key: cord-0288290-p6nj2rbc
authors: Niles, M. T.; Beavers, A. W.; Clay, L. A.; Dougan, M. M.; Pignotti, G. A.; Rogus, S.; Savoie-Roskos, M. R.; Schattman, R. E.; Zack, R. M.; Acciai, F.; Allegro, D.; Belarmino, E. H.; Bertmann, F.; Biehl, E.; Birk, N.; Bishop-Royse, J.; Bozlak, C.; Bradley, B.; Brenton, B. P.; Buszkiewicz, J.; Cavaliere, B. N.; Cho, Y.; Clark, E. M.; Coakley, K.; Coffin-Schmitt, J.; Collier, S. M.; Coombs, C.; Dressel, A.; Drewnowski, A.; Evans, T.; Feingold, B. J.; Fiechtner, L.; Fiorella, K. J.; Funderburk, K.; Gadhoke, P.; Gonzales-Pacheco, D.; Greiner Safi, A.; Gu, S.; Hanson, K. L.; Harley, A.; Harper, K.
title: A Multi-Site Analysis of the Prevalence of Food Security in the United States, before and during the COVID-19 Pandemic
date: 2021-07-25
journal: nan
DOI: 10.1101/2021.07.23.21260280
sha: 99655d680b5e4d274c47e92466cd8fac76cd983a
doc_id: 288290
cord_uid: p6nj2rbc

Background. The COVID-19 pandemic profoundly affected food systems including food security. Understanding how the COVID-19 pandemic impacted food security is important to provide support, and identify long-term impacts and needs. Objective. Our team- the National Food Access and COVID research Team (NFACT) was formed to assess food security over different U.S. study sites throughout the pandemic, using common instruments and measurements. Here we present results from 18 study sites across 15 states and nationally over the first year of the COVID-19 pandemic. Methods. A validated survey instrument was developed and implemented in whole or part across the sites throughout the first year of the pandemic, representing 22 separate surveys. Sampling methods for each study site were convenience, representative, or high-risk targeted. Food security was measured using the USDA six-item module. Food security prevalence was analyzed using analysis of variance by sampling method to statistically significant differences. Results. In total, more than 27,000 people responded to the surveys. We find higher prevalence of food insecurity (low or very low food security) since the COVID-19 pandemic, as compared to before the pandemic. In nearly all study sites, we find higher prevalence of food insecurity among Black, Indigenous, and People of Color (BIPOC), households with children, and those with job disruptions. We also demonstrate lingering food insecurity, with high or increased prevalence over time in sites with repeat surveys. We find no statistically significant differences between convenience and representative surveys, but statistically higher prevalence of food insecurity among high-risk compared to convenience surveys. Conclusions. This comprehensive multi-study site effort demonstrates higher prevalence of food insecurity since the beginning of the COVID-19 pandemic, which in multiple survey sites continues throughout the first year of the pandemic. These impacts were prevalent for certain demographic groups, and most pronounced for surveys targeting high-risk populations.

The coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health 36 Organization in March 2020 (1), with widespread impact across the United States (U.S.) and 37 globally. As of April 12, 2021, the U.S. had over 20% of confirmed cases and about 19% of the 38 COVID-19-related deaths globally (2). Furthermore, COVID-19 was the third leading cause of 39 death in the U.S. in 2020 (3). 40 41

The pandemic caused major disruptions to the U.S. economy, food system, and overall health 42 and wellbeing of Americans. The unemployment rate in the U.S. reached an unprecedented 43 high of 14.8% in April 2020 (4), with job disruptions concentrated in low-paying jobs, 44 disproportionately affecting Black, Indigenous, and People of Color (BIPOC) (5). Although the 45 unemployment rate declined to 6.7% in December 2020, the economic effects of the pandemic 46 are likely to persist for years, consistent with the Great Recession of 2008 (6). The need to 47 convenience sampling in which certain high-risk populations (e.g. low-income, BIPOC, or 123 Supplemental Nutrition Assistance Program (SNAP) participants) were targeted (six sites). In 124 some cases where high-risk populations were targeted, these groups were oversampled to 125 ensure adequate representation in the overall study sample. Table 1 provides specific details  126 about the sampling strategies, target populations, representation of the data, and survey fielding 127 dates. Potential participants under age 18 were excluded across all study sites. All study sites 128 administered the survey in English; in Arizona, California-Bay Area, Maine, Massachusetts, 129

