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NEW ORLEANS -- Adults with self-reported food insecurity were significantly more likely to have a history of urge urinary incontinence (UUI), a large retrospective review showed.

Overall, food insecurity increased the odds ratio for UUI by 70% versus people without food insecurity. A comparison of dietary intake showed that people reporting food insecurity consumed more carbohydrates, and sugars, but surprisingly, caffeine intake was similar and alcohol consumption was lower in the food-insecurity group, reported Chihiro Okada, a third-year medical student at Albert Einstein College of Medicine in New York City, at the American Urological Association (AUA) annual meeting.

The findings raised more questions for future examination. "Based on our data about dietary differences, this association may be independent of diet and instead driven by social inequities associated with food insecurity," said Okada. "Understanding food insecurity and the potential influence of other determinants of health on urge incontinence may be important for developing treatments that address health disparities, as well as screening methods."

"The diet questionnaire that we used asked about the prior 24 hours before the interview was conducted, so that makes it less representative of participants' habitual dietary behavior," Okada noted. "We can explore the question about diet and the role of bladder irritants using a different dietary questionnaire that can be more comprehensive and realistic in terms of survey participants' dietary habits. We can also further evaluate the association between protein content and other social determinants of health, such as occupation and safe housing status."

Bladder Irritants

The results surprised investigators by showing an inconsistent association of caffeine and alcohol with UUI. Historically, both have been considered "irritants" that contribute to or exacerbate UUI. Patients with UUI and food insecurity reported caffeine intake similar to people without food insecurity, and alcohol intake was slightly but significantly lower among food-insure patients with UUI.

"I found it very interesting that your data showed that coffee and alcohol were not consistent," said AUA press briefing moderator Rachel Rubin, MD, of Georgetown University in Washington. "I've always lived on the side of skeptic about bladder irritants because I hate restricting my patients' diet. There is too much messaging out there [about food restriction]...You end up having patients who can have a little piece of bread and some water, and that's no way to live. It has to change."

With respect to bladder irritants, every patient is different, said study co-author Nitya Abraham, MD, also of Albert Einstein College of Medicine and Montefiore Medical Center in New York City.

"What is a bladder irritant for one person is not a bladder irritant for another," said Abraham. "My approach is to have patients keep a diary of a good day and a bad day, and keep track of what they're eating or drinking and try to look for patterns. It's really an individualized approach to what is the bladder irritant for [a specific patient] and try to stay away from the things that you're having on those bad days that could be exacerbating symptoms."

Studies have identified multiple biological factors associated with UUI, including older age, female sex, higher BMI, depression, diabetes, and smoking. However, limited information exists on social factors that may affect UUI, aside from a study suggesting an association with household income said Okada.

Social Determinants of UUI

Investigators examined the potential interaction between UUI and food insecurity, using data from the 2005-2010 National Health and Nutrition Examination Survey (NHANES). UUI was defined by responses to a survey question related to urine leakage and urgency within the previous 12 months. Food insecurity was defined by at least three affirmative answers to a 10-item Department of Agriculture questionnaire on food security, such as worry about running out of food because of lack of money or going hungry because of inability to afford food.

Data analysis included 14,846 NHANES participants, 22.4% of whom reported at least one episode of UUI within the past 12 months and 14.4% who met the definition of food insecurity. The primary finding was a 70% increased likelihood of UUI among the food-insecure subgroup (OR 1.70, 95% CI 1.4-1.9, P<0.001). Three different statistical models that controlled for a variety of demographic, socioeconomic, and health factors yielded odds ratios of 1.65 to 1.87.

"We found this association between food insecurity and urge incontinence, but it wasn't clear whether food-insecure [people] were eating diets that made them more prone to urinary incontinence or because food insecurity is a proxy for social inequity," said Okada.

To address the issue, investigators analyzed data from the food-intake component of the NHANES questionnaire. They found that food-insecure individuals had significantly higher (P≤0.001) caloric, carbohydrate, and sugar intake and lower fat and protein intake. Okada said the findings were consistent with previous studies of food insecurity.

Two inconsistencies stood out: Food-secure and insecure individuals reported similar caffeine intake (158.1 vs 173.4 mg, P=0.8), and alcohol consumption was significantly lower in the food-insecure group (10.1 vs 10.5 g, P<0.001).

"This is an interesting finding because it suggests that the significant association between urge incontinence and food insecurity may be independent of dietary differences," said Okada. "Instead, perhaps food insecurity represents greater social and environmental stressors that can play a role in the pathogenesis of urge incontinence."

The impact of COVID on food insecurity and UUI remains unclear; Okada speculated that the prevalence of both food insecurity and UUI increased during the pandemic.

Referencing her own clinical practice, Rubin said the prevalence of pelvic floor disorders, pelvic pain, and urinary symptoms have increased during the pandemic.

"The bladder is a muscle, the pelvic floor is muscle and everyone is a little bit more stressed during these very uncertain times," she said. "It would be super interesting to see how diet plays a role, how stress plays a role, how working from home plays a role."

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