Food Insecurity and Mental Health among Females in High-Income Countries

Food insecurity is a persistent concern in high-income countries, and has been associated with poor mental health, particularly among females. We conducted a scoping review to characterize the state of the evidence on food insecurity and mental health among women in high-income countries. The research databases PubMed, EMBASE, and psycINFO were searched using keywords capturing food insecurity, mental health, and women. Thirty-nine articles (representing 31 unique studies/surveys) were identified. Three-quarters of the articles drew upon data from a version of the United States Department of Agriculture Household Food Security Survey Module. A range of mental health measures were used, most commonly to measure depression and depressive symptoms, but also anxiety and stress. Most research was cross-sectional and showed associations between depression and food insecurity; longitudinal analyses suggested bidirectional relationships (with food insecurity increasing the risk of depressive symptoms or diagnosis, or depression predicting food insecurity). Several articles focused on vulnerable subgroups, such as pregnant women and mothers, women at risk of homelessness, refugees, and those who had been exposed to violence or substance abuse. Overall, this review supports a link between food insecurity and mental health (and other factors, such as housing circumstances and exposure to violence) among women in high-income countries and underscores the need for comprehensive policies and programs that recognize complex links among public health challenges.


Introduction
Food insecurity is a growing and persistent concern in high-income countries [1,2]. In North America, rates of household food insecurity have remained stable or risen in the last several years [3,4]. High rates have also been documented in the UK and Australia [5,6]. According to the Food and Agriculture Organization, "food security exists when all people, at all times, have physical, social, and economic access to sufficient safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life" [7].Conceptualizations of food insecurity in high-income countries primarily focus on the economic aspect; for example, the Household Food Security Survey Module (HFSSM) [8], which is commonly used in the United States and Canada, measures uncertain or inadequate access to food due to financial constraints. This conceptualization aligns with literature linking vulnerability to food insecurity to high rates of poverty, particularly among population subgroups, such as single-parent households, racial/ethnic minorities, and those relying on social assistance [2][3][4][9][10][11][12][13].
Among population subgroups in high-income countries, food insecurity has been shown to be associated with compromised nutrition [14], poor general health, and a myriad of chronic health conditions [15,16]. Food insecurity has also been shown to be a marker of poor mental health, with studies identifying associations with mood and anxiety disorders and suicidal ideation, particularly among women [16][17][18]. Indeed, severity of household food insecurity appears to be linked with poor mental health in a dose-response manner, with experiences of severe food insecurity representing extreme chronic stress [19] and possibly acting as an independent determinant of suicidal ideation [20].
The relationship between food insecurity and poor mental health among women is of particular concern given that they are disproportionately impacted by food insecurity [2][3][4]21]. Women are overrepresented among low-income groups compared to men, with visible minority women and single mothers experiencing high rates of poverty in Canada and the United States [9][10][11]. Further, the existing literature suggests that women may be particularly vulnerable to poor mental health in conjunction with poverty and food insecurity [12] and for women with children, that the stress associated with these experiences has possible ripple effects, negatively impacting their children's physical and mental health as well [13].
To identify future research needs and inform policy and program responses, we conducted a scoping review to examine the state of the literature on food insecurity and mental health among women living in high-income countries.

Materials and Methods
The scoping review was conducted according to steps outlined by Arksey and O'Malley [22]. Scoping reviews, which use systematic search techniques, are appropriate when the aim is to address a broad question, such as querying the state of the evidence on a topic (especially when study designs may vary) and identifying gaps in that evidence [22] to inform future research and practice. As per Arksey and O'Malley [22], steps in the process include identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. Reporting follows the PRISMA guidelines [23].