Nationally, NY-Capital Region, New Mexico, and Utah, surveys were also administered in 130

Spanish. IRB approval was obtained by each study site prior to commencing data collection. 131 132

Food security was assessed using the United States Department of Agriculture (USDA) 6-item 134 Short Form Food Security Survey Module (30) which is designed to identify households with 135 food insecurity. In most sites, participants were asked to complete 6-items about the year 136 before COVID-19 and since the COVID-19 pandemic began in March 2020, though a few sites 137 only asked these questions since the COVID-19 pandemic began. In some more recent 138 surveys (i.e. Massachusetts, NY-Central/Upstate and the second Washington survey) and in 139

Michigan respondents answered questions about food security in the past 30 days, which is 140 validated through the USDA module. Following standard USDA scoring, a score of 2-6 was 141 categorized as food insecure (30). It is important to note that the pre-pandemic food security 142 responses were retrospective, and were answered at the same time as the questions about 143 current food security. Households with children were determined with a question about 144 household composition by age. Households with any members ages 0-17 years were classified 145 as a household with children. Job disruption was assessed by asking participants if their 146 household experienced a job disruption since the start of the pandemic, including job loss, 147 furlough, or loss of hours/income reduction, categories which were not mutually exclusive. 148 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted July 25, 2021. The sample included 27,168 adults from across the U.S. with data on food insecurity. The racial 167 and ethnic make-up of the sample overall was 70.0% NHW, and 28.6% BIPOC, with 1.4% of 168 respondents not identifying race or ethnicity. Among BIPOC respondents, 8.0% identified as 169 non-Hispanic Black, 11.9% as Hispanic, and 8.1% other races or multiracial (Table 2) . Given 170 the diversity of NFACT study sites, including their sample size and demographic make-up, the 171 number of respondents with demographic characteristics or life experiences (e.g. job disruption 172 or children in the household) varied across study sites. There was a large variation in the 173 proportion of BIPOC respondents across study sites, because of differences in population 174 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted July 25, 2021. ; composition, but also because some study sites oversampled BIPOC respondents. We found higher levels of food insecurity reported since the COVID-19 pandemic began, as 185 compared to reported for the pre-COVID-19 pandemic period. This finding was consistent in all 186 20 sites that asked about food insecurity both before and during the COVID-19 pandemic 187 ( Figure 2) , with the exception of the New Mexico site (where no change was found). The 188 prevalence of food insecurity across study sites during the COVID-19 pandemic ranged from 189 10.8% in a Central/Upstate New York convenience survey from October-December 2020 (which 190 asked about the last 30 days), to 73.9% in a New York City high-risk survey in July/August 2020 191 which oversampled BIPOC, low-income respondents. Among states that represented state 192 characteristics, food insecurity prevalence ranged from 28.8% in Maryland to 36.2% in 193 Wisconsin since the start of the COVID-19 pandemic. In sites that gathered data on the time 194 periods both before and during the COVID-19 pandemic, the rate of increase ranged from 0% in 195 New Mexico to a 65% increase among respondents in the California Bay Area. We found that 196 both convenience and representative samples had significantly lower prevalence of food 197 insecurity both before and since the COVID-19 pandemic, as compared to surveys targeting 198 high-risk populations, though the percent change did not significantly differ across survey 199 sample type (Table 3) . 200 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260280 doi: medRxiv preprint

