Abstract

Food insecurity is a source of daily stress, especially in women. The aim was to investigate the association between mental distress and food insecurity in pregnant women. Cross-sectional study with pregnant women from the public health service, regardless risk stratification, or gestational trimester in Colombo-PR, Brazil. Poisson regression models were progressively adjusted for exposure variables. Results: Among the participating pregnant women (N=513) the prevalence of mental distress was 50.1%; associated with mild food insecurity (PR 1.34, 95%CI 1.12; 1.61) and moderate/severe food insecurity (PR 1.70, 95%CI 1.33; 2.19). The variable that most changed the association between the outcome and mild food insecurity was income (-4.48%) and, for moderate/severe food insecurity, education (-7.60%). For mild and moderate/severe food insecurity, the greatest reduction occurred with socioeconomic variables 4.5% (PR 1.27, 95%CI 1.05; 1.53) and 8.0% (PR 1.50, 95% CI 1.17; 1.93), respectively. The association between food insecurity and mental distress was consistent, and increased with the degree of food insecurity, with a greater reduction for socioeconomic variables.

Key words:
Pregnancy; Mental health; Food and nutrition security; Cross-sectional studies

Resumo

A insegurança alimentar é fonte de estresse diário, especialmente nas mulheres. Objetivou-se investigar associação entre sofrimento mental e insegurança alimentar em gestantes. Estudo transversal com gestantes do serviço público de saúde, independentemente do trimestre ou estratificação do risco gestacional em Colombo-PR, Brasil. Modelos de regressão de Poisson foram ajustados progressivamente para variáveis de exposição. A prevalência de sofrimento mental, entre os participantes (N=513) foi de 50,1%, e esteve associada à insegurança alimentar leve (RP 1,34, IC95% 1,12; 1,61) e moderada/grave (RP 1,70, IC95% 1,33; 2,19). A variável que mais alterou a associação entre o desfecho e insegurança alimentar leve foi renda (-4,48%) e, para insegurança alimentar moderada/grave, escolaridade (-7,60%). Para insegurança alimentar leve e moderada/ grave, a maior redução ocorreu com as variáveis socioeconômicas 4,5% (RP 1,27, IC95% 1,05; 1,53) e 8,0% (RP 1,50, IC95% 1,17; 1,93), respectivamente. A associação entre insegurança alimentar e sofrimento mental foi consistente, e aumentou com o grau de insegurança alimentar, com maior redução para as variáveis socioeconômicas.

Palavras-chave:
Gravidez; Saúde mental; Segurança alimentar e nutricional

Introduction

Food Insecurity refers to the violation of the right to be free from hunger and includes uncertainties about regular and permanent access to food of a sufficient quality and quantity, without compromising access to other fundamental needs¹1 Brasil. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 set..

Food insecurity when assessed by the Brazilian Food Insecurity Scale can be classified into severity levels: mild indicates concern with an upcoming shortage of food; moderate indicates that the food is now restricted in terms of sufficient quality and quantity, and severe food insecurity is characterized by hunger²2 Pérez-Escamilla R, Segall-Corrêa AM, Kurdian Maranha L, Sampaio MFA, Marin-Leon L, Panigassi G. An adapted version of the U.S. Departament of Agriculture Food Insecurity module is a valid tool for assessing household food insecurity in Campinas, Brazil. J Nutr 2004; 134(8):1923-1928.^,33 Segall-Corrêa AM. Insegurança alimentar medida a partir da percepção das pessoas. Estud Av 2007; 21(60):143-154..

Worldwide, the prevalence of food insecurity at the moderate/severe level in 2019 was estimated at 25.9%, approximately two billion people⁴4 Organização das Nações Unidas para a Alimentação e a Agricultura (FAO/IFAD/UNICEF/WFP). World Health Organization (WHO). The State of Food Security and Nutrition in the World 2020. Transforming food systems for affordable healthy diets. Rome: FAO; 2020.. In Brazil, according to the 2017-2018 Family Budget Survey, out of the 68.9 million households in the country, 36.7% had food insecurity, reaching 84.9 million Brazilians⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020.. In a systematic review conducted with pregnant women, the prevalence of food insecurity varied widely, ranged from 5.2 to 87% from studies in North Carolina and South Africa, respectively⁶6 Laraia B, Vinikoor-Imler LC, Siega-Riz AM. Food insecurity during pregnancy leads to stress, disordered eating, and greater postpartum weight among overweight women. Obesity 2015; 23:1303-1310.^,77 Eaton LA, Pitpitan EV, Kalichman SC, Sikkema KJ, et al. Food insecurity and alcohol use among pregnant women at alcohol serving establishments in South Africa. Prev Sci 2014; 15:309-317..

