May 23, 2025 • 31 mins
This week we move into the arena of preventive cardiology when we review a recent report from the team at Northwestern and Princeton on the impact of early childhood food insecurity on cardiovascular health of people in young adulthood. How does food insecurity in young childhood impact the cardiac health of adults? Why is most of the impact seen on BMI but not other measures of cardiovascular health. How can food programs that support improved food and nutrition security work to improve long term cardiovascular health of children and adults? Do the benefits of such programs outweight their costs? Dr. Nilay Shah of Northwestern University shares his deep insights into his work and these questions this week.
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Episode Transcript
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Speaker 1 (00:16):
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai here in New York City, where I
am also the Chief of Pediatric Cardiology. Thank you very
much for joining me for this three hundred and forty
second episode of Pdheart. I hope everybody enjoyed last week's
inspiring episode, in which we spoke with Ms. Caleb Billington
(00:38):
of Patty's Project and doctor Krishna Kumar of the Amrita
Institute about a novel partnership between the two organizations to
provide cardiac surgical care to some of the children in Uganda.
For those of you interested in inspiring tale, i'd recommend
you to take a listen to last week's episode three
hundred and forty one. As I say most weeks, if
you'd like to get in touch with me, my email
(00:59):
is it's easy to remember, It's Pdheart at gmail dot com.
This week, we move on to the world of preventive cardiology.
The title of the work we'll be reviewing is Early Childhood,
Food and Security and Cardiovascular Health in young adulthood. The
first author of this work is Emily Lamb and the
senior author Nilee Shah. And the authors of this work
(01:20):
come to us from Northwestern University as well as Princeton University.
When we're done reviewing this paper, doctor Niel Shap, who
is from the Department of Preventive Medicine at Northwestern University
and the senior author of this work, has kindly agreed
to speak with us about it. Therefore, let's get straight
onto this article and then a brief conversation with the
senior author. This week's work begins with the definition of
(01:42):
what food insecurity is, which is a lack of regular
access to high quality, nutritious food, and the authors explain
that in the United States this problem affects forty four
million people. Food in security has been associated with cardiovascular
and metabolic morbidity and mortality amongst US adults, and the
authors quote prior works demonstrating that it is associated with
(02:03):
a one point three time risk for obesity, one point
four time risk for pre diabetes or diabetes, and one
point five higher risk for cardiovascular disease mortality. The authors
then introduce for us the so called AHA Life's Essential
eight or l E eight score, which is a summary
measure of eight health factors and behaviors, and these are
(02:25):
blood lipids, blood pressure, blood glucose, body mass index, nicotine exposure,
diet quality, physical activity, and sleep health. And for adults
who are aged twenty to thirty nine, the median's score
for this is sixty eight point seven in the US.
The authors then explain that food insecurity disproportionately affects Black
and Hispanic communities in the United States, exacerbating health disparities.
(02:49):
They remind us of the so called SNAP program standing
for Supplemental Nutrition Assistance Program, which is a safety net
program in the United States that serves forty million US
US residents with low income, and they explain that estimates
suggests that it has reduced food and security by up
to thirty percent. Participants in SNAP have a card that's
(03:10):
loaded monthly and is used in the market for payments.
Sixty two percent of SNAP benefits go to families that
have children. The authors then explain that thirty percent of
those with food and security in the United States are children,
and the impact of this on long term cardiovascular health
isn't known, and we know that there are data suggesting
that childhood is an important time in which future cardiovascular
(03:33):
risks can begin. With this as a background, the author's
state and I quote, we evaluated the association of food
and security measured in early childhood with young adult cardiovascular
health defined by the ELY eight score and individual cardiovascular
risk factors among a diverse sample enrolled in twenty US cities.
(03:53):
We also evaluated whether snap participation in early childhood modified
these associations. Then explained that this study is based on
a longitudinal cohort study called the Future of Families and
Child well Being Study or the f FCWS, which enrolled
individuals at birth between February nineteen ninety eight and September
two thousand and followed them through September twenty twenty three.
(04:17):
A high proportion of participants were low income families and
racial and ethnic minority communities by design. An ancillary study
of this cohort is the Future of Families Cardiovasor Health
among Young Adults study, comprising fourteen hundred and twenty one
participants who were examined in person and had comprehensive measurements
of cardiovastor health measured at study year twenty two participants
(04:40):
at that age were examined and completed a self administered
questionnaire addressing demographic information, health behaviors, dietary habits, physical activity,
and nicotine exposure, as well as health history. Measurements of
height and weight, as well as blood work including lipid panels, glucose,
and hemoglobina one C were measured. There were eleven hundred
and five eligible participants for this work's analysis with food
(05:02):
and security between ages three and five who completed the
assessment at age twenty two and those with missing covariates
were excluded, which were thirty four subjects, resulting in a
sample size of one thousand, seventy one. For this work,
a cardiovascer health score was the primary outcome, defined by
the AHA l E eight score with a range of
(05:22):
zero to one hundred. The component l E eight scores
and clinical risk factors for cardiovascer disease at age twenty
two were also primary outcomes. The authors reviewed clinical cardiovascor
health risk factors including BMI of thirty or more, non HDL,
cholesterol levels of one thirty or more, systolic blood pressure
of one thirty or more, chemoglobin A one C, levels
(05:45):
of five point seven per cent or more. Secondary outcomes
were categorical ely eight scores that were high, moderate, and
low or cardiovascular kidney metabolic syndrome state with one being
no risk factors ranging up to stages three and four,
where the US or subclinical or clinical cardiovascular disease and DAUNT.
Of the results of the one thousand and seventy one
(06:06):
participants in this study, fifty three percent were female and
fifty three percent identified as non Hispanic Black, with twenty
five percent Hispanic, meaning roughly three quarters were Black or Hispanic.
In this cohort, food in security was seen in thirty
nine percent in childhood, forty four percent participated in the
SNAP program in childhood, and twenty six percent experienced both
(06:27):
food and security and participated in SNAP. Among those participating
in SNAP, fifty seven percent still experienced food in security,
and only sixty five percent of those who had food
in security in this cohort participated in SNAP, which would
seem like an opportunity to me. Mothers of children with
food in security had lower median household income, lower educational attainments,
(06:50):
and were younger at the time of their child's birth.
