Food insecurity and diabetes are inextricably linked, and patients with diabetes in under-resourced communities may face financial, physical mobility, or transportation issues—all of which contribute to a lack of consistent access to healthy food. To help address this, in September 2020, Janani Arangan—a medical student, National Health Service Corps Scholar, and member of the Association of Clinicians for the Underserved—created a grocery voucher pilot project aimed at addressing food insecurity, enhancing diabetes self-management, and measuring clinical outcomes of patients with diabetes at Fair Haven Community Health Care (FHCHC) in New Haven, Connecticut.
The Beginning Stages: From California to Connecticut
Originally from Southern California, Arangan spent time prior to medical school teaching English and working in a San Francisco community health center as a health educator. She said, “I was familiar with urban populations in community health settings who were dealing with housing and food insecurity and documentation barriers. I knew that I wanted to work with immigrant and Spanish speaking populations in medical school.”
Arangan moved to Connecticut to attend Quinnipiac University’s Frank H. Netter MD School of Medicine. As she began getting to know the families of New Haven, she knew she wanted to do a community-based capstone project and connected with FHCHC’s Dr. Mellisa Pensa, a family medicine physician and clinical lead of health equity.
Dr. Pensa’s passion for treating diabetes and addressing health equity intersected with Arangan’s desire to provide primary care for medically under-resourced populations—and the Fair Haven clinic had a need to fill. Their patients with diabetes couldn’t engage as fully in managing their disease as their providers would have liked, in part because of food insecurity. While FHCHC had programs to help make medications more affordable, sign patients up for insurance, and address transportation barriers, the food insecurity issue was a gap that needed filling. The grocery voucher pilot project was born.
Connecting with Patients
With guidance from Dr. Pensa and the help of an interprofessional team, Arangan began collecting evidence-based research and creating materials. After some fine-tuning and securing a grocery store partnership, the team began working with established patients with poorly controlled diabetes. The patients met with a diabetes nurse educator to create a plan for what foods worked within their dietary restrictions, personal preferences, and food preparation knowledge. This shared decision-making between patient and nurse educator helped the patient enter the store with a plan to purchase items most beneficial to managing their diabetes.
Thirty-eight patients participated in the three-month project, receiving a $25 monthly grocery voucher. As Arangan noted, the program’s intent was not to fund an entire month of groceries, but to incentivize patients to reconnect with the clinic. Many patients had previous initial visits with educators, but due to the pandemic or financial struggles, they had lost contact. “It really was an incentive to say, ‘Hey, we’re here, and we care about you, your health, and your family.’”
Patients met with an educator to discuss their food purchases and have their choices recorded and hemoglobin A1C (blood glucose) levels assessed. Findings indicated that the 25 patients who completed the program experienced a significant decrease in their A1C. “Overall, the grocery voucher program helped patients better control their diabetes through increased clinic support and financial assistance,” said Arangan.
Challenges and Future Changes
Although successful at demonstrating how eliminating food insecurity could help lower diabetes complications, the project was not without challenges. The pandemic slowed the initiative, forcing it to adapt from face-to-face patient interviews to phone visits, and the original strategy of distributing premade grocery boxes shifted to providing patients with the $25 voucher.
But Arangan says these changes made the project even better: “the grocery voucher allowed patients choice compared with premade boxes, and they worked with our educators to receive advice about recipes and ingredients.”
Other challenges and feedback from patients became lessons learned for how to improve. Fair Haven is now considering growing the program by increasing the number of gift cards, and expanding to additional stores, expanding nutrition education programming, incorporating a food pharmacy, and collaborating with locally grown organic options.
A Continuing Commitment to CHCs
Arangan will continue sharing the project’s results at conferences, volunteering at the clinic, and plans to publish a manuscript. Also a member of ACU’s Membership Committee, she graduates from medical school in May 2023 and is applying to residency programs. “I would love to continue doing this research and community-based work wherever I am. As an NHSC Scholar, I will be working at a community health center for at least a couple of years, hopefully more, after residency.”
The grocery voucher project affirmed Arangan’s passion for CHC work, and she encourages other medical students to “reach out to CHCs and local clinics, even if their school doesn’t have a formal relationship, and partner with providers who are committed to working in those communities. I think that makes the whole experience meaningful, and it’s an incredible way to find mentors and engage with the community. My heart and my motivation to be in medicine comes from the CHC setting.”