Key Points
Question
What is the longitudinal association between food insecurity and incident cardiovascular disease in Black and White US adults?
Findings
In this cohort analysis of 3616 adults from the CARDIA (Coronary Artery Risk Development in Young Adults) study, food insecurity was associated with a 41% increased risk of incident cardiovascular disease after adjusting for demographic and socioeconomic factors.
Meaning
Results of this study suggest that food insecurity is associated with an increased risk of developing cardiovascular disease; whether addressing food insecurity can alleviate cardiovascular morbidity and mortality among US individuals deserves further study.
Abstract
Importance
Food insecurity is associated with prevalent cardiovascular disease (CVD), but studies have been limited to cross-sectional data.
Objectives
To study whether food insecurity is associated with incident CVD and to determine whether this association varies by sex, education, or race.
Design, Setting, and Participants
This prospective cohort study was conducted among US adults without preexisting CVD participating in the CARDIA (Coronary Artery Risk Development in Young Adults) study from 2000 to August 31, 2020. Data analysis was conducted from December 2022 to April 2024.
Exposure
Food insecurity, defined as endorsing limitations in household food variety and/or food quantity, assessed in the period 2000-2001.
Main Outcomes and Measures
The primary outcome was CVD events, consisting of fatal and nonfatal coronary heart disease, heart failure, stroke, transient ischemic attack, or peripheral arterial disease, identified annually through August 31, 2020.
Results
Of 3616 total participating adults, mean (SD) age was 40.1 (3.6) years, and 2027 participants (56%) were female. Of 3616 participants, 1696 (47%) self-reported Black race and 529 participants (15%) had food insecurity at baseline. Individuals with food insecurity were more likely to self-identify as Black and report lower educational attainment. The mean (SD) follow-up period was 18.8 (3.4) years, during which 255 CVD events occurred: 57 events (11%) in food-insecure participants and 198 events (6%) in food-secure participants over the study period. After adjusting for age, sex, and field center, food insecurity was associated with incident CVD (adjusted hazard ratio [aHR], 1.90; 95% CI, 1.41-2.56). The association persisted (aHR, 1.47; 95% CI, 1.08-2.01) after further adjustment for the socioeconomic factors of education, marital status, and usual source of medical care.
Conclusions and Relevance
In this prospective cohort study among participants in the CARDIA study, food insecurity was associated with incident CVD even after adjustment for socioeconomic factors, suggesting that food insecurity may be an important social deprivation measure in clinical assessment of CVD risk. Whether interventions to reduce food insecurity programs can potentially alleviate CVD should be further studied.
This cohort study among adult participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study investigates whether food insecurity is associated with incident cardiovascular disease and if this association varies by sex, education, or race.
Introduction
Food insecurity, a condition of inconsistent access to sufficient food for an active, healthy lifestyle, affects 1 in 8 US individuals annually.1 Multiple studies show that food insecurity is associated with cardiovascular disease (CVD) and its risk factors, such as hypertension, diabetes, obesity, and lifestyle behaviors.2,3 Food insecurity is also prevalent among US adults with CVD and has only become more common over the past 2 decades among patients with CVD.4
Food insecurity is hypothesized to cause cardiometabolic diseases through food shortage, constrained and compensatory diet behavior, and stress.5 However, most studies of the associations between food insecurity, cardiovascular risk factors, and CVD are cross-sectional and unable to establish directionality between food insecurity and CVD.2 It is also possible that prevalent CVD, leading to increased household expenditures and competing demands, causes food insecurity.2,5 Limited data suggest that food insecurity may precede CVD. One study that assessed the association between food insecurity and health care expenditures in both directions6 showed that the strength of the association between food insecurity and subsequent health care spending was stronger than increased health care spending leading to subsequent food insecurity. However, longitudinal studies are needed to fully establish the temporal association between food insecurity and CVD.
