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Internacional Journal of Cardiovascular Sciences. 2015;28(2):114-121
ORIGINAL MANUSCRIPT
Food Insecurity in Households of Patients with Hypertension and Diabetes
Sandra Mary Lima Vasconcelos1, Niedja Cristina Paciência Torres1,2, Patrícia Maria Candido Silva1,
Tatiana Maria Palmeira dos Santos1,3, Juliana Vasconcelos Lyra da Silva1,4,
Cristhiane Maria Bazílio de Omena1, Alane Cabral Menezes de Oliveira1
Universidade Federal de Alagoas – Faculdade de Nutrição – Laboratório de Nutrição em Cardiologia – Maceió, AL – Brazil
Universidade de Ciências da Saúde de Alagoas – Programa de Residência Multiprofissional em Saúde da Família – Maceió, AL – Brazil
3
Universidade Tiradentes – Departamento de Nutrição – Aracaju, SE – Brazil
4
Centro Universitário CESMAC – Maceió, AL – Brazil
1
2
Abstract
Background: People living in households with food insecurity typically have a monotonous diet, low in complex
carbohydrates and rich in simple sugars and fats. Such condition associated with obesity, diabetes mellitus (DM)
and hypertension (HA) compromises the quality of life and contributes to an increased risk of morbidity and
mortality, especially from cardiovascular diseases.
Objectives: To evaluate cardiovascular risk factors (CVRF) in patients with HA and/or diabetes mellitus and its
relationship with the socioeconomic status and the situation of food insecurity (IA) in households.
Methods: Cross-sectional study. Patients evaluated: (In) household food security according to the Brazilian Scale
of food insecurity (EBIA): Mild, moderate and severe FI; economic status and CVRF. We used the chi-square test,
bivariate logistic regression, OR with 95% CI and p≤0.05.
Results: The study included 225 patients: 74.0% (n=166) hypertensive (M), 18.0% (n=41) diabetic hypertensive
(HD) and 8.0% (n=18) diabetic patients (D); 80.9% were women, mean age 60.3±11.19 years and 64.0% belonging
to the economy class D. The patients resided in households in FI: 78.0% of H, 73.0% of HD and 78.0% of D. The
frequency of CVRF among individuals in FI was high: 92.0% hypertension, 80.0% hypercholesterolemia,
79.0% hyperglycemia, 76.0% overweight/obesity, 73.0% abdominal obesity and 72.0% hypertriglyceridemia. There
was a positive association between FI and hypertension (p=0.034), abdominal obesity (p=0.009) and
hypertriglyceridemia (p=0.001).
Conclusions: The predominant unsafe condition in the households of the population studied represents an
additional risk factor, since the difficulty of access to healthy food both in quantitative and quality terms
compromises the treatment and control of these diseases.
Keywords: Food security; Hypertension; Diabetes mellitus; Risk factors; Cardiovascular diseases
Introduction
Conceptually, food security (FS) is the realization of
everyone’s right of all to regular and permanent access
to quality food in sufficient quantity, without
compromising access to other needs, based on food
practices that promote health, respect cultural diversity
and that are environmentally, economically and socially
sustainable1. Therefore, food insecurity (FI) relates to
social vulnerability since it results from a combination
of factors that may produce deterioration to the welfare
level of people, families or communities, according to
exposure to certain types of risks2-4.
FI ​​is mainly determined by poverty and social inequalities.
People living in households in food insecurity generally
have a monotonous diet low in complex carbohydrates
and rich in simple sugars and fats, a dietary habit that is
often associated with obesity and other non-transmissible
chronic diseases (NTCD) such as diabetes mellitus (DM)
Corresponding author: Sandra Mary Lima Vasconcelos
Universidade Federal de Alagoas, Faculdade de Nutrição, Nutricardio
Campus AC Simões, BR 104 Norte, km 97 – Tabuleiro dos Martins – 57072-970 – Maceió, AL – Brazil
E-mail: [email protected]
DOI: 10.5935/2359-4802.20150014
Manuscript received on July 21, 2014; approved on February 22, 2015; revised on April 20, 2015.
