key: cord-0725681-pgm1rr6r authors: McCarthy, Ashley C.; Belarmino, Emily H.; Bertmann, Farryl; Niles, Meredith T. title: Food Security Impacts of the COVID-19 Pandemic: Longitudinal Evidence from a Cohort of Adults in Vermont during the First Year date: 2022-03-24 journal: Nutrients DOI: 10.3390/nu14071358 sha: c7ff761daf59b384c64e10534900706259b8e133 doc_id: 725681 cord_uid: pgm1rr6r This study assessed changes in household food insecurity throughout the first year of the COVID-19 pandemic in a cohort of adults in the state of Vermont, USA, and examined the socio-demographic characteristics associated with increased odds of experiencing food insecurity during the pandemic. We conducted three online surveys between March 2020 and March 2021 to collect longitudinal data on food security, use of food assistance programs, and job disruptions during the COVID-19 pandemic. Food security was measured using the USDA six-item module. Among the 441 respondents, food insecurity rates increased significantly during the pandemic and remained above pre-pandemic levels a year after the start of the pandemic. Nearly a third (31.6%) of respondents experienced food insecurity at some point during the first year of the pandemic, with 53.1% of food-insecure households being classified as newly food-insecure. The odds of experiencing food insecurity during the pandemic varied based on socio-demographic factors. Households with children (OR 5.5, 95% CI 1.782–16.936, p < 0.01), women (OR 8.1, 95% CI 1.777–36.647, p < 0.05), BIPOC/Hispanic respondents (OR 11.8, 95% CI 1.615–85.805, p < 0.05), and households experiencing a job disruption (OR 5.0, 95% CI 1.583–16.005, p <0.01) had significantly higher odds of experiencing food insecurity during the first year of the COVID-19 pandemic, while respondents with a college degree (OR 0.08; 95% CI 0.025–0.246; p < 0.001) and household income of ≥USD 50,000 (OR 0.01; 95% CI 0.003–0.038; p < 0.001) had lower odds of experiencing food insecurity. These findings indicate that food insecurity continued to be a significant challenge one year after the start of the pandemic, which is important, given the adverse health impacts associated with food insecurity and health disparities among certain socio-demographic groups. A year after the start of the COVID-19 pandemic in the United States, the pandemic itself and the policies and restrictions put in place to reduce the spread of the virus continued to disrupt economies and labor markets, with serious implications for food insecurity. Food insecurity, defined as the lack of consistent physical and economic access to sufficient, safe, and nutritious food for an active and healthy lifestyle [1], is closely aligned with national and household economic conditions. Trends in food insecurity rates typically parallel those of unemployment, poverty, and food prices [2] [3] [4] , though food insecurity can also result from non-economic drivers including limited physical access to food retailers and lack of transportation [5] [6] [7] . The COVID-19 pandemic likely exacerbated these challenges to food access due to safety concerns about shopping in stores, limited hours at food retailers, and changes in public transit access. What was the trajectory of food insecurity during the first year of the COVID-19 pandemic among a cohort of respondents? 2. What socio-demographic factors and life experiences were associated with increased odds of experiencing food insecurity during the first year of the COVID-19 pandemic? 3. What factors, if any, contributed to the recovery from food insecurity during the first year of the COVID-19 pandemic? We surveyed a cohort of adults in Vermont three times during the first year of the COVID-19 pandemic. The original survey [27] was developed with feedback from key statelevel agencies and hunger relief organizations, as well as reviews of relevant literature [2, 10] , to measure food insecurity, food access challenges, and related concerns and experiences. When possible, this survey utilized existing validated questions and was updated after each round of data collection to add new relevant questions as the pandemic evolved. Using LimeSurvey [28] , the instrument was piloted with 25 adults (18 years and older) from the target population of adults in Vermont. The first survey ran online from 29 March to 12 April 2020, with a total of 3219 respondents. We used four methods for convenience sample recruitment: (1) paid advertisements via Front Porch Forum, a community-level listserv, which reaches approximately 2/3 of Vermont households [29] ; (2) paid digital ads via Facebook to reach populations underrepresented in Front Porch Forum (e.g., males, lower-income households); (3) listservs of community partners; (4) a University of Vermont press release and subsequent newspaper, radio, and television media. Respondents could opt-in to be contacted for future surveys