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Food Insecurity and COVID-19 Infection: Findings From the 2020-2021 National Health Interview Survey

  • Author Footnotes
    1 Address: 1025 E 7th St, Bloomington, IN 47405.
    Jiahui Cai
    Correspondence
    Corresponding author Name: Jiahui Cai, Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, Indiana.
    Footnotes
    1 Address: 1025 E 7th St, Bloomington, IN 47405.
    Affiliations
    Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, Indiana
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  • Author Footnotes
    1 Address: 1025 E 7th St, Bloomington, IN 47405.
Open AccessPublished:January 18, 2023DOI:https://doi.org/10.1016/j.focus.2023.100069

      Highlights

      • This study analyzed nationally representative cross-sectional data in the U.S.
      • Food insecurity unequally affected socioeconomically disadvantaged populations.
      • Food insecurity was independently associated with positive COVID-19 infection.

      Abstract

      Introduction

      The purpose of this study was to examine socio-demographic and health-related factors associated with food insecurity and the association between food insecurity and COVID-19 infection using a nationally representative sample in the U.S.

      Methods

      Cross-sectional data of 61,050 adults (≥18 years) from the 2020 and 2021 National Health Interview Survey were analyzed. Food insecurity was measured by the 10-item U.S. Department of Agriculture (USDA) Food Security Survey Module. Weighted multivariable logistic regression models were used to estimate associations with food insecurity.

      Results

      6.8% of the NHIS participants lived in food-insecure households, and 18.9% tested positive for COVID-19 infection. Young (18-34 years) or middle age (35-64 years), female sex, minor race/ethnicity (Hispanic/non-Hispanic Black/non-Hispanic Asian/others), education level less than high school, unmarried status, unemployment, poverty (below the federal poverty level), having no health insurance, a larger number of adults and children in the household, poorer self-reported health status, and presence of chronic conditions were significantly associated with food insecurity (AOR ranged from 1.20 to 3.15, all p<0.0001). Food insecurity was independently associated with positive COVID-19 infection (AOR=1.25, 95% CI: 1.11, 1.40) controlling for socio-demographic and health-related factors. The greatest magnitude of the association was observed for the non-Hispanic Blacks (AOR=1.47, 95% CI: 1.15, 1.88), females (AOR=1.44, 95% CI: 1.20, 1.71), and those below the federal poverty level (AOR=1.39, 95% CI: 1.12, 1.73) across all the subgroups.

      Conclusions

      Food insecurity disproportionately affected vulnerable subgroups such as young adults, females, minor race/ethnicity groups, and those with lower socioeconomic backgrounds and was associated with positive COVID-19 infection. Policies addressing food insecurity may help reduce the likelihood of COVID-19 infection, especially for those vulnerable subgroups.