Int J Cardiovasc Sci. 2015;28(2):114-121
Original Manuscript
and arterial hypertension (AH). This compromises
quality of life and consequently favors increased risk of
morbidity and mortality, mainly from cardiovascular
diseases5. Thus, food insecurity is involved with NTCD.
The FI phenomenon can be measured by the Brazilian
Scale of Food Insecurity (EBIA)6 that attests FS (the
complete satisfaction of the diet needs) and food
insecurity (FI): mild, moderate and severe, that is, the
individual experiences at levels of progressive severity
of restriction of foods experienced in a given household.
These three degrees of FI are, therefore, assigned
according to the conditions of economic and food
restrictions and indicate a situation of greater social
vulnerability6. This involves measuring the economic
status of the individuals evaluated as an instrument that
measures the individual’s social class according to the
Economic Classification Criteria of Brazil (CCEB)7. The
EBIA has been validated for the Brazilian population
from the American scale called Household Food Security
Survey Module (HFSSM)4,8.
People with FI do not have access to proper food in
quantity and quality and as a result of a monotonous diet
rich in simple carbohydrates, saturated and trans fats
and inadequate in protective nutrients that prevent
NTCD, makes them more susceptible to diseases9.
According to Cesarino et al.10 and Marques et al.11, people
with lower education and under social vulnerability are
more likely to develop diseases such as AH and DM.
Hence, the study of socioeconomic conditions and food
insecurity situation in a population at cardiovascular risk,
as is the case of patients with hypertension and diabetes,
whose appropriate prevention and treatment are key to
prognosis, appears as a possibility to provide a condition
of vulnerability that affects the proper control of these
diseases.
This study aims to evaluate the cardiovascular risk
factors in individuals with AH and/or DM treated at
basic health units in the city of Maceió, AL, and their
relationship with the socioeconomic status and the
situation of food insecurity and nutrition of their
households.
Vasconcelos et al.
Food Insecurity in Hypertensive and Diabetic Patients
registered in the Reorganization Plan for
Managing Arterial Hypertension and
Diabetes Mellitus (HIPERDIA) of the
Brazilian Ministry of Health. This study
was part of a research for SUS - PPSUS
(2007-2009), entitled “Hábitos
alimentares, ingestão de nutrientes e
consumo de alimentos relacionados à
proteção e risco cardiovascular em uma
população de hipertensos do município
de Maceió-AL” (Food habits, ingestion
of nutrients and consumption of foods
related to cardiovascular protection and
risk in a population of hypertensive
patients from the city of Maceió-AL”)
approved by the Research Ethics
Committee of Universidade Federal de
Alagoas under number 004135/2007-70,
of 09/05/2007.
ABBREVIATIONS AND
ACRONYMS
•BHU — Basic Health Unit
•CCEB — Economic
Classification Criteria of
Brazil
•CVRF — cardiovascular risk
factors
•D — diabetic
•DM — diabetes mellitus
•EBIA — Brazilian scale of
food insecurity
•FI — food insecurity
•FS — food security
•FVG — fruits, vegetables
and greens
•H — hypertensive
•HA — arterial hypertension
•HDP — hypertensive
diabetic patient
According to the Health Department of
• HIPERDIA — Reorganization
Maceió, 1293 individuals were registered
Plan for Managing
Hypertension and Diabetes
in HIPERDIA in 200712.To determine the
Mellitus
minimum sample size, we considered
•NTCD — non-transmissible
the expected frequency of 50% of
chronic diseases
individuals in situation of food insecurity
to maximize the sample size. Using a
maximum tolerable error of 10% and a 90% confidence
interval, a minimum sample size of 224 individuals was
calculated. This study evaluated 225 individuals who
completed the protocol.
