The association between food insecurity and incident type 2 diabetes in Canada: A population-based cohort study

Impact of a multicomponent food-as-medicine intervention on behavioral and mental health outcomes for patients with and without food insecurity

BACKGROUND

Increasingly, food-as-medicine (FAM) programs are being implemented as a strategy for improving the health of patients. However, current policies limit nutrition resources to patients with specific chronic condition diagnoses and do not include food insecurity as a qualifying condition.

OBJECTIVE

Explore the impact of Recipe4Health (R4H), a multicomponent FAM intervention, on behavioral and mental health outcomes in patients with and without food insecurity.

METHODS

Patients (n = 336) with diet-related chronic conditions and/or food insecurity were referred to R4H, which included 16-weekly produce deliveries and behavioral intervention sessions. Food security status was assessed using the U.S. Department of Agriculture 6-item survey. Outcomes included vegetable/fruit intake, physical activity (PA) and mental health. Within- and between-group pre-post changes were assessed using repeated-measures linear mixed-effects models, adjusting for baseline.

RESULTS

The majority of patients had one or more chronic conditions (96%) and identified as food insecure (62%). Patients with food insecurity experienced significant increases in daily servings of vegetables/fruit (+0.38 ± 0.15; P = 0.01) and minutes of moderate-to-vigorous PA per week (+28.94 ± 9.84; P < 0.01). Patients with food security did not experience significant increases in vegetables/fruit (P = 0.09) or PA (P = 0.06). Food-insecure and food-secure patients both experienced significant improvements in loneliness, anxiety, and depressive symptoms from baseline (P < 0.01 for all). Between-group differences were observed only for anxiety, where patients with food security experienced significant improvements in anxious symptoms compared to food-insecure patients (-1.24 [-2.33, -0.14]; P = 0.03).

CONCLUSION

Policymakers may consider expanding eligibility criteria to include food insecurity as an independent qualifying condition for FAM.

Exploring the Social Determinants of Health in Nutrition Care for South Asian Communities: A Narrative Review

The South Asian (SA) diasporic communities in Canada experience a greater burden of diabetes and cardiovascular disease (CVD) compared to white populations. Nutrition interventions often focus on individual behaviours and fail to consider that the social determinants of health (SDH) have a greater impact on chronic disease risk. A narrative review was conducted to identify the SDH in nutrition care interventions for the SA diaspora in Canada. The final analysis included fourteen articles from which SDH were identified and categorized based on the Social Ecological Model (SEM). The study analysis yielded the following needs in dietetic practice based on the SEM: (1) intrapersonal - need for language appropriate services, and representation of cultural foods and non-Western health perspectives in dietary guidelines, (2) interpersonal - understanding family and friends as social supports, (3) community - incorporating peer and community leader influences, (4) institution - importance of faith-based locations as community hubs, and client workplaces as a barrier to attending appointments, and (5) policy - advocacy for transportation and childcare access, adequate and secure income, and equitable care. These findings urge dietitians to move beyond cultural awareness, sensitivity, and competence to practicing cultural safety and humility in their practice, which is integral to providing equitable care.

Anxiety moderates the association between severity of food insecurity and sleep duration among young adults in food-insecure households

This study examined associations between food insecurity (FI) severity, anxiety symptoms, and sleep duration among young adults in food-insecure households. We hypothesized that more severe FI and higher anxiety would independently predict shorter sleep duration, and that anxiety would amplify the FI-sleep duration relationship. Analysis was conducted on a subsample (n = 96) of the EAT 2010-2018 young adult cohort. Participants completed the U.S. Household Food Security Survey Module, Generalized Anxiety Disorder-7, and sleep assessment items. Linear regression models, controlling for demographics, showed that increased anxiety symptoms were associated with decreased sleep duration (p < .001), while FI severity was not significantly associated. A synergistic interaction between FI severity and anxiety (p = .04) revealed that individuals with severe FI and high anxiety had the shortest sleep duration. Results suggest that people struggling with both FI and anxiety may be at high risk of short sleep. Future interventions for individuals with FI should consider anxiety's role in influencing sleep disturbance.

Political Parties and Household Food Insecurity Among Canadian Provinces: A Panel Data Analysis, 2005-2014

In Canada, links between social determinants and household food insecurity (HFI) are well-documented, but the influence of political parties remains unclear. This study examines whether political parties predict HFI rates across Canadian provinces and explores the mediating roles of low income and social assistance. Panel data from 2005 to 2014 were obtained from Statistics Canada, with political party strength categorized as left, center, or right. Linear regressions with Driscoll and Kraay standard errors reveal that left-leaning parties are associated with lower HFI rates, right-leaning parties with higher rates, and center parties show no significant effect, controlling for demographic and economic factors. Low income and social assistance fully mediate the effect of left parties but only partially mediate the effect of right parties. These findings provide insights into the politics of food insecurity, with implications for social work in the context of COVID-19.

Prevalence of micronutrient inadequacy differs by severity of food insecurity among adults living in Canada in 2015

Household food insecurity is generally associated with poorer quality diets in Canada, but whether household food insecurity heightens the probability of inadequate micronutrient intakes is unknown. The objective of this research was to investigate how prevalence of micronutrient inadequacy differed by severity of household food insecurity among adults in Canada. Using the 2015 Canadian Community Health Survey Nutrition, this study included participants aged 19-64 years who completed up to two 24 h dietary recalls and provided details about household food insecurity (n = 9486). Children and older adults were not included due to sample size limitations. Usual micronutrient intake distributions were estimated by a four-level measure of food insecurity status using the National Cancer Institute method. Welch's t tests assessed differences in prevalence of inadequacy for selected micronutrients. Prevalence differed for some micronutrients among those living in marginally and moderately food insecure compared to food-secure households. The greatest differences in prevalence of inadequacy were observed between severely food-insecure and food-secure households: vitamin A (60.0%, SE = 11.9 vs. 40.6%, SE = 2.7, p < 0.0001), vitamin B6 (42.7%, SE = 9.1 vs. 12.8%, SE = 2.5, p < 0.0001), folate (39.4%, SE = 10.0 vs. 15.9%, SE = 2.2, p < 0.0001), vitamin C (63.3%, SE = 5.2 vs. 29.1%, SE = 2.8, p < 0.0001), calcium (78.6%, SE = 6.4 vs. 58.7%, SE = 1.3, p < 0.0001), magnesium (75.6%, SE = 9.5 vs. 48.7%, SE = 1.2, p < 0.0001), and zinc (34.9%, SE = 10.0 vs. 23.2%, SE = 2.4, p = 0.0009). Apparent underreporting also differed by severity of food insecurity, with increased underreporting observed with worsening food insecurity. The probability of inadequate micronutrient intakes among adults rises sharply with more severe household food insecurity in Canada.

Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies

Importance

Gestational diabetes is a type 2 diabetes risk indicator, and recurrence further augments risk. In women with a single occurrence across 2 pregnancies, it is unclear whether first- vs second-pregnancy gestational diabetes differ in terms of risk.

Objective

To compare the hazards of incident diabetes among those with gestational diabetes in the first, in the second, and in both pregnancies with women without gestational diabetes in either.

Design, Setting, and Participants

This was a retrospective cohort study with cohort inception from April 1, 1990, to December 31, 2012. Follow-up was April 1, 1990, to April 1, 2019. Participants were mothers with 2 singleton deliveries between April 1, 1990, and December 31, 2012, without diabetes before or between pregnancies, who were listed in public health care insurance administrative databases and birth, stillbirth, and death registries in Quebec, Canada. Data were analyzed from July to December 2023.

Exposure

Gestational diabetes occurrence(s) across 2 pregnancies.

Main outcomes and measures

Incident diabetes from the second delivery until a third pregnancy, death, or the end of the follow-up period, whichever occurred first.

