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Influence of Special Needs: Presentation for IOM Committee on Examination of the Adequacy of Food Resources and SNAP Benefits
Hilary Seligman, MD, MAS, FACP
March 28, 2012
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Objective
Using diabetes as a case example, illustrate the bidirectional relationships between food insecurity, dietary intake, and chronic disease
- Cycles of food adequacy & inadequacy
- Self-management capacity
- Competing demands
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Diabetes: Blood Sugar Balance
• Drive Blood Sugar Up
Food
– Carbohydrates • Sugars, starches, (& fiber)
• Drive Blood Sugar Down
Lack of food
Diabetes medicine (pills
or insulin injections)
Physical Activity
HYPERGLYCEMIA:
Blindness
Amputations
Kidney Failure
HYPOGLYCEMIA:
Poor quality of life
Cognitive dysfunction
Seizures
Coma
Death
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Diabetes Self-Management
• Reliable access to food
• Diabetes-appropriate foods
– Vegetables (and fruits)
– Protein
– Limited carbohydrates
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Food Insecurity
Cycles of Food Adequacy/Inadequacy
Poor Self-Management
Capacity
Competing Demands
Poor Diabetes Control
Increased Diabetes Complications
Increased Health Care Utilization
Worsening of Competing Demands
Cycle of Food Insecurity & Chronic Disease: Diabetes
Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
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Cycles of Food Adequacy and Inadequacy
Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
Hyperglycemia Hypoglycemia
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Hypoglycemia & Food Access
• Pre-recession: Patients with diabetes in an urban, safety net hospital – 1/3 of those who reported hypoglycemia attributed it to
the inability to afford food
• Post-recession: Primary care patients with diabetes
at community health centers (38% food insecure) • Blood sugar ever gotten too low because you couldn’t
afford food (33% FI vs 5% FS) • Ever been to the ER because your blood sugar was too
low (28% FI vs 5% FS)
Nelson, JAMA, 1998; Seligman, JHCPU, 2010.
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Food Insecurity and Hypoglycemia
0
5
10
15
20
1-3 4-6 7-11 12+
%
Number of Severe Hypoglycemic Episodes
Secure
Insecure
Of the 711 participants, 197 (28%) reported at least one significant hypoglycemic episode in the previous year.
4+ episodes:
Adj OR 1.9 (1.1-3.5)
*Adjusted model includes age, race/ethnicity, tobacco use, English proficiency, income, educational attainment, body weight, insulin, renal disease, adherence to medication and blood glucose testing, comorbid conditions, and alcohol abuse.
Seligman, Arch Int Med, 2011.
One health plan estimated that the mean cost per episode of hypoglycemia requiring medical attention was $1186.
(Heaton, Manage Care Interface, 2003)
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Risk Factors for Hypoglycemia
AOR
Food Insecurity 3.0 (1.5-5.9)
Alcohol abuse 2.2 (1.1-4.5)
Comorbid illnesses 1.5 (1.1-2.0)
Obesity 0.3 (0.1-0.7)
Not significant: renal disease, insulin use, hypoglycemia knowledge, English proficiency, age, race/ethnicity, education, income, tobacco use, glucose monitoring, and medication adherence
Seligman, Arch Int Med, 2011.
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Ad
mis
sio
ns
pe
r 1
00
, 00
0
Day of Admission
Hypoglycemia Admissions by Day of Month
Full Sample (n=5177)
n=2.55 million total admissions
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Ad
mis
sio
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pe
r 1
00
,00
0
Day of Admission
Hypoglycemia Admissions by Day of Month
Full Sample (n=5177)
Non Low-Income (n=4386)
p=0.8
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Day of Admission
Hypoglycemia Admissions by Day of Month (Stratified by Income)
Low-Income (n=791)
Full Sample (n=5177)
Ad
mis
sio
ns
pe
r 1
00
, 00
0
Day of Admission
Non Low-Income (n=4386)
p=0.03
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Ad
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00
, 00
0
Day of Admission
Appendicitis Admissions by Day of Month
Non Low-Income
Appendicitis
Low-Income
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Cycles of Food Adequacy and Inadequacy
Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
Hyperglycemia Hypoglycemia
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Food Insecure Adults with Diabetes Have Higher Average Blood Sugars
Food Secure
Food Insecure
HbA1c >7%
(NHANES, known diabetics <200% FPL)
49% 70% Adjusted RR 1.35
(1.05-1.74)
Mean HbA1c (ICHC, n=711) 8.1% 8.5% p=0.007
Mean HbA1c (MFFH, n=621) 7.8% 8.4% p=0.002
Seligman, Jl Nutrition, 2010; Seligman, Diabetes Care, 2012;
Seligman, in progress.
