Dollars v. Fat & Sugar -- How Diabetes, Obesity, and Food Prices Are Linked

by Stine Eckert

When Bill Zorn was writing a play on diabetes in November 2007 little did he know the story would be about him. A month later the 39-year old Ohio University playwright was diagnosed with type 2 diabetes.

Yes, he was obese at 330 pounds and six feet. But he didn’t have a sweet tooth or a family history of diabetes and for the past year his blood sugar level had been normal. One day in December 2007, however, his eyesight went blurry. Very, very blurry. At that time his old furnace got replaced. It was found to be leaking carbon monoxide. He suspected carbon monoxide poisoning and went to the emergency room. The doctors didn't find poison in his blood but a blood sugar level of 982 mg/dl. High blood sugar starts at 140 mg/dl.

"My pancreas had practically stopped working," he says.

Out of the hospital a new life began without sugar, without hamburger buns, but with Metformin pills to control his insulin production. Since he started on his new diet Mr. Zorn dropped 60 pounds.


















Count your carbohydrates, but first find where they are: Trainings material of the Appalachian Rural Health Institute (ARHI) Diabetes Center.


“We don’t even have to get out of the car anymore to get food.”
With almost 30 percent of Ohioans obese in 2008 year, Ohio ranked as the eleventh most obese state in the country last year, above the national average of 27 percent, according to the National Center for Chronic Disease Prevention & Health Promotion.














Almost one in three Ohions is obese.


The number is growing fast. While 1995 saw 18 percent obese Ohioans, 2008 saw almost 30 percent. A trend that is not unique for Ohio.

“It’s happening all over the nation,” says Dr. Darleen Berryman, associate professor for Food, Nutrition and Hospitality at Ohio University. “Factors that play into that, range from lifestyle to environment to what is available to us in terms of exercise, safety, and food.”

Certain genetic make-ups are much more susceptible to obesity, she says.

“But that can’t account for the explosion in obesity we’ve seen over the past twenty years.”

Ohioans might be aware of their growing girth. This past year 74 percent reported that they had exercised the previous month, up by over 17 percentage points from 57 percent in 1996. But that might not be enough movement to balance calorie intake and calorie burning.

“On the food side there already was a lot of negative going on 20 years ago. A trend for prepared food has existed since the 1970,” Dr. Berryman says. “What caught up to us is the [the lack of] physical activity.”

People have created an environment less conducive to activity, she says, with escalators, elevators, television, laptops, video games, and more subtle things like temperature control through air conditioning. Jobs have shifted from physical labor to more sedentary desk jobs. Mr. Zorn says he spends 12 to 14 hours working on campus but now that the quarter is over he wants to ride his bike more often.

“We don’t even have to get out of the car anymore to get food,” she says.

















Not conducive to movement: Technology provides convenience.


When Dr. Berryman graduated in 1994, she says nobody cared about adipose tissue. “It was this fat warehouse and didn’t do much.”

Since then researchers have come to appreciate fat as an endocrine organ and found that not all fat is equal. Some fat doesn't seem to be as harmful, she says. A study showed that in the lab researchers can create a healty environment in which obese mice live much longer than normal mice.

“We have a very simplified view that obesity is bad and lean is good,” Dr. Berryman says.” But there’s definitely a gray area and a lot to learn.”


A rural problem
Within Ohio, people in Appalachia reported the highest average percentage for obesity with over 31 percent as opposed to Ohioans in metro, suburban, or other rural areas. Twenty-two percent of people in Appalachia said they were in poor health and ten percent said they’ve been diagnosed with diabetes according to the 2008 Ohio Family Health Survey.

Whereas in 2004 almost eight percent of Ohioans (63 of 803 survey participants) said they were diagnosed with diabetic, in 2008 almost 10 percent (170 of 1720) said so, according to the National Center for Chronic Disease Prevention & Health Promotion.

Type 2 diabetes has been increasing in epidemic proportions worldwide and in Appalachia over the past thirty years says Dr. Frank Schwartz, Director of the Appalachian Rural Health Institute (ARHI) Diabetes Center and associate professor of Endocrinology at Ohio University College of Osteopathic Medicine.
















