Article In Brief
Seniors who used food benefits under the federal Supplemental Nutrition Assistance Program had about two fewer years of cognitive aging over a 10-year period compared with seniors who did not use SNAP benefits for which they were eligible, a review of data from the National Institute on Aging-sponsored Health and Retirement Study has found.
Eligible seniors who used food benefits under the federal Supplemental Nutrition Assistance Program (SNAP) experienced slower cognitive decline than those who were eligible for but did not use SNAP, according to a new study from investigators at the Columbia University Mailman School of Public Health in New York.
Adina Zeki Al Hazzouri, PhD, assistant professor of epidemiology in the Robert N. Butler Columbia Aging Center, and colleagues reviewed data on 3,555 SNAP-eligible participants aged 50 or older in 1996 from the National Institute on Aging-sponsored Health and Retirement Study.
A total of 15.7 percent of the study participants were SNAP users, and they came from a lower socioeconomic background and had a greater number of chronic conditions than non-users; they also had worse memory scores at baseline than non-SNAP users.
But as memory function was assessed biennially from 1996 to 2016 using a composite score, SNAP users experienced a slower rate of memory decline compared with their counterparts who didn't use SNAP (-0.038 vs. -0.046), the researchers wrote in the Nov. 9 online edition of Neurology.
“Put in other words, our findings suggested that SNAP users had about two fewer years of cognitive aging over a 10-year period compared with non-users,” the authors wrote.
The researchers noted that earlier studies found that SNAP benefits were associated with “increased food security and better physical and mental health” in children, but the results have been mostly mixed for adults.
The researchers also speculated about several “underlying mechanisms” behind the association between SNAP and brain health and cognition.
“By consuming better-quality diets and improving nutritional intake, SNAP may benefit brain health by reducing oxidative stress and neuroinflammation and subsequently promoting neuronal integrity,” they wrote. “SNAP may also increase the purchasing power and investment in other health-preserving behaviors, not only resulting in less health care expenditures, but also resulting in better access to care, which may in turn result in better disease management and management of risk factors for cognitive function.”
Dr. Al Hazzouri added that “SNAP may also reduce stress and overall financial hardship, which has been linked to premature cognitive aging and reduced brain health.”
The Role of Food Insecurity
“I think this is a very important study,” said Charles Windon, MD, assistant professor of clinical neurology at the University of California-San Francisco Memory and Aging Center, who was not involved with the research.
“Screening for food insecurity can at least provide the clinician some sense of the risks their patients might be facing and their potential negative health consequences.”—DR. COLLEEN HEFLIN
“We don't discuss the problem of food insecurity among older adults nearly enough; it gets more attention in the context of children, such as ‘[in discussions of] ‘No Kid Hungry’ programs. But it's a major issue among older adults and has been really exacerbated by the pandemic. In the community work I do, and among my patients in the clinic, I frequently meet older individuals with food insecurity who have cognitive impairment.”
The study does have limitations, he acknowledged. It assessed SNAP use at only one point in time and could only identify an association between SNAP use and slowed cognitive decline, rather than causative factors.
“I would have also been very interested in seeing the inclusion of a biomarker in the analysis, such as hippocampal or cortical volume, although this may not have been possible based on the authors' source of data,” Dr. Windon said.
“But the authors did a very good job in terms of addressing confounding factors, using a propensity score to get at the question of whether or not individuals who use SNAP are different from SNAP-eligible individuals who don't use it.”
And put in context with a large body of scientific literature that demonstrates a link between good nutrition and cognitive performance among seniors, the study does suggest that increased food security access to higher-quality food may benefit brain health in this population.
“Better food security may equip older individuals to better manage chronic health conditions that they may have, such as diabetes and chronic blood sugar abnormalities from poor nutrition, that could be leading to cognitive impairment,” Dr. Windon said.
“It's also possible older individuals who have adequate nutrition are more likely to participate in health-promoting activities, because they have less concern about food insecurity, enjoy more stable blood sugar, and generally feel better.”
Colleen Heflin, PhD, associate dean, chair, and professor in the public administration and international affairs department at Syracuse University's Maxwell School of Citizenship and Public Affairs, said she likes that the paper is “helping us unpack how nutritional assistance is important for health outcomes.”
The federal Healthy People 2030 initiaitve, the fifth iteration of the program, pinpoints public health priorities to improve health and well-being across the country and sets objectives to make those improvements happen over the next decade. It also identifies food security as a social determinant of health, Dr. Heflin said.
