COVID19 has wreaked havoc across the globe, resulting in over 2 million deaths worldwide (almost 400,000 in U.S. alone), creating an economic crisis, and leading to the worst rates of food insecurity. One study estimates that food insecurity more than doubled, impacting 23% of households last year. Older adults are especially at risk of both COVID19 and food insecurity. In my current role, I have a part in ensuring that older adults have consistent access to healthy foods throughout this pandemic.
Before the pandemic, my main goal was to improve and increase participation in our nutrition programs and services, particularly for the most isolated older adults, to reduce malnutrition and related illnesses and to enhance the quality of life to allow seniors to live independently. Before going remote, one of the best perks of my job, I’d say, was that our office was situated right above a Senior Wellness Center. That meant, every lunch, I could take a break and walk one floor downstairs to enter a boisterous room of 40-50 seniors, from 60 to even late 90s, who were happily eating a delicious meal and chatting away, making new friends, often playing cards or Wii bowling. I loved listening to their often-hilarious stories, laughing with them, and best of all, seeing their physical improvements month after month. Other staff members have remarked that several seniors often would start at congregate dining sites frail and require a walker. Within months of creating a new social circle, attending fitness classes, and eating a nutritious meal allowed these seniors to walk without assistance!
Pandemic Impact on Nutrition Programming
Of course, the pandemic changed much of that. Wellness centers and sites closed, businesses closed, public transportation shut down, seniors were told not to leave the homes, people lost their jobs, their families, and support systems. There were massive disruptions in the food supply chain. Already, we live in a society where more than 10% of Americans find it easier to buy grape soda than it is to buy a handful of grapes. According to the Census Household Pulse Survey, the pandemic made matters worse, and 34.6% of people found it challenging to find the foods they require. For example, we found it was tough to get tuna, beans, and green beans for several weeks!
When residents were ordered to stay at home to flatten the curve and minimize trips to the grocery store, we needed to ensure seniors can shelter in place with adequate food. The congregate meals were quickly modified and converted into batches of 7 frozen meals delivered right to the senior’s doorstep, and programming became virtual overnight. We were incredibly fortunate that our food vendor could be so flexible and creatively think of ways to offer this. Door to door delivery was something that not many vendors could provide immediately, even those who specialize in frozen meal deliveries as they could not ramp up production to meet our needs. Our food vendor had to rent three large tractor trucks to use as freezers to keep the food safe. We had a fleet of cabs delivering our meals to seniors. I developed food safety and social distancing training materials for our new delivery staff. Our team also had to completely design a database to keep up with addresses, dietary requirements, delivery routes, phone numbers, missed deliveries, and client contact, often working late into the night.
Before the pandemic, the Home Delivered Meal programs offered through the Older Americans Act supported 1/3 of the nutritional needs of homebound, isolated, or frail seniors. During the pandemic, due to congregate meal sites’ closures and to provide nutritional support to food-insecure seniors, the Home Delivered Meals program requirements relaxed. Rather than a time consuming, high barrier assessment that required a home visit and took 3 hours, we used a screening tool to quickly identify those who were food insecure and nutritionally at risk (scoring >6) according to this scale. The Administration for Community Living allowed nutritional standards (i.e. DRIs and DGAs) to be waived for emergency meals, allowing for more flexibility in meal choices and vendor selection. [Our meals continued to meet the requirements as our vendor accommodated our needs, but it was interesting to see how agencies respond to emergencies.]
Each week, we enrolled more than 200 new participants into our meal delivery program at the peak, and now it has slowed to a still elevated rate of 10-30 new participants weekly. One of our meal delivery programs that once delivered to 250 clients per week, suddenly started delivering to upwards of 4500 clients per week (read more about the D.C.’s response to food insecurity in this report).
Food Insecurity During the Pandemic
The food insecurity rate rose to shocking levels as more and more seniors did not know where their next meal would come from or often did not have enough food to last more than a few days. I have spoken to severely ill clients who had nothing to eat at home and no means to purchase food. Before the Public Health Emergency, already 14.3% of seniors in D.C. were food insecure (the highest in the nation. Compare to 7.3%, the national average). This figure likely increased to at least 20%. The pandemic hit communities of color the hardest: food insecurity rose to 41% for Black households and 39% for Hispanic households. In the Hunger Heat Map above, the darker red regions show more food insecurity in that area and clearly shows that the pandemic impacted every Ward in D.C. Most of our initial clients lived in Ward 4, a region that previously only had 4% of food deserts in D.C. (Ward 7 and 8 had accounted for 82% of D.C. food deserts.]
My clients revealed that their support system completely shattered because of the pandemic. Some had family members who were often afraid of visiting them, even just to drop off food at their doorstep. Some of my client’s sole caregivers had gotten sick or passed away. Some had no kitchen appliances to heat up or store meals (which we assisted with). Many were afraid to leave their homes; in fact, one of our nutritionists reported that 80% of her clients had not left their homes since March. Some suffered from illnesses like severe edema and arthritis that impaired their mobility. Their main sources of food were disrupted as well. Several nonprofit organizations that had offered free food had shut down due to their volunteers being an at-risk group. Many others were simply unable to provide last-mile delivery. It was then I realized that this program was indeed their lifeline.
