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Conteúdo (article):

Efeito positivo da segurança alimentar na diminuição do estado de ansiedade de mulheres durante a gestação e pós-parto.

Positive Effect of Food Security on the Reduction of Anxiety State in Women During Pregnancy and Postpartum.

Efecto positivo de la seguridad alimentaria en la disminución del estado de ansiedad de mujeres durante el embarazo y el posparto.

Maria Augusta Correa Barroso Magno Viana,(1)
Rafaela Lira Formiga Cavalcanti de Lima,(2)
Hugo Ramiro Melgar-Quiñonez,(3)
Poliana de Araújo Palmeira,(4)
Rodrigo Pinheiro de Toledo Vianna.(5)

(1) Núcleo Interdisciplinar de Estudos em Saúde e Nutrição (NIESN), Programa de Pós-graduação em Ciências da Nutrição, Universidade Federal da Paraíba, João Pessoa (PB), Brasil.
Email: m.augustamagno@hotmail.com
ORCID: https://orcid.org/0000-0002-1122-1197
(2) Núcleo Interdisciplinar de Estudos em Saúde e Nutrição (NIESN), Programa de Pós-graduação em Ciências da Nutrição e Programa de Pós-graduação em Modelos de Decisão e Saúde, Universidade Federal da Paraíba, João Pessoa (PB), Brasil.
Email: rafaelanutri@gmail.com
ORCID: https://orcid.org/0000-0003-1272-0067
(3) School of Human Nutrition, McGill University, Quebec, Canadá.
Email : hugo.melgar-quinonez@mcgill.ca
ORCID: https://orcid.org/0000-0001-7014-8260
(4) Centro de Educação e Saúde da Universidade Federal de Campina Grande, Núcleo Interdisciplinar de Estudos em Saúde e Nutrição (NIESN), Programa de Pós-graduação em Ciências da Nutrição, Universidade Federal da Paraíba, João Pessoa (PB), Brasil.
Email: poliana.araujo@professor.ufcg.edu.br
ORCID: https://orcid.org/0000-0002-3503-3414
(5) Núcleo Interdisciplinar de Estudos em Saúde e Nutrição (NIESN), Programa de Pós-graduação em Modelos de Decisão e Saúde, Universidade Federal da Paraíba, João Pessoa (PB), Brasil.
Email: rodrigopissoa@gmail.com
ORCID: https://orcid.org/0000-0002-5358-1967

Resumo
O estudo investigou o efeito da segurança alimentar (SA) no estado de ansiedade de mulheres residentes em João Pessoa-PB, Brasil, usuárias do Sistema Único de Saúde durante a gestação e o pós-parto. Estudo de coorte realizado entre 2018 e 2020 com 122 mulheres recrutadas nas Unidades de Saúde da Família e acompanhadas em seus domicílios. A Segurança e os níveis de Insegurança Alimentar foram avaliados pela Escala Brasileira de Insegurança Alimentar e o estado de ansiedade mensurado pelo Inventário de Ansiedade Traço-Estado. Foram coletadas informações sociodemográficas e econômicas. As análises foram realizadas a partir de um modelo de equação de estimativa generalizada ajustado por idade e renda. As mulheres classificadas em algum nível de insegurança alimentar apresentaram maiores escores de ansiedade. Ao longo do acompanhamento, as mulheres que permaneceram em SA, ou passaram de algum nível de insegurança para SA reduziram seu escore de ansiedade em 9,3%. Os resultados destacam a importância da SA, não apenas como um direito humano, mas também para reduzir transtornos mentais em mulheres durante uma importante fase da vida. Recomenda-se a integração de serviços de saúde mental com ações de garantia da segurança alimentar, especialmente no pré-natal e pós-parto.
Palavras chaves: Segurança Alimentar; Transtornos Mentais; Gravidez; Estudos de Coortes.

