Abstract
Background
Cognitive impairment and dementia are severe public health issues in aging populations, which can be exacerbated by insufficient or unhealthy dietary intake. Food (in)security status is linked to cognitive function among older adults, but the relationship is complex and can vary by sociodemographic characteristics.
Objective
This article aimed to investigate the association between food insecurity and cognitive function among United States older adults and explore potential variations by race and ethnicity groups.
Methods
We prospectively examined changes in cognitive function and incidence of cognitive impairment alongside the presence of self-reported food insecurity among older adults of different racial and ethnic groups. Data were from the 2012–2018 Health and Retirement Study (HRS) and the 2013 Health Care and Nutrition Study (HCNS), including N = 6,638 United States adults aged 50 years and older. Food insecurity was measured by a self-reported United States Household Food Security Survey Module, and cognitive function was assessed by the modified version of the Telephone Interview for Cognitive Status.
Results
Results showed that 17% of United States older adults reported food insecurity in the 2013 HCNS. Compared with food secure older adults, those reporting food insecurity experienced worsened cognitive functioning over time (B = −0.63, p < .001), and they were more likely to have onset of cognitive impairment (OR= 1.46, p < .001) in the 6-y observation. Compared with non-Hispanic White older adults, being non-Hispanic Black, non-Hispanic Other, or Hispanic was associated with 2.96, 2.09, or 1.26 odds (p < .001) of cognitive impairment (2012–2018), respectively. Older adults of racial and ethnic minority groups also had higher risks of experiencing the double burden of cognitive impairment alongside food insecurity compared with non-Hispanic White older adults.
Conclusion
Findings underscore racial and ethnic structural disparities in food security and cognitive health in the United States aging population.
Keywords: food insecurity, cognition, race, older adults, health disparity
Introduction
Food insecurity, broadly defined as insufficient or inconsistent access to nutritional foods for active and healthy living [1], is an underlying public health problem that is often a precursor to physical and mental health declines [[2], [3], [4]]. This presents a particular challenge with increased age because external factors can be at play in simultaneously driving both food insecurity and health decline over time, leaving older adults at higher risks of both experiencing malnutrition and having diet-related diseases [[5], [6], [7]]. In 2019, 9.7% of Americans aged ≥60 y (7.1 million) experienced food insecurity or very low food security [8]. Although older adults in the United States are, on average, less likely to experience food insecurity than younger adults [9], older adults’ risk for insecurity can vary by demographic factors as well as socioeconomic or living conditions [1]. Furthermore, as the United States population is rapidly aging, the number of food-insecure older adults is projected to continue rising in the coming years [8,10]. Studies undertaken to examine the relationship between food access and functional health status demonstrate nutritional pathways linking food insecurity to negative health outcomes. Food-insecure households tend to have poorer nutrient intake, including diets that are lower in protein, iron, magnesium, and vitamins, and higher in added sugar and saturated fats [11,12]. As a result, food insecurity has been associated with diabetes [13,14], frailty and functional impairment [15], cardiovascular disease [16], inflammatory response [7], medication nonadherence [17], and mortality [18]. In addition to these physical health outcomes, food (in)security is associated with cognitive function among older adults [4,19].
Cognitive impairment and dementia are severe public health issues in the United States aging population. As of 2022, an estimated 6.5 million Americans aged ≥65 y were living with Alzheimer’s disease or related dementia [20]. Older adults who are food insecure often experience increased psychological distress [21] and have higher risks of mental health problems [22,23], which in turn contribute to worsened cognitive health. Functional impairments associated with food insecurity also impact cognitive function among older adults [24]. Furthermore, these associations can be self-propagating, as poor health status can contribute to prolonged or more severe food insecurity, which circles back to impact health, ultimately creating a negative feedback loop [6]. However, our understanding of the complex relationship between food insecurity and cognition is still limited, as the existing literature largely ignores the heterogeneity by population characteristics, such as race and ethnicity.
The causes and consequences of food hardship among older adults are not evenly experienced across the population. Older-age food insecurity can vary greatly by sociodemographic characteristics, and it has been established that racial and ethnic minority adults have higher risks for food insecurity as well as poor cognitive function in later life. Results from the 2020 Current Population Survey show that Black older adults have a food insecurity prevalence that is almost 4 times of that of non-Hispanic White older adults, whereas Hispanic older adults are almost twice as likely as non-Hispanic White older adults to be food insecure [25]. Compared with White older adults, Black and Hispanic older adults are consistently found to have worse cognitive function [26] and higher risks of Alzheimer’s disease and dementia incidence [27,28]. Yet, little is known about the extent of these disparities and whether the adverse impact of food insecurity on cognition differs for older adults of different racial/ethnic groups.
Pooling information from a longitudinal survey of United States older adults, this study aims to investigate the association between food insecurity and cognitive function among United States older adults. We also assessed whether the association between food insecurity and cognitive health varies by race and ethnicity. Evaluating the linkage between food insecurity and cognitive health would help to identify the most vulnerable groups that should be prioritized for social and policy support.
