Journal of General Internal Medicine

, Volume 34, Issue 12, pp 2779–2785 | Cite as

Differential Impact of Food Insecurity, Distress, and Stress on Self-care Behaviors and Glycemic Control Using Path Analysis

  • Rebekah J. WalkerEmail author
  • Jennifer A. Campbell
  • Leonard E. Egede
Original Research



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.


food insecurity stress distress epression self-care behaviors 


Author Contributions

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.

Funding Information

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.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Rebekah J. Walker
    • 1
    • 2
    Email author
  • Jennifer A. Campbell
    • 1
    • 2
    • 3
  • Leonard E. Egede
    • 1
    • 2
    • 3
  1. 1.Division of General Internal Medicine, Department of Medicine Medical College of WisconsinMilwaukeeUSA
  2. 2.Center for Advancing Population ScienceMedical College of WisconsinMilwaukeeUSA
  3. 3.University of Wisconsin, Milwaukee, Joseph Zilber School of Public HealthMilwaukeeUSA

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