Diabetes and Food Insecurity: A 'Bidirectional Relationship'

Seth A. Berkowitz, MD, MPH


July 08, 2016

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Hi. I am Seth Berkowitz. I am a physician, primary care doctor, and academic general internist at Massachusetts General Hospital. We are here at the 76th Scientific Sessions of the American Diabetes Association (ADA) in New Orleans, Louisiana. I am talking about food insecurity and its relationship with diabetes.

Food insecurity, as people are becoming increasingly aware, is the limited or uncertain access to nutritious food due to cost. It has been measured by the US Department of Agriculture at the national level in the United States since the mid-1990s. Over the past 5 or 10 years, there has been growing interest in the medical world about how food insecurity may affect many diseases, particularly diabetes and other related cardiometabolic conditions. With our most recent numbers, about 15% of American households, or about 1 in 6 people, experience food insecurity.[1] When you look at people with diabetes, it goes up to about 20%, or about 1 in 5. In people with poorly controlled diabetes with a glycated hemoglobin over 9%, it rises to about 1 in 4, or 25% of the population.[2] A large number of people are affected.

When I started studying food insecurity, I really thought that it was mostly about the food. What are people eating, or not eating? Are they being pushed into cheaper and lower-quality foods in order to stretch the dollar? I studied more and more and still think that food is certainly important, but the insecurity aspect of not knowing whether you will be able to put meals on the table for the duration of the month is really important as well. This type of uncertainty of not knowing whether you will be able to afford everything that you will need—your food, your medications, housing, or transportation—has a really dramatic impact on people's ability to manage their diabetes. The effect of food insecurity goes far beyond just the diet itself and really includes some other aspects of uncertainty.

Food insecurity and poverty are closely linked, but they are not synonymous. Poverty, particularly poverty level, is defined by a set amount of income that is meant to be sufficient or insufficient to meet basic needs. Everyone's standard of living is slightly different. People's costs are different. Their expenses are different. They live in different areas of the country. They may need to take care of more or fewer people. Their ability to increase their earnings during times of financial stress is different. It is not always a one-to-one correlation. People can still be food secure despite having incomes that are below the poverty level. Or, they can be experiencing food insecurity even though their incomes are above the poverty level.

In a lot of ways, food insecurity winds up being a functional measure of financial resources. When you see it, you are seeing that people's resources are not adequate to meet their needs, whatever they are—their needs are above and beyond their certain threshold of income. Food insecurity is telling you that people are experiencing a crisis essentially where they are unable to meet their needs.

We really think about food insecurity as having a bidirectional relationship with diabetes because of things like lower dietary quality, which I mentioned before, and things like medication trade-offs and decreased cognitive bandwidth to do self-care activities that are an important part of diabetes care. We think that food insecurity can worsen people's diabetes. People's diabetes can also worsen their food insecurity by making it more difficult to work, by making them need to take more time off work, or by spending more money on medical care, which reduces the amount of money available for food. You can find yourself in a vicious cycle. That is why it is important for clinicians to be aware of food insecurity even if food insecurity was not what got people into diabetes in the first place. Once food insecurity and diabetes coexist, there can be major problems with getting out of it. It is almost impossible to optimally manage someone's diabetes if they are also experiencing food insecurity.

We are at a point in the United States where we know a lot about whether food insecurity is bad or not. In fact, we know that it is bad from a health perspective in a lot of ways. We do not quite know the best ways to address it yet. People are working on a number of different proposed solutions. One of the most commonly proposed solutions is something that I sometimes call "linkage interventions," which is where food insecurity is identified in a clinical setting. People are screened for it in a clinic and are referred to community resources such as a food bank or food pantry or perhaps given assistance in enrolling in the Supplemental Nutrition Assistance Program (SNAP), formerly called the Public Food Stamp Program. People are taken from the clinic and linked into community resources. This is a very promising approach, and it's is at the heart of something called the Accountable Health Communities Model, which has been proposed by the Centers for Medicare & Medicaid Services and will be evaluated over the next 5 years.

