key: cord-0931527-3umx4175
authors: Adams, Elizabeth L.; Caccavale, Laura J.; Smith, Danyel; Bean, Melanie K.
title: Longitudinal patterns of food insecurity, the home food environment, and parent feeding practices during COVID‐19
date: 2021-04-02
journal: Obes Sci Pract
DOI: 10.1002/osp4.499
sha: 81634f58a86f9534998024756eca0fe00843af2f
doc_id: 931527
cord_uid: 3umx4175

BACKGROUND: The economic impacts of the coronavirus disease 2019 (COVID‐19) have drastically increased food insecurity in the United States. Initial data, collected a few months into the pandemic, showed that families, particularly those experiencing food insecurity, reported detrimental changes to their home food environment and parent feeding practices, compared to before COVID‐19. OBJECTIVE: This follow‐up study obtained longitudinal data from a sample of parents in the United States to quantify changes in food security status, the home food environment, and parent feeding practices, from before to across COVID‐19 as the pandemic continued to persist. METHODS: Parents (N = 433) completed online surveys May (T1) and September (T2) 2020 during COVID‐19. Food security, home food environment, and parent feeding practices were reported at each timepoint. At T1, parents also retrospectively reported on these factors pertaining to before COVID‐19. Chi square analyses and repeated measure mixed models examined associations among study variables. RESULTS: Low or very low food security increased from before COVID‐19 (37%) to T1 (54%) and decreased by T2 (45%). About 30% of families who became food insecure, and 44% who stayed food insecure from T1 to T2, reported a decrease in total food in their home; only 3%–6% who became/stayed food secure reported this decrease. Parents' concern for child overweight and use of monitoring increased from before COVID‐19 to T1, and decreased by T2, but remained elevated above pre–COVID‐19 values. CONCLUSION: Rates of food insecurity remain high as this pandemic persists. Continued assessment of nutrition‐related factors and increased economic supports are critical for families to endure COVID‐19 and prevent long‐term obesity and health risks.

The severe economic impact of the coronavirus disease 2019 pandemic has drastically increased food insecurity for families in the United States. 1, 2 Food insecurity-defined as limited or uncertain access to adequate food 3 -is associated with detrimental health outcomes 4 and disproportionately affects racial/ethnic minority populations facing long-standing health inequities and greater obesity risk. 5 The social and behavioral ramifications resulting from COVID-19, such as greater unstructured time due to in-person school closures and canceled activities, have also raised concern regarding the potential for increased childhood obesity rates. 6 Thus, there is a need for empirical, longitudinal data collected throughout this pandemic to examine food insecurity and nutrition-related factors in this changing environment to inform our understanding of the impact of COVID-19 on child obesity risk.

Previously reported on data from this study team quantified changes in family's food security status, home food environment, and parent feeding practices about 2 months into COVID-19 being declared a pandemic. These results found a drastic increase in the percentage of families reporting very low food security with reported changes to their home food environment and parent feeding practices, compared to before COVID-19. 7 For example, more than half of families with very low food security decreased the total amount of food in their home and increased the amount of nonperishable processed foods. 7 Parents also reported a greater concern for child overweight and controlling feeding practices, with an even greater increase in concern for child overweight and pressure to eat among for families experiencing food insecurity. 7 Since these initial data were collected, nationwide rates of food insufficiency have remained elevated, 2 yet policy changes have occurred through stimulus bills (i. e., coordinated economic measures from the government to stimulate and support the economy) and government assistance programmatic flexibilities to provide some economic relief and address food insecurity. 8, 9 Furthermore, over the course of COVID-19, families (regardless of food security status) might have experienced additional changes in income, increased government assistance benefits, reduced perceived threat of food shortages, and fluctuations in stayat-home orders. Collectively, these factors could influence family's food purchasing behaviors and feeding practices as the pandemic progresses. It is therefore important to examine if the initial changes observed during COVID-19 are sustained months later.

