Food Insecurity Is Associated With Urge Urinary Incontinence: An Analysis of the 2005-2010 National Health and Nutrition Examination Survey - Nitya Abraham

August 1, 2023

Ruchika Talwar interviews Nitya Abraham about her article exploring the association between food insecurity and urge urinary incontinence. Dr. Abraham shares her findings from a study involving around 14,000 participants from the 2005-2010 National Health and Nutrition Examination Survey (NHANES). Contrary to expectations, her team discovered that individuals reporting food insecurity were 65% more likely to experience urge urinary incontinence. Although the mechanism isn't entirely clear, Dr. Abraham proposes that food insecurity may represent a broader issue of unmet social needs contributing to the condition. In the discussion, they underline the importance of assessing social needs and collaborating with social workers and community health workers to provide holistic patient care, further emphasizing the potential role of social inequity in disease severity.


Nitya Abraham, MD, Montefiore Medical Center, Bronx, NY

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hello everyone. My name is Ruchika Talwar. Today in UroToday's Center of Health Policy Excellence, we have Dr. Nitya Abraham, who is an associate professor at Montefiore Medical Center. We'll be discussing her recent article in the Journal of Urology, Food Insecurity is Associated with Urge Urinary Incontinence, an analysis of the 2005 to 2010 National Health and Nutrition Examination Survey. Thanks Dr. Abraham for making time to chat with us today.

Nitya Abraham: Thank you for having me.

Ruchika Talwar: This is a really interesting topic, and I know there's been a lot of discussion lately on different proxies to assess patients' standing in terms of social determinants of health. So why don't you tell me a little bit about what prompted you to look at this question?

Nitya Abraham: Sure. I work in the Bronx. I've been there for about eight years, and my practice is focused on female pelvic medicine and reconstructive surgery. So I see a lot of patients with urge urinary incontinence. We have the standard treatments, behavioral modifications, medical therapy, and then even advanced therapies like chemodenervation and sacral neuromodulation.

I was finding though that I felt like I wasn't making as much progress in the care of my patients. And upon further examination, administering surveys and even just asking questions about the challenges my patients faced, it seemed like it was a lot more complex than just a disease at the level of the bladder, that there were a lot of unmet social needs affecting my patient disease severity and just improvement in their treatments.

And so that led our team to just look at this issue on a broader scale using the NHANES database, which is a national database. It's a national survey administered to randomly selected patients in the US population. Specifically in the past we had looked at the association of poverty or socioeconomic status and urge urinary incontinence, and now we wanted to delve even deeper looking at food insecurity.

Ruchika Talwar: Yeah. Yeah, it's an interesting question. So tell me, what did you find in your study?

Nitya Abraham: We had about 14,000 patients that were included from the database. These were all people who had answered the question, the kidney questionnaire that asked about urinary incontinence, and they had also completed questions related to food insecurity. In the overall cohort, about 22% of them reported urge urinary incontinence, and we found that those who reported food insecurity were 65% more likely to have urge urinary incontinence than those who did not report food insecurity.

Ruchika Talwar: That's interesting because when I read your study, I thought perhaps we would've found something quite the opposite, in fact. People who had less food insecurity maybe were drinking more coffees and teas and sodas and had access to more bladder irritants. What do you think about that observation, that in fact the data suggested the opposite?

Nitya Abraham: Yes, that was a surprising finding, and that's when we looked even in more detail at food diaries. Participants were asked to complete a survey of their food intake in the prior 24 hours, and we had hypothesized that those with food insecurity would have a diet with more bladder irritants, and it turned out they didn't. So that was surprising.

Now, one limitation could be that the food diary was just the 24 hours prior and may not be reflective of their overall diet over several months. That would require collecting a lot more data. So that's a limitation of the food diary.

But that being said, the association between food insecurity and urge urinary incontinence may not be just related to diet. It may be a broader problem of food insecurity just being a marker of several unmet social needs that are contributing to urge urinary incontinence. So it may be a proxy for just social inequity in general, which we know contributes to disease severity.

Ruchika Talwar: Yeah, absolutely. That was my thought as well. Now, as we embark on these discussions with our patients where we try to provide more patient-centered care individualized to a specific patient's barriers to care, needs, et cetera, how can we use food insecurity clinically day-to-day when we're seeing patients? Is it something we should be assessing for? What kind of information can it provide for physicians?

Nitya Abraham: Yes, in an ideal world, it would be wonderful to screen for all kinds of social needs. At our institution we do have a 10 question survey that asks about specific social needs that are relevant to our patient population, including food insecurity, housing security, need for legal assistance, safety at home, et cetera. The 10 question survey is actually not too burdensome, so that's one way to start is including that as part of a new patient intake form.

Now, once you've identified those unmet social needs, what happens next? We actually have a social worker in our department, and so whenever we do identify an unmet social need, we're able to connect our patients with the social worker who will then identify services locally that the patient can take advantage of. In the family medicine departments, they have community health workers who assist when unmet social needs are found.

And so in their studies of all the patients who have reported an unmet social need, one out of four will take advantage of the community health worker. So if we're going to address patient care in a more holistic level, I think that would be the next level of screening and then connecting people with local services.

Ruchika Talwar: Yeah, I think you bring up a great point here in that the burden doesn't necessarily fall on the urologist. A lot of the argument for this is it doesn't really have anything to do with the urologic health issue. I'm already so busy in clinic or burdened by all of this regulatory nonsense in the electronic medical record. But the key is that care is provided in a team-based setting.

And so leaning on our primary care colleagues, our social worker colleagues, and just being aware of different resources, once we recognize, huh, my patients' symptoms really aren't getting better despite the fact that we've been at it for years or months or whatnot. Just taking kind of a step back and looking at everything globally I think is important.

If we want to change healthcare to be more effective on a larger scale, I think this is one of the many ways to do it. So congratulations on an excellent study. I think it really is thought-provoking and hopefully can encourage urologists to assess or at least be aware of food insecurity as a proxy in general.

Nitya Abraham: Agreed. And food insecurity is just the tip of the iceberg. Often patients may have transportation limitation, caregiver issues that they can't come to visit. And so all of this helps us to tailor the treatment of our patients recognizing the limitations they have.

Ruchika Talwar: Thanks again for chatting with us today, Dr. Abraham. To our UroToday audience, we'll see you for our next health policy video.

Nitya Abraham: Thank you.
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