Soc Psychiatry Psychiatr Epidemiol
DOI 10.1007/s00127-015-1018-1
ORIGINAL PAPER
Association of moderate and severe food insecurity with suicidal
ideation in adults: national survey data from three Canadian
provinces
Karen M. Davison • Gillian L. Marshall-Fabien •
Angela Tecson
Received: 1 August 2014 / Accepted: 27 January 2015
Ó Springer-Verlag Berlin Heidelberg 2015
Abstract
Purpose Although the important public health issues of
food insecurity and suicide may be interconnected, they are
rarely studied. Using data from a national survey, we ex-
amined whether household food insecurity was associated
with suicidal ideation after adjusting for relevant covariates.
Methods We examined cross-sectional data from three
Canadian provinces (n = 5,270) that were derived from the
2007 Canadian Community Health Survey and included
adults (18? years). Suicidal ideation was based on affir-
mative response to the question of whether or not the
participant had seriously considered committing suicide in
the previous 12 months. The Household Food Security
Survey Module provided measures of moderate (indication
of compromise in quality and/or quantity of food con-
sumed) and severe (indication of reduced food intake and
disrupted eating patterns) food insecurity status. Logistic
regression determined associations between food insecurity
K. M. Davison (&)
School of Nursing, University of British Columbia, T201 2211
Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
e-mail: karen.davison@kpu.ca
K. M. Davison
Health Science Program, Department of Biology, Kwantlen
Polytechnic University, Surrey, BC, Canada
G. L. Marshall-Fabien
Jack, Joseph and Morton Mandel School of Applied Social
Sciences, Case Western Reserve University, Cleveland, OH,
USA
A. Tecson
Berkowitz and Associates Consulting Incorporated, Vancouver,
BC, Canada
and suicidal ideation with adjustment for demographics,
body mass index, and presence of a mood disorder.
Results There were differences in the proportion experi-
encing suicide ideation according to moderate (14.7 vs 10.0 %
without suicide ideation) and severe (16.4 vs 7.1 % without
suicide ideation) food security (p \ 0.001). With covariate
adjustment, suicidal ideation was significantly associated with
moderate (adjusted OR = 1.32, 95 % CI 1.06–1.64) and
severe (adjusted OR = 1.77, 95 % CI 1.42–2.23) food
insecurity.
Conclusions The findings of a robust association between
food insecurity and suicidal ideation suggest that inter-
ventions targeted at food security may reduce suicide-re-
lated morbidity and mortality. Longitudinal investigations
that examine various dimensions of food insecurity will
advance understanding of etiological pathways involved in
food insecurity and suicide.
Keywords Food insecurity
Suicidal ideation
Adults

Mood disorders
Abbreviations
BMI Body mass index
CCHS Canadian Community Health Survey
HFSSM Household Food Security Survey Module
OR Odds ratio
Introduction
Suicide is a major public health and social issue with an-
nual global prevalence estimates of at least one million
people worldwide [1]. While the mere exposure to suici-
dality can have powerful short- and long-term impacts on
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the survivors [1, 2], understanding the suicide risk factors
is complex as genetic variation, biological, and environ-
mental factors, as well as individual coping behaviors, all
contribute to the etiology of suicide [3, 4]. Suicidal be-
havior, conceptualized as a continuum from suicidal idea-
tion (frequent thoughts about death or plans about how to
kill oneself) to suicide attempt (intentional, self-inflicted
behavior leading to death) and then completed suicide, has
consistently shown a significant association with stressful
life events. In addition, contextual factors, such as socio-
economic status [5], influence the likelihood of suicide
with differing distributions by sex, age, race/ethnicity, as
well as employment and marital status [6, 7].
Food insecurity, usually defined as the inadequate or
insecure access to adequate food due to financial con-
straints [8], and considered as a source of social disad-
vantage, marginalization, and stress [9], has been
investigated vis-à-vis its relationship to different mental
health outcomes, including suicide ideation. The tools used
to measure food insecurity vary widely ranging from uni-
dimensional measures of food insufficiency [10, 11] and
brief screening tools [12] to dietary diversity measures that
focus on diet quality [13]. In many studies, the income-
related Household Food Security Survey Module (HFSSM)
[14], a multi-item questionnaire is used to assess moderate
(indication that the quality and/or quantity of food con-
sumed has been compromised) and severe (food intake is
reduced and eating patterns are disrupted) food insecurity
levels [15]. While defining food insecurity based on
household and financial constraints may be meaningful to
various stakeholders, it is important to note that food in-
security is not entirely income-related [16]. In particular,
important intra-household variations in individual con-
sumption patterns [17], that may or may not be related to
mental-health related stigma and discrimination, could
mask the effects of food insecurity at the individual level.
As such, conceptualizations of food insecurity based on
financial and household contexts may not capture how
inequalities in food access may disproportionately impact
those who are vulnerable to or experiencing mental ill
health.
There are a number of theories and a few studies that
explain links that exist between food insecurity and suici-
dal ideation. Potential biological and stress mechanisms
have been proposed to account for the relationship between
food insecurity and poor mental health [18]. The burden of
poor mental health among those who are food insecure has
been documented among various vulnerable populations
[19–22], and the occurrence of difficult life events has been
directly linked to suicidal ideation, regardless of whatever
psychopathology, if any, is present [5]. The literature on
dieting and starvation suggests several hypotheses such as
micronutrient deficiency and malnutrition as possible links
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Soc Psychiatry Psychiatr Epidemiol
between food intake and suicide [5, 23–26]. Cross-sec-
tional and longitudinal studies have found that there are
relationships between food insecurity or a related measure,
hunger, and the reported presence of chronic mental health
conditions [27], as well as various child and youth mental
health problems in the forms of higher internalizing and
externalizing behaviors and suicide ideation [28–31].
The sparse research that exists specific to food insecurity
and suicidal behavior has, in several ways, been restricted
in scope. The majority of investigations have focused on
women in the perinatal period, children, adolescents, and
young adults [32] and there has been limited examination
in adult populations. In addition, many studies have fo-
cused on single- or limited-item measures of the complex
and multidimensional phenomenon of food insecurity. Fi-
nally, several investigations have used retrospective, rather
than recent, measures of suicidal ideation and as a result
individuals may have inaccurately recalled suicidal be-
havior. Of the few studies on food insecurity that have
included measures of suicidal behavior, associations were
found between thoughts of death, desire to die (i.e.,
thoughts about one’s own death, death of another person,
or death in general and feelings of wanting to die), suicidal
ideation and actual attempts at suicide and food insecurity
[30, 32].
