Food Insecurity and Diabetes Management Among Adults of African Descent: A Systematic Review

Abstract

Aims:

This systematic review explores the established causal link between food insecurity and cardiometabolic conditions among adults of African descent. Specifically, this study examined the relationship between food insecurity and the management of type 2 diabetes, highlighting the prevalence of food insecurity among individuals of African descent with type 2 diabetes.

Methods:

Original English papers were meticulously searched in databases including PubMed, CINAHL, PsycINFO, Medline, Cochrane, Embase, and Web of Science. The Cochrane Risk of Bias Tool for quantitative studies and COReQ for qualitative studies were employed to assess biases. Three independent reviewers meticulously evaluated and synthesized results, reaching a consensus.

Results:

Among the 198 studies identified, 14 met the inclusion criteria for data extraction and analysis, which were conducted independently by three reviewers. The findings indicate that individuals of African descent are more likely to experience food insecurity compared to their White counterparts and are also more prone to diabetes risk factors or the presence of diabetes.

Conclusions:

This study underscores a higher prevalence of food insecurity and type 2 diabetes among adults of African descent, suggesting that ethnicity and food insecurity play significant roles in diabetes management. Future research should prioritize interventions aimed at reducing these disparities.

Introduction

Access to nutritious food is crucial for both physical and mental health, encompassing factors such as proximity to affordable grocery stores, affordability of food, and the availability of transportation to reach grocery stores.^1,2 Being “food secure” also entails having the financial means to acquire foods that meet one’s dietary requirements.^1,2 Type 2 diabetes (T2D), a chronic non-communicable condition requiring dietary management, often incurs substantial costs.³ Ineffective T2D management has been linked to numerous complication.^3,4,5 Given the significant role of dietary habits in diabetes management and its modifiable impact on cardiovascular (CV) disease, regulating one’s diet is pivotal to overall health. ^3,4,5 However, various social determinants of health (SDoH), including structural racism, discrimination, and acculturation, may impede adequate access to resources conducive to a healthy lifestyle.^5,6

Vulnerable and marginalized populations, lacking either the physical or financial means to secure adequate resources, may grapple with insecurities in their basic necessities.^5,6 Groups with lower health literacy, particularly those with lower socioeconomic status, may struggle to comprehend their dietary needs and are unaware of available resources to address food insecurity. ^5,6 Economic factors and health literacy collectively contribute to a person’s food security and health ^4,5. Marginalized populations, such as individuals of African descent, which encompasses various sub-groups (e.g., African Americans, African Caribbeans), face disproportionate challenges in attaining good health due to heightened levels of food insecurity, among other socioeconomic barriers. ^4,5

While existing studies have highlighted elevated rates of food insecurity among the general population of individuals with T2D, more literature needs to be synthesized to specifically examine the implications of food insecurity on the management of diabetes among sub-groups of African descent. Therefore, this study aimed to examine the relationship between food insecurity and the management of T2D, highlighting the prevalence of food insecurity among individuals of African descent with T2D.

Materials and Methods

Eligibility Criteria

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines,⁷ this systematic review focused on understanding the relationship between food insecurity and the management of T2D, as well as the prevalence of food insecurity among adults of African descent with T2D. The term “African descent” was defined broadly to include various Black sub-populations such as African American, African Caribbean, and Haitian adults. Studies were included if they involved individuals of African descent, were published in English, and collected data on one or more food insecurity measures along with one or more objectively measured non-communicable disease-related outcomes. Studies were excluded if they involved other chronic health conditions (e.g., cancer), interventions including pharmacologic treatment interventions, participants under 18 years of age, animal studies, or gestational diabetes, or if they lacked relevant data. The protocol was registered with the PROSPERO registry in the International Prospective Register of Systematic Reviews⁸ (registration number CRD42022334228) before the search was implemented.

