Meals for Me: Managing Diabetes at Home

This is a three-arm, parallel randomized trial study that will assess the impact of home delivery of medically-tailored meals (MTM) to community-dwelling older adults living with diabetes mellitus type 2 on measurements of diabetes control, mental health, and other exploratory outcomes such as healthcare use.

This study aims to: Assess the impact of medically-tailored meals program on diabetes management and mental health in comparison to usual care without such program. Assess the differential impact of two delivery models being considered for payment by the health system on diabetes management and mental health: once-a-week frozen drop shipment model versus daily warm meal delivery model that is more complex to implement but allows for human connection and easier meal preparation. Implementation of program: Meals on Wheels (MoW) of Central Texas (MOWCTX) in Austin, Texas, will provide the meals and delivery service in this study. Meals are all medically tailored (diabetes friendly) and design by MOWCT's team of Registered Dietitians. Participants: Older adults, 55 and over, living in the Austin city limits with poorly controlled diabetes; Inclusion criteria: Adult 55-90 Hemoglobin A1C >=7.5 (as measured at baseline) Living in Austin city limits and within a MOWCTX daily delivery route Interested and available to receive meals during delivery window time Has access to a freezer and a microwave Pass a MOWCTX background check Trial: Eligible participants will be recruited from selected Federally Qualified Health Centers in the Austin area, MOWCTX clients on waitlist, and other (e.g. Medicaid recipients). Participants will be randomized to one of three arms: 1) Waitlisted control; 2) Weekly frozen drop shipment of MTM 3) Daily Warm delivery of MTM with in-person check-ins during delivery. Phase 1 (first 6 months) The intervention arms will receive their assigned method of meal delivery (weekly frozen or daily warm), for a total of 10 meals a week, including two main meals per day and snacks. The control arm will not receive any meals during this phase. All arms will receive printed educational materials at baseline. Phase 2 (month 6 to 12) All arms will receive 2-4 meals a week (depending on participant's availability) delivered via the traditional meal services from MOWCTX, which includes one hot meal plus a snack delivered daily. Meal delivery can also include 1 or more frozen meals to account for a total of 5 meals per week. Primary outcome is Hemoglobin A1C and secondary outcomes include depression as measured by PHQ-8 and other mental health measures.

Food as Medicine, Medically tailored meals, Chronic Disease, Food Insecurity, Food Home Delivery, Implementation Science

Research staff responsible for data collection at the sites are blinded to the arm allocation of the participant. At follow-up time points, however, a set of questions is asked that are different for each of the three arms on food intake and preferences, and for arm 2, for the experience of delivery. To minimize influence of unblinding, we will actively cross-assign research staff to different locations for follow-up visits.

Phase 1 (6 months, months 1-6): Educational materials on healthy eating for diabetes No meal delivery Phase 2 (6 months, months 7-12): Standard MOWCTX home meal delivery: 5 meals a week, delivered daily 2 to 4X a week

Phase 1 (6 months, months 1-6): Educational materials on healthy eating for diabetes 10 medically-tailored meals (MTM) per week, delivered 3-5x per week Mon-Fri Each delivery day, 1 hot and 1 frozen + snack delivered to the participant's home by trained volunteers and/or paid delivery drivers who provide human interaction. Depending on the participant's availability (3-5 days/week), more frozen meals will be given one day to account for a total of 10 meals every week. Phase 2 (6 months, months 7-12): Standard MOWCTX home meal delivery: 5 meals a week, delivered daily 2 to 4X a week

Phase 1 (6 months, months 1-6): Educational materials on healthy eating for diabetes 10 medically-tailored meals (MTM) delivered once a week Each week all meals are frozen. Meals are shipped to the participant's home with no human interaction Phase 2 (6 months, months 7-12): Standard MOWCTX home meal delivery: 5 meals a week, delivered daily 2 to 4X a week.

Phase 1 (6 months) Educational materials on such topics as healthy eating for diabetes, in addition to materials on meal planning and instructions. Food: 10 MTM a week: mix of hot and frozen, and 5-10 snacks per week. Meals and snacks offer approx. 1200 kcal per day. Delivery: 3 to 5x per week. Each delivery day, one meal is warm, the other is frozen. Depending on the participant's availability (3-5 days/week), more frozen meals will be given one day to account for a total of 10 meals every week. Engagement: MOWCTX's trained volunteers and/or paid delivery drivers delivering the meals will have a brief social interaction (at minimum in-person hand-off & visual check) with the participant.

Phase 1 (6 months) Educational materials on such topics as healthy eating for diabetes, in addition to materials on meal planning and instructions. Food: 10 frozen MTM and 5-10 healthy snacks (with the goal of providing 2 meals and 1-2 snacks for 5 days of the week). Meals and snacks offer approx. 1200 kcal per day. Nutritionally similar and frequently the same meal as that delivered in the daily delivery arm. Delivery: 1x per week shipment. Engagement: Meals are shipped to the participant's home. No human engagement.

Phase 2 (6 months) Food: 5 MTM a week plus snacks. Planned to offer approx. 600 kcal per day. Delivery: 2 to 4x a week (depending on participant availability), including daily delivery of 1 hot MTM plus a cold bag (with healthy snacks), with one day or more (depending on the 2 to 4x a week delivery schedule participant is on) also including 1 frozen MTM to total 5 meals per week. Engagement: MOWCTX's trained volunteers and/or paid delivery drivers delivering the meals will have a brief social interaction ("check-in") with the participant. MOWCTX Standard Wraparounds: Participants will have access to a case manager to assist with additional resources within the community and for additional support if needed (e.g., grocery shopping assistance, home repairs, and pet care).

Respondents rate each item as 'Never' , 'Rarely', 'Sometimes' or 'Often'. Scores range from 3 to 9. Higher numbers imply greater loneliness.

Respondents answer to eight questions that reflect the DSM-IV diagnosis criteria of depressive disorders. These questions ask how often in the past 2 weeks the respondent had experienced a particular depressive symptom. Each answer is scored from 0 to 3 and then summed. Total scores go from 0 and 24 points, with higher scores indicating greater depressive symptoms.

Investigators will use the Generalized Anxiety Disorder Scale (GAD-7) to measure anxiety. Scored from 0-3, and a score of 0 indicates lower levels of anxiety while a score of 3 indicates higher levels of anxiety.

Respondents are asked to score their level of confidence (scale from 1, not at all confident, to 10, totally confident) at the present time in doing tasks related to diabetes management (e.g., diet behavior, physical activity, measuring blood glycemia and others). Higher scores indicate higher self-efficacy.

Self-reported with a 30-day lookback period. The sum of affirmative responses to the six questions in the module is the household's raw score on the scale. Higher scores indicate greater food insecurity.

Measures physical and mental health status. Summary scores range from 0-100, with higher scores indicating a better self-reported level of health.

Self-report of trading off paying for food vs. paying for medicine or medical care, for utilities, and for housing

Inclusion Criteria: Adult 55-90 Hemoglobin A1c ≥7.5% Living in Austin city limits and within a MOWCTX daily delivery route Interested and available to receive meals during delivery window time Has access to a freezer and a microwave Pass a MOWCTX background check Exclusion Criteria: Participated in MOW program in previous 3 months. Has any of the following: dementia or cognitive impairment, diagnosis of heart failure, cirrhosis, or active cancer Is receiving hospice care Does not pass a MOWCTX background check