Abstract Body: Introduction Food insecurity, defined as limited access to nutritious food due to financial challenges, has grown substantially over the past two decades in the United States. Stroke survivors are more likely to experience food insecurity compared to the general population. However, the impact of food insecurity on long-term survival post-stroke remains unclear. Hence, we aimed to determine associations between food insecurity post-stroke and all-cause mortality.

Methods The National Health and Nutrition Examination Survey (NHANES) is an iterative cross-sectional study representative of the US population. Using data from 1999-2018, we assessed associations between food insecurity and all-cause mortality among stroke survivors and the general NHANES population, using linkage to death certificates from the National Death Index. Food security was assessed using ten NHANES questions and dichotomized into food security and food insecurity. A Cox proportional hazards model was used to evaluate associations between food insecurity and mortality adjusting for NHANES weighting, sex, age, race/ethnicity, education, marital status, poverty income ratio, BMI, diabetes, stroke, myocardial infarction, and cancer.

Results Among 101,316 NHANES participants, 2,197 (2.2%) self-reported as stroke survivors (mean age 67.6y, 50.8% female). Stroke survivors were more often food insecure compared to the general NHANES population (17.6% [SE:1.3%] vs. 14.3% [SE:0.4%], p=0.0038). Among 1,754 (78.9%) stroke survivors with linked death records, 801 died during a median follow-up of 105 months (IQR 56-159). The 10-year all-cause mortality rate among stroke survivors was 36.2% (SE: 3.0%) for the food secure and 48.4% (SE: 1.8%) for the food insecure group. In the general NHANES population, the corresponding rates were 10.9% (SE: 0.2%) and 14.2% (SE: 0.4%), respectively (Fig 1). Regression analysis showed that food insecurity was associated with a 31% increased risk of mortality in stroke survivors (HR: 1.31, 95%CI:1.00-1.73, P=0.049) and a 40% increase in the general NHANES population (HR: 1.40, 95%CI:1.25-1.57, P<0.001) (Fig 2).

Conclusion Food insecurity is associated with increased mortality rates in both the NHANES general population and stroke survivors, with a more pronounced difference in mortality rates among stroke survivors based on their food security status. Future research should focus on characterizing the biological and social mechanisms underlying these associations.