Differential Impact of Food Insecurity, Distress, and Stress on Self-care Behaviors and Glycemic Control Using Path Analysis
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The aim of this study was to investigate the direct and indirect pathways through which food insecurity influences glycemic control and self-care behaviors.
Using data collected from 615 adults with type 2 diabetes, we investigated pathways between food insecurity and diabetes outcomes using path analysis. We included measures of perceived stress, diabetes distress, diabetes fatalism, and depression as psychosocial factors in the pathway. Self-care behaviors included general diet, specific diet, exercise, blood sugar testing, foot care, and medication adherence. Analyses were conducted using Stata v14, to include both direct and indirect effects, with standardized estimates to allow comparison of paths.
Food insecurity was directly associated with stress (r = 0.43, p < 0.001), depression (r = 0.34, p < 0.001), fatalism (r = 0.09, p = 0.03), and distress (r = 0.36, p < 0.001). The type of stress, however, was differentially associated with outcomes, with distress associated with HbA1c (r = 0.25, p < 0.001), general and specific diet (r = − 0.28 and − 0.17, respectively, p = 0.001), and medication adherence (r = − 0.26, p < 0.001), while stress was associated with specific diet (r = − 0.14, p = 0.005) and medication adherence (r = − 0.15, p < 0.001) and depression was associated with exercise (r = − 0.06, p = 0.007). Food insecurity was indirectly associated with HbA1c (r = 0.08, p = 0.001), and four self-care behaviors (general diet, specific diet, exercise, and medication adherence).
Food insecurity influences self-care behaviors indirectly via multiple psychosocial factors, and glycemic control indirectly through diabetes distress, supporting the hypothesis that stress is an important mechanism. Programs to improve access to resources and manage psychosocial concerns should be combined with food-based programs for food insecure populations with diabetes.
KEY WORDSfood insecurity stress distress epression self-care behaviors
RJW, JAC, and LEE designed the study. RJW and LEE collected data, and conducted analyses. RJW drafted the manuscript. All authors reviewed and edited the manuscript, and contributed to interpretation of results and discussion of implications.
Effort for this study was partially supported by the National Institute of Diabetes and Digestive Kidney Disease (K24DK093699, R01DK118038, R01DK120861, PI: Egede), the National Institute for Minority Health and Health Disparities (R01MD013826, PI: Egede/Walker) and the American Diabetes Association (1-19-JDF-075, PI: Walker).
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 1.Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. 2018. Household Food Security in the United States in 2017, ERR-256, U.S. Department of Agriculture, Economic Research ServiceGoogle Scholar
- 3.Berkowitz SA, Meigs JB, DeWalt D, Seligman HK, Barnard LS, Bright OJ, Schow M, Atlas SJ, Wexler DJ. Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study. JAMA Intern Med. 2015;175(2):257-65.PubMedPubMedCentralGoogle Scholar
- 26.Walker RJ, Williams JS, Egede LE. Pathways between food insecurity and glycemic control in individuals with type 2 diabetes. Public Health and Nutrition. 2018 8: 1-8.Google Scholar
- 27.Mendola ND, Chen T-C, Gu Q, Eberhardt MS, Saydah S. Prevalence of total, diagnosed, and undiagnosed diabetes among adults: United States, 2013–2016. NCHS Data Brief, no 319. Hyattsville, MD: National Center for Health Statistics. 2018.Google Scholar
- 28.Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security, Revised 2000. US Department of Agriculture, Food and Nutrition Scervice, Alexandria VA. 2000.Google Scholar
- 32.Cohen, S. and Williamson, G. Perceived Stress in a Probability Sample of the United States. Spacapan, S. and Oskamp, S. (Eds.) The Social Psychology of Health. Newbury Park: Sage, 1988.Google Scholar
- 34.Fisher L, Glasgow RE, Mullan JT, Skaff, MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Annuls Fam Med. 2008.;6(3):246-252.Google Scholar
- 38.National Center for Health Statistics. Survey Questionnaire, National Health Interview Survey, 2002. National Center for Health Statistics, Hyattsville. 2004.Google Scholar
- 39.Kline RB. Principles and Practice of Structural Equation Modeling, 4th Edition. New York: Guilford Press, 2016.Google Scholar
- 40.Schumacker RE, Lomax RG. A Beginner’s Guide to Structural Equation Modeling, 3rd ed. New York: Taylor and Francis Group, 2010.Google Scholar
- 41.Schreiber JB. Core reporting practices in structural equation modeling. Res Soc Admin Pharm 2008;4:83–97.Google Scholar
- 42.Hooper D, Caughlan J, Mullen MR. Structural equation modeling: guidelines for determining model fit. Electron J Business Res Methods 2008; 6:53–60.Google Scholar
- 43.Epel ES, Crosswell AD, Mayer SE, Prather AA, Slavich GM, Puterman E, Mendes WB. More than a feeling: a unified view of stress measurement for population science. Frontiers Neuroendocrinology. 2018; 49: 146-169.Google Scholar
- 45.Anater AS, McWilliams R, Watkin CA. Food acquisition practices used by food-insecure individuals when they are concerned about having sufficient food for themselves and their households. J Hunger Environ Nutr 2011;6:27–44.Google Scholar