      Keywords

      Introduction

      Food insecurity, measured by the U.S. Department of Agriculture (USDA), is characterized by limited or uncertain access to adequate food.1 The unprecedented COVID-19 pandemic that began in 2020 in the U.S. and its associated economic and social impacts (e.g., high rates of unemployment, stay-at-home orders, closures of schools and business) have contributed to increased food insecurity at the beginning of the pandemic and may have the potential to exacerbate the existing disparities in food insecurity.2 The national estimate of household food insecurity has risen from 11% to 38.3% in March 2020.3 Based on reports from USDA, 10.5% (13.8 million) of all U.S. households were food insecure at least some time in 2020.4 Although the prevalence of food insecurity for all households in 2020 remained unchanged from 2019, subgroups such as households with children and households with Blacks experienced increases in food insecurity since the pandemic.4 Significantly higher prevalence of food insecurity than the national average (10.5%) was observed in subgroups such as female-headed households (27.7%), households with children (14.8%), households with Hispanic (17.2%) or non-Hispanic Black persons (21.7%), households with the unemployed (20.4%), and low-income households (28.6%). 4 Younger adults were also vulnerable to food insecurity during the pandemic (e.g., the relative risk of food insufficiency (often the most extreme form of food insecurity) decreased by 23% with every 10-year increase in age).5
      Food insecurity has been linked to adverse health outcomes such as diabetes, cardiovascular disease, and mental problems such as anxiety and depression disorders.6,7 Food-insecure adults may also be more vulnerable to COVID-19 infection than their food-secure counterparts due to weakened immune function and less engagement in COVID-19 protective behaviors. Poorer diet quality and inadequate nutrients associated with food insecurity could contribute to an impaired immune system, which may increase the susceptibility to virus infection and permit severer symptoms.8,9 Besides, compared to food-secure individuals, food-insecure individuals were less likely to work from home, practice physical distancing in public, and take preventive actions to reduce their exposure to COVID-19 (e.g., stocking up on essentials at a grocery store or pharmacy, washing hands more regularly, filling prescriptions; avoiding crowds or a larger gathering, and avoiding touching face).10 So far, only one cross-sectional study has reported that household food insecurity was associated with a 32%-73% greater likelihood of COVID-19 infection, but the evidence was limited in older U.S. adults (≥50 years) from a random subsample of Health and Retirement Study.11 Few studies have focused on the association between food insecurity and COVID-19 infection in the overall U.S. population and communities that are vulnerable to food insecurity such as young adults, females, the unemployed, and households with children.
      Using the nationally representative data from the 2020 and 2021 National Health Interview Survey (NHIS), this study aimed to examine (1) socio-demographic and health-related factors associated with food insecurity during the COVID-19 pandemic, and (2) the association between food insecurity and COVID-19 infection in the overall U.S. adults (≥18 years) and subgroups that vulnerable to food insecurity including the young (18-34 years), females, the Hispanics/non-Hispanic Blacks, low-income households, households with children, and the unemployed. Identifying disparities in food insecurity could inform disadvantaged food-insecure communities during the pandemic crisis. Understanding the association between food insecurity and COVID-19 infection may provide new insights into the prevention and management of COVID-19 infection.

      Material and methods

      Data used in this study were derived from the 2020 and 2021 NHIS, an ongoing cross-sectional and nationally representative survey which aims to monitor the trends in health, illness, and disability in the U.S. civilian noninstitutionalized population.12 With stratified clustering sampling methods, NHIS randomly selected roughly 30,000 households from the randomly selected clusters within 1,689 originally defined geographic areas.12 Sample adults were then randomly selected from each household. NHIS collected data on both the household level (such as household demographics and food insecurity) and the individual level (such as health conditions and behaviors, health care access and utilization, and functioning and disability). The 2020 and 2021 NHIS also covered COVID-related data such as self-reported diagnosis and symptoms of COVID-19 infection. Due to the impact of the COVID-19 pandemic, the 2020 and 2021 NHIS predominantly collected data using telephone interviews rather than regular in-person visits, which resulted in relatively low response rates during this period than previous years (response rates: 50.7% for sampled households and 48.9% for sampled adults in 2020 NHIS, 52.8% for sampled households and 50.9% for sampled adults in 2021 NHIS).12 Quality controls were conducted by monthly checks on response or completion rates, item response times or non-response, telephone usage rates, and other data quality indicators.
      In the current study, 61,050 adults (≥18 years) were included. The final analytic sample was weighted with two-year sampling weights (two-year weight=annual sampling weights/2) to account for complex survey design (clustering and stratification), non-response bias, and multiple cycles (weighted n= 244351,834). Details about the survey design, dataset, and sampling weights were available on the CDC website: https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm. IRB review was not required since the study relied on the publicly available dataset. Analyses were conducted in 2022.
      Food insecurity was measured by the 10-item U.S. Department of Agriculture (USDA) Food Security Survey Module with a 30-day look-back window.12,13 Participants were asked questions such as “In the past 30 days, did you or others in your family ever cut the size of the meals or skip meals because there was not enough money for food ?” or “In the past 30 days, did you or other adults in your family worry that the food would run out before you got money to buy more ?”. A full list of the 10-item module is provided in Appendix Table 1. Based on the number of affirmative answers, food security status was categorized into four levels: high food security (0 item affirmed), marginal food security (1-2 items affirmed), low food security (3-5 items affirmed), and very low food security (6-10 items affirmed).13 Participants with high or marginal food security were considered food secure, and participants with low or very low food security were considered food insecure.13 Self-reported diagnosis of COVID-19 infection was assessed by asking the participants whether they have tested positive for COVID-19 infection.12 Participants who answered “yes” were considered to have positive COVID-19 infection.
      Socio-demographic and health-related factors associated with food insecurity and COVID-19 infection were selected as covariates. Socio-demographic factors included age (18-34 years, 35-64 years, ≥65 years), sex (male, female), race/ethnicity (Hispanic, non-Hispanic White, non-Hispanic Black, others), education (≤high school, >high school), marital status (married, unmarried), employment (no, yes), poverty (<100% federal poverty line, ≥100% federal poverty line), and the number of adults (1-2, ≥3) and children (0, ≥1) in the household. Considering that presence of chronic conditions was associated with food insecurity and severity or mortality of COVID-19 infection,14,15 we also adjusted for health-related factors including self-reported health status (good or above, fair or poor) and chronic health conditions (yes, no). Participants were asked if they have been told by a doctor or other health care professionals that they had the following chronic conditions: asthma, chronic obstructive pulmonary disease, arthritis, diabetes, hypertension, coronary heart disease (CHD), stroke, and disability.

