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Diabetes Forecast

The Healthy Living Magazine

Homeless With Diabetes

How do you manage your diabetes when you're worried about finding your next meal?

By Lindsey Wahowiak ,

Claudette, 69, has been homeless for more than 10 years. Every day, she faces enormous challenges: finding enough food, getting to social services appointments, staying safe on the streets. But for the former schoolteacher from Washington, D.C., living without a home is even more difficult because she has type 2 diabetes.

More than 3 1/2 million people in the United States are homeless, according to a 2007 study by the National Law Center on Homelessness and Poverty. Some live in shelters, like Claudette (who asked that her last name not be used), while others couch-surf, double- and triple-up temporarily with other people in houses or apartments, or live in cars or on the street. The rate of diabetes among people who are homeless is hard to track, but researchers and advocates estimate that it's higher than it is among the general population (25.8 million children and adults in the United States, or 8.3 percent of the population, live with diabetes).

One of those advocates is Kathleen Gold, RN, MSN, CDE, director of outreach and education with the Diabetes Research and Wellness Foundation. Through that organization, she works as the diabetes advocate at Unity Health Care Clinic at the Community for Creative Nonviolence, a shelter in Washington, D.C. Each Thursday, she sees about a dozen homeless people, checking blood glucose logs, making referrals to specialists, and discussing ways patients can best take care of their health. "What I try to do is spend as much time with them as they need," Gold says. "We touch on other issues, not just diabetes: food, food stamps, depression. … They really are very motivated, and they try to make good choices."

As anyone with diabetes knows, trying to make good choices is only one part of managing diabetes. Gold and some of her patients explained the biggest obstacles to managing diabetes without a home to call one's own.

Food

To say food is a big deal for homeless people is an understatement. For homeless people with diabetes, it's almost an insult. That carefully balanced tightrope act of food, exercise, and medication is made even more dangerous when you don't know where you'll find your next meal, or what it might be.

How to Help

Diabetes nurse Kathleen Gold suggests ways to make sure items that you donate to food banks and shelters are diabetes-friendly.

At a food bank or
soup kitchen:

Donate fresh food. Most of the items at food banks are shelf stable and have added fat, sodium, and sugar. A sack of oranges or a donation of lean meat can be a nutrition boost. Just make sure the location accepts perishable items.
Check in to see what's needed. Some food banks, such as Feeding America, work with local farmers and gardens to glean food for the hungry. Ask where the gaps are (low-fat dairy foods, perhaps) and fill them.

At a shelter:

Give exercise equipment. Gently used workout gear, including hand weights and resistance bands, can be used indoors or out and promote good health. Bicycles double as exercise equipment and a mode of transportation.
Donate toiletries. Gum disease can make blood glucose difficult to manage, so a gift of toothbrushes or toothpaste can be a literal lifesaver. Dry, cracked skin that's been exposed to the elements is more likely to be wounded; lotion is helpful.
Offer ID necklaces. Medical ID jewelry can be especially helpful for someone who may not have any other form of identification. Something that can be written on, such as a wallet card, is useful as well.

Take Claudette, for example: She gets one meal a day at the shelter: dinner at 4:30 p.m. If she's not back from a doctor's appointment or meeting with a social worker about getting a magnifying glass so she can read (her retinopathy, she says, has been getting worse), she misses that guaranteed meal. She needs to have enough money to buy breakfast and lunch. There's a McDonald's just a block from the shelter, but she has to be careful about what she orders so her blood glucose levels don't spike too high. Some evenings, a food truck will stop by the shelter with free soup or sandwiches. But Claudette walks with a cane and must use the elevator to get from her room in the shelter to the truck downstairs.

"By the time I get down, the line is so long. If I can stand that long, they run out," she laments. Sometimes, if she has a few dollars or something to trade, her friends in the shelter will get some food for her. Otherwise, she fuels herself with hard candies (though many shelters ban residents from having food on their person).

This type of food insecurity is common among the homeless, says Gold, for various reasons: Many people who have no home or job also have no set schedule. When you can't plan for lunch at a certain time with a certain carbohydrate count from day to day, regulating blood glucose can become a challenge—if not an impossibility.

The trouble, too, is relying on food stamps, the kindness of others, and prepackaged foods to carry you through the day. Deborah Caldwell, 55, has lived in a Washington women's shelter for five years. She has access to a refrigerator, which is great for storing insulin to manage her type 2 diabetes. But she doesn't have access to a stove, so cooking isn't an option. It's hard, she says, chewing on a glucose tablet. But she makes it work.

Medication

For homeless people, finding food and shelter come well before caring for their health. Yet health care is a huge concern for those who don't have a home. With no permanent address, no reliable transportation, no insurance, and no steady income, getting to a doctor's office can fall lower on the priority list. Yet people who are homeless are more prone to disease and infection than the rest of the population, says Gold. That's why Unity Health Care Clinic is vital: It offers homeless people in the District of Columbia a single location where they can meet with a dentist, optometrist, podiatrist, general practitioner, HIV specialist, and rehab specialist.

