Abstract
Objective
Ensuring access to sufficient foods at all times is critical to veterans’ health and well-being. Food insecurity has not been well explored in the veteran population. We examined the prevalence and predictors of food insecurity among low-income veterans, because the highest rates of food insecurity are among low-income households. We also examined rates of Supplemental Nutrition Assistance Program (SNAP) participation among subgroups at the highest risk of food insecurity.
Methods
We used univariate analyses and 2011-2017 National Health Interview Survey (NHIS) data on veterans aged ≥21 with family incomes <200% of the federal poverty level to estimate the prevalence of food insecurity. We used bivariate analyses to identify correlates of food insecurity and estimate SNAP participation rates among subgroups of low-income veterans. Percentages were weighted using NHIS survey weights.
Results
Of 5146 low-income veterans, 22.5% reported being food insecure in the previous month. Food insecurity was significantly associated with being aged <65 (33.0% aged 45-64 and 29.7% aged 21-44) compared with 15.0% and 6.4% among veterans aged 65-74 and ≥75, respectively (P < .001); unemployed compared with employed or not in the labor force (39.4%, 22.7%, and 20.2%, respectively; P < .001); in fair or poor health compared with good, very good, or excellent heath (31.8% vs 18.2%; P < .001); and having experienced serious psychological distress in the past month (56.3%) compared with not having experienced such distress (19.7%; P < .001). Although overall SNAP participation among low-income veterans was estimated to be 27.0%, participation rates were highest among veterans who had experienced serious psychological distress (44.1%), were unemployed (39.2%), and were renting their home (39.0%).
Conclusions
Some low-income veterans are at greater risk of food insecurity than other veterans. Postseparation programs, civilian support services, and veterans’ health providers should be aware of the characteristics that place veterans at highest risk of food insecurity.
Keywords: veterans, food insecurity, low income, National Health Interview Survey, Supplemental Nutrition Assistance Program
Food insecurity is an economic condition in which households lack sufficient resources to obtain enough food to lead a healthy lifestyle.1 In 2017, 27.5 million adults (11.8%) in the United States lived in households that were food insecure,2 placing them at heightened risk of several adverse health outcomes. Food insecurity is associated with decreased nutrient intake and increased odds of depression, anxiety, diabetes, and hypertension.3 Given the substantial economic and social burden that food insecurity imposes on society, alleviating food insecurity has become a key public health priority in recent years.4,5
In 2018, there were nearly 20 million living US veterans. This number is expected to decline with the deaths of veterans from earlier eras (World War II, the Korean Conflict, and Vietnam Era), and the characteristics of this population will continue to shift.6-8 The composition of veterans will include increasingly greater proportions of younger, female, and racial/ethnic minority groups, characteristics associated with greater risk of food insecurity.6 Veterans’ health status may also put them at higher risk of food insecurity than the civilian US population: veterans tend to be in poorer health, are more likely to smoke or engage in heavy alcohol consumption, and have higher rates of mental illness, such as posttraumatic stress disorder and depression, than civilians.9-11
However, few studies have explored food insecurity among US veterans. One recent study estimated that, on average, 8.4% of households with US Armed Forces veterans had experienced food insecurity between 2005 and 2013. This rate was similar to that of the general US population after controlling for demographic and socioeconomic characteristics.12 Additional studies, however, estimated higher rates of food insecurity among various samples of veterans.13-15 For example, Wang et al13 reported that 24% of veterans receiving care at a Veterans Health Administration clinic during 2002-2008 were food insecure, and Widome et al14 found that 27% of veterans of the wars in Iraq and Afghanistan were food insecure in 2012. These studies found that veterans were at higher risk of food insecurity if they were of younger age, African American, unmarried, had lower income, and experienced depression, as compared with veterans without these characteristics.12-14
In 2015-2017, approximately 1.4 million veterans participated in the Supplemental Nutrition Assistance Program (SNAP).16 SNAP is one of the nation’s largest food safety-net programs and provides resources to low-income people and households for purchasing foods to reduce food insecurity.17,18 To be eligible for SNAP, most households must have incomes <135% of the federal poverty level (FPL), unless residing in a state that allows categorical eligibility (where receipt of cash assistance or other means-tested programs automatically qualifies people for SNAP), in which case gross incomes cannot exceed 185% FPL. One 2015 study examining SNAP participation among veterans reported that for veterans with household incomes <100% FPL, only 24.6% of recent veterans and 31.8% of long-term veterans participated in the program between 2008 and 2012.19
Few studies have explored the correlates of food insecurity among veterans, and among studies that have, few have used nationally representative data.13-15 To our knowledge, no research to date has used nationally representative data to explore the prevalence and correlates of food insecurity among low-income veterans, a notable gap in the literature because this subpopulation is the most likely to have food insecurity.12 This study aimed to fill this gap by using data from the nationally representative National Health Interview Survey (NHIS) to answer the following research questions:
What is the prevalence of food insecurity among veterans in households with incomes <200% FPL?