Diabetes research and treatment: Ohio University's College of Osteopathic Medicine.


He says that people with lower socio-economic status have higher rates of obesity and other chronic diseases. But he adds that the old generalization that poorer people make poor choices because they are less educated doesn’t hold true anymore.

“We know that stress hormones like cortisol and adrenaline are much higher in people who are under economic stress compared to people who aren’t,” he says. “These are diabetegenic hormones, which induce metabolic effects.”

In addition, there’s a higher prevalence of depression in poor and diabetic people, he says. These in turn find it more difficult to maintain their diet, to exercise, and to take their medications, which creates more complications, says Dr. Schwartz.


















Healthy and relatively cheap: Over the past thirteen years the annual average price of romaine lettuce stayed below the Consumer Price Index. But you need more pounds to satisfy calorie needs.


Food choices during survival mode
Karen Bailey, a dietitian in the Appalachian Rural Health Institute Diabetes Cener, provides medical nutrition therapy for diabetics who want to lose weight. Her program recommends a diet with lean meats, not too much meat, monounsaturated and polyunsaturated fats, whole grains, and high fiber.

“Diabetics don’t have to buy foods that have been specially designed for them, they can be expensive,” she says. “Just buy fruits, vegetables, healthy foods; don’t spend money on pop, chips, and empty calories like that.”

But Dr. Schwartz says that it’s a lot cheaper to buy high fat, simple sugar, and bulk foods. “You’re in survival mode and so you’re going to make choices you know may be wrong but for other reasons.”

A look at the average annual price change between 1996 and 2008 shows that for six selected healthy foods, five were higher than the consumer price index (CPI) according to data from the Bureau of Labor Statistics.


Only three of six unhealthy foods were higher than the CPI: bologna, a two-liter bottle of cola, and potato chips were cheaper than the index. Although the price per pound for the healthy foods is lower than for some of the meats and snacks, a person needs to buy more vegetables to get the same calorie count, spending more money for the same amount of calories and over the years more than on other consumer items on average.

Over time people have been eating more processed, frozen, and canned foods and spend less of their household budget on food and more on non-food items, says Dr. Richard Vedder, professor in the Department of Economics at Ohio University focused on economic history.



For Mr. Zorn the opposite is true. He spends more of his household budget to buy adequate food since he started his new diet as a diabetic. Before the diagnosis, he usually spent $100 per month on groceries. Now it’s up by $50 per month. He says for example sugar-free bread costs at least $3. While he, as Ohio University faculty, can afford the food, other people are struggling to purchase healthy food.














Unhealthy but cheap: Over the past thirteen years the average annual price for bologna and cola have lower than the Consumer Price Index.


Invisible hunger
People in the Athens area are using food assistance programs three times more than the rest of Ohio, according to a study by Dr. David Holben, assistant professor for Food, Nutrition, and Hospitality at Ohio University and Director of the Didactic Program in Dietetics.

Among the over 2,500 people surveyed, obesity and diabetes was greater among these so-called food insecure (27 percent) than people who are food secure, he says. Food insecurity means that someone has relied on food assistance at least once during the year and might get enough calories but not enough nutrition.

“The poor, especially women, show a binge-like eating pattern,” Dr. Holben says.

When at the beginning of the month money is more available, people tend to overeat because they are wondering where their next meal is coming from. By the end of the month there's no food available.

“But they may have gained weight already and that does not just fall off,” he says.

Apart from economic barriers, people who start on a diabetic diet struggle the most with counting carbohydrates.

“Portion control is really hard,” says Ms. Bailey. “Because they’ve never had to think about that before.”

Mr. Zorn was educated about his new diet by a nurse named Candy before he left the hospital. He made her a character in his diabetes play titled Lucille, which shows the tricky transition of a freshly diagnosed older woman from the hospital into the world.

“I used my mom as the main character and put her through my experience.”

He says it’s hard to find something to eat on the street. As his job keeps him busy, he can take a meal at home only once a day. Forced to eat out, he orders hamburgers without buns, tacos without shells, and politely declines cookies or pizza when people offer them at meetings.

