |
| Unattached, living with others | 2534 (3.1) | 2038 (2.9) | 152 (5.1) | 212 (5.0) | 132 (5.3) | <0.0001 |
| Couple, no children | 23,395 (28.9) | 21,966 (30.8) | 483 (16.1) | 644 (15.3) | 302 (12.2) | <0.0001 |
| Couple, children | 28,085 (34.7) | 25,587 (35.9) | 1065 (35.5) | 1094 (26.0) | 339 (13.7) | <0.0001 |
| Lone parent | 6219 (7.7) | 4693 (6.6) | 408 (13.6) | 700 (16.6) | 418 (16.9) | <0.0001 |
| Other | 3987 (4.9) | 3440 (4.8) | 203 (6.8) | 248 (5.9) | 96 (3.9) | 0.1641 |
| Number of children younger than 18 years, mean (SD) | 0.5 (0.9) | 0.5 (0.9) | 0.8 (1.1) | 0.7 (1.1) | 0.5 (0.9) | 0.0002 |
| Number of adults, mean (SD) | 2.1 (0.9) | 2.1 (0.9) | 2.0 (0.9) | 1.8 (0.9) | 1.5 (0.7) | <0.0001 |
| Neighborhood income quintile, n (%) | ||||||
| 1 | 15,408 (19.0) | 12,129 (17.0) | 818 (27.3) | 1434 (34.0) | 1027 (41.5) | <0.0001 |
| 2 | 16,080 (19.9) | 13,850 (19.4) | 688 (22.9) | 987 (23.4) | 555 (22.4) | <0.0001 |
| 3 | 16,617 (20.5) | 14,824 (20.8) | 631 (21.0) | 771 (18.3) | 391 (15.8) | <0.0001 |
| 4 | 16,700 (20.6) | 15,328 (21.5) | 489 (16.3) | 598 (14.2) | 285 (11.5) | <0.0001 |
| 5 | 16,137 (19.9) | 15,123 (21.2) | 374 (12.5) | 424 (10.1) | 216 (8.7) | <0.0001 |
| Rural/urban residence, n (%) | ||||||
| Urban | 63,839 (78.9) | 56,071 (78.7) | 2391 (79.7) | 3366 (79.9) | 2011 (81.3) | 0.0003 |
| Rural | 17,103 (21.1) | 15,183 (21.3) | 609 (20.3) | 848 (20.1) | 463 (18.7) | |
| Immigrant, n (%) | ||||||
| No | 67,355 (83.2) | 59,295 (83.2) | 2415 (80.5) | 3471 (82.4) | 2174 (87.9) | 0.0078 |
| Yes | 13,587 (16.8) | 11,959 (16.8) | 585 (19.5) | 743 (17.6) | 300 (12.1) | |
aTests for linear trend (analysis of variance for continuous variables, Cochran-Armitage test for categorical variables) across all 4 levels of food insecurity status.
In the past 12 months, 17.2% of participants received some form of health care for mental health reasons, with similar rates of utilization in each of the prior 3 years (Table 3). The proportion of participants using mental health services in the past 12 months rose significantly, with increasing severity of household food insecurity, irrespective of the type of health service considered. Whereas 40.4% of adults in severely food-insecure households had received some treatment for mental health reasons in the past 12 months, only 15.6% of adults in food-secure households had received such treatment. Similar trends were observed in mental health care service utilization in the 3 preceding years. Whereas 25.2% of food secure adults had used mental health care services in the past 12 months and prior 3 years, this proportion rose to 28.5% among the marginally food insecure, 37.6% among the moderately food insecure, and 42.9% among the severely food insecure.
Table 3.
Mental Health Care Utilization in Past 12 Months (Concurrent with Measure of Food Insecurity Status) and 3 Years Prior, n (%).
| Total Sample, N = 80,942 | Food Secure, n = 71,254 | Marginal Food Insecurity, n = 3000 | Moderate Food Insecurity, n = 4214 | Severe Food Insecurity, n = 2474 | P Valuea | |
|---|---|---|---|---|---|---|
| Hospitalization in past 12 months | 330 (0.4) | 205 (0.3) | 15 (0.5) | 42 (1.0) | 68 (2.7) | <0.0001 |
| Emergency department visit in past 12 months | 762 (0.9) | 493 (0.7) | 43 (1.4) | 106 (2.4) | 120 (4.7) | <0.0001 |
| Outpatient psychiatry visit in past 12 months | 2616 (3.1) | 1900 (2.6) | 124 (4.0) | 293 (6.7) | 299 (11.7) | <0.0001 |
| Primary care visit in past 12 months | 12,559 (15.1) | 10,031 (13.7) | 579 (18.6) | 1070 (24.4) | 879 (34.5) | <0.0001 |
| Any hospitalization, emergency department, psychiatrist, or general practitioner visit in past 12 months | 13,938 (17.2) | 11,081 (15.6) | 645 (21.5) | 1213 (28.8) | 999 (40.4) | <0.0001 |
| Any hospitalization, emergency department, psychiatrist, or primary care visit in first year prior to 12-month measure | 13,904 (17.2) | 11,087 (15.6) | 618 (20.6) | 1199 (28.5) | 1000 (40.4) | <0.0001 |
| Any hospitalization, emergency department, psychiatrist, or primary care visit in second year prior to 12-month measure | 13,778 (17.0) | 11,002 (15.4) | 662 (22.1) | 1153 (27.4) | 961 (38.8) | <0.0001 |
| Any hospitalization, emergency department, psychiatrist, or primary care visit in third year prior to 12-month measure | 13,822 (17.1) | 11,085 (15.6) | 613 (20.4) | 1180 (28.0) | 944 (38.2) | <0.0001 |
a P value from Cochran-Armitage test of trend.