at the first survey. We conducted two follow-up surveys with the same respondents in May/June 2020 and March/April 2021. The second survey ran online from 21 May to 4 June 2020, with a total of 1236 respondents. The third survey ran from 29 March to 21 April 2021. The first two surveys were conducted using LimeSurvey, and the third was conducted through Qualtrics [30] . Respondents with ZIP Codes outside Vermont and empty responses (i.e., people who consented but did not fill in any responses) were removed, leaving 441 eligible individuals who responded to all three surveys ( Figure A1 ). To measure household food security status, we adapted the U.S. Department of Agriculture's (USDA) Household Food Security Survey Module: Six-Item Short Form [31] to ask about different time periods. The six questions are related to having enough food or enough money for food, being able to afford a balanced diet, and disrupted eating patterns (i.e., cutting the size of meals, skipping meals, going hungry). For example, one of the questions reads "Did you ever eat less than you felt you should because there wasn't enough money for food?" with response options of "yes", "no", or "I don't know". We adapted the ends of the questions to ask about specific time periods. Across the three surveys, we assessed five timepoints. In the first survey, respondents were asked about food security both "in the year before the coronavirus outbreak" and "since the coronavirus outbreak". The responses to the pre-pandemic questions about food security were retrospective and were answered at the same time as the questions about current food security. The start of the coronavirus outbreak was set as 8 March 2020, based on the first positive COVID-19 test result in Vermont. In the second survey, respondents were asked about food security "in the last 30 days" to reflect the time since the first survey. In the third survey, respondents were asked about food security both "since June 2020" (to reflect the time since the second survey) and "in the last 30 days". We followed the procedures outlined in the USDA Six-Item Food Security Module [31] to code the responses to the six food security questions and calculate a food security status score for each respondent during each time period. We used a binary food security status score where two or more affirmative responses to the six questions is scored as food-insecure and fewer than two affirmative responses is scored as food-secure. To determine respondents' urban/rural classification, we used their ZIP Codes and the Rural-Urban Commuting Area (RUCA) codes [32] and the four-category classification scheme (urban, large rural, small rural, and isolated) created by the Rural Health Research Center [33] . We condensed this into a binary variable of urban and rural (which includes the categories large rural, small rural, and isolated from the four-category classification). In addition to measuring food security status, the survey included questions related to food access challenges, use of food assistance programs, food purchasing behaviors, concerns about food access and availability, COVID-19 perceptions, and behaviors and demographics. Table A1 lists the specific questions used in this analysis, which primarily focused on understanding food security status, use of food assistance programs, and job disruptions. Future analyses will explore other questions in the survey. To examine differences in household food security during the first year of the pandemic, we created two core categories of respondents: (1) households with food security (n = 307, including households that were always food-secure during the first year of the COVID-19 pandemic as measured for all five time points) and (2) households with food insecurity (n = 134, including households that were food-insecure at any time during the first year of the COVID-19 pandemic). We further categorized food-insecure households into two groups: (1) households with consistent food insecurity (n = 61, including households that were food-insecure both in the year before the COVID-19 pandemic and anytime during the first year of the pandemic) and (2) households with new food insecurity (n = 69, including households that were food-secure before the pandemic, but food-insecure at some point during the first year of the pandemic). There were four food-insecure households that did not respond to the questions about food insecurity in the year prior to the COVID-19 pandemic, and therefore, we could not categorize them as consistently or newly food-insecure. We also categorized food-insecure households into two groups based on their food security status in March 2021, as measured with the 30-day instrument: (1) households that recovered by March 2021, meaning they were food-insecure at any point since the start of the pandemic but were food-secure in March 2021 (n = 48) and (2) that were