A REUTERS SERIES

Out of Control

America’s losing battle against diabetes
A REUTERS SERIES

Out of Control

America’s losing battle against diabetes

Where the need is great, a fresh prescription for diabetes

A growing number of small, local programs across the U.S. provide healthy food and the skills to prepare it to help lower-income people get their disease under control, reduce their reliance on expensive medications, and prolong their lives. Early signs are encouraging.

Filed


SPRINGFIELD, OHIO

Dodging raindrops one afternoon last spring, two community health workers greeted Monica Moss on her small front porch with bags of supplies to help her manage her diabetes. The contents: food.

In addition to the eggs, blueberries, tomato sauce and walnuts, they gave the 50-year-old patient some cookware and kitchen utensils. They reminded her that fresh vegetables would be arriving soon and then dashed off to their next patient in this small Ohio city’s impoverished Southside neighborhood.

It was the first delivery Moss received from the local Rocking Horse Community Health Center. With a small grant of just a few thousand dollars, the clinic launched a program to give low-income type 2 diabetes patients the means to manage their disease with diet, rather than just medications. In addition to regular food deliveries, Rocking Horse handed out $30 grocery gift cards each month and hosted online classes to teach the patients about nutrition, reading food labels and cooking healthy meals.

Monica Moss stuck to healthier eating habits, and after three months, her diabetes went from uncontrolled to well-managed as her blood sugar levels dropped into a much safer range.

Moss was desperate for the help. For years, her diabetes was out of control, her blood sugar levels dangerously high, greatly increasing her risk for heart attack, stroke, amputation and other severe complications of the disease. She knew her diet of readily available, highly processed, high-calorie food only helped elevate her blood sugar, but she lacked the resources to do anything about it. The isolation and disruption of the COVID-19 pandemic only made things worse.

“I’m an emotional eater,” she said. “My anxiety was going through the roof.”

The day after that first delivery, she made a spinach lasagna in her new skillet while she watched her first nutrition class on Zoom. Seven months later, she was still at it. In early December, Moss stood in her kitchen grilling quesadillas packed with zucchini, green peppers, carrots and onions. “I’m not usually a vegetable person,” she said. “But I want to do anything I can to get my diabetes under control.”

In the intervening months, Moss stuck to the healthier eating habits. Her diabetes went from uncontrolled to well-managed as her blood sugar levels dropped into a much safer range.

Against the grain

The Rocking Horse program is part of a nascent movement among a small but growing number of doctors, hospitals and health officials to find a way to tame an epidemic of diabetes in the United States. They are motivated by increasing evidence that the U.S. food system is making people sick by making it easier and cheaper for them to access calorie-dense processed foods than healthier alternatives.

As Reuters detailed earlier this year, diabetes represents a major public health failure in the country. The number of Americans with the disease has exploded in recent decades, and their prognosis has worsened, even though spending on new treatments has soared.

Diet plays a pivotal role in the life and health of people with diabetes, yet it is rarely addressed within the U.S. healthcare system. Offering healthy food goes against the grain of long entrenched norms in the United States, where government programs, insurers and medical providers plow billions of dollars into expensive medications, procedures and medical devices to treat patients.

“We have vastly under-invested in food and nutrition within the healthcare sector,” said Devon Klatell, the Rockefeller Foundation’s managing director of food initiatives. “There is overwhelming evidence that our food system is making lots of us sick” and it has become a “predominant cause for poor health outcomes and high healthcare costs in this country.”

Poor diets, along with sedentary lifestyles, are directly linked to type 2 diabetes, the dominant form of the disease. Consumption of highly processed foods laden with sugars and fats contributes to the high blood sugar levels and obesity that are precursors to type 2. And of the estimated 34 million Americans with diabetes, about 95% are type 2. About 1.6 million Americans have type 1 diabetes, an autoimmune disease of unknown cause that requires lifelong insulin injections.

Unlike type 1 patients, those with type 2 diabetes may be able to manage and even reverse their disease through diet and exercise, greatly reducing the risk of severe complications. With the right diet, some may even be able to live without medication.

But getting people to change their eating habits, often a core part of a person’s identity and culture, isn’t easy. Food insecurity – the lack of access to adequate nutrition – only adds to the challenge. Those who can’t afford more healthful food often turn to relatively cheaper fast food and other calorie-dense alternatives, heavy in refined carbohydrates, added sugars and fats. The problem worsened during the COVID-19 pandemic as millions of Americans lost their jobs and food pantries were overwhelmed.