The aim of this follow-up study was to obtain longitudinal data from a sample of the US parents regarding food insecurity, the home food environment, and parent feeding practices during COVID-19.

The initial survey was completed at the peak of school closures and stay-at-home orders (May 2020). 7 This follow-up survey was completed in September 2020, at another key timepoint during COVID-19 that coincides with children's return to school. Specifically, changes in food security status, the home food environment, and parent feeding practices were quantified across three timepoints: before COVID-19 (retrospective), May 2020, and September 2020.

Next, analyses examined if longitudinal changes in the home food environment and parent feeding practices differed by changes in food security status during this time.

This observational study utilized an online survey to quantify longitudinal changes in food security status, the home food environment, and parent feeding practices. The first survey was administered in May 2020 (T1) where parents reported on their situation before COVID-19 (retrospective report), as well as currently at that time. In 7 The secure Qualtrics platform (Provo, Utah) was used to administer online surveys. Initial screening questions assessed eligibility. If eligible, parents were directed to complete the full survey. An informational letter describing the study was provided at the start of survey. Participants advancing to the survey served as passive consent for participation. In the event that parents had more than one child 5-18 years of age, they were asked to complete the first survey when thinking about their child whose weight most concerns them; for the second survey, parents answered the survey in reference to that same child. The first survey consisted of 144 questions and took approximately 20 min to complete. The second survey consisted of 80 questions and took approximately 10 min to complete. At the end of the first survey, parents provided their contact information so that the study team could send compensation ($10 gift card for each completed survey) and follow-up surveys.

Identifiable information was not linked to participants' responses in any way.

A total of n = 1342 parents started the first survey, and n = 584 parents provided complete, valid data. All n = 584 parents were provided with the second survey link via email. Of these, N = 433 completed the second survey (74% retention) and comprise the sample for the current report. Parents who did not complete the second survey were more likely to be from racial (i.e., Black) and ethnic (i.e., Hispanic/Latino) minority backgrounds (ps < 0.05). No other demographic differences or differences in food security status were observed based on retention. All study and consent procedures were approved by the Institutional Review Board at Virginia Commonwealth University. 

The six-item United States Department of Agriculture Household Food Security Module was used to assess household food security status at each timepoint. 10 This brief measure has high specificity and sensitivity, with minimal bias. 11 Given the rapidly changing environment during COVID-19 and need for acute measures of food insecurity, one question was modified to ask parents to report on the number of days they cut/skipped meals within the past 30 days, rather than in the past 12 months. 10 Responses of ≥3 days were considered as an affirmative response. All affirmative responses were summed, with total scores ranging 0-6. Families were then categorized as having high (0-1), low (2) (3) (4) , or very low (5) (6) food security status at each timepoint based on their total score.

Within-family changes in food security status from T1 to T2 were quantified. Categories of low and very low food security were collapsed into a single "food insecure" category, due to a lower percentage of families in each of these categories and to be consistent with methods used in prior research. 5 This resulted in two categories at each timepoint: food secure versus food insecure. Within-family comparisons of categories at T1 and T2 were characterized as remained food secure, remained food insecure, became food secure, or became food insecure, corresponding to family's stability or change in food security status from T1 to T2.

Five questions quantified changes in the amount and types of food in family's home, 7 asking if the amount of (1) total food, (2) high-calorie snack foods (e.g., chips), (3) desserts and sweets (e.g., cookies), (4) fresh foods (e.g., fruits and vegetables), and (5) nonperishable processed food (e.g., canned food) in their home was more or less at T2, compared to at T1. Response options were provided on a 5-point Likert scale ranging "much less," to "much more." Responses were collapsed into three categories representing an increase (much more/ slightly more), a decrease (much less/slightly less), or no change from T1 to T2.