Results

The 431 980 women with 2 singleton deliveries studied had a mean (SD) age of 30.1 (4.5) years at second delivery, with a mean (SD) of 2.8 (1.5) years elapsed between deliveries; 373 415 (86.4%) were of European background, and 78 770 (18.2%) were at the highest quintile of material deprivation. Overall, 10 920 women (2.5%) had gestational diabetes in their first pregnancy, 16 145 (3.7%) in their second, and 8255 (1.9%) in both (12 205 incident diabetes events; median [IQR] follow-up 11.5 [5.3-19.4] years). First pregnancy-only gestational diabetes increased hazards 4.35-fold (95% CI, 4.06-4.67), second pregnancy-only increased hazards 7.68-fold (95% CI, 7.31-8.07), and gestational diabetes in both pregnancies increased hazards 15.8-fold (95% CI, 15.0-16.6). Compared with first pregnancy-only gestational diabetes, second pregnancy-only gestational diabetes increased hazards by 76% (95% CI, 1.63-1.91), while gestational diabetes in both pregnancies increased it 3.63-fold (95% CI, 3.36-3.93).

Conclusions and relevance

In this retrospective cohort study of nearly half a million women with 2 singleton pregnancies, both the number and ordinal pregnancy of any gestational diabetes occurrence increased diabetes risk. These considerations offer greater nuance than an ever or never gestational diabetes dichotomy.

Modeling chronic disease risk across equity factors using a population-based prediction model: the Chronic Disease Population Risk Tool (CDPoRT)

BACKGROUND

Predicting chronic disease incidence at a population level can help inform overall future chronic disease burden and opportunities for prevention. This study aimed to estimate the future burden of chronic disease in Ontario, Canada, using a population-level risk prediction algorithm and model interventions for equity-deserving groups who experience barriers to services and resources due to disadvantages and discrimination.

METHODS

The validated Chronic Disease Population Risk Tool (CDPoRT) estimates the 10-year risk and incidence of major chronic diseases. CDPoRT was applied to data from the 2017/2018 Canadian Community Health Survey to predict baseline 10-year chronic disease estimates to 2027/2028 in the adult population of Ontario, Canada, and among equity-deserving groups. CDPoRT was used to model prevention scenarios of 2% and 5% risk reductions over 10 years targeting high-risk equity-deserving groups.

RESULTS

Baseline chronic disease risk was highest among those with less than secondary school education (37.5%), severe food insecurity (19.5%), low income (21.2%) and extreme workplace stress (15.0%). CDPoRT predicted 1.42 million new chronic disease cases in Ontario from 2017/2018 to 2027/2028. Reducing chronic disease risk by 5% prevented 1500 cases among those with less than secondary school education, prevented 14 900 cases among those with low household income and prevented 2800 cases among food-insecure populations. Large reductions of 57 100 cases were found by applying a 5% risk reduction in individuals with quite a bit workplace stress.

CONCLUSION

Considerable reduction in chronic disease cases was predicted across equity-defined scenarios, suggesting the need for prevention strategies that consider upstream determinants affecting chronic disease risk.

The relationship between household food insecurity and overweight or obesity among children and adults in Canada: a population-based, propensity score weighting analysis

Household food insecurity is independently associated with adverse health outcomes among Canadians, but its association with overweight and obesity is poorly understood partly because of limited attention to confounding. This study assessed the relationship between food insecurity status and overweight/obesity in Canada. Cross-sectional data for individuals aged 2-64 years were drawn from the 2004 and 2015 Canadian Community Health Survey-Nutrition. Overweight/obesity was defined using body mass index calculated with measured height and weight. Food insecurity status was assessed with the 18-item Household Food Security Survey Module. The relationship was examined among preschool children (n = 2007), girls (n = 5512), boys (n = 5507), women (n = 8317), and men (n = 7279) using propensity score weighted logistic regressions to control for confounding. Relative to their food-secure counterparts, girls in moderately food-insecure households (39.7% vs. 28.5%), boys in severely food-insecure households (54.4% vs. 35.0%), and women in moderately and severely food-insecure households (58.9% and 73.1% vs. 50.7%) had higher overweight/obesity prevalence; men in moderately food-insecure households had a lower prevalence (48.9% vs. 66.3%). With propensity score weighting, no association existed between food insecurity and overweight/obesity among preschool children, girls, boys, or men. For women, moderate (adjusted odds ratio (AOR): 1.61; 95% confidence interval (95%CI): 1.06-2.47) and severe (AOR: 2.33; 95%CI: 1.22-4.44) food insecurity was positively associated with overweight/obesity; the association was strongest for severe food insecurity and obesity (AOR: 3.38; 95%CI: 1.60-7.16). Additional research is needed to better understand the nature of the relationship among women. Problems of food insecurity and overweight/obesity among Canadian children and men should not be conflated in public health interventions.

Improving Client Experience and Charitable Food Reach and Access at Food Pantries: A Qualitative Study

Food pantries are promising community partners in health promotion. This study explored client perspectives in food pantries to inform new approaches to improve client experience, reach, and access. We interviewed 52 adult clients who visited participating food pantries two or more times over 12 months in Cook County, Illinois in English, Spanish, or Cantonese. We analyzed transcripts using the Health Equity Implementation Framework. Participants were 69% female, 48% Black, 29% Asian, and 15% Hispanic/Latino. Participants identified availability of healthy and high-quality foods, client choice models, client-personnel interactions, multilingual services, and wait times as influential to pantry reach and access. Participants felt that client feedback opportunities and client-led community outreach could successfully engage community members who avoided food pantries due to stigma. Creating opportunities for client-centered feedback may improve client experience, reach, and access of food pantries, reduce stigma, and optimize a novel setting for community-based health promotion in diverse populations.

Prediabetes prevalence and awareness by race, ethnicity, and educational attainment among U.S. adults

Introduction

Racial and ethnic minority groups and individuals with limited educational attainment experience a disproportionate burden of diabetes. Prediabetes represents a high-risk state for developing type 2 diabetes, but most adults with prediabetes are unaware of having the condition. Uncovering whether racial, ethnic, or educational disparities also occur in the prediabetes stage could help inform strategies to support health equity in preventing type 2 diabetes and its complications. We examined the prevalence of prediabetes and prediabetes awareness, with corresponding prevalence ratios according to race, ethnicity, and educational attainment.

Methods

This study was a pooled cross-sectional analysis of the National Health and Nutrition Examination Survey data from 2011 to March 2020. The final sample comprised 10,262 U.S. adults who self-reported being Asian, Black, Hispanic, or White. Prediabetes was defined using hemoglobin A1c and fasting plasma glucose values. Those with prediabetes were classified as "aware" or "unaware" based on survey responses. We calculated prevalence ratios (PR) to assess the relationship between race, ethnicity, and educational attainment with prediabetes and prediabetes awareness, controlling for sociodemographic, health and healthcare-related, and clinical characteristics.

Results

In fully adjusted logistic regression models, Asian, Black, and Hispanic adults had a statistically significant higher risk of prediabetes than White adults (PR:1.26 [1.18,1.35], PR:1.17 [1.08,1.25], and PR:1.10 [1.02,1.19], respectively). Adults completing less than high school and high school had a significantly higher risk of prediabetes compared to those with a college degree (PR:1.14 [1.02,1.26] and PR:1.12 [1.01,1.23], respectively). We also found that Black and Hispanic adults had higher rates of prediabetes awareness in the fully adjusted model than White adults (PR:1.27 [1.07,1.50] and PR:1.33 [1.02,1.72], respectively). The rates of prediabetes awareness were consistently lower among those with less than a high school education relative to individuals who completed college (fully-adjusted model PR:0.66 [0.47,0.92]).

Discussion

Disparities in prediabetes among racial and ethnic minority groups and adults with low educational attainment suggest challenges and opportunities for promoting health equity in high-risk groups and expanding awareness of prediabetes in the United States.

