August 2023"Original Research: Food Insecurity Among Medicare Beneficiaries With Type 2 Diabetes

Food Insecurity Among Medicare Beneficiaries With Type 2 Diabetes: Implications for Diabetes Care and Education SpecialistsMcKayla Massey, BSc, YunYing Zhong, PhD, Jacqueline B. LaManna, PhD, APRN, ANP-BC, BC-ADM, CDCES

, and Boon Peng Ng, PhD

The Science of Diabetes Self-Management and Care
2023, Vol. 49(4) 291 –302
© The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/26350106231173674
journals.sagepub.com/home/tdeAbstract
Purpose:The purpose of the study was to examine factors associated with food insecurity among Medicare beneficiaries with type 2 diabetes.Methods: The 2019 Medicare Current Beneficiary Survey Public Use File of beneficiaries ≥65 years old with type 2 diabetes (n = 1343) was analyzed. A binary variable was created to represent food insecurity (1 = food insecurity, 0 = without food insecurity) with ≥2 affirmative responses adapting an established algorithm of the United States Department of Agriculture food insecurity questionnaire. A survey-weighted logistic model was performed to examine factors (ie, sociodemographic characteristics, health status, and insurance coverage) associated with food insecurity.Results: Approximately 11.6% of study Medicare beneficiaries with type 2 diabetes reported food insecurity. Non-Hispanic Black beneficiaries were more likely to report food insecurity than non-Hispanic White beneficiaries. Beneficiaries with incomes < $25 000 were more likely to report food insecurity than those with higher incomes. Beneficiaries enrolled in Medicare Advantage programs (vs traditional Medicare), having Medicare-Medicaid dual eligibility (vs nondual), and living with instrumental activities of daily living or activities of daily living limitations (vs without) were also more likely to report food insecurity than their respective counterparts.Conclusions: Sociodemographic disparities in food insecurity were observed among Medicare beneficiaries with type 2 diabetes. Implementation of screening protocols, interventions related to social determinants of health, and the diabetes care continuum may mitigate the prevalence of food insecurity in this demographic.Food insecurity is “a household-level economic and social condition of limited or uncertain access to adequate food.”¹ Food insecurity is a national public health concern affecting individuals of all ages, including older adults. Findings from The State of Senior Hunger in America in 2020 report revealed that 5.2 million (6.8%) older adults lacked food security, with 2 million of these individuals experiencing very low food security.² Rates of very low food security in people age 60 years and older rose by 222% between 2001 and 2020.² This upsurge in food insecurity in older age groups was most prominent between 2007 and 2009, during the Great Recession, and never returned to baseline rates.² Although the prevalence of food insecurity is lower among older adults compared to the overall US population (eg, 10.5% of all US households in 2020), the resulting health impacts among this demographic pose significant risks due to age-associated declines in health status and higher prevalence rates of chronic conditions requiring diet-supported treatment such as diabetes, hypertension, and cardiovascular disease.^3,4Type 2 diabetes affects almost 30% of adults ages 65 and older and is one of the most common and costly chronic health conditions in later life.⁵ Diabetes is a major contributor to rising Medicare expenditures, primarily due to excess costs associated with hospitalizations and treatment of potentially preventable diabetes-associated complications.⁶ A primary method of prevention and management of many chronic diseases, including diabetes, is the adoption of healthy dietary practices.⁷ However, food costs and accessibility may limit older adults with food insecurity to less expensive, energy-dense food options, resulting in eating patterns that may promote weight gain and higher blood glucose.⁸ Alternately, individuals with food insecurity may miss meals, potentially increasing the risk for hypoglycemia. Individuals with food insecurity and diabetes are more likely to report lower diabetes self-efficacy, lower medication adherence, and higher emotional distress compared to their counterparts who are food secure.^9-11 Furthermore, older adults experiencing food insecurity may experience additional challenges self-managing diabetes due to the presence of multiple chronic diseases and increased reliance on others to assist with their care.