The Association of Food Insecurity With Asthma Control in Adults During COVID-19

Abstract

BACKGROUND:

Food insecurity has been associated with poorer asthma control in children, but research lacks in adults.

OBJECTIVE:

To assess the frequency of food insecurity and its association with asthma control in adults during the coronavirus disease 2019 pandemic.

METHODS:

An online cross-sectional survey study was conducted in US adults with asthma. Survey questions included how worried or concerned participants were about food security since the pandemic. Asthma control was assessed using the Asthma Control Test, with uncontrolled asthma defined as Asthma Control Test score less than or equal to 19. Self-report of food insecurity since the pandemic was assessed. Food insecurity variables were dichotomized into high insecurity (≥3) or low insecurity (<3). Descriptive statistics and bivariate analyses were performed.

RESULTS:

Of the total participants (N = 866), 82.79% were female; mean age of participants was 44 ± 15.05 years, their mean Asthma Control Test score was 19.25 ± 4.54, and 18.48% had high food insecurity. Participants with high food insecurity were more likely to have uncontrolled asthma (74.38%) compared with those with lower food insecurity (34.99%; P < .01). The relationship between asthma control and food insecurity remained significant after adjusting for age, education, sex, race, anxiety, and living stability concerns due to the pandemic.

CONCLUSIONS:

Food insecurity exists in adults with asthma and is associated with uncontrolled asthma. Providers should consider screening their patients for food insecurity when treating individuals with uncontrolled asthma.

INTRODUCTION

Asthma is a prevalent and chronic inflammatory disease of the airways, with more than 8% of adults in the United States having asthma,¹ resulting in a major drive for health care utilization and related expenditure. For example, from 2008 to 2013, the total cost of asthma in the United States was estimated to be $81.9 billion.² The determinants of asthma are complex and multifactorial and have been associated with the intersection of environmental, behavioral, societal, and genetic factors. Although causes of asthma are not well known, social determinants of health such as quality of neighborhood/housing, access to education and health care, and food security have been linked with the condition.³

In the context of asthma, social determinants of health contribute to a reinforcing cycle of poor asthma control, including through decreased access to health services and maintenance medications, suboptimal housing, and increased likelihood of exposure to secondhand smoke.^2,4 Poor asthma control leads to increased hospitalizations and higher health care costs. This cycle further puts people with asthma at a medical disadvantage and has a negative effect on their health.^5–7 In addition, lower income is an independent risk factor for worse asthma outcomes.⁸ Although asthma cannot be solely attributed to poverty, there is evidence documenting associations between poverty and poor asthma control.⁹

Food insecurity is an often-overlooked social determinant of health. Food insecurity is the inability of an individual, family, or community to obtain a sufficient amount of food or nutrition to meet basic needs due to lack of money or access to resources. There has been an established link between food insecurity and increased asthma prevalence.^10,11 Food insecurity has also been linked to poorer asthma control in children.^12,13 Research has shown that even mild food insecurity has a detrimental effect on the health of children.¹⁴ Food insecurity may also increase the level of stress that individuals and households experience,^15,16 and high levels of stress and anxiety have been linked with worse health outcomes in people with asthma.^17–19 Food insecurity is an understudied area in asthma, and there is limited research regarding the relationship between food insecurity and asthma control in adults.

Throughout the coronavirus disease 2019 (COVID-19) pandemic, the percentage of people experiencing food insecurity rose significantly, which further poses a threat to the health of individuals.²⁰ The aims of this study were to examine (1) the prevalence of food insecurity in adults with asthma during the COVID-19 pandemic, and (2) the association of food insecurity with asthma control in adults with asthma.

METHODS

This cross-sectional, online survey, launched in May 2020, included adults 18 years or older who could read and write English, and who self-reported that they have been told by a health professional that they have asthma and continue to experience their asthma. Participants were recruited using multiple strategies including email listservs, social media, and ResearchMatch. Interested and eligible individuals were provided with a link to a Research Electronic Data Capture survey, which took approximately 20 minutes to complete. Participants who completed the survey were entered into a drawing for a $20 gift card. The study had approval by the University of Kansas Medical Center’s Institutional Review Board.^19,21

