Skip to main content
International Journal of Environmental Research and Public Health logoLink to International Journal of Environmental Research and Public Health
. 2018 Sep 15;15(9):2016. doi: 10.3390/ijerph15092016

Food Insecurity and Cardiovascular Disease Risk Factors among Mississippi Adults

Vincent L Mendy 1,*, Rodolfo Vargas 2, Gerri Cannon-Smith 2, Marinelle Payton 1,3, Byambaa Enkhmaa 4, Lei Zhang 2
PMCID: PMC6165024  PMID: 30223555

Abstract

Background: Food insecurity is a public health problem. There is limited data on food insecurity in Mississippi. Methods: We analyzed data from the 2015 Mississippi Behavioral Risk Factor Surveillance System, which included the Social Context Module for 5870 respondents. Respondents who indicated that in the past 12 months they were “always”, “usually”, or “sometimes” “worried or stressed about having enough money to buy nutritious meals” were considered food insecure. Food insecurity was compared across sociodemographic and health characteristics using chi-square tests, and the association between food insecurity and select cardiovascular disease risk factors was assessed using logistic regression. Results: The prevalence of food insecurity was 42.9%. Compared to the referent group, Mississippi adults with high blood pressure had 51% higher odds, those with diabetes had 30% higher odds, those who were not physically active had 36% higher odds, and those who consumed fewer than five fruits and vegetables daily had 50% higher odds of being food insecure. Conclusion: Among Mississippi adults, food insecurity is associated with high blood pressure, diabetes, obesity, fruit and vegetable consumption, physical inactivity, and smoking.

Keywords: cardiovascular disease; risk factors; food insecurity; Behavioral Risk Factor Surveillance System (BRFSS), Mississippi

1. Introduction

Food insecurity, which is defined by the United States Department of Agriculture (USDA) as “a household-level economic and social condition of limited or uncertain access to adequate food” [1], is a public health problem [2]. In 2015, 15.8 million U.S. households (12.7%) were food insecure [3]. Food insecurity is associated with poor diet [4], and is linked to a myriad of negative health outcomes including heart disease, high blood pressure, diabetes, obesity, poorer general health, increased health-care utilization, depression [5,6,7,8,9,10], and cardiovascular health [11,12]. In addition, food insecurity is associated with poor control of high blood pressure [13].

Cardiovascular disease (CVD) (i.e., coronary heart disease, myocardial infarction, heart failure, angina, and stroke) is another significant public health problem, especially in Mississippi, where the condition is the leading cause of death. In 2015, the state’s CVD death rate was 1.4 times higher than the national rate [14]. Further, the prevalence of CVD risk factors such as high blood pressure, diabetes and obesity is disproportionately higher in Mississippi than in the nation as a whole [15]. The Mississippi State Department of Health (MSDH), in collaboration with the Centers for Disease Control and Prevention (CDC) and local stakeholders, is currently implementing programs—through the Mississippi Delta Health Collaborative (MDHC)—that seek to address CVD by increasing access to healthy food and high blood pressure prevention and control in the 18-county Mississippi Delta region (www.healthyms.com/MDHC).

There is limited data on both food insecurity and CVD risk in Mississippi. In 2015, the Behavioral Risk Factor Surveillance System (BRFSS) Social Context Module measured food insecurity for the first time, via a question asking about stress associated with the affordability of nutritious meals. We used the responses to examine the association between select CVD risk factors and food insecurity among Mississippi adults, and to assess differences in food insecurity by sociodemographic and health characteristics.

