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Food Insecurity is Associated with Diabetes Mellitus: Results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999–2002

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Abstract

BACKGROUND

Food insecurity refers to limited or uncertain access to food resulting from inadequate financial resources. There is a clear association between food insecurity and obesity among women, but little is known about the relationship between food insecurity and type 2 diabetes.

OBJECTIVE

To evaluate whether there is an independent association between food insecurity and diabetes.

DESIGN

Cross-sectional analysis of the nationally representative, population-based National Health and Nutrition Examination Survey (1999–2002 waves).

PARTICIPANTS

Four thousand four hundred twenty-three adults >20 years of age with household incomes ≤300% of the federal poverty level.

MEASUREMENTS

We categorized respondents as food secure, mildly food insecure, or severely food insecure using a well-validated food insecurity scale. Diabetes was determined by self-report or a fasting serum glucose ≥126 mg/dl.

RESULTS

Diabetes prevalence in the food secure, mildly food insecure, and severely food insecure categories was 11.7%, 10.0%, and 16.1%. After adjusting for sociodemographic factors and physical activity level, participants with severe food insecurity were more likely to have diabetes than those without food insecurity (adjusted odds ratio [AOR] 2.1, 95% CI 1.1–4.0, p = .02). This association persisted after further adjusting for body mass index (AOR 2.2, 95% CI 1.2–3.9, p = .01).

CONCLUSIONS

Food insecurity may act as a risk factor for diabetes. Among adults with food insecurity, increased consumption of inexpensive food alternatives, which are often calorically dense and nutritionally poor, may play a role in this relationship. Future work should address how primary care clinicians can most effectively assist patients with food insecurity to make healthy dietary changes.

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References

  1. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security, Revised 2000. Alexandria, VA; U.S. Department of Agriculture, Food and Nutrition Service; 2000.

    Google Scholar 

  2. Wunderlich GS, Norwood JL, eds. Food Insecurity and Hunger in the United States: An Assessment of the Measure. Washington, DC: The National Academies Press; 2006.

  3. Nord M, Andrews M, Carlson S. Household Food Security in the United States, 2004. Economic Research Report 11. Alexandria, VA: United States Department of Agriculture; 2005.

    Google Scholar 

  4. Hall B. Hunger and food insecurity increase for 5th straight year. Center on Hunger and Poverty, October 2005.

  5. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79:6–16.

    PubMed  CAS  Google Scholar 

  6. Drewnowski A, Darmon N. The economics of obesity: dietary energy density and energy cost. Am J Clin Nutr. 2005;82:265S–73S.

    PubMed  CAS  Google Scholar 

  7. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of US adults. Am J Epidemiol. 1997;146:214–22.

    PubMed  CAS  Google Scholar 

  8. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2003;26(Suppl 1):S51–61.

    PubMed  Google Scholar 

  9. Ludwig DS. Dietary glycemic index and obesity. J Nutr. 2000;130:280S–3S.

    PubMed  CAS  Google Scholar 

  10. Centers for Disease Control and Prevention (CDC). National Health and Nutrition Examination Survey. Hyattsville, MD: National Center for Health Statistics (NCHS), U.S. Department of Health and Human Services; 2005.

  11. Centers for Disease Control and Prevention (CDC). Analytic and reporting guidelines: the National Health and Nutrition Examination Survey (NHANES). Hyattsville, MD: National Center for Health Statistics (NCHS), U.S. Department of Health and Human Services; 2005.

  12. Bureau of the Census for the Bureau of Labor Statistics. Current Population Survey. Washington DC.

  13. Centers for Disease Control and Prevention (CDC). National Health Interview Survey. Hyattsville, MD: National Center for Health Statistics (NCHS), U.S. Department of Health and Human Services; 2005.

  14. U.S. Census Bureau. Survey of Income and Program Participation. Washington DC.

  15. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. NIH Publ 98(4083), September 1998.

  16. Valsamakis G, Chetty R, Anwar A, Banerjee AK, Barnett A, Kumar S. Association of simple anthropometric measures of obesity with visceral fat and the metabolic syndrome in male Caucasian and Indo-Asian subjects. Diabet Med. 2004;21:1339–45.

