Hilary K. Seligman

Food Insecurity Is Associated with Chronic Disease among Low-Income NHANES Participants

Food insecurity refers to the inability to afford enough food for an active, healthy life. Numerous studies have shown associations between food insecurity and adverse health outcomes among children. Studies of the health effects of food insecurity among adults are more limited and generally focus on the association between food insecurity and self-reported disease. We therefore examined the association between food insecurity and clinical evidence of diet-sensitive chronic disease, including hypertension, hyperlipidemia, and diabetes. Our population-based sample included 5094 poor adults aged 18-65 y participating in the NHANES (1999-2004 waves). We estimated the association between food insecurity (assessed by the Food Security Survey Module) and self-reported or laboratory/examination evidence of diet-sensitive chronic disease using Poisson regression. We adjusted the models to account for differences in age, gender, race, educational attainment, and income. Food insecurity was associated with self-reported hypertension [adjusted relative risk (ARR) 1.20; 95% CI, 1.04-1.38] and hyperlipidemia (ARR 1.30; 95% CI, 1.09-1.55), but not diabetes (ARR 1.19; 95% CI, 0.89-1.58). Food insecurity was associated with laboratory or examination evidence of hypertension (ARR 1.21; 95% CI, 1.04-1.41) and diabetes (ARR 1.48; 95% CI, 0.94-2.32). The association with laboratory evidence of diabetes did not reach significance in the fully adjusted model unless we used a stricter definition of food insecurity (ARR 2.42; 95% CI, 1.44-4.08). These data show that food insecurity is associated with cardiovascular risk factors. Health policy discussions should focus increased attention on ability to afford high-quality foods for adults with or at risk for chronic disease.

Hunger and socioeconomic disparities in chronic disease.

The rate of food insecurity rose by 32% in 2008, to 14.6% of U.S. households. Drs. Hilary Seligman and Dean Schillinger argue that the widening price differential between unhealthful and healthful foods may increase socioeconomic disparities in the incidence and management of obesity, hypertension, diabetes, and other diet-sensitive chronic diseases.

Food Insecurity and Glycemic Control Among Low-Income Patients With Type 2 Diabetes

OBJECTIVE To determine whether food insecurity—the inability to reliably afford safe and nutritious food—is associated with poor glycemic control and whether this association is mediated by difficulty following a healthy diet, diabetes self-efficacy, or emotional distress related to diabetes. RESEARCH DESIGN AND METHODS We used multivariable regression models to examine the association between food insecurity and poor glycemic control using a cross-sectional survey and chart review of 711 patients with diabetes in safety net health clinics. We then examined whether difficulty following a diabetic diet, self-efficacy, or emotional distress related to diabetes mediated the relationship between food insecurity and glycemic control. RESULTS The food insecurity prevalence in our sample was 46%. Food-insecure participants were significantly more likely than food-secure participants to have poor glycemic control, as defined by hemoglobin A1c ≥8.5% (42 vs. 33%; adjusted odds ratio 1.48 [95% CI 1.07–2.04]). Food-insecure participants were more likely to report difficulty affording a diabetic diet (64 vs. 49%, P < 0.001). They also reported lower diabetes-specific self-efficacy (P < 0.001) and higher emotional distress related to diabetes (P < 0.001). Difficulty following a healthy diet and emotional distress partially mediated the association between food insecurity and glycemic control. CONCLUSIONS Food insecurity is an independent risk factor for poor glycemic control in the safety net setting. This risk may be partially attributable to increased difficulty following a diabetes-appropriate diet and increased emotional distress regarding capacity for successful diabetes self-management. Screening patients with diabetes for food insecurity may be appropriate, particularly in the safety net setting.