Search Strategy

A comprehensive search was conducted across PubMed, CINAHL, PsycINFO, Medline, Cochrane, Embase, and Web of Science databases between July 5th and July 10th, 2022. The search was developed by a medical librarian and one investigator. Across all the databases, the search terms used were: ((food insecurity) AND (type 2 diabetes)) AND (‘Haitian’ OR ‘Black’ OR ‘African Caribbean’ OR ‘African American’, OR ‘African descent’)

Study Selection

From the 198 studies identified and uploaded to Covidence,⁹ 60 duplicates were removed, with an additional 4 identified during title and abstract screening. A total of 134 studies underwent screening, where two independent reviewers evaluated each study, resolving conflicts with a third reviewer. Seventy-four studies were deemed irrelevant, leaving 60 studies for full-text review. Figure 1 illustrates the study selection process.

Figure 1.

PRISMA Study Flow Diagram

Data Extraction

Three independent reviewers manually extracted information from the 60 studies undergoing full-text review. Forty-six reports were excluded primarily due to wrong study design or study outcomes where food insecurity was only mentioned but not actually examined. The remaining 14 papers that met inclusion criteria were synthesized based on observed trends and themes.

Quality Appraisal

Two reviewers independently assessed the risk of bias using the Cochrane Risk of Bias Tool for cross-sectional and observational studies. Quantitative studies were rated as low risk, some risk, or high risk. Qualitative studies were evaluated using the Consolidated Criteria for Reporting Qualitative Research’s (COREQ’s) across three domains and rated good, fair, or poor based on seven criteria.¹⁰ Any discrepancies were resolved through group discussion. Most quantitative studies were rated as low or some risk, with two rated as high risk. Of the three qualitative studies selected, two were rated as “good,” with one rated as “fair” due to the population sample. The findings of the risk of bias assessments are summarized in Supplemental Tables 1 and 2.

Data Synthesis

Synthesized data from the 14 included studies are organized in Figure 1, highlighting key points for each study. The synthesis focused on two primary aims: 1) examining the relationship between food insecurity and the management of T2D in adults, and 2) understanding the prevalence of food insecurity specifically among T2D adults of African descent.

Results

Study Characteristics

The review identified 14 studies that met the inclusion criteria and examined them in detail. The studies were published between 2013 to 2022, with the majority (73%) being published after 2016. The study designs varied across the fourteen papers, with the most prevalent being cross-sectional analyses.^{11,12,13,14,15,16} All of the studies were conducted in the United States. The U.S. Household Food Security Scale was the most commonly used method to assess food insecurity (n=6).^{13,15,17,18,19,20} Two studies utilized the National Health & Nutrition Examination Survey. ^20,21 The number of participants ranged from 37 to 22,596, with a total number of 53,809 participants across all included studies.

Aim 1: Association Between Food Insecurity and Type 2 Diabetes Management Among Populations of African Descent

Overall, six studies^{12,13,14,16,18,20} reported a relationship between food insecurity and poor T2D management. Poor T2D management was defined differently across all the studies, including having more diabetes complications,¹² having a glycated haemoglobin A1C (HbA1c) of 8-<9% (64 to <75 mmol/mol), ¹⁶ or having increased HbA1c levels.¹⁴ Diabetes complications were defined as retinopathy, nephropathy, neuropathy, and a poor quality of life.¹⁷

One cross-sectional study used survey data from 2011–2016 to categorize participants by their HbA1c values.¹⁶ HBA1c levels in one study²⁰ were measured several times over 24 months at a community health center. Three studies reported food-insecure participants had higher HbA1c levels than those who were food secure.^13,16,20 In a secondary analysis examining glycemic control and food security, individuals with both a poor diet and food insecurity had significantly higher odds of poor glycemic control (AOR = 6.12). Similarly, Black participants were found to have higher associations with poor glycemic control (AOR = 6.12).¹⁶ In a longitudinal observational study, food-insecure participants were more likely to be on insulin.²⁰ Another cross-sectional study reported that food-insecure individuals had a higher rate of diabetes complications and a lower quality of life.¹⁷ In addition to a clear correlation between food insecurity and poor diabetes management across all populations studied, the results specifically highlighted that individuals of African descent have a disproportionately higher association with poor diabetes management compared to their counterpart.