Food insecurity affects the quality of food and can lead to malnutrition⁸8 Myers CA. Food Insecurity and Psychological Distress: a Review of the Recent Literature. Curr Nutr Rep 2020; 9(2):107-118.. During pregnancy, the resulting malnutrition can compromise the body’s systems and interfere with birth weight⁹9 Chowdhury M, Dibley MJ, Alam A, Huda TM, Raynes-Greenow C. Household food security and birth size of infants: analysis of the Bangladesh Demographic and Health Survey 2011. Current Develop Nutr 2018; 2(3):nzy003. and is associated with a higher prevalence of inadequate blood pressure and blood sugar levels¹⁰10 Oliveira ACMD, Tavares MCM, Bezerra AR. Insegurança alimentar em gestantes da rede pública de saúde de uma capital do nordeste brasileiro. Cien Saude Colet 2017; 22(2):519-526..

Lack of safe access to food, concerns about food and hunger are sources of daily stress, especially for women. Food insecurity involves feelings of despair, shame, anguish, hopelessness, continuous anxiety, which can intensify mental distress¹¹11 Weaver LJ, Hadley C. Moving beyond hunger and nutrition: a systematic review of the evidence linking food insecurity and mental health in developing countries. Ecol Food Nutr 2009; 48(4):263-284.. Thus, food insecurity can be considered an important health factor, associated with a higher risk of mental distress¹²12 Jebena MG, Taha M, Nakajima M, Lemieux A, Lemessa F, Hoffman R, Tesfaye M, Belachew T, Workineh N, Kebede E, Gemechu T, Tariku Y, Segni H, Kolsteren P, al'Absi M. Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design. BMC Preg Childbirth 2015; 15(1):250..

Pregnancy is considered a vulnerable period to the effects of food insecurity on the mental health condition, considering its association with depression, anxiety and stress¹³13 Augusto ALP, Abreu Rodrigues AV, Domingos TB, Salles-Costa R. Household food insecurity associated with gestacional and neonatal outcomes: a systematic review. BMC Preg Childbirth 2020; 20:1-11.. Mental distress can be defined as a set of symptoms characterized by tiredness, lack of memory, irritability, insomnia, difficulty concentrating and symptoms that are not characterized by psychiatric diagnostic criteria¹²12 Jebena MG, Taha M, Nakajima M, Lemieux A, Lemessa F, Hoffman R, Tesfaye M, Belachew T, Workineh N, Kebede E, Gemechu T, Tariku Y, Segni H, Kolsteren P, al'Absi M. Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design. BMC Preg Childbirth 2015; 15(1):250.^,1414 Goldberg D, Huxley P. Commom mental disorders: a bio-social model. London: Tavistock; 1992.. This set of symptoms has been referred to as Common Mental Disorders (CMD)¹⁴14 Goldberg D, Huxley P. Commom mental disorders: a bio-social model. London: Tavistock; 1992..

Adverse events throughout life, such as high stress, social exclusion, inadequate access to health care, malnutrition and sudden changes in income may be some of the explanations for the relationship between CMD and unfavorable socioeconomic conditions¹⁰10 Oliveira ACMD, Tavares MCM, Bezerra AR. Insegurança alimentar em gestantes da rede pública de saúde de uma capital do nordeste brasileiro. Cien Saude Colet 2017; 22(2):519-526.. This situation contributes to the occurrence of food insecurity, which is a stressful event and has direct effects on mental health and quality of life. Women, especially those with low income and education levels, are more susceptible to depression and anxiety¹¹11 Weaver LJ, Hadley C. Moving beyond hunger and nutrition: a systematic review of the evidence linking food insecurity and mental health in developing countries. Ecol Food Nutr 2009; 48(4):263-284..