Food insecurity and unmet healthcare needs in South Korea

BACKGROUND

Food insecurity is a significant risk factor for chronic and infectious diseases. It is also a barrier to accessing healthcare because food insecurity tends to co-occur with other socioeconomic disadvantages. The objective of this study is to examine whether food insecure individuals in South Korea can access desired level of healthcare when needed.

METHODS

This repeated cross-sectional study used data from the 2013-2015 and 2019-2021 waves of the Korean National Health and Nutrition Examination Survey. Multivariable logistic regression models were used to examine the association between household food insecurity and two indicators of unmet healthcare needs - any experience of forgoing medical service and the reasons for unmet needs (problems with availability, acceptability, and accessibility). Covariates indicating predisposing, enabling, and need factors were included in the regression analyses.

RESULTS

Of the 19,394 participants aged 19-64 years, 4.5% were moderately food insecure, 0.9% were severely food insecure, and 9.3% reported unmet healthcare needs. In the adjusted model, moderate food insecurity (OR, 1.47; 95% CI, 1.19-1.82) and severe food insecurity (OR, 3.32; 95% CI, 2.27-4.85) were associated with higher odds of unmet healthcare needs in a dose-graded manner. These associations were largely due to the increased odds of accessibility-related unmet needs among participants with moderate (OR, 2.31; 95% CI, 1.68-3.19) and severe food insecurity (OR, 6.15; 95% CI, 3.91-9.68).

CONCLUSIONS

Food insecurity was associated with higher odds of unmet healthcare needs among Korean adults. Competing life demands may have a cumulative impact on health over the short and long term. Efforts to address trade-offs between healthcare needs and food insecurity may improve the health and well-being of marginalized populations.

Food insecurity is associated with glycemic markers, and socioeconomic status and low-cost diets are associated with lipid metabolism in Mexican mothers

The association between socioeconomic status (SES) and chronic disease has recently become more evident in middle- and low-income countries. We hypothesized that poor socioeconomic conditions, such as food insecurity, low educational level, or low SES, may restrict access to a healthy diet and may be associated with cardiometabolic risk independently of body fat. This study examined the relation between socioeconomic indicators, body fat, and cardiometabolic disease risk markers in a random sample of mothers living in Queretaro, Mexico. Young and middle-aged mothers (n = 321) answered validated questionnaires to determine SES, food insecurity, and educational level and a semiquantitative food frequency questionnaire to determine dietary patterns and the cost of individual diet. Clinical measurements included anthropometry, blood pressure, lipids profile, glucose, and insulin. Obesity was present in 29% of the participants. Women with moderate food insecurity had higher waist circumference, glucose, insulin, and homeostasis model assessment of insulin resistance than women with food security. High triglyceride concentration and lower levels of high-density lipoprotein and low-density lipoprotein cholesterol were associated with lower SES and lower educational level. Women who consumed a lower carbohydrate diet had higher SES, higher education, and better cardiovascular risk markers. The higher carbohydrate diet profile was the least expensive diet. There was an inverse association between the cost and energy-density of foods. In conclusion, food insecurity was associated with glycemic control markers, and lower SES and education were related to a low-cost, higher carbohydrate diet and to a greater cardiovascular risk. The influence of the social environment on obesity and cardiovascular diseases needs to be further explored.

Understanding the Role of a Technology and EMR-based Social Determinants of Health Screening Tool and Community-based Resource Connections in Health Care Resource Utilization

BACKGROUND

Health systems are increasingly investing in social determinants of health (SDoH), but there is limited research on how such efforts impact health care resource use. This study presents pilot work on an SDoH screening and referral platform recently implemented in South Carolina's largest private nonprofit health system.

OBJECTIVES

To assess the feasibility and sustainability of SDoH screening and SDoH-related referrals in a large health system and examine how they affect health resource use.

RESEARCH DESIGN

Observational study using electronic medical records and SDoH screening data from June 1, 2019 to December 31, 2020.

SUBJECTS

Patients (18 y+) engaged in community health, inpatient case management, or ambulatory care and condition management programs.

MEASURES

We describe the use of SDoH screening by providers (community health workers, nurse case managers, and social workers) and SDoH referral volumes among patients. We use multivariate analyses to predict changes in emergency department visits, inpatient admission s (length of stay and volume), and primary care visits from referral volume, SDoH screening question responses, and patient characteristics (eg, comorbidities).

RESULTS

Of 2687 patients, 662 (24.6%) screened positive for 1 or more SDoH domains. SDoH screening performance remained consistent among providers over time. Six hundred fifty-eight (24.5%) patients received SDoH referrals. Patients receiving an increasing volume of referrals had decreasing primary care visits but their comorbidities moderated this effect.

CONCLUSIONS

The study provides initial descriptive information on SDoH needs, implementation of referrals and resource use, guiding SDoH screening implementation in population health, and care management programs.

Addressing food insecurity and chronic conditions in community health centres: protocol of a quasi-experimental evaluation of Recipe4Health

INTRODUCTION

Chronic conditions, such as diabetes, obesity, heart disease and depression, are highly prevalent and frequently co-occur with food insecurity in communities served by community health centres in the USA. Community health centres are increasingly implementing 'Food as Medicine' programmes to address the dual challenge of chronic conditions and food insecurity, yet they have been infrequently evaluated.

METHODS AND ANALYSIS

The goal of this quasi-experimental study was to evaluate the effectiveness of Recipe4Health, a 'Food as Medicine' programme. Recipe4Health includes two components: (1) a 'Food Farmacy' that includes 16 weekly deliveries of produce and (2) a 'Behavioural Pharmacy' which is a group medical visit. We will use mixed models to compare pre/post changes among participants who receive the Food Farmacy alone (n=250) and those who receive the Food Farmacy and Behavioural Pharmacy (n=140). The primary outcome, fruit and vegetable consumption, and secondary outcomes (eg, food security status, physical activity, depressive symptoms) will be collected via survey. We will also use electronic health record (EHR) data on laboratory values, prescriptions and healthcare usage. Propensity score matching will be used to compare Recipe4Health participants to a control group of patients in clinics where Recipe4Health has not been implemented for EHR-derived outcomes. Data from surveys, EHR, group visit attendance and produce delivery is linked with a common identifier (medical record number) and then deidentified for analysis with use of an assigned unique study ID. This study will provide important preliminary evidence on the effectiveness of primary care-based strategies to address food insecurity and chronic conditions.

ETHICS AND DISSEMINATION

This study was approved by the Stanford University Institutional Review Board (reference protocol ID 57239). Appropriate study result dissemination will be determined in partnership with the Community Advisory Board.

Food insecurity is associated with the sleep quality and quantity in adults: a systematic review and meta-analysis

OBJECTIVE

We evaluated associations between food insecurity (FI) and the quality and quantity of sleep in adults (≥18 years).

DESIGN

The current study represented a systematic review and meta-analysis of observational studies.

SETTING

Databases of PubMed, Scopus, Embase and Web of Science were searched from inception until 6 June 2022. Meta-analyses were conducted using random-effects models, and effect sizes were reported as OR and 95 % CI.

PARTICIPANTS

Data from ten eligible observational studies, including 83 764 participants, were included.

RESULTS

FI was associated with an increased risk of poor sleep quality (OR = 1·45; 95 % CI (1·24, 1·70), I2 = 95, P < 0·001, n 7). Besides, subgroup analysis showed increased risk of poor sleep quality corresponding to the severity of FI across mild (OR = 1·31; 95 % CI (1·16, 1·48), I2 = 0 %, P < 0·001, n 5), moderate (OR = 1·49; 95 % CI (1·32, 1·68), I2 = 0 %, P < 0·001, n 5) and severe (OR = 1·89; 95 % CI (1·63, 2·20), I2 = 0 %, P < 0·001, n 5) levels. Similarly, subgroup analysis by sleep problems showed that FI was associated with an increased the risk of trouble falling asleep (OR = 1·39; 95 % CI (1·05, 1·83), I2 = 91 %, P = 0·002, n 3) and trouble staying asleep (OR = 1·91; 95 % CI (1·37, 2·67), I2 = 89 %, P < 0·001, n 3). Moreover, FI was associated with the odds of shorter (OR = 1·14; 95 % CI (1·07, 1·21), I2 = 0 %, P < 0·001, n 4) and longer sleep duration (OR = 1·14; 95 % CI (1·03, 1·26), I2 = 0 %, P = 0·010, n 4).