Suicide risk behaviors are associated with significant
morbidity and mortality and thus are high-priority issues
requiring investigation and preventive interventions. If
suicide is linked with food insecurity, there is substantial
potential to modify its impact through public policy and
program interventions. This investigation utilizes available
data from a large, national sample of the Canadian Com-
munity Health Survey (CCHS) that measures both suicidal
ideation and household food insecurity in the previous
12-month time frame, which enabled analysis as to whether
these cross-sectional data are consistent with the hy-
pothesis that household food insecurity is a causal influ-
ence of suicidal ideation.
Methods
Participants and study design
The cross-sectional sample was derived from the 2007
CCHS (Cycle 4.1) which excludes those living in insti-
tutions, on Indian Reserves, Crown Lands, Canadian
Forces Bases and in very small remote communities. The
CCHS collects health status, health care utilization, and
health determinants data for the Canadian population. The
survey operates on a 2-year collection cycle; the first year
of the survey cycle ‘‘0.1’’ is a large sample, general health
survey, designed to provide reliable estimates at the health
Soc Psychiatry Psychiatr Epidemiol
region level, while the second year of the survey cycle
‘‘0.2’’ has a smaller sample and is designed to provide
provincial level results on specific focused health topics
[33].
In total, 84,973 of the selected households in the CCHS
2007 were considered in scope. Out of these, 71,922
households agreed to participate, resulting in an overall
household-level response rate of 84.6 %. Among the par-
ticipating households, 71,922 individuals (one per house-
hold) were selected to participate, and responses were
obtained for 65,946 individuals. This resulted in an overall
person-level response rate of 91.7 % and a national com-
bined response rate of 77.6 %.
Respondents were randomly recruited based on a
multi-stage sample allocation strategy which assigns
relatively equal importance to the 121 health regions
(HRs) and the provinces. For the HRs included in this
study, two sampling frames to select the sample of
households were used. The first was the area frame
(49.0 %) from the Labour Force Survey (LFS) that is
based on a two-stage stratified design in which each
stratum is formed of clusters. The LFS selects clusters
using a sampling method with a probability proportional
to size, and then the final sample is chosen using a
systematic sampling of dwellings in the cluster. The
CCHS uses the LFS clusters, which it then stratifies by
HRs and subsequently selects a sample of clusters and
dwellings in each HR. The other sampling frame used in
this investigation included a list frame of telephone
numbers (50.0 %) from an external administrative frame
of telephone numbers updated every 6 months. Tele-
phone numbers are selected using a random sampling
process in each HR. In the health regions included in
this study, 50.0 % of the sample was selected from the
area frame and 50.0 % from the list frame of telephone
numbers.
With the CCHS, the size of the sample is enlarged
during the selection process to account for non-responses
and units outside the coverage area such as vacant dwell-
ings, institutions, and telephone numbers not in use. Once
the dwelling or telephone number sample has been chosen,
then a member in each household (12 years of age or
greater) is automatically selected at the time of contact for
data collection using selection probabilities based on age
and household composition. Respondents completed the
survey via computer-assisted interviews either over the
telephone or on their personal computers.
The sample (n = 5,270) for this investigation included
publicly available data from adults (18? years) and in
health regions of three Canadian provinces that participated
in the suicide optional module of the CCHS: British
Columbia (n = 1,584), Alberta (n = 830), and Ontario
(n = 2,856).
Measurements
Dependent variable
Suicidal ideation was assessed as an affirmative response to
two questions: (1) Have you ever seriously considered
committing suicide or taking your own life? and (2) Has
this happened in the past 12 months?
Independent variable
Food insecurity was assessed using The Household Food
Security Survey Module (HFSSM). This 18-item ques-
tionnaire of food insecurity defines the concept primarily in
the context of financial constraints and is used to monitor
national rates in Canada. This measurement tool was
adapted from the food security measurement method de-
veloped in the US and has been used to monitor household
food security annually since 1995 [34]. The HFSSM con-
siders the previous 12 months and focuses on self-reports
of uncertain, insufficient or inadequate food access, avail-
ability and utilization due to limited financial resources,
and the compromised eating patterns and food consump-
tion that may result [14]. The tool is not designed to cap-
ture other possible reasons for compromised food
consumption, such as voluntary dieting or fasting. The
HFSSM is a household measure, that is, it assesses the food
security situation of adults as a group and children as a
group within a household, but does not determine the food
security status of each individual member residing in the
household. Each question specifies either a lack of money
or the ability to afford food, whatever the case may be, as
the reason for the condition or behavior. The questions
range in severity from worrying about running out of food
to children not eating for a whole day. Ten of the 18
questions are specific to the experiences of adults in the
household or the household in general (Adult Scale), while
eight are specific to the experiences of children under the
age of 18 years (Child Scale). Before being asked the items
on the HFSSM, respondents were questioned about the
food situation in their household during the previous year.
This query, also known as the ‘‘food sufficiency question’’
[14], asks respondents whether their household, in the past
12 months: (1) always had enough of the kinds of food
they wanted to eat; (2) had enough, but not always the
kinds of food they wanted to eat; (3) sometimes did not
have enough to eat; or (4) often did not have enough to eat.
This question does not specify a reason for the food
situation that exists, such as ‘‘lack of money’’. Responses
to the question do not contribute directly to the determi-
nation of food security status; however, those who agree
with statements (3) or (4) are ‘‘screened in’’ at the first level
and are asked the second set of questions in The HFSSM.
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This study used The HFSSM (modified version), whereby
individuals are then classified as being in one of three
groups:
1. Food secure (one or two affirmative responses on the
adult and/or child scale): Both the adult status and
child status are food secure. These households had
access, at all times throughout the previous year, to
enough food for an active, healthy life for all
household members.
2. Moderate food insecurity (two to five affirmative
responses on the adult scale; two to four affirmative
responses on the child scale). Either adults or children,
or both adults and children, in the household are
moderately food insecure, and neither is severely food
insecure. These households had indication of compro-
mise in quality and/or quantity of food consumed.
3. Severe food insecurity (Csix affirmative responses on
the adult scale; Cfive affirmative responses on the
child scale). Either adults or children in the household
are severely food insecure. These households had
indication of reduced food intake and disrupted eating
patterns.