Identifying Relevant Studies
The systematic search, developed in consultation with a librarian who is an expert in systematic searching, was conducted using the research databases PubMed, EMBASE, and psycINFO to capture records published up to May 2016. Given the range of possible mental health conditions, the search strategy was quite broad. Key words and Medical Subject Headings (MeSH) included "food" OR "nutrition" OR "diet" AND "security" OR "insecurity" OR "insufficiency" OR "scarcity" OR "*adequacy" OR "hunger" OR "poverty" OR "food supply" OR "nutritional requirements/status" AND "anxiety" OR "depression" OR "mental health" OR "mental health disorder" OR "mental health illness" OR "psychosis" OR "emotional disorder" OR "mania" OR "mental disease" OR "phobia" OR "mental disturbance/health/psychology". The key words and MESH headings to capture women included "women" OR "woman" OR "female" OR "pregnancy" OR "sex factors" OR "women's rights" OR "mothers" OR "girl" (note: * indicates a wildcard, which allows searching a range of terms related to a root word). The initial search elicited a total of 13,645 citations (excluding duplicates) ( Figure 1).

Study Selection
Articles deemed eligible quantitatively examined associations between food insecurity and indicators of mental health, with a focus on females in high-income countries; studies that included both males and females but reported analyses stratified by sex were also considered. Specific criteria related to age were not applied, allowing consideration of studies reporting on adolescent girls as well as women. Studies published since 1990 (to provide insights into relatively recent research on the topic of food insecurity) were considered.
An initial screening of titles and abstracts was conducted by one author (S.P.-M.) to identify potentially relevant peer-reviewed articles that addressed food insecurity and health, leaving 221 citations for further review ( Figure 1). Abstracts for these 221 citations were screened independently by a second author (M.M. or S.I.K.) and discrepancies resolved, leaving 86 citations for full-text review. After full-text screening (conducted independently by two authors), 39 articles remained, representing 31 unique studies/surveys. Separate articles making use of data from the same study or survey were examined and charted to identify salient characteristics related to measurement of food security and mental health and the examination of associations between the two.

Charting the Data
A data abstraction form guided extraction of the characteristics of interest, including study setting and population, study design, main study objectives, measures used to assess food security and mental health and specific mental health states considered, and analytic approach and findings.

Collating, Summarizing, and Reporting the Results
The abstracted data were assessed in terms of patterns in measures and tools used and associations between food insecurity and depression (the most frequently examined mental health measure) and other mental health markers. Given that we conducted a scoping rather than a

Study Selection
Articles deemed eligible quantitatively examined associations between food insecurity and indicators of mental health, with a focus on females in high-income countries; studies that included both males and females but reported analyses stratified by sex were also considered. Specific criteria related to age were not applied, allowing consideration of studies reporting on adolescent girls as well as women. Studies published since 1990 (to provide insights into relatively recent research on the topic of food insecurity) were considered.
An initial screening of titles and abstracts was conducted by one author (S.P.-M.) to identify potentially relevant peer-reviewed articles that addressed food insecurity and health, leaving 221 citations for further review ( Figure 1). Abstracts for these 221 citations were screened independently by a second author (M.M. or S.I.K.) and discrepancies resolved, leaving 86 citations for full-text review. After full-text screening (conducted independently by two authors), 39 articles remained, representing 31 unique studies/surveys. Separate articles making use of data from the same study or survey were examined and charted to identify salient characteristics related to measurement of food security and mental health and the examination of associations between the two.

Charting the Data
A data abstraction form guided extraction of the characteristics of interest, including study setting and population, study design, main study objectives, measures used to assess food security and mental health and specific mental health states considered, and analytic approach and findings.

Collating, Summarizing, and Reporting the Results
The abstracted data were assessed in terms of patterns in measures and tools used and associations between food insecurity and depression (the most frequently examined mental health measure) and other mental health markers. Given that we conducted a scoping rather than a systematic review, formal quality appraisal of studies was not conducted [22]. However, in addition to synthesizing the evidence emerging from this literature, we comment on the characteristics of the available research, in terms of study design for example, to inform future research.