What sociodemographic and health-related characteristics are associated with higher rates of food insecurity among low-income veterans?
What are the rates of SNAP participation among low-income veterans with the highest risk of food insecurity?
Methods
Data Source
We used data from the 2011-2017 NHIS, a nationally representative, annual cross-sectional survey of the US civilian noninstitutionalized population. We extracted NHIS data from the Integrated Public Use Microdata Series Health Surveys.20 For our study, we defined veterans as people who reported having ever served in the US Armed Forces, Reserves, or National Guard but who were not currently serving in the Armed Forces. After identifying veterans, we imposed further restrictions so that our final analytic sample comprised veterans aged ≥21 who were defined as low income (ie, family income <200% FPL). The NHIS public-use data contain a categorical variable for income as a percentage of poverty, which prevented us from accurately identifying all respondents with incomes at a lower threshold; a lower threshold of 150% FPL is possible, but it results in 13% of the sample being excluded because of missing responses. Nevertheless, sensitivity analyses conducted with veteran respondents who could be classified to 150% FPL showed similar results to our findings. We chose 21 as the minimum age for this analysis because the minimum age to enlist is 18 (or 17 with parental consent), and the typical first-term enlistment is 4 years of active duty plus 4 years of inactive duty. Those leaving active-duty military service before age 21 may differ from other, older veterans for reasons we could not observe, so we excluded them from our analysis (n = 16). Sensitivity tests indicated that study results were no different when this population was included. Because all analyses were conducted on deidentified, secondary data, this study was not considered to be human subjects research, and no institutional review board approval was required.
Measures
Outcome
Our outcome of interest was a binary variable for whether a low-income veteran was living in a food-insecure household in the past month. The NHIS administers the 10-item US Adult Food Security Survey Module to assess household food security in the past 30 days. The module asks about a household’s difficulty in meeting food needs; responses of “often true,” “sometimes true,” and “yes” are considered indicative of these challenges. For questions that are based on the frequency of occurrence in the past month, a respondent’s answer is considered affirmative if the reported frequency is ≥3 days. For each household, the NHIS computes a raw food security score based on the number of affirmative responses to the food security questions (0 affirmative responses indicate no difficulties, and 10 affirmative responses indicate difficulty with each behavior/experience accessing food). Households were considered food insecure if their raw food security score ranged from 3 to 10; households with affirmative responses ranging from 0 to 2 were considered food secure.21
Covariates
We included individual- and household-level sociodemographic and health characteristics established in the literature as being important predictors of food insecurity. Demographic characteristics included sex (male or female), age (21-44, 45-64, 65-74, or ≥75), race/ethnicity (non-Hispanic White, non-Hispanic Black/African American, Hispanic, or non-Hispanic other race), education (<high school diploma, high school diploma, some college or 2-year degree, or ≥4-year degree), geographic region of residence (South or another region), and marital status (never married, separated or spouse not present, divorced, widowed, or married or cohabiting). Socioeconomic characteristics included employment status (not in the labor force, unemployed, or employed), annual household income (<$35 000 or ≥$35 000, based on the lowest categorical income available in NHIS), SNAP participation in the previous calendar year (any family member received benefits or no family members received benefits), and housing arrangement (renter or owner/other arrangement). We also included 2 continuous variables for the number of children and adults in the household.
