Exploring the Lived Experience of Food Insecure African Americans with Type 2 Diabetes Living in the Inner City.

PURPOSE: Despite evidence that food insecure African Americans with type 2 diabetes are at particularly high risk for poor health outcomes, there is currently a lack of information on their lived experience. This qualitative study aimed to identify challenges, facilitators, and barriers to effective diabetes care for food insecure African Americans with type 2 diabetes residing in an inner city. METHODS: In fall 2018, we conducted two focus groups attended by a total of 16 food insecure adults with type 2 diabetes residing in the inner city of Milwaukee, Wisconsin. A standardized moderator guide included questions to explore the role of food insecurity in managing diabetes, and facilitators that improve diabetes management within the context of food insecurity. Focus groups were audio recorded and recordings were transcribed by a professional transcription service. A grounded theory approach was used for analysis. RESULTS: Six major challenges existed at the individual level (diet/nutrition, exercise, diabetes knowledge and skills, complications from diabetes, a family history of diabetes, and a preoccupation with food). Five major barriers and facilitators existed both internally and externally to the individuals (access to food, medications, stress, cost of health-related needs and religion/spirituality). CONCLUSIONS: This study identified multiple challenges, barriers, and facilitators to effective care for food insecure African American adults with type 2 diabetes. It is imperative to incorporate this understanding in future work by using an ecological approach to investigate strategies to address food insecurity beyond a singular focus on access to food.

Quantifying the Influence of Individual, Community, and Health System Factors on Quality of Life Among Inner-City African Americans With Type 2 Diabetes.

PURPOSE: The purpose of this study is to examine the association of individual, community, and health system factors on quality of life among inner-city African Americans with type 2 diabetes. METHODS: Primary data from a cross-sectional study with a community sample of 241 inner-city African Americans with type 2 diabetes were analyzed. Paper-based surveys were administered in which the SF-12 was used to capture the physical component (PCS) and mental component (MCS) of quality of life. Four regression approaches (sequential, stepwise with backward and forward selection, and all possible subsets regression) were used to examine the influence of individual, community, and health system factors on PCS and MCS after adjusting for relevant covariates using a conceptual framework. RESULTS: In fully adjusted models, having less than a high school education and having major depression were associated with lower quality-of-life scores for MCS across all 4 regression approaches. Being employed was positively associated with better quality-of-life scores for PCS across all 4 regression approaches. PCS was higher across all 4 regression approaches for those reporting a history of trauma. At the health systems level, usual source of care was associated with better PCS across 3 regression approaches. CONCLUSIONS: These results highlight key factors that influence quality of life among inner-city African Americans with type 2 diabetes that could be targets for interventions in this population. However, additional research is needed to understand existing pathways that may be driving many of these relationships.

Insights about interventions to address food insecurity in adults with type 2 diabetes: Valuable lessons from the stories of African Americans living in the inner city.

OBJECTIVES: This qualitative study aimed to gain insight from the perspectives of food insecure African Americans living in an inner city regarding important diabetes intervention strategies and components. METHODS: Using a grounded theory approach, two focus groups (totaling 16 individuals) were conducted in Milwaukee, Wisconsin. Purposive, convenience sampling was used to identify food insecure adults with diabetes. Questions were asked using a moderator guide to explore challenges and barriers to managing diabetes within the context of food insecurity, and facilitators or resources that helped participants improve diabetes management. Questions were open ended and followed by probes asking for additional perspectives and personal experiences related to the overarching topic, and questions asking to clarify statements. RESULTS: Overarching concepts and themes specific to possible interventions discussed during the focus groups included group education, peer support, access to community resources and programs, stress management, and faith-based programs as desired intervention outcomes. CONCLUSIONS: Key findings from the current study show that inner-city African Americans with diabetes desire interventions that foster social and community support systems. PRACTICE IMPLICATIONS: Given this insight, more robust and comprehensive interventions are needed to account for the multifaceted experience of food insecurity and diabetes within the inner-city environment.

Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes.

