Food and Resources Expanded to Support Health and Type 2 Diabetes for Food Insecure Individuals

Abstract

Diabetes mellitus is a growing public health concern affecting 34.2 million people in the United States, with type 2 diabetes mellitus (T2DM) accounting for 90-95% of diabetes cases. Food insecurity greatly affects the management and long-term consequences of this diet-related disease. There are few food-based diabetes self-management education and support (DSMES) interventions for food insecure individuals with T2DM, and existing interventions have shown limited success in improving indicators of T2DM self-management. To address gaps in prior food -based DSMES interventions, we conducted the Food and Resources Expanded to Support Health (FRESH) Study, a collaboration between a regional food bank, a federally qualified health center (FQHC), and a research university in Southern Arizona. The purpose of this study was to develop and test the feasibility and acceptability of a food-based DSMES intervention to improve management of T2DM for food insecure community members. This study was conducted in three phases. Phase I characterized food bank client diet quality in 197 participants using 24-hour dietary recalls and the Healthy Eating Index-2015 to identify targets for intervention. Phase II explored food bank clients’ perception and utilization of the current food assistance, and whether additional resources were needed to support T2DM management. Findings from Phase I and Phase II produced a therapeutic food assistance package (consisting of food + educational resources) tailored to food bank client social and cultural contexts and T2DM nutrition therapy guidelines. In Phase III, we evaluated the feasibility and acceptability of our therapeutic food assistance package in combination with registered dietitian visits in 21 food insecure patients with T2DM recruited from our FQHC partner (El Rio Community Health Center). Across the three phases, we observed: Phase I: low diet quality of food bank clients in comparison to national food secure samples; food pantry visits within 1-4 days (compared to >5 days) were associated with higher diet quality in non-Hispanic participants, but not Hispanic participants. Hybrid thematic analysis of Phase II qualitative data revealed that food assistance use was influenced by individual and household preferences, and identified multiple foods and resources desired by clients. Participants reported challenges affecting their ability to manage T2DM, yet expressed resilience and interest in improving T2DM management. Analysis of Phase III findings revealed a priori feasibility benchmarks were met, including adherence to the intervention and retention rates. Qualitative findings suggested that the intervention was acceptable to participants, and they had many ideas for strengthening the program; food bank and health clinic personnel interview data suggested staff were overall positive about the intervention, and they provided recommendations on how to refine the intervention to increase sustainability and integration within each organizational structure. Next steps should prioritize participant and staff feedback for future intervention delivery, including expanding strategies to recruit participants at El Rio, developing a standard operating procedure for program delivery at the food bank, and tailoring the intervention to the diverse needs of participants. A randomized controlled trial is needed to determine the efficacy of the refined food-based DSMES intervention for food insecure individuals with T2DM, and to evaluate the long-term sustainability of the program in this setting.