Abstract
The study investigated the effect of food security (FS) on the anxiety state of women living in João Pessoa, Paraíba, Brazil, who were users of the Unified Health System during pregnancy and the postpartum period. This was a cohort study conducted between 2018 and 2020 with 122 women recruited from Family Health Units and followed up in their homes. Food security and levels of food insecurity were assessed using the Brazilian Food Insecurity Scale, and anxiety state was measured using the State–Trait Anxiety Inventory. Sociodemographic and economic information was collected. Analyses were performed using a generalized estimating equation model adjusted for age and income. Women classified at any level of food insecurity presented higher anxiety scores. Throughout the follow-up period, women who remained food secure, or who transitioned from some level of food insecurity to food security, reduced their anxiety score by 9.3%. The results highlight the importance of food security not only as a human right, but also as a means of reducing mental disorders in women during an important stage of life. The integration of mental health services with actions to ensure food security is recommended, especially during prenatal and postpartum care.
Key words: Food security; Mental Disorders; Pregnancy; Cohort studies.

Resumen
El estudio investigó el efecto de la seguridad alimentaria (SA) en el estado de ansiedad de mujeres residentes en João Pessoa, PB, Brasil, usuarias del Sistema Único de Salud durante el embarazo y el posparto. Se trató de un estudio de cohorte realizado entre 2018 y 2020 con 122 mujeres reclutadas en Unidades de Salud de la Familia y acompañadas en sus domicilios. La seguridad y los niveles de inseguridad alimentaria fueron evaluados mediante la Escala Brasileña de Inseguridad Alimentaria, y el estado de ansiedad fue medido por el Inventario de Ansiedad Rasgo-Estado. Se recopilaron informaciones sociodemográficas y económicas. Los análisis se realizaron a partir de un modelo de ecuaciones de estimación generalizada ajustado por edad e ingresos. Las mujeres clasificadas en algún nivel de inseguridad alimentaria presentaron mayores puntuaciones de ansiedad. A lo largo del seguimiento, las mujeres que permanecieron en SA, o que pasaron de algún nivel de inseguridad a SA, redujeron su puntuación de ansiedad en un 9,3%. Los resultados destacan la importancia de la SA, no solo como un derecho humano, sino también como una estrategia para reducir trastornos mentales en mujeres durante una etapa crucial de la vida. Se recomienda la integración de servicios de salud mental con acciones de garantía de la seguridad alimentaria, especialmente durante el prenatal y el posparto.
Palabras clave: Seguridad alimentaria; Trastornos mentales; Embarazo; Estudios de cohortes.

Introduction
The period that begins during pregnancy and extends through the first months of the baby’s life is very important for the health of both the woman and the child, and complications during this phase may have serious lifelong consequences, affecting both the mother’s well-being and the care provided to the newborn.1 The gestational period is a phase of great vulnerability for women due to physiological changes that impact physical health and economic conditions, which may affect mental health and mothers’ quality of life and may extend into the postpartum period.2
Anxiety, a mental disorder characterized by an emotional state of fear, apprehension, discomfort, and behavioral changes, has increasingly been recognized as a public health problem.3 Perinatal anxiety is common during pregnancy, affecting about one in ten women in high-income countries and one in five women in low- and middle-income countries.4
Globally, anxiety represents the sixth largest contributor to non-fatal health loss worldwide, affecting approximately 301 million people globally.5
Several studies show that food insecurity (FI) is a risk factor for anxiety states in women in general and especially during the gestational cycle.6–9
Mothers exposed to food insecurity may develop common mental disorders such as anxiety, resulting from deprivation of access to food, which can lead to feelings of shame and despair and to reduced social engagement.10
Poor mental health reduces productivity, affects social relationships, and perpetuates cycles of poverty,11 which is consistent with the situation of food insecurity, understood as the violation of the human right to regular and permanent access to food of adequate quality and quantity.12 Uncertainty regarding the ability to maintain and acquire sufficient food for household consumption induces a psycho-emotional burden and gives rise to feelings of deprivation, alienation, low self-efficacy, and helplessness.6
In 2019, food insecurity affected 25.9% of the world population, approximately two billion people.13 In Brazil, the national survey conducted between 2017 and 2018 found that 36.7% of the population experienced food insecurity, affecting 84.9 million Brazilians.14
Although the association between food insecurity and mental health is recognized, this study is justified because it seeks to demonstrate and measure the effects of causal relationships between exposure to food security and food insecurity on women’s mental health throughout pregnancy and the postpartum period using a longitudinal design.
Thus, the objective of the present study was to investigate the impact of food security and food insecurity on mental health in a cohort of mothers living in João Pessoa, Paraíba.