When the rates of health service utilization among adults in food-insecure households were considered relative to the total number of adults seeking care for mental health problems, the food insecure comprised 37.9% of all adults hospitalized, 34.9% of those treated in an emergency department, 27.2% of those who saw a psychiatrist, and 20.0% of those who saw a family physician or general practitioner for mental health reasons in the course of the year (Figure 1). The disproportionate use of health services by adults in severely food-insecure households was particularly notable; 1 in 5 of adults hospitalized because of mental illness fell into this category.
Figure 1.
Household food insecurity status of the sample overall and among subgroups who used specific mental health care services in past 12 months.
After adjusting for sociodemographic variables, adults in severely food-insecure households had 2.16 times the odds (95% confidence interval [CI], 1.97 to 2.36) of using any mental health care service over the past 12 months compared with those in food-secure households (Table 4). Moderate food insecurity was associated with 1.61 times the odds (95% CI, 1.49 to 1.73) and marginal food insecurity with 1.23 times the odds (95% CI, 1.12 to 1.35) of using any mental health care service. When individuals’ use of mental health care services in the prior 3 years was taken into account, the odds ratios were attenuated, but all remained statistically significant. (See Supplementary Table S3 for the full models.) When this analysis was repeated, stratified by sex, the associations between use of any mental health care service and severity of food insecurity were fairly similar for men and women, but marginal food insecurity was not significantly associated with mental health care utilization among men (Supplementary Table S4).
Table 4.
Adjusted Odds (95% Confidence Interval) of Using Any Health Care Service and Each Specific Health Care Service for Mental Health Reasons over 12-Month Period, by Household Food Insecurity Status, Comparing Each Group to Adults in Food-Secure Households.
| Marginally Food Insecure | Moderately Food Insecure | Severely Food Insecure | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Health Care Service | Point Estimate | 95% Wald Confidence Limits | Point Estimate | 95% Wald Confidence Limits | Point Estimate | 95% Wald Confidence Limits | |||
| Any health care utilizationa | |||||||||
| Model 1b | 1.26 | 1.14 | 1.38 | 1.59 | 1.47 | 1.71 | 2.14 | 1.95 | 2.35 |
| Model 2c: Model 1 + mental health care in prior 3 years | 1.15 | 1.04 | 1.29 | 1.30 | 1.19 | 1.42 | 1.50 | 1.35 | 1.68 |
| Hospitalization | |||||||||
| Model 1b | 1.01 | 0.59 | 1.74 | 1.35 | 0.93 | 1.97 | 2.37 | 1.68 | 3.35 |
| Model 2c: Model 1 + mental health care in prior 3 years | 0.87 | 0.51 | 1.51 | 1.05 | 0.72 | 1.53 | 1.61 | 1.13 | 2.27 |
| Emergency department visit | |||||||||
| Model 1b | 1.30 | 0.94 | 1.81 | 1.79 | 1.41 | 2.28 | 2.61 | 2.04 | 3.35 |
| Model 2c: Model 1 + mental health care in prior 3 years | 1.20 | 0.86 | 1.67 | 1.50 | 1.18 | 1.91 | 1.93 | 1.50 | 2.48 |
| Visit to a psychiatrist | |||||||||
| Model 1b | 1.23 | 1.01 | 1.49 | 1.60 | 1.38 | 1.84 | 2.09 | 1.79 | 2.44 |
| Model 2c: Model 1 + mental health care in prior 3 years | 1.02 | 0.83 | 1.27 | 1.15 | 0.98 | 1.34 | 1.25 | 1.05 | 1.48 |
| Primary care visit | |||||||||
| Model 1b | 1.28 | 1.16 | 1.41 | 1.53 | 1.41 | 1.65 | 2.12 | 1.93 | 2.34 |
| Model 2c: Model 1 + mental health care in prior 3 years | 1.18 | 1.06 | 1.32 | 1.25 | 1.15 | 1.37 | 1.52 | 1.36 | 1.69 |
aAny hospitalization, emergency department visit, or visit to a psychiatrist or primary care physician in the prior 12 months for reasons of mental health.
bLogistic regression model, estimating the odds of mental health service utilization in the 12 months prior to the Canadian Community Health Survey interview by household food insecurity status over this 12-month period, adjusting for age, sex, respondent’s education, respondent’s immigration status, household structure, number of adults and number of children younger than 18 years living in the household, neighborhood income quintile, main source of household income, homeownership, and urban versus rural residence. The reference category for all odds ratios is food security.
cLogistic regression model, identical to model 1 except for the inclusion of 3 binary variables to indicate any service utilization for mental health reasons in each of the 3 prior years.