Furthermore, the association of food insecurity and CVD may interact with sex, race, and education. Individuals with CVD who are food insecure are more likely to be women or identify as Black,4,7 and they may experience additional stressors associated with CVD that could magnify or attenuate the association between food insecurity and incident CVD. Disparities in education are posited as 1 mechanism by which racial disparities arise in CVD, and food insecurity is associated with low educational attainment.8,9 Understanding the factors that contribute to or modify the association between food insecurity and CVD may identify avenues for intervention.2,10
To explore the temporal association between food insecurity and CVD, longitudinal data from the CARDIA (Coronary Artery Risk Development in Young Adults) study were used to examine whether food insecurity is associated with incident CVD. Due to established disparities in food insecurity, we also studied whether this association varied by sex, race, or education. Food insecurity has been found to be longitudinally associated with CVD risk factors in CARDIA.11 In another national sample, food-insecure adults aged 30 to 59 years had higher 10-year atherosclerotic CVD (ASCVD) risk compared to those without food insecurity, but food-insecure adults aged 60 years and older did not, suggesting that food insecurity may increase risk for ASCVD at a younger age.12 Hence, we hypothesized that food insecurity in early adulthood would be associated with a greater incidence of CVD in middle adulthood and that this association would be stronger in women, Black adults, and adults with lower educational attainment.
Methods
Study Population
CARDIA recruited 5115 Black and White adults aged 18 to 30 years in 1985-1986 from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California.13,14,15 Initial recruitment was balanced on sex, age, race, and education level. The baseline for this analysis was the 2000-2001 CARDIA examination (year 15 CARDIA examination), which was the first year that CARDIA assessed food insecurity. From 3672 CARDIA adults examined in 2000-2001, individuals were excluded if they had missing data on the food security question in 2000-2001 (n = 12), missing data on the CVD outcome (n = 1), a CVD event reported prior to or at the 2000-2001 examination (n = 33), a change in reported sex (n = 1), invalid age of 47 years or older (n = 3), or missing covariate data (n = 6). The final analytical sample included 3616 participants. CARDIA participants provided written informed consent at each examination, and the study was approved by an institutional review board at each of the study centers.14
Measures
This study’s exposure was food security status in 2000-2001, when participant age range was 32 to 46 years old. From 2000 to 2020, participants completed an in-person CARDIA examination every 5 years and an annual contact by telephone, mail, or electronically, with National Death Index searches at approximately 5-year intervals.13 Food security status was assessed in the demographic survey in each 5-year examination starting in 2000-2001. In the CARDIA study, food security status was assessed using a single question (“Which one of these statements best describes the food eaten in your household last year?”) with 4 possible responses. The response “We have enough food to eat and the kinds of food we want” was categorized as food secure, and the responses “We have enough food to eat, but NOT always the kinds of food we want to eat,” “Sometimes we don’t have enough food to eat,” and “Often we don’t have enough food to eat” were categorized as food insecure.
The primary outcome was incident CVD, which consisted of fatal and nonfatal coronary heart disease (myocardial infarction, hospitalization for angina or acute coronary syndrome, or coronary heart disease death, including fatal myocardial infarction), heart failure, stroke, transient ischemic attack, or peripheral arterial disease. Incident CVD was assessed annually using data from examinations, annual contacts, medical records, and death records. The mean (SD) follow-up period for CVD events was 18.8 (3.4) years from the 2000-2001 examination through August 31, 2020. During the follow-up period, interval medical history on hospitalizations, relevant outpatient procedures, and deaths were collected annually by CARDIA investigators. For any of these clinical events, 2 physicians from the CARDIA Endpoints Surveillance and Adjudication Subcommittee independently adjudicated medical records of hospitalizations and procedures for possible events and death records for underlying cause of death. The Subcommittee reviewed and reconciled all cases in which the 2 reviewers disagreed.13
Covariates included age (continuous in years), sex (female or male), race (Black or White), CARDIA field site, education (continuous in years), marital status, and usual source of medical care in 2000-2001. For marital status, CARDIA responses “married” and “living with someone in a marriage-like relationship” were categorized as “married,” “single” and “never married” were categorized as “single,” and all other responses were categorized as “divorced, widowed, separated, other.” For usual source of medical care, those who responded “no” or “yes—hospital emergency room” were categorized as having no usual source of care; all other participants were categorized as having a usual source of care.
