Food insecurity and its impact on young people with diabetes

Food insecurity is prevalent across the globe, with far-reaching consequences for people’s health and well-being – consequences that can be significantly exacerbated for young people with diabetes. A session at last month’s ADA conference looked at how we might address them. Lisa Buckingham reports.

Food insecurity (FI) is defined as limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain availability to acquire acceptable foods in socially acceptable ways.

As part of a session on FI at the American Diabetes Association’s (ADA) 82nd Scientific Sessions, Professor Beth Cummings, paediatric endocrinologist at Dalhousie University and IWK Health, Canada, presented on the insights and struggles of caregivers of children with type 1 diabetes in food-insecure households.

Household food insecurity affects one in six children under 18 in Canada. In the general population, this has adverse health outcomes for them, such as higher rates of iron deficiency, asthma and hospitalisation, as well as adverse mental health outcomes including depression and anxiety (this affects adults too). This, in turn, results in higher healthcare costs for those families.

In 2008, Professor Cummings group hypothesised that the impacts of FI might be greater in households with a child with insulin-requiring diabetes, given the additional impact of diabetes costs and the need for extra focus on nutrition.

They found that children in FI households had an HbA1c 0.6% higher than those in food-secure households, were less likely to use pumps and more likely to require hospital admission for diabetes. Families also reported re-using needles and checking blood glucose less often to save money.

Her group then went on to get a clearer picture of the lived experience using a clinic-based, qualitative study of parents/caregivers of five to 17-year-olds with type 1 diabetes. For context, physician and hospital costs in Nova Scotia are publicly funded; medications and devices funding is variable; low-income families may get a small amount of extra diabetes food allowance; insulin is not administered by schools (no school nurses), so young children often require morning intermediate insulin, making it essential that their food intake matches insulin dose.

Broader factors that affected FI were high cost of healthy food, insufficient support, and unanticipated costs such as car breakdown. All participants reflected that after their child’s diagnosis of type 1 diabetes, financial balance was harder to maintain and that having a child with diabetes was a major contributor to their family’s FI. 

Healthy eating costs more

A new or heightened awareness of the importance of healthy food also came up. Foods that can fill children up, be bought in bulk and cost less money are often processed, nutritionally poor and not suitable.

This was not just a perception, said Professor Cummings, and drew attention to a study that compared a healthy thrifty food plan for a child with type 1 diabetes with a regular thrifty food plan, and found that the healthy plan cost 17% more.

Caregivers in the study also reported increased time and effort for shopping (label reading and calculating quantities) and food preparation. A major theme was the challenge of affording snacks to avoid or treat hypoglycaemia. Some said that pumps provided flexibility with sometimes skipping snacks along with reduced worry about lower quality carbohydrates because they could more easily deal with the resulting hyperglycaemia.

Another major theme was the sacrifices made to combat FI having a disproportionate impact on other family members to shield the child with diabetes. Participants reported sacrificing household needs, paying bills and transportation, buying fewer Christmas and birthday presents, cuts to their general grocery budget, other children in the family going without basic needs or nutritious food, and adults eating less so that the child with diabetes could eat more. The unequal distribution of food among siblings created unique emotional impacts.

The final theme was that caregivers perceive barriers to accessing usual supports to combat FI. Breakfast programmes were difficult to access because of the timing, administration and calculation of insulin dose. Regarding food banks, caregivers felt embarrassed or that other people were more needy, had concerns about the quality of food, and found it difficult to access them when they’re only open during working hours.

Family support

The positives and tips from families included: shopping as a family is helpful; routines and making lists reduces the burden; using reward points, discounts and credits; being on an insulin pump and other flexible dosing enabling them to buy inexpensive foods.

They also offered ideas on ways that they could be better supported, including better communication and tailored advice from clinics that specifically address their FI needs; subsidies for healthy food should be included on government health programmes; access to support groups with people who have similar experiences so that they can share knowledge/strategies; guides or cookbooks about making healthy meals on a budget.

All of this research points to the fact that, when addressing FI with services and programmes, the focus needs to include the whole family. If not, assessments will underestimate the impact of FI, said Professor Cummings.

Her summary included the need for diabetes professionals to identify food insecurity and advocate for improved family support.

Empowering children

Another presentation within the session, from Dr Enza Gucciardi from the School of Nutrition at Toronto Metropolitan University, discussed empowering children with type 1 diabetes and the impact of a virtual food skills programme on food literacy and diabetes self-management.

She discussed their screening initiatives, which consisted of four components: screening questions, awareness posters in clinic, a care algorithm and a community resource package.

The screening questions were:
Within the past three months…

• Did you ever worry about whether your food would run out before you got the money to buy more?
• Was there ever a time when the food you bought just didn’t last and you didn’t have money to get more?
• Did you or others in your house cut the size of your meals or skip meals because there wasn’t enough money for food?

Next was their posters and a care algorithm, which she emphasised is a compassionate, empathetic and non-judgmental process – we are not here to examine and judge how people spend their money, she said. The algorithm and full toolkit can be seen here: enzagucciardi.blog.ryerson.ca/food-insecurity-screening-and-diabetes.

They also developed resource handouts, which should be tailored locally based on the resources available in the area. However, research shows that these often aren’t used and it begs the question whether a resource navigator would be a better option, someone who can help families navigate what’s available and check in with them.

Major takeaways from this pilot were that most people appreciated discussing FI issues and felt comfortable if there was a rapport with the clinician; some expressed fear of being stigmatised and were embarrassed to ask for help; some didn’t want to discuss it in front of their child, and time constraints in a busy clinic was a major barrier to screening and follow-up for dietitians.

Food literacy

Lastly, she covered their pilot Summerlunch+ At Home Programme, an eight-week food literacy programme of virtual cooking classes and hands-on learning with a focus on nutrition skills. It was adapted for children with type 1 diabetes, employed a whole-family approach and was designed to engage children and families. Children could also meet peers with diabetes. Some 14% of families taking part were food insecure.

To reduce barriers to participation, free meal kits were delivered to families containing the ingredients for the virtual classes so no travel costs were involved. The recipes were vegetarian and focused on healthy eating guidelines, along with guidance on snacks and low-carb substitutes. The content focused on self-efficacy, nutrition knowledge and food skills, and included quizzes and games. Parents were encouraged to participate and be involved.

They are still in the process of looking at outcomes, including acceptability and effect on glycemic control. However, feedback from families was positive. Children and youth need to manage diabetes effectively now in order to have a healthy and bright future, concluded Professor Gucciardi, regardless of the barriers they face. Services must be equitable to all, and she challenged the audience to assess the framework of accessibility to reduce the burden of using available services.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.