key: cord-1018721-3c3kh3pc authors: Larison, LeeAnna; Shanks, Carmen Byker; Webber, Eliza; Routh, Brianna; Ahmed, Selena title: The Influence of the COVID-19 Pandemic on the Food Supply in the Emergency Food System: A Case Study at Two Food Pantries date: 2021-09-16 journal: Curr Dev Nutr DOI: 10.1093/cdn/nzab115 sha: 7a562ba4fa2bb8233a6b7a45b2bb8236b684e19d doc_id: 1018721 cord_uid: 3c3kh3pc BACKGROUND: The onset of COVID-19 pandemic increased demand for emergency food assistance and caused operational shifts in the emergency food system. OBJECTIVE: This research explored how the initial phase of the COVID-19 pandemic influenced the food supply of two food pantries. METHODS: A case study approach was applied to collect data during the initial phase of the COVID-19 pandemic. Food supply data was collected weekly at two food pantries in Southwest Montana for 17 weeks in 2020. Surveys and interviews were conducted with food pantry clients and staff, respectively. Descriptive statistics and inferential statistics were applied to analyze quantitative data. Food supply data was analyzed using the Healthy Eating Index-2015 (HEI-2015), NOVA system, and UP3 Framework. Thematic analysis was applied to qualitative data. RESULTS: The food boxes collected between the two food pantries (n = 43) had a mean Total HEI-2015 score of 76.41 (SD = 7.37) of a possible score of 100. According to both the NOVA and the UP3 Framework, 23.4% of the total food distributed was ultra-processed food (UPF). Of the food distributed, 50.0% and 48.3% was fresh, unprocessed food according to NOVA and UP3 Frameworks, respectively. From staff interviews, three themes arose that describe the food pantry operations that experienced change during the COVID-19 pandemic including: Food Procurement, Distribution Preparation, and Food Distribution. Nine supporting subthemes describing the causes and consequences of the operational themes were identified. Staff perceived that the nutrient quality of the food boxes increased from food distributed previous to the COVID-19 pandemic whereas over a third (39.4%) of food pantry clients that responded to surveys preferred the food box model. CONCLUSIONS: The COVID-19 pandemic caused enormous operational challenges within food pantries. Food Pantries overcame these challenges by swiftly and effectively altering operations so as to continue to distribute nutritious food boxes to pantry clients. The onset of the COVID-19 pandemic spurred food insecurity and a monumental shift in the ways the emergency food system (EFS) acquires and distributes food (1) . In the United States, it is projected that 17 million more people experienced food insecurity than did prior to the COVID-19 pandemic (1). Lower socioeconomic populations experience food insecurity and develop obesity and non-communicable chronic disease (NCD) at higher rates than the general public (2) (3) (4) (5) , a situation that was further exasperated during COVID-19 for lower socioeconomic populations (6) . Food insecurity is defined as the condition of being unable to obtain enough nutritious food consistently and reliably, in a safe and socially acceptable manner (7, 8) . Research demonstrates that low-income and food insecure populations are less likely to achieve dietary recommendations compared with more affluent and food secure populations (9, 10) . Simultaneously, low-income and food insecure individuals often consume lower-quality diets due to the higher cost of healthy food, including ultra-processed foods (UPF), which have been shown to contribute to deleterious health outcomes (11) (12) (13) (14) . selection of foods from the food pantry's available items, along with foods obtained through means outside of the food pantry (15). A systematic review conducted by Simmet, et al. (18) concluded that the nutritional quality of the foods provided from the EFS does not support a healthful diet. A 2016 analysis of the food supply of food bank shelves determined that the average total Healthy Eating Index (HEI) score, a standardized method for identifying adherence to the Dietary Guidelines for Americans (DGAs), was 62.7 out of 100 (19, 20) . The occurrence of the COVID-19 pandemic and associated regulatory measures applied potentially has vast implications for the nutritional quality of the foods available within the EFS. There is little known about how the changes implemented in EFS operations impact the nutrient quality of the food supply distributed to EFS clients. The purpose of this research is to identify and evaluate the consequences of the initial phase of the COVID-19 pandemic on food supply, nutrient quality, and distribution methods of two food pantries within Southwestern Montana that offered a self-choice model of food distribution pre-COVID- 19 . This researched aimed to determine how the food distribution system changed within these food pantries and applied findings to identify recommendations for building a healthy food supply within similar food pantries. This research drew upon a case study approach to collect data beginning in April 2020, directly following the operational shifts made by food pantries as a result of COVID-19, and continued until August 2020. Immediately prior to the COVID-19 