Understanding Food Security as a Social Determinant of Diabetes-Related Health during Pregnancy

Abstract

Gestational and pregestational diabetes during pregnancy are substantial and growing public health issues. Low-income individuals and individuals who identify as racial and ethnic minorities are disproportionately affected. Food security, which is defined as the degree to which individuals have capacity to access and obtain food, is at the center of nutritional resources and decisions for individuals with diabetes. While increasingly recognized as an important mediator of health disparities in the United States, food insecurity is understudied during pregnancy and specifically among pregnant individuals with diabetes, for whom the impact of food-related resources may be even greater. Previous research has suggested that food insecurity is associated with type 2 diabetes mellitus diagnoses and disease exacerbation in the general adult population. An emerging body of research has suggested that food insecurity during pregnancy is associated with gestational diabetes mellitus diagnoses and adverse diabetes-related outcomes. Additionally, food insecurity during pregnancy may be associated with adverse maternal and neonatal outcomes. Future research and clinical work should aim to further examine these relationships and subsequently develop evidence-based interventions to improve diabetes-related outcomes among pregnant individuals with food insecurity. The purpose of this article is to offer a working definition of food security, briefly review issues of food insecurity and diabetes, summarize research on food insecurity and diabetes-related pregnancy health, and discuss clinical recommendations and areas for future investigation.

Public Health Importance of Diabetes during Pregnancy

Gestational diabetes mellitus (GDM) affects between 2 and 10% of all pregnancies in the United States.¹ However, low-income individuals and individuals who identify as racial or ethnic minorities are disproportionately affected.^2,3 The rising prevalence of GDM reflects rising national rates of obesity, advanced maternal age, and type 2 diabetes mellitus (T2DM) among reproductive-aged people. Both GDM and pregestational diabetes have clear associations with adverse perinatal outcomes, such as cesarean delivery, macrosomia, and hypertensive disorders.^4,5 Thus, understanding how to optimize the management of diabetes during pregnancy is an essential clinical and public health goal.^4–6

Several explanations for disparities related to diabetes during pregnancy have been proposed, including higher rates of obesity among minority and low-income individuals.^7,8 However, understanding and eliminating these disparities requires the appreciation of social determinants of health.⁹ The cornerstone of treatment for diabetes during pregnancy is medical nutrition therapy (MNT) with a registered dietitian. MNT includes: (1) an assessment of the patient’s nutrition and diabetes self-management knowledge and skills; (2) identification and negotiation of individually designed nutrition goals; (3) nutrition intervention involving a careful match of both a meal-planning approach and educational materials to the patient’s needs; and (4) evaluation of outcomes and ongoing monitoring.¹⁰ Yet, adherence to MNT during pregnancy can be challenging for many reasons, including access to nutrition education, cost, familiarity, knowledge, and preferences.^11,12

Additionally, food security (defined later) is known to affect an individual’s ability to accomplish goals of MNT due to a lack of access to healthy and nutritious food.^13–16 However, food security is poorly understood as a social determinant of perinatal health, particularly in the setting of diabetes, and several critical questions on this topic remain. Thus, the purpose of this article is to offer a working definition of food security, briefly review issues of food insecurity and diabetes, summarize research on food insecurity and diabetes-related pregnancy health, and discuss clinical recommendations and areas for future investigation.

Defining Food Insecurity

Inadequate access to food is a major public health issue in the United States. Approximately 11% of U.S. households reported food insecurity in 2019.¹³ However, defining and quantifying food insecurity continues to be a challenge. The United States Department of Agriculture (USDA) convened in 1992 to standardize the definition of food insecurity and formulate a measure to be used at local and national levels in response to the National Nutrition Monitoring and Related Research Act of 1990. This measure was first implemented in 1995 as a supplement to the Current Population Survey (CPS).¹⁷

The prevailing definition of food security, agreed upon at the 1996 World Food Summit, is “a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.”¹⁴ Households with food insecurity are “at times during the year, uncertain of having, or unable to acquire, enough food to meet the needs of all their members.”¹³ Alternative definitions are described in Table 1.

Table 1.

