Diabetes is one of the most prevalent and costly health conditions in the U.S. (1), and diet plays a fundamental role in managing the condition effectively. Yet prior research raises concerns about the “food security” of people with diabetes (i.e., whether they have access to healthy, affordable food) (2,3). It is unknown, however, how widespread food insecurity is among people with diabetes across different insurance types and, moreover, whether food assistance is adequately addressing the problem (4). This study helps to fill this gap by providing national estimates of the prevalence of food insecurity among Americans with diabetes by insurance status and receipt of Supplemental Nutrition Assistance Program (SNAP) benefits.

We used a new source of data on food security from the Medical Expenditure Panel Survey (MEPS), a nationally representative survey sponsored by the Agency for Healthcare Research and Quality. In 2016 and 2017, the MEPS included an interview module designed to assess food security based on a validated instrument developed by the U.S. Department of Agriculture (5). These data, together with data from the MEPS questionnaire on diabetes care, provide a unique resource for investigating the nexus between food insecurity and diabetes. We restrict our sample to adults ages 18–64 years (N = 38,774).

Our analysis estimated the prevalence of food insecurity (percent who were food insecure) across four groups: those without diabetes, those with diabetes overall, those with insulin-dependent diabetes, and those with diabetes-related eye or kidney problems. Percentages are reported across insurance categories (private coverage all year, Medicaid all year, uninsured all year, or some combination of coverage types) and by receipt of SNAP benefits. The differences discussed were all statistically significant at P < 0.01. All estimates and SEs were adjusted for the complex survey design of MEPS and are, therefore, representative of the U.S. noninstitutionalized population.

Results show that the prevalence of food insecurity was much higher among adults with diabetes compared with those without diabetes (16% vs. 9%) (Table 1). People with diabetes who were taking insulin or who had eye or kidney complications had even higher rates of food insecurity at 19% and 22%, respectively. The prevalence of food insecurity among people with diabetes was much higher among Medicaid enrollees compared with those with other types of insurance. Nearly one-third (32%) of Medicaid enrollees with diabetes were food insecure, 24 percentage points higher than their counterparts with private insurance (7%). The prevalence of food insecurity was highest among Medicaid enrollees with insulin-dependent diabetes; 44% were food insecure, over six times higher than their counterparts with private insurance.

Table 1

Sample size, population, and prevalence of food insecurity by diabetes status, insurance status, and receipt of nutrition assistance