And Gold's patients, she says, are invested in their own health. She says her homeless patients are much more likely to remember to bring their meters to appointments than her patients who have homes. "Homeless people do test. They might not have a log, but they never forget their glucometer," she says. "They like seeing a trend and using that information to make a decision."

Doretha J. Pearce, 45, will tell you she lives "in the wilderness, in the jungle." That is to say, on the streets of D.C. While pregnant with her third child, she developed gestational diabetes. After her fourth, she says, "it stayed." She's been managing her type 2 diabetes ever since and has gotten creative with how to do so. Some pharmacies will give her a single vial of insulin at a time, which she keeps cool on hot days by filling a juice bottle with cold water, then popping the insulin inside. She tests her blood glucose levels at least five times a day, carrying hand-sanitizing spray to keep her hands clean and get an accurate reading. It's not always easy, she says, but it's a necessity. "This life is another life," she says. "When you're homeless, you'll find anything to [take care of your health]."

Some organizations and businesses take steps to help homeless people. One pharmacy in Washington dispenses medication and insulin in very small doses. People with diabetes may have to get refills more often—but they won't have to worry about storage or having a month's supply of medication stolen. Yet that's not always an option. Some shelters lock their refrigerators or have specific staff members in charge of medication. If the person with the key or the medication isn't in, it can be dangerous, says Darlene Jenkins, DrPH, MPH, CHES, research director of the National Health Care for the Homeless Council.

Stress

Anyone with diabetes can tell you that stress absolutely affects blood glucose levels. Very little could be more stressful than living without a place to call home. Scheduling can play a major role in that stress, Jenkins says. "When you have unstable housing, you don't have that routine, as far as meal regularity," she says. "You might be at a church for lunch Tuesday and Thursday, a shelter on Monday and Wednesday, and youth group may be handing out sandwiches on Friday night. Eating regularly at certain times is not there. It can lend itself to more issues," she adds, such as hypoglycemia.

The stress is more than uncertainty about your next meal, Gold says. Even if you live with friends or in a shelter, there's the uncertainty of whether you'll have a bed that night, sleep well, and be able to keep your belongings, such as medications and emergency glucose, with you.

During the day, shelter residents almost always must leave the building, usually in the early morning. Some look for jobs or work, while others try to make their way through the social services system. Meeting with social workers (for mental health support, getting on food stamps, etc.), doctors, and housing officials takes time, almost a job in itself.

Exercise, a pivotal part of controlling diabetes, isn't something many people think of when considering the homeless. But it's an issue in two ways, Gold says: People in rehabilitation programs and some shelters aren't allowed to leave the premises and might not have access to exercise equipment. In contrast, people on the street are constantly moving, walking around. Blood glucose can drop dangerously then, as Pearce knows all too well. It's happened to her a few times. "My sugar dropped to 30. I could feel it coming," she remembers. "When it happens, I've got to sit down, even if it's in the middle of the damn sidewalk. Because if you don't sit, it'll knock you down."

It Could Be You

The stereotypical image of homelessness, Jenkins says, is a man with substance abuse problems, mental health issues, or both. But in the current economic climate, the face of homelessness also includes women, families, and the elderly, often people who are simply down on their luck. "There's a story behind every face, and it could be my story. It could be your story," she says. "People who are experiencing homelessness are our neighbors."

That's Claudette's experience. Nearly a decade ago, she was a teacher, taking a taxi to catch her morning commuter train to work. Her cab driver crashed into an electric company truck, and she was pinned in the back of the car. Claudette was hospitalized for three months and no longer able to work. She lived on her savings for as long as she could, but after a year and a half, she had lost everything. "I thought it was going to improve," she says. "It is foreign to me because I used to be so independent. … I'm reduced to almost nothing and can't control anything anymore.

"These are the things we are going through," she adds. "I'm not crazy, I'm not drunk. It's my disease, and I have to go somewhere to get help."

With unemployment high and the population aging, there are bound to be more people like Claudette seeking help. The National Alliance to End Homelessness reported in 2011 that the U.S. homeless population was likely to increase by 5 percent, or 74,000 people, over the next three years, burdening an already stretched social services system.

But for the people who are getting specialized diabetes care, like Gold's patients at the clinic, things are looking up. "My sugar had been high for so long, but it's dropping now," Pearce says. "I got myself back together."


Homelessness in the United States

  • More than 3 1/2 million people in the United States are homeless (more than 1 percent of the population), according to a 2007 study by the National Law Center on Homelessness and Poverty.
  • The National Health Care for the Homeless Council (NHCHC) served 825,295 patient visits in 2011. Of those, 159,449 visits (19.3 percent) were with people who had diabetes, though visits relating specifically to diabetes care made up only 6 percent of its services.
  • About 650,000 people were "absolute homeless" (on the street or in temporary shelters) on any given night in 2009, according to a Department of Housing and Urban Development study.
  • NHCHC estimates that 70 percent of its clients do not have health insurance.
  • The homeless die at much younger ages on average than other Americans, according to the National Coalition for the Homeless. The average life expectancy in the homeless population is estimated at between 42 and 52 years, compared with 78 years in the general population, a 2005 study found.
 
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