key: cord-328562-g5i838b3
authors: Niles, Meredith T.; Bertmann, Farryl; Belarmino, Emily H.; Wentworth, Thomas; Biehl, Erin; Neff, Roni
title: The Early Food Insecurity Impacts of COVID-19
date: 2020-07-15
journal: Nutrients
DOI: 10.3390/nu12072096
sha: 
doc_id: 328562
cord_uid: g5i838b3

COVID-19 has disrupted food access and impacted food insecurity, which is associated with numerous adverse individual and public health outcomes. To assess these challenges and understand their impact on food security, we conducted a statewide population-level survey using a convenience sample in Vermont from 29 March to 12 April 2020, during the beginning of a statewide stay-at-home order. We utilized the United States Department of Agriculture six-item validated food security module to measure food insecurity before COVID-19 and since COVID-19. We assessed food insecurity prevalence and reported food access challenges, coping strategies, and perceived helpful interventions among food secure, consistently food insecure (pre-and post-COVID-19), and newly food insecure (post COVID-19) respondents. Among 3219 respondents, there was nearly a one-third increase (32.3%) in household food insecurity since COVID-19 (p < 0.001), with 35.5% of food insecure households classified as newly food insecure. Respondents experiencing a job loss were at higher odds of experiencing food insecurity (OR 3.06; 95% CI, 2.114–0.46). We report multiple physical and economic barriers, as well as concerns related to food access during COVID-19. Respondents experiencing household food insecurity had higher odds of facing access challenges and utilizing coping strategies, including two-thirds of households eating less since COVID-19 (p < 0.001). Significant differences in coping strategies were documented between respondents in newly food insecure vs. consistently insecure households. These findings have important potential impacts on individual health, including mental health and malnutrition, as well as on future healthcare costs. We suggest proactive strategies to address food insecurity during this crisis.

The global COVID-19 pandemic, and social distancing efforts implemented to slow its spread [1] , have disrupted economies and food systems globally and locally, with extensive food security ramifications. Food insecurity-the lack of consistent physical, social, and economic access to adequate and nutritious food that meets dietary needs and food preferences [2]-can lead to serious public health consequences. In 2018, 11.1% of American households were considered food insecure at some very low food security (5 to 6 affirmative answers) can be combined and referred to as having food insecurity [23] .

In addition to measuring food security status, the survey also included additional questions related to food access challenges, use of food assistance programs, food purchasing behaviors, concerns about food access and availability, COVID-19 perceptions, and behaviors and demographics. Table A1 details the specific questions utilized in this analysis, which are primarily focused on understanding the relationship of food security status to food access challenges, use of food assistance programs, and concerns about food access and availability. Future analyses will explore other questions in the survey.

To examine differences in household food insecurity during the first weeks of the COVID-19 pandemic, we created three categories of respondents: (1) households with food security (n = 2282, including households food secure before and since COVID-19 and households who were food insecure at some point in the year before COVID-19, but were no longer food insecure during COVID-19);

(2) households with consistent food insecurity (n = 466, both food insecure before COVID-19 and remaining food insecure since COVID-19); (3) households with new food insecurity (n = 258, categorized as food secure before COVID-19, but food insecure since . In some cases, we refer to food insecure households, which encompass both consistently food insecure households and newly food insecure households.

To determine statistically significant differences between groups we utilized Stata [24] , to run Kruskal-Wallis tests, Wilcoxon rank sum tests, t-tests, and one-way analysis of variance (ANOVA) tests, depending on the distribution of the dependent variable. We used a logistical regression model to determine the factors correlated with food insecurity during the COVID-19 pandemic, with coefficients reported in odds ratios. In this model, we estimate food insecurity outcomes during COVID-19, including respondents who were classified as either consistently food insecure or newly food insecure. We used all available data to estimate effect sizes and interactions and assumed any missing data were missing at random.

Reflecting the demographic composition of Vermont [22, 25, 26] , the majority of respondents identified as non-Hispanic White, lived in rural areas, and had a household income below $75,000 ( Table 1, Table A2 ). Women encompassed 79% of our sample, which may be reflective of the fact that women are the dominant food shoppers in households [27] .

