Start with a snapshot: Adults without reliable access to nutritious food are more likely to have heart disease than adults who don’t struggle to eat well. But which comes first, the food insecurity or the illness? Heart attacks or heart failure don’t develop overnight, so figuring out the chain of events means panning out for the long view.
A new analysis did just that, following people who had no heart disease in their late 30s or early 40s to see how their access to food might relate to their heart health 20 years later. The cohort study’s results, published Wednesday in JAMA Cardiology, show people with food insecurity had a 41% higher risk of developing heart disease in middle age compared to people with a secure source of food. That association held up after accounting for other influences, such as race or education.
“Even once we account for socioeconomic factors, we still see that food insecurity itself confers an increased risk of developing heart disease,” study author Jenny Jia, an internist at Northwestern Medicine, told STAT. “These adults actually have not reached the 65-and-above age range when heart disease is most likely to be diagnosed, so they’re not even at the peak diagnosis age but we’re already starting to see that they diverge.”
Jia and her colleagues analyzed data from participants enrolled at about age 18 in an ongoing study called CARDIA. Conducted since 1986 in Birmingham, Ala.; Oakland, Calif.; Chicago; and Minneapolis, 48% of its 3,616 volunteers were Black. The new study didn’t look all the way back to the study’s start because questions about struggling to afford food weren’t asked until 2000, reflecting the relatively recent attention paid to food as medicine, or as a pillar of prevention.
The day before the JAMA Cardiology article appeared, an influential health policy group issued its decision that food insecurity wasn’t well enough defined to suggest including it in screening questions at the primary care doctor’s office.The recommendation hews to a draft published in June 2024, which cited the complexity of social issues involved in food availability.
“The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for food insecurity on health outcomes in the primary care setting,” it stated in JAMA Tuesday.
Survey data collected by USPSTF estimate that 13% of U.S. households experienced food insecurity in 2022, including 8% of households with low food security and 5% with very low food security. Among households with incomes below the federal poverty threshold, nearly one-third had food insecurity.
To establish who had food insecurity in the CARDIA study, participants were asked which of these descriptions fit their household in the previous year. A “yes” answer only to the first question qualified as food secure:
- We have enough food to eat and the kinds of food we want.
- We have enough food to eat, but not always the food we want to eat.
- Sometimes we don’t have enough food to eat.
- Often we don’t have enough food to eat.
After following these people from 2000 through 2020, 11% of those who were food insecure developed heart disease, compared to 6% of those who had adequate access to food. The heart disease measures were serious: fatal and nonfatal heart attack; hospitalization for angina or acute coronary syndrome; heart failure; stroke; or peripheral arterial disease.
Those differences in food security and heart disease held true after factoring in race and in education, which the authors called a more consistent measure than income.
Khurram Nasir, a preventive cardiologist and researcher affiliated with both Weill Cornell Medical College and the Houston Methodist DeBakey Heart & Vascular Center, wasn’t surprised by the connection, but he did find the magnitude of risk concerning. He was not involved in the study.
“Food insecurity isn’t just about hunger, it’s a major cardiovascular risk factor,” he told STAT in an email interview. “A 41% increased risk of cardiovascular disease due to food insecurity, even after adjusting for traditional risk factors, is staggering. This tells us that addressing cholesterol and blood pressure alone is not enough — we need to be tackling the upstream drivers of disease, such as economic instability, neighborhood deprivation, and access to affordable, nutritious food.”
Having established a timeline showing food insecurity comes first, followed by heart disease, Jia did say the sequence may not always be so clear-cut.
“Over time, there is a differential rate of development of heart disease,” she said. “There is probably some bidirectionality because we know that having chronic disease creates an additional socioeconomic pressure on the household because health care is expensive, unfortunately.”
Food insecurity can be cyclical, Nasir said. “People in food-insecure households are more likely to consume processed, high-sodium foods, develop binge-eating behaviors, and experience chronic stress, all of which accelerate cardiovascular disease,” he said. “Food insecurity doesn’t exist in a vacuum. It’s tied to income, housing stability, neighborhood infrastructure, and even transportation access.”
Many experts recommend adding screening questions about food security to primary care visits, but Jia, who is also an instructor of general internal medicine and preventive medicine at Northwestern University Feinberg School of Medicine, also extends that to emergency rooms and specialties including cardiology. Nurses and medical assistants could query patients — or patients themselves could fill out forms.
If in need, people could be connected to existing community resources, Jia said, such as the charitable network of food banks and food pantries throughout the country. “A lot of these strategies are really focused on, how do we make the healthy choice the easy choice,” she said.
Health care systems should take an integrated approach, Jia and Nasir both said. That could mean expanding medically tailored meals and “food pharmacies” in hospitals and clinics. On the policy level, Nasir would advocate for stronger nutrition assistance programs, incentives for grocery store development in food deserts, and subsidies for healthier foods.
“If we fail to address the systemic barriers,” he said, “we will keep treating the consequences of cardiovascular disease instead of preventing it.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.