
==== Front
J Community Health
J Community Health
Journal of Community Health
0094-5145
1573-3610
Springer US New York

38683277
1358
10.1007/s10900-024-01358-1
Article
The Influence of the COVID 19 Pandemic on Food Insecurity Among Cancer Survivors Across New York State
Camacho-Rivera Marlene 1
Haile Katherine 2
Pareek Eshani 3
D’Angelo Debra 3
Gany Francesca 4
Maglione Francesca 5
Jack Kellie 6
Cather Alexina 78
http://orcid.org/0000-0002-6803-2442
Phillips Erica erp2001@med.cornell.edu

69
1 https://ror.org/0041qmd21 grid.262863.b 0000 0001 0693 2202 Department of Community Health Sciences, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY USA
2 https://ror.org/04hf5kq57 grid.238491.5 0000 0004 0367 6866 Bureau of Chronic Disease Evaluation and Research, New York State Department of Health, Albany, NY USA
3 grid.5386.8 000000041936877X Weill Cornell Medicine Division of Biostatistics, Population Health Sciences, New York, NY USA
4 https://ror.org/02yrq0923 grid.51462.34 0000 0001 2171 9952 Immigrant Health & Cancer Disparities Service, Department of Psychiatry & Behavioral Sciences, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY USA
5 grid.413734.6 0000 0000 8499 1112 Department of Food and Nutrition, NewYork-Presbyterian/Weill-Cornell Medical Center, New York, NY USA
6 https://ror.org/02r109517 grid.471410.7 0000 0001 2179 7643 Sandra and Edward Meyer Cancer Center, Office of Community Outreach and Engagement, Weill Cornell Medicine, New York, NY USA
7 Wellness in the Schools, New York, NY USA
8 Center for Food as Medicine, New York, NY USA
9 https://ror.org/02r109517 grid.471410.7 0000 0001 2179 7643 Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 338 East 66th Street, Box #46, New York, NY 10021 USA
29 4 2024
29 4 2024
2024
49 6 10331043
22 3 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
People surviving cancer represent a particularly vulnerable population who are at a higher risk for food insecurity (FI) due to the adverse short- and long-term effects of cancer treatment. This analysis examines the influence of the COVID-19 pandemic on the prevalence of FI among cancer survivors across New York State (NYS). Data from the 2019 and 2021 NYS Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate the prevalence of FI. Multivariable logistic regression was used to explore socioeconomic determinants of FI. Among cancer survivors, FI varied geographically with a higher prevalence in New York City compared to the rest of the state (ROS) prior to (25.3% vs. 13.8%; p = .0025) and during the pandemic (27.35% vs. 18.52%; p = 0.0206). In the adjusted logistic regression model, pre-pandemic FI was associated with non-White race (OR 2.30 [CI 1.16–4.56]), household income <$15,000 (OR 22.67 [CI 6.39–80.43]) or $15,000 to less than <$25,000 (OR 22.99 [CI 6.85–77.12]), and more co-morbidities (OR 1.39 [CI 1.09–1.77]). During the pandemic, the association of FI with non-White race (OR 1.76 [CI 0.98–3.16]) was attenuated but remained significant for low household income and more co-morbidities. FI was newly associated with being out of work for less than one year (OR 6.36 [CI 1.80–22.54] and having one (OR 4.42 [CI 1.77–11.07]) or two or more children in the household (OR 4.54 [CI 1.78–11.63]). Our findings highlight geographic inequities and key determinants of FI among cancer survivors that are amendable to correction by public health and social policies, for which several were momentarily implemented during the pandemic.

Keywords

Food insecurity
Cancer
Social determinants
Disparities
COVID-19
http://dx.doi.org/10.13039/100000054 National Cancer Institute 1U54CA280808 1U54CA280808 Camacho-Rivera Marlene Phillips Erica issue-copyright-statement© Springer Science+Business Media, LLC, part of Springer Nature 2024
==== Body
pmcBackground

As defined by the United States Department of Agriculture, food insecurity is a lack of consistent access to enough food for every person in a household to live an active, healthy life. This can be a temporary situation for a family or can last a long time. In 2019, the year that preceded the Coronavirus Disease (COVID-19) pandemic, an estimated 10.5% of US households (down from 11.1% in 2018) were food insecure at least sometime during the prior year [1]. Historically, rates of food insecurity have been higher than the national average for the following groups: households with incomes near or below the federal poverty level ($14,580 for a household size of 1) [2]; all households with children and particularly households with children headed by single women or single men; women and men living alone; Black- and Hispanic-headed households; and households in principal cities and nonmetropolitan areas. The prevalence of food insecurity also varies by state, ranging from 6.6% in New Hampshire to 15.7% in Mississippi in 2017–2019. Food insecurity rates across New York State (NYS) during this same 3-year period were similar to the national average (10.8%) [3].

