PROJECT SUMMARY/ABSTRACT Food insecurity, “lack of access to enough food for an active, healthy life”, affects over 20% of the 30 million Americans with diabetes. Food insecurity is more common in racial/ethnic minorities and those with lower socioeconomic status. Moreover, food insecurity is associated with worse diabetes control and increased complications, even after adjusting for other risk factors. Food insecurity is a major contributor to disparities in diabetes outcomes. Medically tailored meal (MTM) delivery programs are a promising intervention for individuals with diabetes and food insecurity. MTM programs deliver fully prepared food, tailored by a registered dietitian nutritionist to the specific medical needs of the individual, and provide education to help optimize disease self-management. Food insecurity is typically addressed with food subsidies—offering additional financial resources that can be spent on food. While both food subsidies and MTM can increase healthy food access, MTM can help overcome other barriers to diabetes management including lack of time, ability, knowledge, and skills needed to prepare appropriate meals. The use of these programs is often called ‘food is medicine’, as the purpose is to provide exactly the foods needed to help prevent diabetes complications. MTM are receiving increasing public attention, but there are, as of yet, no full-scale trials to test its effects on diabetes outcomes when compared with other food insecurity interventions. Our research team has developed a medically tailored meal intervention that combines provision of healthy food, tailored to the specific nutrition needs of the individual, with an evidence-based lifestyle intervention that uses the period of meal delivery as springboard to improve diabetes self-management, both while receiving meals and after meal delivery is completed. MTM was highly successful in improving diet quality in a pilot randomized clinical trial. What is missing is an explanatory (efficacy) randomized trial testing whether this medically tailored meal intervention can lead to improvements in diabetes outcomes such as Hemoglobin A1c, and in patient-reported outcomes such as diabetes distress, quality of life, and hypoglycemia. Thus, we propose a randomized trial to assess a community-based medically tailored meals intervention (n=200). It will be conducted among diverse participants referred for medically tailored meals. Adults with type 2 diabetes, Hemoglobin A1c between 7.0% and 12.0%, and BMI ≥ 25 kg/m2 (≥ 23 kg/m2 for those with Asian ancestry) will be enrolled and randomly assigned to intervention or usual care + food subsidy. The intervention group will receive meal delivery and its attendant lifestyle intervention for 6 months, while the usual care + food subsidy group will receive a $30/month healthy food subsidy, along with usual diabetes care. Outcomes will be assessed at 6 and 12 months. The primary outcome is Hemoglobin A1c at 6 months. Secondary outcomes include change in physiologic, behavioral, and psychosocial measures.

PROJECT NARRATIVE Over 30 million Americans have diabetes, and 1 in 6, over 5 million, report food insecurity, or insufficient access to enough food for an active, healthy life. The proposed research program will significantly advance our understanding of how to best address food insecurity in the context of diabetes management by testing an innovative medically-tailored meal delivery intervention for individuals with food insecurity and elevated blood sugar levels. This intervention has the potential to improve health and reduce the impact of food insecurity among vulnerable individuals with diabetes.