While we can provide more clients than ever with nutrient-dense meals that support 1/3 of their RDA, I fear that this is not enough. Prior to the pandemic, our congregate meal clients enjoyed the social atmosphere and community feel. Even our home-delivered meals participants had daily interaction with the staff who delivered their meals. But now, that has gone away. Although I would like to think that optimal nutrition can cure basically everything, it can’t fix social isolation. Social isolation can significantly increase a person’s risk of premature death from all causes and increase dementia, heart disease, and stroke.
Socialization remains a challenge, even though much effort is being put in to allow more seniors to be connected by providing them with technological support and a plethora of virtual programming, including weekly reassurance calls. However, some seniors have neurological conditions that make it challenging to use virtual platforms. Studies have shown links between decreased language capabilities and memory function, and lack of interaction. Several of our nutritionists I have spoken to share that their clients have demonstrated notable decreases in cognition stemming from their lack of socialization.
Causes of Food Insecurity
Vulnerable and marginalized populations are disproportionately affected by both food insecurity and COVID-19. The elderly are susceptible to food insecurity as they face unique challenges. These challenges include fixed incomes, lack of transportation, lack of affordable housing, social isolation (in D.C. more than 50% of seniors live alone), chronic health problems, and high medical bills, all of which make it challenging to stockpile food. I have spoken to several seniors who rely on SSI or retirement income, which can be, on average, $1400/month. Even with rent vouchers, rent and utilities may still be $700/month. Compare this to D.C.’s living wage for one adult 0 children at $3000/month. The Hunger Report even mentions that a household of 4 making less than $79,000 in D.C. also often needs food assistance.
How Food Insecurity May Increase Risk of Severe COVID19 Outcomes
Older adults are also the most vulnerable to contracting a severe course of COVID19. 95% of coronavirus deaths have occurred among Americans older than 50. The increased vulnerability can be because of two significant changes to the immune function as we age: immunosenescence and inflammaging. Immunosenescence is a gradual decline in immune system function in both the innate and adaptive immune systems. Natural Killer (NK) cells decrease during this process, and T cell activation is blocked. Natural Killer Cells and T cells are critical in recognizing and clearing away infected cells. Inflammaging, or chronic inflammation, results in the desensitization of the innate immune system. (Read more about inflammaging and immunosenesence here).
Food insecurity is a significant cause of malnutrition, and malnutrition is an important cause of immunodeficiency and therefore increased risk of chronic diseases and severe acute infections. Deficiencies in essential nutrients are associated with an impairment of T cell and N.K. Cell activity, phagocyte (monocyte and neutrophil) function, and cytokine production in humans. Carotenoids, vitamins, selenium, zinc, and polyphenols are essential modulators of the immune system. Additionally, overnutrition, a form of malnutrition, has been shown to impact our immune system. Obesity, Type 2 Diabetes, and other chronic diseases are characterized by an overstimulated immune system and chronic inflammation. This overstimulation results in a defective innate immunity. While the virus is not a metabolic disease, having metabolic control is critical in surviving this disease (read more about COVID-19 and nutrition here).
Identifying Food Insecurity
Therefore, access to healthy foods is essential for a well-functioning immune system and the protection against COVID19. Many organizations are currently working to help Americans experiencing food insecurity by providing access to healthy foods. I believe every health professional must understand what local food resources are available in their area and be fully equipped to refer their clients to these resources. (Though, I know it can be challenging to figure this out! I have been in the D.C. area for two years, and I am still learning about new resources). I also recommend screening for food insecurity at every visit. This two-item screener below has 97% sensitivity and 83% specificity. If a client says yes to at least one of the below, please provide appropriate referrals.
“Within the past 12 months, we worried whether our food would run out before we got money to buy more.” Reponses: never true, sometimes true, often true
“Within the past 12 months, the food we bought just didn’t last, and we didn’t have the money to get more.” Reponses: never true, sometimes true, often true
Note: I will say, you may have to ask this question in a different way depending on your population. For example, some of my clients have stated they have not worried or food lasted, but later in the conversation, it came up that they had to choose between medication or paying for rent/utilities and buying food.
Area Agencies of Aging: Provides home-delivered meals (in D.C.), and in other states can be either home-delivered meals or grab and go prepared meals. Home delivered meals are perfect for those who cannot leave home due to mobility issues or lack of transportation. These agencies also offer assistance with health insurance enrollment, transportation, case management, home repairs and household chores, personal care, and home health services.
SNAP: Families First benefit increased benefits in response to the pandemic, so participants get the maximum benefit. Some states have allowed online purchasing with SNAP benefits. The D.C. Hunger Solutions has a great website to find out if someone can get SNAP benefits and estimate how much.
Commodity Supplemental Food Program: Provides monthly deliveries of 30-40 pound mostly shelf stable groceries (2 cartons of juice, 2-3 packs of meat protein, 2 cartons of shelf stable milk, 3 plant based proteins, 2 packs of grains, 1 block of cheese, 2-3 cans of fruit, 8 cans of vegetables, 2 breakfast items). Offers Senior Farmers’ Market Nutrition Program (SFMNP) stipend of about $25 each summer to spend on produce at farmers’ markets. Who is Eligible: Adults 60 years or older and <130% Federal Poverty Level (FPL).
D.C. Resources: This website lists every food resource available in the D.C. area for those in need, including grocery pick up locations (there are many in the district) and an interactive map.