Emerging practices supporting diabetes self-management among food insecure adults and families: A scoping review

Summary

Background

Food insecurity undermines a patient’s ability to follow diabetes self-management recommendations. Care providers need strategies to direct their support of diabetes management among food insecure patients and families.

Objective

To identify what emerging practices health care providers can relay to patients or operationalize to best support diabetes self-management among food insecure adults and families.

Eligibility criteria

Food insecure populations with diabetes (type 1, type 2, prediabetes, gestational diabetes) and provided diabetes management practices specifically for food insecure populations. Only studies in English were considered. In total, 21 articles were reviewed.

Sources of evidence

Seven databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Medline, ProQuest Nursing & Allied Health Database, PsychInfo, Scopus, and Web of Science.

Results

Emerging practices identified through this review include screening for food insecurity as a first step, followed by tailoring nutrition counseling, preventing hypoglycemia through managing medications, referring patients to professional and community resources, building supportive care provider-patient relationships, developing constructive coping strategies, and decreasing tobacco smoking.

Conclusion

Emerging practices identified in our review include screening for food insecurity, nutrition counselling, tailoring management plans through medication adjustments, referring to local resources, improving care provider–patient relationship, promoting healthy coping strategies, and decreasing tobacco use. These strategies can help care providers better support food insecure populations with diabetes. However, some strategies require further evaluation to enhance understanding of their benefits, particularly in food insecure individuals with gestational and prediabetes, as no studies were identified in these populations. A major limitation of this review is the lack of global representation considering no studies outside of North America satisfied our inclusion criteria, due in part to the English language restriction.

Keywords:

Pediatrics – Health economics – Patients – Food – hypoglycemia

Introduction

Food insecurity persists among North Americans with diabetes [1–5]. Food insecurity refers to inadequate or insecure access to food due to financial constraints [1]. In 2005, the prevalence of food insecurity in Canada was 9.3% among households with individuals with diabetes, compared to 6.8% among households without [2]. The likelihood of food insecurity increases by 4% with every year earlier an individual is diagnosed with diabetes [2]. For instance, in Nova Scotia, food insecurity prevalence is substantially higher in households with a child with diabetes (21.9%) than with households with only an adult with diabetes (14.6%), suggesting higher risks associated with food insecurity among households with children with diabetes [6]. Persons with pre-diabetes are 39% more likely to experience food insecurity [7,8] as food insecurity of any degree has been shown to increase the risk of pre-diabetes. The likelihood of gestational diabetes is also higher in women who are considered marginally food insecure [9] as pregnant women who are food insecure experience greater weight gain during pregnancy and are more likely to be obese prior to becoming pregnant [9].

A few studies outside of North America have identified a higher prevalence of food insecurity among those with diabetes or have identified food insecurity as a risk factor for poorer diabetes management. For instance, a study in Iran showed that those who were food insecure were 2.8 times more likely to have diabetes than those who were food secure [10]. In Kenya, food insecure individuals with diabetes were more likely to be on insulin or have had been on insulin compared to their food secure counterparts [11]. Another study reported severely food insecure Jordanians with diabetes had a higher body mass index (BMI) despite having a lower caloric intake than food secure or mildly food insecure individuals with diabetes [12].

Healthy eating is key to diabetes prevention and management in both adults and children. However, food insecure individuals with diabetes often eat fewer fruits and vegetables [2] and have poorer quality diets that are low in variety [13,14]. Food insecurity undermines individuals’ ability to purchase and consume recommended foods and follow self-management plans. Growing literature links food insecurity with poor diabetes self-management, adverse health outcomes, and increased healthcare costs. Food insecurity is associated with poor glycemic-monitoring adherence [15], increased likelihood of poor glycemic control [16,17], and higher rates of hospitalization and use of health services [6,15,18]. In children, poor glycemic control can cause hypoglycemia and ketoacidosis, leading to hospital admissions and long-term consequences: retinopathy, nephropathy, neuropathy, and increased risk of cardiovascular disease [6]. Food insecure adults with diabetes report more cost-related medication underuse and poor adherence to oral hypoglycemic agents [19,20]. Additionally, they report skipping meals, eating more energy-dense foods and foods higher in sodium, and have higher levels of diabetes-related emotional distress [21]. Food insecure individuals are more likely to describe their mental health, satisfaction with life, and self-perceived stress in neutral or negative terms [2,22]. Given the link between food insecurity and poor health outcomes for individuals with diabetes, it is not surprising that annualized total American healthcare expenditures on food insecure individuals with diabetes are estimated to be US $4,414 higher than their food secure counterparts [23].