CONCLUSIONS

Collective evidence supports that FI is associated with poor sleep quality and quantity in adults. Preventative and management strategies that address FI may provide health benefits beyond improving nutritional status per se.

Structural violence and the uncertainty of viral undetectability for African, Caribbean and Black people living with HIV in Canada: an institutional ethnography

Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people.

Prevalence and Severity of Food Insecurity Before and During the Coronavirus Disease 2019 Pandemic Among Adults and Youth in Australia, Canada, Chile, Mexico, the United Kingdom, and the United States

BACKGROUND

Disruptions from the coronavirus disease 2019 (COVID-19) pandemic potentially exacerbated food insecurity among adults and youth.

OBJECTIVES

The objective was to examine changes in the prevalence and severity of food insecurity among adults and youth from before (2019) to during (2020) the pandemic in multiple countries.

METHODS

Repeated cross-sectional data were collected among adults aged 18-100 y (n = 63,278) in 5 countries in November to December in 2018-2020 and among youth aged 10-17 y (n = 23,107) in 6 countries in November to December in 2019 and 2020. Food insecurity in the past year was captured using the Household Food Security Survey Module and the Child Food Insecurity Experiences Scale. Changes in the prevalence and severity of food insecurity were examined using logistic and generalized logit regression models, respectively. Models included age, gender, racial-ethnic identity, and other sociodemographic characteristics associated with food insecurity to adjust for possible sample differences across waves. Models were weighted to reflect each country's population.

RESULTS

Adults [adjusted OR (AOR): 1.15; 95% CI: 1.02, 1.31] and youth (AOR: 1.43; 95% CI: 1.19, 1.71) in Mexico were more likely to live in food-insecure households in 2020 compared to 2019. Adults in Australia (AOR: 0.81; 95% CI: 0.72, 0.92) and Canada (AOR: 0.87; 95% CI: 0.77, 0.99) were less likely to live in food-insecure households in 2020. Trends in severity aligned with changes in prevalence, with some exceptions. Youth in Australia (AOR: 2.24; 95% CI: 1.65, 3.02) and the United States (AOR: 1.39; 95% CI: 1.04, 1.86) were more likely to have many compared with no experiences of food insecurity in 2020 compared to 2019. There was no evidence of change among adults and youth in the remaining countries.

CONCLUSIONS

Except for Mexico, few changes in food insecurity among adults and youth were observed from before to during the COVID-19 pandemic. Action is needed to support households at risk of food insecurity. J Nutr 20XX;xx:xx-xx.

Marbling score, cholesterol, and physical-chemical content of male Bali beef fed fermented pineapple peel

OBJECTIVE

The study was conducted to determine the marbling score, fat and meat color, cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and physical-chemical content of male Bali beef fed fermented pineapple peel.

MATERIALS AND METHODS

Twelve heads of male Bali cattle with an initial weight of 168.46 ± 11.95 kg were put into individual cages at random based on a completely randomized design with three treatments and four heads of Bali cattle as replicates, namely T0 = NG + (39% MC + 61% RB + 0% fermented pineapple peel); T1 = NG + (10% MC + 70% RB + 20% fermented pineapple peel with yeast culture); and T2 = NG + (15% MG + 65% RB + 20% pineapple peel fermented by lactic acid bacteria). The sample of Bali cattle meat used in testing the research variables was the LD muscle, with as many as 24 samples for each treatment. The data were analyzed based on the analysis of variance using the Statistical Product and Service Solutions software program, following Duncan's test with 5% confidence.

RESULTS

The results showed that the treatment T2 could increase the marbling quality of the meat from 2.58% to 4.00%. The cholesterol content (80 mg/100 gm), HDL (60 mg/100 gm), LDL (10 mg/100 gm), water-holding capacity (36.10%), cooking loss (29.16%), tenderness/shear force (4.08 kg/cm2), crude protein (22.99%), crude fat (4.23%), and meat collagen (1.65%) were determined.

CONCLUSIONS

Adding 20% of fermented pineapple peel by lactic acid bacteria to the ration can improve the quality of marbling, produce cholesterol, and the physical-chemical value of meat that meets the Indonesian National Standard.

Risk of Food Insecurity in Young Adulthood and Longitudinal Changes in Cardiometabolic Health: Evidence from the National Longitudinal Study of Adolescent to Adult Health

BACKGROUND

Studies have demonstrated relations between food insecurity, the lack of access to enough nutritious food, and greater risk of diet-sensitive chronic diseases. However, most prior evidence relies on cross-sectional studies and self-reported disease.

OBJECTIVES

The objective was to assess the longitudinal relation between risk of food insecurity in young adulthood and changes in diet-sensitive cardiometabolic health outcomes across 10 y among non-Hispanic white, non-Hispanic black, American Indian or Alaska Native, and Hispanic adults.

METHODS

Data from the fourth and fifth waves (n = 3992) of the National Longitudinal Study of Adolescent to Adult Health were used. Measures included risk of food insecurity, body weight, diabetes, and sociodemographic characteristics. Body weight and diabetes were assessed with direct measures. Mixed-effects models assessed the association of risk of food insecurity with BMI, obesity, and diabetes while accounting for sociodemographic characteristics and the complex survey design.

RESULTS

Risk of food insecurity was associated with increases in BMI as well as incidence of obesity and diabetes from young to middle adulthood in unadjusted and adjusted models (all P < 0.01). In models stratified by race and ethnicity, the relations of risk of food insecurity with body weight outcomes and diabetes varied.

CONCLUSIONS

Risk of food insecurity in young adulthood was related to BMI and obesity during young and middle adulthood but not in changes over time. Risk of food insecurity in young adulthood related to an increased incidence of diabetes in middle adulthood. However, the relations among specific racial and ethnic groups were unclear. Estimates of the relation between food insecurity and cardiometabolic health outcomes within racial and ethnic groups experiencing the highest prevalence of these conditions should be refined.

The need for screening, early diagnosis, and prediction of chronic kidney disease in people with diabetes in low- and middle-income countries-a review of the current literature

Chronic kidney disease (CKD) in people with diabetes is becoming an increasing major public health concern, disproportionately burdening low- and middle-income countries (LMICs). This rising burden is due to various factors, including the lack of disease awareness that results in late referral and the cost of screening and consequent treatment of the comorbid conditions, as well as other factors endemic to LMICs relating to inadequate management of risk factors. We critically assessed the extant literature, by performing searches of Medline via PubMed, EBSCOhost, Scopus, and Web of Science, for studies pertaining to screening, diagnosis, and prediction of CKD amongst adults with diabetes in LMICs, using relevant key terms. The relevant studies were summarized through key themes derived from the Wilson and Jungner criteria. We found that screening for CKD in people with diabetes is generally infrequent in LMICs. Also, LMICs are ill-equipped to appropriately manage diabetes-associated CKD, especially its late stages, in which supportive care and kidney replacement therapy (KRT) might be required. There are acceptable and relatively simple tools that can aid diabetes-associated CKD screening in these countries; however, these tools come with limitations. Thus, effective implementation of diabetes-associated CKD screening in LMICs remains a challenge, and the cost-effectiveness of such an undertaking largely remains to be explored. In conclusion, for many compelling reasons, screening for CKD in people with diabetes should be a high policy priority in LMICs, as the huge cost associated with higher mortality and morbidity in this group and the cost of KRT offers a compelling economic incentive for improving early detection of diabetes in CKD.

