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Food insecurity and housing instability as determinants of cardiovascular health outcomes: A systematic review

      Highlights

      • This systematic review finds housing and food insecurity are major correlates of adverse cardiovascular health outcomes.
      • Housing instability and food insecurity are independently associated with many CVD-subtypes related outcomes.
      • Future studies should focus on effectively capturing SDOH in CVD patients and on longitudinal studies.
      • The impact of outine screening for SDOH on improved cardiovascular health should be tested.

      Abstract

      Aims

      The primary objective of this study is to conduct a systematic review of existing literature on the association between food insecurity and housing instability with CVD and its subtypes-related outcomes. Summarizing the comprehensive evidence for independent/interchangeable relationship of food and housing instability with CVD outcomes may inform specific interventions strategies to reduce CVD-risk.

      Data synthesis

      The search focused on English-language articles in PubMed/Medline, from January 1, 2010, to June 1, 2021, with restriction to the US adult population. We included studies estimating the association between food insecurity or/and housing instability(exposure) and CVD-subtypes-related health outcomes (outcome). The study methodological quality was assessed using the Study Quality Assessment Tools (SQAT). Nineteen studies met eligibility criteria, consisted of 15 cross-sectional and 4 cohort studies. Of total studies, 7 examined housing instability, 11 studies focused on food insecurity, and one examined both. Food insecurity/housing instability was associated with increased overall CVD-mortality rate and greater healthcare cost utilization, while evidence were mixed for hospital readmission rate. By subtype, stroke mortality was greater with food insecurity but not with housing instability. The likelihood of myocardial infarction, coronary heart disease, and congestive heart failure was greater with food insecurity. Although mortality with MI was higher with housing instability, readmission and surgical procedure rates were significantly lower than housing stable adults.

      Conclusion

      Findings from this review suggest an urgent need to test the impact of screening for food and housing insecurities, referral services, and community engagement for CV health, within clinical and public health settings.

      Protocol registration

      Prospero CRD4202123352.

      Keywords

      1. Introduction

      Traditional efforts to improve health in the United States have been driven by attention on fixing the health care system. Other approaches have a wider focus to also address social, economic, and environmental factors that influence health. Recently, the central importance of the association of social determinants of health (SDOH) with health outcomes specifically in the context of cardiovascular diseases (CVD) was underscored by the American Heart Association (AHA) and the American College of Cardiology in their 2019 guidelines for clinical risk assessment [
      • Hammond G.
      • Joynt Maddox K.E.
      A theoretical framework for clinical implementation of social determinants of health.
      ]. However, most studies have addressed SDOH defined as education, socioeconomic status, healthcare access, or racial disparities in CVD [
      • Schultz W.M.
      • Kelli H.M.
      • Lisko J.C.
      • Varghese T.
      • Shen J.
      • Sandesara P.
      • et al.
      Socioeconomic status and cardiovascular outcomes: challenges and interventions.
      ,
      • Rosengren A.
      • Smyth A.
      • Rangarajan S.
      • Ramasundarahettige C.
      • Bangdiwala S.I.
      • AlHabib K.F.
      • et al.
      Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study.
      ,
      • Karnati S.A.
      • Wee A.
      • Shirke M.M.
      • Harky A.
      Racial disparities and cardiovascular disease: one size fits all approach?.
      ,
      • Graham G.
      Disparities in cardiovascular disease risk in the United States.
      ,
      • Parekh T.
      • Desai R.
      • Pemmasani S.
      • Cuellar A.
      Impact of social determinants of health on cardiovascular diseases.
      ,
      • Desai R.
      • Patel U.
      • Parekh T.
      • Hanna B.
      • Sitammagari K.
      • Fong H.K.
      • et al.
      Nationwide trends in prevalent cardiovascular risk factors and diseases in young adults: differences by sex and race and in-hospital outcomes.
      ]. Studies of socioeconomic status have focused largely on income and poverty [
      • Schultz W.M.
      • Kelli H.M.
      • Lisko J.C.
      • Varghese T.
      • Shen J.
      • Sandesara P.
      • et al.
      Socioeconomic status and cardiovascular outcomes: challenges and interventions.
      ,
      Economic stability - healthy people 2030.
      ], whereas more granular measures such as food insecurity, housing instability, have received less attention as drivers of CVD outcomes [
      • Parekh T.
      • Desai R.
      • Pemmasani S.
      • Cuellar A.
      Impact of social determinants of health on cardiovascular diseases.
      ,
      • Jilani M.H.
      • Javed Z.
      • Yahya T.
      • Valero-Elizondo J.
      • Khan S.U.
      • Kash B.
      • et al.
      Social determinants of health and cardiovascular disease: current state and future directions towards healthcare equity.
      ,
      • Parekh T.
      Age-standardized prevalence of social determinants of health and associated race-ethnic disparities in stroke survivors.
      ].
      Although the mortality from CVDs has been declining, the prevalence of CVD in the US is expected to rise by 10% by 2030 [
      • Heidenreich P.A.
      • Albert N.M.
      • Allen L.A.
      • Bluemke D.A.
      • Butler J.
      • Fonarow G.C.
      • et al.
      Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.
      ], with persistent geographic disparities in CVD health [
      • Parcha V.
      • Kalra R.
      • Suri S.S.
      • Malla G.
      • Wang T.J.
      • Arora G.
      • et al.
      Geographic variation in cardiovascular health among American adults.
      ]. This trajectory of CVD burden is possibly the result of a dramatic rise in modifiable risk factors such as obesity, hypertension, diabetes, and physical inactivity over the last three decades. While there is no consensus on the precise cause of the increased CVD burden in the US population, research using comparative risk assessment methods on nationally representative data shows that nearly 45% of cardiometabolic deaths are attributable to poor diets, such as high sodium and processed meat intake, and lower consumption of fruits, vegetables, nuts/seeds, which have also been linked to food insecurity [
      • Micha R.
      • Peñalvo J.L.
      • Cudhea F.
      • Imamura F.
      • Rehm C.D.
      • Mozaffarian D.
      Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States.
      ,
      • Hanson K.L.
      • Connor L.M.
      Food insecurity and dietary quality in US adults and children: a systematic review.
      ,
      • Leung C.W.
      • Epel E.S.
      • Ritchie L.D.
      • Crawford P.B.
      • Laraia B.A.
      Food insecurity is inversely associated with diet quality of lower-income adults.
      ]. Moreover, poor adherence to modifiable risk factors has been linked to food insecurity, indicating a stronger association with cardiovascular health [
      • Eicher-Miller H.A.
      A review of the food security, diet and health outcomes of food pantry clients and the potential for their improvement through food pantry interventions in the United States.
      ,
      • Gundersen C.
      • Ziliak J.P.
      Food insecurity and health outcomes.
      ].
      In 2018, more than 1 in 10 adults were food insecure, and nearly 15% of US adults reported having housing instability (state-variation reported in Supplement 1). A growing body of literature indicates greater cardiometabolic risk from food insecurity and housing insecurity by overlapping pathways from physiological stress response, poor coping mechanisms, and ability to manage chronic conditions [
      • Mario Sims
      • Kershaw Kiarri N.
      • Khadijah Breathett
      • Jackson Elizabeth A.
      • Lewis Lisa M.
      • Mujahid Mahasin S.
      • et al.
      Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association.
      ,
      • Palakshappa D.
      • Ip E.H.
      • Berkowitz S.A.
      • Bertoni A.G.
      • Foley K.L.
      • Miller D.P.
      • et al.
      Pathways by which food insecurity is associated with atherosclerotic cardiovascular disease risk.
      ]. More importantly, evidence also indicates a strong positive correlation between food insecurity and housing insecurity as measures reflecting material hardship [
      • King C.
      Food insecurity and housing instability in vulnerable families.
      ,
      • Kushel M.B.
      • Gupta R.
      • Gee L.
      • Haas J.S.
      Housing instability and food insecurity as barriers to health care among low-income Americans.
      ], and a potential bidirectional relationship [
      • Lee C.Y.
      • Zhao X.
      • Reesor-Oyer L.
      • Cepni A.B.
      • Hernandez D.C.
      Bidirectional relationship between food insecurity and housing instability.
      ]. However, there is a lack of synthesis of recent literature to assess how these two factors, independently and interchangeably, may be associated with CVD outcomes. Existing evidence also varies considerably by CVD outcomes and analytical approaches. In particular, substantial heterogeneity in individual-level cardiovascular events (mortality, myocardial infarction, stroke, coronary heart disease, ischemic heart disease, cardiomyopathy) has not been explored before in the context of both food insecurity and housing instability. With these limitations, the primary objective of this study is to conduct a systematic review of existing literature on the association between food insecurity and housing instability with a range of CVD outcomes. Summarizing the comprehensive evidence for the relationship between food and housing instability with CVD outcomes may inform specific interventions strategies to reduce CVD risk. We additionally provide state-level distribution of these measures, acknowledging pervasive spatial disparities in food and housing instability and CVD mortality. Potential intervention design and policy implications are included in the discussion of the findings.

