A county-level survey of diabetes rates indicates much more disparity on the local level than was previously identified. Adjacent counties in North Carolina, for example, have age-adjusted rates of 6.7% and 11.8% – almost twice as many people with diabetes in one county only a few miles away! The counties with extremely high rates of diabetes are largely found in an area now nicknamed the “diabetes belt,” which is a swathe through the poorer parts of the Southeast and some of the Appalachians.

Scientific American’s article waffles a bit about why these disparities might exist. They mention correlations with known risk factors: higher obesity rates and more sedentary lifestyles, plus lower education levels and more African American residents. There’s a brief mention of the fact that a lot of these areas used to be agricultural communities, and some nonsense about people going to more sedentary lifestyles after not working in the fields as much (wtf? when did this commenter think this change took place?) but no real mention of what I strongly suspect would be the biggest correlate: poverty.

Low education levels are a major predictor of low socioeconomic status. Poverty is much more common for African Americans and is pervasive in many African American majority communities, especially in the South, and it’s not because they suddenly stopped working out in the fields; it’s the result of decades of structural inequalities, to say the least. And there’s been a groundswell of work lately about how low socioeconomic status and these unhealthy lifestyles (sedentary, low-quality diet leading to obesity, etc.) are structurally linked: food deserts, the time and financial pressures on families struggling to make ends meet, the artificially-depressed prices that make processed foods heavy on HFCS and meat more affordable and available than fruit and veggies, and so on.

The article points out that “about 30 percent of the extra risk faced by people in diabetes belt counties is tied to lifestyle choices that can be changed,” such as healthier diets and more active lifestyles. I don’t know how they calculated that number, but if we take it as correct, that means that 70% of the “extra risk” can’t be attributed to “choices that can be changed.” If you live in that county, instead of this one, you have a higher risk of disease, and more than half of the difference in risk is something you have no control over. If that doesn’t indicate a systemic problem, I don’t know what does.

But even the idea of “choices that can be changed” is questionable, especially in terms of diet and lifestyle, for the reasons I mentioned above, among others. People from other areas often see choices: “Well, if they’d go to the grocery store instead of Popeye’s, they wouldn’t get diabetes.” “These are the people who invented deep-fried candy bars! No wonder they get sick!” But people on the ground don’t see those as choices. Sometimes it’s that they don’t have time or money or a car to go to the grocery store and buy healthy food and cook at home. And sometimes it’s that they grew up eating deep-fried pork chops, and nothing else means comfort food to them the way chitlins do, or the deep-fried Twinkies that they get every year at the State Fair, even if it does send their sugar out of control for a few days, because they can’t resist that memory of the time when they were five and had their first one, back when life was simple and the State Fair was fun.

We have a word for the combination of systemic, structural factors and human, subjective factors that combine to limit choices to such an extent that the very choice itself becomes invisible. That word is culture. The culture of the Diabetes Belt fosters diabetes, just as the culture of Wall Street investors and major corporations fosters high blood pressure and heart attacks.

Sure, if CEOs learned to relax a little and do some deep breathing, they might be able to control their blood pressure without medication. Sure, people in the Deep South, especially people in poverty, could avoid diabetes or control it without medication if they bought veggies and cooked for themselves. But they’re almost equally impossible – and as a result, neither of those looks to the people in the situation like a “choice” or a matter of “lifestyle.” It would take a superhero to burst out of the constraints of the diabetes belt.

Act I was a review of a live performance of Dr. Horrible’s Sing-Along Blog. Act III: Paging Nurse Empathy, unites the twin themes of culture and compassion.

2 thoughts on “Act II: The Diabetes Belt is for Superheroes!

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