Food insecurity is associated with diabetes self-care behaviours and glycaemic control

Food insecurity and diabetes management among adults of African descent: A systematic review

AIMS

This systematic review explores the established causal link between food insecurity and cardiometabolic conditions among adults of African descent. Specifically, this study examined the relationship between food insecurity and the management of type 2 diabetes, highlighting the prevalence of food insecurity among individuals of African descent with type 2 diabetes.

METHODS

Original English papers were meticulously searched in databases including PubMed, CINAHL, PsycINFO, Medline, Cochrane, Embase and Web of Science. The Cochrane Risk of Bias Tool for quantitative studies and COReQ for qualitative studies were employed to assess biases. Three independent reviewers meticulously evaluated and synthesized results, reaching a consensus.

RESULTS

Among the 198 studies identified, 14 met the inclusion criteria for data extraction and analysis, which were conducted independently by three reviewers. The findings indicate that individuals of African descent are more likely to experience food insecurity compared to their White counterparts and are also more prone to diabetes risk factors or the presence of diabetes.

CONCLUSIONS

This study underscores a higher prevalence of food insecurity and type 2 diabetes among adults of African descent, suggesting that ethnicity and food insecurity play significant roles in diabetes management. Future research should prioritize interventions aimed at reducing these disparities.

Food insecurity and medication restricting behavior among persons with diabetes in the United States

BACKGROUND

Medication restricting behaviours are common among persons with diabetes increasing risk for poor health outcomes. Persons with diabetes are more likely to experience food insecurity than persons without diabetes.

AIM

This study aimed to assess the relationship between food insecurity and medication restricting behaviour among persons with diabetes in the United States.

METHODS

Data from the 2019 National Health Interview Survey (NHIS) data conducted in the United States was used for this analysis. Medication restricting behaviour was assessed by questions asking whether four restricting behaviours were present (skipped medication, took less medication, delayed filling a prescription and/or took less medication due to cost). Food insecurity status was obtained through a 10-item scale and participants were categorized as either food secure, low food security, or very low food security. Poisson regression evaluated the relationship between medication restricting behaviour and food insecurity controlling for confounders.

RESULTS

Participants with very low food security had a significantly higher mean number of medication restricting behaviours than participants who were food secure (adjusted mean ratio (AMR) = 4.01; 95% confidence interval (CI) = (3.09, 5.21)). Similarly, participants with low food security had a significantly higher mean ratio than participants who were food secure (AMR = 3.76; 95% CI = (2.86. 4.94).

CONCLUSION

Persons with diabetes who have low or very low food security are at an increased risk for engaging in medication restricting behaviours.

Acceptability of community health worker and peer supported interventions for ethnic minorities with type 2 diabetes: a qualitative systematic review

Objective

Ethnic minority groups in high income countries in North America, Europe, and elsewhere are disproportionately affected by T2DM with a higher risk of mortality and morbidity. The use of community health workers and peer supporters offer a way of ensuring the benefits of self-management support observed in the general population are shared by those in minoritized communities.

Materials and methods

The major databases were searched for existing qualitative evidence of participants' experiences and perspectives of self-management support for type 2 diabetes delivered by community health workers and peer supporters (CHWPs) in ethnically minoritized populations. The data were analysed using Sekhon's Theoretical Framework of Acceptability.

Results

The results are described within five domains of the framework of acceptability collapsed from seven for reasons of clarity and concision: Affective attitude described participants' satisfaction with CHWPs delivering the intervention including the open, trusting relationships that developed in contrast to those with clinical providers. In considering Burden and Opportunity Costs, participants reflected on the impact of health, transport, and the responsibilities of work and childcare on their attendance, alongside a lack of resources necessary to maintain healthy diets and active lifestyles. In relation to Cultural Sensitivity participants appreciated the greater understanding of the specific cultural needs and challenges exhibited by CHWPs. The evidence related to Intervention Coherence indicated that participants responded positively to the practical and applied content, the range of teaching materials, and interactive practical sessions. Finally, in examining the impact of Effectiveness and Self-efficacy participants described how they changed a range of health-related behaviours, had more confidence in dealing with their condition and interacting with senior clinicians and benefitted from the social support of fellow participants and CHWPs.

Conclusion

Many of the same barriers around attendance and engagement with usual self-management support interventions delivered to general populations were observed, including lack of time and resource. However, the insight of CHWPs, their culturally-sensitive and specific strategies for self-management and their development of trusting relationships presented considerable advantages.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes

BACKGROUND

Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management.

OBJECTIVE

Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care.

DESIGN

Randomized trial from 2019 to 2023.

PARTICIPANTS

A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care.

INTERVENTION

CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes.

MEASURES

Primary outcome was HbA1c, measured at baseline, and 6 and 12 months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups.

RESULTS

Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group.

CONCLUSIONS

On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov ID NCT03950973, May 2019.

Pilot Implementation of a Nutrition-Focused Community-Health-Worker Intervention among Formerly Chronically Homeless Adults in Permanent Supportive Housing

Food insecurity is a known health equity threat for formerly chronically homeless populations even after they transition into permanent housing. This project utilized a human-centered design methodology to plan and implement a nutrition-focused community-health-worker (CHW) intervention in permanent supportive housing (PSH). The project aimed to increase access to healthy foods, improve nutritional literacy, healthy cooking/eating practices, and build community/social connectedness among 140 PSH residents. Validated food-security screening conducted by CHWs identified low or very low food security among 64% of 83 residents who completed the baseline survey, which is similar to rates found in a previous study among formerly homeless populations placed in PSH. Major themes identified through an analysis of resident feedback include (1) lack of needed kitchenware/appliances for food preparation, (2) knowledge gaps on how to purchase and prepare healthier food, (3) positive perceptions of healthy food options, (4) expanded preferences for healthy, easy-to-prepare foods, (5) regaining cooking skills lost during homelessness, (6) positive experiences participating in group activities, (7) community re-entry, and (8) resident ownership. Preliminary findings suggest the use of a human-centered design methodology for planning and implementing this multi-level CHW intervention helped reduce food insecurity, engaged participants in learning and adopting healthy and safe cooking and eating practices, and fostered social connectedness and feelings of community among formerly chronically homeless PSH residents.

Household Food Insecurity Is Associated With Physical Activity in Youth and Young Adults With Diabetes: A Cross-Sectional Study

BACKGROUND

Physical activity (PA) is essential for optimal diabetes management. Household food insecurity (HFI) may negatively affect diabetes management behaviors. The purpose of this study was to cross-sectionally examine the association between HFI and PA in youth and young adults (YYA) with type 1 (N = 1998) and type 2 (N = 391) diabetes from the SEARCH for Diabetes in Youth Study.

