Damian Sendler, M.D. – Poor nutrition and mental health are both leading causes of death, disease, and disability in the world today, according to the UN. Global food security and nutrition (FSN) has traditionally been viewed as a separate research area from mental health. From clinical and primary care orientations to wider sociopolitical approaches to achieve the Sustainable Development Goals (SDGs), both have undergone significant change Researchers’ paths in mental health and FSN are converging more and more in the last few years. Food insecurity and nutrients necessary for neurotransmission are just two examples of how FSN affects mental health in a variety of ways. FSN outcomes are influenced by mental health issues, such as a lack of motivation and the inability to care for a loved one. Complex and interconnected determinants connect them as well. Inferences about these crucial dynamics can’t be drawn because of the evidence’s heterogeneity. In addition, the methodology and impact of interdisciplinary projects and programs are improving, but more guidance in integration is needed. Hypotheses testing and program implementation should be guided by an evidence-based conceptual framework. There is an opportunity to invest in both fields holistically at the intersection of mental health and FSN.
Damian Jacob Sendler: It is estimated that one in nine people worldwide are undernourished, and one in three people are overweight or obese. Consequently, malnutrition affects a significant portion of the world’s population (1). Dietary inadequacies are one of the leading causes of death in the world (2). Furthermore, in many low- and middle-income countries (LMIC), the coexistence of undernutrition and obesity is on the rise, increasing the associated health risks (3). Here, food security is defined as the ability of all people at any given time to have access to a wide variety of safe and nutritious foods at an affordable price, as well as the ability to eat a healthy diet.
Dr. Sendler: Poor mental health is another major cause of illness and incapacity. Mental illness accounted for 15% of all YLD in 2019 and was the world’s second leading cause of years lost due to disability (YLD) (2). According to a recent meta-analysis, about 20% of mothers in developing countries suffer from clinical depression following the birth of their child (5). Despite the fact that LMICs make up more than 80% of the world’s population, they spend only 0.5 percent of their national health budgets on mental health (6).
However, in light of the internationally agreed Sustainable Development Goals (SDGs) on health and well-being (7), it is becoming increasingly apparent that both of these areas should be important focal points for action in order to ensure that no one is left behind (8, 9). There is also an opportunity to focus on the connections between mental health and food security and nutrition (FSN). In this regard, we aim to summarize the developments in both fields as well as how they have intersected empirically, and suggest ways forward to advance progress towards global public health goals.
2007 saw the publication of a paper by Prince and his colleagues that argued that the attainment of global health goals would be impossible without addressing mental health issues (12). Depression and obesity can both cause and be a result of poor mental health in children, according to a study published in the American Journal of Preventive Medicine. Similar to the Lancet series on maternal and child undernutrition in 2008, this series argued that investing in nutrition actions (specifically the impact of scaling 10 effective nutrition-specific interventions to 90% in 36 high-burden countries) would be a significant step toward achieving global health goals (13).
During the final years of the Millennium Development Goals era, both fields underwent significant transformations, placing their respective burdens in a broader context. Nutrition-sensitive interventions and supportive environments were found to be backed by a large body of evidence (13). Even high-quality and large-scale nutrition-specific interventions are limited in their effectiveness because of the importance of underlying factors such as agriculture, food environments, caregiving and gender dynamics (14). Even though this newer approach to mental health was less developed, it was evident in mounting evidence that addressing maternal mental health could have beneficial effects on children’s well-being, in particular (15).
Sustainable Development Goal 17 (SDG 17) incorporates a broader view of FSN in the UN’s post-2015 development agenda. SDG 2 “End hunger, achieve food security and improved nutrition and promote sustainable agriculture” included elements of agricultural productivity, diversity, and sustainability. At least five SDG goals can be achieved by improving nutrition, according to the 2017 Global Nutrition report (16). However, important facets of the world’s food systems and environments aren’t included in the FSN’s targets and indicators.
The SDGs do not prioritize mental health as much as they should. Target 3.4: “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being” brought non-communicable diseases into focus (17). Aside from suicide prevention, little attention is paid to mental health problems as an aspect of NCDs. This means that mental health issues as a whole are underrepresented. The 3rd High-Level Meeting of the UN General Assembly on the Prevention and Control of NCDs made a more comprehensive commitment, particularly in point 11 of the political declaration which states: “Depression alone affects 300 million people globally and is the leading cause of disability worldwide” (18).