In all survey sites that collected data on food insecurity before and during the COVID-19 203 pandemic, we found that food insecurity increased for BIPOC respondents since the onset of 204 the COVID-19 pandemic, with the exception of New Mexico. Furthermore, we found that the 205 prevalence of food insecurity among BIPOC respondents during the COVID-19 pandemic was 206 higher than the overall prevalence of food insecurity in the majority of study sites ( Figure 3) ; 207 however, it is worth noting that this was also true for pre-COVID-19 food insecurity. The highest 208 percent increase in food insecurity was identified in the California Bay Area (54.2% increase in 209 food insecurity among BIPOC respondents). However, the highest prevalence of food insecurity 210 during the COVID-19 pandemic among BIPOC respondents was identified in the NY Capital 211

Region (83.8%). We found the prevalence of BIPOC food insecurity during the COVID-19 212 pandemic was significantly different (p=0.048) for convenience (40.2%) versus high-risk (55.1%) 213 survey types. 214 215 Furthermore, we disaggregated race and ethnicity data when a particular survey had at least 30 216 respondents identifying within a specific race or ethnic group ( Figure 4 ). This additional 217 breakdown further highlights disparities in food insecurity across many study sites among 218 BIPOC respondents, as compared to NHW respondents. For example, while the majority of 219 surveys found the prevalence of food insecurity was higher for BIPOC respondents both before 220 and during the COVID-19 pandemic, the opposite is true of NHW respondents (i.e. the majority 221 of surveys found the prevalence of food insecurity among NHW respondents before and during 222 the COVID-19 pandemic was lower than the site's overall food insecurity). 223

Prevalence of Food Insecurity Among Households with Children 225 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ;

In all but one survey (New Mexico) with data on food insecurity before and during the COVID-19 226 pandemic, food insecurity increased among households with children ( Figure 5 ). The highest 227 reported percent change was in Massachusetts (a 62.1% increase), while the overall highest 228 prevalence during the COVID-19 pandemic was 69.3% food insecurity among households with 229 children in a Utah survey focused on SNAP participants. In surveys representative of the state 230 population, the prevalence of food insecurity among households with children ranged from 231 41.7% in Vermont in August/September 2020 to 56% in Arizona. Convenience surveys had 232 statistically lower food insecurity prevalence as compared to high-risk survey populations both 233 before the COVID-19 pandemic (p=0.042), and during the COVID-19 pandemic (p=0.003) 234 (Table 3) . 235 236

Food insecurity during the COVID-19 pandemic was higher in all surveys and study sites among 238 respondents facing a job disruption, as compared to the overall prevalence of food insecurity in 239 those sites ( Figure 6 ). The range of food insecurity among respondents with job disruptions 240 ranged from 21.5% in Central/Upstate New York up to 77.2% in New York City among all 241 surveys. Among surveys with state-wide representative samples on some characteristics, the 242 prevalence of food insecurity for those with job disruptions ranged from 38.7% in Vermont in 243

August/September 2020 to 59.8% in Wisconsin. Convenience surveys had statistically lower 244 food insecurity prevalence as compared to high-risk survey populations for any job disruption 245 (p=0.003), job loss (p=0.003), and reduction in hours (p=0.036) ( Table 3) . 246 247 Discussion 248

In this study, food insecurity was assessed in multiple sites using a common measurement 249 instrument. Key trends in food insecurity were highly consistent among research sites, albeit 250 with some significant differences in magnitude depending on survey type. This study utilized 251 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260280 doi: medRxiv preprint three different sampling methods (representative, convenience, and targeted high-risk 252 populations), allowing us to compare results between both study sites and sampling strategies. 253

Notably, there were no statistically significant differences in our findings between convenience 254 and representative samples, though high risk populations were consistently more likely to report 255 food insecurity than those recruited through convenience samples. Nearly all study sites that 256 assessed both current and pre-COVID-19 food insecurity found a higher prevalence of food 257 insecurity during the COVID-19 pandemic as compared with before the COVID-19 pandemic. 258

Furthermore, the majority of surveys and sites found higher prevalence among BIPOC 259 respondents as compared to the overall food insecurity prevalence and that of NHW 260 respondents in the same area. All but one survey found higher prevalence of food insecurity for 261 households with children during the COVID-19 pandemic as compared to the overall food 262 insecurity prevalence in a given site, and all surveys found higher prevalence of food insecurity 263 among respondents reporting job disruptions compared to those with no job disruptions. 264