    PubMed  CAS  Google Scholar 

  17. Albu JB, Murphy L, Frager DH, Johnson JA, Pi-Sunyer FX. Visceral fat and race-dependent health risks in obese nondiabetic premenopausal women. Diabetes. 1997;46:456–62.

    PubMed  CAS  Google Scholar 

  18. Despres JP, Lemieux S, Lamarche B, et al. The insulin resistance-dyslipidemic syndrome: contribution of visceral obesity and therapeutic implications. Int J Obes Relat Metab Disord. 1995;19(Suppl 1):S76–86.

    PubMed  Google Scholar 

  19. Okura Y, Urban LH, Mahoney DW, Jacobsen SJ, Rodeheffer RJ. Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure. J Clin Epidemiol. 2004;57:1096.

    PubMed  Google Scholar 

  20. Kehoe R, Wu SY, Leske MC, Chylack LT, Jr. Comparing self-reported and physician-reported medical history. Am J Epidemiol. 1994;139:813–8.

    PubMed  CAS  Google Scholar 

  21. Midthjell K, Holmen J, Bjorndal A, Lund-Larsen G. Is questionnaire information valid in the study of a chronic disease such as diabetes? the Nord-Trondelag diabetes study. J Epidemiol Community Health. 1992;46:537–42.

    PubMed  CAS  Google Scholar 

  22. Koopman RJ, Mainous AG, 3rd, Diaz VA, Geesey ME. Changes in age at diagnosis of type 2 diabetes mellitus in the United States, 1988 to 2000. Ann Fam Med. 2005;3:60–3.

    PubMed  Google Scholar 

  23. Centers for Disease Control and Prevention (CDC). Documentation for the dietary interview—total nutrient intakes file. National Center for Health Statistics (NCHS), U.S. Department of Health and Human Services; 2004.

  24. Centers for Disease Control and Prevention (CDC). Anthropometric reference data, United States, 1988–1994. National Center for Health Statistics (NCHS), U.S. Department of Health and Human Services. Available at http://www.cdc.gov/nchs/about/major/nhanes/Anthropometric%20Measures.htm. Accessed July 6, 2005.

  25. Klesges LM, Pahor M, Shorr RI, Wan JY, Williamson JD, Guralnik JM. Financial difficulty in acquiring food among elderly disabled women: results from the women’s Health and Aging Study. Am J Public Health. 2001;91:68–75.

    PubMed  CAS  Google Scholar 

  26. Vozoris NT, Tarasuk VS. Household food insufficiency is associated with poorer health. J Nutr. 2003;133:120–6.

    PubMed  CAS  Google Scholar 

  27. Wolfe WS, Frongillo EA, Valois P. Understanding the experience of food insecurity by elders suggests ways to improve its measurement. J Nutr. 2003;133:2762–9.

    PubMed  CAS  Google Scholar 

  28. Drewnowski A, Darmon N, Briend A. Replacing fats and sweets with vegetables and fruits—a question of cost. Am J Public Health. 2004;94:1555–9.

    PubMed  Google Scholar 

  29. Lee JS, Frongillo EA, Jr. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr. 2001;131:1503–9.

    PubMed  CAS  Google Scholar 

  30. Tarasuk VS. Household food insecurity with hunger is associated with women’s food intakes, health and household circumstances. J Nutr. 2001;131:2670–6.

    PubMed  CAS  Google Scholar 

  31. Kendall A, Olson CM, Frongillo EA, Jr. Relationship of hunger and food insecurity to food availability and consumption. J Am Diet Assoc. 1996;96:1019–24.

    PubMed  CAS  Google Scholar 

  32. Ford ES, Mokdad AH. Fruit and vegetable consumption and diabetes mellitus incidence among U.S. adults. Prev Med. 2001;32:33–9.

    PubMed  CAS  Google Scholar 

  33. Gross LS, Li L, Ford ES, Liu S. Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessment. Am J Clin Nutr. 2004;79:774–9.

    PubMed  CAS  Google Scholar 

  34. Montonen J, Jarvinen R, Heliovaara M, Reunanen A, Aromaa A, Knekt P. Food consumption and the incidence of type 2 diabetes mellitus. Eur J Clin Nutr. 2005;59:441–8.

