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    • HFI is operationally defined as the lack of access to

    2018-10-24

    HFI is operationally defined as the lack of access to food because of financial constraints (Tarasuk, Dachner & Loopstra, 2014) and in Canada is measured through national survey responses to the Household Food Security Survey Module (HFSSM) (Bickel, Nord, Price, Hamilton & Cook, 2000; Health Canada, 2007). Using this glucocorticoid receptor antagonist metric, recent national estimates indicate that in 2012, 12.5% of Canadian households experienced some level of HFI (4.1% marginally food insecure, 5.7% moderately food insecure, and 2.7% severely food insecure) (Tarasuk, Mitchell & Dachner, 2014). The HFSSM is also the national measurement tool in the United States where the criterion for moderate food insecurity is one affirmative response more stringent, limiting direct comparability between studies using the same metric. Nevertheless, studies, which operationalize HFI using any classification system of the HFSSM by level or as a binary, have repeatedly shown that HFI has an impact on physical health and nutrition, including an increased risk of the development of chronic disease (Seligman, Laraia, & Kushel, 2010), poor self-rated health (Vozoris & Tarasuk, 2003), nutritional vulnerabilities in adolescents and adults (Kirkpatrick & Tarasuk, 2008), poor cardiovascular health (Saiz et al., 2016), diabetes (Gucciardi, Vogt, DeMelo & Stewart, 2009), oral health problems (Muirhead, Quiñonez, Figueiredo & Locker, 2009), anemia in children (Eicher-Miller, Mason, Weaver, McCabe & Boushey, 2009), and increased hospitalization (Cook et al., 2004). A growing body of evidence has also pointed to a detrimental association between HFI and mental well-being from a variety of settings and using variations on the scoring of the HFSSM (Carter, Kruse, Blakely & Collings, 2011; Davison & Kaplan, 2015; Davison, Marshall-Fabien, & Tecson, 2015; Fuller-Thomson & Nimigon, 2008; Heflin, Siefert, & Williams, 2005; Leung, Epel, Willett, Rimm & Laraia, 2015; Muldoon, Duff, Fielden & Anema, 2013; Whitaker, Phillips, & Orzol, 2006; Pryor et al., 2016; Siefert, Heflin, Corcoran & Williams, 2004; Stuff et al., 2004; Tarasuk, Mitchell, McLaren & McIntyre, 2013; Vozoris & Tarasuk, 2003; Wu & Schimmele, 2005). It is hypothesized that HFI impacts mental health due to the unique stresses associated with the biological and social implications of “not having enough money for food” (Health Canada, 2007, p.45), which is the common end to each HFSSM question (Bhattacharya, Currie, & Haider, 2004; Hadley & Crooks, 2012). The evidence presented supports the reasoning for HFI being considered one of 14 social determinants of health in Canada (Raphael & Mikkonen, 2010), or a factor apart from medical care that can shape health in a powerful way (Braveman & Gottlieb, 2014). Importantly, population health researchers emphasize that health risk does not often occur as two extremes of exposure but rather as a continuum of risk (Institute of Medicine, 2003). Therefore, population-based interventions focus on shifting the risk curve for an entire population while paying attention to the social conditions that characterize individual lives (Marmot et al., 2008; Halfon, Larson, & Russ, 2009). The majority of the research conducted on the association between mental health outcomes and HFI has been conducted using a binary measure of food insecurity (Carter et al. 2011; Fuller-Thomson & Nimigon, 2008; Vozoris & Tarasuk, 2003), despite the established predictive power of a three-level (food secure, moderately food insecure and severely food insecure) or four-level (food secure, marginally food insecure, moderately food insecure and severely food insecure) HFI measure on mental health outcomes (Burke, Martini, Çayir; Hartline-Grafton & Meade, 2016; Cook et al., 2004; Davison, et al., 2015; Muldoon et al., 2013; Pryor et al., 2016; Tarasuk et al., 2013; Whitaker et al., 2006). A binary measure treats food insecure respondents as one homogenous group and thus disguises important health outcomes associated with different severities of HFI (Burke et al., 2016; Tarasuk et al., 2015). For example, Burke and associates observed that a three-level measure of HFI severely was positively associated with mental health outcomes in children and adolescents in the United States, using a slightly more stringent criterion for moderate food insecurity compared with Canada (Burke et al., 2016). In addition, in Canada Tarasuk and colleagues showed increasing health care costs (including psychiatric care and prescription drug costs) with increasingly severe HFI, using a four-level variable (Tarasuk et al., 2015). These studies present the idea that HFI could be having a graded, or step-wise, impact on mental health outcomes. The present study contributes to the literature by analyzing the relationship between a four-level HFI variable and six adverse mental health outcomes in Canadian adults.