Covariates
Covariates were selected based on a literature search of
suicide and food insecurity research and included sex, age,
education, relationship status, income, job status [6, 7],
body mass index [35], and reported presence of a mood
disorder [36].
Data analysis
Crude and adjusted odds ratios were estimated to assess the
association between food insecurity and the presence of
suicidal ideation. Logistic regression models tested the
hypothesis that suicidal ideation is associated with food
insecurity, after accounting for the covariates that included
socio-demographics, presence of mood disorder, and BMI.
The modeling procedures included conducting individual
regressions beginning with the variable sex and then add-
ing age followed by food insecurity. Then, subsequent
covariates were included in the model in the order they
appear in Table 3 (i.e., education added first; BMI added
last). With each model, confounding was assessed by
comparing differences in regression estimates and p values.
In addition, a likelihood ratio test was conducted to com-
pare the fit of each added model to the previous one (Null),
one of which is nested within the other. In the bivariate
analysis, trends across sex, age groups, and mood disorder
were indicated, similar to other investigations [6, 7] Thus,
to test for interaction effects, we created interaction terms
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Soc Psychiatry Psychiatr Epidemiol
with food insecurity (e.g., food insecurity 9 age), incor-
porated them in the full logistic regression model and
check for statistical significance of the individual interac-
tion variables. Analyses were conducted using STATA
11.0 (Statacorp, College Station, TX). For the final logistic
regression model, a number of diagnostics and model fit
measures were applied and included the receiver operating
curve, Wald test, collinearity test, goodness of fit statistics,
link test for model specification, as well as outlier detection
graphics and tests (e.g., Pearson residuals, Delta beta in-
fluence measures).
Results
The sample (n = 5,270) consisted mainly of females
(n = 3,184; 60.4 %), individuals between the ages of 30 to
59 (n = 3,399; 64.5 %), with at least post-secondary
education (n = 3,675; 69.7 %), in a relationship
(n = 3,941; 74.8 %), employed (n = 4,752; 90.2 %), and
did not have a mood disorder (n = 3,403; 64.6 %). Ap-
proximately, 60 % of the sample had low household in-
come (n = 2,891; 59.1 %) and were considered to be at
least in the overweight category (BMI C 25, n = 2,979,
56.5 %) (Table 1).
In the total sample (Table 1), about one-fifth
(n = 1,014; 19.2 %) indicated they experienced suicidal
ideation in the past 12 months. The proportion of females
(56.1 %) reporting suicidal ideation was significantly
higher than males (43.9 %). There was significant asso-
ciation of suicide ideation by age (18–29, 30–39, 40–49,
50–59, and 60–69 years) and the prevalence estimates of
suicide ideation in each of the age groups between 18 and
59 years ranged from 19.4 to 23.9 %. The proportion of
those with post-secondary education (62.9 %), in a rela-
tionship (70.4 %), having low household income (62.3 %),
employed (84.5 %), with a mood disorder (57.8 %) and of
overweight or obese status (52.6 %) had significantly
higher prevalence estimates of suicide ideation when tested
against the respective reference group (p \ 0.05–0.001).
Prevalence estimates of moderate and severe food in-
security in the sample were 10.9 % (574/5,270) and 8.9 %
(467/5,270), respectively (Table 1). Significant asso-
ciations were found for suicidal ideation and food insecu-
rity status across the groups defined by socio-
demographics, reported mood disorder (all p’s \ 0.001),
and BMI status (p = 0.013).
There were differences in the proportion experiencing
suicide ideation by moderate (14.7 vs 10.0 % without
suicide ideation) and severe (16.4 vs 7.1 % without suicide
ideation) food insecurity (p \ 0.001) (Table 2). Similar to
findings reported in the scientific literature [6, 7, 30, 32],
significant associations were found between suicidal
 Table 1 Description of sample (n = 5,270): counts of suicide ideation and food security status by covariates
Covariate Proportion-suicide ideationa number (95 % CI) Proportion-food security status number (95 % CI)
2
No suicide ideation Suicide ideation v , p value Food secureb Moderate food Severe food insecurityd v2, p value
(n = 4,256) (n = 1,014) (n = 4,229) insecurityc (n = 467)
(n = 574)

Sex
Males 1,641 (1,603–1,677) 445 (409–483) 9.72, p = 0.002 1,711 (1,675–1,745) 184 (159–211) 191 (166–219) 15.29, p \ 0.001
Females 2,615 (2,571–2,657) 569 (527–613) 2,518 (2,472–2,563) 390 (354–428) 276 (246–309)
Age
Soc Psychiatry Psychiatr Epidemiol

18–29 years 682 (655–707) 224 (199–251) 37.23, p \ 0.001 665 (638–691) 160 (119–163) 81 (72–108) 111.43, p \ 0.001
30–39 years 847 (821–871) 197 (173–222) 815 (787–841) 140 (119–163) 89 (72–108)
40–49 years 918 (890–945) 242 (215–270) 904 (875–931) 126 (106–148) 130 (110–153)
50–59 years 980 (953–1,006) 215 (189–242) 993 (966–1,018) 91 (74–111) 111 (92–132)
[60 years 829 (806–850) 136 (115–159) 852 (831–871) 57 (43–73) 56 (43–72)
Education
Post-secondary graduate 376 (343–410) 638 (593–684) 27.63, p \ 0.001 3,121 (3,077–3,163) 312 (280–347) 242 (213–273) 168.42, p \ 0.001
\Post-secondary education 1,219 (1,185–1,252) 3,037 (2,991–3,082) 1,108 (1,071–1,144) 262 (234–292) 4,225 (198–254)
Relationship status
In a relationship 3,227 (3,178–3,274) 714 (667–763) 12.70, p \ 0.001 3,238 (3,077–3,163) 425 (387–465) 278 (246–311) 64.91, p \ 0.001
Widowed, separated, or divorced 1,029 (998–1,059) 300 (271–331) 991 (959–1,022) 149 (127–173) 189 (165–216)
Household income (n = 4,895)
Adequate household income 2,259 (2,214–2,302) 632 (589–677) 37.58, p \ 0.001 1,891 (1,869–1,910) 82 (65–101) 31 (21–44) 437.85, p \ 0.001
Low household incomee 1,706 (1,673–1,737) 298 (267–331) 2,032 (1,983–2,080) 451 (413–491) 408 (372–446)
Job status
Employed 361 (340–381) 157 (137–179) 45.29, p \ 0.001 288 (265–310) 88 (72–106) 142 (122–163) 286.15, p \ 0.001
Unable to find a job/permanently unemployed 3,895 (3,866–3,971) 857 (805–910) 3,941 (3,889–3,991) 486 (446–529) 325 (292–361)
Mood disorder
Yes 1,281 (1,241–1,320) 586 (547–626) 274.51, p \ 0.001 1,312 (1,271–1,351) 281 (251–313) 274 (245–306) 192.03, p \ 0.001
No 2,975 (2,935–3,012) 428 (391–468) 2,917 (2,875–2,956) 293 (262–327) 193 (167–221)
Body Mass Index (BMI)
Healthy weight (B24.9) 1,810 (1,770–1,848) 481 (443–521) 8.03, p = 0.005 1,862 (1,824–1,898) 217 (190–246) 212 (186–241) 8.74, p = 0.0127
Overweight/obese (C25) 2,446 (2,404–2,487) 533 (492–575) 2,367 (2,322–2,410) 357 (323–393) 255 (226–287)
a
Affirmative responses to two questions: (1) Have you ever seriously considered committing suicide or taking your own life? and (2) Has this happened in the past 12 months?