We found a nearly one-third increase (32.3%) in food insecurity prevalence (p < 0.001) between the year preceding the COVID-19 outbreak, when 18.8% of households (95% CI 17.38-20.13%) reported experiencing food insecurity at some point, and since the COVID-19 outbreak when the percentage rose to 24.8% (95% CI 23.27-26.35%) (Table A3 ). Among those experiencing food insecurity since the outbreak, 64.5% also experienced food insecurity at some point in the year prior to COVID-19, and were also food insecure since COVID-19; in comparison, 35 .5% were newly food insecure. In consistently food insecure households, 59.1% exhibited very low food security since COVID-19 (marked by disrupted eating patterns and reduced intake), while 40.9% had low food security. In newly food insecure households 32.3% exhibited very low food security, while 67.7% had low food security (Table A4) since COVID-19 (p < 0.001). Multivariable logit models predicted the factors contributing to higher odds of food insecurity during COVID-19 (e.g., both consistently food insecure respondents and newly food insecure respondents) ( Table 2 ). Note that we also ran a multinomial logit model to examine whether there were statistically significant differences in newly versus consistently food insecure respondents, which there were not (Table A5) . Respondents experiencing a job loss had three times greater odds of living in a household experiencing food insecurity (OR 3.06; 95% CI, 2.114-0.46), and those experiencing a furlough (OR 2.89; 95%CI, 1.864-0.49), or a loss of hours (OR 2.05; 95% CI, 1.452-0.92) also had significantly greater odds of being in a household experiencing food insecurity (p < 0.001). The odds of experiencing food insecurity since the COVID-19 outbreak were higher among households with children (OR 2.46; 95% CI, 1.823-0.32), while households with higher 2019 incomes had reduced odds (OR 0.56; 95% CI, 0.500-.61) (p < 0.001). Finally, women were 42% more likely to experience household food insecurity during COVID-19, compared to men (p < 0.10) (OR 1.42; 95% CI 0.9632-0.10), while a college degree (OR 0.38, 95% CI 0.290-0.50) was associated with reduced odds of household food insecurity (p < 0.001). 

Respondents indicated multiple physical and economic barriers to food access during COVID-19, with respondents experiencing household food insecurity significantly more likely to express greater access, availability, and utilization challenges than respondents in food secure households (p < 0.001) ( Figure 1 , Table A6 ). These challenges included not finding as much or the kinds of food that someone wanted, going to more places than usual to find food, and not being able to afford the food a household wanted. Challenges also included those related to food assistance, including at food pantries and through school food programs. Consistently food insecure households had a higher average prevalence of food access challenges, as compared to those in newly food insecure households including trouble affording food (p < 0.001), getting food through a food pantry (p = 0.002), and knowing where to find help for getting food (p < 0.001).

households with children (OR 2.46; 95% CI, 1.823-0.32), while households with higher 2019 incomes had reduced odds (OR 0.56; 95% CI, 0.500-.61) (p < 0.001). Finally, women were 42% more likely to experience household food insecurity during COVID-19, compared to men (p < 0.10) (OR 1.42; 95% CI 0.9632-0.10), while a college degree (OR 0.38, 95% CI 0.290-0.50) was associated with reduced odds of household food insecurity (p < 0.001). 

Respondents indicated multiple physical and economic barriers to food access during COVID-19, with respondents experiencing household food insecurity significantly more likely to express greater access, availability, and utilization challenges than respondents in food secure households (p < 0.001) ( Figure 1 , Table A6 ). These challenges included not finding as much or the kinds of food that someone wanted, going to more places than usual to find food, and not being able to afford the food a household wanted. Challenges also included those related to food assistance, including at food pantries and through school food programs. Consistently food insecure households had a higher average prevalence of food access challenges, as compared to those in newly food insecure households including trouble affording food (p < 0.001), getting food through a food pantry (p = 0.002), and knowing where to find help for getting food (p < 0.001). Average frequency of challenging food access situations since COVID-19 among respondents with household food security and food insecurity in a survey of Vermont households, March-April, 2020 (p < 0.001 for comparison among all groups). Standard errors shown with brackets. Differences between newly and consistently food insecure shown through stars (*** p < 0.001), ** p < 0.01) and in Table A6 . Respondents experiencing household food insecurity during COVID-19 (both newly and consistently food insecure) were significantly more likely (p < 0.001 comparison across all groups) to express higher levels of concern and worry about a variety of potential situations related to food access and COVID-19 ( Figure 2 , Table A7 ). These situations included potential for food to become more expensive and for households to have a decrease in income, not enough food, loss of access to food programs, and food availability and safety. As compared to newly food insecure households, consistently food insecure households were also significantly more likely to have higher levels of concern and worry about food access for all situations except for food becoming unsafe (p < 0.05, Table A7 ).

Nutrients 2020, 12, x FOR PEER REVIEW 6 of 23

March-April, 2020 (p < 0.001 for comparison among all groups). Standard errors shown with brackets. Differences between newly and consistently food insecure shown through stars (*** p < 0.001), ** p < 0.01) and in Table A6 .