Methods
Data and sample
Data were obtained from the longitudinal Health and Retirement Study (HRS) and the 2013 Health Care and Nutrition Survey (HCNS). HRS is a nationally representative data set of Americans aged ≥50 y, using a multistage area probability sample in survey design, with oversampling of Blacks, Hispanics, and Floridians [29]. The survey has been conducted every 2 y since 1992 by the University of Michigan (UM Health Sciences/Behavioral Sciences IRB Protocol: HUM00061128) and is funded by the National Institute on Aging (NIA U01AG009740). The HRS contains a rich array of information on physical and mental health status, health behaviors, retirement planning, income, and family structure. In 2013, HCNS collected health care access, food purchases, and diet intake from a subsample of 2012 HRS respondents (N = 8,073). The HCNS sample was equivalent for age and gender composition compared with the 2012 HRS sample, but the 2013 HCNS had slightly higher percentages of non-Hispanic Black and Hispanic participants, and HCNS participants on average had more years of education relative to the HRS sample. However, all estimates were adjusted using the sample weights from the HCNS to be representative of the older adult population in the United States. Baseline characteristics for HCNS respondents were obtained from the core interview information from the 2012 HRS, and longitudinal data were used from the subsequent HRS surveys administered to respondents to ascertain cognitive health, among other socioeconomic and health information, every 2 y (2012–2018).
For this study, the analysis was constrained to a sample of community-dwelling respondents aged ≥50 y in the 2012 HRS survey and who completed the 2013 HCNS. The analysis further excluded respondents who had reported a diagnosis of Alzheimer’s or related dementia at the baseline HRS (2012) and who had zero sample weight in the HCNS. The vast majority (92.5% at baseline) of respondents had complete information on all analytic variables after applying the inclusion and exclusion criteria to create the analytic samples. For the 2-y changes in cognitive function, our sample consisted of all eligible respondents who participated in the 2012 HRS, 2013 HCNS, and 2014 HRS (N = 6,638). For the 6-y changes in cognitive function, we used a longitudinal sample of respondents who participated in the 2012 HRS, 2013 HCNS, and the 2018 HRS. We also utilized the information in 2014 and/or 2016, if the longitudinal respondents were also interviewed in 2014 and/or 2016 HRS. The final analytic sample included N = 6,638 participants from the 2012 baseline and N = 24,475 participant-year observations from 2012 to 2018 HRS.
Measures
Food insecurity was measured based on the Six-item ShortForm United States Household Food Security Survey Module in the 2013 HCNS [23]. Respondents were asked to respond to 6 statements on self-perceived food (in)security, including “The food that we bought just didn’t last and we didn’t have enough money to get more,” “We couldn’t afford to eat balanced meals,” “Anyone in the household ever cut meal size or skipped meals because there wasn’t enough food for food,” “In the last twelve months, you ever eat less than you felt you should because there wasn’t enough money for food,” and “In the last twelve months, you every hungry but didn’t eat because there wasn’t enough money for food”. Each item was dichotomously coded and summed to a food security score (range 0–6; α = .88); a binary indicator was created as food secure (score 0–1) or food insecure (score 2–6) [30].
Cognitive function was assessed by the modified version of the Telephone Interview for Cognitive Status (TICS-m). Based on previous studies using HRS TICS-m, a summary cognitive score was calculated by summing the items of (1) immediate and delayed recall of 10 words, (2) 5 trials of serial 7s, and (3) backward counting. The summary score can range from 0 to 27, with a higher score indicating better cognitive function. The TICS-m has high sensitivity and specificity for cognitive impairment in older adults [31]. A binary variable was created to identify cognitive impairment (score 0–11) or no cognitive impairment (score 12–27) [32] for respondents in each observation year.
The analysis considered respondents’ race and ethnicity (i.e., non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic other race groups) to evaluate the disparities in food security and cognitive health. Control variables were used from the HRS, including age (in years), age-squared, gender (female/male), currently married or partnered (yes/no), number of household members, education (in years), poverty status and participation in Supplemental Nutrition Assistance Program (SNAP; 1 = below poverty line and participating SNAP [reference], 2 = below poverty line and not participating SNAP, 3 = above poverty line and participating SNAP due to other criteria, 4 = above poverty line and not participating SNAP), the number of chronic health conditions (a count of 8 conditions including hypertension, diabetes, cancer, lung disease, coronary artery disease, stroke, arthritis, and psychiatric problems), any limitations with activities of daily living (ADL, yes/no), and health behaviors (i.e., currently smoking, currently drinking alcohol, and engaging in vigorous physical activities – each assessed as yes/no). Time-invariant control variables were taken from the HRS tracker file, and time-varying control variables were used from the RAND longitudinal file (1992-2018v2) and cross-sectional file (version e.2a) for HRS.