Households that are food insecure may be ill-equipped to successfully manage diabetes, as financial strain and competing priorities often force them to cut expenses on diabetes medication and supplies and healthy foods to meet housing costs [21]. Literature now recommends routine screening for food insecurity among individuals with diabetes [5]. This screening can help clinicians tailor diabetes-management plans for food insecure individuals and may significantly reduce medical costs [24–26]. For instance, food insecurity knowledge helps clinicians provide patients with more realistic dietary recommendations [5]; identify patient difficulties in adhering to prescribed medications [27]; and identify patients at increased risk of poor health outcomes associated with food insecurity (e.g., asthma, depression, obesity) [28]. However, for routine screening to succeed, care providers must have guidelines on how best to support diabetes management among food insecure patients and families. No such guidelines exist.

The primary aim of this scoping review is to identify recommendations or emerging practices that health care providers can relay to patients or operationalize to support diabetes self-management among food insecure populations.

To our knowledge, this is the first scoping review to investigate emerging practices to support diabetes self-management in the context of food insecurity in both adult and pediatric populations. Identified emerging practices are not intended as solutions to food insecurity. Instead, our aim is to better support diabetes management among food insecure populations with diabetes.

Methods

This scoping review seeks to answer the question: What recommendations or emerging practices are being conveyed to patients or used by healthcare providers to support diabetes self-management among food insecure populations?

This paper will define emerging practices as recommendations, practices, strategies or “interventions that are new, innovative and which hold promise based on some level of evidence of effectiveness or change that is not research-based and/or sufficient to be deemed a ‘promising’ or ‘best’ practice” yet [29]. As such, practices that are currently in use but have yet to be substantially evaluated have been included. Emerging practices must also be based on “protocols, standards, or preferred practice patterns that [may] lead to effective–health outcomes” [30].

Eligibility

For all searches, studies were included or excluded based on the Population, Concept, and Context (PCC) framework for scoping reviews [31]. As such, the participant population was defined as food insecure populations with diabetes (prediabetes, type 1 or 2, or gestational); the concept was recommendations, practices, strategies, or interventions of any nature that addressed diabetes self-management in a food insecure population; studies of all contexts were considered with no specifications for timing and setting. Studies of all designs were acceptable. The studies needed to be published in English for review.

Data sources and search strategy

We conducted a scoping review focusing on diabetes populations who are food insecure following the guidelines recommended in the PRISMA extension for scoping reviews checklist [32]. Seven databases were electronically searched: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews, Medline, ProQuest Nursing & Allied Health Database, PsychInfo, Scopus, and Web of Science. Combinations of the following key words were used: diabetes, diabetes mellitus, type 1 diabetes, diabetes mellitus, type 1, type 2 diabetes, diabetes mellitus, type 2, gestational diabetes, gestational, prediabetes, prediabetic state, food security, food insecurity, food supply, cooking, food skills, education, patient education, health education, coping strategies, therapeutics, self-efficacy, diabetes management, self-management, self-care, low income, poverty, hunger, pediatric, newborn, infant, preschool child, child, adolescent, family characteristic, family, and household. See Table 1 for search strategy used. Additional articles were found through bibliography hand searching and expert consultation.

Study selection

The search conducted for all dates up to November 2018, retrieved 3066 articles (Fig 1). Seven additional articles were found through bibliography hand searches and expert consultation. Two reviewers independently screened through article titles and abstracts using DistillerSR. Acceptable articles were reviewed in full to confirm eligibility and extract relevant information for the scoping review. Twenty-one articles satisfied inclusion criteria and were reviewed. Any discrepancies were resolved through discussion. Studies were most often excluded because they were not specific to a food insecure population with diabetes, or did not discuss diabetes-management practices, strategies, or interventions for those who are food insecure that can be operationalized by care providers. Only full text-articles were included in this review.

Data analysis and synthesis

For each article reviewed in full, the reference and publication information, objectives, study design and methods, target population and sample size, main results, and emerging practices, strategies, on interventions were extracted, see Tables 2 and 3 for study characteristics. The emerging practices to support diabetes self-management were compiled and first organized into similar strategies or interventions, then placed under larger, theme-based headings. Development meetings were held with co-investigators and care providers who specialize in pediatric and adult diabetes care in Toronto, Canada to discuss these strategies for care. This information was later translated into an algorithm to guide clinical decision making to be published elsewhere.

