Cardiometabolic Mortality by Supplemental Nutrition Assistance Program Participation and Eligibility in the United States

Abstract

Objectives: To investigate total and cause-specific cardiometabolic mortality among Supplemental Nutrition Assistance Program (SNAP) participants, SNAP-eligible nonparticipants, and SNAP-ineligible individuals overall and by age, gender, race/ethnicity, and other characteristics.

Methods: We performed a prospective study with nationally representative survey data from the National Health Interview Survey (2000-2009), merged with subsequent Public-Use Linked Mortality Files (2000-2011). We used survey-weighted Cox proportional hazards models adjusted for age and gender to estimate hazard ratios of total and cause-specific cardiometabolic mortality for 499 741 US adults aged 25 years or older.

Results: Over a mean of 6.8 years of follow-up (maximum 11.9 years), 39 293 deaths occurred, including 7408 heart disease, 2185 stroke, and 1376 diabetes deaths. Individuals participating in SNAP exhibited higher total and cardiovascular disease mortality, largely limited to non-Hispanic Whites and non-Hispanic Blacks, than both SNAP-eligible nonparticipants and SNAP-ineligible individuals, and higher diabetes mortality across races/ethnicities (P < .01).

Conclusions: Participants in SNAP require greater focus to understand and further address their poor health outcomes. Public Health Implications. Low-income Americans require even greater efforts to improve their health than they currently receive, and such efforts should be a priority for public health policymakers.

FIGURE 1—

Risk of All-Cause and Cause-Specific Cardiometabolic Mortality Comparing Supplemental Nutrition Assistance Program (SNAP) Participants, SNAP-Eligible Nonparticipants, and SNAP-Ineligible Individuals; United States, 2000–2011 Note. CHD = coronary heart disease; CI = confidence interval; CVD = cardiovascular disease; SNAP = Supplemental Nutrition Assistance Program. Circles represent hazard ratios, and error bars represent 95% CIs. Values are adjusted for age and gender and weighted to represent the US population. International Classification of Disease, Tenth Revision, codes: coronary heart disease (I00–I009, I11, I13, I20–I51), stroke (I60–I69), diabetes (E10–E14). Cox proportional hazards model, adjusted for age (25–34, 35–44, 45–54, 55–64, 65–74, ≥ 75 years) and gender. The sample size was n = 499 471. *Significantly different than SNAP-eligible nonparticipants for same event and gender at P < .01.

FIGURE 2—

All-Cause Survival According to Supplemental Nutrition Assistance Program Status at Baseline Among US Adults: 2000–2011 Note. SNAP = Supplemental Nutrition Assistance Program. Dotted line = SNAP-ineligible individuals; dashed line = SNAP-eligible nonparticipants; solid line = SNAP participants. Similar findings were observed for cause-specific cardiometabolic mortality (data not shown). The sample size was n = 499 471.

FIGURE 3—

Risk of All-Cause and Cause-Specific Cardiometabolic Mortality Comparing SNAP Participants, SNAP-Eligible Nonparticipants, and SNAP-Ineligible Individuals by Race/Ethnicity: United States, 2000–2011 Note. CHD = coronary heart disease; CI = confidence interval; NHB = non-Hispanic Black; NHW = non-Hispanic White; SNAP = Supplemental Nutrition Assistance Program. Circles represent hazard ratios, and error bars represent 95% CIs. Values are adjusted for age and gender and weighted to represent the US population. International Classification of Disease, Tenth Revision, codes: coronary heart disease (I00–I009, I11, I13, I20–I51), stroke (I60–I69), diabetes (E10–E14). Cox proportional hazards model, adjusted for age (25–34, 35–44, 45–54, 55–64, 65–74, ≥ 75 years) and gender. The sample size was n = 499 471. *Significantly different than SNAP-eligible nonparticipants for same event and race/ethnicity at P < .01.