Shireen Abdullah 0:00

Diabetes care isn’t just clinical, it’s community. We unpack what actually works in underserved neighborhoods, tackling food insecurity, adapting education without digital divide, and teaming with community health workers, health educators, plus we talk about GLP-1s and how they fit in. Stay for one policy change that could unlock significant impact. Stay tuned. 

Shireen Abdullah 0:25

Podcasting from Dallas, Texas. I am Shireen, and this is the Yumlish Podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Shireen Abdullah 1:01

Dr. Melanie Hingle is a nationally recognized nutrition scientist, registered dietitian, and professor at the University of Arizona whose work on diet-sensitive disease integrates community-engaged research, digital health, and food-is-medicine interventions across the Southwest. Welcome, Dr. Hingle. 

Dr. Melanie Hingle 1:19

Thank you so much, glad to be here!

Shireen Abdullah 1:21

And glad to have you on, so Dr. Hingle, let’s start out with a very basic question first, which is around just getting to know you a little bit. Can you tell us a little bit about your background and what really inspired your focus on community-based nutrition interventions for something like diabetes?

Dr. Melanie Hingle 1:39

Sure thing, yeah. I’m a dietitian, as you mentioned, and that’s where I started my career, and I from that very first day interacting with patients, I thought it was very important to understand where they’re coming from, understand their goals, and how they wanted to be well and to achieve health, and the community part just came naturally as a part of that we live in context as humans. We’re not, sort of, in a vacuum, and we interact with not only our environment, but other people throughout the day. And so that context was very important to me as well. 

Dr. Melanie Hingle 2:17

So the community space is how I think about that broadly, and is an integral part to how I conduct my work and how I design programs to help people achieve better health, so that that’s really since day one, been been a part of who I am as a practitioner, and then my research naturally followed that path, when I went to graduate school and beyond, and my focus became more and more on behavior, because environment absolutely plays a role. Genetics plays a role in health and disease risk. But the behavior part is the ongoing question. It was the big question: how do we help people, support people in behavior change, help motivate that, give them the tools they need to achieve that? And that’s just a huge challenge and an interesting challenge, and that’s really what brought me kind of where I am today.

Shireen Abdullah 3:12

Thank you for sharing that. I want to dive right into the questions here. What are some of the biggest barriers, if you had to pinpoint within underserved communities, that they face when it comes to accessing diabetes nutrition education?

Dr. Melanie Hingle 3:28

There’s, there are multiple barriers, I think. And one of the barriers is structural, environmental, and that is a lot of where people live, influences of course, behavior and their ability to enact healthy behaviors and food is super important to helping people manage diabetes, in particular, you know, as a diet sensitive condition, and if you don’t have access to healthy food, that’s it. That’s an enormous barrier to achieving a healthy diet and good health, and that’s structurally a problem for some neighborhoods and people, especially low-income communities. A lot of low-income communities and people just aren’t near a grocery store that has a lot of variety of foods.

Dr. Melanie Hingle 4:18

Prices might be higher as a result of that in the stores that they do have available to them. So that’s one thing, technology we’ve found through our work with digital health and helping people change their health behaviors with smartphones and other wearable sensors, that is also not – that’s a privilege to have that kind of connection. And although most people have phones, they’re not all capable of accessing the same information. People might not live in the same information worlds as we know now; this is just the truth for all, all of us, I think, here on the planet. But, um, in particular, if you’re limited in your ability to access information, that certainly is a foundational element as well as a structural element. 

Dr. Melanie Hingle 5:09

And finally, I think I mentioned this with the proximity to the healthy food, but also the resources that are needed to achieve a healthy diet these days are significant. And food is expensive. Healthy food is very expensive. And you need both the financial resources and also the time to do the finding of the food, preparing of the food, enjoying of the food, you know, and that is, I think, a cost that we don’t talk about as often as the financial cost is the time cost. So those are, I bundle those things together, because I think if you’re especially a very low resource, might not have a lot of time or the money to enact those behaviors that are that are healthy, especially, especially food.

