DESCRIPTION (provided by applicant): Food insecurity, defined as difficulty affording an adequate diet owing to cost, affects over 20% of the 29 million Americans with diabetes. Food insecurity is an important socioeconomic barrier to effective diabetes care: it is associated with worse diabetes control and increased emergency department visits and hospitalization. By incentivizing consumption of calorie-dense foods high in simple carbohydrates and saturated fats, instead of more expensive fresh produce and whole grains, food insecurity may undermine healthy diets that are crucial for diabetes management. This project will help advance our knowledge of the relationship between food insecurity and diabetes by identifying how food insecurity affects current diabetes management and examining the clinical effects of using different strategies to overcome it. Fundamental questions regarding the mechanisms underlying potential interventions remain unanswered. To address these gaps in knowledge, the principal investigator (PI) proposes a career development program that blends rigorous methodologic training with an innovative research agenda. This plan has three scientific objectives: 1) To determine the impact of food insecurity on a lifestyle change intervention: the REAL HEALTH Diabetes trial (R18 DK102737 NCT02320253), a pragmatic adaptation of the Look AHEAD lifestyle intervention to community health centers, 2)To estimate the effect of nutrition assistance program use on diabetes control for patients in a primary care network, and 3) To conduct a pilot randomized controlled trial to assess the feasibility of home-delivered medically tailored meals for food insecure diabetes patients with hyperglycemia. This research program complements the National Institute of Diabetes and Digestive and Kidney Diseases' strategic focus on translating clinical research to practice by overcoming barriers faced by patients in real-world settings, reducing disparities in special populations, making care more patient-centered, and innovating within systems of care. The long-term goal of this career development award is to establish the PI as an independent researcher with expertise in understanding how socioeconomic barriers affect diabetes management and pragmatic interventions to overcome them. Career development activities include training in advanced analytic methods and intervention design through formal coursework as well as mentorship by an exceptionally qualified team of senior scientists. Successful completion of this career development proposal will fill important knowledge gaps, and help improve diabetes management and reduce diabetes complications in patients with food insecurity.

PUBLIC HEALTH RELEVANCE Over 29 million Americans have diabetes, and 1 in 5, nearly 6 million, report food insecurity, or difficulty accessing nutritious food owing to cost. The proposed research program will significantly advance our understanding of the role food insecurity plays in diabetes management, and assess 2 strategies to address food insecurity in diabetes patients: 1) improving food access using nutritional assistance programs, and 2) directly providing medically tailored meals. This program has the potential to expand partnerships between healthcare systems and community organizations, and may reduce the impact of food insecurity among vulnerable diabetes patients