2. Methods

We analyzed data from the 2015 Mississippi BRFSS, which included the Social Context Module. Current analysis has been restricted to respondents who self-identified as black or white; these two racial groups accounted for 96.6% of the study population. The BRFSS is a state-based, random-digit-dialed telephone survey of the U.S. noninstitutionalized civilian population aged 18 years or older. The survey was conducted in all 50 states, the District of Columbia and three U.S. territories (Puerto Rico, Guam and the U.S. Virgin Islands). Data from the BRFSS produced reliable and valid assessments of health risk factors [16]. Post-stratification weights were used to adjust for nonresponse, noncoverage, and disproportionate selection of populations [8,16]. The BRFSS was approved by the human research review board at each state’s department of health. Detailed information about BRFSS is available at www.cdc.gov/brfss/. This study was deemed exempt by the Mississippi State Department of Health Institutional Review Board.

2.1. Food Insecurity

Food insecurity was defined based on the following question: “How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?” Respondents who answered “always,” “usually” or “sometimes” were considered food insecure, and those who responded “rarely” or “never” were considered food secure [8].

2.2. CVD Risk Factors

High blood pressure was defined as a “yes” response to the question, “Have you ever been told by a doctor, nurse or other health professional that you have a high blood pressure?” High cholesterol was defined as a “yes” response to the question, “Have you ever been told by a doctor, nurse or other health professional that your blood cholesterol is high?” Diabetes was defined as a “yes” response to the question, “Have you ever been told by a doctor that you have diabetes?” Current smoking was defined as having smoked at least 100 cigarettes during the respondent’s lifetime and currently smoking at the time of the survey. Body mass index (BMI) (calculated with self-reported height and weight) was classified into three categories (normal weight, BMI < 25.0; overweight, BMI 25.0 to <30.0; and obese, BMI ≥ 30.0). Physical inactivity was defined as a “no” response to the question “During the past month, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?” Binge drinking was defined as having five or more drinks on one occasion for males, and as having four or more drinks on one occasion for females. Fruit and vegetable consumption was based on the total number of fruits and vegetables respondents reported consuming per day. Responses were categorized as either less than five fruits/vegetables, or five or more fruits/vegetables consumed per day.

2.3. Statistical Analyses

Weighted prevalence and 95% confidence intervals (CI) were calculated. Food insecurity was compared across sociodemographic characteristics using chi-square tests, and the associations between food insecurity and select CVD risk factors were assessed using logistic regression models including controls for age, gender, race, education, annual household income, and health insurance. SAS version 9.4 (SAS Institute, Cary, NC, USA) was used to perform all statistical analyses, which accounted for the complex sample design; significance levels were determined based on a p-value less than 0.05.

3. Results

The analyses were based on data from 5870 Mississippi adults. The mean age of respondents was 47.4 years; 38.4% were black, 52.6% were women, just over half (51.7%) had greater than a high school education, 56.8% were employed, and about a quarter (24.9%) had an annual household income of less than $20,000 (Table 1).

Table 1.

Sociodemographic characteristics of Mississippi adults, Behavioral Risk Factor Surveillance System, 2015.

Characteristic N a % b 95% CI
Age (years)
18–34 705 30.3 28.3–32.3
35–49 935 23.0 21.4–24.6
50–64 1869 26.7 25.2–28.2
≥65 2361 20.0 18.9–21.1
Race
Black 2099 38.4 36.5–40.2
White 3746 61.6 59.8–63.5
Sex
Male 2052 47.4 45.5–49.3
Female 3818 52.6 50.7–54.5
Education level
<High school graduate 787 18.4 16.8–20.0
High school or equivalent graduate 1859 29.9 28.2–31.6
>High school graduate 3207 51.7 49.8–53.6
Employment
Employed 2184 56.8 54.8–58.8
Unemployed 631 15.0 13.4–16.6
Student 128 6.8 5.5–8.2
Retired 2067 21.4 20.1–22.7
Marital Status
Married 2701 48.7 46.8–50.5
Widowed 1174 8.9 8.2–9.7
Divorced/separated 1041 15.5 14.2–16.7
Never married 886 27.0 25.0–28.9
Annual household income ($)
<20,000 1485 24.9 23.2–26.5
20,000-34,999 1200 21.5 20.0–23.1
35,000-49,999 622 10.9 9.7–12.1
≥50,000 1512 27.1 25.4–28.7
Don’t know/Refused 1026 15.6 14.3–17.0
Physical Inactivity
Yes 2175 36.6 34.8–38.5
No 3391 63.4 61.5–65.2

CI, confidence interval; a Unweighted; b Weighted percent.