      2. Methods

      We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format for this review [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ]. The review protocol is registered in PROSPERO (CRD42021233527). The SDOH were selected based on the Healthy People 2020 SDOH Model that includes economic stability as a key dimension. Economic stability includes four sub-domains: poverty, employment, housing instability, and food insecurity []. Considering the substantial evidence on poverty and employment as CVD risk factors [
      • Virtanen M.
      • Nyberg S.T.
      • Batty G.D.
      • Jokela M.
      • Heikkilä K.
      • Fransson E.I.
      • et al.
      Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis.
      ], we narrowed our focus to the other two sub-domains on food insecurity and housing instability. We use three indicators of housing instability (homelessness, housing insecurity, and affordability) from AHA's scientific statement and Healthy People 2020 [
      • Mario Sims
      • Kershaw Kiarri N.
      • Khadijah Breathett
      • Jackson Elizabeth A.
      • Lewis Lisa M.
      • Mujahid Mahasin S.
      • et al.
      Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association.
      ,,]. Food insecurity is defined as the disruption of food intake or eating patterns due to financial issues and other resources []. The following CVD subtype outcome categories were selected: CVD-subtype diagnosis; prevalence and incidence; mortality; post-surgical outcomes; hospitalization; and quality of life.

      2.1 Study selection

      Our inclusion criteria consisted of published original research on associations of housing instability and food insecurity with CVD in adults. Exclusion criteria included: (1) non-human studies, (2) study populations < age18, (3) studies not published in English, (4) studies published outside the United States, (5) reviews, case reports, conference, and letters, (6) studies in which the association between housing instability or food insecurity with CVD was not reported, (7) articles focusing on acquired, congenital, or genetic variants of cardiac conditions, (8) studies classifying race/ethnicity and socioeconomic disparities as pre-existing SDOH, (9) studies with CVD and its subtypes as exposure, and housing instability or food insecurity as outcomes.

      2.2 Data source and searches

      A literature search was conducted via PubMed/Medline to retrieve records using natural language and vocabulary related to housing instability, food insecurity, and cardiovascular disease outcomes from January 1, 2010, to June 1, 2021. The initial search using the terms below in combination with MeSH, title or abstract headings yielded 993 articles. Key search terms included: “homeless,” “housing,” “population density,” “deprived areas,” “urban,” “rural,” “public housing,” “housing affordability,” “housing instability,” “shelter,” “eviction,” “foreclosure,” “rent,” “food insecurity,” “food security,” “food hardship,” “food insufficiency,” “hunger,” “food stress,” “food assistance,” “nutritional status,” “heart disease,” “cardiovascular disease,” “ischemic heart disease,” “myocardial infarction,” “pulmonary heart disease,” “coronary heart disease,” “hypertensive heart disease,” and “stroke.”

      2.3 Data extraction, synthesis, and quality assessment

      The reference lists of identified articles were also searched for relevant articles not identified from the search strategy. Of the initial search of 993 articles, 83 were selected for full-text screening based on strict inclusion and exclusion criteria described above. After initial screening, a full-text review was performed using pre-defined criteria to finalize the articles for the systematic review, resulting in 19 included articles (Fig. 1). We simplified the study findings first by the overall summary of the articles and then by sub-types of CVD and related outcomes. Since we found greater variation in how housing and food insecurities were captured, we also synthesized data sources and approaches to collecting such data for future references. The study methodological quality was assessed by the Study Quality Assessment Tools (SQAT) developed by the National Institutes of Health for observational cohort and cross-sectional studies [
      Study quality assessment tools | NHLBI, NIH.
      ].

      3. Results

      The literature search identified a total of 993 potential studies. After removing duplicates, we reviewed the titles and abstracts of 821 articles and identified 83 studies for inclusion. After a full-text review, 19 of the 83 articles were included in this systematic review. The most common reasons for exclusion were studies not examining housing instability or food insecurity (n = 59), and studies conducted outside of the United States (n = 571).
      The 19 studies consisted of 15 cross-sectional and 4 cohort studies (Table 1). Of the total, two studies focused on hospitalized adults, two studies included homeless adults, one study focused on adults with HIV/AIDS, and one studied adults with obesity. One study specifically focused on individuals of Hawaiian race. Sample sizes ranged from 568 to 1,852,790. Of the total, 12 studies drew data from national, 2 studies from state-level, and 5 studies from county-level datasets or surveys. Overall 12 studies were published on or after 2018 and were conducted at a national level.
      Table 1Summary of included studies.
      Study NameStudy DesignStudy populationSample sizeAge, Mean (SD)Female (%)ExposureGeographic Location
      Baggett et al., 2013 [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ]
      Retrospective CohortHomeless adults aged 18 years or older28,03341.0 (12.4)33.6Housing instability – homelessnessGreater Boston, MA
      Balla et al., 2020 [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]
      CSAdult AMI patients aged 18 years or older.110024157.0 (10.0)N/AHousing instability – homelessnessNationwide
      Banerjee et al., 2021 [
      • Banerjee S.
      • Radak T.
      • Khubchandani J.
      • Dunn P.
      Food insecurity and mortality in American adults: results from the NHANES-linked mortality study.
      ]
      CSAdults 20 years or older25,24746.5 (0.22)52.1%Food insecurityNationwide
      Berkowitz et al., 2014 [
      • Berkowitz S.A.
      • Seligman H.K.
      • Choudhry N.K.
      Treat or eat: food insecurity, cost-related medication underuse, and unmet needs.
      ]
      CSAdults aged 19 years or older with at least one chronic condition.969660.9 (0.2)N/AFood insecurityNationwide
      Berkowitz et al., 2017 [
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ]
      CSAdults aged 19 years or older21,196N/A∼ 51.0Food insecurityNationwide
      Dean et al., 2021 [
      • Dean E.B.
      • French M.T.
      • Mortensen K.
      Food insecurity, health care utilization, and health care expenditures.
      ]
      CSAdults aged 18 years or older13,465N/A52.8Food insecurityNationwide
      Dirmyer et al., 2016 [
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ]
      Retrospective CohortHomeless adults aged 18 years or older85043.8 y29.6Housing instability- HomelessnessNew Mexico
      Ford et al., 2013 [
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ]
      CSAdults aged 20 years or older and free of self-reported cardiovascular disease10,455Median: 43.8 y50.0Food insecurityNationwide
      Garcia et al., 2018 [
      • Garcia S.P.
      • Haddix A.
      • Barnett K.
      Incremental health care costs associated with food insecurity and chronic conditions among older adults.
      ]
      CSAdults 50 years or older with chronic conditions14,879N/A57.0Food insecurityNationwide
      Hessol et al., 2019 [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]
      Retrospective CohortIndividuals diagnosed with HIV/AIDS and death at age 19 years or older4158N/A13.0Housing instability - homelessnessSan Francisco, CA
      Palakshappa et al., 2019 [
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ]
      CSObese adults (BMI≥30) aged 20 years or older920348.5 (16.1)65.4Food insecurityNationwide
      Pollack et al., 2010 [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ]
      CSAdults aged 18 years or older10,006N/AN/AHousing instability- AffordabilityFive counties, PA
      Roncarati et al., 2018 [
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ]
      Prospective CohortAdults aged 18 years or older44544.0 (11.4)27.6Housing instability- homelessnessBoston, MA
      Saiz et al., 2016 [
      • Saiz A.M.J.
      • Aul A.M.
      • Malecki K.M.
      • Bersch A.J.
      • Bergmans R.S.
      • LeCaire T.J.
      • et al.
      Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin.
      ]
      CSAdults aged between 21 and 74 years293541.450.0Food insecurityWisconsin
      Stuppelbeen 2019 [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]
      CSNative Hawaiian Adults aged 18 years or older9907N/A55.6%Housing instability - insecurityNationwide
      Stuppelbeen 2019 [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]
      CSNative Hawaiian Adults aged 18 years or older9907N/A55.6%Food insecurityNationwide
      Sun et al., 2020 [
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ]
      CSAdults 40 years or older27,188N/A∼55%Food insecurityNationwide
      Venci et al., 2018 [
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ]
      CSAdults aged 18 years or older30,010N/A50.6Food insecurityNationwide
      Vercammen et al., 2019 [
      • Vercammen K.A.
      • Moran A.J.
      • McClain A.C.
      • Thorndike A.N.
      • Fulay A.P.
      • Rimm E.B.
      Food security and 10-year cardiovascular disease risk among U.S. Adults.
      ]
      CSAdults aged 19 years or older13,518∼ 40 y50.0Food insecurityNationwide
      Wadhera et al., 2020 [
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ]
      CSAdults aged 18 years or older185279065.1 (14.8)N/AHousing instability- HomelessnessNew York, Massachusetts, Florida
      CS: Cross-sectional; N/A: Not Available.
      Of the 19 included studies, 7 studies examined housing instability [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ,
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ,
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ,
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ,
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ,
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ], 11 studies examined food insecurity [
      • Banerjee S.
      • Radak T.
      • Khubchandani J.
      • Dunn P.
      Food insecurity and mortality in American adults: results from the NHANES-linked mortality study.
      ,
      • Berkowitz S.A.
      • Seligman H.K.
      • Choudhry N.K.
      Treat or eat: food insecurity, cost-related medication underuse, and unmet needs.
      ,
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ,
      • Dean E.B.
      • French M.T.
      • Mortensen K.
      Food insecurity, health care utilization, and health care expenditures.
      ,
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ,
      • Garcia S.P.
      • Haddix A.
      • Barnett K.
      Incremental health care costs associated with food insecurity and chronic conditions among older adults.
      ,
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ,
      • Saiz A.M.J.
      • Aul A.M.
      • Malecki K.M.
      • Bersch A.J.
      • Bergmans R.S.
      • LeCaire T.J.
      • et al.
      Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin.
      ,
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ,
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ,
      • Vercammen K.A.
      • Moran A.J.
      • McClain A.C.
      • Thorndike A.N.
      • Fulay A.P.
      • Rimm E.B.
      Food security and 10-year cardiovascular disease risk among U.S. Adults.
      ], and 1 study examined both as social determinants of cardiovascular outcomes [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ].