Health characteristics included self-reported health status (good/very good/excellent or fair/poor), having any of 3 nutrition-related chronic conditions (heart disease, hypertension, or prediabetes/diabetes [yes/no]), and having any limitations in functional activities (based on responses to 12 items that assessed whether the respondent had trouble with activities resulting from a health problem [yes/no]). An additional variable indicated whether the respondent had experienced serious psychological distress in the past month (yes/no). Serious psychological distress was determined based on the Kessler 6 nonspecific psychological distress scale, which asks how often in the previous 30 days the person felt the following: so sad that nothing could cheer them up; nervous, restless, or fidgety; and hopeless, worthless, or that everything was an effort.22 Responses to each question ranged from 0 (none of the time) to 4 (all of the time). When summed, these responses yield a scale ranging from 0 to 24, and those with a score of ≥13 were flagged as having experienced serious psychological distress. Finally, we created a 6-category health insurance variable to indicate veterans with no coverage, private insurance only, Medicare only, Medicaid only, military insurance only, or other coverage (namely, Children’s Health Insurance Program, state health insurance, Indian Health Service, other government program, or multiple coverage).
Statistical Analysis
We first used univariate and bivariate analyses to describe the prevalence of food insecurity among low-income US veterans and to compare the characteristics of veterans with and without food insecurity. All numbers are unweighted; percentages and means were unadjusted estimates calculated by using NHIS survey weights. We used the design-based Pearson χ2 test for categorical variables and the t statistic for continuous variables to test whether bivariate associations were significant. Using summary statistics, we then estimated unadjusted SNAP participation rates for selected subgroups of veterans at the highest risk of food insecurity. We weighted all analyses using NHIS-provided sampling and design weights to account for the probability of selection and clustering in the survey. We used an α level of ≤.05 to denote significance. We used Stata version 15 (StataCorp, LLC) for all analyses.
Results
Sample Description and Prevalence of Food Insecurity
Our study sample comprised 5146 low-income veterans (Table). A substantial share of low-income veterans was older (43.1% aged ≥65), and most were male (90.7%), non-Hispanic White (72.8%), married or cohabiting (50.7%), and had a ≥2-year college degree (50.3%). Most veterans (65.7%) were not in the labor force at the time of the survey, and more than half (58.2%) owned their home or had other arrangements (ie, did not rent). Only 27.0% of veterans lived in a household that had received SNAP benefits in the previous year. Although most veterans’ self-reported health was good, very good, or excellent (68.3%), most also reported a functional limitation (61.6%) and ≥1 nutrition-related chronic condition (62.0%). A small proportion of veterans (7.3%) indicated having experienced serious psychological distress. Finally, most veterans had some form of health insurance (88.0%).
More than one-fifth (22.5%) of low-income veterans were food insecure in the previous month. The food-insecure group was evenly split between veterans who reported low food security and veterans who reported very low food security. Based on bivariate analyses, several demographic, socioeconomic, and health characteristics were associated with food insecurity (Table). Rates of food insecurity were significantly higher among veterans aged 45-64 (33.0%) and <45 (29.7%) than among veterans aged ≥75 (6.4%; P < .001). Rates of food insecurity were also significantly higher among non-Hispanic Black (31.0%), Hispanic (25.9%), and non-Hispanic other (30.9%) veterans than among non-Hispanic White veterans (19.8%; P < .001). Veterans without a ≥4-year college degree had significantly higher rates of food insecurity than veterans with a ≥4-year college degree (P = .01). Food insecurity was also prevalent among veterans who were unemployed (39.4%), renters (32.7%), and SNAP recipients (38.3%). Veterans with fair or poor health (vs good, very good, or excellent health) and veterans who reported experiencing serious psychological distress (vs no serious psychological distress) had higher rates of food insecurity (P < .001).
Table.
