Cultural Beliefs and Dietary Habits of Rural African Americans With Type 2 Diabetes

African-Americans in Louisiana & Type 2 Diabetes Rates

The poor will be always with us, we are biblically admonished. And for Americans we might add to this ancient maxim that the African-American poor will be always with us. Despite the many gains that they have made in the past 30 years African-Americans remain far more likely to be poor than are white Americans. This has a number of different consequences for African-American populations, including higher rates of certain diseases as well as less access to healthcare for those conditions. This paper examines the conjunction of the economic, social, and cultural status of African-Americans in Louisiana and their rates of Type 2 diabetes. African-Americans in Louisiana - as is true across the South and indeed across the nation - suffer from diabetes at least seemingly disproportionately high rates. However, once economic, social and cultural factors are taken into account, those rates no longer seem disproportionate. They are tragic, but comprehensible.

Before proceeding we should provide an overall picture of the seriousness of the rate of Type 2 diabetes in the African-American community and especially for African-American women:

2.8 million African-Americans have diabetes.

On average, African-Americans are twice as likely to have diabetes as white Americans of similar age.

Approximately 13% of all African-Americans have diabetes.

African-Americans with diabetes are more likely to develop diabetes complications and experience greater disability from the complications than white Americans with diabetes.

Death rates for people with diabetes are 27% higher for African-Americans compared with whites (http://diabetes.niddk.nih.gov/dm/pubs/africanamerican/).

It must be noted that despite the terrible conditions under which many African-Americans continue to live that they are in general much better off than were their grandparents. We all know that beginning in the early 1960s the Civil Rights brought to the nation's conscience the terrible conditions under which the majority of black Americans were living and helped begin the steady, if painfully slow, progress toward fuller civil rights and full inclusion in the promise of American citizenship. In large measure as a response to the Civil Rights movement, a number of federal, state, and local government programs were developed and implemented to help combat poverty and the effects of racism on African-Americans (Polednak, 1997, p. 38). While these programs were not directed primarily at diabetes reduction, of course, or even specifically toward improving the health of African-Americans, they tended to do so overall. One of the most important risk factors for early death and for a range of illness from diabetes to cancer to AIDS is poverty. By alleviating poverty, a society also alleviates unnecessary suffering from diseases.

However, by the beginnings of this brand-new shiny millennium, despite the many government anti-poverty programs and equal-opportunity laws that have outlawed discrimination in education, housing, and employment, African-Americans remain unequal partners in U.S. society. Their median (and mean) income and education are below those of whites, and their average rate of unemployment is far greater (www.census.gov).This is true despite the fact that blacks as a group and African-Americans as individuals have made important advances in gaining a larger share of higher paying jobs, raising their median income in both real terms and in relationship to that of whites, and in increasing their college enrollment and overall rates of education (Harris, 1999, p. 21).

Thus despite the current in many ways depressing statistics, it must be remembered that both politically and economically, blacks have made substantial strides in the post-Civil Rights era. Given this fact, it is somewhat surprising that rates of poverty-correlated diseases such as diabetes have not decreased.

This may be explained locally in terms of the higher rates of poverty in Louisiana vis-a-vis the nation as a whole (for both African-Americans and other groups of Louisianans) but this is not a complete explanation. This research proposes that there are cultural factors that extend beyond the strictly economic - that tend to increase rates of Type 2 diabetes in African-Americans.

The economic situation of African-Americans cannot be understood without looking at some specific sets of figures. For example, in 1997, the number and poverty rate of African-Americans was 9.1 million and 26.5%, compared with 24.4 million and 11.0% for whites; 1.5 million and 14.0% for Asians and Pacific Islanders; and 8.3 million and 27.1% for Hispanics (statistically the same as for blacks) (www.census.gov).

For families, the number and percentage of poor in 1997 was 2.0 million and 23.6% for African-Americans; 5.0 million and 8.4% for whites; 244,000 and 10.2% for Asians and Pacific Islanders; and 1.7 million and 24.7% for Hispanics (www.census.gov).