      3.1 Housing instability and CVD

      Eight articles were identified that examined housing instability associations with CVD health outcomes (Table 2). Six studies focused on homelessness [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ,
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ,
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ,
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ,
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ], one on housing affordability [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ], and one on housing insecurity [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ], as characteristics of instability. Three studies included 100% homeless population to identify an association with CVD outcomes [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ,
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ]. The prevalence of housing instability ranged from 0.4% to 14% in other studies. Of the total, five studies used administrative data from hospital discharge and readmission [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ,
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ,
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ,
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ], while three studies used survey data [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ,
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ,
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]. Three studies identified housing status from hospital records [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ,
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ], two from self-reported survey questions [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ,
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ], one from a medical record [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ], one from face-to-face encounters [
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ], and one from diagnostic codes [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]. CVD outcomes ranged from mortality, invasive treatment assessment, in-hospital morbidity, 30-day readmission rate, admission cost, healthcare utilization, and CVD as an opportunistic infection. CVD was reported as a leading cause of death among homeless people, with a 2–3 fold higher rate than the general population [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ]. A study from the surveillance of homeless HIV patients reported a 41% lower likelihood of death from ischemic heart disease than non-homeless HIV-positive individuals [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]. Patients with Acute Myocardial Infarction (AMI) who were homeless were also less likely to undergo coronary angiography (38.1% vs 54%, p < 0.001), percutaneous coronary intervention (24.1% vs 38.7%, p < 0.001), or coronary artery bypass grafting (4.9% vs 6.7%, p < 0.001) than the general population [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]. One study found that patients who were homeless were 52% less likely to be readmitted with a primary diagnosis of CVD [
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ], while another study found a higher rate of 30-day readmission (8.3% vs. 6.2%, p < 0.001) than adults with AMI who were not homeless [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]. There was no significant association found between housing affordability and CVD outcomes [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ]. However, individuals reporting housing insecurities had 85% higher odds of CVD (OR = 1.85; 95% CI 1.04–3.28) than housing-secure respondents of the Hawaiian race [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ].
      Table 2Summary of evidence by SDOH and CVD outcomes.
      Common CVD ConditionsAuthor NameData SourceExposure SourceOutcome SourceOutcomes related to CVDAdjusted variablesBiasFindings
      Housing Insecurity
      Overall CVD
      Baggett et al., 2013 [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ]
      BHCHP data linked with MDPH death occurrence files.

      Data year: 2003–2008
      Hospital recordsICD-10 CodesCVD MortalityDemographicsConservative bias: The study included currently and formerly homeless adults, and those who exited homelessness may have a lower mortality rate.

      Not Addressed
      Heart disease accounted for 15.6% of all causes of death overall, and a leading cause of death among 45- 64-year-old homeless with race-adjusted RR 3.5 (95% CI: 2.8–4.3) in men, and RR 3.0 (95% CI: 1.5–6.1) in women than the general population
      Dirmyer et al., 2016 [
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ]
      State HIDD

      Data year: 2010–2012
      Hospital records and Homeless Shelter DirectoryICD-9 CodesCVD related 30-day readmission rateDemographics, length of stay, admissions, discharge statusN/AThe prevalence of CVD was average 6.43% among homeless adults. Patients with CVD were 52% less likely [unadjusted OR 0.48 (95% CI: 0.27–0.84)] to be readmitted. Association was not significant once adjusted
      Hessol et al., 2019 [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]
      SFDPH HIV surveillance registry.

      Data year: 2002–2016
      Medical recordsICD-10 codes and death certificateCVD as opportunistic infection and cause of death in HIV patientsDemographics, a concurrent initial diagnosis of HIV and AIDS, HIV transmission category, income, county of residence at death, year of deathMisclassification bias from death certificate- cause of death.

      Not Addressed
      No significant results were found for mortality due to CVD among homeless individuals with HIV. [unadjusted PR 0.86 (95% CI: 0.71–1.04)]
      Pollack et al., 2010 [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ]
      SPHHS

      Data year: 2008
      Self-reportedSelf-reportedCVD as health measure and healthcare utilizationDemographics, poverty, county of residence, neighborhood safety, quality food access, and a strong social environmentSelection bias: Addressed with propensity score matchingThere was no significant association between housing affordability and heart disease [OR 1.04 (95% CI: 0.73–1.49)]
      Roncarati et al., 2018 [
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ]
      BHCHP data linked with the MDPH death occurrence files, and NDI.

      Data year: 2000–2009
      Face-to-face encounter recordsICD-10 codes and death certificateCVD MortalityAgeSelection bias by enrollment of homeless adults who sought health services.

