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Changing Health Through Food Support for Diabetes (CHEFS-DM)

Primary Purpose

Type 2 Diabetes, Food Insecurity

Status
Recruiting
Phase
Not Applicable
Locations
United States
Study Type
Interventional
Intervention
Food support
Nutritional Counseling and education
Sponsored by
University of California, San Francisco
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Type 2 Diabetes focused on measuring Food security, Diabetes Mellitus, Food assistance

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Confirmed diagnosis of T2DM confirmed by medical or laboratory records. For T2DM, any of the following criteria will be considered (from the American Diabetes Association):

    • glycated hemoglobin (HbA1c) ≥6.5%, or
    • fasting plasma glucose of ≥126, or
    • a 2-hour plasma glucose level of 200 or higher during a 75 g oral glucose tolerance test, or
    • a random plasma glucose of 200 or higher in patients with symptoms of hyperglycemia
  • Age ≥18 years.
  • Screening positive for food insecurity (at least one positive answer) in the previous 6 months assessed using the 6-item version of the US Household Food Security Survey Module (US Department of Agriculture), or has household income <200% of the federal poverty level.
  • English or Spanish language fluency.
  • Adequate cognitive and hearing capacity to consent and complete study measures.
  • Reside in Alameda County or San Francisco County.

Exclusion Criteria:

  • Type-1 diabetes mellitus
  • Individuals with disorders known to affect the accuracy of the HbA1c measure (e.g., end stage renal disease and individuals with known hemoglobinopathies).
  • Inability to attend the educational workshops.
  • Inability to schedule baseline assessments and/or blood draw after repeated requests.
  • Pregnant individuals, or individuals planning to get pregnant within 6 months, or are lactating, or are postpartum less than 6 months.
  • Current POH clients, past POH clients who stopped services less than 6 months prior, or past or present participants in other POH medically tailored meals studies.
  • Does not have access to food storage, including a refrigerator and freezer to safely keep food.
  • Does not have access to facilities to reheat and prepare meals using Project Open Hand food.
  • Anticipates moving out of study area of Alameda and San Francisco Counties in the next 6 months.
  • Receives more than 1 meal per day from a free food support resource or agency.
  • Allergic to or will not eat eggs, soy, wheat, nuts, seeds or seed oils, or other foods commonly included among ingredients in POH meals.
  • Allergic to dairy products, or unable to tolerate any dairy products including milk, yogurt and cheese.
  • Individual does not eat any or all of POH's meat meal options and will not eat the vegetarian POH meal option.

Sites / Locations

  • Project Open HandRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

No Intervention

Experimental

Arm Label

Standard of care

Food support and nutrition education

Arm Description

Control participants will receive standard of care as offered by clinical partners to all T2DM patients, including referral to nutritional counseling, T2DM support groups, and participation in local diabetes self-management programs. Control participants are also often provided referral information for locally available food support services in the region that provide diabetes-appropriate foods. At the end of follow up, the control arm will receive similar services from POH to what the intervention arm received during the intervention, regardless POH eligibility criteria (6 months of DM-tailored food support to meet 67% of their daily requirements, video recording of the 4 CHEFS-DM education classes, and access to a POH dietitian at their request).

The intervention entails two components: 1) food support that consists of weekly medically tailored meals and healthy groceries that on average covers 75% of daily energy requirements from baseline to six months and 2) diabetes-tailored nutritional education that consists of two individual counseling sessions with a Registered dietitian and four group education sessions.

Outcomes

Primary Outcome Measures

Change in Hemoglobin A1c from baseline to six months by study arm
Change HbA1c levels (%) from baseline to six months by study arms.
Change in food insecurity severity from baseline to six months by study arm
The US household food security survey module from the US Department of Agriculture (USDA) will be used to assess the change in the food security scores from baseline to six months. The score ranges from 0 to 18 in households with children, and 0 to 10 in households without children. Higher score indicates higher severity of food insecurity