METHODS

HFI was measured with the US Household Food Security Survey Module. PA was measured with the International Physical Activity Questionnaire Short Form. Walking, moderate-intensity PA (excluding walking), vigorous-intensity PA, moderate- to vigorous-intensity PA, and total PA were estimated as minutes per week, while time spent sitting was assessed in minutes per day. All were modeled with median regression. Meeting PA guidelines or not was modeled using logistic regression.

RESULTS

YYA with type 1 diabetes who experienced HFI spent more time walking than those who were food secure. YYA with type 2 diabetes who experienced HFI spent more time sitting than those who were food secure.

CONCLUSIONS

Future research should examine walking for leisure versus other domains of walking in relation to HFI and use objective PA measures to corroborate associations between HFI and PA in YYA with diabetes.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

Food insecurity and glycemic goals among Medicare beneficiaries with type 2 diabetes

OBJECTIVE

To examine the association between food insecurity and achieving glycemic goals among Medicare beneficiaries with type 2 diabetes.

METHODS

This study analyzed the nationally representative 2019 Medicare Current Beneficiary Survey of 1340 beneficiaries aged ≥65 years with type 2 diabetes. The binary dependent variable was whether beneficiaries' blood glucose was at target (A1C ≤ 7.5% or average fasting blood glucose of ≤140 mg/dL, all/most of the time). Food insecurity, a binary variable, was adapted based on the USDA's food security questions. A survey-weighted multivariable logistic model, adjusted for sociodemographics and comorbidities, was conducted to estimate predictive margins for comparing prevalence of having above-target blood glucose levels across groups.

RESULTS

Of study beneficiaries, 20.9% reported not achieving glycemic targets. The predictive marginal prevalence of having higher than target blood glucose levels was significantly greater in females over males (23.8% [95% confidence interval [CI], 20.1-27.4] vs 17.6% [14.3-20.9]); those with less than high school education over those with college education (31.0% [23.6-38.3] vs 18.6% [14.8-22.3]); and those reporting food insecurity over their counterparts (33.4% [24.5-42.3] vs 19.1% [16.6-21.7]).

CONCLUSIONS

Sociodemographic disparities related to achieving blood glucose goals were observed. Screening for food insecurity and related interventions should be considered for at-risk beneficiaries with diabetes.

Dietary practice and associated factors among type 2 diabetic patients attending chronic follow-up in public hospitals, central Ethiopia, 2022

BACKGROUND

Diabetes Mellitus (DM) is affecting numerous Ethiopian populations regardless of environmental and social status. Diabetic people all over the world are commonly urged to acquire a healthy eating habit, which necessitates lifelong changes in food habits, beliefs, and meal patterns. Dietary management is considered one of the cornerstones of diabetes care, as it is an important component of the overall treatment plan. Choosing and following a healthy diet is important for everyone, especially people with diabetes.

OBJECTIVE

This study aims to assess dietary practices and associated factors among type 2 diabetes patients in the west Shewa Zone, Oromia Regional State, Ethiopia, in 2022.

METHODS

A hospital-based cross-sectional study design was conducted in West Shewa Zone public hospitals among 421 randomly selected type 2 diabetic patients from February 1 to March 30, 2022. Data were collected using a structured and pre-tested interviewer-administered questionnaire. Descriptive, bivariate, and multivariate binary logistic regression analyses were done using SPSS.

RESULTS

In this study, about 35.6% (95% CI: 30.9-39.9) of type 2 diabetes patients had good dietary practices. Diabetes knowledge (AOR 9 2; 95% CI 4.4-19.4), food-secured households (AOR 3.3; 95% CI 1.6-6.9), high self-efficacy (AOR 6.6; 95% CI 3.2-13.9), diabetes diet information from healthcare professionals (AOR 2.9; 95% CI 1.3-6.4), complete dietary change (AOR = 2.3; 95% CI 1.1-4.8), and female gender (AOR 3.6; 95% CI 1.6-8.1) were independent predictors of good dietary practice.

CONCLUSION

The proportion of patients with type 2 diabetes, who attended follow-up at West Shawa Public Hospitals and practiced good dietary habits, was low. Patients' household food insecurity, diabetes knowledge, self-efficacy, source of information on the diabetic diet, complete dietary change after diabetes diagnosis, and gender were all significantly associated with type 2 diabetic patients' dietary practices. Thus, promoting the provision of continuous, modified, and comprehensive education and advice on the importance of diabetes self-management, particularly adherence to dietary recommendations, is fundamental to decreasing the burden of diabetes complications and massive health expenses among diabetic patients.

Impact of Environmental Factors on Hypertension and Associated Cardiovascular Disease

Hypertension is the primary cause of cardiovascular diseases and is responsible for nearly 9 million deaths worldwide annually. Increasing evidence indicates that in addition to pathophysiologic processes, numerous environmental factors, such as geographic location, lifestyle choices, socioeconomic status, and cultural practices, influence the risk, progression, and severity of hypertension, even in the absence of genetic risk factors. In this review, we discuss the impact of some environmental determinants on hypertension. We focus on clinical data from large population studies and discuss some potential molecular and cellular mechanisms. We highlight how these environmental determinants are interconnected, as small changes in one factor might affect others, and further affect cardiovascular health. In addition, we discuss the crucial impact of socioeconomic factors and how these determinants influence diverse communities with economic disparities. Finally, we address opportunities and challenges for new research to address gaps in knowledge on understanding molecular mechanisms whereby environmental factors influence development of hypertension and associated cardiovascular disease.

The role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Food Security and Medication Adherence in Young and Middle-Aged Adults with Diabetes

Medication nonadherence in individuals with diabetes can lead to adverse health outcomes. Young and middle-aged adults are more likely to have low food security than other age groups. However, little research has focused on the relationship between food security and medication adherence in this population. The objective of this study was to examine the relationship between food security and medication adherence among young and middle-aged adults with diabetes. This study used 2019 National Health Interview Survey data. Persons were included if they were aged less than 50 and had a diabetes diagnosis. Individuals were categorized as nonadherent to medication if they answered "yes" to one question indicating nonadherence. Food security status was categorized as food secure, low food security, and very low food security. Among adults under age 50 with diabetes, nearly a fifth were categorized as having low or very low food security. Approximately a quarter of the participants were not adherent. Respondents with low food security and very low food security were significantly more likely to be nonadherent to medication than those who were food secure. People with diabetes under the age of 50 who have low or very low food security are at an increased risk for nonadherence to medication.

Medically tailored meals for food insecurity and type 2 diabetes: Protocol for the Food as Medicine for Diabetes (FAME-D) trial

BACKGROUND

Food insecurity is associated with worse glycemic management for individuals with type 2 diabetes mellitus (T2DM), but whether medically tailored meals (MTM), a food insecurity intervention, can improve glycemic management is unclear.