pandemic, this research team conducted a study, called the UnProcessed Pantry Project, at two food pantries in Montana that evaluated the quality of the food supply over a one-year period (14, 21) . This research created a strong collaborative relationship between the food pantries and the research team, which allowed for continued data collection during the COVID-19 pandemic. In Montana, stay-at-home orders were issued in mid-March and phased reopening began in late April (22) . Due to stay-at-home orders that closed non-essential businesses, unemployment rates spiked, driving increased rates of food insecurity. As of late August, 28,922 total unemployment insurance claims were filed, nearly triple that of pre-COVID-19 rates (23) . Along with the increase in unemployment, participation in the Supplemental Nutrition Assistant Program (SNAP) increased with growing population need (24) . During 2018, roughly one-tenth of Montana residents received food through the Montana Food Bank Network (25) . In response to the growing COVID-19 related food insecurity, the percentage of Montanans accessing the EFS through food banks increased at least 20 to 30% during 2020, after the onset of the COVID-19 pandemic (26) . As EFS use increased, systematic changes occurred to increase worker and client safety throughout food banks and food pantries nationwide (27) . In Montana, three main shifts occurred across the EFS. First, food donations from the public were no longer accepted and instead money was requested to allow food pantries to purchase large quantities of food for food boxes. Second, food rescue operations from grocery stores were temporarily discontinued or significantly decreased (26) . Third, many food pantry clients were no longer choosing their own food, and rather being provided a prepacked food box. Located in non-metro Southwestern Montana (28) , both food pantry operations offered a self-choice shopping model prior to the COVID-19 pandemic. Both food pantries accepted donations of food and money to varying degrees. Food Pantry 1 also ran a food rescue program, collecting food from grocery stores (29, 30) . Food Pantry 1, which also acts as a food bank, distributed 2,000,000 pounds of food to customers during the same time period (29, 30) . Food Pantry 2 distributed over 200,000 pounds of food during the 2018-2019 fiscal year (29) . Data was collected weekly at the two food pantry sites for 17 weeks. For safety, food pantry clients were provided a pre-packed food box, which were placed directly into their vehicles. All food boxes were packed with enough food for a household size of four to last approximately one week, and families could return to the food pantry as frequently as needed. Data was collected through photographs to follow COVID-19 protocols and social distancing guidelines; the researchers could not directly visit the food pantry. Food pantry staff were directed to randomly select a food box after packaging for distribution and then photograph the food items prior to the client's food pick up (Figure 1 ). Researchers drew upon food photography methods to assess the food boxes (31, 32) . Each photograph depicted the entire contents of a single food box distributed so that labels were clearly identifiable. Staff captured these photos between two to three times per week initially and then transitioned to once per week as the variation in the distribution process stabilized on three occasions early in data collection, staff from one food pantry sent photographs of two different food boxes on a single day. In order to select a single food box for each day of data collection, the food boxes were numbered one or two, and a random generator was used to select which box would be used for analysis. Upon receiving the photographs from the food pantry staff, the lead researcher assessed and recorded each item in each food box according to the inventory protocol. Prepackaged items were counted and recorded individually. For every food item available, the name (e.g., low sodium green beans), brand, number of units, servings per unit, total number of servings, food group (e.g., dairy, vegetable, poultry) were recorded. Items with differing brands were entered separately, even if the item was the same type of food. Items with the same brand, but differences in processing, were also recorded separately. As freshly packaged items, such as bakery breads or fresh fruits, often lack food labels with volume or weight listed, the researchers used USDA Food Data Central to approximate the weight of the item based on the calculated composite of the average serving size across all possibilities within each type of food (33) . For food boxes with unclear photographs, both the lead researcher and a research assistant individually assessed the food boxes, compared results, reached a consensus, and recorded the items. To determine the nutritional value of food items, the identified foods from the food pantry food boxes were compared across multiple databases. Each food item was matched with its corresponding description HEI-2015, NOVA food classification system, and the UP3 Framework were used to assess the nutrient quality and contribution of UPF to the food supply for a well-rounded