There are other potential strategies as well. There are organizations that actually deliver medically tailored meals to people with diabetes and food insecurity. Then, there are a number of other organizations like Meals on Wheels, which is probably the most commonly known organization that does home delivery of food, but it may have less ability to specifically match the content of the meals to the needs of people with diabetes. All of this is to say: This is an area of active investigation as to what the best way to address food insecurity is.

A question that commonly comes up is whether clinicians should screen for food insecurity in their clinics. Unfortunately, there is not a straightforward answer. These are issues that are bigger than one clinician and one patient. It is not something that can be tackled on its own. I always encourage people to try to make a systematic approach if they are seeing a lot of food insecurity in their clinic—numbers suggest that most clinicians probably will come across this. It is not something that you would want to tackle on your own. You should enlist the support and help of people throughout your clinical systems and throughout your community and come up with a coordinated response beyond just one doctor or one diabetes nurse educator trying to solve this problem. It is really quite difficult.

A couple of things can be done in the current clinical environment. The first is really to be aware of food insecurity and some of the problems that it can lead to in the short-term. We know that people with food insecurity are at higher risk for hypoglycemia, especially towards the end of the month. Medications that were adequate for controlling blood sugar earlier in the month may become too strong, given the fact that they are not able to eat in the same way they were before. Clinicians can bring this up with patients and come up with plans for times when people are unable to eat in their normal way. That is very important.

The other thing is, we know that there are a lot of trade-offs between food insecurity and medication affordability, sometimes called the "treat-or-eat" phenomenon. People have to choose whether they are going to spend money on food for themselves and others in their household or on their medication. Really trying to minimize out-of-pocket medication expenses for patients is important. Trying to work with the patient, their pharmacist, and their insurance plan to make that possible is important.

I started this by saying that the question of whether people should screen [for food insecurity] or not often comes up. The answer relies on some of these things. As with all screening tests, it is really only useful if you have something good to do with the answer—a positive response, in this case. It is certainly reasonable to do the screening if you are in a setting where you either can come up with a coordinated response or change your management by changing the medications you prescribe or by counseling people about the hypoglycemia risk.

This year for the first time, the ADA's Standards of Medical Care in Diabetes recommended assessing for food insecurity, which is a very important recommendation and a great step forward. You are on a firm basis for including this as part of your care for diabetes patients. Though diabetes is probably the illness where food insecurity is most closely linked to poor outcomes, there are a lot of other ones for which we think pathophysiology should be similar. People with other cardiometabolic conditions, such as hypertension and high cholesterol, coronary heart disease, or congestive heart failure, are likely at risk for a lot of the same complications that may develop when thinking about food insecurity and diabetes. To go maybe even a little bit further afield, there are a number of situations where the food insecurity really makes it a lot harder to manage what is going on. If we think about someone who has cancer and is actively undergoing chemotherapy, clearly that was not related to having been food insecure in the first place. But if you are undergoing chemotherapy and are food insecure, it makes it that much harder to bounce back from it and really get the adequate nutrition that you need. There really are a number of situations where it may be relevant to think about food insecurity.

That will about do with what I have to say here. The key things to keep in mind are that food insecurity is a common problem and maybe worth assessing if it is going to change your management of patients. The food that people eat is important. Food insecurity certainly can be associated with lower dietary quality, particularly by pushing people into more calorie-dense and less expensive foods and away from things like fresh fruits and vegetables. Also dietary quality is not the only way that food insecurity can affect diabetes management or affect health. It can have an impact on trade-offs between medications and other healthcare services and can really eat up a lot of the mental bandwidth that people need to engage in appropriate self-care.

I hope that you found this presentation on food insecurity interesting. It is a topic that is important to me, and I hope that we make progress on it in the United States. Thank you for watching.


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