OBJECTIVE

To describe the protocol for a trial assessing whether an MTM plus lifestyle intervention improves hemoglobin A1c (HbA1c) and participant-reported outcomes, relative to a food subsidy (money that can be spent on foods participants choose), for adults with both T2DM and food insecurity.

METHODS

The Food as Medicine for Diabetes (FAME-D) randomized clinical trial (goal n = 200) is a pragmatic trial with an active comparator. Participants, who will have T2DM and report food insecurity, will be randomly assigned to a 6-month MTM plus telephone-delivered lifestyle change intervention, or a 6-month food subsidy ($40/month). The primary outcome is HbA1c at 6 months. Secondary outcomes include HbA1c at 12 months to assess whether the intervention effect (if any) is sustained, along with weight, food insecurity, diabetes distress, and health-related quality of life. Qualitative analyses of semi-structured interviews will help understand why, how, and under what circumstances the intervention achieved its observed results.

CONCLUSION

Results from FAME-D will help inform clinical management of food insecurity when it co-occurs with T2DM. Further, results may be useful as healthcare payors are considering coverage for MTM interventions.

CLINICALTRIALS

gov: NCT04828785.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Undergraduate food insecurity, mental health, and substance use behaviors

Objective: Recent epidemiological research has found food insecurity to be a growing public health concern among college students. This study investigated food insecurity, mental health, and substance use behaviors among state university undergraduate students. Study Design: Cross-sectional survey. Methods: This was a secondary data analysis of the Student Health Survey. Undergraduate participants (n = 589) completed the paper-based survey, which had an 84% response rate overall. Results: Approximately 38.5% of students were considered food insecure, 24.8% experiencing low food security, and 13.8% experiencing very low food security. Having a diagnosis of depression, experience of depressive symptoms, and marijuana use in the past 30 days were associated with food insecurity. Conclusion and Implications: Food insecurity is a serious health concern for college students. The results of this study indicate collocating food security and counseling services may enhance existing student resources to better support students facing food and nutrition insecurity, substance use, and depression.

Household food insecurity is associated with diabetic ketoacidosis but not severe hypoglycemia or glycemic control in youth and young adults with youth-onset type 2 diabetes

OBJECTIVE

To examine the association between household food insecurity (HFI), glycemic control, severe hypoglycemia and diabetic ketoacidosis (DKA) among youth and young adults (YYA) with youth-onset type 2 diabetes.

RESEARCH DESIGN AND METHODS

This cross-sectional study included 395 YYA with type 2 diabetes from the SEARCH for Diabetes in Youth Study (2015-2019). HFI was reported by young adult participants or parents of minor participants via the US Household Food Security Survey Module. Glycemic control was assessed by HbA_1c and analyzed as a continuous and categorical variable (optimal: <7.0%, suboptimal: ≥7.0%-9.0%, poor: >9.0%). Acute complications included self-reported severe hypoglycemia or DKA in the last 12 months. Adjusted logistic and linear regression were used for binary and continuous outcomes, respectively.

RESULTS

Approximately 31% reported HFI in the past 12 months. Mean HbA_1c among those with HFI was 9.2% compared to 9.5% without HFI. Of those with HFI, 56% had an HbA_1c  >9.0% compared to 55% without HFI. Adjusted models showed no associations between HFI and glycemic control. Of those with HFI, 14.4% reported experiencing DKA and 4.7% reported severe hypoglycemia. YYA with HFI had 3.08 times (95% CI: 1.18-8.06) the odds of experiencing DKA as those without HFI. There was no association between HFI and severe hypoglycemia.

CONCLUSIONS

HFI was associated with markedly increased odds of DKA but not with glycemic control or severe hypoglycemia. Future research among YYA with type 2 diabetes should evaluate longitudinally whether alleviating HFI reduces DKA.

IMAGINE: A Trial of Messaging Strategies for Social Needs Screening and Referral

INTRODUCTION

Health-related social needs are associated with poor health outcomes. Many primary care practices now screen and refer patients with health-related social needs to assistance organizations, but some patients decline screening or assistance. Improving communication about health-related social needs screening and referral could increase screening response and assistance acceptance rates.

STUDY DESIGN

This is a pragmatic, nonrandomized 3-stage trial of messages and communication strategies for health-related social needs screening and referral. Messages and strategies were informed by qualitative analysis of stakeholder interviews and were developed through an iterative, patient-, and stakeholder-engaged process.

SETTING/PARTICIPANTS

Settings included 3 primary care clinics serving primarily low-income patients in western Colorado.

INTERVENTION

Stage 1 includes usual clinic processes for health-related social needs screening (form given to patients at the front desk without additional explanation), Stage 2 includes adding written patient-friendly messages regarding the purpose of health-related social needs screening and referral to usual clinic processes, and Stage 3 includes adding verbal messages delivered by a medical assistant (form given to patients by a medical assistant during the rooming process).

MAIN OUTCOME MEASURES

Primary outcomes include (1) screening form response rate and (2) acceptance of referral for assistance rate among patients with health-related social needs. Secondary outcomes include (1) comfort with screening, (2) perceived helpfulness of screening, and (3) receipt of explanation about screening.

RESULTS

All data collection and analysis occurred in 2021. Study Stage 2 was not associated with significant changes in any outcomes. Stage 3 was associated with decreased odds of screening form response at 2 of the 3 clinics relative to those of Stage 1 (OR=0.1, 95% CI=0.1, 0.3; OR=0.4, 95% CI=0.2, 0.7) but with increased odds of assistance acceptance (OR=2.1, 95% CI=1.1, 4.0) among patients with needs who responded to the screening form. Stage 3 was also associated with higher odds of patients perceiving screening as helpful and receiving an explanation about screening.

CONCLUSIONS

Altering practice workflows to provide verbal explanations of health-related social needs screening may reduce response rates but may encourage responders to accept assistance referrals. Optimal communication strategies and workflows will likely differ depending on the intended goals of health-related social needs screening and referral.

Self-care practices and correlates among patients with type 2 diabetes in Eastern Ethiopia: A hospital-based cross-sectional study

Objective:

This study investigated the level and correlates of self-care practices among patients with type 2 diabetes on follow-up in two public hospitals in Harar, Eastern Ethiopia.

Methods:

We conducted a hospital-based cross-sectional study on adult patients with type 2 diabetes, surveying diabetes self-care practices using a 15-item Summary of Diabetes Self-Care Activities. Responses ranged from 0 to 7 days, and a composite score was computed representing the mean days of diabetes self-care practices. A generalized Poisson regression model with robust variance was used. The association between the diabetes self-care practices and correlates was examined using the incidence rate ratio with a 95% confidence level. The statistical significance was set at a p value of ⩽0.05.

