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Food Insufficiency and Mental Health in the U.S. During the COVID-19 Pandemic

Published:January 09, 2021DOI:https://doi.org/10.1016/j.amepre.2020.12.004

      Introduction

      During the COVID-19 pandemic, the rates of food insecurity and mental illness have been projected to increase in the U.S. owing to significant social and economic disruption. This study aims to estimate the prevalence of food insufficiency (often the most extreme form of food insecurity), the correlates of food insufficiency, and the associations between food insufficiency and symptoms of poor mental health in the U.S. during the COVID-19 pandemic.

      Methods

      Cross-sectional data from 63,674 participants of the U.S. Census Household Pulse Survey were collected and analyzed in 2020. Multiple Poisson regression models were used to estimate associations with food insufficiency.

      Results

      Food insufficiency rose from 8.1% to 10.0% from March to June 2020. Factors associated with food insufficiency included lower age, Black/African American or Latinx race/ethnicity, being unmarried, larger household size, recent employment loss, income below the federal poverty line, and lower education (all p<0.001). Food insufficiency was independently associated with all symptoms of poor mental health, adjusting for socioeconomic and demographic factors (adjusted RRs ranged from 1.16 to 1.42, all p<0.001). The association between food insufficiency and poor mental health was attenuated among people who received free groceries or meals.

      Conclusions

      Food insufficiency has increased during the COVID-19 pandemic and affects vulnerable populations, placing individuals at higher risk for symptoms of poor mental health. Particularly in the current crisis, clinicians should regularly screen patients for food insufficiency and mental health outcomes as well as provide support in accessing appropriate resources.

      INTRODUCTION

      Food insecurity is the inability to afford or access nutritionally adequate and safe foods for an active, healthy lifestyle.
      • Coleman-Jensen A
      • Rabbitt MP
      • Gregory C
      • Singh A
      Household food security in the United States in 2018.
      Food security is a fundamental, basic need, and serves as a global indicator of a country's overall security.
      • Chilton M
      • Rose D
      A rights-based approach to food insecurity in the United States.
      Food insufficiency, often the most extreme form of food insecurity, generally describes whether households have enough food for their families to eat.
      • Briefel RR
      • Woteki CE
      Development of food sufficiency questions for the third national health and nutrition examination survey.
      With the onset of the unprecedented coronavirus disease 2019 (COVID-19) pandemic, levels of food insecurity and food insufficiency were projected to dramatically increase in the U.S.
      • Schanzenbach D
      • Pitts A
      How much has food insecurity risen? Evidence from the census household pulse survey.
      There are several reasons for this. The social and economic consequences of the pandemic, including stay-at-home orders, changes in consumer demand, school closures, and rising unemployment, have the potential to exacerbate food insufficiency where individuals find themselves unable to safely purchase or afford food for their families.

      Kaiser Family Foundation. State COVID-19 data and policy actions. San Francisco, CA: Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/state-data-and-policy-actions-to-address-coronavirus/. Published January 27, 2021. Accessed January 27, 2021.

      Before the pandemic, nearly 35 million children in the U.S. received free meals at school daily, with a higher proportion of children of color receiving free meals.
      • Dunn CG
      • Kenney E
      • Fleischhacker SE
      • Bleich SN
      Feeding low-income children during the COVID-19 pandemic.
      • Jyoti DF
      • Frongillo EA
      • Jones SJ
      Food insecurity affects school children's academic performance, weight gain, and social skills.
      • Huang J
      • Barnidge E
      • Kim Y
      Children receiving free or reduced-price school lunch have higher food insufficiency rates in summer.
      Disparities in food insecurity are linked to food deserts and food apartheid, where the lack of availability of healthy foods disproportionately affects communities of color.
      • Bradley K
      • Galt RE
      Practicing food justice at Dig Deep Farms & Produce, East Bay Area, California: self-determination as a guiding value and intersections with foodie logics.
      In addition, food system and supply chain disruptions during COVID-19 owing to border closures, essential worker illnesses, and other factors can cause food shortages
      • de Paulo Farias D
      • dos Santos Gomes MG
      COVID-19 outbreak: what should be done to avoid food shortages?.
      and insufficiency, reduce food quality, and inflate food prices.

      Kaiser Family Foundation. State COVID-19 data and policy actions. San Francisco, CA: Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/state-data-and-policy-actions-to-address-coronavirus/. Published January 27, 2021. Accessed January 27, 2021.

      ,
      • Akter S
      The impact of COVID-19 related ‘stay-at-home’ restrictions on food prices in Europe: findings from a preliminary analysis.
      Finally, social isolation due to fear of viral exposure, social distancing policies, or stigma from infection can undermine help seeking from social networks, further exacerbating food insufficiency.
      Worsening food insecurity can in turn worsen health in the context of a COVID-19 illness. Specifically, food insecurity may contribute to weakened host defenses and immunologic decline owing to micronutrient deficiencies.
      • Weiser SD
      • Young SL
      • Cohen CR
      • et al.
      Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS.
      ,
      • Kirkpatrick SI
      • Tarasuk V
      Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents [published correction appears in J Nutr. 2008;138(7):1399].
      Food insecurity is associated with diets high in low-cost, energy-dense packaged foods but low in fruits and vegetables, which may lead to chronic medical conditions such as diabetes and hypertension, both of which are known to be associated with a higher risk for severe COVID-19 illness.
      • Weiser SD
      • Young SL
      • Cohen CR
      • et al.
      Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS.
      ,
      • Seligman HK
      • Laraia BA
      • Kushel MB
      Food insecurity is associated with chronic disease among low-income NHANES participants.
      • Gundersen C
      • Ziliak JP
      Food insecurity and health outcomes.
      • Pooler JA
      • Hartline-Grafton H
      • DeBor M
      • Sudore RL
      • Seligman HK
      Food insecurity: a key social determinant of health for older adults.
      • Nagata JM
      • Palar K
      • Gooding HC
      • Garber AK
      • Bibbins-Domingo K
      • Weiser SD
      Food insecurity and chronic disease in U.S. young adults: findings from the National Longitudinal Study of Adolescent to Adult Health.
      The progression of the COVID-19 pandemic has also led to poor mental health, including anxiety and depression.
      • Talevi D
      • Socci V
      • Carai M
      • et al.
      Mental health outcomes of the COVID-19 pandemic.
      • Ganson KT
      • Tsai AC
      • Weiser SD
      • Benabou SE
      • Nagata JM
      Job insecurity and symptoms of anxiety and depression among U.S. young adults during COVID-19.
      • Ganson KT
      • Weiser SD
      • Tsai AC
      • Nagata JM
      Associations between anxiety and depression symptoms and medical care avoidance during COVID-19.
      Before the COVID-19 pandemic, social isolation was already increasing,
      • Taylor HO
      • Taylor RJ
      • Nguyen AW
      • Chatters L
      Social isolation, depression, and psychological distress among older adults.
      and the opioid epidemic was a national crisis.
      • Lyden J
      • Binswanger IA
      The United States opioid epidemic.
      Food insecurity has the potential to further exacerbate this mental health crisis because it alone is an important contributor to poor mental health. The association between food insecurity and depressive symptoms is especially well studied, with longitudinal studies in the U.S. specifically suggesting a bidirectional relationship.
      • Bruening M
      • Dinour LM
      • Chavez JBR
      Food insecurity and emotional health in the USA: a systematic narrative review of longitudinal research.
      Food insecurity may lead to poor mental health through chronic stress, stigmatization, and perceived powerlessness.
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
      ,
      • Palar K
      • Frongillo EA
      • Escobar J
      • et al.
      Food insecurity, internalized stigma, and depressive symptoms among women living with HIV in the United States.
      Conversely, people experiencing poor mental health symptoms may be less able to work, generate income, or manage financial resources, which could exacerbate food insecurity.
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
      ,
      • Lent MD
      • Petrovic LE
      • Swanson JA
      • Olson CM
      Maternal mental health and the persistence of food insecurity in poor rural families.
      This finding has been shown in diverse geographic contexts and across a wide range of mental health outcomes.
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
      ,
      • Whittle HJ
      • Sheira LA
      • Wolfe WR
      • et al.
      Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States.
      • Whittle HJ
      • Sheira LA
      • Frongillo EA
      • et al.
      Longitudinal associations between food insecurity and substance use in a cohort of women with or at risk for HIV in the United States.
      • Pryor L
      • Lioret S
      • van der Waerden J
      • Fombonne É
      • Falissard B
      • Melchior M
      Food insecurity and mental health problems among a community sample of young adults.
      • Nagata JM
      • Gomberg S
      • Hagan MJ
      • Heyman MB
      • Wojcicki JM
      Food insecurity is associated with maternal depression and child pervasive developmental symptoms in low-income Latino households.
      However, previous studies examining the association between food insecurity and mental health have not examined individual symptoms (in particular worrying and little interest, in addition to anxiety and depression).
      • Arenas DJ
      • Thomas A
      • Wang JC
      • DeLisser HM
      A systematic review and meta-analysis of depression, anxiety, and sleep disorders in U.S. adults with food insecurity.
      Furthermore, there is a paucity of data on how receipt of food aid may modify the association between food insecurity and mental health.
      There is an urgent need to understand the factors associated with food insecurity/insufficiency during the pandemic at the national level because the results of these studies could inform policy and resource allocation for federal pandemic relief legislation currently being discussed. Furthermore, understanding the magnitude of the association between food insecurity/insufficiency and poor mental health specifically during the COVID-19 pandemic and how these associations may be modified among people who receive food aid can further inform screening guidance, policy, and resource allocation for food aid and mental health services during the pandemic. Therefore, the objectives of this study are to use national Census data in the U.S. during the COVID-19 pandemic to estimate (1) the prevalence of food insufficiency, (2) factors associated with food insufficiency, (3) the association between food insufficiency and symptoms of poor mental health, and (4) how receipt of free food may modify the association between food insufficiency and symptoms of poor mental health.