The survey included demographic questions, height/weight, the 5-item Asthma Control Test (ACT), questions addressing food insecurity during the COVID-19 pandemic, living stability during the COVID-19 pandemic, financial difficulty during the COVID-19 pandemic, weight changes since the pandemic, and COVID-19—rerelated anxiety. Survey questions related to the pandemic were adapted from the Adult Self-Report Baseline Current Form, which was developed by the Coronavirus Health and Impact Survey Initiative.^22,23 Food insecurity was measured using the following question: SINCE the CORONAVIRUS/COVID-19 pandemic, to what extent have you worried about whether your food would run out because of a lack of money? Responses were scored on a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely). Food insecurity responses were dichotomized into high insecurity (≥3) or low insecurity (<3). Living stability during the COVID-19 pandemic was measured using the following question: SINCE the CORONAVIRUS/COVID-19 pandemic, to what degree are you concerned about the stability of your living situation? Responses ranged from 1 (not at all) to 5 (extremely), with scores 3 (moderately) to 5 indicating high stability concerns. COVID-19—rerelated anxiety was measured from 8 questions using a 5-point Likert scale as previously described from an earlier study.^19,22 Anxiety scores were categorized into 4 levels (low, 8–16; moderate, 17–24; high, 25–32; and very high, 33–40). Body mass index was calculated using participant’s self-reported height and weight. Uncontrolled asthma was defined as an ACT score of less than 20.

We used χ² statistics to examine the associations of food insecurity with participant characteristics. Binary logistic regression models were used to examine the associations of food insecurity with uncontrolled asthma (ACT score <20). Covariates we controlled for were age in years, education, sex, race, body mass index, weight changes since the pandemic, area of residence, rent/home ownership, type of home, living stability concerns due to the pandemic, financial difficulty due to the pandemic, and anxiety due to the pandemic. Covariates were selected a priori, and we used the backward elimination process and change-in-estimate method to assess the potential confounding effect of these variables on the associations of food insecurity with asthma control. A change of more than 10% in the estimate was considered evidence for confounding.^24,25 Sensitivity analyses were performed to assess confounding associations between food insecurity and asthma control. When living stability concerns were removed from the model, the association between asthma control and food insecurity was strengthened by more than 10% (odds ratio, 2.39; 95% CI, 1.54–3.74), thereby proving a confounding relationship. A subsequent sensitivity analysis was performed removing age, sex, and race, which did not change the relationship between asthma control and food insecurity by 10%; however, the association strengthened minimally (odds ratio, 2.17; 95% CI, 1.29–3.64). Although age, sex, and race did not prove to be confounding variables, they were included in our analysis as important demographic variables based on previously established relationships with asthma control.^26–28 Given the results of the sensitivity analyses, the final logistic model was adjusted for age, education, sex, race, anxiety due to the pandemic, and living stability concerns. Other covariates were not included in the final model because they did not confound the associations examined in this analysis.

Statistical analysis was performed in SAS 9.4 (SAS Institute, Inc, Cary, NC), and a P value of less than .05 indicated statistical significance.

RESULTS

As of September 16, 2020, data were collected from 866 participants residing in the United States, with 861 participants having complete data. Survey respondents were primarily female (82.8%) and had a mean age of 44 ± 15 years. The survey respondent’s mean ACT score was 19 ± 5, and 42.3% of participants had uncontrolled asthma (ACT score <20). Almost 20% of the participants had high food insecurity (18.5%; Table I). Most participants reported living in the Midwest (39.5%), with the Southeast region being second (25.1%).

TABLE I.

Baseline characteristics of participants (n = 866)

Characteristic	Value
Age (y), mean ± SD	44 ± 15.05
Education, n (%)
High school or less	96 (11.09)
Some college or 2-y degree	171 (19.75)
4-y college	179 (20.67)
Postcollege or graduate/professional degree	420 (48.50)
Sex: female, n (%)	717 (82.79)
Race, n (%)
White	694 (80.14)
Non-white	172 (19.86)
Area of residence, n (%)
Large city or suburb	522 (60.28)
Small city, town, or rural area	344 (39.72)
US region, n (%)
Midwest	340 (39.26)
Southeast	216 (24.94)
Southwest	58 (6.70)
Northeast	129 (14.90)
West	117 (13.51)
Unknown	1 (0.12)
Rent/home ownership, n (%)
Rent	282 (32.56)
Live with family/friends/other	127 (14.67)
Own	457 (52.77)
Type of home, n (%)
Single family	550 (63.58)
Apartment	225 (26.01)
Townhouse	53 (6.13)
Mobile home	8 (0.92)
Other	29 (3.35)
Anxiety, n (%)
Low (8–16)	175 (20.05)
Moderate (17–24)	381 (43.64)
High (25–32)	236 (27.03)
Very high (33–40)	81 (9.28)
Food insecurity, n (%)
Low insecurity/secure	706 (81.52)
High food insecurity	160 (18.48)
Living stability concerns since the pandemic, n (%)
Yes	227 (26.24)
No	638 (73.76)
Financial difficulty since COVID-19, n (%)
Not at all	337 (38.96)
Slightly	263 (30.40)
Moderately	135 (15.61)
Very	56 (6.47)
Extremely	74 (8.55)
Weight change since COVID-19, n (%)
Lost some weight	195 (22.52)
Gained some weight	401 (46.30)
Maintained the same weight	270 (31.18)
BMI (kg/m2), mean ± SD	29.87 ± 7.74
ACT score, mean SD	19.25 ± 4.55
Uncontrolled asthma (ACT score <20), n (%)	366 ± 42.26

BMI, Body mass index.