Results:

This study included 879 patients with type 2 diabetes. The overall mean (standard deviation) diabetes self-care practices were 3.7 ± 1.1 days out of the recommended 7 days, indicating low self-care practices. After controlling for other variables, tertiary educational level (incidence rate ratio = 1.06; 95% confidence interval: 1.01, 1.12), adequate diabetes knowledge (incidence rate ratio = 1.04; 95% confidence interval: 1.00, 1.08), moderate (incidence rate ratio = 1.07; 95% confidence interval: 1.02, 1.11) and high perceived self-efficacy (incidence rate ratio = 1.14; 95% confidence interval: 1.09, 1.13) (incidence rate ratio = 1.07; 95% confidence interval: 1.02, 1.11), high to marginal food security (incidence rate ratio = 1.13; 95% confidence interval: 1.03, 1.24), and receiving dietary advice (incidence rate ratio = 1.11; 95% confidence interval: 0.06, 1.15) were positively correlated with diabetes self-care practices. A history of hospitalization, on the other hand, was found to be inversely correlated with diabetes self-care practices (incidence rate ratio = 0.94; 95% confidence interval: 0.88, 0.99).

Conclusion:

The study indicated that adherence of patients with type 2 diabetes to the recommended self-care practices was considerably low. Therefore, tailored diabetes self-management education to enhance self-efficacy and diabetes self-care practices must be in place. This can be achieved through the system or individual-based integrated intervention efforts.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

Sociodemographic characteristics associated with self-care and quality of life among community-dwelling older adults with type 2 diabetes

AIMS

To assess how well community-dwelling older adults in Singapore were coping with their diabetes, and the sociodemographic characteristics that were associated with their level of coping.

METHODS

This was a cross-sectional study involving 257 older adults. Multiple regression was used to assess the associations between various sociodemographic characteristics and coping measures of present quality of life and level of self-care.

RESULTS

Older adults mainly sought care in the primary care setting. They were not coping well given their mean scores for diabetes-dependent quality of life and the self-care index were -3.57 and 3.55 respectively. Compared to those with post-secondary education, individuals who had no formal (adjusted B -0.92, p 0.003), primary level (adjusted B -0.76, p < 0.001) and secondary level (adjusted B -0.50, p < 0.02) education reported lower present quality of life. Those with prior lowest skill level occupations were less likely to consume a healthy diet per week than those with prior highest skill level occupations (adjusted B -1.48, p 0.004).

CONCLUSIONS

There should be provision of diabetes self-care interventions targeting older adults in Singapore especially for those with lower education and work skill levels. As the first line of contacts, primary care providers should advocate for diabetes self-care and develop community-based interventions for these priority groups.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Food insecurity, type 2 diabetes, and hyperglycaemia: A systematic review and meta-analysis

AIMS

Food insecurity (FIS) is a major public health issue with possible implications for type 2 diabetes mellitus (T2DM) risk. We conducted a systematic review and meta-analysis to explore the association between FIS and T2DM.

METHODS

We performed a systematic search in PubMed, Embase, Scopus, and Web of Science. All cross-sectional, peer-reviewed studies investigating the link between FIS and T2DM were included. Population characteristics, study sizes, covariates, T2DM diagnoses, and diabetes-related clinical measures such as fasting blood glucose (FBG) and HbA1c were extracted from each study. Outcomes were compared between food insecure and food secure individuals. Effect sizes were combined across studies using the random effect model.

RESULTS

Forty-nine peer-reviewed studies investigating the link between FIS and T2DM were identified (n = 258,250). Results of meta-analyses showed no association between FIS and clinically determined T2DM either through FBG or HbA1c: OR = 1.22 [95%CI: 0.96, 1.55], Q(df = 5) = 12.5, I2  = 60% and OR = 1.21 [95%CI: 0.95, 1.54], Q(df = 5) = 14; I2  = 71% respectively. Standardized mean difference (SMD) meta-analyses yielded no association between FIS and FBG or HbA1c: g = 0.06 [95%CI: -0.06, 0.17], Q(df = 5) = 15.8, I2  = 68%; g = 0.11 [95% CI: -0.02, 0.25], Q(df = 7) = 26.8, I2  = 74% respectively. For children, no association was found between FIS and HbA1c: g = 0.06 [95%CI: 0.00, 0.17], Q(df = 2) = 5.7, I2  = 65%.

CONCLUSIONS

Despite multiple proposed mechanisms linking FIS to T2DM, integration of the available literature suggests FIS is not associated with clinically determined T2DM or increases in FBG or HbA1c among adult patients.

Dietary Practice among Type 2 Diabetic Ppatients in Southern Ethiopia

BACKGROUND

Diabetic patients' dietary practice is critical to improve glycemic, lipid, and blood pressure control. However, a significant number of patients had poor dietary practice. In Ethiopia, more than half of diabetic patients were not practicing a healthy dietary approach. Therefore, this study assessed variables that were hardly addressed in previous studies. The aim of this study was to assess dietary practice and associated factors among patients with type 2 diabetes.

METHODS

A facility-based cross-sectional study was performed among patients with type 2 diabetes in Arba Minch General Hospital from April 21 to May 20, 2020. A systematic sampling technique was used to select 352 patients. The data were entered into EpiData version 3.1 and exported to SPSS version 21 for cleaning and analysis. Descriptive statistics were performed. All variables in bivariate analysis with p-value <0.25 were entered into a multivariable logistic regression model, and statistical significance was declared at a p-value of less than 0.05.

RESULTS

The prevalence of poor dietary practice was found to be 40.6% (95%CI (35.7-46.0)). After adjusting for other variables in multivariable analysis, not attending formal education (AOR = 3.0; 95%CI (1.6-5.5)), being at primary education level (AOR = 2.2; 95%CI (1.1-4.4)), being moderately food insecure (AOR = 5.3; 95%CI (2.8-9.9)), having depression (AOR = 5.9; 95%CI (3.0-11.4)), and not having nutrition education (AOR = 2.2; 95% (1.1-4.6)) were factors associated with poor dietary practice.

CONCLUSIONS

A significant proportion of patients had poor dietary practice. The poor dietary practice was significantly higher among those with no formal education, at the primary education level, from the moderately food-insecure household, having depression, and not having nutrition education. The results imply the need for strengthening health information dissemination concerning healthy dietary practice in the form of a package.

Black-White racial disparities in health care utilization and self-reported health among cancer survivors: The role of food insecurity

BACKGROUND

Non-Hispanic Blacks continue to have worse cancer outcomes than non-Hispanic Whites. Suboptimal health care utilization and poor self-reported health among non-Hispanic Blacks contribute to these disparities. The relationship between race, food security status (FSS), and health care utilization or self-reported health among cancer survivors is not clear. This study aims to fill this gap in the science.