Defining food security

Source	Food security	Food insecurity	Hunger
United States Department of Agriculture (2006)13	High food security: no reported indications of food-access problems or limitations.	Low food security: reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake.	Refers to a potential consequence of food insecurity that, because of prolonged, involuntary lack of food, results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation.
	Marginal food security: one or two reported indications—typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication of changes in diets or food intake.	Very low food security: reports of multiple indications of disrupted eating patterns and reduced food intake.
World Food Summit (1996)51	Food security exists when all people, at all times, have physical and economic access to sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active and healthy life.	At times during the year, these households were uncertain of having, or unable to acquire, enough food to meet the needs of all their members because they had insufficient money or other resources for food.
Anderson (1990)52		Whenever the availability of nutritionally adequate and safe food or the ability to acquire acceptable good in socially acceptable ways is limited or uncertain.

In 2006, the USDA introduced new labels to further quantify food security as very low, low, marginal, or high.¹³ For instance, households with low food security are able to avoid substantially reducing their food intake by eating less varied diets or accessing community food pantries or food assistance programs, while households with very low food security are unable to do so due to insufficient funds or access to resources.¹³

Additionally, the USDA defined hunger as an individual-level physiological condition from involuntary lack of food for a prolonged period of time that may result from food insecurity.^15,18,19 Hunger can be considered a severe stage of food insecurity but is not present in all circumstances of food insecurity.¹³ Severe food insecurity is a direct result of a reduction in food intake and disruption of eating patterns, which result in hunger.

A contributing factor to food insecurity is the food environment. Food environment refers to the infrastructure or community nutritional resources available such as supermarkets, grocery stores, and full-service fast food restaurants.^13,20 The availability of food is necessary for individual health, yet it does not ensure universal access to sufficient and nutritious food.²¹

Measuring Food Security

Several validated assessments of food security exist (Table 2). These measures consider the number and age of individuals in the household when determining food security. The primary assessment endorsed by the USDA and incorporated as a supplement to CPS is the U.S. Household Food Security Survey Module (HFSSM).^22,23 The HFSSM is an 18-item, self-report questionnaire designed to assess household food security over the previous 12 months. The survey has screener items to reduce respondent burden, and thus many households are only asked three questions. The HFSSM questionnaire addresses uncertain or inadequate food access, availability, and utilization due to limited financial resources, and the compromised eating patterns and food consumption that may result. Each question specifies a lack of money or the ability to afford food as the reason for the condition or behavior.^13,22,23

Table 2.

Validated measures to assess food security

Surveys	Languages validated	No. of questions	Advantages	Disadvantages
USDA Household Food Security Survey Module (HFSSM)23	English Spanish	18	Well-established Validated	Not equipped to assess hunger Lengthy if respondents are food insecure
USDA Adult HFSSM53	English Spanish	10	Less respondent burden Avoids asking unnecessary questions about children’s food security, which can be sensitive	Does not provide specific information on food security of children
USDA HFSSM Six-Item Short Form26	English Spanish	6	Least respondent burden Can screen inadequate food access using three items	Less precise Does not quantify severity of food insecurity Does not provide specific information on food security of children
Survey of Income and Program Participation (SIPP)54	English	6	Representative of population at the state level Samples all household individuals above age 15	No information on food expenditures Oversamples low-income households Part of a larger questionnaire

Using the HFSSM, responses to multiple indicators of food insecurity are combined to determine the food security status of the household. To be considered “food insecure,” households must report three or more of the following: they worried whether their food would run out before they got money to buy more, the food they bought did not last, and they did not have money to get more, or they could not afford to eat balanced meals. To be classified as having “very low food security,” households without children must report the above-listed three conditions and also that: adults ate less than they felt they should, adults cut the size of meals or skipped meals, and did so in three or more months.²² If applicable, experiences and behaviors of children in the house are assessed and an additional two affirmative responses are required for a classification of very low food security. In the context of pregnancy, the 18-item HFSSM survey has been validated in low-income pregnant Latinx individuals, and thus may be a useful screening tool in prenatal care.²⁴

Although the HFSSM is an effective tool in measuring food security, its length creates barriers to practical use among individuals with food insecurity. To address this, a 6-item short form of the survey module was developed^25,26 (Table 3). This version has less respondent burden for food-insecure households and can be reduced to three items when initial questions reveal no food access challenges. Although it may not measure the most severe levels of food insecurity or ask about conditions of household children, the short form has been demonstrated to yield similar prevalence estimates to the original.²⁵

Table 3.

