Food insecurity is related to glycemic control deterioration in patients with type 2 diabetes

doi:10.1016/j.clnu.2011.09.014

Clinical Nutrition

Volume 31, Issue 2, April 2012, Pages 250-254

https://doi.org/10.1016/j.clnu.2011.09.014 Get rights and content

Summary

Background & aims

Poor glycemic control has been shown to play a major role in the development and progression of diabetes complications. This cross-sectional study tested the hypothesis that food insecurity may deteriorate glycemic control in patients with type 2 diabetes. The objectives of this study were to assess the prevalence of food insecurity among type 2 diabetics in a major hospital that serves the area of northern Jordan, and to investigate its relation to glycemic control.

Methods

A sample of 843 patients diagnosed with type 2 diabetes participated in the study. Socioeconomic and health data were collected by interview-based questionnaire. Weight and height were measured by a trained nutritionist. Dietary assessment was done using food frequency questionnaire. Dietary data were processed using food processor software. Food insecurity was assessed by the short form of the U.S. food security survey module. Glycemic control was assessed by measuring glycosyated hemoglobin (HbA1c). Statistical procedures used to analyze the data were chi-square, and post-hoc analysis of variance.

Results

About 22% of the tested sample were food secure (FS); 51% were moderately food insecure (MFIS); and 27% were severely food insecure (SFIS). Higher BMI was associated with SFIS patients. After adjusting for age, gender, income, education, and duration of diabetes, body mass index, and caloric consumption; moderate and severe food insecurity were associated with poor glycemic control (p = 0.04).

Conclusion

food insecurity may be associated with glycemic control deterioration in patients with type 2 diabetes.

Introduction

Diabetes Mellitus, a group of metabolic diseases characterized by hyperglycemia,1, 2 is a global health problem and a leading cause of mortality and morbidity. In Jordan, the prevalence of diabetes mellitus is increasing; there was 31.5% increment in the prevalence of diabetes in 2008 as compared to 1994.³ Poor glycemic control is associated with high risk of developing end organ damage such as retinopathy,⁴ nephropathy,⁵ neuropathy, and cardiovascular disease.6, 7

Food security is defined as access to enough food at all times for an active and healthy life,⁸ and is also considered as indicator of adequacy and stability of food supply to support active healthy living.⁹ Hence, food insecurity is defined as limited or uncertain availability of nutritionally adequate and safe foods in socially acceptable ways.10, 11 Poor quality of food, lack of food choice, unbalanced diets, and skipping meals are major characteristics of food insecure individuals.8, 9, 12, 13, 14, 15 Given the characteristics of food insecure individuals, a plausible explanation for a cause-effect relationship between food insecurity and glycemic control may exist.

Uncontrolled diabetes is extremely costly. Direct costs include costs due to drugs, hospitalizations, consultations and treatment of the complications of diabetes.¹⁶ At the same time, premature mortality along with reduced productivity or disability due to acute and chronic complications raises the indirect costs. Eye complications, for example, affect 36.6% of diabetic Jordanians,¹⁷ and result in higher medical care cost, and lower productivity. Investigating the relationship between food insecurity and glycemic control may contribute substantially to the tertiary prevention of diabetes. Despite all attention given to linking food security to health and disease, there are relatively few studies focused on the relationship between food security and diabetes and almost none aimed to answer the research question “does food insecurity deteriorate glycemic control in food insecure diabetics?” The objective of this study is to evaluate the relationship between food insecurity and glycemic control, measured by HbA1c, among a group of Jordanian patients suffering from type 2 diabetes.

