environment and diabetes mortality and morbidity, especially among low income people who live in areas which are designated as food deserts in Fulton County, Georgia. The study intended to highlight the importance of access to healthy food and its implications on diabetes health status.
Study Limitations
This study had some limitations which could have potentially affected the statistical results in the data analysis. The data available for diabetes mortality and morbidity from OASIS has some data gaps and missing data due to which the results might have some irregularities. Another major limitation in the dataset is that the diabetes data is from the year 1994 to 2010. During this period, the total number of census tracts has changed. The number of census tracts at present is 204 (Census 2010) but previously it was 167. The data for diabetes is based on 167 census tracts, and the rest of the dataset has values for the new increased number of tracts as per 2010 Census. Hence, some census tracts have been split into more than one tract and therefore, there is some inconsistency while comparing the two datasets. Another limitation of the study is that the diabetes data available for this study is the total number of diabetes related cases in the County. This does not differentiate between type 1 and type 2 diabetes. Type 2 diabetes mellitus is responsible for nearly 95% of diabetes cases in the United States (WebMD, 2013). Among the causes of this type of diabetes, overweight, obesity and lack of physical activity are the most common causes (Diabetes Health Center, 2013). Food environment has a profound impact on one’s diet and can affect the health status of people without access to quality food in the form of type 2 diabetes. But this study has not been able to show the relationship of food environment with type 2 diabetes alone. Other limitations of the study include not considering built environment and
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County. The food stores were classified using ReferenceUSA’s customized search terms. The terms used for classifying different food stores were restricted to supermarkets and grocery stores, convenience stores and fast food joints. Hence, the tracts could have other food stores such as farmers market or personal kitchen gardens as source of fresh food. Food store classification errors could have modified the results of the study.
Discussion
The first research question looked at whether there is an association between diabetes mortality and morbidity and living in food deserts. GIS analysis of the data using ArcGIS 10.1 suggests that food desert census tracts have a higher occurrence of diabetes related morbidity and mortality compared to other census tracts in the County. It was hypothesized that there is a negative relationship between living in food deserts and developing diabetes or dying from the disease. This hypothesis stands true. Studies have reported how lack of access to quality food can lead to diet related chronic diseases such as obesity and type 2 diabetes mellitus. But contrary to previous studies, this study area shows a positive correlation between presence of a supermarket and grocery store and diabetes. The areas which have more supermarkets and grocery stores have higher occurrences of diabetes.
The positive correlation between convenience stores in census tracts and number of diabetes related illness and deaths, supports previous research. While this research question was partially answered by the findings, some new questions were generated. Some census tracts that were designated as food deserts have less deaths and hospitalizations from diabetes while other tracts that are not food deserts fare poorer in their diabetes health status. Hence, there are other factors associated with diabetes health status which need to be studied. None of the variables except for income had a strong correlation or was statistically significant, which was expected since there are number of factors which can
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relationship between food environment and diabetes, or car ownership and diabetes might be merely due to chance than caused by the variables studied. The GIS analysis in this study to some extent supports evidence found in the literature review that shows diet related diseases such as obesity and diabetes are more pronounced in food deserts. Although the correlation is weak it still corresponds with previous studies. USDA’s Economic Research Service (ERS) Reported in 2009 that 23.5 million Americans, including 6.5 million children, live in low-income areas more than one mile from a supermarket (Healthy Food Access. Know Your Farmer, Know Your Food Compass). Low income communities with more African Americans suffer from lack of access to grocery stores and supermarkets with fresh food and vegetables (Williams, 2010). They have depended on convenience stores and fast food joints which provide cheap and easy alternative to healthy food. As a result, African Americans are more prone to develop diet related diseases such as diabetes. This study partially supports evidence from previous research that there are few healthy food stores in most of the low income neighborhoods of color. Predominance of convenience stores is observed in the food desert census tracts of Fulton County although the study could not come up with a statistically significant correlation between diabetes mortality, morbidity and presence of convenience stores. Convenience stores do not provide for healthy fruits and vegetables. Many common convenience store choices like hot dogs, candy bars and soft drinks are rich in calories but low in healthy nutrients (Healthy Food at Convenience Stores, 2013).
Apart from food environment and income, lack of personal vehicles has been an important factor associated with diabetes prevalence. Few studies have looked at this aspect of diabetes prevalence. This study shows a positive association with lack of personal vehicle and diabetes related illness in the census tracts. One reason could be since these areas do not have sufficient number of food stores, lack of personal vehicle restrict the residents from travelling greater distances in search of fresh quality food. This could be another reason why they rely more on fast food and convenience store food which is readily available in the low income tracts, triggering occurrence of diabetes among the residents.
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Studies have shown that eating out and particularly fast food consumption has contributed to weight gain and related diseases. Greater access to fast food outlets and other restaurants can contribute to higher levels of obesity, especially in individuals who rely largely on the local environment for their food purchases. Car ownership might moderate this association (Inagami S, Cohen D.A., Brown A.F., Asch S.M., 2009).
Conclusions
This study is among the first to consider association of diabetes and access to food in Fulton County, Georgia. Most of the studies to date have looked at similar associations with obesity. Recommendations have also been made to reduce prevalence of obesity by enhancing access to fresh healthy food in low income neighborhoods through policy changes or by encouraging farmers market so that the residents have easy access to fresh food. But similar recommendations are not in place to alleviate diabetes prevalence. Fulton County ranks high in diabetes related mortality (OASIS). Studies like this one will provide information to County health officials to address diabetes health status by improving access to quality food in low income neighborhoods with higher prevalence of the disease. The study not only demonstrates the geographic distribution of the disease, but also provides a comprehensive picture of the association with factors that can potentially influence this prevalence such as race and income along with supermarket and grocery store distribution and car ownership. The study can serve as a base for future interventions into diabetes related policy changes at micro levels such as census tracts in Fulton County, Georgia.
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