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Maddahi M, Asadimehr S, Ramezani Ahmadi A, Govahi Kakhki F, Sobhani R. Food Insecurity regarding the Diabetes Mellitus in Iran: A Systematic Review and Meta-Analysis. JNFS 2024; 9 (2) :372-382
URL: http://jnfs.ssu.ac.ir/article-1-673-en.html
URL: http://jnfs.ssu.ac.ir/article-1-673-en.html
Mona Maddahi 
, Soheil Asadimehr , Amirhossein Ramezani Ahmadi , Fatemeh Govahi Kakhki , Reza Sobhani *
, Soheil Asadimehr , Amirhossein Ramezani Ahmadi , Fatemeh Govahi Kakhki , Reza Sobhani *
Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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1 Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; 2 Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan,Iran; 3 Department of Nutrition, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran; 4 Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran.
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Food Insecurity regarding the Diabetes Mellitus in Iran: A Systematic Review and Meta-Analysis
Mona Maddahi; MSc1,4, Soheil Asadimehr; MSc1,4, Amirhossein Ramezani Ahmadi; PhD2,
Fatemeh Govahi Kakhki; MSc3 & Seyyed Reza Sobhani; PhD*1
Mona Maddahi; MSc1,4, Soheil Asadimehr; MSc1,4, Amirhossein Ramezani Ahmadi; PhD2,
Fatemeh Govahi Kakhki; MSc3 & Seyyed Reza Sobhani; PhD*1
1 Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; 2 Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan,Iran; 3 Department of Nutrition, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran; 4 Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran.
| ARTICLE INFO | ABSTRACT | |
| SYSTEMATIC REVIEW and META-ANALYSIS |
Background: Food insecurity is an important global challenge associated with various health problems such as diabetes. Diabetes mellitus is one of the most common metabolic diseases and is considered priority in Iran’s health system. The aim of this study is to evaluate the relationship between food insecurity and type 2 dibetes mellitus (T2DM) in Iran. Methods: The authors searched English databases including Scopus, Web of Science, PubMed, and Google Scholar and also Iranian databasesof SID and Magiran for the words food insecurity, Iran, and diabetes up to November 2021. Results: 8 articles, including 2853 participants, ranging from 148 to 440 were included in the meta-analysis. The pooled odds ratios (ORs) of the cross-sectional and case-control studies revealed that household food insecurity was significantly associated with the odds of diabetes (OR=2.04; 95% CI: 1.34- 3.09) and there was no evidence for publication bias (Egger’s test, P = 0.59); however, heterogeneity between studies (I2=85.9%) was observed. Similarly, according to subgroup analyses based on age, there was a significant association between household food insecurity and diabetes among the people under 50 years (OR= 2.9; 95% CI: 2.13-3.93; I2 = 56.4%, P=0.057), but not among people over 50 years (OR=1.32; 95% CI: 0.69-2.52; I2 = 78.3%, P=0.032) or between 30 and 65 years (OR=0.85; 95% CI: 0.49-1.48). Conclusion: This study shows that food insecurity affects the progression of type 2 DM. However, more longitudinal studies are needed for better identification of the link between food insecurity and T2DM. Keywords: Food insecurity; Food security; Diabetes mellitus; Iran. |
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| Article history: Received: 8 Jul 2022 Revised: 19 Nov 2022 Accepted: 19 Nov 2022 |
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| *Corresponding author seyyedrezasobhani@gmail.com Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Postal code: 91779-48564 Tel: 98 513 8002422 |
Introduction
Food insecurity is a major health issue which impacts the quality of life and health of the population (Gundersen and Ziliak, 2015). According to the Food and Agriculture Organization of the United Nations’ (FAO) definiation, “food security exists when all the people, at all times, have physical and economic access to sufficient safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life” (Practical, 2008). In 2017, nearly 10% of the world's population (769.4 million people) suffered from severe food insecurity. The prevalence of severe food insecurity in Asia and West Asia was 6.9% and 10.5%, respectively in this year (Shakiba et al., 2021). Behzadifar et al. conducted a meta-analysis on Iranian experiential studies in 2016 which found the prevalence of food insecurity among Iranian households to be approximately 49% (Behzadifar et al., 2016).
The concept of food insecurity encompasses environmental, cultural, social, behavioral, and economic factors that can be used as a valuable tool for assessing household nutritional patterns (Dastgiri et al., 2006, Fakayode, 2021). Food insecurity is correlated with lower variety of foods and a poorer diet. Choosing low-quality, inexpensive, and calorie-dense foods increase the total energy intake, and as a consequence, visceral fat accumulation (Essien et al., 2016, Kirkpatrick and Tarasuk, 2008). Thus, food insecurity can be considered a risk factor for poor health (Ahuja et al., 2020, Laraia, 2013, Melchior et al., 2009) as well as type 2 diabetes mellitus (T2DM), obesity, and insulin resistance (Essien et al., 2016, Liu and Eicher-Miller, 2021, Van Der Velde et al., 2020).