U.S. Household Food Security Survey Module: six-item short form²⁶

Prompt: I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months—that is, since last (name of current month).
Label	Question	Answer choices a
HH 3.	The first statement is, “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?	[ ] Often true [ ] Sometimes true [ ] Never true [ ] DK or Refused
HH4.	“(I/we) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?	[ ] Often true [ ] Sometimes true [ ] Never true [ ] DK or Refused
AD1.b	In the last 12 months, since last (name of current month), did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn’t enough money for food?	[ ] Yes [ ] No (Skip AD1 a) [ ] DK (Skip AD1 a)
AD1a.	[IF YES ABOVE, ASK] How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?	[ ] Almost every month [ ] Some months but not every month [ ] Only 1 or 2 months [ ] DK
AD2.	In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?	[ ] Yes [ ] No [ ] DK
AD3.	In the last 12 months, were you every hungry but didn’t eat because there wasn’t enough money for food?	[ ] Yes [ ] No [ ] DK
Food security status is assigned as follows: Raw score 0–1—High or marginal food security (raw score 1 may be considered marginal food security, but a large proportion of households that would be measured as having marginal food security using the household or adult scale will have raw score zero on the 6-item scale) Raw score 2–4—Low food security Raw score 5–6—Very low food security

^aResponses of “often” or “sometimes” on questions HH3 and HH4, and “yes” on AD1, AD2, and AD3 are coded as affirmative (yes). Responses of “almost every month” and “some months but not every month” on AD1a are coded as affirmative (yes). The sum of affirmative responses to the six questions in the module is the household’s raw score on the scale.

^bHouseholds that have responded “never” to HH3 and HH4 and “no” to AD1 may skip over the remaining questions and be assigned a raw score of 0.

Other types of food security measures have been used in recent epidemiologic surveys²⁷ (Table 2).

Food Security and Diabetes

With growing recognition of the influence of social determinants on health outcomes, it is important to consider the associations between food insecurity and adverse health outcomes. Among nonpregnant individuals, there is a well-established association between the availability of high-quality food at grocery stores and decreased risk of being overweight and obese,^3,28,29 which is a risk factor for GDM and T2DM.³⁰ In a study of individual proximity to food outlets and prevalence of obesity, each additional supermarket was associated with a reduced odds of obesity (adjusted odds ratio [aOR], 0.93; 95% confidence interval [CI], 0.88–0.99).²⁸ Low access to food stores disproportionately affects people of low income or who identify as racial or ethnic minorities.²⁹ Specifically among low-income and racial and ethnic minority individuals, food insecurity has been associated with obesity and poorer mental health.³

Upon instruction of MNT to prevent and manage hyperglycemia, access to healthy food is essential for individuals at risk of or diagnosed with T2DM. Food insecurity is associated with T2DM prevalence, health-related quality of life, and clinical outcomes.^31,32 Household food insecurity has been associated with increased diagnoses of T2DM and subsequent worse T2DM-related outcomes, such as poor diabetes self-management and higher physician utilization.³² In one study, adults with T2DM reporting insufficient access to food had greater than a twofold increased odds of reporting fair or poor health status than those who were food sufficient.³² Both lack of access and insufficient access to food contribute to food insecurity. Food insecurity has also been associated with worse health-related quality of life among people with T2DM.³² The majority of studies examining food insecurity and T2DM find a positive association between screening positive on the HFSSM and increased odds of T2DM.³³

Emerging evidence also suggests an association between food environment and T2DM among nonpregnant populations.²⁰ A lack of healthy food choices, such as the absence of supermarkets and an abundance of fast food venues, may represent significant impediments to healthy lifestyles.³⁴ Collectively, this growing body of data suggests food insecurity and poor food environment may exacerbate the disparity in diabetes-related morbidity in low-resource communities.