      METHODS

      This study analyzed data from June 11 to June 16, 2020 of the weekly, cross-sectional Household Pulse Survey (HPS) (N=63,674), which is conducted by the U.S. Census Bureau. HPS was developed in collaboration with 5 federal agencies: the U.S. Department of Agriculture Economic Research Service, Bureau of Labor Statistics, National Center for Health Statistics, National Center for Education Statistics, and Department of Housing and Urban Development. HPS aims to survey U.S. adults on the social and economic impacts of the COVID-19 pandemic. The HPS survey was reviewed by the Center for Behavioral Science Methods as well as the Demographic Directorate and subject experts from the 5 partner federal agencies.
      To gather the sample, HPS used the Census Bureau's Master Address File as the primary sampling frame to collect responses from a large sample that would be sufficient for the anticipated low response rates. Sampled households were contacted by e-mail or cell phone text messaging. The online platform Qualtrics was used as the primary data collection method. Once a complete interview was obtained from a household, that household remained in the sample for up to 2 additional weekly interviewing periods. These methods increased efficacy, reduced costs, and provided timely responses despite the anticipated relatively low response rates compared with those of the in-person or mail surveys traditionally conducted by the Census Bureau. Sample weights, based on measures such as the demographic distribution of the survey respondents compared with benchmarks, were produced to address the potential nonresponse bias. Additional details regarding the study and data, which are publicly available and deidentified, may be found on the Census Bureau website.

      Measuring household experiences during the coronavirus pandemic. U.S. Census Bureau. https://www.census.gov/householdpulsedata. Updated January 12, 2021. Accessed July 23, 2020.

      Research involving unidentifiable/deidentified information that is publicly available is not considered human subjects research by the NIH definition because investigators cannot ascertain the identities of the individuals in the data.
      Definition of human subjects research.
      In these cases, IRB review is not required. Measures are described in Table 1.
      Table 1Description of Measures
      MeasureDescription
      Food insufficiencyParticipants were asked, "In the last 7 days, which of these statements best describes the food eaten in your household?" Potential response options included: "Enough of the kinds of food (I/we) wanted to eat", "Enough, but not always the kinds of food (I/we) wanted to eat", "Sometimes not enough to eat", and "Often not enough to eat". The response options "Enough of the kinds of food (I/we) wanted to eat" and "Enough, but not always the kinds of food (I/we) wanted to eat" were categorized as food sufficient, while the response options "Sometimes not enough to eat" and "Often not enough to eat" were categorized as food insufficient as reported by the U.S. Census.
      • Zou G
      A modified Poisson regression approach to prospective studies with binary data.
      The questions regarding food sufficiency were consistent with the U.S. Household Food Security Survey Module.

      United States Department of Agriculture. US Household Food Security Survey Module: Three-Stage Design, with Screeners. Washington, D.C.; 2012. https://www.ers.usda.gov/media/8271/hh2012.pdf. Accessed October 15, 2020.

      Food insufficiency generally describes whether households have enough food for their families to eat and is often the most extreme form of food insecurity.
      • Briefel RR
      • Woteki CE
      Development of food sufficiency questions for the third national health and nutrition examination survey.
      In other surveys, such as the Current Population Survey's Food Security Supplement, 86%‒89% of people reporting food insufficiency were deemed food insecure.
      • Schanzenbach D
      • Pitts A
      How much has food insecurity risen? Evidence from the census household pulse survey.
      Received free food or groceries"During the last 7 days, did you or anyone in your household get free groceries or a free meal?" Response options included "yes" or "no". This item was included in order to determine the extent of receipt of food aid and to determine sources of food aid as below to inform policy and resource allocation during the COVID-19 pandemic.
      Where did you get free groceries or food?This item was asked of participants who responded "yes" to receiving free food or groceries and was measured using the question "Where did you get free groceries or free meals?" Potential response options included "Free meals through the school or other programs aimed at children", "Food pantry or food bank", "Home-delivered meal service like Meals on Wheels, Church, synagogue, temple, mosque or other religious organization", "Shelter or soup kitchen", "Other community program", and "Family, friends, or neighbors". These factors were chosen as part of the U.S. public-use household-level Current Population Survey Food Security Supplement (CPS-FSS), which was designed to understand where Americans receive food aid in relation to food insecurity.

      United States Department of Agriculture. Food Security in the United States. https://www.ers.usda.gov/data-products/food-security-in-the-united-states/. Published 2020. Accessed October 14, 2020.

