Examining Relationships Between Food Security, Nutrition Security, and Diet Quality Among Low-Resource Patients with Type 2 Diabetes: Baseline Findings from a Community-Based Intervention

Abstract

Background: The co-existence of food insecurity and poor diet quality is associated with poorer outcomes for low-resource persons with type 2 diabetes (T2D). Diet quantity and quality are critical to diabetes management, yet few studies have simultaneously assessed food security, nutrition security and diet quality among low-resource populations with T2D. This baseline analysis aimed to explore relationships among these factors to inform a community-based, medically tailored grocery intervention – Food and Resource Expanded to Support Health and type 2 diabetes FRESH-T2D. Methods: Participants were adults with diagnosed T2D and screened positive for being at risk for food insecurity, recruited from a Federally Qualified Health Center to participate in a 12-month, randomized controlled trial. Food security was assessed using the U.S. Household Food Security Survey 6-item Short Form and nutrition security was assessed using the Center for Nutrition and Health Impact 4-item Household Nutrition Security tool. Diet quality was assessed using the HEI-2020, based on two non-consecutive, interviewer-administered 24-hour dietary recalls. Fisher’s exact test and a two-sample t-test examined associations between food, nutrition security, and diet quality. Multivariable linear regression was used to evaluate the independent effects of food security and nutrition security (independent variables) on diet quality (dependent variable), while adjusting for sociodemographic factors. Results: Of 71 enrolled participants, 53 completed baseline assessments. Most (87%) were classified as low/very low food secure and 66% were nutrition insecure (mean nutrition security score: 2 out of 4). Eighteen (34%) were both food and nutrition insecure. Food security and nutrition security were significantly associated (p = 0.004). The mean HEI score was 59.9 (out of 100 possible). No significant differences in diet quality were found between food secure and insecure groups (mean HEI = 58.7 ± 7.8 vs. 60.2 ± 2.2; p = 0.85), or between nutrition secure and insecure groups (mean HEI = 60.6 ± 2.6 vs. 58.9 ± 3.9; p = 0.72). The reference group –females with less than a high school education, income of <$25,000, household size of 1-2, and English as preferred language – was not significantly associated with diet quality. (F =1.8, p = .08, R² = .35). After adjusting for covariates, neither food security (β = -5.8, 95% CI: –22.45, 10.84, p = .48) nor nutrition security (β = 3.4, 95% CI: –9.5, 16.2, p = .59) were significant predictors of diet quality. Only household size of 3-4 was significantly associated with lower HEI scores ((β = –15.4, 95% CI: –26.3, –4.5; p = 0.007). Conclusion: Among food insecure adults with T2D, lower food security was associated with lower nutrition security, although neither was significantly related to diet quality. Overall, diet quality was suboptimal. These findings highlight the complexity of addressing dietary disparities in vulnerable populations. Ongoing research will evaluate how the FRESH-T2D medically tailored grocery intervention impacts these outcomes over time.