Shireen Abdullah 5:57

I’m so fascinated that you took these other elements into account. What brought you to that realization, I guess?

Dr. Melanie Hingle 6:04

Well, really interacting with the participants in all of our programs over the years has shaped that. I also have a real strong appreciation for, as I mentioned, kind of context and how that shapes our behaviors and understanding that and and while I was trained as, you know, a quantitative scientist, and looking at interactions with, you know, what people, what we eat, and our health, and the outcomes, those kinds of outcomes, there’s a strong qualitative side to that, to understanding whole person health that I appreciate and that I always seek out. 

Dr. Melanie Hingle 6:40

And so I think that is come naturally through my kind of mixed methods approach to research, that I not only have the survey data and biomarkers and things that we collect from our participants in our studies, but that we do interviews and we do focus groups and we we listen and integrate those data and lived experiences of people with the quantitative data to give a whole picture. So really important because the survey data don’t tell the whole story, or the biometric data don’t tell the whole story.

Shireen Abdullah 7:12

That’s 100% true. And you probably see me like nodding my head away, because, isn’t that the truth? 

Dr. Melanie Hingle 7:17

Yeah. 

Shireen Abdullah 7:18

You know you were just talking about, like, the barriers in itself. How can, perhaps, for the dietitians listening to this episode, how can dietitians and diabetes educators really better adapt their strategies to overcome these barriers? Because they do exist, right?

Dr. Melanie Hingle 7:35

Yes, absolutely. You know a couple of strategies. One is that I would just also just give a nod to the dietitian profession, and then I think we’re pretty good at listening to clients and taking a motivational interviewing approach a lot of the time, and at least in the one-on-one interactions, and a little bit more difficult to do that in the group settings. But certainly that helps tailor the interaction in a way that you’re listening to the patient or the person you’re working with and understanding their perspective and on why they’re struggling or the challenges they might be facing or the goals they would like to achieve, and then utilizing that information to then customize your advice. I mean, that’s the number one strategy. I think we do a pretty good job of that could obviously always do a better job, but that would be the number one thing I would recommend is listen to the person – really hear them out, don’t have an agenda when you come into the interaction – it’s not going to be the same for everybody. 

Dr. Melanie Hingle 8:47

And then I think the other piece I would recommend, because that helps you understand barriers, but also know your community resources, because we don’t work alone, you know, and I think the healthcare team, but beyond that, there are so many organizations that are dedicated to this kind of health and, you know, and getting the word out. Here are some resources we can connect you to that relate to food and nutrition and diabetes, that if you could become familiar with some of those and refer people to others, I think that’s also a really helpful strategy in helping manage those barriers, or help people surmount those barriers.

Shireen Abdullah 9:20

You know, speaking of food insecurity and just limited access to fresh produce, you mentioned your work within Food As Medicine, but you know, food tends to become this major issue in many areas, and access to healthy, nutritious food can sometimes be a challenge. How do these factors affect something like diabetes management? 

Dr. Melanie Hingle 9:45

Tremendously. I mean, if food insecurity is and nutrition insecurity are characterized by, we’ve already kind of mentioned this, already hinted at it, the lack of access to affordable healthy food options, basically, and so if you don’t have access to that, and you’re not able to achieve to get those foods on a regular basis, that’s going to really challenge you in terms of achieving your health goals and managing diabetes, because nutrition is critical to diabetes management has such a huge outsized influence on blood glucose control and lots of other downstream effects that happen. So the converse of that is like, well, if you have access, that helps you in a tremendous way. And so the kinds of things that produce can do, in particular, you mentioned fresh produce, high in fiber, high in nutrients. 

Dr. Melanie Hingle 10:41

These are things that help people manage, not just the blood glucose a little bit better, but can displace some of the less healthy options, potentially, that we gravitate toward, that are all around us. And so that’s something else we could do. And I think that giving people, helping people access those Food As Medicine programs. That’s where you have a produce prescription, for instance, or medically tailored meals, or medically tailored groceries, is the foundation of everything else in terms of nutrition and diabetes management. So then it’s the dietitian can then come in and do their or the educator can come in and do their job, and say, “Hey, you know, I don’t have to worry about you having access. Let’s talk about how to actually implement this now.”