Statistical Analysis
Baseline characteristics at the 2000-2001 examination were compared by food security status. We used frequencies with percentages for categorical variables and means with standard deviations for continuous variables. Cox proportional hazards models were used to estimate the adjusted hazards ratios (aHRs) and 95% confidence intervals for the association between food security status in 2000-2001 and incident CVD. Participants were considered at risk of developing CVD starting in 2000-2001 until the last known follow-up date at which CVD was first observed or censored at the last observed examination. The Kolmogorov-type supremum test was used to check the proportional hazard assumption.16,17 We used 3 varying levels of model adjustments to examine the association of food security status and incident CVD. Model 1 adjusted for age, sex, and field site, model 2 further adjusted for baseline (2000-2001) education level, marital status, and usual source of medical care, and model 3 further adjusted for self-reported race. The interaction of age, sex, race, and education level with food security status was tested in model 3 to assess differences in the association of food security status and incident CVD by effect modifier measures. All statistical analyses were conducted using SAS version 9.4 (SAS Institute). The Figure was generated using R version 4.2.0 (R Foundation). A 2-sided P < .05 was considered statistically significant.
Figure. Cardiovascular Disease Cumulative Incidence Curves by Food Security Status.
Results
In this sample of 3616 adults at baseline (2000-2001), mean (SD) age was 40.1 (3.6) years, and 2027 participants (56%) were female. Of 3616 participants, 1696 (47%) self-reported Black race, and 529 adults (15%) had food insecurity. Among those with food insecurity, 486 participants (13.4%) endorsed “We have enough food to eat, but NOT always the kinds of food we want to eat,” 35 participants (1.0%) endorsed “Sometimes we don’t have enough food to eat,” and 8 participants (0.2%) endorsed “Often we don’t have enough to eat.” Those with food insecurity were slightly younger (mean [SD] age, 39.6 [3.6] years vs 40.2 [3.6] years), more likely to identify as Black (359 participants [68%] vs 1337 participants [43%]), and had lower educational attainment (mean [SD] years of education, 13.5 [2.2] years vs 15.1 [2.5] years) than those without food insecurity (Table 1).
Table 1. Sociodemographic Characteristics by Food Security Status.
| Characteristic | Participants, No. (%) | ||
|---|---|---|---|
| All (N = 3616) | Food secure (n = 3087 [85%]) | Food insecure (n = 529 [15%]) | |
| Age, mean (SD), y | 40.1 (3.6) | 40.2 (3.6) | 39.6 (3.6) |
| Sex | |||
| Female | 2027 (56) | 1697 (55) | 330 (62) |
| Male | 1589 (44) | 1390 (45) | 199 (38) |
| Racea | |||
| Black | 1696 (47) | 1337 (43) | 359 (68) |
| White | 1920 (53) | 1750 (57) | 170 (32) |
| Education, mean (SD), y | 14.9 (2.5) | 15.1 (2.5) | 13.5 (2.2) |
| Marital status | |||
| Single | 788 (22) | 642 (21) | 146 (28) |
| Married | 2182 (60) | 1957 (63) | 225 (42) |
| Divorced, widowed, separated, other | 646 (18) | 488 (16) | 158 (30) |
| Has usual source of health care | 3398 (94) | 2922 (95) | 476 (90) |
| Study site | |||
| Birmingham, Alabama | 844 (23) | 701 (23) | 143 (27) |
| Chicago, Illinois | 800 (22) | 685 (22) | 115 (22) |
| Minneapolis, Minnesota | 982 (27) | 823 (27) | 159 (30) |
| Oakland, California | 990 (27) | 878 (28) | 112 (21) |
| Smoking status | |||
| Nonsmoker | 2169 (60) | 1909 (62) | 260 (49) |
| Former | 651 (18) | 570 (18) | 81 (16) |
| Current | 789 (22) | 604 (20) | 185 (35) |
| Type 2 diabetes | 157 (4) | 131 (4) | 26 (5) |