The overall prevalence of food insecurity was 42.9% (95% CI, 40.7–45.0). The prevalence of food insecurity differed for several background characteristics: blacks (53.7%, 95% CI, 50.0–57.3, p < 0.0001) had a higher prevalence than whites, females (46.2%, 95% CI, 43.5–48.9, p = 0.0011) had a higher prevalence than males, those with high blood pressure (45.8%, 95% CI, 42.8–48.7, p = 0.0163) had a higher prevalence than those without high blood pressure, and those without health insurance (65.0%, 95% CI, 59.3–70.8, p < 0.0001) had a higher prevalence than those with health insurance. In addition, there were significant differences in the prevalence of food insecurity by age group, educational level, employment status, marital status, annual household income, body mass index, and smoking status (p < 0.0001) (Table 2).

Table 2.

Food insecurity among Mississippi adults by sociodemographic and health characteristics, Behavioral Risk Factor Surveillance System, 2015.

Characteristic Food Insecurity p-Value b
% a (n = 1659) 95% CI
Overall 42.9 40.7–45.0
Age group (years)
18–24 50.7 45.3–56.1 <0.0001
25–44 48.8 44.4–53.2
45–64 41.5 38.2–44.9
≥65 26.8 23.9–29.7
Race
Black 53.7 50.0–57.3 <0.0001
White 36.4 33.8–39.0
Sex
Male 38.9 35.5–42.3 0.0011
Female 46.2 43.5–48.9
Education level
<High school graduate 57.8 52.2–63.4 <0.0001
High school or equivalent graduate 47.7 43.8–51.5
>High school graduate 35.6 32.8–38.3
Employment status
Employed 38.1 35.1–41.2 <0.0001
Unemployed 54.9 48.4–61.4
Student 49.7 34.8–64.6
Retired 25.3 22.0–28.6
Marital Status
Married 35.2 32.4–37.9 <0.0001
Widowed 34.7 29.9–39.6
Divorced/separated 57.7 52.9–62.6
Never married 52.2 46.6–57.8
Annual household income ($)
<20,000 67.6 63.6–71.6 <0.0001
20,000–34,999 49.5 45.0–54.1
35,000–49,999 43.6 37.2–50.0
≥50,000 18.9 15.7–22.1
Don’t know/Refused 37.6 31.6–43.6
Body Mass Index (BMI)
<25.0 36.5 32.2–40.8 <0.0001
25.0–<30.0 40.1 36.5–43.7
≥30 49.5 45.9–53.1
Smoking status
Current 61.1 56.5–65.8 <0.0001
Former 34.4 30.2–38.5
Never 39.0 36.2–41.9
Diabetes
Yes 46.4 41.7–51.0 0.1122
No 42.2 39.8–44.5
High blood pressure
Yes 45.8 42.8–48.7 0.0163
No 40.5 37.5–43.6
High Cholesterol
Yes 40.6 37.4–43.8 0.5749
No 39.4 36.3–42.4
Health insurance
Yes 38.6 36.4–40.9 <0.0001
No 65.0 59.3–70.8

CI, confidence interval; a Weighted percent; b Determined by X2 test.

