Impact of sex and marital status on the prevalence of perceived depression in association with food insecurity.

BACKGROUND: While both food insecurity and depression have been reported to be closely related to sex and marital status, the impact of sex and marital status on the prevalence of perceived depression in association with food security status has not been evaluated. MATERIALS &
METHODS: We performed a nationwide population study using data for 19,866 adults obtained from the 2012-2015 Korean National Health and Nutrition Examination Surveys. Household food insecurity status was evaluated using the 18-item Food Security Survey Module. Perceived depression was measured using one item questionnaire or the 9-item Patient Health Questionnaire (PHQ-9). We cross-sectionally analyzed associations between perceived depression and variables, including socio-demographic factors and food security status. The prevalence of perceived depression was compared according to sex, marital status, and food security status. We applied survey sampling weights in all analyses.
RESULTS: The overall prevalence of perceived depression was 10.5%. Prevalence rates of perceived depression in the high food security group, marginal food security group, low food security group, and very low food security group were 8.9%, 13.6%, 19.7%, and 35.0%, respectively (P < 0.001). Of total participants, 1.8% were categorized as having both perceived depression and food insecurity. After adjusting for confounding covariates, female sex (adjusted odds ratio [aOR]; 2.37), never married (aOR; 1.37), divorced/widowed/separated (aOR; 1.50), low food security (aOR; 1.72), and very low food security (aOR; 3.65) were associated with increased risk of perceived depression. Men with very low food security and divorced/widowed/separated status were most likely to have perceived depression (53.2%), followed by women with very low food security and divorced/widowed/separated status (48.7%), women with very low food security and married status (42.0%), and women with low food security and divorced/widowed/separated status (33.3%).
CONCLUSIONS: Female sex and marital status of divorced/widowed/separated were strongly associated with perceived depression. These two factors and food insecurity synergistically contributed to perceived depression.

Introduction

Food insecurity is defined as limited access to food at the level of individuals or households due to lack of money or other resources [1]. Food insecurity components include insufficient food quantity, inadequate quality, unsafety, and cultural unacceptability [2]. Beyond hunger and increased risk of malnutrition, food insecurity is closely associated with a higher prevalence of chronic diseases such as diabetes mellitus, obesity, hypertension, hyperlipidemia, and metabolic syndrome [3, 4]. Globally, it has been estimated that nearly 821 million people remain food-insecure [1]. Even in the high-income region, more than 10% of all households are suffering from food insecurity [5, 6]. Food insecurity has been recognized as one of the key social determinants of health and a contemporarily important public health issue.

Food insecurity has been associated with unhealthy dietary patterns, including higher consumption of sugar/carbohydrate/meat/alcohol and lower consumption of fish/seafood [7]. Recent cross-sectional and longitudinal studies have shown that unhealthy dietary patterns can adversely affect psychological health [8-11]. Growing evidence has shown that food insecurity is closely linked to depression [12-15]. Both food insecurity and depression can negatively affect the lives of individuals. They can be strongly affected by socioeconomic factors, of which female sex and dissolution of marriage have been recognized as robust risk factors for food insecurity [16, 17] and depression [18-20]. However, to the best of our knowledge, no study has reported the impact of sex or marital status on the prevalence of depression across food insecurity categories. A better understanding of those associations could help us develop and evaluate strategies for economic and social support. Therefore, the objective of this study was to examine the impact of sex and marital status on the prevalence of perceived depression in association with food security status in Korean adults using nationwide population-based data.

Materials and methods

Design and study population

We used nationwide population-based cross-sectional data from the Korean National Health and Nutrition Examination Surveys (KNHANES). The KNHANES is a continuous, nationally representative survey conducted by the Korea Centers for Disease Control and Prevention (KCDC) [21]. KNHANES was designed to assess the health and nutrition status of the Korean people. It surveys non-institutionalized civilian Korean population. The KNHANES comprises in-person health interviews, health examinations, and a nutrition survey. We used 2012–2015 KNHANES data. Among 24,327 adult participants aged 19 years or older, we excluded participants whose household food security data (n = 1,901) or perceived depression data (n = 2,560) were missing. The final analytic sample consisted of 19,866 adults (Fig 1). The KNHNES was approved by the Ethics Committee of the KCDC. All participants provided informed consent. We used only publicly available data at http://knhanes.cdc.go.kr/knhanes.

