Chronic care management for diabetes: Open a food pantry

November 16, 2018

One Ohio family practice has found a way to help food-insecure patients with diabetes by adding a food pantry to its office, meaning patients no longer have to choose between nutritious food and medicine to stay healthy.

It’s a vicious circle: Since poverty is a leading cause of Type 2 diabetes, many diabetic patients lack the money for healthier foods. Consequently, they often buy prepared foods that tend to be overprocessed, low nutrient, and high calorie-the kinds of foods that promote Type 2 diabetes.

It gets worse. Those people also frequently have to choose between buying insulin or buying food, which may mean they skip meals altogether, making it more difficult to manage their diabetes and overall health in the long term.

Food pantries can help people with diabetes, but because of job, family, and other responsibilities, finding time and securing transportation to a food pantry can be difficult-and then there’s the stigma associated with needing food assistance.

But the OhioHealth Riverside Family Practice Center in Columbus, Ohio, is easing the process for patients with diabetes and providing them with much-needed produce for free.

“We’re trying to put a pantry in a place where they already feel safe and hopefully feel connected, so going somewhere to get healthy food isn’t one more new thing they have to do,” says Laurie Hommema, MD, the practice’s program director.

Riverside opened its own food pantry in May 2018 as part of the Food is Health program to encourage healthy eating among food-insecure diabetics. The U.S. Department of Agriculture (USDA) defines food insecurity as a lack of consistent access to enough food for an active, healthy life.

The Food is Health program is an initiative of the Mid-Ohio Foodbank that explores innovative approaches for providing access to affordable and nutritious food to measurably improve health outcomes. Riverside’s program is an offshoot. Because the practice doesn’t track income, it doesn’t qualify as a Mid-Ohio Foodbank pantry site, meaning the the practice isn’t eligible to receive funding for its food and so funds the program entirely itself. However, the practice does buy some of its food from the Mid-Ohio Foodbank.

Riverside’s program offers 100 percent of the recommended weekly produce for participating diabetics and their family members-about 15 pounds per person.

Food pantries in healthcare settings aren’t a unique idea. Still, they are rare. This is Mid-Ohio Foodbank’s first pantry in a doctor’s office in its 680-partner agency network, says Foodbank President and CEO Matt Habash.

 

The proven benefts

Food pantries have been shown to help diabetics manage their blood sugar levels. A 2015 study in the journal Health Affairs followed nearly 700 food pantry clients with diabetes for six months. The authors piloted an intervention that provided them with diabetes-appropriate food, blood sugar monitoring, primary care physician (PCP) referral, and self-management support.

Study results showed improvement in mean A1C from a baseline of 8.11 to 7.96 percent. The percentage of participants with A1C greater than 9 percent declined from 28 to 25 percent. Further, the authors found those with A1C greater than 7.5 percent at the start of the study saw a mean A1C decline from 9.52 to 9.04 percent and improvements in secondary outcomes.

The authors also saw significant improvements in fruit and vegetable intake and self-efficacy. Diabetes distress and medicine nonadherence declined, and participants made fewer trade-offs between buying food or medicine.

Although Riverside is not formally tracking before-and-after measurements, it’s already seeing similar results. It’s also seeing weight loss among participants’ nondiabetic family members-and better morale among the providers who are giving dietary counseling to participants.

 

The local need

In 2016, 69 million meals were missed by the 400,000 people living below the 200 percent federal poverty level in Franklin County, which includes Columbus, because those people couldn’t afford food for every meal, Habash says. The Foodbank, which covers 20 counties in central Ohio, including Franklin County, wanted to establish a Food is Health food pantry in a healthcare setting and found a willing partner in Riverside.

Before launching the Food is Health program, the practice conducted a pilot study to gauge need. About 43 percent of its patients reported they were food-insecure-a percentage that’s higher than the USDA’s national estimate of 11.8 percent. Riverside also has a lower threshold for what constitutes food insecurity-a simple self-assessment by patients about whether they feel they lack enough food throughout the day. The practice asks patients two questions to establish patient eligibility for the Food is Health program: Are you diabetic? Are you food-insecure? If patients answers yes to both, they’re eligible.



As often as once a week, participants enter a former radiology suite that has been converted into the food pantry. Two industrial coolers similar to what might be found in a restaurant kitchen on opposite walls are filled with fresh produce. The rest of the walls are lined with shelves neatly stocked with nonperishable goods such as canned vegetables, whole wheat pasta, peanut butter, and dried beans.

