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.
Women also can become diabetic during pregnancy. This can develop into Type 2 diabetes. But lifestyle and environmental conditions - such as physical inactivity and poor diet - are major causes and are driving the rise in diabetes in the Valley.
Almost 24 million American adults have diabetes. In the Valley, almost a quarter million - 244,000 adults - have been diagnosed, according to estimates based on the 2007 California Health Interview Survey, conducted by researchers at the University of California at Los Angeles.
Diabetes is a leading cause of blindness and kidney failure. And diabetics are two to four times more likely than average to suffer strokes or heart attacks, according to the CDC.
Many people can control their diabetes with diet and exercise, but pills and insulin are a mainstay for others. And more people are on insulin every year. Diabetes rates have been increasing nationally since 1990, reaching an average of 7.5% of adults in 2007. California had a rate of 7.8%, according to the 2007 statewide health survey.
The Valley outpaces both. Here, the diabetes rate is 9.4%.
These numbers are likely underestimates. Health experts say at least a quarter of the people who have diabetes nationally don't know they have it. In its early stages, people don't feel bad.
A web of factors
Obesity and poverty play the biggest roles in diabetes here, but the causes are complex. Many factors combine to make the Valley fertile ground for the disease.
Doctors cite urban sprawl, for example. People drive instead of walk because there's little choice. The result is inactivity, which leads to obesity - as well as air pollution. Recent research suggests air pollution could contribute to diabetes: A study at Ohio State University Medical Center found mice exposed to air pollution and fatty foods didn't process insulin as efficiently.
Experts see rising obesity as the leading cause of the proliferation of diabetes. They expect the number of diabetics worldwide at least to double in the next two decades.
California is analyzing the economic effect of obesity and diabetes, said Dr. Dean Schillinger, chief of the California Diabetes Program. He expects the price tag will be big. Among the the 2.5 million to 3 million diabetics in California, about one in 10 is covered by Medi-Cal - the federal-state insurance for the poor - and an equal number have no insurance, he said. "That poses a tremendous cost burden on the state."
Nationwide, diabetes costs have risen 32% since 2002, according to the American Diabetes Association. The tab for diabetes reached $174 billion in 2007, the association said.
One out of every five dollars spent on health care goes to help diabetics, according to the association.
Diabetics have to shoulder a part of those costs, depending on their insurance coverage - a per-capita average of more than $10,000 a year, the association said.
That's more than many Valley residents make in a year.
Trouble with care
Patients who can't afford care usually delay treatment, said Dr. Soe Naing, a diabetes specialist in Fresno.
Naing sees uninsured patients and those on Medi-Cal. But he's in the minority. Few doctors in the Valley, other than those in federally subsidized clinics, are willing to accept Medi-Cal's low payments, said LaNora Cook, a nurse specializing in diabetes at the Kaweah Delta Health Care District in Visalia.
Even private insurance is no health care guarantee. Patients with good insurance might not be able to get quick appointments with diabetes specialists, who are rare in the Valley.
Family doctors have little time to educate patients about diabetes, a disease that requires a lifelong commitment to self-management. When patients are diagnosed, they have a lot of information to digest - from how to give themselves an insulin shot to foods they should eat in moderation, such as potatoes, rice and beans.
Doctors refer diabetics to certified diabetes educators, but they're in short supply, too. The scarcity of Spanish speaking educators is especially troubling, said Angel Ponce, a registered dietitian and certified diabetes educator who has been working with diabetics for a decade in the Valley.
Diabetes hits minorities the hardest. Almost 8% of deaths among Native Americans were due to diabetes - twice the percentage of deaths from diabetes among whites, according to The Bee's analysis. Five percent of blacks and Asians died from it. And 6% of Hispanics died from diabetes.
A financial struggle
Every month, diabetes outreach worker Maria Zapata gathers Spanish-speaking diabetics at support group meetings offered by the West Fresno Health Care Coalition. Most who attend are low-income. At some point, the conversation invariably turns to the cost of medical supplies.
"We have people who can't buy anything," Zapata said.
A diabetic needs to keep blood-sugar levels in control to avoid complications. Good control means daily checking of blood glucose levels. The goal is to keep levels as close to normal as possible.
According to the American Diabetes Association that means 70 to 130 milligrams per deciliter before meals, and less than 180 two hours after starting a meal.
To know the numbers, a diabetic pricks a finger and puts a drop of blood on a testing strip. The patient checks the blood on a glucose meter, a machine about the size of a deck of cards.
Doctors usually recommend Type 2 diabetics check their blood sugar levels one or two times a day. Each testing strip costs $1, Zapata said.
Many of the support-group members can't afford $60 a month for test strips, she said. So they test less often and can't regulate their medications as well.
Antonia Zamora, 51, of Fresno is one. She was diagnosed with diabetes a year ago and had a blood sugar level at that time of 350, almost three times higher than the normal limit before a meal. For the past year, she's tried to check her blood sugar - but usually only once a day - when she has strips. She had none last month, when she attended the support group. "About a week without them," she said.
Zamora's husband died a year ago, and she hasn't worked as a farm laborer since that time, Zapata said, translating for Zamora, who speaks Spanish. The health care coalition provided Zamora with a glucose meter, Zapata said. But it's useless without the testing strips.
As with many in the support group, Zamora doesn't have health insurance.
Her family helps buy some of the medical supplies, and she gets low-cost health care at the Saint Agnes Holy Cross Clinic at the Poverello House.
Research more and more is tying diabetes to poverty, and for all too many diabetics in the Valley, poverty is a fact of life.
Four of the poorest counties in the state are in the region. Among those four, the poorest is Tulare County. Almost 24% of that county's residents lived in households with incomes below poverty level, according to the U.S. Census Bureau.
This doesn't bode well for the fight against diabetes in the Valley. Mexican-American adults are 1.7 times more likely to have diabetes than whites, according to a new state legislative task force report on diabetes and obesity. But poor whites in the Valley get diabetes as often as poor Hispanics.
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."