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. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: Patient Educ Couns. 2021 Mar 31;104(11):2785–2790. doi: 10.1016/j.pec.2021.03.032

Insights about Interventions to Address Food Insecurity in Adults with Type 2 Diabetes: Valuable Lessons from the Stories of African Americans Living in the Inner City

Rebekah J Walker 1,2, Renee E Walker 3, Elise Mosley-Johnson 1,2, Leonard E Egede 1,2
PMCID: PMC8481339  NIHMSID: NIHMS1689229  PMID: 33838940

Abstract

Objectives:

This qualitative study aimed to gain insight from the perspectives of food insecure African Americans living in an inner city regarding important diabetes intervention strategies and components.

Methods:

Using a grounded theory approach, two focus groups (16 individuals) were conducted in Milwaukee, Wisconsin. Purposive, convenience sampling was used to identify food insecure adults with diabetes. Questions were asked using a moderator guide to explore challenges and barriers to managing diabetes within the context of food insecurity, and facilitators or resources that helped participants improve diabetes management. Questions were open ended and followed by probes asking for additional perspectives and personal experiences related to the overarching topic, and questions asking to clarify statements.

Results:

Overarching concepts and themes specific to possible interventions discussed during the focus groups included group education, peer support, access to community resources and programs, stress management, and faith-based programs as desired intervention outcomes.

Conclusions:

Key findings from the current study show that inner-city African Americans with diabetes desire interventions that foster social and community support systems.

Practice Implications:

Given this insight, more robust and comprehensive interventions are needed to account for the multifaceted experience of food insecurity and diabetes within the inner-city environment.

Keywords: food insecurity, inner-city, African American, type 2 diabetes, qualitative

1. Introduction

Significant health disparities in the prevalence and burden of diabetes exist for minorities, with new cases of type 2 diabetes being highest among non-Hispanic Blacks and people of Hispanic origin (1,2). Compounding this issue, approximately 11 percent of US households are food insecure, with households composed of individuals who are non-Hispanic Black and people of Hispanic origin experiencing low food security at more than twice the percentage of non-Hispanic Whites (3). Research has established that poor health is associated with food insecurity, and growing evidence shows targeting unmet material needs, such as food, are important for improving clinical outcomes (4–7). Additionally, mounting evidence shows associations between food insecurity and diabetes, specifically, people who are food insecure are more likely to have diabetes, be at risk for diabetes, have elevated HbA1c and experience increased rates of complications (8–16).

Major barriers to diabetes management exist at the individual, community, and healthcare system levels for African Americans living with diabetes in inner city environments most affected by urban poverty and food insecurity (17). Inner cities confer additional health risks to the people that reside within them today due to the impact of their historical legacies of disenfranchisement and economic divestment in the African American communities. In a past era, African Americans flourished when there was abundant employment from businesses and manufacturing companies in the central corridors of many rust-belt cities, known as inner cities (18–19). However, the compounding effects of economic divestment from the cities to the suburbs, discriminatory zoning laws, and racial restrictive covenants targeting African Americans and immigrants in the mid to late 20th century resulted in entrenched racial segregation, diminished home values, high income inequality, and depressed economic activity for the African American communities left behind (20–23). As a result, inner city environments create unique barriers to accessing both health care and healthy food options.

Historically, diabetes interventions have focused on problem solving challenges and barriers to diabetes self-management (24), diet modification, behavioral counseling, medication management (25), and improvements in physical activity (26). More recently, diabetes interventions are more innovative and technology-based, and incorporate digital coaching, online support group sessions (25,27), and computer assisted interventions (28). While these intervention components have shown some promise in improving short-term T2D-related biomarkers, long-term benefits are attenuated over time. One theory for this observation is that participants enrolled in diabetes interventions that do not have intervention components that are perceived as beneficial, useful, effective, or desirable, are less likely to engage in the intervention long-term (29). Previous studies identify diabetes self-care (e.g., physical activity, proper diet/nutrition, blood glucose monitoring, smoking, and foot care) as critical intervention components to reach glycemic targets, but there are limited examples of incorporating factors that influence self-care into these interventions (30–32). Given the association between diabetes and food insecurity, and the high number of food insecure households that use food pantries, research focused on food pantry interventions are promising, but, limited with primarily small studies and mixed results (33–34). Food pantry focused interventions have been shown to improve food insecurity status, weight outcomes and elevated HbA1c, though not dietary quality or dietary intake (34–37). In addition, more research is needed incorporating marginalized populations to fully understand the facilitators and barriers to intervention implementation (33–34,38).

