When Access Is Not Enough: The Role of Utilization Barriers in Nutrition Security and Cardiometabolic Risk

Background: Food and nutrition security are key social determinants of cardiometabolic health. While food security reflects access to sufficient food, nutrition security incorporates the quality, consistency, and usability of food that supports long-term health. However, few studies have examined how household-level barriers to food utilization shape these relationships. Objective: This study assessed whether tangible (e.g., equipment, storage) and intangible (e.g., time, knowledge) food utilization barriers modify the associations between food and nutrition security and cardiometabolic outcomes in low-income adults. Methods: A cross-sectional survey was conducted among 486 low-income adults across five U.S. states. Participants reported household food security (USDA 18-item module), nutrition security (four-item scale), and utilization barriers (eight-item scale, categorized into tangible and intangible subscales). Self-reported diagnoses of hypertension, hyperlipidemia, and diabetes were combined into a cardiometabolic outcome. Mixed-effects logistic regression models, adjusted for sociodemographic and program participation factors, were used to assess associations and effect modification. Results: Higher nutrition security was associated with lower odds of cardiometabolic conditions (AOR = 0.59; 95% CI: 0.41-0.83). Tangible barriers significantly modified the relationship between nutrition security and hypertension (p-interaction = 0.04), with stronger protective effects observed in households without such barriers. No significant moderation effects were found for intangible barriers or for food security. Conclusions: Tangible household barriers influence the protective association between nutrition security and cardiometabolic outcomes. Public health strategies should address not only food access but also the practical resources required to store, prepare, and consume healthy foods effectively.