with diabetes, a balanced, low-calorie diet is. important in managing the condition. provider, or diabetes educator to plan an exer- cise program that is …
The Unequal Landscape of Diabetes: Place based solutions to end an epidemic
California Pan-Ethnic Health Network The California Pan-Ethnic Health Network CPEHN works to ensure that all Californians have access to quality health care and can live healthy lives CPHEN gathers the strength of communities of color to build a united and powerful voice in health advocacy Together, we work to evolve health care from a one-size-fits-all approach to a system that works for people from all cultural and ethnic backgrounds For more information about CPEHN and our work go to wwwcpehnorg
Contributing Authors Include: Rachel Larson, MPH, California Pan-Ethnic Health Network Ellen Wu, MPH, California Pan-Ethnic Health Network Ruben Cantu, California Pan-Ethnic Health Network Additional Support Provided by: Leslie Mikkelsen, MPH, Prevention Institute Rebecca Flournoy, MPH, PolicyLink Sarah Samuels, DrPH, Samuels Associates
a
s more and more Californians are diagnosed with diabetes we see our communities facing the debilitating effects every day With more than 18 million Californian adults diagnosed with the disease, diabetes has risen to the seventh leading cause of death in California and the
leading medical cause of amputations, blindness, and kidney disease1,2 However, the burden of diabetes is not equally distributed among all populations instead, Californias racial and ethnic minorities are experiencing higher prevalence rates and increased risk of diabetic complications compared to their White counterparts in order to stem the increasing prevalence of diabetes and eliminate these growing disparities, the health field must work not only to create parity in the medical screening and management of the disease, but also to address the nutritional and physical landscapes of disadvantaged communities it is only by acknowledging the context in which diabetes develops and progresses that we can begin to address the root causes placing communities of color at elevated risk for diabetes
1
The Unequal Landscape of Diabetes
Diabetes Prevalence by Race/Ethnicity Adults Age 18 and over, California, 2005
AMERICAN INDIAN/ ALASKAN NATIVE
LATINO
ASIAN
AFRICAN AMERICAN
WHITES
Diabetes Prevalence
80
65
101
149
60
source: UCla Center for Health Policy research3
overall, racial and ethnic minorities in California are faced with higher rates of diabetes than Whites, with
african american and american indian/alaska native aian adults presenting prevalence rates up to 40 higher than their White counterparts4 These disparities in prevalence rates only increase with age, with over 25 of latino, african american, and aian seniors age 65 and over diagnosed with diabetes compared to only half as many Whites5 Diabetes Prevalence by Age and Race/Ethnicity Adults Age 18 and over, California, 2005
Diabetes Prevalence by Age and Race/Ethnicity, Adults Age 18 and Over, California, 2005
430 Ages 18-49
40
Ages 50-64 Age 65 and Over
30
300 280
210 20 180 180 140 140
130 10
90
80
40 20 0
40 20
Latino
Asian
African American
American Indian/ AlaskanNative
White
2
Place based solutions to end an epidemic
African Americans The american diabetes association ada estimates that nationwide, 28 million 13 african americans have diabetes, and only two-thirds of them have been diagnosed7 in California it is estimated that over 200,000 101 african american adults have been diagnosed with diabetes8 once diagnosed, african americans fare worse compared to their White counterparts in terms of some diabetic complications, including diabetes related blindness,
kidney disease, and lower limb amputations9 african american diabetics have hospital admission rates for uncontrolled diabetes that are twice as high as for Whites 269 per 100,000 compared to 132 and have rates of lower-extremity amputations that are 30 higher than for Whites 392 per 100,000 compared to 29610 Native Americans and Alaskan Natives native american tribes experience the highest rates of diabetes among any ethnic group, with the Pima indians of arizona reaching a 50 prevalence level11 California is home to more aians than any other state in the Us with 627,600 residents12 of these, 149 have been diagnosed with diabetes aians over-65 population is especially afflicted with the disease with a prevalence rate of 43, the highest for any racial or ethnic group13 Asians The category of asian encompasses many ethnic-specific groups but diabetes statistics for this population are usually aggregated There is considerable cultural variance among specific asian ethnic groups; therefore, there is a limited ability to interpret or generalize the available information for this population The prevalence of diabetes among asians in California is 65 among asian sub populations the
highest prevalence of diabetes is seen among Japanese 102, followed by filipinos 86, Vietnamese 74, Koreans 74, and Chinese 4414 Latinos similar to the asian population, the category of latino encompasses many different racial subgroups with varying rates of diabetes, ranging from 82 among mexicans to 139 among Puerto ricans15 The prevalence of diabetes varies by age and is particularly high among older age groups Within California, over one in four latino seniors age 65 and over reports having diabetes This rate is over twice the rate for elderly Whites 14 and among the highest for all racial or ethnic groups16 Type 2 diabetes is the third leading cause of death among latinos of both sexes, ages 55-74, and the fifth leading cause of death across all ages, accounting for 5 of all deaths17 3