Current research on food pantry interventions targeting diabetes and food insecurity account primarily for clinical needs, but few are grounded in the lived experience of the individuals who rely on pantries for food. Given the unique challenges that threaten the livelihoods and quality of life for African Americans living in inner cities, food pantries that provide food for this population are in a unique position to intervene on poor health outcomes with well-planned and tailored interventions. Therefore, this qualitative study aimed to gain insight from the perspectives of food insecure African Americans living in the inner city regarding important diabetes intervention strategies and components.

2. Methods

This study used a grounded theory approach to understand strategies and components needed to develop interventions that improve diabetes care and reduce diabetes complications among food insecure, African Americans with type 2 diabetes living in the inner city. Grounded theory is a qualitative research methodology that allows development of concepts through analysis of focus group or interview data to provide insight into the lived experience of participants (39). Grounded theory is characterized by use of an iterative approach, relying on constant comparisons by facilitators between responses by participants (39). Similarities and differences within the data are investigated, grouping concepts together into themes, which are further grouped into core categories (39). In this study, responses by participants during focus group discussions were grouped into themes that can inform intervention development for food insecure, African Americans with type 2 diabetes living in inner-city environments.

Study Design and Context of Focus Groups

Two focus groups, totaling 16 individuals, were conducted in Milwaukee, Wisconsin, an inner-city environment located in the Midwest United States. The local institutional review board reviewed and approved all study procedures prior to initiation of the focus groups. Participants were given a $25 incentive for participating in 90-minute sessions hosted at community-based sites. At each focus group, two facilitators led discussion using a structured moderator guide and two note takers captured comments throughout the discussion. In addition, focus groups were audio recorded and transcribed by a professional transcription service following completion of both focus groups. Following grounded theory procedures, facilitators and note takers discussed emerging ideas and concepts after each discussion with new ideas incorporated into the next session.

Participants and Procedures for Focus Groups

Purposive, convenience sampling was used to identify food insecure adults with diabetes. Targeted recruitment was conducted in food pantries in the inner-city using recruitment flyers advertising events and referral by food pantry workers. Individuals who were interested in participating called research coordinators to determine if they met eligibility criteria and be placed in a focus group that was convenient for them. Inclusion criteria included: 1) diagnosis of diabetes and 2) over the past year they either found it difficult to obtain enough food or worried they may run out of food before they had money for more.

Sessions lasted 90 minutes. An informational form was reviewed prior to starting the focus group so participants understood the purpose of the focus group and were aware the conversation would be recorded. The facilitator set ground rules and asked participants to introduce themselves, including their name, age, and how long ago they were diagnosed with diabetes prior to beginning the audio recording. Questions were then asked using the moderator guide to explore challenges and barriers to managing diabetes within the context of food insecurity, the role of food insecurity in managing diabetes, and facilitators or resources that helped participants improve diabetes management. Questions were open ended and followed by probes asking for additional perspectives and personal experiences related to the overarching topic, and questions asking to clarify statements. Participants were asked to identify components of interventions that could address barriers or asked to expand on components of facilitators/resources that would be helpful to include in interventions. Facilitators took notes to allow follow-up as necessary and ensured each participant was able to speak on each question.

Data Analysis

Based on discussions following the first and second focus group, facilitators determined themes were similar between the two focus groups, so theoretical saturation had been achieved and no further focus groups were held. Following transcription, transcripts and field notes were reviewed by the four coauthors to allow coding of themes. After reading and re-reading the entire transcript a list of codes was generated by each author. Discussion followed regarding how codes fit into themes that identified different strategies to intervention development with final themes decided on based on consensus. Each individual then reviewed the transcripts again focusing on how quotes fit into themes representing different types of interventions for food insecure African Americans with type 2 diabetes living in an inner city. Further discussion focused on how individuals captured their experiences through stories and offered insight through their experiences. Quotes from each of these individuals and stories were extracted to reflect the different types of interventions discussed by participants.