There are many data from this large data set, and
as I often remind I would strongly recommend that those
interested in this topic consider reading the article, and the
link to the article will be in the show notes. However,
if I were to summarize some of the more important
findings that the authors themselves have highlighted, they would be first,
(07:11):
early childhood food and security was associated with having a
lower Alyeate score in young adulthood. So, to restate it,
food in security in childhood was associated with worse cardiovascar
health as a young adult. When the authors looked to
the Elyate scores and clinical cardiovascular risk factors, food in
security was associated with a lower Elyate score for BMI,
(07:34):
with the higher odds of having a BMI of thirty
or more with an adjusted odds ratio of one point four.
Food in security was also more strongly associated with a
lower Alyate score among those whose households did not participate
in SNAP, suggesting that early childhood food and security was
associated with worse cardiovascer health than young adulthood, but also
(07:55):
that this was particularly marked in those with food and
security who did not participate in SNAW. Interestingly, the authors
explained that those who had food and security and were
participating in SNAP still had worse dietary quality in regards
to avoidance of processed foods and less fresh food, but
they still did statistically better later in life. In regards
to cardiovaser health in young adulthood. It's interesting to note
(08:18):
that when the authors sex stratified the data, food and
security was associated with lower Elyiate scores among female participants,
but not male. In their discussion, the authors stated and
I quote. In this cohort study of children followed up
into young adulthood, household food and security during early childhood
was associated with worse cardiovascer health in young adulthood, and
(08:38):
a higher BMI. Participation in the SNAP program mitigated the
association of childhood food and security and cardiovascer health in
young adulthood. Food and security was associated with worse BMI
and physical activity elyiate scores and in turn a worse
overall ELI eight cardiovascer health score in young adulthood, primarily
(08:59):
among children whose households did not participate in SNAP, suggesting
that participation in SNAP during early childhood may mitigate long
term associations of food and security with health and young
adulthood The authors explain that the association between food and
security and later cardiovasser health seem to be due mostly
to the effect it had on elevations in BMI and
(09:20):
may have been due to poorer dietary quality or lower
levels of physical activity. The authors explain that we should
consider these data very seriously because there is substantial evidence
that suboptimal cardiovassor health in young adulthood is highly associated
with higher premature cardiovascular disease and mortality over the life course.
They common on why some of the other measures of
(09:41):
cardiovasser health are not as affected in young adulthood in
this study, like lipids or blood pressure in this cohort,
and suggests that preclinical obesity may be an earlier stage
of metabolic disease, but ultimately don't know why it seems
to be differentially affecting different risk factors at this younger
adult age. Offer a few theories to explain why food
(10:02):
and security may be associated with cardiovascer health later in life,
suggesting that food and security may be associated with parental
controlling feeding styles that encourage overeating or maladaptive eating, with
more ultra processed foods that have lower nutritional value. And
they also explain how in less affluent homes, food security
will compete with other needs like medication or preventive medical care,
(10:25):
but again this is all highly conjectural. The authors review
the important finding that SNAP was associated with substantial mitigation
of the impact of food and security on later cardivascar health.
They explain that some of the data from other works
have had mixed results regarding the impact of SNAP on outcomes,
and also that the dietary quality is still not optimal
(10:45):
in SNAP supported families, but the results of this work
do show an important impact on improving cardiovascer health amongst
children who participate in this program. The authors provide a
number of possible explanations for why SNAP participation may be
helping children in regards to later cardiovascular health despite the
still lower quality of food that these children are eating,
and I would direct the listener to page e six
(11:08):
for some interesting theories and will discuss some of this
with doctor Shaw's well. Whatever the cause of the improvement
in outcomes, the authors explain that it is their belief
that these findings should have important implications in regards to
decisions to support and promote SNAP participation to reduce food
and Security in childhood, and they remind that only sixty
five percent of those who have food in security actually
(11:30):
took advantage of this program. They point to limitations including
relatively small sample size, the self reported nature of food
and security definition in this work that was determined only
one time in one interview with the child's mother, and
the predominance of black and Hispanic participants who live in
low income urban settings, and the absence of data regarding
(11:51):
poor children in other locales. The author is common on
the inability to control for all factors affecting long term
cardiovascular health and mention that the associateiation with sex that
we've mentioned previously in this work may be by chance.
And so they conclude this cohort study suggests that children
who experience food and security are more likely to have
(12:11):
a higher BMI as young adults, which is associated with
worse overall composite cardiovascar health scores, particularly among children whose
families did not participate in SNAP. Optimizing family use of
SNAP in childhood may help promote more healthful BMI and
better cardiovascar health across the life course. Well, this is
an interesting report that brings the podcast back into the
(12:34):
arena of preventive cardiology that we have reviewed previously, but
perhaps not enough. It seems clear from this work that
there is at least and perhaps more than a signal
here that childhood food and security is associated with worse
later cardiovascar health. And this is really your remarkable observation
and noteworthy as it's so unusual to have a study
(12:55):
with basically two decades a follow up. The impact of
SNAP on the outcome is especially interesting and important, and
as I mentioned, I think the fact that participation clearly
demonstrated benefit for these children, even if the dietary quality
of the participants was not optimal, is important and probably
should inform decisions by politicians and policymakers. Even if one
(13:17):
looks at this entirely through an economic lens, it seems
hard to imagine that the improvement in carnivasser health of
people through this relatively simple intervention could have major cost
savings in the future. There's a lot to unpack, and
in the interests of time, I think we'll move forward
to our conversation with the works senior author doctor Neeela
Shah joining us now to discuss this week's work. As
(13:38):
the work's senior author, doctor Neelay Shah. Neila Shah is
a system professor of cardiology, preventive medicine, and Medical social sciences,
as well as a general and preventive cardiologist in the
Bloom Cardiovascular Institute at Northwestern University Feinberg School of Medicine.