Considering individuals’ use of specific mental health care services, those in severely food-insecure households had significantly higher odds of being hospitalized and having visited an emergency department, primary care physician, or psychiatrist when compared with the food secure (Table 4). Adjusting for individuals’ use of mental health care services in the prior 3 years resulted in an attenuation of the observed odds, but all remained statistically significant. Moderate food insecurity was associated with significantly higher odds of having visited an emergency department, primary care physician, or psychiatrist, but the latter finding lost statistical significance when adjusted for mental health service utilization in the prior 3 years. Compared with those who were food secure, adults in marginally food-insecure households had only a significantly higher odds of seeing a psychiatrist or primary care physician for mental health reasons, and only the latter finding remained statistically significant when adjusted for prior use of health care services for mental health reasons.
Discussion
Our study showed that household food insecurity was a strong predictor of adults’ use of health care services for mental health reasons, independent of other well-established social determinants of health. This pattern persisted across all types of services, including hospitalizations, emergency department visits, and visits to psychiatrists and primary care physicians. The observed effects were graded, with more severe food insecurity associated with higher odds of health service utilization. Our findings importantly extend the previous Canadian research showing greater likelihood of mental health problems among adults in food-insecure households by revealing the disproportionate burden that adults affected by food insecurity place on health care services for mental illness.
Whereas most prior studies have relied on self-reports of symptoms and diagnosed mood and anxiety disorders, our analysis of administrative health care data for a large, population-based sample provides objective evidence of the strong link between mental health problems and household food insecurity. Our use of comprehensive data on adults’ health care utilization with recorded diagnoses of mental illness and a highly validated scale of household food insecurity and our ability to take into account prior mental health care utilization are particular strengths of this study. Although our sample is based on survey data from 2005 to 2012, the prevalence of food insecurity in Ontario was stable over this period and has not changed significantly since.43 Insofar as those excluded because of missing data were more vulnerable (as indicated by their lower level of education and slightly higher health care utilization rates, Supplementary Tables S1 and S2), their omission would have biased our results toward the null. The fact that our study was conducted in the context of a universal health care system minimizes biases associated with financial barriers to health care access, although some adults still experience barriers to accessing mental health care services in the province.42 In addition, it should be noted that our analysis of health care utilization provides an incomplete account of individuals’ service utilization because we could not assess the use of community mental health programs or privately provided treatment services. In addition, our use of health administrative data to categorize individuals with mental illness necessarily relies on access to such services. Since access to mental health services is known to be problematic in Ontario, and access difficulties are seen most prominently in vulnerable populations (e.g., low-income groups),42 it is likely that we have classified food-insecure individuals in the non–mental health category. This implies that we have underestimated the relationship between mental illness ascertained through health service utilization and food insecurity and may have misclassified the vulnerable who cannot access mental health services.
We observed a gradient in health care utilization with increasing severity of household food insecurity, independent of other social determinants of health and prior treatment for mental health problems, but the methods we employed preclude causal inference. The financial stress of food insecurity has been shown to precipitate mental health problems,24,25,36 but there is also prospective evidence that maternal depression increases the risk of food insecurity among low-income families.44 Two studies of very-low-income women have charted bidirectional relationships between food insecurity and depression.45–47 However, almost all of this research is based on self-reported measures of mental health among highly selected population subgroups in the United States. Longitudinal Canadian studies are needed to elucidate the relation between adults’ mental health and food insecurity status.
Although analyses of Canadian population survey data have repeatedly found a higher prevalence of self-reported mental health problems among women than men in food-insecure households,11,13,15,16,36 we found little difference in the relationship between food insecurity and health service utilization by sex. These findings are not necessarily contradictory. Food-insecure women may be more likely than food-insecure men to suffer from mental illness but do not differ in their use of health care services.
The intersection of food insecurity with mental illness has important implications for intervention because, irrespective of which condition came first, the coexistence of these problems can only further erode individuals’ health and their households’ circumstances. The substantially higher rate of hospitalization among severely food-insecure adults observed here implies a greater likelihood of more serious mental health problems among this group. Just as problems of mental illness impede individuals’ abilities to transition out of food insecurity,48 the extreme material hardship denoted by severe food insecurity must compromise adults’ abilities to comply with treatment regimens and manage chronic mental health conditions. The coexistence of household food insecurity and mental illness among adults may also have implications for the health and well-being of other household members, particularly children. There is some evidence to suggest that the negative effects of household food insecurity on children’s health are in part a function of associated maternal depression.20,27,49 While it was beyond the scope of our study to assess the health of other household members, we note that almost 42% of adults in food-insecure households in our sample lived with children, and 38% of these were lone parents. More research is needed to understand how the combination of household food insecurity and mental illness among parents is affecting their children.