Overview of Included Articles
The characteristics of the 39 articles are outlined in Appendix A. Over half (n = 23) were published from 2010 on [15][16][17][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]. The majority (n = 34) analyzed data from studies conducted in the United States, three focused on studies conducted in Canada [16,17,32], one was focused on a sample in New Zealand [43], and one was conducted in England [44]. Twenty-eight articles reported on cross-sectional analyses (one also included qualitative data collection [28]) and eleven reported longitudinal analyses (one included qualitative data collection [45]) (Appendix A). Although all studies assessed the association between food insecurity and a mental health condition or state in some manner, the particular research questions and analytic approaches varied. Some studies examined food insecurity and mental health among general samples of the population, whereas others focused on particularly vulnerable population subgroups or sought to assess the feasibility or other properties of tools. Half (n = 20) focused on mothers or caregivers, another five studied pregnant women, and several focused on other specific subpopulations, including rural women, those living with disabilities, older women, refugees, women experiencing insecure housing or homelessness, and women at risk for HIV (Appendix A).

Food Insecurity Measures
Three-quarters (n = 30) of the reviewed articles drew upon data collected using a version of the Household Food Security Survey Module (HFSSM), developed by the United States Department of Agriculture [8] (Table 1). The full HFSSM contains 18 items and yields a single score indicating the severity of household food insecurity over the past 12 months or 30 days; ten items refer to adults and eight refer to children in the household [8]. Scores are typically used to categorize households as food secure or food insecure with different levels of severity (since a review of the measure conducted in the early 2000s [46], the categories of food insecurity have been referred to as low and very low food security, replacing earlier labels of food insecure with/without hunger). The HFSSM was compared to household food expenditures and income [8] and associated with compromised dietary intakes [14], supporting its validity in capturing constrained food access due to inadequate finances. Fourteen articles drew upon abbreviated versions of HFSSM, including the six-item subset developed by USDA and the ten adult-referenced items, as well as other adaptations (Table 1).
One article reported on data using a single item drawn from the 12-item Radimer-Cornell scale [47], and another used data collected using the Community Childhood Hunger Identification Project (CCHIP) instrument [48]. Both the Radimer-Cornell and CCHIP tools are used to categorize food security status and were shown to have good specificity and sensitivity compared to evaluations of food security status based on household food inventories, dietary recall data, and other measures among a sample of women living with children in rural New York [49]. These tools were drawn upon in the development of the HFSSM [8].
Three articles drew upon data collected using a single item from the National Health and Nutrition Examination Survey-III (NHANES-III) to assess food insufficiency (defined as "an inadequate amount of food intake due to a lack of money or resources") [50]. As opposed to more comprehensive instruments, measures of food insufficiency are less detailed and may misclassify some households [49,51]. Finally, four articles drew upon data from other single-or multi-measures adapted from prior literature (Table 1). Respondents were classified as "food insecure" if they "sometimes" or "often" did not have enough food to eat. Other questions included how many days in the prior month the respondent did not have money for food, reasons for not having enough food, and whether the respondent or child in the household had restricted their food intake due to lack of food [61].  [65]; criterion validity relied upon associations with tobacco smoking. Includes three-item composite measure of food security: "In the last 12 months have you personally made use of special food grants or food banks because you did not have enough money for food?" (yes/no), "In the last 12 months have you personally been forced to buy cheaper food so that you could pay for other things you needed?" (yes/no), "In the last 12 months have you personally gone without fresh fruit and vegetables often so that you could pay for other things you needed?" (yes/no).

Carter et al. 2011 [43] None
Radimer-Cornell scale A 12-item scale developed by Radimer et al. [47] at Cornell University based on qualitative research with low-income women. Twelve items cover aspects of household, adult, and child food insecurity. The content of the items address food anxiety, monotony of diet, financial constraints, food restriction, insufficient intake, and acquiring food in socially acceptable ways [47,66]. Shown to have good specificity and sensitivity compared to evaluations of food security status based on household food inventories, dietary recall data, and other measures among a sample of women living with children in rural New York [49]. Further information about the evolution of the instrument is available [67].