food-insecure at any point since the start of the COVID-19 pandemic and were still food-insecure in March 2021 (n = 78). There were eight food-insecure households that did not respond to the food insecurity questions in March 2021, and therefore, we could not categorize them as recovered or still food-insecure. We used t-tests and chi-square tests to determine statistically significant differences between the groups described above. To determine the factors correlated with food insecurity during the first year of the COVID-19 pandemic, we used a random effects logistic regression model with panel data and calculated cluster robust standard errors to account for intra-subject correlation. We included a variable indicating which survey the observation was from to capture time factors that might have influenced food security given the pandemic-related changes that occurred over time during the study period. The coefficients are reported as odds ratios. To examine differences between groups (newly vs. consistently food-insecure; recovered vs. still food-insecure), we used multivariate logistic regression models, with coefficients reported in odds ratios. We used all available data and assumed any missing data were missing at random. A p-value ≤ 0.05 was considered statistically significant for all tests. All statistical analyses were conducted using Stata v17.1 [34] . The demographics of our respondents were comparable with Vermont state demographics on ethnicity and income distributions, but our respondents were more likely to have a college degree and to identify as female (Table 1; for full demographic results, see Table A2 ). Food insecurity rates increased during the pandemic and remained above pre-COVID levels a year after the start of the pandemic ( Table 2 ). It is important to note that the pre-COVID levels are based on retrospective responses to the questions about food insecurity. Among this cohort, 24.1% of respondents were classified as food-insecure in March 2020 (95% CI 20.0-28.2%) compared with 14.8% in the year before the COVID-19 pandemic (95% CI 11.5-18.2%), representing a 62.8% increase (p < 0.001) (Table A3) . Compared with March 2020, food insecurity prevalence decreased in May/June 2020 to 17.4% (95% CI 13.9-21.0%) (p < 0.05) (Table A4 ) but then fluctuated throughout the first year of the pandemic. By March 2021, the food insecurity prevalence was 18.2% (95% CI 14.6-21.9%), representing a 24.5% decrease as compared with March 2020 (p < 0.05) but was 22.9% higher than pre-COVID levels (p = 0.18) (Tables A5 and A6 ). Nearly a third (31.6%) of respondents experienced food insecurity at some point during the first year of the pandemic. Among those experiencing food insecurity during the first year of the pandemic, 46.9% also experienced food insecurity at some point in the year prior, while 53.1% were newly food-insecure. Of the respondents who experienced food insecurity at any point since the start of the pandemic, 61.9% were still classified as food-insecure in March 2021. More than half of respondents (54.2%) reported suffering a job disruption (i.e., job loss, reduction in work hours or income, furlough) during the COVID-19 pandemic, and 18.7% were still reporting a job disruption in March 2021 ( Table 3 ). The most common type of job disruption was a loss of hours or income (70.7%), followed by job loss (45.6%). The duration of these job disruptions varied, with 35.6% of respondents experiencing a job disruption lasting more than 6 months. More than one in five respondents (23.3%) received unemployment at some point since March 2020. Among those who reported job disruptions during the pandemic, 40.5% received unemployment. We found that food-insecure respondents experienced job disruptions during the pandemic at higher rates than food-secure respondents, with 73.1% of food-insecure households (95% CI 65.5-80.7%) reporting a job disruption compared with 45.9% of food-secure households (95% CI 40.3-51.5%) (p < 0.001) (Table A7 ). More than three-fourths (78.7%) of consistently food-insecure households faced a job disruption. Food-insecure respondents contin- Among our respondents, participation in food assistance programs increased during the first year of the COVID-19 pandemic compared with the year before, except for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), though these differences were not statistically significant ( Figure 1 ). However, by March 2021, participation in all programs had declined compared with time points measured earlier in the pandemic, with an 18.2% decrease in Supplemental Nutrition Assistance Program (SNAP/3SquaresVT), 49.3% decrease in Pandemic-EBT (P-EBT), 8.0% decrease in WIC, 19.1% decrease in school meal programs, and 34.7% decrease in the use of food pantries. Only the decline in P-EBT use was statistically significant, dropping from 7.3% at any time during the first year of the