Diabetes care in the context of food apartheid: patient experiences and the case for structural competency in North Philadelphia

As the number of people living with chronic conditions and food insecurity increases, addressing how structural forces drive poor health outcomes becomes both an ethical obligation and a practical necessity to mitigate health disparities. Few studies have explored patients’ lived experiences managing diabetes while navigating food insecurity. In North Philadelphia, where the average life expectancy is approximately 20 years lower than in Center City–only five miles away–and where food apartheid remains a pressing issue, exploring patients' lived experiences can illuminate how structural forces shape diabetes management and healthcare interactions. This thesis explores the lived experiences of patients with diabetes who are also experiencing food insecurity through qualitative interviews conducted with patients receiving care at a primary care clinic in North Philadelphia. Using thematic analysis, interview transcripts were coded to identify recurring patterns in how participants navigate diabetes management while facing structural barriers to accessing healthy foods. Participants described challenges related to neighborhood food environments, financial barriers to healthy food and medications, and gaps in healthcare system responses to food insecurity. At the same time, participants demonstrated significant agency in attempting to manage their health despite these barriers. These findings reinforce existing literature on the bidirectional relationship between food insecurity and diabetes while providing insight into how structural conditions shape patients’ daily experiences with disease management. Through a health justice lens, this thesis argues that integrating structural competency into primary care practice is essential to addressing the social conditions that undermine diabetes management. Supporting more empathetic and structurally informed clinical encounters can help ensure that patients are able to meaningfully exercise agency in managing their health.