Secondary Outcome Measures

Change in the proportion of participants with low and very low food security
Low and very low food security will be defined as 3 or more items answered affirmatively in the USDA's US household food security survey module. Change in proportion of participants with low or very low food security, from baseline to six months by intervention arms will be reported.
Change in proportion of participants with glucose control by study arm.
Glucose control will be defined as HbA1c lower than 9%. The change from baseline to six months, in the proportion of participants with glucose control will be reported.
Change in systolic and diastolic blood pressure from baseline to six months
Changes in the average of three repeated measurements of systolic and diastolic blood pressure (mm Hg) from baseline to six months by study arm.
Change in medication adherence from baseline to six months by study arm
A single-item Rating Visual Analogue Scale will be used to evaluate diabetes medication adherence. Using the scale, participants self-report the adherence of medication ranging from 0% to 100%. The changes in diabetes medication adherence (percentage) from baseline to six months by study arms will be reported.
Acute health care utilization from baseline to six month by study arm
Proportion of participants that used emergent health care (Emergency department or urgent care) during the 6 months of the study by study arm will be reported.
Hospital admissions from baseline to six months by study arm
Proportion of participants that were hospitalized from baseline to six months of the study by study arms will be reported.
Missed outpatient visits from baseline to six months by study arm
Proportion of participants that missed at least one outpatient visits from baseline to six months by study arms will be reported.
Change in health-related quality of life scores from baseline to six months by study arm
The quality of life will be measured using the standardized 12-item short form health survey (SF-12v2). The SF-12v2 provides a summary score for physical and mental health. he transformed T score has a mean=50 and Standard Deviation=10, in which higher values means better health. The change in SF-12 T scores from baseline to six months by study arm will be reported.
Change in body mass index (BMI) from baseline to six months by study arm
The average of three repeated measurements of weight and height will be obtained at baseline and at six months. The BMI will be calculated (weight (kg)/ (height (m)^2). Changes in in BMI values (kg/ m^2) from baseline to six months by study arm will be reported.
Change in healthy eating index score 2015 (HEI-2015) from baseline to six months by study arm.
Dietary information using an automated self- administered 24-hour dietary recall instrument from the National Cancer Institute's (ASA24) will be collected. The HEI-2015 is a measure of diet quality which evaluates how well the food consumed aligns with the Dietary guidelines for American population. The HEI-2015 score ranges from 0-100 in which a higher score indicates better diet quality. Changes in the HEI-2015 score from baseline to six months by study arm will be reported.
Change in depressive symptoms from baseline to six months by study arm
The 9-item Patient Health Questionnaire (PHQ-9) will be used to evaluate depressive symptoms. The PHQ-9 score ranges from 0 to 27, with higher scores indicating higher levels of depression. The change in PHQ-9 scores from baseline to six months by study arm will be reported.
Change in diabetes distress scale from baseline to six months by study arm
The diabetes distress scale (DDS) has 17 items measuring frustration, anger, and discouragement associated with managing complex diabetes health-care directives. The DDS score ranges from 1 to 6, with higher scores indicating higher levels of distress. The change in diabetes distress scores from baseline to six months by study arms will be reported.
Change in diabetes self-efficacy from baseline to six months by study arm
The 8-item Perceived Diabetes Self-Management (PDSM) scale will be used to assess confidence in one's ability to manage numerous self-care behaviors, including diet, and management of glucose. The PDSM scores ranges from 8 to 40, with higher scores indicating more confidence in self-managing their diabetes. The changes in the PDSM scores from baseline to six months by study arm will be reported.

Full Information

First Posted
June 25, 2021
Last Updated
July 14, 2023
Sponsor
University of California, San Francisco
Collaborators
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Project Open Hand
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1. Study Identification

Unique Protocol Identification Number
NCT04959487
Brief Title
Changing Health Through Food Support for Diabetes
Acronym
CHEFS-DM
Official Title
Food is Medicine: Randomized Trial of Medically-Tailored Food Support for Diabetes Health
Study Type
Interventional

2. Study Status

Record Verification Date
July 2023
Overall Recruitment Status
Recruiting
Study Start Date
August 23, 2021 (Actual)
Primary Completion Date
March 30, 2025 (Anticipated)
Study Completion Date
August 30, 2025 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of California, San Francisco
Collaborators
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Project Open Hand