Diabetes mellitus is a chronic metabolic disorder which is increasing globally as an epidemic burden. Diabetes and its complications are the leading cause of death around the world (Maghsoudi and Azadbakht, 2012). Diabetes prevalence has increased globally in recent decades. Accordingly, diabetes prevalence in Iran was reported to be 11.9% in 2011, a 35% increase since 2005. By 2030, it is estimated that 9.2 million Iranians will have diabetes (Mirzaei et al., 2020). Therefore, it seems necessary to identify the factors that contribute to the increased prevalence of the disease in order to mitigate the problem.
Dietary habits and food insecurity are among the factors that play a major role in the development of diabetes (Kastorini and Panagiotakos, 2009). As food insecurity relates to the lower quality of life as well as higher levels of stress and anxiety, it may lead to increased cortisol production, which may adversely affect insulin sensitivity and glucose tolerance
(Ling et al., 2019, Whitworth et al., 2005).
Although some studies show a connection between food insecurity and T2DM among adults (Fitzgerald et al., 2011, Tait et al., 2018), the results in some other cases have been contradictory (Hasan-Ghomi et al., 2015). For example, the study by Beltrán et al. indicated that there was no association between food insecurity and clinically determined T2DM either through fasting blood glucose (FBG) or hemoglobin A1C (HbA1c) (Beltrán et al., 2022a). Considering that the was a study at global scale, not in Iran as a subgroup, the result can be different from the present study which is only in Iran, because Iran is significantly different from other countries in terms of the prevalence of food insecurity and diabetes. Therefore, the authors conducted a systematic review and meta-analysis to determine the association between household food insecurity and T2DM in Iran.
Materials and Method
Search strategy: English databases such as Scopus, Web of Science, Science Direct, PubMed, and Google Scholar, as well as Iranian databases such as SID and Magiran were searched from the beginning to July 2021. In addition, grey literature and conference proceedings related to the topic were reviewed. Keywords were “"Food Insecurity"[Mesh]” OR “"Food security"[Mesh]” AND “"Diabetes Mellitus"[Mesh]” AND “Iran “OR “Iranian” OR “Iranians”, OR “Persia, OR “Persian”, OR “Persians” in English and the equivalent keywords in Persian in Iranian databases.
Selecting studies and extracting data: The selected studies addressed diabetes and food insecurity among Iranians, were written in English or Farsi, and assessed food insecurity using Household Food Security Survey Module (HFSSM, 18 items), Household Food Insecurity Access Scale (HFIAS) (9 items) ,and USDA questionnaires. Duplicate studies were removed using Endnote x8.
Data were extracted independently by two authors from the selected papers, and any disagreements were resolved through discussion between the authors. In these studies, the area, type of study, age, sex, sample size, year of publication, the questionnaire used, statistical model, and estimated effects of food insecurity related to diabetes were extracted. Inclusion and exclusion criteria based on population, intervention, comparison, and outcome (PICO) were explained in Table 1.
The concept of food insecurity encompasses environmental, cultural, social, behavioral, and economic factors that can be used as a valuable tool for assessing household nutritional patterns (Dastgiri et al., 2006, Fakayode, 2021). Food insecurity is correlated with lower variety of foods and a poorer diet. Choosing low-quality, inexpensive, and calorie-dense foods increase the total energy intake, and as a consequence, visceral fat accumulation (Essien et al., 2016, Kirkpatrick and Tarasuk, 2008). Thus, food insecurity can be considered a risk factor for poor health (Ahuja et al., 2020, Laraia, 2013, Melchior et al., 2009) as well as type 2 diabetes mellitus (T2DM), obesity, and insulin resistance (Essien et al., 2016, Liu and Eicher-Miller, 2021, Van Der Velde et al., 2020).
Diabetes mellitus is a chronic metabolic disorder which is increasing globally as an epidemic burden. Diabetes and its complications are the leading cause of death around the world (Maghsoudi and Azadbakht, 2012). Diabetes prevalence has increased globally in recent decades. Accordingly, diabetes prevalence in Iran was reported to be 11.9% in 2011, a 35% increase since 2005. By 2030, it is estimated that 9.2 million Iranians will have diabetes (Mirzaei et al., 2020). Therefore, it seems necessary to identify the factors that contribute to the increased prevalence of the disease in order to mitigate the problem.
Dietary habits and food insecurity are among the factors that play a major role in the development of diabetes (Kastorini and Panagiotakos, 2009). As food insecurity relates to the lower quality of life as well as higher levels of stress and anxiety, it may lead to increased cortisol production, which may adversely affect insulin sensitivity and glucose tolerance
(Ling et al., 2019, Whitworth et al., 2005).