METHODS

The 2011-2018 National Health Interview Survey data were used. Bivariate and multivariable logistic regression analyses were used to examine the relationship between race (non-Hispanic Whites or non-Hispanic Blacks), FSS (high, marginal, low, or very low), health care utilization, and self-reported health among cancer survivors. Analyzed health care utilization measures included cost-related medication underuse (CRMU), cost-related delayed care, cost-related forgone care, seeing/talking to a medical specialist, seeing/talking to a general doctor, and overnight hospital stay.

RESULTS

A higher proportion of Blacks reported very low food security in comparison with Whites (10.58% vs 4.24%; P ≤ .0001). Blacks were significantly less likely to report a medical specialist visit and more likely to report fair/poor health in the past 12 months even after adjustments for FSS. There was a dose-response relationship between FSS and CRMU, cost-related delayed care, cost-related forgone care, overnight hospital stay, and self-reported health status for both Whites and Blacks.

CONCLUSIONS

Significant disparities in health care utilization and self-reported health across race and FSS persist among cancer survivors. Interventions that target food insecurity have the potential to reduce suboptimal health care utilization and self-reported health among cancer survivors.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

Moderate and Severe Level of Food Insecurity Is Associated with High Calorie-Dense Food Consumption of Filipino Households

Food insecurity is often deeply rooted in poverty. Hence, accessibility and the quality of foods consumed may affect the dietary pattern. The study aims to assess the relationship between food insecurity and dietary consumption. This investigation analyzed the data from the 2015 Updating of Nutritional Nutrition Survey. The Household Food Insecurity Access Scale (HFIAS) was used to determine household food security status and the prevalence of food insecurity. Food weighing, food inventory, and food recall were the methods used to collect food consumption data of sampled households. The study revealed poor nutrient quality and a greater likelihood of inadequacy of nutrients among moderate and severe food insecure households. Mild, moderate, and severe levels of food insecurity were found to affect 12%, 32%, and 22% of the population, respectively. The test showed that both moderate and severe food insecure families have significantly lower mean consumption of meat, milk, and fats and oils in contrast to food secure households. In comparison with food secure households, moderate and severe food insecure households consume higher amounts of cereals and cereal products, rice, and vegetables. Moderate and severe food insecure households have higher consumption of total carbohydrates but have significantly lower average intake of vitamin A, riboflavin, niacin, and total fat related to food stable households. Moreover, the results of the multiple logistic regression revealed that food insecure households have a higher likelihood to be deficient in energy, protein, calcium, vitamin A, thiamin, riboflavin, niacin, and vitamin C intakes, but except for iron (p value <0.05). Indeed, household food insecurity was associated with the higher consumption of calorie-dense food among Filipino households. This explains a lower nutrient quality and a higher likelihood of inadequacy of nutrients among moderate and severe food insecure households.

Relationships Among Neighborhood Poverty, Access to Healthy Food, and Diabetes Self-Management in Women Who Received Perinatal Nurse Home Visits

OBJECTIVE

To examine the relationships among neighborhood poverty, access to healthy food, and diabetes self-management in pregnant women in an urban setting who received perinatal nurse home visits.

DESIGN

Exploratory descriptive secondary analysis of existing individual-level and neighborhood-level data.

SETTING

Philadelphia, Pennsylvania, United States.

PARTICIPANTS

Women who were pregnant, had diabetes, and were enrolled in the citywide perinatal nurse home visiting program because of their diabetes (N = 264).

METHODS

We retrieved neighborhood-level aggregated data on poverty and access to healthy food from PolicyMap, a geographic information system. We retrieved individual-level data from a clinical research database. Access to healthy food was operationalized at the individual level by reported use of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). We operationalized diabetes self-management as good or poor glycemic control. We conducted descriptive and logistic regression analyses.

RESULTS

We found no relationship between neighborhood-level poverty and neighborhood-level access to healthy food with women's glycemic control. However, at the individual level, use of the WIC program was associated with glycemic control (p = .034). Participants who reported not using this program were two times more likely to have poor glycemic control than those who did (OR = 2.045, 95% confidence interval [1.003, 2.045]).

CONCLUSION

It is important to understand how the complex interplay between neighborhoods and individual factors of poverty and access to healthy food influences health outcomes among pregnant women. The WIC program may mediate neighborhood influence on diabetes self-management. Future research is warranted on how this program and nurse home visiting services can optimize maternal health outcomes among women who have diabetes during pregnancy.

Is There a Relationship between County-Level Food Insecurity Rates and Breast Cancer Stage at Diagnosis?

The relationship between county food insecurity (FI) rate and breast cancer stage at diagnosis is not clear. Using 2010-2016 Surveillance Epidemiology and End Results (SEER) and Feeding America data we analyzed the association between county FI rate in quartiles (low, medium, high, very high) and breast cancer stage at diagnosis among adult females (≥18 years). We also analyzed the effect of insurance status and county poverty level on this relationship, and whether this relationship varies among non-elderly (<65 years) and elderly (≥ 65 years) individuals. Bivariate and multivariable multilevel logistic regression were used for analyses. Bivariate analysis showed increased likelihood of late-stage breast cancer with increasing county FI rate. This relationship persisted after adjusting for insurance status but was no longer significant after adjusting for county-level poverty rate. There was a statistically significant association between counties with very high food insecurity rates and late-stage breast cancer diagnosis (OR = 1.07; 95% CI = 1.00, 1.14) among the elderly population. Very high county food insecurity rate was associated with late-stage breast cancer among elderly women. Population-level interventions focused on counties with very high food insecurity rates could reduce disparities in stage at breast cancer diagnosis among elderly women.

Facilitators and Barriers to Access to Pediatric Medical Services in a Community Hospital

Background: Missed medical appointments decrease continuity of medical care, waste resources, and may affect health outcomes. We examined the factors associated with missed children's supervision visits in Eastern Brooklyn, NY, USA. Methods: We surveyed guardians whose children received routine medical care at four pediatric clinics. Participants filled out a questionnaire that queried: demographics, food security, recent relocation, parental support of healthy behaviors, and length of knowing provider. Preexisting disease(s) and missed visits were retrieved from medical records. Regression analyses were used to determine factors that were associated with missing medical appointments. Results: Among 213 families, 33% faced food insecurity and 16.4% reported moving within the past 12 months. Forty percent of children missed at least 1 visit. Food insecurity (adjusted odds ratio [aOR] 2.3, 95% confidence interval [CI 1.0% to 5.2%) and recent relocation (aOR 1.8, 95% CI 1.1-3.4 were associated with missed health supervision visits, whereas greater parental healthy behaviors (aOR 0.5, 95% CI 0.3-0.9) and longer length of knowing provider (aOR 0.8, 95% CI 0.7-1.0) were associated with fewer missed appointments. Conclusion: This study indicates that social inequity may contribute to poor adherence to medical appointments through multiple mechanisms, including food insecurity, lack of social stability, and parental health behaviors. Multidimensional proactive prevention, and reactive tolerance should be considered as opportunities to mitigate the impact of social inequity on health outcomes.

