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

摘要/项目摘要 LIFESPAN-D(通过糖尿病营养补充辅助进行的纵向食品安全试验) 是第一次评估大型自然实验，以确定健康和成本相关的影响 营养援助(SNAP和WIC)对整个生命周期的T2D结果。粮食不安全(FI)是一种常见的 美国低收入人群中患2型糖尿病(T2D)的潜在因素，以及 造成社会经济、种族和民族差异的因素。FI向人们施压，要求他们低成本消费 碳水化合物和能量丰富的食物会增加T2D的风险，并使其临床治疗更容易 具有挑战性；造成长期的压力；呈现出一种“竞争性需求”，排挤了参与其他活动的尝试 促进健康的行为；并迫使患有T2D的个人在支付 药物、监测或医疗保健的成本与购买营养食品或其他基本需求的成本相比-创造了 苏菲的选择可能会恶化T2D控制并加速并发症。FI人口也是 易患T2D的跨代高风险，部分是通过宫内代谢规划。FI有 与从糖尿病前期到T2D的进展增加，妊娠期糖尿病(GDM)增加， 在患有T2D的低收入人群中，因血糖升高事件而住院的人数增加。可以减少FI 通过营养援助计划改善饮食质量，但这样的计划是否能改善 脆弱人群中与T2D相关的结果仍然是一个悬而未决的问题。我们解决了这一关键问题 跨越寿命的问题，研究营养援助政策中的两个自然实验，以解决 问：通过营养援助减少FI在多大程度上以及在哪些人群中产生影响？ T2D和妊娠期糖尿病(GDM)发生率、T2D控制和T2D并发症相关的ED就诊和 住院治疗？这对健康的经济影响是什么？首先，我们将评估一个新的加州 全州范围的政策，允许接受SSI的个人帮助老年人，SSI是一项联邦收入补贴计划， 低收入的盲人和残疾人-现在有资格同时获得联邦补充资金 营养援助计划(SNAP)。使用准实验设计和全州范围的纵向数据集， 我们将在低收入人群中衡量心脏代谢控制、急诊就诊和并发症住院情况 T2D的个体，以及糖尿病前期个体中的事件T2D。第二，我们将评估一个 联邦妇女、婴儿和儿童营养计划(WIC)中的加州新政策正在转变 WIC从纸质凭证转变为电子福利转移(EBT)卡系统，将增加WIC的使用 福利。使用准实验设计以及全州和全国的数据集，我们将衡量 关于围产结局的EWIC，包括妊娠期糖尿病和母亲的妊娠体重增加以及婴儿的出生结局 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， 纳入急诊就诊、住院和长期护理成本以及与更好的相关避免的预计成本 心脏代谢控制和较低的T2D发生率。

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.