"Food apartheid” to blame for diabetes prevalence in Native Americans

Almost 1 in 6 Native American is affected by diabetes, and those who are affected are twice as likely to suffer from complications related to diabetes than white Americans, according to a survey from Podimetrics.  

 “Unfortunately, the challenges of broader access to care, particularly for Native Americans, frequently have a significant impact on their health outcomes,” shared Dr. Janet Simon, executive director of the New Mexico Podiatric Medical Association and a podiatrist who has served the Native American community for almost three decades. 

“In one case, an individual had already undergone a partial foot amputation on one foot. I’ve been monitoring this patient for many years and noticed significant vascular issues in the other foot, necessitating further vascular diagnostics.” 

Finding a specialist to take care of the patient was especially challenging given the provider shortage in New Mexico, but Dr. Simon and her associates managed to quickly locate someone capable of performing the necessary diagnostics.  

A major hurdle was transportation. Although the patient didn’t live very far away, traveling to Albuquerque was still a 30-mile journey. He missed his first appointment because his truck broke down. They rescheduled, only to face insurance push back.  

“To proceed with an angiogram, which was crucial for the patient’s treatment, the insurance company mandated a six-week waiting period. We, along with the vascular service provider, tried to negotiate with the insurance company, but it was challenging.” 

The out-of-pocket cost for an angiogram in Albuquerque ranges from $5,800 at UNM Hospital to upwards of $11,000 at the Presbyterian Hospital. The median income  in Albuquerque is $30,000. 

In the meantime, the patient developed worsening symptoms.  

“The best thing we could say at that point is he needs to go to the emergency room. So that’s what transpired and it led to a second partial foot amputation,” Dr. Simon shared. “Looking back, it’s hard to say if an earlier intervention could have changed the outcome. However, we certainly hoped for a better and earlier response to prevent this progression.” 

“This example illustrates a common challenge we face in podiatry. We often identify problems that are linked to broader systemic issues. These cases require attention from specialists in other fields. However, the scarcity of such specialists can lead to increased morbidity among our patients. Due to the lack of available specialty care, our patients often experience more severe health complications. This situation is a recurring issue that affects a wide range of patients, impacting their health outcomes significantly.” 

SDOH factors affecting Native Americans

While digital health tools, such as remote patient monitoring technology, offer potential benefits, they cannot fully address the more pressing social determinants of health (SDOH) that disproportionately affect Native American patients. This community faces unique challenges, including a higher likelihood of poverty, with more than one in four living below the poverty line – nearly double the national rate and the highest among all racial groups in the U.S., according to data from Indian Health Services. Furthermore, Native Americans have the second-highest rate of homelessness at 10%, significantly impacting their health and access to care.   

Compounding these issues is a lack of transportation and connectivity in many regions where Native Americans live, rendering digital health tools less effective or sometimes entirely inaccessible.  

However, the most critical concern is food insecurity. A reported 60 reservations in the U.S. suffer from this issue. Native American households are significantly more impacted by food scarcity, being 400 times more likely than other U.S. families to report a lack of sufficient food.   

“I am very hopeful about significantly expanding the use of RPM (Remote Patient Monitoring) technology beyond our current capabilities. The main challenge we face is connectivity issues. Depending on the location, patients may not have reliable internet access. However, there are efforts underway to improve this, with substantial investments being made, particularly in New Mexico,” said Dr. Simon. “When considering additional non-clinical support for various tribal groups, a major issue is access to healthier foods and clean drinking water. The challenges in meeting basic needs like these continue to be a significant issue for many tribal groups.” 

“In many places, including where I currently live in Albuquerque, we face the challenges of both a ‘food desert’ and a ‘pharmacy desert.’ [We need] to change the language to instead say what it really is – food apartheid and pharmacy apartheid – and not focus on the environmental usage of the term because people have wrong impressions of what a desert is. Our native peoples have lived in the deserts for many, many years and they’ve subsisted quite well.”   

Currently, Albuquerque is experiencing what Dr. Simon calls a “significant loss of essential service.” Not only has the local Walmart and Walgreens closed, but real estate covenants prohibit selling the property to any entity that would provide  essential services like grocery stores and pharmacies, among other restrictions Dr. Simon explained.  “Personally, I can’t see how that could possibly be legal, but apparently it exists. It’s a reality in Walmart’s property management strategy. This greatly limits the potential buyers for the property, especially those who can’t adhere to these restrictions,” said Dr. Simon. Because of these covenants, she suspects the property might remain vacant for some time.  

“This situation raises serious concerns for the local population, particularly in the International District, which is the most diverse area here. Many folks in this area don’t have cars and rely on walking or public transportation for groceries and pharmacy needs. Let me be specific. We do have a few 7-elevens, I would say that’s not a primary grocery store for most people.” 

Historically, the International District was the site of Albuquerque’s first Walmart, opened in the 1980s. Initially, it was a standard Walmart without a grocery section. 

“When I arrived here in 1991, there was a full-service grocery store and various businesses in the same plaza. However, when Walmart transitioned to their ‘supercenter’ model, it negatively impacted these smaller businesses. Over time, several grocery stores, including a well-known local grocer, attempted to compete but ultimately failed,” said Dr. Simon.  

 The situation has led to a lack of accessible grocery options in the area, which is a significant concern for the local community – including prevalent type 2 diabetes. So far, 17% of Native Americans have already had an amputation due to type 2 diabetes complications, according to Podimetrics data. 

“I love the desert. It’s not a negative thing. It’s not lacking resources, it’s just different resources. Calling it a desert is blameless. It’s like, ‘Oh, that’s just how it is.’ When we reframe it, it’s clear.”