Initiatives like Rocking Horse’s – few in number, limited in scope and relying on scant funding – seek to make it easier for patients to eat right. These programs take many forms. In Pennsylvania, doctors write diabetes patients prescriptions for healthy food to be filled at food pharmacies that resemble small grocery stores. In Santa Barbara, California, a clinic offers bags of produce weekly to dozens of diabetes patients, many of whom are poor and Latino.

“We can improve people’s health as much by offering vegetables as we can in many cases by offering medication,” said Dr Namino Glantz, an associate director at the Sansum Diabetes Research Institute, which runs the Farming for Life program in Santa Barbara.

Fewer emergencies

In Shamokin, Pennsylvania, Geisinger health system opened its Fresh Food Farmacy as a pilot project in 2016 to help counter an alarming rate of diabetic complications in the rural, economically depressed area it serves. Overall, the system operates nine hospitals and dozens of clinics, and its health plan covers more than 500,000 members.

Geisinger doctors write type 2 patients prescriptions for the Fresh Food Farmacy, offering them enough food to make 10 fresh meals a week. Patients also consult dieticians, pharmacists and community health workers to craft meals and manage their disease. Geisinger has added locations in Scranton and Lewistown, and more than 1,300 people have enrolled in the program.

Distributing food as medicine has made financial sense for Geisinger, which is both a healthcare provider and an insurance company ultimately responsible for its members’ medical costs. Geisinger said it spends about $2,200 per patient a year on the food, staffing and facilities to operate the food pharmacies, about half of what it spent initially, when startup costs were higher. Annual medical costs, in turn, decrease by $9,000 on average per patient. A decline in emergency-room visits and hospital admissions accounted for much of the savings. Participants were less likely to miss doctor’s appointments, too.

Allison Hess, Geisinger’s vice president of health services, said the health system is conducting a randomized clinical trial with the Massachusetts Institute of Technology to better quantify the program’s impact on diabetes patients.

“A lot more research like that is needed,” said Dr Seth A. Berkowitz, a researcher and assistant professor of medicine at the University of North Carolina. Without it, government agencies, insurers, hospital systems and other big funders will not know how best to use food programs to treat diabetes. “We’ll learn a lot over the next several years about which sort of interventions work,” Berkowitz said. He isn’t involved in the MIT study.

Tom Shicowich, 61, credits the Geisinger program with saving his life after years of uncontrolled type 2 diabetes led to a toe amputation and kidney disease.

He said he initially didn’t take his condition seriously after he was diagnosed with type 2 diabetes about 15 years ago. He also didn’t have much money or support, working as a grocery-store clerk without health insurance. He deferred medical care, he said, and his diet was poor. “I couldn’t afford to be healthy,” he said. “I lived out of the freezer section at the grocery store.”

His doctor wrote him one of the first prescriptions for the Fresh Food Farmacy in 2016, and within months, he lost over 60 pounds. His blood glucose levels fell to a more manageable level.

Shicowich now works several days a week as a paid part-timer at the Geisinger store in Shamokin. He also helps lead a six-week course for enrollees on nutrition, meal planning and managing diabetes. Over the phone, he urges fellow diabetes patients to regularly check their blood sugar and describes the week’s meal options, encouraging people to try new recipes, such as a cauliflower pizza crust and a salad with beets, carrots and apples.

Many of them ask him questions they might not feel comfortable asking a doctor or nurse. “I’m in the same shoes as them,” he said. “Someone asked me what broccoli is.”

Earlier this year, Lisa Fiorini, 54, was filling her shopping cart at the Fresh Food Farmacy in Scranton. Diagnosed with type 2 diabetes in her 20s, she said that for years, the only dietary advice she got was to avoid sugar.

Since joining the Geisinger program two years ago, Fiorini said, she better understands the importance of lean meats, whole grains and low-fat dairy products in helping her manage her disease. Her long-term goal is to reduce her reliance on insulin and other diabetes medications.

“Before I wasn’t given the tools for what I needed to do,” Fiorini said.

Basic needs unmet

The Springfield, Ohio, area that the Rocking Horse clinic serves bears the signs of prolonged neglect: boarded-up homes, shuttered storefronts and potholed streets. Fast-food restaurants are plentiful. In early 2020, the local Kroger grocery store closed, leaving the area without a supermarket until Groceryland opened this month.