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
This is a pragmatic randomized controlled trial (RCT) of Changing Health through Food Support for Diabetes (CHEFS-DM). This pragmatic RCT will leverage Project Open Hand's (POH) real-world programs to test the impact of a six month medically tailored food support and nutrition intervention ("CHEFS-DM") on glycemic control and other cardiometabolic outcomes, investigate the paths through which CHEFS-DM may durably improve health, and assess the economic value of the intervention to society.
Detailed Description
CHEFS-DM is a six-month intervention providing a diabetes-tailored diet meeting approximately 75% of daily energy requirements and designed based on American Diabetes Association (ADA) guidelines, together with diabetes nutritional education provided by registered dietitians. In this pragmatic RCT, investigators propose to rigorously evaluate the intervention among 440 low-income adults with Type 2 Diabetes Mellitus (T2DM) recruited from networks of safety net clinics in San Francisco and Alameda counties, California. Participants will be randomized 1:1 to the intervention (n=220) versus control (n=220), using a parallel design. The study aims are as follows: Aim 1: To determine the impact of CHEFS-DM on glycemic control and other cardiometabolic outcomes. Aim 2: To determine the impact of CHEFS-DM on intermediate outcomes that may mediate any impact of CHEFS-DM on T2DM health. Participant will be followed for 6 months (control arm) and 12 months (intervention arm) with structured interviews, anthropometric assessments, 24-hour dietary recalls, blood pressure measurements, fasting blood draws, semi structured interviews, and medical record review. Follow-up will be broken up into two phases. From baseline to six months, researchers will implement the CHEFS-DM intervention and follow both intervention and control arm participants (n=440). After the end of the six-month follow-up, the intervention arm will transition to receiving standard POH services comprising 33% to 67% of daily energy requirements depending on health status, and will be followed for an additional six months, in order to assess the extent to which any health benefits are sustained at 12 months (n=220). Hence, the control arm will be followed for six months and participate in two sets of assessments (baseline and at six months), and the intervention arm will be followed for 12 months and participate in three sets of assessments (baseline, six months, and twelve months).

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Type 2 Diabetes, Food Insecurity
Keywords
Food security, Diabetes Mellitus, Food assistance