Food Insecurity, Missed Workdays, And Hospitalizations Among Working-Age US Adults With Diabetes

Food insecurity is associated with poor clinical outcomes among adults with diabetes, but associations with nonclinical outcomes, such as missed work, have not been well characterized. Our objective was to assess the associations between food insecurity, health-related missed workdays, and overnight hospitalizations. We pooled National Health Interview Survey data from the period 2011-18 to analyze food insecurity among 13,116 US adults ages 18-65 who had diabetes. Experiencing food insecurity, compared with being food secure, was associated with increased odds of reporting any health-related missed workdays, more than twice the rate of health-related missed workdays, and increased odds of overnight hospitalization within the prior twelve months. There was no significant association between food insecurity and the number of nights spent hospitalized. These findings underscore the broad impacts of food insecurity on health and wellness for working-age adults with diabetes. When weighing the costs and benefits of proposed interventions to address food insecurity, policy makers should consider potential benefits related to productivity in addition to implications for health care use.

Examining differences in diet quality between Canadian Indigenous and non-Indigenous adults: results from the 2004 and 2015 Canadian Community Health Survey Nutrition Surveys

OBJECTIVES

The Truth and Reconciliation Commission includes a call to action to close gaps in health outcomes, including type 2 diabetes, of which diet quality must be considered an important mediator. The objectives of this study were to compare diet quality between off-reserve Indigenous and non-Indigenous adults in 2004 and 2015, and examine food security as a predictor of diet quality.

METHODS

We employed a repeated cross-sectional design using the 2004 and 2015 Canadian Community Health Surveys-Nutrition. Both surveys include a representative sample of the Canadian population in the 10 provinces, excluding the northern territories and people living on-reserve. Healthy Eating Index (HEI) values were estimated, using 24-hour dietary recalls, for the Indigenous and non-Indigenous population in each time period. After matching, a generalized linear model was applied to test for differences in HEI between groups across time period, adjusting for household food security.

RESULTS

Overall, HEI scores were not significantly different for Indigenous men and women in 2015 as compared with 2004, but continued to be lower compared with those of the non-Indigenous population. Indigenous adults reported significantly lower diet quality independent of food security status and other factors. Scores pertaining to percent energy from 'other' foods improved in 2015 compared with 2004.

CONCLUSION

Dietary disparities persist between Indigenous and non-Indigenous populations. While addressing household food insecurity among Indigenous populations is necessary to improve diet quality, it is not sufficient. Results suggest that factors other than food insecurity and socio-economic status are impacting disparities in diet quality among Indigenous adults.

What is known about the prevalence of household food insecurity in Canada during the COVID-19 pandemic: a systematic review

INTRODUCTION

Household food insecurity (HFI) is a persistent public health issue in Canada that may have disproportionately affected certain subgroups of the population during the COVID-19 pandemic. The purpose of this systematic review is to report on the prevalence of HFI in the Canadian general population and in subpopulations after the declaration of the COVID-19 pandemic in March 2020.

METHODS

Sixteen databases were searched from 1 March 2020 to 5 May 2021. Abstract and full-text screening was conducted by one reviewer and the inclusions verified by a second reviewer. Only studies that reported on the prevalence of HFI in Canadian households were included. Data extraction, risk of bias and certainty of the evidence assessments were conducted by two reviewers.

RESULTS

Of 8986 studies identified in the search, four studies, three of which collected data in April and May 2020, were included. The evidence concerning the prevalence of HFI during the COVID-19 pandemic is very uncertain. The prevalence of HFI (marginal to severe) ranged from 14% to 17% in the general population. Working-age populations aged 18 to 44 years had higher HFI (range: 18%-23%) than adults aged 60+ years (5%-11%). Some of the highest HFI prevalence was observed among households with children (range: 19%-22%), those who had lost their jobs or stopped working due to COVID-19 (24%-39%) and those with job insecurity (26%).

CONCLUSION

The evidence suggests that the COVID-19 pandemic may have slightly increased total household food insecurity in Canada during the COVID-19 pandemic, especially in populations that were already vulnerable to HFI. There is a need to continue to monitor HFI in Canada.

The relationship between diet quality and the severity of household food insecurity in Canada

OBJECTIVE

To examine the relationship between the dietary quality of Canadian children and adults and household food insecurity status.

DESIGN

Dietary intake was assessed with one 24-h recall. Households were classified as food secure or marginally, moderately or severely food insecure based on their responses to the Household Food Security Survey Module. We applied multivariable analyses of variance to determine whether % energy from ultra-processed foods, fruit and vegetable intake, Healthy Eating Index (HEI) scores, macronutrient composition and micronutrient intakes per 1000 kcal differed by food insecurity status after accounting for income, education and region. Analyses were run separately for children 1-8 years and 9-18 years and men and women 19-64 years of age.

SETTING

Ten provinces in Canada.

PARTICIPANTS

Respondents to the 2015 Canadian Community Health Survey-Nutrition, aged 1-64 years, with complete food insecurity data and non-zero energy intakes, N 15 909.

RESULTS

Among adults and children, % energy from ultra-processed foods was strongly related to severity of food insecurity, but no significant trend was observed for fruit and vegetable intake or HEI score. Carbohydrate, total sugar, fat and saturated fat intake/1000 kcal did not differ by food insecurity status, but there was a significant negative trend in protein/1000 kcal among older children, a positive trend in Na/1000 kcal among younger children and inverse associations between food insecurity severity and several micronutrients/1000 kcal among adults and older children.

CONCLUSIONS

With more severe household food insecurity, ultra-processed food consumption was higher, and diet quality was generally lower among both adults and children.

Telecommuting and food E-commerce: Socially sustainable practices during the COVID-19 pandemic in Canada

Telecommuting has become a dominant professional experience for many Canadian business and workers due to the COVID-19 pandemic. Telecommuting has several benefits that are separate from COVID-19. Two prevalent changes have been in regard to telecommuting and online food buying habits, both of which impact social wellbeing as a dimension of social sustainability. We discuss two exploratory surveys on the perception of telecommuting and food e-commerce. We found that while telecommuting has the potential to increase social wellbeing and the social sustainability of both urban and rural Canadian communities through a variety of mechanisms, food e-commerce does not offer similar returns. Instead, the prevalence of food e-commerce merely adds convenience to the lives of those who already have adequate food access while maintaining the status quo, or even worsening access for disadvantaged Canadians.

Identifying Barriers to Effective Patient-Provider Communication About Food Insecurity Screenings in Outpatient Clinical Settings in Central Florida: A Mixed-Methods Study

OBJECTIVE

Screening for food insecurity in health care settings is inconsistently performed among health care providers. This study examined how patient-provider interactions influenced patient comfort discussing food insecurity, an important social determinant of health.

DESIGN

We conducted a convergent mixed-methods study and surveyed patients on their experiences with patient-centered care when communicating and interacting with their providers, and their comfort level being screened for food insecurity. Telephone interviews were also conducted to better understand the concepts in the survey.

SETTING

Various clinical organizations in Central Florida, as well as food pantries affiliated with Second Harvest Food Bank.

PARTICIPANTS

Forty-six patients in Central Florida completed the survey, 12 of whom completed qualitative portions of the study (7 completing the qualitative survey questions and 5 completing a telephone interview).

MAIN OUTCOME MEASURE

Patient comfort discussing food insecurity with their health care providers.

RESULTS

Quantitative findings show that patient involvement in care planning and cultural sensitivity of health care providers were 2 important factors associated with patient comfort being screened for food insecurity. Qualitative findings suggest that providers' effective communication and empathy are other factors that can influence patient comfort.