The social epidemiology of food insecurity in Canada is well established,9,50–56 and there is growing evidence of the sensitivity of household food insecurity to policy interventions that improve household finances.57–61 Yet, to date, no federal or provincial policy interventions or programs have been launched with the explicit goal of reducing or preventing household food insecurity. Government responses have instead focused on initiatives to support community-based charitable food assistance programs.62 Such programs remain the only direct response to food insecurity in Canada, despite an abundance of evidence that the assistance is insufficient to alter household circumstances.63–70 Health care providers have little chance of addressing patients’ food insecurity through referrals to community food programs, but by routinely screening patients for poverty and providing assistance to those struggling to “make ends meet,” they can help patients to access income supports to which they are entitled.71
Our results lend support to calls for evidence-based policy interventions to address problems of financial hardship that underpin food insecurity. The significant reductions in food insecurity observed among social assistance recipients in other provinces following improvements to benefits57,58 suggest that some of the food insecurity observed among our sample could be ameliorated by similar reforms in Ontario. However, most food-insecure households in our sample were not on social assistance, but reliant on income from employment or other sources, and this is similar to the situation nationally.1 Broader, population-level interventions are needed to address vulnerability to food insecurity that is associated with inadequate and insecure incomes more generally. Relatively modest increments in income have been found to reduce food insecurity among low-income families.59,72,73 These findings, coupled with the marked drop in food insecurity among low-income individuals when they become eligible for public old-age pensions (i.e., a guaranteed annual incomes provided to Canadian seniors),60 suggest that interventions such as Ontario’s basic income pilot74 may be particularly effective in reducing food insecurity. Evidence of decreased health care utilization for mental health reasons following implementation of a guaranteed annual income in Manitoba in the 1970s (the MINCOME experiment)75 indicates the potential for a basic income to alleviate mental health problems. The Ontario pilot will provide a unique opportunity to determine how the provision of a more adequate, secure income affects the food insecurity status and mental health of working-aged individuals, while also shedding light on what additional supports are needed to address the co-occurrence of these problems.
In summary, food insecurity is associated with high rates of mental health service utilization, indicating a high burden of mental illness among those with food insecurity. The relationship is graded with more severe food insecurity associated with a higher burden of mental health service utilization. The joint burden of food insecurity and mental illness is worrisome given the heavy burden of each condition separately. Individuals with food insecurity and mental illness represent a uniquely vulnerable population that warrants attention from a policy and health service intervention perspective. Community-based interventions intended to aid those suffering from mental illness need to be prepared to offer additional supports to those struggling to meet basic needs, but evidence-based policy interventions are required to address the underlying causes of household food insecurity. At the same time, more research is needed to determine the optimal policy instruments, services, and supports to address the co-occurrence of food insecurity and mental illness.
Supplemental Material
supplementary_material_revised for The Relation between Food Insecurity and Mental Health Care Service Utilization in Ontario by Valerie Tarasuk, Joyce Cheng, Craig Gundersen, Claire de Oliveira, and Paul Kurdyak in The Canadian Journal of Psychiatry
Appendix A CCHS Household Food Security Survey Modulea
The following questions are about the food situation for your household in the past 12 months.
Q1. Which of the following statements best describes the food eaten in your household in the past 12 months, that is since [current month] of last year?
You and other household members always had enough of the kinds of foods you wanted to eat.
You and other household members had enough to eat but not always the kinds of food you wanted.
Sometimes you and other household members did not have enough to eat.
Often you and other household members didn’t have enough to eat.
- Don’t know/refuse to answer [Go to end of module]
Question Q1 is not used directly in determining household food security status.
STAGE 1: Questions 2-6—ask all households
Now I’m going to read you several statements that may be used to describe the food situation for a household. Please tell me if the statement was often true, sometimes true, or never true for you and other household members in the past 12 months.
Q2. The first statement is: you and other household members worried that food would run out before you got money to buy more. Was that often true, sometimes true, or never true in the past 12 months?
Often true
Sometimes true
Never true
- Don’t know/refuse to answer
Q3. The food that you and other household members bought just didn’t last, and there wasn’t any money to get more. Was that often true, sometimes true, or never true in the past 12 months?
Often true
Sometimes true
Never true
- Don’t know/refuse to answer
Q4. You and other household members couldn’t afford to eat balanced meals. In the past 12 months was that often true, sometimes true, or never true?
Often true
Sometimes true
Never true
- Don’t know/refuse to answer
—IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q5 AND Q6; OTHERWISE, SKIP TO FIRST LEVEL SCREEN—
Now I’m going to read a few statements that may describe the food situation for households with children.
Q5. You or other adults in your household relied on only a few kinds of low-cost food to feed the child(ren) because you were running out of money to buy food. Was that often true, sometimes true, or never true in the past 12 months?
Often true
Sometimes true
Never true
- Don’t know/refuse to answer
Q6. You or other adults in your household couldn’t feed the child(ren) a balanced meal, because you couldn’t afford it. Was that often true, sometimes true, or never true in the past 12 months?
Often true
Sometimes true
Never true
- Don’t know/refuse to answer
FIRST-LEVEL SCREEN (screener for Stage 2): If AFFIRMATIVE RESPONSE to ANY ONE of Q2-Q6 (i.e., “often true” or “sometimes true”) OR response [3] or [4] to Q1, then continue to STAGE 2; otherwise, skip to end.
STAGE 2: Questions 7-11—ask households passing the first-level screen
—IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q7; OTHERWISE SKIP TO Q8—
Q7. The child(ren) were not eating enough because you and other adult members of the household just couldn’t afford enough food. Was that often, sometimes or never true in the past 12 months?