Physician notification of their diabetes patients' limited health literacy: A randomized, controlled trial

AbstractBACKGROUND: Many patients with chronic disease have limited health literacy (HL). Because physicians have difficulty identifying these patients, some experts recommend instituting screening programs in clinical settings. It is unclear if notifying physicians of patients’ limited HL improves care processes or outcomes. OBJECTIVE: To determine whether notifying physicians of their patients’ limited HL affects physician behavior, physician satisfaction, or patient self-efficacy. DESIGN: We screened all patients for limited HL and randomized physicians to be notified if their patients had limited HL skills. PARTICIPANTS: Sixty-three primary care physicians affiliated with a public hospital and 182 diabetic patients with limited HL. MEASUREMENTS: After their visit, physicians reported their management strategies, satisfaction, perceived effectiveness, and attitudes toward HL screening. We also assessed patients’ self-efficacy, feelings regarding HL screening’s usefulness, and glycemic control. RESULTS: Intervention physicians were more likely than control physicians to use management strategies recommended for patients with limited HL (OR 3.2, P=.04). However, intervention physicians felt less satisfied with their visits (81% vs 93%, P=.01) and marginally less effective (38% vs 53%, P=.10). Intervention and control patients’ post-visit self-efficacy scores were similar (12.6 vs 12.9, P=6). Sixty-four percent of intervention physicians and 96% of patients felt HL screening was useful. CONCLUSIONS: Physicians are responsive to receiving notification of their patients’ limited HL, and patients support the potential utility of HL screening. However, instituting screening programs without specific training and/or system-wide support for physicians and patients is unlikely to be a powerful tool in improving diabetes outcomes.

Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes.

More than 14% of the American population is food insecure, or at risk of going hungry because of an inability to afford food. Food-insecure (FI) adults often reduce food intake or substitute inexpensive, energy-dense carbohydrates for healthier foods. We hypothesized these behaviors would predispose FI adults with diabetes to hypoglycemia and impaired diabetes self-management. We therefore assessed whether food insecurity was associated with multiple indicators of diabetes self-management (self-efficacy, medication- and glucose-monitoring adherence, hypoglycemia, or glycemic control) among 40 low-income adults with diabetes. Mean self-efficacy score was lower among FI than food-secure (FS) participants (34.4 vs. 41.2, p=.02). Food-insecure participants reported poorer adherence to blood glucose monitoring (RR=3.5, p=.008) and more hypoglycemia-related emergency department visits (RR=2.2, p=.007). Mean hemoglobin A1c was 9.2% among FI and 7.7% among FS participants (p=.08). Food insecurity is a barrier to diabetes self-management and a risk factor for clinically significant hypoglycemia.

Goal setting in diabetes self-management: taking the baby steps to success.

OBJECTIVE To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals. METHODS We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study. RESULTS We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide. CONCLUSIONS A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals. PRACTICE IMPLICATIONS Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.

Electrocardiographic Criteria for Detecting Acute Myocardial Infarction in Patients With Left Bundle Branch Block: A Meta-analysis