When comparing food insecurity (high vs low), those with high food insecurity were more likely to have uncontrolled asthma (74.38% vs 34.99%; P < .01; Figure 1), a high school education or less (33.13% vs 6.09%; P < .01), self-identify as male (31.25% vs 14.02%; P < .01), self-identify as non-White race (26.88% vs 18.27%; P = .01), and live in a small city, town, or rural area (53.13% vs 36.69%; P < .01). Compared with those reporting low food insecurity, participants with high food insecurity were more likely to report high anxiety (69.38% vs 29.04%; P < .01) and high levels of concern about the stability of their living situation during the pandemic (85.63% vs 12.77%; P < .01; Table II). In addition to the bivariate analysis, a linear analysis supported the negative relationship between food insecurity and asthma control (r = −0.51; P < .01).

FIGURE 1.

Association of food insecurity and uncontrolled asthma.

TABLE II.

Bivariate associations of food insecurity and demographic variables

Variable	High food insecurity	Low food insecurity	P value
Age (y)			.15
18–29	23.13	18.27
30–39	23.13	26.06
40–49	25.63	20.11
50–59	13.13	14.02
60+	15.00	21.53
Education			<.01
High school or less	33.13	6.09
Some college or 2-y degree	25.00	18.56
4-y college	17.50	21.39
Postcollege or graduate/professional degree	24.38	53.97
Sex			<.01
Male	31.25	14.02
Female	68.75	85.98
Race			.01
White	73.13	81.73
Non-white	26.88	18.27
Area of residence			<.01
Large city or suburb	46.88	63.31
Small city, town, or rural area	53.13	36.69
Rent/home ownership			<.01
Rent	42.50	30.31
Live with family/friends/other	28.75	11.47
Own	28.75	58.22
Type of home
Single family	51.25	66.38	.04
Apartment	38.13	23.26
Townhouse	5.00	6.38
Mobile home	2.50	0.57
Other	3.13	3.40
Anxiety
Low/moderate (score 8–24)	30.63	70.96	<.01
High/very high (score 25–40)	69.38	29.04
Living stability concerns since the pandemic
High	85.63	12.77	<.01
Low	14.38	87.23
Financial difficulty since COVID-19
Not at all	5.00	46.67	<.01
Slightly	10.00	35.04
Moderately	27.50	12.91
Very	16.25	4.26
Extremely	41.25	1.13
Weight change since COVID-19
Lost some weight	20.63	22.95	.34
Gained some weight	55.00	44.33
Maintained the same weight	24.38	32.72
ACT score
<20	74.38	34.99	<.01
≥20	25.63	65.01

In the crude logistic regression analysis, individuals with high food insecurity were 5.4 times more likely to have uncontrolled asthma (95% CI, 3.66–7.94). In the adjusted model, the elevated odds for uncontrolled asthma among those with high food insecurity persisted and remained significant (odds ratio, 2.11; 95% CI, 1.25–3.55; Table III).

TABLE III.

Crude and adjusted associations of food insecurity with uncontrolled asthma^*

Association	Odds ratio	95% CI
Crude	5.39	3.66–7.94
Adjusted†	2.11	1.25–3.55

^*Model was based on 861 participants.

^†Adjusted for age in years, education, sex, race, anxiety, and experiencing living stability concerns.

DISCUSSION

We found that adults with asthma experiencing high levels of food insecurity since the COVID-19 pandemic are more likely to have uncontrolled asthma compared with adults with asthma who did not experience food insecurity. The association between food insecurity and poor asthma control persisted after adjusting for demographic factors including COVID-19—related anxiety, which has also been linked with poor asthma control.¹⁹ Thus, our findings are less likely to be driven by these variables.

The current existing literature on food insecurity and its relationship to asthma control has primarily been in the context of children. One study found an association between higher levels of food insecurity and worse asthma control in Peruvian children living in periurban communities with and without asthma. They found that for every 1-unit increase in food insecurity on the Household Food Insecurity Access Scale, there was an 8% increase in odds of children having poorly controlled asthma.¹³ Our findings are in line with what has been found in children with asthma; however, our study differs from the current literature because we assessed these associations in adults during the COVID-19 pandemic and controlled for related factors such as anxiety. Much of the remaining literature regarding food insecurity and asthma focuses on the relationship between asthma prevalence and food insecurity.¹¹ Our study is the first study to assess the associations of asthma control and food insecurity during the COVID-19 pandemic in an adult population.

