Program Rationale

“A Rationale for the Implementation of a Faith-Based Intervention to Improve Nutrition to Reduce the Risk or Progression of Type 2 Diabetes and Hypertension in Baltimore, MD”

 

 

The Problem

 

An estimated 11.3% (or 37.3 million) of adults in the United States (U.S.) have type 2 diabetes (T2D). Of the 37.3 million U.S. adults that have T2D, 23% (or 8.5 million) of those cases are undiagnosed. Black adults are disproportionately affected by T2D in the U. S.  In fact, they are twice as likely as White adults to develop T2D (Brown et al., 2019). According to the Maryland Behavioral Risk Factor Surveillance System (BRFSS), diabetes prevalence is highest among Black Maryland residents at approximately 14.1%, notably above the national average of 11.3% (MD BRFSS, 2022).  The economic cost of T2D for the state is staggering. Maryland’s total direct expenses for diagnosed diabetes were estimated at $4.9 billion, and another $2.1 billion was estimated in indirect costs from lost productivity (MD BRFSS, 2022). While these costs are staggering, the resulting medical complications from the state’s residents with T2D are even more astonishing and include heart disease, stroke, limb amputation, end-stage kidney disease, blindness, and death (American Diabetes Association, 2021).

 

Equally as concerning, while approximately one-third of U.S. adults are hypertensive, Black adults have a higher hypertension prevalence rate of nearly 50%, among the highest of all ethnic groups surveyed (Aggarwal et al., 2021). Hypertension and T2D are comorbidities. Further, hypertension occurs twice as frequently in individuals with T2D than in those without it due to the upregulation of the renin-angiotensin-aldosterone system, oxidative stress, and inflammation (Petrie et al., 2018). In fact, one of the major underlying conditions of T2D is hypertension (Whitney & Rolfes, 2019, p. 582). The prevalence of these two chronic diseases contributes to significant morbidity and mortality. However, with the successful implementation of a nutrition intervention program that includes a robust education component as well as a viable way to address food insecurity, improvements can be made in decreasing disease risk and improving the health status of participants who experience one or both chronic issues.

 

The Priority Population

 

While the prevalence of T2D and hypertension are high among Black adults, the reality is that Black adults are far more likely to experience environmental, cultural, and socio-economic barriers to engaging in healthy nutrition and physical activity. Healthy People 2010 highlights the statistic that the racial/ethnic groups with the worst health status also have the highest poverty rates (Robinson, 2008). In the U.S., poverty rates are higher for African Americans than for Caucasians, which is linked to obesity resulting, in part, from first, the lack of healthy food options in economically disadvantaged communities and, second, the lack of income to be able to afford healthy foods even if food access were not an issue. Additionally, many urban communities lack the physical space that provides opportunities to engage in physical activity such as walking. To exacerbate this challenge, many of these communities do not have recreational facilities or neighborhood parks as options to engage in exercise.  

 

The Opportunity

 

The lack of preventative self-care, poor dietary habits, lack of nutrition education provided, and lack of trust in physicians are behaviors influenced by a collective history passed from generation to generation (Robinson, 2008).  Among the twenty-four Maryland geographical jurisdictions, Baltimore ranks number twenty-one in the highest prevalence of diagnosed T2D in the state (MD, BRFSS, 2022). In urban inner cities such as Baltimore, food deserts, with limited access to supermarkets or grocery stores, increase the difficulty of making healthier food choices. Based on their financial status, for many, their income is too high to qualify for government benefits and too low to afford healthier food options even if they did have adequate access. Health promotion programs do not often target the Black population.

Improving the health of this underserved and vulnerable population requires intervention efforts that target multiple goals and objectives in a setting with [people or entities] who have the community’s trust. The role of the Black Church extends far beyond its role in spiritual care and nurturing. Notably, they [Black churches] have been instrumental in promoting behavior change through disease-specific messaging associated with chronic diseases such as cancer and heart disease (Harmon et al., 2016). Church-based health promotions and interventions report positive results and are associated with improvements in nutrition behavior and health knowledge (Carolyn et al., 2019). For example, a six-week Church-based health promotion intervention, the Health-Smart Behavior Program, was conducted with Black adult church members (n=321) across 21 African Methodist Episcopal (AME) churches in Florida. The results of this intervention revealed significant positive increases in nutrition literacy and overall engagement in health-smart behaviors such as healthy eating, healthy drinking, and physical activity (Tucker et al., 2019).

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Many church interventions inspire and motivate intervention participants by reminding them of the important connection between mind, body, and spirit, as well as the responsibility to care for both their spiritual and physical well-being. For example, one intervention used the Bible scripture Hosea 4:6, which states, “My people are destroyed by a lack of knowledge,” to emphasize the importance of improving nutrition literacy by availing themselves of all opportunities to learn about the best ways to fuel their bodies using nutrition (Brown et al., 2019). While this intervention will be conducted within a church group setting, a long-term strategic goal will be to expand the target audience to be more inclusive of more members of the community who may not be members of this church or any other faith-based organization.

