Impact of Disparities in Food Security on Glycemic Control and Health CareUtilization Among Youth and Young Adults with Diabetes

摘要 2020年，食品不安全影响了11%的美国家庭，年轻人和患有1型糖尿病的年轻人 2型糖尿病(T1D)或2型糖尿病(T2D)的食物不安全率更高，分别为18%和31%。 此外，56%患有T1D的年轻人和46%患有T2D的年轻人没有达到最佳状态 血糖控制，来自代表性不足的种族/民族群体的年轻人经历的 血糖控制不良的比率。我们建议继续由NIDDK资助的粮食安全研究 队列研究(SFS 1)，它收集了1,000名患有糖尿病的年轻人和年轻人的数据，并记录了 粮食不安全在影响血糖控制和相关结果方面的作用。SFS 1数据表明， 与那些食物安全的人相比：(A)患有T1D和食物不安全的年轻人的HbA1c更高 (B)患有T2D和食物不安全的人患糖尿病酮症酸中毒的几率更高(3.1， P=0.02)。然而，粮食不安全的情况每天都有变化，从间歇性到 持续性，而且SFS 1没有捕捉到干预计划所需的日常变化。因此， 我们提出了一种高度科学严谨的研究策略，将纵向、定量和 定性方法，包括生态瞬时评估(EMA)和连续血糖监测 (CGM)，在一项密集的混合方法研究中。这项建议(SFS 2)极大地扩展了我们在SFS 1中的工作 确定时间因果级联和可操作和可接受的干预措施，以消除 粮食不安全。为了实现这些目标，我们的目标是(1)利用正在进行的SFS 1研究，招募一批 360名青年和患有糖尿病的年轻人(260名T1D，100名T2D)，72%有食物不安全史， 重复测量，纵向混合方法研究超过9个月；(2)实时评估差异 不同食物不安全水平的参与者之间的血糖控制，通过 通过CGM在相隔9个月的两个14天时间段内进行范围(TIR)；(3)评估参与者内部 粮食不安全对TIR和使用环境影响评估方法的中间路径的影响，包括动态结构 方程模型；(4)使用纵向、定性的方法同时深入地描述上下文 通过对30名参与者进行同时事件研究，了解参与者的粮食不安全经历和应对过程 T1D患者和15名T2D患者通过深入、一对一、重复 超过9个月的半结构化面试。这项研究将整合小学密集收集的数据 结果(CGM的TIR)和主要暴露(每日粮食不安全)，以及体力指标 活动、饮食和情绪。这些定量数据将得到纵向定性访谈的补充， 这将使我们能够用参与者的亲身经历三角测量定量数据。调查结果将 促进未来的干预措施和政策，旨在中断粮食不安全和 血糖控制不佳，对患有糖尿病的年轻人有效并可接受。

ABSTRACT Food insecurity affected 11% of all US households in 2020, and youth and young adults with type 1 diabetes (T1D) or type 2 diabetes (T2D) experience even higher rates of food insecurity, 18% and 31%, respectively. Moreover, 56% of youth and young adults with T1D and 46% of those with T2D do not achieve optimal glycemic control, with young people from underrepresented racial/ethnic groups experiencing much higher rates of poor glycemic control. We propose a continuation of the NIDDK-funded SEARCH Food Security Cohort Study (SFS 1), which collected data on >1,000 youth and young adults with diabetes and documented the role food insecurity plays in influencing glycemic control and related outcomes. SFS 1 data indicate that compared to those who are food secure: (a) young people with T1D and food insecurity have higher HbA1c (+0.34%, p=0.04) and (b) those with T2D and food insecurity have higher odds of diabetic ketoacidosis (3.1, p=0.02) in fully adjusted models. However, food insecurity varies day-to-day and ranges from intermittent to persistent, and SFS 1 did not capture the day-to-day variation, which is needed for intervention planning. Thus, we propose a research strategy of high scientific rigor that will integrate longitudinal quantitative and qualitative methods, including ecological momentary assessment (EMA) and continuous glucose monitoring (CGM), in an intensive, mixed methods study. This proposal (SFS 2) greatly expands our work in SFS 1 toward identifying the temporal causal cascades and actionable and acceptable interventions for eliminating food insecurity. To achieve these goals, we aim to (1) leverage the ongoing SFS 1 study to enroll a cohort of 360 youth and young adults with diabetes (260 T1D, 100 T2D), 72% with a history of food insecurity, for a repeated-measures, longitudinal mixed methods study over 9 months; (2) evaluate differences in real-time glycemic control between participants with varying levels of food insecurity, assessed by average daily time in range (TIR) via CGM over two 14-day time periods spaced 9 months apart; (3) evaluate the within-participant impact of food insecurity on TIR and intermediate paths using EMA methods, including dynamic structural equation models; (4) use longitudinal, qualitative methods to concurrently and deeply characterize the context of participants’ food insecurity experience and coping process, by conducting a concurrent events study of 30 individuals with T1D and 15 with T2D with a history of food insecurity through in-depth, one-on-one, repeated semi-structured interviews over 9 months. This study will integrate intensive data collection of the primary outcome (TIR by CGM) and the primary exposure (daily food insecurity), as well as measures of physical activity, diet, and mood. These quantitative data will be complemented by longitudinal qualitative interviews, which will allow us to triangulate the quantitative data with participants’ lived experiences. The findings will contribute to future interventions and policies that are designed to interrupt the cycle of food insecurity and poor glycemic control and are effective for and acceptable to young people with diabetes.