Fig 1

Enrollment process for adults with reasons for exclusion.

Measures

Food security status

Food security status was measured at the household level using an 18-item food insecurity questionnaire, which had been modified from the US Household Food Security Survey Module [22]. Responses to these items were scored. Food security was then categorized as high food security, marginal food security, low food security, and very low food security. We considered households with low or very low food security as food-insecure.

Perceived depression

Perceived depression was assessed using the 9-item Patient Health Questionnaire (PHQ-9) (the year of 2014) or one-item questionnaire (the year of 2012, 2013, or 2015) which asked subject in a dichotomous manner (yes/no) on whether he or she felt sadness or despair enough to disturb daily life for more than 14 days consecutively over the past year. A dichotomous variable indicating no perceived depression (one-item questionnaire: no or PHQ-9 total score < 10) or perceived depression (one-item questionnaire: yes or PHQ-9 total score ≥ 10) [23] was created.

Marital status

Marital status was divided into five categories: never married, married, divorced, widowed, or separated. We reclassified these into three categories: never married, married (reference group), or divorced/widowed/separated.

Other covariates

Other sociodemographic covariates included age, education attainment, household income, smoking, alcohol intake, and physical activity. Age was classified into four categories: 19–39 years, 40–59 years (reference group), and more than 60 years. Education attainment was recoded into ≤elementary school, middle school, high school, and ≥ college education (reference group). Household income was divided into quartiles for lowest, lower-middle, upper-middle, or highest (reference group). Smoking status was categorized as current smoker, past smoker, and never smoker (reference group). Alcohol intake was categorized as heavy, moderate, and none (reference group). Those who drank at least seven glasses for men or 5 glasses for women at a time and more than twice per week were considered as heavy alcohol drinkers. Physical activity was divided into regular (reference group), intermittent, and none. Vigorous exercise more than four days per week was considered as having regular exercise. Anthropometric measurements were conducted by trained staff members. Body mass index (kg/m2) was calculated as weight divided by the square of height.

Statistical analyses

Data are presented as a percentage with a standard error for categorical variables and mean with a standard error for continuous variables. Unadjusted differences in socio-demographic characteristics across food security categories were tested using Rao-Scott Chi-square test or one-way analysis of variance (ANOVA). Multiple logistic regression was used to calculate the odds ratio and 95% confidence interval for perceived depression after adjusting for confounding covariates. Potential confounding covariates included sex, age, education attainment, marital status, income, smoking, alcohol, physical activity, food security status, and body mass index. We then compared the difference of perceived depression prevalence according to sex, marital status, and food insecurity status. Based on the statistical guidelines of the KCDC, we applied survey sampling weights in all analyses. We used SURVEY commands in SAS to account for the complex sampling strategy and produce output that was representative of the total Korean population. All statistical analyses were performed using SAS 9.4 software (SAS Institute, Cary, NC, USA). A P value of < 0.05 was considered statistically significant.

Results

Fig 1 includes the distribution of food security status of finally enrolled 19,866 participants. Approximately half (49.3%) of these participants were males. The mean age of all participants was 45.8 years. Percentages (standard error) of those with high food security, marginal food security, low food security, and very low food security were 79.9% (0.6), 11.9% (0.4), 7.0% (0.3), 1.3% (0.1), respectively. Table 1 shows the characteristics of participants stratified by household food security status. Food-insecure participants (low food security or very low food security groups) were more likely to be female, divorced/widowed/separated, current smoker, and non-heavy alcohol drinker. Food-insecure participants also had lower educational attainment, lower-income, and lower physical activity. The overall prevalence of perceived depression was 10.5%. A point estimate of the prevalence of perceived depression in the year 2014 was lower than that of the other three years combined (6.5% vs. 11.9%, P < 0.001). The difference in point estimates was 5.4% (95% confidence interval: 4.2–6.7%). Of total participants, 1.8% were categorized as having both perceived depression and food insecurity. Prevalence rates of perceived depression in the high food security group, marginal food security group, low food security group, and very low food security group were 8.9%, 13.6%, 19.7%, 35.0%, respectively (P < 0.001).

Table 1

Characteristics of participants stratified by household food security status..