The results of the regression models including controls for age, gender, race, education, annual household income, and health insurance also showed associations between food insecurity and sociodemographic and health characteristics. Mississippi adults with high blood pressure had 51% higher odds (adjusted odds ratio (AOR) 1.51, 95% CI, 1.21–1.88, p = 0.00082) than those without high blood pressure, those with diabetes had 30% higher odds (AOR 1.30, 95% CI, 1.02–1.65, p = 0.0365) than those without diabetes, those who were not physically active had 36% higher odds (AOR 1.36, 95% CI, 1.10–1.68, p = 0.0043) than those who were physically active, and those who consumed fewer than five fruits and vegetables daily had 50% higher odds (AOR 1.50, 95% CI, 1.05–2.45, p = 0.0259) of being food insecure than those who consumed five or more fruits and vegetables daily (Table 3). Similarly, relative to those with a BMI < 25.0, the odds of being food insecure were 68% higher (AOR 1.68, 95% CI, 1.28–2.21, p = 0.0002) among those with a BMI of ≥30.0, and 38% higher (AOR 1.38, 95% CI, 1.05–1.81, p = 0.0227) among those with a BMI of 25.0–29.9. Finally, current smokers had 82% higher odds of being food insecure (AOR 1.82, 95% CI 1.40–2.37, p < 0.0001) than nonsmokers (Table 3).

Table 3.

Association between food insecurity and select cardiovascular disease risk factors among Mississippi adults, Behavioral Risk Factor Surveillance System, 2015.

Characteristic AOR a 95% CI p-Value
Diabetes mellitus 0.0365
Yes 1.30 1.02–1.65
No 1.00 Referent
High blood pressure
Yes 1.51 1.21–1.88 0.0002
No 1.00 Referent
High cholesterol
Yes 1.17 0.94–1.45 0.1619
No 1.00 Referent
Body mass index (BMI)
≥30 1.68 1.28–2.21 0.0002
25.0–29.9 1.38 1.05–1.81 0.0227
18.5–24.9 1.00 Referent
Smoking status
Current 1.82 1.40–2.37 <0.0001
Former 0.97 0.75–1.25 0.8003
Never 1.00 Referent
Binge drinking
Yes 1.08 0.73–1.59 0.7018
No 1.00 Referent
Physical inactivity
Yes 1.36 1.10–1.68 0.0043
No 1.00 Referent
Fruits/Vegetables consumed per day
≥5 1.00 Referent 0.0259
<5 1.50 1.05–2.145

AOR, adjusted odds ratio; CI, confidence interval; a Adjusted for age, sex, race, education, health insurance and income.

4. Discussion

In 2015, the prevalence of food insecurity among Mississippi adults was three times the U.S. average (12.7%) [1]. An estimated two out of every five (n = 742,381 (42.9%)) Mississippi adults were food insecure. The prevalence of food insecurity was significantly higher among blacks than whites, and among females than males. In addition, both those with high blood pressure and those without health insurance had a higher prevalence than their counterparts. We also found significant differences in the prevalence of food insecurity by age group, educational level, employment status, marital status, annual household income, body mass index, and smoking status. When age, gender, race, education, annual household income, and health insurance were controlled, food insecurity was significantly associated with high blood pressure, diabetes, obesity, fruit and vegetable consumption, physical inactivity, and smoking status among Mississippi adults.

The significant associations between food insecurity and high blood pressure, obesity, diabetes, and physical inactivity are consistent with the findings of previous reports from other states [8,10,17,18,19]. In 2015, an estimated 955,137 (42.4%) Mississippi adults had high blood pressure, 760,144 (36.4%) were obese, 334,024 (14.7%) had diabetes, and 779,898 (36.8%) were physically inactive [20]. In addition, high blood pressure, diabetes and obesity disproportionately affected black Mississippians (37.0% of the total population). A possible explanation for the association between food insecurity and physical inactivity is that food insecurity might lead to distress or poor health, any of which could lead to a lower level of physical activity [19].