Although depression, anxiety and stress are frequent outcomes in relation to food insecurity in pregnancy, the literature about the relation with mental distress is more sparce¹³13 Augusto ALP, Abreu Rodrigues AV, Domingos TB, Salles-Costa R. Household food insecurity associated with gestacional and neonatal outcomes: a systematic review. BMC Preg Childbirth 2020; 20:1-11. concentrated in African continent¹²12 Jebena MG, Taha M, Nakajima M, Lemieux A, Lemessa F, Hoffman R, Tesfaye M, Belachew T, Workineh N, Kebede E, Gemechu T, Tariku Y, Segni H, Kolsteren P, al'Absi M. Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design. BMC Preg Childbirth 2015; 15(1):250.^,1515 Heyningen TV, Myer L, Onah M, Tomlinson M, Field S, Honikman SJ. Antenatal depression and adversity in urban South Africa. J Affect Dis 2016; 203: 121-129.. In this way, the objective of this study was to investigate the association between mental distress and food insecurity in pregnant women undergoing prenatal care at the Brazilian Unified Health System (SUS).

Methods

Cross-sectional study with pregnant women undergoing prenatal care at SUS, the Brazilian Unified Health System, in the Primary Health Units in Colombo, Paraná, in the southern region of Brazil, carried out between March 2018 and September 2019. The municipality of Colombo belongs to the metropolitan region of Curitiba, capital of the state of Paraná, with an estimated population of 246,540 habitants¹⁶16 Instituto Brasileiro de Geografia e Estatística (IBGE). Colombo. Panorama [Internet]. 2020 [acessado 2020 out 10]. Disponível em: https://cidades.ibge.gov.br/brasil/pr/colombo/panorama.
https://cidades.ibge.gov.br/brasil/pr/co... .

The study population was estimated based on the number of registrations in the 2016 Pregnant Women Monitoring System, which totaled 3,807 pregnant women. The sample calculations considered the prevalence of the outcome to be 50%, for the major study, with other outcomes beyond mental distress, because this is one where the highest variability could be expected, resulting in larger sample; margin of error of four percentage points and 95% confidence level; with that, a minimum sample of 520 participants was obtained. Adding the percentage of 30% for losses and refusals in longitudinal studies resulted in 676 pregnant women to be invited. During the consolidation of the fieldwork, incomplete questionnaires for variables were identified, and additional 59 (11.3%) pregnant women were selected to increase the power of the study (N=735), distributed proportionally in relation to the number of pregnant women in each Unit. For the analysis of this study, pregnant women who had complete data for all variables were included using the listwise deletion procedure. Considering the analytical sample of the study (N=513), maintaining a 95% confidence level, 80% power of the study, the prevalence of the outcome (mental distress) in the unexposed of 42.6%, it would be possible to identify a prevalence ratio of at least 1.29, relative the prevalence of 54.9% among exposed individuals.

The variables were investigated by means of a questionnaire composed of: age group (in years, less than or equal to 19, 20 to 29 and 30 or more), self-declared color/race (white and yellow, or black and brown), marital status (with a partner, without a partner), education in years of study (0-7, 8-10, 11 or more), family income per capita, divided into tertiles (1^st-BRL 0.00-BRL 475.00; 2^nd-BRL 476.00-BRL 750.00; 3^rd-BRL 751.00-BRL 3,000.00), the value of the Brazilian minimum wage in 2019 was R$ 998.00¹⁷17 Federação dos Trabalhadores Aposentados e Pensionistas do Estado do Rio Grande do Sul (FETAPERGS), Tabelas Salário Mínimo [Internet]. [acessado 2021 abr 24]. Disponível em: http://www.fetapergs.org.br/index.php/2015-07-27-16-46-22/tabelas-salario-minimo.
http://www.fetapergs.org.br/index.php/20... and the value of the dollar at that time was R$ 4.16¹⁸18 Índices econômicos - Dólar Comercial 2019 [Internet]. [acessado 2021 abr 24]. Available in: https://www.idealsoftwares.com.br/indices/dolar2019.html.
https://www.idealsoftwares.com.br/indice... ; paid work (yes, no), physical activity through the Physical Activity Questionnaire for Pregnant Women (QAFG), in its translated and validated version¹⁹19 Silva FT, Araujo Júnior E, Santana EF, Lima JW, Cecchino GN, Silva CF. Translation and cross-cultural adaptation of the Pregnancy Physical Activity Questionnaire (PPAQ) to the Brazilian population. Ces Gynekol 2015; 80(4):290-298. and classified as sedentary in mild, moderate and intense levels; smoking (yes, no), alcohol consumption in the last 12 months (consumed, did not consume), number of pregnancies (one, two or three), pregnancy planning (yes, no), gestational trimester (0-13, 14 -26, 27 weeks or more).

