Charlotte J. Talham,Faustine Williams
Household food insecurity during the COVID-19 pandemic is associated with anxiety and depression among US- and foreign-born adults: Findings from a nationwide survey
Food insecurity,Mental health,Depression,Anxiety,COVID-19,Foreign-born
The COVID-19 pandemic led to significant disruptions to household food security with as many as 10.5 % of US households experiencing food insecurity during 2020. Food insecurity is associated with psychological distress including depression and anxiety. However, to the best of our knowledge, no study has analyzed the association between COVID-19 food insecurity and poor mental health outcomes by place of birth. The Understanding the Impact of the Novel Coronavirus (COVID-19) and Social Distancing on Physical and Psychosocial (Mental) Health and Chronic Diseases national survey assessed the physical and psychosocial effects of social and physical distancing during the COVID-19 pandemic among a diverse population of US- and foreign-born adults. Multivariable logistic regression was used to assess the relationship between place of birth and food security status and anxiety (N = 4817) and depression (N = 4848) among US- and foreign-born individuals. Stratified models subsequently analyzed the associations between food security and poor mental health among US- and foreign-born populations separately. Model controls included sociodemographic and socioeconomic factors. Low and very low household food security were associated with greater odds of both anxiety (low: odds ratio (OR) [95 % confidence interval (CI)] = 2.07 [1.42–3.03]; very low: OR [95 % CI] = 3.35 [2.15–5.21]) and depression (low: OR [95 % CI] = 1.92 [1.33–2.78]; very low: OR [95 % CI] = 2.36 [1.52–3.65]). However, this relationship was attenuated among foreign-born individuals compared to US-born individuals in the stratified models. All models found a dose-response relationship between increasing levels of food insecurity and anxiety and depressive symptoms. Further research is needed to explore the factors that attenuated the relationship between food insecurity and poor mental health among foreign-born individuals.
Household food insecurity during the COVID-19 pandemic is associated with anxiety and depression among US- and foreign-born adults: Findings from a nationwide survey

The COVID-19 pandemic led to significant disruptions to household food security with as many as 10.5 % of US households experiencing food insecurity during 2020. Food insecurity is associated with psychological distress including depression and anxiety. However, to the best of our knowledge, no study has analyzed the association between COVID-19 food insecurity and poor mental health outcomes by place of birth. The Understanding the Impact of the Novel Coronavirus (COVID-19) and Social Distancing on Physical and Psychosocial (Mental) Health and Chronic Diseases national survey assessed the physical and psychosocial effects of social and physical distancing during the COVID-19 pandemic among a diverse population of US- and foreign-born adults. Multivariable logistic regression was used to assess the relationship between place of birth and food security status and anxiety (N = 4817) and depression (N = 4848) among US- and foreign-born individuals. Stratified models subsequently analyzed the associations between food security and poor mental health among US- and foreign-born populations separately. Model controls included sociodemographic and socioeconomic factors. Low and very low household food security were associated with greater odds of both anxiety (low: odds ratio (OR) [95 % confidence interval (CI)] = 2.07 [1.42–3.03]; very low: OR [95 % CI] = 3.35 [2.15–5.21]) and depression (low: OR [95 % CI] = 1.92 [1.33–2.78]; very low: OR [95 % CI] = 2.36 [1.52–3.65]). However, this relationship was attenuated among foreign-born individuals compared to US-born individuals in the stratified models. All models found a dose-response relationship between increasing levels of food insecurity and anxiety and depressive symptoms. Further research is needed to explore the factors that attenuated the relationship between food insecurity and poor mental health among foreign-born individuals.