Although some studies show a connection between food insecurity and T2DM among adults (Fitzgerald et al., 2011, Tait et al., 2018), the results in some other cases have been contradictory (Hasan-Ghomi et al., 2015). For example, the study by Beltrán et al. indicated that there was no association between food insecurity and clinically determined T2DM either through fasting blood glucose (FBG) or hemoglobin A1C (HbA1c) (Beltrán et al., 2022a). Considering that the was a study at global scale, not in Iran as a subgroup, the result can be different from the present study which is only in Iran, because Iran is significantly different from other countries in terms of the prevalence of food insecurity and diabetes. Therefore, the authors conducted a systematic review and meta-analysis to determine the association between household food insecurity and T2DM in Iran.
Materials and Method
Search strategy: English databases such as Scopus, Web of Science, Science Direct, PubMed, and Google Scholar, as well as Iranian databases such as SID and Magiran were searched from the beginning to July 2021. In addition, grey literature and conference proceedings related to the topic were reviewed. Keywords were “"Food Insecurity"[Mesh]” OR “"Food security"[Mesh]” AND “"Diabetes Mellitus"[Mesh]” AND “Iran “OR “Iranian” OR “Iranians”, OR “Persia, OR “Persian”, OR “Persians” in English and the equivalent keywords in Persian in Iranian databases.
Selecting studies and extracting data: The selected studies addressed diabetes and food insecurity among Iranians, were written in English or Farsi, and assessed food insecurity using Household Food Security Survey Module (HFSSM, 18 items), Household Food Insecurity Access Scale (HFIAS) (9 items) ,and USDA questionnaires. Duplicate studies were removed using Endnote x8.
Data were extracted independently by two authors from the selected papers, and any disagreements were resolved through discussion between the authors. In these studies, the area, type of study, age, sex, sample size, year of publication, the questionnaire used, statistical model, and estimated effects of food insecurity related to diabetes were extracted. Inclusion and exclusion criteria based on population, intervention, comparison, and outcome (PICO) were explained in Table 1.
| Table 1. Inclusion and exclusion criteria based on PICO. | |
| Population | Iranian household |
| Intervention | Food insecurity |
| Comparison | Food security |
| Outcome | Diabetes |
Data analysis: Food insecurity and diabetes’ pooled odds were calculated with a random-effect model and a 95% level of confidence intervals (CIs). The researchers assessed heterogeneity between the studies by I2 statistic. P-value≤0.001 and OR=2.04 (1.34,3.09) were considered statistically significant. Using subgroup analysis and taking into account study design and sample age, the authors evaluated the heterogeneity of studies. Publication bias was assessed using Egger's test, and data analysis was carried out using STATA 14 (Stata Corporation, College Station, TX, USA).
Study quality assessment: Using the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies (National Heart Lung and Blood Institue, 2021), the two reviewers independently evaluated the quality of the evidence provided in each study. A total score was determined for each study based on the 14 criteria listed in the assessment tool, with zero indicating weak scientific evidence and 14 indicating strong scientific evidence. Inconsistencies were resolved by another author at this stage.
Result
As shown in PRISMA flow diagram (figure 1), 40 published articles were identified from Web of Sciences, PubMed, Scopus, Science Direct, Google Scholar, SID and Magiran. Due to duplication, 9 papers were removed. After reading the titles and abstracts of the 31 remaining articles, 20 were excluded for being unrelated to
the topic. 3 articles were excluded after reviewing the full texts of the 11 remaining articles. 3 of them were cross-sectional and 5 were case-control studies. Thus, 8 articles were finally included in the meta-analysis.
Study quality assessment: Table 2 shows that the selected studies scored 9 out of a possible score of 14, ranging from 8 to 10. All of them clearly stated the research question or objective and used clearly defined, valid, and reliable exposure and outcome measures, which were implemented consistently on all the participants.
Characteristics of the studies: According to Table 3, two studies were from Tehran (Gholizadeh et al., 2018, Hasan-Ghomi et al., 2015), one from each of the following areas; Shiraz (Najibi et al., 2019), Eghlid (a county in Fars Province) (Mohammadi et al., 2020), Mashhad (Bahrami et al., 2018), Khoy (Heidari et al., 2020), Qazvin (Janzadeh et al., 2020) and Abadan (Ariya et al., 2019). In total, from the three cross-sectional and five case-control studies, 2853 participants were included, ranging from 148 in Mohammadi’s study (Mohammadi et al., 2020) to 440 in Heidari’s study (Heidari et al., 2020).
To determine food security, three different questionnaires were used. 6 studies used an 18-item United States Department of Agriculture )USDA( questionnaire (Ariya et al., 2019, Gholizadeh et al., 2018, Hasan-Ghomi et al., 2015, Janzadeh et al., 2020, Mohammadi et al., 2020, Najibi et al., 2019), one used a 6-item Household Food Security Scale (HFSS) (Heidari et al., 2020), and one used a 9-item Household Food Insecurity Access Scale (HFIAS) questionnaire (Bahrami et al., 2018)..
Study quality assessment: Using the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies (National Heart Lung and Blood Institue, 2021), the two reviewers independently evaluated the quality of the evidence provided in each study. A total score was determined for each study based on the 14 criteria listed in the assessment tool, with zero indicating weak scientific evidence and 14 indicating strong scientific evidence. Inconsistencies were resolved by another author at this stage.
