The gap between poor whites and affluent whites is similar to the gap between poor and affluent Hispanics, according to The Bee review of data from the California Health Care Survey, a bi-annual telephone survey of 50,000 Californians.

Federal research shows that ethnic differences in diabetes rates tend to disappear with improvements in living standards, said Ann Albright of the CDC.

Education, which is closely linked to income, also shows up in the statistics. Those with little education are more likely to die from diabetes, an especially troubling trend since the Valley has more high-school dropouts than the state average.

Of those who died from diabetes in the Valley, 43% did not complete 12 years of schooling, The Bee's analysis of death records shows. Statewide, a third of those who died from diabetes did not finish what is considered a high-school education.

You are what you eat

The Valley may be the fruit and vegetable basket of the country, but low-income diabetics aren't buying produce, said Ponce, the diabetes educator. That's partly why nearly two-thirds of Valley adults are obese or overweight and more vulnerable to diabetes.

"If you have limited money, you're going to buy the largest quantity of food," Ponce said. That means buying a loaf of white bread instead of whole-wheat, because white bread is cheaper. Hamburger is less expensive and more filling than lean beef or fish.

Many Valley homes rely disproportionately on foods that are cheap and high in carbohydrates, such as potatoes, beans and rice, said M. Daya Deyhim, a certified nutrition specialist at the Visalia Oak Health Center.

"I talk to some patients who say, 'I ate six tortillas this morning,'" Deyhim said.

Some of her patients only have tortillas in their cupboards, she said.

"Many times, if they are recipients of food aid, and it's the end of the month, that's all that's left in the house."

About 120,500 low-income adults in the San Joaquin Valley skipped meals and occasionally had gone to bed hungry in 2005, a UCLA report found.

Yet three balanced meals a day and exercise are key to diabetes prevention and control.

Sounds simple enough - eat right, exercise more - but nothing could be harder, said Dr. Christopher Rodarte, medical director at the Family Healthcare Network's Visalia Oak Health Center.

Rodarte has been treating diabetic patients there for a dozen years. He doesn't put much faith in diet and exercise alone to control his patient's diabetes, because most patients don't stick with it. "Maybe one of my patients a year will be successful," he said.

Deyhim said some diabetics deny they are obese rather than change their habits.

"People are surprised to find out that they're overweight," she said.

Getting diabetics to education classes can be difficult, said Dori Louie-Kai, program manager of the Community Diabetes Care Center in Fresno. Doctors will refer 20 patients, and 10 won't show, she said.

Some low-income patients don't have transportation or can't leave work, she said. But for others, "it's denial," she said. "They want to think something else is wrong."

Fear also is a factor. Some believe diabetes is an automatic death sentence, Deyhim said.

"It's just as complicated as people," Deyhim said. "There are as many reasons as people, as many perceptions and reasons for not doing things."

'I don't want to die'

Domingo Vega, 47, of Fresno ignored his diabetes for years. When he felt bad, he blamed it on a cold.

"I thought it was going to go away like a cold," he said.

He waited years to be diagnosed. His mother had diabetes, but he didn't think he had it. He nearly passed out from high blood sugar before he went to see a doctor.

The disease has progressed in the 15 years since his diagnosis. His legs hurt most of the time from nerve damage. "It feels like they're burning," he said. He needs to use a cane or walker and sometimes a wheelchair. Six years ago he had to stop working. He had been a window washer.

When he was first diagnosed, Vega said he was given a prescription of insulin and a box of needles. The only advice he got: "Stay away from sweets."

About three months ago, he began coming to the Community Diabetes Care Center. He's learning to take care of his feet so they won't get sores that could become infected, he said. He's eating better. "Before I was drinking sodas and eating like a pig," he said. "I wasn't watching nothing. Now I'm getting better."

And he checks his blood sugar - every day or every other day. "It takes a lot of discipline being a diabetic," he said.

His five children keep him motivated, he said. "I don't want to die right away."