Mental Health Measures
Depression and depressive symptoms were the most prevalent mental health states assessed. Associations between food insecurity and depression were examined in 36 articles (Appendix A). Ten articles drew upon measures assessing clinical diagnoses, while the remainder relied upon self-reported symptoms.
Measures are described in Table 2, along with information about their validation. In reviewed articles, authors sometimes noted that measures have been tested for psychometric properties such as internal consistency, in some cases, in the context of the particular study (Appendix A). Data from the short form of the World Health Organization World Mental Health Composite International Diagnostic Interview (CIDI) [70] were drawn upon to establish a clinical diagnosis of depression or anxiety in six articles. To assess depressive symptoms, the Centre for Epidemiologic Studies Depression Scale (CES-D) [71] was used most frequently, drawn upon in 14 articles. For anxiety, one article drew upon data from Spielberger's Trait Anxiety Inventory [72] and another the Hopkins Symptom Checklist Subscale (HSCL) [73]. Some measures targeted specific life stages such as pregnancy and older age; for example, maternal depressive symptoms were assessed with the Kemper three-item screen [74] and the Edinburgh Postpartum Depression Scale [75], while depressive symptoms among older women were assessed using the Geriatric Depression Scale [76].
Various other mental health markers were measured, including perceived control over one's life, perceived stress, quality of life, self-esteem, mastery, general mental health, psychosis, substance abuse, post-traumatic stress disorder, and disordered eating (Appendix A). Cohen's Perceived Stress Scale (PSS) A 14-item self-report Likert scale that measures the degree of unpredictability of the respondents' life and the degree to which the respondent feels stress regarding these situations. Validated in young adult and post-secondary student population, the PSS correlated with physical and mental health related outcomes [77].
PSS-4 (4-item subset) 10  Spielberger's Trait Anxiety Inventory The Spielberger State-Trait Anxiety Inventory is a 20-item tool commonly used to measure anxiety, with higher scores indicating greater levels of anxiety [72]. The American Psychological Association has noted sensitivity of this inventory to predict distress overtime in caregivers [72].

