By Coshandra Dillard
Coping with diabetes in a rural area can be challenging, as residents deal with social and environmental obstacles. The biggest factor is nutrition — or lack thereof.
East Texas highways and black-top roads are littered with fast-food restaurants and convenience stores that sell a plethora of unhealthy food.
Where there aren't fast-food restaurants, there are country cafes, which offer plenty of Southern staples that have been fried and slathered in gravy or butter.
It's part of East Texas' culinary heritage.
“We fry everything and we bake,” said Dr. Renee Bean, a primary care physician at East Texas Medical Center in Frankston. “It's kind of a country thing to do. We fry our chicken fried steak and eat our mashed potatoes and gravy because that's how Grandma taught us to cook.”
Meanwhile, farmers' markets and produce stands are far and few in between. Medical professionals, along with public health officials cite the lack of affordable, healthy produce as one of the reasons for East Texas' obesity rates and chronic illness. Even at some grocery stores, the produce aisles are becoming littered with unhealthy items.
There are few sidewalks, walking trails, recreation centers and fitness facilities to allow more activity in some rural areas. The effects of poor nutrition and inactivity are far-reaching.
Chris Taylor, executive director of the Cherokee County Public Health Department, said a chronic illness such as diabetes drains an already dire economy. Nationally, it costs the U.S. more than $174 billion each year in direct and indirect costs.
In East Texas, preventable hospital stays from diabetes patients cost more than $219 million between 2005 and 2010, according to data from the Texas Department of State Health Services' Center for Health Statistics.
“Healthy people go to work,” Taylor said. “Healthy people volunteer. Healthy people contribute to an economy. Sick people don't. They draw from the economy. So, if your population is made up of mostly sick people, you will never get the community centers and the sidewalks.”
ANDERSON COUNTY'S CHALLENGES
Among the counties with some of the poorer health outcomes in the state include Anderson and Cherokee. More than 10 percent of Anderson and Cherokee county residents have diabetes, which is slightly higher than surrounding counties as well as state and national figures.
Dr. Bean knows firsthand — as a resident and a physician — how typical Southern foods and lack of resources contribute to poor health. In addition, nearly half of all Anderson County restaurants are fast-food places, further exacerbating health problems.
She cares for patients who hail from surrounding rural towns. Diabetic patients comprise about 60 percent of her practice.
Dr. Bean grew up in Elkhart, a town of about 1,200 in southern Anderson County. She began medical school in 1995 and always knew she'd return to East Texas to practice medicine. The state of health then and now has not changed much, she said.
While life expectancy in Cherokee and most other East Texas counties has improved slightly since 1989, Anderson County has remained relatively flat. At 70.2 years, Anderson County males have the lowest life expectancy in the state. In 1989, their life expectancy was 70.1, and it dropped to 69.2 in 1999.
Anderson County, with a population of about 58,000, has an obesity rate of 33 percent and about 32 percent are inactive, according to the University of Wisconsin's annual County Health Rankings report.
About 22 percent of Anderson County adults are smokers.
“Diabetics never need to smoke,” Dr. Bean said. “Never, ever, under any circumstances should a diabetic be smoking because you're just taking the two highest contributing risk factors for heart attack and stroke, and you're doing them both.”
Thirty-one percent of the county is uninsured, and doctors are spread thin. The ratio of patients to doctor is 2,268:1. The state's ratio is 1,050:1 and 631:1 at the national level.
FINDING GOOD NUTRITION
Cherokee County, population 51,140, has health outcomes that rival Anderson County.
“It's clearly because this is a poor county,” Taylor said. “We don't have a corporate setting where people are being paid competitive salaries.”
From the moment one enters the intersection of U.S. Highways 69 and 79 in Jacksonville, it provides a snapshot of unhealthy eating: a cluster of fast-food restaurants. According to County Health Rankings data, 62 percent of restaurants in the county are fast food.
“Lower-income families suffer the most because they're the ones who get the biggest bang for their buck out of the 99 cent fries and everything else,” Taylor said. “Whereas, people who are more affluent can afford the fruits and vegetables. I like to argue that it's a choice too, but if I have a choice between feeding my kids and getting their medications, too, and I can get both by getting them junk food, which in the back of my mind is once in a while, I may make that choice. But you don't realize how often you do it.”
He added, “The economy is driving what people are selling. Unfortunately, what's fast and quick and cheap is what we're feeding our families.”
Linda Henderson, a nurse practitioner at the health district, estimates that 35 percent of clients, if not greater, are diabetics.
Throughout her nursing career, she's seen the effects of obesity and how choices lead to chronic disease. She's not surprised by the outcomes.