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Food Insecure Adults with Diabetes Have Higher Average Blood Sugars
0
5
10
15
20
25
30
35
40
<=7.0 7.1-8.0 8.1-9.0 9.1-10.0 10.1-11.0 >11
%
HbA1c
Food secure (n=354)
Food insecure (n=296)
Seligman, Diabetes Care, 2012.
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Cycle of Food Insecurity & Chronic Disease: Diabetes
Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
Food Insecurity
Cycles of Food Adequacy/Inadequacy
Poor Self-Management Capacity
Competing Demands
Poor Diabetes Control
Increased Diabetes
Complications
Increased Health Care Utilization
Worsening of Competing Demands
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Poor Self-Management Capacity
• Constrained dietary options
– Energy-dense foods
– High in fat and refined carbohydrates, high glycemic load
– High salt content
• (Decreased physical activity)
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“The end of the month, I start getting out of food…but I have to eat something, ‘cause if I don’t eat behind my [insulin] shot, that shot will make you so sick. I just eat anything I can find during that time just to keep me from getting sick.”
Wolfe, J Aging Health, 1998
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Patient-Related Factors Related to Higher Blood Sugar
Food Insecure (n=325)
Food Secure (n=386)
p-value
Difficulty following a diabetic diet, % 64.3 49.0 <0.001
Confidence in ability to manage their diabetes, mean score 7.1 7.7 <0.001
Emotional distress related to diabetes, mean score 3.9 3.0 <0.001
Seligman, Diabetes Care, 2012.
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Cycle of Food Insecurity & Chronic Disease: Diabetes
Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
Food Insecurity
Cycles of Food Adequacy/Inadequacy
Poor Self-Management Capacity
Competing Demands
Poor Diabetes Control
Increased Diabetes Complications
Increased Health Care Utilization
Worsening of Competing Demands
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Competing Demands
• Hunger in America 2010: 34% of clients reported having to choose at least once in the last 12 months between paying for food and paying for medicine or medical care
• Food insecure patients more likely to put off buying blood testing supplies in order to afford food
Seligman, JHCPU, 2010
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Cycle of Food Insecurity & Chronic Disease: Diabetes
Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
Food Insecurity
Cycles of Food Adequacy/Inadequacy
Poor Self-Management Capacity
Competing Demands
Poor Diabetes Control
Increased Diabetes Complications
Increased Health Care Utilization
Worsening of Competing Demands
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Increased Need for HC Visits
• Food insecure adults have about 5 more physician encounters per year than food secure adults
• Hospitalizations in past year: 13% FI vs 8% FS
• ED visits in past year: 28% FI vs 19% FS
Kushel, Nelson
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Other Diet-Sensitive Chronic Conditions
• Obesity
• High blood pressure (salt)
• Congestive heart failure (salt)*
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Food Insecurity
Cycles of Food Adequacy/Inadequacy
Poor Self-Management Capacity
Competing Demands
Poor Diabetes Control
Increased Diabetes Complications
Increased Health Care Utilization
Worsening of Competing Demands
Cycle of Food Insecurity & Chronic Disease: Diabetes
Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
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Unresolved Questions
• How many SNAP recipients carry a diagnosis of a diet-sensitive chronic disease?
– Estimated 10% of food insecure non-elderly adults with income <200% FPL have diabetes
• How are daily fluctuations in dietary intake related to management of other diet sensitive chronic diseases?
• How do we quantify the degree to which daily fluctuations in dietary intake are related to the adequacy of SNAP benefits?
Seligman, J Nutr, 2010.