Food As MedicinE for Diabetes (FAME-D)

Food is Medicine: A Randomized Clinical Trial of Medically Tailored Meals For Individuals With Type 2 Diabetes Mellitus and Food Insecurity

The investigators propose a single-site, open-label, Phase II, community-based randomized clinical explanatory trial to test the efficacy of a medically tailored meal (MTM) interventions for adults with food insecurity and T2DM (Type 2 Diabetes Mellitus). While the efficacy of MTM needs to be established, given the nature of the population served by MTM, it is important to design the study to enhance the external validity/generalizability of the findings as much as possible. The investigators will recruit 200 participants from the referral list of Community Servings, a Boston-based MTM provider, and randomly assign them to MTM (N=100) or usual care + monthly food subsidy (N=100). MTM intervention will consist of 6 months of weekly delivery of 10 ready-to-eat meals (approximately half an individual's weekly food intake), along with telephone-based lifestyle intervention that prepares participants for the post-treatment period. The usual care + food subsidy recipients will receive usual care along with 6 months of a $40/month food subsidy.

Study Overview

• Status: Completed
• Conditions: Diabetes Mellitus, Type 2
• Intervention / Treatment: Other: MTM; Other: Food Subsidy

Detailed Description

Food insecurity, "lack of access to enough food for an active, healthy life", affects over 20% of the 30 million Americans with diabetes. Food insecurity is more common in racial/ethnic minorities and those with lower socioeconomic status. Moreover, food insecurity is associated with worse diabetes control and increased complications, even after adjusting for other risk factors. Food insecurity is a major contributor to disparities in diabetes outcomes.

Medically tailored meal (MTM) delivery programs are a promising intervention for individuals with diabetes and food insecurity. MTM programs deliver fully prepared food, tailored by a registered dietitian nutritionist to the specific medical needs of the individual, and provide education to help optimize disease self-management. Food insecurity is typically addressed with food subsidies-offering additional financial resources that can be spent on food. While both food subsidies and MTM can increase healthy food access, MTM can help overcome other barriers to diabetes management including lack of time, ability, knowledge, and skills needed to prepare appropriate meals. The use of these programs is often called 'food as medicine', as the purpose is to provide exactly the foods needed to help prevent diabetes complications. MTM are receiving increasing public attention, but there are, as of yet, no full-scale trials to test its effects on diabetes outcomes when compared with other food insecurity interventions.

Our research team has developed a medically tailored meal intervention that combines provision of healthy food, tailored to the specific nutrition needs of the individual, with an evidence-based lifestyle intervention that uses the period of meal delivery as springboard to improve diabetes self-management, both while receiving meals and after meal delivery is completed.

This study is an explanatory-focused randomized trial to assess a community-based medically tailored meals intervention (n=200). It will be conducted among diverse participants referred for medically tailored meals. Adults with type 2 diabetes, Hemoglobin A1c between 7.0% and 12.0%, and BMI ≥ 25 kg/m2 (≥ 23 kg/m2 for those with Asian ancestry) will be enrolled and randomly assigned to intervention or usual care + food subsidy. The intervention group will receive meal delivery and its attendant lifestyle intervention for 6 months, while the usual care + food subsidy group will receive a $40/month food subsidy, along with usual diabetes care.

• Study Type: Interventional
• Enrollment (Actual): 215
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • North Carolina
    • Chapel Hill, North Carolina, United States, 27599
      • University of North Carolina at Chapel Hill

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Diagnosis of Type 2 Diabetes Mellitus
• Hemoglobin A1c ≥ 7.0% and ≤ 12.0% in last 12 months
• Experiencing food insecurity as indicated by 2-item Hunger Vital Sign
• English speaking
• BMI ≥25 kg/m^2 (≥ 23 kg/m^2 if self-report Asian ancestry)
• No plans to move from the area for at least 1 year
• Free living to the extent that participant has control over dietary intake
• Willing and able to provide written informed consent and participate in all study activities

Exclusion Criteria:

