The goal of this clinical trial is to learn if a food is medicine intervention (Healthy Food Rx) improves diabetes-related outcomes in adults diagnosed with type 2 diabetes in a low-income, community-based setting more than usual care. The main questions the study aims to answer are: * Does Healthy Food Rx program participation lead to improved A1C values (a measure of glycemic control over approximately the past three months) over a 6-month period compared to usual care in a highly food insecure population? * Does the Healthy Food Rx program lead to improved diabetes-related behaviors over a 6-month period compared to usual care in a highly food insecure population? Researchers will compare the Healthy Food Rx program to usual care to see if diabetes-related outcomes, including A1C, fruit and vegetable consumption, food security, physical activity, diabetes self-management behaviors and general physical and mental health status, improved more in those receiving Healthy Food Rx. Healthy Food Rx is a program that provides home-delivered, family-sized, recipe-based healthy food boxes with an approximate value of $40 every other week for 6 months to people with Type 2 diabetes living in Stockton, CA. Produce is sourced from local Central Valley growers, and the boxes also include pantry staples like chicken, fish, egg, beans and healthy snacks, such as nuts, yogurt, and cheese. Nutrition education opportunities are also provided to participants. Participants will: * Complete surveys at two time points in either English or Spanish. The surveys last around 10 minutes and will be conducted by trained Health Educators. * Provide HIPAA consent to allow researchers to obtain A1C values and demographic information from their medical record. * Retest A1C around the conclusion of the study. Intervention participants will receive Healthy Food Rx immediately following enrollment and the control group will receive Healthy Food Rx at the end of the study.
Background and purpose The Healthy Food Rx project's goal is to improve diabetes related outcomes by increasing access to fresh, seasonal fruits and vegetables and other healthy foods in low-income communities disproportionately affected by diabetes with the "Healthy Food Prescription (Rx) Program". The project will provide recipe-based healthy food boxes through community partnerships enabling home delivery and complementary nutrition education opportunities (virtual and in-person). The Healthy Food Rx program aims to improve hemoglobin A1C, food security, dietary quality, and diabetes self-management behaviors in patients with Type 2 diabetes at a Federally Qualified Health Clinic (FQHC) in Stockton, CA more than usual care. Methods Intervention Through partnerships with community organizations, Healthy Food Rx provides family-sized, recipe-based healthy food boxes with an approximate value of $40 every other week for 6 months. The boxes are home-delivered and complementary nutrition education opportunities are provided to participants. Produce is sourced from local Central Valley growers, and the boxes also include pantry staples like chicken, fish, egg, beans and healthy snacks, such as nuts, yogurt, and cheese. Design This study builds on the findings of two previous pre-post studies without a comparison group showing significantly improved diabetes-related outcomes in program participants. To evaluate whether the Healthy Food Rx program improves these outcomes significantly more than usual care this study will be a randomized controlled trial with delayed intervention for the control group. To maintain ethical practices, control participants who have been asked to contribute their time and data to this study will receive the program at the conclusion of the follow-up surveys. Enrolled participants will complete two 10-minute interviewer administered surveys either in person or by phone; the baseline survey will be conducted during enrollment and for the intervention group, the follow-up survey will be conducted after completion of the 6-month intervention; for the control group, follow-up surveys will be conducted about 6 months after the baseline survey. Surveys will be conducted by trained Health Educators in the participant's preferred language of English or Spanish. The responses will be recorded in an online, secure data platform. The intervention group will start receiving Healthy Food Rx after completing the baseline survey. A1C and demographic data will be collected from medical records with HIPAA-compliant patient consent. All other outcomes will be included in the surveys using validated questions, where appropriate. Recruitment Recruitment and data collection for this study will be conducted by community-based Health Educators. The Health Educators will have completed formal and informal training prior to patient recruitment as well as CIRTification training for the protection of human subjects. Health Educators will identify potential qualified program participants in their clinic database. Participants will be invited to participate and they will be given information about the program, including a link to the clinic's website, using IRB and clinic approved messaging on the clinic's mass text messaging program. Patient materials and conversation will be in English or Spanish, as preferred. Health Educators will read the approved consent to potential participants and a signed copy of the study consent form as well as a HIPAA authorization form will be required. HIPAA authorization is necessary to allow the clinic staff to extract their demographic and A1C data from their health records. Sample size Desired sample size was calculated based on a clinically relevant difference in A1C of 0.5%, a standard deviation of 1.9 based on previous data, a two-sided test with a significance level of alpha equal to 0.05 and 80% power. This resulted in a necessary follow-up sample size of 179 participants per group, or 358 total was estimated. To account for up to 12% loss to follow-up, 400 participants are planned to be enrolled. Randomization Once participants are enrolled, they will be randomized into intervention or control groups. A randomization schedule will be created by the research team using a stratified randomized block design with block sizes of four. Participants were stratified by baseline A1C values to ensure balance across groups in those with A1C values of 9% or greater since in the previous studies results were more significant in those with higher baseline A1C values. Demographic factors were not related to outcomes in previous studies, therefore they will not be used in the stratification scheme. Blinding is not feasible since the clinic staff must coordinate with the Emergency Food Bank of Stockton to enroll participants in the Healthy Food Rx program, however randomization will occur after the baseline survey. Benefits and Risks Benefits to participants include healthy food boxes and expert instruction on nutrition with a focus