3. Results

Participants in the first focus group included 4 men and 6 women (10 total), aged between 40–57 years. Participants in the second focus group included 1 man and 5 women (6 total), aged between 30–77 years. Of the 16 total participants, 2 were diagnosed in the past year, four were diagnosed in the prior 5 years, and 10 were diagnosed between 10–20 years prior.

Overarching concepts and themes specific to possible interventions discussed during the focus groups are listed in Table 1. Based on extensive discussion during the focus groups surrounding the need for more education, participants agreed that diabetes education and skills training should be an integral component of any approach. The first two strategies involved incorporating social support into the intervention approach – through either group-based education or peer support programs. The third intervention strategy was incorporating access to community resources or programs into intervention components. Fourth, incorporating stress management into intervention components was suggested as a solution. Finally, significant discussion surrounded the importance of religion and spirituality as a coping mechanism, which led to faith-based programs as an intervention strategy.

Table 1:

Potential Interventions Identified through Focus Groups with Food Insecure Adults with Diabetes Residing in the Inner City

Group Based Education

  • Groups of 10–12 people

  • Discuss problems and challenges

  • Discussion about medication management

  • Mixed sex group

  • Healthcare facilitator that is not race dependent

Peer Support

  • Individual living with the disease to serve as a peer mentor

  • Mentor should have mastered disease and have lived with it awhile

  • Opportunities for peers to share experiences, challenges, and success for strategies

Access to Community Resources and Programs

  • Access to community resources

  • Vouchers to farmers markets/grocery stores

  • Stockboxes

  • Combination of stockboxes and vouchers

  • Information about how to use/cook food in boxes

  • Recipes/cookbook

  • Optimal frequency approximately 1–2x/month

Stress Management

  • Meditation

  • Prayer

  • Opportunity to talk openly about stress

  • Having social worker or clinical person available to provide counseling on stress management

Faith Based Programs

  • Positive messaging

  • Prayer

  • Use of scripture verses

  • Motivational messages
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Note: diabetes education and skills training should be an integral component of whatever intervention approach is used

Group Based Education

Participants noted the utility of providing education in a group-based format, combining the process of gaining new knowledge with lessons from fellow group members on applying the knowledge. Participants noted the importance of talking about their experience in a group format and hearing the experiences of others.

Participant 1 – female, 55 years old, diagnosed 2 years ago: “And classes like these. It helps because we can understand more about this disease that’s killing so many of us, so classes like this so we all can talk about it, it helps.”

Participant 2 – female, diagnosed 1 year ago: “Like at a hospital or something every other week have groups for diabetes that way people could understand and know better about their diabetes.”

Participant 3 – female, 50 years old, diagnosed 26 years ago: “And then classes on kind of to maybe reducing your medication intake because every time I go to the doctor, they’re presenting to me different medications, and before you know it, you’ve got a box full of medication. And that right there makes me feel a certain type of way like they’re keeping the diabetes in you instead of trying to help you get rid of that.”

Peer Support

The idea of having a peer who has lived experience with diabetes was noted as well. Participants highlighted the importance of a peer being able to relate to the challenges, struggles, and experiences of a person with diabetes.

Participant 4 – male, 53 years old, diagnosed 5 years ago after a liver transplant: “One diabetic knew another diabetic, what they’re going through, but if you ain’t no diabetic you couldn’t understand what we’re going through and what our body feel because you don’t take the insulin and you don’t have low blood and high sugars. So another diabetic probably could relate to what we’re talking about.”

Access to Community Resources and Programs

During focus group discussions, participants noted several community resources and community programs they found helpful, including meal programs, cooking programs, and community based social workers. They also noted resources that exist but could be more helpful with access to community programs that support healthy eating and access to healthy food.