OverallPrivate only all yearMedicaid only all yearUninsured all yearMixed coverage
Overall
N 38,774 20,382 5,152 6,008 7,232
Population 194,454,784 124,587,675 17,351,435 20,720,503 31,795,171
% Food insecure 22 17 18
95% CI (9, 10) (4, 5) (20, 24) (15, 19) (16, 19)
People without diabetes
N 35,230 18,906 4,539 5,540 6,245
Population 179,541,451 116,572,572 15,561,507 19,421,885 27,985,486
% Food insecure 21 17 17
95% CI (8, 9) (4, 4) (19, 23) (15, 19) (15, 18)
People with diabetes
N 3,199 1,358 526 369 946
Population 13,907,360 7,503,389 1,533,782 1,154,431 3,715,758
% Food insecure 16 32 21 26
95% CI (14, 18) (6, 9) (26, 37) (15, 26) (22, 30)
People with diabetes who take insulin
N 773 320 132 65 256
Population 3,316,659 1,725,391 384,691 217,429 989,147
% Food insecure 19 44 23 29
95% CI (15, 23) (4, 10) (34, 55) (11, 34) (22, 36)
People with diabetes with eye or kidney problems
N 551 175 101 45 230
Population 2,163,697 872,130 275,802 NA 851,895
% Food insecure 22 10 41 NA 28
95% CI (18, 26) (5, 14) (28, 54) NA (21, 35)
Food-insecure people with diabetes
N 633 131 162 83 257
Population 2,210,136 534,913 483,166 237,734 954,324
% Not receiving food assistance 57 80 29 68 56
95% CI (53, 62) (70, 90) (19, 39) (53, 83) (47, 65)
People with diabetes receiving food assistance
N 791 78 300 95 318
Population 2,692,938 327,473 826,313 328,048 1,211,104
% Food insecure 35 33 42 23 35
95% CI (31, 40) (18, 47) (34, 49) (11, 35) (27, 43)
OverallPrivate only all yearMedicaid only all yearUninsured all yearMixed coverage
Overall
N 38,774 20,382 5,152 6,008 7,232
Population 194,454,784 124,587,675 17,351,435 20,720,503 31,795,171
% Food insecure 22 17 18
95% CI (9, 10) (4, 5) (20, 24) (15, 19) (16, 19)
People without diabetes
N 35,230 18,906 4,539 5,540 6,245
Population 179,541,451 116,572,572 15,561,507 19,421,885 27,985,486
% Food insecure 21 17 17
95% CI (8, 9) (4, 4) (19, 23) (15, 19) (15, 18)
People with diabetes
N 3,199 1,358 526 369 946
Population 13,907,360 7,503,389 1,533,782 1,154,431 3,715,758
% Food insecure 16 32 21 26
95% CI (14, 18) (6, 9) (26, 37) (15, 26) (22, 30)
People with diabetes who take insulin
N 773 320 132 65 256
Population 3,316,659 1,725,391 384,691 217,429 989,147
% Food insecure 19 44 23 29
95% CI (15, 23) (4, 10) (34, 55) (11, 34) (22, 36)
People with diabetes with eye or kidney problems
N 551 175 101 45 230
Population 2,163,697 872,130 275,802 NA 851,895
% Food insecure 22 10 41 NA 28
95% CI (18, 26) (5, 14) (28, 54) NA (21, 35)
Food-insecure people with diabetes
N 633 131 162 83 257
Population 2,210,136 534,913 483,166 237,734 954,324
% Not receiving food assistance 57 80 29 68 56
95% CI (53, 62) (70, 90) (19, 39) (53, 83) (47, 65)
People with diabetes receiving food assistance
N 791 78 300 95 318
Population 2,692,938 327,473 826,313 328,048 1,211,104
% Food insecure 35 33 42 23 35
95% CI (31, 40) (18, 47) (34, 49) (11, 35) (27, 43)

NA, not available.

We also found that a sizable fraction of people with diabetes who were food insecure were not receiving SNAP benefits. Over 80% of people with diabetes who had private insurance coverage were not receiving SNAP benefits, likely reflecting SNAP eligibility (individuals who do not qualify for Medicaid are typically not eligible for SNAP). However, even among Medicaid enrollees, 29% of people with diabetes were not receiving SNAP benefits, and over two-thirds (68%) of the uninsured were not receiving SNAP benefits. Even among Medicaid enrollees with diabetes who were receiving SNAP benefits, food insecurity persisted; despite receiving food assistance, over 40% remained food insecure.

These findings show that the prevalence of food insecurity in the U.S. is highest among Americans for whom a healthy diet is especially critical—Medicaid enrollees with insulin-dependent diabetes and diabetes-related eye or kidney complications (over 40% were food insecure). The problem of co-occurring food insecurity and diabetes among the nation’s disadvantaged has likely worsened during the coronavirus disease 2019 pandemic. Our findings are especially revealing when considered together with statistics on national health care expenditures. Twenty seven million Americans, 8% of the total U.S. population, have diabetes, resulting in an estimated $329 billion in direct and indirect costs in 2017 (1). Medicaid alone spent about$34 billion on medical care for nonelderly adults with diabetes. Given the prevalence of food insecurity documented in this study, many people with diabetes who rely on Medicaid coverage or who go without coverage entirely likely find it difficult or impossible to manage their condition effectively. While this situation is dire, it also constitutes an opportunity to develop programs and policies that could simultaneously improve health and save money in an increasingly strapped public health insurance system. To take advantage of this opportunity, more research is needed to identify the most effective ways of improving and supporting food security among people with diabetes.

The views in this article are those of the authors and no official endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services is intended or should be inferred.

Acknowledgments. The authors would like to thank Thomas Selden and Ed Miller (Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality) for their extremely constructive suggestions at numerous points in the revision process.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

Author Contributions. J.K. D.B. and L.L. contributed to the study’s conceptualization and design, and to numerous revisions. J.K. performed the statistical analysis and wrote the first draft. All authors contributed to numerous revisions. J.K. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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