To examine the relationship between food insecurity and coping strategies (actions taken to manage economic stress) hypothesized to worsen glucose control in patients with diabetes.
Using a ...cross-sectional telephone survey and clinical data, we compared food-insecure and food-secure individuals in their use of coping strategies. Using logistic regression models, we then examined the association between poor glucose control (glycated Hb, HbA1c≥8·0 %), food insecurity and coping strategies.
An urban medical centre, between June and December 2013.
Four hundred and seven adults likely to be low income (receiving Medicaid or uninsured and/or residing in a zip code with >30 % of the population below the federal poverty level) with type 2 diabetes.
Of respondents, 40·5 % were food insecure. A significantly higher percentage of the food-insecure group reported use of most examined coping strategies, including foregone medical care, participation in the Supplemental Nutrition Assistance Program (SNAP)) and use of emergency food programmes. Food insecurity was associated with poor glucose control (OR=2·23; 95 % CI 1·22, 4·10); coping strategies that were more common among the food insecure were not associated with poor glucose control. Among the food insecure, receipt of SNAP was associated with lower risk of poor glucose control (OR=0·27; 95 % CI 0·09, 0·80).
While food insecurity was associated with poor glucose control, most examined coping strategies did not explain this relationship. However, receipt of SNAP among food-insecure individuals was associated with better diabetes control, suggesting that such programmes may play a role in improving health.
The aims of the study were to describe the up-to-date trend of total, diagnosed, and undiagnosed diabetes and prediabetes, assess their associated disparities among population subgroups, and examine ...their relationship with sociodemographic factors among adults in the United States.
This was a cross-sectional study from a nationally representative sample of US adults (aged ≥20 years) who participated in the National Health and Nutrition Examination Survey.
Diagnosed diabetes was defined as a self-reported previous diagnosis of diabetes by a physician or any other health professionals (other than during pregnancy). Undiagnosed diabetes was defined as elevated levels of fasting plasma glucose (≥126 mg/dL) or HbA1c (≥6.5%). Total diabetes included those who had either diagnosed or undiagnosed diabetes. Prediabetes was defined as an HbA1c level of 5.7%–6.4% or a fasting plasma glucose level of 100–125 mg/dL. All estimates were age standardized to the 2010 US census population for age groups 20–44, 45–64, and 65+ years. All analyses accounted for the complex survey design. Logistic regressions were used to conduct the analyses.
A total of 21,600 (mean, 47.2 years SD, 14.7) individuals were analyzed. From 1999 to 2018, the age-standardized prevalence increased significantly from 9.17% to 14.7% (difference, 5.52%; 95% confidence interval CI, 2.69%–8.35%; P-trend <0.001) for total diabetes, increased from 6.15% to 11.0% (difference, 4.79%; 95% CI, 2.27%–7.32%; P-trend<0.001) for diagnosed diabetes and remained stable from 3.01% to 3.73% (difference, 0.72%; 95% CI, −0.47% to 1.91%; P-trend = 0.19) for undiagnosed diabetes. The age-standardized prevalence of prediabetes increased significantly from 29.5% to 48.3% (difference, 18.8%; 95% CI, 13.3%–24.4%; P-trend<0.001). Disparities persisted with higher prevalence among adults with obesity and populations that have been marginalized, including racial and ethnic minorities, low income, less educated Americans, and those living in food-insecure household.
The prevalence of diabetes and prediabetes increased significantly from 1999 to 2018 among US adults. There are substantial and persistent disparities among racial and ethnic minorities, populations experiencing socio-economic disadvantages, and adults with obesity.
In this Report from the Field, we reflect on the first six months of the 2018 implementation of a screener aimed at identifying and addressing social determinants of health (SDH) at Pediatric ...Associates, an outpatient clinic in East Harlem, New York City. We share descriptive statistics and reflect on lessons learned.
To estimate racial and ethnic disparities in type 2 diabetes mellitus after gestational diabetes mellitus (GDM) and to investigate baseline pregnancy clinical and social or structural characteristics ...as mediators.
We conducted a retrospective cohort of individuals with GDM using linked 2009-2011 New York City birth and hospital data and 2009-2017 New York City A1c Registry data. We ascertained GDM and pregnancy characteristics from birth and hospital records. We classified type 2 diabetes as two hemoglobin A 1c test results of 6.5% or higher. We grouped pregnancy characteristics into clinical (body mass index BMI, chronic hypertension, gestational hypertension, preeclampsia, preterm delivery, caesarean, breastfeeding, macrosomia, shoulder dystocia) and social or structural (education, Medicaid insurance, prenatal care, and WIC Special Supplemental Nutrition Program for Women, Infants, and Children participation). We used Cox proportional hazards models to estimate associations between race and ethnicity and 8-year type 2 diabetes incidence, and we tested mediation of pregnancy characteristics, additionally adjusting for age and nativity (U.S.-born vs foreign-born).
