Food Insecurity May Drive Heart Failure, CAD Risks in Black Individuals

In Black individuals, food insecurity may be a risk factor for heart failure with reduced ejection fraction (HFrEF) and CAD, according to an analysis from the Jackson Heart Study.

The heightened risk associated with inadequate access to food was independent of traditional CV risk factors and socioeconomic status. Food insecurity was defined as receiving food stamps through the Supplemental Nutrition Assistance Program (SNAP) or not having enough money for groceries, and having two or more low-quality food sources (fast-food restaurants and convenience stores) within 1 mile of where individuals lived.

“These findings support economic food insecurity, which disproportionately affects Black communities, as an important factor in the well-documented racial disparities in CV health, and as a promising potential target for intervention,” write Rani Zierath, BS (Brigham and Women’s Hospital, Boston, MA), and colleagues in JAMA Network Open.

The authors say the current literature suggests that only about 30% to 40% of patients are screened for food insecurity in physician practices and hospitals.

“This study is a good reminder of why these broader social determinants of health should be on our radar,” said Eric J. Brandt, MD (University of Michigan, Ann Arbor), who commented on the study for TCTMD. “I think people are paying more attention to them, but we are just starting to understand their impact.”

Zierath and colleagues found that the risk of incident HFrEF was approximately doubled in Black patients with food insecurity. In a recent study of National Health and Nutrition Examination Survey (NHANES) data, Brandt’s group found that approximately two in five individuals who had any CVD also had food insecurity, with those who identified as non-Hispanic Black and Hispanic being the most susceptible. Another study that analyzed data from the National Health Interview Survey came to the same conclusion.

“It seems like almost any way we cut it . . . a doubling of risk is pretty consistent,” Brandt said. “The way that I connect food insecurity to cardiovascular outcomes is [through] the risk for traditional cardiometabolic diseases like obesity, diabetes, and hypertension.”

One prevailing theory supporting the association is that for people with food insecurity there are cyclical periods of undernutrition and overnutrition from a low-quality diet, said Brandt. This cyclical nature leads to weight shifts and physiological shifts that are associated with a proinflammatory state. Furthermore, all of this may be compounded by other prominent social determinants that can increase physiologic stressors and lead to chronic inflammation and risk for CV diseases and outcomes.

In keeping with this theory, Zierath and colleagues found that Black individuals with economic food insecurity had higher concentrations of renin and C-reactive protein.

Young, Female, Stressed

The 3,024 Black adults (mean age 54 years; 66% women) from counties in the Jackson, MS, metropolitan area were originally recruited for the study between 2000 and 2004 and were followed through November 2021 for this analysis.

Compared with individuals who did not report food insecurity, those who did tended to be younger, female, hypertensive, and had higher body mass index. Other factors associated with food insecurity included stress, lower diet quality, lower income, lower educational level, and more perceived lifetime discrimination.

Over the 14-year follow up, economic food insecurity was associated with greater risk of incident CAD (HR 1.76; 95% CI 1.06-2.91), and incident HFrEF (HR 2.07; 95% CI 1.16-3.70), but not with increased risk of stroke. The findings did not change after adjustment for diet quality and perceived stress.

Although individuals who reported living within a mile of more than 2.5 unfavorable food stores were more likely than those who did not to have hypertension and diabetes, they did not have higher rates of any CV outcome.

Zierath and colleagues say more research is needed to understand the relationships between food insecurity and various social determinants of health and psychosocial responses, looking at “the extent to which they may mediate and/or modulate the association of food insecurity with CVD.”

They add that it remains unclear whether targeted interventions aimed at economic food insecurity will yield reductions in risk of CAD and/or HFrEF.

To TCTMD, Brandt said medically tailored meals for patients with certain diagnoses, such as diabetes and HF, are being studied to understand if they can make an impact. Other food and medicine pilot programs across the US are taking aim at food insecurity, he added.

One of the most crucial steps, though, may be heightened awareness by clinicians of individual patients’ food insecurity because it can allow them to offer ways to connect with help.

“As clinicians we operate within medical systems in which many of us have coworkers that are social workers or case managers,” Brandt said. “Those individuals within our own networks can connect them to, for example, participating in SNAP, because the programs aren't perfect and many people that would qualify may not be participating fully.”