CONCLUSION

To effectively address food insecurity of vulnerable patients and communities, it is important that providers conduct screenings within their practice. This study points to specific actions that providers may employ to increase patient comfort discussing this topic. Efficiently identifying food-insecure patients and connecting them to appropriate community resources would improve patient health and aid in efforts to eliminate health disparities.

Does Amputation Negatively Influence the Incidence of Depression in Diabetic Foot Patients? A Population-Based Nationwide Study

This study aimed to investigate the relationship between diabetic foot ulcer and depression based on treatment methods employed, as evaluated according to Medicare claims data provided by the Health Insurance Review and Assessment Service (HIRA). Data on diabetic foot patients from January 2011 to December 2016 were collected from the HIRA using codes for diabetic foot and depression disorder. The incidence of depression was analyzed based on patients’ demographic variables, and comorbidities were assessed using the Charlson comorbidity index (CCI). The participants were divided into two groups based on the treatment method used: a limb-saving group and an amputation group. The 1-, 3-, and 5-year incidence rates of depression were 10.1%, 20.4%, and 29.5%, respectively, in the limb-saving group and 4.5%, 8.2%, and 11.5%, respectively, in the amputation group. Female sex, the CCI, and the use of limb-saving treatment methods were significant risk factors. It is plausible that depression in diabetic foot patients may be associated with frequent recurrence and chronicity rather than a single intense event. Our findings highlight the need for clinicians to consider the treatment period as a contributor to patient mood disorders when selecting the appropriate course of action in patients.

Telehealth and food insecurity screenings: challenges and lessons learned

Food insecurity remains a persistent problem in the United States and affected 35.2 million Americans in 2019. In the wake of COVID-19, food insecurity has increased in many communities. Given that food insecurity exacerbates poor health or health conditions, screening of food insecurity within medical settings is frequently identified within the literature as an important first step in effectively addressing this social concern and improving the health outcomes of patients. However, health care providers often do not screen for food insecurity for a variety of reasons. In this article review, we discuss the challenges associated with incorporating food insecurity screenings within the medical model and how the COVID-19 pandemic has exacerbated these challenges. Specifically, the COVID-19 pandemic has substantially increased the delivery of health care services via telehealth, making screening for food insecurity even more difficult via remote videoconferencing. We examine the strengths and weaknesses of telehealth and their implications for food insecurity screenings. We discuss how these implications might inform future research regarding the use of telehealth as a means of screening patients for social determinants of health in the COVID-19 era. Given that the use of telehealth is not expected to back to pre-pandemic levels, it is important to understand how to best screen for social determinants of health via videoconferencing.

Food insecurity, type 2 diabetes, and hyperglycaemia: A systematic review and meta-analysis

AIMS

Food insecurity (FIS) is a major public health issue with possible implications for type 2 diabetes mellitus (T2DM) risk. We conducted a systematic review and meta-analysis to explore the association between FIS and T2DM.

METHODS

We performed a systematic search in PubMed, Embase, Scopus, and Web of Science. All cross-sectional, peer-reviewed studies investigating the link between FIS and T2DM were included. Population characteristics, study sizes, covariates, T2DM diagnoses, and diabetes-related clinical measures such as fasting blood glucose (FBG) and HbA1c were extracted from each study. Outcomes were compared between food insecure and food secure individuals. Effect sizes were combined across studies using the random effect model.

RESULTS

Forty-nine peer-reviewed studies investigating the link between FIS and T2DM were identified (n = 258,250). Results of meta-analyses showed no association between FIS and clinically determined T2DM either through FBG or HbA1c: OR = 1.22 [95%CI: 0.96, 1.55], Q(df = 5) = 12.5, I2  = 60% and OR = 1.21 [95%CI: 0.95, 1.54], Q(df = 5) = 14; I2  = 71% respectively. Standardized mean difference (SMD) meta-analyses yielded no association between FIS and FBG or HbA1c: g = 0.06 [95%CI: -0.06, 0.17], Q(df = 5) = 15.8, I2  = 68%; g = 0.11 [95% CI: -0.02, 0.25], Q(df = 7) = 26.8, I2  = 74% respectively. For children, no association was found between FIS and HbA1c: g = 0.06 [95%CI: 0.00, 0.17], Q(df = 2) = 5.7, I2  = 65%.

CONCLUSIONS

Despite multiple proposed mechanisms linking FIS to T2DM, integration of the available literature suggests FIS is not associated with clinically determined T2DM or increases in FBG or HbA1c among adult patients.

Food Insecurity and Cardiometabolic Conditions: a Review of Recent Research

PURPOSE OF REVIEW

To understand recent literature that examines associations between food insecurity and cardiometabolic conditions and risk factors. We included original research, systematic reviews, and meta-analyses on the topic of food insecurity and cardiometabolic risk published from January 1, 2017, to December 31, 2020. Editorials, perspectives, and case reports were excluded. After the initial search, 3 reviewers selected studies for inclusion based on relevance and methods. Ultimately, fifty studies were included.

RECENT FINDINGS

We included 35 studies of adults (20 cross-sectional observational studies, 5 longitudinal observational studies, 5 interventional studies, and 5 meta-analyses/reviews). In adults, food insecurity is associated with greater prevalence of overweight/obesity (especially for women). It is also associated with hypertension, diabetes (including worse glycemic control and more diabetes complications), coronary heart disease, congestive heart failure, stroke, and chronic kidney disease. We included 15 studies of children (11 cross-sectional observational studies and 4 longitudinal observational studies). In children, findings were more nuanced, and in particular, many studies did not find an association between food insecurity and overweight/obesity. However, authors noted that these conditions may not have had time to develop. With notable exceptions, many studies were cross-sectional, and there were few interventions. There is a robust association between food insecurity and cardiometabolic conditions and risk factors in adults, but the picture is less clear in children. Overt cardiometabolic clinical conditions develop more rarely in children, but childhood experiences may set a trajectory for worse health later in life. Detailed life course epidemiologic studies are needed to better understand this relationship. Future interventions should examine how to reduce the prevalence of food insecurity, and how best to improve health for those who experience food insecurity.

Association between food insecurity and cardiometabolic risk in adults and the elderly: A systematic review

Background

Food insecurity is a public health concern that affects health and quality of life, but its association with cardiometabolic risk is not well established. Thus, this systematic review evaluated the association between food insecurity and cardiometabolic risk factors in adults and the elderly.

Methods

Search was conducted according to the PRISMA protocol using Scielo, LILACS and PubMed databases. We included original articles published in Portuguese, English, and Spanish, which assessed the association between food insecurity and cardiometabolic risk factors in adults and the elderly. The search identified 877 articles but only 11 were included in the review.

Results

Food insecurity was directly associated with cardiometabolic risk (excess weight, hypertension, dyslipidemias, diabetes, and stress) after adjusting for interfering factors. A limitation of the cross-sectional study design is that the cause-effect relation between food insecurity and cardiometabolic risk cannot be established.

Conclusions

We conclude that food insecurity has a direct relationship with cardiometabolic risk factors, especially excess weight, hypertension, and dyslipidemias. The identification of food insecurity as health problems can contribute to the implementation of efficient public policies for the prevention and control of chronic diseases.

Protocol registration

This review was registered on PROSPERO-International Prospective Register of Systematic Reviews – CRD4201911549.

Association of loss of Supplemental Nutrition Assistance Program benefits with food insecurity and dietary intake of adults and children

BACKGROUND

Supplemental Nutrition Assistance Program (SNAP) disenrollment among income-eligible households could limit their ability to access food.

OBJECTIVES

To assess the association of loss of SNAP benefits on food security status and dietary intake of household members, using 2011-2016 NHANES data.

METHODS

SNAP participation status among those with a household income ≤130% of the federal poverty level was categorized as 1) current participants, 2) former participants with benefits cut off in the past year, and 3) former participants with benefits cut off for more than a year. Logistic regression examined associations of SNAP participation status with odds of household (n = 7387), adult (n = 7387), and child (n = 5898) food security. Linear regression examined associations of participation status with Healthy Eating Index-2015 (HEI-2015) total and component scores in adults (n = 2784) and children/adolescents (n = 2553).

