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Table 2 Themes and Illustrative quotes

From: “I was able to eat what I am supposed to eat”-- patient reflections on a medically-tailored meal intervention: a qualitative analysis

ThemesQuotes
Satisfaction and experience with MTM
 ConvenienceThe most, I like the special diet I was on for 12 weeks. It helped me a lot and it was done in the very easy for the customer manner because the food was delivered to my door. So this is what I like the most.
What did I like? It was very convenient because I don’t get out too much. And I have no way-- there’s a shuttle bus that comes here once a week that can take you shopping. But sometimes if the weather’s bad or if I don’t feel good, I don’t even get to go. And I live alone so I found it very convenient that they came to the door with those meals. Sometimes I don’t know what I would’ve done without them.
Pretty convenient, it did-- I have to say it did cut into what I can do on Tuesday, which was the day that sometimes I do have other things. So, again, I would have preferred Friday which was a much easier day for me to do deliveries. But I know, again, that they only had a certain day that they could do it. So I’d say that was the one thing that was a little bit difficult for me, for the whole participation.
 Interactions with StaffThe Community Servings people were fantastic. The only problem I had was the first or second delivery. There was no smaller time frame, it was from 8 AM to 4 PM or whatever, the first couple of times. But once they got figured out where I was on a schedule, then it was very easy.
Very accommodating. Yeah. They were very friendly. When I asked about the whole switch of the egg option from the menu, we weren’t able to change it because it was already in place, but she tried. So that was nice of her.
 Food Quantity and ProportionI liked the fact that they were prompt and liked the fact that there was a quantity of food, enough food to kind of-- almost food for a week.
Oh, yes. And as I said, each meal was satisfying, fulfilling. It was not too much, not too little. When I was finished the plate, I was not left wanting.
Food preferences & Cultural Appropriateness
 Quality of MealsYeah. It had spice in it. It had flavoring. It wasn’t flat. See, we will get meal from wheels from the city, but they don’t look out for our health. They give us things that are loaded with sodium, with potassium, carbohydrates. They don’t watch your diet. So this package that you gave to me helped me out immensely.
A number of things. First of all, I liked the variety of foods and the quality of the foods. It gave me some good ideas about things that I could prepare for myself.
That there was a choice of variety in the food. And that it came with the meal, with the dinners, and you also got soups and snacks with it. I’m glad that there was a lot. You go into a meal that-- you had the balance, I guess.
Like I said before, the rice thing; get rid of that. Well, for at me at least. Oh, so I just remembered this. A few times they give you the same meals in the same week. They might give you, we’ll say, like two turkey meals or something, whereas the other ones, they would give you a different one each for five days.
I think that if they had a normal diet, it would really be helpful for diabetes. And it would be helpful, that especially me to have a meal at night, you know to be able to have a meal at night and just heat it up. But I think it has to be something that is normal. You know, a normal type of meal. I don’t know what they put in-- I don’t know what they put in the meal.
 Nutritional ValueThey help me stay away from what my nurse from other hospital said I shouldn’t use for diabetes, like white food. For example, white potatoes, white rice, white pasta; they stay away from this. They gave me vegetables, a lot of salads. It was done for diabetes.
They were bland and what I needed to have at that time. I would not have done such a good job at home with what I needed to get healthy, whereas they were on target, did the right thing, where I probably wouldn’t have done that at home. So, for six weeks, it really got me in a great place and healthy, and it made all the good choices for me.
It may have been better because I’m diabetes so what they bring me help me with my diabetes. Because I buy it. Like I said, I bought them. I cooked them myself, and they helping me. Like everything I see them cook, and then I bought it now, and they helping my blood pressure go down a little bit.
Yes, I think that they could have dedicated it more to a diabetic. I mean, I think most diabetics, eat a piece of meat, and a vegetable, or a potato, or a salad. And this was just food that I never ate before.
 Cultural TailoringFor me it’s like spice. Put more spice on it. I feel like it just doesn’t have enough spice on it to taste good.
Yeah, I think that they could have been chicken, and fish, and meatballs, or a lamb chop, or something normal.
Diabetes Management and Awareness
Access to Healthy MealsIt’s actually helped me out a lot because they cut me down on food stamps, so I was actually unable at the time to be able to eat the foods I was supposed to. So having those meals was perfect timing and I was able to eat what I was supposed to eat.