He's a graduate of Northwestern University for both his MD
and MPH degrees, and he completed residents'en internal Medicine at
(14:01):
Stanford University, followed by cardiology and then Cardiology, Epidemiology and
Prevention fellowships at Northwestern. Doctor Shawn's research group investigates cardiovascar
disease prevention strategies with particular attention to earlier life prevention
in young adults. As this paper demonstrates, is a delight
and honor to welcome him to PD Heart. Welcome doctor
(14:22):
Shaw to PD Heart.
Speaker 2 (14:23):
I'm here now with doctor Nila Shaw. Doctor Shaw, thank
you very much for joining us this week on PD Heart.
Good to be here, real pleasure to have you. You know,
I was wondering if you might be able to share
with the audience what exactly food insecurity is and also
what did we know about it prior to your work
and its impact on adults.
Speaker 3 (14:44):
So food in security refers to the limited or uncertain
access to enough food, and it can encompass both the
quantity of food that someone has available as well as
the reliability of food access. In the study we're talking about,
we define food and security based on the USDA's Food
(15:05):
Insecurity Questionnaire, and the USDA defines food insecurity as a
lack of consistent access to enough food for all members
of a household to live an active and healthy life.
And some important things to know include that food and
security can be temporary because somebody may have lost employment
or lost their income, or it could be chronic and
(15:26):
can involve things like skipping meals or eating less than
is needed, or having an inability to afford a balanced meal.
And there's a related concept that often is kept in mind,
which is this idea of nutrition insecurity, which is similar
but not exactly the same, which is this idea of
not only having limited or uncertain or unreliable access to food,
(15:49):
but having unreliable access to food that is nutritive or
actually provides adequate nutrition. And we knew a fair amount
about food security, especially as it pertains to adults, prior
to this study. So food and security affects about forty
four million people in the US, and it's associated with
a thirty percent higher likelihood of obesity, a forty percent
(16:13):
higher likelihood of diabetes, a fifty percent higher likelihood for
cardiovasc or disease mortality among adults. But thirty percent of
people who experience food and security in the US are children,
and there's very little research focused on how food and
security experienced in childhood may affect the trajectory for health
into adulthood and across the life course.
Speaker 2 (16:32):
Yeah, well that came ringing true. Thank you, that was
really helpful. You know, Nile, you're kind of already getting
into this point, but I was going to ask you.
You know, sometimes when I have an author on the podcast,
I'll ask them to summarize for the audience what they,
as the author themselves, think are maybe the two or
three most important takeaway findings of the work. And I'm
(16:53):
wondering if you could share your thoughts on this, which
is I think a nice segue from what you were
just explaining we know already about adults.
Speaker 4 (17:00):
Of course, I'd be happy to. So this study was
a longitudinal study.
Speaker 3 (17:05):
The individuals were evaluated in childhood into young adulthood, and
we found that experiencing food and security in early childhood
was associated with having worse cardiovascular health in young adulthood,
which seemed to primarily be driven by having a worse
body mass index as young adults. And in these findings,
we found that households that participated in SNAP or the
(17:27):
Supplemental Nutrition Assistance Program seemed to have mitigation of this
association into young adulthood. Specifically, the association of early childhood
food and security with worse cardiovesculor health in young adulthood
was strongest among children's households that did participate in the
SNAP program.
Speaker 2 (17:45):
I say, I say, you know, food in security in
childhood was demonstrated by your work to be associated with
elevations and BMI, as you just mentioned at age twenty two.
But I thought it was interesting that a number of
the other markers of cardivas or risk were did not
seemed to be as adversely affected, such as lipid profiles
(18:06):
for example. And I'm wondering if you have any thoughts
on why this particular metric of BMI was most affected
and why others were not. And I was just thinking,
is it just that we're too early and measuring these
impacts at a twenty two year old versus say a
forty two year old. But I really wasn't sure, so
thought i'd ask you.
Speaker 3 (18:25):
Yeah, that's a great observation, And certainly I think that
is one part of it. I think it is partly
that BMI or body composition, maybe intermediary among the along
the causal pathway between the exposure of food and security
and other cardivast that are risk factors like hypertension and diabetes.
But it may also be that food and security can
(18:46):
influence the quality of the diet that a person follows
into child from childhood, into adolescence and into early adulthood.
And as I think we all know, the quality of
what we eat can affect our body composition, and so
I think that perhaps is why we saw the strong
association with BMI.
Speaker 4 (19:01):
I see, I see.
Speaker 3 (19:03):
You know.
Speaker 2 (19:03):
One of the interesting things your work has shown was
that people who participated in the SNAP program had improved
diets compared to those who did not, which I guess
would be expected. But despite this, their diets were still
pretty suboptimal. They weren't exactly ideal diets. They were just
better than people who didn't have SNAP, and despite what
(19:24):
might be viewed as a lower than optimal nutritional diet,
I thought it was interesting that these patients did actually
have superior cardiovasser health as young adults versus those who
did not participate in those assistance programs. And why do
you think it is that cardiovaser health was still improved
in those patients or families despite the fact that the
(19:44):
diets of people who were participating in SNAP were still
not particularly good.
Speaker 3 (19:48):
Yeah, that's a good question, and I appreciate the opportunity
to address and clarify this finding because we were really
digging into the data when we observed these results. So
we noted that among those that participated in SNAP, those
children who experienced food and security actually had better diet
quality in young adulthood compared to those that did not
experience food and security. But this was only true among
(20:12):
children whose households participated in SNAP. This association was not
present among households that did not participate it in SNAP.
So to me, this association of food and security in
childhood with better dietary quality in young adulthood, seen only
among children whose households participated in the SNAP program, suggests
that SNAP participation may be conferring some protective benefit for
(20:32):
long term health, perhaps not only supporting access to food,
but it may help individuals with food and security in
childhood be on a trajectory to better.
Speaker 4 (20:41):
Quality diets in young adulthood. This idea of nutrition security.
Speaker 3 (20:44):
If we address food and security through something like participating
in the SNAP program, perhaps it will also foster a
better nutrition security as well.
