Cardiovascular
Food Security and Cardiovascular Disease Mortality Among Economically Disadvantaged U.S. Adults: National Health and Nutrition Examination Survey (NHANES) 2011-2018 Jee Won Park* Fadzai Nicola Dube Dube Dube University of Delaware
Food security is a key social determinant of cardiovascular health, yet evidence on its relationship with cardiovascular disease (CVD) mortality among economically disadvantaged U.S. adults is limited. We examined adult food security and CVD mortality and assessed effect measure modification (EMM) by age, sex, race/ethnicity, and SNAP participation.
Using NHANES 2011-2018 data, linked to the 2019 National Death Index, we analyzed 6,905 non-pregnant adults (age ≥ 20 years) with a poverty-income ratio <2. Adult food security was categorized as high (ref), marginal, low, and very low. Cox proportional hazards models estimated HRs and 95% CIs adjusting for sociodemographic, healthcare use, behaviors, SNAP, and survey cycle. Sensitivity analysis used Fine-Gray sub-distribution hazards models to account for competing risks due to non-CVD deaths.
During a median follow-up of 5.08 person-years (25th-75th percentile: 3.17-6.92 person-years), 164 CVD deaths occurred. The adjusted HRs (95% CIs) for marginal, low and very low versus high food security were 0.91 (0.55-1.51), 1.12 (0.70-1.81), and 1.29 (0.75-2.21), respectively. Fine-Gray analysis showed similar results. In general, there was no strong evidence of EMM. However, positive associations were most compatible with the data among non-Hispanic Black adults; for example, adjusted HR (95% CIs) comparing very low versus high food security was 1.97 (0.81-4.80), while negative associations were most compatible among Hispanic and Other group (0.74 (0.21-2.63)). Similarly, positive associations were most compatible among SNAP recipients and negative associations were observed among non-SNAP recipients.
Our findings were mixed. Some suggestions of differences by race/ethnicity and SNAP participation may indicate certain subgroups of the population that are more affected by lower food security. Future studies should consider other structural and social factors and investigate the causal pathways that may explain these differences.