Analytic strategy
First, we stratified the sample by self-reported food insecurity status in 2013 and compared the differences by key demographic, socioeconomic, health status, and health behavior variables. Estimates were adjusted using the sample weights from the HCNS to be representative of the older adult population in the United States. We presented the baseline (2012) characteristics for time varying variables. Next, we conducted longitudinal analysis for 2-y (2012–2014) and 6-y (2012–2018) associations with cognitive health for our research questions. We also examined the association between race and ethnicity and the double burden of cognitive impairment and food insecurity for the 6-y observation period.
For analysis of 2-y changes in cognitive function, linear regression models with a lagged dependent variable were estimated to examine how the experience of self-reported food insecurity (2013) was associated with changes in cognitive function (TICS-m) from 2012 to 2014. Three sets of models were estimated; the unadjusted model only included food insecurity and age because age is one of the key drivers for cognitive health, and the adjusted model further included demographic, socioeconomic status, and health-related control variables, and moderation models. To examine disparities by race and ethnicity, we introduced a set of interaction terms between race and ethnicity group and food insecurity in the model for cognitive function (TICS-m). We then estimated logistic regression models to examine the incidence of cognitive impairment (from 2012 to 2014) as a function of food insecurity with a subsample of respondents who did not have cognitive impairment at the 2012 baseline (n = 5,441). The unadjusted, adjusted, and moderation models were operationalized in the same manner as previous linear regression models.
To examine the 6-y (2012–2018) associations of self-reported food insecurity with cognitive function, we utilized a longitudinal sample of respondents who had participated in the 2012 and 2018 HRS and the 2013 HCNS. For the continuous changes in cognitive function (TICS-m), we estimated linear mixed-effect models for the associations between food insecurity and TICS-m. The first main effect model only included food insecurity and age variables; the second model added race and ethnicity and respondents’ demographic, socioeconomic, and health characteristics; the third model included the interactions between food insecurity and race and ethnicity. To compare the risk of cognitive impairment between food-secure and food-insecure older adults, we estimated logit mixed-effect regression models. Similarly, we estimated three models, one main effect unadjusted model, one fully adjusted model with control variables, and one model with interaction terms between food insecurity and race and ethnicity.
We further sought to assess how race and ethnicity was associated with the risk of a double burden of food insecurity and cognitive impairment. For this, we created a measure representing cognitive impairment in the presence of self-reported food insecurity, in which older adults reported food insecurity in 2013 and cognitive impairment incidence anytime during 2012–2018, and applied this measure as the outcome in the adjusted logistic regression model.
Results
Descriptive characteristics of sample participants are presented in Table 1. Results showed that ∼17% of all respondents aged 50 y and above reported food insecurity in the 2013 HCNS. Older adults who experienced food insecurity reported lower cognitive function score at baseline (14.03 compared with 16.06 in 2012) and over time (13.89 compared with 16.22 in 2018), and were more likely to have onset of cognitive impairment from 2012 to 2018 (48.35% compared with 27.0%) relative to those who reported being food secure (t = 14.12, p < .001). Compared with food-secure older adults, those with food insecurity were more likely to be from racial or ethnic minority groups, younger, female, and unmarried; they were also more likely to have lower education and more co-residing household members, smoke cigarettes, not engage in physical exercise, report more chronic health conditions, and have limitations with ADL.
TABLE 1.
Sample characteristics in 2012 HRS and 2013 HCNS
| Food secure (n = 5,449) |
Food insecure (n = 1,189) |
||||
|---|---|---|---|---|---|
| M/% | (SD) | M/% | (SD) | t or χ2 | |
| Cognitive health | |||||
| Cognitive score (TICS-m, 2012) | 16.06 | (4.09) | 14.03 | (4.38) | ∗∗∗ |
| Cognitive score (TICS-m, 2018) | 16.22 | (4.31) | 13.89 | (4.52) | ∗∗∗ |
| Cognitive impairment (2012) (%) | 14.0 | 31.59 | ∗∗∗ | ||
| Cognitive impairment incidence (2012–2018) (%) | 27.0 | 48.35 | ∗∗∗ | ||
| Demographic characteristics | |||||
| Age (y) | 66.05 | (9.78) | 61.57 | (8.07) | ∗∗∗ |
| Female (%) | 54.11 | 60.01 | ∗∗ | ||
| Race and ethnicity (%) | ∗∗∗ | ||||
| Non-Hispanic White | 83.63 | 52.39 | |||
| Non-Hispanic Black | 7.94 | 19.88 | |||
| Non-Hispanic other | 2.68 | 6.35 | |||
| Hispanic | 5.74 | 21.38 | |||
| Married | 65.96 | 42.73 | ∗∗∗ | ||
| Number of household members | 2.18 | (1.06) | 2.48 | (1.52) | ∗∗∗ |
| Socioeconomic status | |||||
| Education (y) | 13.56 | (2.64) | 11.63 | (3.31) | ∗∗∗ |
| Poverty status and SNAP (%) | ∗∗∗ | ||||
| Below poverty and participated in SNAP | 1.89 | 14.89 | |||
| Below poverty and not participated in SNAP | 4.67 | 13.92 | |||
| Above poverty and participated in SNAP | 3.23 | 13.00 | |||
| Above poverty and not participated in SNAP | 90.21 | 58.19 | |||
| Health status and health behaviors | |||||
| Currently smoking (%) | 10.82 | 28.36 | ∗∗∗ | ||
| Currently drinking alcohol (%) | 44.82 | 25.70 | ∗∗∗ | ||
| Vigorous physical activities (%) | 53.33 | 36.21 | ∗∗∗ | ||
| Chronic conditions | 1.86 | (1.38) | 2.36 | (1.63) | ∗∗∗ |
| Any ADL limitation (%) | 10.72 | 28.10 | ∗∗∗ | ||
ADL, activities of daily living; HCNS, Health Care and Nutrition Study; HRS, Health and Retirement Study; SNAP, Supplemental Nutrition Assistance Program.
