The majority of children with ESKD on chronic dialysis participating in this study lived in food insecure households, and a majority of food insecure families reported worsening of their food insecurity due to the COVID-19 pandemic. We also found that children with FI had increasing serum phosphorus levels during the COVID-19 pandemic.
Children with ESKD may be at higher risk of FI given their frequent healthcare utilization and high medical expenditures. These risk factors may be exacerbated in the setting of a global pandemic . Our finding of increasing serum phosphorus levels during COVID-19 may reflect the impact of increasingly limited access to appropriately low-phosphorous food options during the initial wave of the pandemic. Specifically, a diet higher in processed and shelf-stable foods, which are more readily accessible and affordable, is likely to be higher in phosphorous content . However, other pandemic related factors may have also influenced
phosphorous levels as children not eating school lunches, restaurants were closed, and families were spending more time indoors and isolating. There are too many variables that impact phosphorous intake to draw a conclusion from this finding.
Additionally, we report lower rates of FI at Seattle Children’s Hospital compared to Riley Hospital for Children, as well a lower rate of FI than that reported in a previous FI study at Seattle Children’s among a different clinical cohort of ESKD patients . We speculate that these differences may potentially reflect the positive impact of earlier adoption of FI screening and the availability of an on-site food pantry at Seattle Children’s Hospital, the establishment of which preceded the COVID-19 pandemic. Conversely, no on-site food pantry was available at Riley Hospital for Children during the time of this study. Similar to what has been reported in other patient populations, availability of an on-site food pantry may have decreased barriers to accessing food for families with FI [9, 11, 12]. While no baseline data on FI rates at Riley Hospital for Children is available, we speculate that the lower rates at Seattle Children’s despite the COVID-19 pandemic may reflect the previous work and resources available to this population, particularly the presence of an on-site food pantry.
Both FI and COVID-19 are known to disproportionately affect racial minorities, and structural racism is an important underpinning of these disparities. While we did not observe differences in the prevalence of FI by race, this may have been due to small sample size. A recent cross-sectional study of national data found that during the COVID-19 pandemic, FI did not significantly differ between racial groups, but racial minorities were significantly less confident about their food security compared to white participants.
Food insecurity is an essential social determinant of health that has been tied to higher rates of chronic disease and poorer health outcomes . These concerns are exacerbated by a global pandemic that has highlighted disparities and further strained already-limited social resources. Increased rates of unemployment and poverty, two strong drivers of FI, increased worldwide following the COVID-19 pandemic . Other factors which may contribute to high FI prevalence during COVID-19 include school closures and virtual learning resulting in the loss of SNAP subsidized meals.[17, 18]
This study has several limitations. First, patients and families may have reasons not to disclose FI, thus leading to an underestimate of FI prevalence. Enlisting the help of a social worker or other dialysis team member with good rapport with families may help them to feel more comfortable in disclosing FI. Further, owing to the relative rarity of pediatric ESKD, the sample size is limited. Additionally, we do not have available data on the prevalence of FI at Riley Hospital for Children prior to the COVID-19 pandemic, limiting longitudinal comparions among part of the cohort. Despite these limitations, our study highlights the frequency and importance of FI among children with ESKD.