Food insecurity, a well-established determinant of chronic disease morbidity and mortality, is rapidly increasing due to the coronavirus disease 2019 (COVID-19) pandemic. We present a conceptual model to understand the multiple mechanisms through which the economic and public health crises sparked by COVID-19 might increase food insecurity and contribute to poor health outcomes in the short- and long-term. We hypothesize that, in the short-term, increased food insecurity, household economic disruption, household stress, and interruptions in healthcare will contribute to acute chronic disease complications. However, the impact of the pandemic on food security will linger after social-distancing policies are lifted and the health system stabilizes, resulting in increased risk for chronic disease development, morbidity, and mortality among food-insecure households in the long-term. Research is needed to examine the impact of the pandemic-related increase in food insecurity on short- and long-term chronic health outcomes, and to delineate the underlying causal mechanisms. Such research is critical to inform the development of effective programs and policies to address food insecurity and its downstream health impacts during COVID-19 and future pandemics.

Food insecurity is associated with negative chronic health outcomes, yet few studies have examined how providing medically appropriate food assistance to food-insecure individuals may improve health outcomes in resource-rich settings. We evaluated a communitybased food support intervention in the San Francisco Bay Area for people living with HIV and/or type 2 diabetes mellitus (T2DM) to determine the feasibility, acceptability, and potential impact of the intervention on nutritional, mental health, disease management, healthcare utilization, and physical health outcomes. The 6-month intervention provided meals and snacks designed to comprise 100% of daily energy requirements and meet nutritional guidelines for a healthy diet. We assessed paired outcomes at baseline and 6 months using validated measures. Paired t tests and McNemar exact tests were used with continuous and dichotomous outcomes, respectively, to compare pre-post changes. Fifty-two participants (out of 72 initiators) had both baseline and follow-up assessments, including 23 with HIV, 24 with T2DM, and 7 with both HIV and T2DM. Median food pick-up adherence was 93%. Comparing baseline to follow-up, very low food security decreased from 59.6% to 11.5% (p < 0.0001). Frequency of consumption of fats (p = 0.003) decreased, while frequency increased for fruits and vegetables (p = 0.011). Among people with diabetes, frequency of sugar consumption decreased (p = 0.006). We also observed decreased depressive symptoms (p = 0.028) and binge drinking (p = 0.008). At follow-up, fewer participants sacrificed food for healthcare (p = 0.007) or prescriptions (p = 0.046), or sacrificed healthcare for food (p = 0.029). Among people with HIV, 95% adherence to antiretroviral therapy increased from 47 to 70% (p = 0.046). Among people with T2DM, diabetes distress (p < 0.001), and perceived diabetes self-management (p = 0.007) improved. Comprehensive, medically appropriate food support is feasible and may improve multiple health outcomes for food-insecure individuals living with chronic health conditions. Future studies should formally test the impact of medically appropriate food support interventions for food-insecure populations through rigorous, randomized controlled designs.

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Introduction Food insecurity is a potentially important barrier to the success of antiretroviral treatment (ART) programs in resource-limited settings. We undertook a longitudinal study in rural Uganda to estimate the associations between food insecurity and HIV treatment outcomes. Design Longitudinal cohort study. Methods Participants were from the Uganda AIDS Rural Treatment Outcomes study and were followed quarterly for blood draws and structured interviews. We measured food insecurity with the validated Household Food Insecurity Access Scale. Our primary outcomes were: 1) Antiretroviral therapy (ART) non-adherence (adherence<90%) measured by visual analog scale; 2) incomplete viral load suppression (>400 copies/ml); and 3) low CD4 cell count (<350 cells/mm3). We used generalized estimating equations to estimate the associations, adjusting for socio-demographic and clinical variables. Results We followed 438 participants for a median of 33 months; 78.5% were food insecure at baseline. In adjusted analyses, food insecurity was associated with higher odds of ART non-adherence [Adjusted Odds Ratio [AOR]=1.56, 95% confidence interval [CI]=1.10–2.20; p<0.05], incomplete viral suppression [AOR= 1.52, 95% CI 1.18–1.96; p<0.01], and CD4 cell count <350 [AOR=1.47, 95% CI 1.24–1.74; p<0.01]. Adding adherence as a covariate to the latter two models removed the association between food insecurity and viral suppression, but not between food insecurity and CD4 cell count. Conclusions Food insecurity is longitudinally associated with poor HIV outcomes in rural Uganda. Intervention research is needed to determine the extent to which improved food security is causally related to improved HIV outcomes and to identify the most effective policies and programs to improve food security and health.