Importantly, among study sites that conducted repeated surveys, all found continued increase in 265 food insecurity as the pandemic continued, demonstrating the ongoing and escalating effects of 266 the COVID-19 pandemic. Below we further elaborate on three key findings, and discuss their 267 implications for future programming and policy. 268

First, food insecurity increased across nearly all research sites between the pre-and during-269 pandemic periods. These results are consistent with several other national surveys examining 270 the impact of COVID-19 on food insecurity. For example, data from the Census Household 271

Pulse Survey and the COVID Impact Survey used probability sampling to obtain nationally 272 representative samples. In the COVID Impact Survey, data collected in early April 2020 was 273 extended using models to show that the overall prevalence of food insecurity was more than 274 double the predicted rate (33). These same researchers found similar estimates of food 275 insecurity increases using data from the Census Household Pulse Survey (34). The NFACT 276 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; survey results support these findings across study sites, where direct data collection has 277 occurred (as opposed to modelled results). Notably, NFACT sites that utilized a representative 278 high-risk sampling approach were more likely than surveys using a convenience or 279 representative sample to document higher prevalence of food insecurity since the onset of the 280 COVID-19 pandemic. These results suggest that targeted oversampling of high-risk populations 281 is likely to detect higher food insecurity outcomes, an important finding for future surveys and 282 methodologies. Furthermore, when assessing overall food insecurity before or during the 283 COVID-19 pandemic there were no statistically significant differences in food insecurity 284 prevalence between convenience and representative sampling approaches. Among all survey 285 approaches there were no significant differences in the percent change of prevalence of food 286 insecurity, suggesting that the rate of change was fairly consistent across all survey types. 287

These results provide important findings for researchers who must balance different priorities 288 when determining a sampling approach in the future (e.g. cost, timeframe for data collection, 289 ability to represent data at a state-level). 290

It should also be noted that our results show clear differences in food insecurity in different U.S. 291 regions. These differences may be partially attributed to problems in the food supply-chain and 292 community purchasing behavior (i.e. stockpiling), especially at the beginning of the pandemic 293 (33). Another likely cause for variation is the inconsistent national approach to pandemic 294 related restrictions such as stay-at-home orders, restrictions on businesses, and quarantine 295 requirements. Variation in state response to the threat of rising food insecurity is best 296 exemplified in state waivers authorized through SNAP and the Women, Infants and Children 297 (WIC) program and administered through the USDA Food and Nutrition Services (FNS). 298

Specifically, states had discretion about which benefits and waivers to request. While some 299 states made repeated requests for a wide range of allowances authorized by Congress, others 300 requested only a few (35, 36) . It is likely that variation in states' applications of extra benefits 301 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; and temporary waivers influenced differences in food insecurity across our study sites. We 302 suggest that future research examine the relative effects of extra benefits and waivers granted 303 to states, and their influence on both programmatic enrollment and food security outcomes. 304

Second, our study found that some populations have experienced higher rates of food insecurity 305 since the COVID-19 pandemic. Consistent with recent studies (33, 37), BIPOC populations 306 reported higher rates of food insecurity than NHW respondents in nearly all NFACT study sites 307 both before and since the onset of the COVID-19 pandemic. Moreover, the three sampling 308 approaches used by NFACT sites found strikingly similar results. There was no statistical 309 difference between sampling strategies with the exception of convenience and targeted high-310 risk approaches, specifically when addressing food insecurity among BIPOC respondents 311 during the COVID-19 pandemic. Several other national surveys using professional survey 312 platforms (Qualtrics and Turk Prime) have similarly found higher food insecurity rates among 313

Black and Hispanic respondents compared with NHW respondents (15, 24) . The only study to 314 provide food insecurity data for Native American respondents found that this population also has 315 a higher rate of food insecurity than NHW populations since the beginning of the pandemic (24). 316