Statistics are adjusted using the 2013 HCNS sample weights.
∗p < .05; ∗∗p < .01; ∗∗∗p < .001.
Table 2 presents results from multivariate models for the association of food insecurity and cognitive health among older adults at 2 y (2012–2014). Models 1 and 2 were from linear regression models for cognitive function (i.e., TICS-m) controlling for the 2012 baseline status. Main effect Model 1 showed that food insecurity was associated with lower levels of cognitive functioning among older adults in 2014 (B = −1.32, SE = 0.11), controlling for their 2012 cognitive status. Model 2 controlled for various demographic, socioeconomic, and health characteristics based on Model 1. Results from Model 2 showed that, compared with non-Hispanic White older adults, racial and ethnic minority (i.e., non-Hispanic Black, non-Hispanic other, and Hispanic) older adults reported worsened cognitive function at the 2-y time point. The association between self-reported food insecurity and lower cognitive function remained significant but became weaker (B = −0.50, SE = 0.12) after accounting for all control variables.
TABLE 2.
Results for associations between food insecurity and cognitive function changes from 2012 to 2014
| TICS-m (2014) |
Cognitive impairment incidence (2012–2014) |
|||||||
|---|---|---|---|---|---|---|---|---|
| Model 1 |
Model 2 |
Model 3 |
Model 4 |
|||||
| B | (SE) | B | (SE) | OR | 95% CI | OR | 95% CI | |
| Food insecurity | −1.32∗∗∗ | (0.11) | −0.50∗∗∗ | (0.12) | 2.48∗∗∗ | [1.98−3.11] | 1.21 | [0.93−1.57] |
| Age | −0.08∗∗∗ | (0.00) | −0.08∗∗∗ | (0.00) | 1.05∗∗∗ | [1.04−1.06] | 1.06∗∗∗ | [1.04−1.07] |
| Age2 | −0.00∗∗∗ | (0.00) | −0.00∗∗∗ | (0.00) | 1.00 | [1.00−1.00] | 1.00 | [1.00−1.00] |
| Demographics | ||||||||
| Female | — | — | 0.40∗∗∗ | (0.08) | — | — | 0.91 | [0.75−1.11] |
| Race and ethnicity | ||||||||
| Non-Hispanic White (ref) | — | — | — | — | — | — | — | — |
| Non-Hispanic Black | — | — | −1.24∗∗∗ | (0.12) | — | — | 3.27∗∗∗ | [2.56–4.20] |
| Non-Hispanic other | — | — | −0.84∗∗∗ | (0.24) | — | — | 2.38∗∗ | [1.42–3.99] |
| Hispanic | — | — | −0.47∗∗ | (0.14) | — | — | 1.75∗∗∗ | [1.27–2.41] |
| Married | — | — | 0.22∗ | (0.09) | — | — | 0.86 | [0.70–1.07] |
| Number of household members | 0.05 | (0.04) | 0.99 | [0.91–1.07] | ||||
| Socioeconomic status | ||||||||
| Education | — | — | 0.23∗∗∗ | (0.02) | — | — | 0.83∗∗∗ | [0.81−0.86] |
| Poverty status and SNAP | ||||||||
| Below poverty and participated in SNAP (ref) | — | — | — | — | — | — | — | — |
| Below poverty and not participated in SNAP | 0.11 | (0.24) | 0.67 | [0.42–1.09] | ||||
| Above poverty and participated in SNAP | 0.64∗ | (0.25) | 0.44∗∗ | [0.26–0.76] | ||||
| Above poverty and not participated in SNAP | 0.73∗∗∗ | (0.20) | 0.57∗∗ | [0.38–0.85] | ||||
| Health status and health behaviors | ||||||||
| Currently smoking | — | — | −0.06 | (0.13) | — | — | 1.23 | [0.92−1.64] |
| Currently drinking alcohol | — | — | 0.01 | (0.09) | — | — | 0.99 | [0.81−1.22] |
| Vigorous physical activities | — | — | 0.05 | (0.09) | — | — | 1.04 | [0.85−1.27] |
| Chronic conditions | — | — | −0.09∗∗ | (0.03) | — | — | 1.10∗∗ | [1.03−1.18] |
| Any ADL limitation | — | — | −0.48∗∗∗ | (0.12) | — | — | 1.30∗ | [1.01−1.67] |
| TICS-m (2012) | 0.61∗∗∗ | (0.01) | 0.49∗∗∗ | (0.01) | — | — | — | — |
| Constant | 6.26∗∗∗ (0.18) | (0.18) | 4.34∗∗∗ | (0.33) | ||||
| N | 6,638 | 6,638 | 5,441 | 5,441 | ||||
Models 1 and 2 are based on linear regression models. Models 3 and 4 are based on logistic regression models using a subsample of respondents who did not have cognitive impairment at the 2012 baseline interview.
