Every week in the San Joaquin Valley, at least 19 people die of diabetes - and the death toll is rising.
The disease has reached epidemic proportions nationwide, but few places are as stricken as the Valley's eight counties, from San Joaquin to Kern. Nowhere in California are people more likely to die of diabetes than here.
The complex web of reasons include obesity and poverty.
The Valley's fast-food, car-centered culture is partly to blame, health experts say, because it packs pounds on waistlines. The agriculture-based minimum-wage job market keeps people poor and unable to afford healthier foods, they say. And a doctor shortage has stalled efforts to bring the epidemic under control.
Now the disease touches nearly one out of every 10 people who live in the Valley - compared to 1 in 13 statewide. It steals eyesight, burns nerves, disables organs. It kills. An analysis of state death records and other statistics by The Bee and the Center for California Health Care Journalism at the University of Southern California paints a vivid picture of the disproportionate toll diabetes takes here:
* Minorities are up to two times as likely as whites to die from diabetes and its complications.
* Less educated residents are more at risk. Almost half of those who die lack high school diplomas.
* The poor - regardless of ethnic background - are more likely to get the disease than other Valley residents.
Many people don't even know their bodies are in trouble until it's too late. Symptoms start slowly, and the disease can take years to kill. So diabetes probably is a bigger health menace than anyone knows.
In fact, doctors and health officials say diabetes leads to heart attacks, strokes and high blood pressure but often is not listed as even
a contributing factor on death certificates.
Recent advances in treatment are slow to reach the Valley, where doctor specialists of any type are in short supply.
The Bee's analysis shows diabetes kills people sooner here. Statewide, 27% of people killed by diabetes died before turning 65. In the Valley, the figure is 32%.
Yet despite widespread concern in the medical community about the threat of diabetes, for many patients the diagnosis still comes as a surprise.
'Oh, not me'
When George Nunez of Fresno was younger, he ate fast food and never gave a thought to diabetes, even though it runs in his family. Today, he's legally blind because of the disease.
Nunez, 49, had a stroke about six years ago that ruined his vision and left his voice almost a whisper. He had to quit working at a bio-mass plant in 2000 and is now on disability.
For about the past nine years, he's been on dialysis. A kidney transplant in May 2008 failed after a week.
Nunez's mother has diabetes, and his father had it before he died, Nunez said last month as toxins were removed from his blood by a machine at the Community Dialysis center in Fresno.
"You don't think anything is going to happen," he said. "You know relatives have 'the sickness,' but you just think, oh, not me. And one day you wake up and you're in the same boat your family has been in."
Diabetics have too much glucose, or blood sugar, that builds up in their bodies. It attacks organs, nerves and blood vessels anywhere in the body, blocking nutrients they need to function.
Insulin regulates blood sugar. In Type 1 diabetes - the most common type among children - the body's immune system destroys pancreatic cells that make the hormone insulin.
About 90% to 95% of diabetics have Type 2, in which the body becomes resistant to insulin produced in the pancreas, and gradually the organ stops producing the hormone, allowing blood-sugar levels to rise out of control. Scientists know that genetics play a role: Type 2 diabetes runs in families and is more prevalent in African Americans, Hispanics and Native Americans, according to the federal Centers for Disease Control and Prevention.