==== Front JAMA Netw Open JAMA Netw Open JAMA Network Open 2574-3805 American Medical Association 37389879 10.1001/jamanetworkopen.2023.21375 zld230108 Research Research Letter Online Only Public Health Disparities in Cardiovascular Health by Food Security Status and Supplemental Nutrition Assistance Program Participation Using Life’s Essential 8 Metrics Disparities in Cardiovascular Health by Food Security Status and SNAP Participation Disparities in Cardiovascular Health by Food Security Status and SNAP Participation Leung Cindy W. ScD MPH 1 Wolfson Julia A. PhD MPP 2 3 Brandt Eric J. MD MHS 4 Rimm Eric B. ScD 1 4 5 6 1 Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts 2 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 3 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 4 Division of Cardiovascular Medicine, University of Michigan, Ann Arbor 5 Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts 6 Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts Article Information Accepted for Publication: May 17, 2023. Published: June 30, 2023. doi:10.1001/jamanetworkopen.2023.21375 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Leung CW et al. JAMA Network Open. Corresponding Author: Cindy W. Leung, ScD, MPH, Department of Nutrition, Harvard T. H. Chan School of Public Health, 665 Huntington Ave, Bldg 2, Room 321, Boston, MA 02115 (cindyleung@post.harvard.edu). Author Contributions: Dr Leung had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Leung, Wolfson, Rimm. Acquisition, analysis, or interpretation of data: Leung, Wolfson, Brandt. Drafting of the manuscript: Leung. Critical revision of the manuscript for important intellectual content: Wolfson, Brandt, Rimm. Statistical analysis: Leung. Conflict of Interest Disclosures: Dr Brandt reported consulting for NewAmsterdam Pharma outside the submitted work and receiving research funding from the National Institutes of Health and the Blue Cross Blue Shield of Michigan Foundation. No other disclosures were reported. Data Sharing Statement: See the Supplement. 30 6 2023 6 2023 30 6 2023 6 6 e232137514 4 2023 17 5 2023 Copyright 2023 Leung CW et al. JAMA Network Open. https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License. jamanetwopen-e2321375.pdf This cross-sectional study examines the associations among household food security, Supplemental Nutrition Assistance Program participation, and cardiovascular health among 2013-2018 National Health and Nutrition Examination Survey participants. ==== Body pmcIntroduction The American Heart Association recently updated its definition of ideal cardiovascular health (CVH) to encompass 8 health behaviors and clinical measures (ie, Life’s Essential 8 [LE8]) and to centralize the importance of social determinants of health in cardiovascular disease prevention.1 Food insecurity, a condition of limited food availability due to insufficient resources, is one critical social determinant of health affecting 10% of US households.2 Few studies have examined food insecurity in relation to multidimensional cardiovascular outcomes. Furthermore, this association may be complicated by participation in the Supplemental Nutrition Assistance Program (SNAP), which aims to alleviate food insecurity and also targets populations most vulnerable to poverty and poor health. This study examined the associations among household food security, SNAP participation, and LE8 as a measure of ideal CVH. Methods We used data from the 2013-2018 National Health and Nutrition Examination Survey, a continuous, multistage survey representative of the noninstitutionalized US population. The study population included 11 520 nonpregnant adults 20 years and older. Analysis of publicly available secondary data was deemed exempt from approval by the Harvard University Institutional Review Board, and informed consent was not required. The study followed the STROBE reporting guideline. The primary exposure was household food security, measured using the US Household Food Security Survey Module, and categorized as high, marginal, low, and very low using US Department of Agriculture guidelines.2 The secondary exposure was household SNAP participation in the last 12 months. Nonparticipants were classified as low income (≤130% of the federal poverty level) or higher income (>130% of the federal poverty level). The primary outcomes were the LE8 measures (physical activity, diet, tobacco use, sleep health, body mass index [BMI], blood pressure, and serum glucose and lipid levels).1 Published algorithms were applied to create component scores ranging from 0 to 100.3 The overall LE8 score is the mean of all component scores. We used multivariable linear regression models to examine differences in continuous overall and component LE8 scores by household food security and SNAP participation and multivariable logistic regression to examine joint associations between household food security and SNAP participation with moderate or ideal CVH (overall LE8 score ≥50). Models were adjusted for sociodemographic covariates. Complex sampling weights were applied to all analyses. Results Among the 11 520 participants (51.7% women and 48.3% men; mean [SE] age, 47.9 [0.4] years), 9.9% had marginal food security, 10.2% had low food security, and 6.5% had very low food security. Compared with adults with high food security (66.9 [0.4]), those with marginal (65.4 [0.6]), low (63.9 [0.8]), and very low (62.3 [0.8]) food security had lower overall mean (SE) LE8 scores in a dose-response manner (P < .001 for trend) (Table). Greater severity of food insecurity was also inversely associated with