Result
As shown in PRISMA flow diagram (figure 1), 40 published articles were identified from Web of Sciences, PubMed, Scopus, Science Direct, Google Scholar, SID and Magiran. Due to duplication, 9 papers were removed. After reading the titles and abstracts of the 31 remaining articles, 20 were excluded for being unrelated to
the topic. 3 articles were excluded after reviewing the full texts of the 11 remaining articles. 3 of them were cross-sectional and 5 were case-control studies. Thus, 8 articles were finally included in the meta-analysis.
Study quality assessment: Table 2 shows that the selected studies scored 9 out of a possible score of 14, ranging from 8 to 10. All of them clearly stated the research question or objective and used clearly defined, valid, and reliable exposure and outcome measures, which were implemented consistently on all the participants.
Characteristics of the studies: According to Table 3, two studies were from Tehran (Gholizadeh et al., 2018, Hasan-Ghomi et al., 2015), one from each of the following areas; Shiraz (Najibi et al., 2019), Eghlid (a county in Fars Province) (Mohammadi et al., 2020), Mashhad (Bahrami et al., 2018), Khoy (Heidari et al., 2020), Qazvin (Janzadeh et al., 2020) and Abadan (Ariya et al., 2019). In total, from the three cross-sectional and five case-control studies, 2853 participants were included, ranging from 148 in Mohammadi’s study (Mohammadi et al., 2020) to 440 in Heidari’s study (Heidari et al., 2020).
To determine food security, three different questionnaires were used. 6 studies used an 18-item United States Department of Agriculture )USDA( questionnaire (Ariya et al., 2019, Gholizadeh et al., 2018, Hasan-Ghomi et al., 2015, Janzadeh et al., 2020, Mohammadi et al., 2020, Najibi et al., 2019), one used a 6-item Household Food Security Scale (HFSS) (Heidari et al., 2020), and one used a 9-item Household Food Insecurity Access Scale (HFIAS) questionnaire (Bahrami et al., 2018)..
| Table 2. Quality assessment of included studies. | |||||||||||||||
| Reference | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | Total score |
| Mohammadi et al. (2020) | Y | Y | Y | Y | Y | N | N | Y | Y | N | Y | Y | N | Y | 10 |
| Heidari et al. (2020) | Y | Y | Y | Y | Y | N | N | N | Y | N | Y | Y | N | Y | 9 |
| Janzadeh et al. (2020) | Y | Y | Y | Y | Y | N | N | N | Y | N | Y | Y | N | Y | 9 |
| Najibi et al. (2019) | Y | Y | Y | Y | Y | N | N | N | Y | N | Y | Y | N | N | 8 |
| Ariya et al. (2019) | Y | Y | Y | Y | Y | N | N | N | Y | N | N | Y | N | Y | 8 |
| Bahrami et al. (2018) | Y | Y | Y | Y | Y | N | N | Y | Y | N | N | Y | N | N | 8 |
| Gholizadeh et al. (2018) | Y | Y | Y | Y | Y | N | N | Y | Y | N | Y | Y | N | Y | 10 |
| Hasan-Ghomi et al. (2015) | Y | Y | Y | Y | Y | N | N | Y | Y | N | Y | Y | N | Y | 10 |
| Table 3. The chractristis of the 8 included studies. | |||||||||
| Author Published year |
Study design | Study area | Sample size | Sex | Age(years) | Sample characteristics | Statistical model | Questionnaire | Quality Score |
| M Mohammadi 2020 |
Cross-sectional | Eghlid | 148 | Both | 30 and 65 | With T2DM | Logistic regression | 18-item USDA | 10 |
| Heidari, F. 2020 |
Case-control | Khoy | 440 | Both | 52.9 case/47.9 control | With T2DM without T2DM |
Logistic regression | 6-item HFSS | 9 |
| H Janzadeh 2020 |
Case-control | Qazvin | 400 | Both | 47.14 case/46.32 control | With T2DM Without T2DM |
logistic regression | 18-item USDA | 9 |
| Najibi, N. 2019 |
Case-control | Shiraz | 270 | Both | 46.8 cases/45.9 controls | with T2DM without T2DM |
logistic regression | 18-items USDA | 8 |
| Ariya, Mohammad 2019 |
Case-control | Abadan | 217 | Both | 52.8 case/41.2 control | with T2DM without T2DM |
Logistic regression | 18-item USDA | 8 |
| Leila Sadat Bahrami 2018 |
Cross-sectional | Mashhad | 300 | Both | < 60 ≥ 60 |
Heart failure patients | Chi- square test | 9-item HFIAS | 8 |
| Gholizadeh, F. 2018 |
Cross-sectional | Tehran | 300 | Both | 44.8 case/44.9 control | Pre-diabetes and Healthy people |
Multivariate adjusted means | 18-items USDA | 10 |
| Hasan-Ghomi, M. 2015 |
Case-control | Tehran | 400 | Both | Aged over 40 | with T2DM without T2DM |
Logistic regression | 18-item USDA | 10 |
Association between household food insecurity and diabetes’ risk: After pooling data from 8 cross-sectional and case-control studies, the results revealed that household food insecurity was significantly related to the odds of diabetes (OR= 2.04; 95% CI:1.34-3.09; I2=85.9%). In other words, the likelihood of diabetes is increased by 104% as a result of food insecurity. (Figure 2). In the pooled analysis, there was significant heterogeneity among the studies (P ≤ 0.001, I2=85.9%).
