At the senior center in Kerman, Calif., Rosendo Iniguez demonstrates how to cook a more healthful version of empanadas. Although such traditional Latino dishes are typically high in calories, fat and carbs, Iniguez is showing how diabetics can create healthier versions by making simple substitutions.
With his black hair and engaging smile, Iniquez fields questions in Spanish as he demonstrates how to make dishes more diabetes-friendly by using brown rice instead of white, and trading guacamole for fresh salsa.
“Many of these dishes are engraved in the culture of Latino families and it can be very hard for them to be diagnosed with type 2 diabetes and then told to give up the foods you’ve eaten since childhood,” says Iniguez, program coordinator for the California Health Collaborative’s Diabetes Education Program in Fresno.
Better eating habits are crucial to keeping diabetes under control. In addition to a poor diet, low levels of fitness and high body mass index are also associated with the onset of diabetes.
Iniguez has seen firsthand the tremendous impact diabetes has had on California and the Central Valley in particular. He watched his grandmother die from complications caused by type 2 diabetes and his father has also been diagnosed with the illness.
A report released this past March by the UCLA Center for Health Policy Research says that diabetes and prediabetes have hit epidemic proportions in California, with the Central Valley’s eight counties, from San Joaquin to Kern, being among the hardest hit.
Diabetes can cause heart, kidney, eye and dental disease, stroke, nerve damage, circulation problems, infections of the feet that can lead to amputation, and death.
Pre-diabetes diagnoses surging
In San Joaquin County, 37 percent of young adults ages 18 to 39 and 49 percent of adults overall have also been diagnosed with prediabetes. Overall in California, an estimated 46 percent of adults in the state have prediabetes or undiagnosed diabetes.
The term prediabetes is fairly new. The American Diabetes Association (ADA) set the criteria for prediabetes as an HbA1C level of 6.0 percent to 6.5 percent. The next year, the ADA lowered the threshold for prediabetes to an HbA1c level of 5.7 percent..The HbA1c test is a blood test that measures the history of someone’s blood sugar levels over the past 3 months. It is also used to determine how well as person is managing their diabetes.
The Center for Health Policy Research report also found racial and ethnic disparities, with statistically higher prediabetes rates among young adult Pacific Islanders (43 percent), African Americans (38 percent), American Indians (38 percent), multiracial Californians (37 percent), Latinos (36 percent) and Asian Americans (31 percent) than among white young adults (29 percent).
As the number of people diagnosed with prediabetes increases, some experts have cautioned that the label may not be the best approach to preventing diabetes.
In their research paper published in the July 2014 issue of The BMJ (formerly the British Medical Journal), Victor Montori, professor of medicine at the Mayo Clinic in Rochester, Minn., and John Yudkin, emeritus professor of medicine of University College London, advise doctors to tell their patients that “a diagnosis of pre-diabetes does not mean that you will develop diabetes. In fact, of 100 people like you, fewer than 50 are likely to develop diabetes in the next 10 years.”
“We know prediabetes is receiving a lot of national attention from organizations including the Centers for Disease Control and Prevention (CDC) and the American Medical Association (AMA),” says Gabriela Spencer-Bonilla, a Mayo Clinic researcher who works with Montori in the Knowledge and Evaluation Research Unit at the Mayo Clinic. “Our concern is that if nearly half of all California adults are categorized as having undiagnosed diabetes or prediabetes, it’s likely to overwhelm the state’s health care system.”
At-risk groups reached through community efforts
Spencer-Bonilla says that efforts such as the CDC’s National Diabetes Prevention Program serve to provide important information about healthy eating and being physically active, but she worries that such program might not be accessible to those who need it most.
Relying on a diagnosis to identify people in danger of getting diabetes leaves out a lot of the at-risk population, Spencer-Bonilla says.
“Participants first need to be diagnosed with prediabetes or diabetes before being referred to the program, and this means they need to have health insurance and be under the care of a physician,” Spencer-Bonilla says.
Spencer-Bonilla says community-based programs, similar to the one being offered by the Diabetes Education Program, are needed to truly help those who are at most risk of developing diabetes.
Iniguez estimates that forty to fifty percent of clients in the Diabetes Education Program don’t have health insurance. “They may be undocumented or lack access to health care. If they do receive medical care, it might only be when they suffer complications of diabetes, and are seen in an emergency room.”
Iniguez and his colleague Brandi Muro, program manager of the education program, which is funded by Kaiser Permanente, have provided free diabetes self-management classes to the residents in West Fresno and Kerman for the past two years. The six week series of classes aim to prevent or manage the illness in an at-risk population of Latinos.
At the beginning of the class series, participants are given a health assessment, where they receive an A1C blood test that offers a picture of their average blood glucose (blood sugar) control for the past 2 to 3 months. Their body mass index is also measured.
The six classes cover the pathology of diabetes and stress management, how to control diabetes through nutrition, the dangers of sugary beverages, the importance of physical activity, medical management of diabetes and how to avoid health complications.
Rather than waiting for participants to come to them, the program has partnered with the Fresno Housing Authority, where site managers go door-to-door talking to people who may be at risk of diabetes, and encouraging them to attend classes. Local schools also take a proactive approach in promoting the classes.
Even as they caution against the use of the pre-diabetic label, Montori and Yudkin say that prevention efforts should likewise cast a wider net in medical settings. Doctors should prescribe a healthy diet and regular physical activity to all patients, they say, as the best way to prevent diabetes.