The US Department of Agriculture (USDA) defines food-insecurity as limited or uncertain access to enough food to meet the needs of all members of a household due to insufficient money or other resources (Economic Research Service, 2022a). The COVID-19 pandemic led to significant disruptions to household food security due to a rise in unemployment, interruptions to food supply chains, and temporary pauses to school lunch programs (Ahn and Norwood, 2021; Restrepo et al., 2021). Ten and a half percent of US households were food insecure at some point during 2020 according to the USDA. While the USDA did not report a change in the prevalence of food insecurity between 2019 and 2020 (Coleman-Jensen et al., 2021), several studies estimated that during the spring of 2020, food insecurity may have doubled (Schanzenbach and Pitts, 2020) or even tripled (Ziliak, 2021) compared to pre-pandemic levels. The USDA did, however, report a rise in food insecurity in 2020 among certain groups including households with children as well as sharp increases in food insecurity among non-Hispanic Black and Hispanic/Latino households (Coleman-Jensen et al., 2021). As of 2018, the US was home to around 44.8 million immigrants, representing nearly 14 % of the total population (Budiman et al., 2020). Previous research has shown a higher likelihood of food insecurity among foreign-born individuals and children of foreign-born mothers when compared to their US-born counterparts (Arteaga et al., 2017; Becerra et al., 2018; Myers and Painter, 2017). In the absence of national data on food insecurity among this population, the exact prevalence is difficult to estimate. However, most estimates from small-scale studies on various subpopulations range from 30 to 60 % (Food Insecurity among Immigrants, Refugees, and Asylees in the United States, 2016; Hager et al., 2018). The high prevalence of food insecurity observed among foreign-born individuals in the US is often attributed to lower levels of acculturation and social connectedness compared to US-born individuals (Vu et al., 2020). This leads to unique barriers to accessing employment opportunities as well as governmental and charitable food assistance programs (Vu et al., 2020). As such, disruptions to the food environment during the COVID-19 pandemic created added strains on food security in an already vulnerable population (International Rescue Committee, 2021). Researchers have observed higher prevalence of psychological distress among the general population as a consequence of COVID-19-related stressors including financial loss, social isolation, and fear of infection (Hossain et al., 2020). Additionally, several studies have reported a disproportionate burden of mental unwellness among foreign-born communities during this period. A 2020 survey of US adults found that foreign-born individuals were more likely to experience fear and worry related to the COVID-19 pandemic than US-born individuals (Fitzpatrick et al., 2020). Wu et al. found that foreign-born Asian individuals had higher depression and anxiety scores than US-born White individuals. However, they also reported worse mental health among US-born compared to foreign-born Asian individuals (Wu et al., 2021). Recent literature has found there may be a relationship between food insecurity and poor mental health outcomes including depression, anxiety, and sleep disorders (Arenas et al., 2019; Bruening et al., 2017). Food insecurity during the pandemic, then, may pose an acute threat to mental wellbeing. We are aware of several studies that have found positive associations between food insecurity and poor mental health during the pandemic (Fang et al., 2021; Nagata et al., 2022; Wolfson et al., 2021; Yenerall and Jensen, 2021). However, none have examined this relationship by place of birth (i.e., nativity or US-born vs. foreign-born). To fill this gap in the literature, our study analyzes the association between place of birth, food security status, and poor mental health. We hypothesized that, (1) due to greater social support and financial stability among US-born individuals, a stronger relationship would be observed between food insecurity and poor mental health among foreign-born individuals and (2) we would observe a gradient in the influence of food insecurity on poor mental health. Given that financial resources are correlated with both food security and mental health (Yenerall and Jensen, 2021), we control for financial resources in addition to sociodemographic factors in our analysis.