Subgroup analysis: Regarding the sources of heterogeneity in cross-sectional and case-control studies, subgroup analyses was performed by study design and age (above 50 and under 50 and 30-65); this was because the distribution of studies was such that the authors performed the subgroup analysis based on the criteria of being under and over 50 , but it would be better if it was divided between being over and under 65 (Table 4).
| Table 4. Subgroup analysis base on the study design and age. | ||||
| Subgroups | OR (95% CI) | P-vale | I2 | N |
| Study design Cross-sectional Case-control |
2.22 (1.45, 3.40) 1.97( 0.99, 3.93) |
<0.001 0.03 |
85.9 89.3 |
3 5 |
| Age | ||||
| Under 50 | 2.90 (2.13, 3.93) | 0.05 | 56.4 | 5 |
| 30 and 65 | 0.85 (0.49, 1.48) | - | - | 1 |
| More than 50 | 1.32 (0.69, 2.52) | 0.03 | 78.3 | 2 |
A subgroup analysis of the study design revealed a significant association between household food insecurity and diabetes, both in cross-sectional (OR=2.22; 95% CI: 1.45-3.40; I2=85.9%, P≤0.001) and case-control studies (OR=1.97; 95% CI: 0.99-3.93; I2= 89.3%, P=0.03).
According to a subgroup analysis based on age, there was a significant association between household food insecurity and diabetes among the people under 50 (OR=2.90; 95% CI: 2.13-3.93; I2=56.4%, P=0.05), but not among the people over 50 (OR=1.32; 95% CI: 0.69-2.52; I2=78.3%, P=0.032) or between 30 and 65 (OR=0.85; 95% CI 0.49-1.48)
Sensitivity analysis: To examine the effect of low-quality and high-bias-risk studies in general, a sensitivity analysis was performed by removing data from the meta-analytic model. Based on sensitivity analyses, the studies that may have affected the pooled results were not removed. Household food insecurity is still significantly associated with diabetes (OR=2.04; 95% CI: 1.35-3.09).
Publication bias: In analyzing the funnel plot for asymmetry by visual inspection, the authors found no evidence of publication bias using Egger's test (Egger’s test, P = 0.59).
Discussion
In the present study, systematic reviews and meta-analyses were used to investigate the relationship between household food insecurity and T2DM in Iranian populations. 8 of the articles reviewed were eligible for meta-analysis. A review of studies showed that food-insecure households in Iran were twice as likely to develop T2DM as food-secure households.
The results of this study were in agreement with the findings of Tait CA et al, which indicated that people in food-insecure households showed a more than 2 times risk of developing T2DM compared to those in food secure households (Tait et al., 2018). Similar to the results of this study, Abdurahman AA et al. reported that household food insecurity was significantly associated with T2DM (Abdurahman et al., 2019); however, a study conducted in 2021 showed that there was no association between food insecurity and clinically determined T2DM either through FBG or HbA1c (Beltrán et al., 2022b).
Food insecurity and T2DM may be linked by several possible mechanisms. There is a link between food insecurity, and poor diet quality, inadequate vitamin intake, and reduced fruit and vegetable consumption (Kirkpatrick and Tarasuk, 2008, Smith and Richards, 2008). Food-insecure households choose inexpensive foods because they do not have enough income or financial ability to provide nutritious food. Diabetes can be caused by low-quality foods which are often high in fat and sugar (Vozoris and Tarasuk, 2003). As a defense mechanism against future periods of deficiency, overeating is triggered by biological behavior. Consuming foods which are high in fat and sugar causes the storage of energy in abdominal area, leading to obesity and diabetes (Dallman et al., 2005). In addition to affecting physical health and nutrition, food insecurity can also affect mental health. Food insecurity leads to psychological distresses such as depression by triggering a stress response (Pourmotabbed et al., 2020). Stress disrupts glucose metabolism and insulin sensitivity (Hackett and Steptoe, 2017). Similarly, depression is associated with poorer control of blood sugar as well as poor adherence to diet and medication regimens (Ciechanowski et al., 2000, Lustman et al., 2000). Seligman et al.’s study indicated that food insecurity may be associated with poor glycemic control due to low adherence to a proper diabetes diet and increased emotional distress associated with self-management of diabetes (Seligman et al., 2012).
