Food Insecurity Among Low-Income U.S. Adults During the COVID-19 Pandemic
Authors: Aaron L. Troy, Isabella Ahmad, ZhaoNian Zheng, Rishi K. Wadhera
Journal: Annals of Internal Medicine (2024)

Letters2 January 2024Food Insecurity Among Low-Income U.S. Adults During the COVID-19 PandemicFREEAaron L. Troy, MD, MPH, Isabella Ahmad, ZhaoNian Zheng, MS, Rishi K. Wadhera, MD, MPP, MPhilAaron L. Troy, MD, MPHRichard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, Isabella AhmadRichard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, ZhaoNian Zheng, MSRichard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, Rishi K. Wadhera, MD, MPP, MPhilRichard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MassachusettsAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-2282 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Food insecurity is a major driver of health disparities in the United States. In response to the COVID-19 pandemic, the federal government enacted a series of policies to expand the social safety net, including historic increases in nutritional benefits. Most nutritional spending went toward the federally funded and state-administered Supplemental Nutrition Assistance Program (SNAP), resulting in a near doubling of the average SNAP benefit between 2019 and 2021 (1). However, many of these increases were temporary, with 16 states deimplementing SNAP emergency allotments by 2022 (2). Despite these major policy shifts, little is known about how food insecurity changed among low-income adults over the course of the pandemic, including those with diet-sensitive chronic conditions.Objective: To examine food insecurity among low-income adults during versus before the pandemic.Methods: We used data from the National Health Interview Survey (NHIS), a nationally representative survey from the National Center for Health Statistics. We included 2019 as a prepandemic reference and both 2021 and 2022 cycles but excluded 2020 because the onset of the pandemic created challenges in administering the in-person survey. We included adults aged 18 years or older and defined low-income adults as those with household incomes at or below 200% of the federal poverty limit (3). Our main outcome was food insecurity within the past 30 days, defined as 3 or more affirmative responses on the U.S. Adult Food Security Survey Module (4) (Supplement).Survey-weighted logistic regression models were fit to compare food insecurity among low-income adults in 2021 and 2022 compared with 2019, with adjustment for age and sex. Our models included an interaction term for SNAP benefits and year. We repeated the analysis for subgroups based on receipt of SNAP benefits and presence of diet-sensitive chronic conditions (self-reported diabetes, hypertension, hyperlipidemia, or body mass index >30 kg/m2).Nationally representative estimates and SEs accounted for the NHIS survey design. Analyses were performed using SAS Enterprise Guide, version 7.15 (SAS Institute).Findings: The unweighted sample included 25 127 low-income U.S. adults, of whom 16 518 had diet-sensitive chronic conditions. Weighted baseline characteristics are shown in Table 1 and demonstrate increases in SNAP enrollment and unemployment during the pandemic.Table 1. Baseline Characteristics of Low-Income U.S. Adults in the National Health Interview Survey Before (2019) and During (2021 and 2022) the Pandemic*Characteristic2019† (n = 9388)2021† (n = 8055)2022† (n = 7684)Mean age (SD), y46.3 (0.29)47.0 (0.32)48.0 (0.18)Female sex, %56.1 (54.7–57.5)57.9 (56.6–59.2)56.4 (55.1–57.8)Race and ethnicity, % Non-Hispanic White47.2 (45.0–49.5)45.5 (43.2–47.9)45.8 (43.5–48.0) Non-Hispanic Black17.3 (15.7–19.0)17.9 (16.2–19.6)17.9 (16.1–19.6) Hispanic26.7 (24.4–28.9)27.8 (25.4–30.2)27.6 (25.3–29.8) Non-Hispanic Asian5.4 (4.7–6.2)5.1 (4.3–5.9)5.4 (4.6–6.1) Other‡3.4 (2.4–4.3)3.6 (2.1–5.1)3.5 (2.4–4.6)Urban residence, %§81.7 (79.8–83.6)82.8 (81.0–84.5)81.6 (79.6–83.5)Employed, %‖49.6 (48.2–51.0)46.5 (45.0–47.9)46.3 (44.8–47.8)U.S. citizen, %¶84.6 (83.2–86.0)85.1 (83.6–86.6)84.3 (82.9–85.8)SNAP enrollment in past 30 d, %**25.9 (24.5–27.3)28.8 (27.3–30.2)29.6 (28.3–31.0)Diet-sensitive conditions, % Diabetes††12.5 (11.7–13.3)12.9 (12.1–13.8)12.7 (11.9–13.5) Hyperlipidemia‡‡25.2 (24.1–26.4)26.5 (25.3–27.7)27.5 (26.4–28.7) Hypertension§§35.1 (33.8–36.3)34.6 (33.3–35.9)36.0 (34.7–37.4) Obesity‖‖36.1 (34.8–37.4)37.9 (36.5–39.3)36.4 (34.9–37.9)SNAP = Supplemental Nutrition Assistance Program.