title: Food Insecurity, CKD, and Subsequent ESRD in US Adults.
abstract: BACKGROUND
  Poor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD.
  
  
  METHODS
  Longitudinal cohort study.
  
  
  METHODS
  2,320 adults (aged ≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household income ≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years.
  
  
  METHODS
  Food insecurity, defined as an affirmative response to the food-insecurity screening question.
  
  
  RESULTS
  Development of ESRD.
  
  
  METHODS
  Demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates.
  
  
  RESULTS
  4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts (P<0.05). Median dietary acid load in the food-secure versus food-insecure group was 51.2 mEq/d versus 55.6 mEq/d, respectively (P=0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49).
  
  
  CONCLUSIONS
  Use of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago.
  
  
  CONCLUSIONS
  Among adults with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA. Electronic address: banerjeet@medsfgh.ucsf.edu.
authors.forename: Tanushree
authors.initials: T
authors.lastname: Banerjee
authors.affiliation: Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD.
authors.forename: Deidra C
authors.initials: DC
authors.lastname: Crews
authors.affiliation: Texas A&M College of Medicine and Scott and White Healthcare, Temple, TX.
authors.forename: Donald E
authors.initials: DE
authors.lastname: Wesson
authors.affiliation: Kidney Epidemiology & Cost Center, University of Michigan, Ann Arbor, MI.
authors.forename: Sai
authors.initials: S
authors.lastname: Dharmarajan
authors.affiliation: Kidney Epidemiology & Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Saran
authors.affiliation: Division of Diabetes Translation, Centers for Disease and Control and Prevention, Atlanta, GA.
authors.forename: Nilka
authors.initials: N
authors.lastname: Ríos Burrows
authors.affiliation: Division of Diabetes Translation, Centers for Disease and Control and Prevention, Atlanta, GA.
authors.forename: Sharon
authors.initials: S
authors.lastname: Saydah
authors.affiliation: Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA.
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D018450:Disease Progression; D005260:Female; D005523:Food Supply / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000209:etiology; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology* / Q000209:etiology; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Food insecurity; NHANES; chronic kidney disease (CKD); dietary acid load (DAL); dietary patterns; disease trajectory; end-stage renal disease (ESRD); food deserts; health disparities; incident ESRD; kidney disease progression; modifiable risk factor; nutrient intake; poverty; socioeconomic status