Food security is characterized by the ability to obtain wholesome nutritious foods needed to achieve normal growth and development in childhood and to maintain good health in adulthood (1). Conversely, food insecurity is characterized by the inability to obtain nutritious food and is associated with poor physical and mental health, low academic and economic achievement, and high risk of obesity, diabetes, and other chronic diseases. The American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2023 (Standards of Care) defines food insecurity as “unreliable availability of nutritious food and the inability to consistently obtain food without resorting to socially unacceptable practices” (1).
Data from the Food and Agriculture Organization of the United Nations indicate that in 2019, before the COVID-19 pandemic, 3 billion people globally were unable to afford a healthy diet and nearly 135 million people worldwide faced life-threatening food insecurity (2). Food insecurity became even more prevalent during the pandemic, with worldwide estimates suggesting a doubling. Food insecurity is particularly prevalent in communities of color. In 2021, food insecurity in the U.S. was reported at rates 3 times higher in Black non-Hispanic households (19.6%) compared with White households (7.0%) (3). Hispanic households also had high food insecurity rates (16.2%). Households with children also had higher rates of food insecurity (12.5%) than the national average (10.2%), which is particularly concerning as nutrition is so critical for pediatric growth and development.
Two articles in this issue of Diabetes Care examine food security as reported cross-sectionally during 2016–2019 by young adults and families of children with diabetes in the U.S.-based Search for Diabetes in Youth (SEARCH) study cohort (4,5). Over half (50.8%) of participants with type 2 diabetes and nearly a third (29.4%) with type 1 diabetes affirmed one or more food security concerns. The prevalence of severe (high) food insecurity in the cohort was 19.7% (4), and high insecurity was reported 1.7 times more frequently by participants with type 2 diabetes than by those with type 1 diabetes (30.7% vs. 17.7%). When examined using a multivariable regression model, the odds of high food insecurity were not significantly greater for SEARCH participants with type 2 diabetes than for those with type 1 diabetes; this is perhaps due to socioeconomic and social determinants of health differences, as participants with Medicaid/Medicare or without insurance, with lower parental education, and with lower household income had greater odds of high food insecurity. Supplemental Nutrition Assistance Program (SNAP) participation was threefold higher among SEARCH youth with type 2 diabetes compared with those with type 1 diabetes (34.8% vs. 10.7%).
The accompanying SEARCH article by Reid et al. (5) found that parents of children with diabetes and young adults with diabetes who reported higher food insecurity also had higher fear of hypoglycemia. This is concerning, as fear of hypoglycemia is associated with disordered eating and chronic hyperglycemia. Other articles evaluating SEARCH cohort subsets have indicated that household food insecurity is also related to more hyperglycemia, more emergency department utilization, and greater rates of diabetic ketoacidosis (6,7).
Strengths of the SEARCH cohort reports include 1) a study population drawn from a large multiethnic population-based registry with demographic and clinical characteristics similar to those of the overall U.S. population and 2) availability of data from the 18-item food security instrument. Limitations include 1) the observational cohort study design precluded evaluating intervention strategies, 2) a relatively small sample size of participants with type 2 diabetes that may limit the precision of measurements, 3) nonresponse bias may have affected the food insecurity prevalence estimates, and 4) the data did not include information regarding barriers to using SNAP. A prior mixed-methods study conducted in adult SNAP participants found food insecurity coping strategies included skipping meals/medication, overeating when food is available (cyclical eating patterns), and purchasing less-expensive, energy-dense foods (8). Positive coping strategies included focusing on emotional resilience, and social support, which SNAP recipients endorsed as particularly vital in the final days of monthly SNAP funding cycles (8). In a longitudinal cohort study, food insecurity in older adults with diabetes was associated with more frequent emergency department visits and hospitalizations and higher HbA1c (9). Participants who affirmed having food insecurity were more likely to have comorbidities and report a lower level of general health and quality of life. The adverse outcomes in individuals with diabetes and food insecurity were mediated by social determinants of health that are addressed in the ADA’s Health Equity Bill of Rights (10).
Strategies for eliminating hunger (life-threating food insecurity) and reducing mortality attributable to diabetes and other noncommunicable diseases addressed in the United Nations 2030 Goals for Sustainable Development consider interconnected dimensions (availability, access, utilization stability) (3). Sustainability involves supra-national/regional indicators of ecology, biodiversity and climate change as well as socio-cultural and economic factors. As indicated in Table 1, “availability” may be assessed through considering resources to produce food for consumption within a country or export and reflects agricultural and trade practices and policies as well as other crop yield determinants such as climate/weather. “Access” is determined by the interaction of population group members with the food supply, which is influenced by food distribution policies and practices within and between countries/societies, food economics, (i.e., disposable income, food prices), and available food quality and quality. “Utilization” components include intrahousehold food distribution, purchase and conservation practices, and food preparation. “Stability” and longer-term food security depend on the sustainability of the food and agricultural systems that address dimensions of availability, access, and utilization as pillars for eliminating hunger and supporting healthy ecosystems for food production.