To select the units, we used a simple random draw, which
selected 13 basic health units (BHU) among the 44 units
distributed in the seven health districts of the city of
Maceió with the HIPERDIA system implemented in order
to represent all districts.
Patients with hypertension and/or diabetes with medical
diagnosis recorded and registered in the HIPERDIA of
the BHU, older than 19 years, were included in the study.
The participants signed an Informed Consent Form. The
exclusion criteria were: pregnant women, children under
19 and individuals who did not complete the collection
protocol.
Data collection included anthropometry, interview and
capillary blood collection.
Methods
This is a cross-sectional study of patients with AH and/or
DM treated at basic health units in the city of Maceió, AL,
115
At first, the participants answered a questionnaire with
socioeconomic and demographic questions: age, gender,
family income, number of residents per household,
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Vasconcelos et al.
Food Insecurity in Hypertensive and Diabetic Patients
possession of items and household head’s level of
instruction. The last two variables were used to identify
the economic class through the CCEB that categorizes
the population into economic classes: A1, A2, B1, B2, C,
D and E7,13.
The anthropometric assessment was performed
according to the recommendations of the Ministry of
Health of Brazil. Height, weight and waist circumference
were collected. Weight was measured on a digital
scale Marte ® model L200PS (São Paulo, Brazil)
and height was measured using the transportable
stadiometer WCS® model Wood (Curitiba, Brazil). Waist
circumference was obtained using a non-elastic
measuring tape at the medium point between the last
rib and the iliac crest13.
To diagnosis abdominal obesity, we used the criteria of
the International Diabetes Federation (IDF) adopted by
the IV Brazilian Guidelines for Dyslipidemia14. The
normality parameters used for glucose and lipid levels
were: blood glucose <100 mg/dL, cholesterol <200 mg/
dL and triglycerides <200 mg/dL14.
Diagnosis of overweight/obesity was based on the
classification adopted by the Ministry of Health of Brazil
for adults and elderly individuals15.
Capillary blood analysis was performed by punching the
middle finger to obtain a drop of blood placed on each
strip: glucose test, cholesterol and triglycerides, and
inserted into the device Accutrend GCT® (Roche, São Paulo,
Brazil) for analysis. The patients were instructed, in a
meeting before the collection, to fast for 12 hours before
the tests. The normality parameters adopted for
blood glucose and capillary lipid profile were: glucose
70-100 mg/dL, cholesterol <200 mg/dL and triglycerides
<200 mg/dL.
We evaluated the FI ​​situation in the households according
to the four EBIA categories: 1) 0 points for FS; 2) 0-5 points
for light FI; 3) 6 to 10 points to moderate FI and 4) 11 to
15 points for severe FI6.
The risk factors for cardiovascular disease evaluated
among hypertensive and/or diabetic patients
were: abdominal obesity, overweight/obesity,
hypertriglyceridemia, hypercholesterolemia and
hyperglycemia, in addition to AH itself.
The results were analyzed using the Statistical Package
for the Social Sciences (SPSS) version 20.0, considering
Int J Cardiovasc Sci. 2015;28(2):114-121
Original Manuscript
a statistical significance level of 5%. The chi-square
test and univariate logistic analysis were used to
compare proportions and evaluate associations,
respectively. The strength of association was measured
by calculating the odds ratio (OR) with a 95%
confidence interval.
Results
Of the 225 individuals evaluated, 80.9% (n=182) were
female and 19.1% (n=43) were male, mean age
60.3±11.19 years. Of these, 74.0% (n=166) had
hypertension (H), 18.0% (n=41) had hypertension and
diabetes (HD) and 8.0% (n=18) had diabetes (D). The
population was distributed equitably according to the
age range (46.0% non-elderly and 54.0% elderly),
64.0% belonging to the economic class D, and per capita
income smaller than 1/4 of the minimum wage in
83.0% (Table 1).