Speaker 2 (20:52):
Very interesting. You know, I work with doctor Valancine Fooster
here at Mount Sinai, and he's done quite a bit
of work and trying to figure out ways to get
people to eat healthier and to learn healthy habits younger
in life. And I think he would say probably that
education at a very young age he feels is very
(21:14):
very important, although I know some of his work has
demonstrated that you have to reinforce it many times. You
can't just go in when children are three or four
and then expect that they're going to eat broccoli the
rest of their lives. You have to. But he does
have a strong belief though, that if you set the
stage there and then you intermittently re teach that that
(21:35):
might be actually very beneficial. At least that's one of
his thoughts. Well, of course, now coming towards the end
of this interview, and for those in the audience, it's
actually quite late for Niela to be speaking with us.
I'm very appreciative to you.
Speaker 5 (21:48):
To doing this.
Speaker 2 (21:49):
You know, I'm going to ask you now the millions
dollar a question, which is you know, now that you've
found these made these findings which are so important, what
do you think are the practical implication What are the
actionable steps we might be able to take based upon
what you have demonstrated in this extraordinary long term work.
Speaker 3 (22:07):
Well, Rob, it's really been my pleasure to come here
and speak about this. And as I can imagine anybody
who's listening to this might have already guessed, I think
there are fairly substantial implications at the clinical level, the
public health level, and the policy level. So for clinicians
such as those working in pediatrics, these findings really emphasize
the importance of food and security screening, and in fact,
(22:28):
as many listening probably already know, the American Academy of
Pediatrics recommends routine screening and providing resources for food and
security during well child visits, and so if that's not
already being done, and it should be done really in
clinical encounters across the spectrum. That is perhaps a really
important place for clinicians to start. But from a public
health perspective, these findings suggest that we should really be
(22:51):
doing more to screen and intervene on food and security
in really diverse settings, especially for children. You know, I'm
a clinician myself, and part of my work is volunteer
in the community, for example, in community fairs for cardiovescor
health screening. And we actually have implemented a food in
security brief questionnaire during these community based screenings so that
(23:11):
we can refer people to SNAP benefits and local food
pantries because we've realized that even that move towards improving
food insecurity, even.
Speaker 4 (23:20):
Marginally, can lead to more ready.
Speaker 3 (23:24):
Access to healthful foods for individuals and families. And perhaps
I think the biggest implication is at the policy level.
I think we all kind of are aware that we're
in the midst of this policy environment that seems to
be threatening the social safety net, including the Supplemental Nutritional
Assistance Program. And I think that if we were to
reduce SNAP benefits or put up more barriers to participating
(23:45):
in the SNAP program, we're likely to see more food
and security, and I would worry that that would result
in worse cardiovescor health and more chronic disease across the
like course of anybody who's experiencing food and security. So
from a policy person, anybody who's a policymaker or is
otherwise interested in advocating, I think should particularly go out
(24:06):
of their way to support the maintenance of SNAP benefits
or even expansion of SNAP benefits, because the implications, based
on the findings of our research, I think are pretty clear.
If we don't do that, we're setting people up for
worse health.
Speaker 2 (24:22):
Yeah, all wonderful points. Newlane. You know you don't have
the opportunity to hear what I said about your paper
because I recorded it before. But I thought to myself
that even if one didn't care about humans, you still
from a purely economic perspective, the implications of expanding SNAP,
(24:44):
based on what you've reported, seems to be very obvious
that there'll be massive cost savings over the next few
decades if we can intervene with this what seems to
be a relatively simple intervention.
Speaker 3 (24:57):
Yeah, I absolutely agree with you, and the more I
hear about the policy environment in which we're currently living.
Speaker 4 (25:04):
The more I think that that economic argument is perhaps
the strongest.
Speaker 3 (25:07):
One, because if, just like you said, if you didn't
care about other human beings, or you didn't actually care
what happened to people, and all you cared about were
the cost savings, it's a no brainer. I think some
of these social programs not only help people who are
experiencing the consequences of poverty, but they set people up
for better help across their lives.
Speaker 2 (25:28):
Well, I really can't thank you enough for allowing us
to delve into another area of pediatric cardiology. I know
you are an internist and an adult cardiologist, but it
is you know, most of the time this podcast deals
with congenital heart problems, but preventive cardiology is extraordinarily important,
(25:48):
both in pediatrics and in adult worlds. And so I'm
really excited that we could bring this topic to the
listeners of the podcast. And I want to thank you
and congratulate you and your co investigation on a really
remarkable work highlighting something that is critically important.
Speaker 4 (26:04):
It with my pleasure, thank you for the opportunity.
Speaker 2 (26:06):
Thank you so much.
Speaker 1 (26:07):
Well, as I'm apt to say, when the guest is good.
There's not much to add. I thought Nila shared with
us many ideas regarding the benefits of this work in
supporting expansion of food and nutritional support programs, and think
he made many important arguments as to why policymakers should
be sounding the alarm to not cut these benefits but
instead expand them. This would seem a fairly inexpensive and
(26:30):
effective intervention that could have a massive positive impact on
the health of our young people well into adulthood, and
in so doing have a similarly massive impact and reducing
cost for healthcare, which is something that I think all
people on all sides of the aisle can agree upon.
There's much to think about, and I will certainly replace
some of this interview to remind myself of many of
(26:52):
the important points that doctor Shaw made. I hope you
enjoyed his comments as much as I do, and I'd
again like to thank him for taking time from his
very busy schedule to speak with us this week on Pedihart.
To end today's three hundred and forty second episode of
Peedihart Pediatric Cardiology, Today we remember the great Peruvian tenor
Luigi Alva, who was a fixture of operatic stages from
(27:13):
the nineteen fifties through nineteen eighties, singing mostly light tenor
leading roles in composers like Rossini, Donizetti, and Mozart. Alva
died last week on May fifteenth, at the age of
ninety eight in Milan. Today we hear an example of
his art in this live nineteen sixties performance of Mozart's
Don Giovanni singing the fiendishly difficult Il Mio Tizoro from
(27:36):
this opera. Thank you for joining me for this week's episode,
and thanks once again to doctor Shah. I hope I'll
have a good week ahead.
Speaker 5 (27:43):
Hell miotisart on on HRC shi Chi Shall we call?
Speaker 4 (28:18):
Shall we go? O?
Speaker 5 (28:24):
God chan supa sweet large well made card, Your barble,
(28:54):
your barble, dister wity a boggy see by your thought
see into an on on so devililype for oh che
(30:11):
shood je su he either sweep ah many card you
(30:37):
apoblem a by god.