The Self-Reporting Questionnaire (SRQ-20) was used for evaluating mental distress. The questionnaire was recommended by the World Health Organization (WHO) for studies carried out in primary health care, and comprises 20 questions with a dichotomous answer (yes or no), and each affirmative answer is equivalent to one point²⁰20 Gonçalves DM, Stein AT, Kapczinski F. Avaliação de desempenho do Self-Reporting Questionnaire como instrumento de rastreamento psiquiátrico: um estudo comparativo com o Structured Clinical Interview for DSM-IV-TR. Cad Saude Publica 2008; 24(2):380-390.. The cutoff point used was equal to or greater than seven points used in other studies with pregnant women, which indicate the presence of common mental disorder or mental distress¹²12 Jebena MG, Taha M, Nakajima M, Lemieux A, Lemessa F, Hoffman R, Tesfaye M, Belachew T, Workineh N, Kebede E, Gemechu T, Tariku Y, Segni H, Kolsteren P, al'Absi M. Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design. BMC Preg Childbirth 2015; 15(1):250.^,2121 Silva RA, Ores LC, Mondin TC, Rizzo RNR, Moraes IGS, Jansen K, Pinheiro RT. Transtornos mentais comuns e auto-estima na gestação: prevalência e fatores associados. Cad Saude Publica 2010; 26(9):1832-1838.^,2222 Lucchese R, Simões ND, Monteiro LHB, Vera I, Fernandes IL, Castro PA, Silva GC, Evangelista RA, Bueno AA, Lemos MF. Fatores associados à probabilidade de transtorno mental comum em gestantes: estudo transversal. Esc Anna Nery 2017; 21(3):e20160094..

Food insecurity was investigated using the Brazilian Food Insecurity Scale (EBIA)²2 Pérez-Escamilla R, Segall-Corrêa AM, Kurdian Maranha L, Sampaio MFA, Marin-Leon L, Panigassi G. An adapted version of the U.S. Departament of Agriculture Food Insecurity module is a valid tool for assessing household food insecurity in Campinas, Brazil. J Nutr 2004; 134(8):1923-1928. which classifies the household situation in the last three months, with different cutoff points for households under 18 years old. Food insecurity can be classified as: mild, moderate, or severe²2 Pérez-Escamilla R, Segall-Corrêa AM, Kurdian Maranha L, Sampaio MFA, Marin-Leon L, Panigassi G. An adapted version of the U.S. Departament of Agriculture Food Insecurity module is a valid tool for assessing household food insecurity in Campinas, Brazil. J Nutr 2004; 134(8):1923-1928.. For this study, due to the low small number of pregnant women classified as having severe food insecurity (N=12; 2.34%), it was grouped with moderate food insecurity for analysis.

The collection instrument underwent a pre-test and test with adjustments to improve understanding and reduce the filling time. A pilot study was carried out comprising all research stages. Quality control was carried out with 11.6% (N=64) of interviews with a subsequent telephone contact to check information. Data was entered twice for checking purposes.

Descriptive analyses were performed with absolute (N) and relative (%) frequencies and the respective 95% confidence interval (CI). Prevalence ratios (PR) of the association of the outcome - mental distress - and food insecurity - the main exposition variable - were estimated using Poisson Regression with a robust adjustment of variance. This approach allows more adequate estimates of the measure of effect in cross-sectional studies, considering outcomes with a high prevalence - as mental distress in the evaluated population - when compared to the use of Logistic Regression, with Odds Ratio estimative. The robust adjustment of the variance allows to adjust the scale of the dichotomous variable for the use of Poisson regression²³23 Barros AJD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21.^,2424 Coutinho LMS, Scazufca M, Menezes PR. Métodos para estimar razão de prevalência em estudos de corte transversal. Rev Saude Publica 2008; 42(6):992-998..

The percentage of PR modification after the insertion of each variable was calculated. Subsequently, progressive models were adjusted for blocks of variables: demographic, socioeconomic, health-related behavior and obstetric characteristics. The percentage of difference in the adjusted PR between each model and from the initial model to the final model was calculated. In each block all variables were kept for adjustment independently of the p-value. The adjustment of the models was investigated through the goodness of fit deviance. The collinearity between the variables in the final model was investigated using the VIF - variance inflation factor. The analyses were performed using the Stata 14 program (STATA Corp. College Station, Texas, USA).