      Statistical Analysis

      Characteristics of participants were compared between those with food insecurity and those without using Pearson's chi-square tests. Weighted multivariable logistic regression models were used to estimate associations with food insecurity controlling for socio-demographic (including age, sex, race/ethnicity, education, marital status, employment, poverty, and the number of adults and children in households) and health-related factors (including self-reported health status and presence of chronic health conditions). Adjusted odds ratios (AORs) with corresponding confidence intervals (CIs) were reported. To assess the association between food insecurity and COVID-19 infection in vulnerable subgroups, interactions between food insecurity and age, sex, race/ethnicity, unemployment, federal poverty level, and the number of children were added to the adjusted logistic regression model. And the association between food insecurity and COVID-19 infection by age, sex, race/ethnicity, unemployment, federal poverty level, and the number of children was reported additionally. Multiple imputations (imputation number=20) for variables with missing data were conducted using the “PROC MI” procedure in SAS software.16 Pooled estimates of multiply imputed data were reported. As a sensitivity analysis, we also reported results from data without imputation (Appendix Table 3 and Table 4). All analyses were conducted using SAS software (version 9.4; SAS Institute Inc., Cary, North Carolina).

      Results

      This study included 61,050 non-institutionalized adults with an average age of 48.1 years. In the weighted sample (n=252,604,899), 6.8% of the participants lived in food-insecure households, and 18.9% tested positive for COVID-19 infection. The prevalence of food insecurity and COVID-19 infection for subgroups was also reported (Appendix Figure 1). Across all the subgroups, the prevalence of food insecurity was highest for participants below the poverty line (24.7%), the uninsured (15.6%), and non-Hispanic Blacks (13.8%). The prevalence of positive COVID-19 infection was highest for Hispanics (27.3%), the uninsured (26.1%), and those with ≥3 adults in the household (25.5%) among all the subgroups.
      Table 1 presents the characteristics of participants by food insecurity. Results of the univariate analyses showed that age, sex, race/ethnicity, education, marital status, employment, federal poverty level, the number of adults and children in the household, self-reported health status, and presence of chronic conditions were significantly associated with food insecurity (all p<0.0001). Results of the adjusted logistic regression models in Table 2 further indicated that young (18-34 years) or middle age (35-64 years), female sex, minor race/ethnicity (Hispanic/non-Hispanic Black/non-Hispanic Asian/others), education level less than high school, unmarried status, unemployment, federal poverty level, having no health insurance, a larger number of children in the household, poorer self-reported health status, and presence of chronic conditions were significantly associated with food insecurity (AOR ranged from 1.20 to 3.15, all p<0.001). We also reported socio-demographic and health-related characteristics of participants by COVID-19 infection status in Appendix Table 2. Compared to participants with negative COVID-19 infection, those with positive COVID-19 infection were more likely to be young (18-34 years) or middle-aged (35-64 years), Hispanic, less educated (≤high school), married, below the federal poverty level, uninsured, having a greater number of adults and children in the household, having poor self-reported health status, and living with chronic conditions (all p<0.05).