Participant 5 – female, 65 years old, diagnosed for 14 years: “I think that meal program located on the first floor, I think that has taught me a lot of about portion control and I would first see those trays, I’d be like, “My goodness.” Now I see those trays and it’s like, “I can’t even finish this. ””

Participant 6 – female, 70 years old, diagnosed 35 years ago: “I come every day to the senior center, so they have nice fresh vegetables cooking, every day they cook. It’s fine and we do exercise every day.”

Participant 7 – female, 61 years old, diagnosed 1 year ago: “And that had social workers on staff there. And like once a month we have to meet with them about whatever’s going on which another problem you have. So it’s pretty good.”

Participant 8 – male, 63 years old, diagnosed 23 years ago: “Oh, maybe some kind of a real good cookbook. I remember seeing once a soul food diabetic cookbook. You ever see that one? Yeah. I’d like to get a hold of something like that. Some different recipes or something.”

Participant 2 – female, diagnosed 1 year ago: “And then they give you a Quest card… You’ve got to buy your food that you need and then you’ve got to turn around and try to get vegetables. They don’t even be enough on a Quest card for you to get your fruits and vegetables so what’s the plan on that part? Like how would that work? Like they might give people 100 and something dollars, you’ve got to think about it. That’s for them to get the meals they need and then they’ve got to try and stretch in their apples, the oranges, the fruits and the vegetables. That’s not enough.”

Stress Management

Stress was noted as a primary barrier by participants, with examples of different types of stress including diabetes related distress, work related stress, and family related stress. They noted that understanding the relationship between stress and diabetes, as well as assistance in managing stress would be helpful.

Participant 3 – female, 50 years old, diagnosed 26 years ago: “What stresses me out is not having the right doctor. Going to the doctor, I keep all of my appointments, however, my doctor just basically touch here and there and they don’t take the time to listen to you and what you’re going through and what you want to understand. So that’s one of my biggest stressors because I want to understand my diabetes. I want to know how to do better with myself.”

Participant 2 – female, diagnosed 1 year ago: “I had worked with kids over 25 years working in a juvenile institution and that was stressful because they believed that they taught them they can do whatever they want whenever they want and whatever they can do to anybody else and it was a stressor and I stayed there too long. Because I’ve had two strokes within two years. They were mild kind but it was basically from the stress I was going through. Not recognizing all of the stress and it was amazing that after I got out of there how it was like a weight lifted off your shoulders.”

Participant 5 – female, 65 years old, diagnosed 14 years ago: “For everything I thought I knew, I didn’t even know what that stress was a trigger for a higher number. So, I just get by with dealing with the stress the best way, know-how.”

Participant 9 – male, 43 years old, diagnosed 1 year ago: “[It] I could be your kids, your family. You know what I’m saying? You’re worried about something. You worry about going to the doctor, what the doctor going to say. You might hear bad news so you’re stress level will go up.”

Participant 7 – female, 61 years old, diagnosed 1 year ago: “I’ve been going through a lot of stress lately. I noticed that my sugar is much higher than it was when I’m calm. And that’s only because my daughter, her kids moved back home for a little while. And she got five kids that stayed in a one-bedroom apartment. So that keeps me jumping.”

Faith Based Programs

Finally, significant discussion surrounded the importance of faith and religion as a facilitator and the utility of incorporating faith into interventions. Participants consistently returned to this these throughout the focus groups, highlighting how they viewed scripture, food, and prayer within the context of their lived experience.

Participant 10 – female with T2DM (length of time unknown): “I mean, take a scripture the night before you come to the program. Our daily bread. Read a verse. The daily bread.”

Participant 2 – female, diagnosed 1 year ago: “Yeah, I know I read the book of Leviticus. Telling us what foods to eat. And after that, I love pork I love ribs and all that stuff. Catfish, all that other stuff. But I had to stop eating it because it wasn’t clean. In fact, what it was, it was damaging my body. And I found out and after that, I could do things a little better, control a little better, not eating all that pork.”

