Special Supplemental Nutrition Program for Women, Infants, and Children Enrollment and Adverse Pregnancy Outcomes Among Nulliparous Individuals.

OBJECTIVE: To evaluate the relationship between changes in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment during pregnancy from 2016 to 2019 and rates of adverse pregnancy outcomes in U.S. counties in 2019. METHODS: We conducted a serial, cross-sectional ecologic study at the county level using National Center for Health Statistics natality data from 2016 to 2019 of nulliparous individuals eligible for WIC. The exposure was the change in county-level WIC enrollment from 2016 to 2019 (increase [more than 0%] vs no change or decrease [0% or less]). Outcomes were adverse pregnancy outcomes assessed in 2019 and included maternal outcomes (ie, gestational diabetes mellitus [GDM], hypertensive disorders of pregnancy, cesarean delivery, intensive care unit [ICU] admission, and transfusion) and neonatal outcomes (ie, large for gestational age [LGA], small for gestational age [SGA], preterm birth, and neonatal intensive care unit [NICU] admission). RESULTS: Among 1,945,914 deliveries from 3,120 U.S. counties, the age-standardized rate of WIC enrollment decreased from 73.1 (95% CI, 73.0-73.2) per 100 live births in 2016 to 66.1 (95% CI, 66.0-66.2) per 100 live births in 2019, for a mean annual percent change decrease of 3.2% (95% CI, -3.7% to -2.9%) per year. Compared with individuals in counties in which WIC enrollment decreased or did not change, individuals living in counties in which WIC enrollment increased had lower rates of maternal adverse pregnancy outcomes, including GDM (adjusted odds ratio [aOR] 0.71, 95% CI, 0.57-0.89), ICU admission (aOR 0.47, 95% CI, 0.34-0.65), and transfusion (aOR 0.68, 95% CI, 0.53-0.88), and neonatal adverse pregnancy outcomes, including preterm birth (aOR 0.71, 95% CI, 0.56-0.90) and NICU admission (aOR 0.77, 95% CI, 0.60-0.97), but not cesarean delivery, hypertensive disorders of pregnancy, or LGA or SGA birth. CONCLUSION: Increasing WIC enrollment during pregnancy at the county level was associated with a lower risk of adverse pregnancy outcomes. In an era when WIC enrollment has decreased and food and nutrition insecurity has increased, efforts are needed to increase WIC enrollment among eligible individuals in pregnancy.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study.

BACKGROUND: Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. METHODS: A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. SETTING: Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. DESIGN: 2 × 2 factorial design. INTERVENTIONS: Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. OUTCOMES: Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. DISCUSSION: Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. CLINICALTRIALS: gov: NCT05472441.

Approaches for overcoming barriers to cross-sector data sharing.

OBJECTIVES: To characterize factors influencing the development and sustainability of data sharing in the Mid-Ohio Farmacy (MOF), a produce referral program implemented in partnership between a community-based organization (the Mid-Ohio Food Collective ["Food Collective"]) and an academic medical center (The Ohio State University Wexner Medical Center [OSUWMC]). STUDY DESIGN: We used an in-depth case study approach to identify challenges that arose during implementation of the MOF and related solutions via semistructured interviews with representatives of both organizations (May-September 2020). METHODS: Key informants from OSUWMC (n = 20) and the Food Collective (n = 11) were identified using a combination of purposive and convenience sampling; they included administrators, project champions, clinical providers, and food pantry representatives. Interview transcripts were coded using a deductive dominant approach guided by a logic model aimed at determining the resources and activities relevant to the development of the partnership. RESULTS: Challenges of cross-sector data sharing fit into 3 themes: data sharing regulations, data exchange capabilities, and cross-sector data integration. Overcoming these challenges required creative workarounds-for example, linking patients across organizations was done via establishment of a unique, partnership-specific patient identifier, which was incorporated into the health system's electronic health record for continuity. CONCLUSIONS: Our findings suggest that current regulatory frameworks are misspecified to the growing interest in cross-sector partnerships between health care and community-based organizations. Future efforts to support these relationships should consider clarifying rules around data sharing and increasing Medicaid support for nonmedical, health-related social needs.

Utilization Patterns of a Food Referral Program: Findings from the Mid-Ohio Farmacy.