      Table 1Socio-demographic and Health-related Characteristics of Participants by Food Insecurity, 2020-2021 NHIS Sample
      VariablesTotalFood secureFood insecurep-value
      Age (years)
      18-3429.2 (0.3)29.0 (0.3)32.6 (1.1)<0.0001
      35-6440.3 (0.3)39.9 (0.3)44.9 (1.1)
      ≥6530.5 (0.3)31.1 (0.3)22.5 (0.8)
      Sex
      Male48.3 (0.2)48.8 (0.3)41.6 (1.1)<0.0001
      Female51.7 (0.2)51.2 (0.3)58.4 (1.1)
      Race/ethnicity
      Hispanic16.8 (0.7)16.3 (0.6)25.0 (1.4)<0.0001
      NH-White62.8 (0.8)64.3 (0.8)42.7 (1.4)
      NH-Black11.7 (0.4)10.9 (0.4)23.0 (1.2)
      Others8.6 (0.4)8.5 (0.3)9.3 (1.3)
      Education
      ≤High school39.3 (0.4)37.8 (0.4)60.1 (1.1)<0.0001
      >High school60.7 (0.4)62.2 (0.4)39.9 (1.1)
      Marital status
      Married51.6 (0.3)52.9 (0.3)33.5 (1.0)<0.0001
      Unmarried48.4 (0.3)47.1 (0.3)66.5 (1.0)
      Employment
      Yes61.6 (0.3)62.7 (0.3)45.2 (1.1)<0.0001
      No38.4 (0.3)37.3 (0.3)54.8 (1.1)
      Federal poverty level
      <100%9.9 (0.2)8.1 (0.2)35.1 (1.2)<0.0001
      ≥100%90.1 (0.2)91.9 (0.2)64.9 (1.2)
      Health insurance
      Yes91.2 (0.3)92.0 (0.2)80.1 (1.1)<0.0001
      No8.8 (0.3)8.0 (0.2)19.9 (1.1)
      Number of children in the household
      067.1 (0.3)67.6 (0.3)59.9 (1.1)<0.0001
      ≥132.9 (0.3)32.4 (0.3)40.1 (1.1)
      Number of adults in the household
      1-286.3 (0.3)13.8 (0.3)13.0 (0.9)0.429
      ≥313.7 (0.3)86.2 (0.3)87.0 (0.9)
      Self–reported health status
      Good or above86.3 (0.2)87.7 (0.2)65.7 (1.0)<0.0001
      Fair or poor13.7 (0.2)12.3 (0.2)34.3 (1.0)
      Chronic conditions
      No47.8 (0.3)48.3 (0.3)40.7 (1.1)<0.0001
      Yes52.2 (0.3)51.7 (0.3)59.3 (1.1)
      Positive COVID-19 infection
      Yes18.9 (0.4)18.9 (0.4)23.1 (1.5)<0.0001
      No81.1 (0.4)81.1 (0.4)76.9 (1.5)
      Note. Values were expressed as % (SEs). All percentages (%) and standard errors (SEs) were calculated based on the weighted sample.
      NHIS, National Health Interview Survey; NH, non-Hispanic.
      Table 2Socio-demographic and Health-related Factors Associated with Food Insecurity, 2020-2021 NHIS Sample
      VariablesUnadjusted OR
      Unadjusted ORs, AORs, and 95% CIs were calculated based on the weighted sample.
      (95%CI)
      AOR
      The association between each socio-demographic or health-related factor and food insecurity was adjusted for the remaining factors. All the associations were significant at p<0.001. NHIS, National Health Interview Survey; NH, non-Hispanic; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; Ref, reference group.
      (95% CI)
      Age (years)
      ≥65RefRef
      18-341.57 (1.39, 1.77)2.23 (1.88, 2.64)
      35-641.56 (1.4, 1.73)2.14 (1.85, 2.47)
      Sex
      MaleRefRef
      Female1.23 (1.47, 1.47)1.20 (1.08, 1.32)
      Race/ethnicity
      NH-WhiteRefRef
      Hispanic2.32 (2.06, 2.61)1.44 (1.25, 1.65)
      NH-Black3.26 (2.92, 3.65)2.11 (1.85, 2.39)
      Others1.62 (1.25, 2.1)1.54 (1.24, 1.92)
      Education
      >High schoolRefRef
      ≤High school2.49 (2.28, 2.72)1.51 (1.36, 1.66)
      Marital status
      MarriedRefRef
      Unmarried2.21 (2.01, 2.42)1.64 (1.48, 1.82)
      Employment
      YesRefRef
      No2.06 (1.89, 2.25)1.61 (1.44, 1.79)
      Federal poverty level
      ≥100%RefRef
      <100%6.14 (5.56, 6.79)3.15 (2.79, 3.55)
      Health insurance
      YesRefRef
      No2.85 (2.5, 3.24)2.00 (1.71, 2.33)
      Number of adults in the household
      1-2RefRef
      ≥30.93 (0.8, 1.08)1.31 (1.10, 1.56)
      Number of children in the household
      0RefRef