The Unequal Landscape of Diabetes
Recent Immigrants among non-Us born adults in California the prevalence of diabetes increases with the number of years lived in the United states The prevalence of diabetes is more than three times as high among adults who have lived in the Us 15 years or more 89 as among those who have lived here four years or less 24 approximately 4 of adults who have lived
in the Us between five and 14 years have been diagnosed with diabetes18
Disparities in the Burden of Diabetic Complications
diabetes can have a harmful effect on most of the organ systems in the human body it is a frequent cause of end-stage renal disease and non-traumatic lowerextremity amputations, and a leading cause of blindness among nonelderly adults Certain racial and ethnic minorities suffer higher rates of diabetesrelated complications and death These disparities are illustrated by diabetesrelated hospital admission rates, which even after being adjusted for prevalence, are often much higher for latinos and african americans than for Whites19 Prevalence Adjusted Hospital Admission Rates for Individual with Diabetes, by Race/Ethnicity in California, 2001 per 100,000 population
AMERICAN INDIAN/ ALASKAN NATIVE
Rate of Hospitalization for: Uncontrolled Diabetes Short-Term Complications Long-Term Complications Lower-Extremity Amputation
LATINO
ASIAN
AFRICAN AMERICAN
WHITES
202 365 1064 336
102 150 639 140
269 740 1301 392
70 150 638 202
132 434 910 296
source: office of statewide Health Planning and development20
4
Place based solutions to end an
epidemic
Mortality
african americans, latinos, and asians all experience higher death rates from diabetes than Whites Throughout the different age groups, african americans with diabetes consistently have death rates two to three times higher than their White counterparts21 Diabetes Age-Specific Death Rates by Race/Ethnicity and Age, California 2003
Diabetes Age-Specific Death Rates By Race/Ethnicity And Age, California 2004
450 400
Age-Specific Death Rate
350 300 250 200 150 100 50 0 Age 45 to 54
Latino Asian African American White
Age 55 to 64
Age 65 to 74
Age 75 to 85
85 and Older
45 to 54
55 to 64
65 to 74
75 to 84
85 and OLDER
Latino Asian African American Whites
153 72 322 92
512 200 753 244
1335 505 1534 644
2815 1454 2904 1295
3714 2927 4028 1992
note: The diabetes age-specific death rates for american indian, Pacific islander, and Two or more races were not reliable in 200422
5
The Unequal Landscape of Diabetes
Disparities in Access to Care
Health insurance plays a critical role in whether individuals have access to preventive care as well as receive the wide range of services needed to manage diabetes The disparities between insurance rates for
communities of color and Whites are immense, with uninsured rates of latinos and american indian/ alaskan natives reaching 321 and 188 respectively compared to only 85 of Whites23 These trends continue for the under 65-year-old diabetic population, with 361 of latinos being uninsured for all or part of the year compared to only 116 of White diabetics24 Percentage of the population under the age of 65 reporting being uninsured for all or part of the year by race/ethnicity, California, 2005
AMERICAN AFRICAN INDIAN/ AMERICAN ALASKAN NATIVE
LATINO
ASIAN
WHITES
Population 65 and under Uninsured All or Part of the Year, California 2005 Diabetic population 65 and under Uninsured All or Part of the Year, California 2005
source: 2005 California Health interview survey25
337
177
152
220
125
361
186
113
–
116
6
Place based solutions to end an epidemic
Discussion and Policy Recommendations
There are numerous factors that play into the development of diabetes including family history, genetics, and age; however, the most prominent and preventable is overweight and obesity The solution, however, is not as simple as recommending a diet or providing a pass to a local gym food
consumption reflects both preference and availability The same limited resource communities that are home to many of Californias minority populations are also often without retail grocery outlets, let alone farmers markets or other sources of fresh food These communities are also less likely than more affluent White neighborhoods to have access to safe parks or open spaces to promote physical activity it is these immense inequities between the nutritional and physical activity landscapes of low-income communities of color and those of higher income Whites that must be targeted in addressing the disparate rates of Type 2 diabetes
Changing the nutritional landscape
School Nutrition rising childhood obesity rates have spurred communities to take action on both the state and community level to change our schools food policies Through coalitions and advocacy work, several communities have been successful in improving the quality of school food environments, including setting nutritional standards for foods sold outside the school meal programs, allowing adequate time for meal periods, and improving cafeteria surroundings and menu offerings to increase their appeal to students26 The
oakland Unified school district serving an urban, predominantly lowincome, ethnically diverse student population was one of the first school districts to pass a ban on the sale of all soft drinks and candy in its schools Catalyzed by a public 