Overview of Findings on Food Insecurity and Mental Health
The majority of cross-sectional analyses examining depression and food insecurity (or food insufficiency) reported some form of association deemed to be significant [16,28,29,32,[34][35][36][38][39][40][41][42][43][44]54,[56][57][58][59][60]63,64,68,69,85]. Several longitudinal analyses likewise observed relationships between depression and food insecurity, with food insecurity increasing the risk of experiencing depressive symptoms or a depression diagnosis [44,53,62], or changes in food insecurity associated with changes in depression [62]. For example, a longitudinal analysis of data from 8693 parent-child dyads by Bronte-Tinkew et al. [53] found that mothers affected by food insecurity were more likely to report depressive symptoms compared to food-secure mothers. Some authors reported that the relationship functioned in the opposite direction, with depression leading to food insecurity [15,[24][25][26]45], or was bidirectional [55]. For example, Garg et al., who analyzed data from the Early Childhood Longitudinal Study Birth Cohort (n = 2917), found that mothers who experienced depression were at greater risk of remaining food insecure over time compared to mothers without depression [25]. Food insecurity and depression were also investigated in relation to other markers of material deprivation; for example, Corman et al. [24] found that women who experienced a major depressive episode at baseline had greater odds of experiencing food insecurity and inadequate housing at follow-up.
Several articles focused on pregnant women and revealed associations between prenatal and postpartum depression and food insecurity [33,36,42,56,60]. Food-insecure pregnant women were at increased risk of experiencing prenatal depressive symptoms compared to their food-secure counterparts [33,36]. Although a comprehensive measure of food insecurity was not used, Birmingham et al. [42] tested depression screening methods in a cross-sectional analysis of 195 mothers of newborns and found that those who had concerns about food were 5.5 times more likely to have a positive postpartum depression screen result.
Anxiety and stress were associated with food insecurity in multiple studies [16,17,32,56,59].  [32] indicated that severe food insecurity and a self-reported diagnosis of mood or anxiety disorders were associated among women. Siefert et al. [64] found an association between food insecurity and generalized anxiety disorder in a cross-sectional study of 724 US women receiving welfare, but the relationship was not significant when covariates were taken into account. In two studies, one cross-sectional (n = 606) [56] and one longitudinal (n = 526) [27], Laraia et al. found that food-insecure pregnant women had higher perceived stress compared to food-secure women, and those who had experienced any level of food insecurity during pregnancy or at three months postpartum were more likely to have high perceived stress scores at 12 months postpartum. Martin et al. [17] investigated perceived stress among Canadian adults and found that the prevalence of high levels of stress increased with lower food security status. However, Trapp et al. [31] explored food insecurity among a group of 222 low-income mothers and their children in a cross-sectional analysis and found that levels of perceived stress did not differ between food-insecure and food-secure groups.
Three recent articles explored disordered or emotional eating among women experiencing food insecurity [27,37,39]. Laraia et al. [27] and Sharpe et al. [39] found bivariate associations between food insecurity and disordered or emotional eating; however, in models adjusted for sociodemographic characteristics, Laraia et al. [27] did not observe significant associations between food insecurity and disordered eating behaviors. Dressler et al. [37] examined associations between emotional eating and depression and suggested that emotional eating may mediate associations among food insecurity, mental health, and other food-related outcomes, such as dietary intakes and weight status.
Moreover, some studies examined multiple mental and physical health conditions suggesting comorbid physical and mental health problems increased vulnerability to food insecurity [16,34] and that food insecurity increased vulnerability to poor physical and mental health [41,69]. There was also a focus on implications for others, including children, in the household. For example, Bronte-Tinkew et al. [53] found that mothers living in food-insecure households reported high rates of depression, which was correlated with fair and poor health in children.
Given that the precise focus of the studies varied, a range of covariates was examined. Several studies examined various forms of social support [15,17,35,52,60,63]. Instrumental social support (e.g., ability to borrow money, help with childcare and transportation) was examined in a study conducted by the Detroit Centre for Oral Health Disparities. Cross-sectional analyses by Siefert et al. [63] (n = 824) indicated that the effect of food insufficiency on depression could be reduced with the availability of instrumental social support, while Ajrouch et al. [35] (n = 736) found that this protective effect was dampened when respondents experienced high levels of food insecurity-related stress. Using cross-sectional Canadian data, Martin et al. [17] (n = 100,401) found associations between food insecurity and feelings of community belonging; for example, the prevalences of living in severely food-insecure households were 18% and 25.6% among women reporting high and low community belonging, respectively. In a cross-sectional analysis, Wehler et al. [52] (n = 354) found that financial social support from a sibling reduced the odds of mothers experiencing hunger but did not reduce the odds of children in the same household experiencing hunger. Further, Hanson and Olson [15] (n = 225) found that parenting social support (e.g., having someone to talk to and having help in an emergency) did not reduce the odds of a household experiencing persistent vs. discontinuous food insecurity over a period of three years.
The role of childhood and adulthood adverse experiences, including abuse, was also examined. In multivariable models, Wehler et al. [52] found that sexual abuse in childhood increased the odds of adult hunger, and that this appeared to be mediated by experiences of intimate partner violence in adulthood. Sun et al. [30] examined Adverse Childhood Experiences, including abuse, neglect, and household dysfunction, and found that mothers reporting four or more adverse experiences were more likely to report food insecurity, with adjustment for demographic factors. In bivariate analyses, Harrison et al. [60] found that each of food insecurity, intimate partner violence and depressive symptoms were correlated. In multivariable models accounting for demographic factors, Melchior et al. [44] found that intimate partner violence was higher among women who had reported indications of food insecurity two years prior.

