1. Introduction

The United Nations Food and Agriculture Organization (FAO) indicates that 925 million people in the world are suffering from hunger with many undernourished people living in Asia, the Pacific Islands, and Africa [1]. According to the United Nations, hunger can be described as periods when the population is facing severe food insecurities in which people can go without food for days, due to lack of money, food access, and/or other resources [1].

Food security is a complex issue and defined as “a state where all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary and food preferences for an active and healthy life” [2]. Food insecurity has been described as the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways; whereas food insufficiency has been described as an extreme form of household food insecurity where household members sometimes, or often, do not have enough to eat ^[3][4][3,4]. African countries have been affected by food insecurity and, according to the statistics, 98 million have faced food shortage in 2020 alone [5]. Famine or food insecurity are mostly caused by conflict, climate variability and extremes, inefficient food supply chains, and economic downturns in Africa [1]. Despite growing interest in the mutually reinforcing association between poverty and mental ill-health, there is lack of published evidence in Africa [6].

Studies have identified that long term hunger can have both physical and psychological effects on individuals ^[7][15]. Food insufficiency has impacts on the mental health of individuals with poorer mental health outcomes among children in particular ^[8][9][16,17]. There are also reports that suggest women are disproportionately impacted by food insufficiency in low- and middle-income countries. A study in South Africa among women found that most households were chronically food insecure leading to worries and stress about food ^[10][18]. Similar findings have been reported among Ghanaian women ^[11][19], in Thailand ^[12][20], and among Women in Botswana and Swaziland where food insufficiency is an important risk factor for increased sexual risk-taking ^[13][21]. Some earlier research indicates that food insecurity may be a stronger predictor of poor mental health outcomes compared to other forms of insecurity, due to the important biological and social function of food in the lives of people ^[14][22]. Global evidence suggests that food insecurity is linked with poorer mental health outcomes; for instance, in New Zealand a strong relationship was found between food insecurity and psychological distress ^[15][23]. Similar findings have been reported in the United States ^[16][24], Bangladesh ^[17][25], Ghana ^[18][26], and Canada ^[19][27]. Hadley, et al. ^[20][28] have suggested that there is likely to be a positive influence on adult mental health with interventions that aid food security due to the high association between these variables.

There is severe dearth of published literature about the impact of food insecurity and famine on mental health outcomes in West Africa, as the majority of existing evidence is from developed countries. Undoubtedly, there is an indication for more evidence to unveil the potential impact of famine and food insufficiency on mental health in this region. Understanding the extent and effect of food insufficiency on mental health outcomes can inform relevant policy [-ies] and interventional implications for stakeholders, including governments and donor organizations, about the need to invest resources in food production which will subsequently mitigate the impact of mental ill-health. This review seeks to highlight the gap in the literature, and the need to prioritize research focusing on food insecurity and mental health in West Africa by systematically pulling together the existing evidence from West Africa on the mental health impact of famine and food insufficiency.

2. Impact of Food Insecurity and Insufficiency on Mental Health Outcomes

Food insecurity or insufficiency was linked to mental health problems and general wellbeing of individuals consistent with studies elsewhere, which have demonstrated that food insecurity is a significant factor associated with psychological distress among middle-aged and older adults ^[21][45]. One of the studies reported that moderate and severe food insecurity significantly increased psychological distress outcomes among both men and women, but this effect was greater with increase in age ^[22][36]. Another reported that mental health outcomes due to food insecurity were worse for females than males ^[23][37]. These findings are consistent with earlier studies in other LMICs such as South Africa, Botswana, Swaziland, and Ghana. Further, food insecurity and famine were associated with worries and anxiety, leading to weight and sleep disorders ^[24][43]. These findings are, again, consistent with earlier studies in other LMICs such as that in a study that found food insecurity provoked anxiety and stressful reactions among women in Tanzania ^[25][46]. However, the study by Sweetland et al. ^[26][34] did not find any associations between food insecurity and mental distress in Ghana or Nigeria. This finding contrasts with studies in the United States ^[27][47], Korea ^[28][48], and even in the other included studies in Ghana ^[29][23][35,37]. Overall, nearly all but one of the included studies were consistent with international literature.

Though within the scope of inclusion in this systematic narrative review, very scant evidence of published data is found in the West African sub-region. Other reports and studies from international organizations such as the World Health Organization (WHO) and the FAO confirm the findings of this narrative review. The WHO has reported that poverty increases risk for mental disorders and distress, and the associated disability may further worsen poverty in a vicious cycle [6], whereas positive mental health is associated with improved productivity and earnings, employment, educational achievement, health, and quality of life ^[30][49]. In support of this assertion, a review of studies conducted in low- and middle-income countries found positive associations between poverty and depressive, anxious, and somatoform symptoms ^[31][50].

3. Impact of Food Insecurity and Famine on Cognitive Function

Food insecurity, lack of access to food, and undernutrition have been linked with poor cognitive function ^[32][51]. Ampaabeng and Tan ^[33][42] found that childhood malnutrition negatively affected the cognitive development of 0–2 age group, similar findings were reported by Aurino et al. ^[34][38] among pre-school children. The studies also showed that the resultant effect of this decline in cognition persisted into adulthood ^[33][42]. Other studies have also reported a negative association between food insufficiency experienced in early or later life, and global cognitive function in middle-age and older adults ^[35][52]. Similarly, another study that examined food insufficiency and cognitive function in the elderly found that very low food security was prevalent among the elderly and was associated with lower cognitive performance ^[36][53]. The first five years of childhood is a critical stage for cognitive development and undernutrition at this stage is detrimental (Knudsen et al., 2006). Aurino et al. ^[34][38] reported that persistent food insecurity and undernutrition predicted decreased numeracy, literacy scores, short-term memory, and self-regulation compared with children from households without food insecurity. No significant gender differences were found between the included studies.

Ampaabeng and Tan ^[33][42] and Aurino et al. ^[34][38] studies were conducted in Ghana. The former used an existing dataset from the Ghana Education Impact Evaluation Survey (GEIES) in 2003, which measured intelligence based on Raven’s Progressive Matrices, as well as datasets from the Ghana Living Standards Survey II of 1988/89, the Demographic and Health Survey (DHS) of 1988, and the rainfall data from the World Bank’s Africa Rainfall and Temperature Evaluation System, to estimate the impact of food insufficiency and cognitive development. Aurino et al. ^[34][38], however, used a more recent longitudinal dataset (2015–2018) which was the Quality Preschool for Ghana project, an impact evaluation of a teacher in-service training and parental-awareness program in six districts in the Greater Accra Region. Both studies reported evidence of cognitive decline due to food insufficiency. Similar findings have been reported among immigrant children from food insecure households in the United States ^[37][54]. They found that immigrant children in food insecure households were worse in reading skills than nonimmigrant children in food secure households ^[37][54]. Moreover, food insecurity was associated with faster cognitive decline among Puerto Rican adults living in Boston in the United States ^[38][55]. Food insecurity experienced during the first five years of life is widely recognized as a key period of cognitive and physical development, during which the foundations for later cognitive and social functioning are laid ^[39][56].