A design thinking-led approach to develop a responsive feeding intervention for Australian families vulnerable to food insecurity: Eat, Learn, Grow.

BACKGROUND: Design thinking is an iterative process that innovates solutions through a person-centric approach and is increasingly used across health contexts. The person-centric approach lends itself to working with groups with complex needs. One such group is families experiencing economic hardship, who are vulnerable to food insecurity and face challenges with child feeding. OBJECTIVE: This study describes the application of a design thinking framework, utilizing mixed methods, including co-design, to develop a responsive child-feeding intervention for Australian families-'Eat, Learn, Grow'. METHODS: Guided by the five stages of design thinking, which comprises empathizing, defining, ideating, prototyping, and testing. We engaged with parents/caregivers of a child aged 6 months to 3 years through co-design workshops (n = 13), direct observation of mealtimes (n = 10), a cross-sectional survey (n = 213) and semistructured interviews (n = 29). Findings across these methods were synthesized using affinity mapping to clarify the intervention parameters. Parent user testing (n = 12) was conducted online with intervention prototypes to determine acceptability and accessibility. A co-design workshop with child health experts (n = 9) was then undertaken to review and co-design content for the final intervention. RESULTS: Through the design thinking process, an innovative digital child-feeding intervention was created. This intervention utilized a mobile-first design and consisted of a series of short and interactive modules that used a learning technology tool. The design is based on the concept of microlearning and responds to participants' preferences for visual, brief and plain language information accessed via a mobile phone. User testing sessions with parents and the expert co-design workshop indicated that the intervention was highly acceptable. CONCLUSIONS: Design thinking encourages researchers to approach problems creatively and to design health interventions that align with participant needs. Applying mixed methods-including co-design- within this framework allows for a better understanding of user contexts, preferences and priorities, ensuring solutions are more acceptable and likely to be engaged.

Association of food insecurity with health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic.

OBJECTIVES: To examine the associations between food insecurity and health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic and examine whether the associations were less pronounced among adults with safety nets. STUDY DESIGN: We conducted a retrospective longitudinal cohort study using the 2020-2021 Medical Expenditure Panel Survey. METHODS: Linear probability models were used to assess the associations between food insecurity in one year and the outcomes of interest in the following year while adjusting for baseline characteristics. We performed the analyses for the entire population and then conducted stratified analyses for adults with and without Supplemental Nutrition Assistance Program (SNAP) benefits or Medicaid coverage. RESULTS: Compared with food-secure adults, food-insecure adults were 9.1 percentage points less likely to report life satisfaction and 9.9, 10.2, and 13.2 percentage points more likely to experience delays in getting medical care, postpone or forgo medical care because of cost, and struggle with paying medical bills. Food-insecure adults were 30.4, 27.2, and 23.5 percentage points more likely to face challenges in affording necessities, paying utility bills, and meeting rent or mortgage payments on time than food-secure adults. Notably, the strengths of these associations were attenuated among adults with SNAP benefits or Medicaid coverage. CONCLUSIONS: Food insecurity was associated with poor health, limited access to and affordability of care, and a greater financial burden of care among US adults during the pandemic. Nevertheless, safety net programs can play a critical role in alleviating adverse consequences.

Food Insecurity and Ideal Cardiovascular Health Risk Factors Among US Adolescents.

BACKGROUND: Food insecurity, a social and economic condition of limited availability of healthy food, is a risk factor for adverse cardiovascular health outcomes among adults; few studies have been conducted in adolescents. This study explores the association between food insecurity and cardiovascular health risk factors among a nationally representative sample of US adolescents, adopting the American Heart Association's Life's Essential 8 metric. METHODS AND RESULTS: We analyzed data from 2534 adolescents aged 12 to 19 years from the 2013 to 2018 National Health and Nutrition Examination Surveys. In the sample, 24.8% of adolescents lived in food-insecure households. After multivariable adjustment, food insecurity was associated with a 3.23-unit lower total Life's Essential 8 score (95% CI, -6.32, -0.15) and lower scores on diet quality (ß=-5.39 [95% CI, -8.91, -1.87]) and nicotine exposure (ß=-4.85 [95% CI, -9.24, -0.45]). Regarding diet, food insecurity was associated with 5% lower Healthy Eating Index-2015 scores [95% CI, -7%, -2%], particularly lower intakes of whole grains and seafood/plant proteins and marginally higher intake of added sugar. Regarding nicotine exposure, food insecurity was associated with ever use of a tobacco product among m (odds ratio, 1.74 [95% CI, 1.20-2.53]). Compared with their food-secure counterparts, food-insecure male (odds ratio, 1.98 [95% CI, 1.07-3.65]) and female (odds ratio, 3.22 [95% CI, 1.60-6.45]) adolescents had higher odds of living with a current indoor smoker. CONCLUSIONS: In this nationally representative sample of adolescents, food insecurity was associated with multiple indicators of cardiovascular health risk. These findings underscore the need for public health interventions and policies to reduce food insecurity and improve cardioprotective behaviors during adolescence, with particular efforts targeting diet quality and nicotine exposure.