Respondents experiencing household food insecurity during COVID-19 (both newly and consistently food insecure) were significantly more likely (p < 0.001 comparison across all groups) to express higher levels of concern and worry about a variety of potential situations related to food access and COVID-19 ( Figure 2 , Table A7 ). These situations included potential for food to become more expensive and for households to have a decrease in income, not enough food, loss of access to food programs, and food availability and safety. As compared to newly food insecure households, consistently food insecure households were also significantly more likely to have higher levels of concern and worry about food access for all situations except for food becoming unsafe (p < 0.05, Table A7 ).

Average level of concern for potential food access situations during COVID-19 among respondents with household food security and food insecurity in a survey of Vermont households, March-April, 2020 (p < 0.001 for comparison among all groups). Standard errors shown with brackets. Statistically significant differences were also found between newly and consistently food insecure in all cases except for "food will become unsafe" (shown through stars, *** p < 0.001), ** p < 0.01, * p < 0.05) and in Table A7 .

Households newly and consistently experiencing food insecurity were significantly more likely (p < 0.001) to be implementing coping strategies related to obtaining food as compared to respondents in food secure households. These strategies included those related to disrupted eating patterns (i.e., eating less), buying different, cheaper foods, accepting food from friends and family, and utilizing government programs, credit or food pantries ( Figure 3 , Table A8 ).

Consistently food insecure households, as compared to those newly experiencing food insecurity, were also significantly more likely to currently accept food (p = 0.031) or borrow money from friends or family (p = 0.01), use a food pantry (p < 0.001) and use government assistance programs (p = 0.004), especially the Supplemental Nutrition Assistance Program (SNAP) (p < 0.001) (Tables A8 and A9).

Average level of concern for potential food access situations during COVID-19 among respondents with household food security and food insecurity in a survey of Vermont households, March-April, 2020 (p < 0.001 for comparison among all groups). Standard errors shown with brackets. Statistically significant differences were also found between newly and consistently food insecure in all cases except for "food will become unsafe" (shown through stars, *** p < 0.001), ** p < 0.01, * p < 0.05) and in Table A7 .

Households newly and consistently experiencing food insecurity were significantly more likely (p < 0.001) to be implementing coping strategies related to obtaining food as compared to respondents in food secure households. These strategies included those related to disrupted eating patterns (i.e., eating less), buying different, cheaper foods, accepting food from friends and family, and utilizing government programs, credit or food pantries ( Figure 3 , Table A8 ).

Consistently food insecure households, as compared to those newly experiencing food insecurity, were also significantly more likely to currently accept food (p = 0.031) or borrow money from friends or family (p = 0.01), use a food pantry (p < 0.001) and use government assistance programs (p = 0.004), especially the Supplemental Nutrition Assistance Program (SNAP) (p < 0.001) (Tables A8 and A9) .

Households newly and consistently experiencing food insecurity were also significantly more likely (p < 0.001 across all group comparisons) to report an intention to implement these same coping strategies in the future for assistance with obtaining food during COVID-19. Among food insecure households, those with consistent food insecurity were more likely to indicate that in the future they would accept food from friends or family (p = 0.045), use food pantries (p < 0.001), government assistance programs (p < 0.001), and to stretch the food they have by eating less (p = 0.007), as compared to newly food insecure households (Table A10) .

Compared to food secure households, new and consistently food insecure households were significantly more likely (p < 0.001) to find strategies to address physical or economic food access challenges helpful during COVID-19 (Table A11) . These helpful strategies included extra money to help pay for food or bills, an increase in benefits of existing food assistance programs, greater trust in the safety of going to stores and food delivery, support for food delivery costs, more or different food in stores, and information about and help with food assistance programs, among others. Consistently food insecure households were also significantly more likely than those in newly food insecure households to find access to public transit, extra money for food or bills, increased benefits of food assistance programs, information about food assistance programs (all p < 0.001), help with administrative food assistance problems (p = 0.001), and support for food delivery costs (p = 0.033) more helpful (Table A11) .

Nutrients 2020, 12, x FOR PEER REVIEW 7 of 23 Figure 3 . Prevalence of current coping strategies utilized by households with food security and with food insecurity during COVID-19 in a survey of Vermont households, March-April, 2020 (statistical differences among all groups p < 0.001). Statistical differences between newly and consistently food insecure shown through stars (*** p < 0.001); ** p < 0.01, * p < 0.05) and in Table A8 .