      In addition, from a policy level, it is important to determine what proportion of Americans are receiving free food during the pandemic and where they are getting the food aid from. This can inform resource allocation for federal and state policies as part of the Coronavirus relief legislation.
      Mental health symptomsMental health symptoms were measured using questions adapted from the 7-item Generalized Anxiety Disorder scale (GAD-7)
      • Spitzer RL
      • Kroenke K
      • Williams JBW
      • Löwe B
      A brief measure for assessing generalized anxiety disorder: The GAD-7.
      and the 9-item Patient Health Questionnaire (PHQ-9),
      • Kroenke K
      • Spitzer RL
      • Williams JBW
      The PHQ-9: Validity of a brief depression severity measure.
      which are used to screen for generalized anxiety disorder and major depressive disorder, respectively. Participants were asked how often they had symptoms of anxiety, worry, anhedonia (lack of interest), and depression over the last 7 days. Potential response options for each question included "Not at all", "Several days", "More than half the days", and "Nearly every day". Each variable was dichotomized such that "Not at all" indicated the absence of the symptom and "Several days", "More than half the days", and "Nearly every day" indicated the presence of the symptom (i.e., any days).
      Demographic variablesDemographic variables that may be associated with food insufficiency and potential confounders in the association between food insufficiency and poor mental health include age, sex, race/ethnicity, marital status, number of children in the household, and number of adults in the household.
      • Lyden J
      • Binswanger IA
      The United States opioid epidemic.
      ,
      • Whittle HJ
      • Sheira LA
      • Wolfe WR
      • et al.
      Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States.
      ,
      • Patil SP
      • Craven K
      • Kolasa K
      Food insecurity: how you can help your patients.
      ,
      • Nagata JM
      • Magerenge RO
      • Young SL
      • Oguta JO
      • Weiser SD
      • Cohen CR
      Social determinants, lived experiences, and consequences of household food insecurity among persons living with HIV/AIDS on the shore of Lake Victoria, Kenya.
      SESSocioeconomic variables that may be associated with food insufficiency and potential confounders in the association between food insufficiency and poor mental health include employment loss in the past 7 days, federal poverty level, and education.
      • Nagata JM
      • Palar K
      • Gooding HC
      • Garber AK
      • Bibbins-Domingo K
      • Weiser SD
      Food insecurity and chronic disease in U.S. young adults: findings from the National Longitudinal Study of Adolescent to Adult Health.
      ,
      • Lyden J
      • Binswanger IA
      The United States opioid epidemic.
      ,
      • Nagata JM
      • Magerenge RO
      • Young SL
      • Oguta JO
      • Weiser SD
      • Cohen CR
      Social determinants, lived experiences, and consequences of household food insecurity among persons living with HIV/AIDS on the shore of Lake Victoria, Kenya.
      CPS-FSS, Current Population Survey Food Security Supplement; GAD-7, Generalized Anxiety Disorder scale 7; PHQ, Patient Health Questionnaire-9.

      Statistical Analysis

      Unadjusted differences were calculated using independent samples t-tests (continuous variables) or Pearson's chi-square tests (categorical variables). Multiple Poisson regression analyses
      • Chen W
      • Qian L
      • Shi J
      • Franklin M
      Comparing performance between log-binomial and robust Poisson regression models for estimating risk ratios under model misspecification.
      with robust estimates of variance estimated the associations between demographic/socioeconomic factors and food insufficiency. Multiple Poisson regression models with robust estimates of variance estimated the associations between food insufficiency and mental health symptoms (nervous, anxious, or on edge; not being able to stop or control worrying; little interest or pleasure in doing things; feeling down, depressed, or hopeless) in the past 7 days, adjusting for demographic and socioeconomic covariates. Poisson regression was used for the mental health symptom outcomes because logistic regression only yields valid approximations of RR when the outcome is rare.
      • McNutt LA
      • Wu C
      • Xue X
      • Hafner JP
      Estimating the relative risk in cohort studies and clinical trials of common outcomes.
      As shown by Zou,
      • Zou G
      A modified Poisson regression approach to prospective studies with binary data.
      the incidence RRs estimated using Poisson regression models can be interpreted straightforwardly as RRRs. Interactions between food insufficiency and receipt of free groceries/meals were statistically significant (p<0.05); thus, stratified models by receipt of free groceries/meals (yes/no) were presented additionally. Nonresponse sample weighing was applied. Analyses were conducted using Stata, version 15.1, in 2020.

