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Low food security associated with higher HbA1c, insulin use in type 2 diabetes
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Low food security among patients with type 2 diabetes directly impairs glucose control, even when patients have full access to comprehensive medical management, according to findings published in Nutrition & Diabetes.
“Controlling for correlates of glucose control, lower levels of food security are directly related to higher [HbA1c],” Madeleine Ullman Shalowitz, MD, MBA, director of health services research and the section for child and family health studies at NorthShore University Health System in Evanston, Illinois, and colleagues wrote. “Furthermore, patients who are food secure show consistent benefit from comprehensive diabetes management, but those who are insecure fail to derive this benefit, with the gap in glucose control remaining over time. This finding provides direct support for the importance of the social determinants of diabetes control, which, if replicated, has specific implications for public policy and health care expenditures over the long run.”
In a longitudinal, observational study, Shalowitz and colleagues analyzed data from 336 patients with type 2 diabetes considered to be medically underserved who were referred to a community health center program in Illinois by primary care providers beginning in June 2009 (56% women; mean age, 51 years; median diabetes duration, 5.5 years). Community health center visits provided medication and testing supply assistance, diabetes self-management education, one-on-one and group support, and fitness programs; all patients completed the 18-item U.S. Household Food Security Survey module from the U.S. Department of Agriculture. Researchers assessed HbA1c levels at baseline and at follow-up visits conducted over 24 months.
Within the cohort, 56% of patients were considered food insecure (having low or very low food security); 49.7% were Spanish-speaking Hispanic. The mean HbA1c was 9.1% among those considered food insecure vs. 8.56% in the food secure group (P = .04); 36% of food insecure patients were using insulin therapy vs. 23% of food secure patients (P = .01).
In a multivariable model, researchers found that less food security remained a predictor of increased HbA1c over time (P = .02), as did insulin use over time, years since diagnosis, Hispanic ethnicity and increased BMI. In a trajectory model of HbA1c over time by baseline food security status, food insecure patients showed an initial decrease in mean HbA1c before increasing again, decreasing, and then rising to remain high, according to the researchers. In contrast, the mean HbA1c for food secure patients decreased and remained stable during the 24-month follow-up period.
The researchers noted that the findings are consistent with observations that a diagnosis of diabetes is twice as likely in adults who experience food insecurity and further demonstrate the relationship of food security to the physiology of glucose control, irrespective of obesity status.
“This paper’s demonstration of the link between social and biological determinants for two urgent public health emergencies underscores the need for a more comprehensive, community-based approach to care,” the researchers wrote. “Improving health and quality of life for these patients with diabetes will demand a multi-sector approach combining medicine, public health, the built environment and public policy.” – by Regina Schaffer
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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A common limitation of the scientific literature is the lack of longitudinal studies to confirm cause and effect associations. This current study attempts to clarify the ambiguity in the literature of the impact of food insecurity on glycemic control among individuals with diabetes using a longitudinal approach. It is not uncommon to have a higher rate of patients who are food insecure to be on insulin as insulin is commonly prescribed to patients if glycemic control is consistently poor or erratic. Although both food-secure and food-insecure patients were enrolled in a comprehensive diabetes self-management program, food-insecure patients had higher HbA1c levels at baseline, during the time of the intervention and at follow-up. The program may help mitigate, but did not eliminate, the challenges that food-insecure patients experience. As described by the researchers, diabetes requires a considerable investment in lifestyle change. Limited access to nutrient-dense foods makes it inherently difficult, if not impossible, to meet dietary recommendations. Fluctuations in available money could result in the cycling of purchasing foods and medication — and, consequently, swings in glucose control. The results of this study underscore that, in addition to self-management education, more is needed to better support those who face food insecurity, regardless of knowledge and commitment to change. Screening for food insecurity is the first step to assist care providers to collaborate with patients in developing and tailoring realistic management plans given their circumstances. Furthermore, political will is essential to address the more fundamental causes of food insecurity, such as income, employment and housing.
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