Disparities in Cardiovascular Health by Food Security Status and Supplemental Nutrition Assistance Program Participation Using Life’s Essential 8 Metrics

This cross-sectional study examines the associations among household food security, Supplemental Nutrition Assistance Program participation, and cardiovascular health among 2013-2018 National Health and Nutrition Examination Survey participants.


Introduction
The American Heart Association recently updated its definition of ideal cardiovascular health (CVH)   to encompass 8 health behaviors and clinical measures (ie, Life's Essential 8 [LE8]) and to centralize the importance of social determinants of health in cardiovascular disease prevention. 1 Food insecurity, a condition of limited food availability due to insufficient resources, is one critical social determinant of health affecting 10% of US households. 2 Few studies have examined food insecurity in relation to multidimensional cardiovascular outcomes.Furthermore, this association may be complicated by participation in the Supplemental Nutrition Assistance Program (SNAP), which aims to alleviate food insecurity and also targets populations most vulnerable to poverty and poor health.
This study examined the associations among household food security, SNAP participation, and LE8 as a measure of ideal CVH.

Methods
We used data from the 2013-2018 National Health and Nutrition Examination Survey, a continuous, multistage survey representative of the noninstitutionalized US population.The study population included 11 520 nonpregnant adults 20 years and older.Analysis of publicly available secondary data was deemed exempt from approval by the Harvard University Institutional Review Board, and informed consent was not required.The study followed the STROBE reporting guideline.
The primary exposure was household food security, measured using the US Household Food Security Survey Module, and categorized as high, marginal, low, and very low using US Department of Agriculture guidelines. 2 The secondary exposure was household SNAP participation in the last 12 months.Nonparticipants were classified as low income (Յ130% of the federal poverty level) or higher income (>130% of the federal poverty level).The primary outcomes were the LE8 measures (physical activity, diet, tobacco use, sleep health, body mass index [BMI], blood pressure, and serum glucose and lipid levels). 1 Published algorithms were applied to create component scores ranging from 0 to 100. 3 The overall LE8 score is the mean of all component scores.We used multivariable linear regression models to examine differences in continuous overall and component LE8 scores by household food security and SNAP participation and multivariable logistic regression to examine joint associations between household food security and SNAP participation with moderate or ideal CVH (overall LE8 score Ն50).Models were adjusted for sociodemographic covariates.Complex sampling weights were applied to all analyses.
Compared with adults with high food security (66.9 [0.4]), those with marginal (65. 4    c Calculated from hemoglobin A 1c levels assayed from whole blood biospecimens. d Calculated from the mean of 3 readings (systolic and diastolic).
e Significant difference from the group with high food security (P < .05).
f Significant trend in outcome by severity of food insecurity (P < .05).
g Significant difference between SNAP participants and low-income nonparticipants (P < .05).
h Significant difference between SNAP participants and higher-income nonparticipants (P < .05).

Figure. Estimated Probabilities of Moderate to Ideal Cardiovascular Health
Author affiliations and article information are listed at the end of this article.This is an open access article distributed under the terms of the CC-BY License.manner(P< .001fortrend)(Table).Greater severity of food insecurity was also inversely associated with diet, tobacco use, sleep health, BMI, and serum glucose scores (P < .05for trend).SNAP participants had the lowest overall mean (SE) LE8 score (62.8 [0.6]) compared with low-(65.5 [0.7]) and higher-income (65.4 [0.5]) nonparticipants.SNAP participation was also associated with lower scores for diet, tobacco, sleep, and BMI.

Table .
Least Square Means of Overall and Component Life's Essential 8 Scores by Household Food Security Status and Supplemental Nutrition Assistance Program Participation a Estimates are based on Life's Essential 8 scores of 50 or greater among 11 520 nonpregnant adults (aged Ն20 years) by household food security and Supplemental Nutrition Assistance Program (SNAP) participation, adjusted for age, sex, race and ethnicity, educational attainment, marital status, and ratio of family income to poverty.Error bars indicate 95% CIs.