      Not addressed.
      Higher CVD mortality rates in the unsheltered cohort (18 of 134 deaths [13.4%]) than in the Massachusetts population and in the sheltered adult homeless cohort. Increased SMRs among the unsheltered cohort compared with both the Massachusetts population (SMR, 6.4; 95%CI,3.9–9.9) and the sheltered adult homeless cohort (SMR, 2.4; 95%CI, 1.4–3.7)
      Stuppelbeen 2019 [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]
      BRFSS Survey

      Data year: 2009–2012
      Self-reportedSelf-reportedPrevalence and association with CVDDemographics, number of children in the household, binge drinking, smoking status, body mass index, any exercise in the last 30 days, last doctor checkup, and yearN/ACompared with housing secure respondents, housing insecure NHOPIs had 85% higher odds of CVD [adjusted OR 1.85 (95% CI: 1.04–3.28)].
      Heart Attack/AMI
      Balla et al., 2020 [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]
      NRD

      Data year: 2015–2016
      ICD-9 and ICD-10 code: Z59.0ICD-9/10 codesRates of CVD invasive assessment and revascularization; In-hospital morbidity, mortality, and cost; and 30-day readmission rates and reasons for readmission.DemographicsSelection bias: Addressed with propensity score matching.Homeless patients with AMI hospitalization were less likely to undergo coronary angiography (38.1% vs 54%, p < 0.001), percutaneous coronary intervention (24.1% vs 38.7%, p < 0.001), or coronary artery bypass grafting (4.9% vs 6.7%. p < 0.001). Thirty-day readmission rates were significantly higher in homeless patients (22.5% vs 10%, p < 0.001) than in the general population.
      Wadhera et al., 2020 [
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ]
      SID

      Data year: 2010–2015
      Hospital recordsICD-10 codeIn-hospital CVD mortality; Cost of CVD invasive interventions.Demographics, insurance payer, and clinical comorbiditiesN/AHomeless adults hospitalized for AMI were less likely to undergo coronary angiography compared with non-homeless adults (39.5% vs 70.9%), percutaneous coronary intervention (24.8% vs 47.4%), and coronary artery bypass graft (2.5% vs 7.0%). Risk-standardized mortality was higher for homeless persons with ST-elevation AMI compared with non-homeless persons (8.3% vs 6.2%).
      Ischemic Heart Disease
      Hessol et al., 2019 [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]
      SFDPH HIV surveillance registry. Data year: 2002–2016Medical recordsICD-10 codes and death certificateIschemic heart disease as an opportunistic infection.Demographics, a concurrent initial diagnosis of HIV and AIDS, HIV transmission category, income, county of residence at death, year of deathMisclassification bias from death certificate- cause of death.

      Not Addressed.
      Homeless individuals were 41% less likely [unadjusted PR 0.59 (95% CI: 0.39–0.88)] to die from ischemic heart disease. Association was not significant once adjusted [aPR 0.87 (95% CI: 0.55–1.38)]
      Cardiomyopathy
      Hessol et al., 2019 [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]
      SFDPH HIV surveillance registry.

      Data year: 2002–2016
      Medical recordsICD-10 codes and death certificateCardiomyopathy as an opportunistic infectionDemographics, a concurrent initial diagnosis of HIV and AIDS, HIV transmission category, income, county of residence at death, year of deathMisclassification bias from death certificate- cause of death.

      Not Addressed.
      No significant results were found for mortality due to cardiomyopathy among homeless individuals with HIV. [unadjusted PR 0.89 (95% CI: 0.47–1.66)]
      Stroke
      Balla et al., 2020 [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]
      NRD.

      Data year: 2015–2016
      ICD-9 and ICD-10 code: Z59.0ICD-9/10 codesStroke-related 30-day readmission rate.DemographicsSelection bias: Addressed with propensity score matching.No significant difference was found in clinical stroke as in-hospital outcomes between homeless vs. non-homeless individuals.
      Hessol et al., 2019 [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]
      SFDPH HIV surveillance registry.

      Data year: 2002–2016
      Medical recordsICD-10 codes and death certificateStroke as an opportunistic infectionDemographics, a concurrent initial diagnosis of HIV and AIDS, HIV transmission category, income, county of residence at death, year of deathMisclassification bias from death certificate- cause of death.

      Not Addressed.
      No significant results were found for mortality due to cerebrovascular disease among homeless individuals with HIV [unadjusted PR 0.71 (95% CI: 0.41–1.23)].
      Wadhera et al., 2020 [
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ]
      SID

      Data year: 2010–2015
      Hospital recordsICD-10 codeIn-hospital mortality; Cost of stroke-related invasive interventionsDemographics, insurance payer, and clinical comorbiditiesN/AHomeless adults with stroke were less likely than non-homeless individuals to undergo cerebral angiography (2.9% vs 9.5).
      Food Insecurity
      Overall CVD
      Banerjee et al., 2021 [
      • Banerjee S.
      • Radak T.
      • Khubchandani J.
      • Dunn P.
      Food insecurity and mortality in American adults: results from the NHANES-linked mortality study.
      ]
      NHANES

      Data year: 1999–2010
      Self-reportedICD-10 codeCVD MortalityDemographics, poverty-income ratio, diabetes, CKD, preexisting CVD, and obesityN/AAdjusted HRs for cardiovascular mortality (HR 1.75, 95% CI: 1.19–2.57) were significantly higher among food-insecure individuals
      Berkowitz et al., 2014 [
      • Berkowitz S.A.
      • Seligman H.K.
      • Choudhry N.K.
      Treat or eat: food insecurity, cost-related medication underuse, and unmet needs.
      ]
      NHIS

      Data year: 2011
      Self-reportedSelf-reportedAssociation with history of CVDDemographics, social, and clinical variablesN/AThe prevalence of food insecurity was 4 times higher among adults with CVD [OR 4.25 (95% CI: 3.44–5.24)].
      Dean et al., 2021 [
      • Dean E.B.
      • French M.T.
      • Mortensen K.
      Food insecurity, health care utilization, and health care expenditures.
      ]
      MEPS

      Data year: 2016
      Self-reportedICD-10 codeHealthcare expenditure - overall/outpatient/inpatient/emergency department/drugsDemographics, health insurance, region, SNAP receipt, chronic health conditions.N/ARelative to food-secure households with CVD, very low food secure households with CVD are 1.9% points (AME 0.019, P < 0.001) more likely to have any health care expenditure. Results are not significant for conditional healthcare spending.
      Ford et al., 2013 [
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ]
      NHANES

      Data year: 2003–2008
      Self-reportedSelf-reported10-year cardiovascular disease risk predictionDemographics, health insurance coverage, and alcohol use, clinical profileN/AParticipants aged 30–59 years with very low food security were more likely to have a predicted 10-year cardiovascular disease risk greater than 20% than fully food secure participants (adjusted PR 2.38, 95% CI: 1.31–4.31)
      Saiz et al., 2016 [
      • Saiz A.M.J.
      • Aul A.M.
      • Malecki K.M.
      • Bersch A.J.
      • Bergmans R.S.
      • LeCaire T.J.
      • et al.
      Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin.
      ]
      SHOW

      Data year: 2008–2014
      Self-reportedSelf-reportedIdeal Cardiovascular HealthDemographics, region, military service, and marital status.N/AFood insecurity was associated with being almost half as likely to be in “good” cardiovascular health compared to those who were food secure (OR 0.53, 95% CI: 0.31–0.92)
      Stuppelbeen 2019 [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]
      BRFSS

      Data year: 2009–2012
      Self-reportedSelf-reportedPrevalence and association with CVDDemographics, number of children in the household, binge drinking, smoking status, body mass index, any exercise in the last 30 days, last doctor checkup, and yearN/AFood insecurity was associated with 88% higher odds of CVD (OR 1.88, 95% CI:1.16–3.05) among Whites, and 2-times higher odds (OR 2.08, 95% CI: 1.10–3.78) among NHOPI. Results were not significant for Asians.
      Sun et al., 2020 [
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ]
      NHANES

      Data year: 1999–2014
      Self-reportedICD-10 CodeCVD MortalityDemographics, smoking status, alcohol intake, physical activity levels, total energy intake, and Healthy Eating Index 2010 score.Residual confounding was addressed with propensity score matching.Participants with very low food security had a higher risk of all-cause and cardiovascular disease mortality, with multivariable-adjusted HRs of 1.32 (95% CI, 1.07–1.62), and 1.53 (95% CI, 1.04–2.26), respectively, compared with those with high food security.
      Vercammen et al., 2019 [
      • Vercammen K.A.
      • Moran A.J.
      • McClain A.C.
      • Thorndike A.N.
      • Fulay A.P.
      • Rimm E.B.
      Food security and 10-year cardiovascular disease risk among U.S. Adults.
      ]
      NHANES

      Data year: 2007–2014
      Self-reportedSelf-reported10-year risk for CVD eventAge, sex, race/ethnicity, education, marital status, household income, household SNAP participation, and physical activityBiological data was used to examine CVD risk, to avoid potential biases in self-reported measuresCompared with adults with full food security, those with very low food security had higher odds of ≥20% 10-year cardiovascular disease risk (OR 2.36, 95% CI: 1.25, 4.46)
      Congestive Heart Failure
      Berkowitz et al., 2017 [
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ]
      NHANES

      Data year: 2005–2012
      Self-reportedSelf-reportedAssociation with history of CHFNot clearN/AFood insecurity was greater in participants with congestive heart failure (18.4% vs. 12.1%, p < 0.05)
      Venci et al., 2018 [
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ]
      NHIS