    PubMed  CAS  Google Scholar 

  35. Thompson FE, Taren DL, Andersen E, et al. Within month variability in use of soup kitchens in New York state. Am J Public Health. 1988;78:1298–301.

    PubMed  CAS  Google Scholar 

  36. Wilde PE, Ranney CK. The monthly food stamp cycle: shopping frequency and food stamp decisions in an endogenous switching regression framework. Am J Agric Econ. 2000;82:200–13.

    Google Scholar 

  37. Urbszat D, Herman CP, Polivy J. Eat, drink, and be merry, for tomorrow we diet: effects of anticipated deprivation on food intake in restrained and unrestrained eaters. J Abnorm Psychology. 2002;111:396–401.

    Google Scholar 

  38. Polivy J. Psychological consequences of food restriction. J Am Diet Assoc. 1996;96:589–92; Quiz 93–94.

    PubMed  CAS  Google Scholar 

  39. Duska F, Andel M, Kubena A, Macdonald IA. Effects of acute starvation on insulin resistance in obese patients with and without type 2 diabetes mellitus. Clin Nutr. 2005;24:1056–64.

    PubMed  CAS  Google Scholar 

  40. Mansell PI, Macdonald IA. The effect of starvation on insulin-induced glucose disposal and thermogenesis in humans. Metabolism. 1990;39:502–10.

    PubMed  CAS  Google Scholar 

  41. Newman WP, Brodows RG. Insulin action during acute starvation: evidence for selective insulin resistance in normal man. Metabolism. 1983;32:590–6.

    PubMed  CAS  Google Scholar 

  42. Reaven GM. Hypothesis: muscle insulin resistance is the (“not-so”) thrifty genotype. Diabetologia. 1998;41:482–4.

    PubMed  CAS  Google Scholar 

  43. Hamelin AM, Habicht JP, Beaudry M. Food insecurity: consequences for the household and broader social implications. J Nutr. 1999;129:525S–8S.

    PubMed  CAS  Google Scholar 

  44. Hamelin AM, Beaudry M, Habicht JP. Characterization of household food insecurity in Québec: food and feelings. Soc Sci Med. 2002;54:119–32.

    PubMed  Google Scholar 

  45. Epel ES, McEwen B, Seeman T, et al. Stress and body shape: stress-induced cortisol secretion is consistently greater among women with central fat. Psychosom Med. 2000;62:623–32.

    PubMed  CAS  Google Scholar 

  46. Gluck ME, Geliebter A, Lorence M. Cortisol stress response is positively correlated with central obesity in obese women with binge eating disorder (BED) before and after cognitive-behavioral treatment. Ann N Y Acad Sci. 2004;1032:202–7.

    PubMed  CAS  Google Scholar 

  47. Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21:71–7.

    PubMed  Google Scholar 

  48. Horowitz CR, Colson KA, Hebert PL, Lancaster K. Barriers to buying healthy foods for people with diabetes: evidence of environmental disparities. Am J Public Health. 2004;94:1549–54.

    Article  PubMed  Google Scholar 

  49. Morland K, Wing S, Diez Roux A, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med. 2002;22:23–9.

    PubMed  Google Scholar 

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Acknowledgments

The authors would like to express their gratitude to Dr. Umesh Masharani for his helpful comments on the manuscript. Dr. Seligman was funded by a DHHS-HRSA Primary Care Faculty Development Grant 5 D14HP00178-03-00. Dr. Kushel’s work was supported by the Agency for Healthcare Research and Quality grant K08 HS011415-03. The funders did not participate in any part of the study. Portions of this work were presented in abstract form at the 2006 Society of General Medicine Meeting.

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Correspondence to Hilary K. Seligman MD, MAS.

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Seligman, H.K., Bindman, A.B., Vittinghoff, E. et al. Food Insecurity is Associated with Diabetes Mellitus: Results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999–2002. J GEN INTERN MED 22, 1018–1023 (2007). https://doi.org/10.1007/s11606-007-0192-6

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  • DOI: https://doi.org/10.1007/s11606-007-0192-6

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