Hunger as an uncontroversial predictor of poor adolescent mental health: evidence from a multiverse analysis of 410,213 adolescents across 79 countries.

BACKGROUND: Hunger has established detrimental impacts on physical health, with emerging evidence indicating negative impacts on mental health. However, there is a pronounced knowledge gap outside high-income settings and for adolescents. Previous research also provides differing estimates of hunger's impacts, potentially underpinned by a wide range of researcher degrees of freedom. METHODS: We investigated the relationship between hunger and mental health (proxied by single-item indicator for worrying and three items for suicidality) in the Global School-based Student Health Survey, combining datasets from 79 countries and in a pooled sample of 410,213 adolescents (mean age 14.72 ± 1.56 years; 52% girls). We used a principled multiverse analysis, exploring 15,360 model specifications. RESULTS: Our results show a consistently stable negative relationship between hunger and adolescent mental health (worrying, median beta = .12; suicidality, median beta = .07). This reflects 12 and 7 percentage point increases in the prevalence for worry and suicidality, respectively, when experiencing hunger. This relationship is significant across a variety of analytical choices including sample selection, covariate choice (including country-level controls for wealth and inequality), predictor and outcome manipulation, among others. In a further multiverse analysis, we find evidence of a dose-response relationship, such that more frequently experiencing hunger is associated with greater reported levels of worrying and suicidality. CONCLUSIONS: Our work attests to the experience of hunger as one of the most clearly uncontroversial predictors of poor mental health. Addressing food insecurity and the equitable and efficient distribution of food globally is a crucial consideration for adolescent mental health protection and suicide prevention. Emphasis should be placed on appropriate population-level interventions, such as universal free school or community meal programs.