Recently, the University of California at San Francisco (UCSF) and Feeding America co-authored a study to determine whether the targeted management of diabetes and diet among low-income populations resulted in disease improvement. The study, titled A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic Control among Clients in Three States, provided 687 food pantry clients at three U.S. locations with diabetes-appropriate food, blood sugar monitoring, primary care referral, and self-management support.
The paper, published in the November issue of Health Affairs, found positive results: better diabetes control and medication adherence, and an overall improvement in the consumption of healthy food. While food pantries had not traditionally been thought of as places to provide diabetes education and support, the study suggests a new health promotion model for low-income populations. Food Tank spoke with lead author Hilary Seligman, associate professor of medicine at UCSF and senior medical advisor at Feeding America, to find out more about the study. Her responses have been edited for clarity.
Food Tank (FT): The University of California at San Francisco (UCSF) partnered with Feeding America to co-author a study that examined the effect of diet management and education on the prevalence of diabetes in low-income populations. Can you tell us about how the partnership came about and how the study was conceived and conducted?
Hilary Seligman (HS): Yes, Feeding America has had a long-standing interest in supporting the food needs of their clients, and, as the diabetes epidemic has risen in low-income populations, there has been a real recognition from the leadership of Feeding America that they have a lot of resources that they can bring to the table to address this issue. In particular, they bring their expertise in the collecting and distribution of food, but also in their capacity as an institution providing diabetes health education. So UCSF and Feeding America partnered in order to check off both boxes: rewrite implementation, and utilize the expertise of a food bank, which is what Feeding America bring to the table, and UCSF’s evaluation of disease incidence over time.
FT: Statistics on the widespread prevalence of diabetes are shocking: a third of all households that Feeding America serves have at least one member that is diabetic. What are the primary causative factors behind this?
HS: There are a number of reasons why the incidence of diabetes is so high among Feeding America client populations. The first is that diabetes is an epidemic of the poor. It is really concentrated in low-income populations, and these are the populations that are food bank and food pantry chronic clients.
The second reason is that food insecurity affects diet and nutrition, and food is critical in developing diabetes. So, we shouldn’t be surprised that people who are food insecure over a long period of time develop diabetes and that many of these people are Feeding America clients. The flip-side is that having diabetes increases the risk of food insecurity, and that’s because the out-of-pocket health care expenditures associated with having diabetes are as high as or higher than any other chronic disease. So once you develop diabetes and you have use your own resources to manage your diabetes, that draws money away from the food budget, which, in many cases, makes people more likely to be food insecure.
FT: Why did you at UCSF and your co-authors at Feeding America decide to focus on reducing diabetes in this study? What was the need?
HS: We know that many of our clients have diabetes. And we know that for those people, the stress of not being able to access the food that they need to optimally control their diabetes is really high. And from that perspective, if we’re distributing food that is not diabetes-appropriate, then we’re not helping our clients to achieve optimal health. So really, the focus on diabetes is because food is such a critical part of diabetes health management. When we affect its distribution, we could make a big difference because our expertise is in the management of food. Food is incredibly important.
Another reason is that diabetes is a great model because we can evaluate it very easily through blood work. So part of the goal here is to understand whether food banks can play an important role in community health. If it works with diabetes, then there’s a whole world of cross-promotion and improvement that we could be a part of: high blood pressure, obesity, pre-diabetes, congestive heart failure… All of these chronic conditions have a critical diabetic component.
FT: What are the implications of this study? How can food banks implement the knowledge gained from this research in a meaningful way?
HS: What this study gave us the opportunity to pilot was a bunch of different models for bringing healthy food and very robust health education to a targeted population. What we were able to do is learn the best possible practices for how to do this well. This was not easy; you have to have not only the support of the people at every level of the food chain – the leadership, the staff, and the sources, but also at the food pantry – the people that are actually distributing the food to clients in need. This gave us a model for figuring out how to do all of this.
The distribution of healthy and manageable food has a couple of really important challenges associated with it. One is that food is more often being wasted than given to food banks, and is not being donated for free in many cases. So, we have to develop funding streams and models to access those healthy foods. The second is that an entirely new system has to be developed. That includes things like refrigerated trucks, the distribution of perishable food within 24 hours of receiving it, refrigeration at the food pantry… all the things that allow for the safe handling of the perishables.
FT: What about broader solutions? What kind of action needs to be taken by policymakers and others to address diabetes in low-income populations?
HS: The first thing is that we can implement these studies more broadly, and food banks can be part of community solutions to build a “culture of health,” where healthy food is available to everybody all the time. The second thing is that, in terms of policy solutions, there is no doubt that [Supplemental Nutrition Assistance Program] SNAP is the program that is going to reach the largest number of people with healthy and nutritious food. SNAP gives people access to more nutritious food options, so, from a policy perspective, we have to continue to support the SNAP program because it allows people to better manage their diabetes.
And then the third point to make to policymakers is that the Feeding America network is huge. It reaches every county in the United States; it reaches one out of seven people in America; it reaches a lot of people that we have a challenging time reaching in many other community settings. We have the opportunity to leverage that infrastructure to reach people with health promotion activity, and we should be supporting that.
FT: How does UCSF plan to move forward with the information from this research? What are your action items?
HS: We can use the data we captured initially in conjunction with other data to develop larger health advocacy trials that analyze SNAP and focus on diabetes. We’re also eager to look at other diseases, in particular, pre-diabetes and hypertension, and the extent to which food banks can be a part of health promotion for populations affected by these diseases as well. We know that the incidence of pre-diabetes and hypertension is even higher among Feeding America clients than the incidence of diabetes, and solutions for those diseases can be solutions for diabetes as well.