Of the population studied, 77.0% (n=174) were in FI. The
groups H, HD and D were distributed in similar
proportions between FS and FI: in group H, 78.0% were
in FI and 22.0% were in FS; among the HD, 73.0% were
in FI and 27.0% in FS; and among the D, 78.0% were FI
and 22.0% were in FS (Figure 1). There was no significant
difference (p=0.78) among the groups (H, HD, D) of
patients according to FS/FI.
The study population had a high frequency of
cardiovascular risk factors (CVRF): 92.0% AH, 79.0%
abdominal obesity, 67.0% overweight/obesity,
46.0% hyperglycemia, 43.0% hypercholesterolemia and
41.0% hypertriglyceridemia. Considering the individuals
in food insecurity versus total population (n=174 vs. n=225),
the frequency was much higher for all CVRF (except
for abdominal obesity whose frequency was close:
73.0% vs. 79.0% and AH with equal frequencies:
92.0% vs. 92.0%, for the population’s profile), with
80.0% hypercholesterolemia, 79.0% hyperglycemia, 76.0%
overweight/obesity and 72.0% hypertriglyceridemia.
Positive correlation with FI was observed only with
abdominal obesity (p=0.004).
As for the association among the other variables studied
(sociodemographic and economic variables) with food
insecurity (Table 1), only economy class D and per capita
income smaller than 1/4 of the minimum wage were
positively associated with FI.
Int J Cardiovasc Sci. 2015;28(2):114-121
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Vasconcelos et al.
Food Insecurity in Hypertensive and Diabetic Patients
Table 1
Characteristics of the population studied
Variables
Number of
individuals
Food insecurity
n
%
OR
CI (95%)
p
0.96
0.5-1.81
0.91
Age group
< 60 years
103
80
78.0
≥ 60 years
122
94
77.0
Male
43
31
72.0
Female
182
143
79.0
1.42
0.67-3.02
0.36
Diagnosis
AH
AH + DM
DM
166
41
18
130
30
14
78.0
73.0
78.0
1.23
0.62-2.46
0.56
1.03
0.32-3.27
0.96
Economic class
B2
Sex
10
3
30.0
C
54
38
70.0
0.61
0.9-1.22
0.16
D
145
119
82.0
1.08
1.10-3.93
0.02*
E
16
14
87.0
2.14
0.47-9.76
0.32
≥1 minimum wage
200
154
77.0
<1 minimum wage
18
17
94.0
5.08
0.66-39.19
0.12
≥ ¼ of the minimum wage
180
131
23.0
< ¼ of the minimum wage
38
40
13.0
2.56
0.95-6.92
0.04*
CVRF
≤2
97
76
78.0
>2
128
98
77.0
0.9
0.48-1.70
0.75
46
44
96.0
179
130
73.0
0.12
0.29-0.52
0.004*
73
58
79.0
152
116
76.0
0.83
0.42-1.64
0.6
45
44
98.0
180
30
72.0
0.74
0.67-0.82
0.001*
128
96
75.0
97
78
80.0
1.37
0.72-2.60
0.34
122
93
76.0
103
81
79.0
1.15
0.62-2.15
0.67
Household income**
Per capita income**,***
Abdominal obesity
No
Yes
Overweight/Obesity
No
Yes
Hypertriglyceridemia
No
Yes
Hypercholesterolemia
No
Yes
Hyperglycemia
No
Yes
CVRF — cardiovascular risk factors; AH — arterial hypertension; DM — diabetes mellitus; OR — odds ratio
*Simple logistics regression: p < 0.05. **7 individuals of the population studied not report their income. ***3 individuals from the food
insecurity group did not report their income.
117
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Food Insecurity in Hypertensive and Diabetic Patients
Int J Cardiovasc Sci. 2015;28(2):114-121
Original Manuscript
Following the analysis, only economic classes C and D,
abdominal obesity, arterial hypertension and
hypertriglyceridemia, household income and per capita
income were included in the full logistic model (p≤0.2).
