Claudia Chaufan

The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood

In the United States, low-income immigrant groups experience greater health disparities and worse health-related outcomes than Whites, including but not limited to higher rates of type 2 diabetes (T2DM). The prevention and adequate management of T2DM are, to a great extent, contingent on access to healthy food environments. This exploratory study examines “upstream” antecedent factors contributing to “downstream” health disparities, with a focus on disparities in the structural sources of T2DM risk, especially food environments. Our target group is Latino immigrants receiving services from a non-profit organization (NGO) in Northern California. Methods are mixed and data include focus groups and surveys of our target group, interviews to NGO staff members, and estimation of the thrifty food market basket in local grocery stores. We find that while participants identify T2DM as the greatest health problem in the community, access to healthy foods is severely restricted, geographically, culturally, and economically, with 100% of participants relying on formal or informal food assistance and local food stores offering limited variety of healthy foods and at unaffordable prices. While this article is empirical, its goal is primarily conceptual—to integrate empirical findings with the growing literature underscoring the sociopolitical context of the social determinants of health in general and of T2DM disparities in particular. We propose that interventions to reduce T2DM and comparable health disparities must incorporate a social justice perspective that guarantees a right to adequate food and other health-relevant environments, and concomitantly, a right to health.

‘It's a full time job being poor’: understanding barriers to diabetes prevention in immigrant communities in the USA

This study explores the social determinants of diabetes in a low-income, Latino, and immigrant neighborhood in a Californian city, emphasizing food environments. We conducted focus groups and semi-structured interviews of a convenience sample of staff and clients at a local non-governmental organization. Eight themes emerged as key barriers to healthy eating: (1) cost of food vis-à-vis income; (2) transportation; (3) language; (4) stigma; (5) immigration status; (6) insufficient formal/informal food assistance; (7) work conditions; and (8) competing basic needs/constraints of poverty. We conclude that the public health and health education rhetoric of ‘individual choice’ is a barrier in itself to understanding the diabetes epidemic, and that without the recognition and understanding of, and intervention upon, socioeconomic, policy, and political barriers to healthy lifestyles, the prevention of diabetes will remain out of reach.

The Elephant in the Room: The Invisibility of Poverty in Research on Type 2 Diabetes

Over two hundred years of anecdotal, epidemiological, and experimental evidence indicate that poverty breeds disease. This holds true for type 2 diabetes, which both in the United States and other developed nations disproportionately occurs, cripples, and kills among the poor. In this article we examine rhetorical strategies used in 30 journal articles indexed under type 2 diabetes and poverty. As we show, poverty is rarely highlighted in this literature as a causal factor. Instead, explanations for diabetes among poor people overwhelmingly emphasize features of patients—their biology, behaviors, psychology, culture, or other “risk factors”—while ignoring, reframing or neglecting the links between poverty and disease. By so doing, these discursive strategies naturalize higher rates of diabetes among poor persons, legitimize relations of domination in the larger society, and encourage only research projects, treatment practices and health and social policies that do not challenge existing social relations. We discuss the implications of these discursive practices for medical research and care, and for social and public health policies.

You can’t walk or bike yourself out of the health effects of poverty: active school transport, child obesity, and blind spots in the public health literature

Mainstream public health theories of obesity attribute current, unprecedented numbers of obese youth to changes in eating practices and levels of physical activity, in turn leading to greater energy consumption and lesser energy expenditure. While substantial research has examined energy consumption among school-age children, key modes of energy expenditure such as active school transport (AST) remain underexplored. Using AST data obtained from the California Safe Routes to Schools program and child health data from the California Physical Fitness Test, we examined the association between AST and child obesity among school-age children and disambiguated this relationship introducing the variable poverty. We found that greater AST correlated with higher rates of child obesity and higher rates of child poverty, which in turn correlated with worse child health and obesity rates. Our findings suggest that child poverty explains the positive relationship between AST and child obesity that has puzzled investigators. Our analysis also reveals recurring blind spots in the public health literature, which often acknowledges that poverty begets poor health yet calls for environmental changes while rarely calling for eliminating poverty, one critical social determinant of health, even as these determinants have become legitimate objects of scientific inquiry. We propose that while environmental changes may improve the health of the poor, the only effective way to improve child health and reduce child obesity is to eliminate or dramatically reduce child poverty, a sociopolitical issue. This study is part of a larger project evaluating socio-political determinants of child health.

The safe routes to school program in California: an update

Despite efforts to combat increasing rates of childhood obesity, the problem is worsening. Safe Routes to School (SRTS), an international movement motivated by the childhood obesity epidemic, seeks to increase the number of children actively commuting (walking or biking) to school by funding projects that remove barriers preventing them from doing so. We summarize the evaluation of the first phase of an ongoing SRTS program in California and discuss ways to enhance data collection.