The COVID-19 pandemic caused widespread economic hardships and disrupted food systems across the country, disproportionately impacting the most vulnerable populations, especially in states hardest hit by the pandemic, such as New York. People surviving cancer represent a particularly vulnerable population secondary to their higher oncological risk (recurrent or secondary cancer). Food insecurity may be more prevalent in cancer survivors due to the high cost of treatment, lost wages, unemployment, and increased burden placed on caregivers within the same household [4]. Additionally, among those with a cancer diagnosis, food insecurity has been associated with decreased adherence to cancer treatment, foregone medical care, increased mental health issues such as depression, and adverse physical health outcomes. To our knowledge, the impact of the COVID-19 pandemic on food access has not been assessed among cancer survivors across NYS. Hence, this analysis is the first to (1) describe the prevalence of food insecurity amongst cancer survivors before (2019) and during the COVID pandemic (2021) across the state, as well as any geographic variability; (2) examine demographic and socioeconomic determinants associated with food insecurity among cancer survivors during both periods.

Methods

We used publicly available data from the NYS Behavioral Risk Factor Surveillance System (BRFSS) for 2019 and 2021. BRFSS is sponsored by the Centers for Disease Control and Prevention and is an annual telephone survey administered by individual states to collect state-specific data on health-related risk behaviors, chronic health conditions, and the use of preventive services among the noninstitutionalized civilian population aged 18 years and older [5]. Interviews are conducted throughout the year in both English and Spanish and reach households with landline telephones or cell phones. The BRFSS allows for a sub-division of analysis to compare respondents residing in NYC (five boroughs combined) to residents in the rest of the state (ROS). The data within the BRFSS data set are neither identifiable nor private and thus do not meet the federal definition of “human subject” as defined in 45 CFR 46.102. Therefore, this study did not need to be reviewed and approved by the Institutional Review Board.

The 2021 annual NYS BRFSS was an expanded BRFSS [6] designed to support regional and county-level analysis, resulting in a larger sample size. The BRFSS uses a core set of questions and allows states to include additional questions to serve their specific needs [7]. Food security was a NYS-Added Module in the 2019 and 2021 BRFSS surveys. The module included the following question: How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say—always, usually, sometimes, rarely, never? Food insecure individuals were defined as respondents who indicated they were always, usually, or sometimes worried or stressed about having enough money to buy nutritious meals in the past 12 months. Cancer survivors were defined as respondents who indicated they were ever told by a doctor, nurse, or other health professionals that they had any type of cancer other than skin cancer. Respondents only reporting a skin cancer diagnosis were excluded as the survey does not distinguish between melanoma and nonmelanoma skin cancers, and nonmelanoma skin cancer typically does not require treatment beyond surgery [8].

Statistical Analysis

All statistical analyses were performed in SAS version 9.4 software (Cary, NC, USA). Considering the complex survey design of BRFSS, all statistical analyses incorporated stratification and weighting following the methodology established by the Centers for Disease Control and Prevention [9, 10]. We computed unweighted and survey-weighted descriptive statistics to summarize the demographic and clinical characteristics of respondents in 2019 and 2021 based on cancer survivorship status, then used SAS proc surveyfreq to perform survey-weighted chi-squared tests comparing characteristics among four cohorts: 2019 cancer survivors (A), 2019 respondents without cancer (B), 2021 cancer survivors (C), and 2021 respondents without cancer (D). We performed an additional survey-weighted chi-squared analysis in the subset of cancer survivors to compare the geographic distribution of food insecurity in the following four cohorts: 2019 NYC (A), 2019 ROS (B), 2021 NYC (C), and 2021 ROS (D). We then performed univariable logistic regression models using SAS proc surveylogistic to identify factors associated with food insecurity in 2019 and 2021. We chose the most scientifically and evidence-based relevant variables with a significance of p < 0.10 in the univariable models to include in multivariable models predicting food insecurity among cancer survivors in 2019 and 2021.

Covariates

The following covariates were included in the multivariable analyses: age (18–64, 65+), sex at birth (male, female), self-identified race (White, Others), education (less than high school, high school or higher), income (<$15,000, $15,000 to less than $25,000, $25,000 to less than $50,000, or $50,000 or more), employment status (employed for wages, self-employed, out of work less than 1 year, retired, or unemployed), marital status (married/member of an unmarried couple, widowed/divorced/separated, or never married), number of children (one child, two or more children, no children), health insurance (Medicaid, Medicare, private plan, other insurance, or no coverage) and total number of chronic health conditions (0–7). The chronic conditions included have been previously associated with an increased burden of food insecurity and include diabetes, myocardial infarction, angina/coronary heart disease, asthma, chronic obstructive pulmonary disease, depressive disorder, or kidney disease [11–15].