COVID-19 pandemic (95% CI 4.9-9.8%) to 3.7% in March 2021 (95% CI 1.9-5.4%) (p < 0.05) (Table A10) . Food-insecure households (67.4%; 95% CI 59.3-75.5%) used food assistance programs at over three times the rate of food-secure households (16.3%; 95% CI 12.2-20.5%) (p < 0.001) (Tables 3 and A11). We found that food-insecure respondents experienced job disruptions during the pandemic at higher rates than food-secure respondents, with 73.1% of food-insecure households (95% CI 65.5-80.7%) reporting a job disruption compared with 45.9% of foodsecure households (95% CI 40.3-51.5%) (p < 0.001) (Table A7 ). More than three-fourths (78.7%) of consistently food-insecure households faced a job disruption. Food-insecure respondents continued to report higher rates of job disruption in March 2021 (95% CI 20.6-36.3%) compared with food-secure respondents (95% CI 10.4-18.3%) (p < 0.001) (Table A8) . Additionally, food-insecure households received unemployment insurance (31.7%; 95% CI 23.4-40.0%) at higher rates than food-secure households (19.8%; 95% CI 15.2-24.3%) (p < 0.01) (Table A9) . Among our respondents, participation in food assistance programs increased during the first year of the COVID-19 pandemic compared with the year before, except for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), though these differences were not statistically significant (Figure 1) . However, by March 2021, participation in all programs had declined compared with time points measured earlier in the pandemic, with an 18.2% decrease in Supplemental Nutrition Assistance Program (SNAP/3SquaresVT), 49.3% decrease in Pandemic-EBT (P-EBT), 8.0% decrease in WIC, 19.1% decrease in school meal programs, and 34.7% decrease in the use of food pantries. Only the decline in P-EBT use was statistically significant, dropping from 7.3% at any time during the first year of the COVID-19 pandemic (95% CI 4.9-9.8%) to 3.7% in March 2021 (95% CI 1.9-5.4%) (p < 0.05) (Table A10) . Food-insecure households (67.4%; 95% CI 59.3-75.5%) used food assistance programs at over three times the rate of foodsecure households (16.3%; 95% CI 12.2-20.5%) (p < 0.001) (Tables 3 and A11 ). A random effects logistic regression model predicted the factors contributing to higher odds of experiencing food insecurity at any time during the first year of the COVID-19 pandemic ( Table 4 ). Households that experienced any type of job disruption during the first year of the pandemic had greater odds of experiencing food insecurity (OR 5.03; 95% CI 1.583-16.005; p < 0.01). The odds of experiencing food insecurity were also higher among households with children (OR 5.49; 95% CI 1.782-16.936; p < 0.01), respondents who identified as BIPOC and/or Hispanic (OR 11.77; 95% CI 1.615-85.805; p < 0.05), and women (OR 8.07; 95% CI 1.777-36.647; p < 0.05). Older respondents (OR 0.05; 95% CI 0.012-0.180; p < 0.001) had lower odds of experiencing food insecurity compared with respondents under 63. Having a college degree (OR 0.08; 95% CI 0.025-0.246; p < 0.001) or a household income of ≥USD 50,000 (OR 0.01; 95% CI 0.003-0.038; p < 0.001) were also associated with reduced odds of household food insecurity. Table 4 . Random effects logistic regression predicting odds of food insecurity compared with food security during the first year of COVID-19. Odds We found no statistically significant differences (p < 0.05) using multivariate logistic regression models between newly and consistently food-insecure respondents (Table 5) and between respondents who were still food-insecure in March 2021 and those who had recovered (Table 6 ). This longitudinal study in Vermont documented a statistically significant increase in food insecurity compared with the year prior to the COVID-19 pandemic among a cohort of respondents. Furthermore, we show that while the food insecurity prevalence in March 2021 had decreased compared with the early months of the pandemic, rates remained higher than the year before the pandemic. This trend aligns with evidence from most other studies. For example, a longitudinal study conducted nationally found a reduced risk of food insecurity in November 2020 compared with March/April 2020 [23] . Adams et al. (2021) conducted surveys of a cohort of U.S. households with children in May and September 2020, finding that food insecurity increased in May 2020 compared with before the pandemic and then decreased in September 2020, but food insecurity remained above pre-pandemic levels [20] . However, a recent government report found no change in overall food insecurity prevalence in 2020 compared with 2019 [35] , counter to most existing research. We also demonstrated that certain demographic groups were at higher odds of experiencing food insecurity during the first year of the COVID-19 pandemic, including women, younger people (under 63), BIPOC/Hispanic respondents, people without a college degree, lower income households (