Q&A: What nutrition security can mean for people with diabetes
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Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with Isabel C. Betancourt, MS, RDN, CDCES, about nutrition insecurity and how a model designed to combat its effects on people with HIV can improve the lives of people with diabetes.
Weiner: What is the Food Is Medicine Coalition?
Betancourt: The Food is Medicine Coalition (FIMC) is a national coalition of nonprofit organizations that provide medically tailored meals and medically tailored groceries, medical nutrition therapy, and nutrition counseling and education to people living with severe and chronic illnesses. FIMC agencies in communities across the U.S. are member organizations that follow the medically tailored meal model and maintain FIMC standards for their intervention.
FIMC agencies created the medically tailored meals intervention almost 40 years ago as a response to the HIV/AIDS pandemic. At that time, there was no treatment for the illness and people were dying isolated and alone. Volunteers in communities responded and quickly learned that people needed more than just food — they needed meals tailored to their nutritional needs to help them stay as healthy as possible, for as long as possible.
Registered dietitian nutritionists (RDNs) were part of this intervention early on, and through their services, FIMC has stayed current with nutrition science as it evolved to include other medical conditions, like diabetes.
Medically tailored meals are delivered to the homes of individuals living with complex severe or chronic conditions who are too sick to shop or cook for themselves. These meals are paired with one-on-one nutrition counseling or medical nutrition therapy with an RDN. What makes medically tailored meals different from other meals is that they are individually tailored to the medical needs of recipients according to FIMC nutrition standards. Dietary restrictions are often layered to accommodate multiple comorbid conditions. These meal plans are designed to improve recipients’ health outcomes, lower health care costs and increase patient satisfaction.
Weiner: What is food and/or nutrition insecurity? How does this issue specifically affect people with type 2 diabetes?
Betancourt: Nutrition insecurity is when people do not have consistent access to food that supports their health and nutritional needs. It is slightly different from food insecurity, where people have limited access to enough food or calories.
Nutrition security focuses specifically on the quality of food available. Poor nutrition is associated with increased risks for obesity, diabetes and heart disease and broader impacts, including higher health care costs and decreased productivity.
Unsurprisingly, food insecurity for people living with type 2 diabetes is associated with depression, diabetes distress, low medication adherence and worse ability to meet glycemic targets. When struggling to meet basic needs — like healthy food — diabetes self-management can easily become a secondary priority.
Participation in medically tailored meal programs may alleviate nutrition insecurity and support type 2 diabetes self-management so that clients may not have to choose between purchasing medication or purchasing food. When living with a medical condition like diabetes or HIV, food insecurity is likely to lead to worse health outcomes and added stress and contribute to decreased quality of life.
Most people living with food insecurity and diabetes also tend to reside in high poverty neighborhoods that often present additional stressors outside of limited nutrition access, including a lack of programs and spaces that promote physical activity or safe and stable housing. Additionally, a struggle to cover basic needs, such as energy bills, transportation or medications, can lead people with diabetes to “stretch” insulin or skip medications to make them last longer. It is well known that disparities in the prevalence and severity of type 2 diabetes between racial groups and ethnic populations could be related to poverty and a lack of choice in living environments that do not foster a healthy lifestyle.
Participation in medically tailored meals programs may alleviate nutrition insecurity to lower stress and allow clients to learn skills about diabetes self-management through sessions with their RDN.
Weiner: How can a visit with an RDN or certified diabetes care and education specialist (CDCES) in conjunction with medically tailored meals programs bridge the gap in diabetes care and improve health outcomes?
Betancourt: In an ideal world, all people diagnosed with diabetes would be referred to and visit a CDCES. Unfortunately, only an estimated 25% or fewer people receive formal diabetes education at the time of diagnosis. This percentage may be lower for people experiencing competing social and medical priorities, like poverty, disability and food insecurity. Medically tailored meals interventions extend free access to RDNs, and in some cases CDCESs and diabetes self-management programs, for populations that may not otherwise receive these services.
In 2017, researchers looked at San Francisco Bay-area medically tailored meals recipients living with HIV and/or type 2 diabetes with an income under 300% of the federal poverty index. This was a 6-month intervention that provided medically tailored meals and snacks to cover 100% of daily nutrition needs. The menu varied each week, and the food options were based on the Mediterranean diet pattern, offering fruits and vegetables, lean proteins, healthy fats and whole grains. The carbohydrate and saturated fat levels were based on current recommendations from the American Diabetes Association and American Heart Association, respectively.
Among the participants, diabetes distress scores decreased, and they reported improved perceived self-management of diabetes. BMI also decreased. Additionally, participants experienced reductions in food insecurity, consumed fewer fatty or sugary foods and drinks, reduced binge drinking and reported fewer depressive symptoms. Finally, participants reported fewer instances of sacrificing food for health care or medication, and vice versa. Unfortunately, due to the small number of participants, the study was underpowered to show an impact on HbA1c and fasting blood glucose.