This research was approved by the Ethics Committee on Research with Human Beings at UFPR under the opinion number 2405347 (11/29/2017). Pregnant women over the age of 18 who agreed to participate signed the Informed Consent Form (ICF), and those under the age of 18 signed the Informed Acceptance Form (IAF) and their legal guardians signed the ICF.

Results

Among the 735 invited pregnant women, 605 accepted, and 513 had complete data for the variables. The average age of pregnant women with complete data was 26.2 (95%CI 25.7; 26.7) and did not differ from those who refused to participate (26.6 years, 95%CI 25.7; 27.5). Most lived with a partner (81.3%); 41.1% perform paid work; 40.9% were in their first pregnancy; 34.7% planned the pregnancy and 49.3% were in the third trimester. The prevalence of the outcome - mental distress was 50.1% (95%CI 45.8; 54.4), while for the main exposition variable mild food insecurity 38.2% (95%CI 34.1; 42.5) and for moderate/severe food insecurity 6.4 % (95% CI 4.6; 8.9%) (Table 1).

The prevalence of mental distress was higher for pregnant women with mild food insecurity (PR 1.34, 95%CI 1.12; 1.61) and moderate/severe food insecurity (PR 1.71, 95%CI 1.33; 2.19). Also, among women who lived without a partner, who smoked, who consumed alcohol, were in their third pregnancy and in the third trimester. On the other hand, it was lower among those who had 11 or more years of study, higher income levels, and that planned their pregnancy (PR 0.82, 95%CI 0.68; 0.99) (Table 2).

Individually, income was the variable that most attenuated the PR between mental distress and mild food insecurity (-4.48%); for moderate/severe food insecurity, schooling (-7.60%), parity (-6.43%) and marital status (-4.78%) further reduced the strength of association (Table 3).

The association between mental distress and food insecurity remained significant even after adjusting for all blocks of variables. Socioeconomic characteristics were those that most reduced the association between mild food insecurity and mental distress (4.5%) (PR 1.27, 95%CI 1.05; 1.53), followed by health-related behaviors (3.2%) (PR 1.23, 95%CI 1.02; 1.48) and obstetric characteristics (2.4%) (PR 1.20, 95%CI 1.00; 1.45) and finally, demographic variables (0.8%) (PR 1.33, 95%CI 1.11; 1.59). Whereas for moderate/severe food insecurity, the greatest reduction occurred with the inclusion of socioeconomic variables (8.0%) (PR 1.50, 95%CI 1.17; 1.93), followed by demographic 4.1% (PR 1,63, 95%CI 1.28; 2.08), health-related behaviors (2.7%) (PR 1.46, 95%CI 1.16; 1.87), and finally, for obstetric characteristics (2,1%) (PR 1.43, 95%CI 1.12; 1.83).

The PR difference between the unadjusted model and the final model was 10.5% for mild food insecurity, and 15.9% for moderate/severe food insecurity. (Graphs 1 and 2). Progressive reductions in deviance were observed in relation to the initial model, with values of p=1,000 in all models, which indicates the good fit of the models. The global value of the VIF was 1.16, ranging from 1.02 for the trimester of pregnancy to 1.44 for parity, which indicates an absence of collinearity between the variables.

Discussion

The prevalence of food insecurity in pregnant women was similar to that observed in other national studies carried out with pregnant women: 42.7% in Maceió, being, 24.8% with mild food insecurity, 9.9% with moderate food insecurity and 8% with severe food insecurity¹⁰10 Oliveira ACMD, Tavares MCM, Bezerra AR. Insegurança alimentar em gestantes da rede pública de saúde de uma capital do nordeste brasileiro. Cien Saude Colet 2017; 22(2):519-526. and 45.1% (95%CI 39.6; 50.6) in Colombo, which employed the short scale, which does not differentiate food insecurity levels²⁵25 Fernandes RC, Manera F, Boing L, Höfelmann, DA. Desigualdades socioeconômicas, demográficas e obstétricas na insegurança alimentar em gestantes. Rev Bras Saude Matern Infant 2018; 18(4):815-824.. In Brazil, according to the 2017-2018 Family Budget Survey, out of the 68.9 million households in the country, 36.7% had food insecurity, reaching 84.9 million Brazilians⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020.. Despite this, it is important to highlight that the prevalence of severe food insecurity was lower (2.3%) among the pregnant women evaluated in this study, compared with Maceió (8%)¹⁰10 Oliveira ACMD, Tavares MCM, Bezerra AR. Insegurança alimentar em gestantes da rede pública de saúde de uma capital do nordeste brasileiro. Cien Saude Colet 2017; 22(2):519-526. and the Brazilian prevalence (4.6%)⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020..