Aim/goal 2. Prevalence of Food Insecurity Among Populations of African Descent

The second aim of this study was to examine the prevalence of food insecurity in African descent adults with type 2 diabetes. To highlight the heterogeneity within Black populations, studies that included participants of African descent were separated and re-examined using the same inclusion criteria listed in the search methods. The prevalence of food insecurity among T2D adults of African descent was found in six studies^{14,15,16,21,23,24} (Table 3). These studies indicated that Black or African American participants were more likely to have diabetes or risk factors compared to their counterparts.^{14,15,16,21,23,24} Additionally, seven studies^{14,15,17,19,20,23,24} identified that Black or African American participants were more likely to experience food insecurity when compared to White participants.

Table 3. Results Summary:

Prevalence of Food Insecurity

	Breland et al., 2013[24]	Nikolaus et al., 2022 [14]	Rhee et al., 2021 [21]	Rodriguez et al., 2022 [15]	Shaheen, Kibe & Schrode, 2021 [16]	Strings et al., 2016 [23]
Studies that identified African Descent participants as more likely to be diabetic or have diabetes risk factors	Participan ts reported having diabetes for an average of 8 years. 30% of participant s were African American, 70% were Latino.	Diabetes was the most prevalent among black respondents (15%)	35.9% of Black participants reported diabetes compared to 18.7% of white non- Hispanic participants	African American adults had increased diabetes risk factors and behavior change barriers compared to White adults, including a higher BMI distribution, lower income levels and educational attainment, higher family history of diabetes, higher sugary beverages consumption, fewer exercise, and higher food insecurity.	17.9% of those with an HbA1c ≥ 9 (≥ 75 mmol/mol) were non- Hispanic Black despite the sample being predominantly white. being Black was a risk factor for poor glycemic control	Black women reported the highest percentage of diabetes (12%)
	Breland et al., 2013 [24]	Shalowitz et al., 2017 [13]	Strings et al., 2016 [14]	Lynch et al., 2020 [17]	Rodriguez et al., 2022 [15]	Sattler et al., 2014 [19]
Studies that identified participants of African descent as being more likely to be food insecure when compared to other participants.	The majority (57%) of participants (which were all either African American or Latino) reported a yearly income between $5,000-$15,000, which suggests being unable to afford sufficient or nutritious food.	53 out of the 90 African American participants (59%) were food insecure	Black respondents reported higher levels of very low food insecurity and low food insecurity, 22% and 20% of Black women and 19% and 20% respectively of Black men.	89% of the participants were African American and 44.3% reported food insecurity	The two highest rates of food insecurity were 22% of African American participants and 36% of multiracial participants	Food insecure individuals were more likely to be African American (34.1%)

In a qualitative study involving participants residing in East Harlem, NY, a historically underserved neighborhood, many individuals with diabetes reported financial difficulties as the primary reason for their inability to afford a healthy diet; many also reported a lack of knowledge on how to cook healthfully.²⁴ Both inadequate access to resources and lack of nutritional knowledge contribute to the mismanagement of diabetes among this population.

Four studies^14,15,23,24 specifically examined the association between food insecurity and Black or African American people with T2D. In a qualitative study that surveyed minorities living in East Harlem, NY, where most residents are Black or Latino, all participants had diabetes, and over half reported an income between $5,00-$15,000.²⁴ Participants reported limited access to healthy foods and difficulty finding transportation to stores with more nutritious options. Many also reported high stress levels related to unemployment, financial concerns, and health issues. Some participants had a limited understanding of diabetes and how to manage it, noting inadequate advice from their healthcare providers.²⁴

In a cross-sectional study of over 12000 participants, Nikolaus et al. found that both T2D and food insecurity was most prevalent among Black respondents. The study also linked food insecurity to higher levels of obesity (45%) and diabetes (15%) among Black respondents compared to non-Black counterparts.¹⁴ Rodriguez et al.¹⁵ examined increased diabetes risk factors and barriers, such as food insecurity, among participants. Despite only 32% of participants being Black/African descent/multiracial, this subgroup had the highest rates of food insecurity, noted by statistically significant increased diabetes risk factors and health barriers (such as higher BMI distribution, wealth inequity, and family history of diabetes).¹⁵ In the study by Strings et la.,²³ Black women had the highest rates of diabetes, and Black respondents reported the highest rates of very low food insecurity. ²³ There was a positive association between higher risk of T2D and diabetes-related complications among Black or African descent participants who were food insecure compared with non-African descent populations. ^14,15,23,24

Discussion

This review synthesized data from fourteen studies examining the relationship between food insecurity and T2D management in adults of African descent. The results of this review corroborate earlier studies,^25,26,27 consistently highlighting a significant connection between food insecurity and diabetes.^{3,4,5,25,26,27} The nexus between low income, food insecurity, and poor diet quality suggests a suboptimal nutritional trajectory for this population, as indicated by multiple studies that have linked food insecurity with participants experiencing diabetes and poor diabetes management.