	Food secure n = 18,223		Food insecure n = 1,643
Variable	High food security n = 15,787	Marginal food security n = 2,436	Low food security n = 1,392	Very low food security n = 251	Total n = 19,866	P valueb
Sex						< 0.001
Male	50.1 (0.4)	47.5 (1.1)	43.5 (1.6)	45.6 (3.6)	49.3 (0.4)
Female	50.0 (0.4)	53.0 (1.1)	56.5 (1.6)	54.4 (3.6)	50.7 (0.4)
Age, mean years	45.2 (0.2)	48.6 (0.5)	47.5 (0.6)	49.1 (1.4)	45.8 (0.2)	< 0.001
19–39	39.8 (0.7)	33.9 (1.4)	34.1 (1.7)	29.9 (3.8)	38.6 (0.6)
40–59	41.0 (0.6)	36.1 (1.2)	41.3(1.7)	42.9 (3.6)	40.5 (0.5)
> 60	19.2 (0.5)	29.9 (1.3)	24.6 (1.4)	27.3 (3.4)	20.9 (0.4)
Marital status						< 0.001
Never married	22.6 (0.6)	23.5 (1.3)	22.5 (1.6)	22.8 (3.3)	22.7 (0.5)
Married	69.4 (0.6)	60.6 (1.4)	54.4 (1.9)	39.3 (4.1)	66.9 (0.6)
Divorced/separated/widowed	8.0 (0.3)	15.8 (0.9)	23.1 (1.5)	37.9 (4.0)	10.3 (0.3)
Education attainment						< 0.001
≤ elementary school	13.7 (0.4)	25.6 (1.1)	28.1 (1.5)	39.0 (4.2)	16.4 (0.4)
Middle school	8.3 (0.3)	12.4 (0.9)	11.7 (1.1)	14.3 (2.9)	9.1 (0.3)
High school	38.6 (0.6)	40.0 (1.4)	41.2 (1.8)	31.2 (4.3)	38.8 (0.5)
≥ College	39.5 (0.7)	22.0 (1.3)	19. 0 (1.5)	15.5 (3.3)	35.7 (0.6)
Income						< 0.001
1st quartile (lowest)	10.4 (0.4)	27.8 (1.6)	32.7 (2.0)	58.3 (4.8)	14.6 (0.5)
2nd quartile	22.4 (0.6)	34.1 (1.7)	40.0 (2.3)	27.9 (4.4)	25.0 (0.6)
3rd quartile	31.3 (0.7)	24.3 (1.5)	20.6 (1.8)	12.7 (3.7)	29.5 (0.6)
4th quartile (highest)	35.9 (0.9)	13.7 (1.3)	6.7 (1.4)	1.1 (1.1)	30.8 (0.8)
Smoking						< 0.001
current	22.0 (0.5)	25.2 (1.2)	27.3 (1.6)	31.5 (3.9)	22.9 (0.4)
past	21.0 (0.4)	17.9 (0.9)	17.3 (1.2)	16.8 (2.9)	20.4 (0.3)
none	56.9 (0.5)	56.8 (1.3)	55.4 (1.6)	51.7 (4.0)	56.7 (0.4)
Alcohol intake						< 0.001
Heavy	19.6 (0.5)	16.8 (1.1)	16.3 (1.3)	16.8 (3.6)	19.0 (0.4)
Moderate	51.9 (0.6)	46.5 (1.4)	45.1 (1.8)	33.5 (3.8)	50.5 (0.5)
None	28.5 (0.5)	36.7 (1.4)	38.6 (1.7)	49.7 (4.2)	30.5 (0.5)
Physical activity						< 0.001
None	38.3 (0.6)	42.4 (1.4)	45.7 (1.8)	51.8 (4.2)	39.4 (0.5)
Intermittent	33.6 (0.5)	32.1 (1.3)	31.6 (1.7)	28.9 (3.9)	33.2 (0.5)
Regular	28.2 (0.5)	25.5 (1.1)	22.7 (1.4)	19.3 (3.3)	27.3 (0.4)
Body mass index						0.01
Underweight	4.4 (0.2)	4.6 (0.6)	5.2 (0.7)	6.6 (1.9)	4.5 (0.7)
Normal weight	63.6 (0.5)	61.8 (1.3)	59.0 (1.6)	56.7(3.9)	62.9 (0.4)
Overweight	32.0 (0.5)	33.6 (1.3)	35.8 (1.6)	36.7(3.7)	32.5 (0.4)
Perceived depression						< 0.001
No	91.1 (0.3)	86.4 (0.8)	80.3 (1.4)	65.0 (3.9)	89.5 (0.3)
yes	8.9 (0.3)	13.6 (0.8)	19.7 (1.3)	35.0 (3.9)	10.5 (0.3)

aData are presented as weighted percentage (standard error).

bP values for differences between food-secure participants and food-insecure participants.