      RESULTS

      Demographic characteristics of the participants included in the sample are presented in Table 2by food sufficiency status. Overall, the prevalence of food insufficiency increased from 8.1% to 10.0% from March to June 2020 in the U.S. Nearly one tenth (9.4%) of households received free groceries or meals in June 2020, most often from a school program (4.1%); food pantry or food bank (2.9%); or family, friends, or neighbors (2.5%). Among participants reporting food insufficiency, 76.5% experienced a recent employment loss in the past 7 days, 54.4% had income below the federal poverty level, and 93.8% reported ≥1 mental health symptom, including feeling anxious, worrying, having little interest, or being depressed.
      Table 2Demographic Characteristics of U.S. Census Household Pulse Survey by Food Sufficiency Status, June 2020 (N=63,674)
      DemographicsTotal
      All means and percentages were calculated with weighted data to reflect the representative proportion in the target U.S. population.
      Food sufficient
      All means and percentages were calculated with weighted data to reflect the representative proportion in the target U.S. population.
      Food insufficient
      All means and percentages were calculated with weighted data to reflect the representative proportion in the target U.S. population.
      p-value
      Age, mean ± SE48.46 ± 0.2149.26 ± 0.2341.09 ± 0.56<0.001
      Independent samples t-tests.
      Sex, %0.065
      Pearson's chi-square tests.
       Female51.5051.0955.35
       Male48.5048.9144.65
      Race/ethnicity, %<0.001
      Pearson's chi-square tests.
       White alone, not Hispanic63.7165.9943.71
       Black alone, not Hispanic10.979.9919.32
       Asian alone, not Hispanic4.985.193.17
       A total of ≥2 races + other races, not Hispanic3.933.874.54
       Hispanic or Latino (may be of any race)16.4114.9629.26
      Married, %56.2458.5035.92<0.001
      Pearson's chi-square tests.
      Number of children in household, mean ± SE0.68 ± 0.010.65 ± 0.011.00 ± 0.07<0.001
      Independent samples t-tests.
      Number of adults in household, mean ± SE2.72 ± 0.022.70 ± 0.032.92 ± 0.070.005
      Independent samples t-tests.
      Employment loss, past 7 days, %47.6544.4176.45<0.001
      Pearson's chi-square tests.
      Below federal poverty level, %20.1616.3054.42<0.001
      Pearson's chi-square tests.
      Education, %<0.001
      Pearson's chi-square tests.
       High school or less37.6934.8562.61
       More than high school62.3165.1537.39
      Food insufficiency, June 11‒16, 2020, %10.02
      Food insufficiency, before March 13, 2020, %8.071.8763.52<0.001
      Pearson's chi-square tests.
      Received free groceries or meals, past 7 days, %9.368.2419.46<0.001
      Pearson's chi-square tests.
      School program, %4.073.618.20<0.001
      Pearson's chi-square tests.
      Food pantry or food bank, %2.852.307.91<0.001
      Pearson's chi-square tests.
      Home delivery, %0.310.270.590.085
      Pearson's chi-square tests.
      Religious organization, %1.931.674.36<0.001
      Pearson's chi-square tests.
      Food shelter or soup kitchen, %0.120.070.520.001
      Pearson's chi-square tests.
      Other community program, %1.771.563.570.027
      Pearson's chi-square tests.
      Family, friends, or neighbors, %2.482.036.65<0.001
      Pearson's chi-square tests.
      Any symptoms of poor mental health, past 7 days, %72.4070.0493.76<0.001
      Pearson's chi-square tests.
      Anxious, %65.2162.5589.47<0.001
      Pearson's chi-square tests.
      Worrying, %56.0952.5288.11<0.001
      Pearson's chi-square tests.
      Little interest, %53.5250.4281.68<0.001
      Pearson's chi-square tests.
      Depressed, %52.3748.8783.42<0.001
      Pearson's chi-square tests.
      Note: Boldface indicates statistical significance (p<0.05).
      a All means and percentages were calculated with weighted data to reflect the representative proportion in the target U.S. population.
      b Independent samples t-tests.
      c Pearson's chi-square tests.
      In unadjusted comparisons, younger age, Black/African American race, multiple races, Hispanic/Latinx ethnicity, being unmarried, greater number of children and adults in the household, employment loss in the past 7 days, reporting income below the federal poverty line, and low education were associated with food insufficiency (Tables 2 and 3).
      Table 3Demographic and Socioeconomic Associations With Food Insufficiency in U.S. Census Household Pulse Survey, June 2020
      DemographicsFood insufficiency
      RR (95% CI)p-value
      Age (per 10 years)0.77 (0.74, 0.80)<0.001
      Sex
       Femaleref
       Male0.89 (0.77, 1.04)0.13
      Race/ethnicity
       White alone, not Hispanicref
       Black alone, not Hispanic2.57 (2.15, 3.08)<0.001
       Asian alone, not Hispanic0.89 (0.54, 1.45)0.631
       Atotal of ≥2 races + other races, not Hispanic1.76 (1.31, 2.35)<0.001
       Hispanic or Latino (may be of any race)2.58 (2.14, 3.11)<0.001
      Married0.71 (0.60, 0.83)<0.001
      Number of children in household1.23 (1.16, 1.31)<0.001
      Number of adults in household1.08 (1.04, 1.12)<0.001
      SES
       Employment loss, past 7 days3.45 (2.93, 4.06)<0.001
       Income below federal poverty line4.25 (3.69, 4.90)<0.001
       Education (high school or less)2.74 (2.39, 3.13)<0.001
      Note: Boldface indicates statistical significance (p<0.05).
      The estimated associations between food insufficiency and mental health symptoms, including anxiety, worry, anhedonia, and depression, are presented in Table 4. Participants experiencing food insufficiency had a greater risk of experiencing any symptom of poor mental health (adjusted RR [ARR]=1.16, 95% CI=1.11, 1.21), feeling anxious (ARR=1.26, 95% CI=1.21, 1.32), worrying (ARR=1.39, 95% CI=1.33, 1.45), feeling little interest (ARR=1.35, 95% CI=1.28, 1.43), and feeling depressed (ARR=1.42, 95% CI=1.35, 1.50). The associations between food insufficiency and poor mental health symptoms were attenuated among people who received free groceries or meals.
      Table 4Associations Between Food Insufficiency and Poor Mental Health Symptoms in U.S. Census Household Pulse Survey, June 2020
      Mental health outcomes, past 7 daysFood insufficiency, past 7 days, overall sampleFood insufficiency, past 7 days, among people who received free groceries or mealsFood insufficiency, past 7 days, among people who did not receive free groceries or mealsInteraction
      p-value for food insufficiency and received free groceries or meals interaction. ARR, adjusted RR.
      ARR (95% CI)p-valueARR (95% CI)p-valueARR (95% CI)p-valuep-value
      Any symptoms of poor mental health1.16 (1.11, 1.21)<0.0011.07 (0.99, 1.16)0.0791.20 (1.14, 1.25)<0.0010.004
      Anxious1.26 (1.21, 1.32)<0.0011.15 (1.07, 1.24)<0.0011.29 (1.24, 1.35)<0.0010.001
      Worrying1.39 (1.33, 1.45)<0.0011.28 (1.17, 1.40)<0.0011.42 (1.34, 1.49)<0.0010.003
      Little interest1.35 (1.28, 1.43)<0.0011.25 (1.10, 1.41)<0.0011.38 (1.30, 1.46)<0.0010.024
      Depressed1.42 (1.35, 1.50)<0.0011.28 (1.14, 1.44)<0.0011.46 (1.38, 1.55)<0.0010.005
      Note: Boldface indicates statistical significance (p<0.05).
      All models included age, race/ethnicity, marital status, number of children in household, number of adults in household, employment loss, income, and education as covariates.
      a p-value for food insufficiency and received free groceries or meals interaction.ARR, adjusted RR.