Association of food insecurity with changes in diet quality, weight, and glycemia over two years in adults with prediabetes and type 2 diabetes on medicaid.

Little is known about longitudinal associations between food insecurity (FI) and diet, weight, and glycemia in people with prediabetes and type 2 diabetes (T2D). In a secondary analysis of Medicaid-enrolled health center patients with prediabetes or T2D in Boston, Massachusetts (N = 188), we examined associations between food security (FS) and measures of diet quality, weight, and hyperglycemia. FS (10-item USDA FS module) was ascertained at baseline, 1-year, and 2-year follow-up and categorized as persistently secure, intermittently insecure, or persistently insecure. Associations between FS category and changes in Healthy Eating Index-2020 (HEI-20), body mass index (BMI), and hemoglobin A1c (A1c) from baseline to year 2 were assessed using multivariate generalized linear models. Participants had median (p25, p75) age of 52 (42, 57); 71.8% were female and 62.8% Hispanic. Over follow-up, 32.4% were persistently food secure, 33.0% intermittently insecure, and 34.5% persistently insecure. Baseline mean (SD) HEI-20, BMI, and A1c were 55.8 (14.5), 35.9 (8.7) kg/m2, 7.1% (1.6) and did not differ by FS category. FS category was not associated with changes in HEI-20, BMI, and A1c at 2 years (all p > 0.05). Results suggest that Medicaid-enrolled adults with prediabetes or T2D, regardless of FS status, would benefit from dietary and weight management interventions.

Food insecurity and coping strategies associate with higher risk of anxiety and depression among South African households with children.

OBJECTIVE: To investigate food insecurity and related coping strategies, and their associations with the risk of anxiety and depression, among South African households with children. DESIGN: Nationally representative cross-sectional study. Tools for assessing food insecurity, coping strategies, risk of anxiety and depression were assessed from the Community Childhood Hunger Identification Project, Coping Strategies Index, Generalised Anxiety Disorder-7 and Patient Health Questionnaire-9, respectively. We used ordered logistic regression to test associations of food insecurity and coping strategies with the risk of anxiety and depression. Moderating effects of each coping strategy were tested in the associations of food insecurity with anxiety and depression. SETTING: South Africa, post COVID-19 restrictions, May-June 2022. PARTICIPANTS: 1,774 adults, weighted to 20,955,234 households. RESULTS: Food insecurity prevalence was 23·7 % among households with children. All coping strategies were used to some extent, but relying on less preferred and less expensive foods was the most used strategy (85·5 % of food-insecure households). Moving to a higher level of food insecurity was associated with >1·6 greater odds of being in a higher risk of anxiety and depression. Sending a household member to beg for food was the strongest associated factor (OR = 1·7, P < 0·001). All coping strategies partly moderated (lessened) the associations of food insecurity with a higher risk of anxiety and depression. CONCLUSIONS: Food insecurity among households with children was high following the COVID-19 pandemic. Collaborative efforts between government, private sector and civil society to eradicate food insecurity should prioritise poorer households with children, as these populations are the most vulnerable.