Table 2 shows the unadjusted and adjusted odds ratio (aOR) and 95% confidence interval for perceived depression. Multiple logistic regression showed that female sex (aOR: 2.39), never married (aOR: 1.37), divorced/widowed/separated (aOR: 1.48), low food security (aOR: 1.75), and very low food security (aOR: 3.74) were associated with a greater likelihood of experiencing perceived depression. Other significant factors included non-college education attainment (aOR: 1.27–1.82), lowest household income (aOR: 1.33), current smoking (aOR: 1.72), and past smoking (aOR: 1.38). Age, body mass index, and physical activity were not significantly associated with perceived depression. A separate analysis of data in the year 2014 and the other years (2012, 2013, or 2015) also showed similar results (S1 Table).

Table 2

Unadjusted and adjusted odds ratio and 95% confidence interval for perceived depression.

	Unadjusted odds ratio(95% confidence interval)	P value	(95% confidence interval)	P value
Sex
Male	1		1
Female	2.06 (1.48–2.86)	<0.001	2.39 (2.00–2.92)	< 0.001
Marital status
Never married	1.66 (1.16–2.39)	0.01	1.37 (1.14–1.64)	< 0.001
Married	1		1
Divorced/separated/widowed	2.70 (2.03–3.60)	<0.001	1.48 (1.24–1.76)	< 0.001
Food security status
High	1		1
Marginal	2.46 (1.63–3.73)	<0.001	1.34 (1.12–1.60)	0.001
Low	3.79 (2.41–5.93)	<0.001	1.75 (1.42–2.16)	< 0.001
Very low	8.24 (4.11–16.55)	<0.001	3.74 (2.62–5.33)	< 0.001
Education
≤ elementary school	2.21 (1.51–3.23)	<0.001	1.71 (1.40–2.10)	< 0.001
Middle school	1.10 (0.65–1.87)	0.72	1.82 (1.45–2.30)	< 0.001
High school	1.25 (0.87–1.80)	0.23	1.27 (1.07–1.51)	0.01
≥ College	1		1
Household income
1st quartile (lowest)	3.53 (2.25–5.53)	<0.001	1.33 (1.07–1.66)	0.01
2nd quartile	1.37 (0.88–2.13)	0.17	0.96 (0.79–1.17)	0.69
3rd quartile	0.78 (0.50–1.25)	0.33	0.93 (0.76–1.13)	0.45
4th quartile (highest)	1		1
Smoking
current	1.21 (0.84–1.74)	0.30	1.72 (1.36–2.17)	< 0.001
past	0.57 (0.38–0.87)	0.01	1.38 (1.12–1.71)	< 0.01
none	1		1
Alcohol intake
Heavy	0.84 (0.51–1.41)	0.52	1.03 (0.84–1.27)	0.76
Moderate	0.62 (0.45–0.85)	0.001	0.86 (0.75–0.99)	0.03
None	1		1

The prevalence of perceived depression in association with sex, marital status, and food security status is shown in Table 3 and Fig 2. Men with very low food security and divorced/widowed/separated status were most likely to have perceived depression (53.2%), followed by women with very low food security and divorced/widowed/separated status (48.7%), married women with very low food security (42.0%), and women with low food security and divorced/widowed/separated status (33.3%). These findings were consistent throughout the study period (S2 Table).

Table 3

Prevalence of perceived depression in association with sex-marital staus and food security status.