“When you go to the stores, buying fresh fruit, fresh veggies, it's a whole lot more expensive to buy those items than it is to buy, say, a box of macaroni and cheese that will fill you up and will go longer,” Ms. Henderson said. “It's cheaper to eat junk.”
As for exercise, she said it's as simple as moving the legs.
“I don't advocate joining a gym, necessarily, or going to the track, buying equipment,” she said. “Get up and move. Walk in place, if that's all they can do, something to exercise.”
Learning to make the right choices is a key to managing diabetes, Ms. Henderson said. An important change is not drinking concentrated sweets such as soda, which she calls “liquid diabetes.”
“We teach,” Ms. Henderson said. “We teach that you have a choice to eat that candy bar or have your circulation cut off or end up on dialysis.”
She added, “My goal to my patients is to be healthy. You exercise. You eat right. Eventually if you stick to that plan, you can get your blood sugar down to a level where you can cut back on medication.”
In Alto — a community of about 1,200 just south of Rusk in Cherokee County — residents don't have many options for grocery shopping. One produce stand is only available during the summer. There is another produce stand outside of the city limits and a small grocery store, where some residents say the items are too pricy.
Kathy Davis, with the Alto Economic Development Corp., said many people are starting to grow their own produce. Others travel to Lufkin, Nacogdoches or Jacksonville for their medical and grocery needs, which can be a challenge while the price of gas and other necessities remain high.
She said there are no parks, gyms, nor sidewalks except for downtown.
“It's so rural,” Ms. Davis said. “We have no clinics, no hospitals, no health resources whatsoever that the citizens of Alto can take advantage of.”
In April, Ms. Davis established a program, Alto Health for All, which offers health screenings and information to residents. Through the program, the organization has partnered with the Alto Food Pantry and is interested in joining forces with area health care providers. She ultimately would like to attract a clinic there.
“We're trying to make it easier to access or at least maintain the screenings so they know what's going on and report back to their doctor,” Ms. Davis said.
She is also interested in establishing a farmer's market. Meanwhile, she is researching grant opportunities to aid the small town.
EDUCATION AND RESPONSIBILITY
When Dr. Bean diagnoses a patient with diabetes, she immediately sends them to a diabetes class. There, patients can learn about proper nutrition, signs and symptoms of hyper- and hypoglycemia, how to use a glucometer, managing medications and insulin injections, long-term efforts of poor maintenance, and more.
“It teaches you everything that you never wanted to know about diabetes, but you must know in order to extend your life,” she said.
Most hospitals have some type of diabetes education, but it isn't always free.
“If you have insurance, insurance typically covers it,” Dr. Bean said. “If they don't have a lot of extra money lying around, they're probably not going to spend it on a Saturday course at the hospital to learn about their disease. They don't think they need all of that information.”
Lack of education clearly is the root of many noncompliant patients' health woes.
“I don't want to use the word ignorant, but it is ignorance,” Dr. Bean said. “It's not that they're ignorant as a person but they're ignorant of the seriousness of the disease. Part of that is our fault. That's a physician's fault not to explain to them that diabetes is not just a 'little sugar.' ... You'd be surprised how many patients I get that transfer to me who have been seeing another doctor, and they've never been educated on what they should and shouldn't eat, and exercise. They never went to diabetes education.”
She said many residents in the two counties are manual laborers with jobs that do not offer health insurance. So, as Dr. Bean explained, they may only go to the doctor when they absolutely must.
This is risky for diabetics, as they must follow up every three months for blood work. The most frequent complication of diabetes she sees is heart disease.
“They've never been educated on their disease process, for multiple reasons,” Dr. Bean said. “Some of it is that they don't take it seriously enough to attend the diabetes education courses that we try to set them up for.”
There are social issues as well as ingrained behaviors passed down in each family that make it difficult for physicians to solve Americans' obesity and chronic disease problems.
Nonetheless, Dr. Bean — a mother of four — said she has to do her part by leading by example. She runs half-marathons and adopts healthy habits.
“Lord knows, I try,” she said. “No one will take care of me but me. You have to do the same thing. I know it's hard, trust me. At some point in time, you have to find time to take care of yourself or you won't be there to take care of your kids.”
She added, “I can do everything I can, but only you can take care of you. Most people, if they have the facts, they will do something with them.”
With all of the education, establishment of programs and messaging, it still takes more, public health officials say.
“It is motivation,” Taylor said. “It is getting them to undertake a behavior change, not because we tell them to, but we have convinced them that it's good for them.”
Dr. Bean doesn't think much will change in some rural areas. There's no peer pressure to be active like in big cities, she said, and furthermore, people want to hold onto the way things have been done for generations.
“A lot of it is just the way we were raised,” Dr. Bean said. “Honestly, I think that's what people consider the beauty of the country is things just don't change. … Things don't change much around here.”