Methodology
Study design, sample, and data collection
A prospective cohort study was conducted with pregnant women recruited from ten Family Health Units (Unidades de Saúde da Família, USF), linked to Health District III of the municipality of João Pessoa, Paraíba, Brazil.
The municipality has five Health Districts, distributed across neighborhoods that encompass the USFs providing care to the resident population.
To optimize data collection logistics, a survey of the locations of the Health Districts was carried out in order to select those closest to the Federal University of Paraíba (UFPB) and to assess the prenatal care demand of the FHUs linked to these districts, considering the number of interviewers available for data collection. Thus, among the 18 FHUs linked to Health District III, ten FHUs were selected because they had a higher number of prenatal care visits and were located close to the aforementioned university, facilitating access for the interviewers.
Pregnant women aged 18 years or older with a normal pregnancy were included, regardless of gestational age. Women with neurological or psychiatric problems, communication difficulties, or serious conditions or illnesses requiring special care were excluded.
During the recruitment period, all pregnant women who attended the Family Health Units for their prenatal consultations were invited to participate in the study. Recruitment occurred on all days of the week in order to avoid selection bias in the study sample.
The study was conducted between November 2018 and March 2020 and was divided into three moments. Recruitment began with 271 participants (1st moment), decreasing to 184 in the subsequent stage, the first home visit (2nd moment), and ending with 122 women at the second home visit (3rd moment) (Figure 1). Throughout the follow-up, there were 21 refusals, and most losses resulted from unsuccessful attempts to conduct home visits. These were considered unsuccessful when the woman was not found during home visits carried out on three different days and at three different times. Losses were considered random, as no differences were identified in the predictor variable between the complete and reduced databases at the different follow-up moments.
The sample of the present study originated from a larger study that aimed to evaluate the impact of food insecurity on the health of pregnant/postpartum women, their children, and non-pregnant women.15 For the present analysis, only women who did not have interruptions in follow-up and had complete data were considered. Thus, the final sample size comprised 122 women.
Considering a significance level of 5% and a test power of 80%, with an observed outcome frequency of approximately 20% among the unexposed, this sample size made it possible to observe events with a relative risk equal to or greater than 2.2.16
Data collection was carried out at approximately three-month intervals, with one month of fieldwork for each collection, totaling an estimated follow-up of 12 months, thus making it possible to obtain information during pregnancy and the postpartum period. This interval was an adopted strategy that allowed observation of food security and food insecurity status according to the validity period of the employed instrument – the Brazilian Food Insecurity Scale (Escala Brasileira de Insegurança Alimentar, EBIA).17
Data collection was performed through face-to-face interviews conducted by previously trained interviewers who used the KoboCollect® application18 on their mobile phones to ask the questions and record responses.
At recruitment, carried out in the FHUs while the pregnant woman was waiting for her prenatal consultation, telephone contact information and address were requested in order to schedule home visits. In addition, sociodemographic information was collected, including: race (white; black; mixed; indigenous), marital status (living with a partner; not living with a partner), who was considered the head of the household (the interviewee herself; husband/partner; others), type of residence (house; apartment), number of household residents (up to three residents; four to six residents; ≥ seven residents), type of sanitation (public sewage system; open sewage; inadequate; does not know), and source of water used in the household (public network; cistern at home; artesian well at home). Economic variables included: education level (illiterate; elementary school; high school; completed higher education), receipt of government cash transfers (yes; no), and per capita income (up to ½ minimum wage; greater than ½ minimum wage). Health-related variables included gestational trimester (1st trimester; 2nd trimester; 3rd trimester) and whether the pregnancy was primiparous or not. In addition to collecting these data, questionnaires on household food insecurity exposure and women’s mental health were administered.
For the home visits, women were previously contacted by telephone to schedule the day and time when they would be available to receive the interviewer at their homes. For those who could not be contacted by telephone, unscheduled visits were carried out on different days and at different times as a strategy to minimize follow-up losses. In these situations, when it was not possible to locate the participants at home, the visits were classified as unsuccessful attempts.
Participants whose addresses could not be located, those who chose not to continue in the study, those who lost the baby, and those who moved out of the municipality of João Pessoa were considered losses.
At the two subsequent home visits, the mental health and household food insecurity exposure questionnaires were reapplied. Information on the number of household residents, household income, and receipt of government income transfers was also obtained.
All questionnaires used were pre-tested in a pilot study through home visits to pregnant women from an FHU not included in the study.
Predictor Variable