b
Both the adult and child status are food secure. These households had access, at all times throughout the previous year, to enough food for an active, healthy life for all household members
c
Either adults or children, or both adults and children, in the household are moderately food insecure. These households had indication of compromise in quality and/or quantity of food
consumed
d
Either adults or children in the household are severely food insecure. These households had indication of reduced food intake and disrupted eating patterns
e
Based on Statistics Canada defined low income cutoffs (LICO) [37]

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 Table 2 Proportions of suicidal ideation by food security status for all covariates
Covariate Proportion-food security status by suicide ideation (95 % CI)

123
Food securea (n = 4,229) Moderate food insecurityb (n = 574) Severe food insecurityc (n = 467)
Suicide ideationd No suicide ideation Suicide ideationd No suicide ideation Suicide ideationd No suicide ideation
(n = 699) (n = 3,530) (n = 149) (n = 425) (n = 166) (n = 301)

Sex*
Males 45.2 (42.2–48.2) 60.5 (57.5–63.5) 30.9 (22.8–38.9) 67.5 (59.3–75.8) 50.0 (41.0–59.0) 64.1 (55.1–73.1)
Females 54.8 (51.8–57.8) 39.5 (36.5–42.5) 69.1 (61.1–77.2) 32.5 (24.2–40.7) 50.0 (41.0–59.0) 35.9 (26.9–44.9)
Age**
18–29 years 20.7 (17.7–23.7) 14.7 (11.7–17.7) 32.9 (24.8–40.9) 26.1 (17.9–34.4) 18.1 (9.0–27.1) 16.9 (8.0–25.9)
30–39 years 18.7 (15.7–21.7) 19.4 (16.4–22.4) 22.8 (14.8–30.9) 24.9 (16.7–33.2) 19.3 (10.2–28.3) 18.9 (10.0–27.9)
40–49 years 23.0 (20.0–26.0) 21.0 (18.0–24.1) 20.1 (12.1–28.2) 22.6 (14.4–30.8) 30.7 (21.7–39.8) 26.2 (17.3–35.2)
50–59 years 21.9 (18.9–24.9) 23.8 (20.8–26.8) 18.1 (10.1–26.2) 15.1 (6.8–23.3) 21.1 (12.0–30.1) 25.2 (16.3–34.2)
[60 years 15.6 (12.6–18.6) 21.0 (18.0–24.1) 6.0 (2.0–14.1) 11.3 (3.1–19.5) 10.8 (1.8–19.9) 12.6 (3.7–21.6)
Education**
Post-secondary graduate 67.8 (64.8–70.8) 75.0 (63.8–78.0) 52.3 (44.3–60.4) 55.1 (46.8–63.3) 51.8 (42.8–60.8) 51.8 (42.9–60.8)
\Post-secondary education 32.2 (29.2–35.2) 25.0 (22.0–28.0) 47.7 (39.6–55.7) 44.9 (36.7–53.2) 48.2 (39.2–57.2) 48.2 (39.2–57.1)
Relationship status**
In a relationship 25.9 (22.9–28.9) 77.1 (74.1–80.1) 29.5 (21.5–37.6) 72.9 (64.7–81.2) 45.2 (36.1–54.2) 62.1 (53.2–71.1)
Widowed, separated, or divorced 74.1 (71.1–77.1) 22.9 (19.9–25.9) 70.5 (62.4–78.5) 24.7 (16.5–32.9) 54.8 (45.8–63.9) 37.9 (28.9–46.8)
Household income**
Low household incomee 53.9 (50.9–56.9) 46.9 (43.9–49.9) 76.5 (68.5–84.6) 79.3 (71.1–87.5) 84.9 (75.9–94.0) 88.7 (79.7–97.7)
Adequate household income 37.9 (34.9–40.9) 46.1 (43.1–49.1) 13.4 (5.4–21.5) 14.6 (6.4–22.8) 7.8 (1.2–16.9) 6.0 (3.0–15.0)
Job status**
Employed 90.4 (87.4–93.4) 93.7 (90.7–96.7) 80.5 (72.5–88.6) 86.1 (77.9–94.4) 63.3 (54.2–72.3) 73.1 (64.1–82.1)
Unable to find a job/permanently unemployed 9.6 (6.6–12.6) 6.3 (3.3–9.3) 19.5 (11.4–27.5 % 13.9 (5.6–22.1) 36.7 (27.7–45.8) 26.9 (17.9–34.2)
Mood disorder**
Yes 51.2 (48.2–54.2) 27.0 (24.0–30.0) 65.8 (57.7–73.8) 43.1 (34.8–51.3) 78.3 (69.3–87.3) 47.8 (38.9–56.8)
No 48.8 (45.8–51.8) 73.0 (70.0–76.0) 34.2 (26.2–42.3) 56.9 (48.7–65.2) 21.7 (12.7–30.7) 52.2 (43.2–61.1)
BMI?
