Food Insecurity Contributes to Heart Failure Mortality in Populations

September 12, 2021

DENVER — Measures of greater food insecurity, including increasing prevalence of seniors with poor access to grocery stores and scarcity of grocery stores in general, are independently associated with higher heart failure (HF) mortality in the United States.

That assessment comes from a county-level analysis comparing HF mortality to socioeconomic data and measures of food security, as well as the Food Environmental Index (FEI), a metric that considers a range of geographic and economic limitations on access to healthy food.  

In fact, the analysis found that the FEI — an index that ranges from 0 to 10, poorest to best food environment — is itself significantly and inversely associated with HF mortality, at least in the United States, where the average is 7.5.

Food deserts and other contributors to food insecurity have been associated with poor cardiovascular health, including elevated blood pressure in kids. But fewer studies have directly linked them to specific cardiovascular outcomes, such as HF hospitalization.  

The effect of food insecurity on nutrition is likely a big contributor to the increased HF mortality seen in the current study, Keerthi T. Gondi, MD, University of Michigan, Ann Arbor, told | Medscape Cardiology.

"Counties that had lower heart failure mortality rates had a lower density of fast food restaurants and greater access to fresh food sources, like grocery stores and farmers markets. So I definitely think the quality of food, in addition to the quantity, and the ability to access it in the first place does play a huge role," said Gondi, who presented the analysis at the Heart Failure Society of America (HFSA) 2021 annual scientific meeting, conducted virtually and live in Denver.

But poor nutrition alone can't account for the entire effect. Much of it, Gondi said, may be "that food security is a stand-in for a lot of different socioeconomic factors that couldn't be controlled for, that we didn't have access to in the data sets we used." For example, the analysis was adjusted for income, education, and many other socioeconomic factors but not housing security, transportation concerns, or access to childcare, he said.

When Gondi and his colleagues replicated the analysis at the state level, they saw the greatest levels of food insecurity in the South. For example, "The states with the lowest Food Environmental Index were Mississippi, Alabama, and Louisiana. Georgia, Kentucky, and Arkansas were also on the lower end as well," he said.

"The states that appeared to be doing better were in the West and Northeast. The state with the highest food index was New York, followed by Colorado."

The team obtained, in addition to the FEI by county, age-adjusted data on HF mortality and data on food security, medical comorbidities, and socioeconomic factors from the National Death Index and the USDA Food Environment Atlas.

Age-adjusted HF mortality by county averaged 30 per 100,000 people. Counties with the highest HF mortalities also showed, per capita, the fewest grocery stores and food stores participating in government food assistance initiatives like the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) nutritional program. They also had the highest percentage of seniors with low access to food stores. All these associations were significant (P <.0001).

Table. Access to Stores and Other Healthy Food Sources by Lowest and Highest HF Mortality Quartile

Endpoints Lowest HF Mortality Quartile Highest HF Mortality Quartile P Value
FEI 7.9 7.3 <.0001
Limited access to healthy food (%) 6.5 7.3 .032
Insecure food access (%) 12.6 15.2 <.0001
Seniors with low access to food stores (%) 1.8 4.4 <.0001

A higher FEI was inversely associated with HF mortality after adjustment for age and other demographic and socioeconomic and medical factors.  Age-adjusted HF mortality fell 4.3% for every 1-unit increment in FEI.

In another model adjusted for demographic characteristics, Gondi reported, the relative risk (RR) for age-adjusted HF mortality per 1-unit increase in FEI was 0.77 (95% CI, 0.73 - 0.82; P < .0001).

Age-adjusted HF mortality was lower in counties with an FEI at the U.S. mean or higher compared with less than the mean: 26.4 vs 32.8 (P < .0001).

Counties with lower-than-average FEI had greater proportions of people whose race was nonwhite, who had obesity or diabetes, and who lacked medical insurance (P < .0001 for all associations). Those counties also, on average, had fewer primary care physicians per capita: 65.4 per 100,000 vs 70.4 per 100,000 (P < .05).

Beyond standard dietary risk assessment of patients with HF, "I think it's important for clinicians, at discharge or in the community, to tackle some of these social determinants of food access," Gondi said.

"That can be something as simple as assessing need for transportation or financial assistance, to some of the more unique interventions that have been designed," he said, "such as a cardiac 'Meals on Wheels' programs for getting heart healthy food directly to the patients' homes. I think investigating those interventions specifically may help ameliorate some of these disparities."

Gondi had no disclosures.

Heart Failure Society of America (HFSA) 2021. Abstract 021. Moderated Poster Session I, September 10, 2021.

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