Food insecurity and sociodemographic factors in Latin America during the COVID-19 pandemic / Inseguridad alimentaria y factores sociodemográficos en América Latina durante la pandemia de COVID-19 / Insegurança alimentar e fatores sociodemográficos na América Latina durante a pandemia de COVID-19

[ABSTRACT]. Objective. To understand the association of food insecurity with sociodemographic factors in a sample popu- lation in Latin America during the COVID-19 pandemic. Methods. This was a multicenter cross-sectional study conducted in 10 countries in Latin America using an online survey through various digital platforms from October 14, 2020 to February 15, 2021. Statistical analysis of data was performed by applying descriptive statistics, chi-square test, and logistic regression analysis. Results. Of a total of 6 357 surveys, 58.2% of respondents experienced food security, 29.3% were slightly food insecure, 9.2% were moderately food insecure, and 3.3% were severely food insecure. Concerning the association food insecurity and sociodemographic variables, there is a significant association in the variables studied, including area of residence, education level, occupation, number of persons in the household, house- hold with children younger than 10 years of age, and socioeconomic level. Conclusions. These findings indicate that sociodemographic factors associated with food insecurity during the COVID-19 pandemic in Latin America were rural residence; complete and incomplete basic and secondary schooling; occupation (homemaker, unemployed, and self-employed); low, medium-low, and medium socioeco- nomic level; household with more than four persons; and household with children younger than 10 years of age.

[RESUMEN]. Objetivo. Determinar la asociación de la inseguridad alimentaria con factores sociodemográficos en una muestra de población de América Latina durante la pandemia de COVID-19. Métodos. Se llevó a cabo un estudio transversal multicéntrico en diez países de América Latina mediante una encuesta en línea a través de diversas plataformas digitales, entre el 14 de octubre del 2020 y el 15 de febrero del 2021. Se realizó un análisis estadístico de los datos usando procedimientos de estadística descriptiva, la prueba ji al cuadrado y un análisis de regresión logística. Resultados. En un total de 6 357 encuestas, el 58,2% de las personas encuestadas gozaba de seguridad ali- mentaria, el 29,3% tenía una inseguridad alimentaria leve, el 9,2% una inseguridad alimentaria moderada y el 3,3% una inseguridad alimentaria grave. Por lo que respecta a la asociación entre la inseguridad alimentaria y las variables sociodemográficas, hay una asociación significativa para algunas de las variables estudiadas, como la zona de residencia, el nivel de estudios, la actividad laboral, el número de personas en el hogar, el hogar con menores de 10 años y el nivel socioeconómico. Conclusiones. Estos resultados indican que los factores sociodemográficos asociados a la inseguridad alimentaria durante la pandemia de COVID-19 en América Latina fueron la residencia en zonas rurales; la edu- cación primaria y secundaria completa o no; la actividad laboral (trabajo doméstico, personas desempleadas y trabajadores autónomos); el nivel socioeconómico bajo, medio bajo, y medio; el hogar con más de cuatro personas; y el hogar con menores de 10 años.

[RESUMO]. Objetivo. Compreender a relação entre insegurança alimentar e fatores sociodemográficos em uma amostra populacional da América Latina durante a pandemia de COVID-19. Métodos. Estudo transversal multicêntrico realizado em 10 países da América Latina por meio de uma pesquisa on-line conduzida em diferentes plataformas digitais de 14 de outubro de 2020 a 15 de fevereiro de 2021. A análise estatística dos dados foi realizada por meio da aplicação de estatísticas descritivas, teste qui-quadrado e análise de regressão logística. Resultados. De um total de 6 357 questionários, 58,2% dos entrevistados afirmaram ter segurança alimentar, 29,3% indicaram um nível de insegurança alimentar leve, 9,2% tinham insegurança alimentar moderada e 3,3%, insegurança alimentar grave. No que diz respeito à relação entre insegurança alimentar e variáveis sociodemográficas, há uma relação significativa com as variáveis estudadas, incluindo área de residência, nível de escolaridade, ocupação, número de pessoas no domicílio, domicílio com crianças com menos de 10 anos de idade e nível socioeconômico. Conclusões. Os achados apontam que os fatores sociodemográficos associados à insegurança alimentar durante a pandemia de COVID-19 na América Latina foram residência em zona rural; ensino fundamental e médio completo e incompleto; ocupação (do lar, desempregado(a) e autônomo(a)); nível socioeconômico baixo, médio-baixo e médio; domicílio com mais de quatro pessoas; e domicílio com crianças menores de 10 anos de idade.