We can see how these figures compare historically by examining the incomes of black and white Americans over the last twenty years:

Blacks Whites (www.census.gov).

The narrowing gap between black and white Americans is an excellent proxy to use to understand in practical terms the economic gains that were the direct and indirect results of the political and cultural gains made by black Americans as a result of advances made during the civil rights era. Although the racial disparity in poverty rates has narrowed only slightly overall, the black middle class has grown substantially and about 43% of African-Americans now own their homes (Harris, 1999, p. 61).

However, approximately one-third of the African-American population lives in poverty, a rate three times that of white Americans, a fact that can be explained both by the unemployment gap between blacks and whites, which has over the past decade actually grown larger: In 1973 African-Americans were 2.2 times as likely to be unemployed as whites while in 1997 the unemployment rate among African-Americans was 2.3 times the rate for whites (Harris, 1999, p. 67).

Blacks are not only less likely to be employed than whites but they are also likely to be paid less for the same jobs (and of course this is exacerbated for black women who are paid in general much less than black men). The income gap between black and white families also continues to widen in large measure because of these wage and employment gaps: Employed blacks earn only 77% of the wages of whites in comparable jobs, down from 82% in 1975 (Polednak, 1997, p. 84). African-Americans are also less likely to receive full health benefits with their jobs. Thus they are more likely to get sick (at least from certain illnesses) while at the same time they are also less likely to have the resources to seek medical care.

The economic problems of African-Americans can also be linked to education rates and family structure: 12.2% of blacks earned bachelor's degrees in 1993, down from 14.5% in 1975, and in contrast to 22.6% of whites who had finished their undergraduate education in 1993. Although rates of births to unwed mothers among both blacks and whites have risen since the 1960s, the rate of such births among African-Americans is three times the rate of whites. Single-parent households are more likely to be poor simply as a result of there being fewer possible hands to work (Harris, 1999, pp. 27-9).

The higher rates of poverty for blacks take their toll in terrible ways: African-Americans have shorter life expectancies than the national average and suffer disproportionately from heart disease, AIDS, hypertension, and stroke, in addition to diabetes (Harris, 1999, p. 34). The poor may be always with us, but this does not make their condition any less terrible.

Orem Self-Care Deficit Model useful theoretical model through which to view the dynamics of diabetes in the African-American community is the Orem Model (Saucier 1984, Mulkeen 1989, Bracher 1989, Bowers & Patterson 1986). This model emphasizes the importance for both mental and physical health of a person's being able to learn to take responsibility for himself or herself. The Orem model underscores the importance of each individual's using his or her capabilities to learn to be more self sufficient through taking care of - and responsibility for - themselves. Orem's model for responsibility includes the following points:

The individual should participate in learned, goal-oriented activity directed by individual to regulate factors that affect their own functioning

The individual should be goal-directed, and should pursue goal-directed and purposeful

The individual should engage in self-care, which for some individuals may be psychologically tantamount to taking care of the members of his or her family as well http://web.odu.edu/webroot/orgs/hs/nurs/nursing.nsf/files/n610orem.pdf/$FILE/n610orem.pdf).

Orem's model emphasizes that self-care is complex and that it is a set of skills that can and in many cases must be taught. Orem argues that the ability to care for oneself - to be an agent in one's own self-care - allows an individual to do the following:

To meet continuing needs

To maintain the physical and psychological health of the human structure

To allow for normal human development

To promote will-being http://web.odu.edu/webroot/orgs/hs/nurs/nursing.nsf/files/n610orem.pdf/$FILE/n610orem.pdf).

One of the key dynamics in terms of using the Orem model is that of gender, for it allows us to understand the connection between negative stereotypes of black women and their high level of diabetes. The first of these stereotypes is the "Mammy" figure, a female who is dedicated to the welfare of children (either her own or her owner's) while at the same time dominating her husband:

Although she treated whites with respect, the Mammy was a tyrant in her own family. She dominated her children and husband, the Sambo, with her temper. This image of the Mammy as the controller of the African-American male, was used as further evidence of his inferiority to whites (http://www.students.vcu.edu/counsel/MC/stereo.html).