Section snippets

Setting

The design of the study was a cross-sectional survey study. Participants were assessed for their (1) food security status, and (2) glycemic control measured by glycosylated hemoglobin (HbA₁c). The study was conducted in the Endocrinology Clinics in King Abdullah University Hospital (KAUH) in Al-Ramtha. KAUH, that serves a proximately 1.5 million people in the north of Jordan. This study met the criteria set by the Institutional Review Board (IRB) Committee at Jordan University of Science and

Results

This study included 843 participants (327 males and 516 females) with type 2 diabetes aged between 22 and 84 years. Table 1 shows the socio-demographic characteristics of participants. The majority of the participants were more than 40 years old. About half of the participants had an education of 12 years or less, and 31.2% of the participants were illiterate. Around 85% of the participants have total family monthly incomes of 600 JD ($850) or less. Hundred eighty nine patients (22.4%) were FS,

Discussion

Few studies reported the prevalence of food insecurity among patients with diabetes. Seligman et al. evaluated the relationship between food insecurity and diabetes.²² They found that diabetes prevalence in the food secure, mildly food insecure, and severely food insecure categories was 11.7%, 10.0%, and 16.1%, respectively. The finding of the current study that only 22.4% of type 2 diabetic patients were FS may be terrifying; however, investigating the nature and socioeconomic characteristics

Funding sources

This research was supported by the Deanship of Research at Jordan University of Science and Technology (JUST) (grant number 20070089).

Conflict of interest

The authors have no conflict of interests.

Authorships section

Authors developed the study design, supervised data collection, and drafted the manuscript. HAB designed the study and interpreted the results; FA supervised data collection; DA collected the data; YSK performed statistical analysis; SF helped in data collection; RFT helped in data interpretation.

Acknowledgment

The authors would like to thank the Deanship of Research at Jordan University of Science and Technology (JUST) for providing financial support for this project. Authors would also like to thank Ms. Amal Dwairy for her help during data collection. The collaboration of the volunteers was also greatly appreciated.