Results

Respondents who did not answer the question regarding a cancer diagnosis were excluded from the analysis, resulting in 14,182 respondents in 2019 and 38,927 respondents in 2021. Tables 1 and 2 depict the characteristics of the respondents to the BRFSS survey in 2019 and 2021, stratified by those who met the criteria of being a cancer survivor versus those who never had a cancer diagnosis. In both years, cancer survivors were more often older (57.4% vs. 18.6%; 60.1% vs. 19.9% p < 0.0001), female (61.6% vs. 51.3%; 60.8% vs. 51.4% p < 0.0001), self-identified as white (70.9% vs. 54.4%; 75.9% vs. 55.0% p < 0.0001), disabled (41.1% vs. 24.8%; 41.8% vs. 25.4% p < 0.0001), retired (44.5% vs. 16.31%; 49.5% vs. 17.41% p < 0.0001), divorced/separated or widowed (31.0% vs. 17.2%; 31.4% and 17.1%; p < 0.0001), resided with no children in the household (86.4% vs. 63.9%; and 86.1% vs. 65.8% p < 0.0001), and had Medicare as their primary health insurance (43.5% vs. 16.2%; 49.7% vs. 19.1% p < 0.0001). Regarding cancer risk factors, cancer survivors were more often former smokers (38.4% vs. 22.4%; 37.6% vs. 19.9% p < 0.0001) and less physically active (32.3% vs. 26.8%; 32.1% vs. 25.3% p < 0.0001). They also self-reported a higher proportion of other chronic health conditions, including diabetes (19.5% vs. 11%; 20.5% vs. 11.9%; p < 0.0001), myocardial infarction (9.6% vs. 3.5%; 8.0% vs. 3.2%; p < 0.0001), angina/CHD (9.1% vs. 3.5%; 9.1% vs. 3.6% p < 0.0001), chronic obstructive lung disease (13.94% vs. 5.11%; 13.69% vs. 4.88% p < 0.0001), depression (18.2% vs. 15.1% p = 0.0308; 21% vs. 16.7%; p = 0.0010) and kidney disease (7.5% vs. 2.1%; 8.2% vs. 2.4%; p < 0.0001).Table 1 Characteristics of New York State (NYS) BRFSS survey respondents by cancer survivorship status in 2019 (N = 14,182)