 

The Potential

 

A similar faith-based community health program, the HOSEA project, was implemented in 2019 in North Carolina, where T2D is the fourth leading cause of death. A follow-up study to the HOSEA project found that HOSEA participants self-reported eating healthier foods, controlling portions, and understanding the difference between the three macronutrients and their functions (Brown et al., 2019). Therefore, the Church is a viable and culturally prominent institution in the Black community with proven potential to promote the health and well-being of the community members.  In the short-term, participants will be given a series of nutrition lessons that outline the key components of a diet that improve T2D or hypertensive status. The nutrition options promoted in these lessons will be nutrients that are rich in vegetables/fiber, whole grains, fruits, and low in sodium, added sugar, and saturated fats. These options can help to reduce diabetes risk and complications and improve hypertensive status. This program will likely be successful because the participants' self-efficacy will be increased from nutrition lessons and activities where they learn what nutrients (foods) can provide optimal health benefits, understand how those nutrients can decrease the risk or progression of T2D or hypertension, and consequently make better nutrition choices.  For example, lessons will focus on ways to increase fiber intake, decrease processed food consumption (offering alternatives), and promote physical activity. In the long-term, engagement with convenience stores and local ‘carry-out’ owners may garner further support by obtaining buy-in to expand their health food offerings, increasing food access. An organized intervention/program team effort to establish a community Farmer’s Market provides an opportunity for local vendors to sell fresh fruits and vegetables, increasing availability and offering income opportunities for vendors or farmers. The collective efforts between the Church and intervention team have the potential to benefit the community by improving T2D and hypertensive disease status through increased nutrition literacy and food access, as well as the promotion of self-efficacy.

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REFERENCES:

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Aggarwal, R., Chiu, N., Wadhera, R., Moran, A., Raber, I., Shen, C., Yeh, R. & Kazi, D. (2021). Racial/Ethnic disparities in hypertension prevalence, awareness, treatment, and control in the United States, 2013 to 2018. Hypertension, 78, 1719-1726. https://doi.org/10.1161/HYPERTENSIONAHA.121.17570

American Diabetes Association. (October, 2021). The burden of diabetes in Maryland. https://diabetes.org/sites/default/files/2021-11/ADV_2021_State_Fact_sheets_Maryland_rev.pdf

 

Brown, C., Alexander, D., Ellis, S., Roberts, D. & Booker, M. (2019). Perceptions and practices of diabetes prevention among African Americans participating in a faith-based community health program. Journal of Community Health, 44(4), 694-703. https://www.doi.org/10.1007/s10900-019-00667-0

 

Carolyn, T., Kang, S., Ukonu, N., Linn, G., DiSangro, C., Arthur, T. & Ralston, P. (2019). A culturally sensitive church-based health-smart intervention for increasing health literacy and health-promoting behaviors among black adult churchgoers. Journal of Health Care for the Poor and Underserved, 30(1), 80-101. https://www.doi.org/10.1353/hpu.2019.0009

 

Harmon, B., Chock, M., Brantley, E., Wirth, M. & Hébert, J. (2016). Disease Messaging in Churches: Implications for Health in African-American Communities. Journal of Religion and Health, 55(4),1411-25. https://doi.org/10.1007/s10943-015-0109-3

 

Maryland Behavioral Risk Factor Surveillance Brief, February 2022. Diabetes in Maryland, Vol. 4, No. 1. https://health.maryland.gov/phpa/ccdpc/Reports/Documents/Diabetes%20in%20Maryland%E2%80%94Maryland%20BRFSS%20Surveillance%20Brief%202022.pdf

 

Peters, R., Aroian, K. & Flack, J. (2006). African American culture and hypertension prevention. Western Journal of Nursing Research, 28(7):831-54. https://www.doi.org/10.1177/0193945906289332

 

Petrie, J., Guzik, T., & Touyz, R. (2017). Diabetes, Hypertension, and Cardiovascular Disease: Clinical Insights and Vascular Mechanisms. Canadian Journal of Cardiology, 34(5), 575-584. https://doi.org/10.1016/j.cjca.2017.12.005

 

Robinson, T. (2008). Applying the socio-ecological model to improving fruit and vegetable intake among low-income African Americans. Journal of Community Health, 33(6), 395-406. https://www.doi.org/10.1007/s10900-008-9109-5

 

Tucker, C., Kang, S., Ukonu, N., Linn, G., DiSangro, C., Arthur, T. & Ralston, P. (2019). A Culturally Sensitive Church-Based Health-Smart Intervention for Increasing Health Literacy and Health-Promoting Behaviors among Black Adult Churchgoers. Journal of Health Care for the Poor and Underserved, 30(1), 80-101. https://doi.org/10.1353/hpu.2019.0009

 

Whitney, E. & Rolfes, S. (2019). Understanding Nutrition (15th edition). Cengage Learning, Inc.