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Food insecurity, diabetes, and perceived diabetes self-management among Latinos in California: Differences by nativity and duration of residence
2022, Preventive Medicine Reports
Citation Excerpt :
Among these, food insecurity, which is defined as a lack of access by all people at all times to enough food for an active, healthy life, has been found to be an important risk factor (Hill et al., 2013; USDA, 2017). Previous studies have found that individuals living in food-insecure households have a higher proportion of T2D when compared to their food-secure counterparts (Gucciardi et al., 2014; Essien et al., 2016; Seligman et al., 2007; Fitzgerald et al., 2011; Bawadi et al., 2012; Seligman et al., 2010). One study among low-income Americans found that participants with food insecurity were more than two times more likely to have T2D compared to their food-secure counterparts after adjusting for sociodemographic factors, physical activity level, and body mass index (Seligman et al., 2007).
We examined associations between food security (FS) status and type 2 diabetes (T2D) prevalence and perceived T2D self-management by nativity and US duration of residence among Latinos living in California. We used the California Health Interview Survey (2012–2017) and included Latinos who lived below 200% of the federal poverty line (n = 16,254) and for our management outcome, those with T2D (n = 2284). Latinos with low FS (OR = 1.44, 95% CI 1.14–1.83) or very low FS (OR = 1.87, 95% CI 1.33–2.61) had a higher odds of T2D compared to their food-secure counterparts. When stratified by nativity/duration in the US, US-born Latinos and Latino immigrants with >10 years duration had a higher odds of T2D if they reported low FS (US-born: OR = 1.60, 95% CI 1.02–2.52; >10 yrs: OR = 1.48, 95% CI 1.12–1.97) or very low FS (US-born: OR = 2.37, 95% CI 1.45–3.86; >10 yrs: OR = 1.78, 95% CI 1.15–2.76) compared to their food-secure counterparts. There was no association among immigrants with <10 years duration. For perceived T2D self-management, those with low or very low FS had lower odds of reporting proper management (OR = 0.56, 95% CI 0.36–0.86; OR = 0.46, 95% CI 0.26–0.83) compared to their food-secure counterparts. When stratified by nativity, the US-born did not differ in their perceived self-management by FS status, while immigrants with low or very FS had lower odds of perceived self-management (OR = 0.54, 95% CI 0.34–0.86; OR = 0.36, 95% CI 0.17–0.74), compared to their food-secure counterparts. Food insecurity may be an important contributor to T2D prevalence and perceived T2D self-management for Latino immigrants.
A conceptual model for understanding the rapid COVID-19-related increase in food insecurity and its impact on health and healthcare
2020, American Journal of Clinical Nutrition
Food insecurity, a well-established determinant of chronic disease morbidity and mortality, is rapidly increasing due to the coronavirus disease 2019 (COVID-19) pandemic. We present a conceptual model to understand the multiple mechanisms through which the economic and public health crises sparked by COVID-19 might increase food insecurity and contribute to poor health outcomes in the short- and long-term. We hypothesize that, in the short-term, increased food insecurity, household economic disruption, household stress, and interruptions in healthcare will contribute to acute chronic disease complications. However, the impact of the pandemic on food security will linger after social-distancing policies are lifted and the health system stabilizes, resulting in increased risk for chronic disease development, morbidity, and mortality among food-insecure households in the long-term. Research is needed to examine the impact of the pandemic-related increase in food insecurity on short- and long-term chronic health outcomes, and to delineate the underlying causal mechanisms. Such research is critical to inform the development of effective programs and policies to address food insecurity and its downstream health impacts during COVID-19 and future pandemics.
Inflammation and Stress Biomarkers Mediate the Association between Household Food Insecurity and Insulin Resistance among Latinos with Type 2 Diabetes
2019, Journal of Nutrition
Household food insecurity (HFI) is a stressor that is associated with type 2 diabetes (T2D). However, little is known about HFI and the insulin resistance (IR) underlying T2D, and the mechanisms involved.
We examined the cross-sectional association between HFI and IR among low-income Latinos with T2D and tested whether inflammation and stress hormones mediated this association.
HFI was measured with the 6-item US Household Food Security Survey module. IR was calculated from fasting plasma blood glucose and serum insulin. Inflammation was indicated by high-sensitivity C-reactive protein (hsCRP), and stress hormones included urinary cortisol, metanephrine, and normetanephrine. To test for an indirect effect of HFI on homeostasis model assessment of IR, a parallel multiple mediation model was run with biological markers that significantly differed between food security status—entered as mediators in the model. We used 95% bias-corrected bootstrap CIs, with 10,000 bootstrap samples, to assess the significance of the indirect effects.