Participant 1 – female, 55 years old, diagnosed 2 years ago: “Spiritual food is the best food. And I wouldn’t be here if it wasn’t for talking to God because I have to rely on Him. Because most of the stuff that I eat, I know I don’t supposed to be eating. So, I’m trying to work on that now, eating right. Eating more healthier and trying to get this weight down. Because once you get a lot of weight on you like I have, it’s hard to get it off. It’s really hard. So for me, I have to pray about it. And just want to leave it alone. I know that He going to sit me down. And when I’m hungry, I just start drinking a lot of water. Besides eating all this unhealthy stuff, Hot Pockets, and all that, I just stopped eating it. So, prayer works for me.”

Participant 9 – male, 43 years old, diagnosed 1 year ago: “I pray that he [God] take it, the diabetes, away from you because I believe it can be healed. It can be taken away from your body. But you got to pray on it, do the right thing, and prayer do help.… I don’t think you’ll never be able to be clear from diabetes. I think once you get it, you going to always have it. That’s my opinion but if you have power, [God] can take it away, I think he can.”

Participant 11 – female, 40 years old with T2DM (length of time unknown): “You know I wake up every morning, every morning, maybe really all day, I pray to God. But anyway, it’s like, me, my spirituality, me praying to him, he says that you ask me for whatever and you need whatever you need, he’s there. He’s there. You’ve got to have that relationship with him to get that. A person that doesn’t have that relationship, they wouldn’t know. So it’s like the relationship I have with God, we all have our own angels… I need spirituality along with my physical activity every day. You know what I’m saying? I know he ain’t going to come down here and help me. You know what I’m saying? I got to do it myself but me praying to him, he will lead me the way if I just listen to him. He will lead me to the right direction. It’s only me that have to listen and follow the direction. I can’t just do it myself.”

Participant 11 – female, 40 years old with T2DM (length of time unknown): “Too much stress, you know what I’m saying? That’s too much energy. You don’t have to be stressed out. Pray and when I pray I leave it there. I don’t need to go back and talk about that no more. I just leave it there with him and let him deal with it. Because I can’t do it. He all holy and I’m not.”

4. Discussion and Conclusion

4.1. Discussion

The lessons learned by listening to stories from inner-city African Americans with type 2 diabetes and food insecurity provide a better understanding of the strategies needed to improve diabetes care and reduce diabetes complications among this specific population. Key findings include a desire for interventions that foster social and community support systems. Specifically, participants identified group education, peer support, access to community resources and programs, stress management, and faith-based programs as desired interventions. While results from this study identified five different strategies to intervention development, current intervention strategies use primarily one – access to community resources and programs. Given this insight, more robust and comprehensive interventions are needed to account for the multifaceted experience of food insecurity and diabetes within the inner-city environment.

Group education was a preferred intervention format, possibly due to the camaraderie and informal social support networks that are characteristic of group education (40). Benefits of group education based on the literature include being more cost effective given multiple participants are counseled by one educator, and group interactions allow participants to learn from each other (41,42). However, logistical, and organizational challenges in scheduling and delivery are limitations of group education (42). It is important to ensure the intervention can be tailored to each participant within the group format, and a strong and meaningful relationship based on mutual trust is built between the participant and the educator (41).

Peer support as a desired intervention captures the significance of social ties from an individual with the same characteristics as the individual seeking support (43,44). In type 2 diabetes research, peers refer to someone with type 2 diabetes who is recruited and educated in problem solving, decision making, accessing healthcare, diabetes self-management, and strategies for easing the mental toll from living with diabetes (45). Based on interviews with African American adults with type 2 diabetes, Okoro et al. identified the most salient aspects of peer support as having someone who shows care and concern and helping participants feel they are not alone, while encouraging them to engage in self-management (45). Prior work found three critical uses for peer support: 1) providing advice on healthy diet/nutrition and physical activity behaviors, 2) providing regular support by connecting with participants via frequent phone calls, and 3) providing emotional support. (46)

Addressing food insecurity among people with diabetes is intuitive given the role of diet/nutrition in diabetes self-management. (47,48) However, lower income African Americans with diabetes are more likely to experience reduced food availability, variability, and desirability, thereby exacerbating the challenges associated with diet/nutrition (47,48). Additionally, these individuals may experience challenges to transportation for food resources, stigma with using food pantries, or discomfort in disclosing their food insecurity status (48). This highlights the importance of adequate and affordable food and whole foods available at food pantries for managing diabetes. The existing literature on food pantry interventions for diabetes management suggest food pantries as an appropriate and relevant location for diabetes interventions given the infrastructure and capacity to provide nutrition education or counseling by registered dietitians and other diabetes self-management support services (49).