From 2018, nutrition and global mental health were reframed in relation to sustainable development. A shift from etic, clinical health arguments to social determinant frameworks embedded mental health and FSN across the spectrum of environmental, (psychosocial), and biological factors was evident in each discipline. However, despite the enormous burden that mental health places on society, researchers and practitioners have attempted to place it in almost every one of the 17 SDG goals. There was a focus on environmental and climate change threats, as well as the double burden of nutrition-related chronic conditions and undernutrition, in the presentation of these issues (3, 19).
There is more evidence that mental health and FSN are intertwined than previously thought. Depression, stress, and anxiety have been linked to an increased risk of food insecurity in a variety of situations (20). Micronutrients and dietary patterns have also been studied in relation to mental health in various settings and populations (21–25). Poor diets, low nutrient intake, and low and high BMI have been linked to poor mental health in studies (26, 27). However, these links between FSN and mental health are not always supported by the evidence (28, 29).
Agriculture, food systems, nutrition, and nutrition-related health outcomes all share a connection to mental health as a determinant in these theories. Much of this work has been devoted to the health of mothers and their children (30, 31). Premature birth and sub-optimal breastfeeding practices have been linked to depression and stress, which are often characterized by low motivation and drive, poor appetite, and neglect of oneself and others (32, 33). Poor child development and illness have been linked to parents’ poor mental health, particularly that of mothers, in various contexts (34), but these findings are inconsistent (28). Studies on obesity have focused on the importance of mental health and eating habits, but the evidence is still inconclusive. (35). (36).
A wide range of factors, including poverty, physiological stress, emotional stress, conflict, harmful gender norms, domestic violence, and a lack of control over economic resources, are linked to mental health and FSN (37–39). Because of social inequity, vulnerable groups such as the elderly and low-income adults are more likely to suffer from poor mental health and poor nutrition outcomes than the general population (1, 40).
Damian Sendler
There are still some connections that have yet to be discovered or discovered. In many studies of mental health, food and nutrition aspects are overlooked. It’s only recently that other aspects like food production’s benefits for mental health, empowerment, and the effects of food environments on mental health have been studied more thoroughly. When it comes to caring for someone with dementia, gardening programs in Uganda have provided more than just food (41). Similar causal mechanisms may also support other evidence, strengthening the theoretical framework for the connections between the two. We can expect to learn more about the link between mental health issues and poor nutrition from the Covid-19 pandemic (42).
When it comes to mental health and FSN, there are now many different studies using different measures in different populations. If the research hypothesis is based in one direction, however, much of this evidence does not reveal causal mechanisms. For example, a lack of food can lead to an increase in stress and worry, which can lead to depression (20). Depressed women, according to other studies, show less interest or motivation in self-care and socializing, all of which could lead to poorer dietary choices, less attention paid to meal preparation, and a lack of concern for children’s nutritional needs (43). As a result, food insecurity or an earlier exposure to it might have an effect on mental health.
Damian Jacob Markiewicz Sendler: Even in cross-sectional studies, it is almost universally assumed that maternal depression is associated with poor child feeding practices, reduced caregiving, and a lower child growth rate (34, 44). However, it is possible that poor child outcomes, especially in families where child health is viewed as a reflection of the mother and the family, are the cause of poor mental health (45). A lack of key nutrients can impede optimal neurotransmission and lower moods, but there are also ways in which poor mental health can lead to changes in appetite and dietary habits, which could have a negative impact on nutrition.
In general, we can’t draw many conclusions about these important dynamics because of the heterogeneity of the evidence base, which includes a wide range of theoretical and analytical approaches, intervention design elements such as screening measures, tool validation, measurement timing, and study populations. An evidence-based conceptual framework should guide hypothesis testing even in the case of feedback loops between FSN and mental health. For the most part, studies of the link between mental health and FSN are conducted after the fact.
While working on cross-disciplinary projects, researchers in the fields of mental health and FSN are confronted with the challenge of integrating methods and measurements from other fields. There is a growing need for both theoretical and technical guidance from both groups of researchers.
Food security, nutrition, and nutrition-sensitive outcomes can now be measured using a wide range of indicators, from anthropometry and micronutrient deficiencies to proximal or underlying factors such as diet quality and food security or poverty. There are numerous contextual and methodological limitations to nutrition, but there is a biophysical element to nutrition that is universally measurable. Many of these measures have undergone extensive development and validation over the last few decades, particularly those targeted at low- and middle-income countries (LMICs) and fragile states (frail states).
