Healthy Eating Barriers
Many members of the diabetes online community are making an effort, often succeeding, to eat a “healthy diet.” I put that term in quotes because there’s no consensus in the community about what a healthy diet is.
The low carbers view carbs almost as poison but don’t worry about fat, even saturated fat. The low fatters are the opposite and see fat as almost poison but carbs, especially high-fiber carbs like whole grains, as good. There are many other iterations of a “healthy diet,” but that’s not what I want to write about.
I think most of us, despite our disagreement about the perfect ratio of carbs, protein, and fat, would agree that fast food is not healthy. I think we would agree that highly processed food is not healthy. I think we would agree that a diet totally devoid of any fresh foods is not healthy. I think we would agree that a diet high in both fat and carbohydrate and thus also high in calories is not healthy.
Some of us eat only organic food, and only grass-fed meats and eggs. Some of us have gardens and eat a lot of food right out of our gardens. Clearly this is healthy, not only because the food is superfresh but because tending a garden provides a lot of exercise.
But what if you can’t afford organic food, and especially not organic grass-fed meat? What if you can’t even afford much protein at all? What if you can’t afford fresh vegetables? Or what if even if you can afford protein foods and fresh vegetables, they aren’t for sale in your neighborhood?
This is the problem faced by many inner-city residents, where the only nearby convenience stores, or bodegas, usually stock sodas, beer, chips, and other snack food, and only a little real food like bananas. And what produce they do stock is often not fresh. Many of the residents don’t own cars and hence can’t drive long distances to good supermarkets where there’s not only more food but the food is cheaper. And studies have shown that “food insecurity” (meaning you worry about being able to get enough nutritious food for your family for reasons of availability or ability to pay) is related to poor metabolic control. Here is one such study.
In order to examine these problems and how people with type 2 diabetes view the situation, Jessica Breland (who kindly provided me with the full text of the article) and colleagues organized a series of focus groups with residents of East Harlem, NY. The groups included 37 African American and Hispanic people with diabetes ranging in age from 27 to 80; they had had diabetes for an average of eight years.
The researchers used a model called Common Sense Model of Self-Regulation (CSM), which assumes that perceptions of medical care (including nutrition) are based on personal experience. Thus “patients are unlikely to adhere to advice if medical recommendations are not validated by or are inconsistent with personal experience.”
Many of us have been in this situation. If the doctor tells you to eat “healthy whole grains” but you find that all grains make your blood glucose (BG) go high, you’re not apt to eat a lot of them.
In this study, the researchers hypothesized that barriers to constructive lifestyle changes would include “the inaccessibility of healthy foods and the inconsistencies between physicians’ prescriptions for and patients’ experiences with healthy eating to control diabetes.”
They found that indeed, the patients’ environment limited their access to healthy foods. In addition, the patients found that the short-term negative consequences of healthy eating outweighed the benefits. For example, in order to eat better, they either had to convert their families to the same diet (which most said their families were unwilling to do; “They don’t like broiled food”) or to eat separate meals, which meant more work, social isolation, and additional expense.
“Diabetic food is gonna be more expensive than regular food, so you’ve got to have the regular food and eat in moderation.” But we all know how difficult it is to “eat in moderation,” especially when everyone around us is eating huge portions. Diabetic complications take years to surface, so it’s sometimes difficult to see the long-term benefits of your dietary sacrifices; you have to take someone else’s word for it, and if you’ve had bad experiences with medical/dietary experts in the past, you’d not be apt to believe them about this.
This is one advantage of having the means to join an online community. You can exchange experiences with other patients from all walks of life.
Another finding was that the patients felt that stress, mostly from poverty and racial discrimination, caused both poor eating habits and diabetes. Many in the online community also find that stress makes control of BG levels more difficult and can even precipitate diabetes in someone with a strong diabetic predisposition.
Finally, the researchers found that the patients felt that “communication with clinicians about healthy eating was limited and abstract.” One patient said, “The only thing my doctor told me, not to drink Coke.” I think we’ve all experienced this, even if we have access to good doctors. Most physicians are not trained in nutrition.
