https://orcid.org/0000-0002-1154-8974
Figures
Abstract
Limited evidence exists on the association between food insecurity (FI) and the hypertension care cascade in the Caribbean despite the high burden of both. The objective of this study is to examine the relationship between FI and hypertension prevalence, awareness, and control in the Eastern Caribbean. We conducted a cross-sectional analysis of baseline data (2013–2018) from the Eastern Caribbean Health Outcomes Research Network Cohort Study (n = 2961). Food insecurity was measured using the Latin American and Caribbean Food Security Scale (ELCSA) and classified as secure, mild, moderate, and severe. Hypertension was defined using guidelines from the Seventh Report of the Joint National Committee on Prevention and Caribbean Health Research Council. Poisson regression was used to estimate prevalence ratios for the association between FI and hypertension prevalence, awareness, and control, adjusting for covariates. Overall prevalence of FI was 28 percent in our sample. Seventeen percent experienced mild, 6 percent moderate, and 4 percent experienced severe FI. Fifty-eight percent had hypertension, 65 percent were aware of their hypertension, and among those aware, 56 percent had uncontrolled hypertension. Model results showed no association between FI and hypertension prevalence and awareness. Results for control showed moderate FI (PR = 1.33, CI = 1.09–1.64) and severe FI (PR = 1.30, CI = 1.05–1.62) were associated with 30 percent higher prevalence of uncontrolled hypertension compared to those who are food secure. Sex-stratified results showed women with moderate (PR = 1.39, CI = 1.13–1.71) and severe FI (PR = 1.41, CI = 1.16–1.72) had 40 and 41 percent higher prevalence of uncontrolled hypertension compared to food secure women, respectively. Results for men were not statistically significant. Findings align with prior evidence of greater FI prevalence among women and associations with hypertension control. Nutrition policies are needed to reduce FI prevalence and increase access to affordable, nutritious foods. Results warrant further studies to understand sex differences in FI prevalence and the impact on hypertension.
Citation: Oladele CR, Khandpur N, Galusha D, Nair S, Hassan S, Wambugu V, et al. (2025) Food insecurity and hypertension prevalence, awareness, and control in the Eastern Caribbean Health Outcomes Research Network Study. PLOS Glob Public Health 5(5): e0003296. https://doi.org/10.1371/journal.pgph.0003296
Editor: Farzana Kapadia, New York University, UNITED STATES OF AMERICA
Received: May 30, 2024; Accepted: March 20, 2025; Published: May 5, 2025
Copyright: © 2025 Oladele et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: At the time that this cohort was empaneled, the public sharing of data was not anticipated. We therefore did not indicate to any of the five Institutional Review Boards we applied to for ethical approval, that we would be sharing data. Our informed consent form stated specifically: “Only aggregated (everybody who participates will have their information joined together so no one person can be identified) anonymous (no names) data will be presented in any publicly disseminated materials”. We believe making data in a non-aggregated form freely available in a public repository will breach this commitment and the IRB approvals we obtained. The corresponding author had full access to all the data in the study and takes responsibility for its integrity and the data analysis. Data can be requested through The ECHORN Data Access and Scientific Review (DASR) committee via our website (https://www.echorn.org/request-echorn-data) or via email to the ECHORN Coordinating Center: ecc@yale.edu.