Our research and the work of others (38, 39) clearly shows that the short-term effects of the 317 pandemic expose underlying racial and economic inequalities, but also highlights that BIPOC 318 respondents faced higher prevalence of food insecurity before the COVID-19 pandemic. As a 319 result, strategic policy interventions that include short-term relief and long-term programmatic 320 efforts to support underserved individuals, households, and communities is needed (38). 321

As well, our research also found that the pandemic has disproportionately affected households 322 with children. While it is estimated that the overall prevalence of food insecurity doubled in the 323 early days of the pandemic, it is estimated that food insecurity among households with children 324 tripled during that time period (37). Again, our analysis showed few differences in our results by 325 sampling strategy, with these differences being limited to comparing convenience and high-risk 326 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260280 doi: medRxiv preprint approaches. Several other studies support our findings, showing consistently that households 327 with children are experiencing high levels of food insecurity during the COVID-19 pandemic (15, 328 24) . 329

One likely contributor to this trend was the shift to online education, which increased challenges 330 for families that depended on free or reduced price school meals. While federal support such as 331 the Pandemic EBT (P-EBT) program provided additional benefits to families who normally would 332 qualify for these free and reduced-price meals (40), additional hurdles in accessing school 333 meals were reported. For example, the national NFACT survey conducted in the summer of 334 2020 found that participation in the school meals program dropped during the beginning of the 335 pandemic. Further, between 45 and 55% of survey respondents who utilized school meal pick-336 ups during the pandemic reported difficulties with availability of delivery, meal pick-up sites 337 being open, and the quantity of food provided (41). Compounding these challenges, low income 338 families with children were more likely to lose income during the COVID-19 pandemic compared 339 to households without children (40). These findings strongly suggest a need for increased 340 support for school food programs, enabling these important programs to ensure that meals 341 reach families in need. Similarly, NFACT sites universally found higher prevalence of food 342 insecurity among households that experienced job or income loss during the pandemic 343 compared to households with no change in employment status, a finding aligned with other 344 recent research (15, 24, 42) . 345

Third, several of our sites conducted repeated surveys, providing insights into the prevalence of 346 food insecurity over time, both within and across regions. Four NFACT study sites have 347 conducted more than one round of surveys (New York City, New York Capital Region, Vermont, 348 and Washington state), while more recent surveys (Massachusetts and the second Washington 349 state survey) were designed to elucidate respondent experiences with food insecurity within the 350 past 30-days, providing a more current understanding of food insecurity prevalence. All follow-351 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 up studies found an increasing prevalence of food security as the pandemic continues, with 352 each additional survey demonstrating higher prevalence of food insecurity. All of these rounds 353 of surveys measured food insecurity since the COVID-19 pandemic began, suggesting that 354 additional numbers of individuals continue to become food insecure, even after the initial 355 impacts of COVID-19 have been felt. Likewise, the recent NFACT Massachusetts survey, 356 measuring food insecurity prevalence in the last 30 days, found that nearly 30% of respondents 357 were classified as food insecure at the end of 2020. This prevalence is significantly higher than 358 the pre-pandemic level of 8.4% for this state (13), though it should be noted the pre-pandemic 359 level for Massachusetts respondents was much higher than observed pre-pandemic levels. 360

This evidence corroborates other studies suggesting that food insecurity levels are likely to 361 persist above pre-pandemic levels for an extended period of time as occurred after the Great 362

Recession and past disasters (13, 17, 20) . As noted by Hernandez and Holtzclaw (43) , the 363 combined impact of a pandemic and a recession are unique in modern memory. However, the 364 slow recovery from the 2008 Great Recession in the United States is instructive. It took eleven 365 years for food insecurity levels to return to pre-recession levels after the Great Recession; 366 according to national data, food insecurity went from 11.1% in 2007 to 14.6% in 2008, reaching 367 a peak of 14.9% in 2011, and back to 11.1% only in 2018 (13). Similarly, high levels of food 368 insecurity were observed up to five years following other disasters, such as after Hurricanes 369 Katrina and Harvey (20, 44) . Besides factors such as age, race/ethnicity, and income, other 370 factors such as support systems, community and generalized self-efficacy are also critical when 371 addressing food insecurity in a post-disaster context. A 5-year follow-up study on Hurricane 372