	Cancer survivors (n = 1422)	Respondents without a cancer diagnosis (n = 12,760)	p-Values	
Unweighted Freq	Weighted Freq	Weighted percent (95% CI)	Unweighted Freq	Weighted Freq	Weighted percent (95% CI)	
Age (years)	
 18–64	454	440,820	42.58 (38.68, 46.48)	8370	11,377,145	81.37 (80.54, 82.2)	<0.0001	
65 or older	938	594,395	57.42 (53.52, 61.32)	4028	2,604,987	18.63 (17.8, 19.46)		
Sex at birth	
 Female	851	652,334	61.63 (57.89, 65.37)	6785	7,364,693	51.32 (50.05, 52.6)	<0.0001	
 Male	571	406,136	38.37 (34.63, 42.11)	5975	6,984,864	48.68 (47.4, 49.95)		
Race/ethnicity	
 White	1145	726,433	70.95 (67.01, 74.88)	8618	7,565,249	54.41 (53.17, 55.64)	<0.0001	
 Black	96	109,628	10.71 (7.9, 13.52)	1191	1,987,624	14.29 (13.33, 15.25)		
 Hispanic	81	133,580	13.05 (9.97, 16.12)	1534	2,694,311	19.38 (18.32, 20.43)		
 Multiracial, non-Hispanic	19	13,859	1.35 (0.53, 2.18)	180	100,593	0.72 (0.58, 0.87)		
 Other race, non-Hispanic	40	40,438	3.95 (2.04, 5.85)	846	1,557,338	11.2 (10.17, 12.23)		
Education	
 Less than high school grade	103	136,459	12.97 (9.95, 15.99)	974	1,946,119	13.69 (12.66, 14.72)	0.6625	
 High school grad or higher	1310	916,002	87.03 (84.01, 90.05)	11,675	12,270,235	86.31 (85.28, 87.34)		
Disability statusa	560	408,138	41.01 (37.15, 44.86)	3356	3,287,636	24.89 (23.77, 26.02)	<0.0001	
Income	
 <$15,000	98	83,734	10.65 (7.7, 13.6)	902	989,630	9.13 (8.29, 9.98)	0.2387	
 $15,000 to less than $25,000	188	112,140	14.26 (11.21, 17.31)	1687	1,832,745	16.92 (15.83, 18)		
 $25,000 to less than $50,000	273	158,813	20.2 (17.03, 23.37)	2150	2,179,399	20.12 (18.95, 21.28)		
 $50,000 or more	536	431,500	54.89 (50.58, 59.19)	5171	5,831,982	53.83 (52.39, 55.27)		
Employment status	
 Employed for wages	304	276,314	26.56 (23.12, 30.01)	5329	6,668,291	47.88 (46.60, 49.17)	<0.0001	
 Self-employed	98	77,503	7.45 (5.39, 9.51)	1234	1,505,311	10.81 (10.00, 11.61)		
 Out of work for less than 1 year	14	11,461	1.10 (0.18, 2.03)	309	467,759	3.36 (2.85, 3.87)		
 Retired	741	462,894	44.50 (40.70, 48.29)	3414	2,271,382	16.31 (15.50, 17.12)		
 Unemployed	241	212,041	20.38 (17.17, 23.59)	2171	3,013,134	21.64 (20.50, 22.78)		
Marital status	
 Never married	175	131,850	12.57 (10.09, 15.05)	2814	4,249,559	30.04 (28.80, 31.29)	<0.0001	
 Married/living as married	646	591,642	56.40 (52.66, 60.14)	6348	7,467,373	52.79 (51.51, 54.08)		
 Divorced/widowed/separated	590	325,545	31.03 (27.64, 34.42)	3423	2,427,174	17.16 (16.31, 18.01)		
No. of Children in the household	
 0	1256	899,400	86.43 (83.76, 89.09)	9127	8,861,644	63.93 (62.64, 65.22)	<0.0001	
 1	78	84,210	8.09 (5.85, 10.33)	1460	2,100,818	15.16 (14.16, 16.15)		
 2 or more	65	57,048	5.48 (3.87, 7.10)	1843	2,898,671	20.91 (19.79, 22.03)		
Primary health insurance	
 Private plan	465	385,702	37.97 (34.18, 41.77)	5821	6,701,793	50.64 (49.32, 51.95)	<0.0001	
 Medicare	697	441,531	43.47 (39.71, 47.23)	3075	2,130,804	16.1 (15.26, 16.94)		
 Medicaid	114	109,746	10.8 (8.2, 13.41)	1406	1,894,920	14.32 (13.36, 15.28)		
 Other insurance	78	50,035	4.93 (3.34, 6.51)	651	713,251	5.39 (4.79, 5.99)		
 No coverage	38	28,699	2.83 (1.71, 3.94)	1095	1,794,025	13.56 (12.55, 14.56)		
Smoking status	
 Current smoker—every day	126	96,239	9.68 (7.38, 11.97)	1078	1,075,825	8.18 (7.49, 8.88)	<0.0001	
 Current smoker—some days	33	18,380	1.85 (1.04, 2.66)	471	594,880	4.52 (3.93, 5.12)		
 Former smoker	539	382,638	38.48 (34.67, 42.28)	3255	2,945,654	22.4 (21.36, 23.44)		
 Never smoked	645	497,202	50 (46.07, 53.92)	7040	8,534,651	64.9 (63.67, 66.13)		
Heavy drinkingb	102	101,991	10.76 (7.75, 13.76)	1736	2,168,077	17.21 (16.19, 18.23)	0.0008	
No exercisec	420	314,581	32.33 (28.65, 36.01)	3109	3,431,670	26.77 (25.57, 27.96)	0.0033	
Presence of comorbidities	
 Diabetes	293	205,974	19.49 (16.59, 22.39)	1668	1,571,880	10.98 (10.20, 11.76)	<0.0001	
 Myocardial Infarction (MI)	144	100,515	9.58 (7.34, 11.82)	609	492,647	3.46 (3.03, 3.9)	<0.0001	
 Angina/coronary heart disease (CHD)	146	94,116	9.06 (6.7, 11.43)	599	493,835	3.47 (2.99, 3.95)	<0.0001	
 Asthma	219	180,761	17.19 (14.10,20.28)	1856	2,083,924	14.57 (13.68,15.45)	0.0900	
 Chronic obstructive lung disease	225	146,901	13.94 (11.41, 16.47)	976	729,630	5.11 (4.62, 5.6)	<0.0001	
 Depressive disorder	276	192,162	18.18 (15.32, 21.03)	2104	2,146,142	15.06 (14.15, 15.97)	0.0308	
 Kidney disease	111	77,885	7.46 (5.61, 9.31)	373	301,412	2.11 (1.8, 2.41)	<0.0001	
Food Insecure	171	149,172	17.78 (14.31, 21.25)	1683	2,033,389	19.5 (18.31, 20.69)	0.3716	
aRespondents who reported at least one type of disability (cognitive, self-care, independent living, vision, mobility or hearing)

bHeavy drinking is defined as consuming 8 or more drinks per week for women and 15 or more drinks per week for men

cLeisure time physical activity is defined as any physical activities or exercises engaged in not related to one’s regular job

Table 2 Characteristics of New York State (NYS) BRFSS survey respondents by cancer survivorship status in 2021 (N = 38,297)