Speaker 2 (30:53):
It so.
Speaker 1 (30:58):
You you oh, no Lord, your nor.
Speaker 5 (31:09):
A body. It's all a gymon on your body, say,
oh your body
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai here in New York City, where I
am also the Chief of Pediatric Cardiology. Thank you very
much for joining me for this three hundred and forty
second episode of Pdheart. I hope everybody enjoyed last week's
inspiring episode, in which we spoke with Ms. Caleb Billington
(00:38):
of Patty's Project and doctor Krishna Kumar of the Amrita
Institute about a novel partnership between the two organizations to
provide cardiac surgical care to some of the children in Uganda.
For those of you interested in inspiring tale, i'd recommend
you to take a listen to last week's episode three
hundred and forty one. As I say most weeks, if
you'd like to get in touch with me, my email
(00:59):
is it's easy to remember, It's Pdheart at gmail dot com.
This week, we move on to the world of preventive cardiology.
The title of the work we'll be reviewing is Early Childhood,
Food and Security and Cardiovascular Health in young adulthood. The
first author of this work is Emily Lamb and the
senior author Nilee Shah. And the authors of this work
(01:20):
come to us from Northwestern University as well as Princeton University.
When we're done reviewing this paper, doctor Niel Shap, who
is from the Department of Preventive Medicine at Northwestern University
and the senior author of this work, has kindly agreed
to speak with us about it. Therefore, let's get straight
onto this article and then a brief conversation with the
senior author. This week's work begins with the definition of
(01:42):
what food insecurity is, which is a lack of regular
access to high quality, nutritious food, and the authors explain
that in the United States this problem affects forty four
million people. Food in security has been associated with cardiovascular
and metabolic morbidity and mortality amongst US adults, and the
authors quote prior works demonstrating that it is associated with
(02:03):
a one point three time risk for obesity, one point
four time risk for pre diabetes or diabetes, and one
point five higher risk for cardiovascular disease mortality. The authors
then introduce for us the so called AHA Life's Essential
eight or l E eight score, which is a summary
measure of eight health factors and behaviors, and these are
(02:25):
blood lipids, blood pressure, blood glucose, body mass index, nicotine exposure,
diet quality, physical activity, and sleep health. And for adults
who are aged twenty to thirty nine, the median's score
for this is sixty eight point seven in the US.
The authors then explain that food insecurity disproportionately affects Black
and Hispanic communities in the United States, exacerbating health disparities.
(02:49):
They remind us of the so called SNAP program standing
for Supplemental Nutrition Assistance Program, which is a safety net
program in the United States that serves forty million US
US residents with low income, and they explain that estimates
suggests that it has reduced food and security by up
to thirty percent. Participants in SNAP have a card that's
(03:10):
loaded monthly and is used in the market for payments.
Sixty two percent of SNAP benefits go to families that
have children. The authors then explain that thirty percent of
those with food and security in the United States are children,
and the impact of this on long term cardiovascular health
isn't known, and we know that there are data suggesting
that childhood is an important time in which future cardiovascular
(03:33):
risks can begin. With this as a background, the author's
state and I quote, we evaluated the association of food
and security measured in early childhood with young adult cardiovascular
health defined by the ELY eight score and individual cardiovascular
risk factors among a diverse sample enrolled in twenty US cities.
(03:53):
We also evaluated whether snap participation in early childhood modified
these associations. Then explained that this study is based on
a longitudinal cohort study called the Future of Families and
Child well Being Study or the f FCWS, which enrolled
individuals at birth between February nineteen ninety eight and September
two thousand and followed them through September twenty twenty three.
(04:17):
A high proportion of participants were low income families and
racial and ethnic minority communities by design. An ancillary study
of this cohort is the Future of Families Cardiovasor Health
among Young Adults study, comprising fourteen hundred and twenty one
participants who were examined in person and had comprehensive measurements
of cardiovastor health measured at study year twenty two participants
(04:40):
at that age were examined and completed a self administered
questionnaire addressing demographic information, health behaviors, dietary habits, physical activity,
and nicotine exposure, as well as health history. Measurements of
height and weight, as well as blood work including lipid panels, glucose,
and hemoglobina one C were measured. There were eleven hundred
and five eligible participants for this work's analysis with food
(05:02):
and security between ages three and five who completed the
assessment at age twenty two and those with missing covariates
were excluded, which were thirty four subjects, resulting in a
sample size of one thousand, seventy one. For this work,
a cardiovascer health score was the primary outcome, defined by
the AHA l E eight score with a range of
(05:22):
zero to one hundred. The component l E eight scores
and clinical risk factors for cardiovascer disease at age twenty
two were also primary outcomes. The authors reviewed clinical cardiovascor
health risk factors including BMI of thirty or more, non HDL,
cholesterol levels of one thirty or more, systolic blood pressure
of one thirty or more, chemoglobin A one C, levels
(05:45):
of five point seven per cent or more. Secondary outcomes
were categorical ely eight scores that were high, moderate, and
low or cardiovascular kidney metabolic syndrome state with one being
no risk factors ranging up to stages three and four,
where the US or subclinical or clinical cardiovascular disease and DAUNT.
Of the results of the one thousand and seventy one
(06:06):
participants in this study, fifty three percent were female and
fifty three percent identified as non Hispanic Black, with twenty
five percent Hispanic, meaning roughly three quarters were Black or Hispanic.
In this cohort, food in security was seen in thirty
nine percent in childhood, forty four percent participated in the
SNAP program in childhood, and twenty six percent experienced both
(06:27):
food and security and participated in SNAP. Among those participating
in SNAP, fifty seven percent still experienced food in security,
and only sixty five percent of those who had food
in security in this cohort participated in SNAP, which would
seem like an opportunity to me. Mothers of children with
food in security had lower median household income, lower educational attainments,
(06:50):
and were younger at the time of their child's birth.
