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Master's Theses University of Connecticut Graduate School

5-10-2020

Household Food Security Status, Dietary Patterns and Diabetes Household Food Security Status, Dietary Patterns and Diabetes

Risk (Hemoglobin A1c) among Cambodian Refugees with Risk (Hemoglobin A1c) among Cambodian Refugees with

Depression Depression

Shanjida Jui jui@uchc.edu

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Household Food Security Status, Dietary Patterns and

Diabetes Risk (Hemoglobin A1c) among Cambodian

Refugees with Depression

Shanjida Arbie Jui

B.S., B.A., University of Connecticut, 2020

A Thesis

Submitted in Partial Fulfillment of the

Requirements for the Degree of

Master of Public Health

at the

University of Connecticut

2020

ii

Copyright by

Shanjida Arbie Jui

2020

iii

APPROVAL PAGE

Masters of Public Health Thesis

Household Food Security Status, Dietary Patterns and Diabetes

Risk (Hemoglobin A1c) among Cambodian Refugees with

depression

Presented by

Shanjida Arbie Jui, B.S., B.A.

Major Advisor

Stacey L. Brown, Ph.D.

Associate Advisor

Angela Bermúdez-Millán, Ph.D., MPH

Associate Advisor

Julie Wagner, Ph.D.

University of Connecticut

2020

iv

Acknowledgements

I couldn’t believe a girl from a small country like Bangladesh would be able to finish

graduate school during the worst public health crisis, COVID-19 Pandemic. Amidst home

quarantining and social distancing, as I reflect upon my higher education journey, I can’t help

but think what a privilege it is to be able to complete a milestone of my academic endeavors in

this global trying time. None of this would have been possible without my parents. Not only

they made it possible to protect myself during the virus spread, they supported me both

financially and emotionally through the entire graduate school. Growing up in a culture that

didn’t value a girl’s education, my father, Khalilur Rahman, not only went against the society to

advocate for me and provide me a quality education, he left his entire life behind migrating to a

total new country with nothing for the sake of my better education. My mother, Mahmuda

Rahman who is visibly Muslim and never worked in her life before, worked incredibly hard in a

new country with her broken English despite countless hate attacks, bullying and discrimination,

just so I don’t quit pursuing higher education. I can thank them all my life, and it still won’t be

enough. Every success I had, have and will have, I owe all of it to them. I would also like to give

a special thanks to my sister, Sadia Arbie for being my best friend. She stood by me during every

struggle and all my successes. I wouldn’t have thought of finishing graduate school without the

love and support of her. Shout- out to the rest of the extended family- my uncles, aunts,

grandparents, cousins, especially little Noorvi.

I would like to express my sincere gratitude to my thesis advisor, Dr. Angela Bermúdez-

Millán, for having faith in me and taking me under her wings for this thesis. I can’t express in

words how much I appreciated your knowledge, understanding and compassion for the

importance of food and nutrition in the field of public health. I genuinely would like to thank you

for the time you have given to teach and guide me in this project. Additionally, I thank Dr. Julie

Wagner for allowing me to join one of her passion projects and providing her direction and

support. Last but not least, my sincere thanks to my major advisor, Dr. Stacey Brown who I

greatly admire for going above and beyond for me- whether it was advocating for me, guiding

me or just simply checking in on me. This journey would have been much harder without you.

Lastly, thanks to UCONN and the Public Health Student Association for giving me the

opportunity to make new friends and second family. Thanks to all my MPH family for

friendship, love and support. I learned, laughed, and created many wonderful memories with you

guys, and I am eternally grateful for that. Additionally, a special shout-out to my other amazing

outside-of-school friends – Sorna, Tahmin, Nazmun, Mou, Arup, Esha, Ruba, Rabeya - (too

many to list) for always inspiring and supporting me. I’m thankful to have you guys in my life.

v

Table of Contents Pages

Acknowledgements……………………………………………………………... iv

Abstract…………………………………………………………………………. vi

Foundational and Concentration Competencies…………………………………1-3

Systems Thinking …………...……………...…………………………………...3-6

Background……………………………………………………………………...6-12

Specific Aims of the projects/hypothesis……………………………………….12-13

Materials and Methods………………………………………………………….13-20

Research Results………………………………………………………………...20-28

Discussion……………………………………………………………………… 28-35

Conclusion………………………………………………………………………35-36

Appendix………………………………………………………………………...37-39

Bibliography…………………………………………………………………….40-46

vi

Abstract

Background

Cambodian refugees who experienced famine and trauma from the Khmer Rouge genocide are

disproportionately at high risk of type 2 diabetes. This risk is exacerbated when this vulnerable

population experiences a high prevalence of food insecurity upon resettlement in the U.S. As a

result, refugee dietary intake and nutrition uniquely contribute to the rise of often long-term

health consequences and pose an unexpected burden on the U.S. healthcare system.

Objectives

(1) To describe household food security status of Cambodians refugees (2) To examine the

association between food security status and socioeconomic status (SES) of Cambodian

refugees; (3) To describe dietary patterns, especially rice and sugar-sweetened beverages

consumption of this population; (4) To examine the association between household food

insecurity and diabetes risk marker (Hemoglobin A1c, HbA1c); (5) To examine preliminary

associations between household food insecurity, dietary patterns and HbA1c.

Methods

The preliminary cross-sectional baseline data was collected from the Diabetes Risk Reduction

through Eat, Walk, Sleep and Medication Therapy Management for Depressed Cambodians

(DREAM) study. Cambodian participants (n=205) were enrolled who met the inclusion criteria

including age 35-70, Khmer speaking, scored >=3 on the ADA Diabetes Risk Test, self-reported

anti-depressant medication or indicated elevated depressive symptoms on the Khmer version of

the depression subscale of the Hopkins Symptom Checklist. Household food security status for

the past 12 months was assessed using the 6-item, validated Khmer language version of the U.S.

Household Food Security Survey Module. Dietary patterns were assessed using a short semi-

quantitative Food Frequency Questionnaire (FFQ). Hemoglobin A1c (HbA1c) levels were

assessed by centrally collecting and assaying fasting blood samples at a clinical laboratory.

Results

Participants’ mean age was 55 years old, 77% (n=145) were female, 50% (n=93) were married,

68% (n=128) were unemployed, 41% (n=76) were Supplemental Nutritional Assistance Program

(SNAP) recipients, and 56% (n=104) earned between $30,000- above $40,000. Out of a total 189

participants, 72% (n=148) were found food secure and 19% (n=39) were food insecure. There

were statistically significant differences in food security status on marital status, income,

employment status, SNAP status and communication barrier (p-value <0.05). Also, 97% (n=172)

of the participants consumed white rice daily and 50% (n=89) of the participants consumed

regular non-diet soda. There were no significant associations between daily carbohydrate intake

from rice/beverages and food security status. However, there was a statistically significant

association between food security status and HbA1c (p-value <0.05). Among all rice dishes and

beverages, only daily carbohydrate intake from rice porridge and fruit shakes were significantly

correlated with HbA1c levels (p-value <0.05).

Conclusions

Food insecurity was significantly associated with elevated diabetic risk marker (HbA1c).

Although dietary patterns didn’t show any association with food insecurity or HbA1c levels,

future studies need to consider a more robust mediation model and control for mental illnesses to

further explore the association.

1

Foundational and Concentration Competencies

Concentration

Competency

Assessment opportunities

(Check all the foundational

competencies that apply)

Competencies demonstrated by…

1. Utilize principles of

community-based

participatory

research (CBPR) to

collect, interpret and

disseminate data to

inform public health

practice.

Foundational Competencies:

☒ Criterion 1. Apply

epidemiological methods to

the breadth of settings and

situations in public health

practice.

☒ Criterion 7. Assess

population needs, assets and

capacities that affect

communities’ health.

☒ Criterion 9. Design a

population-based policy,

program, project or

intervention.

▪ Criterion 1. Performed a secondary

baseline data analysis on a population at

risk for type 2 diabetes.

▪ Criterion 7. This community-based

participatory research (CBPR) study

assessed the needs on a population at

risk for type 2 diabetes

▪ Criterion 9. The completion of this

project required: IRB training; literature

reviews; data management and

analyses; and discussions with

committee advisors.

2. Consider evidence-

informed practices

across related

disciplines to define

comprehensive,

system-level

approaches to public

health issues.

Foundational Competencies:

☒ Criterion 2. Select

quantitative and qualitative

data collection methods

appropriate for a given public

health context

☒ Criterion 3. Analyze

quantitative and qualitative

data using biostatistics,

informatics, computer-based

programming and software, as

appropriate.

☒ Criterion 4. Interpret results

of data analysis for public

health research, policy or

practice.