	Cancer survivors (n = 3897)	Respondents without a cancer diagnosis (n = 35,030)	p-Values	
Unweighted Freq	Weighted Freq	Weighted percent (95% CI)	Unweighted Freq	Weighted Freq	Weighted percent (95% CI)	
Age (years)	
 18–64	1198	390,846	39.87 (36.81, 42.93)	22,498	11,644,783	80.1 (79.43, 80.77)	<0.0001	
 65 or older	2606	589,469	60.13 (57.07, 63.19)	11,382	2,892,912	19.9 (19.23, 20.57)		
Sex at birth	
 Female	2343	613,404	60.84 (57.96, 63.73)	18,684	7,705,418	51.46 (50.53, 52.39)	<0.0001	
 Male	1554	394,765	39.16 (36.27, 42.04)	16,346	7,267,831	48.54 (47.61, 49.47)		
Race/ethnicity	
 White	3302	747,907	75.96 (73.08, 78.84)	25,096	7,988,311	55.07 (54.18, 55.96)	<0.0001	
 Black	169	98,347	9.99 (8.02, 11.96)	2720	2,068,126	14.26 (13.59, 14.92)		
 Hispanic	139	90,855	9.23 (7.17, 11.28)	3441	2,717,702	18.74 (18.02, 19.45)		
 Multiracial, non-Hispanic	83	6894	0.7 (0.42, 0.98)	666	119,226	0.82 (0.69, 0.95)		
 Other race, non-Hispanic	107	40,605	4.12 (2.53, 5.72)	2112	1,612,294	11.11 (10.39, 11.84)		
Education	
 Less than high school grad	207	87,181	8.7 (6.87, 10.53)	2528	1,939,708	13.07 (12.36, 13.77)	0.0002	
 High school grad or higher	3674	914,904	91.3 (89.47, 93.13)	32,265	12,906,098	86.93 (86.23, 87.64)		
Disability statusa	1,626	394,585	41.83 (38.74, 44.93)	9450	3,475,575	25.48 (24.63, 26.32)	<0.0001	
Income	
 <$15,000	200	43,057	6.08 (4.46, 7.7)	1759	754,172	7 (6.45, 7.55)	0.1345	
 $15,000 to less than $25,000	378	68,557	9.68 (7.89, 11.47)	3128	1,231,727	11.43 (10.74, 12.12)		
 $25,000 to less than $50,000	925	206,109	29.1 (25.83, 32.37)	7255	2,693,043	24.99 (24.07, 25.92)		
 $50,000 or more	1409	390,529	55.14 (51.63, 58.65)	14,102	6,095,862	56.58 (55.52, 57.63)		
Employment status	
 Employed for wages	736	234,038	23.69 (20.96, 26.42)	14,314	6,904,709	47.74 (46.79, 48.68)	<0.0001	
 Self-employed	210	71,161	7.20 (5.60, 8.80)	2973	1,363,163	9.42 (8.88, 9.97)		
 Out of work for less than 1 year	53	28,089	2.84 (1.29, 4.39)	957	515,909	3.57 (3.21, 3.93)		
 Retired	2283	489,018	49.50 (46.48, 52.51)	10,055	2,518,357	17.41 (16.78, 18.05)		
 Unemployed	559	165,703	16.77 (14.55, 18.99)	5809	3,162,003	21.86 (21.03, 22.69)		
Marital status	
 Never married	396	115,326	11.61 (9.72, 13.51)	7313	4,386,832	29.72 (28.83, 30.61)	<0.0001	
 Married/living as married	1934	566,022	56.98 (54.05, 59.92)	18,132	7,849,858	53.18 (52.25, 54.12)		
 Divorced/widowed/separated	1531	311,939	31.40 (28.74, 34.07)	9099	2,523,431	17.10 (16.46, 17.74)		
Number of children in the household	
 0	3479	845,853	86.11 (83.69, 88.54)	25,231	9,473,339	65.76 (64.84, 66.68)	<0.0001	
 1	187	76,974	7.84 (5.79, 9.89)	3746	2,119,585	14.71 (14.01, 15.42)		
 2 or more	162	59,422	6.05 (4.55, 7.55)	4919	2,813,349	19.53 (18.76, 20.30)		
Primary health insurance	
 Private plan	1079	319,086	33.15 (30.14, 36.15)	14,810	6,847,125	49.34 (48.38, 50.3)	<0.0001	
 Medicare	2030	478,234	49.68 (46.61, 52.75)	9519	2,653,110	19.12 (18.42, 19.82)		
 Medicaid	286	81,840	8.5 (6.84, 10.16)	3641	2,020,901	14.56 (13.85, 15.28)		
 Other insurance	284	72,083	7.49 (5.85, 9.13)	3509	1,471,992	10.61 (10.01, 11.2)		
 No coverage	43	11,391	1.18 (0.63, 1.74)	1433	883,160	6.36 (5.89, 6.84)		
Smoking status	
 Current smoker—every day	325	66,057	6.55 (5.31, 7.80)	3400	1,081,328	7.22 (6.76, 7.68)	<0.0001	
 Current smoker—some days	120	31,401	3.11 (2.17, 4.06)	1295	569,617	3.80 (3.46, 4.15)		
 Former smoker	1521	378,622	37.56 (34.68, 40.43)	8959	2,977,084	19.88 (19.18, 20.58)		
 Never smoked	1715	465,715	46.19 (43.20, 49.19)	18,543	8,944,165	59.73 (58.83, 60.64)		
Heavy drinkingb	232	60,355	6.66 (5.1, 8.22)	4272	2,013,629	15.47 (14.73, 16.2)	<0.0001	
No exercisec	1271	323,586	32.12 (29.35, 34.9)	8717	3,782,815	25.33 (24.51, 26.15)	<0.0001	
Presence of comorbidities	
 Diabetes	883	206,654	20.50 (18.16, 22.84)	4884	1,775,625	11.89 (11.28, 12.50)	<0.0001	
 Myocardial Infarction (MI)	398	79,468	7.99 (6.62, 9.35)	1689	476,727	3.21 (2.91, 3.52)	<0.0001	
 Angina/coronary heart disease (CHD)	418	90,688	9.11 (7.48, 10.75)	1705	527,642	3.55 (3.23, 3.87)	<0.0001	
 Asthma	621	145,560	14.48 (12.49,16.47)	5090	2,112,386	14.16 (13.50,14.82)	0.7640	
 Chronic obstructive lung disease	661	137,561	13.69 (11.72, 15.66)	2678	726,779	4.88 (4.48, 5.28)	<0.0001	
 Depressive disorder	865	206,071	20.54 (18.21, 22.87)	6816	2,485,946	16.74 (16.08, 17.41)	0.0010	
 Kidney disease	348	81,696	8.15 (6.36, 9.94)	1171	360,975	2.42 (2.15, 2.69)	<0.0001	
Food Insecure	362	177,161	20.36 (17.15, 23.56)	3907	3,143,774	25.12 (24.04, 26.19)	0.0061	
aRespondents who reported at least one type of disability (cognitive, self-care, independent living, vision, mobility or hearing)