Food Security, Diabetes, and Pregnancy: Unique Needs

There is limited research on food security during pregnancy, and much existing work has focused on food environment. For example, previous research has suggested that pregnant individuals living greater than 4 miles from a supermarket have twofold greater odds of poor diet quality compared with individuals living within 2 miles of a supermarket (aOR, 2.16; 95% CI, 1.2–4.0).³⁵ Fast food and supermarket density have been linked to adverse obstetrical outcomes; Tipton et al reported that the odds of having at least one morbidity condition in pregnancy was greater for patients living in food deserts.³⁶ Limited data on food security during pregnancy have demonstrated that living in a food-insecure household during pregnancy was significantly associated with severe pregravid obesity, higher gestational weight gain, and higher adequacy of weight gain ratio, which is defined as the ratio of observed total weight gained over expected weight gain.³⁷

Although previous research has suggested an association between food insecurity and adverse health outcomes in nonpregnant individuals with T2DM and among a general population of pregnant individuals, minimal research has investigated this relationship specifically among pregnant individuals with diabetes. Recommended food prescriptions for individuals with diabetes may be similar in pregnancy than in nonpregnant adults, yet the focus on tighter glycemic control required for pregnancy instills greater burdens for a pregnant individual with diabetes.⁵ Thus, it is plausible that the effects of food insecurity may be amplified in this intersectional setting of pregnancy and diabetes.

Qualitative research on pregnant patients with diabetes identified financial barriers to nutrition as an impediment to following clinical guidelines for diabetes management. Pregnant individuals with food insecurity may be unable to incorporate prescribed foods due to lack of access and affordability. For instance, Yee et al reported that a participant stated “either [she] could get that stalk of celery or [she] could get those four boxes of pasta that [she] could have for dinner for a couple more days, instead of that one snack.”³⁸ Similarly, in a cohort of minority, low-income, pregnant individuals with GDM or T2DM, multiple challenges to MNT adherence were identified, including knowledge-based, attitudinal, and resource-related barriers.¹² Food prescriptions commonly require more expensive food sources that also may not align with taste preferences.³⁸ In addition, the unique responsibilities of motherhood are often accompanied by familial sacrifices. In contrast to single adults, parents may prioritize the nutrition needs of their children. Mild forms of food insecurity can still result in dietary insufficiency and poor GDM control among individuals with children.³⁷

The limited epidemiologic data on food security, diabetes, and pregnancy have focused on food environment. Proximity to supermarkets and food security may be associated with health outcomes among pregnant individuals with diabetes.^39,40 For example, Kahr et al employed geospatial modeling to characterize the association between fast food restaurants and supermarkets and GDM in metropolitan Houston.³⁹ Living in neighborhoods with a high prevalence of fast food restaurants was associated with increased odds of GDM, and higher fast food-to-supermarket ratio was associated with elevated hemoglobin A1C levels during pregnancy.³⁹ Such findings have been replicated in other cities. In Los Angeles and Orange counties in California, Young et al found that the risk of GDM was reduced in ZIP codes with greater concentration of grocery stores and supermarkets.⁴¹ This trend was similar among individuals with GDM in Delaware.⁴² However, Chicago data did not corroborate these trends; individuals living within food deserts had lower odds of GDM and did not experience poorer maternal and neonatal outcomes compared with individuals not living in food deserts.⁴³ Also, in Chicago, among patients with GDM, household residence in denser fast food regions was associated with lower odds of a large for gestational age status neonate compared with residing in lower fast food density areas, suggesting further work on food environment is required.⁴⁴

Although research exploring the relationship between food insecurity and diabetes outcomes in pregnancy is limited, it is clear that pregnant individuals with diabetes experience unique and complex dietary needs and challenges. While this article focuses on food security and diabetes during pregnancy, it is important to acknowledge the future risk of T2DM after GDM.⁴⁵ The role of food security in the postpartum development of T2DM is unknown, yet it is clear that food insecurity is likely a relevant social determinant on the continuum of diabetes-related health from preconception, pregnancy, and postpartum.