"It Can Be Confusing": Family Perspectives on Food Insecurity Screening in Urban Pediatric Primary Care Clinics.

Food insecurity, for which families are routinely screened at medical visits, has deleterious health consequences. This study sought to understand the lived experiences of families with lower incomes participating in food insecurity screening at two urban pediatric primary care clinics. Forty-three semi-structured interviews were performed in English and Spanish with families with public insurance after well visits where food insecurity screening was documented. Immersion-crystallization analysis was used to identify salient themes. Families reported discomfort with food insecurity screening, but nonetheless found screening acceptable when performed universally and privately. Families shared confusion about how their screening responses would be used and expected that resources would be available promptly for those who screen positive. Food insecurity screening may be improved for families through explanations of how responses will be used, allowing families to opt out, soliciting family preferences for resource referral, and offering promptly available resources for families with food insecurity.

"We're Trained to Survive.": Veterans' Experiences Seeking Food Assistance.

PURPOSE: Food insecurity threatens veterans' health, yet little is known about their experiences seeking food assistance. Thus, we studied veterans' experiences as they navigated from food insecurity to food assistance. METHODS: We built a journey map using thematic analysis of interviews with 30 veterans experiencing food insecurity. FINDINGS: The map focuses on: (1) identifying contributing circumstances, (2) recognizing food insecurity, (3) finding help, and (4) obtaining assistance. Contributing circumstances included unemployment/under-employment, mental health challenges, and interpersonal violence. Veterans did not recall being screened for food insecurity. Military training also inhibited some veterans from recognizing their own food insecurity. Locating and accessing food assistance was a struggle. While many veterans applied for the Supplemental Nutrition Assistance Program, few qualified. Food pantries were a last resort. CONCLUSIONS: Opportunities to help veterans include (1) addressing contributing circumstances, (2) improving identification, (3) sharing knowledge of resources, and (4) reexamining sufficiency of food assistance programs.

The impact of food insecurity on mental health among older adults residing in low- and middle-income countries: A systematic review.

Over the past few years, food insecurity has been increasing globally due to the COVID-19 pandemic, climate change, economic downturns and conflict and a number of other intersecting factors. Older adults residing in low- and middle-income countries are more vulnerable to food insecurity. While the impacts of food insecurity on physical health outcomes have been thoroughly researched, the effect on mental health outcomes remains under-researched, especially among older adults. Hence, this systematic review aims to investigate existing literature to assess how food insecurity impacts the mental health of older persons residing in LMICs. A systematic search of six databases and Google for studies was conducted. The search was limited to studies written in English and published between 2000 to the present. We identified 725 studies, out of which 40 studies were selected for a full-text review and 12 studies were included for a final analysis. The significant finding in all the included studies was that food insecurity is associated with the worsening mental health of older adults. We also found a complex interplay of factors such as gender, age, rural/urban and health conditions associated with the aggravation of several mental health outcomes. The findings of this study illuminate the need for improved food programs to improve food security and, consequently, mental health among older adults.

Trends in Recurring and Chronic Food Insecurity Among US Families With Older Adults.

Importance: Food insecurity is a critical social determinant of health for older adults. Understanding national food insecurity trends among families with older adults has important policy implications. Objective: To compare food insecurity trends among US families with an older adult from 1999 to 2003 and 2015 to 2019 and further stratify the analysis by race and ethnicity, socioeconomic status markers, and enrollment in the federal Supplemental Nutrition Assistance Program (SNAP). Design, Setting, and Participants: In this cohort study using biennial data from the nationally representative Panel Study of Income Dynamics, balanced panels of families with at least 1 older adult (≥60 years) who participated from 1999 to 2003 (n = 1311) and 2015 to 2019 (n = 2268) were created. Analysis was completed in 2023. Main outcome: Food insecurity was assessed using the US Household Food Security Survey Module. Within each 5-year period, we defined recurring food insecurity as 2 or more episodes of food insecurity and chronic food insecurity as 3 episodes of food insecurity. Results: Overall, food insecurity among US families with older adults increased from 12.5% in 1999 to 2003 to 23.1% in 2015 to 2019. Rates of recurring food insecurity more than doubled (5.6% to 12.6%), whereas rates of chronic food insecurity more than tripled (2.0% to 6.3%). Across both time periods, higher rates of food insecurity persisted among Black and Hispanic families, with lower socioeconomic status, and participating in SNAP. Conclusions and Relevance: These results highlight how rates of recurring and chronic food insecurity among families with older adults rose substantially over the past 20 years. Monitoring national trends in food insecurity among older adults has direct programmatic and policy implications.

