Discussion
A substantial number of YYA with T1D and T2D in the study sample experienced FI. Specifically, 6.6% of YYA with T1D and 16.5% of those with T2D exhibited persistent FI, and 20.3% of YYAs with T1D and 42.3% of those with T2D experienced IFI over time. These longitudinal results extend findings from earlier cross-sectional work on prevalence of FI and illustrate the intermittent nature of FI that is the dominant experience for those who report any FI.3 29 We observed more PFI and IFI among YYAs with T2D compared with those with T1D, highlighting a distinct FI pattern in PFI and IFI, which is consistent with prior population-based work showing higher FI prevalence among individuals with T2D.4 30 31 Differences in access to T2D monitoring or lower income may also influence psychosocial outcomes. Although we adjusted for CGM use and insulin regimen, residual confounding by insurance coverage or healthcare access may persist.
FI experienced as either PFI or IFI was associated with greater depressive, anxiety, and stress symptoms for YYA with T1D. The magnitude of the associations was correlated with the severity of the FI experience, with larger associations found for the PFI group than for the IFI group. Similarly, PFI and IFI were associated with an increase in these symptoms from the second to the third time point after adjustment for the second time point. Findings from a previous study showed that people with diabetes have increased depressive and anxiety symptoms, and poorer glycemic control, leading to higher rates of complications.26 Additionally, FI has an influence on mental health among various age, gender, and ethnicity groups, where the impact is evident among individuals who self-report lower general health status.32 33 Our work extends previous work by establishing a connection between particular patterns of FI and mental health consequences, thus addressing a gap in existing knowledge.
In the general US population, approximately 13–15% of young adults experience FI, compared with substantially higher rates among those with diabetes.4 Roughly 14% of FI youth with either type of diabetes had mild depressive symptoms, while 8.6% had moderate or severe symptoms.34 Among FI young adults, those with T1D had average depression scores that were 7.4 points higher than their food-secure counterparts, whereas those with T2D had scores that were 4.8 points higher.35 Observed mean depressive, anxiety, and stress scores generally reflected mild-to-moderate symptoms, consistent with prior research showing elevated but subclinical psychological distress among youth and young adults with diabetes.36
Consideration of the association between FI and mental health outcomes needs to distinguish between those with and without diabetes.7 37 While one study focused on broad demographic groups, such as adolescents and adults with mental health issues, another specifically examined the links between FI and mental health in people with T2D.7 37 While these studies demonstrated that FI is associated with greater mental health issues in individuals with and without diabetes, other studies in populations without diabetes have been inconclusive.38 39 Together with our own findings supporting an association, the body of evidence to date suggests that FI and mental health relationships may be more pronounced among individuals with diabetes, indicating a potentially greater vulnerability in this population.40 41
Depressive disorder, in turn, affects physical well-being, self-care and functioning, resulting in considerable impairment across multiple domains and economic burdens.40 Individuals with significant depressive symptoms may struggle with employment and financial management, potentially leading to a state of FI or exacerbating a tenuous living situation.6 42 Depressive, anxiety and stress symptoms were worse among people with very low food security compared with those who are food secure in low-income populations.38 This emphasizes that severe FI has a greater association with more detrimental mental health, suggesting that addressing food security is crucial in mitigating these negative outcomes.
FI can lead to poor dietary choices, depression, stress, and anxiety, which can in turn worsen diabetes management.43 Our study provides support that addressing FI is essential in individuals living with diabetes, demonstrating that FI is associated with frequency of mental health symptoms over time.33 44 A recent study highlighted the link between FI and mental health issues, specifically diabetes distress, independent of changes in the individuals’ diabetes condition throughout the same time frame.45 The study explored American Indian adults with T2D, while our study represented diverse YYA with T1D and T2D in three locations of the continental USA. In addition, their follow-up period was 6 months, while ours was from 18 to 27 months.
While our analyses focused on overall associations between FI and mental health, there is evidence from intervention research that specific improvements in these domains may also confer benefits. A study among adults with T2D has shown that increased access to fresh produce and diabetes self-management support is associated with improved mood and metabolic outcomes.8 38 46 For instance, policies that increase access to nutritious food through food assistance programs and subsidies can mitigate FI.47 To address the link between poor mental health and inadequate diabetes management, it is crucial to expand mental health services, integrate mental health screenings into routine diabetes care, and train providers on this intersection.7 48 These actions hold the potential to improve health outcomes and reduce healthcare costs associated with managing diabetes complications exacerbated by poor mental health and FI.49
The primary limitation of this study is its cohort, which included only YYAs living with T1D and T2D. SFS 1 data collection related to FU2 had been initiated shortly before the onset of the COVID-19 pandemic occurred and may have affected access to resources as well as the stability of reported mental health between SFS 1 FU1 and FU2. Ongoing follow-up of the SFS cohort may allow examination of pandemic-related and post-pandemic trends. Because SFS follow-up occurred at three SEARCH sites, contextual factors (such as local healthy food availability, transportation barriers, and state-level social safety net policies) may shape both the prevalence of FI and its relation to mental health. Almost one-third of participants were lost to follow-up from baseline; they were more likely to be male, from South Carolina, and less likely to be Hispanic (online supplemental table 1). Also, the sample size of T2D individuals was noticeably small, which may limit generalizability. Data collection timing likely had minimal effect due to the predominantly young adult sample.
At present, there is no chronic disease or nutrition-sensitive disease-specific validated version of the HFSSM. We have evaluated the HFSSM in our study of people with diabetes and found that there is room for improvement in its metrics for this population.50 The use of the general-population HFSSM may not fully reflect diabetes-specific challenges such as the need for daily access to appropriate foods or non-financial barriers like food environment and storage capacity. The 12-month reference period may also obscure intermittent fluctuations in food access. We are working on this issue through the SFS 2 project, which is using a modified questionnaire within a shorter reference period (1 month) and additional items addressing the daily and dietary stability challenges specific to diabetes.
The study design does not allow for full generalization to all individuals with youth-onset diabetes in the USA. Although measures were administered in age-appropriate ways, the wide age range introduces potential heterogeneity in both experience and reporting of FI and mental health. Additionally, caregiver stress or mental health could influence both reporting of FI and diabetes management, potentially biasing observed associations between FI and mental health outcomes. The strengths of this study include a longitudinal design that spans several years (2016–2022), a large and racially and ethnically and geographically diverse group of participants, and the use of reliable and validated measures that helped reduce recall bias to assess both FI and mental health.
To disrupt the cycle of FI, mental health issues, and diabetes, integrated strategies, including routine screenings, direct food supports, and behavioral interventions are needed. While many system-level strategies, such as integrated behavioral health and social work linkage, are broadly applicable, tailoring interventions is crucial. For T1D, emphasis should be placed on reliable carbohydrate access, insulin and CGM affordability, and hypoglycemia prevention. For T2D, interventions may be most effective when addressing comorbid conditions, medication access, and structured lifestyle supports in combination with food provision. These integrated models of care, which can also include practical approaches like clinic-based food programs and supplemental nutrition assistance program (SNAP), require managed care providers, including Medicaid plans, to cover and implement them.
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