Bridge to Health/ Puente a la Salud: Rationale and design of a pilot feasibility randomized trial to address diabetes self-management and unmet basic needs among racial/ethnic minority and low-income patients

Introduction

Racial/ethnic and socioeconomic disparities in diabetes prevalence and management persist. Unmet basic needs such as food insecurity and unstable housing interfere with optimal diabetes self-management. Bridge to Health/Puente a la Salud is a randomized pilot trial designed to examine the feasibility of testing the effectiveness of addressing unmet basic needs via navigation services versus navigation plus diabetes self-management support (DSMS) on improving diabetes-related outcomes among racial/ethnic minority and low-income patients with uncontrolled diabetes.

Material and methods

We recruited and randomized 110 African American, Hispanic, and Medicaid patients (any race/ethnicity) with diabetes and recent hemoglobin A1C ≥ 8% to one of two 6-month interventions: 1) Navigation only; or 2) Navigation + DSMS. In both arms, practice-embedded patient navigators help participants navigate social services and community-based resources to address unmet basic needs. In Navigation + DSMS, participants are also assigned to a community health worker (CHW) embedded in a local community-based organization who provides additional navigation support and delivers DSMS. A1C and unmet basic needs data are collected via routine lab and survey, respectively, at baseline and 6-month follow-up. Qualitative interviews with participants, health system leaders, CHWs, and patient navigators are conducted to explore intervention acceptability and determinants of implementation in a health care setting.

Discussion

Findings from this pilot feasibility study will enhance understanding about acceptability, preliminary clinical effectiveness, and facilitators and barriers to implementation of the Navigation only and Navigation + DSMS interventions and inform refinements of the overall study design for the larger, randomized clinical trial.

Prevalence of Unmet Basic Needs and Association with Diabetes Control and Care Utilization Among Insured Persons with Diabetes

Unmet basic needs (eg, food insecurity, inadequate housing) are major barriers to diabetes self-management. The purpose of this study was to identify the prevalence of unmet basic needs and examine the association with diabetes control and care utilization among insured persons with diabetes. A total of 4043 adult patients with diabetes were screened for unmet basic needs using Your Current Life Situation, a screener for unmet basic needs, during a clinical encounter or as an online survey, during the study period (January 1, 2016-August 31, 2017). Hemoglobin A1c and care utilization (outpatient, emergency department [ED], hospitalization, diabetes-related prescription refills) were extracted from the electronic health record 12 months prior to screening. The authors compared patients with unmet basic needs to those with no needs on poor diabetes control (ie, A1c ≥8%) and care utilization using multivariable regression models. Of the 4043 patients screened, 25% endorsed ≥1 unmet basic need. In adjusted analyses, the presence of unmet basic needs was associated with an increased likelihood of having an A1c ≥8% (OR = 1.77; 95% CI 1.47, 2.13), more outpatient visits (incidence rate ratio [IRR] = 1.3; 1.2, 1.4), more ED visits (IRR = 2.3; 2.0, 2.6), more hospitalizations (IRR = 1.8; 1.5, 2.2), and more delays in refilling diabetes medication (IRR = 1.21; 1.13, 1.30). Findings indicate that unmet basic needs are highly prevalent, even among an insured patient population, and are associated with poor diabetes-related clinical outcomes and excess utilization. Future studies to determine best strategies to integrate this information into treatment planning are warranted.

Food insecurity is associated with magnetic resonance-determined nonalcoholic fatty liver and liver fibrosis in low-income, middle-aged adults with and without HIV

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disease in the United States. Food-insecure individuals often depend on low-cost, energy-dense but nutritionally poor foods, resulting in obesity and chronic diseases related to NAFLD.

OBJECTIVES

To determine whether food insecurity is associated with NAFLD in a cohort of HIV and hepatitis C virus (HCV) infected and uninfected adults.

METHODS

We conducted a cross-sectional analysis of low-income, middle-aged adults from the Miami Adult Studies on HIV (MASH) cohort without a history of excessive alcohol consumption. Food security was assessed with the USDA's Household Food Security Survey. MRIs were used to assess liver steatosis and fibrosis. Metabolic parameters were assessed from fasting blood, anthropometrics, and vitals.

RESULTS

Of the total 603 participants, 32.0% reported food insecurity. The prevalences of NAFLD, fibrosis, and advanced fibrosis were 16.1%, 15.1%, and 4.6%, respectively. For every 5 kg/m2 increase in BMI, the odds of NAFLD increased by a factor of 3.83 (95% CI, 2.37-6.19) in food-insecure participants compared to 1.32 (95% CI, 1.04-1.67) in food-secure participants. Food insecurity was associated with increased odds for any liver fibrosis (OR, 1.65; 95% CI, 1.01-2.72) and advanced liver fibrosis (OR, 2.82; 95% CI, 1.22-6.54), adjusted for confounders. HIV and HCV infections were associated with increased risks for fibrosis, but the relationship between food insecurity and liver fibrosis did not differ between infected and uninfected participants.

CONCLUSIONS

Among low-income, middle-aged adults, food insecurity exacerbated the risk for NAFLD associated with a higher BMI and independently increased the risk for advanced liver fibrosis. People who experience food insecurity, particularly those vulnerable to chronic diseases and viral infections, may be at increased risk for liver-related morbidity and mortality. Improving access to adequate nutrition and preventing obesity among low-income groups may lessen the growing burden of NAFLD and other chronic diseases.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Foods for Health: An Integrated Social Medical Approach to Food Insecurity Among Patients With Diabetes

PURPOSE

Examine a clinic-based approach to improve food security and glycemic control among patients with diabetes.

DESIGN

One-group repeated-measures design.

SETTING

Federally Qualified Health Centers in a large Midwest city.

SAMPLE

Of the 933 patients with diabetes who consented at baseline, 398 (42.66%) returned during the follow-up period for a visit that included Hemoglobin A1c (HbA1c) results.

INTERVENTION

Integrated social medicine approach that includes food insecurity screening, nutrition education, and assistance accessing food resources as a standard-of-care practice designed to minimize disruptions in how patients and providers experience medical care.

MEASURES

HbA1c collected as part of a standard blood panel.

ANALYSIS

Repeated-measure, mixed-effect linear regression models.