Healthy weight (18.5–24.9) 47.2 (44.2–50.2) 43.4 (40.4–46.4) 45.6 (37.6–53.7) 35.1 (26.8–43.3) 50.0 (41.0–59.0) 42.9 (33.9–51.8)
Overweight/obese (C25) 52.8 (49.8–55.8) 56.6 (53.6–59.6) 54.4 (46.3–62.4) 64.9 (56.7–73.2) 50.0 (41.0–59.0) 57.1 (48.2–66.1)
*
Significant association found among the suicide ideation and no suicide ideation groups at p \ 0.05; for sex p = 0.001
**
Significant association found among the suicide ideation and no suicide ideation groups at p \ 0.001
?
Significant association found among the no suicide ideation groups at p = 0.004; no significant association among the suicide ideation group
a
Both the adult status and child status are food secure. These households had access, at all times throughout the previous year, to enough food for an active, healthy life for all household
members
b
Either adults or children, or both adults and children, in the household are moderately food insecure. These households had indication of compromise in quality and/or quantity of food
consumed
c
Either adults or children in the household are severely food insecure. These households had indication of reduced food intake and disrupted eating patterns
d
Affirmative responses to two questions: (1) Have you ever seriously considered committing suicide or taking your own life? and (2) Has this happened in the past 12 months?
e
Based on Statistics Canada defined low income cutoffs (LICO) [37]
Soc Psychiatry Psychiatr Epidemiol
Soc Psychiatry Psychiatr Epidemiol

Table 3 Odds ratios for suicidal ideation: unadjusted and derived from all inclusive and reduced logistic regression models
Variable (reference) Odds ratio, unadjusted p value Model 1 all inclusive Final model
(95 % CI)
Odds ratio, adjusted p value Odds ratio, adjusted p value
(95 % CI) (95 % CI)

Food insecurity status (food secure)

Moderate food insecuritya 1.77 (1.43–2.18) \0.001 1.24 (0.98–1.56) 0.071 1.32 (1.06–1.64) 0.012
Severe food insecurityb 2.79 (2.25–3.44) \0.001 1.62 (1.33–2.15) \0.001 1.77 (1.42–2.23) \0.001
Covariates
Sex (female) 1.25 (1.08–1.43) 0.002 1.52 (1.30–1.77) \ 0.001 1.49 (1.28–1.73) \ 0.001
Age (18–29 years)
30–39 years 0.71 (0.57-0.88) 0.002 0.68 (0.54–0.87) 0.002 0.68 (0.54–0.85) 0.001
40–49 years 0.80 (0.65–0.99) 0.037 0.65 (0.52–0.83) \0.001 0.66 (0.53–0.83) \0.001
50 to 59 years 0.67 (0.54–0.83) \0.001 0.59 (0.46–0.75) \0.001 0.56 (0.44–0.71) \0.001
[60 years 0.50 (0.39–0.64) \0.001 0.44 (0.33–0.58) \0.001 0.44 (0.33–0.57) \0.001
Education (post-secondary graduate) 0.68 (0.59–0.79) \0.001 0.84 (0.71–0.99) 0.037 0.82 (0.71–0.96) 0.015
Relationship status (in a relationship) 1.32 (1.13–1.54) \0.001 1.32 (1.10–1.59) 0.003 1.40 (1.17–1.67) \0.001
Income (adequate household income) 1.60 (1.37–1.87) \0.001 1.13 (0.95–1.35) 0.168 – –
Job status (Unable to find a job/ 1.97 (1.61–2.43) \0.001 1.25 (0.99–1.58) 0.064 1.28 (1.02–1.60) 0.036
permanently unemployed)
Mood disorder (no) 3.18 (2.76–3.67) \0.001 3.02 (2.58–3.54) \0.001 3.06 (2.63–3.55) \0.001
BMI (C25) 0.82 (0.71–0.94) 0.005 0.79 (0.68–0.92) 0.002 0.77 (0.66–0.89) \0.001
a
Either adults or children, or both adults and children, in the household are moderately food insecure. These households had indication of
compromise in quality and/or quantity of food consumed
b
Either adults or children in the household are severely food insecure. These households had indication of reduced food intake and disrupted
eating patterns

ideation and the three food security status types by all
covariates (p \ 0.05–0.001) except BMI status where only
significant associations were found among those without
suicidal ideation (p \ 0.05). Suicidal ideation for those
experiencing moderate food insecurity tended to be more
prevalent in females (69.1 %), individuals between the
ages of 18–29 years (32.9 %), not in a relationship
(70.5 %), having low household income (76.5 %), em-
ployed (80.5 %), with a mood disorder (65.8 %), and of
overweight or obese status (54.4 %). For those experienc-
ing severe food insecurity, suicide ideation was more
prevalent in those 40–49 years (30.7 %), widowed,
separated, or divorced (54.8 %), with low household in-
come (84.9 %), employed (63.3 %), and with a mood
disorder (78.3 %).
The crude odds ratios of suicidal ideation and food in-
security status showed significant association for both
moderate (OR = 1.77, 95 % CI 1.43–2.18, p \ 0.001) and
severe (OR = 2.79, 95 % CI 2.25–3.44, p \ 0.001) levels
(Table 3). In comparison to the reference groups for all
covariates, there was significant association with suicidal
ideation (p values ranging from 0.037 to \0.001). In the
full model, all adjusted odds ratios were significant (all
p values \0.05) with the exception of income. For the final
model, income was excluded from the analysis as it was
not significant and all of the other covariates remaining in
the selected model were significant (all p values \0.05).
With adjustment for all covariates in the final model, in-
cluding presence of a mood disorder, those experiencing
moderate food insecurity were 32 % (OR = 1.32, 95 % CI
1.06–1.64, p = 0.012) more likely to report suicidal idea-
tion; the likelihood of suicidal ideation increases to 77 % in
those experiencing severe food insecurity (OR = 1.77,
95 % CI 1.42–2.23, p \ 0.001). The various tests applied
to assess the adequacy of the final fitted logistic regression
model indicated appropriate results including goodness of
fit (Hosmer–Lemeshow v2 (8) = 4.14, p = 0.84). While
deviance and Pearson residual plots showed a few outliers,
they were determined to not have a substantial impact on
the fitted logistic regression.
Discussion
The significant associations found in this study are con-
sistent with the hypothesis that household food insecurity is
a causal influence on suicidal ideation. Given that the
likelihood of suicide ideation increased with level of food
insecurity severity, there is some evidence that could point
to a dose–response relationship. However, the inference of

123

an incremental effect by food security severity may be
challenged based on issues of insufficient statistical power,
confounding, bias, and temporality.