STUDY OBJECTIVE Numerous investigators have evaluated the ECG algorithm described by Sgarbossa et al to predict acute myocardial infarction in the presence of left bundle branch block and have arrived at divergent conclusions. To clarify the utility of the Sgarbossa ECG algorithm, we perform a systematic review and meta-analysis of these trials. METHODS A structured search was applied to MEDLINE and Scopus databases, beginning with the year that the algorithm was derived (1996). Two reviewers independently screened citations, assessed for method quality, and extracted data (individual study characteristics, screening performance, and interobserver agreement) with a standardized extraction tool. We assessed qualifying studies for heterogeneity and generated summary estimates for the sensitivity, specificity, and positive and negative likelihood ratios with fixed-effect models. RESULTS We identified 11 studies with 2,100 patients that met criteria for at least 1 component of the analysis. Ten studies with 1,614 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 3. These yielded a summary sensitivity of 20% (95% confidence interval [CI] 18% to 23%), specificity of 98% (95% CI 97% to 99%), a positive likelihood ratio of 7.9 (95% CI 4.5 to 13.8), and a negative likelihood ratio of 0.8 (95% CI 0.8 to 0.9). The summary diagnostic odds ratio revealed homogeneity. Seven studies with 1,213 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 2. These yielded sensitivities ranging from 20% to 79% and specificities ranging from 61% to 100%. Positive likelihood ratios ranged from 0.7 to 6.6 and negative likelihood ratios ranged from 0.2 to 1.1. The summary diagnostic odds ratio revealed heterogeneity. Intra- and interobserver agreement was substantial. Sensitivity analysis using the highest-quality studies yielded similar results. CONCLUSION A Sgarbossa ECG algorithm score of greater than or equal to 3, representing greater than or equal to 1 mm of concordant ST elevation or greater than or equal to 1 mm ST depression in leads V1 to V3, is useful for diagnosing acute myocardial infarction in patients who present with left bundle branch block on ECG. The scoring system demonstrates good to excellent overall interobserver variability. A score of 2, representing 5 mm or more of discordant ST deviation, demonstrated ineffective positive likelihood ratios. A Sgarbossa ECG algorithm score of 0 is not useful in excluding acute myocardial infarction.

Material Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources Results of the Measuring Economic Insecurity in Diabetes Study

IMPORTANCE Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear. OBJECTIVE To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%). MAIN OUTCOMES AND MEASURES The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits). RESULTS Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39 [95% CI, 1.18-1.63]) and increased use of health care resources (IRR for outpatient visits, 1.09 [95% CI, 1.03-1.15]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]). CONCLUSIONS AND RELEVANCE Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.

Food Insecurity and Hypoglycemia Among Safety Net Patients With Diabetes

In 2008, 1 in every 7 US households was food insecure, or at risk of going hungry because of an inability to afford food.(1) Food insecurity generally occurs cyclically and episodically, with periods of food adequacy followed by food scarcity; the average food insecure household experiences seven episodes of food scarcity annually.(2) We hypothesized that the cyclic nature of food insecurity, and its associated fluctuations in dietary intake, would predispose patients with diabetes to wide variations in blood glucose levels, including clinically significant hypoglycemia.

Disease-related distress, self-care and clinical outcomes among low-income patients with diabetes

Background The purpose of this study is to determine the prevalence of diabetes distress and its relationship with health behaviours and clinical outcomes in low-income patients. Methods Secondary analyses were conducted using baseline data from a clinical trial evaluating a diabetes self-management intervention. Interviews were conducted with 666 participants receiving care at nine safety net clinics in Missouri. Distress was measured using the Diabetes Distress Scale, and outcomes included medication adherence, physical activity, nutrition and clinical biomarkers (haemoglobin A1C (HbA1C), blood pressure, low-density lipoprotein (LDL) cholesterol). Results In a sample of 666 participants, 14.1% and 27.3% of patients were identified as highly and moderately distressed, respectively, with higher rates among younger, female and lower income patients. When compared with moderately and no distress groups, highly distressed patients were less adherent to medications (20.7% vs 29.9% vs 39.4%, p<0.001) and had higher HbA1C values (9.3% (SD=2.0) vs 8.2% (SD=1.8) vs 7.8% (SD=1.7), p<0.001), diastolic blood pressure (81.8 (SD=9.4) vs 80.2 (9.7) vs 78.9 (SD=8.8), p=0.02) and LDL cholesterol (104.6 (SD=42.4) vs 97.2 (34.3) vs 95.5 (37.9)) In multivariable analyses, high and moderate distress were associated with lower medication adherence (OR=0.44; 0.27 to 0.23, p=0.001) and (OR=0.58; 0.42 to 0.79; p=0.001), respectively, and higher HbA1C in only the highly distressed group (B=1.3; 0.81 to 1.85; p<0.001) compared with the no distress group. Conclusions Diabetes distress is prevalent and linked to poorer adherence to health behaviours and glycemic control in a sample of patients receiving care from low-income clinics.