* Low-income was defined as household income ≤200% of the federal poverty limit, which is the cutoff for broad-based categorical SNAP eligibility in many states (3).† Except where indicated, data are national estimates (percentages [95% CIs]) after application of survey weights provided by the National Health Interview Survey.‡ Other race was defined as self-reported race other than White, Black/African American, or Asian paired with non-Hispanic ethnicity.§ Urban residence was defined according to the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties.‖ Employment was based on self-report of working within the past week.¶ Citizenship status was based on self-reported U.S. citizenship.** SNAP enrollment was based on self-reported receipt of SNAP benefits within the past 30 days.†† Diabetes was based on self-report of ever having diabetes.‡‡ Hyperlipidemia was based on self-report of participant ever being told they have high cholesterol.§§ Hypertension was based on self-report of participant ever being told they have hypertension.‖‖ Obesity was based on calculated body mass index >30 kg/m2 based on self-reported height and weight. Download table Table 1. Baseline Characteristics of Low-Income U.S. Adults in the National Health Interview Survey Before (2019) and During (2021 and 2022) the Pandemic*Food insecurity among low-income adults decreased from 20.6% (95% CI, 19.4% to 21.7%) in 2019 to 15.5% (CI, 14.3% to 16.7%) in 2021 (adjusted risk difference [aRD], −5.1 percentage points [CI, −6.7 to −3.5 percentage points]) and returned to prepandemic levels in 2022 (20.1% [CI, 18.9% to 21.3%]; aRD, −0.4 percentage points [CI, −2.1 to 1.3 percentage points]). Among the subset receiving SNAP benefits, food insecurity decreased from 34.6% (CI, 32.1% to 37.0%) in 2019 to 21.6% (CI, 19.3% to 23.9%) in 2021 (aRD, −12.8 percentage points [CI, −16.0 to −9.6 percentage points]) and remained lower in 2022 (27.0% [CI, 24.8% to 29.3%]; aRD, −7.3 percentage points [CI, −10.6 to −4.0 percentage points]). Changes in food insecurity among low-income adults without SNAP benefits were more modest, decreasing from 15.4% (CI, 14.3% to 16.5%) in 2019 to 12.9% (CI, 11.6% to 14.1%) in 2021 (aRD, −2.6 percentage points [CI, −4.3 to −0.9 percentage points]) and 16.9% (CI, 15.5% to 18.2%) in 2022 (aRD, 1.5 percentage points [CI, −0.3 to 3.2 percentage points]).Food insecurity was higher among low-income adults with any diet-sensitive chronic condition. Food insecurity decreased from 23.3% (CI, 21.8% to 24.8%) in 2019 to 17.1% (CI, 15.5% to 18.6%) in 2021 (aRD, −6.4 percentage points [CI, −8.5 to −4.3 percentage points]) but then returned to prepandemic levels in 2022 (21.9% [CI, 20.4% to 23.4%]; aRD, −1.2 percentage points [CI, −3.4 to 1.0 percentage points]). Greater differences were seen in 2022 in adults with more chronic conditions (Table 2).Table 2. Food Insecurity Among Low-Income U.S. Adults During (2021 and 2022) Compared With Before (2019) the Pandemic*SubgroupFood Insecurity in 2019 (95% CI), %Food Insecurity in 2021 (95% CI), %Adjusted Risk Difference† (95% CI) for 2021 vs. 2019, percentage pointsFood Insecurity in 2022 (95% CI), %Adjusted Risk Difference† (95% CI) for 2022 vs. 2019, percentage pointsOverall20.6 (19.4 to 21.7)15.5 (14.3 to 16.7)−5.1 (−6.7 to −3.5)20.1 (18.9 to 21.3)−0.4 (−2.1 to 1.3)Receiving SNAP benefits‡34.6 (32.1 to 37.0)21.6 (19.3 to 23.9)−12.8 (−16.0 to −9.6)27.0 (24.8 to 29.3)−7.3 (−10.6 to −4.0)Not receiving SNAP benefits‡15.4 (14.3 to 16.5)12.9 (11.6 to 14.1)−2.6 (−4.3 to −0.9)16.9 (15.5 to 18.2)1.5 (−0.3 to 3.2)Diet-sensitive chronic conditions Any23.3 (21.8 to 24.8)17.1 (15.5 to 18.6)−6.4 (−8.5 to −4.3)21.9 (20.4 to 23.4)−1.2 (−3.4 to 1.0) 120.9 (18.8 to 22.9)15.8 (13.6 to 18.0)−5.1 (−8.1 to −2.2)21.8 (19.6 to 24.0)1.3 (−1.7 to 4.3) >225.6 (23.6 to 27.6)18.3 (16.4 to 20.1)−7.7 (−10.6 to −4.8)21.9 (19.9 to 24.0)−3.9 (−6.9 to −0.8) None§16.3 (14.6 to 17.9)12.9 (11.2 to 14.6)−3.2 (−5.4 to −1.1)17.2 (15.3 to 19.0)1.1 (−1.3 to 3.5)SNAP = Supplemental Nutrition Assistance Program.* Food insecurity in the National Health Interview Survey was determined on the basis of whether respondents provided ≥3 affirmative responses on a 10-item questionnaire derived from the U.S. Adult Food Security Survey Module (4). The rate of missing responses to the Food Security Survey Module was low (<4%); therefore, complete-case analyses were performed. Low-income was defined as household income ≤200% of the federal poverty limit, the cutoff for broad-based categorical SNAP eligibility in many states (3).† Risk difference was adjusted for age and sex.