Often true
Sometimes true
Never true
- Don’t know/refuse to answer
The following few questions are about the food situation in the past 12 months for you or any other adults in your household.
Q8. In the past 12 months, since last [current month] did you or other adults in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?
Yes
No (Go to Q9)
- Don’t know/refuse to answer
Q8b. How often did this happen?
Almost every month
Some months but not every month
Only 1 or 2 months
- Don’t know/refuse to answer
Q9. In the past 12 months, did you (personally) ever eat less than you felt you should because there wasn’t enough money to buy food?
Yes
No
- Don’t know/refuse to answer
Q10. In the past 12 months, were you (personally) ever hungry but didn’t eat because you couldn’t afford enough food?
Yes
No
- Don’t know/refuse to answer
Q11. In the past 12 months, did you (personally) lose weight because you didn’t have enough money for food?
Yes
No
- Don’t know/refuse to answer
SECOND-LEVEL SCREEN (screener for Stage 3): If AFFIRMATIVE RESPONSE to ANY ONE of Q7-Q11, then continue to STAGE 3; otherwise, skip to end.
STAGE 3: Questions 12-16—ask households passing the second-level screen
Q12. In the past 12 months, did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food?
Yes
No (IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q13; OTHERWISE SKIP TO END)
- Don’t know/refuse to answer
Q12b. How often did this happen?
Almost every month
Some months but not every month
Only 1 or 2 months
- Don’t know/refuse to answer
—IF CHILDREN UNDER 18 IN HOUSEHOLD, ASK Q13-16; OTHERWISE SKIP TO END—
Now, a few questions on the food experiences for children in your household.
Q13. In the past 12 months, did you or other adults in your household ever cut the size of any of the children’s meals because there wasn’t enough money for food?
Yes
No
- Don’t know/refuse to answer
Q14. In the past 12 months, did any of the children ever skip meals because there wasn’t enough money for food?
Yes
No
- Don’t know/refuse to answer
Q14b. How often did this happen?
Almost every month
Some months but not every month
Only 1 or 2 months
- Don’t know/refuse to answer
Q15. In the past 12 months, were any of the children ever hungry but you just couldn’t afford more food?
Yes
No
- Don’t know/refuse to answer
Q16. In the past 12 months, did any of the children ever not eat for a whole day because there wasn’t enough money for food?
Yes
No
- Don’t know/refuse to answer
END OF MODULE
aHealth Canada. 2007. Canadian Community Health Survey, Cycle 2.2, Nutrition (2004)—Income-related Household Food Security in Canada. Ottawa, ON: Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada. No. 4696.
Appendix B. Determination of Household Food Insecurity Status Based on the Household Food Security Survey Module1
| Status | Interpretation | 10-Item Adult Food Security Scale | 8-Item Child Food Security Scale |
|---|---|---|---|
| Food secure | No report of income-related problems of food access | No items affirmed | No items affirmed |
| Marginal food insecure | Some indication of worry or an income-related barrier to adequate, secure food access | Affirmed no more than 1 item on either scale | |
| Moderate food insecure | Compromise in quality and/or quantity of food consumed by adults and/or children due to a lack of money for food | 2 to 5 positive responses | 2 to 4 positive responses |
| Severe food insecure | Disrupted eating patterns and reduced food intake among adults and/or children | 6 or more positive responses | 5 or more positive responses |
aAdapted from Canadian Community Health Survey, Cycle 2.2, Nutrition (2004): Income-Related Household Food Security in Canada.
Footnotes
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is funded by a programmatic grant from the Canadian Institutes of Health Research (CIHR; FRN 115208). The analysis was also supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by CIHR, ICES, or the MOHLTC is intended or should be inferred. The study sponsors had no role in the design of the study; the collection, analysis, or interpretation of data; the writing of the report; or the decision to submit the article for publication.
Supplemental Material: Supplemental material for this article is available online.