Prior studies have shown that food insecure individuals report a higher juice intake and are less likely to engage in fat-lowering behaviors [21]. Similarly, among adults, food insecurity is adversely associated with dietary quality [22]. Mississippi adults with these chronic health conditions (high blood pressure, obesity, diabetes, and physical inactivity) could benefit from focused interventions that address the availability, accessibility and affordability of healthy food options in the state. The MSDH (Mississippi Delta Health Collaborative) and the CDC, through a cooperative agreement, are currently implementing interventions across the 18-county Mississippi Delta region (a region with a disproportionately high burden of high blood pressure and obesity). These interventions target the ABCS (aspirin for those eligible, blood pressure control, cholesterol management, and smoking cessation) of heart disease and stroke prevention. In particular, the Mayoral Health Council Initiative addresses access to healthy food (electronic benefit transfer (EBT) cards for farmers’ markets or increasing fruit/vegetable access at corner/convenience markets) and physical activity options (shared-use agreements) in the 18-county Mississippi Delta region.

Our findings are subject to the following limitations. First, the BRFSS consists of self-reported information on food insecurity and CVD risk factors, and therefore the data is subject to recall bias and social desirability bias. Second, the Mississippi BRFSS sample includes only adults (18 years of age and older); therefore, the findings may not be generalizable to children. Third, food insecurity was assessed based on a single question. Finally, because the data is cross-sectional, we cannot make causal inferences based on the results.

5. Conclusions

In this study, we found that food insecurity was associated with high blood pressure, diabetes, obesity, fruit and vegetable consumption, physical inactivity, and smoking status among Mississippi adults. Programs and interventions that target food insecure individuals are needed in the state, particularity for adult Mississippians who have high blood pressure or diabetes, who are obese or physically inactive, or who currently smoke. Identifying food insecure adults and linking them to available resources in the state could play an important role in addressing disparities in high blood pressure, diabetes and obesity prevention and control in Mississippi.

Acknowledgments

We sincerely thank Cassandra Dove, Victor Sutton, Ron McAnally, and Mary Currier of the Mississippi State Department of Health and Fleetwood Loustalot of the Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention.

Author Contributions

V.L.M. led in conceiving, designing and writing the manuscript; R.V. performed the analyses; G.C.-S. assisted with the concept and edited the manuscript; E.B. assisted with the concept and writing the manuscript; M.P. reviewed and edited the manuscript and L.Z. assisted with the concept and edited the manuscript.

Funding

This research was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number P20MD006899.

Conflicts of Interest

The authors of this study declare no conflict of interest.