Households newly and consistently experiencing food insecurity were also significantly more likely (p < 0.001 across all group comparisons) to report an intention to implement these same coping strategies in the future for assistance with obtaining food during COVID-19. Among food insecure households, those with consistent food insecurity were more likely to indicate that in the future they would accept food from friends or family (p = 0.045), use food pantries (p < 0.001), government assistance programs (p < 0.001), and to stretch the food they have by eating less (p = 0.007), as compared to newly food insecure households (Table A10) .

Compared to food secure households, new and consistently food insecure households were significantly more likely (p < 0.001) to find strategies to address physical or economic food access challenges helpful during COVID-19 (Table A11) . These helpful strategies included extra money to help pay for food or bills, an increase in benefits of existing food assistance programs, greater trust in the safety of going to stores and food delivery, support for food delivery costs, more or different food in stores, and information about and help with food assistance programs, among others. Consistently food insecure households were also significantly more likely than those in newly food insecure households to find access to public transit, extra money for food or bills, increased benefits of food assistance programs, information about food assistance programs (all p < 0.001), help with administrative food assistance problems (p = 0.001), and support for food delivery costs (p = 0.033) more helpful (Table A11 ).

This statewide survey in Vermont documented a statistically significant increase in food insecurity since the state's first reported case of COVID-19 and the stay-at-home executive order (which began March 24, 2020). We demonstrate a nearly one-third increase in household food Figure 3 . Prevalence of current coping strategies utilized by households with food security and with food insecurity during COVID-19 in a survey of Vermont households, March-April, 2020 (statistical differences among all groups p < 0.001). Statistical differences between newly and consistently food insecure shown through stars (*** p < 0.001); ** p < 0.01, * p < 0.05) and in Table A8 .

This statewide survey in Vermont documented a statistically significant increase in food insecurity since the state's first reported case of COVID-19 and the stay-at-home executive order (which began March 24, 2020). We demonstrate a nearly one-third increase in household food insecurity among respondents, with individuals experiencing job loss or disruption at significantly greater odds of experiencing household food insecurity since COVID-19, as compared to other demographic controls. Further, we find that the majority of consistently food insecure households and nearly one-third of newly food insecure households were classified as having very low food security, marked by disrupted eating and cutting meals or going hungry. Fully, two-thirds of Vermont respondent households with food insecurity during COVID-19 are already eating less to stretch their food. The findings indicate challenges to all food security dimensions, including economic and physical access, availability, utilization, and stability, and may have profound potential health impacts.

We further demonstrate physical and economic barriers to food access during COVID-19 and the respondents' coping strategies in food insecure households. Previous research [10, 11] suggests links between job loss and food insecurity, indicating that the profound increase in Americans experiencing job loss and disruption [28] will present acute and large-scale impacts across the population. Since Vermont unemployment claims reflect the national trend, these results likely reflect a broader U.S. phenomenon of rising food insecurity rates, evidenced by early non-peer reviewed studies [29, 30] . In addition to these new economic barriers, the pandemic presents many new physical barriers for food access, reductions in public transportation, and new distribution models, and in a rural state like Vermont, a lack of income for transportation costs including fuel. In rural areas where food assistance programs, such as food pantries, are limited, closures due to illness, social distancing, or lack of volunteers may be particularly challenging. This presents opportunities to expand food pantries and support mobile pantry units, as well as encourage the expansion of programs such as fruit and vegetable prescription programs, shown to positively affect food security [31] and improve health outcomes [32] . Ultimately, this research demonstrates a need to increase food assistance programs and provide resources to remove food access barriers now, and likely in the future, during state and national economic and health emergencies.

This rise in food insecurity presents many potential health impacts. Food insecurity is negatively associated with health outcomes [5, 6] and some evidence indicates it is positively associated with poor diet quality [33, 34] . Further, higher rates of anxiety and mental health disorders among children and adults have been documented in food insecure households [6, 33] . Indeed, survey respondents in this study experiencing household food insecurity demonstrated significantly higher rates of concern and worry about food. Disrupted eating, found in two-thirds of respondent households with food insecurity, is associated with decreased immune function and can negatively impact mental and emotional health [33] . Further research is needed to understand how food insecurity during the COVID-19 pandemic relates to diet quality, particularly if disrupted eating patterns persist and increase.

Healthcare providers can address food insecurity through simple interventions. Screening for food insecurity and providing resources now may reduce short-and long-term consequences, including the potential long-term impacts on child health outcomes associated with the duration of household food insecurity [35] and higher health care expenditures associated with food insecurity [9] . The Hunger Vital Sign, a validated two-question food insecurity screening tool based on the USDA Household Food Security Survey Module [36] , can quickly determine risk for food insecurity in clinical and community settings. This tool is widely utilized, especially in pediatrics [37, 38] , and could be made standard in health care and other service settings during COVID-19 and beyond. Providers could refer families in need to locally available resources or to United Way, which aggregates these resources locally. However, during this heightened time of unemployment, there is also potential for government agencies, particularly those distributing unemployment benefits, to help connect families in need to available resources as well.