ADL, activities of daily living; SNAP, Supplemental Nutrition Assistance Program; TICS-m = Telephone Interview for Cognitive Status modified.
∗p < .05. ∗∗p < .01. ∗∗∗p < .001.
Models 3 and 4 of Table 2 constrained the sample to those participants who did not have cognitive impairment at the 2012 baseline. Results from main effect Model 3 demonstrated that older adults who had food insecurity would have higher risks of cognitive impairment incidence over 2 years (OR: 2.48; 95% CI: [1.98–3.11]). With regard to race and ethnicity (Model 4), non-Hispanic Black (OR: 3.27; 95% CI: [2.56–4.20]), non-Hispanic other (OR: 2.38; 95% CI: [1.42–3.99]), and Hispanic (OR: 1.75; 95% CI: [1.27–2.41]) older adults had higher risks of cognitive impairment than non-Hispanic White older adults. However, the association between food insecurity and cognitive impairment incidence was no longer significant (OR: 1.21; 95% CI: [0.93–1.57]) after the inclusion of all control variables. Although not reported in Table 2, we also estimated models by including interaction terms between food insecurity and race and ethnicity into adjusted Models 2 and 4. No significant interactions were found, suggesting there was no significant variation in the association between food insecurity and cognitive health (TICS-m or cognitive impairment) by race and ethnicity for this duration.
Table 3 summarizes the multilevel model results for the longitudinal association between food insecurity and cognition (i.e., TICS-m and cognitive impairment incidence) from 2012 to 2018. Similar to the results of the 2-y changes, we found lower cognitive function over time among older adults with food insecurity (B = −2.65, SE = 0.07) and belonging to racial/ethnic minority groups (non-Hispanic Black: B = −2.02, SE = 0.07; non-Hispanic other: B = −1.21, SE = 0.14; Hispanic: B = −0.53, SE = 0.08), compared with counterparts who were food secure and who were non-Hispanic White, respectively (Models 1 and 2). Moreover, moderation results from Model 3 showed a significant interaction between food insecurity and race and ethnicity, suggesting the disparity in cognitive function by food (in)security was smaller in Hispanic older adults compared with non-Hispanic White older adults. Food-insecure Hispanic and White older adults had similar levels of TICS-m, but food-secure Hispanic older adults had significantly lower TICS-m than their White counterparts. The moderation analysis results are summarized in Figure 1, showing the intersection of food insecurity and race and ethnicity for cognitive function among older adults. Although observed differences in cognitive function between food-secure and food-insecure older adults were smaller for Hispanic older adults compared with White older adults, the results still demonstrate disparities in cognitive health by race and ethnicity. Racial/ethnic minority older adults generally had worse cognitive function compared with White older adults, regardless of their status of food (in)security. Additionally, non-Hispanic Black older adults with food insecurity had the worst cognitive function compared with other groups.
TABLE 3.
Mixed-effects results for associations between food insecurity, race and ethnicity, and cognitive function changes from 2012 to 2018
| TICS-m |
Cognitive impairment incidence |
|||||
|---|---|---|---|---|---|---|
| Model 1 |
Model 2 |
Model 3 |
Model 4 |
Model 5 |
Model 6 |
|
| B | B | B | OR | OR | OR | |
| (SE) | (SE) | (SE) | 95% CI | 95% CI | 95% CI | |
| Food insecurity | −2.65∗∗∗ | −0.63∗∗∗ | −0.79∗∗∗ | 3.42∗∗∗ | 1.46∗∗∗ | 1.55∗∗∗ |
| (0.07) | (0.07) | (0.10) | [3.16–3.70] | [1.33– 1.61] | [1.34–1.78] | |
| Race and ethnicity | ||||||
| Non-Hispanic White (ref) | — | — | — | — | — | — |
| Non-Hispanic Black | — | −2.02∗∗∗ | −2.05∗∗∗ | — | 2.96∗∗∗ | 3.02∗∗∗ |
| (0.07) | (0.08) | [2.70–3.26] | [2.71–3.78] | |||
| Non-Hispanic other | — | −1.21∗∗ | −1.21∗∗ | — | 2.09∗∗∗ | 1.95∗∗∗ |
| (0.14) | (0.17) | [1.70–2.56] | [1.50–2.53] | |||
| Hispanic | — | −0.53∗∗∗ | −0.67∗∗∗ | — | 1.26∗∗∗ | 1.30∗∗∗ |
| (0.08) | (0.10) | [1.09–1.40] | [1.12–1.51] | |||
| Food insecurity × race and ethnicity | ||||||
| Food insecurity × Non-Hispanic Black | — | — | 0.19 | — | — | 0.92 |
| (0.16) | [0.75–1.13] | |||||
| Food insecurity × Non-Hispanic other | — | — | 0.09 | — | — | 1.16 |
| (0.32) | [0.76–1.78] | |||||
| Food insecurity × Hispanic | — | — | 0.48∗∗ | — | — | 0.86 |
| (0.17) | [0.68–1.08] | |||||
Models 1 and 4 are adjusted for age and age-squared. Models 2 and 3 and 5 and 6 are adjusted for age, age-squared, gender, marital status, number of household members, education, poverty status and SNAP participation, smoking, drinking alcohol, vigorous physical activity, chronic conditions, and activity of daily living limitations. Models 1–3 are based on results from linear mixed models and Models 4–6 are based on logit mixed models.