And you can open up my refrigerator and there’s food there. Not that there wasn’t food before, but when I went out, I’d spend a lot of money on junk and foods that maybe I shouldn’t have been eating. But it did, it helped me out tremendously, financially. It really, really did.
Perhaps what I think of as a happy meal, but if we buy our own food, we tend to shop the discount centers in the stores, the day-old bread that’s cheaper. We basically live off the discount corners in the stores or the food pantry and the senior lunches that we get. I guess what I’m trying to say is, lack of funds often reduce the choices in our meals.
I think that helped me in many ways because some people have diabetes-- some of them they can’t afford that the nutrition they want them to eat. When Community Servings have them send them the food, they help them out, to help them, you know, in a way you can manage your diabetes.
 Money ManagementYes, it did. It just saved me not being broke for the rest of the month to pay my bills, actually.
Oh, you don’t know, honey, you don’t know. I was down. I cut out a lot. I cut out the channels on the television, the computer because we’re living on limited income, and they take a third of it for our rent, a third of it for if you have half the package with the Internet and everything. So it did help me. At the end of the month, I could put my hand in my pocket and have $10. And that’s a good feeling.
Yes, they did. My particular case, yeah, they helped me save money. It did actually really help me save money.
 Health PromotionI would say, just, it was a helpful reminder about eating right, and taking care of myself, and taking medication properly, and all of that as part of a comprehensive way of living, so eating and doing things that are helpful for the diabetes, which is a way of sort of helping promote that.
My diet. To control myself because before, I knew I’m diabetic, but sometimes I didn’t have a choice, in what I ate in the day. But soon I started this program, I take it serious.
Well, another thing I was gonna tell somebody was that-- was keeping a record, that’s was really a good saying. It’s hard to keeping a record of what eat, when you eat was really a good idea. Because you have a little bit more time. But I think manuals of keeping your record manual, they’re really important. They’re really great. You have to educate yourself to it. Take a look at what you’ve done to have accountability because you-- if you live in a society with a lot of fast food and a lot of convenient food had been and I think, your record has been very good. Your record would have to spin to mind to a certain way of thinking. And your records were really good. I liked your records. A little bit hard to fill out, but I liked them. It’s a little bit time-consuming, but I like the idea of having records.
 Improvements in HealthWell, this diet definitely brings down my sugars. When I started the program the first time-- the program that is-- which I think this interview may be part of, it brought down my sugars from an A1C of 10-something to 9, in the 3 months that I was on it.
My AC1 or A1C, whatever it’s called, dropped significantly. I was over the seven something, and now I’m under. I’m in the six something, six point something-- I don’t know the numbers off the top of my head, I’m sure you have it in the records. I used to give myself four shots of insulin a day, and now I just take a pill in the morning. So that is a huge difference in my life.
I noticed when I tested my blood, which I did on a regular basis, my numbers were lower than before. It took a few weeks to see the difference, of course. But I noticed that. And I didn’t feel as fatigued, in a way. I had a little more energy, also.
Well, I guess it helped me understand that healthy food makes me feel good, health-wise. Whereas, let’s say on a Wednesday night when I have Bible study, I would have to eat out. I would notice the difference.
 Weight ManagementIt does help to manage the weight, also because I’m getting pre-portioned package of food, A. B, I actually get more food than I would have eaten. And so I relied more on carbohydrates in the past, that are cheap, affordable, and easy to make and eat. Whereas, this is definitely an asset.
Well, everything is portioned so it did make it easier. And again, the whole variety of if I don’t want to do a dinner for work, I’d do the stew and then the apple for snack. So it helps manage my weight. Whereas, if I bought something from the cafeteria at work, then you know how everything is oversized. It helps keep everything in perspective and in good portions, which helps with the weight.
Oh, it certainly managed my weight and helped me lose a significant amount of weight, because, it was all-- everything was determined for me. And I know they were determined based on what my need was, and, because of that, those-- I didn’t have make those decisions, and there was a packet with all the meals, explaining what’s in it and what’s on-- so that was a significant help.
 Model for Food PreparationWell, usually the couple of meals each that I liked a lot, and I wrote down-- I kept a diary and I wrote down what my favorites were for each. They had some interesting ideas, like using barley or bulgur wheat which I hadn’t really thought of, and the portions were also helpful to see what was recommended for somebody with diabetes. So it wasn’t just the quality of the meals, or what was being served, but also the size of the meals was helpful to me, to see what was allowable and also the various kinds of things. It was helpful to see what was acceptable for somebody with diabetes.