      ≥11.4 (1.28, 1.54)1.20 (1.07, 1.36)
      Self–reported health status
      Good or aboveRefRef
      Fair or poor3.76 (3.43, 4.13)2.63 (2.35, 2.95)
      Chronic conditions
      NoRefRef
      Yes1.36 (1.24, 1.49)1.46 (1.28, 1.66)
      a Unadjusted ORs, AORs, and 95% CIs were calculated based on the weighted sample.
      b The association between each socio-demographic or health-related factor and food insecurity was adjusted for the remaining factors. All the associations were significant at p<0.001.NHIS, National Health Interview Survey; NH, non-Hispanic; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; Ref, reference group.
      Table 3 provides the association between food insecurity and COVID-19 infection in the overall population and subgroups. Multicollinearity was checked by correlation coefficients (absolute value of all correlation coefficients<0.31) and values of variance inflation factor (VIF) (ranged from 1.01 to 1.76, all values<10). Food insecurity was significantly associated with positive COVID-19 infection in the overall population adjusting for socio-demographic and health-related factors (AOR=1.25, 99% CI: 1.11, 1.40). Noticeably, the greatest magnitude of the association was observed for non-Hispanic Blacks (AOR=1.20, 99% CI: 1.19, 1.20), females (AOR=1.29, 99% CI: 1.28, 1.30), and low-income households (below the federal poverty level) (AOR=1.21, 99% CI: 1.21, 1.22) across all the groups. However, we did not any significant interaction between food insecurity and age, sex, race/ethnicity, employment, federal poverty level, or the number of children.
      Table 3The Association Between Food Insecurity and COVID-19 Infection Among the Overall Population and Subgroups, 2020-2021 NHIS Sample
      AOR
      AORs and 95% CIs were calculated based on the weighted sample. Participants without food insecurity were set as the reference group (AOR=1). Age, sex, race/ethnicity, education, marital status, employment, federal poverty level, the number of adults and children in the household, self-reported health status, and chronic health conditions were adjusted.
      (95% CI)
      Interaction p-value
      p-value for interactions between food insecurity and age, sex, race/ethnicity, employment, federal poverty level, or the number of children. NHIS, National Health Interview Survey; NH, non-Hispanic; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval.
      Overall1.25 (1.11, 1.40)
      Age (years)0.981
      18-341.33 (1.06, 1.68)
      35-641.32 (1.08, 1.61)
      ≥651.29 (1.00, 1.66)
      Sex0.112
      Male1.20 (0.99, 1.46)
      Female1.44 (1.20, 1.71)
      Race/ethnicity0.151
      Hispanic1.26 (0.99, 1.59)
      NH-White1.08 (0.90, 1.31)
      NH-Black1.47 (1.15, 1.88)
      Others1.49 (0.99, 2.25)
      Employment0.945
      Employed1.31 (1.08, 1.59)
      Unemployed1.32 (1.09, 1.59)
      Federal poverty level0.363
      ≥100%1.24 (1.05, 1.46)
      <100%1.39 (1.12, 1.73)
      With Children0.791
      No1.29 (1.05, 1.59)
      Yes1.34 (1.12, 1.59)
      a AORs and 95% CIs were calculated based on the weighted sample. Participants without food insecurity were set as the reference group (AOR=1). Age, sex, race/ethnicity, education, marital status, employment, federal poverty level, the number of adults and children in the household, self-reported health status, and chronic health conditions were adjusted.
      b p-value for interactions between food insecurity and age, sex, race/ethnicity, employment, federal poverty level, or the number of children.NHIS, National Health Interview Survey; NH, non-Hispanic; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval.

