Prescribing Food as Medicine among Individuals Experiencing Diabetes and Food Insecurity in the United States

Researchers:
John Bulger
John Cawley
Joseph Doyle
Andrea Feinberg
Fieldwork by:
Location:
Pennsylvania, United States of America
Sample:
500 individuals
Timeline:
2019 - 2022
Outcome of interest:
  • Non-communicable diseases
Intervention type:
  • Health care delivery
AEA RCT registration number:
AEARCTR-0004098
Research papers:
Partners:

Diabetes is one of the most costly and prevalent diseases in the United States and is closely linked to unhealthy diets and food insecurity. Researchers are evaluating the impact of a food-as-medicine program that provides fresh food and diabetes education on health and health care utilization for individuals experiencing both diabetes and food insecurity. 

Policy issue

Each year, millions of Americans are affected by diabetes, making it one of the most costly diseases in the United States. According to the American Diabetes Association, 9.4 percent of the US population had diabetes in 2015 and the estimated total cost of diagnosed diabetes (i.e., direct medical costs and reduced productivity) was US$327 billion in 2017.1 Researchers forecast that the prevalence of diabetes will increase by 54 percent to more than 54.9 million Americans between 2015 and 2030, and the medical and societal costs associated will amount to more than US$622 billion by 2030.2 Furthermore, adults who fall below 100 percent and 199 percent of the Federal Poverty Line experience the highest rates of diabetes at 12 percent and 12.7 percent, respectively.3 It is also widely acknowledged that the high prevalence of diabetes in the United States is linked to low-quality diets and food insecurity.45 Food insecurity is defined as the disruption of food intake or eating patterns due to lack of money and other resources.6 People experiencing poverty are more likely to experience food insecurity and are often led to purchase cheaper, higher-calorie foods that contribute to weight gain and increase susceptibility to diet-related diseases such as diabetes.7 Difficulty accessing healthy foods also complicates management of diabetes, a disease requiring a diet-specific regimen. Despite the acknowledged link between poor diets and diabetes, there is little rigorous evidence on how to effectively increase access to high-quality, nutritious foods among individuals with diabetes and especially for those experiencing poverty. If diets are part of the problem, can they also be part of the solution?

Context of the evaluation

Food-as-medicine programs include produce prescription programs and medically tailored meals. In these programs, health care providers supply or fund nutritious ingredients or meals to patients. They aim to address food insecurity and diet-related chronic diseases like diabetes.

Researchers evaluated a produce prescription program run by a large integrated health care system in the mid-Atlantic, spanning both urban and rural areas. 

The program targeted individuals with type 2 diabetes, which is characterized by a patient becoming resistant to insulin (in contrast to type 1 diabetes, which is characterized by the inability to create insulin). Specifically, program participants had an HbA1c level of 8.0 or higher. HbA1c is a measure of diabetes management that measures average blood sugar levels over three months. An HbA1c level of 6.5 is considered the threshold for diabetes; with under 7.0 as a common goal for diabetes management. An HbA1c level of 8.0 is therefore considered high.10 In addition, program participants all experienced food insecurity (determined by a two-question survey instrument), lived within the geographic reach of the program and were already affiliated with the program’s health care system.

Details of the intervention

In this ongoing study, researchers are testing the impact of the food-as-medicine program on clinical outcomes and health care utilization for patients experiencing diabetes and food insecurity across two clinic locations, one rural and one urban. This study will include approximately 500 adults, roughly 250 from each site. Recruitment, including patient consent, is being conducted by phone, and potential participants are randomly assigned to either the treatment or control groups. For individuals in the treatment group, study staff immediately schedule patients’ initial program visit. Individuals in the control group are informed that they will be contacted in approximately six months to schedule a program start date.

Once enrolled in the program, patients receive regular prescriptions of fresh food from a health system dietitian. The prescription, picked up at a program clinic at no charge, includes enough food for two meals per day over five days per week for the patients and their families. Additionally, participants have access to complementary services, including case management, recipes, medication management, self-management training, and biometric tracking. The program lasts indefinitely with no predetermined end date. Those in the control group have access to regular type 2 diabetes care, which typically includes regular monitoring of blood sugar, diabetes medications, and doctor’s appointments.11

Researchers are measuring outcomes using participant electronic health records and participant surveys. The primary outcome of interest is HbA1c, an indicator of blood sugar control. Other outcomes of interest include fasting glucose, weight, BMI, blood pressure, cholesterol, LDL cholesterol, and triglycerides which will be collected through routine lab work paid for as part of the research. Additionally, researchers are tracking health care utilization in the form of emergency room and inpatient visits through electronic health records. Participant surveys will ask about food choices, attitudes toward health behaviors, diabetes knowledge, self-assessed health, self-efficacy, and patient satisfaction. Participants will be compensated for completing lab work and surveys with a US$50 gift card.
 

Results and policy lessons

Study ongoing; results forthcoming.

1.
“Statistics About Diabetes.” America Diabetes Association. Accessed January 10, 2020. https://www.diabetes.org/resources/statistics/statistics-about-diabetes.
2.
Rowley, William R., Clement Bezold, Yasemin Arikan, Erin Byrne, and Shannon Krohe. “Diabetes 2030: Insights from Yesterday, Today, and Future Trends.” Population Health Management 20, no. 1 (2017): 6–12. https://doi.org/10.1089/pop.2015.0181.
3.
Gaskin, Darrell J, Roland J Thorpe, Emma E McGinty, Kelly Bower, Charles Rohde, J Hunter Young, Thomas A LaVeist, and Lisa Dubay. “Disparities in Diabetes: The Nexus of Race, Poverty, and Place.” American Journal of Public Health 104, no. 11 (November 2014): 2147–55. https://doi.org/10.2105/AJPH.2013.301420.
4.
“Dietary Guidelines for Americans 2015–2020 8th Edition.” 2015-2020 Dietary Guidelines. Accessed October 7, 2019. https://health.gov/dietaryguidelines/2015/guidelines/.
5.
Gucciardi, Enza, Mandana Vahabi, Nicole Norris, John Paul Del Monte, and Cecile Farnum. “The Intersection between Food Insecurity and Diabetes: A Review.” Current Nutrition Reports 3, no. 4 (February 2014): 324–32. https://doi.org/10.1007/s13668-014-0104-4.
6.
“Food Insecurity.” HealthyPeople.gov. Office of Disease Prevention and Health Promotion. Accessed December 6, 2019. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/food-insecurity.
7.
Gucciardi, Enza, Mandana Vahabi, Nicole Norris, John Paul Del Monte, and Cecile Farnum. “The Intersection between Food Insecurity and Diabetes: A Review.” Current Nutrition Reports 3, no. 4 (December 2014): 324–32. https://doi.org/https://doi.org/10.1007/s13668-014-0104-4.
8.
Gucciardi, Enza, Mandana Vahabi, Nicole Norris, John Paul Del Monte, and Cecile Farnum. “The Intersection between Food Insecurity and Diabetes: A Review.” Current Nutrition Reports 3, no. 4 (February 2014): 324–32. https://doi.org/10.1007/s13668-014-0104-4.
9.
“Map the Meal Gap.” Feeding America. Accessed December 6, 2019. https://map.feedingamerica.org/county/2017/overall/pennsylvania.
10.
Centers for Disease Control and Prevention. (2022). All About Your A1C. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html