¹²Food insecurity is more common in older adults with multiple chronic conditions that often include diabetes. Individuals with multiple chronic conditions endure substantial personal economic impacts associated with the compounded costs of simultaneously managing varied treatments and added health care utilization. Medical office visits, overnight hospitalization, and emergency department visits occur more often in older adults with food insecurity, leading these individuals to incur additional health care costs.^13,14 Older adults experiencing food insecurity are more likely to engage in cost-related medication underuse as a means of controlling health care costs while on limited budgets.⁴ Some people with food insecurity will forgo medical care as a cost-saving strategy, while others may have erratic dietary patterns based on available food types and, at times, skip meals. The interaction of food insecurity with poor diet quality increases the risk that a person with diabetes will have an A1C of at least 8% by 6-fold.⁹ In fact, Health and Retirement Study respondents with diabetes and food insecurity were more likely to have elevated A1C levels and diabetes-associated chronic kidney disease, a complication with additional dietary implications. These patient-driven cost-control interventions may lead to the destabilization of a chronic condition, such as diabetes, resulting in increased health care utilization and costs.Although there is an emerging body of literature describing the impacts of food insecurity on the health risks of adults with diabetes, studies specifically focused on factors associated with food insecurity among older adults with diabetes are lacking. Most previous studies concentrated on factors associated with food insecurity in the general US population. Low income, lower educational attainment, having a disability, and being of a racial/ethnic minority are associated with higher likelihoods of food insecurity.^15-19 Additional factors related to food insecurity among older adults include multiple chronic conditions, functional limitations, and residing in rental housing.^20-22 Consistent with the general population, food insecurity is more prevalent among Black and Hispanic older adults, who also experience some of the highest rates of diabetes.²It is important to explore factors associated with food insecurity among older adults with diabetes because improving the ability to meet basic dietary needs may be an effective strategy to reduce adverse diabetes outcomes and lower the economic burden of diabetes-related care for this at-risk population. Identifying and understanding these factors can guide local, state, and federal programs aimed at improving the effectiveness of current nutrition and health services for older Americans and encourage new, more targeted policy changes. Therefore, this study aimed to examine factors associated with food insecurity based on sociodemographic characteristics, health status, and insurance coverage type of Medicare beneficiaries with type 2 diabetes.MethodsDataData from the 2019 Medicare Current Beneficiary Survey Public Use File (MCBS PUF) was analyzed in this study. The MCBS PUF is a publicly accessible version of the MCBS and includes only responses from community-dwelling Medicare beneficiaries.²³ The MCBS is representative of the Medicare population with a multistage cluster sample design and contains survey data regarding beneficiaries’ sociodemographic information, health status, health care utilization and satisfaction, and food security status. The university’s institutional review board determined this study was non-human subject research.Study PopulationThe study population included Medicare beneficiaries ages 65 years and older with self-reported type 2 diabetes (N = 1343). Medicare beneficiaries were asked whether they had been diagnosed with diabetes by a health care provider. Beneficiaries who responded “yes” were then asked to specify diabetes type: type 1, type 2, or other (see Table1 for the questionnaire by MCBS).Tab1Table 1. Question and Response Levels of Key Variables From the 2019 Medicare Current Beneficiary SurveyMeasuresDependent variable. The dependent variable was food insecurity, which was measured by 4 questions concerning beneficiaries’ experience over the past 12 months: (1) the food purchased didn’t last and didn’t have money to get more, (2) couldn’t afford to eat balanced meals, (3) cut the size of meals or skipped meals because there wasn’t enough money for food, and/or (4) ate less than should because there wasn’t enough money for food (Table 1). Similar measures and algorithms have been used in previous studies to determine food insecurity.