“Exhaustion of food budgets might be an important driver of health inequities” – Hilary Seligman and colleagues

By Zuleyka Zevallos, PhD
The internet is filled with many science blogs and websites holding themselves up as experts on all sorts of research topics. It’s frustrating to see the high volume of articles where non-experts feel qualified to dismiss social science research. The damage is worse when it’s journalists and scientists without social science training, because the public doesn’t always know that these people aren’t qualified to write about social science. I will demonstrate this through a case study of the sociology of diabetes.

With increased media attention on diabetes, the public has come to expect certain behaviours from people who have this condition. While some people understand that there are some differences between the two broad types of Diabetes (Type 1 and Type 2), there are many misconceptions about what causes diabetes and how this condition should be treated. With these misconceptions comes judgements about the people who get diabetes, and why this may be the case.

I am not an expert on the biology of diabetes. I can however speak to the sociological aspects of this disease. As an applied researcher, I have worked on projects in the sociology of health, such as examining the influence of organisational practices on health outcomes. I’ve also researched socio-economic disadvantage amongst minority and vulnerable groups and the impact this has on social integration, help-seeking behaviour and wellbeing. Social disadvantage will be the focus of my analysis here. I use my discussion on the socio-economics of diabetes to explore the problems that arise when non-experts wade into social science issues using individual explanations (such as personal experience and opinion) rather than scientific evidence about societal processes. I call this “arm chair” social science because it does not adhere to the social theories and methods for analysing social issues.

My post begins with the social science research on diabetes, centred on the research of Hilary Seligman. Her team’s work was refuted by a science blogger who is not a social scientist, and who subsequently posted this critique to Science on Google+, a large multidisciplinary Community that I help moderate. Below I discuss Seligman’s longitudinal research on how poverty affects the experience and management of diabetes. Seligman uses the concept of “food insecurity” to situate her research. I draw on other studies that lend further support to this concept. I discuss the influence of social location on the management of diabetes. That is, I will examine the socio-economics of where people live as a key factor in diabetes care. I end with a discussion of the exchange on the Science on Google+ Community and the problems of viewing diabetes from an individual perspective.

Social Science of Diabetes

Let’s start with the new study published in the peer-reviewed journal Health Affairs. Epidemiologist Hilary Seligman (MD) and colleagues find that Americans from low socio-economic backgrounds who have diabetes are more likely than other income groups to end up visiting a hospital due to hypoglycaemia.

Hypoglycaemia occurs when blood glucose level is too low. Common causes include strenuous exercise, alcohol, too much insulin, but also “Delaying or missing a meal; (and) Not eating enough carbohydrates [my emphasis].”

Seligman’s team examined hospital admissions for an eight year period (2000-2008). Hospital visits increase by 27% at the end of the month for poor people, though there are no temporal fluctuations for people from higher socio-economic backgrounds. Seligman’s team argues that food insecurity is a key factor in these patterns.

Food Insecurity

Food insecurity: “The limited or uncertain availability of nutritionally adequate and safe foods or uncertain ability to acquire acceptable foods in socially acceptable ways.”

The USA National Research Council defines  food insecurity as having limited access to safe nutritional foods that are obtained through “socially acceptable ways.” That is, without resorting to “emergency food supplies, scavenging, stealing, or other coping strategies.”

Returning to Seligman’s study, diabetic patients from poor backgrounds are running out of money to pay for food towards the end of a monthly pay cycle, which affects their low blood sugar levels, triggering a health emergency.

This research is one of various longitudinal projects led by Seligman, who examines the link between food insecurity, poverty and diabetes. For example, using longitudinal data from the National Health Examination and Nutrition Examination Survey from 1999–2002, and involving a sample of over 4,400 Americans, Seligman’s team finds that a higher proportion of people who experienced severe food insecurity are also diabetic (16% versus 12% of food secure and 10% of mildly food insecure). Food insecure people also experience greater levels of anxiety and stress which further exacerbates their health problems. Elsewhere Seligman has also found that food insecurity leads to multiple heath issues increasing cardiovascular risk. Furthermore 69% of people with diabetes who also live with food insecurity are unable to achieve a healthy blood sugar level (hemoglobin A1c). In comparison, 49% of food-secure diabetes sufferers experienced this problem, suggesting that food insecurity plays an important role in managing diabetes.

Poverty and Health Disadvantage

Data from numerous studies support the conclusions of Seligman’s team study. The social science on the material reality of poverty, food insecurity and health shows that diabetes management is not really a simple matter of personal choices. A review study shows that up until the mid-2000s, research on diabetes firmly established that poverty significantly impacted the risks and management of diabetes, but these studies initially downplayed the institutional impact of poverty on diabetes. At that time, most studies focused on individual-level causes and treatments, such as the dietary, lifestyle and exercise habits of individuals. These studies did not examine the material reality and institutional constraints under which these habits are made.

In the present-day, studies continue to find a link between food insecurity, diabetes and health management, but the focus is now firmly on the institutional and social factors.

