17 September 2011

"More fruits and vegetables" strategy is not preventing Diabetes in New York

A friend of mine recently sent me this article. He lives in Arizona so probably isn’t familiar with the demographics of New York City, and those new to New York might also be surprised to see how the neighborhoods can sometimes drastically change from one street to the next. This article highlights this very phenomenon, and the author’s observation of people missing limbs because of diabetes in one neighborhood and not the next is an extremely sad example of the health disparities between rich and poor in this country.

Nourishing New York's Low-Income Communities

When Gina Keatley first moved to New York to attend culinary school, she noticed that many of her neighbors were missing limbs.

"I lived on 99th Street across from some projects," she said. "I would walk to the train and think, 'Why are there so many amputees?'"

Keatley found out that many of them had to have amputations because of complications from diabetes. Diabetes can reduce blood flow to extremities and cause nerve damage, and sometimes amputations are necessary if serious infection sets in and there is severe damage to the tissue and bone.

The neighborhood where Keatley lived, East Harlem, has the highest diabetes rate in Manhattan, according to city health officials. It also has the highest obesity rate: One-third of adult residents are obese or overweight.

"It's so shocking to me to see people who are poor and unhealthy and literally dying in the street," said Keatley, an award-winning chef and nutritionist.

Keatley said that when she would visit more affluent neighborhoods near East Harlem, she wouldn't see nearly as many amputees. And she was pretty sure she knew why.

"You go over this invisible line, and there are people with farmers' markets, people with organic food ... healthy sandwich shops," she said.

This “invisible line" that Keatley speaks about between East Harlem (one of the poorest communities in NYC) and the Upper East Side (one of the wealthiest communities in NYC) has always existed. It has just presented itself visibly in many different ways - the recent rise in amputees as a result of the spike in diabetes being one of the most dismal reminders.

I used to work in some of these neighborhoods that are considered "food deserts"- the term that has been assigned by advocacy groups to areas where there is a lack of supermarkets and access to fresh food. Most of the programs designed to improve nutrition in these areas focus on bringing more fruits and vegetables to these families, either through increased vegetable markets and produce stands, food stamp programs that can be used at farmers markets, and education programs (teaching families to eat more fruits and vegetables). Ten years in and it doesn't seem like these food programs are really working since morbidity rates keep going up. This leads me to believe that simply providing more fruits and vegetables may not be the answer.

Obesity, diabetes, and other associated chronic diseases are associated with poverty. In the past, poor Americans suffered from being underweight due to malnutrition and food insecurity. Today, poor Americans suffer from being overweight due to malnutrition and food insecurity. Cheap, processed nutritionally poor foods (or food stuff) are more ubiquitous and abundant in the US then they ever have been in the history of this country. So are poor people eating more junk food? Probably, but bad choices are not the only reason and are only part of the picture. Poverty is associated with many determinants of bad health - it's not just about eating fast food. Other significant factors are stress (social, financial, work), lack of health care, lack of education, depression, disrupted routines because of familial or employment insecurity, cultural norms (i.e. - fear of food insecurity can cause parents to over feed children), lack of outdoor space for physical activity, lack of resources for any activity, and reliance on poor quality food either in “food desert” neighborhoods or in the form of food aid, to name just a few.

So while these programs are well-meaning, and I do think that increasing good supermarkets, farmers markets, and fruit and vegetable stands in food deserts are positive steps in the right direction, I think new approaches to food access and nutrition must address these other problems with multi-pronged strategies at different policy levels for improvement - not just teaching people "how to..."

First, I think it's paternalistic, elitist, and irresponsible for government or non-profit organizations to think they should "teach" people how to eat, and that lesson being: eat like a vegan. This is not to say that we, especially those of us with chronic diseases, shouldn't be provided with nutritional information and guidelines on what we should and shouldn't be eating (obviously no sugar and carbs for diabetics). But most of you already know where I stand on carb and protein intake - so you know where I'm going with this. Of course, convincing people to cut back on processed fast food and getting them to cook fresh food at home would be ideal. But trying to convince people to eat expensive organic fruits and vegetables to fill bellies that have been used to calorie-dense starchy, sugary carbs is not exactly the most satisfying alternative or realistic approach.

Along with plenty of vegetables and some fruits (but not for diabetics), part of these guidelines should also include healthy animal proteins and fats - which are both energy and nutritionally dense foods. They fill you up, give you energy, and won't cause insulin resistance or diabetes. Our present nutritional guidelines that are promoted both by government and non-government agencies are created from junk science, ideological trends, and advertising. They distract us from our traditional diets that have kept our ancestors healthy for generations. Until we start promoting REAL food again and stop believing there is a magic bullet (like non-fat, soy, spelt, gluten-free, whole grain, organic cane juice, agave sweetened, nugget/food/stuff), we will continue to get fat and sick. And until we approach the root causes of poverty and tackle the different problems associated with bad health outcomes, we will continue to see a rise in these chronic diseases and mortalities.

I want to mention one aspect of the obesity/diabetes problem that no one ever seems to address. We have become a culture that is obsessed with eating all day long. I find this to be more significant than the idea that we may be more sedentary than we used to be. Food is everywhere, available all the time, and there is so much of it. Think about all the new restaurants, cafes, bakeries, cupcake shops, food trucks, and vending machines that keep popping up everywhere you look. And what about all the food that we now bring to our offices, schools, and common spaces where we spend our time?

Think back to 20, 30, or 40 years ago (if you are my age) and try to remember how many restaurants were in your neighborhood. How many times a week did you eat out? And how big were the portions? How many times during the day did you eat? Were there vending machines at your office? Was there a never-ending supply of cupcakes, muffins, and brownies at your workplace? Did you celebrate birthdays in school with cake every day? Were ice cream shops even open in the winter? Did you eat your meals at a table with your family, or in front of a TV or computer screen? or on the run? Did food trucks exist? Were so many fruits and vegetables available all year round? Was there such thing as "turducken?" Were there such things as soy burgers or soymilk? These answers may be different for everyone, but then ask yourself this: Were you or your friends obese? Were your parents obese? Were your grandparents obese? And if they weren’t, what and how did they eat? It seems pretty simple, huh? So while we may have been more active as kids back in the day, we never ate as much as people do today either.

Which brings me to my last point: Food in this country should be expensive. I’m sorry. This is the last thing people want to hear… but mass production of cheap, subsidized food is killing us, killing animals in the most inhumane ways, killing our land, killing the livelihood of farmers worldwide, killing competition, creating market fluctuations that make it impossible for poor countries to maintain, and force poor people here to eat cheap non-nutritional food while the majority of us just overeat. Clearly food economics is a completely different topic for research and discussion, but I think it’s something to think about – especially if you’re of the libertarian mindset and believe in the power of supply and demand.