diet, tobacco use, sleep health, BMI, and serum glucose scores (P < .05 for trend). SNAP participants had the lowest overall mean (SE) LE8 score (62.8 [0.6]) compared with low- (65.5 [0.7]) and higher-income (65.4 [0.5]) nonparticipants. SNAP participation was also associated with lower scores for diet, tobacco, sleep, and BMI. Table. Least Square Means of Overall and Component Life’s Essential 8 Scores by Household Food Security Status and Supplemental Nutrition Assistance Program Participationa Status LE8 domain score Diet Physical activity Tobacco use Sleep health BMI Serum lipid levelb Serum glucose levelc Blood pressured Total Food security High 43.0 (0.8) 57.0 (1.4) 70.9 (1.1) 81.5 (0.7) 60.5 (0.7) 65.5 (0.8) 77.6 (0.7) 80.0 (0.5) 66.9 (0.4) Marginal 40.4 (1.2) 59.7 (1.8) 66.7 (2.1)e 79.5 (1.1) 57.4 (1.5)e 65.7 (1.4) 74.0 (1.2) 80.4 (0.7) 65.4 (0.6)e Low 40.1 (2.0) 57.2 (2.2) 64.2 (2.0)f 78.1 (1.1) 54.6 (1.6)e 65.9 (1.3) 73.9 (1.2)e 78.5 (1.1) 63.9 (0.8)e Very low 33.8 (1.5)e,f 58.8 (2.6) 56.0 (2.1)e,f 76.8 (1.6)e,f 58.0 (1.8)e 63.9 (2.0) 74.3 (1.7)f 77.7 (1.4) 62.3 (0.8)e,f SNAP participation Higher-income nonparticipant 39.7 (1.1) 59.1 (1.2) 66.6 (1.3) 80.5 (0.7) 58.7 (1.3) 65.5 (1.2) 75.6 (1.0) 78.6 (0.7) 65.4 (0.5) Low-income nonparticipant 40.8 (1.5) 57.3 (2.4) 69.2 (2.0) 78.8 (1.2) 59.3 (1.7) 64.1 (1.6) 74.5 (1.3) 80.9 (1.2) 65.5 (0.7) SNAP participant 38.0 (1.6)g 56.8 (1.6) 58.5 (2.0)g,h 76.1 (1.0)g,h 54.9 (1.2)g,h 65.2 (1.2) 73.8 (1.2) 79.6 (0.7) 62.8 (0.6)g,h Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); LE8, Life’s Essential 8; SNAP, Supplemental Nutrition Assistance Program. a Includes 11 520 participants from the 2013-2018 National Health and Nutrition Examination Surveys. Data are expressed as mean (SE). Means were adjusted for age, sex, race and ethnicity, educational attainment, marital status, and ratio of family income to poverty. Scores of 50 or greater indicate moderate to ideal cardiovascular health. b Calculated from non–high-density lipoprotein (HDL) cholesterol level in measured total and HDL nonfasting cholesterol levels. c Calculated from hemoglobin A1c levels assayed from whole blood biospecimens. d Calculated from the mean of 3 readings (systolic and diastolic). e Significant difference from the group with high food security (P < .05). f Significant trend in outcome by severity of food insecurity (P < .05). g Significant difference between SNAP participants and low-income nonparticipants (P < .05). h Significant difference between SNAP participants and higher-income nonparticipants (P < .05). SNAP participation modified the association between household food security and moderate to ideal CVH (Figure). Greater severity of food insecurity was associated with lower probabilities of moderate to ideal CVH for all SNAP participation groups. SNAP participants with very low food security had the lowest probability of moderate to ideal CVH (74.9% [95% CI, 66.4%-81.8%]). Figure. Estimated Probabilities of Moderate to Ideal Cardiovascular Health Estimates are based on Life’s Essential 8 scores of 50 or greater among 11 520 nonpregnant adults (aged ≥20 years) by household food security and Supplemental Nutrition Assistance Program (SNAP) participation, adjusted for age, sex, race and ethnicity, educational attainment, marital status, and ratio of family income to poverty. Error bars indicate 95% CIs. Discussion The findings of this nationally representative cross-sectional study suggest that food insecurity and SNAP participation may be critical barriers to CVH, specifically for diet, tobacco use, sleep health, and BMI. SNAP participants with very low food security had the lowest probability of moderate to ideal CVH, suggesting nutrition-forward policies may improve food security and CVH among program participants.4 This study is cross-sectional, which precludes temporality or causality. Our results align with findings from prior studies, supporting the robustness of the results.5,6 Programmatic and policy interventions should consider more holistic approaches to improve behavioral disparities among populations at risk of food insecurity. Supplement. Data Sharing Statement Click here for additional data file. ==== Refs References 1 Lloyd-Jones DM, Allen NB, Anderson CAM, ; American Heart Association. Life’s Essential 8: updating and enhancing the American Heart Association’s construct of cardiovascular health: a presidential advisory from the American Heart Association. Circulation. 2022;146 (5 ):e18-e43. doi:10.1161/CIR.0000000000001078 35766027 2 Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food Security in the United States in 2021, ERR-309. Economic Research Service, US Department of Agriculture; 2022. 3 Lloyd-Jones DM, Ning H, Labarthe D, . Status of cardiovascular health in US adults and children using the American Heart Association’s new “Life’s Essential 8” metrics: prevalence estimates from the National Health and Nutrition Examination Survey (NHANES), 2013 through 2018. Circulation. 2022;146 (11 ):822-835. doi:10.1161/CIRCULATIONAHA.122.060911 35766033 4 Mande J, Flaherty G. Supplemental Nutrition Assistance Program as a health intervention. Curr Opin Pediatr. 2023;35 (1 ):33-38. doi:10.1097/MOP.0000000000001192 36354297 5 Leung C, Tester J, Laraia B. Household food insecurity and ideal cardiovascular health factors in US adults. JAMA Intern Med. 2017;177 (5 ):730-732. doi:10.1001/jamainternmed.2017.0239 28319225 6 Vercammen KA, Moran AJ, McClain AC, Thorndike AN, Fulay AP, Rimm EB. Food security and 10-year cardiovascular disease risk among US adults. 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