Sociodemographic and health characteristics of low-incomea US veterans (N = 5146), overall and by food security status, National Health Interview Survey (NHIS), 2011-2017b
| Characteristic | Total (N = 5146) | Food insecure (n = 1133) | Food secure (n = 4013) | P valuec |
|---|---|---|---|---|
| Demographic characteristics | ||||
| Age, y | <.001 | |||
| 21-44 | 905 (21.2) | 248 (29.7) | 657 (70.3) | |
| 45-64 | 1786 (35.7) | 615 (33.0) | 1171 (67.0) | |
| 65-74 | 1104 (19.3) | 186 (15.0) | 918 (85.0) | |
| ≥75 | 1351 (23.8) | 84 (6.4) | 1267 (93.4) | |
| Sex | .002 | |||
| Male | 4615 (90.7) | 972 (21.8) | 3643 (78.2) | |
| Female | 531 (9.3) | 161 (29.6) | 370 (70.4) | |
| Race/ethnicity | <.001 | |||
| Non-Hispanic White | 3618 (72.8) | 678 (19.8) | 2940 (80.2) | |
| Non-Hispanic Black | 886 (15.3) | 283 (31.0) | 603 (69.0) | |
| Non-Hispanic other | 271 (4.5) | 80 (30.9) | 191 (69.1) | |
| Hispanic | 364 (7.5) | 90 (25.9) | 274 (74.1) | |
| Education | .01 | |||
| <High school diploma | 812 (14.2) | 156 (19.8) | 656 (80.2) | |
| High school diploma or GED | 1801 (35.6) | 398 (22.5) | 1403 (77.5) | |
| Some college or 2-year degree | 1920 (39.0) | 484 (25.1) | 1436 (74.9) | |
| ≥4-year college degree | 599 (11.3) | 93 (16.4) | 506 (83.6) | |
| Mean no. of children per household | 5146 (0.5) | 1133 (0.5) | 4013 (0.4) | .046 |
| Mean no. of adults in household | 5146 (1.8) | 1133 (1.9) | 4013 (1.8) | .27 |
| Marital status | <.001 | |||
| Never married | 865 (13.5) | 218 (24.7) | 647 (75.3) | |
| Married or cohabiting | 1819 (50.7) | 353 (20.9) | 1466 (79.1) | |
| Separated or absent spouse | 279 (4.2) | 103 (35.3) | 176 (64.7) | |
| Divorced | 1441 (21.0) | 383 (28.2) | 1058 (71.8) | |
| Widowed | 736 (10.6) | 74 (10.7) | 662 (89.3) | |
| Resides in the South | .07 | |||
| Yes | 1968 (42.3) | 484 (24.2) | 1484 (75.8) | |
| No | 3178 (57.7) | 649 (21.3) | 2529 (78.7) | |
| Socioeconomic characteristics | ||||
| Employment status | <.001 | |||
| Unemployed | 427 (8.7) | 163 (39.4) | 264 (60.6) | |
| Employed | 1186 (25.6) | 258 (22.7) | 928 (77.3) | |
| Not in labor force | 3532 (65.7) | 712 (20.2) | 2820 (79.8) | |
| Housing | <.001 | |||
| Rents house | 2324 (41.8) | 724 (32.7) | 1600 (67.3) | |
| Owns/other arrangement | 2820 (58.2) | 409 (15.2) | 2411 (84.8) | |
| SNAP recipient in previous year | <.001 | |||
| Yes | 1375 (27.0) | 532 (38.3) | 843 (61.7) | |
| No | 3763 (73.0) | 601 (16.7) | 3162 (83.3) | |
| Annual household income, $ | .03 | |||
| <35 000 | 4802 (89.8) | 1071 (23.0) | 3731 (77.0) | |
| ≥35 000 | 302 (10.2) | 51 (16.1) | 251 (83.9) | |
| Health and health coverage characteristics | ||||
| Health status | <.001 | |||
| Good, very good, or excellent | 3504 (68.3) | 585 (18.2) | 2919 (81.8) | |
| Fair or poor | 1642 (31.7) | 548 (31.8) | 1094 (68.2) | |
| Functional limitation | <.001 | |||
| Yes | 3298 (61.6) | 842 (25.8) | 2456 (74.2) | |
| No | 1839 (38.4) | 290 (17.2) | 1549 (82.8) | |
| Nutrition-related chronic condition | .33 | |||
| Yes | 3288 (62.0) | 738 (23.1) | 2550 (76.9) | |
| No | 1850 (38.0) | 394 (21.5) | 1456 (78.5) | |
| Experienced serious psychological distress in past month | <.001 | |||
| Yes | 354 (7.3) | 204 (56.3) | 150 (43.7) | |
| No | 4682 (92.7) | 902 (19.7) | 3780 (80.3) | |
| Health insurance | <.001 | |||
| None | 586 (12.0) | 202 (34.9) | 384 (65.1) | |
| Private insurance only | 481 (11.8) | 89 (20.3) | 392 (79.7) | |
| Medicare only | 928 (17.8) | 149 (14.8) | 779 (85.2) | |
| Medicaid only | 315 (6.5) | 118 (34.4) | 197 (65.6) | |
| Military insurance only | 857 (16.8) | 241 (28.8) | 616 (71.2) | |
| Other coverage | 1969 (35.2) | 329 (17.4) | 1640 (82.6) | |
Abbreviations: GED, general educational development; SNAP, Supplemental Nutrition Assistance Program.
aLow income is defined as having an annual household income <200% of the federal poverty level.
bData source: NHIS.20 All values are number (percentage) unless otherwise indicated. All numbers are unweighted; percentages and means were unadjusted estimates calculated by using NHIS survey weights.
