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Food as a Critical Social Determinant of Health Among Older Adults During the Coronavirus Disease 2019 (COVID-19) Pandemic

  • 1Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
  • 2Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor
  • 3VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
  • 4Department of Internal Medicine, University of Michigan Medical School, Ann Arbor

At the end of 2019, before the coronavirus disease 2019 (COVID-19) pandemic upended daily life, 1 in 7 adults (14%) aged 50 to 80 years experienced food insecurity (ie, difficulty acquiring healthy food due to insufficient financial resources). In a December 2019 nationally representative poll of 2048 adults aged 50 to 80 years old in the United States, we found that among those who experienced food insecurity, 42% had severe food insecurity, meaning they sacrificed the quality or amount of food they consumed because they lacked sufficient resources. Food insecurity is associated with many adverse health outcomes among older adults, including poorer physical and mental health. The health consequences of food insecurity have almost certainly become more pervasive as the COVID-19 pandemic has disrupted daily life and routine health behaviors as well as caused financial hardships for many older adults.

Immediately prior to the COVID-19 pandemic, older adults also cooked frequently at home. In fact, in December 2019, nearly half of adults between the ages of 50 and 80 years cooked dinner at home 6 to 7 days a week and another 40% cooked dinner at home 3 to 5 days a week. Older adults also frequently went shopping for food. A total of 1 in 5 (20%) shopped for food more than once a week, and another 45% shopped for food once a week. Only 5% of older adults reported getting groceries through curbside pickup or home delivery.

Stay-at-home orders since March 2020 have necessitated that US residents cook at home more than eat out. On average, cooking at home has been shown to be associated with better diet quality,1 and stronger cooking skills have also been associated with better food security status,2 so a shift to more cooking at home could have positive health outcomes. However, whether cooking at home during the pandemic results in better or worse diet quality for older Americans will depend in large part on whether they have the sufficient financial resources (ie, whether they are food secure) and whether their community has continued availability of healthy foods.

The COVID-19 pandemic has illuminated the precarious position many US residents are in regarding food security. As the economy shut down and stay at home orders went into place, individuals lost their jobs and incomes, and rates of food insecurity rapidly climbed. Older adults were particularly susceptible, given that they had to navigate new ways of procuring food while they sheltered in place to avoid exposure to COVID-19. Therefore, as the pandemic evolves and the deleterious economic effects continue, it is critical that policymakers ensure that a robust suite of policies and programs are in place to provide food assistance to older Americans who need it. Immediate priorities should include the following.

Strengthen the Supplemental Nutrition Assistance Program

The Supplemental Nutrition Assistance Program (SNAP) is our nation’s first line of defense against food insecurity, providing monetary benefits to purchase food. As part of the pandemic response, recent efforts, such as the Pandemic Electronic Benefits Transfer program and expansion of the Online Purchasing Pilot, have allowed more US residents, particularly families with children, to access SNAP benefits and use them for grocery delivery. However, SNAP benefits, which have long been believed to be inadequate, should be increased for all SNAP participants to allow for stocking up on food or to account for rising food prices during supply chain disruptions. Current federal legislation would provide a temporary boost to SNAP benefits and expand SNAP access to all low-income US residents through September 2021.

Expand the Older Americans Act Nutrition Program

The Older Americans Act (OAA) provides congregate and home-delivered meals to adults aged 60 years and older through programs like Meals on Wheels. However, the demand for home-delivered meals has doubled since March 2020, and additional costs related to food preparation, storage, and safety supplies have limited the program’s ability to meet current needs. The Heroes Act would provide an additional $19 million to OAA to support the provision of nutritious meals to older adults.

Provide Additional Funding to Support Food Banks, Food Pantries, and Other Emergency Food Assistance Programs

It is estimated that 3 million adults aged 65 years and older receive food from food banks and other emergency sources annually, but this number has dramatically increased due to COVID-19. Feeding America has set up a $2.65 million COVID-19 Response Fund to help meet its growing needs. The Heroes Act would provide an additional $150 million to local food banks to distribute additional food within their communities.

