Direct and Indirect Pathways Between Food Insecurity and Glycemic Control in Adults with Diabetes

Extensive research identifies food insecurity as a driver of poor glycemic control in adults with diabetes. The goal of this study was to investigate the direct and indirect relationships between food insecurity and glycemic control, focusing on three possible pathways: body composition, anthropometrics, and healthy eating.

Using 2011-2018 National Health and Nutrition Examination Survey (NHANES) data, we created measures for body composition (total fat, total lean, fat mass index, lean mass index), anthropometrics (body mass index, waist circumference) and healthy eating index (HEI) (food group component scores and overall HEI score), food insecurity (USDA scale), and glycemic control (continuous HbA1c). Structural equation modeling using Stata v17 was used to investigate direct and indirect relationships in a sample of adults with diabetes. Total lean, waist circumference, and overall HEI score served as indicators for each of the three possible pathways based on preliminary correlations.

The final model was well fit (RMSEA = 0.00, CFI = 1.0, pclose 1.0) and showed higher food insecurity was directly associated with higher HbA1c (B = 0.09, p < 0.001) and indirectly associated through waist circumference and HEI score (B = 0.008, p < 0.001) in adults with diabetes. Food insecurity was significantly associated with higher waist circumference (B = 0.07, p < 0.001) and lower healthy eating (B =  - 0.09, p < 0.05). Higher waist circumference (B = 0.03, p < 0.001) and lower healthy eating (B =  - .06, p < 0.05) were significantly associated with higher HbA1c. Body composition was not a significant pathway.

Waist circumference and overall healthy eating index are significant pathways through which food insecurity is associated with worse glycemic control in adults with diabetes.