Food environment as a determinant of post-transplant diabetes and regional variation in the United States.

Liver transplant (LT) recipients are at risk of post-transplant diabetes mellitus (PTDM), and the incidence varies by region. We explored the relationship between county-level food environment and PTDM and whether food insecurity mediates regional variation. First-time LT recipients from July 2004 to December 2022 without pre-existing diabetes were identified in the UNOS SRTR database. Data on 3 measures of healthy food access at the county level were obtained: population experiencing food insecurity, low-income population with low access to grocery stores (food deserts), and ratio of unhealthy to healthy food options (food swamps), all expressed by quartile. The primary endpoint was PTDM. Subdistribution hazard models were used to estimate associations, adjusting for demographic and clinical characteristics and county-level social vulnerability. Mediation analyses quantified the extent to which the food environment explained regional variation in PTDM. A total of 68,273 LT recipients met the inclusion criteria; 15.5% developed PTDM. All 3 food environment measures were independently associated with higher PTDM risk, even after adjustment for recipient, donor, and county-level factors. These measures were also significant mediators of regional variation in PTDM. Food insecurity mediated 48% of regional variation in PTDM, while food deserts and food swamps mediated 20% and 23%, respectively. LT recipients in counties with decreased access to healthy foods were significantly more likely to develop PTDM. Food environment accounted for a meaningful proportion of regional differences in PTDM. Identifying and addressing food insecurity among LT recipients may represent a modifiable pathway to improve long-term outcomes.

Duke Scholars

Author Jacqueline Boykin Henson Medicine, Gastroenterology

Author Andrew Joseph Muir Medicine, Gastroenterology