General Psychiatry

Study Author Q&A: COVID-19, Food Insufficiency, and Mental Health in the United States

Mary Beth Maslowski
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Volunteers help load a vehicle with boxes of food at a food bank in the Los Angeles County city of Duarte, California on July 8, 2020 as the record for most coronavirus cases in a single day is set in California. – Oxfam, the confederation of 19 charitable independent organizations focusing on the alleviation of global poverty, is due to release an embargoed report on July 9 suggesting that COVID-19 may kill more people worldwide due to hunger than the illness itself. (Photo by Frederic J. BROWN / AFP) (Photo by FREDERIC J. BROWN/AFP via Getty Images)
With food insecurity on the rise in the United States, we interview two authors of a study on food insufficiency in the US and its impact on mental health.

Food insufficiency in the United States increased from 8.1% to 10% between March and June 2020 when coronavirus disease 2019 (COVID-19) cases were spiking, according to researchers writing in the January 9 issue of the American Journal of Preventive Medicine.1

The authors, who were led by Jason M. Nagata, MD, MSc, an Assistant Professor of Pediatrics in the Division of Adolescent and Young Adult Medicine at the University of California San Francisco, describe food insecurity as inherently linked to one’s ability to secure employment, but it also affects mental health. He and his colleagues found that among 63,674 men and women surveyed, most experienced mental distress including anxiety, worry, apathy or depression.

Food insecurity, according to the United States Department of Agriculture, is defined as a lack of nutritionally adequate and safe foods to support an active, healthy lifestyle2.   

Dr. Nagata and his colleagues stress the importance of addressing food insecurity in COVID-19 public health relief programs. They suggest providing additional funding for school food programs and food banks. Doing so, they wrote, could “mitigate poor mental health outcomes.” They also suggest the adoption of health and social support service interventions to provide healthy meals and mental health support. Paid sick leave, rent/mortgage delays, and stimulus funding for the unemployed should also be considered, the authors urged.

 Jason M. Nagata, MD, MSc

In this Q&A, we talk with Dr. Nagata, and Kyle T. Ganson PhD, MSW, Assistant Professor at the University of Toronto Factor-Inwentash Faculty of Social Work, who discuss the study’s findings and their recommendations in more detail.

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Receiving free food or food aid alleviated the relationship between food insufficiency and poor mental health, Dr. Nagata said.

​“As the pandemic continues, and the new administration takes office, additional stimulus will be critical to strengthen various public assistance programs aimed at reducing food insufficiency,” Dr. Ganson said.

Regarding future research, the study authors said that the effectiveness of various food assistance programs and interventions during the pandemic should be evaluated.

Psychiatry Advisor: What are the highlights of your study?

Kyle T. Ganson PhD, MSW

Dr. Nagata & Dr. Ganson:  Using a large national sample of nearly 64,000 adults, we found that food insufficiency rose by one quarter, from 8.1-10.0%, during the pandemic (from March to June 2020). People of color and younger adults had a higher risk of food insufficiency. Women and men living in poverty or experiencing recent job loss were at higher risk of food insufficiency. Food insufficiency was associated with symptoms of anxiety, worrying, and depression. Nearly two-thirds of Americans reported anxiety symptoms and over one-half reported depressive symptoms in the past week.

Psychiatry Advisor: Why is this study important?

Dr. Nagata & Dr. Ganson: While rates of food insecurity have been projected to rise during the COVID-19 pandemic, prior studies did not examine the relationship between food insufficiency — the most extreme form of food insecurity — and mental health.

​This study also shows how specific demographic groups, for example those who identify as Black or Hispanic and those who live below the federal poverty level, are at greater risk of food insufficiency during COVID-19. The ripple effects of COVID-19 disproportionately impact people of color and people with lower incomes.

Psychiatry Advisor: How has food insecurity worsened in the United States since the start of the COVID-19 pandemic?

Dr. Nagata & Dr. Ganson: Using a large national sample of nearly 64,000 adults, we found that food insufficiency rose by a quarter, from 8.1-10.0%, during the pandemic. Nearly one-tenth of Americans reported receiving free groceries or meals in the past week, most commonly from school programs, food banks, or food pantries.

Psychiatry Advisor: What is the bidirectional relationship between food insecurity and depressive symptoms?

Dr. Nagata & Dr. Ganson: Hunger, exhaustion, and worrying about not getting enough food to eat may worsen depression and anxiety symptoms. On the other hand, poor mental health can make it harder for someone to concentrate, work, generate income, and prepare meals, leading to food insecurity.

Psychiatry Advisor: In your study you wrote that food insufficiency limits engagement with mental health services, worsens treatment adherence, and elevates the risk for psychiatry emergency care and hospitalization. Can you explain how food insufficiency contributes to these issues?

Dr. Nagata & Dr. Ganson: We have previously shown that food insecurity was associated with higher suicide risk, which would be considered a psychiatric emergency and require hospitalization. People who are food insecure may have worse adherence to medications as some medications have unpleasant side effects when taken on an empty stomach.

Psychiatry Advisor: Based on the findings of your study, what advice do you have for clinicians?

Dr. Nagata & Dr. Ganson: Clinicians should assess for food insecurity and poor mental health during the pandemic. There are brief 2-question screeners for food insecurity validated for use in primary care. Clinicians can also provide referrals and support for programs such as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the National School Lunch Program and School Breakfast Program.

Resource

In Food Insecurity and Health: A Tool Kit for Physicians and Health Care Organizations, put out by FeedingAmerica.org, the organization lists how physicians/clinicians can help address food insecurity.

Physicians and clinicians can play a critical role in identifying and addressing patient food insecurity. By screening for social determinants of health, they can easily add food insecurity to the clinical dialogue and make referrals to community resources if needed.

The food insecurity screening and referral process consists of five steps:

  1. Identifying patients living in food insecure households
  2. Connecting patients with proper resources
  3. Considering clinical needs that result from food insecurity
  4. Following up with patients at their next office visit
  5. Measuring the impact of food insecurity intervention(s) on patients’ food insecurity status and health3

Reference

1.     Nagata JM, Ganson KT, Whittle HJ, et al. Food insufficiency and mental health in the US during the COVID-19 pandemic. Am Journal Prev Med. Published online January 7, 2021.  doi:10.1016/j.amepre.2020.12.004

2. Coleman-Jensen A, Rabbitt MP, Gregory C, Singh A. Household food security in the United States in 2018: Summary. U.S. Department of Agriculture, Economic Research Report, Number 270. https://www.ers.usda.gov/publications/pub-details/?pubid=94848. Published 2019. Accessed February 5, 2021.

3. Food Insecurity and Health: A Tool Kit for Physicians and Health Care Organizations. Hunger + Health Feeding America. https://hungerandhealth.feedingamerica.org/wp-content/uploads/2017/11/Food-Insecurity-Toolkit.pdf. Accessed February 5, 2021