BACKGROUND: Health disparities disproportionately impact inner-city African Americans; however, limited information exists on the contribution of individual, community, and health system barriers on diabetes outcomes in this population. METHODS: A cross-sectional study collected primary data from 241 inner-city African Americans with type 2 diabetes. A conceptual framework was used to specify measurements across the individual level, such as age and comorbidities; community level, such as neighborhood factors and support; and health system level such as access, trust, and provider communication. Based on current best practices, four regression approaches were used: sequential, stepwise with forward selection, stepwise with backward selection, and all possible subsets. Variables were entered in blocks based on the theoretical framework in the order of individual, community, and health system factors and regressed against HbA1c. RESULTS: In the final adjusted model across all four approaches, individual-level factors like age (ß = - 0.05; p < 0.001); having 1-3 comorbidities (ß = - 2.03; p < 0.05), and having 4-9 comorbidities (ß = - 2.49; p = 0.001) were associated with poorer glycemic control. Similarly, male sex (ß = 0.58; p < 0.05), being married (ß = 1.16; p = 0.001), and being overweight/obese (ß = 1.25; p < 0.01) were associated with better glycemic control. Community and health system-level factors were not significantly associated with glycemic control. CONCLUSION: Individual-level factors are key drivers of glycemic control among inner-city African Americans. These factors should be the key targets for interventions to improve glycemic control in this population. However, community and health system factors may have indirect pathways to glycemic control that should be examined in future studies.

Lowering the impact of food insecurity in African American adults with type 2 diabetes mellitus (LIFT-DM) - Study protocol for a randomized controlled trial.

BACKGROUND: There is strong evidence that disparities in the burden of diabetes exist by both race and poverty. Food insecurity, or an inability to or limitation in accessing nutritionally adequate food, is an important modifiable social determinant of health, particularly in adults with chronic disease. African Americans are more likely to be diagnosed with diabetes and more likely than whites to be food insecure. METHODS: We describe a 4-year ongoing randomized controlled trial, which will test the separate and combined efficacy of monthly food vouchers and monthly food stock boxes layered upon diabetes education in improving glycemic control in low income, food insecure, African Americans with type 2 diabetes mellitus using a 2 × 2 factorial design. Three hundred African American adults with clinical diagnosis of diabetes and HbA1c ≥ 8% will be randomized into one of four groups: 1) diabetes education alone; 2) diabetes education plus food vouchers; 3) diabetes education plus stock boxes; and 4) diabetes education plus combined food vouchers and stock boxes. Our primary hypothesis is: among low-income, food insecure, African Americans with type 2 diabetes, those receiving diabetes education enhanced with food supplementation (food vouchers alone, stock boxes alone, or combination) will have significantly greater reduction in HbA1c at 12 months compared to those receiving diabetes education only. DISCUSSION: Results from this study will yield valuable insight currently lacking on how best to design and deliver diabetes interventions to low-income, food insecure, African Americans with diabetes that takes into account both clinical and social determinants of health. TRIAL REGISTRATION: This study was registered on November 29, 2019 with the United States National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT04181424).

Facilitating Factors and Barriers to Weight Management in Women: Physician Perspectives.

PURPOSE: The complexity of addressing overweight and obesity in women has been an ongoing public health and health care challenge. While the mechanism for addressing overweight and obesity in women remains unclear, it has been speculated that disparities in overweight and obesity by race and gender contribute to the complexity. The purpose of the present study was to examine perceptions of primary care physicians when discussing weight management with their patients. METHODS: We conducted focus group discussions exploring facilitators and barriers to discussing weight management and weight loss among women patients. Participants included 18 family medicine and internal medicine physicians who were recruited using a snowball sampling technique from two large urban institutions. Focus group discussions were transcribed verbatim. Responses were then codified and analyzed in frequency of occurrence using specialized computer software. RESULTS: Nine themes emerged from group discussions. These recurring themes reflected three overarching critical points: 1) potential utility of the primary care setting to address weight management; 2) the importance of positive patient-provider communication in supporting weight loss efforts; and 3) acknowledgement of motivation as intrinsic or extrinsic, and its role in obesity treatment. CONCLUSIONS: Physician perceptions of their own lack of education or training and their inability to influence patient behaviors play crucial roles in discussing weight management with patients.

Patient Barriers for Weight Management Among African American Women.

