Pathways by Which Food Insecurity Is Associated With Atherosclerotic Cardiovascular Disease Risk

Abstract

Background Food insecurity (FI) has been associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk; however, the pathways by which FI leads to worse cardiovascular health are unknown. We tested the hypothesis that FI is associated with ASCVD risk through nutritional/anthropometric (eg, worse diet quality and increased weight), psychological/mental health (eg, increased depressive symptoms and risk of substance abuse), and access to care pathways. Methods and Results We conducted a cross-sectional study of adults (aged 40-79 years) using the 2007 to 2016 National Health and Nutrition Examination Survey. Our primary exposure was household FI, and our outcome was 10-year ASCVD risk categorized as low (<5%), borderline (≥5% -<7.5%), intermediate (≥7.5%-<20%), and high risk (≥20%). We used structural equation modeling to evaluate the pathways and multiple mediation analysis to determine direct and indirect effects. Of the 12 429 participants, 2231 (18.0%) reported living in a food-insecure household; 5326 (42.9%) had a low ASCVD risk score, 1402 (11.3%) borderline, 3606 (29.0%) intermediate, and 2095 (16.9%) had a high-risk score. In structural models, we found significant path coefficients between FI and the nutrition/anthropometric (β, 0.130; SE, 0.027; P<0.001), psychological/mental health (β, 0.612; SE, 0.043; P<0.001), and access to care (β, 0.110; SE, 0.036; P=0.002) pathways. We did not find a significant direct effect of FI on ASCVD risk, and the nutrition, psychological, and access to care pathways accounted for 31.6%, 43.9%, and 15.8% of the association, respectively. Conclusions We found that the association between FI and ASCVD risk category was mediated through the nutrition/anthropometric, psychological/mental health, and access to care pathways. Interventions that address all 3 pathways may be needed to mitigate the negative impact of FI on cardiovascular disease.

Keywords: atherosclerotic cardiovascular disease; food insecurity; social determinants of health.

Figure 1. Conceptual framework for examining the association between food insecurity and increased atherosclerotic cardiovascular disease (ASCVD) risk.

Compensatory/behavioral includes 2 aspects, access to care and medication adherence.

Figure 2. Path diagram showing the relationship between food insecurity and atherosclerotic cardiovascular disease (ASCVD) risk category.

A, Binary food insecurity (food insecure vs food secure). B, Categorical food security (high, marginal, low, and very low food security). All associations adjusted for age, income‐to‐poverty ratio, highest education level achieved, and marital status. Includes β coefficient (SEs), and bold indicates significance of P<0.05. BMI indicates body mass index; Drugs, self‐reported use of cocaine, heroin, or methamphetamines; HEI, Healthy Eating Index‐2015; MH, mental health (provider seen in the past 12 months); No place, place participant goes if sick or needs advice about health (yes or no); No use, how many times participant saw a doctor or other health care professional in the past 12 months (none or ≥1 time); PHQ‐9, Patient Health Questionnaire‐9; Usual source, place participant goes for health care (clinic/doctor’s office or other); and Waist, waist circumference.