- Adults with hypertension who screened positive for food insecurity more often used thiazide diuretics than those who screened negative. Among patients using thiazides, those with food insecurity had lower blood pressure (BP) control at 12 months, even though medication adherence was similar.
- These differences were largest among Black patients. These findings support examining treatment patterns and BP outcomes alongside social needs screening to advance more equitable hypertension care.
Social conditions are associated with differences in hypertension control. Higher income, health insurance coverage, and favorable neighborhood characteristics have been linked to better control (1). Food insecurity is associated with poorer nutritional quality, higher salt intake, and chronic stress, all of which may link limited food access to cardiovascular risk (2). Thiazide diuretics are guideline-recommended and low-cost. However, prior electronic health record (EHR) research found that Black patients had poorer BP control despite greater use of guideline-recommended treatment patterns (3).
Using a subset of Truveta Data, we examined whether food insecurity is associated with differences in antihypertensive drug class use and 12-month BP control among adults with hypertension. We also looked at how these patterns varied by race.
Methods
Study design
We conducted a retrospective cohort study using de-identified EHR data from US health systems. The index date was the date of a documented food insecurity screening between January 2022 and April 2025. Patients were followed for 12 months, through April 2026.
Study population
We included adults with hypertension, an active antihypertensive prescription, and a documented food insecurity screen. We excluded patients with end-stage renal disease or dialysis on or before the index date.
Food insecurity
We classified food insecurity using the Hunger Vital Sign, supplemented by the US Food Security Survey. Patients who screened positive were considered food-insecure, and those who screened negative were considered food-secure.
Medications and adherence
We identified baseline antihypertensive use from medication dispenses during the 365 days before and including the screening date. Medications were grouped into eight drug classes at the ingredient level.
Among patients with baseline thiazide use, we measured adherence as the proportion of days covered over the 365 days after index. Patients were considered adherent if this proportion was at least 0.80.
BP control
BP control was defined as systolic BP below 130 mmHg at 12 months after index, among patients with a follow-up BP measurement.
Analysis
We used descriptive analyses and chi-square tests to compare drug class use and BP control by food insecurity status, overall and within racial groups.
Results
Food-insecure patients more often used thiazides but had lower BP control
We identified 333,182 adults with hypertension and a food insecurity screen. Of these, 227,500 (68.3%) screened positive and 105,682 (31.7%) screened negative. Mean age was 63.1 years, and 56.7% of patients were female. Age and sex were similar between groups. Black patients made up a larger share of the food-insecure group than the food-secure group (21.5% vs. 14.0%).
Food-insecure patients more often used thiazide diuretics than food-secure patients (32.8% vs. 28.0%; p < 0.0001). Among patients using thiazides:
- Adherence was similar between groups (80.9% vs. 82.4%)
- 12-month BP control was lower among food-insecure patients (45.7% vs. 47.2%; p < 0.0001)
Because adherence was similar, the gap in BP control raises the possibility of differences in treatment intensity or clinical complexity, which were not assessed in this analysis.
Differences were most pronounced among Black patients
Among Black patients, those with food insecurity had:
- higher thiazide use: 45.6% vs. 37.6% (p < 0.0001)
- lower BP control: 41.6% vs. 44.6% (p < 0.0001)
These results are shown in Figure 1 of the poster.
Among White patients, differences were smaller for both thiazide use (29.2% vs. 26.3%; p < 0.0001) and BP control (49.3% vs. 50.3%).
Discussion
In this large real-world cohort of adults with hypertension, patients with food insecurity more often used thiazide diuretics yet had lower 12-month BP control, even though adherence was similar. These differences were most pronounced among Black patients. This is consistent with prior research showing poorer BP control among Black patients despite treatment that followed guideline recommendations (3). Thiazides are an appropriate, low-cost first-line option. These findings raise questions about whether treatment is optimized for patients facing social barriers.
Because these comparisons were unadjusted, differences in patient characteristics may contribute to the patterns observed. Future research should examine treatment intensity, clinical complexity, and the social barriers behind these patterns. Considering treatment patterns and BP outcomes together with social needs screening may help advance more equitable hypertension care.
Data are constantly changing and updating. These findings are consistent with data analyzed for the ISPOR Europe 2026 study.
Citations
- E. Metlock, T. Hinneh, C. Benjasirisan, et al., Impact of social determinants of health on hypertension outcomes: a systematic review. Hypertension 81, 1675–1700 (2024).
- Beltrán, M. Pharel, C. T. Montgomery, I. J. López-Hinojosa, D. J. Arenas, H. M. DeLisser, Food insecurity and hypertension: a systematic review and meta-analysis. PLoS One 15, e0241628 (2020).
- K. Holt, G. Gildengorin, L. Karliner, et al., Differences in hypertension medication prescribing for Black Americans and their association with hypertension outcomes. J Am Board Fam Med. 35, 26–34 (2022).