      DISCUSSION

      Overall, the prevalence of food insufficiency, often the most extreme form of food insecurity, increased from 8.1% to 10.0% from March to June 2020 during the COVID-19 pandemic, with 9.4% of people receiving free groceries or meals. The correlates of food insufficiency included lower age, Black/African American race, multiple races, Latinx ethnicity, being unmarried, greater number of children and adults in the household, having recent employment loss, reporting income below the federal poverty line, and having lower education. Food insufficiency was associated with symptoms of poor mental health independent of these other socioeconomic and demographic factors, and this association was attenuated among people who received free groceries or meals.
      The correlates of food insufficiency identified in this study likely represent a complex and multifaceted network of vulnerabilities among affected individuals. Food insecurity is closely interlinked with other forms of economic insecurity, such as insecurities in employment and income, for which racial and ethnic minorities are at an elevated risk.
      • Whittle HJ
      • Leddy AM
      • Shieh J
      • et al.
      Precarity and health: theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States.
      The intersection between these material need insecurities can shed light on how the current COVID-19 pandemic has sharply intensified racial, health, and socioeconomic disparities among marginalized groups in the U.S.
      • van Dorn AV
      • Cooney RE
      • Sabin ML
      COVID-19 exacerbating inequalities in the U.S.
      For example, although non-White racial and ethnic minorities are disproportionately represented as essential workers (such as in the public transportation, health care, public safety, retail, warehouse, and agricultural labor sectors), during the COVID-19 pandemic, these jobs carry a high risk of occupational exposure to COVID-19.
      • McClure ES
      • Vasudevan P
      • Bailey Z
      • Patel S
      • Robinson WR
      Racial capitalism within public health: how occupational settings drive COVID-19 disparities.
      Many of these individuals also work for hourly wages on precarious contractual arrangements without the option of working from home.
      • Himmelstein KEW
      • Venkataramani AS
      Economic vulnerability among U.S. female health care workers: potential impact of a $15-per-hour minimum wage.
      Not only could this constraint in itself make purchasing enough food difficult, but limited resources may equally be required for other more important or time-critical needs, such as paying rent, household utilities, health insurance premiums, or hospital bills, further exacerbating food insecurity/insufficiency.
      • Whittle HJ
      • Leddy AM
      • Shieh J
      • et al.
      Precarity and health: theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States.
      ,
      • Harris OO
      • Leblanc N
      • McGee K
      • Randolph S
      • Wharton MJ
      • Relf M
      Alarm at the gate-health and social inequalities are comorbid conditions of HIV and COVID-19.
      In addition, COVID-19 exacerbates conditions that exist because of institutional and structural racism.
      • van Dorn AV
      • Cooney RE
      • Sabin ML
      COVID-19 exacerbating inequalities in the U.S.
      ,
      • Boyd RW
      • Lindo EG
      • Weeks LD
      • Mclemore MR
      On racism: a new standard for publishing on racial health inequities.
      The higher prevalence of food insufficiency among racial/ethnic minorities could also lead to worse disease control and further worsen morbidity and mortality from COVID-19. Future research can examine racial/ethnic disparities in other forms of economic insecurities, such as in employment, income, and education insecurities, both before and during the COVID-19 pandemic.
      Furthermore, according to the most recent employment data from the Bureau of Labor Statistics of the U.S. Department of Labor, Blacks (15.4%) and Hispanics (14.5%) account for a higher proportion of the population affected by the current rise in unemployment rate than their White counterparts (11.2%).
      Bureau of Labor Statistics, U.S. Department of Labor
      The employment situation–June 2020.
      In addition, Black (20.8%) and Latinx (17.6%) communities have higher rates of poverty than Whites (8.1%) or the general population (11.8%).
      • Iriondo J
      Income, poverty and health insurance coverage in the United States: 2018.
      ,
      • Semega J
      • Kollar M
      • Creamer J
      • Mohanty A
      Income and poverty in the United States: 2018.
      These data corroborate the findings that race (Black and Latinx), reporting a low income, and having recent employment loss are all factors associated with food insufficiency. Finally, the COVID-19 pandemic has further exacerbated social and structural inequalities among Black, Latinx, and other low-income families in the U.S. by limiting their access to social support services, such as the Supplemental Nutrition Assistant Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). These 2 programs are especially relevant because they provide needed food assistance to families living below the federal poverty level; they are designed to specifically protect against the food insufficiency observed in this study.
      • van Dorn AV
      • Cooney RE
      • Sabin ML
      COVID-19 exacerbating inequalities in the U.S.
      Food insufficiency has known links with poor mental health that likely operate in a bidirectional relationship.
      • Bruening M
      • Dinour LM
      • Chavez JBR
      Food insecurity and emotional health in the USA: a systematic narrative review of longitudinal research.
      A depressed mood in particular can manifest as having low energy, decreased motivation, feelings of hopelessness, pessimism around the future, and poor concentration. All of these features may erode the capacity of an individual at risk for food insufficiency to navigate the eclectic mixture of public and private provision that constitutes the U.S. social safety net.
      • Whittle HJ
      • Palar K
      • Seligman HK
      • Napoles T
      • Frongillo EA
      • Weiser SD
      How food insecurity contributes to poor HIV health outcomes: qualitative evidence from the San Francisco Bay Area.
      For those experiencing insecure or hourly wage work, a depressed mood and anxiety may also interfere with work capabilities and lead to lost income, again elevating the risk of food insufficiency. These potential mechanisms position poor mental health as a risk factor for food insufficiency and may explain some of the associations seen in this study, especially in the context of concerns around rising depression and anxiety amidst the pandemic.
      • Talevi D
      • Socci V
      • Carai M
      • et al.
      Mental health outcomes of the COVID-19 pandemic.
      Equally, food insecurity and food insufficiency are known risk factors for poor mental health, including depression and anxiety.
      • Bruening M
      • Dinour LM
      • Chavez JBR
      Food insecurity and emotional health in the USA: a systematic narrative review of longitudinal research.
      ,
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
      ,
      • Whittle HJ
      • Sheira LA
      • Frongillo EA
      • et al.
      Longitudinal associations between food insecurity and substance use in a cohort of women with or at risk for HIV in the United States.
      In addition to feelings, such as hunger, exhaustion, worry, and frustration, that may directly give rise to depressive and anxious symptoms, the experience of food insecurity in the U.S. is often characterized by salient stigma, shame, and self-blame.
      • Whittle HJ
      • Palar K
      • Seligman HK
      • Napoles T
      • Frongillo EA
      • Weiser SD
      How food insecurity contributes to poor HIV health outcomes: qualitative evidence from the San Francisco Bay Area.
      ,
      • Hamelin AM
      • Beaudry M
      • Habicht JP
      Characterization of household food insecurity in Québec: food and feelings.
      Qualitative research has shown that these latter aspects of food insecurity often reflect a perceived failure of self-sufficiency and personal success among affected individuals, which is particularly damaging amid the individualist interpretations of wealth and achievement that are culturally prominent in the U.S.
      • Whittle HJ
      • Palar K
      • Seligman HK
      • Napoles T
      • Frongillo EA
      • Weiser SD
      How food insecurity contributes to poor HIV health outcomes: qualitative evidence from the San Francisco Bay Area.
      In this respect, food insecurity is a profoundly relational experience that derives much of its potency from the context in which it occurs. Experiencing acute food insufficiency at such a significant and uncertain macrocontextual juncture as the COVID-19 pandemic may accentuate an individual's sense of vulnerability, isolation, and despair.
      • Bergmans RS
      • Wegryn-Jones R
      Examining associations of food insecurity with major depression among older adults in the wake of the Great Recession.
      At the same time, personal or community resources that help to mitigate the mental health impacts of food insecurity may be disrupted during the pandemic, and some individuals may be newly exposed to food insecurity. In this respect, it is plausible that food insufficiency may drive the poor mental health outcomes seen in this study and significantly contribute to rising rates of depression and anxiety during the pandemic. This is especially concerning because previous studies have also suggested that food insufficiency may limit engagement with mental health services, worsen treatment adherence, and consequently elevate the risk for psychiatric emergency care and hospitalization, thus posing further challenges at an already difficult time for health services.
      • Afulani PA
      • Coleman-Jensen A
      • Herman D
      Food insecurity, mental health, and use of mental health services among nonelderly adults in the United States.
      • Baggett TP
      • Singer DE
      • Rao SR
      • O'Connell JJ
      • Bharel M
      • Rigotti NA
      Food insufficiency and health services utilization in a national sample of homeless adults.
      • Mangurian C
      • Sreshta N
      • Seligman H
      Food insecurity among adults with severe mental illness.
      • Whittle HJ
      • Wolfe WR
      • Sheira LA
      • et al.
      Associations between food insecurity and psychotropic medication use among women living with HIV in the United States.
      Food insecurity and mental health remain among the top public health areas of concern identified by the Healthy People 2030 national objectives but warrant even more attention owing to exacerbation from the COVID-19 pandemic.

      Healthy People 2030. HHS, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople. Accessed October 14, 2020.