RESULTS

There was a decrease in mean HbA1c (Δ = -0.22, P = 0.01) over the study period. The model examining change over time, glycemic control (GC), and food security status (F_{1, 352} = 5.80, P = 0.02) indicated that among participants with poor GC (33.12%), food secure (FS) participants exhibited significantly greater levels of improvement than food insecure (FI) participants (Δ = -0.55, P = 0.04). Among participants with good GC, changes in HbA1c were not significantly different between FS and FI participants (Δ = 0.23, P = 0.21).

CONCLUSION

Providing nutrition education and food assistance improved HbA1c profiles among FS and FI participants, but FI participants may face social and structural challenges that require additional support from health care teams.

Food Security Status of Native Hawaiians and Pacific Islanders in the US: Analysis of a National Survey

OBJECTIVE

To document food insecurity prevalence among a nationally representative sample of Native Hawaiian and Pacific Islander (NHPI) adults and compare differences in food security status across races/ethnicities in the US.

METHODS

Using 2014 National Health Interview Survey and 2014 NHPI-National Health Interview Survey data, food insecurity among the NHPI population is described and food security status across racial/ethnic groups is compared using Rao-Scott chi-square and multinomial logistic regression.

RESULTS

Food insecurity prevalence was 20.5% among NHPI adults, and NHPI had significantly higher odds of experiencing low and very low food security than white individuals. Food insecurity among Hispanic individuals, black people, and other races/ethnicities was also significantly higher than that among white people. Significant variation in food security status was observed by race/ethnicity (P < .001).

CONCLUSIONS AND IMPLICATIONS

This study provides documentation of food insecurity prevalence among NHPI adults and will inform chronic disease and nutrition research and programs conducted with NHPI communities in the US.

Emerging trends and the clinical impact of food insecurity in patients with diabetes

Food insecurity is a major public health concern in the United States affecting 15 million households according to data in 2017 from the US Department of Agriculture. Food insecurity, or the inability to consistently obtain nutritious food, disproportionately affects socioeconomically disadvantaged households, as well as those with chronic diseases including diabetes mellitus (DM). This review article explores the literature over the past 10 years pertaining to the complex relationship between food insecurity, social determinants of health, and chronic disease with an emphasis on diabetes and glycemic control. Those with diabetes and food insecurity together have been shown to have worse glycemic control compared to those who are food secure, but it remains unclear exactly how food insecurity affects glycemic control. Prior interventional studies have targeted aspects of food insecurity in patients with diabetes but have reported variable outcomes with respect to improvement in glycemic control despite effectively reducing rates of food insecurity. Additionally, few data exist regarding long-term outcomes and diabetes-related complications in this population. It is likely that many factors at both the community and individual levels impact glycemic control outcomes in the setting of food insecurity. Further studies are needed to better understand these factors and to create multifaceted targets for future interventional studies aimed at improving glycemic control in this population.

The assessment and management of quality of life of older adults with diabetes mellitus

Introduction: As the population ages, the number of older adults with diabetes mellitus will continue to rise. The burden of diabetes on older adults is significant due to the disease itself, its complications, and its treatments. This is compounded by geriatric syndromes such as frailty and cognitive dysfunction. Consequently, health and diabetes-related quality of life (QoL) are diminished.Areas covered: This article reviews the value of assessing QoL in providing patient-centered care and the associations between QoL measures and health outcomes. The determinants of QoL particular to diabetes and the older population are reviewed, including psychosocial, physical, and cognitive burdens of diabetes and aging and the impact of hypoglycemia on QoL. Strategies are described to alleviate these burdens and improve QoL, and barriers to multidisciplinary patient-centered care are discussed. QoL measurement instruments are reviewed.Expert opinion: The goals of treating diabetes and its complications should be considered carefully along with each patient's capacity to withstand the burdens of treatment. This capacity is reduced by socioeconomic, psychological, cognitive, and physical factors reduces this capacity. Incorporating measurement of HRQoL into clinical practices is possible, but deficiencies in the systems of health-care delivery need to be addressed to facilitate their use.

Food Insecurity, Cardiometabolic Health, and Health Care in U.S.-Mexico Border Immigrant Adults: An Exploratory Study

Household food insecurity (HFI) has been linked to poorer cardiometabolic health and reduced health care access but few studies have examined these issues in the large Mexican immigrant population living on the U.S.-Mexico border. This exploratory study examined the association of HFI with cardiometabolic conditions and health care in 40-84 year urban border immigrants (n = 75). Data were collected on HFI, self-reported and clinical cardiometabolic conditions, health care sources and use. HFI affected 45% of participants. HFI was associated with self-reported and clinical diabetes but not hypertension, hyperlipidemia, obesity, or metabolic syndrome. It also was associated with increased emergency room visits and hospitalizations but not source of primary health care or preventative health care use. These findings highlight the need for additional research on the relationship of HFI with cardiometabolic health and health care in border immigrants as well as reassessment of current immigrant food security and health laws and policies.

Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial

Despite the burdens costs can place on adults with diabetes, few evidence-based, scalable interventions have been identified that address prevalent health-related financial burdens and unmet social risk factors that serve as major obstacles to effective diabetes management. In this study, we will test the effectiveness of CareAvenue - an automated e-health tool that screens for unmet social risk factors and informs and activates individuals to take steps to connect to resources and engage in self-care. We will determine the effectiveness of CareAvenue relative to standard care with respect to improving glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial burden. We will also examine the role of patient risk factors (moderators) and behavioral factors (mediators) on the effectiveness of CareAvenue in improving outcomes. We will recruit 720 patients in a large health system with uncontrolled Type 1 diabetes mellitus (T1DM) or Type 2 diabetes mellitus (T2DM) who engage in CRN or perceive financial burden. Participants will be randomized to one of two arms: 1) receipt of a 15-20 min web-based program with routine follow-up (CareAvenue); or 2) receipt of contact information for existing health system assistance services. Outcomes will be assessed at baseline and 6- and 12-month follow-up. Clinical Trial Registration: ClinicalTrials.gov ID NCT03950973, May 2019.

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Food Insecurity May Be an Independent Risk Factor Associated with Nonalcoholic Fatty Liver Disease among Low-Income Adults in the United States

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD), considered a "barometer" of metabolic health, is the leading cause of liver disease in the United States. Despite established associations between food insecurity and obesity, hypertension, and diabetes, little is known about the relation between food insecurity and NAFLD.

OBJECTIVE

We sought to evaluate the association of food insecurity with NAFLD among low-income adults in the United States.

METHODS

We conducted a cross-sectional analysis of a nationally representative sample of adults from the NHANES (2005-2014 waves). Participants included adults in low-income households (≤200% of the federal poverty level) without chronic viral hepatitis or self-reported heavy alcohol use. Food insecurity was measured using the Household Food Security Survey. Our primary outcome was NAFLD, as estimated by the US Fatty Liver Index, and our secondary outcome was advanced fibrosis, as estimated by the NAFLD fibrosis score. The association between food insecurity (defined as low and very low food security) and hepatic outcomes was assessed using multivariable logistic regression, adjusting for sociodemographic factors.