Feasibility and Impact Assessment of a Food Insecurity Protocol in a Large Urban Pediatric Primary Care Network.

INTRODUCTION/OBJECTIVES: In 2022, 1 in 6 households with children experienced food insecurity (FI) in the United States. The negative impact of FI on child health is well documented and pediatric clinicians are encouraged to actively screen and intervene in clinical settings. This study aims to evaluate the feasibility and impact of a FI management protocol implemented in 2017 at a pediatric primary care health network serving patients who are Medicaid-eligible in Washington, DC. METHODS: In 2019, an 18-item electronic survey was sent to a convenience sample of 42 pediatric clinicians within the health network to understand their knowledge, attitudes, and behaviors surrounding implementation. Both quantitative and qualitative responses were collected and analyzed. We report frequencies of the Likert-type responses, including perceived compliance with protocol components and intervention efficacy. We evaluated the relationship between FI knowledge level and rates of clinician documentation compliance by chi square and Cramer's V statistic for effect size. Open-ended responses were reviewed, and common themes were identified and used to provide context for quantitative results. RESULTS AND CONCLUSIONS: Out of 42 clinicians invited to complete the survey, 35 completed responses. All respondents reported universal screening for FI (100%) at routine examinations, 80% reported frequently electronically documenting FI in medical records, and 91% of clinicians reported frequently referring families who screened positive for FI to at least one FI resource, with 24% reporting that resources met families' needs. Open-ended responses revealed increased awareness of FI prevalence and of patient experiences in households experiencing FI, increased satisfaction with clinical management of FI, but also concerns around having limited clinical time to do the protocol and the usefulness and accessibility of referred resources. In conclusion, implementing this pilot FI protocol was feasible, but clinicians perceived limited impact of the protocol on alleviating FI and desired more robust intervention options. Further improvements include shifting the burden of performing the protocol away from the clinician, such as by streamlining the protocol or identifying a resource staff member, and establishing more accessible and effective FI interventions such as "Food as Medicine" offerings in partnership with community organizations.

Healthy, Inclusive and Sustainable Catering in Secondary Schools-An Analysis of a Transformation Process with Multiple Tensions.

Interest in catering for public sector schools is increasing due to its potential role in addressing the prevailing problems of malnutrition, food insecurity and non-sustainable food habits. Based on the case of secondary schools in Berlin, this study aims to explore this potential by focusing on the process of transformation towards healthy, inclusive and sustainable school catering. It employs a multi-perspective analysis based on the two concepts of food environment and social cohesion. Results are based on quantitative and qualitative data collected via an online survey of pupils from 25 secondary schools in Berlin as well as field notes from six stakeholder events. The survey findings were analyzed by descriptive means and provide explanations for the fact that most of the pupils (66.7%) never eat lunch at school. Based on the qualitative analysis of the stakeholder events, key tensions between actors from the federal state, municipal, school and private levels could be identified. Major areas of conflict arise due to (1) a lack of public funding and catering standards, (2) incompatible demands and preferences, (3) a lack of resources and opportunities for complementary education and participation, and (4) peer and parental influence. Transforming school food environments requires integrative strategies with interventions introduced by multiple actors operating on different levels.

Prevalence of Food Insecurity and Associations with Academic Performance, Food Consumption and Social Support among University Students during the COVID-19 Pandemic: FINESCOP Project in Iceland.