However, it was not possible to build the final logistic
model due to the lack of significance among the variables.
While most individuals belonging to economic classes
C, D and E are found in food insecurity, only class D had
a positive association with food insecurity (p=0.02).
Therefore, belonging to this economic class can be
considered a potential risk factor for food insecurity.
In the analysis of the degrees of food insecurity (mild,
moderate and severe) with cardiovascular risk factors
(Table 2), we found a statistical difference between the
degrees of insecurity with hypertension (p=0.034),
abdominal obesity (p=0.009) and hypertriglyceridemia
(p=0.001). There was a higher frequency for light FI.
Figure 1
Food security (FS) and food insecurity (FI) in the
population studied, according to the groups: H (patients
with hypertension), HD (patients with hypertension and
diabetes) and D (patients with diabetes).
Table 2
Cardiovascular risk factors prevailing in the population studied according to the levels of food insecurity
Food insecurity
CVRF
n
%
Light
Moderate
Severe
p*
n
%
n
%
n
%
Abdominal obesity*
Yes
49
27.0
76
43.0
34
19.0
20
11.0
No
2
4.0
26
57.0
13
28.0
5
11.0
Yes
36
22.0
68
41.0
40
24.0
22
13.0
No
15
25.0
34
58.0
7
12.0
3
5.0
0.009
Arterial hypertension*
0.034
*chi-square: p < 0.05
CVRF — cardiovascular risk factors
Discussion
Food insecurity is mainly determined by poverty and
social inequalities. Studies analyzing factors associated
with food insecurity are critical to the planning of public
programs and policies for the purposes of prevention and
promotion of health. The repercussions of food insecurity
can be observed mainly in the most vulnerable groups8,16-18.
Being exposed to the condition of not having regular and
permanent access to quality food in sufficient amounts
was a reality found in more than 75.0% of the patients
evaluated. This characterizes a situation of food insecurity
which indicates an additional risk that this population is
exposed. This fact hinders adherence and compliance to
the diet, which is necessary for the control of AH and
DM. The lack of adherence to diet therapy resulting from
no access to adequate food affects the clinical management
of these illnesses. In addition, it favors risk factors such
as obesity, hypercholesterolemia, hypertriglyceridemia
and hyperglycemia, which are closely related to
inadequate selection of food19-23. Under these conditions,
high-energy density foods high in fats and sugars, often
more affordable, predominate to the detriment of fresh
foods of a higher nutritive content20-23.
Another aspect to consider is that individuals with
greater social vulnerability, in addition to food insecurity,
Int J Cardiovasc Sci. 2015;28(2):114-121
Original Manuscript
have more difficulty in acquiring inputs for their treatment,
such as medicines. This makes this group more susceptible
to complications resulting from non-compliance to
treatment10,11,24,25.
The acquisition of food is limited by low income or
poverty, therefore, the association of per capita income
with food insecurity is consistent with the studies
conducted by Salles-Costa et al.16 and Marin-Leon et al.25.
According to Claro et al.26, Bezerra and Sichieri27 and
Panigassi et al.9 there is a strong relationship between
income, food prices and consumption of fruits, vegetables
and greens (FVG). Claro et al.26 found that a 1% decrease
in the price of FVG would increase by 0.2% their share
in the total calories and a 1% increase in the household
income would increase their share by 0.04%.
Income plays an important role in determining food
intake and may reflect consumption of cheap, less healthy
foods in the lower ranges10,27. According to the I Brazilian
Guideline for cardiovascular prevention28, mortality from
cardiovascular diseases is higher in individuals with
lower socioeconomic status, therefore, low household
income and food insecurity are aggravating factors that
compromise the management of individuals with
hypertension and diabetes since a healthy diet is key in
their treatment25.