The American Dietetic Association has identified that food insecurity is a contributing factor to diabetes. Food insecurity is correlated with chronic illnesses including diabetes.

Low-income people who are diabetic are more likely to experience food insecurity and as a result they are more likely to require treatment by physicians relative to people with diabetes who do not experience food insecurity. Other studies have identified that people with diabetes experience hypoglycaemic reactions as a direct outcome of not being able to afford food. Food insecurity and socio-economic factors influence how people with diabetes access quality care and their “ability to adhere to recommended medication, exercise, and dietary regimens, and treatment choices” [my emphasis]. The same conclusions on food insecurity and diabetes are supported in other nations like Australia.

Social location

Socio-economic & material constraints on illness & wellbeing. This includes the spread & management of disease plus access to safe & adequate resources of care.

The sociology of health examines the socio-economic and material constraints on well-being. Social location matters to the management of diabetes. In low-income urban areas, it is not so much that people choose to eat “bad” food that impacts their blood sugar levels, such as high sugar or high fat junk food. The fact is that, in some areas such as urban poor neighbourhoods, healthy food is not readily available at local food stores or when such healthy food exists, it is too expensive. Travelling to another neighbourhood to buy fresh vegetables and other healthy food have to be factored into the costs of purchasing food. Where people are tenuously employed, underemployed, unemployed and otherwise suffering from food insecurity, the costs of food rise.

The same is also true in poor rural areas. In one study of over 2,500 people, those suffering from diabetes (12%) were significantly more likely to live in food-insecure households (37.9%).

Moreover, when poor people make food choices, these decisions are weighted against everyday necessities, such as their bills. Their food needs and personal health comes secondary to paying the rent and other essentials. For example, the Hunger In America study included 62,000 clients who receive emergency food assistance by the national Food America (FA) national network, and a further 37,000 FA agencies including food programs such as food pantries, soup kitchens and emergency shelters. This study finds that almost half of the clients had to choose between paying for food versus utilities and heating (46%); 39% were forced to choose between food and rent or mortgage; 34% were choosing between food and medicine or medical care, and similar proportions were choosing between food and transportation to sustain other living costs such as travelling to work.

Most poor people still rely on walking and public transport to buy food, which negatively impacts their health, specifically by greatly limiting their ability to access secure healthy food sources. This situation is especially acute amongst minority people of Black and Hispanic backgrounds, the elderly and poor families with young children.

All of these data do not negate that diabetes is a complex disease involving genetics, nutrition and other factors. What this body of research shows is that there is a sociological component to this disease. Socio-economic relations hamper the risks and management of diabetes for different groups. A sizeable proportion of poor people with diabetes are, as Seligman and colleagues suggest, foregoing food in order to survive. So if the social science evidence supports this phenomenon, why can’t non-social scientists accept the conclusions?

When Non-Social Scientists Comment on Social Science

Stephen Macknik, who has a PhD in neurobiology, decided to write about Seligman’s latest study and refute her findings based on his personal experience of diabetes. Macknik is a blogger for Scientific American, writing a column called “Illusion Chasers.” He filed his post under “Fat Tuesday.” He believes that Seligman’s conclusions on food insecurity are wrong. He thinks these people aren’t experiencing hypoglycaemia at the end of their pay cycle because they have run out of money. He thinks it’s because they’re spending the last of their money on junk food. He says what is actually happening is that they overindulge in high carbohydrates, which triggers hyperglycaemia, and then as their blood sugar levels crash they experience hypoglycaemia. What evidence does he have for this? None.

He notes that he is diabetic, but he has never been poor, unlike the participants in Seligman’s study. He dismisses the concept of food insecurity because he simply believes that poor people with diabetes are making bad dietary choices. This is an individual level perspective on health based on speculation, not science. Moreover and most problematically, Macknik does not actually draw on the peer-reviewed science. He simply comments on a report about the study from the New York Times.

Macknik then posted a link to his blog to our Science on Google+ Community, which is how I learned of his post. One of our Community members, Michael Verona, questioned Macknik’s rationale, noting that the study has empirical evidence to back up its findings, while Macknik goes off personal musings. Macknik replies at length on his academic credentials. None of which include social science. I responded with a summary of the information I include here on my blog. Macknik did not respond.

Part of my critique to Macknik goes to the heart of my recent writing on public science outreach. The media dominates how lay people find out about science. Sometimes this reporting is correct. Often times it is skewed because it goes off a press release. (For the record, the New York Times article is brief but faithful to the ideas of the study.)

Blogging and social media have expanded how people read about science, but with this comes a host of problems. Non-experts feel entitled to refute scientific evidence based on subjective understandings of the world. Tom Nichols has outlined a powerful argument against this sense of entitlement. Speaking of the lay person wanting to dismiss expert analysis based on personal opinion, Nichols writes: “The expert isn’t always right… But an expert is far more likely to be right than you are.”

As I noted last week, personal attitudes are shaped by cultural beliefs and values, which in turn influenced by socio-economic status and other forms of social privilege. I showed that even amongst scientists, social privileges influences how people engage with scientific evidence.