Household food insecurity was assessed using the Brazilian Food Insecurity Scale (Escala Brasileira de Insegurança Alimentar - EBIA), a questionnaire adapted from the U.S. Household Food Security Survey Module (HFSSM) and validated for the Brazilian population.17 This scale consists of 14 items that make it possible to assess the experience of food insecurity in the three months preceding the interview. Each item has dichotomous responses (yes/no), and the final score, obtained by summing the positive responses, allows classification into: food security, when there are no positive responses (zero points); mild food insecurity (one to five points); moderate food insecurity (six to ten points); and severe food insecurity (eleven to fourteen points).19 In this study, three categories were used: food security, mild food insecurity, and moderate/severe food insecurity. The moderate/severe categories were combined to allow better interpretation of the analyses.
Dependent Variable
The dependent variable of the study was mental health, analyzed using the anxiety scale known as the State Anxiety Inventory (Inventário de Ansiedade Traço-Estado - Estado, IDATE-E), adapted into Portuguese and validated in Brazil.20–22 This scale makes it possible to identify variations in the tendency to react to psychological pressure with different degrees of intensity, thereby allowing identification of the actual levels of anxiety states.23 The IDATE-E consists of 20 items with responses on a four-point Likert scale. According to the literature, a cutoff point of 40 was adopted, with scores above this value indicating signs of a high anxiety state.24
Covariates
The variables income and women’s age were used to adjust the multiple model.
Per capita income was assessed at each data collection moment. For its calculation, the total household income, together with any government income transfer benefit, was divided by the number of household residents. Some data on total household income were not reported by the participants. Age was calculated in years of life.
Statistical Analysis
Categorical variables were described using absolute and relative frequencies, while continuous variables were described using means and standard deviations.
An analysis of the pattern of missing data was performed for the variable “total household income” (4.9% missing) in order to investigate the underlying mechanism of data absence. For this purpose, Little’s test was applied, which assesses the plausibility of the hypothesis that the data are missing completely at random (Missing Completely at Random—MCAR). The test result (p > 0.05) did not indicate statistically significant evidence against this hypothesis, suggesting that the MCAR assumption is compatible with the observed data, although it cannot be conclusively confirmed.25
In light of this evidence, multiple imputation was chosen to handle the missing values. This approach allows the estimation of missing values based on statistical models that incorporate the variability and uncertainty associated with imputation, thereby reducing potential bias in the analysis. The procedure was conducted using chained equations (multiple imputation by chained equations—MICE), generating five imputed datasets. The imputation model included variables relevant to income prediction, such as age, education level, number of household residents, and food insecurity status. Subsequent analyses were performed separately in each imputed dataset, and the results were combined according to Rubin’s rules, yielding final estimates adjusted for imputation uncertainty.26
To investigate whether the effect of exposure to food insecurity on women’s anxiety state varied over time (i.e., the presence of an interaction between time and exposure), a generalized estimating equations (GEE) model with an interaction term between these variables was used.27
In the adopted model, time was included as an independent variable, allowing the assessment of variations in anxiety state over the observed period. The analysis considered the longitudinal structure of the data, with repeated measures on the same individual over time. For this purpose, a first-order autoregressive working correlation structure (AR(1)) was specified, which assumes that observations closer in time are more highly correlated than those farther apart. This structure represents an assumption about the pattern of correlation between measurements over time and does not imply that the model errors follow a specific multivariate distribution. A robust variance estimator was used to ensure valid inference even in cases of incorrect specification of the correlation matrix.28 The outcome was modeled using a Gamma distribution with a logarithmic link function. Model selection was based on the quasi-likelihood under the independence model criterion (QIC), adopting the model with the lowest value. Analyses were adjusted for the covariates per capita income and maternal age. Model adequacy was assessed through inspection of residuals, with normality verified using Q–Q plots, which were considered satisfactory for the purposes of the analysis.28-29
The main effects of the model were evaluated using the Wald chi-square statistic (Wald χ²), which tests the significance of the coefficients estimated in the model, indicating whether each independent variable shows a statistically significant association with the outcome after adjustment for the other variables in the model. Following this analysis, the sequential Sidak post hoc test was applied for pairwise comparisons in order to identify specific differences between groups.28-29
In order to assess the magnitude of the effects of the associations found, effect size for repeated measures was estimated using Cohen’s d, which takes into account the correlation between different time points. For this purpose, differences between means for each group (FS, MFI, M/SFI) at different time points were calculated, as well as the mean differences, variance, and standard deviation of the diferences.29,30 Interpretation was as follows: small effect (d ≤ 0.2), medium effect (d = 0.5), and large effect (d ≥ 0.8).31
Statistical analyses were performed using IBM SPSS Statistics version 21.0 (IBM SPSS Inc., USA), and the level of significance was set at 0.05.
Ethical Aspects
This study was approved by the Ethics Committee of the Center for Health Sciences of the Federal University of Paraíba (78557717.60000.5188). All participants were previously informed about the purposes and procedures of the research and signed the Informed Consent Form. At the time of recruitment, participants were also informed that they were free to choose whether or not to answer the questions.