OR, odds ratio; TICS-m, Telephone Interview for Cognitive Status modified.
∗p < .05. ∗∗p < .01. ∗∗∗p < .001.
FIGURE 1.
Cognitive function by food security status and race and ethnicity among older adults. Data are used from the 2012–2018 Health and Retirement Study and 2013 Health Care and Nutrition Study. Cognitive function is measured by the modified Telephone Interview for Cognitive Status among United States older adults aged ≥50 y.
For the incidence of cognitive impairment as a function of food insecurity (2012–2018), Table 3 (Models 4–6) presents the results from multilevel logistic regression models. Consistent with the findings for cognitive impairment incidence over 2 y, we found that food insecurity and being a racial/ethnic minority were independently associated with higher risks of cognitive impairment incidence. Older adults who were food insecure had 3.42 times the odds of cognitive impairment incidence in the unadjusted Model 4 (95% CI: [3.16–3.70]). The association between food insecurity and cognitive impairment incidence decreased but remained significant after controlling for demographic, socioeconomic, and health-related covariates (Model 5: OR: 1.46; 95% CI: [1.33–1.61]). Meanwhile, being non-Hispanic Black, non-Hispanic Other, or Hispanic was associated with 3.02, 1.95, or 1.30 odds of cognitive impairment compared with non-Hispanic White older adults, respectively. No significant interaction was found between food insecurity and race and ethnicity for cognitive impairment incidence over the 6-y observation (Model 6).
Finally, Table 4 presents results for the association between race and ethnicity and the double burden of experiencing food insecurity and cognitive impairment. Results show that racial/ethnic minority older adults had much higher risks of experiencing both food insecurity and cognitive impairment incidence, where being non-Hispanic Black, non-Hispanic Other, or Hispanic was associated with 6.72, 6.40, or 8.29 odds of experiencing this double burden compared with non-Hispanic White older adults in the unadjusted Model 1, respectively. These associations were reduced but remained high and statistically significant after controlling for socioeconomic and health status and behaviors in Model 2.
TABLE 4.
Results for associations between race and ethnicity and double burden of food insecurity and cognitive impairment (2012–2018)
| Model 1 |
Model 2 |
|||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Race and ethnicity | ||||
| Non-Hispanic White (ref) | — | — | — | — |
| Non-Hispanic Black | 6.72∗∗∗ | [4.97–9.09] | 3.24∗∗∗ | [2.31–4.58] |
| Non-Hispanic other | 6.40∗∗∗ | [3.83−10.69] | 3.21∗∗∗ | [1.72−6.01] |
| Hispanic | 8.29∗∗∗ | [6.09−11.30] | 1.78∗∗∗ | [1.17–2.70] |
| Age | — | — | 1.01 | [1.00−1.03] |
| Age2 | — | — | 1.00∗ | [1.00−1.00] |
| Female | — | — | 0.65∗∗ | [0.50−0.86] |
| Married | — | — | 0.78 | [0.58−1.05] |
| Number of household members | 1.11∗ | [1.03−1.20] | ||
| Socioeconomic status | ||||
| Education | — | — | 0.79∗∗∗ | [0.76−0.82] |
| Poverty status and SNAP | ||||
| Below poverty and participated in SNAP (ref) | — | — | — | — |
| Below poverty and not participated in SNAP | 0.76 | [0.52–1.12] | ||
| Above poverty and participated in SNAP | 0.82 | [0.54–1.25] | ||
| Above poverty and not participated in SNAP | 0.33∗∗∗ | [0.23–0.48] | ||
| Health status and health behaviors | ||||
| Currently smoking | — | — | 2.21∗∗∗ | [1.61−3.04] |
| Currently drinking alcohol | — | — | 0.58∗∗ | [0.40−0.82] |
| Vigorous physical activities | — | — | 0.86 | [0.64−1.15] |
| Chronic conditions | — | — | 1.18∗∗∗ | [1.09−1.29] |
| Any ADL limitation | — | — | 1.79∗∗∗ | [1.35−2.36] |
The double burden of food insecurity and cognitive impairment was assessed from 2013 to 2018, and the participant characteristics were assessed in 2012.