The second is the "Sapphire" stereotype, a demanding woman who refuses to take moral responsibility either for her own actions or for the actions that she demands of others.

Sapphire was a stereotype solidified through the hit show "Amos 'n' Andy" (Jewell, 1993). This profoundly popular series began on the radio in 1926 and developed into a television series, ending in the 1950s (Boskin, 1986). This cartoon show depicted the Sapphire character as a bossy, headstrong woman who was engaged in an ongoing verbal battle with her husband, Kingfish (Jewell, 1993). Sapphire possessed the emotional makeup of the Mammy and Aunt Jemimah combined. Her fierce independence and cantankerous nature placed her in the role of matriarch. She dominated her foolish husband by emasculating him with verbal put-downs (http://www.students.vcu.edu/counsel/MC/stereo.html).

African-American women are often put in the position of having to care for both themselves and their extended families without realistically being able to do so. Because of this many strike out, seeking to find others to take over some of the responsibility - or at least someone else to blame. This combination of roles (and stereotypes) can be deadly and may well explain at least a large part of the very high degree of Type 2 diabetes in African-American women.

Purnell Transcultural Health Model

This research also draws on the Purnell Transcultural Health Model, which argues that we can neither understand nor treat disease without considering the cultural context in which the subject herself or himself understands the disease (Camphinha-Bacote 1996, Camphinha-Bacote 1998). Purnell argues that there are cultural bases to both disease and health and that these often interfere with biomedicine as a culture that is as rule-governed as other systems of belief. This refutes the commonsense attitude of many people - both lay and health professionals - that dictates that the concepts of health and illness seem at first glance to be entirely biological constructs. After all, a person contracts tuberculosis not because she belongs to a certain religion or because he is a certain ethnicity but because a particular type of bacillus enters into her or his body and infects its human host. People get epilepsy because of a particular mis-wiring in their brains. Diabetes is caused through a failure of the endocrine system. Nothing could seem more straightforwardly objective and clear-cut and scientific. But in fact the picture is more complicated than this.

Purnell argues that health (and the absence of health, or sickness) is culturally constructed. Both concepts of sickness and perhaps to an even degree ideas about health are in fact deeply culturally rooted in the specific belief systems of a given role and society. We get sick for a number of reasons - and through the invasion of our bodies by a number of parasites. This is as close to an objective Truth as any of us is likely to get. But health, and sickness (and what to do about either) is not only a matter of objective truth; belief matters at least as much as truth.

It is often the case that health-care workers and African-Americans fail to share cultural assumptions about diabetes. But perhaps even more damningly what they often fail to share is an understanding that culture limits the way in which we can understand the world. This is actually a good thing about culture: If every time that we had to do something or decide anything we had to consider every possible alternative then we should all be paralyzed by the possibilities always before us. One of the functions of culture is that it limits the range of possible ways of seeing (and acting in the world). Culture simplifies the world so that we do not go mad.

But each culture simplifies the world in different ways, blotting out different details, erasing different bits of "reality." This results all too often in the fact that people from different cultures find it almost impossible to communicate with each other. Members of different cultures are in fact living in different worlds because their cognitive maps (formed by their languages and customs and material culture) highlight different elements of the "real" world. This often prevents health-care professionals and African-Americans at risk of diabetes or those who already have diabetes from communicating with each other.

Chapter Two: Pathopsychology of Diabetes Mellitus

Although diabetes is a very common ailment among Americans, most of those who are not directly affected by it remain relatively ignorant of what exactly causes the disease, the different types of diabetes, and the forms of treatment. It may be helpful to begin with a basic definition of this disease. Diabetes is a metabolic disorder of carbohydrate metabolism that results from an insufficient production of (or a reduced sensitivity) to insulin (American Diabetes Association, 1996, p. 8).