Results
More than half of the women began the study in a situation of food security (56.6%), while the remaining 43.4% (n = 53) were in a situation of food insecurity, of whom 31.1% had mild food insecurity and 12.3% (n = 15) had moderate/severe food insecurity.
The mean age of the participants was 29.51 years, with minimum and maximum values of 19 and 44 years, respectively. The sample characterization data are presented in Table 1, showing that most women did not consider themselves white (70.5%), lived with a partner (70.5%), and considered the husband/partner to be the head of the household (44.3%).
Most participants lived in houses (80.3%), with up to three household residents (59.0%), had access to basic sanitation (74.6%), and used water from the public supply network (98.4%). More than half of the participants had completed high school (59.0%), did not receive government assistance (66.4%), and had a per capita income above half of the minimum wage (55.7%). With regard to pregnancy, most women were in the third trimester (47.5%) and were experiencing their first pregnancy (63.1%). Regarding anxiety state, most participants presented high anxiety at the first moment of the study (53.3%) (Table 1).
he study was divided into three phases, characterized as moments: the first moment corresponds to the beginning of follow-up, the second moment to the second phase, and the third moment to the final phase of the study.
Women entered the study at different stages of pregnancy. At the second moment, 20% of the women were still pregnant, and by the end of follow-up all participants had already given birth and were mostly between the third and ninth month postpartum.
The comparison of anxiety state across the different study moments according to food security status and levels of food insecurity is presented in Figure 2. At the first moment, on average, women presented high anxiety regardless of food security (FS), mild food insecurity (MFI), or moderate/severe food insecurity (M/SFI) [FS: 42.29 (SD 1.16 points); MFI: 42.51 (SD 1.51 points); M/SFI: 44.62 (SD 2.61 points)].
he generalized estimating equations analysis did not identify a statistically significant difference between mean anxiety levels across the three moments (Wald χ² = 2.39; p = 0.30). Complementing this finding, it can be observed that mean anxiety scores were similar across the three evaluated moments, as shown in Table 2.
However, a main effect was observed when anxiety was stratified by food security and levels of food insecurity (Wald χ² = 17.77; p < 0.0001), with mean values indicating lower anxiety levels among women in food security compared to those with mild and moderate/severe food insecurity (Table 2).
In addition, a significant interaction between moments and food security and food insecurity status was identified (Wald χ² = 11.87; p = 0.018), revealing distinct patterns of variation across the three moments. In particular, there was a significant reduction in anxiety in the food security group over the course of follow-up (Moment 1 > Moment 3, p < 0.0001). Anxiety was also lower in the food security group compared to the moderate/severe food insecurity group at the second and third moments, respectively (p < 0.0001) (Figure 2). This is described in Table 2, where it can be observed that mean anxiety scores progressively decreased in the food security group, remained relatively stable in the mild food insecurity group, and fluctuated—with greater elevation at the second moment—in the moderate/severe food insecurity group.
The effect sizes of this interaction are presented in Table 3. At the first moment, a small effect of high anxiety state was observed when comparing food security with moderate/severe food insecurity (Cohen’s d = 0.239). This effect intensified, becoming large, at the second and third moments, respectively (Cohen’s d = 1.211; 0.828).

