**3. Results**

Table 1 shows the characteristics of the 8613 respondents by food security groups in 2007 and 2014. Respondents included 3999 women and 4614 men. The prevalence rates of food insecurity (borderline and poor) increased from 2007 to 2014. The borderline FCG prevalence rates increased from *n* = 1474 (17.11%) in 2007 to *n* = 2911 (33.80%) in 2014. Meanwhile, the prevalence rates of poor FCG also increased from *n* = 693 (8.05%) in 2007 to *n* = 1713 (19.89%) in 2014. The majority of respondents in this study had a low level of education (less than 12 years of school attainment) in both year 2007 and 2014 (*p* < 0.001). The percentage of food-insecure people living in urban areas increased from 2007 (borderline = 18.87%; poor = 9.55%) to 2014 (borderline = 35.31%; poor = 23.46%) (*p* < 0.001). The percentage of food-insecure people with abdominal obesity increased from 2007 (borderline = 15.74%; poor = 6.81%) to 2014 (borderline = 32.75%; poor = 18.00%) (*p* < 0.001). As shown in Table 1, the number of respondents who had depressive symptoms increased from *n* = 955 in 2007 to *n* = 2616 people in 2014. To compare body mass index (BMI), body shape index, waist circumference, blood pressure, food consumption score, physical activity days, and CES-D score, we used a one-way analysis of variance (ANOVA) with Bonferroni post hoc test. The results of the Bonferroni post hoc test are in Tables S1 and S2 of the Supplementary Materials.

Table 2 presents the overall and age-specific proportions of food consumption groups among people with depressive symptoms. In 2007, the overall (range of age-specific proportion) proportion of acceptable, borderline, and poor FCG was 11.65% (range: 0.13%–52.46%), 9.02% (range: 0.75%–54.89%), and 10.24% (range: 0.00%–57.75%), respectively. In 2014, corresponding figures were 32.09% (range: 10.70%–35.70%), 29.34% (range: 10.66%–33.49%), and 28.14% (range: 10.79%–39.63%), respectively. The prevalence of depressive symptoms significantly varied with age. Except for the borderline group in 2007, the proportion of other food consumption groups in both years also significantly varied.

Table 3 demonstrates the association between food consumption groups and the depressive symptoms outcomes among adults. The food consumption score was negatively significantly associated with the CES-D score both in the unadjusted model (β-Coefficients: <sup>−</sup>9.51 <sup>×</sup> <sup>10</sup>−<sup>3</sup> (95% CI: <sup>−</sup>6.45 <sup>×</sup> <sup>10</sup><sup>−</sup>3, <sup>−</sup>1.26 <sup>×</sup> <sup>10</sup><sup>−</sup>2)) and adjusted models (β-Coefficients: <sup>−</sup>9.71 <sup>×</sup> <sup>10</sup>−<sup>3</sup> (95% CI: <sup>−</sup>6.62 <sup>×</sup> <sup>10</sup><sup>−</sup>3, <sup>−</sup>1.28 <sup>×</sup> <sup>10</sup><sup>−</sup>2) to <sup>β</sup>-Coefficients: <sup>−</sup>1.04 <sup>×</sup> 10−<sup>2</sup> (95% CI: <sup>−</sup>7.26 <sup>×</sup> 10−3, <sup>−</sup>1.36 <sup>×</sup> 10−2)). Further, we used the logistic models to compare food security as represented by acceptable FCG and food insecurity as represented by borderline and poor FCG. The borderline group was positively associated with the depressive symptoms of both the unadjusted and adjusted models with exponentiated β-Coefficients of 1.13 (95% CI: 1.06 to 1.21) to 1.18 (95% CI: 1.10 to 1.26). The depressive symptoms of the borderline group will increase by 1.13–1.18 units for every one-unit increase of the acceptable group. On the other hand, the poor group was also significantly positively associated with the depressive symptoms in both the unadjusted and adjusted models, with exponentiated β-Coefficients of 1.17 (95% CI: 1.07 to 1.27) to 1.22 (95% CI: 1.12 to 1.33). The depressive symptoms of the poor group will increase by 1.17–1.22 units for every one-unit increase of the acceptable group.