      Data year: 2011
      Self-reportedSelf-reportedPrevalence and association with CHDDemographics, number of children in the household, region of residence, weight, and smoking status.N/AAdults with low food security had 75% higher odds of CHD (OR: 1.75; 95% CIs: 1.37, 2.24) than food-secure adults.
      Coronary Artery Disease/Coronary Heart Disease
      Berkowitz et al., 2017 [
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ]
      NHANES

      Data year: 2005–2012
      Self-reportedSelf-reportedAssociation with history of CHDNot clearN/AFood insecurity was greater in participants with CHD (20.5% vs. 11.9%, p < 0.05)
      Garcia et al., 2018 [
      • Garcia S.P.
      • Haddix A.
      • Barnett K.
      Incremental health care costs associated with food insecurity and chronic conditions among older adults.
      ]
      MEPS linked with NHIS

      Data year: 2013–2015
      Self-reportedSelf-reportedPrevalence and Healthcare cost of CADDemographics, region, poverty level, health insurance status, adult living alone, SNAP participation, year, and chronic conditions.N/AIncremental costs associated with food insecurity among older adults with CHD were $650 (95% CI: −280 to 1680) without any other chronic conditions.
      Palakshappa et al., 2019 [
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ]
      NHANES

      Data year: 2007–2014
      Self-reportedSelf-reportedObesity-related prevalence and association with coronary artery diseaseDemographics, income-to-poverty ratio, smoking status, health insurance, food support program participation.Residual confounding was addressed with propensity score matching.Food insecurity was associated with 50% higher odds of CAD (OR: 1.5, 95% CI: 1.1, 2.0).
      Stroke
      Garcia et al., 2018 [
      • Garcia S.P.
      • Haddix A.
      • Barnett K.
      Incremental health care costs associated with food insecurity and chronic conditions among older adults.
      ]
      MEPS linked with NHIS

      Data year: 2013–2015
      Self-reportedSelf-reportedPrevalence and healthcare cost of strokeDemographics, region, poverty level, health insurance status, adult living alone, SNAP participation, year, and chronic conditions.N/AIncremental costs associated with food insecurity among older adults with stroke was $950 (95% CI: 80 to 1980) without any other chronic conditions.
      Sun et al., 2020 [
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ]
      NHANES

      Data year: 1999–2014
      Self-reportedICD-10 CodeStroke mortalityDemographics, smoking status, alcohol intake, physical activity levels, total energy intake, and Healthy Eating Index 2010 score.Residual confounding was addressed with propensity score matching.Compared with participants with high food security, the multivariable-adjusted Stroke HRs (95% CIs) for participants with marginal food security, low food security, and very low food security were 1.08 (0.59–1.98), 1.35 (0.63–2.90), and 1.76 (0.65–4.77), respectively.
      Venci et al., 2018 [
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ]
      NHIS

      Data year: 2011
      Self-reportedSelf-reportedPrevalence and association with strokeDemographics, number of children in the household, region of residence, weight, and smoking status.N/AAssociation was not significant between food insecurity and stroke [OR: 1.10 (95% CI: 0.82–1.48)].
      Heart Attack/AMI
      Venci et al., 2018 [
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ]
      NHIS

      Data year: 2011
      Self-reportedSelf-reportedPrevalence and association with a heart attackDemographics, number of children in the household, region of residence, weight, and smoking status.N/AAdults with low food security had 40% higher odds of heart attack (OR: 1.40; 95% CI: 1.08, 1.81) than food-secure adults.
      Three studies reported stroke mortality as an outcome among adults who were homeless and not homeless, and found no differences[
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ,
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ,
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ]. However, adults with stroke who were homeless were less likely to undergo cerebral angiography (2.9% vs. 9.5%, p < 0.001) than their counterparts [
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ].

      3.2 Food insecurity and CVD

      Eleven studies assessed the effect of food insecurity on CVD outcomes [
      • Berkowitz S.A.
      • Seligman H.K.
      • Choudhry N.K.
      Treat or eat: food insecurity, cost-related medication underuse, and unmet needs.
      ,
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ,
      • Dean E.B.
      • French M.T.
      • Mortensen K.
      Food insecurity, health care utilization, and health care expenditures.
      ,
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ,
      • Garcia S.P.
      • Haddix A.
      • Barnett K.
      Incremental health care costs associated with food insecurity and chronic conditions among older adults.
      ,
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ,
      • Saiz A.M.J.
      • Aul A.M.
      • Malecki K.M.
      • Bersch A.J.
      • Bergmans R.S.
      • LeCaire T.J.
      • et al.
      Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin.
      ,
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ,
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ,
      • Vercammen K.A.
      • Moran A.J.
      • McClain A.C.
      • Thorndike A.N.
      • Fulay A.P.
      • Rimm E.B.
      Food security and 10-year cardiovascular disease risk among U.S. Adults.
      ,
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]. All studies were conducted using cross-sectional surveys. Of the total, only one study used a state-level health survey [
      • Saiz A.M.J.
      • Aul A.M.
      • Malecki K.M.
      • Bersch A.J.
      • Bergmans R.S.
      • LeCaire T.J.
      • et al.
      Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin.
      ], whereas the other studies used national survey data, mainly National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey (NHANES), Medical Expenditure Panel Survey (MEPS), and Behavioral Risk Factor Surveillance System (BRFSS) (Table 3). The prevalence of food insecurity ranged from 5.7% to 18.8% in these studies. Food insecurity was measured using self-reported survey questions in all studies. Five studies were conducted using NHANES, which measured food insecurity using a validated questionnaire [
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ,
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ,
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ,
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ,
      • Vercammen K.A.
      • Moran A.J.
      • McClain A.C.
      • Thorndike A.N.
      • Fulay A.P.
      • Rimm E.B.
      Food security and 10-year cardiovascular disease risk among U.S. Adults.
      ]. Two studies used NHIS, one used MEPS, and one with BRFSS data, which measured self-reported food insecurity [
      • Berkowitz S.A.
      • Seligman H.K.
      • Choudhry N.K.
      Treat or eat: food insecurity, cost-related medication underuse, and unmet needs.
      ,
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ,
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ].
      Table 3Housing instability and food insecurity database and questionnaires.
      DatabaseQuestionnaire
      Housing Instability
      BHCHPIdentified by the federal definition of homelessness under Boston Health Care for Homeless Program (BHCHP). Unsheltered adults were identified if they reported sleeping outside for 1 or more nights during the survey year and had at least one face-to-face encounter with BHCHP's street team staff on the street or at an outside location during daytime or nighttime clinical session in the same year.

      Source: www.bhchp.org

      Availability – restricted
      NRDICD9 V60.0 & ICD-10 Z59.0 code

      Source: https://www.hcup-us.ahrq.gov/nrdoverview.jsp

      Availability – restricted, purchase required
      HIDDA homeless record was defined by the patient's address; either recorded as “homeless,” “none,” or an address for a shelter in Albuquerque from Homeless Shelter Directory (2015) website.

      Source: https://www.nmhealth.org/about/erd/hsep/hidd/Availability – restricted, purchase required from HCUP
      SFO HIV Surveillance RegistryAn individual is defined as homeless based on federal definition if their periodic review of medical records denote that the patient is not housed or homeless at the time of HIV or AIDS diagnosis, at follow-up, or at death.

      Source: https://www.sfdph.org/dph/comupg/oprograms/HIVepiSec/HIVepiSecReports.asp

      Availability – restricted, access upon request
      Southeastern Pennsylvania Household Health SurveyHousing affordability was assessed with a single item: Housing costs refer to the money that you and your household spend on utility bills, rent, mortgage payments, and property taxes. Overall, how difficult was it for you to afford your housing costs during the past year? Response options were very difficult, somewhat difficult, not very difficult, and not difficult at all.

      Source: https://research.phmc.org/52-project-spotlight/248-southeastern-pennsylvania-household-health-survey

      Availability – restricted, access upon request
      BRFSS“How often in the past 12 months would you say you were worried or stressed about having enough money to pay for your rent/mortgage?” was scored on a 5-point scale from “always” to “never.”

      Source: https://www.cdc.gov/brfss/annual_data/annual_data.htm

      Availability – publicly available to download, free
      SIDHomelessness is directly reported by the hospitals. There is an indicator for each discharge from inpatient hospitals or hospital-affiliated Eds regarding patients' homelessness status.

