Hypertension is a major risk factor for cardiovascular disease and the leading cause of death for Black women in the United States.1–3 According to the Cardiovascular Lifetime Risk Pooling Project, nearly all Black women will likely develop hypertension during their lifetime. The lifetime risk for hypertension, when using American Heart Association guidelines, from ages 20 to 85 years was 85.7% for Black women compared with 69.3% for White women in 2020.2 Furthermore, Black women are less likely to have controlled hypertension (48.5%) compared with their White counterparts (57.1%).4 Dietary behavior, access to healthy foods, access to preventative care, and the patient-provider relationship have contributed to uncontrolled hypertension for Black women.5–7
Changing dietary behavior is a significant lifestyle modification, and it has been shown to reduce hypertension incidence and prevalence, particularly through the adoption of the Dietary Approaches to Stop Hypertension (DASH) diet. In 2021, the American College of Cardiology revised its guidance to recommend lifestyle modifications for those with elevated blood pressure (>120–129/<80 mm Hg) and with stage 1 hypertension for those who do not have a history of atherosclerotic cardiovascular disease and a 10-year atherosclerotic cardiovascular disease risk of less than 10%.8 The DASH diet, rich in fruits and vegetables and low in sugar-sweetened beverages, plus reduced sodium intake (<2300 mg per day) is associated with lower blood pressure, especially for those with elevated blood pressure and stage 1 hypertension.9 In the DASH-Sodium study, a reduced sodium DASH diet with sodium intake of less than 1200 mg per day had a greater effect on Black adults than White adults in reducing systolic blood pressure, making the DASH diet an excellent option for slowing the progression of hypertension for Black women with elevated or stage 1 hypertension.9
Racial disparities along with dietary patterns play an important role in hypertension risk and control. It has been reported that Black women are less likely to engage in healthy dietary behaviors, have a higher body mass index, and have higher energy intakes than White and Hispanic women.10,11 Black-White differences in patterns of dietary intake have been observed including higher energy intake in Black adults.10 Taken together, available data have pointed to the importance of emphasizing patterns of dietary intake as a target for prevention and management of hypertension.
Environmental factors play a significant role in access to healthy foods and subsequently uncontrolled blood pressure. In 2020, 21.7% of Black households were food insecure, and in 2019, 18% of Black women lived in poverty.12,13 Black women who live in predominantly Black communities may find that access to high-quality food items is limited while fast-food restaurants are heavily promoted.14,15 The lack of access to healthy foods is associated with increased cardiovascular risk.14
Lack of trust and a poor patient-provider relationship also contribute to uncontrolled hypertension through nonadherence to medication and dietary modifications.7 Healthcare providers can play a vital role in the management of hypertension and encouragement of lifestyle modifications such as dietary behavior changes.16 Black patients who trust and have a collaborative relationship with their providers are more likely to adhere to provider recommendations.17
Food is Medicine (FIM) programs can provide much-needed support that can address gaps in the local food environment and patient-provider relationships and assist in managing a healthy diet.18 Food is Medicine interventions are often implemented in the form of provider food prescription programs, offering access to healthy food items and tailored meal delivery, which is reserved for those with severe chronic health conditions. The FIM prescription programs use cash vouchers and prescriptions to community gardens, farms, or markets near or on the site of the clinic, or on an on-site grocery store.19 In addition to food, a majority of FIM programs provide nutrition education, nutritional counseling, recipes, and cooking demonstrations.19 Food is Medicine connects the community to the primary care setting to reduce barriers to accessing healthy foods, promotes positive experiences with primary care providers, and reinforces dietary and disease-related knowledge.18,19 These interventions take place in a clinical setting and are adaptable based on the needs of the patient and can serve as a preventative measure to maintain a healthy lifestyle or as a treatment of specific chronic health conditions.18
Many positive outcomes have been demonstrated with FIM programs. Food is Medicine interventions are associated with improved dietary quality, blood pressure, blood lipids, and glucose levels.20 Food is Medicine programs have also been associated with a decrease in hospital utilization and emergency room visits, and a 16% net reduction in healthcare costs.21 However, some challenges are lack of investment in research, lack of provider nutrition knowledge, provider awareness of FIM, and low access to appropriate services and programs.18
Despite these challenges, there are opportunities for policy changes that can advance FIM research and increase participation from healthcare providers. The Food is Medicine Coalition, a nationwide FIM advocacy organization, has recommended increasing National Institutes of Health funding for research to address the lack of investment in FIM.22 In the recent Strategic Plan for Nutrition Research, FIM has been identified as Strategic Goal 4, “Reduce the Burden of Disease in Clinical Settings—How can we improve the use of food as medicine.”23 Additional research is needed to establish FIM processes that support the prevention and management of hypertension and develop culturally tailored interventions to support the needs of Black women with hypertension. Medicare and Medicaid reimbursement for FIM programs is another avenue for legislative change.22 Reimbursement for FIM programs may accelerate and encourage more widespread use by providers and collaborations with local farms and gardens. This collaboration can hold promise and potentially promote sustainability of local farms while also improving the local food landscape in communities that lack food access.
Food is Medicine initiatives at the federal level have been addressed in Congress and through the U.S. Department of Agriculture. H.R. 6774 Medically Tailored Home-Delivered Meals Demonstration Pilot Act of 2020 was introduced but failed in the 2020 Congress. It was reintroduced in 2021 under H.R. 5370.24 This Act would have required the Department of Health and Human Services to assess outcomes associated with a hospital providing medically tailored meals to qualified patients.24 The 2018 Farm Bill provided funding for early initiatives for demonstration and pilot programs through the Gus Schumacher Nutrition Incentive Program, which included funding of up to $25 million to examine the impact of produce prescriptions on healthcare, fruit, and vegetable consumption, and decrease in food insecurity.25 Although this is a strong start toward obtaining more federal funds to support FIM initiatives, this bill would not have supported local farms that would provide fresh produce for produce prescription programs, and this is also an area that needs additional advocacy and support. In the face of increasing food insecurity during the COVID-19 pandemic, there is renewed interest in the role of food in chronic health conditions and how the federal government can play a role in improving access to healthy foods to support healthy living.26
Hypertension is a serious health condition with significant risks for Black women leading to cardiovascular disease and death. Fortunately, when hypertension is identified early in the life course and lifestyle modifications are used, the risk of severe morbidity and mortality can be significantly reduced. Clearly, cardiovascular nurses have an important role in screening as well as in prevention and management of hypertension.
By providing access to foods that support a heart-healthy lifestyle and wraparound support, FIM programs contribute in a beneficial manner to both the prevention and management of hypertension. Furthermore, FIM interventions are at face value less difficult to administer; successful insurance reimbursement of FIM programs has been demonstrated in California, New York, and Massachusetts.27 There is a need for local, state, and federal support to continue the work being conducted in FIM research and establish funding priorities for improving access to healthy foods for all Americans regardless of the limitations of their food environment. Cardiovascular nurses and nursing must be at the forefront of advocating for FIM initiatives in clinical and community settings as well as at local, state, and federal levels. As an essential part of the healthcare team, nurses are in a unique position to collaborate and advocate with healthcare providers in establishing FIM programs and working with local farms to ensure sustainability of the programs.
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