| Body mass index, mean (SD)b | 28.8 (6.8) | 28.5 (6.6) | 30.3 (7.9) |
| Physical activity, mean (SD), exercise units | 347.7 (283.4) | 359.7 (288.2) | 277.9 (242.7) |
| Systolic blood pressure, mean (SD), mm Hg | 113.1 (14.8) | 112.6 (14.5) | 116.5 (16.2) |
| Diastolic blood pressure, mean (SD), mm Hg | 74.4 (11.5) | 74.1 (11.3) | 76.4 (12.6) |
| Total cholesterol, mean (SD), mg/dL | 184.8 (35.6) | 185.2 (35.6) | 182.2 (35.6) |
SI conversion note: To convert total cholesterol from mg/dL to mmol/L, multiply by 0.0259.
Race was self-reported by participants and measured as a binary variable (Black/White) by CARDIA investigators.
Calculated as weight in kilograms divided by height in meters squared.
After the 2000-2001 examination, 255 CVD events occurred through August 31, 2020, with 57 events (11%) in food-insecure participants and 198 events (6%) in food-secure participants. The unadjusted CVD incidence rate was 6.0 events per 1000 person-years in food-insecure participants, compared to 3.4 events per 1000 person-years in food-secure participants. The Figure shows the age-adjusted cumulative incidence curves for CVD between CARDIA participants with and without food insecurity. In a Cox proportional hazards model adjusting for age, sex, and field center, food insecurity was associated with incident CVD (aHR, 1.90; 95% CI, 1.41-2.56) (Table 2). After adjusting further for education, marital status, and usual source of medical care, food insecurity remained significantly associated with incident CVD in model 2 (aHR, 1.47; 95% CI, 1.08-2.01). Including race in the final model 3 did not markedly change the measure of association (Table 2). Interactions of age, sex, race, and education level with food security status were not statistically significant.
Table 2. Association of Food Insecurity and Incident Cardiovascular Disease (CVD).
| Food status | No.CVD | Follow-up, person-years | HR (95% CI) | ||
|---|---|---|---|---|---|
| Model 1a | Model 2b | Model 3c | |||
| Food secure | 198 | 58 615.75 | Reference | Reference | Reference |
| Food insecure | 57 | 9558.57 | 1.90 (1.41-2.56) | 1.47 (1.08-2.01) | 1.41 (1.03-1.92) |
Abbreviation: HR, hazard ratio.
Adjusted for age, sex, and field center.
Adjusted for age, sex, field center, education, marital status, and usual source of medical care.
Adjusted for age, sex, field center, education, marital status, usual source of medical care, and race.
Sensitivity Analyses
In our main analysis, food insecurity was assessed at a single time point in 2000-2001, but other ways of defining food insecurity were considered using longitudinal data from the food security question to create alternative binary and time-varying exposure variables. HRs were regenerated from sequential Cox proportional hazards models using each of these food insecurity categorizations as the exposure. For the alternative binary classification, using food security data from four 5-year CARDIA examinations between 2000 and 2016, all participants who always endorsed “We have enough food to eat and the kinds of food we want” from 2000 through 2016 were categorized as having “no food insecurity” (reference group). All other participants were categorized as having “any food insecurity,” meaning they experienced at least 1 episode of food insecurity from 2000 to 2016 captured in a CARDIA examination. In the sample, 2540 participants (70.2%) had no food insecurity, and 1076 participants (29.8%) had any food insecurity. The strength of the association between food insecurity and incident CVD using this alternative binary exposure classification was similar to results of our main analysis (eTable 1 in Supplement 1).