References
- 1. Tarasuk V, Mitchell A, Dachner N. Household food insecurity in Canada, 2012. Toronto (ON; ): Research to Identify Policy Options to Reduce Food Insecurity (PROOF: ); 2014. [Google Scholar]
- 2. Kirkpatrick S, Dodd KW, Parsons R, Ng C, Garriguet D, Tarasuk V. Household food insecurity is a stronger marker of adequacy of nutrient intakes among Canadian compared to American youth and adults. J Nutr. 2015;145(7):1596–1603. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Kirkpatrick S, Tarasuk V. Food insecurity is associated with nutrient inadequacies among canadian adults and adolescents. J Nutr. 2008;138(3):604–612. [DOI] [PubMed] [Google Scholar]
- 4. Pirkle C, Lucas M, Dallaire R, et al. Food insecurity and nutritional biomarkers in relation to stature in Inuit children from Nunavik. Can J Public Health. 2014;105(4):e233–e238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. McIntyre L, Wu X, Kwok C, Patten S. The pervasive effect of youth self-report of hunger on depression over 6 years of follow up. Soc Psychiatry Psychiatr Epidemiol. 2017;52(5):537–547. [DOI] [PubMed] [Google Scholar]
- 6. Kirkpatrick S, McIntyre L, Potestio M. Child hunger and long-term adverse consequences for health. Arch Pediatr Adolesc Med. 2010;164(8):754–762. [DOI] [PubMed] [Google Scholar]
- 7. McIntyre L, Williams J, Lavorato D, Patten S. Depression and suicide ideation in late adolescence and early adulthood are an outcome of child hunger. J Affect Disord. 2012;150(1):123–129. [DOI] [PubMed] [Google Scholar]
- 8. Vozoris N, Tarasuk V. Household food insufficiency is associated with poorer health. J Nutr. 2003;133(1):120–126. [DOI] [PubMed] [Google Scholar]
- 9. Che J, Chen J. Food insecurity in Canadian households. Health Rep. 2001;12(4):11–22. [PubMed] [Google Scholar]
- 10. Fuller-Thomson E, Nimigon-Young J, Brennenstuhl S. Individuals with fibromyalgia and depression: findings from a nationally representative Canadian survey. Rheumatol Int. 2012;32(4):853–862. [DOI] [PubMed] [Google Scholar]
- 11. Tarasuk V, Mitchell A, McLaren L, McIntyre L. Chronic physical and mental health conditions among adults may increase vulnerability to household food insecurity. J Nutr. 2013;143(11):1785–1793. [DOI] [PubMed] [Google Scholar]
- 12. Fitzpatrick T, Rosella L, Calzavara A, et al. Looking beyond income and education: socioeconomic status gradients among future high-cost users of health care. Am J Prev Med. 2015;49(2):161–171. [DOI] [PubMed] [Google Scholar]
- 13. Muldoon K, Duff P, Fielden S, Anema A. Food insufficiency is associated with psychiatric morbidity in a nationally representative study of mental illness among food insecure canadians. Soc Psychiatry Psychiatr Epidemiol. 2012;48(5):795–803. [DOI] [PubMed] [Google Scholar]
- 14. Jessiman-Perreault G, McIntyre L. The household food insecurity gradient and potential reductions in adverse population mental health outcomes in Canadian adults. SSM Pop Health. 2017;3:464–472. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Martin M, Maddocks E, Chen Y, Gilman S, Colman I. Food insecurity and mental illness: disproportionate impacts in the context of perceived stress and social isolation. Public Health. 2016;132:86–91. [DOI] [PubMed] [Google Scholar]
- 16. Davison K, Marshall-Fabien G, Tecson A. Association of moderate and severe food insecurity with suicidal ideation in adults: national survey data from three Canadian provinces. Soc Psychiatry Psychiatr Epidemiol. 2015;14(1):21–30. [DOI] [PubMed] [Google Scholar]
- 17. Stuff JE PHC, Szeto KL, Gossett JM, et al. Household food insecurity is associated with adult health status. J Nutr. 2004;134(9):2330–2335. [DOI] [PubMed] [Google Scholar]
- 18. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children. Pediatrics. 2006;118(3):e859–e868. [DOI] [PubMed] [Google Scholar]
- 19. Rose-Jacobs R, Black M, Casey P, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121(1):65–72. [DOI] [PubMed] [Google Scholar]
- 20. Bronte-Tinkew J, Zaslow M, Capps R, Horowitz A, McNamara M. Food insecurity works through depression, parenting, and infant feeding to influence overweight and health in toddlers. J Nutr. 2007;137(9):2160–2165. [DOI] [PubMed] [Google Scholar]
- 21. Wang E, McGinnis K, Goulet J, et al. Food insecurity and health: data from the veterans aging cohort study. Public Health Rep. 2015;130(3):261–268. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Allen N, Becerra B, Becerra M. Association between food insecurity and the severity of psychological distress among African-Americans. Ethn Health. 2017;1–10. [DOI] [PubMed] [Google Scholar]
- 23. Leung C, Epel E, Willett WC, Rimm EB, Laraia BA. Household food insecurity is positively associated with depression among low-income supplemental nutrition assistance program participants and income-ineligible nonparticipants. J Nutr. 2015;145:622–627. [DOI] [PubMed] [Google Scholar]
- 24. Okechukwu C, El Ayadi A, Tamers S, Sabbath E, Berkman LF. Household food insufficiency, financial strain, work-family spillover, and depressive symptoms in the working class: the work, family, and health network study. Am J Public Health. 2012;102(1):126–133. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Liu Y, Njai R, Greenlund K, Chapman D, Croft J. Relationship between housing and food insecurity, frequent mental distress, and insufficient sleep among adults in 12 US states, 2009. Prev Chronic Dis. 2014;11:E37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Brucker D. The association of food insecurity with health outcomes for adults with disabilities. Disabil Health J. 2017;10(2):286–293. [DOI] [PubMed] [Google Scholar]
