Date of Award

Spring 2023

Document Type

Open Access Dissertation


Epidemiology and Biostatistics

First Advisor

Angela Liese


Household food insecurity (HFI) disproportionally affects people with diabetes living in the United States and is more likely to occur in households with children and in minority race/ethnicity households. Food insecure people with youth-onset diabetes likely have increased risk for poor mental health due to dealing with stress and cost related to diabetes management, especially if facing additional health-related social needs that intersect with HFI. If left untreated, poor mental health among youth and young adults (YYA) with diabetes can lead to diabetes-related complications, increased health care costs, and mortality. Yet few studies have examined associations between HFI and mental health among YYA with diabetes, especially for those with type 2 diabetes (T2D). Compared to new cases of type 1 diabetes (T1D), incidence rates for diagnosis of T2D in young people under age 20 are considerably higher. Mental health also tends to be poorer among YYA with T2D versus T1D. To add to current literature this dissertation research examined how HFI, other health-related social needs, and sociodemographic characteristics are associated with mental health outcomes including depressive symptoms, anxiety symptoms, and quality of life (QOL) in YYA with T1D or T2D. Change in mental health over time, and baseline predictors of this change, were of particular interest for YYA with T2D.

Sociodemographic predictors of change in depressive symptoms and health-related quality of life (HRQOL) over time among YYA with T2D were assessed using multivariable linear regression models. Cohort data from two data collection cycles of the SEARCH for Diabetes in Youth (SEARCH) study from 2012 to 2020 were utilized. HFI and other measures of health-related social need were not collected repeatedly in SEARCH and thus could not be assessed as predictors for this analysis. Results showed that there was no change in depressive symptoms or HRQOL over time. Compared to those with a parent(s) who had completed some college, YYA with a parent who had less education was associated with decreased depressive symptoms when holding constant time between SEARCH 3 and SEARCH 4 and covariates. Female YYA had decreased HRQOL and Hispanic YYA had increased HRQOL in adjusted models.

SEARCH data from 2015 to 2020 were used to examine how HFI was cross-sectionally associated with depressive symptoms and QOL in YYA with T1D or T2D. HFI was linked to increased depressive symptoms and decreased QOL and HRQOL among YYA with T1D or T2D. Associations between HFI and mental health were modified by socioeconomic characteristics, but only for YYA with T1D. Lastly, data from the SEARCH Food Security (SFS) Cohort Study, which is ancillary to SEARCH and collected data from 2018 to 2020, were used to identify intersecting patterns between HFI and additional health-related social needs of housing insecurity, need for reliable transportation, and experiences of discrimination in predicting depressive and anxiety symptom risk groups for YYA with T1D or T2D. Classification tree analyses showed that household food security status overlapped with experiences of discrimination to predict depressive and anxiety symptom risk groups for T1D YYA, and including these specific health-related social needs improved the overall prediction accuracy of models. Discrimination was the sole predictor of depressive symptom outcome groups for T2D YYA and HFI predicted anxiety symptoms groups for T2D YYA.

This research indicates that HFI and discrimination are key health-related social needs which influence mental health among YYA with T1D or T2D. We found that HFI and discrimination are better indicators of moderate-to-severe depressive and anxiety symptoms than demographic and socioeconomic measures. Clinicians and interventions should increasingly screen for and collect data on HFI and experiences of discrimination among YYA with diabetes in order to improve the identification, treatment, and health outcomes of those with the greatest likelihood for poor mental health. In particular, HFI should be considered a critical health-related social need to prioritize for screening among YYA with diabetes given that the U.S. already has funding mechanisms and social services in place to address and/or improve support for HFI among this population. Future research should assess associations between health-related socials needs and change in mental health over time among YYA with T1D or T2D.

Available for download on Thursday, May 15, 2025

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