Table 4 shows the results of age-specific analyses for the relationship between food insecurity (as represented by FCS and FGC) and depression or depressive symptoms (as represented by the CES-D score). The current study used a full adjustment model (model 3) in the analysis to examine the findings' post hoc stability and decide whether the regression analysis differed based on the age group. The poor food consumption group was significantly and independently positively associated with depressive symptoms among respondents aged 40–49 years, with an exponentiated β-Coefficient of 1.24 (95% CI: 1.08 to 1.42). The depressive symptoms of the poor food consumption group will increase by 1.24 units for every one-unit increase of the acceptable food consumption group only among respondents aged 40–49 years. The remaining age groups did not report a food consumption score nor food consumption groups that were significantly associated with depressive symptoms.





Index used the cutoff values for the Indonesian adults from the Ministry of Health of Indonesia. \* Depression = CES-D 10 score ≥10.


Notes: Depressive symptomsconsumption groupswithin the age group were significant (*p*-value = 0.004–0.011).


**Table3.**Theassociationbetweenfoodconsumptiongroupsandthedepressivesymptomsoutcomesamongadults.

Notes: CI, confidence interval; FCS, food consumption score. FCS is continuous data of the food security assessment. Depressive symptoms were defined as CES-D 10 score ≥10. Model1: Unadjusted model. Model 2: Model 1 with adjustment for age and gender. Model 3: Model 2 with adjustment for level of education, marital status, geographical areas of living,smoking habit status, physical activity days, blood pressures, body mass index, diabetes, and cardiovascular diseases. \* The exponentiated β*-*coefficient was used for the logistic modelsof generalized estimating equation.


**Table4.**Theassociationbetweenfoodconsumptiongroupsandthedepressivesymptomsoutcomesamongadultsbyspecific

cardiovascular

 diseases. \* The

exponentiated

β-coefficient was used for the logistic models of generalized estimating equation.

### **4. Discussion**

The present study aimed to explore the association between food insecurity and depressive symptoms among adults aged 18–65 years in Indonesia. The borderline and poor food consumption groups represent food insecurity. The present study results suggest that food insecurity was positively significantly associated with depressive symptoms in Indonesian adults. As expected, the secondary findings confirmed that the high prevalence of depressive symptoms occurred among respondents with food insecurity across all ages of adults. Further, the total prevalence rates of food-insecure respondents with depressive symptoms (borderline FCG: 29.3%; poor FCG: 28.1%) was higher than the prevalence rates of food-secure respondents with depressive symptoms (acceptable FCG: 32.1%). The present study's prevalence rates are higher than the national crude prevalence rate of depressive symptoms, which was 3.7% in 2015 [4]. Therefore, the government, health practitioners, and relevant stakeholders need to be more concerned about the issue of food insecurity and depressive symptoms.

One possible action that might help is a food insecurity and depressive symptoms' screening and monitoring process, along with the nutrition health programs for adults. Previous researchers found that the level of education is associated with food insecurity and the increased individual level of stress, which may lead to depressive symptoms [47–49]. Another possible reason is people with less education will more likely experience economic hardship, due to a lower-paid work type or unemployment, which is associated with food insecurity and depressive symptoms [50]. The findings in this study were in line with those of previous research, indicating that the majority of food-insecure respondents had a low level of education and lived in urban areas, with a greater associated risk of economic hardship compared to people with a higher level of education [51].

