Person:

Berkowitz, Seth A.

OBJECTIVE We sought to determine whether food insecurity is associated with worse glycemic, cholesterol, and blood pressure control in adults with diabetes. RESEARCH DESIGN AND METHODS We conducted a cross-sectional analysis of data from participants of the 1999–2008 National Health and Nutrition Examination Survey. All adults with diabetes (type 1 or type 2) by self-report or diabetes medication use were included. Food insecurity was measured by the Adult Food Security Survey Module. The outcomes of interest were proportion of patients with HbA1c >9.0% (75 mmol/mol), LDL cholesterol >100 mg/dL, and systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg. We used multivariable logistic regression for analysis. RESULTS Among the 2,557 adults with diabetes in our sample, a higher proportion of those with food insecurity (27.0 vs. 13.3%, P < 0.001) had an HbA1c >9.0% (75 mmol/mol). After adjustment for age, sex, educational attainment, household income, insurance status and type, smoking status, BMI, duration of diabetes, diabetes medication use and type, and presence of a usual source of care, food insecurity remained significantly associated with poor glycemic control (odds ratio [OR] 1.53 [95% CI 1.07–2.19]). Food insecurity was also associated with poor LDL control before (68.8 vs. 49.8, P = 0.002) and after (1.86 [1.01–3.44]) adjustment. Food insecurity was not associated with blood pressure control. CONCLUSIONS Food insecurity is significantly associated with poor metabolic control in adults with diabetes. Interventions that address food security as well as clinical factors may be needed to successfully manage chronic disease in vulnerable adults.

Background: Adults with chronic disease are often unable to meet medication and/or food needs, but no study has examined the relationship between cost-related medication underuse and food insecurity in a nationally representative sample. We examined which groups most commonly face unmet food and medication needs. Methods: Cross-sectional analysis of data from chronically ill participants (self report of arthritis, diabetes mellitus, cancer, asthma, chronic obstructive pulmonary disease, stroke, hypertension, coronary heart disease, or presence of a "psychiatric problem"), age >/=20 years, of the 2011 National Health Interview Survey. We fit logistic regression models to identify factors associated with food insecurity, cost-related medication underuse, or both. Results: 9,696 adult NHIS participants reported chronic illness; 23.4% reported cost-related medication underuse; 18.8% reported food insecurity; and 11% reported both. Adults who reported food insecurity were significantly more likely to report cost-related medication underuse (adjusted odds ratio [aOR] 4.03). Participants with both cost-related medication underuse and food insecurity were more likely to be Hispanic (aOR 1.58) non-Hispanic Black (aOR 1.58), and have more chronic conditions (aOR per additional chronic condition 1.56) than patients reporting neither. They were also less likely to have Public, non-Medicare insurance (aOR 0.70) and report to WIC participation (aOR 0.39). Conclusions: Approximately 1 in 3 chronically-ill NHIS participants are unable to afford food, medications, or both. WIC and public health insurance participation are associated with less food insecurity and cost-related medication underuse.

Background: Food insecurity, uncertainty about the ability to acquire adequate food, is associated with cardiometabolic disease in pregnant women. Whether food insecurity interventions improve cardiometabolic health is unknown. Methods: We conducted a retrospective analysis of women who visited the obstetrics clinic in a community health center from 2013 through 2015. Patients could be referred to the Food for Families (Food for Families) program, which connects food insecure women to food resources. We hypothesized that participation in Food for Families would be associated with better blood pressure and blood glucose trends during pregnancy. We used a propensity score–matched design to reduce bias from differential entry into Food for Families. Results: Eleven percent of women who visited the obstetrics clinic were referred to Food for Families. In propensity score–matched analyses, we found no difference in baseline systolic blood pressure (SBP) between those who were referred and enrolled in Food for Families (113.5 mm Hg), those who were referred and did not enroll in Food for Families (113.9 mm Hg), and those who were not referred to Food for Families (114 mm Hg) (P = .79). However, during pregnancy, women who were referred to and enrolled in Food for Families had a better SBP trend (0.2015 mm Hg/wk lower, P = .006). SBP trends did not differ between women who were referred and did not enroll in Food for Families and those who were not referred. We observed no differences in blood glucose trends between groups (P = .40). Conclusions: Food for Families participation was associated with better blood pressure trends in pregnant women but no differences in blood glucose trends. Food insecurity reduction programs may improve cardiovascular health for vulnerable pregnant women, and this topic deserves further study incorporating randomized program entry.