outcry around a potential 5 million school district contract with PepsiCo in 2000, staff, parents, and public health advocates came together to mobilize for change responding to the community, the school board rejected the contract and formed a nutrition policy committee that ultimately set one of the strictest school food nutrition policies in the nation27 Supermarkets, Small Stores and Farmers Markets low-income communities have used many strategies to enhance their neighborhoods food environments Through attracting and developing new grocery stores, improving existing small stores and starting and sustaining farmers markets, communities are fighting for equal access to fresh fruits and vegetables and more healthy options for their families28 West fresno food max residents of West fresno came together in 1995 to advocate for a supermarket for their community Through a creative campaign including news conferences, demonstrations, public
hearings, and petitions, 7
The Unequal Landscape of Diabetes
this group of concerned citizens pushed the need for supermarkets onto the political agenda four years later, the West fresno food max supermarket, opened and continues to successfully serve this community29
Changing the Physical Landscape
Parks, Recreation and Physical Education With tightening budgets causing school districts to cut their physical education programs and leaving municipal park departments financially hard pressed to maintain existing parks and recreation services, a new breed of community partnerships has evolved to provide impetus for local governments to improve urban parklands and services Through addressing safety concerns, ensuring the walkability and bikeability of streets, and enhancing local open spaces, communities are striving to create vibrant, active neighborhoods30 los angeles state Historic Park - in the foreground of a familiar downtown skyline, 32 acres of formerly abandoned land is quickly being transformed into los angeles first urban park The original reuse plans for the site consisted of the construction of a light-industrial warehouse complex However, with the dedication and
perseverance of a public coalition of more than 25 community groups, the project was redirected to a more beneficial use for the los angeles community in 2002, the state Urban Parks and Healthy Community program made funds available for the 32-acres to be converted to an urban park With the surrounding communitys full support, the park project will provide a much needed recreational use for residents living near downtown los angeles31 Health Impact Assessments With the growing body of research indicating that a wide range of sectors business, transportation, and economic development can impact community health, it is vital that we begin to analyze our future policies and development projects in terms of their impact on the creation of health promoting environments including analyses of these potential health impacts, known as Health impact assessments Hia, can increase our knowledge on the interaction between the environment and health and serve to reorient the actions of both public health and planning departments32 east Bay greenway Project The greenway Project proposes to build twelve miles of walking and biking paths under the elevated BarT tracks between the northern
California cities of oakland and Hayward Through the use of Hias, local community based organizations partnered with community members to analyze ways to maximize the potential health impacts of the proposed project as well as investigate and mitigate some of the main barriers to its use Through the Hia process the group generated several concrete recommendations including connecting the sidewalks from the greenway 8
Place based solutions to end an epidemic
to the interior of local neighborhoods to increase access and use; implementing traffic calming measures around the park to ensure pedestrian/bicyclist safety; and developing trail designs that provide proper sight lines and eyes on the street to increase safety33
State Level Solutions
Californias 2008 legislative session has several key bills pushing for the creation of healthier environments The bills listed below are a sample of the innovative approaches that have been developed to help reduce Californias rates of diabetes and promote health equity
Changing the nutritional landscape:
sB 1420 Padilla: requires restaurant menu labels to include caloric information adjacent to items aB 441 Torlakson: mandates nutritious
foods in vending machines on state property aB 2704 leno: Prevents school boards from entering into contracts with corporations selling unhealthy beverages that discourage free tap water in schools aB 2708 solario: Bans the advertising of non-nutritious foods in schools
Changing the physical landscape:
aB 1472 leno: Creates a program to provide grants and technical assistance to health departments and community organizations to conduct Health impact assessments to assess the impact of land use decisions on community health and health disparities aB 211 Jones: specifies that Public Health officers can be involved with land use decisions to increase consideration of the impact of planning decisions on community health aB 2072 Hayashi: awards recognition to schools doing well in physical education aB 2989 fuentes: Creates an outdoor environmental education and recreation fund, providing access to outdoor exercise opportunities for the underserved and at-risk for more information on these bills visit the Take action page on CPeHns website, wwwcpehnorg