For the time-varying variable, participants with no food insecurity remained the reference group (n = 2540 [70.2%]), and we further classified those who were ever food insecure into 4 different groups: (1) those who initially endorsed food insecurity then later endorsed food security had “early food insecurity” (n = 224 [6.2%]); (2) those who initially endorsed food security then later endorsed food insecurity had “late food insecurity” (n = 265 [7.3%]); (3) those who alternated between endorsing food security and food insecurity statements had “inconsistent food insecurity” (n = 409 [11.3%]); and (4) those who endorsed food insecurity statements in all CARDIA examinations had “chronic food insecurity” (n = 178 [4.9%]). Results showed that the association with incident CVD was isolated to participants who had early food insecurity (HR, 1.60; 95% CI, 1.04-2.47) and chronic food insecurity (HR, 1.63; 95% CI, 1.01-2.67) (eTable 2 in Supplement 1).
In addition, we also considered additional covariates in our models, including using income instead of education level as the markers of socioeconomic position and including CVD risk factors. Education level was chosen for the main analysis due to its stability over time and location, as income can vary and fluctuate over adulthood, and its purchasing power differs by US geography. In a sensitivity analysis, education level was replaced with income (categorized as <$25 000, $25 000-$49 999, or ≥$50 000) in adjusted models. In model 2, the association between food insecurity and incident CVD was attenuated when adjusting for income (aHR, 1.38; 95% CI, 1.00-1.90) (eTable 3 in Supplement 1) compared to adjusting for education level (Table 2).
Discussion
In this analysis of longitudinal data from the CARDIA study, food insecurity was associated with incident CVD in middle-aged adults after adjusting for socioeconomic factors. Food insecurity was more prevalent in this CARDIA sample (15%) compared to the national prevalence in 2000 (10%). These findings suggest that food insecurity, like other markers of social deprivation, is associated with a higher rate of CVD events. This highlights the potential for developing strategies to alleviate food insecurity and its associated health conditions, as well as the use of food insecurity measures to refine individual CVD risk assessment. Further research to confirm the association between food insecurity and incident CVD should be conducted in larger studies with more diverse adults of a wider age range and longer follow-up to fully capture the risk of CVD. In our study, these associations did not differ by sex, race, or education level.
The findings from this study are consistent with the limited longitudinal data on food insecurity and CVD. A prior analysis of CARDIA data11 demonstrated a longitudinal association between food insecurity and the CVD risk factors of body mass index, waist circumference, and blood pressure. Another study of the association between food inadequacy and incident CVD in the Jackson Heart Study18 showed that Black participants with food inadequacy had a higher risk of coronary heart disease (HR, 1.76; 95% CI, 1.06-2.91) and incident heart failure with reduced ejection fraction (HR, 2.07; 95% CI, 1.16-3.70) over a median period of 13.8 years. However, the prior study differs markedly from this study for multiple reasons. Instead of food insecurity, investigators assessed food inadequacy, which was measured using self-reported use of public food assistance and self-reported economic difficulty purchasing groceries, as well as environmental food measures. The Jackson Heart Study18 also exclusively recruited Black participants from a single site study in Mississippi, which likely differed from the multicity sample of Black and White participants in the CARDIA study. In addition, the analysis included older participants (mean [SD] age, 54 [12] years). Due to the young age at CARDIA enrollment, most participants in this study were in middle adulthood at the end of the follow-up period, which did not capture age ranges in which CVD is most prevalent in US individuals.19 Our results also support multiple studies linking cross-sectional assessments and mortality data in national samples that have demonstrated an association between food insecurity and CVD mortality. A 2023 study20 showed that marginal food security and food insecurity was associated with greater CVD deaths (odds ratio, 1.17; 95% CI, 1.01-1.39), while another analysis21 found the association with CVD deaths only for those with very low food security (HR, 1.48; 95% CI, 1.02-2.17). These prior studies, in conjunction with the current analysis, demonstrate that food insecurity is longitudinally associated with CVD risk factors, incident disease, and mortality, providing evidence that food insecurity is an important contributor to cardiovascular risk among US individuals.