RESULTS

Former SNAP participants with benefits cut off in the past year had greater odds of severe household (OR: 2.18; 95% CI: 1.25, 3.78) and adult (OR: 2.09; 95% CI: 1.24, 3.54) food insecurity compared with current participants. Benefit cutoff in the past year was significantly related to low child food security (OR: 1.80; 95% CI: 1.04, 3.11) and lower child/adolescent greens and beans score (estimate: -0.40; SE: 0.18). Loss of benefits for more than a year was significantly associated with increased marginal child food security odds (OR: 2.07; 95% CI: 1.23, 3.47), lower adult dairy score (estimate: -0.63; SE: 0.24), and lower child/adolescent greens and beans (estimate: -0.34; SE: 0.16), whole grains (estimate: -0.50; SE: 0.21), and dairy scores (estimate: -0.93; SE: 0.29).

CONCLUSIONS

This study suggests that loss of benefits may increase household food insecurity. Although child/adolescent intakes of certain HEI-2015 adequacy components were lower among former SNAP participants, overall diet quality score did not differ. Findings collectively imply the need for policies that protect households from the adverse effects of benefits loss.

The impact of novel and traditional food bank approaches on food insecurity: a longitudinal study in Ottawa, Canada

Background

Food insecurity is strongly associated with poor mental and physical health, especially with chronic diseases. Food banks have become the primary long-term solution to addressing food insecurity. Traditionally, food banks provide assistance in the form of pre-packed hampers based on the food supplies on hand, such that the food items often do not meet the recipients’ cultural, religious or medical requirements. Recently, new approaches have been implemented by food banks, including choice models of food selection, additional onsite programming, and integrating food banks within Community Resource Centres.

Methods

This study examined changes in food security and physical and mental health, at four time points over 18 months at eleven food banks in Ottawa, Ontario, Canada. The participants – people who accessed these food banks – were surveyed using the Household Food Security Survey Module (HFSSM) and the Short-Form Health Survey Version 2 (SF-12). Statistical analyses included: pairwise paired t-tests between the mean perceived physical and mental health scores across the four waves of data collection, and longitudinal mixed effects regression models to understand how food security changed over time.

Results

The majority of people who were food insecure at baseline remained food insecure at the 18-month follow-up, although there was a small downward trend in the proportion of people in the severely food insecure category. Conversely, there was a small but significant increase in the mean perceived mental health score at the 18-month follow-up compared to baseline. We found significant reductions in food insecurity for people who accessed food banks that offered a Choice model of food distribution and food banks that were integrated within Community Resource Centres.

Conclusions

Food banks offer some relief of food insecurity but they don’t eliminate the problem. In this study, reductions in food insecurity were associated with food banks that offered a Choice model and those that were integrated within a Community Resource Centre. There was a slight improvement in perceived mental health at the 18-month time point; however, moderately and severely food insecure participants still had much lower perceived mental health than the general population.

Prevalence of Food Insecurity Among Pregnant Women: A Canadian Study in a Large Urban Setting

OBJECTIVE

Nutritional and financial needs increase during pregnancy, making pregnant women particularly vulnerable to food insecurity. Our objective was to document the prevalence of food insecurity among pregnant women receiving prenatal care in an urban centre in Canada and to identify factors associated with food insecurity.

METHODS

This cross-sectional study recruited pregnant women receiving prenatal care at one of two Toronto hospitals: Site 1 and Site 2 (serving a more disadvantaged population) between October 1, 2018 and October 1, 2019. Demographic information was collected, and the U.S. Household Food Security Survey Module was used to assess food security. Comparisons were made using χ² tests, two-tailed t tests, or Mann-Whitney tests for categorical and continuous variables, as appropriate. Binary logistic regression and multivariate analyses were performed to assess associations with food insecurity and differences between hospitals sites.

RESULTS

We recruited 626 participants (316 at Site 1 and 310 at Site 2). Prevalence of food insecurity was 12.8% among all participants with Site 2 having nearly 5 times the prevalence of Site 1 (66/310 [21.3%] vs. 14/316 [4.4%]; P = 0.001). Several factors were associated with food insecurity, with non-White ethnicity (OR 2.04; 95% CI 0.98-4.25, P = 0.055] and lower household income (OR 37.53; 95% CI 14.04-100, P < 0.001 when less than CAD $23 000/y) being the most robust.

CONCLUSION

This Canadian study documented the prevalence of and factors associated with food insecurity in pregnancy. Targeted interventions to help low-income women and programs geared towards non-White women may be beneficial in addressing food insecurity among pregnant women.

Wage-Setting Policies, Employment, and Food Insecurity: A Multilevel Analysis of 492 078 People in 139 Countries

Objectives. To examine the association between wage-setting policy and food insecurity.Methods. We estimated multilevel regression models, using data from the Gallup World Poll (2014-2017) and UCLA's World Policy Analysis Center, to examine the association between wage setting policy and food insecurity across 139 countries (n = 492 078).Results. Compared with countries with little or no minimum wage, the probability of being food insecure was 0.10 lower (95% confidence interval = 0.02, 0.18) in countries with collective bargaining. However, these associations varied across employment status. More generous wage-setting policies (e.g., collective bargaining or high minimum wages) were associated with lower food insecurity among full-time workers (and, to some extent, part-time workers) but not those who were unemployed.Conclusions. In countries with generous wage-setting policies, employed adults had a lower risk of food insecurity, but the risk of food insecurity for the unemployed was unchanged. Wage-setting policies may be an important intervention for addressing risks of food insecurity among low-income workers.

Food Insecurity amid the COVID-19 Pandemic: Food Charity, Government Assistance, and Employment

To mitigate the effects of the coronavirus disease 2019 (COVID-19) pandemic, the federal government has implemented several financial assistance programs, including unprecedented funding to food charities. Using the Canadian Perspectives Survey Series 2, we examine the demographic, employment, and behavioural characteristics associated with food insecurity in April-May 2020. We find that one-quarter of job-insecure individuals experienced food insecurity that was strongly associated with pandemic-related disruptions to employment income, major financial hardship, and use of food charity, yet the vast majority of food-insecure households did not report receiving any charitable food assistance. Increased financial support for low-income households would reduce food insecurity and mitigate negative repercussions of the pandemic.

Providing culturally safe care to Indigenous people living with diabetes: Identifying barriers and enablers from different perspectives

In recent years, cultural safety has been proposed as a transformative approach to health care allowing improved consideration of Indigenous patient needs, expectations, rights and identities. This community‐based participatory study aimed to identify potential barriers and enablers to cultural safety in health care provided to Atikamekw living with diabetes in Québec, Canada. Based on a qualitative descriptive design, the study uses talking circles as a data collection strategy. Three talking circles were conducted with Atikamekw living with diabetes and caregivers, as well as with health professionals of the family medicine teaching clinic providing services to the community. Two team members performed deductive thematic analysis based on key dimensions of cultural safety. Results highlight four categories of barriers and enablers to cultural safety for Atikamekw living with diabetes, related to social determinants of health (including colonialism), health services organization, language and communication, as well as Atikamekw traditional practices and cultural perspectives of health. This study is one of the few that provides concrete suggestions to address key aspects of diabetes care in a culturally respectful way. Our findings indicate that potential enablers of cultural safety reside at different (from individual to structural) levels of change. Solutions in this matter will require strong political will and policy support to ensure intervention sustainability.

Patient or public contribution

Partners and patients have been involved in identifying the need for this study, framing the research question, developing the data collection tools, recruiting participants and interpreting results.