The Child Feeding Questionnaire (CFQ) was used to quantify parent feeding practices at each timepoint. Four subscales were used from this validated measure, 12 including parents' concern for child overweight, restriction (i.e., restricting child's access to certain foods), pressure to eat (i.e., pressuring child to eat more food), and monitoring (i.e., parent supervision of child's eating). Response options were rated on a 5-point Likert scale. All items within each subscale were averaged. Possible scores ranged from 1-5.

Descriptive statistics were calculated using means and standard deviations for continuous variables and percentages for categorical variables. For Aim 1, patterns of food security status, the home food environment, and parent feeding practices were examined for the overall sample. Food security status was examined using a chisquare analysis (3 � 3) to examine distribution differences in three food security categories (food secure; low food security; and very low food security) at each timepoint (before COVID-19; T1; and T2). Home food environment changes were reported as the percentage of parents who responded to each categorical response option at each timepoint. Longitudinal patterns in parent feeding practices were examined using mixed models that accounted for repeated measures within families across time. A main effect of time was the independent variable, and CFQ subscales were the dependent variables tested in separate models. Post hoc comparisons examined where specific differences occurred between timepoints, with "before COVID-19" serving as the reference group. Values are presented as adjusted means and 95% confidence intervals.

For Aim 2, differences in patterns of the home food environment and parent feeding practices by change in food security status were examined. A chi square analysis (3 � 4) examined home food environment changes at three timepoints by four food security status categories that represented a change from T1 to T2 (became food insecure; stayed food insecure; became food secure; stayed food insecure). Results indicate distribution differences across these categories and timepoints. Differences in longitudinal patterns in parent feeding practices by change in food security status were examined using mixed models that accounted for repeated measures ADAMS ET AL. within families across time. An interaction (time � change in food security status category) was the independent variable, and CFQ subscales were the dependent variables, tested in separate models.

In the presence of a significant interaction term, models were stratified by change in food security status category to permit post hoc comparisons and examine where specific differences occurred between timepoints. "Before COVID-19" served as the reference group, and a Tukey post hoc comparison was applied to correct for multiple testing. Values are presented as adjusted means and 95% confidence intervals. In the absence of a significant interaction term, post hoc comparisons were not examined. All analyses were conducted in SAS statistical software version 9.4 (SAS Institute Inc).

Significance was defined a priori as p < 0.05.

Results are presented below starting with longitudinal patterns of food security status, the home food environment and parent feeding practices, followed by how longitudinal patterns of the home food environment and parent feeding practices differed by families' change or stability in food security status across COVID-19.

Parent and child demographics are listed in Table 1 

Parents' concern for child overweight increased, and remained elevated, from before to across COVID-19 for families who became or remained food insecure; these values increased, but returned to pre-COVID-19 values by T2, for families who became or stayed food T A B L E 3 Subscale scores for parent feeding practices reported on the Child Feeding Questionnaire, pertaining to before, and at two timepoints during, the COVID-19 pandemic in a nationwide sample of the US parents of children 5-18 years of age (N = 433) 

This study provides follow-up data on longitudinal patterns of food security, the home food environment, and parent feeding practices across COVID-19. Initial patterns showed a large increase in the percentage of families experiencing food insecurity compared to before COVID-19, with a decrease 4 months later when policy changes were in place to provide some economic relief. However, food insecurity rates in September 2020 remained considerably higher than before COVID-19. Parents also reported an increase in concern for child overweight from before COVID-19 to May 2020, which decreased but remained elevated in September 2020, partic- The severe economic impacts of this global pandemic have occurred in parallel with a drastic increase in food insecurity in the United States. 13 At the height of government closures and stayat-home orders, 54% of families in this study reported low or very low food security. 7 Four months later, 45% of families reported low or very low food security as this pandemic persisted. These patterns indicate a change in a positive direction yet leave considerable room for further improvement. Throughout these months, unemployment rates declined, 14 stay-at-home orders were lifted, 15 and stimulus bills provided some relief. 8, 9 For example, SNAP issued emergency allotments for families to receive the maximum benefit as well as operating flexibilities, such as the expansion of online purchasing. 8 The