^15,24 A binary indicator of food insecurity was constructed with the value of 1 for those who answered “often” or “sometimes” on 2 or more of those questions and 0 for those who answered “often” or “sometimes” on 1 or fewer questions.Covariates. The independent variables included beneficiaries’ sociodemographic characteristics, health-related covariates, and insurance coverage type. These variables were selected because they have been previously established as potential factors associated with food insecurity and measure beneficiaries’ access to care.¹⁵ Several sociodemographic covariates were included in the analysis: age (65-74, ≥75), sex (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), marital status (married, widowed, divorced/separated, and never married), education level (<high school, high school, and >high school), income level (<$25 000, ≥$25 000), and residing area (metro, nonmetro).The following covariates regarding beneficiaries’ health status were also included: reported general health (excellent/very good, good, fair/poor), the number of reported chronic conditions (<1 condition, 2-3 conditions, and ≥4 conditions), functional limitations (no functional limitations, instrumental activities of daily living [IADLs] only limitation, activities of daily living [ADLs] limitation), and body mass index (BMI; underweight/normal, overweight, obese).For insurance coverage/type, 2 variables were included: the variable for Medicare-Medicaid dual eligibility (not dual eligible, part-year dual eligible, full-year dual eligible) and the variable for beneficiaries who were enrolled in a full year of traditional Medicare (fee-for-service [FFS]), a full year of Medicare Advantage (MA), or a part year of FFS or MA.Statistical AnalysesSociodemographic information, health-related characteristics, and insurance coverage plans/types were stratified by food insecure status using cross-tabulations and Wald chi-square tests. A multivariable logistic regression model was used to examine the association between food insecurity and factors such as beneficiaries’ sociodemographic information, health-related characteristics, and insurance plans/types. To represent the Medicare population, results from the descriptive statistics and logistic regression model were weighted using the survey weights in the data set with related SAS complex survey commands based on the MCBS user guide.²³ All analyses were conducted using SAS Enterprise Guide 7.1 (SAS Institute), and the level of significance was P < .05.ResultsTable 2 shows the sociodemographic characteristics, health status, and insurance coverage plans/types of the study sample by food insecurity status. In this study population of Medicare beneficiaries with type 2 diabetes, 11.6% reported food insecurity. Compared to Medicare beneficiaries who were food secure, those with food insecurity included more female (62.2% vs 49.1%; P = .012) and more minority beneficiaries (eg, non-Hispanic Black; 26.4% vs 12.5%, P < .001). Higher proportions of beneficiaries with food insecurity had less than a high school education (26.1% vs 14.0%; P = .005) and an income <$25 000 (67.0% vs 27.9%; P < .001). Many beneficiaries who were food insecure had poorer self-reported health status, including IADL/ADL limitations (eg, more than 1 ADL, 55.8% vs 32.0%; P < .001), multiple chronic conditions (eg, ≥4 chronic conditions; 56.3% vs 44.9%, P < .001), and fair/poor general health status (46.7% vs 25.1%; P < .001). Regarding insurance coverage, higher proportions of beneficiaries with food insecurity belonged to MA programs (56.0% vs 37.9%; P < .001) and had Medicare-Medicaid dual eligibility (36.7% vs 11.0%; P < .001).Results from the multivariable logistic regression analysis are summarized in Figure 1 (please also see Table 3). Compared with Medicare beneficiaries ages 75 years and older, younger beneficiaries (ages 65-74) were more likely to report food insecurity (odds ratio [OR] = 1.65, 95% CI, 1.06, 2.56). Non-Hispanic Black beneficiaries were more likely to report food insecurity than non-Hispanic White beneficiaries (OR = 2.44; 95% CI, 1.36, 4.29). Those who have never been married were less likely to report food insecurity than those who were married (OR = 0.29, 95% CI, 0.10, 0.82). Having an income <$25 000 was also associated with higher odds of food insecurity (OR = 2.76, 95% CI, 1.34, 5.71) than those with higher incomes. Compared with those with no functional limitations, those who had limitations of IADLs (OR = 2.32, 95% CI, 1.15, 4.67) or ADLs (OR = 2.74, 95% CI, 1.64, 4.59) had higher odds of food insecurity. Finally, having MA (vs FFS or traditional Medicare; OR = 1.62, 95% CI, 1.07, 2.45) or full-year Medicare-Medicaid dual eligibility (vs nondual; OR = 2.14, 95% CI, 1.18, 3.90) was associated with a higher likelihood of food insecurity.DiscussionResults of this study show that sociodemographic disparities in food insecurity exist among Medicare beneficiaries with type 2 