A small, qualitative study on “Challenges to Health Eating for People with Diabetes in a Low-Income, Minority Neighborhood” appears in the October 2013 issue of Diabetes Care. It caught my eye because I have been thinking a lot about the impact of community on health and healthcare. It is clear to me, and is a finding of this study, that it is easier to live healthy in some communities compared to others.
I am lucky. I live in one of the healthiest communities in the country, Marin County, California. The weather permits almost daily outdoor exercise. It is safe to walk by yourself most places (there are no drive-by shootings and few random acts of violence). Fresh locally grown foods are in abundance – there are farmer’s markets 6 days a week and Molly Stone’s or Whole Foods Markets are close by and, people in Marin can and do pay the high prices charged for all of this abundance. We do have fast food restaurants, but many of them post the calories of the burger or fries right on the menu to help customers with their decision-making process. I could go on and on about the health promotional aspects of my community, but I will, instead, simply acknowledge that I live in LaLaLand. Not so for everyone. How would I fare if I had to overcome the challenges to healthy eating faced by the folks in this study? Not well, I think. Here’s the study:
The researchers used focus groups and something called the Common Sense Model of Self-Regulation to try to learn how Black and Latino diabetics living in East Harlem viewed healthy eating. Some of the results are surprising.
There were four major themes expressed by the thirty-seven adults who participated in the focus groups. The first is not a surprise. Participants pointed out that there were no supermarkets in their neighborhoods (as is true in many low income communities) and many didn’t have cars to drive to other parts of the city where these larger, better-stocked stores were found. The local stores were more convenient even though it was acknowledged that quality was not as good. Also, when it came to eating out, there was a preference for take-out or fast food restaurants because that is what they can afford. Formal sit-down restaurants were only for rare splurges.
The second theme was that their understanding of diabetes was limited, often including cultural beliefs that were viewed as fact (e.g., drinking coffee suppresses the appetite, cinnamon lowers blood sugar, no one in the South has diabetes). Another part of this theme was communication with clinicians about healthy eating was limited and abstract. One woman described her doctor talking about portion control, but she said, “She didn’t have nothing there to show me what the portions were.” There were also complaints about dietary recommendations that didn’t take individual preferences into account….”Your don’t give us each the same prescriptions, you should not give us each the same [meal] plan.”
The third theme was that short-term, negative consequences of healthy eating were viewed as outweighing the benefits. In particular, people complained about healthy eating interfering with social pleasantries, like family meals, that were important to them. “I can go by diabetic rules, but what about them? They don’t like broiled food.”
The part that was surprising to me was the strongly held view that stress due to poverty and discrimination was seen as a cause of both poor eating habits and diabetes. Worrying about diabetes was viewed as a stressor (“diabetics are always in stress”). Trying to eat healthy was also considered stressful and, therefore, was perceived as possibly doing more harm than good. There was also a belief that the food environment of their community was shaped by racism and poverty. Some black participants even traced the roots of traditional, unhealthy foods to slavery, “….Massa….ate healthy foods, and what was left from those meals were thrown to us….You know, the cracklin’ bread, chicken feet….” Others described the “whole race thing” being experienced when shopping in supermarkets not part of their neighborhood.
Healthy eating for most folks requires behavior change, something that is hard for everybody regardless of income or race or education. But now pile on the the realities of low income, minority status and limited education and the challenges become even more difficult. It is time to face the fact that improving the health and well-being of people in inner city low-income neighborhoods is going to take more than health education, it is going to require the creation of healthy communities. And that is going to be really, really hard. If any of you have been involved in doing this, I would love to hear from you.