The unequal distribution of income and access to goods
and services resulting from social exclusion compromise
diet conditions15,25. Besides, the cost of food for most
households is very high and absorbs a significant portion
of their income. There is an inverse relationship between
the levels of food security/insecurity and the percentage
of household budgets on food. This probably contributes
to the adoption of a diet low in nutrients and with high
energy density, since these foods are less costly, favoring
high consumption24,26. However, the I Guideline on the
consumption of fats and cardiovascular health29 indicates
that the intake of FVG intake is low in all social classes,
which would justify, in this work, the high percentage
of abdominal obesity, overweight/obesity and
hypercholesterolemia in this group of individuals.
FVG have complex carbohydrates, which have a lower
glycemic index and promote greater satiety compared to
simple carbohydrates 30. The intake of diets low in
complex carbohydrates and rich in simple sugars and
fats are associated with obesity and other chronic diseases
such as diabetes and hypertension, which affect the
quality of life and increase the risk of cardiovascular
morbidity and mortality11,19,20,23,26,30.
Vasconcelos et al.
Food Insecurity in Hypertensive and Diabetic Patients
Gubert et al.31, in a study on the distribution of severe
food insecurity in Brazilian cities show that it is present
throughout Brazil, being predominant in the north and
northeast and that there is a wide variation of insecurity
among the cities. They also reveal that this situation is
related not only to reduced amount of food, but the loss
of nutritional quality bringing various physical and
biological consequences in the short and long term,
affecting generations of parents in FI. As an example, FI
in a pregnant woman can compromise a child’s
development not only during pregnancy, but after
birth31.
The results of this study, associating food insecurity with
abdominal obesity and hypertriglyceridemia, confirm
literature data on nutritional transition, that is, there is a
high reduction of malnutrition and simultaneous increase
in the prevalence of obesity, including in the poorest
classes as a result of life habits including physical
inactivity and changes in the dietary pattern, with high
consumption of simple fats and sugars. These factors
explain the significant frequency of abdominal obesity
and hypertriglyceridemia9,11,23,32.
Constitutional Amendment No. 64 of 2010, Article 633
included nutrition as a fundamental right and guarantee;
however, nutrition must be in sufficient quantity and
quality as established by the 2nd National Conference on
Food and Nutritional Security1, to avoid compromising
the health of individuals. This prerogative turns out to
be decisive if food is a key part of the treatment of patients
with hypertension and diabetes.
Finally, it is important to mention that although EBIA is
an internationally validated instrument and validated
for the Brazilian version4,6, adopted in studies worldwide,
the questionnaire is an instrument with limitations, since
it depends on the story told by the interviewee regarding
their experiences in everyday life and accessibility to
food, which includes confidential information. Still, it
revealed an important condition of food insecurity in a
population highly vulnerable to cardiovascular morbidity
and mortality.
Conclusions
In this present study, food insecurity was a significant condition
among patients with hypertension and diabetes, with significant
association with economic class D, per capita income, abdominal
obesity, hypertension and hypertriglyceridemia.
119
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Food Insecurity in Hypertensive and Diabetic Patients
Considering that the food pattern is determined by the
socioeconomic conditions, the condition observed represents
an additional risk factor, since the difficulty of access to healthy
food in quantity and quality compromises the treatment and
control of these diseases.
Acknowledgements
To the financing institutions MS-DECIT-PPSUS/CNPq/
FAPEAL/SESAU-AL.
Int J Cardiovasc Sci. 2015;28(2):114-121
Original Manuscript
Potential Conflicts of Interest
No relevant potential conflicts of interest.
Sources of Funding
This study was partially funded by the Ministry of Health/
CNPq/FAPEAL/SESAU-AL, proceeding Proj_332_113873
88.2007PPSUS-AL.
Academic Association
This article represents the Final Term Paper (TCC) in Nutrition
of Niedja Cristina Paciência Torres, from Faculdade de Nutrição
da Universidade Federal de Alagoas.
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