• Participant in diabetes, nutrition, or weight research intervention in last 12 months
• Another family member or household member is a study participant. Only one member of each household may take part in this study.
• Considering bariatric surgery in the next year or prior bariatric surgery in the past 2 years
• Lack of safe, stable residence and ability to store meals
• Lack of telephone
• Pregnancy/breastfeeding or intended pregnancy in the next year
• History of malignancy, other than non-melanoma skin cancer, unless surgically or medically cured > 5 years ago or in remission. Patients with localized prostate and breast cancer diagnosed during the course of routine screening will not be excluded.
• Advanced kidney disease (estimated creatinine clearance < 30 mL/min)
• Known drug or alcohol misuse in the past 2 years
• Known psychosis or major psychiatric illness that prevents participation with study activities
• Intermittent use of medications (e.g., oral or intravenous glucocorticoids) that are likely to affect blood sugar

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Medically Tailored Meal (MTM); The Medically Tailored Meal (MTM) intervention consists of weekly home meal delivery; an explanation of the medical tailoring of the meals; and a 6-session telephone lifestyle intervention change program designed to complement the period of meal delivery and prepare for the period after meal delivery with behavioral and skill-building approaches to sustain the benefit of the intervention.	Other: MTM; weekly home meal delivery; an explanation of the medical tailoring of the meals; and a 6-session telephone lifestyle intervention change program designed to complement the period of meal delivery and prepare for the period after meal delivery with behavioral and skill-building approaches to sustain the benefit of the intervention.
Active Comparator: Food Subsidy; As a comparison group, those not randomized to receive the MTM intervention will receive usual care provided by their clinicians not associated with the study, plus a food subsidy ($40/month) for 6 months, along with healthy eating information to guide use of that subsidy.	Other: Food Subsidy; $40/month food subsidy