The Understanding the Impact of the Novel Coronavirus (COVID-19) and Social Distancing on Physical and Psychosocial (Mental) Health and Chronic Diseases was a national survey administered by Qualtrics LLC, a market research firm specializing in conducting web-based surveys. Qualtrics recruited, screened, and enrolled participants using their existing survey panels. Qualtrics randomly matched eligible panel members to a theoretical cohort, or target sample, based on demographic characteristics. The target sample was randomly drawn from the American Community Survey and included US- and foreign-born adults aged ≥18 years living in the US. The foreign-born target subsample included 330 African, 158 Caribbean, 1096 Hispanic/Latino (including 800 Mexican), and 200 Asian individuals. The US-born target subsample included 800 Hispanic/Latino, 800 White, 800 Black/African American, 185 Asian, 385 American Indian/Alaskan Native, 385 Native Hawaiian/Pacific Islander individuals. Our total target sample size was thus (n = 5139). Qualtrics oversampled low income (<$30,000 annual household income) and rural (self-reported residing in rural area, cross-reference with zip codes already collected by Qualtrics) adults among US-born White, Black, and Hispanic and foreign-born participants. The 116-item survey assessed the physical and psychosocial effects of social and physical distancing during the COVID-19 pandemic among a diverse population of US- and foreign-born adults. The survey was created and distributed in English. Ten thousand surveys were distributed between 13 May 2021 and 09 January 2022. Each participant received a $5–$10 gift card from Qualtrics upon completion. Initial surveys received by Qualtrics were assessed via Expert Review Fraud Detection to prevent multiple submissions and detect “bots” to protect the integrity of the data. Qualtrics received 5938 surveys. Information Management Services (IMS), Inc.—a research support firm that provided analytic services—was given the de-identified survey data to clean and manage. To improve study integrity, initial data cleaning by IMS included flagging surveys based on completion rate and timing to complete the survey. Participants were flagged and removed from analysis if they completed <80 % of the survey based on 102 questions after accounting for skip pattern items, or if they took <5 min to complete the survey. The final sample included 5413 completed surveys. Participants were excluded from the present analysis if information on food security status was not provided in survey responses (n = 103). Our final sample size was thus N = 5310.

The outcomes of interest in our analysis were symptoms of anxiety and depression. These were assessed using the 2-item Generalized Anxiety Disorder questionnaire (GAD-2) and the 2-item Patient Health Questionnaire (PHQ-2), respectively. The GAD-2 asks participants, “Over the last two weeks how often have you been bothered by the following problems? 1. Feeling nervous, anxious or on edge. 2. Not being able to stop or control worrying.” Survey takers select from the following responses: “Not at all”, “Several days”, “More than half the days”, “Nearly every day”. Participant responses were scored for each item as Not at all (0); Several days (+1); More than half the days (+2); Nearly every day (+3). Responses were summed and scores of 3 or higher were considered as having symptoms of anxiety. The cutoff was selected based on validation studies that found good specificity at this level (Plummer et al., 2016). The PHQ-2 asks participants, “Over the last 2 weeks, how often have you been bothered by the following problems? 1. Little interest or pleasure in doing things. 2. Feeling down, depressed, or hopeless.” Survey takers select from the following responses: “Not at all”, “Several days”, “More than half the days”, “Nearly every day”. Participant responses were scored for each item as Not at all (0); Several days (+1); More than half the days (+2); Nearly every day (+3). Responses were summed and scores of 3 or higher were considered as having symptoms of major depressive disorder. This threshold was selected due to its high specificity (Arroll et al., 2010; Manea et al., 2016).

Participants who reported being born in the US were considered US-born (i.e., all 50 states including District of Columbia) and participants who were born in any other country were considered foreign-born (including Puerto Rico and other US territories). Household food security was assessed using the US Department of Agriculture's US Household Food Security Survey Module: 6-item short form (Economic Research Service, 2022b). The following questions were asked of participants: “How often were the following statements true for you/your household in the last 12 months: 1. The food that you bought just didn't last, and you didn't have money to get more. 2. You couldn't afford to eat balanced meals (Often; Sometimes; Never)”; “3. In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food? (Yes; No)”; “3a. If yes, in the last 12 months, how often did this happen? (Almost every month; Some months but not every month; Only 1 or 2 months)”; “4. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food? (Yes; No)”; “5. In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food? (Yes; No)”. Responses of “Often” or “Sometimes” to questions 1 and 2, “Yes” on questions 3, 4, and 5, and “Almost every month” and “Some months but not every month” on question 3a were scored as affirmative responses. Participants received a score equal to the sum of their affirmative responses. Food security status was assigned per USDA practices as follows: 0–1 were scored as high/marginal food security, 2–4 as low food security, and 5–6 as very low food security.