Katrina revealed that post-disaster food insecurity levels were associated with poor physical and 373 mental health, as well as low social support, generalized self-efficacy, and sense of community 374 (17, 44) . Considering that the pandemic has disproportionately affected racial and ethnic 375 minorities, these populations are likely to experience higher levels of food insecurity and be 376 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101/2021.07.23.21260280 doi: medRxiv preprint affected by its long-lasting health effects even after the economy recovers. Taken together, 377 these results suggest that the impact of COVID-19 on food security in the U.S. is far from over, 378 and additional support systems and policies will be necessary to continue to alleviate the long-379 term impacts of the global pandemic and recession. 380

Limitations 382

In presenting our results, we recognize two key limitations. First, research that requires 383 participants to report eating or food-related behaviors is challenged by both recall and social 384 desirability bias (45). Retrospectively asking participants about food insecurity has been shown 385 to lead to overestimation of pre-COVID prevalence of food insecurity (34), suggesting our study 386 may contain similar overestimations. However, we try to address this potential limitation by 387 reporting percent change between pre and during COVID-19 food security, in addition to 388 absolute prevalence of food insecurity, though if the overall pre-pandemic levels of food 389 insecurity are lower, our absolute food insecurity prevalence is likely underestimated. While 390 there has been some skepticism about the high prevalence of food insecurity reported since the 391 COVID-19 pandemic began, our results confirm this high prevalence while providing a more 392 robust measure to benchmark changes. Second, surveys across all research sites included in 393 this study were administered online, limiting respondents to those with computer skills and 394 internet access. This potentially introduced a barrier for some (though not all) elderly or low-395 income potential respondents (46, 47), as well as those living in rural areas without reliable 396 internet (48). Our study employed a number of methods to overcome this challenge across 397 different sampling strategies. These strategies included partnering with non-profit and 398 community organizations as well as government assistance programs to advertise the survey, 399 and seeking economic representation through sampling targets. Notably, our results show no 400 statistically significant difference between sites using convenience and representative samples, 401 indicating that even for study sites that employed a convenience sampling approach, this 402 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; potential bias did not have a significant influence on our findings. While differences did emerge 403 when representative and targeted high-risk samples were compared, we argue that this shows 404 the importance of purposeful sampling in target communities. 405 406 A number of U.S. studies have explored the impact of COVID-19 on food insecurity prevalence 407 since the beginning of the COVID-19 pandemic, though most have been national samples, 408 modelling efforts, or single site-specific studies. Here, we report the results from a nationwide 409 collaborative effort across 18 study sites and a nationally representative sample, including 22 410 surveys since the beginning of the COVID-19 pandemic. The scale of our work provides data 411 from more than 27,000 people, and more completely demonstrates the economic hardship the 412 COVID-19 pandemic has had for many people. Consistent increases in food insecurity are 413 prevalent, as well as further evidence that the pandemic has exacerbated racial and ethnic 414 disparities in food insecurity that existed prior to the pandemic. Surveys conducted in study 415 sites more than once also demonstrate an increasing prevalence of food insecurity since the 416 COVID-19 pandemic began, and more recent studies reaffirm that high prevalence of food 417 insecurity, compared to before the COVID-19 pandemic, continues. These findings point to the 418 clear continued need for additional programmatic and policy assistance to provide food 419 insecurity and economic relief. Our future work will continue to conduct additional surveys and 420 comparative analysis to quantify changes in food access, food security, and food assistance use 421 as the U.S. recovers from the COVID-19 pandemic. 422

Acknowledgements: 424

This research is conducted as part of The National Food Access and COVID research Team 425 (NFACT), which is implementing common measurements and tools across study sites in the 426 US. NFACT is a national collaboration of researchers committed to rigorous, comparative, and 427 timely food access research during the time of COVID. We do this through collaborative, open 428 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 access research that prioritizes communication to key decision-makers while building our 429 scientific understanding of food system behaviors and policies. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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