Addressing food insecurity for people with diabetes: recommended approaches and resources
Setting . | Selected screening approaches and resources . |
---|---|
Individual care provider | Incorporate hunger vital sign into social history and refer, as needed, and arrange follow-up assessment. Webinar: https://professional.diabetes.org/content-page/diabetes-and-food-insecurity-resources-what-who-when-where-and-how ADA listing of local resources by zip code: https://diabetes.org/healthy-living/recipes-nutrition/food-insecurity-diabetes Feeding American national network with local food pantry links: https://hungerandhealth.feedingamerica.org/explore-our-work/community-health-care-partnerships/addressing-food-insecurity-in-health-care-settings/ |
Solo or multidisciplinary team independent practice | From above + potential “clinical champion” to lead potential evaluation (number screened; positive screening with referrals and referral follow-up): https://cvquality.acc.org/docs/default-source/public-reporting-toolkit/data-quality-checklist/3c-characteristics-of-clinical-champions-92314.pdf |
Hospital-based or ambulatory care network practice | From above + network: https://www.networkforphl.org/resources/additional-food-security-resources/ |
Health system | From above + community engagement via Community Health Needs Assessment and Service Plan: https://foodcommunitybenefit.noharm.org/resources/community-health-needs-assessment/engaging-community-understand-food-needs |
Setting . | Selected screening approaches and resources . |
---|---|
Individual care provider | Incorporate hunger vital sign into social history and refer, as needed, and arrange follow-up assessment. Webinar: https://professional.diabetes.org/content-page/diabetes-and-food-insecurity-resources-what-who-when-where-and-how ADA listing of local resources by zip code: https://diabetes.org/healthy-living/recipes-nutrition/food-insecurity-diabetes Feeding American national network with local food pantry links: https://hungerandhealth.feedingamerica.org/explore-our-work/community-health-care-partnerships/addressing-food-insecurity-in-health-care-settings/ |
Solo or multidisciplinary team independent practice | From above + potential “clinical champion” to lead potential evaluation (number screened; positive screening with referrals and referral follow-up): https://cvquality.acc.org/docs/default-source/public-reporting-toolkit/data-quality-checklist/3c-characteristics-of-clinical-champions-92314.pdf |
Hospital-based or ambulatory care network practice | From above + network: https://www.networkforphl.org/resources/additional-food-security-resources/ |
Health system | From above + community engagement via Community Health Needs Assessment and Service Plan: https://foodcommunitybenefit.noharm.org/resources/community-health-needs-assessment/engaging-community-understand-food-needs |
Food security advocacy recommendations with resource links . |
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Availability. National or regional food supply with emphasis on food production determinants considering factors that may adversely affect the sustainability of the ecosystem. In the U.S., the Farm Bill serves as a major food availability policy determinant (20). |
Resources |
• U.S. Department of Agriculture programming increases production of wholesome nutritious foods grown by sustainable methods: https://www.nifa.usda.gov/grants/programs/about-efnep/efnep-where-you-live-partner-websites |
• Reauthorizing 2018 Farm Bill for 2023–2028: https://frac.org/blog/on-the-road-to-the-2023-farm-bill |
• Federal commodity funding for corn sweetener: https://www.ers.usda.gov/data-products/sugar-and-sweeteners-yearbook-tables/ |
Access. State and local policies (taxes, innovative distribution methods) can increase access to and price of healthy and unhealthy foods. Governmental and community service organizations provide a wide range of services to provide access to healthy foods. |
Resources |
• Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps: https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program |
• Home delivery of food boxes to food insecure people with diabetes: https://www.hungercare.org/food-box |
• Connecting to local food banks via the national network (Call 311) (21): https://www.feedingamerica.org/find-your-local-foodbank |
• Community Supported Agriculture Farm Share: https://www.ams.usda.gov/local-food-directories/csas |
• ADA-listed resources by zip code: https://diabetes.org/healthy-living/recipes-nutrition/food-insecurity-diabetes |
Utilization. Food selection, preparation, distribution, and consumption by and within households. |
Resources |
• Diabetes medical nutrition therapy: https://www.cdc.gov/diabetes/dsmes-toolkit/reimbursement/medical-nutrition-therapy.html |
• U.S. Department of Agriculture–sponsored educational programs for people with food insecurity and diabetes: https://www.ars.usda.gov/docs/educational-resources/ |
• Culinary medicine to integrate food preparation into therapeutic goal setting: https://culinarymedicine.org/certified-culinary-medicine-specialist-program/culinary-medicine/culinary-medicine-continuing-education-training-certification/ |
Stability. Food security could become stabile globally or for large geographic regions when availability is assured (food production is adequate for global or large region needs), access is assured (food is available where it is needed), and utilization is assured (food intake of population aligns with nutritional needs). Metrics for tracking progress related to the Food and Agriculture Organization of the United Nations 2030 Sustainable Development Goals. |
Resource |
• https://www.fao.org/sustainable-development-goals/tracking-progress/en/ |
Food security advocacy recommendations with resource links . |
---|
Availability. National or regional food supply with emphasis on food production determinants considering factors that may adversely affect the sustainability of the ecosystem. In the U.S., the Farm Bill serves as a major food availability policy determinant (20). |