Background: Food insecurity, the uncertain ability to access adequate food, can limit adherence to dietary measures needed to prevent and manage cardiometabolic conditions. However, little is known about temporal trends in food insecurity among those with diet-sensitive cardiometabolic conditions. Methods: We used data from the Continuous National Health and Nutrition Examination Survey (NHANES) 2005–2012, analyzed in 2015–2016, to calculate trends in age-standardized rates of food insecurity for those with and without the following diet-sensitive cardiometabolic conditions: diabetes mellitus, hypertension, coronary heart disease, congestive heart failure, and obesity. Results: 21,196 NHANES participants were included from 4 waves (4,408 in 2005–2006, 5,607 in 2007–2008, 5,934 in 2009–2010, and 5,247 in 2011–2012). 56.2% had at least one cardiometabolic condition, 24.4% had 2 or more, and 8.5% had 3 or more. The overall age-standardized rate of food insecurity doubled during the study period, from 9.06% in 2005–2006 to 10.82% in 2007–2008 to 15.22% in 2009–2010 to 18.33% in 2011–2012 (p for trend < .001). The average annual percentage change in food insecurity for those with a cardiometabolic condition during the study period was 13.0% (95% CI 7.5% to 18.6%), compared with 5.8% (95% CI 1.8% to 10.0%) for those without a cardiometabolic condition, (parallelism test p = .13). Comparing those with and without the condition, age-standardized rates of food insecurity were greater in participants with diabetes (19.5% vs. 11.5%, p < .0001), hypertension (14.1% vs. 11.1%, p = .0003), coronary heart disease (20.5% vs. 11.9%, p < .001), congestive heart failure (18.4% vs. 12.1%, p = .004), and obesity (14.3% vs. 11.1%, p < .001). Conclusions: Food insecurity doubled to historic highs from 2005–2012, particularly affecting those with diet-sensitive cardiometabolic conditions. Since adherence to specific dietary recommendations is a foundation of the prevention and treatment of cardiometabolic disease, these results have important implications for clinical management and public health.

Introduction: Cross-sectional studies show an association between food insecurity and higher body mass index (BMI), but this finding has not been evaluated longitudinally. Patient perspectives on food choice in resource-constrained environments are not well understood. The objective of this study was to evaluate the longitudinal association between food insecurity and BMI. Methods: This mixed methods study used both a retrospective matched cohort and focus groups. For the quantitative analysis, all patients in a community health center who reported food insecurity from October 2009 through March 2010 (n = 457) were followed through August 2013 and compared with controls matched by age, sex, and race/ethnicity (n = 1,974). We evaluated the association between food insecurity and change in BMI by using linear, mixed effects longitudinal models. The qualitative analysis included patients with food insecurity, stratified by BMI. Qualitative data were analyzed by using open coding and grounded theory. Results: The mean age of participants was 51 years; 61% were women, and 73% were Hispanic. Baseline BMI was similar in food insecure participants and matched controls. After adjustment in longitudinal analyses, food insecurity was associated with greater increase in BMI (0.15 kg/m2 per year more than controls, P < .001). Themes identified in 4 focus groups included attitudes and knowledge about food, food access, and food practices. Participants with BMI of 30 kg/m2 or less highlighted skills such as budgeting and portion control. Conclusion: Food insecurity is associated with increase in BMI. The skills of food insecure participants who were not obese, such as portion control and budgeting, may be useful in weight management interventions for vulnerable patients.