Expand Screening for Food Insecurity in Health Systems

In addition to robust public policies, the health care system also has an important role to play3 in identifying older adults most at risk of food insecurity and inadequate nutrition. Health care professionals, particularly in primary care and community settings, should screen for food insecurity4 and have information about SNAP application assistance, local food distributions, and other community food resources available to connect patients to resources5 to access healthy food. Given the unique challenges to procuring and affording healthy food presented by the COVID-19 pandemic for older adults, it is especially important that health care professionals be prepared to frankly engage with patients regarding food shopping, food choices, food behaviors, and food security.

Having adequate, healthy food is a key determinant of health outcomes during the short and long term. Prior to the COVID-19 pandemic, too many low-income older adults experienced food insecurity and struggled with poor health despite cooking frequently at home. The financial strain so many households across the United States are experiencing as a result of the pandemic will only exacerbate existing disparities in food insecurity and health outcomes if steps are not taken by policy makers to protect the social safety net and ensure that US residents in general, and older adults in particular, have access to sufficient, nutritious food.

Article Information

Correction: This article was corrected on August 10, 2020, to fix an error in an author’s degrees.

Corresponding Author: Julia Wolfson, PhD, MPP, Department of Health Management and Policy, University of Michigan School of Public Health, M3240 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109 (jwolfson@umich.edu).

Conflict of Interest Disclosures: Dr. Wolfson reported receiving grants from the National Institutes of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health outside the submitted work. Dr Leung reported receiving grant funding from the Eunice Kennedy Shriver National Institute for Child Health and Human Development of the National Institutes of Health outside the submitted work. Dr Kullgren reported receiving grant and salary support for the University of Michigan National Poll on Healthy Aging from AARP and the Institute for Healthcare Policy and Innovation at the University of Michigan; receiving grants and nonfinancial support from the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service outside the submitted work; receiving consulting fees from SeeChange Health, HealthMine, and the Kaiser Permanente Washington Health Research Institute outside the submitted work; receiving honoraria from the Robert Wood Johnson Foundation, AbilTo, the Kansas City Area Life Sciences Institute, and the American Diabetes Association outside the submitted work; and receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Additional Contributions: We acknowledge the contributions of Preeti Malani, MD, MS, MSJ; Erica Solway, PhD, MSW, MPH; Matthias Kirch, MS; and Dianne Singer, MPH (University of Michigan).

References
1.
Wolfson  JA, Leung  CW, Richardson  CR.  More frequent cooking at home is associated with higher Healthy Eating Index-2015 score.   Public Health Nutr. 2020;1-11. doi:10.1017/S1368980019003549PubMedGoogle Scholar
2.
Engler-Stringer  R, Stringer  B, Haines  T.  Complexity of food preparation and food security status in low-income young women.   Can J Diet Pract Res. 2011;72(3):133-136. doi:10.3148/72.3.2011.133PubMedGoogle ScholarCrossref
3.
Andermann  A.  Screening for social determinants of health in clinical care: moving from the margins to the mainstream.   Public Health Rev. 2018;39:19. doi:10.1186/s40985-018-0094-7PubMedGoogle ScholarCrossref
4.
Pooler  JA, Hoffman  VA, Karva  FJ.  Primary care providers’ perspectives on screening older adult patients for food insecurity.   J Aging Soc Policy. 2018;30(1):1-23. doi:10.1080/08959420.2017.1363577PubMedGoogle ScholarCrossref
5.
Buitron de la Vega  P, Losi  S, Sprague Martinez  L,  et al.  Implementing an EHR-based screening and referral system to address social determinants of health in primary care.   Med Care. 2019;57(Suppl 6 Suppl 2):S133-S139. doi:10.1097/MLR.0000000000001029PubMedGoogle ScholarCrossref
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