      Currently, screening for food insecurity is recommended at least annually by multiple professional medical organizations, including the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians.
      • Patil SP
      • Craven K
      • Kolasa K
      Food insecurity: how you can help your patients.
      Given the associations between food insufficiency and mental health symptoms during the COVID-19 pandemic, clinicians should consider food insecurity and mental health screening at every in-person or telehealth visit using validated 1- to 2-question measures.
      • Patil SP
      • Craven K
      • Kolasa K
      Food insecurity: how you can help your patients.
      ,
      • Kleinman RE
      • Murphy JM
      • Wieneke KM
      • Desmond MS
      • Schiff A
      • Gapinski JA
      Use of a single-question screening tool to detect hunger in families attending a neighborhood health center.
      Clinicians can provide referrals to or aid in enrollment in SNAP, WIC, National School Lunch and Breakfast Programs, and community food distribution programs for patients who experience food insecurity.
      • Nagata JM
      • Seligman HK
      • Weiser SD
      Perspective: the convergence of coronavirus disease 2019 (COVID-19) and food insecurity in the United States.
      Interventions for food insecurity and mental health may also be integrated into social service programs. For example, programs aimed to assist people who are food insecure, such as SNAP and WIC, could incorporate screening for mental health in their assessments.
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
      Conversely, public mental health programs may also screen for and address issues of food insecurity.
      Although policies and legislation made early in the pandemic such as the Families First Coronavirus Response Act (H.R. 6201)

      Families First Coronavirus Response Act. H.R. 6201, 116th Cong. (2019–2020).

      and the Coronavirus Aid, Relief, and Economic Security Act (H.R. 748)

      CARES Act. H.R. 748, 116th Cong. (2019–2020).

      temporarily suspended time limits for SNAP enrollment and allocated funding for newly eligible households, further legislation is needed given the persistence of the pandemic and subsequent food insufficiency. Congress should support the Increasing Access to SNAP Delivery During COVID-19 Act of 2020 (H.R. 6904),

      Increasing Access to SNAP Delivery During COVID-19 Act of 2020. H.R. 6904, 116th Cong. (2019–2020).

      which increases access to food delivery during the pandemic, and the SNAP Online Purchasing Flexibility Act of 2020 (H.R. 6510),

      SNAP Online Purchasing Flexibility Act of 2020. H.R. 6510, 116th Cong. (2019–2020).

      which authorizes all states to participate in the SNAP online purchasing program and approved retail stores to accept SNAP benefits through online transactions.

      Limitations

      There are several limitations in this study. First, all measures used in the study are self-reported, which may be subject to reporting bias. However, the anonymity and online nature of the survey may minimize this concern. Second, respondents could choose to view questions and not select a response, which may introduce some selection bias. Third, this survey was cross-sectional, thus limiting the study's ability to ascribe a causal interpretation of the observed association between food insufficiency and symptoms of poor mental health. Finally, the Census HPS used a single-item measure of food insufficiency (often considered the most extreme form of food insecurity) rather than the more comprehensive measure of food insecurity. Although this is an important limitation, a number of previously published studies also used this or a similar single-item measure,
      • Nagata JM
      • Palar K
      • Gooding HC
      • Garber AK
      • Bibbins-Domingo K
      • Weiser SD
      Food insecurity and chronic disease in U.S. young adults: findings from the National Longitudinal Study of Adolescent to Adult Health.
      ,
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
      ,
      • Nagata JM
      • Palar K
      • Gooding HC
      • et al.
      Food insecurity, sexual risk, and substance use in young adults.
      ,
      • Nagata JM
      • Weiser SD
      • Gooding HC
      • Garber AK
      • Bibbins-Domingo K
      • Palar K
      Association between food insecurity and migraine among U.S. young adults.
      and previous research demonstrated the ability to estimate food insecurity using food insufficiency measures from the Census HPS.
      • Schanzenbach D
      • Pitts A
      How much has food insecurity risen? Evidence from the census household pulse survey.
      The study's strengths included nationally representative data recently collected during the COVID-19 pandemic.

      CONCLUSIONS

      This study adds to previous literature by demonstrating that the association between food insufficiency and poor mental health symptoms is attenuated among people who receive free groceries and meals. Future COVID-19‒related policies should aim to increase public awareness of and provide additional funding to school food programs and food banks.
      • Jablonski BBR
      • Casnovsky J
      • Clark JK
      • et al.
      Emergency food provision for children and families during the COVID-19 pandemic: examples from five U.S. cities.
      These sources of free groceries and meals may increase access to food among those who are food insufficient and help to mitigate poor mental health outcomes. Given the confluence of material need insecurities, nonfood-related interventions to alleviate food insufficiency should be considered, including paid sick leave, rent/mortgage delays, and stimulus funding for the recently unemployed. Targeted studies that improve the understanding of the social and structural impact of COVID-19 on food security/sufficiency are needed to effectively mitigate the virus's negative effects, especially in communities of color. Health and social support service interventions that grant access to healthy nutritious meals as well as mental health support are urgently needed.

      ACKNOWLEDGMENTS

      The authors would like to thank Sam Benabou for providing editorial assistance.
      The funders had no role in the study design, data collection, and analysis, the decision to publish the study, or the preparation of the manuscript.
      JMN is supported by the American Heart Association Career Development Award (CDA34760281). ACT is supported by the Sullivan Family Foundation. SDW is supported by the National Institute of Allergy and Infectious Diseases (K24AI134326).
      JMN conceptualized the study, conducted the analyses, led the writing, and revised the manuscript. KTG, HJW, and OOH drafted and revised the manuscript. JC contributed to the analyses and drafted and revised the manuscript. ACT and SDW conceptualized the study, reviewed and revised the manuscript, and supervised the study.
      No financial disclosures were reported by the authors of this paper.

      REFERENCES

        • Coleman-Jensen A
        • Rabbitt MP
        • Gregory C
        • Singh A
        Household food security in the United States in 2018.
        Economic Research Service, U.S. Department of Agriculture, Washington, DC2019 (Published September)
        • Chilton M
        • Rose D
        A rights-based approach to food insecurity in the United States.
        Am J Public Health. 2009; 99: 1203-1211https://doi.org/10.2105/AJPH.2007.130229
        • Briefel RR
        • Woteki CE
        Development of food sufficiency questions for the third national health and nutrition examination survey.
        J Nutr Educ. 1992; 24: 24S-28Shttps://doi.org/10.1016/S0022-3182(12)80134-8
        • Schanzenbach D
        • Pitts A
        How much has food insecurity risen? Evidence from the census household pulse survey.
        Institute for Policy Research Rapid Research Report, Northwestern University, Evanston, IL2020 (Published June 10)
      1. Kaiser Family Foundation. State COVID-19 data and policy actions. San Francisco, CA: Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/state-data-and-policy-actions-to-address-coronavirus/. Published January 27, 2021. Accessed January 27, 2021.