Resources |
• U.S. Department of Agriculture programming increases production of wholesome nutritious foods grown by sustainable methods: https://www.nifa.usda.gov/grants/programs/about-efnep/efnep-where-you-live-partner-websites |
• Reauthorizing 2018 Farm Bill for 2023–2028: https://frac.org/blog/on-the-road-to-the-2023-farm-bill |
• Federal commodity funding for corn sweetener: https://www.ers.usda.gov/data-products/sugar-and-sweeteners-yearbook-tables/ |
Access. State and local policies (taxes, innovative distribution methods) can increase access to and price of healthy and unhealthy foods. Governmental and community service organizations provide a wide range of services to provide access to healthy foods. |
Resources |
• Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps: https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program |
• Home delivery of food boxes to food insecure people with diabetes: https://www.hungercare.org/food-box |
• Connecting to local food banks via the national network (Call 311) (21): https://www.feedingamerica.org/find-your-local-foodbank |
• Community Supported Agriculture Farm Share: https://www.ams.usda.gov/local-food-directories/csas |
• ADA-listed resources by zip code: https://diabetes.org/healthy-living/recipes-nutrition/food-insecurity-diabetes |
Utilization. Food selection, preparation, distribution, and consumption by and within households. |
Resources |
• Diabetes medical nutrition therapy: https://www.cdc.gov/diabetes/dsmes-toolkit/reimbursement/medical-nutrition-therapy.html |
• U.S. Department of Agriculture–sponsored educational programs for people with food insecurity and diabetes: https://www.ars.usda.gov/docs/educational-resources/ |
• Culinary medicine to integrate food preparation into therapeutic goal setting: https://culinarymedicine.org/certified-culinary-medicine-specialist-program/culinary-medicine/culinary-medicine-continuing-education-training-certification/ |
Stability. Food security could become stabile globally or for large geographic regions when availability is assured (food production is adequate for global or large region needs), access is assured (food is available where it is needed), and utilization is assured (food intake of population aligns with nutritional needs). Metrics for tracking progress related to the Food and Agriculture Organization of the United Nations 2030 Sustainable Development Goals. |
Resource |
• https://www.fao.org/sustainable-development-goals/tracking-progress/en/ |
The call to action for Diabetes Care readers begins with the ADA’s population-based Standards of Care recommendation, supported by A level evidence, to “Assess food insecurity, housing insecurity/homelessness, financial barriers, and social capital/social community support to inform treatment decisions, with referral to appropriate local community resources” (1). Food insecurity screening should be done annually and whenever household economics change. ADA-recommended screening questions align with the “hunger vital sign” initiative and focus on both on “worrying” about running out of food and “actually” running out of food without money to purchase more (11,12). Despite the importance of nutrition as a cornerstone of diabetes care, the high prevalence of food insecurity, and the intertwined relationship of food security with other social determinants of health, clinical screening for food insecurity is not widespread. A 2017–2018 survey found that only about 16% of private-practices and 24% of hospital-based practices in the U.S. screened their clinical populations for food insecurity (13).
Information that may affect referral options includes immigration status, transportation accessibility, competing priorities, cooking/storage facilities, and perceived stigma (8,9,14). Qualitative interview data from food-insecure individuals suggest that privacy, geographically accessible referrals, and developing creative strategies to enhance families’ connection to resources including using mobile technology should be considered in developing screening and referral procedures (14). The Affordable Care Act–mandated Community Health Needs Assessment and Service Plan requires not-for-profit hospitals to obtain community input and collaborate with local agencies to develop a triannual plan to address food insecurity and other social determinants from a population health perspective (15).
Global, U.S. national, and SEARCH data regarding the connection between food insecurity and diabetes represent a clarion call for individual and collective actions. In 2015, many United Nations member countries signed on to the 2030 sustainable development goals, intended to eliminate life-threatening hunger and reduce mortality attributable to diabetes and other noncommunicable diseases (16–18). Although the U.S. did not initially ratify these goals, the U.S. government has now addressed them through the 2022 White House National Strategy on Hunger, Nutrition, and Health (19).
Providers of diabetes care have individual and shared responsibility for addressing food security as a health equity right within their practice setting. Table 1 provides tailored resources. Patient-centered collaborative care requires coordination of services across the systems responsible for health care, community social services, and government services. We must implement universal screening for food insecurity, connect people with diabetes and food insecurity to available nutrition resources, and advocate for sustainable healthy community environments.
Article Information
Funding. J.W.-R. was partially supported by the New York Regional Center for Diabetes Translation Research (National Institute of Diabetes and Digestive and Kidney Diseases P30-DK111022).
Duality of Interest. No potential conflicts of interest relevant to this article were reported.