      Source: https://www.hcup-us.ahrq.gov/sidoverview.jsp

      Availability – restricted, purchase required
      Food Insecurity
      NHIS/MEPS
      • 1.
        I worried whether our food would run out before we got money to buy more.
      • 2.
        The food that we bought just didn't last, and we didn't have money to get more.
      • 3.
        We couldn't afford to eat balanced meals.
      • 4.
        In the last 30 days, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?
      • 5.
        How often did this happen — range 1–30 days
      • 6.
        In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money to buy food?
      • 7.
        In the last 30 days, were you ever hungry but didn't eat because you couldn't afford enough food?
      • 8.
        Sometimes people lose weight because they don't have enough to eat. In the last 30 days, did you lose weight because there wasn't enough food?
      • 9.
        In the last 30 days, did you or other adults in your household ever not eat for a whole day because there wasn't enough money for food?
      • 10.
        How often did this happen — range 1–30 days.
      Source:

      NHIS: https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm

      MEPS: https://www.meps.ahrq.gov/mepsweb/data_stats/download_data_files.jsp

      Availability – publicly available to download, free
      BRFSSHow often in the past 12 months would you say you were worried or stressed about having enough money for nutritious meals? The score ranged on a 5-point scale from “always” to “never.”

      Source: https://www.cdc.gov/brfss/annual_data/annual_data.htm

      Availability – publicly available to download, free
      NHANES
      • 1.
        I worried whether our food would run out before we got money to buy more.
      • 2.
        The food that we bought just didn't last, and we didn't have money to get more.
      • 3.
        We couldn't afford to eat balanced meals.
      • 4.
        In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?
      • 5.
        How often did this happen — almost every month, some months but not every month, or in only one or two months?
      • 6.
        In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money to buy food?
      • 7.
        In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?
      • 8.
        Sometimes people lose weight because they don't have enough to eat. In the last 12 months, did you lose weight because there wasn't enough food?
      • 9.
        In the last 12 months, did you or other adults in your household ever not eat for a whole day because there wasn't enough money for food?
      • 10.
        How often did this happen — almost every month, some months but not every month, or in only one or two months?
      Source: https://wwwn.cdc.gov/nchs/nhanes/Default.aspx

      Availability – publicly available to download, free
      SHOWIn the last 12 months, have you been concerned about having enough food for you or your family? – Yes/No

      Source: https://show.wisc.edu/data/Availability – Restricted, access upon request, free
      BHCHP: Boston Health Care for Homeless Program; MDPH: Massachusetts Department of Public Health; NDI: National Death Index; HIDD: Hospital Inpatient and Discharge Database; HCUP: Healthcare Cost and Utilization Project; SFDPH: San Francisco Department of Public Health; SPHHS: Southeastern Pennsylvania Household Health Survey; BRFSS: Behavioral Risk Factor Surveillance System; NRD: National Readmission Database; SID: State Inpatient Database; NHANES: National Health and Nutrition Examination Survey; NHIS: National Health Interview Survey; MEPS: Medical Expenditure Panel Survey; SHOW: Survey of the Health of Wisconsin.
      All studies measured self-reported CVD outcomes, except two studies measuring with ICD-10 codes. All studies reported a positive association between food insecurity and CVD outcomes. The prevalence of food insecurity was significantly higher among adults with a history of CVD. Overall, food insecurity was associated with 2–4 times greater odds of CVD. One study found 75% higher odds of CHD (OR = 1.75; 95% CI: 1.37–2.24) among adults with low food security. The mean incremental cost of CHD was $650, and $950 for stroke among adults with food insecurity and without any other chronic conditions. Adults aged 30–59 years with food insecurity had a predicted 10-year cardiovascular risk 20% greater than food-secure individuals [
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ]. Of two studies with CVD outcomes based on ICD-10 codes, one reported a 53% greater CVD mortality due to food insecurity compared to food-secure individuals, while the other reported higher healthcare expenditure [
      • Dean E.B.
      • French M.T.
      • Mortensen K.
      Food insecurity, health care utilization, and health care expenditures.
      ,
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ].

      3.3 Quality of studies

      Fifteen studies were assessed as fair quality, and 4 studies as poor quality (Table 4). All studies had a participation rate greater than 50%. Most studies had self-reported exposure of interest (food insecurity or housing instability) prior to CVD outcomes. Moreover, 10 studies also relied on self-reported CVD outcomes. These findings were more common in studies focused on food insecurities. Since many studies were cross-sectional in nature, the designs were weak and lacked a convincing comparison group. Further, the timeframe would not be insufficient to reasonably expect to see any association between food insecurity or housing instability and CVD outcomes. The factors contributing to a fair quality assessment included cohort studies with a reasonable timeframe for someone to expect any association, clearly defined exposures, and outcomes with valid and reliable sources, and attempt to address study biases.
      Table 4Study quality assessment.
      Study1234567891011121314Overall
      Baggett et al., 2013 [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ]
      YYYYYYYNNNYNYYFair
      Balla et al., 2020 [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]
      YYYYYYNNYNYNYYFair
      Banerjee et al., 2021 [
      • Banerjee S.
      • Radak T.
      • Khubchandani J.
      • Dunn P.
      Food insecurity and mortality in American adults: results from the NHANES-linked mortality study.
      ]
      YYYYYNNYYNYNYYFair
      Berkowitz et al., 2014 [
      • Berkowitz S.A.
      • Seligman H.K.
      • Choudhry N.K.
      Treat or eat: food insecurity, cost-related medication underuse, and unmet needs.
      ]
      YYYYYNNYYNYNYYPoor
      Berkowitz et al., 2017 [
      • Berkowitz S.A.
      • Berkowitz T.S.Z.
      • Meigs J.B.
      • Wexler D.J.
      Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005-2012.
      ]
      YYYYYNNNYNYNYNPoor
      Dean et al., 2021 [
      • Dean E.B.
      • French M.T.
      • Mortensen K.
      Food insecurity, health care utilization, and health care expenditures.
      ]
      YYYYNNNYYNYNNYPoor
      Dirmyer et al., 2016 [
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ]
      YYYYYYNNYNYNYYFair
      Ford et al., 2013 [
      • Ford E.S.
      Food security and cardiovascular disease risk among adults in the United States: findings from the National Health and Nutrition Examination Survey, 2003-2008.
      ]
      YYYYYNYYYNYNYYFair
      Garcia et al., 2018 [
      • Garcia S.P.
      • Haddix A.
      • Barnett K.
      Incremental health care costs associated with food insecurity and chronic conditions among older adults.
      ]
      YYYYYNNYYNYNYYFair
      Hessol et al., 2019 [
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]
      YYYNYYYNYNYNYYFair
      Palakshappa et al., 2019 [
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ]
      YYYYYNNYYNYNYYFair
      Pollack et al., 2010 [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ]
      YYYYYNNNYNYNYYFair
      Roncarati et al., 2018 [
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ]
      YYYYYYYNYNYNYYFair
      Saiz et al., 2016 [
      • Saiz A.M.J.
      • Aul A.M.
      • Malecki K.M.
      • Bersch A.J.
      • Bergmans R.S.
      • LeCaire T.J.
      • et al.
      Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin.
      ]
      YYYYYNNYYNYNYYFair
      Stuppelbeen 2019 [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]
      YYYYYNNNYNYNYYPoor
      Sun et al., 2020 [
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ]
      YYYYYNNYYNYNYYFair
      Venci et al., 2018 [
      • Venci B.J.
      • Lee S.-Y.
      Functional limitation and chronic diseases are associated with food insecurity among U.S. adults.
      ]
      YYYYYNYYYNYNYYFair
      Vercammen et al., 2019 [
      • Vercammen K.A.
      • Moran A.J.
      • McClain A.C.
      • Thorndike A.N.
      • Fulay A.P.
      • Rimm E.B.
      Food security and 10-year cardiovascular disease risk among U.S. Adults.
      ]
      YYYYYYYNYNYNYYFair
      Wadhera et al., 2020 [
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ]
      YYYYNNNNYNYNYYFair
      Questions.
      1. Was the research question or objective in this paper clearly stated?.
      2. Was the study population clearly specified and defined?.
      3. Was the participation rate of eligible persons at least 50%?.
      4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?.
      5. Was a sample size justification, power description, or variance and effect estimates provided?.
      6. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?.
      7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?.
      8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as a continuous variable)?.
      9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?.
      10. Was the exposure(s) assessed more than once over time?.
      11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?.
      12. Were the outcome assessors blinded to the exposure status of participants?.
      13. Was loss to follow-up after baseline 20% or less?.
      14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcomes(s)?.
      Of the total, four studies provided information on variance and effect estimates and used propensity score matching to ensure covariate balancing in both treatment and control groups and thus partially controlled for selection bias at least on observable factors [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ,
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ,
      • Palakshappa D.
      • Speiser J.L.
      • Rosenthal G.E.
      • Vitolins M.Z.
      Food insecurity is associated with an increased prevalence of comorbid medical conditions in obese adults: NHANES 2007-2014.
      ,
      • Sun Yangbo
      • Liu Buyun
      • Rong Shuang
      • Yang Du
      • Xu Guifeng
      • Snetselaar Linda G.
      • et al.
      Food insecurity is associated with cardiovascular and all-cause mortality among adults in the United States.
      ]. There was also a high risk of detection bias, as outcome assessors and data analysts were unblinded in all studies. Since most studies used surveys with self-reported measures rather than objective measures, they are also subject to recall and other biases.

