Influence of Special Needs: Presentation for IOM Committee on Examination of the Adequacy of Food Resources and SNAP Benefits

Transcription

1 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

2 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

3 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

4 Diabetes Self-Management Reliable access to food Diabetes-appropriate foods Vegetables (and fruits) Protein Limited carbohydrates

5 Cycle of Food Insecurity & Chronic Disease: Diabetes Food Insecurity Worsening of Competing Demands Cycles of Food Adequacy/Inadequacy Poor Self-Management Capacity Competing Demands Increased Health Care Utilization Poor Diabetes Control Increased Diabetes Complications Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

6 Cycles of Food Adequacy and Inadequacy Hyperglycemia Hypoglycemia Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

7 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.

8 % Food Insecurity and Hypoglycemia Of the 711 participants, 197 (28%) reported at least one significant hypoglycemic episode in the previous year Secure One health plan estimated that the Insecure mean cost per episode of hypoglycemia requiring medical attention was $1186. (Heaton, Manage Care Interface, 2003) Number of Severe Hypoglycemic Episodes 4+ episodes: Adj OR 1.9 ( ) *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.

9 Risk Factors for Hypoglycemia AOR Food Insecurity 3.0 ( ) Alcohol abuse 2.2 ( ) Comorbid illnesses 1.5 ( ) Obesity 0.3 ( ) 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.

10 Admissions per 100, 000 Hypoglycemia Admissions by Day of Month n=2.55 million total admissions Full Sample (n=5177) Day of Admission

11 Admissions per 100,000 Hypoglycemia Admissions by Day of Month Full Sample (n=5177) Non Low-Income (n=4386) p=0.8 Day of Admission

12 Admissions per 100, 000 Hypoglycemia Admissions by Day of Month (Stratified by Income) Full Sample (n=5177) Low-Income (n=791) p=0.03 Non Low-Income (n=4386) Day of Admission

13 Admissions per 100, 000 Appendicitis Admissions by Day of Month Non Low-Income Appendicitis Low-Income Day of Admission

14 Cycles of Food Adequacy and Inadequacy Hyperglycemia Hypoglycemia Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

15 Food Insecure Adults with Diabetes Have Higher Average Blood Sugars HbA1c >7% (NHANES, known diabetics <200% FPL) Food Secure Food Insecure 49% 70% Adjusted RR 1.35 ( ) 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.

16 40 Food Insecure Adults with Diabetes Have Higher Average Blood Sugars % Food secure (n=354) Food insecure (n=296) <= >11 HbA1c Seligman, Diabetes Care, 2012.

17 Cycle of Food Insecurity & Chronic Disease: Diabetes Food Insecurity Worsening of Competing Demands Cycles of Food Adequacy/Inadequacy Poor Self- Management Capacity Competing Demands Increased Health Care Utilization Poor Diabetes Control Increased Diabetes Complications Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

18 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)

19 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

20 Patient-Related Factors Related to Higher Blood Sugar Food Insecure (n=325) Food Secure (n=386) p-value Difficulty following a diabetic diet, % <0.001 Confidence in ability to manage their diabetes, mean score Emotional distress related to diabetes, mean score < <0.001 Seligman, Diabetes Care, 2012.

21 Cycle of Food Insecurity & Chronic Disease: Diabetes Food Insecurity Worsening of Competing Demands Cycles of Food Adequacy/Inadequacy Poor Self- Management Capacity Competing Demands Increased Health Care Utilization Poor Diabetes Control Increased Diabetes Complications Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

22 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

23 Cycle of Food Insecurity & Chronic Disease: Diabetes Food Insecurity Worsening of Competing Demands Cycles of Food Adequacy/Inadequacy Poor Self- Management Capacity Competing Demands Increased Health Care Utilization Poor Diabetes Control Increased Diabetes Complications Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

24 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

25 Other Diet-Sensitive Chronic Conditions Obesity High blood pressure (salt) Congestive heart failure (salt)*

26 Cycle of Food Insecurity & Chronic Disease: Diabetes Food Insecurity Worsening of Competing Demands Cycles of Food Adequacy/Inadequacy Poor Self-Management Capacity Competing Demands Increased Diabetes Complications Increased Health Care Utilization Poor Diabetes Control Adapted from Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

27 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.

28 Thank You Hilary Seligman