Social and Health Risk Factor Levels of Preschool Children Living Along the Texas-Mexico Border

BACKGROUND

Childhood obesity is a public health concern that disproportionately affects populations from low socioeconomic status (SES) and minority groups. Evaluation of social and health risk factors of preschool children living along the Texas-Mexico border provides feedback to design health interventions.

METHODS

South Texas Early Prevention Study-PreK (STEPS-PreK) is a cluster randomized trial designed to assess the effect of the Bienestar coordinated school health program on children's health outcomes. Family characteristics, dietary intake, fitness, and anthropometric data were collected from 1277 preschool students enrolled in 28 preschools.

RESULTS

The response rate was 67%. Overall, 57% of families lived in poverty. The mean age of students was 4.7 years, 95% were Hispanic, and 51% were male. The average serving of fruits and vegetables per day were 1 and 1/3, respectively. Of these, students consumed 39.7% of fruits and 18.9% of vegetables. Obesity prevalence for boys was 19.2% and for girls 16.8%. Nearly one-half reported some form of food insecurity.

CONCLUSIONS

Children living in low-income areas are affected by high levels of social and health risk factors. It is these families who should be targeted with early-age and culturally appropriate health programs.

Food insecurity, gestational weight gain and gestational diabetes in the National Children’s Study, 2009–2014

Background

Household food insecurity (HFI) and gestational diabetes mellitus (GDM) are both common during pregnancy, yet it is unknown if these two factors are related. We aimed to determine the independent and joint associations between HFI, gestational weight gain (GWG) and GDM among pregnant women in the USA.

Methods

We used data from 592 women in the National Children’s Study, Initial Vanguard Study from 2009 to 2014. HFI was assessed using the Household Food Security Survey Module at the first study visit; GDM was assessed through questionnaires and medical chart review. Logistic regression models were used to investigate the exposures of HFI, GWG and their joint effect on GDM.

Results

Among participants, 20.1% were marginally food secure or food insecure and 7.4% were diagnosed with GDM. The elevated unadjusted association between HFI and GDM was attenuated after adjustment (aOR: 1.12; 95%CI: 0.47, 2.66). There was an elevated risk of GDM associated with inadequate GWG, (aOR: 2.42; 95%CI: 0.97, 6.00), but results were imprecise. There were no statistically significant associations in the joint exposure analysis.

Conclusion

The relationship between HFI and GDM is mostly explained by other covariates, but there is some evidence that inadequate GWG is a possible risk factor for GDM.

Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006-2017

INTRODUCTION

The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population.

RESEARCH DESIGN AND METHODS

Data were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region.

RESULTS

After increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years.

CONCLUSIONS

Diabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people.

Food insecurity, health care utilization, and health care expenditures

Objective

To disentangle the relationships among food insecurity, health care utilization, and health care expenditures.

Data Sources/Study Setting

We use national data on 13 465 adults (age ≥ 18) from the 2016 Medical Expenditure Panel Survey (MEPS), the first year of the food insecurity measures.

Study Design

We employ two‐stage empirical models (probit for any health care use/expenditure, ordinary least squares, and generalized linear models for amount of utilization/expenditure), controlling for demographics, health insurance, poverty status, chronic conditions, and other predictors.

Principal Findings

Our results show that the likelihood of any health care expenditure (total, inpatient, emergency department, outpatient, and pharmaceutical) is higher for marginal, low, and very low food secure individuals. Relative to food secure households, very low food secure households are 5.1 percentage points (P < .001) more likely to have any health care expenditure, and have total health care expenditures that are 24.8 percent higher (P = .011). However, once we include chronic conditions in the models (ie, high blood pressure, heart disease, stroke, emphysema, high cholesterol, cancer, diabetes, arthritis, and asthma), these underlying health conditions mitigate the differences in expenditures by food insecurity status (only the likelihood of any having any health care expenditure for very low food secure households remains statistically significant).

Conclusions

Policy makers and government agencies are focused on addressing deficiencies in social determinants of health and the resulting impacts on health status and health care utilization. Our results indicate that chronic conditions are strongly associated with food insecurity and higher health care spending. Efforts to alleviate food insecurity should consider the dual burden of chronic conditions. Finally, future research can address specific mechanisms underlying the relationships between food security, health, and health care.

Emerging trends and the clinical impact of food insecurity in patients with diabetes

Food insecurity is a major public health concern in the United States affecting 15 million households according to data in 2017 from the US Department of Agriculture. Food insecurity, or the inability to consistently obtain nutritious food, disproportionately affects socioeconomically disadvantaged households, as well as those with chronic diseases including diabetes mellitus (DM). This review article explores the literature over the past 10 years pertaining to the complex relationship between food insecurity, social determinants of health, and chronic disease with an emphasis on diabetes and glycemic control. Those with diabetes and food insecurity together have been shown to have worse glycemic control compared to those who are food secure, but it remains unclear exactly how food insecurity affects glycemic control. Prior interventional studies have targeted aspects of food insecurity in patients with diabetes but have reported variable outcomes with respect to improvement in glycemic control despite effectively reducing rates of food insecurity. Additionally, few data exist regarding long-term outcomes and diabetes-related complications in this population. It is likely that many factors at both the community and individual levels impact glycemic control outcomes in the setting of food insecurity. Further studies are needed to better understand these factors and to create multifaceted targets for future interventional studies aimed at improving glycemic control in this population.

Food Bank-Based Diabetes Prevention Intervention to Address Food Security, Dietary Intake, and Physical Activity in a Food-Insecure Cohort at High Risk for Diabetes

Purpose and Objectives

Although food insecurity is associated with poor dietary intake and risk of chronic disease, few studies have demonstrated the effectiveness of diabetes prevention interventions delivered through food banks. Food banks serve vulnerable communities. The purpose of this pilot project was to assess the effectiveness of a food bank–delivered intervention aimed at improving food security and reducing risk factors for type 2 diabetes among at-risk clients.

Intervention Approach

We screened adult English- and Spanish-speaking food bank clients for type 2 diabetes risk at 12 community food distribution sites in Alameda County, California. Screening and enrollment for a pilot intervention took place from November 2017 to March 2018. Intervention components were delivered from November 2017 through March 2019. The intervention included monthly diabetes-appropriate food packages, text-based health education, and referrals to health care.

Evaluation Methods

Food bank staff members administered surveys to participants at baseline, 6 months (midpoint), and 12 months (postintervention); participants self-reported all responses. Primary outcomes assessed were food security status, dietary intake, health-related behaviors, and body mass index (BMI). Information on demographic characteristics, food pantry access, health care use, and symptoms of depression was also collected.

Results

We screened 462 food bank clients for eligibility. Of the 299 who were eligible, 244 enrolled; 90.6% were female, 80.1% were Hispanic, and 49.1% had an annual household income less than $20,000. At baseline, 68.8% of participants had low or very low food security. At midpoint, participants had significant improvements in food security status, dietary intake, physical activity, health status, and depression scores. Mean BMI did not change.

Implications for Public Health

This intervention demonstrated that food banks can effectively screen clients at high risk for diabetes and improve household food security and other risk factors for diabetes. Food banks may be an important and strategic partner for health care systems or community-based organizations working to prevent diabetes in food-insecure populations.

Diabetes and the Built Environment: Evidence and Policies

PURPOSE OF REVIEW

To explore the relationship between the built environment and type 2 diabetes, considering both risk factors and policies to reduce risk. The built environment refers to the physical characteristics of the areas in which people live including buildings, streets, open spaces, and infrastructure.

RECENT FINDINGS

A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways-physical activity and the food environment. Other hypothesized mechanisms linking the built environment and type 2 diabetes include housing policy, but evidence in these areas is underdeveloped. Policies designed to enhance the built environment for diabetes risk reduction are mechanistically plausible, but as of yet, little direct evidence supports their effectiveness in reducing in type 2 diabetes risk. Future work should rigorously evaluate policies meant to reduce type 2 diabetes via the built environment.