BY, MBA, RD, LDN
Food insecurity is an issue plaguing America that has only increased since the beginning of the COVID-19 pandemic. According to the Nutrition Journal, nearly 15% of U.S. households—and almost 18% of households with children—reported food insecurity early in the COVID-19 pandemic (https://nutritionj.biomedcentral.com/track/pdf/10.1186/s12937-021-00732-2.pdf). Before the pandemic, approximately 11% of households reported food insecurity. These are the same people who were already experiencing some degree of food insecurity and are now facing even more significant hardships since COVID-19.
When looking at Black and Hispanic communities, both are particularly hard hit by the health and economic crises, including more jobs lost, higher rates of mortality and a higher likelihood of evictions and food insecurity, versus their white counterparts. When taking a further look at the discrepancies, Black and Hispanic poverty levels are consistently two to three times higher than those of white Americans. In 2020, 21.7% of Black households experienced food insecurity, as did 17.2% of Hispanic households and 7.1% of white households (https://www.americanprogress.org/article/new-poverty-food-insecurity-data-illustrate-persistent-racial-inequities/). This clear disparity should be considered when moving forward and expanding the food benefit coverage and federal policy.
Low-income individuals and families face many challenges in achieving enough nutritious foods for a healthy and active life. High costs for nutritious foods are the most compelling challenge to acquiring high diet quality. We must also consider the availability and access to healthier food options for those living in low-income areas, which are traditionally considered more likely to be food deserts. Food deserts are defined as geographical locations that have limited or no affordable healthy food options within a reasonable and accessible distance, making it even more difficult for people to buy nutritious foods regularly. While many may think that food prices are the main reason low-income individuals purchase less nutrient-dense foods, studies have shown that it may also include education and nutrition knowledge as barriers in the prevention of healthy food purchases (https://reader.elsevier.com/reader/sd/pii/S0749379716303099?token=3CAD746D064F2874A3298BB3809715E9DE85708EC12FFEAFBEBA23B34F9DC0E93B8DD0597CB42B5974FEE2A43269DE67&originRegion=us-east-1&originCreation=20220131185949).
Food insecurity is extremely stressful (https://www.sciencedirect.com/science/article/pii/S0749379716303099). When people do not know when or where they will eat their next meal, finding food may become their primary focus. It can de-prioritize health-related behaviors, such as managing medications and making doctor appointments (https://www.amjmed.com/article/S0002-9343(14)00030-8/fulltext). Many households must rely on charitable food programs, such as Feeding America, Meals on Wheels, Action Against Hunger, and The Hunger Project.
Specifically, households that are food-insecure reported choosing between:
- Food and medical care (66%)
- Food and utilities (69%)
- Food and transportation (67%)
- Food and housing (57%)
To complicate matters, we must study the accompanying psychological and biobehavioral factors experienced by low-income individuals and households. Social and environmental exposures can influence behavior. Stress can impact the nervous, immune and endocrine systems in response to poverty, housing, food, employment and safety. These stresses influence food choices and quantity behaviors. This cascade of events is directly related to chronic disease progression (https://www.sciencedirect.com/science/article/pii/S0749379716303099).
Living in poverty and extreme poverty directly affects stress, sleep and cognitive abilities. Also, uncertainty and threat to one’s well-being associated with employment, food and housing insecurities are the primary reasons why poverty triggers elevated stress levels, poor sleep quality and cognitive burden.
Being food-insecure impacts food access and nutritional status and can have a cascading effect on overall health. Adults who experience food insecurity have a higher risk of poor health outcomes or health disparities. For example, food-insecure individuals may be at an increased risk of obesity and chronic disease (https://www.cdc.gov/pcd/issues/2006/jul/05_0127.htm). Adults who reported food insecurity were significantly more likely to report cost-related medication underuse (https://www.amjmed.com/article/S0002-9343(14)00030-8/fulltext). The problem only worsens with the increased risk of developmental problems for children (https://www.ers.usda.gov/webdocs/publications/44419/9360_eib56_1_.pdf?v=41055).
A study from 2017 by the United States Department of Agriculture found that food insecurity is also associated with 10 of the most costly and deadly preventable diseases in the United States (https://www.ers.usda.gov/webdocs/publications/84467/err-235_summary.pdf?v=2983.5). These diseases include diabetes, hypertension, coronary heart disease, hepatitis, stroke, cancer, asthma, arthritis, chronic obstructive pulmonary disease and kidney disease. Furthermore, this study evaluated the differences in the level of food security status. From marginal, low and very low food security levels, the differences between these three groups can be significant, often with similar results within the progression of their chronic disease. The study concluded that food security status might be more predictive of chronic disease than income. Income is linked to three of the top 10 chronic diseases, and as previously stated, food insecurity is associated with all 10.
Food insecurity-induced stress activates stress hormones that favor highly palatable foods (https://doi.org/10.3945/an.112.003277). Household food insecurity can be related to inexpensive, unhealthy energy-dense foods rather than more nutrient-dense foods, such as fruits, vegetables and whole grains. Such dependence, and the cyclical nature of having enough food at the beginning of the month followed by food scarcity at the end of the month, could lead to weight gain over a short period. Dependence on energy-dense foods and weight gain may play a direct role in developing chronic conditions. Other compounding factors that result from exposure to household food insecurity have been well described, including pathways by which stress promotes visceral fat accumulation and chronic disease.
Food assistance programs, such as Supplemental Nutrition Assistance Program (SNAP), Women, Infants and Children (WIC) Program or the National School Lunch Program break down barriers related to food access. Additionally, frozen, home-delivered meals via state governments or insurance plans can offer better access to consistent food avenues, eliminating the stresses of where the next meal will come from. Many low-income individuals may qualify for ongoing meal benefits, which would help minimize or eliminate food insecurity.
Interventions to eliminate food insecurity in the United States must acknowledge the variety of ways in which poverty influences dietary patterns. Poverty, when combined with the stress of uncertainty—such as that related to employment status, food access, housing access, etc.—may have a tangible impact on physiological and hormonal responses, ultimately leading to poorer diet quality. Case managers have the unique opportunity to directly affect patients’ food insecurity by connecting them to essential programs and benefits.
Cook JT, Frank DA. Food security, poverty, and human development in the United States. Ann N Y Acad Sci. 2008;1136(1):193-209.
Burke MP, Martini LH, Çayare, Hartline-Grafton HL, Meade RL. Severity of household food insecurity is positively associated with mental disorders among children and adolescents in the United States. J Nutr. 2016;146(10):2019-26. doi: 10.3945/jn.116.232298.