The model adjusted for sociodemographic factors including race/ethnicity (American Indian/Alaskan Native, Asian, Black/African American, Hispanic/Latino, Other race/multi-racial, White), age (≤40, >40), gender (man, woman, transgender and non-binary), marital status (married/living with partner, divorced/widowed/separated, never married), children in household (yes, no), and education (college degree or higher, some college/vocational training, high school/GED or less). Gender was assessed with the question, “What terms best express how you describe your gender identity? Check all that apply. (Man; Woman; Transgender; Non-binary; Other, specify)”. For the purposes of this analysis, participants who selected only man and only woman were identified as ‘man’ or ‘woman’, respectively, and all others were identified as ‘transgender and non-binary’. Additionally, participant responses to the following financial hardship questions were included as controls: “Since the Coronavirus/COVID-19 pandemic began, have you received unemployment insurance/benefits? (yes, no)”; “Since the Coronavirus/COVID-19 pandemic began, how difficult has it been for you to cover your expenses and pay all your bills? (yes/no)”; “Since the Coronavirus/COVID-19 pandemic began, has there been a time that you did not have enough money to pay your rent, mortgage, or other housing costs? (yes, no)”.

A multivariable logistic regression model was used to assess the relationship between place of birth and food security status and poor mental health including an interaction term between exposure variables of interest for each outcome—anxiety and depression. Stratified models retaining all covariate and control variables subsequently analyzed the associations between food security and poor mental health among US- and foreign-born populations separately. Listwise deletion was used for each analysis which resulted in a sample size of N = 4817 for the overall anxiety model and N = 4848 for the overall depression model. All analyses were conducted using StataSE 16. The National Institutes Health Institutional Review Board (IRB) approved the study on 12/23/2020 as an exempt (IRB #000308).

Table 1 shows the detailed participant characteristics by food security. The overall sample consisted of 5310 individuals of who 4109 (77 %) were born in the US and 1201 (23 %) were born outside of the US. The sample was primarily White (40 %), Black/African American (23 %) and Hispanic/Latino (18 %). A majority of the sample identified as women (62 %), was over 40 years of age (52 %) and was married (55 %). Additionally, most participants did not have children in their household (58 %), attained some college or vocational training or higher (71 %), did not receive unemployment benefits during the COVID-19 pandemic (81 %), had difficulty covering expenses during the pandemic (57 %) and did not have difficulty making housing payments during the pandemic (71 %). Around a quarter of the sample reported symptoms of anxiety (27 %) and depression (26 %). Most of the sample was food secure (61 %), however, 21 % reported low food security and 19 % reported very low food security. The sample distribution by food security and birthplace is presented in Supplementary Table S1. In general, the distribution for individuals born in the US is similar to the overall study sample.

Among the total sample, individuals with both low (odds ratio (OR) = 2.07; 95 % confidence interval (CI) = 1.42–3.03) and very low (OR = 3.35; 95 % CI = 2.15–5.21) household food security had greater odds of anxiety than those from food secure households. There was not a significant relationship between place of birth and symptoms of anxiety. However we estimate that the odds ratio for reporting anxiety symptoms comparing two groups of US-born individuals who differ by household food security (secure vs. very low food security) is 1.65 (95 % CI = 1.03–2.63) times the odds for anxiety comparing two groups of foreign-born individuals who differ in food security status. In the stratified model for US-born participants, those with low (OR = 2.98; 95 % CI = 2.41–3.69) and very low (OR = 5.36; 95 % CI = 4.26–6.74) household food security were found to have greater odds of anxiety symptoms compared to individuals from food secure households. Among foreign-born participants, those with low (OR = 2.22; 95 % CI = 1.47–3.35) and very low (OR = 4.31; 95 % CI = 2.55–7.27) household food security were found to have greater odds of anxiety symptoms than individuals from food secure households. See Table 2 for complete results from the logistic regression models for anxiety symptoms.