Food insecurity has also been associated with worse outcomes for patients who have chronic conditions such as cardiovascular disease and type 2 diabetes.^29,30 There is an association with food insecurity and increased risk of death from cardiovascular diseases.²⁹ In addition, food insecurity was found to be an independent risk factor for poor glycemic control in individuals with type 2 diabetes.³⁰

The association between food insecurity and asthma control could be hypothesized through a series of mechanisms. One explanation regarding the relationship is that food insecurity is associated with delayed prescription fills.⁴ One study found that adults with asthma who are food insecure are 1.5 times more likely to delay prescriptions as compared with adults with asthma who are not food insecure.⁴ Although as a multifactorial process there is no definitive explanation, one mechanism to consider is that individuals who are food insecure are choosing to allocate money toward food rather than medications, causing a delay in prescription fill and contributing to worse asthma control. Additional explanations to consider are that food insecurity can increase the stress that individuals experience on a daily basis.¹⁵ Higher levels of stress have been associated with worse outcomes in adults with asthma.^17–19 However, we controlled for stress in our analysis and food insecurity was still independently associated with uncontrolled asthma. Lastly, food insecurity is associated with poorer diet quality and a diet containing high-fat foods.³¹ Lower quality and higher fat foods can cause greater systemic inflammation and contribute to an increase in asthma prevalence.³² In addition, poorer diet quality has been linked to uncontrolled asthma and increased airway hyperresponsiveness.³³

Some limitations of the study are that the survey participants were largely female, White, and well educated, which limits the generalizability of our findings. In adults, women are more likely to have asthma, which may account for the greater number that participated in our survey.³⁴ Comparing self-identified sex, we found that more females had higher food insecurity. In addition, females are more likely to be food insecure in the United States.³⁵ However, higher food insecurity was associated with self-identified male sex. These incongruent findings might be due to low sample size of males in our study, and further studies need to be done. It is important to consider the possibility that those facing more food insecurity or worse asthma control were more likely to respond to surveys. The inability to further characterize the non-White population is another limitation. The prevalence of food insecurity is higher in Black and Hispanic households (21.7% and 17.2%, respectively) compared with the national average of 10.5%.³⁵ Furthermore, this was a cross-sectional study; thus, we cannot confirm causality and can only describe an association between food insecurity and asthma control. Given that food insecurity is intertwined with poverty and there is an established link between worse asthma outcomes and poverty, further testing is required to determine causality.⁹ Lastly, because this was a survey-based study, the self-reported data could lead to information bias.

As the pandemic continues, it is important to understand the negative physical and mental health consequences associated with food insecurity. In addition, climate change and global warming will lead to an increase in individuals facing food insecurity due to the combination of decreased food production from harsh weather conditions and increased food costs.³⁶ Food insecurity as it relates to poor asthma control can lead to a myriad of outcomes including increased health care costs, decreased quality of life, and increased morbidity/mortality for patients.⁵ Our results further emphasize the importance of maintaining food security during times of global hardship such as a pandemic, because it can be detrimental for individuals with chronic conditions such as asthma.

In summary, our findings indicate that during the COVID-19 pandemic, adults who have high food insecurity are significantly more likely to have uncontrolled asthma. Our results highlight the relationship between poor asthma control and food insecurity in adults during the COVID-19 pandemic. Creative solutions to address food insecurity are needed; future interventional work with multidisciplinary teams including physicians, nurses, and social workers can work to mitigate the health consequences associated with food insecurity in the health care setting. Solutions that make strong connections between health care settings and community resources, including referrals to food prescription programs and food pantries/community fridges,^37,38 can provide an integrated and community-tailored approach to this health care and human rights issue.

What is already known about this topic?

Food insecurity has been associated with poor asthma control in children, but research with adults with asthma is lacking, especially during the coronavirus disease 2019 pandemic.

What does this article add to our knowledge?

Food insecurity is associated with worse asthma control in adults during the coronavirus disease 2019 pandemic.

How does this study impact current management guidelines?

Providers should be aware of the possible relationship between food insecurity and asthma control. They should consider screening for food insecurity when treating individuals with uncontrolled asthma because food insecurity is associated with worse control.

Abbreviations used

ACT

Asthma Control Test

COVID-19

coronavirus disease 2019