Food Environments Tied to HF Deaths in Surrounding County

Patrice Wendling

October 26, 2022

A new analysis of nearly 3000 counties in the United States found that a poorer local food environment is associated with higher heart failure (HF) mortality at the county level.

Previous research has established that food insecurity increases the risk for worse health outcomes. But few studies have looked specifically at HF outcomes and much of the work was restricted to single metropolitan areas or health systems, which may not have captured the diversity and variance of access to food across the US, explained study author Keerthi Gondi, MD, University of Michigan in Ann Arbor.

Further fueling their desire to look at the population level was the acute rise in food insecurity with the COVID-19 pandemic, he noted.

For the study, initially reported as a poster presentation at HFSA 2021, Gondi and colleagues examined associations with county HF death rates and the Food Insecurity percentage (FI%) and Food Environment Index (FEI). FEI is a comprehensive metric of whether a neighborhood is a "food desert," scored from 0 (worst) to 10 (best), based on access to healthy food, grocery store proximity, income, and local geographic and socioeconomic factors.

The full paper, published online October 25 in Circulation: Heart Failure, includes 2956 countries with an average FI% of 13% and average FEI of 7.8.

Counties with an FI% above the national median of 13.7% had higher HF mortality than those below the national median (30.7 vs 26.7 deaths per 100,000 people; P < .001).

The association with mortality was stronger for heart failure than with non-HF cardiovascular disease and all-cause mortality, Gondi said. "This, I think, demonstrates a unique relationship between heart failure and food insecurity."

Counties with high HF mortality had more residents with low access to stores and limited transportation; poorer access to stores for adults 65 years old and older; and fewer grocery stores and supercenters (all P < .001). These counties also had lower participation in the Supplemental Nutrition Assistance Program (SNAP) and lower SNAP participant store access, despite having higher density of SNAP-authorized stores.

After adjusting for county demographic, socioeconomic, and health factors such as income ratio, poverty rate, rural-urban distribution, obesity, diabetes, and cigarette use, a 1% decrease in county FI% was associated with 1.3% lower HF mortality. Likewise, a 1-unit increase in FEI was associated with a 3.6% lower HF mortality rate.

The association between FI% and FEI was stronger in counties with the highest income inequity and poverty rate.

A pre-pandemic paper found that poverty is the strongest socioeconomic factor associated with HF and coronary heart disease mortality. The overall findings also corroborate at the population level a 2020 study identifying a 1.5-fold excess risk of cardiovascular mortality in US adults with very high food insecurity, the authors note.

"The takeaway is that in our patients with heart failure, food insecurity and more broadly socioeconomic deprivation is incredibly important and addressing this will increasingly become important as these socioeconomic determinants continue to rise in the coming decades," Gondi said.

In terms of next steps, "first and foremost, we need to investigate the best way to identify these patients at the time of their discharge and, specifically, what is the best way to determine the cause of their food insecurity: Is it an affordability issue? Is it a ZIP code issue living in a food desert?" he said.

Studies are also needed to trial novel community and health system interventions to identify patients and provide them with a specific treatment option, such as home delivery of heart-healthy meals, Gondi added.

The results come at a time of greater scrutiny, with the first White House Conference on Hunger, Nutrition, and Health in more than half a century held this year and the recent American Heart Association (AHA) policy statement promoting equity in nutrition security in the US.

"What the pandemic did is to show how vulnerable people are to food insecurity," Anne Thorndike, MD, MPH, lead author of the AHA statement and director of the Cardiac Lifestyle Program at Massachusetts General Hospital in Boston, said in an interview. "There's always been this baseline rate of food insecurity in our population that a lot of people just weren't paying attention to, but it's still there."

According to the US Department of Agriculture, the prevalence of food insecurity in 2021 was unchanged from 2020 at 10%, but rates vary across states and 32.1% of households with incomes below the federal poverty line were food insecure.

Thorndike said physicians should incorporate screening for food insecurity into daily practice but can also link patients to community-based food and transportation resources. Some health systems have their own food pantries on-site and in Massachusetts, she noted, they're experimenting with the Flexible Services program for Medicaid ACO patients.

Thorndike has also done extensive research on interventions using traffic light labels and product placement to promote healthy food and beverage choices in the hospital worksite and community setting.

"A lot of times physicians think, 'Well, what can I do about food insecurity? You're not going to go out to somebody's house and deliver them food.' However, there's a lot of steps that we can take as physicians and more health systems that are starting to screen for food insecurity," she said.

Thorndike noted that this is the first study to look specifically at HF mortality and food environments but cautioned that the associations cannot determine causality and requires further study. "This is an association that raises some really important questions and suggests that this would be an important area for preventing cardiovascular disease complications."

In an accompanying editorial, Jelani Grant, MD, and Chiadi E. Ndumele, MD, PhD, both with Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, applaud the authors for highlighting the links between food environments and HF mortality but say the lack of patient-specific factors and outcomes is another limitation.

"We do not yet understand what aspects of the food environment have the greatest impact on HF outcomes, which is key to developing effective strategies to provide nutritional support for HF patients living in low FEI areas," the editorialists write. "Additionally, determining the role of an individual's experience within the food environment, the role of activity spaces, and the impact of a person's travel routes within nonresidential food environments on dietary behavior and other HF-related health markers remain important areas for future research."

Nevertheless, Grant and Ndumele stress repeatedly that in everyday practice "it is essential that we begin to incorporate food security/environments into the social determinants of health framework when managing patients with HF."

Gondi, Grant, and Ndumele have disclosed no relevant financial relationships. Thorndike reported a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

Circ Heart Fail. 2022;0:e009651. Abstract, Editorial

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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