Well, it’s as I said, following the example of both their ingredients and their preparations was a very useful educational tool, kind of like setting the example of what we should be eating. And learning proportions, which is a biggie, following the example of the size of the proportions helps also when eating on our own, not over-filling the plate.
But it made me actually see what ideas I can incorporate to help me measure stuff out, because sometimes I do tend to overeat, and that helps me get an idea of what to use as a mental measurement when I’m proportioning meals out from whatever we’re fixing for supper.
And I hardly eat that stuff anymore. That’s Italian stuff that I was brought up with, but I noticed lately it bothers my stomach. I stopped eating all that and I eat more salads. Like I’ll eat in the morning-- like yesterday I had eggs, but most of the time I like cereal. I like oatmeal. And I love that quinoa, and that’s something new I’m eating.
I learned what to prepare. I don’t cook a lot of rice. I see when they bring the food, I see what kind of thing they put is good for diabetes. I put it myself. Now I cook it for myself.
Well, the portion size. Because when you cook for one person, it’s harder to-- because I was used to feeding people [laughter]. But cutting down on the portion size. And I didn’t realize doing that doing that, you can still feel satisfied. You don’t have to have a whole bunch, like a cup of this, where you can have half of it. So that kind of taught me I was satisfied with the meals and everything, and I didn’t need all that much food to feel full.
I think it’s helped me think about options that are healthy and, particularly, buying fresh foods and cooking it myself, and also, the mix of foods, the protein, the starch, and the vegetables. I think just eating that over the course of a number of months, you just get used to doing that. And so, you sort of become more used to that. And also, fresh vegetables and fruits, I’m thinking more about eating those. So, yeah, I think it was a good way to sort of get me on track towards eating them.
They taught me how to eat because we’re not told enough about diabetes. I was just told I have it, and they send me to a nutritionist, but like I say, all they do is give you a printout list of foods to pick from. It wasn’t chosen for you. So, you can only hope to God you’re eating the right things.
I’ve learned to spice chicken up now, And I’ve learned different things that they did that is still healthy instead of just plain old chicken, thinking that was what I had to do, and it was frustrating, and it was boring, and it made me want to cheat, whereas now I’ve learned, because of the prepared meals, how to try different things. So I think that’s a positive influence.
Yeah, because I can see what I have before. And when I have the food to see how I can prepare my food better, that is a good experience.
 Difficulties to Diabetes ManagementMostly, that I can’t-- I’m physically unable to exercise, and that’s the second part of fighting, combating diabetes. So I would say it has been very little to do with the program, and more to do with my physical limitations.
I still have a little bit of trouble preparing a wide range of different foods, and the foods that the Community Servings didn’t cover. I still have to make my own foods. And although it has been a help, especially it’s also been a financial help. I’ve had to spend less money purchasing food, so that was certainly a consideration. So I would say that those are the things that I would mention.
Suggestions for Improvement
 Seasonings & SpicesYes, some people like spicy foods, some people don’t. Like when you making the fish, the island people like the fish spicy. Or maybe you can make it have some barbecue chicken. That would be good, too. They have red hot pepper. You make a little bit and you give those food a little more flavor.
I like garlic. Cocoa, garlic, and parsley, stuff like that. I make my own spice. I put green pepper and white pepper all together and-- but they didn’t have all that on their foods.
Well, right now I’m having a water retention problem. My legs and my feet are swollen. So I’m really trying to lay off the salt. I don’t know how much sodium was in those meals, but I would say less salt.
 Food optionsThe only thing I’d have to say is more of a selection. It was a good selection, but it seemed like every now and then it would be the same thing.
The breakfast options would be important for certain lifestyles that people have. I think it’s an important lifestyle thing. The breakfast every morning is so important. Okay?
I’ve already stated that I do think that they should be correlated more to the weather. They do occasionally have a chicken salad or a tuna salad, maybe they would do more of those in the summer months when you really can’t eat a heavy beef meal or-- fish is always, of course, appropriate in the summer. But some of the heavier chicken meals or beef meals seem inappropriate for a day that’s humid, where your appetite is just diminished. And I would like to see - but I know this is food that is in part contributed to Community Servings, so it’s a little hard to be demanding - but it would be nice if there were more fresh fruits. There’s an occasional apple and an orange, but it would be nice if there could be more fresh fruits.