bHeavy drinking is defined as consuming 8 or more drinks per week for women and 15 or more drinks per week for men

cLeisure time physical activity is defined as any physical activities or exercises engaged in not related to one’s regular job

Prior to the COVID pandemic, the proportion of cancer survivors across the state experiencing food insecurity in comparison to respondents with no prior cancer diagnosis did not significantly differ (17.78% vs. 19.5%; p = 0.3716). However, food insecurity among cancer survivors varied geographically, with a higher prevalence in the five boroughs of NYC compared to the ROS (25.3% vs. 13.8%; p = 0025), as shown in Table 3. While food insecurity rates increased across the state because of the pandemic, the geographic difference among cancer survivors persisted (27.35% vs. 18.52%; p = 0.0206).Table 3 Food insecurity—NYC vs. Rest of State (ROS), 2019 and 2021

	Cancer survivors 2019	Cancer survivors 2021	
Unweighted Freq	Weighted Freq	Weighted percent	95% CI	p-Value	Unweighted Freq	Weighted Freq	Weighted percent	95% CI	p-Value	
New York City	53	73,520	25.26	17.52–33.01	0.0025	61	49,581	27.35	20.29–34.42	0.0206	
Rest of the state	118	75,653	13.81	10.57–17.04		301	127,580	18.52	15.05–21.98		

The multivariable survey-weighted logistic regression models predicting food insecurity among cancer survivors in both years are shown in Table 4. Pre-pandemic cancer survivors had higher odds of being food insecure if they self-identified as non-White race (Odds Ratio 2.30 [95% Confidence Interval, 1.16, 4.56], had a household income <$15,000 (22.67 [6.39, 80.43]) or $15,000 to less than <$25,000 (22.99 [6.85, 77.12]), and had more cumulative chronic health conditions (1.39 [1.09, 1.77]). During the pandemic, the odds of being food insecure among cancer survivors were attenuated for non-White race (1.76 [0.98–3.16]) but remained significant for those with a household income <$15,000 (15.25 [5.3–43.91]) or $15,000 to less than <$25,000 (OR 11.81 [4.80–29.06]) as well as those with more co-morbidities (1.56 [1.28, 1.90]). Cancer survivors out of work for less than one year (6.36 [1.80, 22.54) and those with children in the household (one child: 4.42 [1.77, 11.07]; two or more children; 4.54 [1.78, 11.63]) also had a higher odd of being food insecure. The odds of food insecurity were lower among cancer survivors with private health insurance (0.20 [0.06, 0.64]) compared to no health insurance.Table 4 Determinants of food insecurity among cancer survivors across NYS State in 2019 and 2021