The 121 participants with T2D were primarily Puerto Rican (85.8%), aged mean = 60.7 y, and 74% were female. Eighty-two (68%) were classified as food insecure. Compared with food-secure individuals, food-insecure individuals had a significantly higher IR [mean difference (Δ) = 7.21, P = 0.001], insulin (Δ = 9.7, P = 0.019), glucose (Δ = 41, P < 0.001), hsCRP (Δ = 0.8, P = 0.008), cortisol (Δ = 21, P = 0.045), and total cholesterol (Δ = 29, P = 0.004). Groups did not differ on other lipids, metanephrine, normetanephrine, or A1c. The mediation model showed a significant direct effect of HFI on hsCRP (P = 0.020) and on cortisol (P = 0.011). There was a direct effect of cortisol (P = 0.013), hsCRP (P = 0.044), and HFI on IR (P = 0.015). The total combined indirect effect of HFI through cortisol and hsCRP indicated partial mediation.
Among Latinos with T2D, HFI is associated with IR partially through inflammation and stress hormones. Interventions to ameliorate HFI and mitigate its effects on inflammation, stress, and IR are warranted. This trial was registered at clinicaltrials.gov as NCT01578096.
The global diabetes epidemic and the nonprofit state corporate complex: Equity implications of discourses, research agendas, and policy recommendations of diabetes nonprofit organizations
2019, Social Science and Medicine
Important insights have been gained from studying how corporate social actors -- such as Big Tobacco or Big Food -- influence how global health issues are framed, debated, and addressed, and in so doing contribute to reproducing health inequities. Less attention has been paid to the role of nonprofit organizations (NPOs), even when all too often NPOs actively contribute to these inequities through normalizing discourses and practices that legitimize establishment views, poor public policies and existing relations of power. Our study attempts to fill this gap by assessing the influence on global health inequities of major NPOs -- specifically three disease associations -- whose mission includes preventing type 2 diabetes (henceforth diabetes) or reducing inequities in the global diabetes epidemic.
No longer considered a “disease of prosperity”, diabetes is known to affect the poor and racialized minorities disproportionately, in countries at all levels of income. While the contribution of the social and political determinants of health is well established, major NPOs ostensibly committed to eradicate, or at least moderate the effects of, diabetes give short shrift to these determinants, framing them at best as the context that promotes behaviours that combine with genetic predispositions to drive the inequitable, global distribution of diabetes.
Drawing from Marxian theory and critical discourse analysis, we assess publicly available information – on educational and policy prescriptions, funding sources, corporate affiliations, funded research and social media presence -- pertaining to one Canadian, one US and one international NPO to identify discourses and practices that may contribute to the global, unequal distribution of diabetes and elaborate on their implications for health equity more broadly.
Developing and Implementing a Food Insecurity Screening Initiative for Adult Patients Living With Type 2 Diabetes
2018, Canadian Journal of Diabetes
Citation Excerpt :
Food insecurity significantly compromises one's ability to follow dietary recommendations for diabetes management; people living with food insecurity report skipping meals more often, eating fewer fruits and vegetables, and consuming more energy-dense, high-salt foods (2). Being food insecure can limit access to essential medications and testing supplies, which contributes to poor glycemic control (A1C > 9) (4), more emergency room visits because of hypoglycemia (5), more cost-related medication underuse (6) and nonadherence to oral hypoglycemic agents (7). Routine screening for food insecurity is recommended to help care providers tailor diabetes-management plans for food-insecure patients, including realistic dietary recommendations (5,8–14).
Routine food insecurity screening is recommended in diabetes care to inform more tailored interventions that better support diabetes self-management among food-insecure patients. This pilot study explored the acceptability and feasibility of a food insecurity screening initiative within a diabetes care setting in Toronto.
A systematic literature review informed the development of a food insecurity screening initiative to help health-care providers tailor diabetes management plans and better support food-insecure patients with type 2 diabetes. Interviews with 10 patients and a focus group with 15 care providers elicited feedback on the relevance and acceptance of the food insecurity screening questions and a care algorithm. Subsequently, 5 care providers at 4 sites implemented the screening initiative over 2 weeks, screening 33 patients. After implementation, 7 patients and 5 care providers were interviewed to assess the acceptability and feasibility of the screening initiative.
Our findings demonstrate that patients are willing to share their experiences of food insecurity, despite the sensitivity of this topic. Screening elicited information about how patients cope with food insecurity and how this affects their ability to self-manage diabetes. Care providers found this information helpful in directing their care and support for patients.
Using a standardized, respectful method of assessing food insecurity can better equip health-care providers to support food-insecure patients with diabetes self-management. Further evaluation of this initiative is needed to determine how food insecurity screening can affect patients' self-management and related health outcomes.