Experiences with poverty, discrimination, housing insecurity, food insecurity, unemployment, and other social challenges increase stress and exacerbate adverse diabetes outcomes (50–52). It is documented that psychological factors, such as stress, can impede reaching glycemic targets (53,54). Mindfulness training including mind-body and meditative training has been successfully used in reducing stress among African Americans (55,56). Findings from one study showed that participants in the mindfulness group had decreased perceived stress, lower body mass index, lower caloric intake, and lower fat and carbohydrate consumption. (57)

The importance of religion and spirituality as a basis for resiliency among African Americans and in coping with health outcomes is widely documented (58–60). It is believed that religion and spirituality lead to positive diabetes self-management, overall health, and well-being (61). In a qualitative study to examine the role of religion and spirituality on resilience in diabetes care practices among African American adults, Choi and Hastings found participants who reported good physical health also reported a strong connection to their faith, and reported consistent blood glucose monitoring, and increased consumption of fruits and vegetables (58). It is interesting to note that few participants blamed their faith or God when glucose levels were not in target range. Participants spoke of believing in a forgiving and supportive God who helped them make healthy choices. To that end, participants relied on biblical scripture and prayer to assist in coping with their diabetes (58).

4.2. Conclusion

It is imperative that diabetes interventions for inner-city African Americans include components that participants desire. Next steps include developing interventions for inner-city African Americans that incorporate components highlighted in this study. For example, lessons learned from this research suggest that successful diabetes interventions can include faith-based interventions, peer-led group interventions, interventions that focus on stress management, and interventions that provide community resources to support diabetes self-management and diabetes self-care.

4.3. Practice Implications

The importance of diabetes self-management education and support has been noted as an important aspect of addressing the clinical, educational, psychosocial, and behavioral care needed to navigate daily self-care for adults with type 2 diabetes. (62) This was echoed by participants in highlighting a desire for programs that incorporated diabetes education, and specifically recommended to be delivered in a group format or incorporate peers to provide examples and experiences from people with diabetes. Incorporation of support members, such as family and peers has also been noted as a helpful cultural navigator in applying information and linking to resources within communities. (62) Though food resources tend to be the focus of interventions targeting food insecure adults, findings from the current study suggest that community resources, such as programs at community centers, may additionally be desired by inner-city African Americans with diabetes and food insecurity. Community-based programs may include cooking and food preparation demonstrations, touring local grocery stores for healthy food options, and sharing recipes (50).

Given the importance of including the voice of food insecure, African Americans with diabetes in intervention development, it is recommended that future programs use community-based participatory approaches to develop, implement, and promote programs and provide holistic programs focused on spiritual, mental, emotional, and physical well-being (50). Lessons learned from participants in the current study include a variety of sources of perceived stress ranging from family and work obligations to understanding their diabetes. The recent consensus report on diabetes self-management and education highlights the importance of incorporating psychosocial assessments (62), which can include the various stressors noted by participants, in addition to standard psychosocial scales. Participants expressed a willingness to openly discuss stressors and stress management, and interest in incorporating meditation and prayer as part of their overall health, well-being, and diabetes self-care. Based on these findings, faith-based diabetes interventions may be successful and may complement strategies tested to address stress management for food insecure, African American adults coping with type 2 diabetes.

Highlights.

  • Perspectives regarding important diabetes intervention strategies are needed.

  • Themes included peer support, community resources, stress management, and faith.

  • Participants desired interventions that foster social and community support.

  • More comprehensive interventions are needed for the inner-city environment.

Funding:

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).

Financial Disclosures:

No financial disclosures are reported by the authors of this paper.

Footnotes

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Conflict of Interest: The authors declare that they do not have a conflict of interest.

Competing interests: The authors declare that they have no competing interests.

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