Shireen Abdullah 11:29

And you know, in talking about such type of program. So, you know, mentioned the produce, prescriptions, medically tailored meals, even pantry partnerships that exist. How do you keep engagement high in these programs? What needs to be done there? I guess.

Dr. Melanie Hingle 11:44

I think that’s where the partnerships with the community organizations come into play in the healthcare organizations. Because as you just sort of hinted at and mentioned, people have a lot of things going on their life and engagement. Maybe you know, even if it’s coming and getting fresh produce or food is somewhere on the list, maybe not number one, because they have other things they’re managing and dealing with. And so what is the value, or the added value, or the return on their time investment, especially if they’re making an extra trip and have limited transportation, or they’re working another job, and they have a little bit of time in between? You have to make these decisions on how you’re spending your time and financial resources, and other resources. So I can give you two examples. And one we delivered a Food As Medicine program partnership with our local food bank, and that delivery was made directly to the participants’ homes, so it made it a lot easier to kind of overcame the transportation barrier that a lot of people face.

Dr. Melanie Hingle 12:49

However it we realized people liked it, but their, they didn’t feel connected to something larger. And so in our next version of our program, we offered the same medically tailored groceries program, but in the context of the medical home, which is a federally qualified health center that we’re partnering with and so patients of the health center would come to their clinic location, and not only would they receive the food, but they’d be connected to the dietitian, they’d be connected to the community health worker. They would be able to receive referrals to behavioral health if they needed it, and lots of other things that went on only at that location. And so I think that feeling supported by their healthcare team and having that integrated was a really critical piece that made that successful and helped kind of again add value and access in a way that the delivery, the home delivery, did not do by itself.

Shireen Abdullah 13:47

How do you involve families in diabetes prevention or management-related interventions, especially when multiple generations influence the household eating pattern?

Dr. Melanie Hingle 13:58

We have done this in a variety of ways. That’s a great question, because you didn’t say this. But change is not done alone. So if somebody with diabetes is looking to make some behavior changes and they live in… if most people live in a family structure of some kind or with other people, if those others are not on board, that can make it very challenging to make the change. And so our family programs have tried a variety of different approaches. Of course, we always begin by understanding again, like what kinds of things families need and want to be kind of moving forward as a team. And then anybody who prepares the food is a is a particular partner, or is a particular area of focus for us and partner? Because, um, whether it’s spouses or partners living together, there’s usually one person who does a little bit more of the food preparation than somebody else, and that person is really important to the success as well. Because they often do the shopping, not just the cooking. 

Dr. Melanie Hingle 15:04

And so helping people manage what comes into the home, as far as ingredients, and then getting the whole family involved in when eating out, choosing foods that are healthier options. So our programs have often involved all the family members, including multiple generations, you know, grandparents and aunts and uncles, and sometimes siblings. If there’s an older sibling and a younger one, people who are invested in you can have the participant select who they’d like to be as their primary supporter. Or, I mean, we usually just invite everybody to come. And that does get very busy. It creates logistical challenges, but ultimately a more successful program. If everyone is feeling a part of that change.

Shireen Abdullah 15:50

You know, one question for you that I think too, especially more so in the news, and what we’re seeing today, which is around everything related to GLP-1s and how its use is on the is on the rise, and even in low-income populations, for instance. But how do you integrate something like medication management with nutrition counseling without losing focus on that food access element or the behavior change element? How does that happen? 

Dr. Melanie Hingle 16:21

This is a very big and emerging challenge. And yeah, I’m glad you asked this question, and we don’t really know yet – we’re taking a run at it a couple of different ways, and seeing what, what is the best way. But as you, as you mentioned, you have to pair any GLP-1 prescription with a behavior program in order for this to be a lasting change. You know they work really well for a lot of people. These medications, however, they do come at risk. They have side effects with them that can help, can be mitigated by behavior programs.