In a recent study by Levi et al.²⁵ the correlation between food insecurity and cardiometabolic conditions was explored in patients with T2D, revealing a significant relationship. Moreover, the literature suggests that individuals of African descent are more likely to experience food insecurity and diabetes.^{14,15,16,21,23,24} However, not all studies have thoroughly examined the relationship between these factors,¹⁸ and one study¹⁸ noted that food-insecure individuals were more likely to be of African descent, underscoring the need for further investigation.

Collectively, the studies highlight the importance of addressing psychosocial barriers alongside diabetes self-management.

It is evident that poor glycemic control in adults of African descent contributes to negative health outcomes, increased morbidity, and mortality. Individuals with poorer glycemic control are at higher risk of diabetes-related complications, such as nephropathy and neuropathy, and face higher odds of negative health outcomes, including mortality. The findings indicate a barrier to health equity for populations of African descent.

While systems of inequities contribute to food insecurities within the African descent populations, there must be a greater focus within healthcare on the correlations between high HbA1c levels, medication adherence, health literacy, and social determinants of health.^24,25 The studies collectively conclude that there needs to be more emphasis on self-management education, including strategies such as promoting healthier and more consistent eating habits.

Given the gaps in the literature that specifically examine sub-groups of African descent, such as Afro-Caribbean populations, there is a clear need for better representation of these sub-populations. Future research should provide more detail and thoroughness in demographic descriptions to better understand the ethnic background of study participants. A limitation of the evidence used is that only studies written in English were examined. If language barriers were not present, more studies might have been included, potentially leading to a more holistic data analysis. Furthermore, while data was available from studies that included Black or African American participants, it is unclear if any participants were African Caribbean. This lack of African Caribbean representation highlights a gap in the literature on type 2 diabetes and food insecurity.

Future Considerations and Implications

The implications of this review are multifaceted and highlight the need for increased attention to the intersection of food insecurity and T2D among individuals of African descent. Addressing these coexisting issues requires targeted approaches from researchers, clinicians, and policymakers, rather than one-size fits-all solutions. Future research direction would be to measure food insecurity and diabetes management in specifically African Caribbeans and their respective countries of origin. This review underscores that individuals of African descent in America face significant barriers to health equity; however, distinct psychosocial climates exist in various African Caribbean countries. While this review provides important indicators that African American and African Caribbean people in America face barriers to health equity, different psychosocial climates exist in various African Caribbean countries. The next step is to design interventions that provide resources and teaching strategies explicitly addressing the challenge of managing diabetes while experiencing food insecurity. Moreover, sustainable policy changes are urgently needed to acknowledge food insecurity as a modifiable factor in future research and diabetes management interventions. Such policies could lead to better health outcomes and improve self-management behaviors among populations of African descent. Policies at the federal level, such as those proposed at the historic White House Conference on Hunger, Nutrition, and Health and corresponding National Strategy recommended polies, are a great starting point.

Conclusions

Food insecurity and T2D are interconnected through various pathways. This review highlights the importance of considering psychosocial barriers when developing improved diabetes education. The findings collectively demonstrate a gap in equal access to food security and diabetes management among individuals of African descent from different perspectives and measures. This correlation underscores the need for deeper research on Blacks and within-group examinations, including but not limited to African Caribbean groups, to fully understand the extent of health barriers.

More personalized education and assessments of the social determinants of health for food-insecure participants are essential to ensure best practices in self-management, treatment adherence, and improved health outcomes.

Table 1.