INTRODUCTION: There is limited evidence describing utilization of clinic-based food referral programs intended to support healthy eating for food-insecure patients. To address this gap, this study aims to describe the utilization of the Mid-Ohio Farmacy (MOF). MOF is a partnership between a regional foodbank and local health care providers, including an academic medical center (AMC), that enables referrals of patients that experience food insecurity to a network of participating food pantries. METHODS: This observational study uses data from 2 AMC family medicine clinics that offered the MOF referral from September 2019 to November 2020. Patients who screened positive for food insecurity and had an eligible chronic disease (eg, diabetes, hypertension, obesity) were referred to the MOF. We compared demographic and clinical characteristics of patients that filled their referral (ie, visitors) to those that did not (ie, non-visitors). Among visitors, we also assessed patterns of pantry utilization. RESULTS: In total, 51% (164 of 322) of patients referred to the MOF visited a food pantry at least once. Visitors were more likely to be older, have diabetes, and have visited a food pantry before their referral. Patients with uncontrolled hypertension were less likely to visit a food pantry following their referral. Patients that had visited a food pantry before their referral had more visits in total and more produce-specific visits following their referral. CONCLUSIONS: Our results suggest that while the MOF can connect patients to food resources, further attention may be needed to encourage its use among patients who have not previously accessed pantries.

A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic Control Among Clients In Three States.

Food insecurity--defined as not having adequate quantity and quality of food at all times for all household members to have an active, healthy life--is a risk factor for poor diabetes control, yet few diabetes interventions address this important factor. Food pantries, which receive food from food banks and distribute it to clients in need, may be ideal sites for diabetes self-management support because they can provide free diabetes-appropriate food to people in low-income communities. Between February 2012 and March 2014, we enrolled 687 food pantry clients with diabetes in three states in a six-month pilot intervention that provided them with diabetes-appropriate food, blood sugar monitoring, primary care referral, and self-management support. Improvements were seen in pre-post analyses of glycemic control (hemoglobin A1c decreased from 8.11 percent to 7.96 percent), fruit and vegetable intake (which increased from 2.8 to 3.1 servings per day), self-efficacy, and medication adherence. Among participants with elevated HbA1c (at least 7.5 percent) at baseline, HbA1c improved from 9.52 percent to 9.04 percent. Although food pantries are nontraditional settings for diabetes support, this pilot study suggests a promising health promotion model for vulnerable populations. Policies supporting such interventions may be particularly effective because of food pantries' food access and distribution capacity.

Comparison of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a randomized controlled trial.

Mindful eating may be an effective intervention for increasing awareness of hunger and satiety cues, improving eating regulation and dietary patterns, reducing symptoms of depression and anxiety, and promoting weight loss. Diabetes self-management education (DSME), which addresses knowledge, self-efficacy, and outcome expectations for improving food choices, also may be an effective intervention for diabetes self-care. Yet few studies have compared the impact of mindful eating to a DSME-based treatment approach on patient outcomes. Adults 35 to 65 years old with type 2 diabetes for ≥1 year not requiring insulin therapy were recruited from the community and randomly assigned to treatment group. The impact of a group-based 3-month mindful eating intervention (MB-EAT-D; n = 27) to a group-based 3-month DSME "Smart Choices" (SC) intervention (n = 25) postintervention and at 3-month follow-up was evaluated. Repeated-measures ANOVA with contrast analysis compared change in outcomes across time. There was no significant difference between groups in weight change. Significant improvement in depressive symptoms, outcome expectations, nutrition and eating-related self-efficacy, and cognitive control and disinhibition of control regarding eating behaviors occurred for both groups (all p < .0125) at 3-month follow-up. The SC group had greater increase in nutrition knowledge and self-efficacy than the MB-EAT-D group (all p < .05) at 3-month follow-up. MB-EAT-D had significant increase in mindfulness, whereas the SC group had significant increase in fruit and vegetable consumption at study end (all p < .0125). Both SC and MB-EAT-D were effective treatments for diabetes self-management. The availability of mindful eating and DSME-based approaches offers patients greater choices in meeting their self-care needs.

Comparative effectiveness of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a pilot study.