cP values derived from the Pearson χ2 test for categorical variables and the t test for continuous variables; P < .05 was considered significant.
We estimated overall SNAP participation for low-income veterans to be 27.0%. Among low-income adults in general (that is, combining veterans and nonveterans with incomes <200% FPL), the corresponding SNAP participation rate was 37.6%. SNAP participation was typically higher among groups at higher risk of food insecurity than among low-income veterans in general but highest among veterans who had experienced serious psychological distress (44.1%), unemployed veterans (39.2%), and veterans renting their homes (39.0%; Figure).
Figure.
Supplemental Nutrition Assistance Program (SNAP) participation among selected subgroups of low-income veterans at high risk for food insecurity, National Health Interview Survey (NHIS), 2011-2017.20 Percentages are unadjusted estimates of SNAP participation for selected subgroups calculated using NHIS survey weights; error bars show variability in the estimates.
Discussion
This study used nationally representative data from the NHIS to identify the prevalence and predictors of food insecurity among veterans with household incomes <200% FPL. We estimated that more than 1 in 5 low-income veterans had experienced past-month food insecurity during 2011-2017. Additional analyses found that low-income people in the general population had slightly higher rates of food insecurity than low-income veterans (25.5% vs 22.5%). In contrast, the corresponding rate of food insecurity among higher-income veterans (with incomes ≥200% FPL) was 3.4%.
Consistent with other studies of both veterans and nonveterans, our findings indicate a declining likelihood of food insecurity with increasing age.12,23 This age gradient is not well understood, and additional research is needed to better understand its causes and whether food insecurity among veterans of different eras follows this same pattern. Also, similar to previous studies examining the predictors of food insecurity, including those focused on the veteran population, we found that food insecurity was higher among veterans who were unemployed (vs employed or not in the labor force), had <4-year college degree (vs ≥4-year college degree), rented their home (vs owned it or had some other arrangement), and participated in SNAP (vs did not participate in SNAP).12-14
In addition, the NHIS allowed us to identify several health-related characteristics associated with food insecurity among low-income veterans, namely, fair or poor self-reported health status, having ≥1 functional limitation, and experiencing serious psychological distress. Similar to our study, previous studies have also linked food insecurity with poor health outcomes, including mental illness.24,25 The higher rates of food insecurity among low-income veterans with poor health, activity limitations, and/or serious psychological distress are of particular concern, because conditions that often co-occur may prevent veterans from finding and maintaining employment that is sufficient to meet their basic needs. In addition, some studies have shown higher rates of mental illness and substance use among veterans compared with nonveterans, which may place some veterans at greater risk of food insecurity than the US civilian population.9-11
Food insecurity is an economic condition linked intrinsically with employment, earnings, and wages. Some studies have reported that many veterans return to civilian life without a job in place and find it challenging to secure civilian employment that matches their skills and salary expectations.26,27 Although fewer than 10% of veterans in our low-income sample reported being unemployed, nearly 90% reported annual household incomes <$35 000, a group that had significantly higher rates of food insecurity than their higher-income counterparts. These findings suggest that even for employed or retired veterans, earned wages and income may be insufficient to meet basic needs.
