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CME / ABIM MOC / CE

What Is the Relationship Between Cardiovascular Disease and Food Insecurity?

  • Authors: News Author: Fran Lowry; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 11/18/2022
  • Valid for credit through: 11/18/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, diabetologists/endocrinologists, public health and prevention officials, nurses, nurse practitioners, family medicine/primary care clinicians, pharmacists, physician assistants, and other members of the health care team for patients with cardiovascular disease.

The goal of this activity is for the healthcare team to be better able to describe the 20-year prevalence of food insecurity among individuals with cardiovascular disease or cardiometabolic risk factors, both overall and among racial and ethnic groups, based on a cross-sectional study of noninstitutionalized US adults enrolled in the National Health and Nutrition Examination Survey from 1999 through 2018.

Upon completion of this activity, participants will:

  • Assess the 20-year prevalence of food insecurity among individuals with cardiovascular disease or cardiometabolic risk factors, both overall and among racial and ethnic groups, based on a cross-sectional study of noninstitutionalized US adults enrolled in the National Health and Nutrition Examination Survey from 1999 through 2018
  • Evaluate the clinical and public health implications of the 20-year prevalence of food insecurity among individuals with cardiovascular disease or cardiometabolic risk factors, both overall and among racial and ethnic groups, based on a cross-sectional study of noninstitutionalized US adults enrolled in the National Health and Nutrition Examination Survey from 1999 through 2018
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Fran Lowry

    Freelance writer, Medscape

    Disclosures

    Fran Lowry has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    For Nurses

  • Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

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    For Pharmacists

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  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 11/18/2023. PAs should only claim credit commensurate with the extent of their participation.

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CME / ABIM MOC / CE

What Is the Relationship Between Cardiovascular Disease and Food Insecurity?

Authors: News Author: Fran Lowry; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 11/18/2022

Valid for credit through: 11/18/2023

processing....

Clinical Context

In the US, cardiovascular disease (CVD) is the leading cause of death, with diet the greatest contributor. Food insecurity may increase CVD risk because of poorer dietary quality, including lower fruit and vegetable consumption, which raises risk for intermediary cardiometabolic risk factors.

Certain racial, ethnic, and socioeconomically disadvantaged groups are at greatest risk for lower-quality diets and CVD, with widening disparities. Multiple factors co-occurring with food insecurity, including heightened stress response and poor prescription adherence, may also explain the association of food insecurity with increased total and cardiovascular mortality.

Study Synopsis and Perspective

A growing number of Americans with CVD have limited or uncertain access to food, results of a new study suggest.

An analysis of data from the National Health and Nutrition Examination Survey (NHANES), representing more than 300 million American adults, found that, overall, 38.1% of people with CVD were food insecure from 2017 to 2018.

Twenty years earlier, that rate was 16.3%.

The findings were published online September 28 in JAMA Cardiology.

"What really stood out from our study is how frequent food insecurity is among people with [CVD], compared to those without [CVD]," lead author, Eric J. Brandt, MD, MHS, a cardiologist at the University of Michigan Health Frankel Cardiovascular Center, Ann Arbor, told theheart.org | Medscape Cardiology.

"We believe that the relationship between food insecurity and [CVD] is bidirectional. Food insecurity puts people at risk for CVD, which then makes them vulnerable to events like myocardial infarction or stroke, which in turn may make them less able to work, thereby worsening their financial situation, and increasing their vulnerability to food insecurity," Dr Brandt said.

For the analysis, Dr Brandt and his team used an analytic sample of 57,517 adults to represent 312 million noninstitutionalized adults in the US.

Overall, 6770 individuals (11.8%) in the analytic sample reported food insecurity.

Food insecurity was more prevalent among Hispanic (n = 1938; 24.0%) and non-Hispanic Black (n = 1202; 18.2%) adults compared with non-Hispanic Asian (n = 100; 8.0%) and non-Hispanic White (n = 3221; 8.5%) adults.

The prevalence of CVD in the sample was 7.9% (n = 4527).

Hypertension was the most prevalent CVD risk factor, reported in 49.6% of the sample. This was followed by obesity in 33.2%, dyslipidemia in 30.8%, and diabetes in 11.2%.

"All [CVD] and cardiometabolic diseases except coronary artery disease were more prevalent among those with food insecurity," Dr Brandt noted.

"The results of our study are especially timely, as the White House just hosted its first conference on Hunger, Nutrition, and Health in over 50 years. Food insecurity is a focus of that conference. In the last few years, especially in relation to the pandemic, there has been expansion of some of the federal programs to prevent food insecurity. I would like to see a continued effort to solve this," he said.

Dr Brandt added that he hopes clinicians will be more cognizant of the problem of food insecurity and other social determinants of health when they see their patients.

"If someone is not going to be able to afford the food on their table, they're probably not going to pay for their medications. Recognizing these social determinants in the clinical setting and helping our patients access local resources may address the underlying factors contributing to heart disease," he said.

Uphill Battle

Johanna Contreras, MD, an advanced heart failure and transplant cardiologist at the Mount Sinai Hospital, New York City, treats food insecure cardiovascular patients in her practice and tries to educate them about good nutrition. But it is an uphill battle.