Discussion
The findings of the present study show that exposure to food security throughout the postpartum period, as well as the transition to this condition, are associated with a reduction in maternal anxiety disorders.
This study investigated the impact of continued exposure to food (in)security on the mental health of women who are users of the Brazilian Unified Health System (SUS), living in João Pessoa, Paraíba, located in the Northeast region of Brazil. Historically, the Northeast is one of the regions most affected by regional inequalities, particularly with regard to violations of the human right to adequate food.32–36 In 2022, according to the report of the Brazilian Research Network on Food and Nutrition Sovereignty and Security (Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar, PENSSAN), the most severe form of food insecurity—hunger—affected approximately 33 million Brazilians, of whom 12.127 resided in the Northeast region.35
The results of this study showed that anxiety is higher among women experiencing food insecurity at its most severe levels. There is a “dose–response” effect, in which symptoms of mental disorders increase as the severity of food insecurity increases, becoming more severe among those who reduce food consumption or experience hunger.37–40
This relationship can be understood as resulting from feelings of deprivation, despair, and family social interaction dynamics arising from exposure to food and nutrition insecurity⁴¹. These findings are consistent with the study by Liebe et al. (2024), conducted with 570 low-income mothers in the state of Virginia, United States, which found that mothers in households where both adults and children were exposed to food insecurity had worse overall mental health compared with households in food security.42 This association is also highlighted in the study by Elgar et al. (2021), which used data from the Gallup World Poll and demonstrated an association between food insecurity and mental health symptoms in 160 countries.43
Anxiety, the mental disorder examined in this study, represents a challenge to well-being and quality of life. This disorder arises due to environmental stimuli and experiences of suffering, such as physical or emotional abuse, family conflict, lack of emotional support, financial problems, and living in poverty, among others.5,44 Physiologically, these experiences trigger a fight-or-flight response and manifest as psychophysiological reactions such as sweating, dizziness, and increased heart rate. If chronic anxiety is not adequately treated, it may lead to heart problems, hypertension, and dementia, in addition to impairing self-care and care for dependentes.5,45,46
The results of the present study innovatively show that achieving food security and/or remaining in this condition over time reduces anxiety levels among the women studied. Although participants were not at the same gestational stage at the time of inclusion, all were recruited from Family Health Units with similar structural characteristics and sociodemographic profiles, and no differences were observed in gestational age classification among the different exposure groups—those in food security, mild food insecurity, and moderate or severe food insecurity—ensuring comparability between groups.
At the beginning of the study, the women were pregnant and subsequently became mothers of children under one year of age. Thus, the results remain valid even during a life stage in which changes occur both in family organization due to the birth of a new family member and in the emergence of possible physical problems, such as fatigue and breast-related issues.47
The mean anxiety state score of the women at the first moment of the study was above 40 and subsequently decreased to below 40, the cutoff point adopted in the present study.24 These findings could be assessed due to the follow-up methodology employed, which confirmed the temporality criterion, since the outcome was observed after exposure.48 This allowed observation of how variations in exposure—food security and food insecurity—impacted participants’ anxiety. Cohort studies are considered more robust for causal inference, as they allow the calculation of incidence of multiple outcomes resulting from a given exposure.49
This type of study has demonstrated the impact of food insecurity on various health outcomes, reinforcing the relevance of investigating its consequences in specific populations, such as the one analyzed here. A study conducted by Bhawra et al. (2021),50 for example, followed 2,149 adults aged 19 to 30 years over three years in five Canadian cities and found that living in food-insecure households increased the likelihood of developing health problems by 7.09 times. In addition, individuals experiencing moderate or severe food insecurity had a higher likelihood of poor diet quality (OR = 2.19 and OR = 2.63, respectively).50
Similarly, in the Brazilian context and closer to the reality of the population analyzed in this study, a study conducted in the semi-arid region of Northeast Brazil by Palmeira et al. (2020), which followed rural and urban households between 2011 and 2014, identified that increases in household income—particularly mediated by the Bolsa Família Program—were decisive for the transition from food insecurity to food security.51 This program is internationally recognized as an effective strategy to combat hunger.52
These findings align with the data from the present study by showing that income improvement not only ensures the human right to adequate food but also promotes improvements in population mental health.
The data from the present study reflect a concerning trend of two highly prevalent problems in the Brazilian population: hunger and anxiety. In recent years, Brazil has experienced a reduction in investments in public policies aimed at reducing food insecurity and combating extreme poverty.35,52,53 According to Javaid et al. (2023), over recent decades Brazil has experienced a significant increase in anxiety prevalence rates, rising from 5,894 cases per 100,000 inhabitants in 1990 to 7,410 per 100,000 inhabitants in 2019.44 This scenario highlights the need to strengthen public policies that address both food insecurity and mental health, in order to mitigate the adverse effects of these conditions on the Brazilian population.