understanding of the food supply. The HEI is a metric that can be used to determine how well a diet pattern or food environment is in alignment with the Dietary Guidelines for Americans (21) . The HEI is a scoring system with a scale ranging from 0-100, where a score of 100 represents a diet or food environment in alignment with the Dietary Guidelines (37) . To calculate the HEI score, 13 nutritional components are assessed in terms of adequacy or moderation recommendations. The adequacy components are composed of foods that the Dietary Guidelines encourage Americans to consume. Comparatively, the moderation group is composed of foods that should be limited (37, 38) . NOVA (which is not an acronym, but rather means -new‖ in Portuguese) and the UP3 classification systems were applied to each food item (39) . Classifications were made by reading each item's list of ingredients and nutrition facts panel, and then referring to both the UP3 and NOVA classification criteria to identify which category within both systems the item belonged (14, 39) . The NOVA system classifies foods as either unprocessed or minimally processed (group 1), processed culinary ingredients (group 2), processed foods (group 3), and ultra-processed foods (group 4) (39, 40) . Comparatively, the UP3 Framework expands upon the NOVA classification system by establishing five categories, namely, fresh foods, pantry staples, lightly prepared, heavily prepared, and ultra-processed foods (14) . Phone interviews with paid food pantry staff were conducted by the lead researcher to learn about staff perceptions regarding the shifts in operations as a result of COVID-19 ( Table 1) . Written consent was first obtained from staff to participate in the interview and demographic information was also collected. The semi-structured interviews lasted approximately one hour and followed an interview guide. Ten open-ended questions were asked and prompts for each question were used to further probe for information. Thirteen staff members between the two food pantries were invited to participate and eight staff agreed to partake in the interview process. Brief multiple-choice surveys (Supplementary Table 1 to the lead researcher by food pantry staff and entered into excel. All entries were checked against the survey three times and a second researcher verified the data. Descriptive statistics were used to summarize customer survey responses, count emerging themes regarding gained and lost efficiencies with food distribution as a result of COVID-19, and to assess each food pantries' food supply and food box composition individually and by month, to detect changes over time in the distribution of total calories, pounds, and servings of food in each UP3 and NOVA classification category (41) . SAS macros provided by the National Cancer Institute were used to compute HEI-2015 scores for each month of data collection, using the Simple HEI Scoring Algorithm (42) . Mean scores were assessed overall, by food pantry, distribution model, month, and stratified by UP3 and NOVA classification. A two-tailed t-test was then used to assess difference in means between Food Pantry 1 and and then merged into a codebook. Next, the interviews were split into individual quotes that contributed to the research question. Each individual quote ranged from short answers of about ten words to longer responses of approximately 100 words. Following, the codebook was refined with definitions and applied to individual quotes independently by two researchers. Researchers discussed and resolved coding discrepancies. Coding frequency within one interview and across interviews was tabulated. From this process, the codes were organized into themes and subthemes regarding changes that occurred due to the COVID-19 pandemic. In total, 43 food boxes were collected between the two food pantries. Of these, 22 The food boxes contained 14,581 servings of food in total. Of which, 50% was fresh, <0.1% was processed culinary ingredients, 26.3% was processed and 23.4% was ultra-processed when classified according to NOVA. By UP3 classification system, food boxes were comprised of 48.3% fresh food, 0.2% pantry staples, 17.2% lightly prepared food, 10.7% heavily prepared food, and 23.4% ultraprocessed food servings ( Table 5) . According to the UP3 classification system, the most frequent fresh foods by total number of servings provided in the food boxes were onions (8.6%), potatoes (7.2%), 2% milk (6.5%), egg (5.3%), and pasta (4.8%) ( Table 6) . Butter was the only pantry staple provided within the food boxes with a total of 24 servings (100%) of the 14,581 total food servings in the data collected. The most frequent lightly prepared items by total number of servings distributed were salted pistachio nuts (7.63%), whole wheat bread made from a home recipe or bakery (7.6%), dried plums (5.2%), multi-grain bread (4.8%), and reduced-sodium canned chickpeas (4.0%). The most frequent heavily prepared items by total servings distributed were nut and fruit trail mix (10.3%), canned salmon (9.4%), cheddar cheese (5.1.