▪ Criterion 2. The survey included

quantitative (i.e. socio-demographic

characteristics, food security; food

frequency questionnaire; blood

biomarkers) data.

▪ Criterion 3. IBM SPSS 26 software

was utilized to analyze quantitative the

data. Frequency analysis, T-tests, Chi-

square tests and correlation analysis

were performed to analyze associations.

▪ Criterion 4. Summarized variables

using descriptive statistics and

interpreted data for associations.

3. Engage with

community

stakeholders to

disseminate

evidence-based

public health

information to

varied audiences.

Foundational Competencies:

☒ Criterion 13 Propose

strategies to identify

stakeholders and build

coalitions and partnerships for

influencing public health

outcomes.

☒ Criterion 16. Apply

principles of leadership,

governance and management,

which include creating a

vision, empowering others,

fostering collaboration and

guiding decision-making.

☒ Criterion 18 Select

communication strategies for

▪ Criterion 13. The DREAM study was

established as a collaboration between

Khmer Health Advocates, University of

Connecticut and Penn State University,

funded by NIH/NIDDK.

▪ Criterion 16. Interdisciplinary,

multicultural teams of professionals and

community health workers were

employed to reach out to the

community, recruit participants and

collect survey data.

▪ Criterion 18. All surveys and

nutritional information materials in the

DREAM study were written in English,

then translated in Khmer.

▪ Criterion 19. ILE Thesis was

submitted for evaluation by the

2

different audiences and

sectors.

☒ Criterion 19 Communicate

audience-appropriate public

health content, both in writing

and through oral presentation.

☒ Criterion 21 Perform

effectively on

interprofessional teams.

advisory committee. A poster

presentation of the ILE thesis was

submitted.

▪ Criterion 21. The thesis project was

satisfactorily completed and reviewed

by a 3-member advisory committee,

consisting of 2 program faculty and 1

outside reader.

4. Employ legal-ethical

reasoning to advance

inter-professional

public health policy

& practices.

Foundational Competencies:

☒ Criterion 6 Discuss the means

by which structural bias,

social inequities and racism

undermine health and create

challenges to achieving health

equity at organizational,

community and societal

levels.

☒ Criterion 8 Apply awareness

of cultural values and

practices to the design or

implementation of public

health policies or programs.

☒ Criterion 14 Advocate for

political, social or economic

policies and programs that

will improve health in diverse

populations.

☒ Criterion 20 Describe the

importance of cultural

competence in communicating

public health content.

▪ Criterion 6. There’s no national data

on hard-to-reach high-risk subgroups

such as Cambodian refugees who

survived the Khmer Rouge genocide.

Cambodian refugees with depression

face excess barriers to access health and

medical care due to language barriers,

low socioeconomic status post-

resettlement, culturally based health

beliefs regarding chronic diseases and

its treatment, low acculturation, new

food environment, mistrust or lack of

confidence in western medicine, and

social isolation.

▪ Criterion 8 & 20. Bilingual and

bicultural community health workers

(CHWs) bridged the community and

the healthcare establishment by infusing

cultural competence, audience-

appropriate communication strategies,

and inter-professionalism. CHWs

provided language interpretation,

enrollment facilitation, screening, and

nutritional education materials.

Interdisciplinary and multicultural

professionals were involved in the

DREAM study.

▪ Criterion 14. This study found a

significant association between food

insecurity and diabetes risk. The results

advocated for better access to more

federal nutritional programs such as

SNAP and emergency foods to reduce

food insecurity. Culturally and

linguistically appropriate behavioral

interventions were advocated to create a

meaningful change in diabetes risk

among refugees.

5. Demonstrate

advanced use of

Systems Thinking

(ST) in promoting

effective

interprofessional

Foundational Competencies:

☒ Criterion 22 Apply systems

thinking tools to a public

health issue.

▪ Criterion 22. A system map of

identifying different levels (individual,

interpersonal, institutional, community

and public policy) of contributors to

type 2 diabetes risk among Cambodians

was created adopting from the socio-

3

public health

programs and

policies.

ecological model. That concept map

illustrates different factors relevant to

prevent the future incidence of type 2

diabetes.

Systems Thinking

Although genetics, ethnicity, and an individual’s lifestyle can contribute to the

development of type 2 diabetes, it is a complex, multifaceted health issue that is influenced by

the social, cultural, and environmental factors as well. The ultimate goal is to prevent type 2

diabetes before it begins, especially among high-risk groups such as Cambodian refugees.

Prevention requires understanding the range of inter-related factors that put people at risk for

type 2 diabetes or protect them from developing type 2 diabetes. A general diabetes prevention

approach that only focuses on individualized strategies often fails in reaching high-risk

racial/ethnic minority groups. That is because most often, racial/ethnic minority groups such as

refugees cope with food insecurity that shapes their dietary intake, health-related behaviors and

ultimately contribute to diabetes. Therefore, a comprehensive approach using the socio-

ecological model is essential for examining interlinked influences at multiple levels.

The socio-ecological approach emphasizes the complexities and interdependencies

between socioeconomic, intrapersonal, behavioral, political, environmental, physiological, and

organizational determinants that influence the specific health outcome.46 The model thus offers

an integration of multiple levels of influence, which are defined as individual, interpersonal,

institutional, community, and public policy (societal) levels.46 This study uses the CDC’s

iteration of the socio-ecological model as a framework.12 It helps to identify various factors

across multiple levels that need to be acted upon simultaneously to prevent food insecurity and,

consequently, prevent type 2 diabetes among depressed Cambodian refugees. How factors at one

level influence factors at another level are illustrated in overlapping rings in the model below.

4

Figure: A socio-ecological model, applied to address food insecurity and type 2 diabetes risk

among Cambodian refugees with depression46

The first individual level identifies demographic and socioeconomic factors that increase

the likelihood of becoming food insecure and diabetic. Some of these factors include age,

gender, socioeconomic status (education, income), language barrier, mental illnesses such as

depression, trauma, the experience of past-starvation, diabetes risk (HbA1c), food nutrition

knowledge and skills and dietary patterns. Prevention at this level promotes strategies at the

individual level that prevent food insecurity. Specific approaches may include accessing

nutritional assistance and food programs, foods, nutrition and health programs, adult education

programs, job placement services, and low-cost healthy cooking recipes.

5

The second level examines intrapersonal relationships that may increase the risk of

experiencing food insecurity and type 2 diabetes. Household size and poverty level, household

food practices based on cultural traditions, friends, and social networks influence how refugees

cope with food insecurity and contribute to their health outcomes. Prevention strategies at this

level may include household-focused prevention programs such as adequate food assistance

programs for families, automatic eligibility to food assistance programs if enrolled in TANF or

SSI or general assistance, lending programs, low-budget healthy family meals recipes/cooking

classes, gardening tips and mentoring or peer programs to facilitate finding other communities.

The third level explores the institutions such as community organizations/centers,

temples, and food stores, which influence the degree to which people have access to healthy food

or influence cultural food traditions, norms, and values. Preventive strategies at this level involve

social and physical environments. Strategies can include more cultural food stores with fresh

produce and seasonal fruits, available transportation to supermarkets/farmer markets, fostering

formal and informal support/network organizations such as Khmer Health Advocate,

immigration/refugee alliances and temples, job training and job placement services, and

multilingual programs to help align their preferences with dietary guidelines.

The fourth level assesses social settings at the community level, such as workplaces and

neighborhoods. For example, having food desserts or more convenient stores/junk food stores

per area influences food choices among refugees coping with food insecurity. Strategies such as

reducing social isolation, increasing nutritious food retail options in low-income neighborhoods,

fostering public awareness programs, child and adult food program, summer food service

program, and community-based food nutritional assistance, and providing linguistically

appropriate nutrition information have the potential for broader community-level impact.

6

The fifth level looks at broader public policy at the societal level, including local, state,

and federal laws, policies, and programs. Substantial societal factors include the health,

economic, educational, and social policies that create food insecurity via economic inequalities.

In order to prevent food insecurity, making changes at this level is essential. Government and

policymakers need to reassess measures of poverty, ensure minimum wage, revise zoning laws to

include nutritious food retailers/supermarkets, establish national monitoring on nutrition, fund

research in food insecurity and diabetes interventions employing community health workers,

hold government agencies accountable for actively addressing disparities in food insecurity.

Additionally, prevention strategies can incorporate better access to the health care system for

immigrants and refugees, including more Medicaid coverage, food insecurity screening along

with diabetes screening, culturally competent provider/nutritionist, and health psychologists for

behavioral interventions. The Emergency Food Assistant Program (TEFAP) by the USDA, such

as food banks, food pantries, soup kitchens, and nutritional assistance programs such as SNAP,

WIC needs to be expanded. Lastly, more inclusive policies and programs for refugees are

necessary to reduce food insecurity in order to alleviate the burden of rising type 2 diabetes.

