COVID-19 Drives a Vicious Cycle Between Food Insecurity and Chronic Illness

COVID-19 Drives a Vicious Cycle Between Food Insecurity and Chronic Illness

                            By Julian Xie, MPP, Geoff Crisanti, Hannah Malian, and Natalie Wickenheisser

“I can’t get enough food because I’m afraid to go out.”

“With COVID-19, I’ve been having trouble getting enough food for the week.”

These are just a couple things we’ve heard from food-insecure patients in Durham. Access to nutritious food helps people stay at home safely and maintain their health. But the interplay of food insecurity and COVID-19is a vicious cycle -one that the healthcare community needs to help break as part of the fight against this pandemic.

COVID-19 not only disproportionately impacts patients with chronic disease, but also drives unemployment and poverty that will lead to more severe food insecurity. COVID-19 may lead up to 17.1 million additional Americans at risk to become food insecure and, by one estimate, the national food insecurity rate has doubled to 23%, up from 11% before the pandemic. Even more than before, people will face impossible choices between paying for food, rent, and medication. This will make it harder for people to manage chronic disease and increase their future risk too.

In 2015, 17.9% of Durham residents were food insecure. The history of segregation and economic marginalization have contributed to food desert and food swamp conditions, especially for people of color in Durham. Food insecurity is linked to many common chronic diseases, including obesity, diabetes, depression, hypertension, and heart disease. Patients with comorbidities, the most common being high blood pressure, diabetes, and cardiovascular disease, are 71% more likely to be hospitalized and 78% more likely to be in intensive care than those not having comorbidities. These impacts are even higher for people of color, who are already disproportionately affected by both chronic illnesses and COVID-19 itself. The pandemic will likely exacerbate these inequalities.

COVID-19 has also added new obstacles to food assistance. Food pantries need to find high-quality cold storage for fresh foods, and volunteers to meet an influx of need. Many pantries have converted to a drive-through model to increase social distancing. But there are many more people whose transportation barriers and physical mobility limitations are now compounded by the fear that going on a bus could put them at risk for COVID-19 infection.

Food-insecure people are also highly vulnerable to housing insecurity (see Brown and Xie reflection) and trouble accessing healthcare (see Durbha, Holtzman, and Matula reflection). This puts people at risk for even further physical, mental, and economic harm. This vicious cycle of COVID-19 and chronic disease requires us to fix the problem at its source -food security and economic inequality.

Durham’s response to protect food security

The Durham County and City governments, and key food security organizations have recognized that supporting food access will help support our COVID-19 response. The County Commissioners formed the Durham Food Security Task Force under the County Emergency Operations Center. On May 12, the County Commissioners allocated $152,000 to support End Hunger Durham, Meals on Wheels, and El Centro Hispano’s food relief efforts.

The Task Force offers food delivery for individuals who are in isolation for suspected or confirmed COVID-19. The Task Force created Durham FEAST (a collaboration of the DPS Foundation, Food Insight Group, and the Durham Hotel). Durham FEAST provides meals, shelf-stable ingredients, and family-style casseroles for children and their families. This program is vital since schools are normally a key source of food, with two-thirds of Durham Public School students qualifying for free and reduced school lunches. The Task Force also works with El Centro Hispano, Lincoln Community Health Center, and other immigrant and refugee organizations to serve Durham’s immigrant population, including refugees and undocumented people. This coalition is delivering food and providing translation and assistance to help people get connected to necessary services.

End Hunger Durham and the Duke Benefits Enrollment Center have delivered hot meals to over 900 seniors. Several local catering businesses have participated in this effort, including the restaurant Zweli’s (who also coordinated meal relief for McDougald Terrace residents displaced by an environmental health crisis). Now that nutrition and chronic disease education must now be virtual, the Durham Innovative Nutrition Education program now sends out a recipe newsletter and plans to hold virtual cooking demonstrations.

Many of the same organizations that compose the Durham Food Security Task Force are members of Partnership for a Healthy Durham. Partnership for a Healthy Durham is a coalition of organizations and community members who collaborate to improve Durham’s physical, mental, and social health and well-being. The Partnership’s Obesity, Diabetes and Food Access committee(ODAFA) leads a collaborative approach to improving food security, and preventing obesity and chronic illnesses. The ODAFA committee is now supporting the Food Security Task Force and also engaging in ongoing work on the Durham Community Health Assessment. This will guide the hard work and cooperation that is needed among the healthcare, government, community, and private sectors to build a more resilient and equal Durham food system -one that will make fewer people vulnerable to a pandemic like COVID-19.