%), canned corn (4.9%), and Colby jack cheese (4.1%). The most frequent ultra-processed food items by number of servings were peanut butter (12.5%), dry mashed potato mix (8.2%), cheese with additives and colorings (6.1%), packaged bread (4.3%), and chocolate milk (6.6%) ( Table 6 ). The results from the 104 client surveys conducted are listed in Supplementary Table 1 . Of the clients surveyed, 74.2% from Food Pantry 1 and 73.5% of respondents from Food Pantry 2 stated that they were receiving just the right amount of food to meet their family's needs. 6.1% of respondents from Food Pantry 1 stated they were receiving slightly too much food and 12.1% stated they were receiving slightly too little food. 11.8% of respondents from Food Pantry 2 stated they were receiving slightly too much food and 11.8% of respondents stated they were receiving slightly too little food. When asked about specific food items that Food Pantry 1, 53% stated they were receiving too little meat Interviews were conducted with eight staff members between two food pantries to better understand how the COVID-19 pandemic created challenges and opportunities within their work. In total, three operational themes and nine subthemes emerged (Figure 2) . Staff responses to open-ended interview questions illuminated three themes that distinguished operations of the food pantries that were disrupted by COVID-19, including Food Procurement, Food Distribution Preparation, and Food Distribution. Food Procurement is defined as the means taken by the food pantry to obtain food to provide to clients. These methods vary and include food rescue operations, food donations from the public, and food purchases from food distributors or grocery stores, and foods received from USDA programs such as The Food Distribution is defined as how clients received food from the food pantry. Food Distribution was impacted as food pantry clients no longer self-selected their own foods. One staff member emphasized that with the food box distribution model, -The biggest thing we've lost is that our clients aren't choosing the food that they are receiving, which was a huge aspect of our food bank that we were proud of and that worked really well.‖ Staff responses indicated nine subthemes that describe the causes and impacts of the operational changes, people in and out as quickly as possible.‖ and -We're working on recipes and meal kits and menu ideas for the week.‖ Staff also mentioned that for some the drive-through distribution model might be preferred. One staff member stated, -Specifically, an example is with the senior commodities program, I think for that particular program we may just continue with the curbside pick option, so that these seniors don't have to park and get out and come in, instead they can just pull into line and we'll put the food into their car and off they go.‖ Perceptions of Nutrition Quality is defined as the anecdotal thoughts by staff of how healthy the foods in the food boxes being distributed were. Staff mentioned this subtheme 51 times. Sample quotes from staff interviews on this theme include, -What we are putting in their box is the healthiest stuff that we have‖. Staff also noted, -The majority of the box is pretty unprocessed. It's mostly produce, dairy, bags of grains, real pasta, rice, dry beans, so the majority is pretty, pretty simple and healthy‖. Lastly, one staff member stated, -I believe for some customer it probably improved the quality because they were not able to choose.‖ Food Access is defined as the ability of food pantry clients to obtain food that is nutritionally adequate, socially appropriate, and culturally acceptable. Staff mentioned this subtheme 46 times during interviews. On this subtheme staff noted, -We're still here and able to give out food, and we still have plenty of food that is a big difference‖. Food pantries' goal to support food security of local communities through providing nutrient-dense foods that promote high dietary quality and human health was challenged during the COVID-19 pandemic. Our study found that the COVID-19 pandemic caused operational changes within the two food pantries that presented both opportunities and challenges. Both food pantries were able to quickly adapt to a food distribution model that allowed for the efficient delivery of food with limited contact between staff and clients. In Montana, food insecurity in 2020 is estimated to have risen 5-8% (1). In some counties, more than 25% of the population is likely experiencing food insecurity (1) . The shift in food distribution, from a shopping model to a drive-through distribution model, ensured that these food pantries were able to safely meet the rise in demand for Coronavirus Food Assistance Program and enabled the USDA to begin the purchase up to $4.5 billion of produce, processed dairy, and packaged meat from American food companies on May 15 th , 2020 to then distribute to organizations in need, such as food pantries, non-profits, and faith-based organizations (44) . Notably, the program ended one year later (45) . The USDA packaged approximately 25lbs worth of food items into family-sized boxes (44) . Both food pantries in this study participated; this participation may have mitigated food supply chain challenges that arose during the COVID-19 pandemic and ensured that the food boxes distributed had a minimum quantity of meat, produce, and dairy, all