Therefore, because of the relationship between food insecurity and T2DM, it is beneficial to prioritize improvements in food security for this particular group of people among the various programs and policies of the country. Food insecurity is a complex phenomenon with a number of factors including inadequate food production, inadequate access to food, poverty, low income, low level of education, as well as political, environmental, cultural, and religious aspects (Tarasuk, 2001). Food insecurity can be reduced through a variety of interventions, including interventions aimed at increasing nutritional knowledge and household purchasing power. Government agencies should continue to provide extensive support to public interventions in future (Mortazavi et al., 2021).
This review had some limitations. It is possible that additional articles were missed while every effort was made to ensure this review was comprehensive. As a result of the variety of approaches taken to measure food insecurity, comparing the results of different studies was challenging. As this systematic review included cross-sectional and case-control studies, it is unlikely to conclude that food insecurity and diabetes are linked longitudinally.
Conclusion
This systematic review and meta-analysis provides a significant association between FIS and T2DM in Iran. For a more comprehensive conclusion, additional studies are needed on the association between FIS and T2DM in larger populations. Practical interventions and policy support are needed to reduce food insecurity and the risk of diabetes.
Acnowledgments
This study was extracted from a research project, approved on 03/11/2021 by Mashhad University of Medical Sciences (code: 992310), and sponsored by the University Research Council. The authors appreciate the cooperation and assistance of the University Vice Chancellor for Research.
Authors’ contributions
Sobhani SR and Asadimehr S designed the research study. Govahi Kakhki F, Maddahi M and Asadimehr S performed the research. Ramezani Ahmadi A and Asadimehr S analyzed the data. Sobhani SR, Maddahi M and Asadimehr S prepared the draft manuscript. Sobhani SR critically reviewed and revised the manuscript. All authors have read and approved the final manuscript.
Confilict of interest
There is any conflicts of interest.
Funding
None
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Hackett RA & Steptoe A 2017. Type 2 diabetes mellitus and psychological stress—a modifiable risk factor. Nature Reviews Endocrinology. 13 (9): 547-560.
Hasan-Ghomi M, et al. 2015. Relationship of Food Security with Type 2 Diabetes and Its Risk Factors in Tehranian Adults. International journal of preventive medicine. 6: 98.
Heidari F, Khamnian Z, Sharafkhani R, Baradaran-Binazir M & Sarshar H 2020. The association of food insecurity with type 2 diabetes and hypertension: A multicenter case-control study in urban population. Malaysian Journal of Medicine and Health Sciences. 16 (3): 169-175.
Janzadeh H, Mozaffari-Khosravi H & Javadi M 2020. The Association of Food Insecurity, Inflammation, and Several Socioeconomic Factors with Type 2 Diabetes: A Case-Control Study. Journal of Nutrition and Food Security. 5 (1): 38-46.
Kastorini C-M & Panagiotakos DB 2009. Dietary patterns and prevention of type 2 diabetes: from research to clinical practice; a systematic review. Current diabetes reviews. 5 (4): 221-227.
Kirkpatrick SI & Tarasuk V 2008. Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. The Journal of nutrition. 138 (3): 604-612.
Laraia BA 2013. Food insecurity and chronic disease. Advances in Nutrition. 4 (2): 203-212.
Ling J, Robbins LB & Xu D 2019. Food security status and hair cortisol among low-income mother-child dyads. Western journal of nursing research. 41 (12): 1813-1828.
Liu Y & Eicher-Miller HA 2021. Food Insecurity and Cardiovascular Disease Risk. Current Atherosclerosis Reports. 23 (6): 1-12.
Lustman PJ, et al. 2000. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes care. 23 (7): 934-942.
Maghsoudi Z & Azadbakht L 2012. How dietary patterns could have a role in prevention, progression, or management of diabetes mellitus? Review on the current evidence. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences. 17 (7): 694.
Melchior M, et al. 2009. Mental health context of food insecurity: a representative cohort of families with young children. Pediatrics. 124 (4): e564-e572.
Mirzaei M, Rahmaninan M, Mirzaei M & Nadjarzadeh A 2020. Epidemiology of diabetes mellitus, pre-diabetes, undiagnosed and uncontrolled diabetes in Central Iran: results from Yazd health study. BMC Public Health. 20 (1): 1-9.
Mohammadi M, Djazayeri SA & Jafari AA 2020. The association of food insecurity with diabetes control and self-care in diabetes type 2 patients: A cross-sectional study.
Mortazavi Z, Dorosty AR, Eshraghian MR, Ghaffari M & Ansari-Moghaddam A 2021. Nutritional education and its effects on household food insecurity in Southeastern Iran. Iranian Journal of Public Health. 50 (4): 798.
Najibi N, et al. 2019. Food insecurity is an important risk factor for type 2 diabetes: a case-control study of new referrals to the University clinics, Shiraz, Southern Iran. BMC Public Health. 19 (1): 1-8.