Rocking Horse launched its three-month pilot food program earlier this year with a grant of about $6,000 from a private Medicaid insurer and donations from a local food bank. Zyrene Marsh, a nurse practitioner at Rocking Horse who organized the Purple Apron program, said she saw how food insecurity and poverty affected her diabetes patients and realized that medication and technology couldn’t address their basic health needs.

“In the algorithm from the American Diabetes Association, they tell you every single detail on what medication to start with and if that doesn’t work, what you do next,” Marsh said. “But they don’t tell you what to do if your patient … can’t find the right food to eat.”

In its current treatment guidelines, the American Diabetes Association says that “food prescription programs are considered promising practices to address food insecurity by integrating community resources into primary care settings.” Earlier this year, the advocacy group backed a community garden project in Alabama to expand access to fruits and vegetables for type 2 diabetes patients and their families.

Moss particularly appreciated the set of knives and the air fryer she received under the program – luxuries she couldn’t have afforded on her own.

The Rocking Horse clinic originally enrolled 20 patients in its three-month program. A few dropped out because they became too sick to participate, either hospitalized or frequently in the emergency room. Others decided they didn’t need the help.

Among the 12 who completed the program was Moss. Marsh had treated her and knew she was perfect for the program.

Moss was diagnosed with type 2 diabetes in 2015. After that, her disease was dangerously uncontrolled much of the time. Her A1c score – a measure of average blood glucose over the previous three months – was above 11%. Medical guidelines consider a score of 9% or above as out of control; the higher the number, the worse it is.

Moss said she was eating the same unhealthy foods over and over and rarely tried anything new. When the pandemic hit, she feared venturing out, limiting herself to quick trips to nearby fast-food restaurants.

Other health problems arose. Worsening pain in her back and hip led to diagnosis of a fungal infection in her spine. She spent five weeks in the hospital before returning home in August 2020. She still has back pain and walks with a cane. In April this year, Moss spent a week in the hospital with COVID-19. While there, her blood sugar levels rose further. “The past year was not nice to me,” she said.

‘I was shocked’

Moss embraced the Rocking Horse program when it started the following month. She gave up meat except for baked chicken. Fast-food sandwiches and soft drinks were out, as were her longtime favorites: fried chicken and mashed potatoes.

In their place were meals featuring French-style green beans, broccoli and cabbage. She and fellow participants shared what they liked and didn’t like from their food deliveries and classes. Creative ideas for salads were a hit. Fish tacos were met with skepticism.

The equipment Moss received was a big help, too. She particularly appreciated the set of knives for cutting vegetables and the air fryer for cooking chicken – luxuries she couldn’t have afforded on her own. She receives food stamps and health coverage through Medicaid, the government insurance program for the poor.

Initial results of the Rocking Horse program were encouraging. Eight of the 12 participants who completed it had a lower A1c score. Also, fewer of them reported having food insecurity afterward.

Moss did especially well. She said that as she maintained her diet, she felt less lethargic and regained some mobility, allowing her to keep up with her 3-year-old grandson. Her A1c score dropped to 9.3% in June, a month into the program, and then below 8% after completing it. “I was shocked it was that low,” Moss said. At her doctor’s appointment Dec. 16, her A1c was still below 8%.

She hopes she can keep her A1c score in a good range long enough for her doctor to take her off her two diabetes medications. She said food stamps allow her to afford the type of food the Rocking Horse program introduced her to. “My diabetes is finally being managed well,” she said. “I really pay attention to the calories and carbs on the boxes now when I go shopping. Even my daughter is eating healthier like me, too. That is a plus.”

Rocking Horse plans to enroll more patients in Springfield and expand to a neighboring county in February. It hopes that as pandemic precautions ease, it can offer in-person learning and cooking demonstrations to improve participation and overall results.

Dr Yamini Teegala, chief medical officer at Rocking Horse, said that the clinic will fund the expansion for now, but that she hopes Medicaid and other insurers will eventually cover such food programs and reimburse health workers for the time they spend on them. She said the current reimbursement model fails to invest in preventive services for diabetes patients, and physicians like herself can only do so much during routine appointments.

“A prescription drug impacts an individual,” Teegala said. “Healthy food and eating habits affect communities for generations to come.”


Out of Control: America’s losing battle against diabetes

By Robin Respaut and Chad Terhune

Photography: Megan Jelinger and Hannah Beier

Photo editing: Corinne Perkins

Art direction: Troy Dunkley

Edited by Michele Gershberg and John Blanton