measured by the HEI. Food Pantry 1 added the entire contents of a Farmers to Families Box to the food box they were already distributing to clients, and Food Pantry 2 split the 25lbs between food boxes for two families. These food boxes consistently provided plain Greek yogurt, raw spinach, apples, milk, carrots, processed meats, and cheddar cheese to the overall wholesome food boxes already being prepared by both food pantries. The fresh foods provided by the Farmers to Families program may have offset some of the increase in TEFAP foods distributed by both food panties, as these foods are generally more processed and shelf stable. Although attempts were made at both food pantries to pack food boxes that were diverse and healthful, inherent limitations exist with a pre-packed food box system. In a pre-packed food box system, clients select the food items that are appropriate or preferred by them and their families (46) , running counter to the core principles of both food pantries in this study that emphasize client empowerment (47, 48) . Further research has demonstrated that client choice shopping models at food pantries allow clients to maintain some dignity through a situation as potentially difficult and humbling as asking for food assistance (49) . (18) . A food box filled with a variety of healthful food items therefore may sway a client to try an item they otherwise may not try. Similarly, research demonstrates that nudges can be very successful in encouraging the consumption of a healthful diet (50) . Nudges are defined by as -environmental cues such as signage, colors, packaging and product placement, have been identified as factors that influence consumer choice‖ (51) . Generally, nudges are techniques employed in food environments such as self-choice groceries (50) . However, the food boxes distributed at these two food pantries during the COVID-19 pandemic may have the ability to act as a nudge promoting the consumption of healthful food items by food pantry clients, since our analysis found the food boxes to be composed of foods having an overall total HEI score above that of the average Americans diet (20) . This research is not without limitations. While the purpose of this study is to gain a better understanding of how the food box distribution method has impacted the quality of the food provided to customers during COVID-19, a convenience sample of food items were recorded and analyzed. The results regarding the food supply within food pantries may not be generalizable to all geographies. However, strengths of this study include its case study and the use of triangulation where findings from one data source were used to strengthen our understanding of the findings from another (52) . Moreover, several metrics were applied to analyze the quality of the food boxes distributed, which provides a comprehensive understanding of food quality. Lastly, the timing and length of food supply data collection, over 17 weeks, is a strength as it allowed for accurate and detailed illumination of the food distributed during the height of the COVID-19 pandemic, which was only possible due to already existing projects with the food pantries included in this study. In conclusion, this study determined that a food box distribution model can provide healthful food to individuals and families in need during emergency circumstances, as the food pantry operational changes implemented by these two food pantries during the COVID-19 pandemic have demonstrated. Although the food quality distributed to food pantry clients decreased slightly according to the HEI, the proportion of food that was ultra-processed within the food boxes compared to the food supply from the previous year decreased, indicating that the HEI score does not show the entire picture of food quality. Importantly, both food pantries in this study will return to a shopping distribution model once they can do so safely, since this method supports client autonomy (53) . However, as was highlighted by the client surveys and staff interviews, the changes that occurred because of the COVID-19 pandemic demonstrated that for some food pantry clients, such as the elderly, drive-through food box distribution is an efficient and less burdensome pathway toward receiving healthy food. Lastly, the operational changes that occurred as a result of the COVID-19 pandemic allowed food pantries to reassess their methods of obtaining food to focus on healthful food options. Although nutrition policies were not studied in this research, the opportunity exists for food pantries to build upon changes implemented during the COVID- 19 pandemic and designate what types of food items the food pantry will accept. The translational goal of this research was to create recommendations for supporting a healthy food supply within food pantries, and ultimately support the healthful food intake of food pantry clients. Recommendations to elevate include: What changes occurred due to COVID-19 that caused the food bank or food pantry to become more efficient? Will any of the changes be continued? 2 What changes made due to COVID-19 caused the food pantry or food bank to become more inefficient? 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