Food for thought: menu labeling as obesity prevention public health policy

This article discusses the evidence for menu labeling as obesity prevention public health policy. While sympathetic to providing nutritional information, whether food is consumed at restaurants or purchased for home consumption, the authors raise a word of caution against the assumption that menu labeling will significantly lead to healthier food choices, lower obesity rates, and decreased obesity disparities. The authors find little empirical evidence that this will be the case, critique the theoretical model that informs menu labeling as obesity prevention public health policy, and instead encourage policies that draw on a fundamental social causes approach to obesity prevention and health promotion generally.

Sin-food taxes and sugar-sweetened beverages--the right policy for the wrong reasons?

As obesity rates continue to rise, taxing calorie-dense foods of little nutritional value—‘‘sin foods’’ such as sugar-sweetened beverages (SSBs)—as a strategy to confront an impending epidemic is gaining popularity among researchers, the popular media, and policy makers. Leading academic proponents of a tax on SSBs (henceforth, soda tax) argue that it would reduce consumption and even encourage a consumption switch to healthier alternatives, thus leading to reduced calorie intake and less weight gain. Influential newspapers suggest that a soda tax ‘‘should help young people limit their intake of soda,’’ and in so doing, help fight the obesity epidemic; policy makers have seized on the idea on similar grounds. In this article, we question the claim that taxing SSBs will reduce obesity rates. It does not follow that we endorse SSBs, however. Quite the contrary, we wholeheartedly agree that they offer no nutritional value and may lead to serious health problems, including obesity. Yet for a soda tax to achieve the public health goal of reducing obesity and obesity disparities, it must be the case that reduced consumption of SSBs lead to a switch to healthier consumption patterns (rather than to a mere replacement by equally unhealthy ones) enough so as to have a significant public health impact on obesity rates and their distribution. As we argue below, we find this assumption problematic. We still believe that there is merit to taxation policies. However, if the generated revenue is to accomplish public health goals, they must be earmarked for such goals—in the case of obesity prevention, for reinvestments in improving the quality of food and built environments of low-income and minority communities to reduce the impact of the societal factors that drive obesity and obesity disparities in the first place.

A Critical Analysis of Debates Around Mental Health Calls in the Prehospital Setting

Paramedics, health care workers who assess and manage health concerns in the prehospital setting, are increasingly providing psychosocial care in response to a rise in mental health call volume. Observers have construed this fact as “misuse” of paramedic services, and proposed as solutions better triaging of patients, better mental health training of paramedics, and a greater number of community mental health services. In this commentary, we argue that despite the ostensibly well-intentioned nature of these solutions, they shift attention and accountability away from relevant public policies, as well as from broader economic, social, and political determinants of mental health, while placing responsibility on those requiring services or, at best, on the health care system. We also argue that the perspective of paramedics, who are exposed to, and interact with, individuals in their everyday environments, has the potential to inform a better, structural and critical, understanding of the factors driving the rise in psychosocial crises in the first place. Finally, we suggest that a greater engagement with the political and social determinants of mental health would lead to preventing, rather than primarily reacting to, these crises after the fact.

“It’s Not the Doctor – It’s Me”: How Self-Blame Obscures Language and Other Structural Barriers to Diabetes Care among Low-Income Latinos with Limited English Proficiency

Abstract Purpose Professional interpreter use improves care in patients with limited English proficiency (LEP) but inequalities in outcomes remain. We explore the experience of US Latinos with LEP and diabetes in language discordant care. Methodology/approach We conducted in-depth interviews of 20 low-income Latino patients with diabetes and LEP. We interviewed participants in Spanish, digitally recorded and transcribed interviews, and read transcripts to identify themes and interpret meanings using interpretive phenomenology as theoretical framework. Findings While patients preferred, and experienced greater trust in, language concordant clinical encounters, they did not believe that language discordance affected outcomes because they felt that these depended largely on their compliance with physicians’ recommendations. Patients also downplayed structural barriers to care and outcomes. Self-blame was paradoxically encouraged by physicians’ praise vis-a-vis favorable outcomes. Research limitations/implications Limitations include small and convenience sample and limited generalizability. However, findings illustrate communicational dynamics between patients and clinicians with important implications for health care practice and policy. They support the perception that trust develops best within language concordant care, which underscores the importance of recruiting clinicians with diverse language skills. They highlight the importance of sensitizing clinicians to the social determinants of health, which may be overlooked when treating patients with conditions requiring substantial self-management, like diabetes. Language barriers in health care must be understood in the broader context of structural inequalities in health care. The necessary emphasis on self-management may (inadvertently) strengthen the hegemonic view that places responsibility for diabetes outcomes on patients’ ability to self-manage their condition to the neglect of social/political determinants of diabetes. Originality/value Studies have quantitatively examined the effects of language discordant care on diabetes outcomes, yet few have done so qualitatively. To our knowledge, no study has attempted to understand the experience of language discordance from the perspective of LEP patients with diabetes and how this experience may explain observed differences in outcomes.

Cost-Effectiveness And Health Care Costs

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