Dr. Melanie Hingle 16:58

And so, working with healthcare partners who see that and value that is really, is really important, our federally qualified health center partners, just to go back to my earlier example, do prescribe these for some of their patients, including low-resource patients, low-income patients, and there is a behavioral prescription along with that, so to speak. Where they have support of the dietitian, they’re made aware of exercise programs that can help with that, too. So it is always presented as this complementary kind of set of things, not just the medication by itself, doing its job because it will, but to a certain extent, it’s like anything, you have to have that other foundation in order to sustain the change that the medication initiates. It’s a tool. It’s not the ultimate solution.

Shireen Abdullah 17:49

And I’m glad you use the word. It’s not an ultimate solution, because that’s, I think, that’s where that focus kind of like, derails a little bit like that quick fix, or that quick win. 

Dr. Melanie Hingle 17:58

Exactly. 

Shireen Abdullah 17:59

And then what? And then what happens after that? 

Dr. Melanie Hingle 18:01

Yeah. 

Shireen Abdullah 18:01

That’s fascinating. You know, you talked about from a community lens, even the FQHC partners, for instance. How do you train and support community health workers, for instance, or peer navigators, so they can deliver consistent, evidence-based nutrition guidance when they may not – you know, have like, the nutrition, the RD background? For instance.

Dr. Melanie Hingle 18:25

Yeah, I don’t directly train. I work with several people who do train, CHWs. I have, again, here at the University of Arizona, we have a cooperative extension, which is our outreach arm of our university. We’re the land grant university here in Arizona, and we do have quite a few educators who are trained as community health workers, who come from those communities in which they work and the people they serve, and our FQHC partners also use community health workers. And Pima County Health Department, I’m in Pima County here in Arizona, also use community health workers. These are really important people who are part of the healthcare team and the health promotion team. Training varies, but typically it would consist of whatever the program is, getting certified in the program. So in the case of our medically tailored groceries program, we did work with a couple of community health workers who are from our healthcare partner. They receive training and get certified in different areas of health promotion. And so the folks we worked with were certified in nutrition. They became very familiar with our program, our intervention program that we were delivering, which consisted of mentally tailored grocery boxes. 

Dr. Melanie Hingle 19:38

And they, you know, of course, we’re familiar with all the contents of that. The dietitian was there as well. They partnered with them, and so their role was really greeting the participants who would come to our program, helping them orient around the lesson of the week, because we would have diabetes self-management education included in our medically tailored groceries box that they would orient them to those materials. They would be there to refer participants who had additional questions that were outside of their scope to the dietitian or to other healthcare providers who were there, but really, they’re absolutely the connector. And I think that’s a critical piece, because people are often intimidated to go to, I know, to, you know, the doctor, they don’t like to go, or the healthcare setting, or you name it, to the place. But if they have a familiar, friendly, knowledgeable person who’s there to help them navigate that, that makes all the difference. And so they are just critical to the functioning of you know, our program.

Shireen Abdullah 20:40

We’re coming toward the end of the episode here. I wanted to, I wanted to sort of look ahead with you. So if we look at policy and system-level changes coming up ahead, do you think what policies, I guess, could have the biggest impact on reducing some of the diabetes disparities? And then I’m going to tag on a second part to that, which is, if you could change one reimbursement or policy rule tomorrow to expand community-based nutrition services, what would it be?

Dr. Melanie Hingle 21:10

Sure. Well, I’ll answer all in one, and then I’ll add some color commentary to that. But I think that the one policy right now that we have inconsistently implemented in across the United States is reimbursement for Food As Medicine programs, and so again, those programs are the produce prescriptions and the medically tailored groceries, the medically tailored meals. This is where we’re providing, directly providing food to patients with a diet-sensitive condition. And in the case of diabetes, there are opportunities in some other states, not Arizona, yet. – where I am. To receive, if you’re a healthcare organization or other certified organization, get reimbursement from Medicare and Medicaid for patients who are receiving food as a primary kind of therapy, if you will, right before, in addition to the other things that they’re using to manage their diabetes. And I think that is a giant opportunity we have, just to segue a little bit on cost. I think that’s one of our major challenges, to not doing this in all the states right now. 