PURPOSE: The primary aim of this study was to assess the perceptions of local African American women who are overweight or obese using semi-structured focus groups to identify barriers to weight management and factors that support strategy success. The secondary aim of this study was to determine recommendations for patient-centered weight management interventions established specifically for African American women in the Milwaukee-area community. METHODS: Three semi-structured focus groups to explore barriers to weight management were performed among women patients. Participants (N=41) were recruited via email, postal mail, and phone as available from an academic medical center in Milwaukee, Wisconsin. Focus group discussions were transcribed verbatim, reviewed by the study team, and coded based on recurring themes within and across interviews. Responses were analyzed by frequency of occurrence using qualitative computer software. RESULTS: Five primary barriers to weight management were identified from focus groups: food choices, lifestyle changes, social support, locus of control, and health education. Based on participant reports, improvements to present practice and health literacy for patients may be merited. There was expressed interest by patients for being involved in future research and development of patient-centered interventions. CONCLUSIONS: This study provides support for the use of a community-based participatory research approach in determining appropriate considerations for weight management interventions suitable for this patient population. Future research should include stakeholders not included in this study, such as community organization leaders, and primary care physicians to develop a refined intervention targeting the primary barriers to weight management.

Neighborhood racial composition and poverty in association with pre-pregnancy weight and gestational weight gain.

BACKGROUND: Studies of neighborhood racial composition or neighborhood poverty in association with pregnancy-related weight are limited. Prior studies of neighborhood racial density and poverty has been in association with adverse birth outcomes and suggest that neighborhoods with high rates of poverty and racial composition of black residents are typically segregated and systematically isolated from opportunities and resources. These neighborhood factors may help explain the racial disparities in pre-pregnancy weight and inadequate weight gain. This study examined whether neighborhood racial composition and neighborhood poverty was associated with weight before pregnancy and weight gain during pregnancy and if this association differed by race. METHODS: We used vital birth records of singleton births of 73,061 non-Hispanic black and white women in Allegheny County, PA (2003-2010). Maternal race and ethnicity, pre-pregnancy body-mass-index (BMI), gestational weight gain and other individual-level characteristics were derived from vital birth record data, and measures of neighborhood racial composition (percentage of black residents in the neighborhood) and poverty (percentage of households in the neighborhood below the federal poverty) were derived using US Census data. Multilevel log binomial regression models were performed to estimate neighborhood racial composition and poverty in association with pre-pregnancy weight (i.e., overweight/obese) and gestational weight gain (i.e., inadequate and excessive). RESULTS: Black women as compared to white women were more likely to be overweight/obese before pregnancy and to have inadequate gestational weight gain (53.6% vs. 38.8%; 22.5% vs. 14.75 respectively). Black women living in predominately black neighborhoods were slightly more likely to be obese prior to pregnancy compared to black women living in predominately white neighborhoods (PR 1.10; 95% CI: 1.03, 1.16). Black and white women living in high poverty areas compared with women living in lower poverty areas were more likely to be obese prior to pregnancy; while only white women living in high poverty areas compared to low poverty areas were more likely gain an inadequate amount of weight during pregnancy. CONCLUSIONS: Neighborhood racial composition and poverty may be important in understanding racial differences in weight among childbearing women.

The Use of Lifestyle and Behavioral Modification Approaches in Obesity Interventions for Black Women: A Literature Review.

The alarming obesity prevalence in Black women is well documented yet poorly understood. Obesity interventions for Black women have failed to produce long-term reductions in weight. Recommendations to incorporate a lifestyle and behavioral modification approach have been made to address obesity in this population. The purpose of this article was to provide a comprehensive review of the literature to identify lifestyle and behavioral modification obesity intervention studies for Black women. We included articles published between February 1992 and January 2013. This search identified 28 articles from the PsycInfo, MEDLINE, CINAHL, and SPORTDiscus databases. Results of these studies were summarized primarily into six categories. The importance of modest improvements in health outcomes that result from adapting healthier behaviors was highlighted. Future research is required for identifying the most salient intervention component or combination of components that lead to the best outcomes for ensuring intervention success and minimizing weight regain postintervention.

Use of concept mapping to explore the influence of food security on food buying practices.

