Food Insecurity, Diabetes, and COVID-19: What Is Working, and What Can We Do About It?

By Karena Yan

Melissa Akers, who helps lead a fruit and vegetable voucher program for people without consistent access to healthy food, shares with us the impact of COVID-19 on food insecurity, what food assistance programs are doing to help, and where we can still feel hopeful

During the COVID-19 pandemic, many people are facing economic difficulty – and people with diabetes are especially affected. As more people experience food insecurity, we wanted to spotlight Vouchers 4 Veggies (V4V), which provides fruit and vegetable vouchers to low-income individuals and households in San Francisco, CA. V4V works to reduce food insecurity and, by extension, reduce the prevalence of chronic diseases like diabetes. diaTribe interviewed Melissa Akers, the Associate Director of EatSF, the San Francisco branch of Vouchers 4 Veggies.

What is food insecurity and how does it relate to diabetes?

Food security is when people have access to enough food for themselves and their family to lead an active and healthy lifestyle. Food insecurity is the exact opposite of that: the economic and social conditions of limited and uncertain access to enough, healthy food.

In 2018, 11.1% of Americans (or 1 in 9 households) were found to be food insecure at some point during the year, according to the USDA. Moreover, Black and Latinx communities have a higher likelihood of experiencing food insecurity, with rates of 21.2% and 16.2%, respectively, as do households by a single woman (27.8%).

Food insecurity is particularly harmful for people with diabetes. Akers stressed that the relationship between food insecurity and health is a cycle. When someone is experiencing food insecurity, it is a natural response to buy food that is cheap and filling. However, in the United States the most affordable food is also usually the worst food for you – the most calorie-dense and nutrient-deficient option (or more simply put, it contains lots of carbs). Moreover, food insecurity can lead to habits like binge-eating, or trying to consume a lot of food at once because the timing of your next meal is uncertain.

Such behaviors make people more likely to develop chronic diseases like type 2 diabetes; this emphasizes a negative cycle, as chronic diseases are more difficult to manage when people don’t have access to nutritious food. In this position, people are often faced with a decision between spending money on food or medication. If a person with diabetes prioritizes food over medication, their risk of hyperglycemia increases. However, if medication is prioritized, then they are at a higher risk of severe hypoglycemia. These tradeoffs are serious – 20% of people with diabetes experience food insecurity, a rate that is almost double the national average. To learn more, read our article Food Insecurity and Diabetes, A Dangerous Combination.

How has the COVID-19 pandemic impacted food insecurity in the US?

While the exact numbers are still unfolding, Akers says, we do know that food insecurity has increased dramatically due to the COVID-19 pandemic. Previously, about 37 million people were experiencing food insecurity in the United States; now, the estimated number is close to 55 million.

Rising unemployment plays a large role in food insecurity, but another major factor behind the increase is the fact that children have not been in school. For low-income households whose children rely on free or reduced school lunch programs, many students were eating two meals a day at school before the pandemic. Without that resource for meals, it’s now significantly harder for many families to have enough food.

How does Vouchers 4 Veggies work to combat food insecurity, and how has that changed since the start of the pandemic?

Vouchers 4 Veggies was founded by Dr. Hilary Seligman, who’s a leader in the field of food insecurity and its health effects and a physician at Zuckerberg San Francisco General Hospital. As a physician, Dr. Seligman spent many years treating low-income individuals, diagnosing chronic conditions like diabetes at high rates. While she counseled people to change their diet, she often heard that the foods she recommended were not affordable. From these experiences, Dr. Seligman identified a need to make healthy food accessible. Thus, Vouchers 4 Veggies was launched in San Francisco, providing free fruit and vegetable vouchers to low-income individuals and families through a network of community-based organizations and clinics.

V4V provides families with monthly vouchers of $20-$40 that can be used at a wide network of local grocery stores and farmers’ markets to buy fruits and vegetables. It is funded by the sugar-sweetened beverages tax in San Francisco, as well as a number of donors (including the Hellman Foundation and the San Francisco Department of Public Health). By partnering with community-based organizations, including the diabetes clinic at San Francisco’s Zuckerberg General Hospital, V4V is able to identify specific populations to help, including low-income households with chronic conditions like diabetes. This network-based approach enables local organizations to enroll eligible community members in the program and hand out vouchers and program materials wherever they see the most need. This way, the number of vouchers each person receives can be determined by a community-based organization that is more familiar with the household’s circumstances.

At the start of COVID-19, Vouchers 4 Veggies (known as EatSF in San Francisco), quickly shifted tactics to respond to the growing crisis. Recognizing that many families may be in need of essentials and long-lasting pantry items, the program altered their voucher program to provide not only fruits and vegetables, but also any SNAP-eligible food item. Moreover, V4V has distributed over 100,000 of these emergency food vouchers, with a special focus on pregnant women, Black and Latinx populations, and older adults. Click to learn about COVID-19 changes to SNAP, the Supplemental Nutrition Assistance Program.

What has been the effect of Vouchers 4 Veggies in San Francisco?

Currently, V4V partners with over 100 community-based clinics and organizations and serves 5,000 households annually (more than 9,000 individuals). V4V surveyed 2,606 participants between 2015 and 2018, and found that:

• Participants increased their average fruit and vegetable intake by more than one daily serving – enough to have immediate health effects.

• Food security increased by 13 percent.

• The vast majority of participants reported feeling more confident making healthy food choices on a budget, and they reported eating less unhealthy food.

• Grocery store owners saw more customers and more sales of fruits and vegetables.

The survey also showed lasting effects of the program. Six to twelve months after stopping their participation in the program (no longer receiving vouchers), 83% of former participants maintained positive dietary changes as a result of the program – including eating less junk food and eating more fruits and vegetables.

What should everyone know about food insecurity, and how can people help those who are experiencing food insecurity?

Akers said that the perception that “low-income people do not want to eat healthy” is simply not true. Vouchers 4 Veggies has found that participants love the dignity of choice that the program provides. The vouchers let them make their own healthy choices that work best for their preferences, cultures, and families.

There are several ways to help people who are experiencing food insecurity:

• Donate – Programs like Vouchers 4 Veggies exist in other parts of the country; to find one in your area you may want to visit your local farmers’ market, where many similar programs have started. 

• Volunteer – Programs like Vouchers 4 Veggies, food banks, and other organizations that provide food to households in need can always benefit from more volunteers, as well as donations.

• Advocate – Use your voice to support increases to SNAP and WIC, two federal programs that provide food and nutrition assistance to low-income individuals and families.

Despite the COVID-19 pandemic and rise in food insecurity, where can we find hope?

While it may seem difficult to feel hopeful during these uncertain times, Akers points to two places where we can still find optimism.

On the policy front, there is a huge opportunity for action around increases to SNAP and WIC. Before the pandemic, advocacy for increasing the number of people who receive SNAP and improving the size and variety of WIC food packages was met with resistance. However, the urgency brought on by the pandemic has given this important issue a larger audience and a greater incentive to pass some of these policy changes.

At the local level, optimism has come from the outpouring of assistance from community members. Across the country, we have seen individuals and organizations working to support those in need in their community, through food delivery, medical assistance, and other means. By continuing to look out for one another, and ensuring that people do not fall through the cracks, we can continue to build hope as we forge through this pandemic.