	High food security	Marginal food security	Low food security	Very low food security	Total	P value
Male
never married (n = 1,495)	8.8 (1.0)	3.9 (1.5)	19.1 (4.2)	24.3 (9.7)	9.0 (0.8)	< 0.001
married (n = 6,313)	5.5 (0.4)	5.8 (1.0)	8.1 (1.6)	11.3 (5.2)	5.7 (0.4)	0.13
divorced/widowed/separated (n = 497)	12.8 (2.4)	15.6 (5.0)	22.8 (5.8)	53.2 (10.9)	17.6 (2.1)	< 0.001
Subtotal (n = 8,305)	6.7 (0.4)	5.6 (0.8)	13.1 (1.8)	28.4 (5.6)	7.2 (0.4)	<0.001
Female
never married (n = 1,478)	12.8 (1.1)	17.8 (3.3)	21.7 (4.9)	17.4 (7.9)	14.1 (1.0)	0.07
married (n = 7,835)	9.7 (0.5)	20.9 (1.7)	20.6 (2.1)	42.0 (7.2)	11.8 (0.5)	< 0.001
divorced/widowed/separated (n = 2,248)	16.3 (1.2)	22.4 (2.6)	33.3 (3.8)	48.7 (6.4)	21.4 (1.1)	< 0.001
Subtotal (n = 11,561)	11.1 (0.4)	20.8 (1.3)	24.8 (1.9)	40.5 (4.9)	13.7 (0.4)	<0.001

aData are presented as weighted percentage (standard error).

Fig 2

Prevalence of perceived depression in association with sex, marital status, and food security status.

Discussion

We demonstrated that female sex and divorced/widowed/separated marital status independently had a strong impact on the prevalence of perceived depression in adults. When one or more of these factors showed a link with food insecurity, the likelihood of perceived depression was much greater. These findings indicate that sex, marital status, and food security status should be taken into account together as key factors for perceived depression.

We found strong dose-response pattern associations for food insecurity and perceived depression in adults. That is, the magnitude of the association was the strongest among those who had very low food security (35.0%), followed by those with low food security (19.7%) and marginal food security (13.6%). These findings are consistent with results of prior studies [24-27]. The strength of the current study was that we used large population-based data not confined to socio-economically vulnerable subgroups. Given the cross-sectional design, however, we could not provide any conclusion of a causal relationship between food insecurity and perceived depression. Several longitudinal studies have shown that food insecurity and depression are related in a bidirectional manner [15, 28, 29]. Since food insecurity is a modifiable factor, food insecurity interventions may yield benefits for the prevention, early detection, and management of depressive symptoms. Recently, a USA group has demonstrated that participation in a Supplemental Nutrition Assistance Program (SNAP) can significantly reduce psychological distress after six months of participation [30]. An evaluation of a poverty-alleviation program for the ultra-poor in Bangladesh has also shown that food insecurity is the most important mediator for relieving psychosocial distress [31]. Further food insecurity interventional studies employing a study design relevant to regional socioeconomic context and population are warranted.

The novel aspect of this study is the investigation of the simultaneous effect of sex, marital staus, and food insecurity on perceived depression. While male sex was a strong protective factor for perceived depression, men with very low food security and divorced/widowed/separated status had the highest risk of perceived depression (53.2%). Even in the same group of men with very low food security, the rate of perceived depression widely ranged from 11.3% (married men) to 53.2% (divorced/widowed/separated men). Our findings indicate that concurrent analysis of significant factors for perceived depression and detailed subgroup analysis can be helpful for the determination of target population for support.

Our study has several limitations. First, as stated earlier, the cross-sectional study design precluded our ability to make a causal relationship. Second, we used a one-item questionnaire in the year of 2012, 2013, or 2015 and PHQ-9 for the year of 2014. A point estimate of the prevalence of perceived depression in the year 2014 was lower than that of the other three years combined. Different usage of screening tool might have been associated with some biases. However, when we analyzed the data in the year 2014 and the other years, the main findings were similar regardless of the study period, supporting our conclusion. Third, the amount or impact of inadequate nutritional intake was not directly evaluated. Fourth, we grouped households with marginal food security as food secure group. There have been arguments that households with marginal food security have poorer adverse health outcomes than households with high food security [32]. Finally, we grouped subjects with divorced, widowed, or separated status into one group because of a relatively small number of each group of participants. Each status might have a differential impact on the perceived depression.

In conclusion, female sex and divorced/widowed/separated marital status were independent predictors for perceived depression in Korean adults. Food insecurity was closely associated with perceived depression in a dose-response fashion and synergistically contributed to a higher prevalence of perceived depression. These findings suggest that multidisciplinary efforts including economical, nutritional, and psychiatric support should be preferentially focused on these high-risk groups.

Adjusted odds ratio and 95% confidence interval for perceived depression.

(DOC)

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Prevalence of perceived depression in association with sex-marital staus and food security statusa.