(1) Background: Food insecurity (FI) among university students has received less attention in Europe than in other regions before and during the COVID-19 pandemic. (2) Methods: A cross-sectional study was conducted between January and March 2022 using an online questionnaire (n = 924). The questionnaire addressed food security status; demographic, socioeconomic, and educational variables; academic performance; food consumption; and social support networks. The validated Food Insecurity Experience Scale was used to measure food security. Binary logistic regressions adjusted by age and gender were applied to identify FI-related factors. (3) Results: Just over 17% of the students were living with some level of FI, nearly one in three students reported having consumed few kinds of food, and 3.9% spent an entire day without eating due to a lack of resources. Food insecurity was associated with a higher likelihood of negative academic performance, decreased food consumption, and a lower likelihood of having a large support network, when compared to food-secure respondents. (4) Conclusions: The findings suggest that FI negatively impacts students' academic performance and food consumption. Future public health programs should be prioritized to prevent students from experiencing hunger due to financial or resource constraints.

Food is Medicine Initiative for Mitigating Food Insecurity in the United States.

OBJECTIVES: While several food assistance programs in the United States tackle food insecurity, a relatively new program, "Food is Medicine," (FIM) initiated in some cities not only addresses food insecurity but also targets chronic diseases by customizing the food delivered to its recipients. This review describes federal programs providing food assistance and evaluates the various sub-programs categorized under the FIM initiative. METHODS: A literature search was conducted from July 7, 2023 to November 9, 2023 using the search term, "Food is Medicine", to identify articles indexed within three major electronic databases, PubMed, Medline, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Eligibility criteria for inclusion were: focus on any aspect of the FIM initiative within the United States, and publication as a peer-reviewed journal article in the English language. A total of 180 articles were retrieved; publications outside the eligibility criteria and duplicates were excluded for a final list of 72 publications. Supporting publications related to food insecurity, governmental and organizational websites related to FIM and other programs discussed in this review were also included. RESULTS: The FIM program includes medically tailored meals, medically tailored groceries, and produce prescriptions. Data suggest that it has lowered food insecurity, promoted better management of health, improved health outcomes, and has, therefore, lowered healthcare costs. CONCLUSIONS: Overall, this umbrella program is having a positive impact on communities that have been offered and participate in this program. Limitations and challenges that need to be overcome to ensure its success are discussed.

Racial discrimination is associated with food insecurity, stress, and worse physical health among college students.

BACKGROUND: Students of color disproportionately experience racial discrimination and food insecurity, which both lead to poor academic and health outcomes. This study explores the extent to which the location of racial discrimination experienced is associated with food insecurity, stress, physical health and grade point average among college students METHODS: A cross sectional study design was implemented to survey 143 students from a racially diverse public university. Logistic regression models assessed if discrimination at various locations was associated with food insecurity and linear models assessed how racial discrimination was associated with physical health, stress and grade point average RESULTS: Student's experiencing food security had an average discrimination score of 2.3 (1.23, 3.37), while those experiencing food insecurity had a statistically significant (P < 0.001) higher average discrimination score 7.3 (5.4, 9.21). Experiencing any racial discrimination was associated with increased odds of experiencing food insecurity when experienced from the police (OR 11.76, 95% CI: 1.41, 97.86), in the housing process (OR 7.9, 95% CI: 1.93, 32.34) and in the hiring process (OR 6.81, 95% CI: 1.98, 23.48) compared to those experiencing no racial discrimination after adjusting for race, gender, age and income. CONCLUSION: The location in which a student experienced racial discrimination impacted the extent to which the racial discrimination was associated with food security status. Further research is needed to explore potential mechanisms for how racial discrimination may lead to food insecurity.

A Systematic Review of Interventions That Address Food Insecurity for Persons With Prediabetes or Diabetes Using the RE-AIM Framework.