Importantly, this research demonstrates there are still a significant number of food insecure households which, even if aware of food assistance programs, may not use them. Low rates of seeking assistance in our results, especially among newly food insecure households, may be partly related to the stigma associated with assistance programs [39, 40] . Prior research suggests that populations living outside major metropolitan areas may be more likely to use friends and family for support [41] and to see government assistance programs as a "last resort" [42] . However, with social distancing and widespread financial challenges, such personal safety nets may be eroded, and these households may be particularly vulnerable. Additional research is needed to understand the barriers to using food assistance programs, especially among those that may be newly food insecure since COVID-19.

This study suggests some of the first population-level impacts of COVID-19 and social distancing policies on food insecurity. The limitations are partly rooted in the need to rapidly administer this survey in the early days of the pandemic, to provide data that can be tracked over time. Though our respondent population matches statewide census statistics closely on many metrics, this was a convenience sample; further research is expanding these results using similar questions with representative samples across states and populations. It is worth noting that our observed overall rate of food insecurity prior to COVID-19 (18.8%) is above the most recently available state figure (11.9%) in 2018. There are potentially multiple reasons for this. First, this is likely to be due, in part, to a higher than average number of female respondents and respondents in households with children; both groups have been documented, in Vermont and elsewhere, to have elevated rates of food insecurity [43] . Second, our measurement instrument for documenting food security, the USDA 6-Item Food Security Module, includes a subjective experience domain that measures concern about household food supplies. According to the local media [44] , anxiety about household food supplies Nutrients 2020, 12, 2096 9 of 19 preceded the Stay Home/Stay Safe order and may explain the higher than expected level of food insecurity prior to COVID-19. Further, we used an internet-based survey, given the necessity of social distancing during COVID-19 and the need for a rapid response, which may limit the capacity of some people to participate, although 81% of Vermonters do have internet plans [26] . The study's strengths include its large sample size, early administration, population-based assessment, and survey instrument addressing the multiple dimensions of food security.

We implemented this survey in the beginning of a stay at home order and COVID-19 economic impacts. As such, it is likely that many respondents experiencing job loss or disruption had not yet received unemployment benefits and federal stimulus checks were not distributed. Future research will examine the evolution of food security impacts, and how various interventions, including the CARE Act and unemployment benefits, as well as food assistance expansion and health care screenings, may affect food insecurity outcomes as COVID-19 unfolds. Since the coronavirus outbreak (March 8th), how often did these happen to your household? 1 = Never, 2 = Sometimes, 3 = Usually, 4 = Always, Not Applicable

Could not afford the amount or kind of food my household wanted to buy Could not find as much food as I wanted to buy (e.g., food not in store) Could not find the kinds of food my household prefers to eat Delivered food to a friend, neighbor, or family member Had challenges getting food through a food pantry Had challenges getting food through a school food program Had challenges knowing where to find help for getting food Had to go to more places than usual in order to find the food my household wanted Had to stand "too close for safety" to other people, when getting food (less than six feet) Table A1 . Cont.

On a scale from 1 (not at all worried) to 6 (extremely worried), what is your level of worry for your household about the following as it relates to coronavirus.

1= not at all worried, 6= extremely worried, not applicable There will not be enough food in the store Food will become more expensive for my household Food will become unsafe My household will lose access to programs that provide free food or money for food My household will have a decrease in income and won't be able to afford enough food My household won't have enough food if we have to stay at home and can't go out at all What, if anything, would make it easier for your household to meet its food needs during the coronavirus pandemic? 1 = Not Helpful, 2 = Somewhat Helpful, 3 = Helpful, 4 = Very Helpful, Not Applicable Access to public transit or rides Different hours in meal programs or stores Extra money to help pay for food or bills Help with administrative problems (like applying for food assistance) Increase benefits of existing food assistance programs (like SNAP or WIC) Information about food assistance programs or food pantries More (or different) food in stores More trust in safety of food delivery More trust in safety of going to stores Support for the cost of food delivery The base outcome comparison is food secure households. We find no significantly differences between the factors predicting food insecurity since COVID-19 for newly or consistently food insecure households, so report the combined results of a multivariable logit model in the main results of both newly and consistently food insecure households together. 

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We would like to thank those who assisted in the dissemination of the survey including