	2019	2021	
Cancer survivors (N = 897)	Cancer survivors (N = 1631)	
OR (95% CI)	p-Values	OR (95% CI)	p-Values	
Level	Overall	Level	Overall	
Age (18–64 vs. 65 years or older)	1.49 (0.55, 4.03)	–	0.430	0.88 (0.42, 1.86)	–	0.735	
Sex (Female vs. male)	1.02 (0.50, 2.07)	–	0.964	1.23 (0.73, 2.07)	–	0.440	
Race (Others vs. White)	2.30 (1.16, 4.56)	–	0.017	1.76 (0.98, 3.16)	–	0.059	
Education (High school or higher vs. less than high school)	1.13 (0.44, 2.89)	–	0.798	1.10 (0.47, 2.53)	–	0.831	
Income	
 <$15,000 vs. $50,000 or more	22.67 (6.39, 80.43)	0.002	<0.0001	15.25 (5.30, 43.91)	0.003	<0.0001	
 $15,000 to less than $25,000 vs. $50,000 or more	22.99 (6.85, 77.12)	0.0004	11.81 (4.80, 29.06)	0.005	
 $25,000 to less than $50,000 vs. $50,000 or more	8.09 (2.77, 23.63)	0.989	4.68 (2.31, 9.46)	0.458	
Employment status	
 Employed for wages vs. unemployed	0.76 (0.26, 2.23)	0.436	0.252	0.81 (0.35, 1.88)	0.463	0.001	
 Self-employed vs. unemployed	0.24 (0.03, 1.75)	0.267	0.41 (0.12, 1.34)	0.043	
 Out of work <1 year vs. unemployed	0.65 (0.14, 3.01)	0.784	6.36 (1.80, 22.54)	0.0001	
 Retired vs. unemployed	0.45 (0.20, 0.99)	0.571	0.54 (0.26, 1.13)	0.016	
Marital status	
 Widowed/divorced/separated vs. never married	1.25 (0.48, 3.29)	0.823	0.860	0.30 (0.14, 0.63)	0.010	0.006	
 Married/member of an unmarried couple vs. never married	1.33 (0.47, 3.72)	0.668	0.36 (0.16, 0.77)	0.134	
Number of children	
 1 child vs. no children	2.07 (0.55, 7.88)	0.794	0.156	4.42 (1.77, 11.07)	0.110	0.001	
 2 or more children vs. no children	3.05 (0.94, 9.96)	0.209	4.54 (1.78, 11.63)	0.098	
Health insurance	
 Medicaid vs. no coverage	0.40 (0.06, 2.67)	0.569	0.877	0.40 (0.10, 1.58)	0.989	0.041	
 Medicare vs. no coverage	0.40 (0.06, 2.54)	0.477	0.26 (0.08, 0.87)	0.096	
 Other insurance vs. no coverage	0.50 (0.06, 4.56)	0.936	0.51 (0.13, 1.97)	0.489	
 Private plan vs. no coverage	0.49 (0.08, 2.91)	0.873	0.20 (0.06, 0.64)	0.008	
Total number of chronic health conditions	1.39 (1.09, 1.77)	–	0.009	1.56 (1.28, 1.90)	–	<0.0001	

Discussion

In this study, the prevalence of food insecurity even before the COVID-19 pandemic was disproportionally experienced by cancer survivors residing in NYC compared to the ROS. The burden of food insecurity amongst this vulnerable population exceeds the national average (11%) by almost twofold and is higher than the overall state average (24.9%) [16]. While other studies have reported a prevalence of food insecurity among cancer survivors in the range of 4.0–26.2%, we are unaware of any studies that have described a similar geographic inequity with urban areas outpacing more suburban or rural areas [17–19]. Among cancer survivors, the most significant determinant of food insecurity during both periods was an annual household income of less than $25,000. Our findings of low-income and non-White race as independent factors that increase the likelihood of being food insecure align with previous studies [20].

While the goal of this study was to assess whether cancer survivors experienced higher rates of food insecurity because of the pandemic, we instead observed an interesting attenuation of the disparity related to the social construct of race and ethnicity accompanied by a lowering of the odds based on household income. This finding may have occurred due to the increased availability of food assistance programs, unemployment insurance, and stimulus payments across NYS [21–23], especially in NYC as the pandemic’s epicenter. Evaluations of NYS policies demonstrate that food policy reforms gained significant momentum during the COVID-19 pandemic. More than 300 policy provisions were implemented across the State during the state of emergency (March 2020–June 2021). About two-thirds of the policies focused on supporting food businesses and workers, while the other third targeted ensuring adequate food access (32%) for needy communities [24]. These additional state programs layered on top of federal programs like the Federal Pandemic Unemployment Compensation program may have buffered the most vulnerable populations. Evidence of social protection programs in other countries resulting in reductions in food insecurity because of the pandemic further demonstrates the capabilities of these programs to close critical gaps in food access created by social determinants such as poverty, race, and ethnicity [25–28].

