On the west side of Chicago in the heart of one the city’s ethnic neighborhoods, stands a red and yellow brick building reminiscent of the Spanish colonial architecture found throughout Puerto Rico. The first floor space of this building is occupied by the Greater Humboldt Park Community Diabetes Empower Center. The Center, which opened in April 2010, provides a physical home to the Block by Block Campaign Against Diabetes, an ambitious program that was formed by neighborhood activists and area academics after they realized they faced epidemics of diabetes and obesity unmatched by most other communities in the city. One such leader and the Campaign’s Director, Jaime Delgado, explained that the program was launched to empower the people in their own backyard, instead of relying on the “top down” approaches of the current health care system.
The new approach was needed because the current system was certainly not working.
In 2004, a local health survey conducted by the Sinai Urban Health Institute (SUHI) of the Sinai Health System in Chicago, revealed to the community that over 14% of the Humboldt Park community was diagnosed with diabetes, orders of magnitude higher than the 5% prevalence in the rest of Chicago and the 7% in the United States at the time. About 35% of the neighborhood was obese, compared to 24% in the rest of the U.S. in the year 2000. What was most startling was that almost 21% of the ethnically Puerto Rican community in this and the neighboring West Town community had diabetes, twice as high as the New York Puerto Rican community (11%) and the highest of any non-Native American community in the country. The prevalence among African-Americans (about half the population there) was 14%, also astonishingly high, and their rate of obesity was nearly 40% among several similar neighborhoods.
The Humboldt Park-West Town community’s problems and the ethnic disparity that they exposed are extreme, but not surprising, examples of the scourge we face with diabetes and obesity at the national level. In January, the CDC reported data from the National Health Interview Survey of 2008 showing that the age-adjusted rates of diagnosed diabetes are widely disparate among ethnic groups, an 11% prevalence for Blacks and Hispanics and 7% for Whites. These rates have each increased by 1% point since 2004, but the disparity remains steady. While the racial/ ethnic health inequity is distressing, the disparities by income and education group are the greatest, with Americans of less than high school education having the highest rates.
Obesity, which goes hand-in-hand with diabetes both epidemiologically and physiologically, has been insidiously rising in prevalence as well, from 15% to 34% for all adult Americans from the 1960s to now. Black females at all age groups are more likely to be obese (51% for those above age 20 years, compared to 33% for white women), and young adult Black men ages 20-39 years old are at increased risk compared to Whites (37% prevalence compared to 26% for non-Hispanic Whites). (Figure depicts the trend for women ages 20-39)
In primary care, when we treat men and women with diabetes or diagnose them with obesity by their body mass index, we are instructed by national guidelines to provide counseling on “therapeutic lifestyle changes” (TLC), namely increased exercise, nutritional guidance, and weight loss. But as most primary care providers know, the task is far more difficult than advised, and efforts seem too ineffective and frankly not worth the time. Perhaps they would be more successful if there was enough clinic time to truly dig into one’s behavioral habits, or if clinicians were trained more on nutrition, or if reimbursements for such counseling were higher.
In truth, far more important than these provider-centered factors are patient- or environment-dependent factors. Patients’ buy-in to behavioral change, their education and health literacy, the level that their environment and culture promote nutritious eating and physical activity, and, all too importantly, their ability to afford such healthy living are the real mediators of success after patients go home from their 15-minute doctor’s appointment. As the Sinai Survey and the CDC reports both discuss (as well other Progress Notes blogs), lack of health insurance and poverty are among the most important drivers of health disparities. Poor neighborhoods are plagued by “food deserts,” or large areas where grocery stores are scarce, but where liquor stores and gas stations provide plenty of junk food and sugar-sweetened beverages. Even cultural norms about body image, such as viewing overweight children as “healthy” in many Latino communities, pose barriers to health education. Breastfeeding is less common among African-American women compared to White women even though this may reduce risks for childhood obesity. In public policy, some criticize the “nanny state” for proposing to positively incentivize healthy food choices, all while politicians maintain the sugar and corn subsidies, thereby keeping unhealthy food options cheap and accessible, and attractive to the poor. We as a society may need to take responsibility for creating environments conducive to good health.
Such a resolve would require incredible investment, change in psychology, and a paradigm shift, far more effort than writing prescriptions and even performing risky bariatric surgery. It’s no wonder that the physician community, strapped for time in their clinic, and the medical industry, incentivized by short-term financial gain, lean towards the latter methods.
However, when addressing health disparities, a paradigm shift in the environment and culture may be all the more necessary. The fact that these diseases hit the poor, less educated, and ethnic minorities at a greater rate may demonstrate that the disease prevention and health promotion models could have more impact than the medical treatment model.
And this is where the Humboldt Park Community rose to the occasion, as a November New York Times article described. Rather than being shocked at the results of the Sinai survey, Mr. Delgado and other community members were part of the data-gathering from the get-go, and grassroots interventions were integrated with the research efforts. Envisioning a paradigm shift, Mr. Delgado explained that the Block by Block Campaign endeavors to create a “community of wellness” (which, by the way, is the name of another grassroots organization in the neighborhood), changing the way residents view health ideologically. The Center provides a physical structure for this ideology, offering Muevete (“Movement for Life!”), a collection of classes on aerobics, yoga, Tai Chi, and even Zumba, as well as cooking and nutrition classes. Even though these interventions are not quantitatively studied, Leony Calderon, Coordinator for Muevete, stated “Participants report feeling better; they report weight loss, improvement in chronic pain, and more energy.”
Where are the hospitals and physicians? “It’s understandable,” said Mr. Delgado, “that they are not able to engage in change at the community level. But that’s okay.” As long as there is consistency of message about the necessity to change behavior and that people with diabetes and obesity know that the TLC advice their primary care physicians provide is supported by the community and the Center. Extensive collaboration was undertaken with both academic centers and community hospitals to achieve this consistency.
The Block-by-Block program has an ambitious goal of lower the community’s Hemoglobin A1c by 0.5% over the next few years. Separate from the challenges of measuring the success of the interventions, significant ideological and cultural challenges abound. Mr. Delgado notes that among many residents in this ethnically segregated community, feelings of “alienation” and “fatalism” exists and that “oppression is disorienting,” making it difficult for them to trust their own neighbors without suspecting they want something in return. In addition, long-term health may not be top priority in the face of being jobless and trying to feed and educate your children. The psychological and social change will take substantial time.
But persistence in striving for such ambitious goals is necessary. Racial/ethnic and income disparities in health have fueled their own vicious cycle. As the Affordable Care Act will fund more and more public health endeavors, like Humboldt Park’s, building more Federally Qualified Health Centers, incentivizing primary care prevention practices overall, we will see more communities galvanize to attack their own health problems. The paradigm shift will certainly be slow, but it’s absolutely worth the wait.