"A lot of my patients live in the South Bronx. They have hypertension, hypercholesterolemia, and there are no grocery stores where they can buy fresh vegetables. I talk to them about eating healthy. They tell me it's impossible. The stores only have prepackaged foods. So even in the South Bronx, even though it is in New York City, it is very hard to get fresh food. And when it is available, it is very expensive," Dr Contreras told theheart.org | Medscape Cardiology.

"Fresh pineapples can cost $8. A fast-food burger costs $3. So that is what they buy, it's what they can afford. Even the store managers don't want to stock fresh produce because it can spoil. They open stores, like Whole Foods, but in the more affluent neighborhoods. They should open one in poor neighborhoods," she said.

Dr Contreras says she spends much of her time educating her patients about good nutrition. She asks them to keep a food diary and analyses the results at each visit.

"I look at what they eat, and I try to see how I can use this information in a good way. I advise them to use frozen foods and avoid canned, because it is a lot healthier. I am pragmatic, because I know that if I tell my patients to eat salmon, for example, they aren't going to be able to afford it, if they can even access it."

She also informs them about relatively healthy fast-food choices.

"I tell them to order 100% fruit juice, water, or milk when they go to McDonalds or other fast-food places. So I think this study is very important. Food insecurity is a very important component of [CVD], and unfortunately, minority communities are where this occurs."

Dr Brandt and Dr Contreras have disclosed no relevant financial relationships.

JAMA Cardiol. Published online September 28, 2022.[1]

Study Highlights

  • This serial cross-sectional study included NHANES data (1999-2018) for 57,517 noninstitutionalized US adults.
  • Food insecurity, assessed using the Department of Agriculture Adult Food Security Survey Module, was reported by 6770 adults (11.8%), and was more prevalent among Hispanic adults (n = 1938; 24.0%) and non-Hispanic Black adults (n = 1202; 18.2%) than non-Hispanic Asian adults (n = 100; 8.0%) and non-Hispanic White adults (n = 3221; 8.5%).
  • Among 57,517 adults, 4527 (7.9%) had any CVD, 2933 (5.1%) coronary artery disease, 1536 (2.7%) stroke, 1363 (2.4%) heart failure, 28,528 (49.6%) hypertension, 17,979 (33.2%) obesity, 6418 (11.2%) diabetes, and 19,178 (30.8%) dyslipidemia.
  • Those with food insecurity had greater prevalence of all CVD and cardiometabolic diseases except coronary artery disease.
  • Food insecurity among those with CVD increased over time, going from 16.3% in 1999 to 2000 to 38.1% in 2017 to 2018 (P<.001 for trend).
  • From 2011 to 2018, food insecurity prevalence decreased in non-Hispanic Black adults with CVD (from 36.6% [95% CI, 23.9%-49.4%] to 25.4% [95% CI, 21.4%-29.3%]; P=.04) but did not change significantly among subgroups of other races, ethnicities, or cardiometabolic risk factors.
  • Among individuals with food insecurity, SNAP participation was higher among those with vs without CVD (54.2% [95% CI, 46.6%-61.8%] vs 44.3% [95% CI, 40.5%-48.1%] P=.01).
  • The investigators concluded that food insecurity prevalence among patients with CVD increased over time and food insecurity disparities persisted across groups based on race, ethnicity, and CVD presence.
  • Non-Hispanic Blacks and Hispanics had the highest food insecurity, but non-Hispanic Blacks with CVD were the only group to have a significant decrease in food insecurity since 2011.
  • Blacks and Hispanics, as well as adults with CVD, disproportionately experience food insecurity, which can increase the risk for negative CVD outcomes.
  • Food insecurity therefore can exacerbate existing racial and ethnic health disparities.
  • Food insecurity occurred in approximately 2 in 5 of those with any CVD and was approximately twice as common as in those without CVD.
  • Among those with food insecurity, more than 4 in 10 did not participate in SNAP, an important federal program for food assistance.
  • Increased recognition of food insecurity and resources for treating it are needed to mitigate the negative effects of food insecurity on CVD outcomes.
  • Public policy, health care systems, and clinicians should address food insecurity (eg, the permanent increase in SNAP benefits in 2021), which may disproportionately benefit Blacks because of their higher proportional SNAP participation than other racial and ethnic groups.
  • Clinicians and health care systems can increase use of validated screening, such as the 2-question Food Insecurity Screener, to detect food insecurity.
  • A team-based approach to food insecurity should incorporate referral to social workers, caseworkers, or state social service departments for individuals to apply for food programs (eg, SNAP).
  • Clinicians should realize that individuals with food insecurity and other negative SDOH may also be unable to pay for medications.
  • The association between food insecurity and CVD is likely bidirectional: food insecurity increases CVD risk, making patients vulnerable to myocardial infarction, stroke, or other cardiac events, which in turn may make them less able to work, worsen their financial situation, and increase their risk for food insecurity.
  • The findings support current views that health differences across racial and ethnic groups are closely linked to social circumstances and differences in life experience.
  • Study limitations include reliance on self-report and cross-sectional design precluding determination of causality or directionality of the association between food insecurity and CVD.

Clinical Implications

  • Food insecurity prevalence among patients with CVD increased over time.
  • Public policy, health care systems, and clinicians should address food insecurity.
  • Implications for the Health Care Team: A team-based approach to food insecurity should incorporate referral to social workers, caseworkers, or state social service departments for individuals to apply for food programs.

 

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