diabetes. Approximately 12% (representing an estimated 1 005 711 Medicare beneficiaries) of Medicare beneficiaries ≥65 years old with type 2 diabetes reported food insecurity. These findings suggest that age, race, income, and marital status are sociodemographic characteristics associated with food insecurity among this population. Maintaining a healthy diet is a key method to prevent and manage diabetes and associated chronic conditions. Therefore, these findings indicate the need to consistently assess individuals at risk for food insecurity, provide them with resources to increase their food access, and ensure programs are targeted toward this demographic.Younger Medicare beneficiaries (ages 65-74) had a higher likelihood of food insecurity compared to those age 75 years and older. This result is consistent with the findings of Madden et al,¹⁵ which examined risk factors associated with food insecurity among the Medicare population, independent of diabetes status. As individuals age, they can often experience reduced or loss of appetite, resulting in a lower caloric intake.²⁵ These factors can result in unmet dietary needs, experienced as a result of food insecurity, going undetected or being masked in this older demographic. Clinical-community partnership models have been successful in recognizing and supporting adults with food insecurity, including those with diabetes.^26,27 Standardized screening is an important clinical intervention for identifying and coordinating resources for those with food insecurity. A Food Insecurity Vital Sign assessment in which responses of “sometimes true” and “always true” to the following 2 questions is effective in identifying food insecurity in adults over the age of 60 years: (1) “We worried whether (my/our) food would run out before (I/we) got money to buy more” and (2) “The food that (I/we) bought just didn’t last and (I/we) didn’t have money to get more.”²⁸ Positive screens can then prompt referral to local, state, and national resources such as the Supplemental Nutrition Assistance Program (SNAP) and other programs targeted toward older adults (eg, Commodity Supplemental Food Program and Senior Farmers’ Market Nutrition Program).²⁹Tab2Tab2aTable 2. Characteristics of Medicare Beneficiaries Ages ≥65 With Type 2 Diabetes by Food Insecurity StatusFig1Figure 1. Selected results from the multivariable analysis.Beneficiaries who have never been married had lower odds of experiencing food insecurity than those who are married. The authors theorize that single or never married individuals potentially have fewer financial obligations and greater autonomy, resulting in less emphasis being placed on their dietary-related needs, and may in part explain this finding. Additionally, older married couples may incur significant out-of-pocket medical expenses if both survive to advanced age and are affected by chronic health conditions.Regarding race, non-Hispanic Black beneficiaries were more likely to experience inadequate food security compared to non-Hispanic White beneficiaries. Among all age groups, being of a racial minority group is a significant predictor of food insecurity.^19,30 Minority-focused, community-based programs that offer health education at community events (eg, religious services) and include traditional foods in meal services have shown to have high engagement and utilization rates.^31,32 The high prevalence of food insecurity among minority populations highlights the need for health care providers and policymakers to ensure that culturally appropriate interventions and nutrition programs are available to help mitigate this disparity.³³Tab3Tab3aTable 3. Multivariable Analysis Results for Factors Associated With Food Insecurity Among Medicare Beneficiaries Ages ≥65 With Type 2 DiabetesLow income was also positively associated with food insecurity and has been well established as a significant predictor of food insecurity.^17,19 Individuals who reside in low-income neighborhoods often have limited access to grocery stores and lack transportation options, making it difficult to obtain healthy foods.³⁴ Providing access to sufficient food options through enrollment in meal delivery programs such as Meals on Wheels can help individuals who may have limited transportation options and accessibility to food stores.Consistent with previous findings, beneficiaries who experience functional limitations (IADLs or ADLs) reported significantly higher rates of food insecurity, and these characteristics were shown to be predictive of food insecurity.^35,36 This is an important finding because adults with diabetes experience significantly higher rates of cognitive impairment and frailty and their associated limitations on function.