“I think we have a general understanding of how it's important, but this really focuses on one key critical dimension for peoples' ability to live independently,” Dr. Heflin said. “There are clear biological mechanisms through which this association makes sense, and it's also consistent with some of my own work, which looks at the other side of the coin.”
Food insecurity is known to be a significant problem among the elderly population in the United States. In 2020, over 9 million Americans in households with people 50 and older had food insecurity, yet most older eligible adults do not participate in the SNAP program.
Dr. Heflin's research has found that this may be in part because of barriers posed by cognitive decline.
“There are a lot of logistical challenges to participating in SNAP,” she observed. “You have to show up with all the right documents within a specified timeframe. Cognitive impairment interferes with your sense of time, so you might miss appointments or leave necessary documents at home.”
In a study published in August 2022 in the Journals of Gerontology, also based on data from the Health and Retirement Study, Dr. Heflin and colleagues found that reduced levels of cognitive functioning that rise to the classification of dementia were strongly associated with reductions in the probability of SNAP take-up among eligible older adults, particularly among women and those living alone.
“Taken together, this [Neurology] study and ours suggest that there is a strong relationship between SNAP and cognition in older adults that probably goes in both directions,” she said. “Having nutritional access via SNAP helps prevent or mitigate cognitive decline, but once you are experiencing cognitive decline, it is harder to get the resources you need to ensure food security.”
What Can Neurologists Do?
What can neurologists do both to identify their patients at risk for food insecurity and assist patients with cognitive impairment in accessing needed food benefits?
A two-item screening measure, known as the Hunger Vital Sign, has been validated as identifying household food insecurity. Although it is often promoted as tool for assessing food insecurity among families with children and is specifically endorsed by the American Academy of Pediatrics, it is used in many general clinical settings as well; the Veterans Administration offers it in all of its medical centers.
“It can be used to identify adults of any age who are food insecure,” Dr. Heflin said. “Screening for food insecurity can at least provide the clinician some sense of the risks their patients might be facing and their potential negative health consequences.”
The Hunger Vital Sign includes these two statements: “Within the past 12 months, we worried whether our food would run out before we got money to buy more, and, within the past 12 months, the food we bought just didn't last and we didn't have money to get more.”
Families or individuals are identified as being at risk for food insecurity if they answer that either or both statements are “often true” or “sometimes true” (as opposed to “never true”).
“This info can be useful to guide conversations with our patients about a comprehensive action plan that addresses all the factors contributing to cognitive impairment,” Dr. Windon said.
“It forces us to think about the social determinants of health that we may have the ability to do something about. Many of us are excited about the novel therapies for dementia that may soon become available, but if we can prevent significant cognitive decline through interventions like improved nutrition, this will be more cost-effective in the long run and allow us to have a much greater impact.”
Once you know that a patient with cognitive impairment is on SNAP, and given the specific barriers identified by research like Dr. Heflin's, it would be beneficial to check in periodically to make sure the patient still has access to those benefits, said Eric Rimm, PhD, professor of epidemiology and nutrition and director of the program in cardiovascular epidemiology at the Harvard T.H. Chan School of Public Health and professor of medicine at Harvard Medical School.
“The last thing you want is for someone's cognitive impairment to get in the way of their ability to stay on SNAP,” Dr. Rimm said.
He noted that in addition to SNAP, some states, including Massachusetts and California, have pilot programs that include insurance reimbursement within Medicare and Medicaid for food insecurity screening, counseling, and referral to an array of “food is medicine” programs.
“This can be a regular, reimbursable part of our regular clinical screening practices, just like cholesterol and blood pressure,” he said.
If your state does not have such a program, a number of other resources exist that neurology practices should be aware of for patients who have food insecurity, Dr. Heflin said.
“In most areas, [the phone number] 211 offers a connection to social services, including emergency food assistance; that's the way to find immediate help,” she said. “You could also develop relationships with the local community-supported offices on aging, senior centers, and other congregant meal and home-delivered meal providers.”
Dr. Windon said the new findings have implications for further longitudinal research.
“The role of SNAP has been studied more in terms of how it affects children as they grow into adulthood, he said. “It would be interesting to assess what happens longitudinally among these populations. We know that the risk of developing cognitive impairment, or a neurodegenerative disease, doesn't start when you are 50 or 60 years old but much earlier in life, and individuals from socioeconomically disadvantaged backgrounds are at higher risk. Do children who have these interventions early in life not only do better in school, but do they also have lower risk of cognitive impairment when they are aging because of the early developmental impact of adequate nutrition?”