The prevalence of mental distress was 50.1%. In national studies carried out with pregnant women and using the same screening instrument, a prevalence of 41.4% was found in Pelotas in Rio Grande do Sul²¹21 Silva RA, Ores LC, Mondin TC, Rizzo RNR, Moraes IGS, Jansen K, Pinheiro RT. Transtornos mentais comuns e auto-estima na gestação: prevalência e fatores associados. Cad Saude Publica 2010; 26(9):1832-1838. and in a medium-sized municipality in Central Brazil (57.1%, 95%CI 51.7; 62.6)²²22 Lucchese R, Simões ND, Monteiro LHB, Vera I, Fernandes IL, Castro PA, Silva GC, Evangelista RA, Bueno AA, Lemos MF. Fatores associados à probabilidade de transtorno mental comum em gestantes: estudo transversal. Esc Anna Nery 2017; 21(3):e20160094..

Socioeconomic characteristics were those that most reduced the association between mild food insecurity and mental suffering, followed by health-related behaviours and obstetric characteristics and finally, demographic variables. While for moderate/severe food insecurity the greatest reduction occurred with the inclusion of socioeconomic variables, followed by demographic, health-related behaviours, and finally, for obstetric characteristics.

Pregnant women with food insecurity had a higher prevalence of mental distress, and the strength of association was greater for moderate/severe food insecurity. A study carried out in Ethiopia (2013) with pregnant women found that the prevalence of CMD was higher in pregnant women with food insecurity (48.3%), compared to those with food security (19.9%)¹²12 Jebena MG, Taha M, Nakajima M, Lemieux A, Lemessa F, Hoffman R, Tesfaye M, Belachew T, Workineh N, Kebede E, Gemechu T, Tariku Y, Segni H, Kolsteren P, al'Absi M. Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design. BMC Preg Childbirth 2015; 15(1):250.. The mechanisms of the association between mental distress and food insecurity are complex and multifactorial. Hunger and low nutrient intake can result in high stress, changes in body weight, embarrassment due to the situation, poor nutrition, factors directly linked to mental distress²⁶26 Gyasi RM, Obeng B, Yeboah JY. Impact of food insecurity with hunger on mental distress among community-dwelling older adults. PLoS One 2020; 15(3):e0229840.. The evidence points to the bidirectional action between the variables, that is, food insecurity can lead to mental distress, and mental distress can lead to food insecurity²⁷27 Birhanu TT, Tadesse AW. Food Insecurity and Mental Distress among Mothers in Rural Tigray and SNNP Regions, Ethiopia. Psychiatry Journal 2019; 7458341:1-6..

In the present study, the association between food insecurity and mental distress remained even after adjusting for all blocks of variables under study. Although the association between mental distress and food insecurity was consistent throughout the adjustments, the socioeconomic and demographic variables were those that most reduced the strength of the association between the variables, with the greatest impact on moderate/severe food insecurity. In fact, when analyzed individually, the variables with the highest percentage of change were income for mild food insecurity and education for moderate/severe food insecurity.

In general, low income is related to the difficulty of entering the labor market, uncertain living conditions and low self-worth. This association can lead to worse quality of life and reflects on mental distress²⁸28 Souza LPS, Barbosa BB, Silva CSDO, Souza AGD, Ferreira TN, Siqueira LDG. Prevalência de transtornos mentais comuns em adultos no contexto da Atenção Primária à Saúde. Rev Port Enferm Saude Mental 2017; (18):59-66.. Situations such as adverse events throughout life, social exclusion, sudden changes in income, inadequate access to health care and stress, may be linked to the onset of CMD²⁹29 Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, Swartz L, Patel V. Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med 2010; 71(3):517-528.^,3030 Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ 2003; 81(8):609-615.. Food insecurity is an expression of social inequality, and is directly related to socioeconomic factors, such as high food prices, low income, and unemployment³¹31 Sousa LRM, Segall-Corrêa AM, Saint Ville A, Melgar-Quiñonez H. Food security status in times of financial and political crisis in Brazil. Cad Saude Publica 2019; 35(7):e00084118..