This context underscores the need to restore social public policies that ensure the right to food, considering their impacts not only on physical health but also on mental health. Within the Unified Health System (Sistema Único de Saúde, SUS), the treatment of mental health problems presents a challenge, as diagnoses often occur late, after recurrent episodes and clinical worsening. Given women’s increased vulnerability at certain stages of life, especially during the pregnancy–postpartum cycle, ensuring regular and adequate access to food may represent an important preventive strategy. Food insecurity, in addition to not being readily perceived as a risk factor, may contribute to the emergence and maintenance of psychological distress that extends throughout life, negatively affecting both women and the development and well-being of their children.4
Our findings demonstrate consistency by having been conducted with the same participants, making it possible to assess changes in the studied outcome at different moments of motherhood. The generalized estimating equations analysis allowed modeling of the correlation between repeated observations of the same individual, adjusted for variables collected during follow-up.23 However, the study has some limitations.
The sample size prevented the formation of groups of women who remained in food security or in each level of food insecurity throughout the entire study. This represents a limitation, as the small number of participants in these situations did not allow for subgroup analyses. Therefore, further studies using similar methodologies but larger sample sizes are needed. The analysis group consisted of women who remained food secure or who transitioned to food security during follow-up; in both cases, this represents a favorable condition, which helps reduce potential classification biases.
This is not a population-based study of women in João Pessoa, as the aim was solely to compare groups. However, the results may be extrapolated to women with similar characteristics—users of the SUS and residents of capital cities in the Northeast region. To our knowledge, this was the first study to use the Brazilian Food Insecurity Scale (Escala Brasileira de Insegurança Alimentar, EBIA) with a reference period aligned with the instrument’s questions—three months—thus preventing variations in food security or insecurity status from going unnoticed between successive data collections.
Despite inevitable sample losses, the study maintained its analytical viability by focusing on women who participated in all stages of follow-up. One of the main difficulties encountered was contacting and locating participants at their residences after the initial recruitment at the Family Health Unit. The COVID-19 pandemic also hindered continuation of follow-up, such that the fourth and final planned data collection was only partially completed.
As shown in the literature and confirmed in this study, mental disorders are directly related to food insecurity; therefore, further studies addressing other disorders are needed to better understand this consequence of food insecurity.
Conclusion
The study began with pregnant women and followed them through the postpartum period, which made it possible to observe variations in food security status and in the different levels of food insecurity. It was possible to analyze cause-and-effect relationships between these conditions and women’s anxiety during a phase of life marked by great vulnerability.
Participants in this study, who were users of the Brazilian Unified Health System (SUS) and residents of the capital of a Northeastern Brazilian state, presented, on average, high anxiety scores and a high prevalence of food insecurity. These results highlight the importance of implementing policies aimed at addressing these problems, such as the inclusion of mental health services and food security programs to support women during pregnancy and the postpartum period.
Ensuring food security over a continuous period proved to be effective in reducing mean anxiety scores among women. Thus, the implementation of policies that guarantee the Human Right to Adequate Food, that help prevent individuals from being exposed to food insecurity, and that also ensure economic and social stability are fundamental, as is the maintenance of social policies aimed at promoting food security.
Food security and mental health are essential elements for reducing public health costs, increasing quality of life, and improving overall population well-being. Together, they enhance care for individuals and their dependents, contributing to a more balanced and productive life by facilitating access to opportunities and essential resources for economic and social progress and by enabling the interruption of the intergenerational cycle of poverty.
Investing in food security and mental health not only reduces long-term healthcare costs but also contributes to building a more just and resilient society.

Data Availability Statement
The research data are available upon request from the corresponding author.

Acknowledgements
We thank the National Council for Scientific and Technological Development (CNPq, Brasília, Brazil) for the financial support provided for the conduct of this research, in accordance with the Universal Call, process no. 4727725/2016-0. The lead author also thanks the Coordination for the Improvement of Higher Education Personnel (CAPES, Brazil), the Research Support Foundation of the State of Paraíba (FAPESQ, Paraíba, Brazil; Grant Agreement no. 1222/2021), and CNPq for the granting of scholarships, including the Sandwich Doctorate scholarship (process no. 200110/2022-5).

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