The analytic data set included 22,338 patients with GDM. The 8-year type 2 diabetes incidence was 11.7% overall and 18.5% in Black, 16.8% in South and Southeast Asian, 14.6% in Hispanic, 5.5% in East and Central Asian, and 5.4% in White individuals with adjusted hazard ratios of 4.0 (95% CI 2.4-3.9), 2.9 (95% CI 2.4-3.3), 3.3 (95% CI 2.7-4.2), and 1.0 (95% CI 0.9-1.4) for each group compared with White individuals. Clinical and social or structural pregnancy characteristics explained 9.3% and 23.8% of Black, 31.2% and 24.7% of Hispanic, and 7.6% and 16.3% of South and Southeast Asian compared with White disparities. Associations between education, Medicaid insurance, WIC participation, and BMI and type 2 diabetes incidence were more pronounced among White than Black, Hispanic, and South and Southeast Asian individuals.
Population-based racial and ethnic inequities are substantial in type 2 diabetes after GDM. Characteristics at the time of delivery partially explain disparities, creating an opportunity to intervene on life-course cardiometabolic inequities, whereas weak associations of common social or structural measures and BMI in Black, Hispanic and South and Southeast Asian individuals demonstrate the need for greater understanding of how structural racism influences postpartum cardiometabolic risk in these groups.
New York State Medicaid's Health Home program is an example of a natural experiment that could affect individuals with diabetes. While evaluations of interventions such as the Health Home program are ...generally based solely on clinical and administrative data and rarely examine patients' experience, patients may add to the understanding of the intervention's implementation and mechanisms of impact.
The objective of this study was to qualitatively examine the health and nonmedical challenges faced by Medicaid-insured patients with diabetes and their experiences with the services provided by New York's Health Homes to address these challenges.
We performed 10 focus groups and 23 individual interviews using a guide developed in collaboration with a stakeholder board. We performed a thematic analysis to identify cross-cutting themes.
A total of 63 Medicaid-insured individuals with diabetes, 31 of whom were enrolled in New York's Health Home program.
While participants were not generally familiar with the term "Health Home," they described and appreciated services consistent with Health Home enrollment delivered by care managers. Services addressed challenges in access to care, especially by facilitating and reminding participants about appointments, and nonmedical needs, such as transportation, housing, and help at home. Participants valued their personal relationships with care managers and the psychosocial support they provided.
From the perspective of its enrollees, the Health Home program primarily addressed access to care, but also addressed material and psychosocial needs. These findings have implications for Health Home entities and for research assessing their impact.
Racial/ethnic-specific estimates of the influence of gestational diabetes mellitus (GDM) on type 2 diabetes remain underexplored in large population-based cohorts. We estimated racial/ethnic ...differences in the influence of GDM on diabetes risk and glycemic control in a multiethnic, population-based cohort of postpartum women.
Hospital discharge and vital registry data for New York City (NYC) births between 2009 and 2011 were linked with NYC A1C Registry data between 2009 and 2017. Women with baseline diabetes (n = 2,810) were excluded for a final birth cohort of 336,276. GDM on time to diabetes onset (two A1C tests of ≥6.5% from 12 weeks postpartum onward) or glucose control (first test of A1C <7.0% following diagnosis) was assessed using Cox regression with a time-varying exposure. Models were adjusted for sociodemographic and clinical factors and stratified by race/ethnicity.
The cumulative incidence for diabetes was 11.8% and 0.6% among women with and without GDM, respectively. The adjusted hazard ratio (aHR) of GDM status on diabetes risk was 11.5 (95% CI 10.8, 12.3) overall, with slight differences by race/ethnicity. GDM was associated with a lower likelihood of glycemic control (aHR 0.85; 95% CI 0.79, 0.92), with the largest negative influence among Black (aHR 0.77; 95% CI 0.68, 0.88) and Hispanic (aHR 0.84; 95% CI 0.74, 0.95) women. Adjustment for screening bias and loss to follow-up modestly attenuated racial/ethnic differences in diabetes risk but had little influence on glycemic control.
Understanding racial/ethnic differences in the influence of GDM on diabetes progression is critical to disrupt life course cardiometabolic disparities.