Although several social determinants of health (SDOHs), such as food insecurity, have been identified, the most used CVD risk assessment tool in clinic practice in the US, the American College of Cardiology/American Heart Association Pooled Cohort risk equations,22 does not incorporate SDOH factors. In contrast, the most used tool in the UK, the QRISK,23 incorporates a neighborhood deprivation measure. Also, the new American Heart Association Predicting Risk of CVD Events risk calculator includes a measure of SDOH (using zip code to approximate social deprivation index) to enhance the tool’s predictive utility.24 Findings from our study further support the need to consider SDOHs or other measures of socioeconomic status in clinical CVD risk assessment. Food insecurity is typically included in SDOH clinical screenings and may help improve CVD risk prediction. Recent studies on incorporating such measures highlight the need for further research on which measures best improve CVD risk prediction when social needs are identified.25,26
Another important knowledge gap is whether addressing food insecurity can prevent cardiovascular morbidity and mortality. In this study, food insecurity was associated with incident CVD, even after accounting for certain individual-level indicators of socioeconomic position. However, food insecurity often coexists with low socioeconomic position and limited household resources. While socioeconomic characteristics can be parsed out using statistical methods for the purposes of causal inference, in reality, these factors all strongly coexist in individuals and families. Hence, it is possible that food insecurity interventions could modify CVD risk, whether through addressing food insecurity directly or alleviating the economic stress of low socioeconomic position and limited household resources. It is also possible that programs targeting other social needs could affect food insecurity and reduce CVD risk. Expanding large-scale interventions effective for addressing food insecurity, such as the Supplemental Nutrition Assistance Program, may reduce CVD at the population level.10 Furthermore, individuals facing food insecurity tend to eat fewer healthy foods, a risk factor for CVD over the lifespan.27 Novel approaches to addressing food insecurity that emphasize diet quality and nutrition include local regional incentives for healthy food purchasing, medically tailored and prescriptive charitable foods, and health care linkages.28,29 Further research on these different types of food insecurity programs is needed to understand their role in cardiovascular prevention and addressing the root causes of health disparities.
Limitations
This study has limitations. The food insecurity assessment in CARDIA was not the criterion standard or a previously validated tool for food insecurity, and the analysis did not account for changes in participant food insecurity over time. While ascertainment of CVD events was rigorous, with up to 20 years of follow-up, participants were relatively young by the end of the follow-up period, and future CVD events as the CARDIA cohort ages may further influence the association between food insecurity and incident CVD. In addition, the 3672 CARDIA individuals examined in 2000-2001 (this study’s baseline) was a subset of the initial 5115 CARDIA adults. Loss to follow-up was likely differential, as predictors of continued CARDIA participation were older age, White race, and higher educational attainment, whereas food insecurity is correlated with younger age, racial or ethnic minority status, and less educational attainment. Finally, our sample size was small, which limited representation of different degrees and trajectories of food insecurity in the sensitivity analyses. Furthermore, interaction analyses between food insecurity and sex, race, or education level were likely inadequately powered to detect meaningful differences. However, CVD event follow-up through August 31, 2020, was high, with 77% of CARDIA participants contacted within the prior 2 years and periodic searches of the National Death Index. Our sample also had some geographic and racial diversity, having recruited Black and White adults from 4 different cities; however, results may not be widely generalizable.
