In a Perspective, Hilary Seligman and Sanjay Basu discuss future scenarios of food assistance programs to improve population health in a changing political environment.

To reduce obesity and type 2 diabetes rates, lawmakers have proposed modifying Supplemental Nutrition Assistance Program (SNAP) benefits to encourage healthier food choices. We examined the impact of two proposed policies: a ban on using SNAP dollars to buy sugar-sweetened beverages; and a subsidy in which for every SNAP dollar spent on fruit and vegetables, thirty cents is credited back to participants' SNAP benefit cards. We used nationally representative data and models describing obesity, type 2 diabetes, and determinants of food consumption among a sample of over 19,000 SNAP participants. We found that a ban on SNAP purchases of sugar-sweetened beverages would be expected to significantly reduce obesity prevalence and type 2 diabetes incidence, particularly among adults ages 18-65 and some racial and ethnic minorities. The subsidy policy would not be expected to have a significant effect on obesity and type 2 diabetes, given available data. Such a subsidy could, however, more than double the proportion of SNAP participants who meet federal vegetable and fruit consumption guidelines.

Objective

To examine the association between level of food security and diabetes self-management among food pantry clients, which is largely not possible using clinic-based sampling methods.

Design

Cross-sectional descriptive study.

Setting

Community-based food pantries in California, Ohio and Texas, USA, from March 2012 through March 2014.

Subjects

Convenience sample of adults with diabetes queuing at pantries (n 1237; 83 % response). Sampled adults were stratified as food secure, low food secure or very low food secure. We used point-of-care glycated Hb (HbA1c) testing to determine glycaemic control and captured diabetes self-management using validated survey items.

Results

The sample was 70 % female, 55 % Latino/Hispanic, 25 % white and 10 % black/African American, with a mean age of 56 years. Eighty-four per cent were food insecure, one-half of whom had very low food security. Mean HbA1c was 8·1 % and did not vary significantly by food security status. In adjusted models, very-low-food-secure participants, compared with both low-food-secure and food-secure participants, had poorer diabetes self-efficacy, greater diabetes distress, greater medication non-adherence, higher prevalence of severe hypoglycaemic episodes, higher prevalence of depressive symptoms, more medication affordability challenges, and more food and medicine or health supply trade-offs.

Conclusions

Few studies of the health impact of food security have been able to examine very low food security. In a food pantry sample with high rates of food insecurity, we found that diabetes self-management becomes increasingly difficult as food security worsens. The efficacy of interventions to improve diabetes self-management may increase if food security is simultaneously addressed.