Association Between Food Insecurity and Hypertensive Disorders of Pregnancy Among Participants in the All of Us Research Database

Background: Hypertensive disorders of pregnancy (HDP) are important contributors to maternal morbidity and mortality in the United States. Food insecurity may influence maternal cardiovascular health through inadequate nutrition, chronic stress, and limited access to health-promoting resources. However, evidence regarding the relationship between food insecurity and HDP remains limited.

Objective: To examine the association between food insecurity and HDP among pregnant participants in the National Institutes of Health All of Us Research Program.

Methods: This retrospective cohort study analyzed electronic health record and survey data from the All of Us Research Program. Food insecurity was assessed using the two-item Hunger Vital Sign and categorized as food secure or food insecure. An exploratory burden score classified participants as food secure or as having lower, moderate, or higher food-insecurity burden. The composite HDP outcome included chronic hypertension during pregnancy, gestational hypertension, preeclampsia-eclampsia, and preeclampsia superimposed on chronic hypertension. Participant characteristics were summarized by HDP status. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Adjusted models included race, ethnicity, education, diabetes, and smoking history.

Results: The analytic sample included 14,339 participants, of whom 3,849 (26.8%) were classified as food insecure and 957 (6.7%) had HDP. Among participants with HDP, 239 (25.0%) were food insecure, compared with 3,610 (27.0%) of those without HDP. Food insecurity was not significantly associated with HDP in the unadjusted model (OR = 0.90; 95% CI: 0.77–1.05; p = 0.177) or adjusted model (adjusted OR [aOR] = 0.94; 95% CI: 0.80–1.12; p = 0.506). In the exploratory burden analysis, lower burden (aOR = 0.92; 95% CI: 0.70–1.20; p = 0.565) and moderate burden (aOR = 1.11; 95% CI: 0.90–1.38; p = 0.323) were not significantly associated with HDP. Higher burden was associated with lower odds of HDP (aOR = 0.70; 95% CI: 0.51–0.94; p = 0.022).

Conclusion: Binary food insecurity was not significantly associated with HDP after adjustment for selected demographic and clinical characteristics. The unexpected association observed for the higher-burden category was not accompanied by a dose-response pattern and should be interpreted cautiously. Additional research using pregnancy-specific timing, validated exposure classifications, and additional maternal risk factors is needed to clarify the relationship between food insecurity and HDP.