A neurobiologist refuting the structural forces on disease based on a personal hunch (and coloured by privilege) is no better than a lay person refuting science based on something they watched on TV or YouTube.

Macknik admits that something needs to be done to address diabetes on a social level. The problem is that he feels qualified to disagree on why it’s happening based solely on stereotypes of what he thinks poor people do with their money. Blaming a specific subset of people for exacerbating their health problems only serves to increase the stigma they already face. These people are doubly disadvantaged, being both poor and afflicted with an illness that is not well-understood.

Science blogging carries with it tremendous responsibility. As Verona pointed out to Macknik, blogging under the Scientific American banner lends Macknik’s ideas additional authority. The average reader may not immediately be able to distinguish between a neurobiologist writing about this than a social scientist. Not all science experts are qualified to speak to other fields, and certainly not without valid scientific evidence.

When scientists write on other people’s research, our insights should be qualified within our disciplinary expertise. If we’re going to write about other studies, we need to add value. Most academic research sits behind a paywall and it is written in scholarly language. This means we have a responsibility to carefully explain the science using plain language, and to expand on or critique the findings using scientific evidence. Whether we have a PhD or not, extrapolating from personal experience is not science. The fact that Macknik is not poor perhaps makes him less sympathetic to the social reality faced by disadvantaged people, but I noted in my response to him that, had he been from the same background, this is still not scientific evidence. Social science analysis relies on empirical evidence, just as neurobiology and other fields do.

Macknik muses that poor people are splurging the last of their money on the “dollar menu,” resulting in “too many carbs rather than too few calories.” He draws on his subjective experience about diabetes as well as his personal ideas about how poor people live. There is a connection between obesity and poor nutrition for Type 2 diabetes, but the link is not so simple. First, obesity and associated chronic illnesses such as diabetes are also linked to food insecurity. This is especially a problem for children as well as women, two groups at a higher vulnerability to illness due to poverty. Second, these effects are compounded for racial minorities from lower socio-economic backgrounds, such as Hispanic people and Black Americans.

Either way, diabetes isn’t simply about individual neglect or simply making frivolous snacking choices. For some people with diabetes – the disadvantaged sub-group that Seligman was studying – the reality of living below the poverty line means having to choose between eating a proper meal and paying bills as well as keeping the roof over their family’s heads.

Seeing the food practices of people with diabetes as an individual choice – regarding high and low carb food – fails to take into consideration the socio-economics of food insecurity and public health. Given that the social science is solid, why would a science writer feel entitled to use their subjective ideas to argue against empirical evidence?

Moving Forward

Social Science: Evidence-based Expertise. Don’t rely on personal opinions on social issues. This can increase misconceptions & stigma of vulnerable groups. Original photo Anssi Koskinen, CC 2.0. Adapted by Other Sociologist

There may be a couple of explanations why non-social scientists think they are qualified to speak about sociological matters even when they lack the expertise.

First, as sociologist Duncan Watts argues, because social science deals with social issues, people see that the topics are familiar enough to be understood through “common sense.” Subjective experiences feel compelling because they give us first-hand experience in a topic. The problem is that common sense is often incorrect when we try to apply it to other groups outside our personal networks. Personal opinions are also informed by cultural beliefs that individuals don’t always understand in connection to history and social forces.  Experience is not the same as expertise. Understanding social phenomena is the speciality of social science.

Second, different societies understand health and illness in specific ways. Western societies tend to focus on health as an individual management issue. Social scientists like Seligman go beyond this individual perspective. Sociologists see diseases like diabetes as a public health matter. This is very hard for the general public to accept because specifically because it goes against “common sense.”

Diabetes involves self-care for sure. For example, individuals enter into dietary and lifestyle changes; they monitor their blood sugar levels; and they continue to see specialists. As I’ve shown, however, these individual actions are constrained by social pressures. Eating healthy is not just about avoiding junk food, it’s about what food is available, and in this case, whether enough food is available at all. Following doctors’ orders is easier when an individual does not have to cope with additional financial stress. In a society where values of individualism are the norm, health is perceived as a private matter that individuals manage alone.

Health and illness are not always just about an individual choices. While people have agency to make decisions about what’s best for them, these decisions are prioritised according to material and social constraints. In the case of poor people experiencing diabetes, their personal health sometimes has to take secondary position to their financial reality.

As the research shows, when people don’t have much money, food and health become a day-to-day management strategy, but other living expenses like shelter take priority.

The public doesn’t need further confusion from “common sense” and “arm chair” social science. We need real social science and collective social action. Diabetes research is a multidisciplinary research site, dependant upon collaboration across various disciplines. The causes and solutions of different types of diabetes need to be tackled from various angles, with diffusion of knowledge flowing across the life and social sciences.

Subjective ideas about diabetes are distracting. Let’s move away from individual explanations. Diabetes has a strong social component that is not about individual failure. Instead, it demonstrates public health inequality. The sooner society accepts this, the better we can move forward and better support those who need help most.

Connect With Me

Follow me @OtherSociology or click below!