Food Insecurity is Associated with COPD Prevalence and Mortality: Evidence from U.S. County-Level Data

RATIONALE: Although unreliable access to healthy food has been linked to lower lung function, a higher burden of respiratory symptoms, and more frequent respiratory exacerbations in individuals with COPD, its association with COPD prevalence and mortality remains understudied. OBJECTIVE: To determine the associations between food insecurity and COPD prevalence and COPD mortality at the county level in the United States. METHODS: We obtained 2018 U.S. county-level data on food insecurity prevalence (FI%) and the Food Environment Index (FEI; lower values indicate worse food desert conditions) from County Health Rankings. We then queried the CDC's National Environmental Public Health Tracking and WONDER databases for county-level COPD prevalence (2018) and COPD-related mortality (2018-2020), respectively. We constructed negative binomial regression models adjusted for demographic, socioeconomic, and health factors to examine the associations of FI% and FEI with COPD prevalence and mortality. The mortality model was additionally adjusted for county COPD prevalence. RESULTS: Counties with FI% at or above the median (13.2%) and those with FEI below the median (7.6) had lower median household income, lower primary care physician density, higher average daily PM2.5 concentration, and higher prevalence of poverty, uninsured status, rural residence and cigarette smoking (P < .001 for all analyses). In fully adjusted models, a 1% higher FI% was associated with a 1.62% higher COPD prevalence (95% CI 1.40-1.83%; P < .001), and a 1-unit lower FEI was associated with a 1.85% higher COPD prevalence (95% CI 1.17-2.54%; P < .001). A 1% higher FI% was independently associated with a 3.54% increase in COPD-related mortality (95% CI 2.86-4.22%; P < .001), and a 1-unit lower FEI with a 10.05% increase in COPD-related mortality (95% CI 7.82-12.27%; P < .001). CONCLUSION: Unreliable food access is associated with higher COPD prevalence and mortality at the county level. These results suggest that improving food access may be a target for improving population-level COPD outcomes.