But unlike him, a lot of people Ms. Bailey trains don’t apply their new knowledge at home and need to come back for refreshers, she says. During the first year after a person has been diagnosed, Medicare reimburses for six to ten hours of so-called diabetes nutrition management training. After that, Medicare only pays for two hours a year for follow-ups. But in addition to initial training, Ms. Bailey can bring people under other programs back to the ARHI Diabetes Center, which was established in 2003. Its mission is to reach and treat people in Southeastern Ohio and to lead diabetes research at Ohio University.











The Appalachian Rural Health Institute Diabetes Center is located in the Cornwell Center of O'Bleness Hospital, Athens, Ohio.


Staffed with Dr. Schwartz, Ms. Bailey, another dietitian, and a nurse, the ARHI Diabetes Center helped 228 people in 2004. With 305 patients, the center saw its highest count in 2005, but fewer people came the following years, down to 295 in 2007, the most recent number provided by the ARHI Diabetes Center. Even though there’s been an increase in diabetes, classrooms don’t get too crowded, Ms. Bailey says. People live far away from classrooms and sometimes don’t have money for gas.

“Because we’re in a rural area we actually have to push to get people to show up for classes.”


So what’s the solution?
Early prevention and identification of those with pre-diabetes is “really, really” important, says Ms. Bailey. She hopes that any new health-care legislation covers more prevention than now.

But if a national health-care program would be implemented in the United States, some of the food assistance programs might go away, worries Dr. Holben. He’s seen this happening in Canada. He says community initiatives such as the West State Community Gardens in Athens make a difference.

“President Obama and his wife have a garden at the White House, which is encouraging.”




















Let them eat peaches: Annual average price for the fuzzy-skinned healthy fruit was higher than the Consumer Price Index for the past thirteen years.


Legislation could help to make healthier foods cheaper and unhealthier foods more expensive or to build communities that promote walking, safe biking, and activity, says Dr. Berryman. Especially in schools, she says, activity has been a low priority. Some states turn it into a high priority, some don't, Dr. Berryman says. In addition, government surplus food served in schools is very high in fat and very high sugar, says Dr. Schwartz.

“There’s a lot to do in nutrition education,” says Dr. Berryman. “Soda is just not appropriate for a two-year-old.”

But the most important things for the Athens area are jobs, better health care, and economic development.

Many people don't even get personal time for doctor's appointments, says Dr. Schwartz.
“If you don’t show up for a day at work, you’ve lost that income, you’ve acquired the bill for seeing the physician, and your boss is mad at you for leaving,” he says.

But people suffering from a chronic disease such as diabetes need routine appointments, not just quick care at night.

Even though Mr. Zorn doesn’t face the economic barriers himself, his new play on diabetes will address them and the social pressure diabetics face such as when families get together and offer pumpkin pie along with mocking commentary that one piece "isn’t gonna hurt".

“Even if people around you aren’t helpful, it’s about your own will power," Mr. Zorn says. "It's about self-preservation.”


More on the topic on my blog:

Not All Fats Are Equal -- Dr. Darleen Berryman, Ohio University, on the Causes of the Obesity Epidemic and New Research Paths (extended video Interview)

The Greatest Barriers Are Economic -- Dr. Frank Schwartz, Ohio University, on the Struggles of His Diabetes Patients (extended video interview part 1)

Soft Spot Health Care -- A U.S.-European Dialogue with Dr. Frank Schwartz, Ohio University (extended video interview part 2)

Counting Carbs for the First Time – Karen Bailey, OU Dietician, Helps Obese Diabetics Lose Weight (audio slide show with extended interview)

Info box: Where Does the BMI Come From?
Info box: What Is Food Insecurity?
Info box: How Much Food Is Enough?
Info box: What Is Diabetes?


Other helpful links:

Obesity

http://news.research.ohiou.edu/notebook/index.php?item=151
This offers more details on Dr. Berryman’s obesity research – fat mice lived longer than normal mice. How did that happen? Find out!

http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm
The National Health and Nutrition Examination Survey (NHANES) offers a wealth of data sets ranging back to the 1970s.

Diabetes

http://www.oucom.ohiou.edu/ARHI/education_links.htm
The Appalachian Rural Health Institute Diabetes Education Center provides ten links and phone numbers of major institutions with information on diabetes, also for children (all links were working as of May 26, 2009).

http://www.hhs.ohiou.edu/chhs/gallery_of_research_david_holben.aspx
More details on the 1999 study by Dr. Holben on diabetes and food insecurity.

