Evaluation of Natural Experiments of Nutrition Assistance to Prevent and Control Diabetes among Low-Income Communities

摘要/项目总结 LIFESPAN-D（通过营养补充援助糖尿病的长期粮食安全实验）， 是第一次评估大规模的自然实验，以确定健康和成本相关的影响， 营养援助（SNAP和WIC）对整个生命周期T2 D结果的影响。粮食不安全（FI）是一种常见的， 美国低收入人群中2型糖尿病（T2 D）发展的潜在因素，以及 造成了社会经济、种族和民族差异。FI迫使人们低成本消费 碳水化合物和能量丰富的食物，增加了T2 D的风险，使其临床管理更 具有挑战性;造成慢性压力;提出一种“竞争性需求”，挤出参与其他活动的尝试。 促进健康的行为;并迫使T2 D患者在支付 药物、监测或医疗保健的成本与营养食品或其他基本需求的成本相比， 苏菲的选择，可以恶化T2 D控制和加速并发症。人口也是 易患T2 D跨代风险升高，部分原因是通过子宫内代谢程序。FI有 与从糖尿病前期到T2 D的进展增加、妊娠糖尿病（GDM）增加有关， 低收入T2 D人群中因血糖事件住院的人数增加。可以降低FI 通过营养援助计划改善了饮食质量，但这些计划是否能改善 脆弱人群中T2 D相关的结果仍然是一个悬而未决的问题。我们解决这一关键问题 研究了营养援助政策方面的两项自然实验， 问题：通过营养援助减少FI在多大程度上以及在哪些人群中影响 T2 D和妊娠期糖尿病（GDM）发生率、T2 D控制和T2 D并发症相关艾德访视， 住院？卫生经济影响是什么？首先，我们将评估一个新的加州 全州范围内的政策，允许个人谁收到SSI -一个联邦收入补充计划，以帮助老年人， 低收入的盲人和残疾人-现在有资格同时领取联邦补充补助金 营养援助计划（SNAP）。使用准实验设计和全州纵向数据集， 我们将测量低收入人群的心脏代谢控制、艾德就诊率和并发症住院率， 2型糖尿病患者，以及糖尿病前期患者中的2型糖尿病。第二，我们将评估一个 联邦妇女、婴儿和儿童营养计划（WIC）中的一项新的加州政策正在改变 WIC从纸质凭证转变为电子福利转账（EBT）卡系统，这将增加WIC的使用率 效益使用准实验设计和全州和全国的数据集，我们将测量 eWIC对围产期结局的影响，包括母亲中的GDM和妊娠期体重增加以及 他们的后代。第三，我们将评估政策（SSI-SNAP和WIC政策）的成本效益， 将艾德就诊、住院和长期护理费用以及与更好地 心脏代谢控制和较低的T2 D发病率。

ABSTRACT/PROJECT SUMMARY LIFESPAN-D (LongItudinal Food security Experiments via SuPplemental Assistance with Nutrition for Diabetes), is the first evaluation of large-scale natural experiments to determine the health and cost-related effects of nutrition assistance (SNAP and WIC) on T2D outcomes across the lifespan. Food insecurity (FI) is a common, potent factor in the development of type 2 diabetes mellitus (T2D) among low-income populations in the US, and a contributor to socioeconomic, racial and ethnic disparities. FI pressures people to consume low-cost carbohydrate- and energy-rich foods that increase the risk of T2D and makes its clinical management more challenging; creates chronic stress; presents a “competing demand” that crowds out attempts to engage in other health-promoting behaviors; and forces individuals with T2D to make difficult choices between paying share of costs for medicine, monitoring or healthcare vs. paying for nutritious food or other essential needs—creating a Sophie's Choice that can worsen T2D controls and accelerate complications. FI populations are also predisposed to trans-generational elevated risk for T2D, in part, through in utero metabolic programming. FI has been associated with increased progression from prediabetes to T2D, increased gestational diabetes (GDM), and increased hospitalizations for glycemic events among low-income populations with T2D. FI can be reduced and dietary quality improved through nutrition assistance programs, yet whether such programs can improve T2D-related outcomes among vulnerable populations remains an unanswered question. We address this critical question across the lifespan, studying two natural experiments in nutrition assistance policy to address the question: To what extent, and among which populations, does reducing FI through nutrition assistance affect T2D and gestational diabetes (GDM) rates, T2D control, and T2D complication-related ED visits and hospitalizations? And what are the health economic implications? First, we will evaluate a new California statewide policy that allows individuals who receive SSI - a federal income supplement program to help aged, blind and disabled people of low income – to now be concurrently eligible for the federal Supplemental Nutrition Assistance Program (SNAP). Using a quasi-experimental design and statewide longitudinal datasets, we will measure cardiometabolic control, ED visits and hospitalizations for complications among low-income individuals with T2D, as well as incident T2D among individuals with prediabetes. Second, we will evaluate a new California policy within the federal Nutrition Program for Women, Infants, and Children (WIC) that is shifting WIC from a paper voucher to an Electronic Benefits Transfer (EBT) card system that will increase uptake of WIC benefits. Using a quasi-experimental design and statewide and national datasets, we will measure effects of eWIC on perinatal outcomes, including GDM and gestational weight gain among mothers and birth outcomes of their offspring. Third, we will estimate the cost-effectiveness of the policies (SSI-SNAP and WIC policy), incorporating ED visits, hospitalizations and long-term care costs and projected costs averted related to better cardiometabolic control and lower T2D incidence.