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hemoglobin A1c at Month 6	Hemoglobin A1c Level	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hemoglobin A1c at Month 12	Hemoglobin A1c Level	12 months
Food Insecurity Score at Month 6	Food Insecurity Score. Score ranges from 0-10, with higher scores indicating greater food insecurity.	6 months
Food Insecurity Score at Month 12	Food Insecurity Score. Score ranges from 0-10, with higher scores indicating greater food insecurity.	12 months
Depressive Symptom Score at Month 6	Depressive Symptoms as assessed by PROMIS SF (Short Form) v1.0 - Depression 4a. Raw scores are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on depression indicates more severe depressive symptoms.	6 months
Depressive Symptom Score at Month 12	Depressive Symptoms as assessed by PROMIS SF v1.0 - Depression 4a. Raw scores are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on depression indicates more severe depressive symptoms.	12 months
Health-Related Quality of Life Score as Assessed by PROMIS (Patient-Reported Outcomes Measurement Information System)-29 at Month 6	The PROMIS-29 includes seven health related quality of life domains (Physical Functioning, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, and Pain), and the pain domain has two subdomains (interference and intensity). Raw scores, except pain intensity, are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on physical function indicates better functioning, whereas a higher score on depression indicates more severe depressive symptoms. These scores are then used to calculate a PROMIS-Preference (PROPr score) (PROPr scores range from -0.022 (worst) to 1.0 (best)).	6 months
Health-Related Quality of Life Score as Assessed by PROMIS-29 at Month 12	The PROMIS-29 includes seven health related quality of life domains (Physical Functioning, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, and Pain), and the pain domain has two subdomains (interference and intensity). Raw scores, except pain intensity, are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on physical function indicates better functioning, whereas a higher score on depression indicates more severe depressive symptoms. These scores are then used to calculate a PROMIS-Preference (PROPr score) (PROPr scores range from -0.022 (worst) to 1.0 (best)).	12 months
Diabetes Distress Score as Assessed by PAID (Problem Areas in Diabetes)-11 at Month 6	Score ranges from 11-55 with higher scores indicating greater diabetes distress	6 months
Diabetes Distress Score as Assessed by PAID-11 at Month 12	Score ranges from 11-55 with higher scores indicating greater diabetes distress	12 months
Number of Participants With Self-reported Hypoglycemia at Month 6	Reported hypoglycemia between 0 and 6 months after randomization	6 months
Number of Participants With Self-reported Hypoglycemia at Month 12	Reported hypoglycemia between 6 and 12 months after randomization	12 months
Number of Participants With Self-reported Severe Hypoglycemia at Month 6	Reported severe hypoglycemia between 0 and 6 months after randomization	6 months
Number of Participants With Self-reported Severe Hypoglycemia at Month 12	Reported severe hypoglycemia between 6 and 12 months after randomization	12 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Bodyweight at Month 6	Bodyweight measured in Kg	6 months
Bodyweight at Month 12	Bodyweight measured in Kg	12 months
Systolic Blood Pressure at Month 6	Systolic blood pressure in mm Hg	6 months
Systolic Blood Pressure at Month 12	Systolic blood pressure in mm Hg	12 months
Diastolic Blood Pressure at Month 6	Diastolic blood pressure measured in mm Hg	6 months
Diastolic Blood Pressure at Month 12	Diastolic blood pressure in mm Hg	12 months
ARMS-D (Adherence to Refills and Medications Scale-Diabetes) Medication Adherence Score at Month 6	Medication Adherence as assessed by 7-item ARMS-D scale. Scores range from 7 to 28, with higher scores indicating more problems with adherence.	6 months
ARMS-D Medication Adherence Score at Month 12	Medication Adherence as assessed by 7-item ARMS-D scale. Scores range from 7 to 28, with higher scores indicating more problems with adherence.	12 months
Diabetes Self-Care Activities Medication Adherence Score at Month 6	Medication Adherence as assessed by 1-item summary of diabetes self-care activities measure. Scores range from 0-7 with higher scores indicating better adherence.	6 months
Diabetes Self-Care Activities Medication Adherence Score at Month 12	Medication Adherence as assessed by 1-item summary of diabetes self-care activities measure. Scores range from 0-7 with higher scores indicating better adherence.	12 months
Food/Medication Trade-offs at Month 6	Single item-indicators of trading off medication for food or food for medication. An affirmative response indicates the presence of a trade-off.	6 months
Food/Medication Trade-offs at Month 12	Single item-indicators of trading off medication for food or food for medication. An affirmative response indicates the presence of a trade-off.	12 months
Housing Insecurity at Month 6	Self-report of being worried about losing housing	6 months
Housing Insecurity Score at Month 12	Self-report of being worried about losing housing	12 months
Transportation Barriers at Month 6	Self-report of transportation barriers to attending medical appointments	6 months
Transportation Barriers at Month 12	Self-report of transportation barriers to attending medical appointments	12 months
Financial Strain	Self-report of financial strain	6 months
Financial Strain	Self-report of financial strain	12 months
Care Delay at Month 6	Self-report of delaying healthcare due to cost	6 months
Care Delay at Month 12	Self-report of delaying healthcare due to cost	12 months
Diet Self-Efficacy Score at Month 6	Diet Self-Efficacy as assessed by cardiac diet self-efficacy scale. Scores range from 16 to 80 with higher scores indicating greater self-efficacy.	6 months
Diet Self-Efficacy Score at Month 12	Diet Self-Efficacy as assessed by cardiac diet self-efficacy scale. Scores range from 16 to 80 with higher scores indicating greater self-efficacy.	12 months
Perceived Diabetes Self-Management Self-Efficacy Score at Month 6	Diabetes Self-Efficacy as assessed by Perceived Diabetes Self-Management Scale. Scores range from 8 to 40 with higher scores indicating greater self-efficacy	6 months
Perceived Diabetes Self-Management Self-Efficacy Score at Month 12	Diabetes Self-Efficacy as assessed by Perceived Diabetes Self-Management Scale. Scores range from 8 to 40 with higher scores indicating greater self-efficacy	12 months
Diet Quality Score at Month 6	Diet Quality as assessed by Brief Dietary Assessment Scale. The total score (range 0-50) is reported (higher score indicates better diet quality). The total score is comprised of 3 sections (or subscales) used to assess dietary patterns. The subscales are: Vegetables, Fruit, Whole Grains, and Beans subscale (range 0 - 20), Drinks, Desserts, Snacks, Eating Out, and Salt subscale (range 0- 20), and Fish, Meat, Poultry, Dairy, and Eggs subscale (range 0-10). Total score equals the sum of the 3 subscales.	6 months
Diet Quality Score at Month 12	Diet Quality as assessed by Brief Dietary Assessment Scale. The total score (range 0-50) is reported (higher score indicates better diet quality). The total score is comprised of 3 sections (or subscales) used to assess dietary patterns. The subscales are: Vegetables, Fruit, Whole Grains, and Beans subscale (range 0 - 20), Drinks, Desserts, Snacks, Eating Out, and Salt subscale (range 0- 20), and Fish, Meat, Poultry, Dairy, and Eggs subscale (range 0-10). Total score equals the sum of the 3 subscales.	12 months
Probability of Cost-Related Medication Underuse at Month 6	Any affirmative response to one or more of four cost-related medication underuse items derived from the Medical Expenditure Panel Survey. These items ask about not filling a prescription due to cost; skipping medication doses to save money; taking less medication than prescribed to save money; or 4) delaying filling a prescription to save money. Participants with ≥1 affirmative response were classified as having Cost-Related Medication Underuse (CRMU), and the reported values represent the estimated probability of CRMU.	6 months
Probability of Cost-Related Medication Underuse at Month 12	Any affirmative response to one or more of four cost-related medication underuse items derived from the Medical Expenditure Panel Survey. These items ask about not filling a prescription due to cost; skipping medication doses to save money; taking less medication than prescribed to save money; or 4) delaying filling a prescription to save money. Participants with ≥1 affirmative response were classified as having Cost-Related Medication Underuse (CRMU), and the reported values represent the estimated probability of CRMU.	12 months
Stress Score at 6 Months	Stress as assessed by perceived stress scale. Scores range from 0 to 40 with higher scores indicating higher perceived stress.	6 months
Stress Score at 12 Months	Stress as assessed by perceived stress scale. Scores range from 0 to 40 with higher scores indicating higher perceived stress.	12 months