Discussion
Overall, the evidence reviewed here supports a link between food insecurity and compromised mental health among women in high-income countries. Although longitudinal data were limited, associations between food insecurity and depression appear to operate in both directions. There are multiple plausible potential pathways by which food insecurity and poor mental health may be linked. The experience of food insecurity itself is characterized by worry and anxiety about the household food supply. Toxic stress, which refers to chronic and unyielding stress without adequate social and environmental supports [13], may be one pathway through which food insecurity and mental health are intertwined. Depending on the availability and regularity of finances, periods of household food insecurity can occur repeatedly or chronically; households in the United States that were food insecure in 2016 experienced food insecurity in seven months on average [3]. Therefore, food insecurity may represent a chronic stressor that could contribute to the development of poor mental health. Conversely, a mental health condition could inhibit an individual from maintaining steady employment, thereby increasing vulnerability to food insecurity. Further, Seligman and Schillinger [86] posit that the relationship between food insecurity and poor health is cyclical; food insecurity increases the likelihood of trade-offs in food choices among those who receive low income and challenges the self-management of health conditions. Poor self-management results in higher health care and medication costs for the individual, which further contribute to financial instability and food insecurity [86]. Once an individual enters this cycle, it may be very difficult to exit, particularly in countries where there are disparities in access to health care and social supports, impacting access. Additionally, studies found an association between instances of abuse and depression and food insecurity [26,44,52,60]. The early life stress hypothesis argues that stressors experienced during key developmental periods can enhance vulnerability to mental health outcomes in adult life [87].
The majority of the available literature is cross-sectional, and further longitudinal research could shed light on the nature of the observed relationships and factors that underlie them. For example, research is needed to examine the interconnections among various markers of mental health and experiences of food insecurity across the lifespan, as well as to further examine the influence of potential mediating factors, such as social support or experiences of abuse. Many existing studies have focused on women with children, and pregnant women have also been investigated. A population of growing interest in regards to food insecurity is postsecondary students [88][89][90][91]; given that this is a life stage during which vulnerability to poor mental health is also high [89,92,93], research examining the root causes of both issues and how they interact is of public health importance. At the other end of the spectrum, we also identified little research focused on older women.
Food insecurity is a complex and multidimensional phenomenon [51,94] and its measurement is also complex. Many of the reviewed studies relied upon data from the HFSSM, or an adaptation, to assess food security. The HFSSM is considered the standard in household food insecurity measurement in North America and is used widely in research and surveillance [3,4]. While this tool provides an indicator of quantitative deprivation, it focuses on economic access to food and does not capture aspects that are likely to be relevant to mental health, such as the social acceptability of food acquisition strategies [51]. For example, Hamelin et al. have described alienation that accompanies lack of access to adequate food [67], as well as the social implications [95]. Nonetheless, the HFSSM has been widely-used and, within the North American context, provides data that are comparable to those from national surveys [4,8,21]. The Household Food Insecurity Access Scale (HFIAS) [94] is a standardized tool that uses similar questions as the HFSSM and is designed to differentiate food-secure from food-insecure households across cultural contexts; this tool may be appropriate depending on the setting and populations of interest. Whenever feasible, a comprehensive tool is recommended over single or brief measures that may not accurately classify households and cannot provide insights into severity of food insecurity (thus potentially missing the opportunity to shed insights into those who are most vulnerable). Additionally, studies using mixed methods can generate unique information not yielded by a standardized measure such as the HFSSM.
There was greater variety in measures used to assess mental health compared with those used to determine household food security status, the majority involving screening for depressive symptoms, along with diagnostic measures that use more stringent criteria. Many authors noted that these tools had been tested and are widely used, but the range of tools used makes it difficult to compare across studies. As with food insecurity, abbreviated measures, such as those assessing depression and depressive symptoms, may have been limited in sensitivity and specificity compared to full measures, potentially dampening observed relationships or creating spurious effects. While the use of comprehensive measures and greater standardization of tools used to assess depression and other mental health conditions may allow for greater comparability across this body of literature and more robust inferences, it is critical for any study that the measure be well suited to the research question and the population/setting. Furthermore, much of the existing research has focused on depression; widening this scope could enable policy and program responses that consider the potential range of mental health conditions related to inadequate food access. An emerging area of research is the link between food insecurity and disordered eating; in addition to the studies reviewed here focused on women, recent findings from a study of US adult men and women accessing a food pantry indicated a positive association between food insecurity and indicators of eating disorder pathology, such as binge eating and engaging in compensatory behaviors [96]. Additionally, few studies examined food security in relation to schizophrenia/psychosis or bipolar disorder among females.
The findings of the reviewed articles should be interpreted in light of several considerations. Most of the available research is based on US populations. While several studies were conducted among subpopulations such as women with children and African-American women, more research is needed to assess how food insecurity and mental health interact with other markers of vulnerability (such as single parenthood, insecure housing, drug use, experiences of violence, and immigrant/refugee status) in diverse subgroups. The majority of studies were cross-sectional, and causal inferences were not possible. Additionally, for longitudinal studies, in some cases, it was challenging to ascertain the timing of baseline and follow-up data collections. Adherence to checklists such as STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) [97] could help promote transparency and accurate interpretation. Many authors noted limitations of self-reported data on mental health outcomes and food insecurity [16,17,26,[29][30][31][32]34,40,44,55,62]. Some also noted temporal incongruence between measures of food insecurity and indicators of mental health [25,39,41] that may have affected their findings. Due to the varied emphases of the studies (including assessing feasibility and other characteristics of measures), a range of covariates and potential confounders were examined; in some cases, they were used to characterize samples whereas in others, they were included in statistical models such that it is difficult to compare estimates from one study to another. Finally, explicit approaches to account for the potential conceptual overlap between food insecurity and mental health indicators, such as feelings of worry or anxiety that are conceptualized as part of the experience of food insecurity and are also markers of psychological distress, were not common.
Considerations related to the review itself also warrant highlighting. We followed methodology for a scoping study [22] and, thus, did not conduct a formal appraisal of the quality of the included evidence, nor weight the evidence. Rather, our objective was to characterize the existing literature as to identify directions for future research. Further, although we employed a systematic search strategy and careful screening, our search was broad and it is possible that some relevant articles were inadvertently excluded. Additionally, we did not consider studies that presented pooled estimates for males and females. Although our interest was in females, this does not preclude the existence of associations between food insecurity and mental health among males, as observed in some reviewed studies that include stratified analyses. Additionally, given that we relied upon published articles, we did not account for publication bias in that research not supporting relationships between food insecurity and mental health may be less likely to have been identified.