Diabetes mellitus is a group of diseases characterized by high levels of blood glucose. It results from defects in insulin secretion, insulin action, or both. Diabetes can be associated with serious complications and premature death, but people with diabetes can take measures to reduce the likelihood of such occurrences (http://diabetes.niddk.nih.gov/dm/pubs/africanamerican/#1).

Insulin itself is a hormone that regulates the level of glucose (a form of sugar) in the bloodstream. Insulin is produced in the pancreas, specifically by the beta cells of the islets of Langerhans. In a person who is not suffering from one of the forms of diabetes, the normally functioning pancreas secretes insulin whenever the level of blood glucose rises - most commonly after an individual eats. When the level of blood glucose falls in a person without diabetes (as it normally does after a meal is digested) the pancreas stops secreting insulin; this is accompanied by a release of glucose by the liver into the bloodstream. This allows a non-diabetic individual to maintain sufficient ready energy stores.

However, the metabolic picture is quite different for people with diabetes. In diabetics, the normal ability of body cells to use glucose as the basic source of energy is inhibited: Because cells cannot use glucose the way that they should there is a rise in blood sugar levels - the condition called hyperglycemia. More and more glucose accumulates in the bloodstream, which triggers the body to release high levels of sugar in the urine (which is called glycosuria). Sugar in the urine is one of the key ways in which diabetes is usually diagnosed, along with other common symptoms such as urinary volume and frequency, high levels thirst, itching across the body, disproportionate feelings of hunger, disproportionate weight loss, and overall weakness and fatigue. These symptoms can be extremely debilitating to the person with uncontrolled diabetes preventing him or her from attending school or going to work or otherwise participating in daily activities (Hanas, 1998, p. 61).

There are two basic types of diabetes and it is important to distinguish between the two of them. Insulin-dependent diabetes usually starts in younger people (and so is often referred to as juvenile-onset diabetes) when their islets of Langerhans begin to secrete too little insulin and sometimes cease to secrete insulin at all. People with this form of the disease must inject insulin at least once each day to control their blood glucose. Development of this type of diabetes is not related to diet - which is often a surprise to people who consider all diabetes to result from poor diet and obesity (Hanas, 1998, p. 78). In fact the cause of insulin-dependent diabetes is entirely perfectly understood; scientists believe that it may result either from some form of viral infection or from damage to the islets of Langerhans caused by an autoimmune response (American Diabetes Association, 1996, p. 42).

Type Two diabetes, which is also called non-insulin-dependent diabetes (sometimes abbreviated to NID) is far more common amongst African-Americans (and indeed among all Americans and all citizens of the developed world). Non-insulin-dependent diabetes usually begins in middle age. In this form of the disease, an individual's islets of Langerhans secrete normal amounts of insulin, but that individual's body has become resistant to insulin. The result is that the blood glucose levels respond weakly to the insulin. This type of diabetes is very closely linked to obesity and accounts for 90% of all diabetes (Hanas, 1998, p. 11).

Incidence of Diabetes in Rural African-Americans

Most African-Americans who suffer from diabetes suffer from Type II diabetes.

The proportion of the African-American population that has diabetes rises from less than 1% for those aged younger than 20 years to as high as 32% for women age 65-74 years. Overall, among those age 20 years or older, the rate is 11.8% for women and 8.5% for men.

About one-third of total diabetes cases are undiagnosed among African-Americans. This is similar to the proportion for other racial/ethnic groups in the United States (http://diabetes.niddk.nih.gov/dm/pubs/africanamerican/#1).

The following graph suggests the degree of the problem of diabetes in the African-American community.

Figure 1. -- Prevalence of diagnosed and undiagnosed diabetes in African-Americans, U.S., http://diabetes.niddk.nih.gov/dm/pubs/africanamerican/images/fig1.gif (http://diabetes.niddk.nih.gov/dm/pubs/africanamerican/#1)