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Association Between Food Insecurity and A1C

Feb 9, 2019
Editor: Joy Pape, MSN, FNP-C, CDE, WOCN, CFCN, FAADE

Author: Annahita Forghan, Pharm.D. Candidate 2019, LECOM College of Pharmacy

Is it true that individuals paying for diabetes care and management using fee-for-service clinics may have better outcomes in their glucose levels?

As of 2017, 9.4 percent of the American population has diabetes, according to the Centers for Disease Control and Prevention, and the percentage is even higher along the Diabetes Belt (644 counties in 15 mostly southern states) in the United States. When household members do not have enough access to food for an active and healthy lifestyle, the household is considered food insecure. Food insecurity is seen as a diabetes onset risk factor, where the risk is double or three times that of adults experiencing food security. In addition to a higher risk of diabetes incidence, there is the added risk of poor control for those with diabetes  when there is food insecurity (poor glycemic and cholesterol management in people who already have diabetes).

Low economic status is also associated with a higher risk of type 2 diabetes. For people in this group, food security is less prevalent thus making it harder to manage a healthy lifestyle, especially if the person has specific dietary needs. For example, individuals with low economic status and diabetes often must choose between buying medications and supplies needed for the management of their disease or purchasing healthy food. As a consequence, glycemic management is shown to be poorer in adults who already have diabetes and do not have food security. It has been demonstrated that food insecurity can result in concomitant diseases for people with diabetes. Also, there isn’t much research done on the effectiveness of low-cost or free clinics for diabetes management in low economic areas. The services of these clinics may be limited.

Inconsistency of care may also be a problem for food insecure households, even in free clinics. “Such free care does not come without costs to patients,” says the study authors. “For example, individuals still must find transportation to attend appointments.” Therefore, access to care may not be available.

This study wanted to evaluate the population in two ways: 1) the differences in food security status and indicators of diabetes management/control between clients using free and fee-for-service clinics for diabetes care and management in a rural, Appalachian region and 2) the relationship of food security status to blood glucose control, regardless of clinic type. Food security differences would be measured in both cases to see how they affect diabetes management, but the second method did not include the kind of clinic that the patients use (this may clarify the effect of an individual’s economic status on the risk of diabetes).

One hundred and sixty-six adults with diabetes volunteered to participate in this study from Ohio’s University-based clinics. Individuals with both type 1 and type 2 diabetes were interviewed for half a year. Participants with other comorbidities, such as ges­tational diabetes, prediabetes, or other endocrine conditions, were excluded.1

The volunteers were given surveys that included The Food Security Survey Module, which allowed the researchers to identify the participants’ food security status [household food security (HFS) and household adult food security (HAFS) ].1

SPSS version 18.0 (IBM Corp., Chicago, Ill.) was used to interpret data from all surveys.

Differences between clin­ic groups for HFS and HAFS were analyzed with Mann-Whitney U tests. Differences between the groups’ BMI, A1C, blood lipids (to­tal, HDL, and LDL cholesterol), and sys­tolic and diastolic blood pressure were analyzed with t Tests. The association of HFS status and HAFS status with A1C was evaluated with Pearson r correlations.

Of all the participants, 91.9% were Caucasian. The participants had an average age of 53. Most of them were educated and had type 2 diabetes. There were more patients who lived in food-insecure households if they attended free clinics than if they used fee-for-service clinics. Volunteers who used free clinics were shown to not manage their diabetes as well compared to volunteers who used fee-for-service clinics. “A1C was the only statistically significant discriminating variable… (A1C 8.71 {free} vs. 7.83 {fee} %, P =0.005). Regardless of the type of clinic used, A1C values increased as HFS (r = 0.293, P <0.001) and HAFS (r = 0.288, P = 0.001) worsened,” according to the study.

This study demonstrated in the results that individuals who used free clinics (as opposed to fee-for-service clinics) had worse glycemic management, based on their A1C levels. The people using free clinics were food insecure. Glycemic management also became worse as food insecurity worsened. Therefore, a negative association was demonstrated between food insecurity and high glucose in this study. This study still may not be applicable externally because of its small sample size, amongst other things, such as needing to qualify for the free clinic, which limited randomization of study subjects. Yet, this study shows that patients should be screened for food security when being educated on diabetes. “This is especially important given recent research finding that food insecurity coupled with diabetes increases health care expenditures,” according to the study’s authors.

Practice Pearls:

  • Diabetes (both types 1 and 2) is harder to manage when there is food insecurity, which is often related to poverty.
  • Free clinics still come with a cost to both patients and health care expenditures. Individuals in this study using free clinics were found to have higher A1C levels than those using fee-for-service clinics.
  • Future studies could include more diverse populations, but this one emphasized the importance of including food insecurity in diabetes education for patients.


Brown, Kara A.; Holben, David H.; Shubrook, Jay H. “Food Insecurity Is Associated With Poorer Glycemic Control in Patients Receiving Free Versus Fee-Based Care.” Clinical Diabetes Journals. 2019. http://clinical.diabetesjournals.org/content/37/1/44. 20 January 2019.

Annahita Forghan, Pharm.D. Candidate 2019, LECOM College of Pharmacy