Damian Jacob Sendler
Measurement of common mental disorders in LMIC has also developed, as has summary guidance on tools for doing so (48). However, it is particularly difficult to measure mental health with standard tools in various contexts. In addition to cultural differences in epistemology and contextual equivalence, these issues stem from the wide range of problems associated with mental illness stigma and the relocation of mental health services as well as from disparities in training and implementation (49, 50). Many mental health measures are based on a narrow understanding of the disease and its treatment, which may not capture the many intersectoral and interdisciplinary outcomes we now consider important. Mental health problems around the world, however, have been found to share many similarities (51). A shift away from disease classification and toward a more holistic view of symptoms is under way to better identify the commonalities and specifics of mental health in the general population (52–54).
Damien Sendler: Common mental disorders in low-resource settings can most often be detected in the population through screening tools. The validation process, proper cultural and technical adaptation and translation, training for those asking for these modules, the construction of analyses, and the interpretation of those results often have weaknesses in situ. LMIC populations may not be able to rely on the gold standard of mental health care: the clinical interview (51). Even more bias may be introduced if screening tools are tested against clinical interviews. The use of concurrent validity, establishing a locally defined gold standard, or developing new types of screening tools have all been proposed solutions to these problems (55–57).
Attempting to link FSN and mental health raises a slew of new issues in terms of research design. There are many factors that could influence a person’s ability to accurately recall and perceive their food intake, such as their mental health. However, there is a strong connection between the two. LMICs and high-income countries alike experience an increase in anxiety, worry, and depression due to a lack of affordable, healthy food (60). Understanding how mental health conditions are experienced and linked to FSN in different populations is critical to reducing both burdens.
There was a focus on integrating assessment and services into primary care in the MDGs that included FSN and mental health. From community-based initiatives to acute and emergency humanitarian responses, multi-sector integration and multi-disciplinary approaches to FSN and mental health were then extended laterally.
People of all ages, including caregivers and children, benefit from low-cost mental health interventions delivered by non-specialized or community health providers (61, 62). Gender disparities, social cohesion, peer support, decision-making, and agricultural practices can all be improved through FSN programs, which may also have a positive effect on mental health and increase participation in healthy eating habits (63).
The idea here is to see if improving FSN will have a positive impact on mental health outcomes, so some current FSN projects without any mental health intervention components are doing so. These interventions are still yielding results, which are still being analyzed. These two metrics have been viewed as de facto indicators of vulnerability. As an example, self-efficacy, depressive symptoms, or anxiety have been used to measure latent characteristics of resilience and well-being (64). Resilience is often measured in terms of a person’s ability to maintain a healthy diet (65). Mental health and Family Support Network (FSN) components have been incorporated into some studies but aren’t necessarily part of strategic planning and the results aren’t consistent across all studies that include these components.
Mental health and FSN research have new avenues for collaboration, but nutrition research is already well-integrated. Research agendas that include both mental health and FSN will have to carefully consider their approach because both have complex determinants. For example, both FSN and mental health have been linked independently to water, sanitation and hygiene, care practices, social and gender dynamics, violence and conflict, and poverty. Advanced research methods are essential to achieving this goal. Risks include increasing the complexity of research and programs, which may burden implementation and research staff, as well as a loss of focus by attempting to incorporate too many goals at once. Creating models that are scale-appropriate can have advantages and disadvantages, depending on the context at hand. It’s also possible to present analyses that lack theoretical foundation.
Even though both fields have incorporated social-determinant perspectives, there is a chance to strengthen understanding and action on how to leverage both to improve mental health outcomes. Investing in progress toward the SDGs holistically while also advancing the thinking on dynamics between and within mental health and FSN is possible at the intersection of the two fields.
Agriculture, Nutrition and Health (ANH) Academy has formed a working group of experts in mental health and food and nutrition, as well as methodologists with expertise in the design and evaluation of implementation research programs in these fields for 2020. Group members hope to synthesize information about the intersection of these themes in order to encourage a more systematic approach to research, policy, or program implementation. Assessment of current knowledge on mental health and its relationship to FSN; Prioritizing key gaps and questions; and developing guidance and resources on best practice for applied research on linkages between mental health and FSN are the three main goals of the study.
The Covid-19 pandemic has shown that progress in both FSN and mental health has been fragile. FSN and mental health issues are already on the rise and are expected to continue to do so in the coming years due to the social and economic upheaval caused by the pandemic and the consequent decrease in health care access and resources. There are still important connections between FSN and mental health that may be revealed by the pandemic, which may provide an opportunity to learn more about them.
As a result, progress in these areas is even more urgent and timely. Developing frameworks for investigation and action on these critical issues will require systematic thinking in this space. To achieve universal health and well-being, progress toward global FSN and improved mental health is critical post-Covid-19.