Mindful eating offers promise as an effective approach for weight management and glycemic control in people with diabetes. Diabetes self-management education (DSME) is an essential component of effective self-care. Yet, little research has compared the effect of mindful eating to DSME-based treatment. This study compared the impact of these two interventions in adults with type 2 diabetes mellitus. A prospective randomized controlled trial with two parallel interventions was used. Participants included adults age 35 to 65 years with type 2 diabetes mellitus for 1 year or more, body mass index (BMI) of 27 or more, and hemoglobin A1c (HbA1c) of 7% or more who were randomly assigned to a 3-month mindful eating (MB-EAT-D; n=27) or Smart Choices (SC) DSME-based (n=25) intervention. Follow-up occurred 3 months after intervention completion. Dietary intake, physical activity, weight, HbA1c and fasting plasma glucose, and fasting insulin were assessed using repeated measures analysis of variance with contrast analysis. There was no significant difference between groups in the change in weight or glycemia at study end. Significant difference occurred between groups in the change in dietary intake/1,000 kcal of trans fats, total fiber, and sugars (all P<0.05). Mean (± standard error) reduction in weight (-2.92 ± 0.54 kg for SC vs -1.53 ± 0.54 kg for MB-EAT-D) and HbA1c (-0.67 ± 0.24% for SC and -0.83 ± 0.24% for MB-EAT-D) were significant (P<0.01). Significant reduction in energy intake and glycemic load occurred (all P<0.0001) for both groups. Training in mindful eating and diabetes self-management facilitate improvement in dietary intake, modest weight loss, and glycemic control. The availability of effective treatments gives patients with diabetes choices in meeting their self-care needs.

Goal difficulty and goal commitment affect adoption of a lower glycemic index diet in adults with type 2 diabetes.

OBJECTIVE: Few studies have examined the effect of goal difficulty on behavioral change even though goal setting is widely used in diabetes education. The effect of a goal to consume either 6 or 8 servings/day of low glycemic index (LGI) foods was evaluated in this study. METHODS: Adults 40-65 years old with type 2 diabetes were randomly assigned to the 6 or 8 serving/day treatment group following a 5-week GI intervention. Perceived goal difficulty, commitment, satisfaction, and self-efficacy were evaluated, and four day food records assessed dietary intake. RESULTS: Both groups increased consumption of LGI foods (P<0.001); there were no significant differences in the change in consumption between groups. Participants who were more committed to the goal perceived the goal to be less difficult (P<0.01). Those with greater efficacy beliefs were more committed to their goal, perceived the goal to be less difficult, and were more satisfied with their performance (all P<0.05). CONCLUSION: A specific goal regarding LGI foods can facilitate the adoption of a lower GI diet. Future research is needed to determine if goal commitment or goal difficulty mediate the process. PRACTICE IMPLICATIONS: Clinicians should help clients set specific goals regarding dietary change.

A behavioural intervention incorporating specific glycaemic index goals improves dietary quality, weight control and glycaemic control in adults with type 2 diabetes.

OBJECTIVE: A lower glycaemic index (GI) diet is associated with a reduction in glycosylated Hb (HbA(1c)) in people with diabetes. Yet, little research has been conducted to determine the effects of specific goals regarding consumption of low GI (LGI) foods on diabetes outcomes. The present study evaluated a behavioural intervention on dietary intake, weight status and HbA(1c), which included a goal to consume either six or eight servings of LGI foods daily. DESIGN: A parallel two-group design was used. Following the 5-week intervention, participants were randomly assigned to the group of six (n 15) or eight (n 20) servings of LGI foods daily and followed up for 8 weeks. Dietary intake was assessed using the mean of 4 d food records. SETTING: A metropolitan community in the USA. SUBJECTS: Individuals aged 40-65 years with type 2 diabetes of ≥1 year and HbA(1c) ≥ 7·0 % were eligible. RESULTS: There was no significant difference between goal difficulty groups with regard to GI servings at the end of the study. However, mean consumption of LGI foods increased by 2·05 (SE 0·47) and 1·65 (SE 0·40) servings per 4184 kJ in the six (P < 0·001) and eight (P < 0·001) LGI serving groups, respectively. For all participants combined, there were significant decreases in mean HbA(1c) (-0·58 (SE 0·21) %; P = 0·01), weight (-2·30 (SE 0·78) kg; P = 0·01), BMI (-0·80 (SE 0·29) kg/m(2); P = 0·01) and waist circumference (-2·36 (SE 0·81) cm; P = 0·01). CONCLUSIONS: An intervention including a specific goal to consume six to eight servings of LGI foods daily can improve diabetes outcomes. Clinicians should help patients set specific targets for dietary change and identify ways of achieving those goals.