Conclusion
While medical care at the individual level is important, it is not enough to stem the growing prevalence of diabetes
nor can it adequately address the inequities that lie at the root of the disparate rates experienced by Californias communities of color stepping away from this traditional paradigm and treating whole communities, partnerships and innovations like the ones described above are beginning to have an impact By working to improve our communities nutritional and physical landscapes we can prevent diabetes and lay the foundation for our communities to thrive 9
Notes/References
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
25 26 27 28 29 30 31 32 33
diamant al, Babey sH, Brown er and Hasert Ta 2007 diabetes: The growing epidemic UCla Center for Health Policy research accessed January 2008, http://wwwhealthpolicyuclaedu/pubs/files/diabetes_pb_122005pdf dH Cox 2004 diabetes deaths in California California department of Health services accessed July 2007, http://wwwdhscagov/hisp/chs/ oHir/reports/leadingcause/diabetes2004pdf diamant 2007, op cit s Holtby, e Zahnd, n lordi, C mcCain, YJ Chia, JH Kurata 2006 Health of Californias adults, adolescents and Children: findings from CHis 2003 and CHis 2001 UCla Center for Health Policy research, accessed July 2007,
http://wwwhealthpolicyuclaedu/pubs/files/Hlth_Cas_ rT062906pdf diamant al, Babey sH, Brown er and Hasert Ta 2005 diabetes on the rise in California los angeles: UCla Center for Health Policy research accessed July 2007, http://wwwhealthpolicyuclaedu/pubs/files/diabetes_pb_122005pdf diamant 2007op cit samuels se, stone-francisco s, Cardoza Clayson Z 2004 an ethnographic Case study synthesis mapping environmental factors related to diabetes in six ethnic Communities in samuels associates, The social environmental experience of diabetes: implications for diabetes Prevention, management and Treatment Programs, a series of Case studies Woodland Hills: The California endowment diamant 2007 op cit african americans and diabetes 2007 american diabetes association ada accessed July 2007 http://diabetesorg/communityprograms-andlocalevents/africanamericansjsp Carlisle d 2003, racial and ethnic Health disparities in Healthcare in California office of statewide Health Planning and development accessed July 2007, http://wwwoshpdcagov/HQad/racialethnic/factBookpdf samuels, opt cit satter d, Burros nr, gatchell m, Taulii m, Welch dT 2003 diabetes among american indians and alaska natives in
California: Prevention Key UCla Center for Health Policy research diamant 2007 op cit ibid ibid ibid anderson, rn 2005 deaths: leading causes for 2002 national vital statistics report; vol 53 no 17 Hyattsville, maryland: national Center for Health statistics accessed July 2007, http://wwwcdcgov/nchs/data/nvsr/nvsr53/nvsr53_17pdf diamant 2005 op cit Carlisle, opt cit ibid dH Cox, opt cit ibid er Brown, sa lavarreda, n Ponce, J Yoon, J Cummings, T rice 2007 The state of Health insurance in California: findings from the 2005 California Health interview survey los angeles, Ca: UCla Center for Health Policy research 2005 California Health interview survey ask CHis Pro: query: entire state, main topic: any time during past year without insurance under 65 years, compare by: ever diagnosed with diabetes, population: 0-65 and then each race/ethnicity subcategory: latino, asian, african american, american indian/alaska native, and Whites Collapse Had no insurance the entire past year and had insurance only part of the past year run January 22, 2008 ibid Williams e, Blackwell a a Place for Healthier living: improving access to Physical activity and Healthy foods Joint Center for Political
economic studies and Policylink 2004 http://wwwpolicylinkorg/pdfs/JointCenter-Healthylivingpdf accessed January 2008 Craypo l, schwarte l, Boyle m, stone s, samuels s ahead of the Curve: adopting and implementing school district a la Carte food and Bervage Polices oakland Unified school district: Case study report samuels and associates september 2005 accessed January 2008 http://www calendoworg/uploadedfiles/nutrition_case_study_oUsdpdf flournoy r Treuhaft s Healthy food, Healthy Communities: improving access and opportunities Through food retail Policylink, 2005 http:// wwwpolicylinkorg/pdfs/HealthyfoodHealthyCommunitiespdf accessed January 2008 ibid mikkelsen l, Chehimi s, Cohen l Healthy eating and Physical activity: addressing inequities in Urban environments Prevention institute, 2007 http://wwwpreventioninstituteorg/sa/pdf/rWJnCpdf accessed January 2008 Brownfield revitalization success story: Cornfield site los angeles Urban Park state of California department of Toxic substance Control 2006 http://wwweurowhoint/document/Pae/gothenburgpaperpdf accessed January 2008 Health impact assessment main Concepts and suggested approach gothenburg Consensus Paper WHo regional office
for europe, european Centre for Health, eCHP Brussels 1999 http://wwweurowhoint/document/Pae/gothenburgpaperpdf accessed January 2008 Heller JC, Bhatia r The east Bay green Way Health impact assessment Human impact Partners 2007 accessed January 2008 http://www humanimpactorg/greenway_final_reportpdf accessed January 2008
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