National Heart Lung and Blood Institue 2021. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, https:// www. nhlbi.nih.gov/health-topics/study-quality-assessment-tools.
Pourmotabbed A, et al. 2020. Food insecurity and mental health: a systematic review and meta-analysis. Public health nutrition. 23 (10): 1778-1790.
Practical G 2008. An Introduction to the Basic Concepts of Food Security.
Seligman HK, Jacobs EA, López A, Tschann J & Fernandez A 2012. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes care. 35 (2): 233-238.
Shakiba M, Salari A & Mahdavi-Roshan M 2021. Food insecurity status and associated factors among rural households in the north of Iran. Nutrition and Health. 0260106021996840.
Smith C & Richards R 2008. Dietary intake, overweight status, and perceptions of food insecurity among homeless Minnesotan youth. American Journal of Human Biology: The Official Journal of the Human Biology Association. 20 (5): 550-563.
Tait CA, L’Abbé MR, Smith PM & Rosella LC 2018. The association between food insecurity and incident type 2 diabetes in Canada: a population-based cohort study. PloS one. 13 (5): e0195962.
Tarasuk V 2001. Discussion paper on household and individual food insecurity. Citeseer.
Van Der Velde LA, et al. 2020. Exploring food insecurity and obesity in Dutch disadvantaged neighborhoods: a cross-sectional mediation analysis. BMC public health. 20 (1): 1-11.
Vozoris NT & Tarasuk VS 2003. Household food insufficiency is associated with poorer health. The Journal of nutrition. 133 (1): 120-126.
Whitworth JA, Williamson PM, Mangos G & Kelly JJ 2005. Cardiovascular consequences of cortisol excess. Vascular health and risk management. 1 (4): 291.
According to a subgroup analysis based on age, there was a significant association between household food insecurity and diabetes among the people under 50 (OR=2.90; 95% CI: 2.13-3.93; I2=56.4%, P=0.05), but not among the people over 50 (OR=1.32; 95% CI: 0.69-2.52; I2=78.3%, P=0.032) or between 30 and 65 (OR=0.85; 95% CI 0.49-1.48)
Sensitivity analysis: To examine the effect of low-quality and high-bias-risk studies in general, a sensitivity analysis was performed by removing data from the meta-analytic model. Based on sensitivity analyses, the studies that may have affected the pooled results were not removed. Household food insecurity is still significantly associated with diabetes (OR=2.04; 95% CI: 1.35-3.09).
Publication bias: In analyzing the funnel plot for asymmetry by visual inspection, the authors found no evidence of publication bias using Egger's test (Egger’s test, P = 0.59).
Discussion
In the present study, systematic reviews and meta-analyses were used to investigate the relationship between household food insecurity and T2DM in Iranian populations. 8 of the articles reviewed were eligible for meta-analysis. A review of studies showed that food-insecure households in Iran were twice as likely to develop T2DM as food-secure households.
The results of this study were in agreement with the findings of Tait CA et al, which indicated that people in food-insecure households showed a more than 2 times risk of developing T2DM compared to those in food secure households (Tait et al., 2018). Similar to the results of this study, Abdurahman AA et al. reported that household food insecurity was significantly associated with T2DM (Abdurahman et al., 2019); however, a study conducted in 2021 showed that there was no association between food insecurity and clinically determined T2DM either through FBG or HbA1c (Beltrán et al., 2022b).
Food insecurity and T2DM may be linked by several possible mechanisms. There is a link between food insecurity, and poor diet quality, inadequate vitamin intake, and reduced fruit and vegetable consumption (Kirkpatrick and Tarasuk, 2008, Smith and Richards, 2008). Food-insecure households choose inexpensive foods because they do not have enough income or financial ability to provide nutritious food. Diabetes can be caused by low-quality foods which are often high in fat and sugar (Vozoris and Tarasuk, 2003). As a defense mechanism against future periods of deficiency, overeating is triggered by biological behavior. Consuming foods which are high in fat and sugar causes the storage of energy in abdominal area, leading to obesity and diabetes (Dallman et al., 2005). In addition to affecting physical health and nutrition, food insecurity can also affect mental health. Food insecurity leads to psychological distresses such as depression by triggering a stress response (Pourmotabbed et al., 2020). Stress disrupts glucose metabolism and insulin sensitivity (Hackett and Steptoe, 2017). Similarly, depression is associated with poorer control of blood sugar as well as poor adherence to diet and medication regimens (Ciechanowski et al., 2000, Lustman et al., 2000). Seligman et al.’s study indicated that food insecurity may be associated with poor glycemic control due to low adherence to a proper diabetes diet and increased emotional distress associated with self-management of diabetes (Seligman et al., 2012).
Therefore, because of the relationship between food insecurity and T2DM, it is beneficial to prioritize improvements in food security for this particular group of people among the various programs and policies of the country. Food insecurity is a complex phenomenon with a number of factors including inadequate food production, inadequate access to food, poverty, low income, low level of education, as well as political, environmental, cultural, and religious aspects (Tarasuk, 2001). Food insecurity can be reduced through a variety of interventions, including interventions aimed at increasing nutritional knowledge and household purchasing power. Government agencies should continue to provide extensive support to public interventions in future (Mortazavi et al., 2021).
