With the passage of the Patient Protection and Affordable Care Act into law more people, especially low-income people, have access to health care. However, having health care doesn’t guarantee good health. Economic instability, racial inequalities in health care treatment, and cost shifting by insurance companies, conspire to affect chronic disease outcomes negatively, especially for those affected by chronic diseases like diabetes that depend on access to healthy food. And if access to health care doesn’t guarantee good health, several studies also show it’s not likely to lower health care costs in the long run.

Increasingly, personal health is affected by the social determinants of health, namely all the places where people live, work, learn, and play. These are conditions outside the clinic or doctor’s office that we don’t have direct control over: the state of our neighborhoods and schools, zoning issues, and whether there are bus and subway services that can take us to work. So if your neighborhood has poor public transportation, underperforming schools, no access to fresh, healthy foods, and few opportunities for living wage work, your health will suffer. It’s not a matter of willpower. Patients bring the poor health outcomes resulting from their environments into the doctor’s office, forcing healthcare systems to deal with the consequences.

Non-whites suffer disproportionate rates of poverty due to racism, but racism alone can increase the odds of developing chronic disease, especially type 2 diabetes. CivilEats.com recently posted an article detailing how “…rates of diet-related disease break down dramatically along racial lines.” And that “…one in two African Americans born in 2000 is expected to develop type 2 diabetes. Compared with white adults, the risk of diabetes is 77 percent higher among blacks.” While too many of us eat diets too high in processed foods, poor neighborhoods are filled with fast-food restaurants and corner stores and few if any supermarkets. The stress of poverty severely affects people’s health over the long term.

Economic insecurities caused by poverty, are “associated with poor diabetes control and increased health care use.” That according to a study in the JAMA Network Journals. Economic insecurities relate to a person’s ability to pay for heat, housing, food, and medication. When people have to make choices between paying a heating bill or the rent and buying food, they invariably choose food they can afford. Cheap food is usually processed food or “fast food” the very “food” shown to cause a variety of metabolic diseases, most notably type 2 diabetes. When people have to balance those same choices with buying needed maintenance medications, they will underuse prescriptions or cut dosages. The study also showed that outpatient visits increased but health indicators did not improve.

Food insecurity is especially pernicious in children. New research published in September 2015 in the Journal of the American Osteopathic Association, indicates that: “household food insecurity dramatically increases the likelihood of metabolic diseases in children, with many showing chronic disease markers before they graduate from high school.”

More doctors, clinics, and hospitals are helping patients identify food resources like local food banks or the Federal Supplemental Nutrition Assistance Program offices. For instance, Boston Medical Center has a Preventive Food Pantry. Doctors can refer food-insecure clients through “prescriptions” for healthy food. An important component in the food given to families is perishable foods, including meats. Items that are hard to find in low-income neighborhoods and costly, so they’re often missing at the dinner table. BMC also offers cooking demonstration classes and has recipe handouts and recipe lists online.

When people with diabetes suffer from economic insecurities, this has a direct negative effect on their glucose control as well as increased usage of the health care system. The JAMA article concludes that “strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities.” Helping patients address those insecurities especially relating to food, could be a real-world target yielding positive real-word results in diabetes management.


JAMA Internal Med online article

Social determinants of health

Preventive Food Pantry