Clinical Recommendations

Recognizing the importance of food security in the management of diabetes and the increasing incidence of diabetes during pregnancy, we propose that clinicians consider screening for food insecurity at the onset of prenatal care and again when there is a change in clinical status, such as a diagnosis of GDM. We recommend clinicians consider the universal use of the 6-point HFSSM survey in clinical practice. This scale can be distributed at prenatal intake, along with screening for other social determinants of health as recommended by American College of Obstetricians and Gynecologists (ACOG).⁴⁶ Special consideration should be made for individuals who are at greater risk of food insecurity, such as individuals in large households, with greater socioeconomic or neighborhood barriers to obtaining healthy food, or other major social determinants of health.^5,9 Although the impact of food insecurity on diabetes during pregnancy warrants further exploration, screening should be considered to recognize and identify the issue during prenatal care.

To follow up with and monitor patients’ access to food, we recommend that clinicians document food insecurity (ICD-10 code Z59.4) in the electronic medical records.⁴⁶ While there are no specific guidelines to treat food insecurity during pregnancy, clinicians should be familiar with local and federal resources.⁴⁷ Resources will vary by community but may include wellness programs, food exchange, or distribution programs, as well as local diabetes prevention programs. Federal resources may include referrals to the Special Supplemental Nutrition Program for Women, Infants, and Children or the Supplemental Nutrition Assistance Program. In communities where local resources are not abundant, health care professionals can refer to Centers for Disease Control and Prevention’s (CDC) recommendations on food assistance and resources.^44,45 Additionally, outpatient clinics may have registered dietitians or social workers familiar with food resources; the involvement of a dietitian may be beneficial when clinicians are concerned about food scarcity or malnutrition due to very low food security. It should also be noted that such interventions may vary by urban versus rural status. Although connecting patients to these resources is not a complete solution to address food insecurity, it may provide patients with necessary access to quality food for a safe and healthy pregnancy.

There are challenges in implementing food security screening in daily clinical practice. The U.S. health care environment typically consists of high patient volumes with limited time and resources. In-depth assessment and counseling may not be feasible in all clinical settings. Moreover, obstetric patients who screen for food insecurity may also have the most complex medical comorbidities. The requirement to screen and discuss nutrition barriers may limit time available to discuss obstetrical issues. Clinical providers may lack the time, energy, and expertise to address food insecurity, and thus may be reliant to dietitians or social work experts, who may not be universally available.

Despite these challenges, we propose that even the use of short screeners may make a profound difference in quality of care. Incorporating the HSFFM with routine intake may be a simple way to engage patients and understand their lived experiences, which may aid in identifying optimal treatment programs.²⁵ Universal screening for food security may also reduce stigma around food access, which may limit individuals from seeking resources. Additionally, involving the entire health care team in optimizing care can reduce the physician burden of these recommendations to introduce patients to known community resources.

Future Directions

Further work is required to better understand food security as a social determinant of health during pregnancy and how suboptimal access to food can undermine clinical management of diabetes in pregnancy. Future research should investigate the effects of integrating and implementing food security screening into routine care on disease management while better understanding the unique needs of food-insecure pregnant people. Moreover, we need to better understand how to optimize nutrition resources for patients whose pregnancies are complicated by diabetes and how to develop and best utilize community resources for sustained improvements in maternal and neonatal outcomes. Given the financial and psychological stresses of pregnancy, the impact of food security on diabetes self-management and obstetric outcomes is likely significant and warrants future exploration. Such efforts should be directed beyond identifying food insecurity and instead focus on developing evidence-based interventions, particularly since pregnancy provides an opportune time for health interventions given documented elevated levels of patient activation.⁴⁸ Although interventions targeting food insecurity during pregnancy exist, such as the incorporation of food vouchers into prenatal care or group prenatal care,^49,50 there are no existing interventions focused on the unique needs of food-insecure pregnant people with diabetes. Further, the specific impact of these interventions on diabetes-related health during pregnancy is unknown.

In summary, food-insecure pregnant individuals are vulnerable within the health care system, and health disparities in both diabetes and perinatal outcomes remain major clinical and public health challenges. Although many questions remain unanswered, addressing issues of food insecurity may be critical to the goal of improving quality of care and diabetes- and pregnancy-related health outcomes for all individuals, but especially those most underserved.

Key Points.

• Research on food insecurity and diabetes-related health is limited.

• The impact of food security on diabetes management and obstetric outcomes is likely significant.

• Future work to evaluate perinatal food security screening is warranted.