There are many data from this large data set, and
as I often remind I would strongly recommend that those
interested in this topic consider reading the article, and the
link to the article will be in the show notes. However,
if I were to summarize some of the more important
findings that the authors themselves have highlighted, they would be first,
(07:11):
early childhood food and security was associated with having a
lower Alyeate score in young adulthood. So, to restate it,
food in security in childhood was associated with worse cardiovascar
health as a young adult. When the authors looked to
the Elyate scores and clinical cardiovascular risk factors, food in
security was associated with a lower Elyate score for BMI,
(07:34):
with the higher odds of having a BMI of thirty
or more with an adjusted odds ratio of one point four.
Food in security was also more strongly associated with a
lower Alyate score among those whose households did not participate
in SNAP, suggesting that early childhood food and security was
associated with worse cardiovascer health than young adulthood, but also
(07:55):
that this was particularly marked in those with food and
security who did not participate in SNAW. Interestingly, the authors
explained that those who had food and security and were
participating in SNAP still had worse dietary quality in regards
to avoidance of processed foods and less fresh food, but
they still did statistically better later in life. In regards
to cardiovaser health in young adulthood. It's interesting to note
(08:18):
that when the authors sex stratified the data, food and
security was associated with lower Elyiate scores among female participants,
but not male. In their discussion, the authors stated and
I quote. In this cohort study of children followed up
into young adulthood, household food and security during early childhood
was associated with worse cardiovascer health in young adulthood, and
(08:38):
a higher BMI. Participation in the SNAP program mitigated the
association of childhood food and security and cardiovascer health in
young adulthood. Food and security was associated with worse BMI
and physical activity elyiate scores and in turn a worse
overall ELI eight cardiovascer health score in young adulthood, primarily
(08:59):
among children whose households did not participate in SNAP, suggesting
that participation in SNAP during early childhood may mitigate long
term associations of food and security with health and young
adulthood The authors explain that the association between food and
security and later cardiovasser health seem to be due mostly
to the effect it had on elevations in BMI and
(09:20):
may have been due to poorer dietary quality or lower
levels of physical activity. The authors explain that we should
consider these data very seriously because there is substantial evidence
that suboptimal cardiovassor health in young adulthood is highly associated
with higher premature cardiovascular disease and mortality over the life course.
They common on why some of the other measures of
(09:41):
cardiovasser health are not as affected in young adulthood in
this study, like lipids or blood pressure in this cohort,
and suggests that preclinical obesity may be an earlier stage
of metabolic disease, but ultimately don't know why it seems
to be differentially affecting different risk factors at this younger
adult age. Offer a few theories to explain why food
(10:02):
and security may be associated with cardiovascer health later in life,
suggesting that food and security may be associated with parental
controlling feeding styles that encourage overeating or maladaptive eating, with
more ultra processed foods that have lower nutritional value. And
they also explain how in less affluent homes, food security
will compete with other needs like medication or preventive medical care,
(10:25):
but again this is all highly conjectural. The authors review
the important finding that SNAP was associated with substantial mitigation
of the impact of food and security on later cardivascar health.
They explain that some of the data from other works
have had mixed results regarding the impact of SNAP on outcomes,
and also that the dietary quality is still not optimal
(10:45):
in SNAP supported families, but the results of this work
do show an important impact on improving cardiovascer health amongst
children who participate in this program. The authors provide a
number of possible explanations for why SNAP participation may be
helping children in regards to later cardiovascular health despite the
still lower quality of food that these children are eating,
and I would direct the listener to page e six
(11:08):
for some interesting theories and will discuss some of this
with doctor Shaw's well. Whatever the cause of the improvement
in outcomes, the authors explain that it is their belief
that these findings should have important implications in regards to
decisions to support and promote SNAP participation to reduce food
and Security in childhood, and they remind that only sixty
five percent of those who have food in security actually
(11:30):
took advantage of this program. They point to limitations including
relatively small sample size, the self reported nature of food
and security definition in this work that was determined only
one time in one interview with the child's mother, and
the predominance of black and Hispanic participants who live in
low income urban settings, and the absence of data regarding
(11:51):
poor children in other locales. The author is common on
the inability to control for all factors affecting long term
cardiovascular health and mention that the associateiation with sex that
we've mentioned previously in this work may be by chance.
And so they conclude this cohort study suggests that children
who experience food and security are more likely to have
(12:11):
a higher BMI as young adults, which is associated with
worse overall composite cardiovascar health scores, particularly among children whose
families did not participate in SNAP. Optimizing family use of
SNAP in childhood may help promote more healthful BMI and
better cardiovascar health across the life course. Well, this is
an interesting report that brings the podcast back into the
(12:34):
arena of preventive cardiology that we have reviewed previously, but
perhaps not enough. It seems clear from this work that
there is at least and perhaps more than a signal
here that childhood food and security is associated with worse
later cardiovascar health. And this is really your remarkable observation
and noteworthy as it's so unusual to have a study
(12:55):
with basically two decades a follow up. The impact of
SNAP on the outcome is especially interesting and important, and
as I mentioned, I think the fact that participation clearly
demonstrated benefit for these children, even if the dietary quality
of the participants was not optimal, is important and probably
should inform decisions by politicians and policymakers. Even if one
(13:17):
looks at this entirely through an economic lens, it seems
hard to imagine that the improvement in carnivasser health of
people through this relatively simple intervention could have major cost
savings in the future. There's a lot to unpack, and
in the interests of time, I think we'll move forward
to our conversation with the works senior author doctor Neeela
Shah joining us now to discuss this week's work. As
(13:38):
the work's senior author, doctor Neelay Shah. Neila Shah is
a system professor of cardiology, preventive medicine, and Medical social sciences,
as well as a general and preventive cardiologist in the
Bloom Cardiovascular Institute at Northwestern University Feinberg School of Medicine.
He's a graduate of Northwestern University for both his MD
and MPH degrees, and he completed residents'en internal Medicine at
(14:01):
Stanford University, followed by cardiology and then Cardiology, Epidemiology and
Prevention fellowships at Northwestern. Doctor Shawn's research group investigates cardiovascar
disease prevention strategies with particular attention to earlier life prevention
in young adults. As this paper demonstrates, is a delight
and honor to welcome him to PD Heart. Welcome doctor
(14:22):
Shaw to PD Heart.