‡ SNAP benefits were based on self-reported receipt of SNAP benefits within the past 30 days.§ Diet-sensitive chronic conditions were based on respondent self-report of ever having diabetes, ever being told they have high cholesterol, ever being told they have hypertension, or body mass index >30 kg/m2 based on self-reported height and weight. Download table Table 2. Food Insecurity Among Low-Income U.S. Adults During (2021 and 2022) Compared With Before (2019) the Pandemic*Discussion: Food insecurity decreased in 2021 compared with prepandemic levels among low-income adults, despite worsening unemployment and economic loss. Although food insecurity returned to prepandemic levels in 2022, rates remained lower for those enrolled in SNAP and those with multiple diet-sensitive chronic conditions.Our finding that food insecurity improved most among SNAP beneficiaries (who had greater prepandemic food insecurity) highlights the importance of financial relief and nutritional benefits, particularly in this more vulnerable group. Unfortunately, many states elected to end SNAP emergency allotments early, which may explain some of the increase in food insecurity in 2022 (2). Our findings extend prior studies by examining food insecurity through the end of 2022 and evaluating a higher-risk subpopulation (5). Limitations include that outcomes were based on self-reports and were not assessed in the same participants from year to year.Food insecurity among low-income adults reached levels well below prepandemic levels in 2021 but returned to prepandemic levels in 2022. Our findings highlight the implications of pandemic-era SNAP and financial benefits on food insecurity and provide important insights as Congress debates the upcoming farm bill, which will determine the next 5 years of nutritional policy in the United States.References1. U.S. Department of Agriculture Food and Nutrition Service. SNAP Data Tables. Accessed at www.fns.usda.gov/pd/supplemental-nutrition-assistance-program-snap on 7 July 2023. Google Scholar2. Center on Budget and Policy Priorities. States Are Using Much-Needed Temporary Flexibility in SNAP to Respond to COVID-19 Challenges. 31 March 2020. Accessed at www.cbpp.org/research/food-assistance/states-are-using-much-needed-temporary-flexibility-in-snap-to-respond-to on 30 March 2023. Google Scholar3. U.S. Department of Agriculture. Broad-Based Categorical Eligibility (BBCE). Accessed at www.fns.usda.gov/snap/broad-based-categorical-eligibility on 7 July 2023. Google Scholar4. Wunderlich GS, Norwood JL. Food Insecurity and Hunger in the United States: An Assessment of the Measure. National Academies Pr; 2006. Google Scholar5. Coleman-Jensen A, Rabbitt MP, Gregory CA, et al. Household Food Security in the United States in 2021. U.S. Department of Agriculture Economic Research Service; September 2022. Accessed at www.ers.usda.gov/publications/pub-details/?pubid=104655 on 29 March 2023. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Aaron L. Troy, MD, MPH; Isabella Ahmad; ZhaoNian Zheng, MS; Rishi K. Wadhera, MD, MPP, MPhilAffiliations: Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MassachusettsGrant Support: This research was supported by a grant from the National Heart, Lung, and Blood Institute (K23HL148525) at the National Institutes of Health.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2282.Reproducible Research Statement: Study protocol: Available from Dr. Wadhera (e-mail, rwadhera@bidmc.harvard.edu). Statistical code: Not available. Data set: Available from the Centers for Disease Control and Prevention (www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm).Corresponding Author: Rishi K. Wadhera, MD, MPP, MPhil, Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215; e-mail, rwadhera@bidmc.harvard.edu.This article was published at Annals.org on 2 January 2024. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoFood Insecurity in the COVID-19 Era: A National Wake-up Call to Strengthen SNAP Policy Julia A. Wolfson , Cindy W. Leung Metrics Cited byFood Insecurity in the COVID-19 Era: A National Wake-up Call to Strengthen SNAP PolicyJulia A. Wolfson, PhD, MPP, Cindy W. Leung, ScD, MPH Current IssueFebruary 2024Volume 177, Issue 2Page: 260-262KeywordsCOVID-19Food insecurityHealth care policyHealth disparitiesHealth statisticsNutritionPandemicsPrevention, policy, and public health ePublished: 2 January 2024 Issue Published: February 2024 Copyright & PermissionsCopyright © 2024 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...