Much of the literature that links food insecurity and
suicidal ideation comes from studies of depression, a
common experience that occurs with suicidality. Among
populations encountering food insecurity, rates of depres-
sion are much higher than in the general population [38,
39], and longitudinal research has demonstrated that a
bidirectional relationship exists between food insecurity
and depression [40, 41].
An important finding of our study is that the association
between food insecurity and suicidal ideation remained
after adjustment for income. Similar results were found in
one longitudinal investigation that food insecurity may be a
causal or contributing factor to depression, independent of
poverty [42]. Our findings suggest food insecurity is an
isolated determinant of suicidal ideation and highlights the
areas of where future investigation may be undertaken. The
association between levels of household food insecurity
and suicidal ideation may be related to exposure to vio-
lence, abuse and neglect and their profound impacts on
mental health such as the elicitation of self-loathing, feel-
ings of hopelessness, and thoughts that death may serve as
a means of relief [20, 42]. Thus, a challenge for future
investigative work and systems designed to address suicide
should account for the ramifications of trauma and house-
hold food insecurity.
There are many possible explanations for the association
we found between food insecurity and suicidal ideation.
One is the potential role of nutritional deficiencies and their
impact on mental health. Food insecurity has been asso-
ciated with nutritional inadequacies of various micronu-
trients such as iron and calcium [43, 44]. Similarly,
potential deficiencies of folate, vitamin C, and iron have
been indicated in depression and mania [45], mood states
with strong links to suicide [46]. Finally, persons who at-
tempted suicide have been found to have larger amounts of
fat and lower quantities of meat, fish, fruits and vegetables
in their diets, as well as decreased essential fatty acid levels
in their blood when compared with non-attempting indi-
viduals [47, 48].
Another mechanism linking suicide and food insecurity
relates to the physiological responses to stress from the
extreme worry and anxiety of not having enough money
to feed oneself and/or one’s family [42, 49], which could
contribute to maladaptive responses, including impairment
in thought processes, concentration, and decision making
[21], leading to suicidal ideation. Studies have demon-
strated an association between lifetime prevalence of
suicidal ideation and food insecurity, which suggests that
the relationship may be due to the cumulative effects of
stress.
123
Soc Psychiatry Psychiatr Epidemiol
While some interesting associations between several of
the sociodemographic measures and suicidal ideation were
found in this investigation, they may not necessarily be valid
due to the effects of random error or bias. As previously
mentioned, no association between income and suicidal
ideation was found. Possible explanations for this may be
due to reporting of household rather than the individual level
of income. In addition, another study [50] has shown that the
association between income and suicide ideation occurs
only in males. It was also surprising that post-secondary
graduation was associated with suicidal ideation, however,
other research has suggested that individuals with higher
educational achievement are more prone to suicide and this
may be more likely when facing failures, public shame, and
high premorbid functioning [51]. The association between
being employed and suicidal ideation also seems counter-
intuitive, however, the CCHS’s measure of work status in-
cluded under-employment which has been shown to be
significantly correlated with high suicide rates [52].
Limitations
The main limitation of this study is its cross-sectional de-
sign and the inability to ascertain the direction of causality
between food insecurity and suicidal ideation. However,
longitudinal research suggests that relationships between
food insecurity and mental health outcomes related to
suicide (i.e., depression) are both reinforcing and bidirec-
tional [53].
Another limitation of this study was the measurement of
food insecurity. Because the HFSSM is a household-level
measure, it is possible that the participants’ individual
experiences of food insecurity were under-reported. Fur-
thermore, the means in which food insecurity is defined in
this study does not necessarily capture the complexity and
scope of its effects at the individual level of those vul-
nerable to and experiencing mental ill health. The various
measures of food insecurity serve different purposes that
include for research, programmatic needs assessment and
design, monitoring and evaluation, or clinical management.
In mental health populations, the impact of food insecurity
may be unique in that physiological, economic, socio-cul-
tural, and/or psychosocial factors intersect. Health re-
searchers, policy makers, practitioners, and decision
makers need to understand how these factors may converge
with individual and household-level food insecurity and
create differing trajectories related to suicidal behavior.
Finally, a few additional study limitations are worthy to
note. This study used self-report of suicidal ideation which
may be subject to underreport due to associated stigmas.
While suicide attempts and completions are part of the
same clinical and familial spectrum of suicidal behavior
[5], suicidal ideation may not be; however, suicidal
Soc Psychiatry Psychiatr Epidemiol
ideation is a predictor of suicide [54]. Finally, the com-
position of the sample and lack of availability of other
important variables such as exposure to childhood stres-
sors, immigration status, and ethnicity, all of which may
increase vulnerability to food insecurity [53], could not be
included in the analysis. To fully understand the relation-
ship between suicidal ideation and food insecurity, several
factors such as genetic inheritance, stressors (e.g., life
events), mediators (e.g., coping, nutritional status), mod-
erators (e.g., social support, negative affectivity), and epi-
genetic modifications [55, 56] would need to be examined.
While we were unable to statistically control for different
mental health conditions, mood disorders were included in
our analysis; the most common psychiatric diagnosis
linked with suicide [46]. However, mood disorder status
was based on self-report which is not necessarily a reliable
and valid indicator of diagnosis.
Food insecurity is a foundational determinant of health
and an increasingly urgent public health challenge as rates
have risen dramatically since the global economic decline
[8]. The results of this study have shown an important
association between a validated multi-item measure of
household food insecurity and suicidal ideation that was
robust to alternative specifications. These findings in-
crease awareness of the scope and seriousness of food
insecurity, a specific and policy-relevant mark of uncer-
tainty experienced in daily living. The association be-
tween suicidal ideation and food insecurity offers policy
makers and professionals an important role in the reduc-
tion of morbidity and mortality that is amenable to policy
and program interventions such as those that target suf-
ficient income and secure employment [57, 58]. Addi-
tional research, especially prospective, longitudinal
investigations that include measures of the various di-
mensions of food insecurity, nutritional status, and stress,
is needed to understand the etiological pathways of food
insecurity and suicide.
Acknowledgments The researchers would like to thank statistician
Dr. Jonathan Berkowitz for providing his expertise and assistance
with the analysis of the data. Financial support for analysis associated
with this project was made available from Public Health Agency of
Canada which played no role in carrying out the study, analyzing the
results, or influencing publication.