      4. Discussion

      This systematic review is the first to synthesize the literature regarding the impact of food insecurity and housing instability on cardiovascular disease outcomes in adults. Of total 19 articles, 7 studies examined housing instability, 11 studies examined food insecurity, and 1 study examined both as social determinants of CVD outcomes. All studies were observational rather than interventional. For the most part, studies were cross-sectional or cohort design, limiting the causal interpretation. Many examined the most extreme forms of housing or food insecurity, limiting their generalizability. However, based on the studies reviewed, there is an association with CVD-related hospitalization, frequent readmission, mortality, invasive procedural outcomes, and cost of care to varying degrees. This suggests that further study is needed on how food insecurity and housing instability as SDOH influence the progression of cardiovascular health and to identify intervention points. One testable intervention approach could be to routinely screen CVD patients for housing and food insecurities across care settings, including annual and routine visits, diabetes or obesity clinics, community health centers, primary care, and specialty practices and to connect patients with food and housing resources where they exist.
      The review findings indicate that CVD is a leading cause of death among individuals who are homeless. Evidence shows that barriers to CVD care in individuals who are homeless are likely to be prevalent, such as locating nightly shelter, necessary clothing, adequate and appropriate food, access to regular health care, and medication adherence [
      • Mario Sims
      • Kershaw Kiarri N.
      • Khadijah Breathett
      • Jackson Elizabeth A.
      • Lewis Lisa M.
      • Mujahid Mahasin S.
      • et al.
      Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association.
      ]. The prevalence of CVD risk factors may also be higher among individuals who confront housing instability [
      • Charkhchi P.
      • Fazeli Dehkordy S.
      • Carlos R.C.
      Housing and food insecurity, care access, and health status among the chronically ill: an analysis of the behavioral risk factor surveillance system.
      ]. One study reported that developing CVD may have led to housing insecurity. However, the cross-sectional nature of this study limits the identification of the possible direction of this relationship. Another study using similar data from BRFSS, examined data on respondents in Hawaii and found that housing insecurity was associated with CVD in native Hawaiian and other Pacific Islanders [
      • Stupplebeen D.A.
      Housing and food insecurity and chronic disease among three racial groups in hawai'i.
      ]. In contrast, a study of Philadelphia metropolitan residents found no association between housing insecurities and self-reported CVD [
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      ]. A study using hospital discharge data from New Mexico state found that patients who were homeless were less likely to be readmitted with a primary diagnosis of CVD [
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ], while another study using national hospital discharge data found a higher rate of 30-day readmission [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ]. Another factor driving readmission and lower surgical rates for individuals who are homeless may be physicians’ concern about lack of medication adherence post-surgery and potential harm [
      • Mario Sims
      • Kershaw Kiarri N.
      • Khadijah Breathett
      • Jackson Elizabeth A.
      • Lewis Lisa M.
      • Mujahid Mahasin S.
      • et al.
      Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association.
      ,
      • Wadhera R.K.
      • Khatana S.A.M.
      • Choi E.
      • Jiang G.
      • Shen C.
      • Yeh R.W.
      • et al.
      Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
      ,
      • Omerov P.
      • Craftman Å.G.
      • Mattsson E.
      • Klarare A.
      Homeless persons' experiences of health- and social care: a systematic integrative review.
      ]. Homeless adults in one study were found to be less likely to undergo cardiac procedures than the general population, which could be attributable to a variety of reasons such as stress, hygiene, and medication adherence challenges [
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ]. In this study the uninsured rate among individuals who were homeless was 4.9%, indicating that financial access to health care was not a barrier for most. However, this study included only three states, Massachusetts, New York, and Florida, and uninsured rates may be higher in other parts of the country, particularly in states that have not expanded Medicaid. Moreover, not all providers participate in Medicaid which covers a disproportionate fraction of adults who are homeless.
      We noted inconsistencies in how housing instability has been measured across the studies. Four studies identified housing instability using hospital records, two used medical records (ICD codes), one used a self-rated survey, and one a face-to-face interview. In contrast, food insecurity measurement was more consistent across studies, mainly because they relied on national survey data. Two major databases, NHIS and NHANES, have consistent 10-item food insecurity measures. In contrast, the BRFSS survey measures food insecurity with one to three questions. However, a study published by the CDC researchers noted greater reliability of the BRFSS food insecurity module when compared with USDA's CPS-FSS measure with the primary purpose of having a concise measure in a single-question format for the benefit of larger health surveys in capturing SDOH [
      • Njai R.
      Prevalence of perceived food and housing security — 15 states, 2013.
      ].
      We also noted a lack of well-designed studies aimed at unraveling causality between food insecurity or housing instability and poor CVD outcomes, which is at odds with the widespread acceptance of these conditions as risk factors for CVD [
      • Havranek Edward P.
      • Mujahid Mahasin S.
      • Barr Donald A.
      • Blair Irene V.
      • Cohen Meryl S.
      • Cruz-Flores Salvador
      • et al.
      Social determinants of risk and outcomes for cardiovascular disease.
      ]. To be more clear, consider the case of food insecurity. In the reviewed studies, food insecurity is interpreted as leading to poor CVD outcomes—meaning, in regression analysis, CVD outcomes are the dependent variable and food insecurity is one of the independent variables. In contrast, several studies have used CVD as a predictor variable and food insecurity as a dependent variable [
      • Charkhchi P.
      • Fazeli Dehkordy S.
      • Carlos R.C.
      Housing and food insecurity, care access, and health status among the chronically ill: an analysis of the behavioral risk factor surveillance system.
      ,
      • Mendy V.L.
      • Vargas R.
      • Cannon-Smith G.
      • Payton M.
      • Enkhmaa B.
      • Zhang L.
      Food insecurity and cardiovascular disease risk factors among Mississippi adults.
      ]. In all reviewed studies, the causal effects of housing instability and food insecurity were not clearly identified after controlling for other observed characteristics from the database. Two studies from the Boston Healthcare for Homeless Program (BHCHP) measured homelessness from a one-time face-to-face encounter with staff members and measured CVD from ICD codes [
      • Baggett T.P.
      • Hwang S.W.
      • O'Connell J.J.
      • Porneala B.C.
      • Stringfellow E.J.
      • Orav E.J.
      • et al.
      Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period.
      ,
      • Roncarati J.S.
      • Baggett T.P.
      • O'Connell J.J.
      • Hwang S.W.
      • Cook E.F.
      • Krieger N.
      • et al.
      Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009.
      ]. One of these two studies controlled only for age, while the other additionally controlled for sex and race. Neither controlled for food insecurity. Future studies should consider strong designs to account for confounding and interactive effects of food insecurity and housing instability on CVD outcomes. Addressing these modifiable risk factors likely to reduce stress and increase medication adherence among other pathways by which food insecurity and housing instability affect CVD health [
      • Mario Sims
      • Kershaw Kiarri N.
      • Khadijah Breathett
      • Jackson Elizabeth A.
      • Lewis Lisa M.
      • Mujahid Mahasin S.
      • et al.
      Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association.
      ,
      • Palakshappa D.
      • Ip E.H.
      • Berkowitz S.A.
      • Bertoni A.G.
      • Foley K.L.
      • Miller D.P.
      • et al.
      Pathways by which food insecurity is associated with atherosclerotic cardiovascular disease risk.
      ].
      One major takeaway from the literature was the lack of interventional studies or strong natural experiments to identify the effects of housing and food insecurities on CVD and related risk factors. There have been many interventions including healthy home education, housing and food vouchers, and affordable housing initiatives to improve overall health [
      • Sandel M.
      • Desmond M.
      Investing in housing for health improves both mission and margin.
      ,
      • Blewett L.A.
      • Owen R.A.
      Accountable care for the poor and underserved: Minnesota's hennepin health model.
      ,
      • Basu S.
      • Gardner C.D.
      • White J.S.
      • Rigdon J.
      • Carroll M.M.
      • Akers M.
      • et al.
      Effects of alternative food voucher delivery strategies on nutrition among low-income adults.
      ], however, we still have not explored the effects of such programs on CVD as a leading cause of death. Future research should consider using longitudinal studies with appropriate methods to address causality.