Food insecurity

http://www.invisiblehunger.blogspot.com/
In this local blog, journalism senior Taylor Randall of Ohio University writes about social problems including food insecurity and poverty in rural communities.

http://jfs.athenscountygovernment.com/gfx/media/PovertyReport.2006.pdf
Athens County Poverty Report 2006

http://www.ruralrambler.org/
This website in blog style relates to the local organization Rural Action, whose mission is to foster social, economic, and environmental justice in Appalachian Ohio.

http://esj09.wordpress.com/projects/you-can’t-eat-coal/
You Can’t Eat a Lump of Coal: Agriculture in Southeast Ohio
by Mary Nally and Leah Crone-Magyary, Spring 2009

This is an extensive report on the larger issues of community food initiatives as a chance for sustainable employment and food security in a region wrecked by mining industry. Ohio University students Mary Nally and Leah Crone-Magyary wrote the report during their spring quarter 2009 class on environmental and science journalism taught by Dr. Bernhard Debatin.

(This report is part of an excellent blog, which compiles thoroughly researched stories about the impact of the coal mining industry on humans and the environment in the Athens regions.)

http://www.athensinteractivist.org/news/other/presidential_research_scholar_dr_ann_tickamyer_gives_insig
Presidential Research Scholar Dr. Ann Tickameyer gives insight on plight of rural poverty
by Christina Green

Article in the Athens local magazine Interactivist, self-proclaimed "Ohio's Only Progressive Magazine"

The InterActivist asked Ohio University Presidential Research Scholar Dr. Ann Tickamyer, a professor and department chair of Sociology and Anthropology at Ohio University, her opinions regarding rural poverty. Tickamyer’s areas of specialization are inequality; gender and work; and rural poverty and development and she has taught several classes and seminars regarding poverty including Sociology of Poverty; Poverty, Development and Social Welfare provision; and a Proseminar in International Development Studies. She has been published at least 20 times according to the Ohio University Department of Sociology and Anthropology website and has done extensive research on poverty, inequality, poverty in rural areas and welfare reform. This interview focuses on Tickamyer’s experiences researching rural poverty and her opinions of how it should be handled.

http://www.athensinteractivist.org/spotlights/group_spotlights/community_food_initiatives
Community Food Initiatives
by Crystal Edmunds, June 5, 2009

An article in the Athens local magazine Interactivist, self-proclaimed "Ohio's Only Progressive Magazine"

Lovingly known as the "Garden Lady" throughout Athens, Liz Shaw, Community Gardens Manager, has transformed the food security movement. With overflowing compassion and a wealth of ideas in improving the community and the world at large, Shaw has changed the way countless Athens residents view their connection to the food system and their own personal nutrition. She has planted the seeds of self-sufficiency throughout Athens, Ohio, and is expanding her mission as quickly as the Earth allows!

http://feedingamerica.org
How much do you know about hunger in the United States? This website gives you an idea who goes to food banks. You can read personal stories, find on an interactive map which food bank serves which counties in Ohio, and prove your newly gained knowledge in a hunger quiz.

http://www.ers.usda.gov/Briefing/FoodSecurity/
This website of the Economic Research Service of the U.S. Department of Agriculture provides current graphics and statistics on food insecurity.

http://www.hungercenter.org/resources.htm
The Congressional Hunter Center is an anti-hunger non-profit organization in Washington D.C. that includes members of Congress. It provides lists of national and international hunger and poverty organizations.

http://www.irp.wisc.edu/
The Institute for Research on Poverty at the University of Wisconsin in Madison tells you who is poor, how many children are poor, and a list of publications on poverty research.

http://www.acfb.org/projects/community_garden/plant_a_row/
Plant a Row for the Hungry: An initiative that encourages people who have a garden plant to an extra row of corn or lettuce you something else you can donate to your local food bank.

Food prices

http://data.bls.gov/PDQ/outside.jsp?survey=ap
Bureau of Labor Statistics Consumer Price Index Average Price Data U.S. City Average