Nutrition to Optimize, Understand, and Restore Insulin Sensitivity in HIV for Oklahoma (NOURISH OK)

An interdisciplinary team leading the Nutrition to Optimize, Understand and Restore Insulin Sensitivity in HIV for Oklahoma (NOURISH-OK) investigates how food insecurity contributes to insulin resistance among people living with HIV (PLWH). NOURISH-OK responds to the shift in HIV care toward chronic disease prevention and management by focusing on diabetes risk, especially insulin resistance, as a growing concern for an aging population of PLWH. The study applies a novel, multi-level, integrated conceptual framework to examine how upstream determinants of health, including early life events, discrimination, and community food access, may influence food insecurity and thereby shape downstream pathways such as dietary patterns, other behavioral risk factors, chronic inflammation, and ultimately insulin resistance.

The initial protocol, summarized here, outlines a cross-sectional sampling approach that will purposefully enroll 500 PLWH across four levels of food insecurity to empirically test the conceptual framework developed with community stakeholders. Data collection for the first aim includes anthropometric measurements, fasting blood draws, non-blood biomarkers and 24-hour dietary recalls to estimate the Dietary Inflammatory Index (DII®) score. Survey instruments will capture a range of exposures and covariates, including measures of food security, discrimination, early life experiences and community food access. The study team will use structural equation modeling to explore hypothesized pathways linking upstream determinants to insulin resistance via intermediary factors such as diet quality, lifestyle behaviors, and chronic inflammation.

A nested, one-month prospective observational sub-study enrolled 100 participants (25 in each food security group) to collect weekly 24-hour dietary recalls and stool samples. This sub-study is designed to identify temporal associations between food insecurity, short-term dietary intake variation, and gut microbiome composition, providing biological insight into potential mechanistic pathways between food environment and metabolic outcomes. Findings from the cross-sectional and short-term prospective data will inform subsequent aims of NOURISH-OK, which include qualitative exploration of identified pathways and the development and testing of a food-as-medicine intervention. That intervention will focus on low-DII® foods intended to reverse insulin resistance among PLWH; the intervention phase is registered with ClinicalTrials.gov.

NOURISH-OK is positioned as a community-engaged, multi-disciplinary effort combining epidemiology, clinical biomarkers, nutrition assessment, microbiome analysis, and advanced statistical modeling to address a critical gap in understanding how social determinants such as food insecurity contribute to metabolic disease in PLWH. By explicitly linking social and structural determinants to biological mechanisms and clinical outcomes, the study aims to generate evidence to support tailored, food-based interventions that could reduce insulin resistance and related co-morbidities in this vulnerable population.