Conclusions
In this cohort study among adult participants in the CARDIA study, food insecurity was associated with incident CVD even after accounting for socioeconomic factors, suggesting that addressing food insecurity may alleviate cardiovascular morbidity and mortality. Food insecurity may be an important social deprivation measure to consider in clinical assessment of individual CVD risk. Further research is needed to determine if recognizing and incorporating food insecurity improves CVD risk prediction models and whether food insecurity interventions can modify CVD risk.
eTable 1. Association of Food Insecurity (Alternative Classification) and Incident Cardiovascular Disease
eTable 2. Association of Time-Varying Food Insecurity and Incident Cardiovascular Disease
eTable 3. Association of Food Insecurity and Incident Cardiovascular Disease
Data Sharing Statement
References
- 1.Rabbitt MP, Hales LJ, Burke MP, Coleman-Jensen A. Household food security in the United States in 2022. US Department of Agriculture Economic Research Service . Accessed February 9, 2024. https://www.ers.usda.gov/webdocs/publications/107703/err-325.pdf?v=2661
- 2.Chang R, Javed Z, Taha M, et al. Food insecurity and cardiovascular disease: current trends and future directions. Am J Prev Cardiol. 2021;9:100303. doi: 10.1016/j.ajpc.2021.100303 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mendy VL, Vargas R, Cannon-Smith G, Payton M, Enkhmaa B, Zhang L. Food insecurity and cardiovascular disease risk factors among Mississippi adults. Int J Environ Res Public Health. 2018;15(9):2016. doi: 10.3390/ijerph15092016 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Brandt EJ, Chang T, Leung C, Ayanian JZ, Nallamothu BK. Food insecurity among individuals with cardiovascular disease and cardiometabolic risk factors across race and ethnicity in 1999-2018. JAMA Cardiol. 2022;7(12):1218-1226. doi: 10.1001/jamacardio.2022.3729 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med. 2010;363(1):6-9. doi: 10.1056/NEJMp1000072 [DOI] [PubMed] [Google Scholar]
- 6.Johnson KT, Palakshappa D, Basu S, Seligman H, Berkowitz SA. Examining the bidirectional relationship between food insecurity and healthcare spending. Health Serv Res. 2021;56(5):864-873. doi: 10.1111/1475-6773.13641 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Mahajan S, Grandhi GR, Valero-Elizondo J, et al. Scope and social determinants of food insecurity among adults with atherosclerotic cardiovascular disease in the United States. J Am Heart Assoc. 2021;10(16):e020028. doi: 10.1161/JAHA.120.020028 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Javed Z, Haisum Maqsood M, Yahya T, et al. Race, racism, and cardiovascular health: applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease. Circ Cardiovasc Qual Outcomes. 2022;15(1):e007917. doi: 10.1161/CIRCOUTCOMES.121.007917 [DOI] [PubMed] [Google Scholar]
- 9.Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304-310. doi: 10.3945/jn.109.112573 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Liu Y, Eicher-Miller HA. Food insecurity and cardiovascular disease risk. Curr Atheroscler Rep. 2021;23(6):24. doi: 10.1007/s11883-021-00923-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Vercammen KA, Moran AJ, Carnethon MR, et al. Longitudinal analysis of food insufficiency and cardiovascular disease risk factors in the CARDIA study. Am J Prev Med. 2022;62(1):65-76. doi: 10.1016/j.amepre.2021.06.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ford ES. Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008. Prev Chronic Dis. 2013;10:E202. doi: 10.5888/pcd10.130244 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Carr JJ, Jacobs DR Jr, Terry JG, et al. Association of coronary artery calcium in adults aged 32 to 46 years with incident coronary heart disease and death. JAMA Cardiol. 2017;2(4):391-399. doi: 10.1001/jamacardio.2016.5493 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Elfassy T, Swift SL, Glymour MM, et al. Associations of income volatility with incident cardiovascular disease and all-cause mortality in a US cohort. Circulation. 2019;139(7):850-859. doi: 10.1161/CIRCULATIONAHA.118.035521 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Friedman GD, Cutter GR, Donahue RP, et al. CARDIA: study design, recruitment, and some characteristics of the examined subjects. J Clin Epidemiol. 1988;41(11):1105-1116. doi: 10.1016/0895-4356(88)90080-7 [DOI] [PubMed] [Google Scholar]