on diabetes self-management. Study participants who complete pre and post surveys will also receive a $10 digital grocery gift card. Taking part in this program does not pose risks that are above and beyond the exposure of daily living for individuals participating in programs to manage diabetes, with the possible exception of risk associated with the transmittal of health-related data. All precautions will be taken to protect confidentiality and secure data. The questionnaire used in this study will address food insecurity. Recognition of food insecurity may present discomfort for participants. Disclosure of an individual's food-insecure status to people outside of the study could present the risk of harm to reputation or discrimination. Additionally, they will need to complete at least one lab test during the study to obtain a recent A1C value which is conducted regularly as part of the patient's clinical care. Those randomized to the control group could experience disappointment or frustration with the delay in receiving food boxes. Confidentiality Health Educators will be enrolling participants and using the UniteUs software platform to record all data. The UniteUS platform stores information securely by encrypting all the information, regardless of personal identifiable information. To protect the participants' enrollment into the Healthy Food Rx program, UniteUs has agreed to label the Healthy Food Rx program as a sensitive organization making study information only visible to the sender and recipient. Once data collection has ended, health educators from the Community Medical Centers will download the data and provide de-identified data to researchers at PHI CWN. Signed HIPAA authorization forms will also be stored by PHI CWN in a locked file cabinet. These will not be linked to any other program data. Data procedures All data will be examined for completeness and values out of range will be removed from the analysis. Missing data will also be excluded from analysis. Demographics and baseline A1C will be compared to ensure similarity between groups using Chi-square tests for homogeneity. Descriptive statistics (frequencies and means) will be calculated for all demographic and outcome variables at both time points. Within group baseline to follow-up analyses will be conducted using tests appropriate for paired data including paired t-tests, Wilcoxon signed rank and McNemar's tests. To compare change over time between the intervention and control groups as well as assess the influence of demographic factors on the outcomes, multi-variate linear mixed models will be conducted. P-values less than 0.05 are considered statistically significant for this analysis. Data analyses will be conducted using IBM SPSS Statistics V28, and SAS Software for Windows V9.4. Reporting A final report with all findings will be completed as well as presentations and other dissemination materials as requested by the funder. A manuscript will also be submitted for publication.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
405
Healthy Food Rx provides family-sized, recipe-based healthy food boxes with an approximate value of $40 every other week for 6 months. The boxes are home-delivered and complementary nutrition education opportunities are provided to participants. Produce is sourced from local Central Valley growers, and the boxes include pantry staples like chicken, fish, egg, beans and healthy snacks, such as nuts, yogurt, and cheese.
Community Medical Centers
Stockton, California, United States
Hemoglobin A1C
A1C is a measure of glycemic control over approximately the past three months. Measures will be extracted from patient's medical records with HIPAA consent.
Time frame: They will be measured at 2 points in time. Baseline value is valid up to 3 months before enrollment Follow-up, A1C measures are valid from 60 days before to 90 days after the last food box delivery.
Food insecurity
This measure is based on Hunger Vital Sign™, a validated 2-question food insecurity screening tool based on the U.S. Household Food Security Survey Module was used to identify participants at risk of food insecurity. Participants were classified as food insecure if they answered sometimes or often true to either of the following: "We worried whether our food would run out before we got money to buy more," or "The food that we bought just didn't last, and we didn't have money to get more."
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Fruit consumption
Fruit consumption will be captured using a 6-level Likert scale with questions from The Expanded Food and Nutrition Education Program (EFNEP) adult education survey where one equals 'I rarely eat fruits' and six equaled 'more than four times per day'
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Vegetable consumption
Vegetable consumption will be captured using a 6-level Likert scale with questions from The Expanded Food and Nutrition Education Program (EFNEP) adult education survey where one equals 'I rarely eat vegetables' and six equals 'more than four times per day'
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Water consumption
Water consumption will be captured using a 6-level Likert scale with questions from The Expanded Food and Nutrition Education Program (EFNEP) adult education survey where one equaled 'I never drink water' and six equaled 'five times per day.'
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Physical activity
Number of days per week conducting at least 10 minutes of physical activity will also be included, adapted for older adults from the 30 minutes used in the EFNEP question.
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Self-reported physical health status
Physical health will be self-reported on a 5-point Likert scale where one equaled 'poor' and 5 equaled 'excellent.' Questions adapted from the Centers for Disease Control and Prevention (CDC) overall health status measure.
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Self-reported mental health status
Mental health will be self-reported on a 5-point Likert scale where one equals 'poor' and 5 equals 'excellent.' Questions were adapted from the Centers for Disease Control and Prevention (CDC) overall health status measure .
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
Diabetes self-management
Participants will be asked about the frequency of performing diabetes self-management tasks over the past month, including checking blood sugar with a glucose monitor, coming in for clinic appointments, and taking diabetes medications as prescribed on a five-point scale where one equaled 'Never' and five equaled 'Always.' These measures were adapted from the Self Care Inventory-Revised Version (SCI-R). Diet and physical activity questions were omitted since they were asked elsewhere.
Time frame: Measured in baseline and follow-up surveys at enrollment and approximately 6 months after enrollment.
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