When analyzing the relationship of each variable with mental distress and moderate/severe food insecurity, it was found that education, parity, and the absence of a partner stood out as potential confounding factors. Lower possession of consumer goods, unemployment and low education are factors associated with moderate and severe food insecurity³²32 Santos TGD, Silveira JACD, Longo-Silva G, Ramires EKNM, Menezes RCED. Tendência e fatores associados à insegurança alimentar no Brasil: Pesquisa Nacional por Amostra de Domicílios 2004, 2009 e 2013. Cad Saude Publica 2018; 34:e00066917.. Higher education can indicate some protection against hunger, the most serious expression of food insecurity, by indicating better opportunities in the labor market and increased family income, as well as access to food³²32 Santos TGD, Silveira JACD, Longo-Silva G, Ramires EKNM, Menezes RCED. Tendência e fatores associados à insegurança alimentar no Brasil: Pesquisa Nacional por Amostra de Domicílios 2004, 2009 e 2013. Cad Saude Publica 2018; 34:e00066917.. In situations where the person responsible for the household has a low level of education, the tendency is that their children follow the same path with educational limitations, and thus, fewer opportunities, lower wages, contributing to the cycle of intergenerational poverty³³33 Silva Netto Junior JL, Ramalho HMB, Silva EK. Transmissão intergeracional de educação e mobilidade de renda no Brasil. Econ Desenv 2013; 12:6-34..

The prevalence of mental distress is higher among women who have a greater number of children, a condition in which the overload of housework is greater, and social vulnerability is increased³⁴34 Araújo TM, Pinho PS, Almeida MMG. Prevalência de transtornos mentais comuns em mulheres e sua relação com as características sociodemográficas e o trabalho doméstico. Rev Bras Saude Matern Infant 2005; 5(3):337-348.. Women, especially in the role of mothers and pregnant women, are vulnerable to social and gender inequality, burden and stigma in the exercise of motherhood³⁵35 Mattar LD, Diniz CSG. Hierarquias reprodutivas: maternidade e desigualdades no exercício de direitos humanos pelas mulheres. Interface (Botucatu) 2012; 16(40):107-120.. Reports of mothers who were unable to feed their children due to lack of food at home include feelings of sadness, worry, frustration, tiredness, headache and stomach aches resulting from the feeling of failure in fulfilling their social role³⁶36 Piperata BA, Salazar M, Schmeer KK, Herrera Rodríguez A. Tranquility is a child with a full belly: Pathways linking food insecurity and maternal mental distress in Nicaragua. Ecol Food Nutr 2020; 59(1):79-103.. The strong association among gestational trimester and mental distress also highlight the importance of attention to those aspect with the advance of pregnancy.

In the absence of a partner, the responsibility for the provision of financial resources and care for the family falls more markedly on the woman, often the only one responsible for the family’s income³⁷37 Sabóia RCBD, Santos MMD. Prevalência de insegurança alimentar e fatores associados em domicílios cobertos pela Estratégia Saúde da Família em Teresina, Piauí, 2012-2013. Epidemiol Serv Saude 2015; 24(4):749-758., without being able to share the financial issue³⁸38 Robles TF, Slatcher RB, Trombello JM, McGinn MM. Marital quality and health: a meta-analytic review. Psychol Bull 2014; 140(1):140-187.. Women with a partner have a larger budget to increase the purchase of food at home³⁹39 Pellowski JA, Barnett W, Kuo CC, Koen N, Zar HJ, Stein DJ. Investigating tangible and mental resources as predictors of perceived household food insecurity during pregnancy among women in a South African birth cohort study. Soc Sci Med 2017; 187:76-84.. On the other hand, households headed by women have a higher prevalence of food insecurity. This is explained by the placement of women in the labor market, related to the perception of lower wages, occupation of less prestigious, in addition to what is still a traditional role as caregiver for children and homes, which implies that they are expected to stay at home and hinders the process of entering and establishing a career in the job market³⁷37 Sabóia RCBD, Santos MMD. Prevalência de insegurança alimentar e fatores associados em domicílios cobertos pela Estratégia Saúde da Família em Teresina, Piauí, 2012-2013. Epidemiol Serv Saude 2015; 24(4):749-758..