Speaker 2 (14:23):
I'm here now with doctor Nila Shaw. Doctor Shaw, thank
you very much for joining us this week on PD Heart.
Good to be here, real pleasure to have you. You know,
I was wondering if you might be able to share
with the audience what exactly food insecurity is and also
what did we know about it prior to your work
and its impact on adults.
Speaker 3 (14:44):
So food in security refers to the limited or uncertain
access to enough food, and it can encompass both the
quantity of food that someone has available as well as
the reliability of food access. In the study we're talking about,
we define food and security based on the USDA's Food
(15:05):
Insecurity Questionnaire, and the USDA defines food insecurity as a
lack of consistent access to enough food for all members
of a household to live an active and healthy life.
And some important things to know include that food and
security can be temporary because somebody may have lost employment
or lost their income, or it could be chronic and
(15:26):
can involve things like skipping meals or eating less than
is needed, or having an inability to afford a balanced meal.
And there's a related concept that often is kept in mind,
which is this idea of nutrition insecurity, which is similar
but not exactly the same, which is this idea of
not only having limited or uncertain or unreliable access to food,
(15:49):
but having unreliable access to food that is nutritive or
actually provides adequate nutrition. And we knew a fair amount
about food security, especially as it pertains to adults, prior
to this study. So food and security affects about forty
four million people in the US, and it's associated with
a thirty percent higher likelihood of obesity, a forty percent
(16:13):
higher likelihood of diabetes, a fifty percent higher likelihood for
cardiovasc or disease mortality among adults. But thirty percent of
people who experience food and security in the US are children,
and there's very little research focused on how food and
security experienced in childhood may affect the trajectory for health
into adulthood and across the life course.
Speaker 2 (16:32):
Yeah, well that came ringing true. Thank you, that was
really helpful. You know, Nile, you're kind of already getting
into this point, but I was going to ask you.
You know, sometimes when I have an author on the podcast,
I'll ask them to summarize for the audience what they,
as the author themselves, think are maybe the two or
three most important takeaway findings of the work. And I'm
(16:53):
wondering if you could share your thoughts on this, which
is I think a nice segue from what you were
just explaining we know already about adults.
Speaker 4 (17:00):
Of course, I'd be happy to. So this study was
a longitudinal study.
Speaker 3 (17:05):
The individuals were evaluated in childhood into young adulthood, and
we found that experiencing food and security in early childhood
was associated with having worse cardiovascular health in young adulthood,
which seemed to primarily be driven by having a worse
body mass index as young adults. And in these findings,
we found that households that participated in SNAP or the
(17:27):
Supplemental Nutrition Assistance Program seemed to have mitigation of this
association into young adulthood. Specifically, the association of early childhood
food and security with worse cardiovesculor health in young adulthood
was strongest among children's households that did participate in the
SNAP program.
Speaker 2 (17:45):
I say, I say, you know, food in security in
childhood was demonstrated by your work to be associated with
elevations and BMI, as you just mentioned at age twenty two.
But I thought it was interesting that a number of
the other markers of cardivas or risk were did not
seemed to be as adversely affected, such as lipid profiles
(18:06):
for example. And I'm wondering if you have any thoughts
on why this particular metric of BMI was most affected
and why others were not. And I was just thinking,
is it just that we're too early and measuring these
impacts at a twenty two year old versus say a
forty two year old. But I really wasn't sure, so
thought i'd ask you.
Speaker 3 (18:25):
Yeah, that's a great observation, And certainly I think that
is one part of it. I think it is partly
that BMI or body composition, maybe intermediary among the along
the causal pathway between the exposure of food and security
and other cardivast that are risk factors like hypertension and diabetes.
But it may also be that food and security can
(18:46):
influence the quality of the diet that a person follows
into child from childhood, into adolescence and into early adulthood.
And as I think we all know, the quality of
what we eat can affect our body composition, and so
I think that perhaps is why we saw the strong
association with BMI.
Speaker 4 (19:01):
I see, I see.
Speaker 3 (19:03):
You know.
Speaker 2 (19:03):
One of the interesting things your work has shown was
that people who participated in the SNAP program had improved
diets compared to those who did not, which I guess
would be expected. But despite this, their diets were still
pretty suboptimal. They weren't exactly ideal diets. They were just
better than people who didn't have SNAP, and despite what
(19:24):
might be viewed as a lower than optimal nutritional diet,
I thought it was interesting that these patients did actually
have superior cardiovasser health as young adults versus those who
did not participate in those assistance programs. And why do
you think it is that cardiovaser health was still improved
in those patients or families despite the fact that the
(19:44):
diets of people who were participating in SNAP were still
not particularly good.
Speaker 3 (19:48):
Yeah, that's a good question, and I appreciate the opportunity
to address and clarify this finding because we were really
digging into the data when we observed these results. So
we noted that among those that participated in SNAP, those
children who experienced food and security actually had better diet
quality in young adulthood compared to those that did not
experience food and security. But this was only true among
(20:12):
children whose households participated in SNAP. This association was not
present among households that did not participate it in SNAP.
So to me, this association of food and security in
childhood with better dietary quality in young adulthood, seen only
among children whose households participated in the SNAP program, suggests
that SNAP participation may be conferring some protective benefit for
(20:32):
long term health, perhaps not only supporting access to food,
but it may help individuals with food and security in
childhood be on a trajectory to better.
Speaker 4 (20:41):
Quality diets in young adulthood. This idea of nutrition security.
Speaker 3 (20:44):
If we address food and security through something like participating
in the SNAP program, perhaps it will also foster a
better nutrition security as well.
Speaker 2 (20:52):
Very interesting. You know, I work with doctor Valancine Fooster
here at Mount Sinai, and he's done quite a bit
of work and trying to figure out ways to get
people to eat healthier and to learn healthy habits younger
in life. And I think he would say probably that
education at a very young age he feels is very
(21:14):
very important, although I know some of his work has
demonstrated that you have to reinforce it many times. You
can't just go in when children are three or four
and then expect that they're going to eat broccoli the
rest of their lives. You have to. But he does
have a strong belief though, that if you set the
stage there and then you intermittently re teach that that
(21:35):
might be actually very beneficial. At least that's one of
his thoughts. Well, of course, now coming towards the end
of this interview, and for those in the audience, it's
actually quite late for Niela to be speaking with us.
