Household Food Insecurity and Ideal Cardiovascular Health Factors in US Adults

Food insecurity is a condition of limited food availability owing to a lack of money and resources, affecting 12.7% of US households in 2015.¹ Food insecurity has been previously associated with poor diet quality and obesity, which may have long-term implications for chronic disease.^2,3 In 2011, the American Heart Association defined ideal cardiovascular health (CVH) as adherence to 7 health factors and behaviors,⁴ ranging from physical activity to blood pressure and total cholesterol levels, which have been associated with lower risk of major chronic disease and mortality.^5,6 However, populations vulnerable to food insecurity may be less likely to achieve ideal CVH. The objective of this study was to examine the associations between household food insecurity and ideal CVH metrics in a national sample of US men and women.

Data came from years 2007 through 2012 of the National Health and Nutrition Examination Survey. Approval from the University of California, San Francisco, institutional review board was waived because this research was a secondary analysis of deidentified data. Participants were 7802 adults (20-65 years) with household incomes no more than 300% of the federal poverty level, to reduce the potential for confounding by socioeconomic status. The primary exposure was household food insecurity, measured using the US Food Security Survey Module. Food insecurity was categorized as follows: 0 affirmative responses, food security; 1 to 2 affirmative responses, marginal food security; and at least 3 affirmative responses, food insecurity. The outcomes were attainment of standards for 4 health behaviors (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared], diet, physical activity, and smoking) and 3 health factors (blood pressure, fasting plasma glucose level, and total cholesterol level), as defined by the American Heart Association.⁴ Because less than 1% of adults in the study met the ideal diet criteria, we redefined ideal diet as being the upper 2 quintiles of Alternate Healthy Eating Index 2010. Logistic regression models examined associations between household food insecurity and ideal CVH metrics. Heterogeneity by sex was determined using a Wald test. All models were adjusted for age, sex, race/ethnicity, educational attainment, marital status, and household income, and incorporated sampling weights recalculated to reflect sampling probabilities and participation rates across the study period.

In the study sample, 4013 (57.7%) adults were food secure, 1302 (15.1%) were marginally food secure, and 2487 (27.2%) were food insecure. After multivariable adjustment, food insecurity was inversely associated with ideal smoking behavior (odds ratio [OR], 0.58; 95% CI, 0.48-0.70) (Table 1). Associations for BMI, physical activity, and diet differed by sex. Food insecurity was inversely associated with ideal physical activity (OR, 0.71; 95% CI, 0.58-0.87) in men, and ideal BMI (OR, 0.71; 95% CI, 0.57-0.89) and diet quality (OR, 0.71; 95% CI, 0.54-0.93) in women. There were graded associations between household food insecurity and meeting ideal CVH metrics (Table 2). Compared with food-secure adults, food-insecure adults had lower odds of meeting at least 3 metrics (OR, 0.73; 95% CI, 0.60-0.89; P = .002), at least 4 metrics (OR, 0.69; 95% CI, 0.59-0.80; P < .001), at least 5 metrics (OR, 0.63; 95% CI, 0.49-0.81; P < .001), and at least 6 metrics (OR, 0.50; 95% CI, 0.30-0.84; P = .009).

In this nationally representative study, household food insecurity was inversely associated with multiple health behaviors and clinical measures that collectively make up ideal CVH. The constellation of these nonideal CVH metrics may explain why food insecurity has been previously associated with diet-sensitive chronic disease, suggesting long-term implications for adverse CVH outcomes.^2,3 This study is limited by the cross-sectional nature of the data, which precludes clear notions about temporality. However, corroboration of our results by prior studies helps lend confidence that health behaviors are affected by food insecurity, rather than vice versa.^2,3 Results of this study highlight another important health consequence of food insecurity. Rather than focusing solely on nutrition, those designing interventions or policies may want to consider a holistic approach to health promotion to reduce disparities among populations at risk for food insecurity.

Corresponding Author: Cindy Leung, ScD, MPH, University of California, San Francisco, 3333 California St, Suite 465, San Francisco, CA 94118 (cindyleung@post.harvard.edu).

Published Online: March 20, 2017. doi:10.1001/jamainternmed.2017.0239

Author Contributions: Dr Leung had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Leung, Laraia.

Acquisition, analysis, or interpretation of data: Leung, Tester.

Drafting of the manuscript: Leung, Laraia.

Critical revision of the manuscript for important intellectual content: Tester, Laraia.

Statistical analysis: Leung.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Leung was supported by grant 5K99HD084758 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr Tester was supported by grant 5K23HD075852 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Role of the Funder/Sponsor: The Eunice Kennedy Shriver National Institute of Child Health and Human Development had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.