        • Dunn CG
        • Kenney E
        • Fleischhacker SE
        • Bleich SN
        Feeding low-income children during the COVID-19 pandemic.
        N Engl J Med. 2020; 382: e40https://doi.org/10.1056/NEJMp2005638
        • Jyoti DF
        • Frongillo EA
        • Jones SJ
        Food insecurity affects school children's academic performance, weight gain, and social skills.
        J Nutr. 2005; 135: 2831-2839https://doi.org/10.1093/jn/135.12.2831
        • Huang J
        • Barnidge E
        • Kim Y
        Children receiving free or reduced-price school lunch have higher food insufficiency rates in summer.
        J Nutr. 2015; 145: 2161-2168https://doi.org/10.3945/jn.115.214486
        • Bradley K
        • Galt RE
        Practicing food justice at Dig Deep Farms & Produce, East Bay Area, California: self-determination as a guiding value and intersections with foodie logics.
        Local Environ. 2014; 19: 172-186https://doi.org/10.1080/13549839.2013.790350
        • de Paulo Farias D
        • dos Santos Gomes MG
        COVID-19 outbreak: what should be done to avoid food shortages?.
        Trends Food Sci Technol. 2020; 102: 291-292https://doi.org/10.1016/j.tifs.2020.06.007
        • Akter S
        The impact of COVID-19 related ‘stay-at-home’ restrictions on food prices in Europe: findings from a preliminary analysis.
        Food Secur. 2020; 12: 719-725https://doi.org/10.1007/s12571-020-01082-3
        • Weiser SD
        • Young SL
        • Cohen CR
        • et al.
        Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS.
        Am J Clin Nutr. 2011; 94: 1729S-1739Shttps://doi.org/10.3945/ajcn.111.012070
        • Kirkpatrick SI
        • Tarasuk V
        Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents [published correction appears in J Nutr. 2008;138(7):1399].
        J Nutr. 2008; 138: 604-612https://doi.org/10.1093/jn/138.3.604
        • Seligman HK
        • Laraia BA
        • Kushel MB
        Food insecurity is associated with chronic disease among low-income NHANES participants.
        J Nutr. 2010; 140: 304-310https://doi.org/10.3945/jn.109.112573
        • Gundersen C
        • Ziliak JP
        Food insecurity and health outcomes.
        Health Aff (Millwood). 2015; 34: 1830-1839https://doi.org/10.1377/hlthaff.2015.0645
        • Pooler JA
        • Hartline-Grafton H
        • DeBor M
        • Sudore RL
        • Seligman HK
        Food insecurity: a key social determinant of health for older adults.
        J Am Geriatr Soc. 2019; 67: 421-424https://doi.org/10.1111/jgs.15736
        • Nagata JM
        • Palar K
        • Gooding HC
        • Garber AK
        • Bibbins-Domingo K
        • Weiser SD
        Food insecurity and chronic disease in U.S. young adults: findings from the National Longitudinal Study of Adolescent to Adult Health.
        J Gen Intern Med. 2019; 34: 2756-2762https://doi.org/10.1007/s11606-019-05317-8
        • Talevi D
        • Socci V
        • Carai M
        • et al.
        Mental health outcomes of the COVID-19 pandemic.
        Riv Psichiatr. 2020; 55: 137-144https://doi.org/10.1708/3382.33569
        • Ganson KT
        • Tsai AC
        • Weiser SD
        • Benabou SE
        • Nagata JM
        Job insecurity and symptoms of anxiety and depression among U.S. young adults during COVID-19.
        J Adolesc Health. 2021; 68: 53-56https://doi.org/10.1016/j.jadohealth.2020.10.008
        • Ganson KT
        • Weiser SD
        • Tsai AC
        • Nagata JM
        Associations between anxiety and depression symptoms and medical care avoidance during COVID-19.
        J Gen Intern Med. 2020; 35: 3406-3408https://doi.org/10.1007/s11606-020-06156-8
        • Taylor HO
        • Taylor RJ
        • Nguyen AW
        • Chatters L
        Social isolation, depression, and psychological distress among older adults.
        J Aging Health. 2018; 30: 229-246https://doi.org/10.1177/0898264316673511
        • Lyden J
        • Binswanger IA
        The United States opioid epidemic.
        Semin Perinatol. 2019; 43: 123-131https://doi.org/10.1053/j.semperi.2019.01.001
        • Bruening M
        • Dinour LM
        • Chavez JBR
        Food insecurity and emotional health in the USA: a systematic narrative review of longitudinal research.
        Public Health Nutr. 2017; 20: 3200-3208https://doi.org/10.1017/S1368980017002221
        • Nagata JM
        • Palar K
        • Gooding HC
        • et al.
        Food insecurity is associated with poorer mental health and sleep outcomes in young adults.
        J Adolesc Health. 2019; 65: 805-811https://doi.org/10.1016/j.jadohealth.2019.08.010
        • Palar K
        • Frongillo EA
        • Escobar J
        • et al.
        Food insecurity, internalized stigma, and depressive symptoms among women living with HIV in the United States.
        AIDS Behav. 2018; 22: 3869-3878https://doi.org/10.1007/s10461-018-2164-8
        • Lent MD
        • Petrovic LE
        • Swanson JA
        • Olson CM
        Maternal mental health and the persistence of food insecurity in poor rural families.
        J Health Care Poor Underserved. 2009; 20: 645-661https://doi.org/10.1353/hpu.0.0182
        • Whittle HJ
        • Sheira LA
        • Wolfe WR
        • et al.
        Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States.
        J Nutr. 2019; 149: 1393-1403https://doi.org/10.1093/jn/nxz093
        • Whittle HJ
        • Sheira LA
        • Frongillo EA
        • et al.
        Longitudinal associations between food insecurity and substance use in a cohort of women with or at risk for HIV in the United States.
        Addiction. 2019; 114: 127-136https://doi.org/10.1111/add.14418
        • Pryor L
        • Lioret S
        • van der Waerden J
        • Fombonne É
        • Falissard B
        • Melchior M
        Food insecurity and mental health problems among a community sample of young adults.
        Soc Psychiatry Psychiatr Epidemiol. 2016; 51: 1073-1081https://doi.org/10.1007/s00127-016-1249-9
        • Nagata JM
        • Gomberg S
        • Hagan MJ
        • Heyman MB
        • Wojcicki JM
        Food insecurity is associated with maternal depression and child pervasive developmental symptoms in low-income Latino households.
        J Hunger Environ Nutr. 2019; 14: 526-539https://doi.org/10.1080/19320248.2018.1434101
        • Arenas DJ
        • Thomas A
        • Wang JC
        • DeLisser HM
        A systematic review and meta-analysis of depression, anxiety, and sleep disorders in U.S. adults with food insecurity.
        J Gen Intern Med. 2019; 34: 2874-2882https://doi.org/10.1007/s11606-019-05202-4
      2. Measuring household experiences during the coronavirus pandemic. U.S. Census Bureau. https://www.census.gov/householdpulsedata. Updated January 12, 2021. Accessed July 23, 2020.