Background

Diabetes, a non-communicable multi-factorial chronic disease, has become a pandemic

with one of the most increased incidence rates in the U.S. The Centers for Disease Control and

Prevention (CDC) reported that diabetes affected about 30.3 million people of all ages or 9.4%

of the U.S. population in 2015 at the cost of more than $245 billion.12 Another 7.2 million people

or 23.8% of people with diabetes remain undiagnosed, while another 84.1 million adults 18 years

and older have prediabetes.12 This diabetes incidence rate is estimated to increase to 21-33% by

2050, which predicts an unsustainable burden on the economy, health expenditure, and quality of

7

life among the U.S. population.11 Diabetes also increases the risk of developing many other

diseases such as coronary heart disease, stroke, hypertension, depression, functional disability,

blindness, end-stage renal failure, and non-traumatic limb amputations.12

The increased prevalence of diabetes in recent years has been highly influenced by the

social determinants of health, especially food insecurity. Previous research on the relationship

between food insecurity and dietary patterns links food insecurity with a lower consumption of

healthy food groups and poor diet quality. Poor diet quality place an individual at risk for worst

health consequences.59 U.S. Department of Agriculture (USDA) defines food insecurity as a

“household-level economic and social condition of limited or uncertain access to adequate food”.

80 Food insecurity is often experienced by the low-income population as they struggle to buy

food amidst other necessary needs, such as medical care.8 In 2018, 11.1 percent or 14.3 million

U.S. households reported being food insecure.81 A study of Cambodian refugee women residing

in Lowell, MA found that 24% of Cambodian refugees experienced some levels of food

insecurity.52. In 2014, 43% of Cambodians in Connecticut reported running out of food “often”

or “sometimes in the past year.3 Limited financial resources steer these people to buy cheaper,

high-calorie foods with reduced intake of micronutrients, fruits, and vegetables and increased

consumption of simple carbohydrates. 38 It is well-demonstrated that higher carbohydrate diets

are linked to higher prevalence and incidence of type 2 diabetes.35 As a result, food insecurity is

increasing the risk of many food-related chronic diseases, including diabetes. A study in Canada

found that the risk of developing type 2 diabetes increased more than twice for individuals living

in a food-insecure household compared to an individual in a food secure household.74 Another

study from the National Health Examination and Nutrition Examination Survey (NHANES)

8

1999–2002 reported that food insecurity acted as a risk factor since food insecure people were

more likely to have diabetes than those without food insecurity.64

As the prevalence of diabetes and food insecurity problematically grows, almost all social

groups in the United States have been affected. However, low-income racial and ethnic minority

groups, especially resettled refugees, often endure a disproportionately higher rate of many

chronic diseases, including diabetes, compared to the US-born residents or first-generation

immigrants.32,51,88 Cambodian refugees were identified to have more than twice the rate of

diabetes (28%) relative to the age- and gender-adjusted U.S. population (12%).49

Refugees in America:

Refugees refer to "individuals who reside outside of their home country and are unable to

return home because of suffering, feared persecution, violence, or war”. 86 The United States

accounts for the largest refugee resettlement, admitting about 3,042,413 refugees and

permanently resettling nearly three-quarters of them from 1980 to 2018.17 Many refugees

resettled in the U.S. come from refugee camps and places where they experienced extreme

starvation or food deprivation due to war or genocide. The experience of hunger, starvation,

violence, stress, and war might have caused physiological damage, trauma, and chronic mental

health sequelae including depression, post-traumatic stress disorder, and social isolation for the

majority of these refugees.48 Many people with mental illness already have difficulty accessing

medical and mental healthcare in the U.S. Refugees with mental illness who are from

racial/ethnic minority groups face even more access challenges, including language barriers,

post-settlement socioeconomic status, culturally based health beliefs regarding mental illness and

its treatment, mistrust or lack of confidence in western medicine, and social isolation.90 In

conjunction to access challenges, acculturating to a new culture and food environment creates an

9

additional challenge for them to maintain a healthy lifestyle. As a result, refugees face

disproportionately higher rates of health-related problems such as obesity, hypertension, and

diabetes than other immigrant groups and native-born Americans.25,41 These challenges make

refugee post-settlement dietary intake and food adaption an under-investigated complex

phenomenon that uniquely contributes to the rise of often long-term health consequences and

pose an unexpected burden on the U.S. healthcare system. Limited research exists on the full

spectrum of refugee dietary intake and health outcomes post-resettlement in subsequent years,

especially those who previously experienced food deprivation, starvation, and malnutrition.

The Khmer Rouge Regime and Cambodian refugees in the U.S.:

Many studies suggest that experiences of trauma from past food deprivation or starvation

due to war/genocide impacted post-resettlement dietary intake among many refugee groups as

they also tend to financially for years in the new country.58,63 One of the prominent examples of

such refugees is Cambodians who survived genocide during the Khmer Rouge. The majority of

refugees from Cambodia suffered severe famine from 1975-1979 during the period of

Democratic Kampuchea (D.K.). The Khmer Rouge was the Communist Party in Kampuchea in

Cambodia. The Communist Party of Kampuchea (CPK) of Cambodia came into power by

defeating the Khmer Republic and established "Democratic Kampuchea" (D.K.), the official

government of Cambodia during the Cambodian civil war.16 This regime, led by Pol Pot from

1975-1979, sought to create a pure agrarian socialist nation that would be financially and

economically independent from the outside world by relying on agriculture, especially rice

production.16 Through enforcement of flawed agricultural policies, forced overwork in the rice

field, state expropriation of rice, and other policies such as the abolishment of private ownership

and communal eating to achieve absolute socialism, the CPK led the country to severe famine

10

and mass starvation.16 The Khmer Rouge regime created mass famine not only through extreme

policies but also through extreme violence and terror. The regime carried out mass

imprisonments, tortures, and killings of groups who were distrusted, and those who survived

were translocated, enslaved, and forced to work or starve to death on farms, making famine

especially dire to specific minority groups.26 Even acknowledging the existence of famine was

considered a crime, and anyone who opposed was arrested, tortured, and executed.26 The food

situation improved during the Vietnamese occupation of Cambodia, and for those who escaped

to the refugee camps in Thailand.26 However, eating patterns and dietary intake were disrupted

even in the refugee camps due to inadequate access and insufficient foods before some who

resettled as refugees in other countries.58 A large number of Cambodian refugees who were

survivors of the Khmer Rouge regime were resettled in the U.S. in the early 1980s.58 The

majority of them settled in California.63

As a result, food insecurity in the host countries, including the United States, can pose a

particular threat to such refugees who experienced high levels of trauma and starvation in their

home countries. Several studies demonstrate that people with a long-term experience of trauma,

starvation, or both developed harmful binge-eating habits and obsession with foods in abundant

access to the food environment, increasing the rates of risk factors of diabetes.58,61,71 History of

starvation and current high rates of food insecurity may trigger survival techniques such as food

hoarding or unsafe dietary intake habits among refugees, including Cambodian Americans. It

was reported that the Khmer Rouge regime forbade Cambodians to even consume their own rice

they produced, forcing them to survive on foods such tadpoles, small fish, or, bugs and nonfood

items including roots and grasses and punished them to death if they were caught stealing

foods.58 This experience of long food deprivation and trauma shaped dietary practices among

11

Cambodians long after their resettlement in a new country. Further, rice is a staple food and a

primary source of carbohydrate for Asian populations, especially for Cambodians.16 Due to years

of rice consumption practice long before and during the Khmer Rouge, Cambodians acquired a

preference for white rice over brown rice.58,59 It has been documented that brown rice was fed to

prisoners during the Khmer Rouge regime.16 Unfortunately, compared to brown rice, white rice

has a higher glycemic index, which is associated with an increased risk of type 2 diabetes.72,83

Mental illness such as depression is demonstrated to be a risk factor of diabetes by

worsening many lifestyle factors such as a healthy dietary pattern that include less consumption

of simple carbohydrates and lower levels of physical activity.62,70,87 Similar to other refugees,

Cambodian refugees who experienced trauma or starvation also developed many mental health

illnesses such as depression and post-traumatic stress disorder (PTSD) and thereby, are at high

risk of developing diabetes.42,53,87 A cross-sectional survey study of 136 Cambodian Americans

from Connecticut and Massachusetts in 2014 showed that 73% of Cambodian adults have

depression, post-traumatic stress disorder (PTSD) or both.9 A study comparing a probability

sample of US-residing Cambodian refugees (N=331) to a probability sample of the U.S.

population (N=6360) from the 2009-2010 National Health and Nutrition Examination Survey

revealed that the prevalence of diabetes among Cambodians was 28% significantly exceeding

other high-risk groups, including non-Hispanic blacks (12.7%) and Hispanics (12.1%).12,49

Rationale:

This paper aims to assess the association between food insecurity and diabetes risk

marker (HbA1c) among Cambodian refugees suffering from depression who survived the Khmer

Rouge genocide and are at risk of type 2 diabetes mellitus. The study also intends to explore the

socioeconomic status and dietary patterns and its association with household food security status

12

among this hard-to-reach, generally ignored, high-risk Cambodian communities. Generally, there

is no national data on subgroups. Several studies on the risk of diabetes among the Asian

population or refugees that exist are aggregated and, as a result, mask the burden of type 2

diabetes among high-risk non-Hispanic Asian subgroups. Knowledge and data on household

food insecurity, dietary patterns, and diabetes risk among Cambodians either as an Asian sub-

group or as a refugee subgroup are equally far understudied. More comprehensive data on the

burden of diabetes risk among Cambodian refugees can help prepare both clinicians and

community-based organizations to address the health concern impacting this population better.