      Discussion

      Overall, 6.8% of the participants lived in food-insecure households, and 18.9% tested positive for COVID-19 infection. Young (18-34 years) or middle age (35-64 years), female sex, minor race/ethnicity (Hispanic/non-Hispanic Black/non-Hispanic Asian/others), education level less than high school, unmarried status, unemployment, below the federal poverty level, having no health insurance, a larger number of adults and children in the household, poorer self-reported health status, and presence of chronic conditions were significantly associated with food insecurity. Food insecurity was independently associated with positive COVID-19 infection controlling for socio-demographic and health-related factors. The magnitude of the association was greatest for the non-Hispanic Blacks, females, and those below the poverty level across all the groups.
      Socio-demographic and health-related factors associated with food insecurity highlight vulnerable communities that should be considered when allocating food resources and benefits during the pandemic. Our results were consistent with a cross-sectional study that examined socio-demographic disparities in food insufficiency (the most extreme form of food insecurity) during the pandemic (October 2020) with participants from the US Census Household Pulse Survey.5 Although the overall food insecurity in the U.S. has improved during the past decades, socially and economically disadvantaged groups such as females, Hispanics/non-Hispanic Blacks, and low-income populations are still vulnerable to food insecurity.17,18 The widespread COVID-19 pandemic that began in 2020 has substantially affected the same disadvantaged populations.19 For example, pandemic-induced unemployment unequally affected employment sectors such as restaurants, public transportation, personal services, and retails which had a high percentage of young adults, females, Hispanics/non-Hispanic Blacks, and those with lower socioeconomic backgrounds.20 Disrupted food supply chains and food benefits such as the National School Lunch Program, and continuously rising food prices also placed vulnerable communities such as households with children at an increased risk of food insecurity.21,22
      Food insecurity was associated with positive COVID-19 infection. The results were consistent with a cross-sectional study using a random subsample of 3,212 older participants from the Health and Retirement Study.11 Older adults with household food insecurity had significantly higher odds of reporting positive COVID-19 infection within their households (AOR=1.73, 95% CI: 1.03, 2.90) and among their acquaintances (AOR=1.32, 95% CI: 1.05, 1.65).11 Besides, we observed the highest magnitude of the association between food insecurity and COVID-19 infection for non-Hispanic Blacks, females, and low-income households. Being vulnerable to both food insecurity and COVID-19 infection may account for the relatively higher magnitudes of the association in those subgroups. For example, our data suggested that the prevalence of food insecurity was highest in those below the federal poverty level (24.7%) across all groups and was higher in the non-Hispanic Blacks (13.8%) and females (7.7%) than the overall population (Appendix Figure 1(a)). The prevalence of positive COVID-19 infection was also higher for females (18.4%) and the low-income communities (22.4%) than the overall level (Appendix Figure 1(b)).
      Food insecurity may be associated with COVID-19 infection through (1) poorer diet quality and insufficient nutrient intake; (2) less practicing physical distance in public or taking preventive actions. When compared to food-secure individuals, those with household food insecurity had significantly lower Healthy Eating Index scores, a measure of diet quality (difference in score=-2.22 unit, 95% CI: -3.35, -1.08).23,24 Food insecurity was also associated with less consumption of fruit, vegetables, dairy products, and whole grains, and a lower intake of vitamins A and B-6, calcium, magnesium, and zinc.25,26 Nutrients such as vitamins, calcium, magnesium, and zinc are important for supporting immune systems (e.g., providing energy, regulating immune cell metabolism, functioning as antibacterial or anti-viral products, and being substrates for the intestinal microbiota).27,28,29 Weakened immune system due to a lack of essential nutrients and its associated inflammation, oxidative stress, and gut dysbiosis may further contribute to poorer defense against pathogens, increased susceptibility to virus infection, and severer disease symptoms.30 The other explanation which may account for the observed association between food insecurity and COVID-19 infection is that the food-insecure population may be less likely to practice physical social distancing in public and take protective actions than the food-secure population. For example, compared with food-secure individuals, food-insecure individuals were less likely to comply with public health recommendations to stock up on two weeks of food to avoid excess trips and practice social distancing.31 Our results suggested that food-insecure individuals were more likely to have lower socioeconomic backgrounds than food-secure individuals. Studies have shown that lower socioeconomic status (e.g., lower income or education level) was significantly associated with less engagement in COVID-19 protective behaviors such as avoiding leaving home, hand washing, cleaning, or disinfecting.32 Besides, food-insecure adults were more likely to report challenges in getting medications or having needed healthcare during the pandemic.31 Individuals with poorer health status due to unmet health care needs may be more vulnerable to COVID-19 infection and experience disease symptoms than those with better health conditions.33,34
      Our study was strengthened by using a nationally representative sample from the NHIS. To the best of our knowledge, this is the first study to examine the association between food insecurity and COVID-19 infection in the overall U.S. adults and communities vulnerable to food insecurity. The results had practical implications for policymakers and future pandemic prevention. Allocations of food benefits such as nutrient assistance programs should target disadvantaged communities such as females, Hispanics/non-Hispanic Blacks, and those with lower socioeconomic backgrounds. Policies addressing food insecurity may help reduce the likelihood of COVID-19 infection, especially for vulnerable subgroups such as the young, females, and non-Hispanic Blacks.