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Model Description
Participants (n=440) will be randomized to the intervention (n=220) or control (n=220) arms, stratified by county (San Francisco vs. Alameda County) and poor diabetes control (A1c < 9%, vs. ≥ 9%). The intervention consists of providing diabetes-tailored food support and nutritional education (two sessions of individual counseling and four session of in-group diabetes-tailored nutrition education sessions) over six months to patients with type 2 diabetes.
Masking
InvestigatorOutcomes Assessor
Masking Description
Double (Investigator, Outcomes Assessor) The analyst(s) and investigator(s) conducting and reviewing the analyses of the data will be masked to whether participants were in the intervention or control arm.
Allocation
Randomized
Enrollment
440 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Standard of care
Arm Type
No Intervention
Arm Description
Control participants will receive standard of care as offered by clinical partners to all T2DM patients, including referral to nutritional counseling, T2DM support groups, and participation in local diabetes self-management programs. Control participants are also often provided referral information for locally available food support services in the region that provide diabetes-appropriate foods. At the end of follow up, the control arm will receive similar services from POH to what the intervention arm received during the intervention, regardless POH eligibility criteria (6 months of DM-tailored food support to meet 67% of their daily requirements, video recording of the 4 CHEFS-DM education classes, and access to a POH dietitian at their request).
Arm Title
Food support and nutrition education
Arm Type
Experimental
Arm Description
The intervention entails two components: 1) food support that consists of weekly medically tailored meals and healthy groceries that on average covers 75% of daily energy requirements from baseline to six months and 2) diabetes-tailored nutritional education that consists of two individual counseling sessions with a Registered dietitian and four group education sessions.
Intervention Type
Other
Intervention Name(s)
Food support
Intervention Description
1. Diabetes-tailored food support. Project Open Hand will provide intervention participants six months of supplemental food support meeting on average 75% of their daily energy requirements. Food support will consist of a mix of meals tailored for T2DM, and T2DM-healthy groceries, consistent with American Diabetes Association (ADA) guidelines for diabetes healthy diets under the responsibility of a registered dietitian.
Intervention Type
Other
Intervention Name(s)
Nutritional Counseling and education
Intervention Description
2. Nutritional counseling and education: The registered dietitian will provide individual nutritional counseling two times (at baseline and month 5-6) during the intervention. In addition, group-based DM nutrition education will be conducted over four 1-hour-long sessions. The nutrition education will be conducted by a POH dietitian, and the curriculum will be consistent with published diabetes self- management education principles, utilizing effective strategies in lower wealth, lower literacy populations.
Primary Outcome Measure Information:
Title
Change in Hemoglobin A1c from baseline to six months by study arm
Description
Change HbA1c levels (%) from baseline to six months by study arms.
Time Frame
Baseline and six months
Title
Change in food insecurity severity from baseline to six months by study arm
Description
The US household food security survey module from the US Department of Agriculture (USDA) will be used to assess the change in the food security scores from baseline to six months. The score ranges from 0 to 18 in households with children, and 0 to 10 in households without children. Higher score indicates higher severity of food insecurity
Time Frame
Baseline and six months
Secondary Outcome Measure Information:
Title
Change in the proportion of participants with low and very low food security
Description
Low and very low food security will be defined as 3 or more items answered affirmatively in the USDA's US household food security survey module. Change in proportion of participants with low or very low food security, from baseline to six months by intervention arms will be reported.
Time Frame
Baseline and six months
Title
Change in proportion of participants with glucose control by study arm.
Description
Glucose control will be defined as HbA1c lower than 9%. The change from baseline to six months, in the proportion of participants with glucose control will be reported.
Time Frame
Baseline and six months
Title
Change in systolic and diastolic blood pressure from baseline to six months
Description
Changes in the average of three repeated measurements of systolic and diastolic blood pressure (mm Hg) from baseline to six months by study arm.
Time Frame
Baseline and 6 months
Title
Change in medication adherence from baseline to six months by study arm
Description
A single-item Rating Visual Analogue Scale will be used to evaluate diabetes medication adherence. Using the scale, participants self-report the adherence of medication ranging from 0% to 100%. The changes in diabetes medication adherence (percentage) from baseline to six months by study arms will be reported.
Time Frame
Baseline and six months
Title
Acute health care utilization from baseline to six month by study arm
Description
Proportion of participants that used emergent health care (Emergency department or urgent care) during the 6 months of the study by study arm will be reported.
Time Frame
Baseline and six months
Title
Hospital admissions from baseline to six months by study arm
Description
Proportion of participants that were hospitalized from baseline to six months of the study by study arms will be reported.
Time Frame
Baseline to six months
Title
Missed outpatient visits from baseline to six months by study arm
Description
Proportion of participants that missed at least one outpatient visits from baseline to six months by study arms will be reported.
Time Frame
Baseline to six months
Title
Change in health-related quality of life scores from baseline to six months by study arm
Description
The quality of life will be measured using the standardized 12-item short form health survey (SF-12v2). The SF-12v2 provides a summary score for physical and mental health. he transformed T score has a mean=50 and Standard Deviation=10, in which higher values means better health. The change in SF-12 T scores from baseline to six months by study arm will be reported.
Time Frame
Baseline and six months
Title
Change in body mass index (BMI) from baseline to six months by study arm
Description
The average of three repeated measurements of weight and height will be obtained at baseline and at six months. The BMI will be calculated (weight (kg)/ (height (m)^2). Changes in in BMI values (kg/ m^2) from baseline to six months by study arm will be reported.
Time Frame
Baseline and six months
Title
Change in healthy eating index score 2015 (HEI-2015) from baseline to six months by study arm.
Description
Dietary information using an automated self- administered 24-hour dietary recall instrument from the National Cancer Institute's (ASA24) will be collected. The HEI-2015 is a measure of diet quality which evaluates how well the food consumed aligns with the Dietary guidelines for American population. The HEI-2015 score ranges from 0-100 in which a higher score indicates better diet quality. Changes in the HEI-2015 score from baseline to six months by study arm will be reported.
Time Frame
Baseline and six months
Title
Change in depressive symptoms from baseline to six months by study arm
Description
The 9-item Patient Health Questionnaire (PHQ-9) will be used to evaluate depressive symptoms. The PHQ-9 score ranges from 0 to 27, with higher scores indicating higher levels of depression. The change in PHQ-9 scores from baseline to six months by study arm will be reported.
Time Frame
Baseline and six months
Title
Change in diabetes distress scale from baseline to six months by study arm
Description
The diabetes distress scale (DDS) has 17 items measuring frustration, anger, and discouragement associated with managing complex diabetes health-care directives. The DDS score ranges from 1 to 6, with higher scores indicating higher levels of distress. The change in diabetes distress scores from baseline to six months by study arms will be reported.
Time Frame
Baseline and six months
Title
Change in diabetes self-efficacy from baseline to six months by study arm
Description
The 8-item Perceived Diabetes Self-Management (PDSM) scale will be used to assess confidence in one's ability to manage numerous self-care behaviors, including diet, and management of glucose. The PDSM scores ranges from 8 to 40, with higher scores indicating more confidence in self-managing their diabetes. The changes in the PDSM scores from baseline to six months by study arm will be reported.
Time Frame
Baseline and six months
Other Pre-specified Outcome Measures:
Title
Durability of HbA1c values from six months to twelve months in the intervention arm.
Description
To evaluate durability of the HbA1c after the intervention ended, the change in HbA1c levels (%) from six months to twelve months in the intervention group will be reported.
Time Frame
Six and twelve months
Title
Durability in scores of food security from six to twelve months in the intervention arm.
Description
To evaluate durability of food security after the intervention ended, the change in food insecurity scores from six months to twelve months in the intervention group will be reported. The US household food security survey module from the USDA will be used. The score ranges from 0 to 18 in households with children, and 0 to 10 in households without children. Higher score indicates higher severity of food insecurity.
Time Frame
Six and twelve months

