Food Insecurity in Households of Patients with Hypertension and Diabetes

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.


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 sustainable 1 .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 risks [2][3][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)   and arterial hypertension (AH).This compromises quality of life and consequently favors increased risk of morbidity and mortality, mainly from cardiovascular diseases 5 .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 vulnerability 6 .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 diseases 9 .
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.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.

Methods
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.
At first, the participants answered a questionnaire with socioeconomic and demographic questions: age, gender, family income, number of residents per household, 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 E 7,13 .
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 crest 13 .
To diagnosis abdominal obesity, we used the criteria of the International Diabetes Federation (IDF) adopted by the IV Brazilian Guidelines for Dyslipidemia 14 .The normality parameters used for glucose and lipid levels were: blood glucose <100 mg/dL, cholesterol <200 mg/ dL and triglycerides <200 mg/dL 14 .
Diagnosis of overweight/obesity was based on the classification adopted by the Ministry of Health of Brazil for adults and elderly individuals 15 .
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 FI 6 .
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 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 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.

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 groups 8,[16][17][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 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.
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 food [19][20][21][22][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 content [20][21][22][23] .
Another aspect to consider is that individuals with greater social vulnerability, in addition to food insecurity, Food Insecurity in Hypertensive and Diabetic Patients 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 treatment 10,11,24,25 .
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 Sichieri 27 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 ranges 10,27 .According to the I Brazilian Guideline for cardiovascular prevention 28 , 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 treatment 25 .
The unequal distribution of income and access to goods and services resulting from social exclusion compromise diet conditions 15,25 .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 consumption 24,26 .However, the I Guideline on the consumption of fats and cardiovascular health 29 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 mortality 11,19,20,23,26,30 .
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 birth 31 .
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 hypertriglyceridemia 9,11,23,32 .
Constitutional Amendment No. 64 of 2010, Article 6 33 included nutrition as a fundamental right and guarantee; however, nutrition must be in sufficient quantity and quality as established by the 2 nd National Conference on Food and Nutritional Security 1 , 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 version 4,6 , 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. 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.

Figure 1
Figure 1Food 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).
Food Insecurity in Hypertensive and Diabetic Patients

Table 1 Characteristics of the population studied
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.

Table 2 Cardiovascular risk factors prevailing in the population studied according to the levels of food insecurity
*chi-square: p < 0.05 CVRF -cardiovascular risk factors Vasconcelos et al.Food Insecurity in Hypertensive and Diabetic Patients Int J Cardiovasc Sci.2015;28(2):114-121 Original Manuscript