Results

From the scoping review, we compiled emerging practices to better support diabetes self-management among food insecure populations with diabetes. For our review, we only reported emerging practices that are not already commonplace in practice guidelines for general diabetes management [33]. Most were conducted in the United States, except for 8 studies from Canada. Only 3 of the 21 studies assessed diabetes self-management in food insecure pediatric populations [6,34,35]. The studies comprised of reviews [4,21,36,37], randomized control trials [38], secondary analyses [28,39], cross-sectional studies [5,6,15,27,40,41], pilot interventions [42,43], qualitative studies [25,35], commentaries [24,44], and grey literature [34,34].

The emerging practices for diabetes management among food insecure populations are organized according to interventions: food insecurity screening, nutrition counseling, improving glycemic control through medication management, building supportive care provider-patient communication and relationships, constructive coping, education, referring clients to food resources and supporting smoking cessation (see Table 4).

Discussion

Food Insecurity screening

The first step in addressing food insecurity among people with diabetes is identifying them. There is growing consensus about the necessity for routine food insecurity screening among adults and children with diabetes, conducted in a respectful and non-judgmental manner [5,6,15,21,24,25,27,28,34,40,44,45,46]. Vivian et al. recommend comprehensive assessments of food insecure adults with diabetes to identify knowledge gaps and harmful self-care behaviours that could impact patients’ glycemic control [40]. Similarly, a study not in our review but conducted in low income patients, Pilkington et al., recommend learning about patients’ life circumstances, exploring challenges to diabetes self-management, and helping patients access available resources [47]. Such assessments can enable care providers to tailor self-management plans, resulting in more realistic dietary advice and more appropriate medication regimens [40]. Although comprehensive assessment is time consuming, the information provided by patients following screening is rich and helpful for care providers [42]. Furthermore, these discussions can be spread out over several visits.

An unpublished thesis of a food insecurity screening initiative with 561 low-income adults with diabetes used two simple screening questions [45]. A treatment algorithm was then developed to guide care for patients identified as food insecure. The program increased the proportion of vulnerable patients with diabetes screened for food insecurity from 0% to 82%, and after 3 months there was a significant 18% reduction in the number of participants with hemoglobin A1C (A1C) levels above 7% [45]. Discussions regarding diabetes management on a budget (i.e. grocery shopping advice on healthy and affordable food), education on self-management when quantity and frequency of food intake were compromised, applicable information on local food assistance programs, and provision of nutrition information handouts to patients were instrumental to the intervention’s success [45]. A pilot screening initiative reported by Thomas et al. examined the acceptability and feasibility of food insecurity screening among adults with diabetes in a community health center [42]. The initiative, which included three screening questions and a care algorithm, demonstrated that patients are willing to share their experiences of food insecurity, despite acknowledging the sensitivity of the topic. Furthermore, screening elicited valuable information from patients that directed care providers’ tailoring of treatment and care to best support food insecure patients [42]. Similarly, a food insecurity screening initiative implemented in a pediatric diabetes clinic revealed that most families were comfortable sharing food insecurity circumstances with care providers and appreciated the additional resources and care that accompanied a positive screening result [34]. These pilot studies provide promising examples of the acceptability and feasibility of food insecurity screening in routine diabetes care and its potential to improve glycemic control.

Nutrition counseling

The role of dietary counseling for individuals with diabetes in guiding their purchase and preparation of healthy foods is well documented [27,41,48]. Regardless of food security status, maintaining a therapeutic diet is one of the more difficult elements of diabetes management [49]. However, the costs associated with such diets, as well as lack of access to cooking equipment, such as stoves, pose significant barriers to those who are food insecure [8]. In addition to findings from our review, challenges have been reported with portion size control and consumption of unbalanced meals with high starch and low vegetable content for low income individuals [49]. Those who are food insecure often resort to low-cost, energy-dense foods that contain refined carbohydrates, added sugars, and added fats [15,39,44].

Food insecure households may benefit from specific and tailored advice on extending their budgets, planning healthy-yet-affordable meals, and learning how to use their available resources more effectively [13,8]. Hence, referring food insecure patients with diabetes to registered dietitians is recommended [25], as they can support patients in following therapeutic diets on low budgets. For example, rather than recommending that patients choose healthier, more expensive brown rice, it may be more effective to focus on reduced portion sizes of more affordable white rice [15,44]. However, such practices may not be appropriate for children, as they have specific nutritional requirements during vital growth periods. Working within the budgets and foods accessible to individuals or families will make dietitians’ recommendations more cost neutral and realistic [25]. Cost-saving strategies include eating out less, buying out-of-season frozen or canned fruits and vegetables with no added salt or sugar, and supporting individuals to eat cheaper proteins, such as beans and lentils, by showing clients how to cook these proteins [44]. Print resources that acknowledge the challenges of healthy eating on low budgets may reduce stigma and open conversations with clinicians about food insecurity [5]. Encouraging parents to enroll children in subsidized-school-meal programs can also relieve pressure on family budgets [44].