- 16.Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika. 1994;81(3):515-526. doi: 10.1093/biomet/81.3.515 [DOI] [Google Scholar]
- 17.Lin DY, Wei LJ, Ying Z. Checking the Cox model with cumulative sums of martingale-based residuals. Biometrika. 1993;80(3):557-572. doi: 10.1093/biomet/80.3.557 [DOI] [Google Scholar]
- 18.Zierath R, Claggett B, Hall ME, et al. Measures of food inadequacy and cardiovascular disease risk in Black individuals in the US from the Jackson Heart Study. JAMA Netw Open. 2023;6(1):e2252055. doi: 10.1001/jamanetworkopen.2022.52055 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Heart disease prevalence. US National Center for Health Statistics . Accessed September 28, 2023. https://www.cdc.gov/nchs/hus/topics/heart-disease-prevalence.htm
- 20.He J, Bundy JD, Geng S, et al. Social, behavioral, and metabolic risk factors and racial disparities in cardiovascular disease mortality in U.S. adults: an observational study. Ann Intern Med. 2023;176(9):1200-1208. doi: 10.7326/M23-0507 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Sun Y, Liu B, Rong S, et al. Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States. J Am Heart Assoc. 2020;9(19):e014629. doi: 10.1161/JAHA.119.014629 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Muntner P, Colantonio LD, Cushman M, et al. Validation of the atherosclerotic cardiovascular disease pooled cohort risk equations. JAMA. 2014;311(14):1406-1415. doi: 10.1001/jama.2014.2630 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study. BMJ. 2017;357:j2099. doi: 10.1136/bmj.j2099 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Khan SS, Coresh J, Pencina MJ, et al. ; American Heart Association . Novel prediction equations for absolute risk assessment of total cardiovascular disease incorporating cardiovascular-kidney-metabolic health: a scientific statement from the American Heart Association. Circulation. 2023;148(24):1982-2004. doi: 10.1161/CIR.0000000000001191 [DOI] [PubMed] [Google Scholar]
- 25.Colantonio LD, Richman JS, Carson AP, et al. Performance of the atherosclerotic cardiovascular disease pooled cohort risk equations by social deprivation status. J Am Heart Assoc. 2017;6(3):e005676. doi: 10.1161/JAHA.117.005676 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Henderson K, Kaufman B, Rotter JS, et al. Socioeconomic status and modification of atherosclerotic cardiovascular disease risk prediction: epidemiological analysis using data from the atherosclerosis risk in communities study. BMJ Open. 2022;12(11):e058777. doi: 10.1136/bmjopen-2021-058777 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Leung CW, Epel ES, Ritchie LD, Crawford PB, Laraia BA. Food insecurity is inversely associated with diet quality of lower-income adults. J Acad Nutr Diet. 2014;114(12):1943-53.e2. doi: 10.1016/j.jand.2014.06.353 [DOI] [PubMed] [Google Scholar]
- 28.Seligman HK, Berkowitz SA. Aligning programs and policies to support food security and public health goals in the United States. Annu Rev Public Health. 2019;40(1):319-337. doi: 10.1146/annurev-publhealth-040218-044132 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Food as medicine: translating the evidence. Nat Med. 2023;29(4):753-754. doi: 10.1038/s41591-023-02330-7 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Association of Food Insecurity (Alternative Classification) and Incident Cardiovascular Disease
eTable 2. Association of Time-Varying Food Insecurity and Incident Cardiovascular Disease
eTable 3. Association of Food Insecurity and Incident Cardiovascular Disease
Data Sharing Statement