This review had some limitations. It is possible that additional articles were missed while every effort was made to ensure this review was comprehensive. As a result of the variety of approaches taken to measure food insecurity, comparing the results of different studies was challenging. As this systematic review included cross-sectional and case-control studies, it is unlikely to conclude that food insecurity and diabetes are linked longitudinally.
Conclusion
This systematic review and meta-analysis provides a significant association between FIS and T2DM in Iran. For a more comprehensive conclusion, additional studies are needed on the association between FIS and T2DM in larger populations. Practical interventions and policy support are needed to reduce food insecurity and the risk of diabetes.
Acnowledgments
This study was extracted from a research project, approved on 03/11/2021 by Mashhad University of Medical Sciences (code: 992310), and sponsored by the University Research Council. The authors appreciate the cooperation and assistance of the University Vice Chancellor for Research.
Authors’ contributions
Sobhani SR and Asadimehr S designed the research study. Govahi Kakhki F, Maddahi M and Asadimehr S performed the research. Ramezani Ahmadi A and Asadimehr S analyzed the data. Sobhani SR, Maddahi M and Asadimehr S prepared the draft manuscript. Sobhani SR critically reviewed and revised the manuscript. All authors have read and approved the final manuscript.
Confilict of interest
There is any conflicts of interest.
Funding
None
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Janzadeh H, Mozaffari-Khosravi H & Javadi M 2020. The Association of Food Insecurity, Inflammation, and Several Socioeconomic Factors with Type 2 Diabetes: A Case-Control Study. Journal of Nutrition and Food Security. 5 (1): 38-46.
Kastorini C-M & Panagiotakos DB 2009. Dietary patterns and prevention of type 2 diabetes: from research to clinical practice; a systematic review. Current diabetes reviews. 5 (4): 221-227.
Kirkpatrick SI & Tarasuk V 2008. Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. The Journal of nutrition. 138 (3): 604-612.
Laraia BA 2013. Food insecurity and chronic disease. Advances in Nutrition. 4 (2): 203-212.
Ling J, Robbins LB & Xu D 2019. Food security status and hair cortisol among low-income mother-child dyads. Western journal of nursing research. 41 (12): 1813-1828.
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Mohammadi M, Djazayeri SA & Jafari AA 2020. The association of food insecurity with diabetes control and self-care in diabetes type 2 patients: A cross-sectional study.
Mortazavi Z, Dorosty AR, Eshraghian MR, Ghaffari M & Ansari-Moghaddam A 2021. Nutritional education and its effects on household food insecurity in Southeastern Iran. Iranian Journal of Public Health. 50 (4): 798.
Najibi N, et al. 2019. Food insecurity is an important risk factor for type 2 diabetes: a case-control study of new referrals to the University clinics, Shiraz, Southern Iran. BMC Public Health. 19 (1): 1-8.
National Heart Lung and Blood Institue 2021. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, https:// www. nhlbi.nih.gov/health-topics/study-quality-assessment-tools.
Pourmotabbed A, et al. 2020. Food insecurity and mental health: a systematic review and meta-analysis. Public health nutrition. 23 (10): 1778-1790.
Practical G 2008. An Introduction to the Basic Concepts of Food Security.
Seligman HK, Jacobs EA, López A, Tschann J & Fernandez A 2012. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes care. 35 (2): 233-238.
Shakiba M, Salari A & Mahdavi-Roshan M 2021. Food insecurity status and associated factors among rural households in the north of Iran. Nutrition and Health. 0260106021996840.
Smith C & Richards R 2008. Dietary intake, overweight status, and perceptions of food insecurity among homeless Minnesotan youth. American Journal of Human Biology: The Official Journal of the Human Biology Association. 20 (5): 550-563.
Tait CA, L’Abbé MR, Smith PM & Rosella LC 2018. The association between food insecurity and incident type 2 diabetes in Canada: a population-based cohort study. PloS one. 13 (5): e0195962.
Tarasuk V 2001. Discussion paper on household and individual food insecurity. Citeseer.
Van Der Velde LA, et al. 2020. Exploring food insecurity and obesity in Dutch disadvantaged neighborhoods: a cross-sectional mediation analysis. BMC public health. 20 (1): 1-11.
Vozoris NT & Tarasuk VS 2003. Household food insufficiency is associated with poorer health. The Journal of nutrition. 133 (1): 120-126.
Whitworth JA, Williamson PM, Mangos G & Kelly JJ 2005. Cardiovascular consequences of cortisol excess. Vascular health and risk management. 1 (4): 291.
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Received: 2022/07/8 | Published: 2024/05/21 | ePublished: 2024/05/21
Received: 2022/07/8 | Published: 2024/05/21 | ePublished: 2024/05/21
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