Root Causes delivers fresh produce to food-insecure patients

We also wanted to highlight the work of one of this paper’s authors, Margolis Scholar Julian Xie, who leads the Root Causes Fresh Produce Program, which is currently home-delivering fresh produce to at-risk patients. Root Causes is a Duke medical student organization with collaborators from multiple healthcare and graduate schools, and funding from American Heart Association and Blue Cross Blue Shield Foundation of North Carolina.

Root Causes works with Farmer Foodshare and the Food Bank of Central and Eastern North Carolina to deliver locally-sourced produce and shelf-stable items. Patients are referred from the Duke Outpatient Clinic, Duke Healthy Lifestyles Clinic (Duke’s child obesity clinic), and Lincoln Community Health Center. Many of these patients have multiple chronic health conditions that make them particularly vulnerable to unstable food access.

Since April 1st, Root Causes has delivered food to 160 patients and their families with biweekly deliveries, totaling over 7500 pounds of fresh fruits, vegetables, and shelf-stable foods. Based on surveys from 39 of our patients, we have heard that half of respondents have had trouble with getting adequate food in a given week. One in five have lost their jobs. Both before and during COVID-19, they report low food security.

Beyond food, Root Causes partners with the Duke Hotspotting Initiative to procure and deliver non-food essentials such as protective masks (made by Cover the Triangle), soap (made locally by Fillaree), hand sanitizer, disinfecting wipes, paper towels, and toilet paper. We have also delivered over 25 grow-it-yourself home gardening kits for pediatric patients. The kits are made of recycled wood, soil, seeds, and a colorful gardening guide in English and Spanish. We will also soon be procuring blood pressure cuffs, glucometers, pulse oximeters, and other portable medical devices to help our patients manage chronic illness at home.

One patient recently sent us a message: “Good afternoon, I received my delivery today and I am beyond words right now!!!! Thank you so much for the masks, I am still working but I didn't get access to any. This was such a big help and the food as well.”Another said, “We’ve been really enjoying all the types of produce, we’ve never cooked Bok Choy before but it has been fun to look up new recipes and it was delicious!”


We encourage the healthcare community to get engaged in the ODAFA committee which meets on the 2nd Wednesday of the month at 9 AM. The Task Force coordinates organizations through a weekly call, and for anyone looking to volunteer, please check out the Durham Food Security Task Force Feeding Together Portal or contact the paper’s authors.

This reflection was authored by some of the 2019-2020 Duke University Margolis Scholars as part of a five-part series reflecting on the disparate impacts of the COVID-19 pandemic on the health of the Durham community. Each of the five reflection pieces centers around one of the five top health priorities in Durham, identified by the community in the 2017 Durham County Community Health Assessment. For more information, visit


Key input on this paper came from Kelly Warnock (Durham Food Security Task Force and Durham County Health Department), Chelsea Hawkins (Durham County Health Department and ODAFA Co-Chair), Jeff Howell (United Way of the Triangle and ODAFA Co-Chair), and Marissa Mortiboy (Coordinator of Partnership for a Healthy Durham). We’d also like to thank Tamar Chukrun, Willis Wong, Nila Masha, and many others on the Root Causes team.


About the Authors

Julian Xie (MPP'20 and MD'21) is a student at the Duke University School of Medicine and Sanford School of Public Policy and a Margolis Scholars in Public Policy.

Geoff Crisanti is an MBA student at the Duke University Fuqua School of Business and a Margolis Scholar in Business.

Hannah Malian completed her B.S. in Nutrition and Exercise from Virginia Tech in May of 2018. Hannah is currently a Research Specialist and Coordinator for the Psychiatry Department at Duke and serves as a recipe developer and research coordinator for Root Causes. In August, she will start her Master of Public Health in Nutrition at UNC Gillings School of Global Public Health.

Natalie Wickenheisser is a MD Candidate at the Duke University School of Medicine. She serves as the co-research coordinator for Root Causes.