This study can also enlighten refugee agencies, health programs, or policy approaches on how to

devote resources and implement culturally appropriate intervention programs strategically. Thus,

it can ensure successful acculturation to the U.S. food environment, long-term food security, and

better health outcomes of Cambodian refugees. The results can be applied to other refugees with

collective trauma histories and associated mental illnesses who face similar barriers to care. This

study explores whether a health disparity exists and addresses this critical gap in the literature.

Specific aims/hypotheses

The primary aims of the study are to (1) describe household food security status of

Cambodians refugees who suffered trauma and starvation during the Khmer Rouge genocide,

suffering from depression and elevated risk of diabetes; (2) examine the association between

household food security status and socioeconomic status (SES) of Cambodian refugees; (3)

describe dietary patterns, especially different rice dishes and sugar-sweetened beverages

consumption of this population; (4) examine the association between household food insecurity

and diabetes risk marker (HbA1c); and (5) assess preliminary associations between household

food insecurity, dietary patterns and diabetes risk marker (HbA1c) within the population.

13

Hypotheses:

H1: Food insecure group will have a different pattern of socioeconomic and demographic

characteristics compared to food secure group.

H2: Daily consumption patterns of carbohydrate-rich foods such as rice and sugar-

sweetened beverages in food insecure group will be different than food secure counterparts.

H3: Food insecure group will have higher HbA1c levels than food secure group.

H4: Daily carbohydrate intake from rice and beverages will exhibit an impact on HbA1c.

The study aims to analyze the preliminary cross-sectional baseline data results and explore these

specific aims to better understand many factors influencing the high risk of diabetes among

Cambodian refugees with depression.

Materials and Methods:

Sample and Setting:

For this study, the preliminary cross-sectional baseline data analyzed from a National

Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funded R01 study (PI: Julie

Wagner): Diabetes Risk Reduction through Eat, Walk, Sleep and Medication Therapy

Management for Depressed Cambodians (DREAM) study, listed at ClinicalTrials.gov as

NCT02502929. The DREAM study was established as a collaboration between the Khmer

Health Advocates (KHA), The University of Connecticut, and Penn State University. The Khmer

Health Advocates (KHA) is the national Cambodian health organization that assesses,

intervenes, and provides care for this hard-to-reach Cambodian refugee population from the

Khmer Rouge regime in Connecticut and Massachusetts. A sample of 205 Cambodian American

participants was recruited from Connecticut, Massachusetts, and Rhode Island. Participants were

enrolled by Community Health Workers (CHW) at three community agency sites of KHA’s

14

national network of community-based organizations including two community agency sites –

KHA in West Hartford CT, and the Center for Southeast Asians of Providence, RI.

DREAM Study’s Baseline Inclusion and Exclusion Criteria:

Participants were screened using a 3-Stage screening process that employed the screening

inclusion and exclusion criteria for each stage. Each stage was created to develop standardized

criteria for recruiting participants and screen out participants who did not meet the criteria.

Stage 1:

In stage 1 screening, community health workers (CHW) identified recruits through direct

outreach at community centers. Participants were screened for basic demographic and health

information. The inclusion criteria for stage 1 included someone who self-identified as

Cambodian or Cambodian American, age between 35-70, Khmer speaking, had no prior

diagnosis of diabetes at that time, had the ability to walk unassisted for at least 30 minutes

without stopping, could consume meals by mouth and could provide consent for themselves.

Participants who had a diagnosis of diabetes per self-report were excluded. When participants

screened out at stage 1, they were not enrolled in the study, but were given diabetes prevention

educational materials written in Khmer language from the National Diabetes Education Program.

Stage 2:

The participants who screened in stage 1 were recruited in stage 2 screening, where they

were interviewed at a place of their choices in a private room-either their homes or community

centers. Participants were assessed for diabetes risk using the ADA diabetes Risk Test and

assessed for depression eligibility using the Khmer version of the depression subscale of the

Hopkins Symptom Checklist and/or self-reported anti-depressant medication for the treatment of

depression. Those who scored >=3 that indicated elevated risk per ADA guidelines on the ADA

15

Diabetes Risk Test. To meet eligibility for depression, a recruit could either score =>26 (standard

cut off mean=1.75) on the 25 items Hopkins symptom Checklist met inclusion criteria for the

DREAM study and/or respond affirmatively that they were taking a prescription medication for

the treatment of depression.

Stage 2 screening exclusion criteria included: having thinking or memory problems (e.g.,

schizophrenia, dementia); had vision or hearing problems that would prevent participation in

group sessions; had been followed by a physician for any significant medical problems (e.g.,

heart attack in past 12 months, active cancer, HIV/AIDS, hepatitis); was enrollment in another

research study; had spent three consecutive days in a psychiatric hospital, or history of self-harm

in the past two years; and if a women, were pregnant or plans to become pregnant in the next 15

months at the time of data collection.

Stage 3:

Participants who satisfied the depression criteria in stage 2 by demonstrating elevated

depressive symptoms received Stage 3 screening, were assessed again using the Hopkins

Symptom Checklist one week later to confirm their evaluated depressive symptoms and screened

out those who had only temporary elevated symptoms. Those who scored =>26 (standard cut off

mean=1.75) again met eligibility and were included in the study. Participants without depression

were not eligible for the study. Then the approved recruits were socialized to the study by

CHWs, given time to consider participation, had their questions answered, showed a willingness,

and then invited to complete an informed consent form and the HIPAA authorization form in

English and Khmer according to IRB procedures.

Measures:

16

For this proposed sub-study, participants completed baseline survey assessments

regarding food insecurity, dietary patterns, and blood biomarkers.

The baseline survey questionnaire was developed in English, translated into Khmer by

the bilingual Study Coordinator, and then field tested in Connecticut with 5 individuals. Several

small changes were made to the translation, as slight rural variations on dialect existed.

However, no changes were made to the meaning/composition of any of the questions.

All assessment data were collected by bilingual, bicultural, community health workers at

home visits using REDCap.

Descriptive demographic, socioeconomic characteristics. Demographic information

including age, gender (male or female), marital status, language spoken (Khmer or English) was

obtained. Socioeconomic information included income, education, employment status, health

insurance (yes or no), transportation (can drive-yes/no and access to a car-yes/no), participants of

the Supplemental Nutrition Assistance Program (SNAP) benefits (yes or no) and difficulty

speaking or understanding a healthcare provider due to language barrier (yes or no).

Independent variable:

Food insecurity. Food insecurity was assessed for the past 12 months using the 6-item,

validated Khmer language, version of the U.S. Household Food Security Survey Module.60 The

short version of the food security scale surveys was used to save time since the individual

interview session already lasted approximately 2 hours. The six-item short form of the survey

was developed by the National Center for Health Statistics and found to have an overall 92%

sensitivity and 99.4% specificity in identifying food insecurity.10,82 According to the USDA, this

six-items short survey identified “food-insecure households and households with very low food

17

security with reasonably high specificity and sensitivity and minimal bias compared with the 18-

item measure”.82 A sample food security survey is provided in Appendix A.

The sum of affirmative responses to the six questions ranged from a score of (0-6). The

study dichotomized household food security status to two categories-food secure and food

insecure.7 Participants who scored equal to zero were considered as food secure (high food

security) and those who scored ≥1 were considered as food insecure (including marginal, low,

and very low food security).7

Dependent variable:

Hemoglobin A1c biological marker. The hemoglobin A1c (HbA1c) or glycated

hemoglobin is a form of a protein found in red blood cells that carries oxygen linked to

glucose.69 The HbA1c test is used to measure the average blood glucose level for the past two to

three months. The HbA1c is a reliable biomarker for blood glucose concentration, and thereby,

the HbA1c test is recommended to diagnose and monitor diabetes. 69 The HbA1c was measured

in the local Quest laboratory using High Pressure Liquid Chromatography (HPLC) and reported

according to National Glycemia Standardization Program (NGSP) guidelines. A HbA1c level of

higher than 6.4% was considered as diabetes, between 5.7% and 6.4% were considered

prediabetes and below 5.7% was considered normal.69 A sample HbA1c data collection form is

provided in Appendix B.