I’m a fruit lover so I would’ve liked more fruit. And they only gave you two yogurts, and I love yogurt. Sometimes I eat that for lunch as a meal. Yeah, I would’ve liked more yogurt.
I told you just maybe explain those meals on the container or receipt when they make something foreign, like some ethnic food from another country or something like that because I didn’t know what I was eating.
No, just find out if the person has an allergy before they sign up for the-- I mean, when they going to get into the program. Then if they have a head start that way, it helps.
 Meal QuantityBut what I’m saying is that can be improved. The quality is good, but the amount of the food, it could be a little bit more. If they want to really want to have a good-- how can I say? They really make an improvement to the patient, you know?
I did think those cereals, by the way, were a bit small. I thought the cereals were tiny. The cereals just only last-- cereals were very small. They lasted maybe one time or something. So, yeah, so asked for more foods.
And the desserts were-- they gave you that sliced pound cake sometimes with some peaches or something like that. But it was only a scanty little, little thin slice. But I know they’re diabetic meals and they’re counting calories and all that. But I would’ve liked a bigger piece of pound cake.
Suggestions for Future Assistance
 Diabetes Education and Support GroupsI would take anything they gave to me, to be honest with you, really, because like I say, I learned a lot about diabetes, and I didn’t have that before. I’ve seen people in my building that had diabetes that have lost their legs from the way they eat, the way they don’t exercise. So, I mean, you’re learning more about the disease itself, which we’re not told at all. And it’s we’re just getting my Metformin, and that would be it.
I think that would be enormously because it’s very clandestine. If I don’t see it-- if I didn’t see it in other people, and see if it’s effectual to people, I probably would be less-- a little bit more careless. I try not to be careless. I’m not going to try to postpone it anymore. I’ve seen the effect of diabetes in other people. I see people losing their legs, so I’m aware of that. Community support groups are important I think.
Probably a support group with other people that are in the same boat.
Well, I have read that diabetes is caused by a slight infection in the pancreas. I think addressing that issue would have a long-term effect on diabetes patients in general.
 Financial Assistance with Medication and FoodYes, that will be good because some medication very expensive, some patient they can’t afford it, but if they can-- any way they can help them with the medication, that would be wonderful, too.
Well, I have all of that available to me through my PCP. Except when you say medication assistance, is that financial assistance? I most probably could use help with that. I do only have my Social Security, is what I’m living off of. And I think most people know that’s very hard to live off of, but I guess that would be what I would be interested in.
That would be something I’d be interested in, because those things are very expensive. Yeah. Yes. So the meals in hand with the medication management would be super helpful.
I think it would be great if there was a special kind of program that could disperse some money to help diabetics get the food that they need. Because the food stamps, people don’t really care-- not getting into that, but they go by your income. And even though your income is so much, they don’t realize the bills that you have pay. So if there was some kind of grants, or something, or some special store just for diabetic, that would be great.
The only thing I would like to add is, is there a way that they can give people the food, and they can make it themselves? That’s the only thing I would like them to do. Not cook it, and just bring it to them that they can make it themselves?
I would say the nutrition counseling. Fitness would be another one. And the other thing that could help me a lot would be trying to get food, you know? Because it’s one of my major problems is getting the right food.
 Fitness and Nutrition ProgramsYeah. The fitness program because I think it all comes together in a way. It’s like stop eating as much and reduce the food. Yeah, you can do that. But I think exercising also increases muscle. Because you start losing muscle and stuff like that and with the exercise, you’ll be to keep your-- going and plus even lose faster than just reducing calories and stuff like that, too.
Nutrition counseling would be good. I would love to go to-- what do you call someone who just deals with vitamins? I am a very strong and firm believer of vitamins and I take a lot of them, and the doctor says that’s what keeps me going.
I think nutritious counseling would be excellent. I always think the program--- although you mentioned something about physical therapy. I think that would be magnificent. I’m the type of person where growing up, I was an exercise freak. After the bad, bad accident that made me disabled, I tend to not to do exercise routines on my own unless I go to the gym or I go to the physical therapist. For me, that would be a big one.
The nutrition is good, and the people can talk to tell you how much you can do the exercise, the portion of food you can eat, what kind of food you can eat, what kind of thing you can do for helping you with the diabetes.