³⁷ Living with functional impairments can hinder one’s ability to access, prepare, and consume sufficient amounts of food necessary to meet nutritional needs.²⁰ Increased utilization and expansion of home delivery nutrition programs that provide beneficiaries with appropriate food options can provide those with functional limitations with easier access to food.Lastly, older adults who were enrolled in MA or who had Medicare-Medicaid dual eligibility experienced a higher prevalence of food insecurity. Both covariates were positively associated with food insecurity. Enrollment in MA versus traditional FFS Medicare has more than doubled in the past decade, with 48% of the Medicare population enrolled in MA as of 2022.³⁸ Compared to FFS (traditional Medicare), MA has a higher share of enrollment of racial minorities (30% vs 20%) and low-income beneficiaries.³⁹ The higher enrollment of racial minorities and low-income beneficiaries may explain the higher prevalence of food insecurity in this group. However, more research is needed to untangle this observation. In 2019, the Centers for Medicare and Medicaid Services expanded MA plans to include nonmedical supplemental benefits such as transportation and meal delivery services to beneficiaries with chronic conditions.⁴⁰ As of 2021, more than half of MA plans have expanded benefits to offer meal services; however, most of these plans only provide meals for 30 days or less per year.⁴⁰ Continued expansion and enrollment of at-risk individuals into plans that offer nonmedical supplement benefits should be encouraged to address beneficiaries’ long-term nutritional needs. Similarly, those with dual eligibility are at an increased risk for food insecurity because many with low socioeconomic status may lack financial resources for diet-related needs. Older adults who qualify for dual eligibility are typically eligible for supplemental food programs such as SNAP, creating an opportunity for states to coordinate enrollment and renewal procedures to increase utilization of these programs.⁴¹Participation of individuals with food insecurity in emergency food programs such as SNAP improves health outcomes, including blood glucose values, reduces avoidable health care utilization (including emergency department visits and hospitalizations), and improves medication usage.^9,42 Unfortunately, less than half of older adults meeting SNAP eligibility criteria enroll in the program due to barriers such as poor understanding of the program, unrecognized personal eligibility, the need for assistance with enrollment processes, or fear of stigma.^42,43 Providerlevel barriers also contribute to inadequate attention to food insecurity in healthcare settings. In a qualitative study, primary care providers acknowledged the association of food insecurity with poor patient health outcomes, but they reported inadequate time and insufficient referral resources to address this problem.⁴⁴Community clinical programs that integrate case management, education on cost-effective meal planning, vouchers for community programs that provide fresh produce, and referral to food pantries have shown success in addressing food insecurity in the general population.²⁶ One program in federally qualified health centers incorporated food insecurity screening, resource referral, and nutrition education as standards of care for all adult patients with diabetes.²⁷ Follow-up evaluation showed that among patients with elevated A1Cs, those with higher food security demonstrated the greatest improvements in glucose values. The authors suggested that individuals with the combined problems of elevated glucose and food insecurity may face unique challenges in self-managing diabetes that warrant more intensive collaboration with the health care providers.²⁷ Interestingly, a separate study reported that adults with food insecurity and A1C values >9% were more likely to have had a least 1 visit with a diabetes care and education specialist (DCES), an opportunity for the intervention.⁴⁵It has been well established that food insecurity has negative impacts on nutritional status, health outcomes, and overall well-being, particularly among older adults with diabetes. Interventions such as increased screening during Medicare wellness visits⁴⁶ and expansion of supplemental food programs^47,48 are important components in reducing the prevalence of food insecurity in this population. Proper screening during wellness visits can ensure providers refer high-risk individuals or those already experiencing food insecurity to case managers and social workers who can help enroll them in food assistance programs.LimitationsLimitations of this study include limited generalizability because the MCBS PUF contains only responses from community-dwelling Medicare