References

  • 1.United States Department of Agriculture Economic Research Service. [(accessed on 2 March 2017)]; Available online: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security/
  • 2.Murthy V.H. Food Insecurity: A Public Health Issue. Public Health Rep. 2016;131:655–657. doi: 10.1177/0033354916664154. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Coleman-Jensen A., Rabbitt M.P., Gregory C.A., Singh A. Household Food Security in the United States in 2015. [(accessed on 2 March 2017)]; Available online: https://www.ers.usda.gov/publications/pub-details/?pubid=79760.
  • 4.Davison K.M., Gondara L., Kaplan B.J. Food insecurity, poor diet quality, and suboptimal intakes of folate and iron are independently associated with perceived mental health in Canadian adults. Nutrients. 2017;9:274. doi: 10.3390/nu9030274. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Heerman W.J., Wallston K.A., Osborn C.Y., Bian A., Schlundt D.G., Barto S.D., Rothman R.L. Food insecurity is associated with diabetes self-care behaviours and glycaemic control. Diabet Med. 2016;33:844–850. doi: 10.1111/dme.12896. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Ramsey R., Giskes K., Turrell G., Gallegos D. Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences. Public Health Nutr. 2012;15:227–237. doi: 10.1017/S1368980011001996. [DOI] [PubMed] [Google Scholar]
  • 7.Seligman H.K., Schillinger D. Hunger and socioeconomic disparities in chronic disease. N. Engl. J. Med. 2010;363:6–9. doi: 10.1056/NEJMp1000072. [DOI] [PubMed] [Google Scholar]
  • 8.Pan L., Sherry B., Njai R., Blanck H.M. Food insecurity is associated with obesity among US adults in 12 states. J. Acad. Nutr. Diet. 2012;112:1403–1409. doi: 10.1016/j.jand.2012.06.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Gucciardi E., Vahabi M., Norris N., Del Monte J.P., Farnum C. The intersection between food insecurity and diabetes: A review. Curr. Nutr. Rep. 2014;3:324–332. doi: 10.1007/s13668-014-0104-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Blue Bird Jernigan V., Wetherill M.S., Hearod J., Jacob T., Salvatore A.L., Cannady T., Grammar M., Standridge J., Fox J., Spiegel J., et al. Food insecurity chronic diseases among American Indians in rural Oklahoma: The THRIVE study. Am. J. Public Health. 2017;107:441–446. doi: 10.2105/AJPH.2016.303605. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Saiz A.M., Aul A.M., Malecki K.M., Bersch A.J., Bergmans R.S., LeCaire T.J., Javier Nieto F. Food insecurity and cardiovascular health: Findings from a statewide population health survey in Wisconsin. Prev. Med. 2016;93:1–6. doi: 10.1016/j.ypmed.2016.09.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Ford E.S. 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;10:202. doi: 10.5888/pcd10.130244. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Calif A.T., Vargas R. Is food insecurity associated with chronic disease and chronic disease control? Ethn. Dis. 2009;19:3–6. [Google Scholar]
  • 14.Centers for Disease Control and Prevention, National Center for Health Statistics Underlying Cause of Death 1999–2015 on CDC WONDER Online Database, released December, 2016. [(accessed on 6 April 2017)]; Data Are from the Multiple Cause of Death Files, 1999–2015, as Compiled from Data Provided by the 57 Vital Statistics Jurisdictions through the Vital Statistics Cooperative Program. Available online: http://wonder.cdc.gov/ucd-icd10.html.
  • 15.Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health BRFSS Prevalence & Trends Data 2015. [(accessed on 6 April 2017)]; Available online: https://www.cdc.gov/brfss/brfssprevalence/
  • 16.Pierannunzi C., Hu S.S., Balluz L. A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004–2011. BMC Med. Res. Methodol. 2013;13:49. doi: 10.1186/1471-2288-13-49. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Nguyen B.T., Shuval K., Bertmann F., Yaroch A.L. The supplemental nutrition assistance program, food insecurity, dietary quality, and obesity among U.S. adults. Am. J. Public Health. 2015;105:1453–1459. doi: 10.2105/AJPH.2015.302580. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Irving S.M., Njai R.S., Siegel P.Z. Food insecurity and self-reported hypertension among Hispanic, black, and white adults in 12 states, Behavioral Risk Factor Surveillance System, 2009. Prev. Chronic Dis. 2014;11:161. doi: 10.5888/pcd11.140190. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.To Q.G., Frongillo E.A., Gallegos D., Moore J.B. Household food insecurity is associated with less physical activity among children and adults in the U.S. population. J. Nutr. 2014;144:1797–1802. doi: 10.3945/jn.114.198184. [DOI] [PubMed] [Google Scholar]
  • 20.Mississippi Behavioral Risk Factor Surveillance System (BRFSS) [(accessed on 2 March 2017)];2015 Available online: http://msdh.ms.gov/brfss/
  • 21.Mello J.A., Gans K.M., Risica P.M., Kirtania U., Strolla L.O., Fournier L. How is food insecurity associated with dietary behaviors? An analysis with low-income, ethnically diverse participants in a nutrition intervention study. J. Am. Diet Assoc. 2010;110:1906–1911. doi: 10.1016/j.jada.2010.09.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Hanson K.L., Connor L.M. Food insecurity and dietary quality in US adults and children: A systematic review. Am. J. Clin. Nutr. 2014;100:684–692. doi: 10.3945/ajcn.114.084525. [DOI] [PubMed] [Google Scholar]

Articles from International Journal of Environmental Research and Public Health are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

RESOURCES