Conflict of interest None.
Ethics approval Not required for population-based dataset.
References
1. World Health Organization (2012) Public health action for the
prevention of suicide: a framework. World Health Organization,
Geneva. http://apps.who.int/iris/bitstream/10665/75166/1/978924
1503570_eng.pdf
2. Swanson SA, Colman I (2013) Association between exposure to
suicide and suicidality outcomes in youth. CMAJ 185(10):870–877.
doi:10.1503/cmaj.121377
3. Hawton K, Van Heeringen K (2009) Suicide. Lancet 373(9672):
1372–2381. doi:10.1016/S0140-6736(09)60372-X
4. Mann JJ (2002) A current perspective of suicide and attempted
suicide. Ann Intern Med 136(4):302–311
5. Liu X, Tein JY (2005) Life events, psychopathology, and suicidal
behavior in Chinese adolescents. J Affect Dis 86(2–3):195–203
6. Wray M, Colen C, Pescosolido B (2011) The Sociology of Sui-
cide. Annu Rev Sociol 37:505–528. doi:10.1146/annurev-soc-
081309-150058
7. Clouston SA, Rubin MS, Colen CG, Link BG (2014) Social
inequalities in suicide: the role of selective serotonin reuptake
inhibitors. Am J Epidemiol 180(7):696–704. doi:10.1093/aje/
kwu191
8. Tarasuk V, Mitchell A, Dachner N (2014) Household food in-
security in Canada, 2012. Research to identify policy options to
reduce food insecurity (PROOF): 2014. Toronto. Retrieved from
http://nutritionalsciences.lamp.utoronto.ca/wp-content/uploads/
2014/05/Household_Food_Insecurity_in_Canada-2012_ENG.pdf.
Accessed 30 Dec 2014
9. Power E (2015) Dietitians of Canada—background to position:
Individual and Household Food Insecurity in Canada. Dietitians
of Canada, Toronto. (in press)
10. Alaimo K, Briefel RR, Frongillo EA Jr, Olson CM (1998) Food
insufficiency exists in the United States: results from the third
National Health and Nutrition Examination Survey (NHANES
III). Am J Public Health 88(3):419–426
11. Rose D (1999) Economic determinants and dietary consequences
of food insecurity in the United States. J Nutr 129(2S Suppl):
517S–520S
12. Che J, Chen J (2001) Food insecurity in Canadian households
[1998/99 data]. Health Rep 12(4):11–22
13. Bukusuba J, Kikafunda JK, Whitehead RG (2007) Food security
status in households of people living with HIV/AIDS (PLWHA)
in a Ugandan urban setting. Br J Nutr 98(1):211–217
14. Health Canada (2012) The Household Food Security Survey
Module (HFSSM). Health Canada, Ottawa
15. Health Canada (2007) Canadian Community Health Survey Cy-
cle 2.2, Nutrition -Income-Related Household Food Security in
Canada. Health Canada, Ottawa
16. Markwick A, Ansari Z, Sullivan M, McNeil J (2014) Social de-
terminants and lifestyle risk factors only partially explain the
higher prevalence of food insecurity among Aboriginal and
Torres Strait Islanders in the Australian state of Victoria: a cross-
sectional study. BMC Public Health 14:598. doi:10.1186/1471-
2458-14-598
17. Hyder AA, Maman S, Nyoni JE, Khasiani SA, Teoh N, Premji Z,
Sohani S (2005) The pervasive triad of food security, gender
inequity and women’s health: exploratory research from sub-Sa-
haran Africa. Afr Health Sci 5(4):328–334
18. Stuff JE, Casey PH, Szeto KL, Gossett JM, Robbins JM,
Simpson PM, Connell C, Bogle ML (2004) Household food
insecurity is associated with adult health status. J Nutr
134(9):2330–2335
19. Siefert K, Heflin CM, Corcoran M, Williams DR (2004) Food
insufficiency and physical and mental health in a longitudinal
survey of welfare recipients. J Health Soc Behav 45:171–186
20. Chilton M, Booth S (2007) Hunger of the body and hunger of the
mind: African American women’s perceptions of food insecurity,
health and violence. J Nutr Educ Behav 39(3):116–125
21. Melchior M, Caspi A, Howard LM, Ambler AP, Bolton H,
Mountain N, Moffitt TE (2009) Mental health context of food
insecurity: a representative cohort of families with young chil-
dren. Pediatrics 124(4):e564–e572
123

22. Anema A, Wood E, Weiser SD, Qi J, Montaner JS, Kerr T (2010)
Hunger and associated harms among injection drug users in an
urban Canadian setting. Subst Abus Treat Prev Policy 5:20
23. Polivy J (1996) Psychological consequences of food restriction.
J Am Diet Assoc 96:589–592
24. Heller J, Edelmann RJ (1991) Compliance with a low calorie diet
for two weeks and concurrent and subsequent mood changes.