There is a need for diabetes prevention efforts targeting vulnerable populations. Our community–academic partnership, the East Harlem Partnership for Diabetes Prevention, conducted a randomized ...controlled trial to study the impact of peer led diabetes prevention workshops on weight and diabetes risk among an economically and racially diverse population in East Harlem, New York. We recruited overweight/obese adults from more than 50 community sites and conducted oral glucose tolerance testing and completed other clinical assessments and a health and lifestyle survey. We randomized prediabetic participants to intervention or delayed intervention groups. Intervention participants attended eight 90-minute peer-led workshop sessions at community sites. Participants in both groups returned for follow-up assessments 6 months after randomization. The main outcomes were the proportion of participants who achieved 5% weight loss, percentage weight loss, and change in the probability of developing diabetes over the next 7.5 years according to the San Antonio Diabetes Prediction Model. We enrolled 402 participants who were mainly female (85%), Latino (73%) or Black (23%), foreign born (64%), and non-English speaking (58%). At 6 months, the intervention group lost a greater percentage of their baseline weight, had significantly lower rise in HbA1c (glycated hemoglobin), decreased risk of diabetes, larger decreases in fat and fiber intake, improved confidence in nutrition label reading, and decrease in sedentary behavior as compared with the control group. Thus, in partnership with community stakeholders, we created an effective low-resource program that was less intensive than previously studied programs by incorporating strategies to engage and affect our priority population.
Background: Women with gestational diabetes (GDM) are at increased risk of developing type 2 diabetes, a leading cause of premature morality. While data suggest racial/ethnic minority women bear the ...disproportionate burden of gestational diabetes, current postpartum GDM cohorts lack adequate diversity to examine whether racial/ethnic disparities persist in the transition to type 2 diabetes. To address this gap, we make use of two NYC public health surveillance databases to construct a novel population-based cohort of women with gestational diabetes and their progression to diabetes diagnosis.
Methods: We used a systematic matching process to identify unique cases of women who gave birth between 2009 and 2011 and diabetes diagnosis (two A1c results6.5%) in the following 8 years using linked NYC vital statistics and HbA1c registry data.
Results: Of 16,231 women with gestational diabetes, the cumulative incidence of diabetes in 8 years of follow-up was 14.4% (N=2,333 cases) in the overall cohort, 21.1% among non-Hispanic Black women, 15.9% among Hispanic women, 12.3% among Asian women, and 6.1% among non-Hispanic white women. Using this diverse cohort, future analyses will examine racial/ethnic differences in disease progression (e.g., from diabetes to glycemic control) among women with gestational diabetes, which has not been well studied in prior cohorts.
Conclusions: This study makes use of diverse public health surveillance data to construct a population-based postpartum cohort of pregnant women to produce pioneering evidence of diabetes disease progression (using HbA1c levels) following pregnancies complicated by GDM. Future research will leverage this novel cohort to investigate how social determinants influence lifecourse racial-ethnic disparities in diabetes.
Disclosure
T. Janevic: None. K. J. Mccarthy: None. J. J. Kennedy: None. H. Chan: None. G. Van wye: None. V. L. Mayer: None. S. H. Liu: None. M. Huynh: None.
Funding
National Institutes of Health (R21DK122266)
An estimated 17.6 million American households were food insecure in 2012, meaning they were unable to obtain enough food for an active and healthy life. Programs to augment local access to healthy ...foods are increasingly widespread, with unclear effects on food security. At the same time, the US government has recently enacted major cuts to federal food assistance programs. In this study, we examined the association between food insecurity (skipping or reducing meal size because of budget), neighborhood food access (self-reported access to fruits and vegetables and quality of grocery stores), and receipt of food assistance using the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. Of 11,599 respondents, 16.7 % reported food insecurity; 79.4 % of the food insecure found it easy or very easy to find fruits and vegetables, and 60.6 % reported excellent or good quality neighborhood grocery stores. In our regression models adjusting for individual- and neighborhood-level covariates, compared to those who reported very difficult access to fruits and vegetables, those who reported difficult, easy or very easy access were less likely to report food insecurity (OR 0.62: 95 % CI 0.43–0.90, 0.33: 95 % CI 0.23–0.47, and 0.28: 95 % CI 0.20–0.40). Compared to those who reported poor stores, those who reported fair, good, and excellent quality stores were also less likely to report food insecurity (OR 0.81: 95 % CI 0.60–1.08, 0.58: 95 % CI 0.43–0.78, and 0.43: 95 % CI 0.31–0.59). Compared to individuals not receiving food assistance, those receiving Supplemental Nutrition Assistance Program (SNAP) benefits were significantly more likely to be food insecure (OR 1.36: 95 % CI 1.11–1.67), while those receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (OR 1.17: 95 % CI 0.77–1.78) and those receiving both SNAP and WIC (OR 0.84: 95 % CI 0.61–1.17) did not have significantly different odds of food insecurity. In conclusion, better neighborhood food access is associated with lower risk of food insecurity. However, most food insecure individuals reported good access. Improving diet in communities with high rates of food insecurity likely requires not only improved access but also greater affordability.
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