Dietary Patterns. Dietary consumption was assessed using a translated Khmer short

semi-quantitative Food Frequency Questionnaire (FFQ). The rice items were pilot-tested with the

study coordinator, community health workers, and the first 5 participants. The items on the food

frequency questionnaire food list were selected to include the principal sources of energy and

selected vitamins and minerals in the typical Cambodian diet, special attention to rice food items

18

frequency. The frequency of consumption and portion size of the food items was assessed over

the past 3 months’ timeframe. Culturally appropriate food models, a ruler and kitchen utensils

(measuring spoons, cups, and plates, bowls) were used to estimate portion sizes. A sample first

page of FFQ is provided in Appendix C.

Subject Compensation

Participants were compensated with a $20 worth of gift cards to a local pharmacy upon

completion of the baseline assessment.

Statistical Analyses

All statistical analyses and survey database management were done using IBM SPSS

(Version 23) software. For all tests, P < 0.05 was considered statistically significant. First,

descriptive statistics including mean, median, mode, standard deviation, sum, percentiles,

skewness, kurtosis, homoscedasticity were used to characterize the participants’ socioeconomic

characteristics. Characteristics with multiple categories including language spoken at home,

marital status, employment status, and income were dichotomized. T-tests were conducted to

determine the differences in means between continuous demographic/socioeconomic status

categories and categorical household food security status. Similarly, bivariate chi-square tests

were conducted to determine the difference between categorical demographic/socioeconomic

status categories and categorical household food security status.

Descriptive statistics were run to examine the frequency of different dietary patterns,

including various rice and beverages consumed in the past three months. Participants reported

consuming some form of rice and beverage daily; therefore, all rice consumption (white, brown,

mixed, sticky and rice porridge) and beverages consumption (regular non-diet soda, 100% fruit

juice, fruit shake, and other fruit drinks) were converted and reported as daily intake to examine

19

differences of consumption between food secure and food insecure individuals. Bivariate chi-

square tests were conducted to determine differences between categorical rice/ beverage

categories and categorical household food security status.

Daily total carbohydrates from rice (grams) and beverages (grams) were calculated using

the ESHA’s Food Processor® Nutrition Analysis software. Culturally appropriate portion sizes

were used to calculate carbohydrates from rice and beverages consumption. For example, one

small bowl of rice (white, brown, mixed, sticky, and rice porridge) was equal to one standard cup

of cooked rice, one medium bowl of rice was equal to three standard cups of cooked rice, and

one large bowl was equal to five standard cups of cooked rice. For the beverages, one small cup

of beverages (regular non-diet soda, 100% fruit blend, fruit shake, and other fruit drinks) was

equal to 12 oz, one medium cup of beverages was equal to 16 oz., and one large cup was equal to

26 oz. Grams of carbohydrates from one small, medium, and large bowls of rice (white, brown,

mixed, sticky, and rice porridge) were calculated using the ESHA software and multiplied by the

number of times the participants consumed them daily to get total daily carbohydrates from rice.

For the beverages, grams of carbohydrates from portion sizes (one small, medium, and large cup)

were calculated and multiplied by the number of times the participants consumed them daily to

get total daily grams of carbohydrates from beverage consumption. T-tests were conducted to

determine the differences in continuous total daily grams of carbohydrates from rice

dish/beverages consumption between food secure and food insecure individuals.

T-test was used to compare food-secure with food-insecure groups on the A1c biological

marker. A test for normality, Q-Q plot and histograms showed that HbA1c levels were normally

distributed but daily carbohydrate intake from rice and beverages was not normally distributed.

Therefore, Spearman’s Correlations were conducted to determine an association between total

20

grams of carbohydrates from different rice and beverages and hemoglobin A1c (HbA1c). In this

sub-study, “dietary intakes/grams of carbohydrates” were compared to both household food

security status and hemoglobin A1c levels to explore the preliminary association between food

insecurity, dietary patterns/behaviors, and HbA1c levels.

Results

Although the baseline sub-study initially had 205 participants, data from four participants

were excluded due to their updated diabetic status, two participants did not answer/refused to

answer, and about 16 participant’s data were missing dietary data, leaving 189 participants for

the final analysis. Based on the cross-sectional baseline data, 187 participants (91%) out of a

total number of 189 participants were born in Cambodia and reported living in the Khmer Rouge

regime for 3.23±1.14 years. All participants except one reported living in a refugee camp for 3.0

±5.12 years.

1) Household food security status and demographic characteristics of Cambodian refugees:

Table 1 describes the demographic and socioeconomic characteristics of the studied

sample. The table shows that the mean age of the participants was 55 years and had a mean of 7

years of education. 77% (n= 145) were female, 50% (n= 93) were married, 87% (n=162) spoke

Khmer at home and 44% (n= 82) expressed difficulty speaking or understanding a health care

provider due to language barrier. Among socioeconomic characteristics, 68% (n=128) were

unemployed and 44% (n=59) earned less than $20000 to $30000 annually, 41% (n=76) reported

receiving SNAP benefits and 75% (n=140) had access to a car. Surprisingly, 95% (n=178) of the

participants reported having health insurance.

(2) Sample characteristics by household food security status:

21

Table 1 also illustrates sample characteristics by household food security status. There

were no statistically significant differences found in household food security status by age,

education, gender, health insurance, language spoken, and transportation (ability to drive or

access to car). However, participants who reported receiving SNAP benefits in the household

significantly differed in food security status (p=0.006 <0.05). Participants who were SNAP

recipients (31.6%, n=24) were more likely to be food insecure than participants who did not

receive SNAP benefits (13.6%, n=15). Unmarried participants (29.8%, n=28) were significantly

more likely to be food insecure compared to married participants (11.8, % n=11) (p= 0.004

<0.05). Similarly, low income participants who reported earning less than $20,000-$30,000

annually (28.9%, n=24) were significantly more likely to be food insecure than participants who

earned $31,000 to more than $40,000 (p=0.019). That was also verified when significant

differences were found between employment and household food security status. Unemployed

participants (28.1%, n=36) were more likely to be food insecure than employed counterparts

(5.1%, n=3) (p-value =0.000). Food insecurity was significantly associated with having difficulty

speaking with or understanding a health care provider due to a language barrier (p-value=0.018).

Therefore, food insecurity was significantly associated with marital status, income, employment

status, receiving SNAP benefits and having a communication/language barrier.

Table 1. Sample Characteristics by Household Food Insecurity Status1

Characteristics Total

Mean ± SD

or n%

Food Secure1

Mean ± SD or

n%

Food Insecure1

Mean ± SD or

n%

P value

Age, Mean ± SDa 55.20±8.79 148 (79.1) 39 (20.9) 0.778

Education, years, Mean ± SDa 6.98±5.03 148 (79.1) 39 (20.9) 0.750

Characteristics* Total

n (189)

Food secure1

n (%)

Food insecure1

n (%)

P value

Gender (%)b

Female 145 (77.5) 112 (77.2) 33 (22.8) 0.285

Male 42 (22.5) 36 (85.7) 6 (14.3)

22

Marital Status (%)b

Yes 93 (49.7) 82 (88.2) 11 (11.8) 0.004

No 94 9 (50.3) 66 (70.2) 28 (29.8)

Income (%)b

Less than $20,000-$30,000 83 (44.4) 59 (71.1) 24 (28.9)

0.019 $31,000-above $40,000 104 (55.6) 89 (85.6) 15 (14.4)

Employment Status (%)b

Employed 59 (31.6) 56 (94.9) 3 (5.1) 0.000

Unemployed 128 (68.4) 92 (71.9) 36 (28.1)

Health Insurance

Yes 178 (95.2) 142 (79.8) 36 (20.2) 0.398

No 9 (4.8) 6 (66.7) 3 (33.3)

SNAP Recipient (%)b

Yes 76 (40.9) 52 (68.4) 24 (31.6) 0.006

No 110 (59.1) 95 (86.4) 15 (13.6)

Language spoken at home (%)b

Khmer 162 (86.6) 127 (78.4) 35 (21.6) 0.608

English 25 (13.4) 21 (84) 4 (16)

Communication: difficulty

speaking with or understanding

a health care provider due to

language barrier? (%)b

Yes 82 (43.9) 58 (70.7) 24 (29.3) 0.018

No 105 (56.1) 90 (85.7) 15 (14.3)

Transportation (%)b

Can you drive?