Among the total sample population, those with both low (OR = 1.92; 95 % CI = 1.33–2.78) and very low (OR = 2.36; 95 % CI = 1.52–3.65) household food security had greater odds of depression than those from food secure households. Foreign birth was not significantly associated with symptoms of depression. Nonetheless, we estimate that the odds ratio for reporting depressive symptoms comparing two groups of US-born individuals who differ by household food security (secure vs. very low food security) is 1.87 (95 % CI = 1.18–2.97) times the odds for depression comparing two groups of foreign-born individuals who differ in food security status. Among US-born individuals in the stratified model, those with low (OR = 2.91; 95 % CI = 2.36–3.60) and very low (OR = 4.32; 95 % CI = 3.44–5.43) household food security had greater odds of depressive symptoms than individuals from foods secure households. Among foreign-born individuals, low (OR = 2.04; 95 % CI = 1.36–3.06) and very low (OR = 2.80; 95 % CI = 1.68–4.68) household food security were associated with greater odds of depressive symptoms than high household food security. See Table 3 for complete results from the logistic regression models for depressive symptoms.

The present analysis found that the interaction between food insecurity and place of birth was significantly associated with symptoms of anxiety and depression. Higher levels of food insecurity were associated, with increasing strength, with poor mental health in all analyses. However, the relationship between food insecurity and poor mental health appeared attenuated among foreign-born individuals for both anxiety and depression compared to US-born individuals, contrary to our hypothesis. A possible explanation for this unexpected finding is that the demographics of our sample did not match previous research done on the prevalence of food insecurity among foreign-born individuals in the US. Numerous studies have estimated significantly higher prevalence of food insecurity among foreign-born individuals compared to US-born individuals (Food Insecurity among Immigrants, Refugees, and Asylees in the United States, 2016; Hager et al., 2018). Foreign-born individuals in our sample, however, were overall more food-secure than the US-born. Sixty-seven percent of foreign-born participants reported high household food security compared to 59 % among US-born participants. Additionally, households with very low food security comprised merely 12 % of the foreign-born sample versus 20 % of the US-born subpopulation. This inconsistency could relate to the nature of our sampling methods. Our survey was administered on a computer and was only available in English meaning our foreign-born subsample may have higher English literacy than the general foreign-born population in the US. English literacy may be helpful when it comes to building support networks and taking advantage of governmental and charitable food assistance programs (Vu et al., 2020). Additionally, our sample overall may be more technologically literate than the US population at large. Despite this, the finding that food insecurity is increasingly associated with poor mental health is consistent with past research done in the context of the COVID-19 pandemic. Nagata et al. found that food insufficiency, an extreme form of food insecurity, was associated with symptoms of poor mental health after controlling for socioeconomic and demographic factors (Nagata et al., 2022). An analysis by Wolfson et al. showed that greater food insecurity was associated with a dose-response relationship to psychological distress among low-income adults, consistent with our findings. Similarly, Fang et al. found that food insecurity was associated with over 2.5 times higher odds of anxiety and depression among low-income participants in their survey after robustly controlling for COVID-19-related disruptions to employment and income (Fang et al., 2021). Our findings are also broadly consistent with research conducted prior to the pandemic on the association between food insecurity and psychological distress. A meta-analysis by Arenas et al. (2019) found strong correlations between food insecurity and depression, anxiety, and sleep disorders in US adults. Further, in a systematic review of longitudinal research, Bruening et al. (2017) found a bidirectional relationship between food insecurity and poor emotional health. Further research, particularly longitudinal studies, is needed to elucidate the causal mechanisms at play in this relationship. The finding that the relationship between food insecurity and poor mental wellbeing was attenuated among the foreign-born subpopulation is consistent with results from a study among the food insecure in Canada (Muldoon