During the pandemic, about 40% of cancer survivor survey respondents were of working age (18–64). While the overall percentage (2.84%) of cancer survivors in 2021 who reported they were out of work for less than a year was small, it represented a significant increase compared to the prevalence in 2019 (1.1%). Employed individuals diagnosed with cancer have a variety of postdiagnosis employment trajectories [29]. While some survivors may report their most significant limitations in the first year postdiagnosis, in at least one study, cancer survivors more than 11 years postdiagnosis reported nearly double the number of work absence days within the preceding year versus their colleagues with no cancer diagnosis [30]. Unfortunately, in 2019 and 2021, NYS did not include the optional module of years since the first cancer diagnosis. Thus, we were unable to factor that into the analysis. However, data from the 2020 BRFSS module demonstrates that about 43% of respondents in that year were diagnosed with cancer more than 10 years, 19% 6–10 years, 38% 5 years or less, and 18% were still actively undergoing treatment.

There are several study strengths and limitations to consider in the context of our findings. Strengths of the study include the use of survey data provided by the BRFSS, which provides population-based estimates of food insecurity that are generalizable to all NYS adults. Furthermore, the pre- and intra-pandemic data comparisons allow for further examination of secular trends in food insecurity. To our knowledge, this is the first study to examine this trend in association with cancer. Most recently, Crossa et al., using data from the 2017–2018 NYC Community Health Survey, explored the associations between food insufficiency, a more severe form of food insecurity, and the chronic health conditions of hypertension, diabetes, obesity, and depression [31]. Food insufficiency was associated with a higher odd for all chronic health conditions except obesity. Similarly, they found geographic inequities regarding the neighborhoods with the highest prevalence of food insufficiency being those areas with the “greatest social and economic inequities associated with the legacy of structural racism.” As recent findings have demonstrated that the Bronx has the highest rate of food insecurity (39%) in the state our findings of geographic inequities of food insecurity among cancer survivors across the state is not surprising.

Lastly, the sample size of the BRFSS permitted more nuanced examination of food insecurity patterns across social and demographic characteristics, as well as geography, yielding novel insights in subgroups that are at increased risk for experiencing food insecurity and its sequelae. Unfortunately, given the cross-sectional nature of the BRFSS, we are unable to examine the persistence of food insecurity within NYS households over time, or the trajectory of cancer patients’ illness. Furthermore, we are unable to ascertain the impacts of food insecurity on chronic disease prevention or management, including among cancer survivors, which may have clinical implications for individuals living with cancer. More longitudinal data is needed to fully elucidate the associations and pathways between food insecurity and health status, including poor diet quality, adverse mental health outcomes, or avoidance of medical treatment or medication adherence due to cost.

In light of the Biden Administration’s commitment coming out of the White House Conference on Hunger, Nutrition, and Health to Ending Hunger and Reducing Diet-Related Diseases and Disparities, continued research highlighting the deleterious effects of food insecurity on cancer risk, early detection, and cancer treatment response and outcomes, as well as on interventions to address food insecurity, are warranted [32]. Research is currently being conducted on the effectiveness of monthly unconditional guaranteed income for people with cancer and its impact on food insecurity and cancer outcomes [33]. Within NYC, interventions to address food insecurity through vouchers and linkages to food pantries have shown promise in improving cancer treatment completion [34]. NYC has also taken steps to institutionalize long-term food systems planning through the 10-year food policy plan, “Food Forward NYC,” mandated by local law LL 2020/040. The plan outlines five strategic areas for developing future food policy around food access and food security, food economy and good jobs, supply chains and regional infrastructure, environmental sustainability, and food system knowledge and governance [35].

Implementing ongoing, embedded food insecurity screening across all cancer care sites, at an evidence-based cadence to be determined, could serve as a cancer and food insecurity surveillance system and an indicator of the impact of food insecurity policies, which could be an essential policy intervention. This should be coupled with community-engaged interventions and advocacy for upstream policy approaches, including food voucher systems for low-income individuals, potentially coupled with Medicaid and Emergency Medicaid enrollment, to ensure progress toward addressing health inequities across the cancer continuum.

Acknowledgements

The authors would like to acknowledge the larger membership of the New York Cancer Consortiums Healthy Eating and Active Living (HEAL) Action Team. Collectively the action team aims to reduce the burden of obesity-associated cancers in at-risk groups across the state by addressing structural determinants, such as food insecurity, that hinder healthy lifestyle behaviors.

Funding

Drs. Marlene Camacho-Rivera and Erica Phillips efforts are supported in part by National Cancer Institute 1U54CA280808.

Data Availability

The data underlying this article are available by request to the Behavioral Risk Factor Surveillance System Data New York State Department of Health Bureau of Chronic Disease Evaluation and Research. The data analysis code used for analysis is available by contacting the corresponding author.

Declarations

Conflict of interest

There are no potential conflicts of interests in regard to the authors of this manuscript and any funding sources for the study.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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