Coronavirus Aid, Relief, and Economic Security Act provided a onetime stimulus payment to families earning below a certain threshold, 9 and based on reported income, approximately 77% of families in this sample qualified for this stimulus payment. While these and other factors may have contributed to a temporary decline in food insecurity, evidence suggests that they are not enough. Only 15% of families in this study became food secure, while 6.2% became food insecure, between May and September 2020. Furthermore, less than half of this sample reported receiving benefits from SNAP, local food banks, unemployment, and school-provided meals in September 2020. Other policy-level factors, such as expired supplemental unemployment benefits, 16 failure to pass a second stimulus payment at the time of this study's data collection, 17 and not raising the maximum SNAP benefits that are insufficient to providing nutritious, adequate foods, 18 all likely contribute to persistent elevations in food insecurity. Moving forward, greater legislative efforts are needed to support families with limited access to adequate foods, including continued increased support of federal nutrition assistance programs, programmatic flexibilities and waivers, and enhanced unemployment benefits as our nation endures and recovers from COVID-19.

Furthermore, dissemination and implementation science will be crucial from a scientific perspective to ensure that evidence around food insecurity and child nutrition programs can be adopted and integrated into more equitable and sustainable policies beyond COVID-19, thus enhancing these program's long-term public health impact. 19 In May 2020, about one-third of families in this sample reported an increase in the amount of desserts/sweets in the home. 7 Other studies conducted around this time also showed an increase in children's 20 and adults 21 unprecedented public health crisis, it is imperative that our nation continues to provide creative supports and strengthened initiatives to reach more families and provide food and financial resources to those in need.

Our previous data showed an increase in parents' concern for child overweight from before COVID-19 to May 2020, 7 During the initial wave of COVID-19, cross-sectional analyses indicated that greater parental stress was associated with both positive and negative changes in child feeding practices, such as using food to manage children's emotions, creating routines around eating occasions, and engaging with children at mealtime more often. 20 These longitudinal data showed that parents' use of restriction and pressure to eat initially rose during COVID-19 but returned to baseline values a few months later. This temporary change has positive implications on children's health, given these feeding practices are most commonly associated with child weight and unhealthful eating behaviors. 31 37 It is likely that parental monitoring is beneficial for some children, based on certain characteristics like age and temperament, and for other children too much can become counterproductive. 38 Furthermore, the clinical significance for the magnitude of change in CFQ subscales is uncertain, given the lack of a clinically meaningful change or cut-off score.

Some childhood obesity interventions have modified parent feeding practices at a similar magnitude of change as shown in these data and demonstrated associations with body mass index and dietary intake. [38] [39] [40] However, ultimately, these findings should be interpreted as overall patterns showing how parent feeding practices fluctuate alongside the social, environmental, and financial impacts of COVID-19.

The limitations of this study include the use of a convenience sample, with limited racial/ethnic diversity, that is not nationally representative of all the US parents. While the retention rate was high, the parents lost to follow-up tended to be from racial/ethnic minoritized backgrounds and given that these populations tend to experience more adverse impacts from COVID-19, 41 

This follow-up study provides novel data on the longitudinal changes in food security, the home food environment, and parent feeding practices across COVID-19. These findings reveal some positive changes, yet there is substantial room for improvement, particularly related to amount of families experiencing food insecurity. The length of this pandemic remains uncertain, and the lingering effects will likely persist for years to come. As such, empirical data, such as these, are critical to informing public health policies and supports for families in need, in order to reduce the negative impacts of COVID-19 on family's nutrition and health.

This study was funded by the Virginia Commonwealth University 

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The authors declare that there are no conflict of interests.

Elizabeth L. Adams and Melanie K. Bean conceptualized the research questions and obtained grant funding. Elizabeth L. Adams completed data collection, data analyses, and drafted the initial version of the manuscript. All authors designed the study, interpreted the data, critically reviewed the manuscript, and approved the final version as submitted.

https://orcid.org/0000-0002-5602-8470