Conclusions
Overall, this review supports a link between food insecurity and poor mental health among women in high-income countries. Despite gaps, the existing evidence is sufficient to warrant policy and program interventions to address these major public health challenges in a coordinated manner. An underlying theme of the literature is the complex ways in which food insecurity and mental health are connected both to each other and to an array of other issues, such as experiences of violence, housing circumstances, and life transitions such as pregnancy. These links underscore the need for coordinated approaches that consider how policy and program interventions can best address these complex issues and their interactions. Such approaches may be informed by systems methods [98][99][100] that consider the interplay among factors and how interventions to address one issue may affect another issue, influencing overall health and well-being.
Strategies to address financial inadequacy, such as a guaranteed basic income, have been called for to reduce vulnerability to food insecurity [19,101,102], and could play a role in ameliorating mental health conditions [103]. Additionally, food security screening has been recommended within clinical settings to enable referral to available community resources [13,[104][105][106] (although it is imperative that practitioners have effective resources to which they can make referrals). While addressing the financial circumstances that underlie food insecurity is critical, screening for food access issues among those seeking treatment for mental health conditions could help build momentum in addressing the whole person instead of tackling issues in isolation, for example, helping health practitioners to understand, and potentially address, reasons for non-adherence to recommendations related to diet or other factors. Health and social service settings with integrated care models, in which women have access to a range of services that provide support during periods of food insecurity and poor mental health, may allow complex challenges to be addressed simultaneously [107]. In addition, health care providers are uniquely positioned to support individuals in accessing services such as government income-related benefits, dietary allowance benefits, or legal supports [16,106,108], and alongside individuals with lived experience of vulnerability, to advocate for increased financial supports and access to mental health care.

Longitudinal analyses
Heflin et al.