Food insecurity can cause feelings like anguish, despair, less social involvement, shame, nutritional deficiencies, as well as anxiety and depressive feelings. Pregnant women with depression are at a greater risk of remaining in poverty, and in a situation of food insecurity due to the increase in health expenses, social exclusion, reduced work opportunities and lower income. During pregnancy, considered a period of vulnerability, women’s income potential decreases, and there is an increase in needs related to their own health and that of their children⁴⁰40 Abrahams Z, Lund C, Field S, Honikman S. Factors associated with household food insecurity and depression in pregnant South African women from a low socio-economic setting: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 2018; 53(4):363-372..

In the other blocks of the investigated variables, there was a reduction in the PR of mental distress in relation to food insecurity, albeit of a lesser magnitude. The adjustment for behavioral characteristics reduced the strength of association by 3.2% for mild food insecurity and 2.7% for moderate/severe food insecurity. The high stress that food insecurity causes can increase alcohol and tobacco consumption. In some cases, they are used as strategies to decrease appetite, which results in inadequate food intake. In situations of insufficient food supply, part of the income can be used to buy tobacco and alcohol, instead of food⁴¹41 Yim KS. Health-related behavioral factors associated with nutritional risks in Korean aged 50 years and over. Korean J Community Nutr 2007;12(5):592-605.

42 Iglesias-Rios L, Bromberg JE, Moser RP, Augustson EM. Food insecurity, cigarette smoking, and acculturation among Latinos: data from NHANES 1999-2008. J Immigr Minor Health 2015; 17(2):349-357.^-4343 Chun IA, Ryu SY, Park J, Ro HK, Han MA. Associations between food insecurity and healthy behaviors among Korean adults. Nutr Res Pract 2015; 9(4):425-432..

Thus, it is important to observe data related to social, economic, behavioral, and cultural factors that are associated with mental distress in the creation of public policies allowing offer comprehensive health programs for pregnant women. The human right to proper food is contained in the Universal Declaration of Human Rights by the United Nations (UN) of 1948⁴⁴44 Organização das Nações Unidas (ONU). Declaração Universal dos Direitos Humanos. Paris: ONU; 1948., and in Brazil, food is a basic right, recognized in the Brazilian Constitution since 2010⁴⁵45 Brasil. Emenda constitucional nº 64, de 4 de fevereiro de 2010. Altera o art. 6° da Constituição Federal, para introduzir a alimentação como direito social. Diário Oficial da União 2010; 5 fev..

Food insecurity is considered a determinant factor that can elevate mental distress. However, the mechanism of this association is not yet clearly understood. Prospective longitudinal studies are needed to investigate and understand this bidirectional relationship¹²12 Jebena MG, Taha M, Nakajima M, Lemieux A, Lemessa F, Hoffman R, Tesfaye M, Belachew T, Workineh N, Kebede E, Gemechu T, Tariku Y, Segni H, Kolsteren P, al'Absi M. Household food insecurity and mental distress among pregnant women in Southwestern Ethiopia: a cross sectional study design. BMC Preg Childbirth 2015; 15(1):250.. In Brazil, it is essential that these studies be carried out and address the vulnerability to food insecurity among families with pregnant women, monitor and evaluate public policies and actions that guarantee food security for this population group and attempt to fight food insecurity¹⁰10 Oliveira ACMD, Tavares MCM, Bezerra AR. Insegurança alimentar em gestantes da rede pública de saúde de uma capital do nordeste brasileiro. Cien Saude Colet 2017; 22(2):519-526..

A systematic review corroborates the findings of this study, which highlights the importance of ensuring mental health in women with food insecurity, and attention to the social factors involved in this relationship that can lead to food insecurity and thus the prevention of depression, stress and anxiety¹³13 Augusto ALP, Abreu Rodrigues AV, Domingos TB, Salles-Costa R. Household food insecurity associated with gestacional and neonatal outcomes: a systematic review. BMC Preg Childbirth 2020; 20:1-11..

Although this study is innovative in the context of investigating the relationship between food insecurity and mental health and the association with a variety of determinants in pregnant women. Due to the cross-sectional design of this study, it was not possible to establish cause and effect inference between the variables. For future studies, we recommend applying longitudinal and qualitative research, which can investigate in depth the relationships and consequences of food insecurity and mental distress during pregnancy, and that health services, especially policies and public actions are attentive to this population group, so that pregnant women’s health can be considered in full relation with the social context that promotes and maintains the conditions of vulnerability associated with mental distress and food insecurity.

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