Yes 144 (77) 114 (79.2) 30 (20.8) 0.989

No 43 (23) 34 (79.1) 9 (20.9)

Access to a car?

Yes 140 (74.9) 114 (81.4) 26 (18.6) 0.214

No 47 (25.1) 34 (72.3) 13 (27.7)

Values are presented either in means ± SDs or n (%). Percentages for Total Participants in each

socioeconomic status category, Food Secure and Food Insecure are calculated horizontally

within each row.

1Three people answered “didn’t know” or refused to answer to several of the Food Security

Survey Module items, therefore, were excluded from final analyses, totals, horizontally, may be

off by n=1, n=2, n=3a,b

*Data only available for categorical demographic/socioeconomic status characteristics, n=189

aT-tests were conducted to determine the differences in means between continuous

demographic/socioeconomic status categories and categorical household food security status.

b Chi-square tests were conducted to determine difference between categorical

demographic/socioeconomic status categories and categorical household food security status

23

(3) Dietary patterns of Cambodian refugees:

Table 2 and Table 3 show daily dietary (rice and beverages) consumption patterns of the

participants. As demonstrated in Table 2, 97.2% (n=172) of the participants consumed white

rice, 76% (n=133) of the participants consumed rice porridge, and 46.3% (n=82) of the

participants consumed sticky rice daily as compared to only 24.9% (n=44) consumed brown rice,

and 13% (n=23) consumed mixed rice. There were no statistically significant differences in food

security status by consumption of all rice dishes (all p-values >0.05).

1Two people answered “didn’t know” or refused to answer to several of the Food Security

Survey Module items, therefore, were excluded from final analyses, totals, horizontally, may be

off by n=1, n=2a

*Data only available for: White rice, n=177; Brown rice, n=177; Mixed rice, n=177, Rice

Porridge, n=175; Sticky rice, n=177

a Chi-square tests were conducted to determine differences between categorical rice categories

and categorical household food security status.

Table 3 shows that about 50% of the participants consumed regular non-diet soda

(50.3%, n=89) and 100% fruit blend juice (54%, n=95). Fruit shakes (Taro Bubble Tea) and

other fruit drinks (Grass Jelly Drink) were not as popular as 24.9% (n=50) of the participants

Table 2. Daily Rice Consumption Patterns by Household Food Insecurity Status1

Rice Dish* Total

n (%)

Food secure1

n (%)

Food insecure1

n (%)

P value

White Rice a

Yes 172 (97.2) 136 (79.1) 36 (20.9) 0.156

No 4 (2.3) 3 (75.0) 1 (25.0)

Brown Rice a

Yes 44 (24.9) 36 (81.8) 8 (18.2) 0.510

No 131 (74.4) 101 (77.1) 30 (22.9)

Mixed Rice a

Yes 23 (13.0) 19 (82.6) 4 (17.4) 0.147

No 153 (86.4) 119 (77.8) 34 (22.2)

Rice Porridge a

Yes 133 (76.0) 103 (77.4) 30 (22.6) 0.159

No 41 (23.4) 33 (80.5) 8 (19.5)

Sticky Rice a

Yes 82 (46.3) 65 (79.3) 17 (20.7) 0.163

No 94 (53.1) 73 (77.7) 21 (22.3)

24

consumed fruit shakes, and 35.2% (n=62) consumed other fruit drinks. Also, there were no

statistically significant differences in food security status by consumption of different sugar-

sweetened beverages (all p-values >0.05).

Table 3. Sugar-Sweetened Beverages Consumption Patterns by Household Food Security

Status1

Beverage* Total

n (178)

Food Secure1

n (%)

Food Insecure1

n (%)

P value

Regular Non-Diet Soda a

Yes 89 (50.3) 68 (76.4) 21 (23.6) 0.374

No 88 (49.7) 70 (79.5) 18 (20.5)

100% Fruit Blend Juice a

Yes 95 (54.0) 76 (80.0) 19 (20.0) 0.354

No 81 (46.0) 62 (76.5) 19 (23.5)

Fruit Shakes (Taro Bubble

Tea) a

Yes 50 (24.9) 37 (74.0) 13 (26.0) 0.272

No 127 (62.0) 101 (79.5) 26 (20.5)

Other Fruit Drinks (Grass

Jelly Drink) a

Yes 62 (35.2) 48 (77.4) 14 (22.6) 0.532

No 114 (64.8) 89 (78.1) 25 (21.9)

1Two people answered “didn’t know” or refused to answer to several of the Food Security

Survey Module items, therefore, were excluded from final analyses, totals, horizontally, may be

off by n=1, n=2a

*Data only available for: Regular non-diet soda, n=178; 100% Fruit Blend Juice, n=178; Fruit

Shakes (Taro Bubble Tea), n=178; Other Fruit Drinks (Grass Jelly Drink), n=177

a Chi-square tests were conducted to determine difference between categorical sugar-sweetened

beverages categories and categorical household food security status.

(4) Diabetes risk marker (HbA1c) by household food security status:

Table 4 displays the association between hemoglobin A1c and household food security

status. The normal HbA1c level was <5.7, prediabetes was 5.7 to 6.4, and diabetes was >6.4.

Food insecure participants had an average HbA1c that approached the pre-diabetic range (5.67 ±

0.49) compared to food secure participants who had an average HbA1c that was normal (5.46 ±

0.41) (p = 0.006). Thus, the result reveal that household food security status was significantly

associated with HbA1c.

25

Table 4. Hemoglobin A1c by Household Food Security Status Association1

Total

(Mean ±

SD)

Food Secure

(Mean ± SD)

Food Insecure

(Mean ± SD)

P value

Hemoglobin A1ca 5.5± 0.44 5.46 ± 0.41 5.67 ± 0.49 0.006

aT-tests were conducted to determine the differences in means between continuous Hemoglobin

A1c and categorical household food security status.

(5) Daily carbohydrate intake from diet, household food security status, and hemoglobin A1c:

Table 5, 6 and 7 present daily carbohydrate intakes from rich dishes and sugar-sweetened

beverages by household food security status. Table 5 includes daily carbohydrate intake from

rice dishes. The mean daily carbohydrate intakes were 131.4 grams (SD =73.4) for white rice,

119.3 grams (SD =64.4) for brown rice, 130.7 grams (SD = 67.4) for mixed rice, 94.4 grams

(SD= 40.1) for rice porridge, and 57.6 grams (SD= 75.1) for sticky rice. There were no

statistically significant differences in food security status by daily carbohydrate intake from

individual rice dishes or combined rice dishes (all p-values >0.05).

Table 5. Daily Carbohydrate Intake from Rice by Household Food Insecurity Status1

Rice Dish Total (Mean ± SD) a Food Secure1

(Mean ± SD)

Food Insecure1

(Mean ± SD)

P

value

White Ricea 131.4 ± 73.4 128.2 ± 70.2 143.4 ± 84.3 0.277

Brown Ricea 119.3 ± 64.4 124.8 ± 65.9 94.2 ± 56.9 0.265

Mixed Ricea 130.7 ± 67.4 139.4 ± 68.6 93.0 ± 54.2 0.233

Rice Porridgea 94.4 ± 40.1 96.0 ± 39.9 86.0 ± 40.4 0.197

Sticky Ricea 57.6 ± 75.1 62.1 ± 82.6 41.8 ± 35.7 0.314

Combined Rice Dishesa

(White, Brown, Mixed,

Sticky and Rice

Porridge)

270.9 ± 161.5 274.8 ± 165.8 256.7 ± 145.5 0.547

Values are presented in means ± SDs. Four people were found diabetes, therefore, were

excluded from final analyses.

1Two people answered “didn’t know” or refused to answer to several of the Food Security

Survey Module items, therefore, were excluded from final analyses, totals, horizontally, may be

off by n=1, n=2a

aT-tests were conducted to determine the differences in means between continuous total daily

grams of carbohydrates from rice dish and categorical household food security status.

26

Table 6 indicates the daily carbohydrate intake from sugar-sweetened beverages. The

mean daily carbohydrate intakes were 37.3 grams (SD = 12.8) for regular non-diet soda, 48.4

grams (SD= 48.4) for 100% fruit blend juice, 91.9 grams (SD= 54.7) for fruit shakes (Taro

bubble tea) and 55.2 grams (SD= 77.1) for other fruit drinks (Grass Jelly Drink). Participants

who were food insecure did not significantly differ from participants who were food secure by

daily carbohydrate intake from different sugar-sweetened beverages (all p-values > 0.05).