In a randomized crossover study conducted in 2019, Boston-area participants living with type 2 diabetes and food insecurity received medically tailored meals for 12 weeks. Participants received 10 refrigerated and/or frozen meals once a week. Like most medically tailored meals programs, the meals were fully cooked, and recipients only needed to use a microwave or oven to reheat. The meals improved diet quality as measured by the 2010 U.S. Department of Agriculture’s Healthy Eating Index (HEI). The average HEI score for participants was 73.1, where 100 represents the healthiest diet. In comparison, the average HEI score for those not receiving medically tailored meals was 39.9. While receiving medically tailored meals, participants also reported lower food insecurity, fewer incidents of hypoglycemia and fewer days where mental health interfered with quality of life.
Although these are the positive outcomes we aim to achieve with all our clients, it is essential to note that both studies included only the medically tailored meals portion of the intervention, excluding the medical nutrition therapy or RDN counseling. RDNs were involved in the nutrition analysis and menu design of the interventions, but additional research investigating the efficacy of a more complete intervention, including medical nutrition therapy and/or diabetes self-management education, is needed. Further studies are likely to yield even more impactful outcomes.
Medical nutrition therapy is a powerful and effective intervention for type 2 diabetes, and we predict that when people living with diabetes and food insecurity receive medically tailored meals and diabetes self-management education or medical nutrition therapy, we will see improvements in short-term and long-term diabetes management measures. Additionally, decreases in hospitalizations and diabetes complications and improved quality of life measures would be anticipated.
Weiner: What about cost savings by using medically tailored meals and reduction of economic burden on the health care system?
Betancourt: Today, type 2 diabetes is the most expensive chronic disease in the U.S. Though only about 11% of the American population is diagnosed with diabetes, the CDC estimates that one of every four dollars spent on health care goes to treating diabetes, and between 48% and 64% of those dollars are spent on related complications. Moreover, 61% of those costs are for people older than 65 years and mostly paid for by Medicare. In 2017, the total annual cost of diabetes in the U.S. came to around $327 billion, a 26% increase from 2012; the increase in spending is likely to continue.
Nutrition and lifestyle counseling and expansion of insurance-covered access to medical nutrition therapy before diagnosis are well-studied preventive interventions. While FIMC organizations typically work in treatment rather than prevention, many who enroll are also at elevated risk for diabetes, meaning the medically tailored meals intervention may work as treatment for the primary condition and as prevention for comorbidities like type 2 diabetes.
FIMC organizations find their most effective cost-reduction role in decreasing complications from diabetes. Nutrition counseling related to meeting glycemic targets can reduce risks for eye, kidney and nerve diseases by up to 40%. Additionally, medically tailored meals’ heart-healthy parameters can lower risk for cardiovascular complications by up to 50%. These effects combine to help reduce the need for inpatient hospital visits.
In more direct outcomes, those who received medically tailored meals have reported less food insecurity and better glycemic control — the largest component of the direct costs of diabetes. Recipients of medically tailored meals experienced 49% fewer hospital admissions, 70% fewer emergency department visits and 72% fewer admissions to skilled nursing facilities. Cost-effectiveness studies have shown an average of 16% in net cost savings, which factors in the cost of meals and medical nutrition therapy interventions. In fact, a recent study modeled the potential cost savings if everyone in the country who qualified were enrolled in medically tailored meals programs. The outcomes were stunning: In just the first year of service provision, an estimated 1,594,000 hospitalizations could be avoided for a net cost savings of $13.6 billion. The question is not whether we can afford to support medically tailored meal programs; the question is whether we can afford not to.
Weiner: Does using medically tailored meals have any effect on activities of daily living?
Betancourt: Our clients tend to live with multiple medical conditions at once and typically experience high burdens of disability, illness and/or health care utilization, resulting in complex dietary restrictions and often requiring the assistance of family or caregivers. As a result, many clients cannot take advantage of traditional emergency food support systems that require participants to leave their homes or shop in stores. The medically tailored meals intervention can allow clients to live more independently by lowering the physical burden of grocery shopping and preparing nutritious meals for themselves. Medically tailored meals are designed to be microwave- and oven-safe meals that are ready to heat and heat in just a few minutes.
References:
- Berkowitz SA, et al. J Gen Intern Med. 2019;doi:10.1007/s11606-018-4716-z.
- Hager K, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.36898.
- Palar K, et al. J Urban Health. 2017;doi:10.1007/s11524-016-0129-7.
- Silverman J, et al. J Gen Intern Med. 2015;doi:10.1007/s11606-015-3351-1.
For more information:
Isabel C. Betancourt, MS, RDN, CDCES, is nutrition services manager at Moveable Feast, in Baltimore, whose mission is to improve the health of Marylanders experiencing food insecurity and chronic illness by preparing and delivering medically tailored meals and providing nutrition education, thereby achieving racial, social and health equity. As a certified diabetes care and education specialist, Betancourt helps guide all diabetes-related interventions and works with all Spanish-speaking clients at Moveable Feast. She can be reached at ibetancourt@mfeast.org; X (Twitter): @Moveable_Feast.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; X (Twitter): @susangweiner; Instagram: @susanweinernutrition.
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