Funding: This work was supported by the National Institutes of Health: National Heart, Lung and Blood Institute (1K01HL145347-01A1 to CO) and National Institute on Minority Health and Health Disparities (Yale-TCC—U54MD010711 to MNS; ECHORN—U24MD006939 to MNS). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Food insecurity (FI) is defined by the World Health Organization (WHO) as when all people at all times have physical, social, and economic access to sufficient, safe, nutritious food that meets their dietary needs and food preferences [1]. Estimates from the Food and Agriculture Organization of the United Nations (FAO) show that 2.3 billion people (29%) experienced moderate or severe food insecurity in 2021 [2]. Evidence also shows a widening gender disparity in the prevalence of FI [2]. FI has increased during the last ten years, with much of the increase stemming from the COVID-19 pandemic. An estimated 41 percent of Caribbean households experienced food insecurity in 2020, an increase from 32 percent pre-pandemic [3]. There has also been a 38 percent increase in the number of people who reported going without food for an entire day between 2021 and 2022 [4]. FI is associated with cardiovascular risk factors, including hypertension [5,6]. In the Caribbean region, hypertension prevalence ranges 18–38 percent and is a leading cause of morbidity and a primary risk factor for heart disease and stroke, both leading causes of death in the Caribbean [7,8].
While findings are mixed, some evidence shows FI is positively associated with hypertension and poor hypertension control. Studies show FI is associated with higher systolic blood pressure and higher odds of hypertension compared to those without FI, independent of demographic, economic, and lifestyle risk factors [5,9–11]. This positive association has been demonstrated across population groups and varied methods of assessing hypertension. Studies also show that individuals with FI are less likely to achieve hypertension control and adhere to medication regimens compared to those who are food secure [10,12]. Women are also more likely to experience FI and related negative health consequences compared to men. Though fewer studies focus on hypertension compared to other outcomes, findings are consistent with evidence for outcomes like diabetes and obesity that demonstrate negative health impacts of FI. Most of the existing evidence, however, is concentrated in the US and other areas within the Americas. Limited research has been conducted in the Caribbean, leading to significant knowledge gaps in the region.
Several factors have been identified as important contributors to FI in the Caribbean. These include strong reliance on imported food, poverty, and climate change impacts [13]. Countries in this region import 60–90 percent of their food [14–16]. The high reliance on imported food contributes to FI as these foods tend to be expensive, have limited nutritional value, and are oftentimes ultra-processed. Prior work in the Eastern Caribbean showed affordability as a main determinant of fruit and vegetable consumption, primarily affecting individuals who experienced FI [17]. Increasing poverty due to weak economic markets and joblessness has also been correlated with higher prevalence of FI [18]. Extreme weather events due to climate change have affected food production and availability in the region, leading to increased reliance on food imports [13]. These interrelated factors have wide-ranging consequences, including poor dietary quality—a major risk factor for diet-sensitive diseases like hypertension— and increased difficulty in managing risk factors like hypertension according to clinical guidelines. [19]. Given the dual burden of FI and hypertension, evidence of negative health consequences, and paucity of evidence in the region, we aimed to explore the relationship between food insecurity and the hypertension cascade, including prevalence, awareness, and control.
Methods
Data source and study sample
We analyzed baseline data from the Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS) for this cross-sectional study. The ECS is an ongoing longitudinal cohort study conducted across four Caribbean sites that aims to identify novel risk and protective factors for non-communicable diseases in the Eastern Caribbean region. The sites included are the U.S. Virgin Islands, Puerto Rico, Trinidad and Tobago, and Barbados. The cohort was empaneled between 2013 and 2018 across the four sites using varied sampling methods to obtain randomized samples in each site (n = 2,961)[20]. Eligible participants were English or Spanish-speaking community-dwelling adults 40 years of age and older who had been residents of the island for at least 10 years and intended to live on the island for the next 5 years. Participants completed a self-administered health survey including items about demographic, lifestyle, and chronic disease risk factors. They also underwent clinical examinations. Details about the ECS study methodology have been previously published [20]. ECS participants were included in the current study if they had complete blood pressure and food insecurity data at baseline. Access to ECS data can be found online at ECHORN.org [21].