RESULTS

Among 2627 adults included in the analysis, 29% (95% CI: 26%, 32%) were food insecure. The median age was 43 y, 58% were female, and 54% were white. The weighted estimated prevalence of NAFLD did not differ significantly by food security status (food secure 31% compared with food insecure 34%, P = 0.21). In the multivariable model, food-insecure adults were more likely to have NAFLD (adjusted OR: 1.38; 95% CI: 1.08, 1.77) and advanced fibrosis (adjusted OR: 2.20; 95% CI: 1.27, 3.82) compared with food-secure adults.

CONCLUSIONS

Food insecurity may be independently associated with NAFLD and advanced fibrosis among low-income adults in the United States. Future strategies should assess whether improved food access, quality, and healthy eating habits will decrease the growing burden of NAFLD-associated morbidity and mortality among at-risk adults.

Food Insecurity and Chronic Disease in US Young Adults: Findings from the National Longitudinal Study of Adolescent to Adult Health

BACKGROUND

Food insecurity, or the limited or uncertain access to food resulting from inadequate financial resources, is associated with a higher prevalence of chronic disease in adulthood. Little is known about these relationships specifically in young adulthood, an important time for the development of chronic disease.

OBJECTIVE

To determine the association between food insecurity and chronic disease including diabetes, hypertension, obesity, and obstructive airway disease in a nationally representative sample of US young adults.

DESIGN

Cross-sectional nationally representative data collected from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health was analyzed using multiple logistic regression models.

PARTICIPANTS

US young adults ages 24-32 years old MAIN MEASURES: Food insecurity and general health; self-reported diabetes, hypertension, hyperlipidemia, "very overweight," and obstructive airway disease; measured obesity derived from body mass index; and inadequate disease control (hemoglobin A1c ≥ 7.0%, blood pressure ≥ 140/90 mmHg) among those with reported diabetes and hypertension.

KEY RESULTS

Of the 14,786 young adults in the sample, 11% were food insecure. Food-insecure young adults had greater odds of self-reported poor health (2.63, 95% confidence interval (CI) 1.63-4.24), diabetes (1.67, 95% CI 1.18-2.37), hypertension (1.40, 95% CI 1.14-1.72), being "very overweight" (1.30, 95% CI 1.08-1.57), and obstructive airway disease (1.48, 95% CI 1.22-1.80) in adjusted models compared with young adults who were food secure. Food insecurity was not associated with inadequate disease control among those with diabetes or hypertension.

CONCLUSIONS

Food insecurity is associated with several self-reported chronic diseases and obesity in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate. Future research should evaluate the impact of early interventions to combat food insecurity on the prevention of downstream health effects in later adulthood.

Differential Impact of Food Insecurity, Distress, and Stress on Self-care Behaviors and Glycemic Control Using Path Analysis

BACKGROUND

The aim of this study was to investigate the direct and indirect pathways through which food insecurity influences glycemic control and self-care behaviors.

METHODS

Using data collected from 615 adults with type 2 diabetes, we investigated pathways between food insecurity and diabetes outcomes using path analysis. We included measures of perceived stress, diabetes distress, diabetes fatalism, and depression as psychosocial factors in the pathway. Self-care behaviors included general diet, specific diet, exercise, blood sugar testing, foot care, and medication adherence. Analyses were conducted using Stata v14, to include both direct and indirect effects, with standardized estimates to allow comparison of paths.

RESULTS

Food insecurity was directly associated with stress (r = 0.43, p < 0.001), depression (r = 0.34, p < 0.001), fatalism (r = 0.09, p = 0.03), and distress (r = 0.36, p < 0.001). The type of stress, however, was differentially associated with outcomes, with distress associated with HbA1c (r = 0.25, p < 0.001), general and specific diet (r = - 0.28 and - 0.17, respectively, p = 0.001), and medication adherence (r = - 0.26, p < 0.001), while stress was associated with specific diet (r = - 0.14, p = 0.005) and medication adherence (r = - 0.15, p < 0.001) and depression was associated with exercise (r = - 0.06, p = 0.007). Food insecurity was indirectly associated with HbA1c (r = 0.08, p = 0.001), and four self-care behaviors (general diet, specific diet, exercise, and medication adherence).

CONCLUSIONS

Food insecurity influences self-care behaviors indirectly via multiple psychosocial factors, and glycemic control indirectly through diabetes distress, supporting the hypothesis that stress is an important mechanism. Programs to improve access to resources and manage psychosocial concerns should be combined with food-based programs for food insecure populations with diabetes.

Diabetes Self-Management Education (DSME) - Effect on Knowledge, Self-Care Behavior, and Self-Efficacy Among Type 2 Diabetes Patients in Ethiopia: A Controlled Clinical Trial

PURPOSE

Diabetes patients must be equipped with the necessary knowledge to confidently undertake appropriate self-care activities. We prepared a diabetes self-management education (DSME) intervention and assessed how it affected patients' self-reported levels of diabetes knowledge, self-care behaviors, and self-efficacy.

PATIENTS AND METHODS

A before-and-after, two-group intervention study was conducted at Jimma University Medical Centre among adult patients with type 2 diabetes. At baseline, we randomly assigned 116 participants to the DSME intervention and 104 to a comparison group. Six interactive DSME sessions supported by an illustrative handbook and fliers, experience-sharing, and take-home activities were administered to the intervention group by two nurses during a six-month period. Diabetes knowledge, self-care behaviors, and self-efficacy were measured at baseline and at nine months following the commencement of DSME intervention (endpoint) in both groups.

RESULTS

At the endpoint, data from 78 intervention group participants and 64 comparison group participants were included in final analysis. The difference in the mean Diabetes Knowledge Scale scores before and after the DSME intervention was significantly greater in the intervention group (p = 0.044). The measured self-care behaviors included diet, exercise, glucose self-monitoring, footcare, smoking, alcohol consumption, and khat chewing. The mean number of days per week on which the intervention group participants followed general dietary recommendations increased significantly at the endpoint (p = 0.027). The intervention group followed specific dietary recommendations (p = 0.019) and performed footcare (p = 0.009) for a significantly greater number of days. There were no significant differences within or between the groups in other self-reported diabetes self-care behavior regimens or in diabetes self-efficacy.

CONCLUSION

Our study found significant improvements in the intervention participants' diabetes knowledge scores and in their adherence to dietary and footcare recommendations. This demonstrates that our DSME intervention may be of clinical importance in developing countries such as Ethiopia.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier NCT03185689, retrospectively registered on June 14, 2017: https://clinicaltrials.gov/ct2/show/NCT03185689.