Food Insecurity, CKD, and Subsequent ESRD in US Adults

Abstract

Background

Poor access to food among low income adults has been recognized as a risk factor for CKD, but there is no data on the impact of food insecurity on progression to ESRD. We hypothesized that food insecurity would be independently associated with risk of ESRD among persons with and without CKD.

Study Design

Longitudinal cohort study

Setting & Participants

2,320 adults (≥20 years) with CKD and 10,448 adults with ‘No-CKD’ enrolled in NHANES III (1988–1994) with household income ≤400% of the federal poverty level linked to Medicare ESRD Registry for a median follow-up period of 12 years.

Predictor

Food insecurity, defined as an affirmative response to the food insecurity screening question.

Outcome

Development of treated ESRD.

Measurements

Demographics, income, diabetes, hypertension, eGFR, and albuminuria. DAL was estimated from the 24-hr dietary recall. We used a Fine-Gray competing risk model to estimate the relative hazard [RH] for ESRD associated with food insecurity after adjusting for covariates.

Results

4.5% adults with CKD were food insecure. Food insecure individuals were more likely to be younger, have diabetes (29.9%) and hypertension (73.9%), or have albuminuria (90.4%) as compared to their counterparts (V p<0.05). Median DAL in the food secure vs. food insecure group was 51.2 mEq/day vs 55.6 mEq/day, respectively (p=0.05). Food insecure adults were more likely to develop ESRD (RH [95% CI]: 1.38 [1.08–3.10]) compared to food secure adults after adjustment for demographics, income, diabetes, hypertension, eGFR and albuminuria. In the No-CKD group, 5.7% were food insecure. Here, we did not find a significant association between food insecurity and ESRD (0.77 [0.40–1.49]).

Limitations

use of a single 24-hr diet recall, lack of laboratory follow-up data, and measure of changes in food insecurity over time; follow-up of the cohort ended 10 years ago.

Conclusion

Among individuals with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.