Before selecting food items, participants must attend a small-group session run by a physician or medical student-Riverside is a residency training facility-to learn about nutrition and healthy eating. A dietitian helped develop the program’s curriculum, and participants have the option to meet with a diabetes educator for more in-depth education.

“Some of these patients only get 10 minutes every three months with their PCP,” Hommema says. “Obviously, their PCP is going to talk to them about diet, but there are s so many other things going on in their regular appointment, particularly when they’re a diabetic. Now, they’re getting 15 to 20 minutes of face-to-face time with the physician or medical student every time they visit the food pantry to reinforce those dietary lessons.”

As of late September, there were 58 participants who have been seen more than once, 35-45 of whom return every week. Riverside has capacity to provide food for 150 people a week, and including participants’ family members, it has nearly reached that number, Hommema says.

On average, the practice spends $7 to $8 per person for produce per week, Hommema says. The $40,000 used to buy the food comes out of the practice’s supplies budget. Riverside receives funding to train residents, and there’s flexibility in how the money is spent, Hommema says. “We had some extra money [in the supplies budget] that we could put towards this. In the grand scheme of things, that isn’t very much. Compared to the cost of healthcare, insulin, and medicine, it’s a pretty low-cost budget.”

 

The hoped-for effects

Providing the produce might be relatively low-cost, but it’s not low value to those participants who receive it.

Because the program doesn’t measure weight or blood sugar levels when participants join, it relies on measurements such as weight and A1C count from regular PCP visits to track progress. Those figures are already showing significant improvement after four months.

Of the 12 patients tracked, nine have seen reduced A1C levels-and six saw more than 1 percent reduction. Ten have lost more than 5 pounds.

“Patients come in every week and tell us about how they discovered their blood sugar’s better controlled, or their clothing is loose,” says Miriam Chan, PharmD, director of research and evidence-based medicine education for Riverside.

One participant related the story of grabbing a pair of jeans from the dryer and throwing them on in a hurry, only later to discover they were her daughter’s jeans, which are four sizes smaller than the participant usually wears. Now those slimmer jeans fit her.

Family members are also reaping the benefits because they’re eating better, Chan says. “One parent told us how her granddaughter who is not diabetic has lost 20-some pounds.”

Actually seeing those benefits is the most important result, Hommema says.

“It’s exciting when their A1C is better, but they sometimes don’t feel any different,” she says. “If they’re seeing change and feeling different, that’s reinforcing and keeping them engaged. It’s not some crazy diet or exercise. We just changed the food they’re eating and making it easy and accessible for them [to get it].”

 

The unforeseen side effects

The benefits of the Food is Health program go beyond patients and family members. It’s benefiting the physicians, as well.

“Physicians don’t learn about food insecurity in medical school, and it’s such an embarrassing issue for patients that they’re not likely to talk about it,” Hommema says. “When their doctor is telling them they need to eat more vegetables, cut down on carbs, and eat healthy, patients will just say, ‘OK,’ because they’re embarrassed to admit they can’t afford those healthier foods.”

Being aware of the possibility that patients may be food-insecure, and asking questions to probe for that situation, can help physicians better understand their patients and meet them where they are, she says. Having a food pantry on-site reinforces that physicians care about their patients’ health.

 The residents and physicians are developing closer relationships with the patients through the program, and Hommema has noticed that is improving those doctors’ morale.

“One side effect of this program that we weren’t looking for but have seen has been how engaged, excited, and happy this has made our providers,” Hommema said. “Those who are participating love it. They’re asking to do more, actually.”

One resident was frustrated with practicing medicine, even though she wasn’t even in private practice yet, Hommema says. “After she did a month with the Food is Health program, her actual quote was, ‘This is exactly what my heart needed right now.’

“That means a lot to me. I expected they would enjoy it, but I didn’t realize that it could really change their perception of patients, disease management, and really their meaning in work. It’s been really great to see.”

Often, physicians get frustrated when they’re treating diabetic patients but aren’t seeing any improvement because of factors they have no control over, such as patients’ diets, Chan says. Helping patients get access to healthy food is one thing physicians can do to make a difference for patients with diabetes.

If physicians understand the benefits patients can experience from increased access to healthy food, they can refer the patient to a food pantry, collaborate with other practitioners, or even set up their own pantry, she says.

As for the Riverside Family Practice Center, there’s a lot of places it can go with this program, Hommema says. She’d like to expand it to include patients with chronic heart failure or high blood pressure, or who are obese.

“There are a lot of patients we could expand it to to help their long-term health outcomes,” she says.

Dave Schafer is a freelance writer based in Columbus, Ohio.