Collaborators and Investigators

• Sponsor: University of North Carolina, Chapel Hill
• Collaborators: Massachusetts General Hospital; National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); Community Servings
• Investigators: Principal Investigator: Seth Berkowitz, MD, UNC

Publications and helpful links

General Publications

• Berkowitz SA, Kruse GR, Ball Ricks KA, Burch J, Ouimet E, Kitzis B, Forrest C, Terranova J, Stewart PW, Buse JB, Keyserling TC, Wexler DJ, Delahanty LM. Medically tailored meals for food insecurity and type 2 diabetes: Protocol for the Food as Medicine for Diabetes (FAME-D) trial. Contemp Clin Trials. 2023 Jan;124:107039. doi: 10.1016/j.cct.2022.107039. Epub 2022 Dec 5.

Study record dates

Study Major Dates

• Study Start (Actual): July 2, 2021
• Primary Completion (Actual): September 11, 2025
• Study Completion (Actual): February 12, 2026

Study Registration Dates

• First Submitted: March 30, 2021
• First Submitted That Met QC Criteria: March 30, 2021
• First Posted (Actual): April 2, 2021

Study Record Updates

• Last Update Posted (Actual): September 2, 2026
• Last Update Submitted That Met QC Criteria: August 11, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Lifestyle Intervention; Socioeconomic Factors; Food Insecurity
• Additional Relevant MeSH Terms: Endocrine System Diseases; Metabolic Diseases; Glucose Metabolism Disorders; Diabetes Mellitus; Nutritional and Metabolic Diseases; Diabetes Mellitus, Type 2
• Other Study ID Numbers: 20-2847; R01DK125831 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Individual participant data that can be deidentified without risk of confidentiality breach will shared upon written request made to study investigators. In addition, all NIH policies regarding data sharing will be followed. Deidentified individual data that supports the results will be shared provided the investigator who proposes to use the data has approval from an Institutional Review Board (IRB), Independent Ethics Committee (IEC), or Research Ethics Board (REB), as applicable, and executes a data use/sharing agreement with UNC.
• IPD Sharing Time Frame: Unless preempted by NIH policy, data will become available 12 months after publication of main findings, and be available for 60 months.
• IPD Sharing Access Criteria: Unless otherwise required by NIH policy, ability to deidentify data, plan for secure storage of data and agreement to protect participant privacy, relevant research question, to be assessed by study investigators.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; ICF; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No