Table 6. Daily Carbohydrate Intake from Sugar-Sweetened Beverages by Household Food

Security Status

Beverage Total

(Mean ± SD)

Food Secure

(Mean ± SD)

Food Insecure

(Mean ± SD)

P value

Regular Non-diet sodas 37.3 ± 12.8 38.3 ± 13.0 33.2 ± 10.9 0.143

100% Fruit Blend Juicea 48.4 ± 16.5 48.7 ± 16.1 46.8 ± 18.4 0.656

Fruit Shakes (Taro Bubble Tea)a 91.9 ± 54.7 95.3 ± 58.8 82.3 ± 41.0 0.466

Other Fruit Drinks (Grass Jelly

Drink)a

55.2 ± 77.1 60.2 ± 84.1 32.7 ± 15.0 0.338

Combined Beverages (Regular

non-diet soda, 100% fruit juice,

fruit shakes, and other fruit

drinks)a

103.1 ±80.2 104.1 ± 82.1 98.9 ± 72.9 0.760

Values are presented either in means ± SDs. Four people were found diabetes, therefore, were

excluded from final analyses.

1Two people answered “didn’t know” or refused to answer to several of the Food Security

Survey Module items, therefore, were excluded from final analyses, totals, horizontally, may be

off by n=1, n=2a

abT-tests were conducted to determine the differences in means between continuous total daily

grams of carbohydrates from sugar sweetened beverages and categorical household food

security status.

Table 7 illustrates a combined daily carbohydrate intake from rice dishes and sugar-

sweetened beverages by household food security status. The mean daily carbohydrate intake

from all rice and beverages was 351.1 grams (SD = 199.3). Similar to Table 3 and Table 5, Table

6 also showed no statistically significant difference in household food security status by a total

daily carbohydrate intake from rice and beverages. Overall, based on the results, food security

status was not associated with dietary patterns (rice or beverages, or both) of the participants.

27

Table 7. Daily Carbohydrate Intake from Rice and Sugar-Sweetened Beverages by

Household Food Security Status1

Total

(Mean ± SD)

Food Secure

(Mean ± SD)

Food Insecure

(Mean ± SD)

P value

Combined ricea

-White Rice

- Brown Rice

- Mixed Rice

-Sticky Rice

-Rice Porridge and

Combined Beverages

-100% Fruit Juice

-Regular Non-diet Soda

-Fruit Shakes

-Other Fruit Drinks

351.1 ±199.3 356.3± 202.0 331.6±190.4 0.503

1Four people were found diabetes, therefore, were excluded from final analyses, totals,

horizontally

aT-tests were conducted to determine the differences in means between continuous total daily

carbohydrates from dietary (all rice and sugar-sweetened beverages/items) characteristics and

categorical household food security statu

Table 8 analyzes unadjusted correlations between daily carbohydrate intake from rice

and sugar-sweetened beverages and HbA1c. Out of all food items, only daily carbohydrate intake

from rice porridge and fruit shakes (taro bubble tea) were significantly correlated with HbA1c

levels (p <0.05). Daily carbohydrate intake from rice porridge was negatively correlated with

HbA1c levels (-0.19) and daily carbohydrate intake from fruit shakes (Taro bubble tea) was

positively correlated with HbA1c levels (0.31). All other rice dishes, including white, brown,

mixed, and sticky, had a non-significant weak correlation with HbA1c level (-0.04, 0.03, -0.08,

and -0.07 respectively, all p-values >0.05). Similarly, all sugar-sweetened beverages including

regular non-diet soda, 100% fruit blend juice, and other fruit drinks (Grass Jelly Drink) also had

a weak non-statistically significant correlation with HbA1c (0.02, 0.11, and -0.1) respectively, all

p-values >0.05).

28

Discussion

Household food insecurity is prevalent among Cambodian refugees. The primary findings

from this were that Cambodian refugees experiencing food insecurity food had significantly

higher mean HbA1c levels than their food-secure counterparts. One potential explanation for this

is that food insecure households often meet their dietary and caloric needs by consuming

inexpensive, calorically dense foods due to financial constraints.19 Caloric and energy-dense

foods generally cost per less per calorie compared to healthy foods such as whole grains, fruits

and vegetables and include a high proportion of added fats, sugars, sodium, and other refined

carbohydrates.19 When consumed in large portions, these cheap, nutritionally deficient foods can

have a significant impact on glycemic levels.65

29

Food insecurity also tends to be a cyclic phenomenon with recurrent periods of food

scarcity before having adequate food for a few weeks.66 This anticipation of cyclic food scarcity

is stressful, accompanied with mental distress may trigger refugees who experienced past-

starvation and lead to overconsume when plenty of foods is available.66 Binge-eating can

contribute to the accumulation of excess abdominal fat and insulin resistance, consequently

result in increased HbA1c levels.66 This study is one of the few studies to assess the difference in

HbA1c level by household food security status among Cambodian refugees who had mental

illnesses such as depression, had a high risk of developing diabetes and had experiences of

trauma and starvation from the Khmer Rouge regime. The results are consistent with other

literature on other minority groups who face similar barriers as well.

Household food security status demonstrated to have associations with several other

demographic and socioeconomic characteristics of Cambodian refugees, including marital status,

income, employment status, SNAP recipient, and communication barrier. The sample in this sub-

study was mostly women, and many of them were single or widowed due to the deliberate killing

of men during the Khmer Rouge genocide.14 Cambodian refugees who were unmarried or single,

especially women, were significantly likely to be food insecure compared to those who were

married. Women have more difficulty in accessing financial sources such as jobs, fair wages,

equal pay, credits, lands, and services.36 It is especially difficult for single women or a single

mother or widowed woman since they tend to suffer much greater financial and economic

instability as their role of solo earners, caregivers, and preparers of food of the family.36

Socioeconomic hardships place single women at a heightened risk of experiencing food

insecurity and negatively affect dietary outcomes, including high intakes of carbohydrates and a

lower intake of fruits, vegetables, and macro and micronutrients.37,75 A mother’s entrance into

30

marriage or cohabitation was found to reduce food insecurity in Hispanic households due to

improved economic and familial stability.34 The experience of food insecurity increases the risk

of being overweight or obese in women, which is a risk factor of type 2 diabetes.40

Among other socioeconomic (SES) characteristics, the study found an association

between household food insecurity and income, employment as well as receiving SNAP benefits.

One of the critical components of these SES is income, which is a strong predictor of food

insecurity.29 In this study, low-income, unemployed, and SNAP recipients were more likely to be

food insecure compared to their high-income, employed, and non-SNAP recipient counterparts.

Income in these households often falls below the federal official poverty line was found to be

significantly associated with household food insecurity.15 More than half of the participants

stated being unemployed that most likely explained almost half of the participants’ household

was earning a low income (most cases below the federal poverty line) and receiving SNAP

benefits. Employment often provides improved access to credit, prescription drug, and dental

insurance, reducing household expenses, which can allow allocating more money for food.45

Food insecurity results from these inadequate economic or financial resources that limit the

access to purchase sufficient, nutritious foods. As potential coping strategies, food-insecure

households may overconsume low-cost, high-energy, nutritionally deficient foods to avoid

hunger or develop binge eating habits when food is plentiful during the SNAP (Food Stamp)

cycle.19,20 They generally consume fewer fruits, vegetables, and protein.36 These dietary practices

can contribute to weight gain and obesity and eventually increase susceptibility to type 2

diabetes.4,56,84 Other studies also identified low socioeconomic status (SES) as a risk factor of

type 2 diabetes.23,39,75 Many low-income neighborhoods only have access to convenience stores

with energy-dense foods (e.g., canned, pre-cooked) or fast food options.65 Many low-income

31

households with food insecurity also rely on free food available at food banks, soup kitchens, or

drop-in meals where they have limited control over foods.65 Hence, accessing nutritious foods

and maintaining a healthy dietary regimen necessary to diabetes prevention is extremely

challenging while coping with food insecurity. The episodical food restriction, along with the

replacement of a healthy diet with a high carbohydrate and empty calorie-rich diet, can severely

impair an individual’s capacity to manage blood sugar levels and increase the risk of developing

type 2 diabetes in food-insecure low-income individuals.19,3378

This study presented a strong association between difficulty speaking with or

understanding the healthcare provider and household food security status. Cambodian

participants who had difficulty speaking with or understanding the healthcare provider (almost

all spoke Khmer at home) were more likely to be food insecure than participants who spoke

English. Difficulty speaking with or understanding the healthcare provider is quite prevalent

among immigrants/refugees. It is indicative of a language barrier or limited English proficiency,

or low acculturation.67 One of the possible explanations for this result may be difficulties

navigating the American food environment and lack of nutrition information due to a language

barrier. Despite the abundance of foods, many refugees feel uncomfortable with the American

pasteurized, packaged foods, and unfamiliarity/lack of vegetables and seasonal fruits.5 Therefore,

they tend to adhere to familiar foods in cultural food stores, which are likely more expensive due

to limited food items, making households more food insecure.5 A language barrier can also

impede income, job opportunities, access to care, and nutritional knowledge. Unfamiliarity with

American foods coupled with low socioeconomic status, language barrier, and food insecurity

perhaps influence post-settlement dietary patterns for refugees with higher past food-deprivation.