Many patients “were unconvinced that dietary changes lower BG levels.” This is sad. With today’s technology, we have the means to prove that food affects BG levels. But even if you can get a free meter, strips are expensive, and patients may be told to test only once a day, or even once a week. There’s no way to tell which foods make your BG go up if you test so rarely.
Another attitude was that eating too little would cause other problems. “My mother, she’s a diabetic . . . she went into bad health because she didn’t eat enough.” Thus some patients said they tried to reduce stress instead of trying to control BG levels, and many believed that a strict diet would increase stress and thus cause more harm than good. “The day I stopped worrying, I said, ‘I’m going to eat everything. I don’t care about diet or sugar or anything.’ I checked the sugar, and it was good.’
Stress can affect BG levels, because stress increases stress hormones like adrenaline, which causes insulin resistance. When Dr Richard Bernstein, the type 1 author of The Diabetes Solution, has to give a talk, he says his BG levels go up about 100 points. But diet also affects BG levels. One has to try to control them both, and this is difficult in a stressful healthy-food-poor environment.
So how can people deal with problems like this?
One solution would be to provide access to affordable healthy foods in inner cities. And one such approach in New York City is called Green Cart, in which the city has provided 1000 permits for street vendors who sell fresh produce in areas considered to be “food deserts,” meaning they lack easy access to supermarkets. A hundred years ago, city dwellers often got produce from vegetable carts, so this is hardly a new idea.
Another solution is to encourage convenience stores to stock fresh produce. A program attempting this is called Healthy Bodegas. Farmers Markets are another approach, and although they are often found in upscale areas whose residents want arugula and goat cheese cheesecake, there are some farmers markets in inner cities.
However, not every area of the country has such programs, and access to healthy food is not the only problem, as illustrated by the study by Breland and colleagues. The attitude of patients is also crucial. If you think diabetic complications are inevitable, you won’t want to spend money or time on preparing and eating healthy meals.
So somehow we need to change the attitudes of the patients themselves.
For those who have access to the Internet, participating in, or just lurking on, diabetes discussion groups can be a big motivator to change. One patient said she learned more about diabetes care in a week reading the posts at one site than she’d learned in 6 months with her health care providers. If patients have had bad experiences with health care providers who didn’t have time to individualize their treatment, or who didn’t understand that the local bodega didn’t sell the food they were suggesting, they may stop listening to those people. Hearing patients in the same situation they are explain how they solved some problem may be extremely helpful.
How difficult getting Internet access in the inner city is, I don’t know. But most libraries have computers that people can use, and perhaps group sessions explaining how to search for credible health information at the library would be more useful than sessions with a diabetes educator who wants you to eat X% carbohydrate with every meal, as if anyone ever sits down with a scale and a calculator to figure out the percentage of nutrients in some meal they’re ordering.
Another approach might be to clearly explain and emphasize the hemoglobin A1c test, which measures average BG levels over a period of about three months. We might not feel any different after we eat a healthy meal or we eat a cheap and quick fast-food meal. This is one of the biggest problems in treating type 2 diabetes: the effects aren’t immediate. But over time, unhealthy eating, especially overeating, will destroy our sight, our kidneys, and the feeling in our extremities.
The A1c gives us a number so we can chart our progress, or lack thereof. If we can’t afford enough strips to see what our postmeal numbers are so we don’t know which foods make our BG levels go up, at least the A1c gives us a good summary of our control over the past three months. If someone has a big improvement in the A1c, that person might be willing to continue to eat good food even if it is expensive and time-consuming. Having a better A1c should also remove the stress that many of the participants felt contributed to diabetes problems, and lower stress might produce even lower A1cs, a virtuous circle.
Reading about the problems some of these patients face in controlling their BG levels, I realized how lucky I am that I have enough test strips as well as access to nutritious and tasty, food, and enough time to take a walk almost every day without worrying that I’ll be mugged.
Society needs to learn that helping patients in the inner city control their BG levels will reduce costs in the long run as fewer patients will require amputations and dialysis, both very expensive complications. Changing patients’ attitudes is not easy, but it’s worth trying to do.