Examining the Links Among Diabetes Education, Activity, and Food Insecurity

The presentation at Virtual ISPOR 2020 found that 7% of a group of Medicare beneficiaries with type 2 diabetes was experiencing food insecurity, a rate the lead author found "alarming."

For 20 years, Medicare has covered diabetes education, to help beneficiaries with the disease better manage their diet, properly dose their medications, recognize the onset of high or low blood sugar, and understand the importance of getting enough exercise.

Better management of diabetes can help people with diabetes reduce their risk of cardiovascular disease, stroke, amputations, kidney failure, or blindness. It could also save tax dollars: according to the American Diabetes Association, Medicare spent $42 billion on diabetes in 2016, and 67.3% of all the care for diabetes in the United States is paid for by the government.

Research shows that a course of education, known in Medicare as diabetes self-management training, or DSMT, has positive benefits. A chief point of conflict in recent years between CMS and diabetes educators—who prefer the term diabetes self-management education and support, or DSMES—is that education should not be a “one and done” opportunity; a person with diabetes needs a refresher as circumstances change.

Very little information exists, however, on the connections among food insecurity, DSMT and physical activity. And that was the point of a presentation made last week by Boon Peng Ng, a health care economist and assistant professor at the University of Central Florida College of Nursing, who outlined findings from a study during Virtual ISPOR 2020, the annual meeting of the International Society for Pharmacoeconomics and Outcomes Research.

Ng and fellow researchers looked at 1263 Medicare beneficiaries over 65 years old with type 2 diabetes (T2D). The review found that 7% of the group were experiencing food insecurity, a result that Ng called “alarming.”

Among the group, 51% reported engaging in recommended levels of physical activity. Ng did not define what the recommended levels were; however, the World Health Organization recommendations for older adults call for at least 150 minutes per week of moderate intensity physical activity or 75 minutes of vigorous activity, including period of at least 10 minutes of aerobic activity. Those with poor mobility should perform physical activity to prevent falls at least 3 days per week.

Ng’s team found that among the seniors who had met recommended levels of physical activity, 51% had taken DSMT; among those who had not met recommended levels, only 41% had taken DSMT.

Beneficiaries who reported participating in recommended weekly exercise were more likely to be male, younger, married, more educated, higher earners, living with others, and less afflicted with chronic conditions.

“Our findings show that as patients have diabetes management training, it has a positive effect on engagement in recommended weekly physical activity,” Ng said. But the fact that just half of beneficiaries with T2D reported engagement with recommended physical activity indicates that additional outreach efforts are needed to increase the number who are exercising, he said.

The proportion of patients who exercised and the effects of DSMT on the levels of physical activity were consistent with previous findings. Findings from an earlier study showed that 42% of noninstitutionalized American older adults with diabetes complied with the recommended amount of physical activity. According to an additional study, DSMT and education led to a positive improvement in physical activity.

Particular elements of DSMT that work best to promote physical activity engagement could not be measured because the study did not examine participants’ behavior to that extent, Ng said. “As we know, there are various programs related to DSMT. So, there are certainly limitations of the study for sure.”

Investigators also observed the relationship between food insecurity and weekly exercise. Ng said 4.6% of beneficiaries who took part in weekly exercise had food insecurity, compared with 9.6% of those who did not take part in weekly exercise. Investigators said while was not a statistically significant finding, it was noteworthy.


Ng BP, Kim K, LaManna J, Li Y. Food insecurity, participation of diabetes self-management education and support, and physical activity among Medicare beneficiaries with type 2 diabetes. Presented at: Virtual ISPOR 2020; May 18-20, Lawrence Township, NJ. Abstract CV1.

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