PONE-D-25-06411Association between food insecurity, ethnicity, and mental health in the UK: An analysis of the Family Resource SurveyPLOS ONE

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Reviewers' comments:

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1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Immediately, this is obvious to researchers familiar with UK household food insecurity research that should have been completed/reported on previously so the merit of this analysis is clear. This builds on the authors' previous work well.

There are some good potential contributions here, however, the use of the anxiety question from the day before and the statistical methods are problematic. With some revision to focus on the ethnicity and long term illness only, this can still make a good contribution to the literature and I hope the authors will find my comments useful.

The abstract structure is different from usual PLoS ONE.

In the introduction, bring in the more recent data on FI from the 2024 report (noting the 2021 report appears later), which puts it at 10% (https://www.gov.uk/government/statistics/united-kingdom-food-security-report-2024/united-kingdom-food-security-report-2024-theme-4-food-security-at-household-level#household-food-security-status). Good to see the link to Food Foundation's work.

To build the literature up further, please include a link to the systematic review )https://pmc.ncbi.nlm.nih.gov/articles/PMC10200655/pdf/S136898001900435Xa.pdf) and a paper exploring the demographics associated with FI (doi:10.1017/S1368980020000087). I am less comfortable to see food bank use applied as a proxy for very low FI (line 67) given how relatively few people who are FI use food banks - again as shown in the updated Govt 2024 report. The discussion around how there is a two way relationship between IF and mental health was good to read. This recent systematic review about FI and severe mental illness may also help to extend the literature (https://onlinelibrary.wiley.com/doi/full/10.1111/jpm.12969).

Further regarding ethnicity, is it a consideration that minority ethnic groups may be less likely to report FI and mental health in both cases due to cultural expectations? Perhaps this was picked up in your earlier work in Bradford which has been referenced. So rather than kinship networks mitigating FI, it can also be 1) less awareness of the support available such as food banks or other aid 2) cultural barriers to seeking support (stigma, as with many other populations – this does appear in the discussion); 3) issues with the food available if they do seek help being inappropriate or unfamiliar. Many years ago Donkin and Dowler wrote about this issue in the context of food deserts. It would be beneficial to outline the possible mechanisms.

While I very much agree, wholeheartedly, that current welfare/social policies in the UK contribute to food bank use, please do not use a Trussell Trust report to substantiate this. Have a look at Milbourne's recent work on more than food banks, Loopstra’s work on the impact of the UC roll out on food insecurity, or Williams and May's genealogy of food banks to use academic sources. As you note elsewhere, when there was the £20 uplift on UC and furlough, there were much lower rates of FI. Further, Trussell Trust does not represent all food banks so their data will be incomplete.

Overall in the intro, mental health as a label needs to be specified. When discussing mental health for the analysis, please clarify if the mental health being assessed here is common mental disorders (typical) only for the longer term conditions, then only anxiety for recent experiences. Also add in the population prevalence of the relevant mental health outcome as you have done for FI.

Methods:

Overall there are two substantial concerns: the use and coding of the anxiety variable to identify mental health issues and the use of linear regression.

Hopefully in the discussion it will be noted that all data used are cross section so causation cannot be inferred from this analysis (yes, lines 375-6). Understanding Society did briefly collect data on FI.

Limitations around the FRS data collection are well described.

Is there any report to show how often the HRP may not claim benefits, but someone else in the household does? (lines 172-177). What about Pension Credit?

As the section progresses, there are more concerning issues with the analysis plans, variable choice and coding.

Is the anxiety question validated elsewhere (in the limitations, it states no)? This does not sound like the typical measures used to assess anxiety, such as GAD 7. Only asking how someone felt the day before is not adequate to identify a mental health outcome; the GHD-12 and GAD 7, or Wemwebs, ask about the previous 2 weeks and are validated. I realise you are working with what is available in the FRS.

There are issues with the anxiety variable and coding of it, which is unclear as described (lines 200-210). If the scale is 0-10, this is not what would be considered a continuous variable, but an ordinal variable as there are only 11 possible answers.

Re-reading, I think that longstanding mental illness is someone who said ‘yes’ to conditions lasting 12 months or more. However, in table 1 there is not reporting of longstanding illness on its own, only where it impacts on mental health. Looking at the table, anxiety is relatively low if the median is 2 with an IQR of 0- 5.

