Food Insecurity Rose Over the Past 20 Years in Patients With CVD

(UPDATED) The prevalence of food insecurity among patients with cardiovascular disease in the United States has doubled over the prior two decades, with those identifying as non-Hispanic Black and Hispanic the most susceptible, according to new data from the National Health and Nutrition Examination Survey (NHANES).

The study is not the first to suggest ties between food insecurity and CVD, but lead author Eric J. Brandt, MD (University of Michigan, Ann Arbor), told TCTMD these data are the most contemporary. “Through the last 20 years, there's been this continual increase in food insecurity among individuals with cardiovascular disease,” he said. “I think there's a lot of recognition that could happen [on the part of doctors] to find individuals among our clinical practice that are food insecure that might benefit from connection to resources that could help to manage them.”

Commenting on the new report for TCTMD, Khurram Nasir, MD (Houston Methodist DeBakey Heart & Vascular Center, Houston, TX), who authored a similar study last year, said in an email that while it is sad that “the richest nation country in the world” has seen increases in food insecurity, “more saddening is the disparities are worse across vulnerable minority groups.”

Income, aside from racial disparities,  seems to be the driving factor behind several social determinants of risk, Nasir continued. “America’s poor—of any race or ethnicity—as shown in this paper, are more likely to have food insecurity than well-off Americans,” he said. “Disparities due to poverty hurt racial and ethnic minorities more than other groups because they make up a large proportion of the poor. These data illustrate the notion of the potential ‘double jeopardy’ with nondominant racial groups, who experience much higher food insecurity risks.”

Physicians, he urged, should not be making medical decisions “in siloes, considering that housing and food insecurity independently increased the likelihood of healthcare access hardship, poorer health status, and poor medication adherence. Usually, it’s shown to last until there is no food insecurity.”

Lack of Money, Meals

For the latest study, published online yesterday ahead of print in JAMA Cardiology, Brandt and colleagues defined food insecurity using a US Department of Agriculture survey with 10 questions that captured whether study participants had enough money to buy more food, had enough food on hand, could afford balanced meals, had intentionally reduced portions or skipped meals, or felt hungry or lost weight due to a lack of money for food.

The researchers included a sample of 57,517 adults from NHANES (1999-2018). A total of 6,770 individuals (11.8%) reported food insecurity, with higher rates among those who identified as Hispanic (24.0%) and non-Hispanic Black (18.2%) and lower rates among the non-Hispanic white (8.5%) and Asian (8.0%) groups. Only 7.0% of adults reported participating in the Supplemental Nutrition Assistance Program (SNAP).

Overall, 7.9% of the study population had any CVD, 5.1% had CAD, 2.7% had stroke, 2.4% had heart failure, 49.6% had hypertension, 33.2% had obesity, 11.2% had diabetes, and 30.8% had dyslipidemia. All of these diseases, with the exception of CAD, were more common in those with food insecurity than those without.

The prevalence of food insecurity increased over time in the overall cohort, with a greater rise among patients with CVD (16.3% in 1999-2000 to 38.1% in 2017-2018; P < 0.001 for trend).

From 2011 to 2018, there was a drop in the prevalence of food insecurity for non-Hispanic Black adults with CVD (36.6% to 25.4%; P = 0.04 for trend), but there were no similar changes observed for adults of other races and ethnicities or those with cardiometabolic risk factors.

For individuals who had food insecurity, SNAP participation was higher among those with CVD compared with those without between 2015 and 2018 (54.2% vs 44.3%; P = 0.01). “Because the data are cross-sectional, we can't assign any causality in one direction or another,” Brandt observed about this last finding.

“But just understanding food insecurity as a whole and how it may impact risk for disease, I think there's a bidirectional relationship here wherein individuals that are food insecure, because maybe they have lower access to healthy foods, which may drive metabolic disease, they increase their risk for developing cardiovascular events,” he explained. “And then in the other direction, those that had cardiovascular events, after the cardiovascular event—either because of the financial toxicity from undergoing medical care or loss of job or disability—they may have reasons why they may be more likely to be food insecure.”

Broad Implications

Taking a broad view, Brandt said the push toward better identifying social determinants of health in patients “may have a bigger impact on cardiovascular outcomes than some of the medications we prescribe.”

Many of these social determinants are not only recognizable, but treatable through societal resources, he continued. “[This] can be an important part of medical care and medical practice and how we think about really broadly managing cardiovascular disease,” Brandt said. Also, “it can be such that social determinants of health may go along with each other—that, for example, someone who's food insecure could also have low access to medical care because of either a lack of transportation or because of insurance reasons.”

Because of all this, Brandt said he’d like to see more research looking about how to “best recognize food insecurity within clinical settings.” Some tools have been validated, though there is uncertainty about how to best implement them and how to act on the results, he added.

“With already the very high clinical burden, we have to make sure that we can streamline this to make it easy to be part of routine medical care and for clinicians to know how to act and what to do with that information,” Brandt concluded. “I also think there needs to be more research to understand how food insecurity connects with cardiovascular disease and how participation [in federal food programs] leads to differential health outcomes. We need to know more about how all those processes work.”

Merely pointing to the scope of the problem will not suffice. Khurram Nasir

Nasir, for his part, said he would like to see more prospective studies designed “to clarify the chronological sequence and long-term effects of food insecurity on cardiovascular health. The intersections of food insecurity with characteristics like family structure, race/ethnicity, and age should also be investigated to assess the specific cardiovascular risk levels of various demographic subgroups.”

Also, he argued, SNAP programs should be expanded in “scope and size” to eliminate food insecurity for its recipiences. “Collaboration between local and federal organizations can be considered such as dollar-for-dollar ‘matches’ for SNAP users allowing to maximize the desired impact of these programs,” Nasir suggested.

Nasir said he’s hopeful that solutions will emerge to mitigate these problems now that they have been identified.

“However, merely pointing to the scope of the problem will not suffice,” he said. “One, we need to systematically screen patients at risk for food insecurity, tailoring management accordingly as well as connecting with health-system and community resources to support these vulnerable patients.” Nor should cardiologists be shy about playing an active role in working with local “support programs to provide financial assistance to those who need it the most,” Nasir added.