Dr. Melanie Hingle 22:19

And, you know, and not having a federal sort of policy is that we’re left to figure out how to pay for these things, and we need more data from systematic research that shows the return on investment of this type of a strategy. Basically, that’s what we’re looking at right now. In one of our studies, we’re looking at healthcare utilization changes. We’re looking at cost for not only the participant, but for the healthcare organization, and offering these things because we want to be able to say with certainty, these help people achieve better health, and also lower financial burden on the participant or patient, but also for the payers. And I think that that is a compelling discussion for a lot of people. 

Dr. Melanie Hingle 23:14

“Wow, my own financial burden will be lowered, but also, you know, the people who are helping me with my care will be paying less.” That’s a win-win for everybody. So we need more of that data in order to, I think, convincingly show that these programs have a positive net effect that are that should be the primary prescription, I guess, to begin with, right like we think of food as the foundation of health, I truly think so. I truly think it is, and it is not always looked at that way, by healthcare providers and thought about even by people with diabetes, because of just how we’re structured here and our systems are structured in the United States. So that’s what I hope for in terms of policy change, and that’s the kind of information, the data that we’re collecting to add to, like a national conversation about this, because I think that’s the only way we can make the changes, to just demonstrate it, the evidence overwhelmingly is like this direction.

Shireen Abdullah 24:17

Much needed, clearly, and we certainly should be following that which takes me to the last question here, which is, how can our listeners connect with you and learn more about your work and follow this type of the traction that you’re making here?

Dr. Melanie Hingle 24:30

Thanks so much. Yeah, well, I always love hearing from people, and so please email me. I’m at the University of Arizona. You can find me in Nutritional Sciences, and I would love to hear questions and connect with you. I’m not in private practice as a dietitian, but I work with lots of people who do that work, and have many, many community partners. So anywhere here in Arizona can help connect people to programs if they’re here, and as well as a few other states that are nearby. But I just – please reach out. I enjoy that.

Shireen Abdullah 25:03

Love it. You heard it here, folks, just go ahead and reach out and really appreciate it. Thank you so much for your time today. It was such a pleasure talking to you. And you know, Dr. Hingle, what you’re doing is really near and dear to my heart with what we do at Yumlish, and just trying to influence and, you know, move that needle forward. And like, there’s a lot that can be done via these behavior change mechanisms you just have to make it accessible, have to make it community-based, like in the work that you’re doing. So kudos to you. 

Dr. Melanie Hingle 25:31

Thank you.

Shireen Abdullah 25:33 

 We are toward the end of the episode again. Thank you so much. Dr. Hingle, and to our listeners, thank you for joining us on another episode of the Yumlish podcast. Next, head over to our social media. Answer this quick question, which is around, How might you help advocate for better nutrition, support for diabetes, resources in your community? What can you do? And you can, if you heard this episode! What can you do? What can you do to be able to do that in your community? Head over to Instagram, to Facebook, whichever one you prefer. Find this podcast post, find us @Yumlish. Find this podcast post and comment below to tell us again, how might you help advocate for better nutrition support and diabetes resources in your community? With that, we will leave it at that. Dr. Hingle, thank you so much again. 

Dr. Melanie Hingle 26:16

Thank you for having me.

Shireen Abdullah 26:20

Thank you for listening to the Yumlish podcast. Make sure to follow us on social media, @yumlish_ on Instagram and Twitter, and @Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions, and to chat and connect with us about your journey and perspective. You can also visit our website, Yumlish.com, for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week’s show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we’ll see you next time. Remember, your health always comes first. Stay well.

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Connect with Dr. Melanie Hingle!

University of Arizona Website Profile: https://profiles.arizona.edu/person/hinglem

Email: hinglem@arizona.edu