(DOC)

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29 Apr 2020

PONE-D-19-21715

Impact of sex and marital status on the prevalence of perceived depression in association with food insecurity

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Reviewer #1: This study is of interest and is mostly technically sound. The only concern is that the PHQ-9, a respectable screener for depressive symptoms, was only used in one year (2014). The other years used a yes/no response regarding symptoms for at least 14 days over the last year. At face value this is not totally unreasonable approach, but this reviewer would be like to know if the prevalence estimates for the PHQ-9 year (2014) were comparable to the other years (2012, 2013, 2015). For this purpose it will be sufficient to estimate the overall prevalence of depression in year 2014 vs the other 3 years combined, with a t test. 95% CIs would be preferable for these estimates as a more informative epidemiological approach than standard errors re the precision of the point estimates.

Re Table 1. BMI is not mentioned in the text unless I missed it

Model of Table 2: suggest dropping non-significant variables (age, BMI and physical activity). This will modify the other ORs a little, and that they are non-significant can be mentioned in the text.

Line 165: I do not understand the sentence beginning with “An alarmingly high…..”

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16 May 2020

Response letter

Dear Dr. Kotozaki,

Thank you for reviewing our manuscript PONE-D-19-21715 entitled “mpact of sex and marital status on the prevalence of perceived depression in association with food insecurity”. We appreciate your in-depth review and helpful comments. We have made corrections and modifications accordingly. The following are itemized lists stating our disposition in detail of each point raised by the reviewer. Thank you for your consideration of our manuscript. We look forward to a favorable decision on this revision.

Sincerely yours,

Yookyung Kim, Ph D

Professor

Department of Human Ecology, Graduate School, Korea University

#1 reviewer:

Reviewer comment: This study is of interest and is mostly technically sound. The only concern is that the PHQ-9, a respectable screener for depressive symptoms, was only used in one year (2014). The other years used a yes/no response regarding symptoms for at least 14 days over the last year. At face value this is not totally unreasonable approach, but this reviewer would be like to know if the prevalence estimates for the PHQ-9 year (2014) were comparable to the other years (2012, 2013, 2015). For this purpose it will be sufficient to estimate the overall prevalence of depression in year 2014 vs the other 3 years combined, with a t test. 95% CIs would be preferable for these estimates as a more informative epidemiological approach than standard errors re the precision of the point estimates.

Response: Thanks for the reviewer’s thoughtful comments. As the reviewer recommended, we compared the overall prevalence of depression in the year 2014 vs. the other three years combined. To see whether different usage of screening tool has influenced our conclusion, we also separately performed multiple regression analysis for perceived depression in the year 2014 vs. the other three years. A t-test showed that the point estimate of the prevalence of perceived depression in the year 2014 was lower than that of 3 years combined (5.6% vs. 11.9%, P < 0.001). The difference in point estimates was 5.4% (95% confidence interval: 4.2-6.7%). Multiple regression analysis showed similar results regardless of the year/period. That is, female sex and dissolution of marriage had a significant impact prevalence of perceived depression and synergistically contributed to a higher prevalence of perceived depression with food insecurity. We described these findings in the text (page 7, line 119-122; page 8, line 133-134. line 140-141; page 10, line 176-180 ) and newly prepared Supplementary Tables 1 & 2.

Reviewer comments: Re Table 1. BMI is not mentioned in the text unless I missed it. Model of Table 2: suggest dropping non-significant variables (age, BMI and physical activity). This will modify the other ORs a little, and that they are non-significant can be mentioned in the text.

Response: As the reviewer recommended, we deleted non-significant variables in Table 2. We mentioned it in the text (page 8, line 132-134). We revised the ORs in Table 2 (page 15: Adjusted odds ratio) and the text (page 8, line 127-131).

Reviewer comment: Line 165: I do not understand the sentence beginning with “An alarmingly high…..”

Response: We deleted the sentence in the revised manuscript (page 8, line 168-169).

Submitted filename: Response to reviewers.doc

Click here for additional data file.

20 May 2020

Impact of sex and marital status on the prevalence of perceived depression in association with food insecurity

PONE-D-19-21715R1

Dear Dr. Yookyung Kim,

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

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With kind regards,

Yuka Kotozaki

Academic Editor

PLOS ONE

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Reviewer #1: (No Response)

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Reviewer #1: Yes: Dr Andrew Bulloch

1 Jun 2020

PONE-D-19-21715R1

Impact of sex and marital status on the prevalence of perceived depression in association with food insecurity

Dear Dr. Kim:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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