As a result, they face an increased risk of obesity, leading to diabetes.83

32

The preliminary findings from this study found no significant associations between daily

rice and beverage consumption patterns and household food insecurity status. Although daily

carbohydrate intake from rice among food insecure households remained high despite small

sample, the difference in daily carbohydrates intake was not statistically significant. One of the

possible explanations of this result maybe is the secondary nature of data analyses and the low

sample size in the food insecure group. Descriptive results indicated a strong tie to native

Cambodian foods and traditional diet. In Southeast Asia, especially in Cambodia, rice is an

everyday staple food in the diet, and other rice dishes such as rice porridge, sticky rice is

consumed frequently.21,58 Almost all of the participants in the study reported eating white rice

daily, while more than half of them consumed rice porridge and sticky rice daily. One qualitative

study exploring lower dietary quality among immigrants and refugees in the U.S. quoted a

Cambodian participant, “Some [of us] prefer Asian food just because [we] are used to eating it

and feel like it stays in the stomach longer. Whereas, if you eat American food, you eat for a

little bit, and you feel hungry again.” on the barrier to healthy eating.77 The transmission of

cultural eating practices such as higher refined grain consumption such as white rice may be

related to an increased risk of type 2 diabetes.35 A higher intake of rich in high-fiber whole grains

such as brown rice has shown an association with favorable glycemic control and lower risk of

type 2 diabetes, but not with a refined grain such as white rice.44 This finding is a concern for the

Cambodian refugees as whole-grain consumption was low among the participants. Since rice is

very culturally important in Cambodian culture and something that most people would eat daily

due to familial traditional eating practices, the study did not seem to find any significant

difference in daily carbohydrate intake from rice consumption by household food security

status.59,77The risk of food insecurity among Cambodians is shown to increase with higher

33

acculturation of foods.59,60 Since participants were older and showed lower acculturation of

foods; daily carbohydrate intake did not make a significant difference between food secure and

insecure groups.

The non-significant difference between household food security status and the patterns of

sugar-sweetened beverages or daily carbohydrate intake from beverages might be a result of no

change in consumption of high-status and frequently consumed foods in Cambodia such as fruits,

meats, and soft drinks after U.S. resettlement because of a preference for traditional diets.73

Participants who consumed regular non-diet soda were likely to be food insecure than those who

did not consume regular non-diet soda; however, the result was not significant. Due to low

acculturation to the U.S. food environment among the participants, Cambodians arriving in the

1990s and 2000s might mostly have stuck to the familiar foods and beverages from the

Cambodian stores in the U.S. rather than consuming general sweet-sweetened beverages

available in the U.S. supermarkets.60 Many Cambodian refugees used to own rice paddy lots and

vegetable gardens in Cambodia, they might have preferred drinking fresh fruit juices and shakes

made from seasonal fresh fruits and vegetables rather than consuming unfamiliar packaged

beverages found at American supermarkets.73

The study also investigated the relationship between daily carbohydrate intake from rice

and sugar-sweetened beverages and HbA1c levels. Daily carbohydrate intake from all food items

yielded a negligible association with hemoglobin A1c levels, except rice porridge and bubble tea.

Higher consumption of rice porridge was significantly associated with the lower mean of HbA1c.

Rice porridge, often known as “Bobor Pek” or “Bobor Prong,” is mainly linked to the Khmer

Rouge regime when almost every Cambodians were only given rations of thin, watery rice soup

with a few grains and very little to no meat.16 Hence, it may be less carbohydrate-dense and

34

reduced in calorie compared to regular white rice for an equivalent volume of food. Low

carbohydrate food has a low glycemic index, which can improve glycemic control and, thus, can

show a beneficial effect on diabetes.89 However, the result must be interpreted with caution as it

may only be applicable to watered-down version of rice porridge with no protein eaten at the

time of Khmer Rouge, not to rice porridge found in America. As all of the participants of this

study lived through the Khmer Rouge, and practice habitual traditional diets, it is not surprising

that rice porridge still is commonly eaten as a breakfast food among Cambodians and more

participants experiencing food insecurity reported eating it.58,77 White rice is most commonly

eaten among almost all Cambodians regardless of all socioeconomic status and household food

security status.58,60 Therefore, the possibility of increased HbA1c levels due to daily consumption

of white rice may be approximately equal for both food-secure and insecure participants,

resulting in a non-significant association. However, high consumption of rice porridge among

participants may be a result of developing eating habits due to forced food restrictions and

starvation during the Khmer Rouge, and hence, found to have a significant association with

HbA1c levels. It is most likely specific to Cambodians who survived the Khmer Rouge genocide,

not to all Cambodians or Cambodian Americans.

Higher consumption of fruit shakes, especially taro bubble tea, was associated with

higher HbA1c. It is possibly attributed to the excess of sugar used in bubble teas. Taro bubble tea

is a calorically-dense purple drink that contains starchy taro root with milk, sweetened condensed

milk, black tea, and tapioca pearls.68 Tapioca pearls are not high in calories but they typically

soaked in a sugar mixture for bubble teas.68 Bubble tea also contains sweetened condensed milk,

which is loaded with sugar as well. When milk tea combined with sweetened condensed milk

and tapioca pearls in bubble teas, it becomes one of the primary sources of rapidly absorbable

35

carbohydrates such as various forms of sugar.47 When consumed in large quantities, bubble tea

can contribute to dietary glycemic index load, leading to inflammation and insulin resistance and

eventually type 2 diabetes, independently of obesity.47

Study Limitations and Next Steps

Small Sample Size. Although the baseline sub-study initially had 205 participants, only

189 participants were available for data analyses. With decreasing sample size, the power of the

study decreased too, which might have contributed to Type II errors. Further, the sample size for

food secure and food insecure groups was vastly disproportional, which might have enhanced the

inability to find significant associations between household food security status and dietary

patterns of Cambodian refugees.

Cross-Sectional Study. We employed a secondary analysis of cross-sectional data, and

thus, we cannot establish temporal precedence or causality. Prospective studies would better

describe the temporal sequencing of household food insecurity and diabetes risk.

Selection Criteria. This sub-study is part of a larger intervention study. One of the

inclusion criteria for the larger study was screening positive for depressive symptoms.

Depressive symptoms are known to have associations with food insecurity, hemoglobin A1c

levels, dietary patterns, and thus, poor health outcomes. 42,53,85,87 Multivariate logistic regression

analysis needs to be performed to control for mental illnesses such as depressive and trauma in

the future to establish real associations between variables. Besides, the results may not be

generalizable to Cambodians who do not have depressive or trauma symptoms.

Conclusion

The experience of genocide and starvation creates a unique set of long-term health effects

for survivors. The experience of food deprivation coupled with high rates of mental illness and

36

post-settlement food insecurity with low acculturation in the host country lead refugees to adopt

harmful eating behaviors that contribute to increasing their risk of developing chronic health

conditions such as weight, obesity, and diabetes. To date, relatively little research attention has

been paid to the extent of chronic disease risk, such as diabetes-related to food insecurity among

this population. Food insecurity is associated with clinical indicators of diabetes, including

higher mean HbA1c levels, and a dramatic increase in the prevalence of both has become a

public health crisis in the United States. Given the national priority of eliminating health

disparities, uncovering the burden of food insecurity and chronic diseases related to unhealthy

dietary patterns of post-resettlement refugees in the United States is necessary. The results of

Cambodian refugees’ studies may also apply to other refugees.

The rise of the prevalence of type 2 diabetes of refugees also poses a significant burden

on the health care system. More attention needs to be devoted to documenting the mental and

chronic health needs of Cambodians and other minority refugee groups. Physicians who treat

chronic diseases such as diabetes need to be aware of the patient’s history of food deprivation,

trauma, and cultural diet aspects while proposing dietary changes as an intervention. If possible,

dietary interventions for refugees who experienced starvation or trauma due to war needs to be

culturally appropriate, empathetic, and relevant to improving their quality of life. Policies to

improve access to consistent, safe, nutritious, and culturally appropriate healthy foods through

financial empowerment, education, and resources need to be considered as a priority in the

healthcare system to improve the health outcome of high diabetes risk communities. More

systematic measures need to be employed to identify food-insecure households in the healthcare

system and assess effective strategies for low income high-risk racial/ethnic communities to

achieve culturally appropriate, healthier diets.

37

Appendix A

38

Appendix B

39

Appendix C

40

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