ADL, activities of daily living; OR, odds ratio; SNAP, Supplemental Nutrition Assistance Program.
∗p < .05; ∗∗p < .01; ∗∗∗p < .001.
We conducted the following sensitivity analyses to check the robustness of analytic results. First, we estimated models for cognitive function by excluding cognitive impaired respondents to examine the associations between food insecurity and cognitive function. We also examined 2 alternative coding strategies of cognitive status based on the continuous TICS-m score (1) no probable dementia (score 7–27) and probable dementia (score 0–6), (2) 3 categories of no cognitive impairment (score 12–27), mild cognitive impairment but no dementia (score 7–11), and probable dementia (score 0–6). Additionally, we examined results after excluding non-Hispanic other respondents due to limited information about their specific race classifications. All results remained similar to what was reported here (results are available upon request).
Discussion
In this longitudinal study of a national sample of older adults in the United States, we found food insecurity had lasting implications for cognitive health. For older adults with similar levels of cognition at baseline, experiencing food insecurity was linked to worsened cognitive function and higher risk of cognitive impairment incidence within 2 y, and up to ≥6 y later. The observed associations between food insecurity and cognition decline were in part influenced by social, demographic, and health factors. The adverse impact on cognitive function may be partially attributed to worse socioeconomic environments, poorer physical conditions, and unhealthy behaviors more common among older adults who are food insecure. Indeed, many of the factors we found to be associated with food insecurity – being from a racial or ethnic minority group, having lower education and household income, smoking cigarettes, not engaging in physical exercise, comorbidities of chronic health conditions, and having limitations with ADL – are also independent risk factors for greater cognitive decline [19,33,34]. Given the increasing societal burden of supporting individuals and families who live with cognitive diseases [18], providing food and nutritional support may be an effective policy tool to ameliorate the burden and prevent cognitive decline.
Existing research has repeatedly shown that food-insecure older adults have poorer cognitive function [19,34,35] and higher risks of cognitive impairment and dementia [4,36]. The inverse association between food insecurity and cognitive function demonstrated in this study is consistent with results of previous research using other study cohorts, despite different measures of food insecurity and cognitive function [19,34,35,37]. Moreover, the significant relationship between food insecurity and cognitive impairment in this study is demonstrated using a population-based survey data, providing strong evidence that is nationally representative of United States older adults. With older adults representing the fast-growing demographic group in the United States, alongside persisting structural disparities in social resources, it is important to better understand the prevalence and health implications of older-age food insecurity – particularly among older adults whose disadvantaged conditions are exacerbated by structural inequalities such as economic hardship and insufficient health care access and utilization [15].
The temporal relationship between food (in)security and cognitive health is difficult to characterize, however, as prior studies have primarily been conducted using data from a single time point, the nature of which only allows conclusions based on cross-sectional associations, meaning direction of causation may not be inferred. In the present study, the availability of data at 2- and 6-y time points allowed us to conduct longitudinal assessments of cognitive function changes and impairment incidence over time. Significantly higher risk of cognitive impairment was found over 2 and 6 y among older participants who reported food insecurity and had no dementia at baseline, compared with food-secure participants. This provides further evidence that food insecurity could be a driver of cognitive decline among older adults. However, our results cannot fully elucidate the causal direction of the relationship, as ongoing cognitive function decline can make it more challenging to obtain sufficient and nutritionally adequate foods [17,38]. Further investigation to characterize the cyclic influence and synergistic effect of each on the other is required.
This study further sought to enhance current understanding of heterogeneity in the relationship between food (in)security and cognitive function across population racial/ethnic groups. Because dietary intake and food insecurity assessment have historically not be regularly incorporated in many large-scale surveys [39], prior studies on older-age food insecurity and cognition often use smaller study samples of limited size, which may not be sufficient to differentiate variable effects in minority populations. Findings from this study demonstrate the important role of race and ethnicity in longitudinal associations between food insecurity and cognitive health among United States older adults. In addition to the existing racial/ethnic disparities in cognitive health, food insecurity places older adults from racial/ethnic minority groups at even higher risks for cognitive decline. Extensive studies have demonstrated severe racial disparities in public health, including Alzheimer’s and related dementias [40]. Our findings add to the literature by showing race and ethnicity and food insecurity have both independent and additive impacts on cognition among older adults. Compared with non-Hispanic White older adults, older adults from racial/ethnic minority groups have worsened cognitive health, in part due to their higher likelihood of food insecurity. Barriers to food access and structural inequities may contribute to the double burden of food insecurity and cognitive impairment experienced by racial/ethnic minorities. Such racial/ethnic disparities can be partially attributed to their disadvantages in socioeconomic and health status, as associations weakened upon controlling for these covariates – although remained significant. The risk of experiencing the double burden of food insecurity and cognitive impairment were much higher among all racial/ethnic minority groups compared with non-Hispanic White older adults, with Black older adults being the most vulnerable group for such additional hardship. Understanding the heterogeneity is important to design and implement food and nutrition support programs to address health inequity in aging populations.