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Confirmed diagnosis of T2DM confirmed by medical or laboratory records. For T2DM, any of the following criteria will be considered (from the American Diabetes Association): glycated hemoglobin (HbA1c) ≥6.5%, or fasting plasma glucose of ≥126, or a 2-hour plasma glucose level of 200 or higher during a 75 g oral glucose tolerance test, or a random plasma glucose of 200 or higher in patients with symptoms of hyperglycemia Age ≥18 years. Screening positive for food insecurity (at least one positive answer) in the previous 6 months assessed using the 6-item version of the US Household Food Security Survey Module (US Department of Agriculture), or has household income <200% of the federal poverty level. English or Spanish language fluency. Adequate cognitive and hearing capacity to consent and complete study measures. Reside in Alameda County or San Francisco County. Exclusion Criteria: Type-1 diabetes mellitus Individuals with disorders known to affect the accuracy of the HbA1c measure (e.g., end stage renal disease and individuals with known hemoglobinopathies). Inability to attend the educational workshops. Inability to schedule baseline assessments and/or blood draw after repeated requests. Pregnant individuals, or individuals planning to get pregnant within 6 months, or are lactating, or are postpartum less than 6 months. Current POH clients, past POH clients who stopped services less than 6 months prior, or past or present participants in other POH medically tailored meals studies. Does not have access to food storage, including a refrigerator and freezer to safely keep food. Does not have access to facilities to reheat and prepare meals using Project Open Hand food. Anticipates moving out of study area of Alameda and San Francisco Counties in the next 6 months. Receives more than 1 meal per day from a free food support resource or agency. Allergic to or will not eat eggs, soy, wheat, nuts, seeds or seed oils, or other foods commonly included among ingredients in POH meals. Allergic to dairy products, or unable to tolerate any dairy products including milk, yogurt and cheese. Individual does not eat any or all of POH's meat meal options and will not eat the vegetarian POH meal option.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Kartika Palar, PhD
Phone
415 226 6839
Email
kartika.palar@ucsf.edu
First Name & Middle Initial & Last Name or Official Title & Degree
Aron O'Donnell
Phone
415 226 6839
Email
aron.odonnell@ucsf.edu
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Kartika Palar, PhD
Organizational Affiliation
University of California, San Francisco
Official's Role
Principal Investigator
Facility Information:
Facility Name
Project Open Hand
City
San Francisco
State/Province
California
ZIP/Postal Code
94109
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Ana Ayala
Phone
415-447-2330
Email
aayala@openhand.org
First Name & Middle Initial & Last Name & Degree
Aron O'Donnell
Email
aron.o'donnell@ucsf.edu
First Name & Middle Initial & Last Name & Degree
Sheri Weiser, MD, MPH, MA
First Name & Middle Initial & Last Name & Degree
Kartika Palar, PhD
First Name & Middle Initial & Last Name & Degree
Elizabeth Murphy, MD
First Name & Middle Initial & Last Name & Degree
Hilary Seligman, MD