Paradoxically, individuals with food insecurity have been observed to have higher rates of obesity compared with their counterparts with food security. The factors influencing food purchasing behaviors in households with food security vs food insecurity are poorly understood. Using the mixed methods approach of concept mapping, we examined the perceptions and preferences driving the food purchasing behaviors of households with food security vs food insecurity. Twenty-six men and women with food security and 41 men and women with food insecurity from four neighborhoods in Boston, MA, completed the concept mapping process during 2010. Prevalence of overweight and obesity was greater among participants with food insecurity (80.5%) compared with those with food security (61.5%). Participants identified 163 unique factors that influenced their food purchasing behavior. Using multivariate analyses, these factors were grouped into eight unique concepts or clusters that reflected their perceptions of factors hindering healthy eating. Average cluster ratings were similar between participants with food security and food insecurity, suggesting that similar food purchasing behaviors are employed and are perceived similarly in how they hinder or promote healthy eating. The use of emergency food assistance programs may play a role in minimizing the burden of food insecurity while providing access to foods with varying degrees of nutritional quality that may be associated with increased risk of overweight and obesity observed in individuals and households with food insecurity.

Do residents of food deserts express different food buying preferences compared to residents of food oases? A mixed-methods analysis.

BACKGROUND: Many people lack access to food stores that provide healthful food. Neighborhoods with poor supermarket access have been characterized as "food deserts" (as contrast with "food oases"). This study explored factors influencing food buying practices among residents of food deserts versus food oases in the city of Boston, USA. METHODS: We used the mixed-methods approach of concept mapping, which allows participants to identify, list, and organize their perceptions according to importance. Resulting maps visually illustrate priority areas. RESULTS: Sixty-seven low-income adults completed the concept mapping process that identified 163 unique statements (e.g. relating to affordability, taste, and convenience) that influence food buying practices. Multivariate statistical techniques grouped the 163 statements into 8 clusters or concepts. Results showed that average cluster ratings and rankings were similar between residents of food deserts and food oases. CONCLUSIONS: The implication of this study pertains to the importance of community resources and emergency food assistance programs that have served to minimize the burden associated with hunger and poor food access among low-income, urban populations.

Disparities and access to healthy food in the United States: A review of food deserts literature.

Increasingly, studies are focusing on the role the local food environment plays in residents' ability to purchase affordable, healthy and nutritious foods. In a food desert, an area devoid of a supermarket, access to healthy food is limited. We conducted a systematic review of studies that focused on food access and food desert research in the United States. The 31 studies identified utilized 9 measures to assess food access. Results from these studies can be summarized primarily into four major statements. Findings from other countries offer insight into ways, in which future research, policy development and program implementation in the U.S. may continue to be explored.

Un Corazón Saludable: factors influencing outcomes of an exercise program designed to impact cardiac and metabolic risks among urban Latinas.

A high prevalence of physical inactivity, metabolic risk factors, and depression place Latinas in peril of developing cardiovascular disease. "Un Corazón Saludable: A Healthy Heart" was developed to engage urban Latinas in physical activity and increase awareness of cardiac and metabolic risk factors. Two hundred and twenty-five Latinas enrolled in the program that included salsa aerobics and culturally sensitive health education modules. Cardiac and metabolic risk factors measured in this study were body mass index (BMI), waist-to-hip ratio, abdominal obesity, and blood pressure. Psychosocial risk factors measured included depressive symptoms and perceived social support. Fifty-two percent of the enrollees completed the program. Results indicated decreases in BMI, abdominal obesity, and symptoms of depression among Latinas who completed the program. Those who did not complete the program were younger, had greater depressive symptomatology, reported poorer social support, and they tended to be caregivers and U.S. born. Focus groups of program participants ascertained that caregiving and family obligations were major barriers to exercise while social support was a major facilitator of exercise. This research indicates that programs developed to recognize and address cultural barriers can impact physical and psychosocial risk factors among urban Latinas who are able to attend. Program retention may improve if future exercise programs conducted through community-base organizations offered support to Latinas regarding issues that interfere with self-care and health promotion. Future programs should consider including mental health and social service case management as part of comprehensive exercise/educational programs.