Food insecurity remains a severe issue for public health and social justice. The trend of older-age food insecurity is influenced by population demographic changes as well as food and nutrition policy and programs. The increasing United States populations of older ages and widening socioeconomic inequalities project a growing prevalence of food insecure aging populations, who are more likely to live under the poverty line, with no spouse or partner, and with a disability [25]. That food insecurity is more prevalent among already-disadvantaged groups, or that the experience may be episodic or purposefully hidden due to stigmatization, can pose further challenges to recognizing and addressing older-age food insecurity [6]. Public resources to support these vulnerable older adults exist, but they may not be uniformly available and effective. SNAP remains one of the most widely implemented and effective nutrition support programs to address hunger and malnutrition in the United States. Our results demonstrate that poverty is a persistent risk for cognitive health among older adults. However, SNAP participation is not significantly related to different levels of cognitive health among those who live below poverty line, in part because not all eligible older adults have access to and utilize available support programs. Racial and ethnic minority older adults are more likely to be put on the waitlist for participating meals-on-wheels services [41], and they are also less likely to use formal support from local senior centers, potentially due to language barriers and concerns about migration history. These findings provide further evidence of vulnerable population groups who may benefit from additional screening and appropriate services to mitigate or prevent food instability. It also demonstrates how food insecurity is linked to cognitive impairment and should therefore be part of routine health assessments in clinical practice [6].
Strengths and limitations
This study has several strengths, through its utilization of a large and diverse sample of an aging population for longitudinal analysis. In a review of community-based cohorts that obtained information on dietary intake among older adults in the United States conducted by Shea et al. [39], a few were nationally representative and fewer still included cognitive assessment. Furthermore, a systematic review of studies on food insecurity and brain health, conducted by McMichael et al. [4], found that about 4/5 of the 30 articles reviewed were cross-sectional. In combining information from two national surveys (HRS and HCNS), this work was able to use multiple measures of cognitive health (function and impairment incidence) to conduct longitudinal analysis. Findings based on repeated measures in a nationally representative study add important evidence to the current body of literature on the role of food insecurity in cognitive decline. Additionally, this work has helped to discern racial and ethnic disparities in the double burden of food insecurity and cognitive function.
The study also acknowledges several limitations. First, the measures of cognitive health are based on self-report rather than clinical diagnosis and may yield biases based on health literacy. Although several studies have demonstrated that HRS cognitive tests have high precision with diagnosis reports, we must acknowledge the possibility of misclassification of cognitive impairment. Second, there may be unmeasured confounders that impact both food insecurity and cognitive health, such as the quality of food intake, access to food, living environment, daily discrimination, and other social stressors. Future studies with more information and larger sample size may further validate the findings in this study and explore the mechanisms linking food insecurity to cognitive health. Finally, the food insecurity measure in this study only captures the financial constraints to obtain and maintain food intake and is unable to represent other aspects of food insecurity, such as the anxiety of insufficient food and experiencing hunger, inability to afford healthy food, and lack of control of food consumption type and frequency. Future research will explore multiple aspects of food insecurity and malnutrition risks for older adults’ health.
Conclusion
Findings from this study demonstrate that older adults have a greater likelihood of worsened cognitive function and higher risks of cognitive impairment over time if they experience food insecurity. As food insecurity is a modifiable potential precursor and health risk for cognitive decline, increased support and efforts to alleviate insufficient food access and intake can have long-term benefits for mental health and well-being in our aging population. Furthermore, this study underscores the structural disparities in food security and cognitive health in diverse aging populations, as evidenced by greatly increased risk of experiencing both food insecurity and incidence of cognitive impairment among older adults belonging to racial/ethnic minority groups. The odds of this double burden was found to be from 1.8 to as high as 3.2 times among Hispanic, non-Hispanic Black and non-Hispanic Other, respectively, compared to non-Hispanic White older adults, after controlling for socioeconomic and health status and behaviors. Special attention is, therefore, warranted for these population groups, to address social and structural disparities that may reduce food insecurity prevalence, and thereby help mitigate the associated risks to cognition with aging.
Author contributions
The authors’ responsibilities were as follows – HW: designed the research and conducted the analysis; HW and NE: wrote the paper; and all authors: read and approved the final manuscript.
Funding
Funding was provided by the USDA Agricultural Research Service under Cooperative Agreement No. 58-8050-9-004. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the USDA. This research was presented at the 2023 Population Association of American annual conference.
Data availability
The data that support the findings of this study are publicly available as the Health and Retirement Study (HRS) at https://hrs.isr.umich.edu/, produced and distributed by the University of Michigan with funding from the National Institute on Aging (grant number NIA U01AG009740). Ann Arbor, MI.
Conflict of interest
The authors report no conflicts of interest.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are publicly available as the Health and Retirement Study (HRS) at https://hrs.isr.umich.edu/, produced and distributed by the University of Michigan with funding from the National Institute on Aging (grant number NIA U01AG009740). Ann Arbor, MI.