Appetite 17(1):23–28
25. Coelho JS, Polivy J, Herman CP (2006) Selective carbohydrate or
protein restriction: effects on subsequent food intake and crav-
ings. Appetite 47(3):352–360
26. Keys A, Brozek J, Henschel A, Mickelsen O, Longstreet Taylor
H (1950) The biology of human starvation, vol 2. University of
Minnesota Press, Minneapolis
27. Weinreb L, Wehler C, Perloff J, Scott R, Hosmer D, Sagor L,
Gundersen C (2002) Hunger: its impact on children’s health and
mental health. Pediatrics 110(4):e41
28. Slopen N, Fitzmaurice G, Williams DR, Gilman SE (2010)
Poverty, food insecurity, and the behavior for childhood inter-
nalizing and externalizing disorders. J Am Acad Child Adolesc
Psychiatry 49(5):444–452
29. Belsky DW, Moffitt TE, Arseneault L, Melchior M, Caspi A
(2010) Context and sequelae of food insecurity in children’s
development. Am J Epidemiol 172(7):809–818. doi:10.1093/aje/
kwq201
30. Alaimo K, Olson CM, Frongillo EA Jr (2001) Food insufficiency
and American school-aged children’s cognitive, academic, and
psychosocial development. Pediatrics 108(1):44–53
31. McIntyre L, Williams JVA, Lavorato DH, Patten S (2013) De-
pression and suicide ideation in late adolescence and early
adulthood are an outcome of child hunger. J Affect Disord
150(1):123–129. doi:10.1016/j.jad.2012.11.029
32. Alaimo K, Olson CM, Frongillo EA (2002) Family food insuf-
ficiency, but not low family income, is positively associated with
dysthymia and suicide symptoms in adolescents. J Nutr 132(4):
719–725
33. Statistics Canada (2008) Canadian Community Health Survey—
Annual Component (CCHS). Statistics Canada, Ottawa. Avail-
able from: http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=
getSurvey&SurvId=50653&InstaId=29539&SDDS=3226 (cited
July 15, 2014)
34. Bickel G, Nord M, Price C, Hamilton W, Cook J (2010) Mea-
suring Food Security in the United States: Guide to Measuring
Household Food Insecurity. Office of Analysis, Nutrition, and
Evaluation, Food and Nutrition Service, Alexandria
35. Sörberg A, Gunnell D, Falkstedt D, Allebeck P, Åberg M,
Hemmingsson T (2014) Body mass index in young adulthood and
suicidal behavior up to age 59 in a cohort of Swedish men. PLoS
One 9(7):e101213. doi:10.1371/journal.pone.0101213
36. Rihmer Z (2007) Suicide risk in mood disorders. Curr Opin
Psychiatry 20(1):17–22
37. Statistics Canada (2008) Low income cut-offs for 2008 and low
income measures for 2007. Statistics Canada, Ottawa. Available
from: http://www.statcan.gc.ca/pub/75f0002m/75f0002m2009002-
eng.pdf (cited July 15, 2014)
38. Vozoris N, Tarasuk V (2003) Household food insufficiency is
associated with poorer health. J Nutr 133(1):120–126
39. Muldoon KA, Duff PK, Fielden S, Anema A (2013) Food in-
sufficiency is associated with psychiatric morbidity in a nation-
ally representative study of mental illness among food insecure
Canadians. Soc Psychiatry Psychiatr Epidemiol 48(5):795–803.
doi:10.1007/s00127-012-0597-3
40. Heflin CM, Siefert K, Williams DR (2005) Food insufficiency
and women’s mental health: findings from a 3-year panel of
welfare recipients. Soc Sci Med 61(9):1971–1982
123
Soc Psychiatry Psychiatr Epidemiol
41. Huddleston-Casas C, Charigo R, Simmons LA (2008) Food inse-
curity and maternal depression in rural, low-income families: a
longitudinal investigation. Public Health Nutr 12(8):1133–1140.
doi:10.1017/S1368980008003650
42. Chilton MM, Rabinowich JR, Woolf NH (2014) Very low food
security in the USA is linked with exposure to violence. Public
Health Nutr 17(1):73–82. doi:10.1017/S1368980013000281
43. Eicher-Miller HA, Mason AC, Weaver CM et al (2009) Food
insecurity is associated with iron deficiency anemia in US ado-
lescents. Am J Clin Nutr 90(5):1358–1371. doi:10.3945/ajcn.
2009.27886
44. Eicher-Miller HA, Mason AC, Weaver CM, McCabe GP, Boushey
CJ (2011) Food insecurity is associated with diet and bone mass
disparities in early adolescent males but not females in the United
States. J Nutr 141:1738–1745. doi:10.3945/jn.111.142059
45. Davison KM, Kaplan BJ (2011) Vitamin and mineral intakes in
adults with mood disorders: comparisons to nutrition standards
and associations with sociodemographic and clinical variables.
J Am Coll Nutr 30(6):547–558
46. Fawcett J (2012) Diagnosis, traits, states, and comorbidity in
suicide. In: Dwivedi Y (ed) The neurobiological basis of suicide.
CRC Press, Boca Raton
47. Huan M, Hamazaki K, Sun Y, Itomura M, Liu H, Kang W,
Watanabe S, Terasawa K, Hamazaki T (2004) Suicide attempt
and n-3 fatty acid levels in red blood cells: a case control study in
China. Biol Psychiatry 56(7):490–496
48. Li Y, Zhang J, McKeown R (2009) Cross-sectional assessment of
diet quality in individuals with a lifetime history of attempted
suicide. Psychiatry Res 165(1–2):111–119. doi:10.1016/j.psy
chres.2007.09.004
49. Hammen C, Brennan PA (2002) Interpersonal dysfunction in
depressed women: impairments independent of depressive
symptoms. J Affect Disord 72(2):145–156
50. Crump C, Sundquist K, Sundquist J, Winkleby MA (2014) So-
ciodemographic, psychiatric and somatic risk factors for suicide:
a Swedish national cohort study. Psychol Med 44(2):279–289.
doi:10.1017/S0033291713000810
51. Pompili M, Vichi M, Qin P (2013) Does the level of education
influence completed suicide? A nationwide register study. J Af-
fect Disord 147(1–3):437–449. doi:10.1016/j.jad.2012.08.046
52. Page A, Milner A, Morrell S, Taylor R (2013) The role of under-
employment and unemployment in recent birth cohort effects in
Australian suicide. Soc Sci Med 93:155–162. doi:10.1016/j.socs
cimed.2013.03.039
53. Tarasuk V, Mitchell A, McLaren L, McIntyre L (2013) Chronic
physical and mental health conditions among adults may increase
vulnerability to household food insecurity. J Nutr 143:1785–1793.
doi:10.3945/jn.113.178483
54. Brown GK (2002) A review of suicide assessment measures for
intervention research in adults and older adults. Technical report
submitted to NIMH under Contract No. 263-MH914950. National
Institute of Mental Health, Bethesda
55. Taylor SE (2010) Mechanisms linking early life stress to adult
health outcomes. Proc Nat Acad Sci 107(19):8507–8512. doi:10.
1073/pnas.1003890107
56. Szyf M, McGowan P, Meaney MJ (2008) The social environment
and the epigenome. Environ Mol Mutagen 49:46–60. doi:10.
1016/j.bbagen.2009.01.009
57. Forget EL (2011) The town with no poverty: the health effects of
a Canadian Guaranteed Annual Income field experiment. Can
Public Policy 37(3):283–305
58. Loopstra R, Tarasuk V (2013) Severity of household food inse-
curity is sensitive to change in household income and employment
status among low-income families. J Nutr 143(8):1316–1323.
doi:10.3945/jn.113.175414