Characteristics of the Study Population

Author/Year	Location	Sample Size	% Food Insecurity	% Women	% Men	Avg. Age (Years)	Ethnic Breakdown
Breland et al. (2013)	East Harlem, NY, USA	37	40%	73%	27%	54.97	30% African American, 70% Latino
Caraballo et al. (2020)	USA	8967	40.30%	49.10%	50.90%	51.6	19.9% non-Hispanic black
Davis et al. (2019)	USA	117	100%	N/A	N/A	51.1 for group 1 and 61.4 for group 2	100% non-Hispanic African American
Heerman et al. (2015)	Tennessee, USA	401	73%	61%	39%	52	17% Black, non-Hispanic
Flint et al. (2019)	USA	243	53%	N/A	N/A	56.25	100% African American
Lynch et al. (2020)	West Side Chicago, USA	1106	44.3% (490 participants)	57.40%	42.60%	53	989 African American (89%)
Nikolaus et al. (2022)	USA	3992	11%	55.90%	44.10%	37.73	13.8% Black or African American
Nikolaus et al. (2022 - June)	USA	12799	11%	50%	50%	28.83	2666 participants were Black
Rhee et al. (2021)	USA	954	5.40%	55.70%	44.30%	73.2	26% non-Hispanic Black (247 out of 954)
Rodriguez et al. (2022)	CA & MI, USA	336	22% of African American participants	74% for African American participants	26% for African American participants	54 for African American participants	116 were African American (35%)
Sattler et al. (2014)	USA	243	54.30%	77.40%	22.60%	74.2	27.2% African American
Shaheen, Kibe & Schrode (2021)	USA	1682	31.80%	48.50%	51.50%	47.9% between 60–85	14.7% non-Hispanic Black
Shalowitz et al. (2017)	USA	336	56%	56%	44%	51	26.8% African American
Strings et al. (2016)	CA & MI, USA	22596	42%	42.40%	57.60%	31% were 18–30	1486 participants were Black

Table 2. Results Summary:

Association Between Food Insecurity and T2D Management

	Heerman et al., 2015 [13]	Flint et al., 2019 [12]	Nikolaus et al., 2022 [14]	Nikolaus et al., 2022 [18]	Shaheen, Kibe & Schrode, 2021 [16]	Shalowitz et al., 2017 [20]
Association Between Food Insecurity and Type 2 Diabetes Management	In the adjusted proportional odds regression models, food insecurity was associated with general diet, activity/exercise behaviors, calorie restriction, and adherence to refills and medication. The median HbA1c for food insecure participants was 9.3% (78 mmol/mol) compared to (8.6%) 71 mmol/mol for food secure participants (this relationship remained significant after adjustment)	Food insecure individuals had a higher percentage of diabetes complications (neuropathy, retinopathy, nephropathy, and hypoglycemia) as well as a lower quality of life.	In both unadjusted models and when adjusting for socio demographic characteristics, risk of food insecurity was significantly associated with greater odds of diabetes.	Presence of diabetes at wave 5 was more prevalent in those who reported food insecurity at wave 4.	37.7% of those with an HbA1c ≥ 9% (≥ 75 mmol/mol) had food insecurity and a poor diet, compared to 20.8% HbA1c < 7% (<53 mmol/mol).	Food insecure participants had, on average, a longer time since diabetes diagnosis (median 6.5 years compared to 5 years). The mean HbA1c was also higher in the food insecure group. Food insecure participants were more likely to be on insulin (36% compared to 23%). Less food security was associated with increasing HbA1c levels.

Novelty Statement.

What is already known?

• Extensive evidence supports the existence of a significant association between food insecurity and cardiometabolic conditions.

What this review found:

• This review delves into the prevalence and impact of food insecurity on diabetes self-management among Adult of African descent with type 2 diabetes.

• The collective findings underscore the significance of addressing psychosocial barriers concurrently with diabetes self-management in the African descent population.

Implications of the study:

The studies collectively highlight an existing disparity in equal access to food security and diabetes management among individuals of African descent, as observed from diverse perspectives and measures.

This correlation emphasizes the need for further research focusing on populations of African descent, including within-group examinations such as those involving African Caribbeans. Such investigations are crucial to accurately assess the true extent of health barriers within these ethnic populations.

The overall aim is to comprehensively examine health barriers within the broader Black community and ascertain the true extent of these challenges.