Lack of access to healthy food may raise risk of death from heart failure

Food insecurity occurs when healthy food is not readily available on a daily basis, due to poverty or socioeconomic challenges, causing people to go hungry or eat food that is of reduced quality, variety or desirability. While previous research has confirmed that food insecurity is associated with adverse cardiovascular outcomes, little research is available about the local food environment and its potential relationship to death from heart failure. A 2019 paper published in the Journal of the American Heart Association found that, on a county level in the U.S., poverty was the strongest socioeconomic factor associated with heart failure and coronary heart disease, and the association was stronger for heart failure than coronary heart disease.

"Heart failure mortality is on the rise in populations that live in socioeconomic deprivation, and, importantly, we believe that nutrition plays a role in heart failure mortality, and food insecurity may be particularly detrimental in this population," said lead study author Keerthi T. Gondi, M.D., an internal medicine resident at the University of Michigan Health System in Ann Arbor, Michigan. "We know that important relationships exist among food access and food affordability and heart health. This will have to be addressed in order to make changes to the burden of cardiovascular disease in populations that live in socioeconomic deprivation moving forward."

This study is one of the first analyses to investigate the association between local food environments and heart failure mortality. Heart failure is a chronic, progressive condition in which the heart muscle becomes so weak it no longer pumps blood as it should. According to Gondi, he and his colleagues examined the death rate from heart failure because it is a consistent metric reported across all US counties, providing an ability to comprehensively evaluate heart failure outcomes at the population level. In 2019, heart failure death accounted for nearly more than 86,000 deaths in the U.S., according to the Association's Heart Disease and Stroke Statistics Update for 2022.

The researchers sought to determine whether food environment by county level was associated with heart failure death rates. They reviewed 2018 data from the National Vital Statistics System -- a database of all births and deaths in the U.S. -- and examined the potential for associations among the heart failure death rates in each county with the county's 2018 Food Insecurity Percentage score and Food Environment Index score.

The researchers collected each county's Food Insecurity Percentage score -- the percentage of the population who lack adequate, consistent access to healthy food -- and Food Environment Index score -- an index ranked from 0 (worst) to 10 (best) based on a composite of metrics including affordability of nutritious food, food insecurity, grocery store proximity, transportation and socioeconomic factors -- from the USDA's Food Environment Atlas and the Robert Woods Johnson Foundation County Health Rankings. The Food Environment Atlas assembles statistics on food environment indicators and provides a spatial overview of a community's ability to access healthy food.

Evaluated together, the Food Insecurity Percentage and Food Environment Index provide a clear picture of a population's food environment.

Of the 2,956 counties in the study, the analysis found:

• The average Food Insecurity Percentage was 13% for all counties, and the average Food Environment Index score was 7.8.
• Counties with a Food Insecurity Percentage above the national median of 13.7% had a higher rate of deaths from heart failure compared to counties with a Food Insecurity Percentage below the median (30.7 deaths versus 26.7 deaths per 100,000 people, respectively).
• After adjusting for a range of socioeconomic and health factors -- including the poverty rate, income inequity, rural vs. urban locations, Type 2 diabetes, obesity and smoking -- a 1% decrease in Food Insecurity Percentage by county was associated with a 1.3% lower heart failure death rate. Similarly, a 1-unit increase in the Food Environment Index score by county was associated with a 3.6% decrease in the heart failure death rate.
• On the county level, decreases in the Food Environment Index and increases in the Food Insecurity Percentage were found to have a stronger association with the death rate from heart failure than with the death rate for other subtypes of cardiovascular disease, as well as with the all-cause death rate.
• The strongest association between food environment and heart failure death rate was found in counties with the highest income inequity and the highest poverty rate.

"The findings of this study are unfortunate yet not surprising. These results are consistent with prior studies that have demonstrated the association of cardiovascular disease and food insecurity," said Anne Thorndike, M.D., M.P.H., FAHA, who was not involved in this study, director of the Cardiac Lifestyle Program at Massachusetts General Hospital in Boston, immediate past chair of the Association's Nutrition Committee and a member of the Association's Lifestyle Council. "This study provides a robust evaluation of the food environment by U.S. counties and shows that characteristics of the food environment are strongly associated with death from heart failure."

A limitation of the study is that it only captures data from one year, before the COVID-19 pandemic, therefore, it may have limited generalization at this time. More studies are needed to examine these associations over a longer period of time.

The study also revealed that counties with higher heart failure death rates also had fewer food stores, poorer access to healthy foods for adults older than age 65 and a lower participation rate in SNAP, the Supplemental Nutrition Assistance Program. SNAP is the U.S. government's program that supplements food budgets to help reduce food insecurity for families and individuals who have an annual income level at or below 130 percent of the federal poverty criteria (for a family of three, those with annual income below $29,940 quality for SNAP).

According to the Association's Life's Essential 8, dietary intake, which is affected by food insecurity, is one of the key contributors to cardiovascular disease risk, and the low prevalence of ideal diet drives the overall low prevalence of ideal cardiovascular health in the U.S. Better cardiovascular health helps lower the risk for heart disease, stroke and other major health problems.

"Food insecurity and lack of access to healthy food are key contributors to poor dietary quality and what is referred to as 'nutrition insecurity,'" Thorndike said. "The American Heart Association and others are now acknowledging that to help Americans achieve ideal cardiovascular health, particularly ideal diet, we need to broaden our efforts to address both the psychological and social determinants of our health behaviors and well-being. These efforts need to include policy, health care, and community interventions that improve access to nutritious food for people at every stage of life."

Co-authors are John Larson, M.D.; Aaron Sifuentes, M.D.; Neil B. Alexander, M.D., M.S.; Matthew C. Konerman, M.D.; Kali S. Thomas, Ph.D., M.A.; and Scott L. Hummel, M.D. Authors' disclosures are listed in the manuscript.

The authors reported no funding sources for this study.