Improving glycemic control and access to medications

Glycemic control depends, in-part, on quality of food choices and medication adherence [15]. Lopez & Seligman recommend screening food insecure patients for hypoglycemia at every visit [44] (e.g., asking patients about hypoglycemia symptoms or any blood glucose values below 4 mmol/L). If food insecure patients skip meals, clinicians can reduce their hypoglycemia risk by prescribing medications less likely to cause hypoglycemia (e.g., metformin, GLP-1s, DPP-4 inhibitors, SGLT-2s) and scheduling medication-taking with meals, not time of day [25,44]. Prescriptions for longer-acting insulin analogs, or insulin degludec can prevent hypoglycemia during unpredictable food supply periods [44]. More intensive diabetes-management methods (e.g., multiple daily basal- and bolus-insulin injections) can be modified to omit doses without food. Essien et al. propose loosening medical management restrictions to prevent hypoglycemia; for example, teaching patients to alter medications when dietary intake is low or absent [36] and raising adult glycemic targets to reduce hypoglycemia risk [15]. Patient-specific glycemic targets may be more appropriate for children. Care plans for food insecure patients should further consider their medical and drug-formulary coverage to decrease expenditure (e.g. prescribing medications covered by social-assistance drug benefits or compassionate drug assistance programs) [46]. Essien et al. highlight the importance of balancing hypo- and hyperglycemia risk, particularly at times when patients are likely have used up their monthly income [36].

Improving care provider-patient communication and relationships

Food insecurity, a sensitive topic, must be addressed without judgement in terms of how households prioritize their spending [42]. Genuine, empathetic, and non-judgmental, care is critical in supporting diabetes self-management [25] in this population. To enable food insecurity disclosure, positive patient-care provider communication and relationships are needed. A strong rapport with care providers has been shown to increase patients’ comfort in answering food security screening questions [42]. Care providers are most helpful when they communicate clearly, elicit patient concerns, explain laboratory results and exam findings, and involve patients in decision-making [25,50]. Furthermore, it has been reported that socially disadvantaged individuals (i.e. individuals who are racialized or of a low socio-economic status) with diabetes benefit from frequent contact [35] of at least 10 hours in duration with nutrition educators over 6 months [51,52], allowing them to discuss challenges in following self-management recommendations.

Coping strategies

Food insecure adults in general report more frequent stress, anxiety, and depression associated with a sense of powerlessness [28]. Higher stress levels may lead to decreased diabetes self-care and diabetes distress, both of which have been shown to be associated with suboptimal glucose control [28]. Poorly coping individuals may be less likely to adhere to medication regimes because of stress and/or financial strain, and their distress may increase when blood glucose levels rise, contributing to a vicious cycle of suboptimal blood glucose control. It is therefore important to assess patients’ coping strategies and stress management skills [28,53,54] and to treat signs of stress or poor coping (e.g. depression, burnout, frustration, concern, apathy) to remediate food insecurity effects on glycemic control and potentially refer them to counseling services [28]. More attention should be given to stress management as a point of intervention to improve health outcomes of food insecure individuals with diabetes given the elucidated pathway between high stress levels, decreased diabetes self-care, and poor glycemic control [22].

Referral to community resources

Referrals to sources of inexpensive food for food insecure households among people with diabetes support diabetes self-management [6,27]. These referrals may be to food banks/pantries, social assistance programs, affordable grocery stores, meal delivery services, organizations providing free or low-cost meals, and other supplemental food programs [25,27,36,44]. Connecting households with such government and community programs not only enables food access but may help ease other competing budget demands [36]. However, in a very recent published study not included in our review described how solely informing patients of services is insufficient and results in low usage rates. Instead, active enrolment on-site (i.e. in a clinic) that is straightforward and facilitated by staff has shown to be more effective in achieving higher service usage rates [17]. Service providers must also ensure non-judgmental interactions with patients, as food insecurity often elicits a sense of shame and loss of dignity which can result in a reluctance to use food assistance services [55]. As such, suitable and appropriate referrals are necessary to help patients receive optimal care [25].