Measures
Our main exposure was food insecurity which was measured using the 9-item version of the Latin American and Caribbean Food Security Scale (ELCSA) previously validated in the Caribbean [22]. The ELCSA captured household food insecurity within the past 90 days. Response options were binary (yes/no), and one point was given for each question with a “yes” response. Responses were summed for each participant and ranged from 0 to 9. Those who scored 0 were classified as having no food insecurity, 1–6 as having mild/moderate food insecurity, and 7–9 as having severe food insecurity. The ninth ELCSA item addresses the social acceptability dimension of FI and was included as part of ELCSA’s summative score based on psychometric testing. Rasch’s modeling of the ELCSA scale in the ECS sample indicated that the full 9-item scale was the best fit [23]. The Cronbach’s Alpha for the scale was 0.90.
Our outcomes were hypertension prevalence, awareness, and control. Hypertension was defined using guidelines established by the Seventh Report of the Joint National Committee [24] and Caribbean Health Research Council [25], which were clinical guidelines used to identify hypertension during the period ECS data were collected. Hypertension was assessed using self-reported and clinical assessment data. Details about the clinical assessment processes have been previously described [26]. Participants were classified as having hypertension if they had systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg during the clinical exam or answered “yes” to the following question, “Has a doctor or other health provider EVER told you that you have high blood pressure?” and reported taking blood pressure lowering medication. Participants who responded “no” to this question and had blood pressure <140 mmHg and diastolic blood pressure < 90 mmHg were classified as not having hypertension.
Hypertension awareness was determined by the question, “Has a doctor or other health provider EVER told you that you have high blood pressure?” Those who responded “yes” and reported taking blood pressure lowering medication were categorized and defined as “Aware.” Participants who responded “no” and had elevated systolic or diastolic blood pressure during the clinical exam were categorized as “unaware.” Hypertension control was determined among those who were aware and reported taking medication. Control was assessed using blood pressure values from the clinical exam and defined as having systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg.
Potential confounders examined included demographic characteristics, healthcare utilization, and site. Demographic characteristics included age, sex, and educational attainment, which were measured via self-report during the ECS baseline survey. We categorized age into four groups (40–49, 50–59, 60–69, and 70+). Sex was measured on the baseline survey using the following question, “What sex were you at birth?” Educational attainment was measured using the question, “What is the highest year of school that you completed?” Responses were categorized into less than high school (or secondary school), high school graduate, some college, and college and higher. Usual source of care was used to characterize healthcare utilization and was measured using the question, “Is there one place you usually go when you need routine or non-emergent/non-emergency care (for example, regular check-up)”? Responses were categorized into three categories: none, one, or more. For analysis, usual source of care responses were categorized into two categories: none and one or more due to the low frequency of responses that indicated having two or more usual sources of care. Similar to prior study approaches [27–29], variables along the causal pathway were not included as covariates, as this may obscure the relationship between FI and hypertension prevalence, awareness, and control and result in overadjustment.
Statistical analysis
Univariate analyses were conducted to examine the frequencies and distribution of variables. We conducted bivariate analyses using chi-square tests to examine associations between FI, demographic, and healthcare characteristics. Poisson regression was used to estimate prevalence ratios and determine unadjusted and adjusted associations between FI and hypertension prevalence, awareness, and control. Adjusted models included age, sex, educational attainment, site, and usual source of care. These covariates were selected based on evidence from prior literature [30–32]. Sex-stratified modeling was performed to determine potential differences in the impact of FI for men and women. Analyses were conducted using SAS statistical software, version 9.4 (Research Triangle Institute, Research Triangle Park).
Ethics statement
The ECS study was approved by the Yale University Human Subjects Investigation Committee (protocol 2000026077), the Institutional Review Boards of the University of Puerto Rico Medical Sciences Campus (protocol 2290033151R001), the University of the Virgin Islands (protocol 460911–18), and the University of the West Indies Cave Hill Campus (IRB Number: 171102-A), as well as by the Ministry of Health of Trinidad and Tobago. Formal written consent was obtained from study participants. The current analysis was approved by the Data Access and Scientific Review Committee of the ECS. This study was reported according to STROBE guidelines.