I'm very appreciative to you.
Speaker 5 (21:48):
To doing this.
Speaker 2 (21:49):
You know, I'm going to ask you now the millions
dollar a question, which is you know, now that you've
found these made these findings which are so important, what
do you think are the practical implication What are the
actionable steps we might be able to take based upon
what you have demonstrated in this extraordinary long term work.
Speaker 3 (22:07):
Well, Rob, it's really been my pleasure to come here
and speak about this. And as I can imagine anybody
who's listening to this might have already guessed, I think
there are fairly substantial implications at the clinical level, the
public health level, and the policy level. So for clinicians
such as those working in pediatrics, these findings really emphasize
the importance of food and security screening, and in fact,
(22:28):
as many listening probably already know, the American Academy of
Pediatrics recommends routine screening and providing resources for food and
security during well child visits, and so if that's not
already being done, and it should be done really in
clinical encounters across the spectrum. That is perhaps a really
important place for clinicians to start. But from a public
health perspective, these findings suggest that we should really be
(22:51):
doing more to screen and intervene on food and security
in really diverse settings, especially for children. You know, I'm
a clinician myself, and part of my work is volunteer
in the community, for example, in community fairs for cardiovescor
health screening. And we actually have implemented a food in
security brief questionnaire during these community based screenings so that
(23:11):
we can refer people to SNAP benefits and local food
pantries because we've realized that even that move towards improving
food insecurity, even.
Speaker 4 (23:20):
Marginally, can lead to more ready.
Speaker 3 (23:24):
Access to healthful foods for individuals and families. And perhaps
I think the biggest implication is at the policy level.
I think we all kind of are aware that we're
in the midst of this policy environment that seems to
be threatening the social safety net, including the Supplemental Nutritional
Assistance Program. And I think that if we were to
reduce SNAP benefits or put up more barriers to participating
(23:45):
in the SNAP program, we're likely to see more food
and security, and I would worry that that would result
in worse cardiovescor health and more chronic disease across the
like course of anybody who's experiencing food and security. So
from a policy person, anybody who's a policymaker or is
otherwise interested in advocating, I think should particularly go out
(24:06):
of their way to support the maintenance of SNAP benefits
or even expansion of SNAP benefits, because the implications, based
on the findings of our research, I think are pretty clear.
If we don't do that, we're setting people up for
worse health.
Speaker 2 (24:22):
Yeah, all wonderful points. Newlane. You know you don't have
the opportunity to hear what I said about your paper
because I recorded it before. But I thought to myself
that even if one didn't care about humans, you still
from a purely economic perspective, the implications of expanding SNAP,
(24:44):
based on what you've reported, seems to be very obvious
that there'll be massive cost savings over the next few
decades if we can intervene with this what seems to
be a relatively simple intervention.
Speaker 3 (24:57):
Yeah, I absolutely agree with you, and the more I
hear about the policy environment in which we're currently living.
Speaker 4 (25:04):
The more I think that that economic argument is perhaps
the strongest.
Speaker 3 (25:07):
One, because if, just like you said, if you didn't
care about other human beings, or you didn't actually care
what happened to people, and all you cared about were
the cost savings, it's a no brainer. I think some
of these social programs not only help people who are
experiencing the consequences of poverty, but they set people up
for better help across their lives.
Speaker 2 (25:28):
Well, I really can't thank you enough for allowing us
to delve into another area of pediatric cardiology. I know
you are an internist and an adult cardiologist, but it
is you know, most of the time this podcast deals
with congenital heart problems, but preventive cardiology is extraordinarily important,
(25:48):
both in pediatrics and in adult worlds. And so I'm
really excited that we could bring this topic to the
listeners of the podcast. And I want to thank you
and congratulate you and your co investigation on a really
remarkable work highlighting something that is critically important.
Speaker 4 (26:04):
It with my pleasure, thank you for the opportunity.
Speaker 2 (26:06):
Thank you so much.
Speaker 1 (26:07):
Well, as I'm apt to say, when the guest is good.
There's not much to add. I thought Nila shared with
us many ideas regarding the benefits of this work in
supporting expansion of food and nutritional support programs, and think
he made many important arguments as to why policymakers should
be sounding the alarm to not cut these benefits but
instead expand them. This would seem a fairly inexpensive and
(26:30):
effective intervention that could have a massive positive impact on
the health of our young people well into adulthood, and
in so doing have a similarly massive impact and reducing
cost for healthcare, which is something that I think all
people on all sides of the aisle can agree upon.
There's much to think about, and I will certainly replace
some of this interview to remind myself of many of
(26:52):
the important points that doctor Shaw made. I hope you
enjoyed his comments as much as I do, and I'd
again like to thank him for taking time from his
very busy schedule to speak with us this week on Pedihart.
To end today's three hundred and forty second episode of
Peedihart Pediatric Cardiology, Today we remember the great Peruvian tenor
Luigi Alva, who was a fixture of operatic stages from
(27:13):
the nineteen fifties through nineteen eighties, singing mostly light tenor
leading roles in composers like Rossini, Donizetti, and Mozart. Alva
died last week on May fifteenth, at the age of
ninety eight in Milan. Today we hear an example of
his art in this live nineteen sixties performance of Mozart's
Don Giovanni singing the fiendishly difficult Il Mio Tizoro from
(27:36):
this opera. Thank you for joining me for this week's episode,
and thanks once again to doctor Shah. I hope I'll
have a good week ahead.
Speaker 5 (27:43):
Hell miotisart on on HRC shi Chi Shall we call?
Speaker 4 (28:18):
Shall we go? O?
Speaker 5 (28:24):
God chan supa sweet large well made card, Your barble,
(28:54):
your barble, dister wity a boggy see by your thought
see into an on on so devililype for oh che
(30:11):
shood je su he either sweep ah many card you
(30:37):
apoblem a by god.
Speaker 2 (30:53):
It so.
Speaker 1 (30:58):
You you oh, no Lord, your nor.
Speaker 5 (31:09):
A body. It's all a gymon on your body, say,
oh your body
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