      4.1 Policy implications

      Our study findings have important implications for clinical practice, research, and policy, as we have identified several unanswered questions. No published studies were identified that addressed the interdependent association of housing and food insecurities with CVD outcomes. While it is likely that individuals who are homeless may suffer from food insecurities [
      • Lee C.Y.
      • Zhao X.
      • Reesor-Oyer L.
      • Cepni A.B.
      • Hernandez D.C.
      Bidirectional relationship between food insecurity and housing instability.
      ,
      • Baggett T.P.
      • Singer D.E.
      • Rao S.R.
      • O'Connell J.J.
      • Bharel M.
      • Rigotti N.A.
      Food insufficiency and health services utilization in a national sample of homeless adults.
      ], these two conditions together could potentially have larger effects on CVD. Although this review considers homelessness, affordability, and insecurity as a measure of instability, it is important to understand that other housing constructs such as quality and safety, accessibility, and neighborhood environment may also influence cardiovascular health outcomes [
      • Mario Sims
      • Kershaw Kiarri N.
      • Khadijah Breathett
      • Jackson Elizabeth A.
      • Lewis Lisa M.
      • Mujahid Mahasin S.
      • et al.
      Importance of housing and cardiovascular health and well-being: a scientific statement from the American heart association.
      ,
      • Lloyd E.L.
      • McCormack C.
      • McKeever M.
      • Syme M.
      The effect of improving the thermal quality of cold housing on blood pressure and general health: a research note.
      ,
      • Chambers E.C.
      • Hanna D.B.
      • Hua S.
      • Duncan D.T.
      • Camacho-Rivera M.
      • Zenk S.N.
      • et al.
      Relationship between area mortgage foreclosures, homeownership, and cardiovascular disease risk factors: the Hispanic Community Health Study/Study of Latinos.
      ,
      • Diez Roux A.V.
      Residential environments and cardiovascular risk.
      ]. The majority of studies have measured housing and food insecurities using valid and reliable survey questions. However, there is no standardized questionnaire or measurement scale, leading to variation in findings. Moreover, none of the studies attempted to capture the duration of housing instability and food insecurity over time. The dimensions of these conditions are measured in a variety of surveys and administrative databases. However, our current measurements are still limited in capturing how people become housing or food insecure, how they move between different types of housing instability or food insecurity, and how they exit from these conditions into a more stable environment. Future efforts should target collecting such information, which could help policymakers and practitioners make decisions about how and where to target resources.
      Public programs like Housing Choice Vouchers and Supplemental Nutrition Assistance Program (SNAP) address housing and food insecurities. However, evidence of their effectiveness relative to CVD is mixed. A prospective study of a large study sample found that individuals participating in SNAP had higher CVD mortality than nonparticipants, highlighting differences in the client characteristics of those who select into these programs [
      • Conrad Z.
      • Rehm C.D.
      • Wilde P.
      • Mozaffarian D.
      Cardiometabolic mortality by supplemental nutrition assistance program participation and eligibility in the United States.
      ]. A report from the Center on Budget and Policy Priorities (CBPP) stated that 75% of low-income at-risk renters do not receive federal rental assistance [
      • Center on Budget and Policy Priorities
      Three in four low-income at-risk renters do not receive federal rental assistance.
      ]. These findings highlight the potential for a broader partnership of healthcare, food, and housing sectors in improving health disparities [
      • Hostetter M.
      • Klein S.
      In focus: hospitals invest in building stronger.
      ,
      • Amarasingham R.
      • Xie B.
      • Karam A.
      • Nguyen N.
      • Kapoor B.
      Using community partnerships to integrate health and social services for high-need, high-cost patients.
      ]. ProMedica, a health system in Ohio and Michigan began screening hospitalized patients for food insecurity with their two-questionnaire screening tool and opened two “food pharmacies,” where food-insecure patients are referred by primary care physicians, and counseled by dietitians [
      • Hostetter M.
      • Klein S.
      In focus: hospitals invest in building stronger.
      ]. Different forms of this innovative approach could be studied in other health systems. Other testable approaches could be financial incentives embedded in the accountable care models and other value-based payments, which are designed to encourage health systems to play a larger role in identifying, referring, and possible directly addressing housing and food challenges [
      Using Medicaid Resources to Pay for Health-Related Supportive Services: Early Lessons
      Cent health care strategy.
      ].
      Several studies recorded housing instability using hospital records or ICD codes, which highlights an opportunity to implement a program or data collection strategy that captures SDOH in electronic health records [
      • Balla S.
      • Alqahtani F.
      • Alhajji M.
      • Alkhouli M.
      Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with Acute myocardial infarction.
      ,
      • Dirmyer V.F.
      The frequent fliers of New Mexico: hospital readmissions among the homeless population.
      ,
      • Hessol N.A.
      • Eng M.
      • Vu A.
      • Pipkin S.
      • Hsu L.C.
      • Scheer S.
      A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco.
      ]. Recent trends in the United States have raised grave concern, as we are witnessing for the first time in decades a decline in the slowdown of CVD mortality against persistent health disparities [
      • Curtin S.C.
      Trends in cancer and heart disease death rates among adults aged 45-64: United States, 1999-2017.
      ,
      • Sidney S.
      • Go A.S.
      • Jaffe M.G.
      • Solomon M.D.
      • Ambrosy A.P.
      • Rana J.S.
      Association between aging of the US population and heart disease mortality from 2011 to 2017.
      ]. One way to tackle this situation would be to reduce the knowledge gap related to successful interventions among vulnerable populations, such as adults who are homeless or food-insecure.

      4.2 Limitations

      The result of this systematic review should be interpreted in the context of the following limitations. First, the search was restricted to studies published in the English language and conducted in the United States only, which limits the generalizability of these findings. Second, the majority of studies were of poor to fair quality, which limits their usefulness in guiding efforts related to CVD. Many of the studies measured exposures and outcomes from self-reported survey questions. However, some of these studies utilized national survey data with validated survey questions. Third, all but 4 studies used a cross-sectional design. While cross-sectional designs are useful in determining the prevalence of exposures in a given population, these studies are limited in their ability to determine predictive and causal relationships. Fourth, owing to the heterogeneity among the included studies (e.g., different CVD outcomes, various sources, variation in SDOH measurement), it was not possible to conduct a meta-analysis.

      5. Conclusion

      Food and housing are the major correlates of adverse cardiovascular health outcomes in adults. This review findings underscore that housing instability and food insecurity are independently associated with many CVD-subtypes related outcomes, including mortality, frequent hospitalizations, readmission, limited invasive procedures, worse outcomes, and greater financial burden and inpatient resource utilization. Future studies should focus on effectively capturing SDOH in CVD patients and conducting longitudinal studies with innovative interventions. Findings from this review suggest an urgent need to test a holistic vision of cardiovascular health with routine SDOH screening and referral services, along with community engagement.

      Disclaimers

      None.

      Funding source

      None.

      Financial disclosure

      No financial disclosures were reported by the authors of this paper.

      Declaration of competing interest

      The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

      Acknowledgments

      During the realization of this work, Tarang Parekh was a research assistant partially supported by the National Science Foundation, Division of Engineering Education and Centers (NSF EES) grant (ID 1840399 , PI Sikdar).

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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