Results
Our final analytic dataset included 2,323 observations. We excluded 638 participants with missing FI and blood pressure data (Fig 1). The mean age of participants was 57. Sixty-five percent of participants were women, 35 percent had less than a high school education, and most (85%) had one or more usual places where they received healthcare. The overall prevalence of FI was 28 percent among participants, and prevalence was higher in Puerto Rico and Trinidad and Tobago compared to other sites. Among those with FI, 17 percent experienced mild FI, 6 percent moderate FI, and 4 percent experienced severe FI.
Bivariate analyses showed statistically significant differences in FI by age, sex, educational attainment, and site (Table 1). Those living in households with moderate or severe FI were younger compared to those who were living in households that were food secure or had mild FI. Women and those with less than a high school education were more likely to experience mild, moderate, or severe FI compared to men and those with higher educational attainment (p < 0.05).
Table 2 presents prevalence and prevalence ratio estimates for the relationship between FI and hypertension prevalence, awareness, and control. Hypertension prevalence was 54 percent among persons with mild FI, 51 percent for moderate FI, and 52 percent for persons with severe FI. Unadjusted and adjusted model results for FI and hypertension prevalence were not statistically significant.
Results for lack of awareness showed that 35 percent of those who lived in food-secure households and 39 percent of mild food-insecure households were unaware of their hypertension, compared to 32 percent and 36 percent among those with moderate and severe FI. Unadjusted and adjusted model results showed that FI was not significantly associated with lack of awareness of hypertension. Results for lack of hypertension control showed that 57 percent of households with mild FI, 68 percent of those with moderate FI, and 74 percent of those with severe FI did not have their hypertension controlled, compared to 57 percent among persons who were food secure. Unadjusted model results showed mild and moderate FI were not significantly associated with lack of hypertension control. However, results for severe FI were statistically significant and showed individuals in severely FI households had 30 percent higher prevalence of uncontrolled hypertension compared to those in food secure households (CI = 1.05–1.61). Adjusted model results were similar and showed moderate and severe FI was associated with 33 percent (PR = 1.33 (1.09–1.64)) greater prevalence of uncontrolled hypertension compared to those who were food secure.
Table 3 presents sex-stratified model results. Results showed that overall, women who experienced moderate or severe FI were more likely to have hypertension and lack control compared to men. Fifty-four and 58 percent of women with moderate and severe FI had hypertension, compared to 40 percent among men with moderate and severe FI. Similarly, results for lack of hypertension control showed that women with moderate (72% vs. 43%) and severe FI (81% vs. 50%) were more likely to lack control of their hypertension compared to men. Unadjusted and adjusted model results showed statistically significant positive associations between moderate and severe FI and lack of control of hypertension for women. Adjusted model results showed that women with moderate and severe FI had 40 percent higher prevalence of uncontrolled hypertension. Results for men were not statistically significant.
Discussion
This study aimed to determine the relationship between FI and hypertension prevalence, awareness, and control in the Eastern Caribbean. Our findings showed that FI prevalence was 28 percent and 10 percent of those households experienced moderate or severe FI. Findings also showed sex differences in experiences with FI and the relationship between FI and hypertension control. Women were more likely to experience food insecurity, and a higher proportion of women with FI had hypertension compared to men. Findings also showed a statistically significant and positive association between FI and uncontrolled hypertension among women. Results for FI and hypertension prevalence and awareness were not statistically significant. These findings further substantiate FI as a significant public health issue in the Caribbean and demonstrate its role in poor blood pressure control. In addition, our findings highlight the differential impact of FI on health outcomes among women. This study contributes to a growing evidence base on the health impacts of FI in the Caribbean, where evidence is limited yet needed to guide the creation of region-specific solutions.
