NOURISH - A Healthcare-community Partnership to Improve Nutrition for Optimal Glycemic Control and Pregnancy Outcomes With Pregestational Diabetes

Nutrition insecurity (inclusive of food insecurity + poor diet quality) is a fundamental non-medical, health-related social need that impacts \>20% of pregnant women and up to 50% of individuals with pregestational diabetes in the United States. Nutrition insecurity has devastating health consequences for the \>100,000 pregnant women with pregestational diabetes (type 1 or 2) and their exposed infants every year for whom a healthy diet is critical. Pregnant women with pregestational diabetes and nutrition insecurity are more likely to experience poor glycemic control, and as a result, adverse pregnancy outcomes. The risk of these adverse health outcomes increases when glycemic control is not achieved and social needs go unaddressed. Enhancing healthy food access and providing nutrition education-i.e., building "nutrition security"-is critical to improving outcomes for pregnant women with diabetes and poor glycemic control. Our transdisciplinary team designed NOURISH: a theory- and evidence-based and collaborative healthcare-community partnership to enhance healthy food access, provide nutrition education and support, and address unmet social needs to improve glycemic control and pregnancy outcomes for high-risk pregnant women with pregestational diabetes, poor glycemic control, and food insecurity. The investigators propose the tripartite sustainable NOURISH intervention: 1) weekly nutritious produce home delivery by the Mid-Ohio Farmacy (MOF+), 2) monthly clinic-integrated diabetes, nutrition, and culinary group education by the OSU Cooperative Extension's Dining with Diabetes Program (DWD), and 3) continuous community health worker-led social needs assessment and support by the Health Impact Ohio Central Ohio Pathways Hub (Hub). Our central hypothesis is the combined NOURISH intervention (MOF + DWD + Hub) versus standard care will achieve glycemic control (hemoglobin A1c \<6.5% by delivery), prevent adverse pregnancy outcomes (gestational weight gain and neonatal morbidity), and improve diet quality and nutrition security. The investigators will randomize 174 eligible pregnant women (87 NOURISH, 87 standard care) with pregestational diabetes, poor glycemic control, and food insecurity. The investigators will accomplish three specific aims: 1: use a pragmatic randomized controlled trial to test the effect of NOURISH-enhanced nutrition provision (MOF+), nutrition and diabetes education (DWD), and social needs referrals (Hub)-on improving glycemic control by delivery and secondarily, pregnancy outcomes (maternal gestational weight gain, neonatal morbidity), nutrition quality, and nutrition security.; 2: use cost- effectiveness analysis to assess the NOURISH intervention's value relative to standard care; and 3: use process evaluation to characterize intervention and contextual factors influencing uptake, effectiveness, and sustainability of the NOURISH intervention. NOURISH is a scalable and mutually beneficial healthcare-community partnership to improve nutrition security, glycemic control, and outcomes for pregnant women living with diabetes.