      Limitations

      There were a few limitations of this study. First, the cross-sectional study prevented causality inference. Food insecurity was measured with a 30-day look-back window and the temporal relationship between food insecurity and COVID-19 infection could not be determined. Therefore, reverse causality should not be excluded. Poorer health conditions may alternatively increase vulnerability to food insecurity by affecting the employment or income status and adding additional financial burden.35 Second, COVID-19 infection status and health-related covariates were self-reported thus being subject to recall bias. Positive COVID-19 infection was possibly underestimated since the asymptomatic populations were not tested. Although sampling weights have been applied to account for non-response bias, the prevalence of food insecurity and positive COVID-19 infection may still be underrepresented due to lower response rates during the pandemic. Last, the association between food insecurity and symptoms or severity of COVID-19 infection was not analyzed due to the limited sample size of positive cases. Unmeasured factors associated with food insecurity and COVID-19 infection may still exist and confound the association.

      Conclusions

      Food insecurity unequally affected vulnerable groups and was associated with positive COVID-19 infection. Policies addressing food insecurity may help reduce the likelihood of COVID-19 infection and improve public health. Allocation of food resources during the pandemic should target the most disadvantaged groups such as the young, females, minor race/ethnicity groups, and those with lower socioeconomic backgrounds. Screening of health conditions and providing affordable health resources are also necessary for food-insecure populations.

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      Financial disclosure

      No financial disclosure is reported by the author of this manuscript.

      Author CRediT statement

      J.C.: Conceptualization; Methodology; Software; Formal analysis; Writing-original draft; Writing-review&editing.

      Conflict of interest statement

      No conflict of interest is reported by the author of this manuscript.

      Acknowledgments

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Appendix. Supplementary materials