beneficiaries. Due to this, the results may not be generalizable to younger populations or individuals who live in long-term care facilities. Also, surveys were restricted to only English- or Spanishspeaking beneficiaries, potentially excluding individuals who do not speak one of these languages. This is a cross-sectional study, therefore, only associations between variables can be established. Data collected from this survey are subject to recall bias because it relies on beneficiaries’ recollections of events.Implications for DCESsDCESs have unique opportunities to assist older adults facing the combined challenges of diabetes and food insecurity. DCESs should incorporate screening for social determinants of health, including food insecurity, into all intake assessments and consider this as a program performance metric. Additionally, because older adults with an A1C >9% are more likely to participate in diabetes self-management education, it is imperative for the DCES to conduct focused interviews addressing food insecurity and other financial concerns associated with diabetes care and chronic disease self-management. Recognizing the association between food insecurity and medication underuse, the DCES should confirm medication-taking habits, assessing for medication underusage. Additionally, the DCES may provide recommendations for more cost-effective pharmacologic treatment and therapies with less hypoglycemia potential if food intake is erratic.Because so many older adults with food insecurity participate in MA programs, it is imperative for the DCES to have familiarity with medication formularies to support selection of agents with lower copayments. DCESs have the skills to include economical diet strategies with referral to community and national resources, including SNAP, food pantries, and farmer’s markets. The underutilization of SNAP suggests that DCESs are in a unique position to mentor patients in application to this vital program for people with food insecurity and understand patientspecific barriers. Assessment of older adults should incorporate evaluation of IADLs and ADLs. Those with evidence of functional impairment and frailty should have focused assessment for food insecurity and be considered for referral to a rehabilitation specialist for conditioning.⁴⁹ Because individuals with food insecurity utilize more acute care services, it is important for DCESs practicing in these settings to incorporate detailed assessments for food insecurity risk into care.DCESs have an obligation to understand and partner with community organizations that support hunger prevention in diverse populations. Finally, DCESs must advocate for policies within their practice settings that support universal assessment for food insecurity and targeted follow-up referral for positive screens. DCESs also have an obligation to advocate for local, state, and national policies aimed at reducing food insecurity.ConclusionThe findings of this research strongly suggest that factors such as age, race, income, marital status, functional limitations, dual eligibility, and enrollment in MA are associated with food insecurity among Medicare beneficiaries with type 2 diabetes. Implementation of screening protocols during Medicare wellness visits and within diabetes self-management education programs can help identify food insecurity in at-risk individuals and allow for appropriate referrals. Enrollment in nutritional support programs (ie, SNAP, Meals on Wheels, community food banks) should be encouraged, and interventions to improve and expand these services are necessary. The high prevalence of diabetes among older adults and coexistence of food insecurity suggest that DCESs play an essential role in recognizing food insecurity and initiating mitigating interventions in at-risk individuals.Declaration of Conflicting InterestsNone.FundingNo financial disclosures were reported by the authors of this article.ORCID iDsJacqueline B. LaManna

https://orcid.org/0000-0003-0171-5000Boon Peng Ng

https://orcid.org/0000-0001-6070-661XReferences

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From College of Medicine, University of Central Florida, Orlando, Florida (Ms Massey); Disability, Aging, and Technology Cluster, College of Nursing, University of Central Florida, Orlando, Florida (Dr Zhong, Dr Ng); Department of Hospitality Services, University of Central Florida, Orlando, Florida (Dr Zhong); and College of Nursing, University of Central Florida, Orlando, Florida (Dr LaManna).Corresponding Author:
Boon Peng Ng, College of Nursing & Disability, Aging and Technology Cluster, University of Central Florida, 12201 Research Parkway Suite 300, Orlando, FL 32826, USA.
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