The statistical approaches are difficult to understand.

Food security is coded into four groups, then collapsed into two: food secure or insecure. Why use linear regression for (now) categorical outcome variables? However reading this again I think the linear regression was only for anxiety. The Kruskal-Wallis tests is sensible for categorical variables, but linear regression assumes a normal distribution of data, or it needs to be transformed, and linear variables for the outcome or dummy coding for categorical predictor variables. Binary logistic regression would be an appropriate choice, as has been used in table 3 where there are obvious odds ratios. Please make it clear in the table that the outcome is food insecure.

The beta coefficients are very high, and look more like ORs. Typically they range between -1 and 1. It would be better to recode anxiety into above and below the mean or median and re-run as a logistic regression model.

As it is written, this analysis is not appropriate for the research aims. The anxiety variable needs to be shown to be appropriate for use to identify anxiety (how does this coding compare to GHQ-12 for common mental disorders, for example?

Or, the paper would be sufficient without the anxiety data included. The issue of minority ethnic food insecurity, and long term illness, is enough.

Discussion:

The discussion brings in a lot of good literature to describe the results and picks up on some points I raise about the introduction. Long term mental health outcomes are discussed specifically (lines 312-313; 329-334) but I cannot see that they were measured sperate to long term physical health condition. The question asks if the LLTI is affecting mental health, this is different to long term mental health problems. I did not see where the data were collected to show that specifically mental health problems lasted 12 months or more (line 320).

Reviewer #2: A beautifully written article. The study utilises the 2019/20 Family Resource Survey. This enhances the credibility of the findings and made use of a large sample size of households for generalisation to a broader population. The focus on ethnicity provides a nuanced understanding of how food insecurity impacts mental health across diverse groups, something I know the lead author has specific expertise in.

I think this article is excellent, really well written and well-articulated. I have not found any computational or discussion errors, or significant issues with this. In fact, I have really enjoyed reading it. The authors should be extremely proud of this argument. My review below is mainly about minor areas of clarification.

• I think the discussion and focus on HRP and anxiety was absolutely fascinating and an absolute pleasure (and interest) to read, really well and clearly articulated too (145-157).

• I really liked the discussion about Sociodemographics (159-177). However, as food insecurity deals with issues of enough income, I was left wondering - What about either Before Housing Costs or After Housing Costs? And were these considered? If not, does this change the discussion?

• 227-228 – perhaps a note and a reference to Sociological literature about the gendered difference in HRP

• 241 – following reading your data here, I’m now wondering about the rising cost of living and the recent fluctuations in inflation. Is there something to discuss about the relative cost of food vs incomes here?

• 353 – whilst I agree that the HRP may well shoulder the burden of financial anxiety associated with earning enough and being able to feed the household, I also wonder about those who do not have this power, or seem to be powerless in this, i.e. those without a financial ability (not responsibility), perhaps those with lower earnings and do not make financial decisions – do they suffer with more anxiety through a lack of power? Could the authors add a sentence or two about those who are dependent on the ability of others, as they have less say and may feel even more anxious (if not, perhaps, totally excluded from being able to make food/financial decisions).

o I note that discussions happen around this in the following sentences (354-366), so perhaps you have covered this, but there is an interesting discussion to have about HRP and gender.

• 369-376 – I also tend to agree with what you hint at here. Perhaps you are either food secure, or food insecure (and no shades of grey) as having levels of (in)security may not be that beneficial to understanding the concept. Is it more binary than current accounts allow for?

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Reviewer #1: No

Reviewer #2: Yes:  Dave Beck

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Association between food insecurity, ethnicity, and mental health in the UK: An analysis of the Family Resource Survey

PONE-D-25-06411R1

Dear Dr. Power,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

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1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the taking the time to address the reveiw comments thoroughly, I can appreciate the effort involved. The paper will be a good contribution to the literature, well done.

Reviewer #2: Thanks for the update. All comments that I made have been met. Still really liked this article, I think it was really well written and I added some minor comments, which have also now been met.

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Reviewer #1: No

Reviewer #2: Yes:  Dave Beck

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