Original article Household food insecurity and antepartum depression in the National Children's Study Megan Richards, PhD a, * , Margaret Weigel, PhD b , Ming Li, PhD a , Molly Rosenberg, PhD a , Christina Ludema, PhD a a Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington b Department of Environmental Health, School of Public Health, Indiana University, Bloomington article info Article history: Received 5 August 2019 Accepted 20 January 2020 Available online xxx Keywords: Food insecurity Depression Pregnancy Inverse probability of sampling weights abstract Purpose: The purpose of this study was to determine the association between household food insecurity (HFI) and elevated antepartum depressive symptoms (EADS) in the National Children's Study, 2009e2014, as well as standardize our results to the U.S. pregnant population. Methods: HFI was collected at participants’ baseline visits using the U.S. Household Food Security Survey Module; antepartum depression symptoms were collected twice during pregnancy using the Center for Epidemiologic Study Depression scale. Generalized estimating equations for binary outcomes were used to estimate the association between HFI and EADS. Inverse probability weighting was used to generalize the effect to the U.S. population using the National Health and Nutrition Examination Survey. Results: Among 746 participants, 20.6% were food insecure. Women who were food insecure were 3.39 times (95% confidence interval: 1.73, 6.62) as likely to report EADS compared with women who were food secure. This estimate was marginally strengthened in a weighted analysis (odds ratio: 3.68; 95% confidence interval: 1.43, 9.43). Conclusions: This study suggests that women who are food insecure are at a greater risk of EADS, and HFI should be evaluated when assessing antepartum depression. © 2020 Elsevier Inc. All rights reserved. Purpose Food insecurity during pregnancy has the potential to increase the risk of antepartum and postpartum depression [1e4]. Food insecurity, the limited or uncertain availability of nutritionally adequate food, is estimated to affect between 10 and 35% of preg- nancies [2,5,6]. Within the total U.S. population, 11.8% of house- holds are food insecure, and food insecurity is more common among low-income, single mothers [7]. Among adult populations, there is an established relationship between food insecurity and mental health conditions [8e10]. Although much of this relation- ship is thought to be an emotional response to difficult circum- stances (i.e., helplessness, shame, humiliation) [11], there is also the possibility that there is a physiologic link between lack of nutritious food and mental health [4, 12, 13]. Independent of food insecurity, hormonal and psychological changes during pregnancy may lead to an increased risk of antepartum depression, even among women with no history of mental illness [14]. Up to 15% of pregnant women experience depressive symptoms during pregnancy, which can have lasting effects for both the mother and baby [8, 15, 16]. The confluence of food insecurity and pregnancy plausibly increases the risk for depression during this vulnerable time; however, only two studies have examined this relationship to date [2,4]. Both previous studies that examined the association between food insecurity and pregnancy did so in single-state samples of low- income women. The first study found that antepartum depressive symptoms predicted food insecurity during pregnancy (odds ratio [OR]: 1.59; confidence interval [CI]: 1.27, 2.00) [4]. A second study reported that women who were food insecure were more likely to experience depressive symptoms during pregnancy compared with those who were food secure (OR: 2.59; CI: 1.03, 6.52) [2]. Both studies lack generalizability to the U.S. population because of the unique populations from which the estimates were produced. In randomized clinical trials, lack of generalizability is a recog- nized and frequently cited limitation, but observational studies often are not critically evaluated with regard to generalizability [17e19]. Prior estimates may have been internally unbiased but may differ from the effect in our target population of U.S. pregnant * Corresponding author. School of Community Health Sciences, University of Nevada Reno, 1664 N Virginia St., Reno, NV, 89557. E-mail address: meganrichards@unr.edu (M. Richards). Contents lists available at ScienceDirect Annals of Epidemiology https://doi.org/10.1016/j.annepidem.2020.01.010 1047-2797/© 2020 Elsevier Inc. All rights reserved. Annals of Epidemiology xxx (xxxx) xxx Please cite this article as: Richards M et al., Household food insecurity and antepartum depression in the National Children's Study, Annals of Epidemiology, https://doi.org/10.1016/j.annepidem.2020.01.010