1. Food Insecurity and Material Deprivation: The Impact of Unmet Basic Needs on Diabetes Management JOHN BILLIMEK, PHD ASSISTANT PROFESSOR IN-RESIDENCE HEALTH POLICY RESEARCH INSTITUTE

2. Today’s session 1.What is Food Insecurity, and how far does it reach? 2.What are the ripple effects of food insecurity? 3.How can the health system respond?

3. Food insecurity a lack of access to nutritious food due to a lack of money and resources

4. Food insecurity with chronic disease of NHIS participants with chronic illness report food insecurity

5. Berkowitz data

7. California Health Interview Survey (CHIS) Annual survey Random-digit dial Population-weighted sampling N ≈ 20,000 per year

8. Orange County, CA Anaheim 9.3% Santa Ana 15.1% Irvine 2.2%

9. Prevalence of Food Insecurity with type 2 diabetes (2012-2014 CHIS)

10. Access to healthy food * *

11. Post ACA  fewer FI uninsured 2011 2012 2013 2014 21.3% 12.7% 17.4% 19.2% ACA Medicaid Expansion Jan 1, 2014

12. Insurance enrollment for low income households in California Food Secure, Low Income Food insecure ACA Medicaid Expansion Jan 1, 2014 ACA Medicaid Expansion Jan 1, 2014

13. Recommended processes of care *

14. Delays in care * *

15. Patient-centered care * *

16. R2D2C2 Study NIDDK, RWJ, Novo Nordisk funded RCT Disparities in diabetes management Low-income, ethnically diverse sample (N=1484) Data collection ◦Patient questionnaires ◦Chart review ◦Audio recordings Analytic subset for current study ◦Latino patients treated at FQHC (N=738) Kaplan 2013. J Gen Int Med 28(10): 1340-9

17. Food insecurity/material deprivation of Latino participants report food insecurity/material deprivation In the last 12 months, have you spent less on food, heat or other basic needs so you would have enough money for your medicines?

18. Participant Characteristics Food Secure (N=490) Food Insecure (N=248) Age57 ± 1153 ± 10 *** Age at diagnosis47 ± 1243 ± 11 *** Gender, % female64%72% * Education, years7 ± 57 ± 4 Born outside US, %16%13% * p<0.05, *** p<0.001

19. Similar income levels, different insurance access INCOME Food Secure Food Insecure <$20,000 58.4%63.3% $20,000-39,999 13.9%13.7% $40,000-59,999 2.7%1.6% $60,000+ 4.1%2.8% Declined to report 21.0%18.5% INSURANCE Food Secure Food Insecure Uninsured 28.8%50.0% Commercial 6.7%6.0% Medicare 19.4%10.9% Medicaid 31.0%29.0% Medicare + Medicaid 14.1%4.0% p>0.05 p<0.001

20. A1c and LDL control

21. Recommended processes of care

22. Stressful life events * * * *

23. Barriers to access * * *

24. Patient-provider relationship * *

25. Medication nonadherence * * * *

26. How can the health system respond?

28. Patient-Provider Communication about barriers may improve outcomes p=0.014 In audio-recorded medical visits (N=263)

30. Conclusions o Food insecurity disproportionately affects individuals with type 2 diabetes o % Uninsured falling, but still high o Delays in care and less patient-centered care o Food insecurity reflects crisis o Many co-occuring stressors and barriers accompany a lack of food o A symptom as well as a risk factor o Medication adherence plummets with Food insecurity o Problem-solving in the patient-provider encounter may help mitigate bad outcomes

31. Questions? John Billimek, PhD UC Irvine Health Policy Research Institute jbillime@uci.edu