- 27. Melchior M, Caspi A, Howard L, et al. Mental health context of food insecurity; a representative cohort of families with young children. Pediatrics. 2009;124(4):e564–e572. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Power M, Uphoff E, Kelly B, Pickett K. Food insecurity and mental health: an analysis of routine primary care data of pregnant women in the born in Bradford cohort. J Epidemiol Community Health. 2017;71(4):324–328. [DOI] [PubMed] [Google Scholar]
- 29. Ramsey R, Giskes K, Turrell G, Gallegos D. Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences. Public Health Nutr. 2012;15(2):227–237. [DOI] [PubMed] [Google Scholar]
- 30. Carter K, Kruse K, Blakely T, Collings S. The association of food insecurity with psychological distress in New Zealand and any gender differences. Soc Sci Med. 2011;72:1463–1471. [DOI] [PubMed] [Google Scholar]
- 31. Jones A. Food insecurity and mental health status: a global analysis of 149 countries. Am J Prev Med. 2017;53(2):264–273. [DOI] [PubMed] [Google Scholar]
- 32. Cox J, Hamelin AM, McLinden T, et al. Food insecurity in HIV-hepatitis C virus co-infected individuals in Canada: the importance of co-morbidities. AIDS Behav. 2016;21(3):792–802. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Weiser S, Young S, Kushel MB, et al. Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. Am J Clin Nutr. 2011;94(suppl):1729S–1739S. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Palar K, Kushel M, Frongillo EA, et al. Food insecurity is longitudinally associated with depressive symptoms among homeless and marginally-housed individuals living with HIV. AIDS Behav. 2015;19(8):1527–1534. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Silverman J, Kreiger J, Kiefer M, Hebert P, Robinson J, Nelson K. The relationship between food insecurity and depression, diabetes distress and medication adherence among low-income patients with poorly-controlled diabetes. J Gen Intern Med. 2015;30(10):1476–1480. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Wu Z, Schimmele C. Food insufficiency and depression. Sociological Perspectives. 2006;48(4):481–504. [Google Scholar]
- 37. Statistics Canada. Canadian Community Health Survey: annual component (CCHS). 2012. Ottawa (ON): Statistics Canada; http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SurvId=50653&InstaId=135927&SDDS=3226. Accessed June 30, 2013. [Google Scholar]
- 38. MHASEF Research Team. The mental health of children and youth in Ontario: 2017 scorecard. Toronto (ON: ): Institute of Clinical and Evaluative Sciences; 2017. [Google Scholar]
- 39. Steele L, Glazier R, Lin E, Evans M. Using administrative data to measure ambulatory mental health care service provision in primary care. Med Care. 2014;42(10):960–965. [DOI] [PubMed] [Google Scholar]
- 40. Mustard C, Derkson S, Berthelot J, Wolfson M. Assessing ecologic proxies for household income: a comparison of household and neighbourhood level income measures in the study of population health status. Health Place. 2014;5(2):157–171. [DOI] [PubMed] [Google Scholar]
- 41. Health Canada. Canadian Community Health Survey, cycle 2.2, nutrition (2004)—income-related household food security in Canada. No. 4696 Ottawa (ON): Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada; 2007. [Google Scholar]
- 42. Brien S, Grenier L, Kapral M, Kurdyak P, Vigod S. Taking stock: a report on the quality of mental health and addiction services in Ontario. An HQO/ICES report Toronto (ON): Health Quality Ontario and Institute for Clinical Evaluative Sciences; 2015. [Google Scholar]
- 43. Tarasuk V, Mitchell A, Dachner N. Household food insecurity in Canada, 2014. Toronto (ON): Research to Identify Policy Options to Reduce Food Insecurity (PROOF); 2016. [Google Scholar]
- 44. Garg A, Toy S, Tripodis Y, Cook J, Cordella N. Influence of maternal depression on household food insecurity for low-income families. Acad Pediatr. 2015;15(3):305–310. [DOI] [PubMed] [Google Scholar]
- 45. Heflin CM, Corcoran ME, Siefert K. Work trajectories, income changes, and food sufficiency in a Michigan welfare population. Soc Serv Rev. 2007;81(1):3–25. [Google Scholar]
- 46. Heflin CM, Siefert K, Williams DR. Food insufficiency and women’s mental health: findings from a 3-year panel of welfare recipients. Soc Sci Med. 2005;61(9):1971–1982. [DOI] [PubMed] [Google Scholar]
- 47. Huddleston-Casas C, Charnigo R, Simmons L. Food insecurity and maternal depression in rural, low-income families: a longitudinal investigation. Public Health Nutr. 2009;12(8):1133–1140. [DOI] [PubMed] [Google Scholar]
- 48. Lent M, Petrovic L, Swanson J, Olson C. Maternal mental health and the persistence of food insecurity in poor rural families. J Health Care Poor Underserved. 2009;20(3):645–661. [DOI] [PubMed] [Google Scholar]
- 49. Melchior M, Chastang J, Falissard B, et al. Food insecurity and children’s mental health: a prospective birth cohort study. PLoS One. 2012;7(12):e52615. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50. McIntyre L, Connor SK, Warren J. Child hunger in Canada: results of the 1994 national longitudinal survey of children and youth. Can Med Assoc J. 2000;163(8):961–965. [PMC free article] [PubMed] [Google Scholar]