Ippolito et al. examined the association between food security and diabetes self-management among food pantry clients and concluded that food insecure individuals are less likely to access clinical care as frequently as their food secure counterparts [41]. As a result, food banks have also begun to partner with registered dietitians, delivering diabetes self-management support and glucose monitoring [41,38]. Offering healthcare support services through food banks and pantries reaches marginalized populations and addresses care gaps they may periodically experience [2,41,38,37]. An intervention study conducted by Seligman et al. demonstrated the effectiveness of providing diabetes-appropriate foods and self-management education in food banks to increase access to diabetes-appropriate foods and consumption of fruits and vegetables and reduce food insecurity [38]. Using a diabetes educational guide suited to all literacy levels, Lyles et al.’s diabetes self-management education intervention supports development of patient-centered self-management plans [39]. This approach resulted in significantly lower A1C and greater self-efficacy among food insecure individuals, compared with food secure individuals, even when the intervention is not focused directly on food insecurity [39]. Findings suggest targeted self-management educational support can improve clinical and behavioural outcomes among food insecure patients with diabetes.

Furthermore, programs that allow healthcare providers to write food prescriptions (i.e., coupons for healthy foods redeemable at participating retailers) can also improve diet quality [41]. Food prescription programs, beginning to emerge in America, legitimize the need for nutritionally adequate foods required for therapeutic diets. Additionally, having food prescriptions for healthy foods (i.e. fruits and vegetables, whole grains, seafoods, and nuts and seeds) being covered by Medicaid/Medicare has been shown in a simulation study by Lee et al. to potentially reduces formal healthcare expenditure by $100.2 billion and prevent 0.12 million diabetes diagnoses over the lifetime of those currently under the coverage of Medicaid/Medicare [56]. This finding suggests the cost-effectiveness, favourability, and need for healthy food prescriptions [56]. Similarly, two studies showed the effectiveness of food assistance programs in improving health outcomes. A food assistance intervention by Palar et al. provided meals that fully satisfied caloric and nutritional requirements to low-income participants with HIV or diabetes and observed an increase in fruit and vegetable consumption, and reduced frequency of sugar and fat intake, food insecurity, diabetes distress, and depressive symptoms [57]. There was also a reduction in participants forgoing food for healthcare and medication [57]. Cavanaugh et al. also showed that food prescription programs reduced BMI in a low-income population with diabetes [58]. These food prescriptions may also reduce stigma associated with households’ need to use food assistance programs.

Smoking cessation

Approximately a third of adults with diabetes are cigarette smokers, and those who are food insecure are twice as likely to smoke [2]. Asking about smoking habits in clinical assessments and non-judgmentally supporting patients to quit smoking, could help to alleviate budgetary constraints [40,44]. Care providers are urged to inform patients with diabetes about the risks of smoking and benefits of quitting [44]. When patients express interest in quitting, clinicians should provide information about public health programs that offer free smoking cessation counseling and non-prescription nicotine replacement therapy [44]. Some community health centers may have respiratory therapists who can counsel referred patients on smoking cessation [44]. By reducing smoking, clinicians can support patients in decreasing expenditure on cigarettes and use the resulting additional funds on healthy foods as there is a dose-response relationship between increased cigarette spending and lower food spending [44]. Additionally, smoking has been linked to increased insulin resistance; thus, smoking cessation can improve glycemic control and prevent vascular complications that are common in those with diabetes [59].

Limitations and future research

A major limitation of this scoping review is the dearth of research on interventions supporting food insecure people with diabetes, especially children, and no information was available for gestational diabetes and pre-diabetes. Additionally, although the search was not specific to North American studies, all eligible studies were from Canada or the United States. The lack of identified studies outside North America can be partly attributed to the English language inclusion criteria. As such, our results do not inform a global perspective. More studies with evaluative components are also needed to better direct clinical practice. Many of the interventions we reviewed do not measure clinical outcomes maintenance after participation ends. Given the above-mentioned limitations and until further evidence is available, our recommendations describe emerging practices, rather than inform practice guidelines. Research is needed to evaluate the effectiveness of these interventions on short- and long-term diabetes-related health outcomes.

Conclusion

Clinicians can adopt several strategies to better support diabetes self-management among food insecure populations. Routine household food insecurity screening is a logical first step, followed by tailoring of diabetes management plans and interventions via medication management, community referrals, assessing coping strategies, supportive care provider-patient relationships, and smoking cessation. However, given the lack of studies, especially outside North America and in populations with gestational and prediabetes, more studies that evaluate the effectiveness of the identified emerging practices are needed to better inform health care providers and provide a global perspective.

Supporting information

S1 File [docx]
PRISMA checklist.