Furthermore, we observed that nearly two-thirds of low-income veterans were not in the labor force, which seemed high given that only 43% were of retirement age (ie, ≥65). Although labor force nonparticipation was associated with lower rates of food insecurity compared with the unemployed, we found that 74.1% of veterans not in the labor force also had functional limitations, which could contribute to working-age veterans deciding not to pursue employment. A 2012 study highlighted the challenges that injured veterans may face in obtaining employment, noting that veterans returning from Afghanistan and Iraq are more likely than veterans of earlier eras to have service-related injuries, which includes physical injuries and “invisible wounds” (eg, hearing impairment, posttraumatic stress disorder, brain injury).28 The NHIS did not contain data on service-related injury or disability, and further research should be undertaken to explore the links among service-related disabilities, employment, income, and food insecurity.
Lastly, slightly more than 1 in 4 low-income veterans participated in SNAP in the year before the survey, including fewer than half of veterans experiencing food insecurity. Although some veterans in the study may not be eligible for SNAP benefits because of income limits or not meeting work requirements (for those without dependents), our findings point to an unmet need for food assistance among low-income veterans. For example, a 2018 Feeding America report indicated that veterans were present in 20% of the 46 million households served by the organization’s network of food banks.29 Although the distribution of veterans in households seeking assistance does not indicate that veterans are overrepresented among households using food pantries (nationally, 17.1% of households include veterans),12 it does highlight that a considerable share of veteran households have limited access to food resources.
Limitations
This study had several limitations. First, the NHIS purposefully excludes people who are actively serving in the military and does not include veterans who are homeless or living in nontraditional housing arrangements. As a result, our estimates of food insecurity may be lower than what is occurring among the population of low-income veterans overall. Second, SNAP participation may also be underreported in the NHIS, which would result in estimates that are lower than actual participation among low-income veterans.30
Conclusion
Continuous, uninterrupted access to safe and adequate food is imperative in supporting the health and well-being of veterans throughout their life course and especially during their transition to civilian life. Among low-income veterans, food insecurity occurs most frequently among veterans who are also struggling with physical and mental health issues and low socioeconomic status. These findings are similar to previous research identifying associations between food insecurity and poor physical and mental health.3,31 This association is particularly important because veterans may be in poorer physical health and more likely to experience serious mental illness than the general US population.9-11,32 The high rate of food insecurity observed among veterans who had experienced serious psychological distress in the NHIS is concerning. One avenue for addressing food insecurity in this population is the integration of food security screening during primary care and behavioral health visits along with referrals to resources to help veterans address food access issues. Behavioral health professionals could also incorporate food insecurity as a factor in veterans’ mental health treatment plans.
Given the sacrifices made by service members and their families, addressing economic hardships, such as food insecurity, that can occur upon reintegration into civilian life should be a national priority. Postseparation programs, civilian support services, and veterans’ health providers should be aware of the characteristics that place veterans at highest risk of food insecurity and have plans in place for helping them access needed foods.
Acknowledgments
The authors acknowledge the staff of the Minnesota Population Center and State Health Access Data Assistance Center for maintaining and updating the IPUMS Health Surveys data. This resource was invaluable in our research.
Footnotes
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Jennifer A. Pooler, MPP https://orcid.org/0000-0003-0825-1202
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