- 51. McIntyre L, Bartoo A, Emery J. When working is not enough: food insecurity in the canadian labour force. Public Health Nutr. 2012;17(1):49–57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52. McIntyre L, Wu X, Fleisch V, Emery J. Homeowner versus non-homeowner differences in household food insecurity in Canada. J Hous Built Environ. 2015;31(2):349–366. [Google Scholar]
- 53. McIntyre L, Pow J, Emery J. A path analysis of recurrently food-insecure Canadians discerns employment, income, and negative health effects. J Poverty. 2015;19(1):1–17. [Google Scholar]
- 54. Ledrou I, Gervais J. Food insecurity. Health Rep. 2005;16(3):47–50. [PubMed] [Google Scholar]
- 55. Willows ND, Veugelers P, Raine K, Kuhle S. Prevalence and sociodemographic risk factors related to household food insecurity in Aboriginal peoples in Canada. Public Health Nutr. 2009;12(8):1150–1156. [DOI] [PubMed] [Google Scholar]
- 56. Tarasuk V, Vogt J. Household food insecurity in Ontario. Can J Public Health. 2009;100(3):184–188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57. Li N, Dachner N, Tarasuk V. The impact of changes in social policies on household food insecurity in British Columbia, 2005-2012. Prev Med. 2016;93:151–158. [DOI] [PubMed] [Google Scholar]
- 58. Loopstra R, Dachner N, Tarasuk V. An exploration of the unprecedented decline in the prevalence of household food insecurity in Newfoundland and Labrador, 2007-2012. Canadian Public Policy. 2015;41(3):191–206. [Google Scholar]
- 59. Ionescu-Ittu R, Glymour M, Kaufman J. A difference-in-difference approach to estimate the effect of income-supplementation on food insecurity. Prev Med. 2015;70:108–116. [DOI] [PubMed] [Google Scholar]
- 60. McIntyre L, Dutton D, Kwok C, Emery J. Reduction of food insecurity in low-income Canadian seniors as a likely impact of a guaranteed annual income. Canadian Public Policy. 2016;42(3):274–286. [Google Scholar]
- 61. Gundersen C, Kreider B, Pepper J, Tarasuk V. Food assistance programs and food insecurity: implications for Canada in light of the mixing problem. Empirical Economics. 2017;52(3):1065–1087. [Google Scholar]
- 62. McIntyre L, Lukic R, Patterson P, Anderson L, Mah C. Legislation debated as responses to household food insecurity in Canada, 1995-2012. J Hunger Environ Nutr. 2016;11(4):441–455. [Google Scholar]
- 63. Loopstra R, Tarasuk V. The relationship between food banks and household food insecurity among low-income Toronto families. Canadian Public Policy. 2012;38(4):497–514. [Google Scholar]
- 64. Tarasuk V, Dachner N, Hamelin AM, et al. A survey of food bank operations in five Canadian cities. BMC Public Health. 2014;14:1234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65. Kirkpatrick S, Tarasuk V. Food insecurity and participation in community food programs among low-income Toronto families. Can J Public Health. 2009;100(2):135–139. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66. Hamelin AM, Mercier C, Bedard A. Discrepancies in households and other stakeholders viewpoints on the food security experience: a gap to address. Health Educ Res. 2010;25(3):401–412. [DOI] [PubMed] [Google Scholar]
- 67. Hamelin AM, Mercier C, Bedard A. Needs for food security from the standpoint of Canadian households participating and not participating in community food programmes. International Journal of Consumer Studies. 2011;35:58–68. [Google Scholar]
- 68. McIntyre L, Bartoo A, Pow J, Potestio M. Coping with child hunger in Canada: have household strategies changed over a decade? Can J Public Health. 2012;103(6):428–432. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 69. Runnels V, Kristjansson E, Calhoun M. An investigation of adults’ everyday experiences and effects of food insecurity in an urban area in Canada. Can J Commun Ment Health. 2011;30(1):157–172. [Google Scholar]
- 70. Williams PL, Macaulay R, Anderson BJ, et al. “I would have never thought that I would be in such a predicament”: voices from women experiencing food insecurity in Nova Scotia, Canada. J Hunger Environ Nut. 2012;7:253–270. [Google Scholar]
- 71. The College of Family Physicians of Canada. Best advice: social determinants of health. 2015; Mississauga (ON): College of Family Physicians of Canada; http://patientsmedicalhome.ca/files/uploads/BA_SocialD_ENG_WEB.pdf. Accessed November 14, 2017. [Google Scholar]
- 72. Loopstra R, Tarasuk V. Severity of household food insecurity is sensitive to change in household income and employment status among low-income families. J Nutr. 2013;143(8):1316–1323. [DOI] [PubMed] [Google Scholar]
- 73. McIntyre L. Food security: more than a determinant of health. Policy Options. 2003;24(3):46–51. [Google Scholar]
- 74. Ontario basic income pilot. 2017. https://www.ontario.ca/page/ontario-basic-income-pilot#section-10. Accessed August 29, 2017.
- 75. Forget E. The town with no poverty: the health effects of a Canadian guaranteed annual income field experiment. Canadian Public Policy. 2011;37(3):283–305. [Google Scholar]
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Supplementary Materials
supplementary_material_revised for The Relation between Food Insecurity and Mental Health Care Service Utilization in Ontario by Valerie Tarasuk, Joyce Cheng, Craig Gundersen, Claire de Oliveira, and Paul Kurdyak in The Canadian Journal of Psychiatry