et al., 2013). Past literature has found that foreign-born individuals in the US are overall at lower risk for psychiatric disorders than their US-born counterparts (Breslau et al., 2007; Breslau et al., 2009). A possible explanation for this is that increased acculturation is associated with adverse physical and mental health outcomes due to cultural stress and stressful experiences associated with migration (e.g., discrimination) (Salas-Wright et al., 2018). Additionally, recent immigrants are less likely to access health care and are less likely to receive psychiatric diagnoses (Muldoon et al., 2013). Further, many commonly used assessments are not designed with cross-cultural sensitivity or validated for different subgroups. This presents a challenge to capturing the true prevalence of mental illness in populations that are not White and US-born (Muldoon et al., 2013). While our findings fill an important gap in the COVID-19 food insecurity literature, it is important to interpret these results with caution as the foreign-born population in the US is highly heterogeneous. Foreign-born individuals possess diverse cultural, linguistic, and gastronomical practices and the homogenization of this population can mask disparities between subgroups. An analysis on food insecurity among Asian Americans in California, for instance, found a large discrepancy in the prevalence of food insecurity ranging from <3 % among Japanese to as high as 16 % among Vietnamese individuals (Becerra et al., 2018). Higher levels of acculturation have been found to be positively associated with food security (Becerra et al., 2018; Munger et al., 2015). Additionally, documentation status is an important determinant of access to supplemental food resources (Munger et al., 2015). Undocumented individuals are precluded from participating in the Supplemental Nutrition Assistance Program that could otherwise help alleviate food scarcity in this population. Furthermore, culture-based stigma may impact willingness of certain subgroups to utilize food assistance programs especially as many lack culturally appropriate food items (Becerra et al., 2018). Future analyses should disaggregate foreign-born populations in order to identify possible interventions. It follows that a limitation of the present analysis is the homogenization of the foreign-born population. We were unable to analyze differences between foreign-born subgroups due to small sample sizes in certain populations. As the survey was only made available in English, we were only able to capture data from individuals with moderate English literacy. This may have precluded a large number of foreign-born individuals from participating in the study. Additionally, as the survey was administered online, our sample was limited to individuals with access to a computer and who possess a moderate level of technological literacy. Despite these limitations the present analysis makes a valuable contribution to the literature on food insecurity and mental illness during the COVID-19 pandemic. These findings will guide future analyses to look more closely at the relationship between food insecurity and mental illness among foreign-born subgroups.

In summary, COVID-19-related stressors are related to psychological distress (Hossain et al., 2020) and food insecurity during the pandemic is no exception. We found higher levels of food insecurity to be associated, with increasing strength, with anxiety and depression. Further research is needed to investigate the protective factors that attenuated this relationship among foreign-born individuals. The following is the supplementary data related to this article.Table S1Study population descriptive statistics by food security and place of birth.Table S1

The research protocol for this study went to exempt review by the National Institutes of Health – Intramural Research Program Institutional Review Board – Human Research Protections Program – Office of Human Subjects Research Protections and received an exemption on 23 December 2020 (IRB#000308). This material is the authors' own original work, which has not been previously published elsewhere. The paper is not currently being considered for publication elsewhere. The paper reflects the authors' own research and analysis in a truthful and complete manner.

Charlotte J. Talham: Conceptualization, Methodology, Software, Formal analysis, Investigation, Data curation, Writing- Original draft preparation, and Visualization. Faustine Williams: Conceptualization, Methodology, Software, Investigation, Resources, Writing- Reviewing and Editing, and Supervision. All authors have read and agreed to the published version of the manuscript.

The authors have no conflicts of interest to declare.