Our finding of an association between FI and poor blood pressure control is novel within the Caribbean context, where few studies have examined FI and chronic diseases like hypertension. While prior studies have examined associations between FI and chronic diseases, the preponderance of evidence focuses on outcomes including diabetes, obesity, and dietary quality [33,34]. Fewer studies have examined the association between FI and hypertension or examined the role of FI in poor blood pressure control, even though it has been linked to poor dietary quality, which is known to impact hypertension control [5,35]. A recent systematic review of FI and hypertension only included 36 articles, demonstrating the paucity of evidence.
This study contributes to a growing yet mixed body of evidence on the relationship between FI and hypertension. Our results align with most prior studies, which fail to demonstrate a statistically significant association between FI and hypertension irrespective of the methods used to ascertain hypertension (e.g., self-report, clinical measures)[5,6]. While most study findings are negative, some studies that assess hypertension via self-report show statistically significant associations between FI and hypertension [5,36,37]. Evidence on the relationship between FI and hypertension awareness and control is limited. Studies that have examined FI and hypertension control association show positive associations and that individuals who experience FI are more likely to lack control of their hypertension [5,35,38,39]. Potential mechanistic pathways to explain the association between FI and poor blood pressure control include poor dietary quality, inflammation, and gut microbiome disruptions [40–42]. Social and structural factors that co-occur with FI may also explain the association. Lived experiences that include negative social and structural determinants like underemployment, unemployment, poverty, unstable housing, lack of social support, and poor quality of care can compound experiences of FI and contribute to poor hypertension control [43,44].
Findings on sex differences in FI prevalence and the differential impact of FI on blood pressure control among women are also consistent with prior studies. The consistency of these findings spans context, culture, race, and ethnicity. Several explanations have been offered. Gendered roles and inequities in earning power and household responsibilities are some explanations for the observed differences in FI between men and women [45]. In most cases, women are responsible for food purchasing and preparation. Some evidence suggests that women are more likely to sacrifice in households experiencing FI by employing strategies like reducing food consumption, reducing the diversity of foods they consume, and consuming cheaper energy-dense foods to provide for others in the household [45]. Evidence also suggests women are less likely to absorb economic and household shocks related to FI due to inequities in access to assets and resources to cope with FI [46]. Mounting evidence that shows sex differences in the relationship between FI and obesity [47–49], a risk factor for hypertension, may offer yet another explanation. Evidence shows a positive relationship between FI and obesity among women [50,51] but not men, which may complicate hypertension control among women with FI [52].
The current findings are generalizable to populations represented in the ECHORN sites and have several implications. The high burden of FI across the region and the demonstrated association with poor blood pressure control suggest an urgent need for policy and healthcare system interventions. A recent review of nutrition interventions and policies in the small island developing states, including those in the Caribbean, highlighted the paucity of nutrition policies in the region and the overall low proportion of states where policies were fully implemented [53].
Limitations
This study has a few limitations. The cross-sectional design of our study precludes the ability to make inferences about temporality in the relationship between FI and hypertension. This may have contributed to our inability to observe a relationship between FI and hypertension prevalence and awareness. The small sample size available to examine associations between moderate and severe FI and hypertension outcomes may have precluded the ability to detect statistically significant differences despite observing significant prevalence ratios for outcomes like lack of hypertension control. Given the age of our cohort and findings that show higher FI among younger persons, our study may underestimate the overall true burden of FI in the Caribbean region. Despite these limitations, findings remain salient to efforts to reduce FI and improve blood pressure control in the region. Future studies will seek to identify food environment and healthcare system solutions that can reduce FI and improve blood pressure control among individuals experiencing FI.
Conclusions
This study highlights the high burden of FI in the Caribbean and sex differences in the association between FI and poor hypertension control. Our findings suggest a complex interplay of social, behavioral, and clinical factors that may hinder women’s ability to achieve blood pressure control. Our study findings have implications for nutrition policies to reduce FI burden and healthcare system solutions to identify and address factors, including FI, that contribute to poor blood pressure control. Finally, studies are needed to identify and understand factors that explain sex differences in the association between FI and hypertension.
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