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
28097614
Citation
Palar K, Napoles T, Hufstedler LL, Seligman H, Hecht FM, Madsen K, Ryle M, Pitchford S, Frongillo EA, Weiser SD. Comprehensive and Medically Appropriate Food Support Is Associated with Improved HIV and Diabetes Health. J Urban Health. 2017 Feb;94(1):87-99. doi: 10.1007/s11524-016-0129-7.
Results Reference
background
PubMed Identifier
26526255
Citation
Seligman HK, Lyles C, Marshall MB, Prendergast K, Smith MC, Headings A, Bradshaw G, Rosenmoss S, Waxman E. A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic Control Among Clients In Three States. Health Aff (Millwood). 2015 Nov;34(11):1956-63. doi: 10.1377/hlthaff.2015.0641.
Results Reference
background
PubMed Identifier
20592297
Citation
Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med. 2010 Jul 1;363(1):6-9. doi: 10.1056/NEJMp1000072. No abstract available.
Results Reference
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PubMed Identifier
23799677
Citation
Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty N. Examining health care costs among MANNA clients and a comparison group. J Prim Care Community Health. 2013 Oct;4(4):311-7. doi: 10.1177/2150131913490737. Epub 2013 Jun 3.
Results Reference
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PubMed Identifier
29608345
Citation
Berkowitz SA, Terranova J, Hill C, Ajayi T, Linsky T, Tishler LW, DeWalt DA. Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries. Health Aff (Millwood). 2018 Apr;37(4):535-542. doi: 10.1377/hlthaff.2017.0999.
Results Reference
background
PubMed Identifier
31009050
Citation
Berkowitz SA, Terranova J, Randall L, Cranston K, Waters DB, Hsu J. Association Between Receipt of a Medically Tailored Meal Program and Health Care Use. JAMA Intern Med. 2019 Jun 1;179(6):786-793. doi: 10.1001/jamainternmed.2019.0198.
Results Reference
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PubMed Identifier
22210570
Citation
Seligman HK, Jacobs EA, Lopez A, Tschann J, Fernandez A. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care. 2012 Feb;35(2):233-8. doi: 10.2337/dc11-1627. Epub 2011 Dec 30.
Results Reference
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PubMed Identifier
21747017
Citation
Seligman HK, Jacobs EA, Lopez A, Sarkar U, Tschann J, Fernandez A. Food insecurity and hypoglycemia among safety net patients with diabetes. Arch Intern Med. 2011 Jul 11;171(13):1204-6. doi: 10.1001/archinternmed.2011.287. No abstract available.
Results Reference
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PubMed Identifier
30939269
Citation
Marpadga S, Fernandez A, Leung J, Tang A, Seligman H, Murphy EJ. Challenges and Successes with Food Resource Referrals for Food-Insecure Patients with Diabetes. Perm J. 2019;23:18-097. doi: 10.7812/TPP/18-097.
Results Reference
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Changing Health Through Food Support for Diabetes

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