Le dépistage systématique de l'insécurité alimentaire est recommandé lors des soins aux diabétiques afin d'élaborer des interventions plus personnalisées qui soutiendront davantage la prise en charge autonome du diabète chez les patients aux prises avec l'insécurité alimentaire. La présente étude pilote portait sur l'acceptabilité et la faisabilité d'une initiative de dépistage de l'insécurité alimentaire dans le cadre des soins aux diabétiques à Toronto.
Une revue systématique de la littérature a contribué à l'élaboration d'une initiative de dépistage de l'insécurité alimentaire pour aider les prestataires de soins à personnaliser les plans de prise en charge du diabète et à soutenir les patients atteints de diabète de type 2 qui vivent l'insécurité alimentaire. Des entrevues menées auprès de 10 patients et un groupe de discussion formé de 15 prestataires de soins ont suscité des commentaires sur la pertinence et l'acceptation des questions sur le dépistage de l'insécurité alimentaire et d'un algorithme de soins. Par la suite, 5 prestataires de soins de 4 établissements ont mis en œuvre l'initiative de dépistage durant 2 semaines auprès de 33 patients. Après la mise en œuvre, 7 patients et 5 prestataires de soins ont passé des entrevues pour évaluer l'acceptabilité et la faisabilité de l'initiative de dépistage.
Nos résultats démontrent que les patients sont prêts à partager leurs expériences d'insécurité alimentaire en dépit du caractère délicat de ce sujet. Le dépistage a permis d'obtenir des informations sur la façon dont les patients font face à l'insécurité alimentaire et sur la façon dont cela nuit à leur capacité de prendre en charge de manière autonome leur diabète. Les prestataires de soins trouvent ces renseignements utiles pour orienter leurs soins et apporter leur soutien aux patients.
L'utilisation respectueuse d'une méthode normalisée d'évaluation de l'insécurité alimentaire peut mieux préparer les prestataires de soins à soutenir les patients aux prises avec l'insécurité alimentaire dans leur prise en charge autonome du diabète. Il y aurait lieu de faire d'autres évaluations de cette initiative pour déterminer comment le dépistage de l'insécurité alimentaire peut influer sur la prise en charge autonome et les résultats cliniques des patients.
Functional limitation and chronic diseases are associated with food insecurity among U.S. adults
2018, Annals of Epidemiology
Citation Excerpt :
Food-insecure status includes low food security (7.4%), “reduced quality, variety, or desirability of diet but little or no indication of reduced food intake” and very low food security (4.9%), “multiple indications of disrupted eating patterns and reduced food intake” [1]. Food insecurity has been associated with certain chronic diseases, including hypertension [2,3], diabetes [4–6], heart disease, hypoglycemia [7,8], and metabolic syndrome [9]. In addition, the prevalence of obesity/overweight, a risk factor for the chronic diseases, was higher among individuals from food-insecure households than among those from food-secure households [8–11].
This study examined associations of functional limitation due to any health problems and six chronic diseases (arthritis, diabetes, coronary heart disease, heart attack, hypertension, and stroke) with food security among U.S. adults.
The 2011 National Health Interview Survey data for 30,010 adults (≥18 years) were used. Adults were categorized into food secure, low food secure, or very low food secure. Multivariable logistic regressions were used to estimate adjusted odds ratio (OR) and 95% confidence interval (CI) for having functional limitation and chronic diseases while adjusting for sociodemographic and lifestyle factors.
The prevalence of functional limitation and the chronic diseases were higher in low–food-secure and very low–food-secure than food-secure adults. The adjusted ORs were significant in both low food secure and very low food secure, respectively, for functional limitation (OR: 1.87; 95% CI: 1.63, 2.14), (OR: 2.20; 95% CI: 1.91, 2.52), inflammatory diseases or joint/muscular pain (OR: 1.42; 95% CI: 1.21, 1.68), (OR: 1.74; 95% CI: 1.49, 2.04), diabetes (OR: 1.26; 95% CI: 1.06, 1.51), (OR: 1.23; 95% CI: 1.02, 1.48), and hypertension (OR: 1.18; 95% CI: 1.04, 1.35), (OR: 1.42; 95% CI: 1.22, 1.65) when compared with food-secure adults.
Findings indicate that food insecurity is associated with functional limitation and chronic diseases, whereas directionality is unknown. Besides the traditional food assistance program for food-insecure populations, interventions to prevent or manage chronic diseases may be necessary to help them reduce the risk of the diseases and manage their conditions.

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Original articleFood insecurity is related to glycemic control deterioration in patients with type 2 diabetes

Summary

Background & aims

Methods

Results

Conclusion

Introduction

Section snippets

Setting

Results

Discussion

Funding sources

Conflict of interest

Authorships section

Acknowledgment

J Diabetes Complications

J Nutr

J Nutr

J Nutr

J Nutr Edu Behav

Nurs Clin North Am

Connecticut J Nutr

J Nutr

J Nutr

Soc Sci Med

J Nutr

JADA

J Nutr

Diabetes control and its measurement

Standards of medical care in diabetes

Diabetes Care

Diabetic retinopathy

Diabetes Care

Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes

Diabetes Care

The epidemiology of complications

Diabetes Care

High prevalence of diabetes in Adana, a southern province of Turkey

Diabetes Care

Hunger and food insecurity in the fifty states: 1998-2000

The association of child and household food insecurity with childhood overweight status

Pediatrics

Original article
Food insecurity is related to glycemic control deterioration in patients with type 2 diabetes