      3. Definition of human subjects research.
        HHS, NIH, 2020 (Updated January 13)
        • Chen W
        • Qian L
        • Shi J
        • Franklin M
        Comparing performance between log-binomial and robust Poisson regression models for estimating risk ratios under model misspecification.
        BMC Med Res Methodol. 2018; 18: 63https://doi.org/10.1186/s12874-018-0519-5
        • McNutt LA
        • Wu C
        • Xue X
        • Hafner JP
        Estimating the relative risk in cohort studies and clinical trials of common outcomes.
        Am J Epidemiol. 2003; 157: 940-943https://doi.org/10.1093/aje/kwg074
        • Zou G
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706https://doi.org/10.1093/aje/kwh090
        • Whittle HJ
        • Leddy AM
        • Shieh J
        • et al.
        Precarity and health: theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States.
        Soc Sci Med. 2020; 245112683https://doi.org/10.1016/j.socscimed.2019.112683
        • van Dorn AV
        • Cooney RE
        • Sabin ML
        COVID-19 exacerbating inequalities in the U.S.
        Lancet. 2020; 395: 1243-1244https://doi.org/10.1016/S0140-6736(20)30893-X
        • McClure ES
        • Vasudevan P
        • Bailey Z
        • Patel S
        • Robinson WR
        Racial capitalism within public health: how occupational settings drive COVID-19 disparities.
        Am J Epidemiol. 2020; 189: 1244-1253https://doi.org/10.1093/aje/kwaa126
        • Himmelstein KEW
        • Venkataramani AS
        Economic vulnerability among U.S. female health care workers: potential impact of a $15-per-hour minimum wage.
        Am J Public Health. 2019; 109: 198-205https://doi.org/10.2105/AJPH.2018.304801
        • Harris OO
        • Leblanc N
        • McGee K
        • Randolph S
        • Wharton MJ
        • Relf M
        Alarm at the gate-health and social inequalities are comorbid conditions of HIV and COVID-19.
        J Assoc Nurses AIDS Care. 2020; 31: 367-375https://doi.org/10.1097/JNC.0000000000000190
        • Boyd RW
        • Lindo EG
        • Weeks LD
        • Mclemore MR
        On racism: a new standard for publishing on racial health inequities.
        HealthAffairs. 2020; (July 2)https://doi.org/10.1377/hblog20200630.939347
        • Bureau of Labor Statistics, U.S. Department of Labor
        The employment situation–June 2020.
        Bureau of Labor Statistics, U.S. Department of Labor, Washington, DC2020 (Published July 2)
        • Iriondo J
        Income, poverty and health insurance coverage in the United States: 2018.
        U.S. Census Bureau, Suitland-Silver Hill, MD2019 (Published September 10)
        • Semega J
        • Kollar M
        • Creamer J
        • Mohanty A
        Income and poverty in the United States: 2018.
        U.S. Census Bureau, Suitland-Silver Hill, MD2019 (Published September 10)
        • Whittle HJ
        • Palar K
        • Seligman HK
        • Napoles T
        • Frongillo EA
        • Weiser SD
        How food insecurity contributes to poor HIV health outcomes: qualitative evidence from the San Francisco Bay Area.
        Soc Sci Med. 2016; 170: 228-236https://doi.org/10.1016/j.socscimed.2016.09.040
        • Hamelin AM
        • Beaudry M
        • Habicht JP
        Characterization of household food insecurity in Québec: food and feelings.
        Soc Sci Med. 2002; 54: 119-132https://doi.org/10.1016/s0277-9536(01)00013-2
        • Bergmans RS
        • Wegryn-Jones R
        Examining associations of food insecurity with major depression among older adults in the wake of the Great Recession.
        Soc Sci Med. 2020; 258113033https://doi.org/10.1016/j.socscimed.2020.113033
        • Afulani PA
        • Coleman-Jensen A
        • Herman D
        Food insecurity, mental health, and use of mental health services among nonelderly adults in the United States.
        J Hunger Environ Nutr. 2020; 15: 29-50https://doi.org/10.1080/19320248.2018.1537868
        • Baggett TP
        • Singer DE
        • Rao SR
        • O'Connell JJ
        • Bharel M
        • Rigotti NA
        Food insufficiency and health services utilization in a national sample of homeless adults.
        J Gen Intern Med. 2011; 26: 627-634https://doi.org/10.1007/s11606-011-1638-4
        • Mangurian C
        • Sreshta N
        • Seligman H
        Food insecurity among adults with severe mental illness.
        Psychiatr Serv. 2013; 64: 931-932https://doi.org/10.1176/appi.ps.201300022
        • Whittle HJ
        • Wolfe WR
        • Sheira LA
        • et al.
        Associations between food insecurity and psychotropic medication use among women living with HIV in the United States.
        Epidemiol Psychiatr Sci. 2020; 29: E113https://doi.org/10.1017/S2045796020000232
      4. Healthy People 2030. HHS, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople. Accessed October 14, 2020.

        • Patil SP
        • Craven K
        • Kolasa K
        Food insecurity: how you can help your patients.
        Am Fam Physician. 2018; 98 (Accessed January 28, 2021): 143-145
        • Kleinman RE
        • Murphy JM
        • Wieneke KM
        • Desmond MS
        • Schiff A
        • Gapinski JA
        Use of a single-question screening tool to detect hunger in families attending a neighborhood health center.
        Ambul Pediatr. 2007; 7: 278-284https://doi.org/10.1016/j.ambp.2007.03.005
        • Nagata JM
        • Seligman HK
        • Weiser SD
        Perspective: the convergence of coronavirus disease 2019 (COVID-19) and food insecurity in the United States.
        Adv Nutr. 2020; (In press. Online September 24)
      5. Families First Coronavirus Response Act. H.R. 6201, 116th Cong. (2019–2020).

      6. CARES Act. H.R. 748, 116th Cong. (2019–2020).

      7. Increasing Access to SNAP Delivery During COVID-19 Act of 2020. H.R. 6904, 116th Cong. (2019–2020).

      8. SNAP Online Purchasing Flexibility Act of 2020. H.R. 6510, 116th Cong. (2019–2020).

        • Nagata JM
        • Palar K
        • Gooding HC
        • et al.
        Food insecurity, sexual risk, and substance use in young adults.
        J Adolesc Health. 2021; 68: 169-177https://doi.org/10.1016/j.jadohealth.2020.05.038
        • Nagata JM
        • Weiser SD
        • Gooding HC
        • Garber AK
        • Bibbins-Domingo K
        • Palar K
        Association between food insecurity and migraine among U.S. young adults.
        JAMA Neurol. 2019; 76: 1121-1122https://doi.org/10.1001/jamaneurol.2019.1663
        • Jablonski BBR
        • Casnovsky J
        • Clark JK
        • et al.
        Emergency food provision for children and families during the COVID-19 pandemic: examples from five U.S. cities.
        Appl Econ Perspect Policy. 2020; (In press. Online October 22)
      9. United States Department of Agriculture. US Household Food Security Survey Module: Three-Stage Design, with Screeners. Washington, D.C.; 2012. https://www.ers.usda.gov/media/8271/hh2012.pdf. Accessed October 15, 2020.

      10. United States Department of Agriculture. Food Security in the United States. https://www.ers.usda.gov/data-products/food-security-in-the-united-states/. Published 2020. Accessed October 14, 2020.

        • Spitzer RL
        • Kroenke K
        • Williams JBW
        • Löwe B
        A brief measure for assessing generalized anxiety disorder: The GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097https://doi.org/10.1001/archinte.166.10.1092
        • Kroenke K
        • Spitzer RL
        • Williams JBW
        The PHQ-9: Validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613https://doi.org/10.1046/j.1525-1497.2001.016009606.x
        • Nagata JM
        • Magerenge RO
        • Young SL
        • Oguta JO
        • Weiser SD
        • Cohen CR
        Social determinants, lived experiences, and consequences of household food insecurity among persons living with HIV/AIDS on the shore of Lake Victoria, Kenya.
        AIDS Care - Psychol Socio-Medical Asp AIDS/HIV. 2012; 24: 728-736https://doi.org/10.1080/09540121.2011.630358