PURPOSE: The purpose of this study is to systematically review interventions that address food insecurity for persons with prediabetes or type 2 diabetes using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. METHODS: Six databases (OVIDMEDLINE, OVIDEMBASE, OVID APA PsycINFO, Web of Science, Cochrane Central Registry of Controlled Trials, and EBSCO CINAHL Complete) were searched through January 2023. Research team members independently performed screening of abstracts and full texts, data abstraction, and risk assessment. RESULTS: In all, 3,139 unique citations were identified, and 20 studies met inclusion criteria. Interventions included medically tailored meals/groceries (n = 10) or produce prescriptions/vouchers (n = 10). Reach and effectiveness were the highest reported RE-AIM elements. Interventions reached a high-risk population via food banks, community-based outreach, and federally qualified health centers. A majority of participants identified as female, Black, or Hispanic/Latinx and were living below the federal poverty level. Most studies reported at least 1 diabetes outcome (ie, A1C, hypoglycemia, diabetes distress, diabetes self-management). Seventeen studies reported impact on A1C, with the majority reporting a decrease in A1C and 53% (9/17) of studies demonstrating a decrease over time. Self-management improved in 50% (3/6) of studies that evaluated this outcome. Self-efficacy improved in 40% (2/5) of studies, and improvements were seen in depressive symptoms/diabetes distress (4/7 studies) and quality of life (5/5 studies). Seven studies reported statistically significant improvements in food insecurity. CONCLUSION: Food insecurity has been associated with higher risks and adverse clinical outcomes in adults with diabetes. Implementing interventions that address food insecurity among adults with or at risk for diabetes can enhance food security and clinically important diabetes-related outcomes. Additional research dedicated to the sustainability of interventions is needed.

Food insecurity, poor diet, and metabolic measures: The roles of stress and cortisol.

Food insecurity is highly prevalent and linked to poorer diet and worse metabolic outcomes. Food insecurity can be stressful, and could elicit chronic psychological and physiological stress. In this study, we tested whether stress could be used to identify those at highest risk for worse diet and metabolic measures from food insecurity. Specifically, we hypothesized that cortisol (a physiological marker of stress) and perceived psychological stress would amplify the link between food insecurity and hyperpalatable food intake as well as metabolic measures. In a sample of 624 Black and White women aged 36-43 who participated in the NHLBI Growth and Health Study's midlife assessment, we assessed associations between food insecurity with hyperpalatable food intake (high fat + high sodium foods; high fat + high sugar foods; and high carbohydrate + high sodium foods), and metabolic measures (fasting glucose, insulin resistance, and waist circumference). We found that food insecurity was associated with higher levels of perceived stress (R2 = 0.09), and greater intake of high fat + high sugar (hyperpalatable) foods (R2 = 0.03). In those with higher cumulative cortisol (as indexed by hair cortisol), food insecurity was associated with higher levels of fasting glucose. Neither cortisol nor perceived stress moderated any other relationships, and neither variable functioned as a mediator in sensitivity analyses. Given these largely null findings, further research is needed to understand the role stress plays in the chronic health burdens of food insecurity.

Food insecurity in urban American Indian and Alaska Native populations during the COVID-19 pandemic.

BACKGROUND: Food insecurity is an important social determinant of health that was exacerbated by the COVID-19 pandemic. Both food insecurity and COVID-19 infection disproportionately affect racial and ethnic minority groups, particularly American Indian and Alaska Native communities; however, there is little evidence as to whether food insecurity is associated with COVID-19 infection or COVID-19 preventive behaviors such as vaccination uptake. The purpose of this study was to evaluate associations between food insecurity, COVID-19 infection, and vaccination status among urban American Indian and Alaska Native adults seen at 5 clinics serving urban Native people. METHODS: In partnership with health organizations in Alaska, Colorado, Kansas, Minnesota, and New Mexico, the study team conducted a cross-sectional survey in 2021 to assess food security status and attitudes, barriers, and facilitators for COVID-19 testing and vaccination. Logistic regression was used to examine the association of food security status with sociodemographic factors and COVID-19 infection and vaccination status. Marginal standardization was applied to present results as prevalence differences. RESULTS: Among 730 American Indian and Alaska Native adults, the prevalence of food insecurity measured during the pandemic was 38%. For participants who reported persistent food security status before and during the pandemic (n = 588), the prevalence of food insecurity was 25%. Prevalence of COVID-19 infection and vaccination did not vary by food security status after adjustment for confounders. CONCLUSIONS: High rates of food insecurity among American Indian and Alaska Native communities likely increased during the COVID-19 pandemic. However, despite the high prevalence of food insecurity, community-led efforts to reduce COVID-19 infection and increase vaccination uptake across Indian Health Service and Tribal healthcare facilities may have mitigated the negative impacts of the pandemic for families experiencing food insecurity. These successful approaches serve as an important reference for future public health efforts that require innovative strategies to improve overall health in American Indian and Alaska Native communities.