Moreover, adults who experience a high-burden work type with less income may have depressive symptoms, which can interfere with the ability to manage financial affairs related to food choice and preparation [52,53]. Furthermore, former researchers suggest that unhealthy food choices, for example, Western dietary patterns, which are more likely to contain high calories, high fat, and less diversity, are (partly) associated with depressive symptoms [54,55]. The food consumption score analysis based on the WFP concept is more concerned with the food frequency and quality, and the diversity of diet [25]. One of the explanations is in the food consumption analysis, in which the calculation of food consumption score includes the number of days during which the respondent eats the food type in the FFQ, multiplied by the weight score of each food group type. The highest score refers to all of the food with relatively high energy, good-quality protein, and micronutrients [28]. Therefore, the higher the food consumption score, the better and more diverse the diet and the less food insecurity. However, the present study found that food-insecure respondents had lower food consumption scores than food-secure respondents, indicating that food-insecure respondents possibly consumed lower quality and less diverse food, with high energy and fat density.

Food insecurity is associated with depressive symptoms, overweight and obesity, hypertension, diabetes, and cardiovascular diseases [56–62]. The results of the present study were in line with previous research. The respondents in borderline and poor FCG have lower FCS, and higher body mass index, waist circumference, systolic blood pressure, and CES-D score, than the respondents in the acceptable FCG. One of the reasons to explain the mechanism between food insecurity, overweight, hypertension, and depression is when food-insecure people are unable to choose a properly balanced meal for themselves, and thus eat a low-quality and less diverse diet (high energy, high fat), which eventually leads to being overweight [56]. Food-insecure people are not only at a higher risk of being overweight, but also of increased levels of stress, possibly from a lack of sleep quality due to hunger or worries about providing food the next day [52,63]. On the other hand, continuous food insecurity in a person's life may lead to the onset of depression [11,64]. Pryor and colleagues suggested that food insecurity during young adulthood (18–35 years) co-occurs with three types of mental health problems (i.e., depression, suicidal ideation, and substance use problems in young adulthood) [65].

Furthermore, people with food insecurity are more likely to experience depression and undertake less leisure-time physical activity than those with food security [66–69]. The current study results support the evidence from previous research that the mean of vigorous physical activity (VPA) and moderate physical activity (MPA) days was different between the acceptable FCG (food-secure) and borderline or poor FCG (food-insecure). Moreover, the association between food insecurity and depressive symptoms might be affected by several health factors, which need further exploration using a longitudinal study or more variables. Thus, we further tested the association between food insecurity and depressive symptoms using regression analysis. The results suggested the association was constant even after gradually adjusting for the covariates. The covariates included health and sociodemographic characteristics, such as age, gender, level of education, marital status, geographical area of living, smoking habit status, blood pressure, BMI, incidence of diabetes, and cardiovascular diseases. Taken together, food insecurity was found to have a positive effect on depressive symptoms even after adjustment. The post hoc result showed that respondents aged 40–49 years independently reported levels of poor FCG that were significantly associated with depressive symptoms. The present study results were in line with a previous study that showed that people aged 40–49 are confronted with the most severe problems of food insecurity [18]. The study by Ziliak and Gundersen reported that the "youngest old" suffer from the most severe form of food insecurity compared to those of a younger age or even those over 70 years [70]. The middle-aged food-insecure people might face a recession of income, live in poverty in urban areas, be raising grandchildren, have a limitation on their activities of daily living, or be in a minority [71].

There are several limitations in the present study. First, the dataset that we used was restricted to the selected variables (i.e., the use of the food frequency questionnaire to conduct the food insecurity assessment) for the original study because we used secondary data in this study. However, the FFQ used in this study was widely used from the first wave of the Indonesia Family Life Survey, initiated in 1993, and has also been used in several previous studies [72–74]. Second, the assessment of food insecurity and depressive symptoms was limited to self-reported data. However, the food insecurity measurement from the FFQ was relevant when we defined it from the food frequency and diversity diet [24,25]. Moreover, the use of the CES-D 10 items is widely used to measure the depression or depressive symptoms among adults [30,75]. Third, we could not control for the respondents who received antidepressants or therapy because the IFLS questionnaire did not include a related question. Thus, we suggest future research should further explore the socio-environmental and dietary risk factors of depression and food insecurity. The present study concerns a very important and, at the same time, complex topic of depressive symptoms and lack of food security. These are two public health problems in developing countries that, along with obesity-related non-communicable diseases, significantly affect people's quality of life.
