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Changing the Diabetes Forecast for Minorities in Arkansas
Sylvester usually prepared multiple turkeys: grilled, roasted, smoked and fried, as well as the rest of the dinner. "He said he had the flu," Smith said, "but I didn't believe it. There were dark, dark circles all around his eyes, and you could see the skin on his hands changing before your eyes. It looked like he was aging at light speed." Because her husband did not want to go to the doctor, Smith started making calls to family members, describing his symptoms and trying to find out if anyone had an idea what was going on with her husband's health. A family member recognized his symptoms as the same that had claimed the life of another relative, who had died in his sleep from diabetes without ever being diagnosed. Only after looking up the symptoms of diabetes online did Sylvester Smith agree to go to the hospital. "We're both college-educated, but we didn't know what the signs of diabetes were. We didn't know he had a family history of diabetes. We didn't know African Americans were more at risk. We just didn't know," Smith said. On Thanksgiving Day, Sylvester Smith was admitted into intensive care, where he stayed for three days while doctors worked to get his blood sugar stabilized. That's when Judy Smith became passionate about educating minority groups, the highest risk demographic for diabetes, about the many dangers of the disease and the steps to prevent it. Five months later, she was promoting diabetes prevention, early detection and self-management, as well as other public health issues, from her new pulpit of the Arkansas Minority Health Commission. "It's an epidemic," she said of diabetes, "And it's hitting our African Americans and Hispanics harder than anyone. We've got to get quality information into the hands of as many Arkansans as possible." Hard Numbers Alarming new figures confirm Smith's assertion. A study led by Dr. K.M. Venkat Narayan of the Centers for Disease Control's (CDC) diabetes epidemiology and statistics branch and published in the September 2006 issue of Diabetes Care predicted that 48.3 million Americans will have diabetes by 2050. This is an almost 20 percent increase over the CDC's predictions just three years ago, and a 198 percent increase from the 16.2 million Americans with diabetes in 2005. Even more disturbing are Narayan's projected diabetes rates for minority groups. While whites are expected to experience a 113 percent increase over the next 44 years, the increase for blacks is almost twice that at 208 percent, and 481 percent for Hispanics. The hardest hit age/race ethnicity group is African Americans over 75 years old, who can expect a 606 percent rise in diabetes in the coming decades. Narayan stated that the projections have limitations. The study assumes the rate of new cases will level off at 2004 levels, unlikely if obesity prevalence continues to rise. Calling implementation of evidence-based primary prevention "an urgent national priority," the article cautioned: "For a chronic disease such as diabetes, small shifts in incidence have large implications for future prevalence of and numbers with the disease. If incidence rates continue to rise, the impact on future numbers with diabetes, and consequent healthcare costs, will be much more devastating." Another study, commissioned by the Arkansas Minority Health Commission in 2003, found that there was a 152 percent disparity in the mortality rates of black diabetics as compared to white diabetics in Arkansas. She said that studies have found a disproportionate number of amputees among African American diabetics as well. Barriers Within Barriers Arkansas minorities face "barriers within barriers" to getting effective diabetes care and prevention, Smith said. While matters of insurance, money, transportation, literacy, education, and the severe lack of Spanish-language translators and bilingual materials are major challenges for minority healthcare in general, diabetes carries with it additional burdens unique to the disease. Smith said she thinks there is a lack of understanding among many minorities about the importance of going to the doctor for diabetes even though they are "truly afraid" of a diagnosis. "In the African American community, especially, we hear people say, 'Oh, I've just got a bit of sugar' as a way of dismissing it since it's so common," she said. "It is such an overwhelming disease, and most people do know someone who has diabetes, know an amputee or a diabetic who has gone blind, and no one wants to face that they might be next." The disease, too, is rife with complications and instructions that affect almost every aspect of a diabetic's daily life, from what insulin dosages are required for different blood sugar levels to what shoes the person puts on in the morning. Smith said that the two-and-a-half hour consultation she had with her husband's nutritionist after his initial diagnosis was the most overwhelming experience of her life. "I felt completely inadequate to give my husband the kind of care the dietitian said he needed to stay alive," she said. Sylvester Smith was the cook of the family; Judy Smith had not cooked or shopped for a meal in the eight years she served in the legislature. So the Smiths decided they would order the diabetic meal from the hospital cafeteria three times a day for two weeks to see what diabetic cooking looked and tasted like. She now recommends that course of action for newly diagnosed diabetics and their families. "It was the best education of my life," she said. "Doctors just don't have time to give diabetes patients all the information and explanations they need, even when they can finally get them in the office," she explained. "It's a lot more involved than just getting people to eat better, exercise and take their medicine. We have to find new ways and systems that work to reach these people and help them be smart about their health before there's a family crisis." It's a daunting problem, but a number of creative and non-traditional initiatives are underway in the state to meet the needs of those at highest risk. Community-Based Lifestyle Changes The people of the predominantly African American Arkansas Delta region are among the most rural, isolated and economically disadvantaged in the nation. The regional culture, lifestyle, geography and economics converge to create the ideal circumstances for a diabetes epidemic. But something positive is happening in Marvell and soon, possibly the entire Delta. Marvell, population 1,395, is a typical small Delta town. Almost 36 percent of the households make less than $15,000 a year. Twenty percent have no vehicles, and some 12 percent have no phone service. A quarter of the population is over age 60, and the town is about 60 percent African American. And diabetes rates there are up to triple the considerably high national average. Marvell is the target site in Arkansas for a United States Department of Agriculture (USDA) human nutritional research program designed to combat diabetes and other health risks in impoverished rural areas by improving access to and education about healthy living choices. Nutritionist Margaret Bogle is executive director of the USDA's Lower Mississippi Delta Nutrition Intervention Research Initiative, a collaboration of the UAMS College of Public Health, the Arkansas Children's Hospital Research Institute, the University of Arkansas at Pine Bluff and the University of Arkansas Cooperative Extension Service. The project has three test cities — besides Marvell, there is one in Mississippi and one in Louisiana. All three states in the project rank in the top five nationally in diagnosed diabetes cases, Bogle said. "One of the very basic health problems we've found in the Delta," she said, "is access to quality food. It's a myth that rural areas are full of homegrown fruits and vegetables. There are large-scale farms, but almost no produce grown for local consumption." Markets of any kind are scarce in Marvell. The city has one grocery, a general mercantile establishment about the size of a fast-food restaurant. Although it has a quaint Southern feel and old hardwood floors, the store's produce section is miniscule. "What fruits and vegetables are available in Marvell are few and not very good quality," Bogle said. "And the nearest supermarket is over 20 miles away in Helena." As part of the nutritional intervention, the project has begun teaching people to grow their own fruits and vegetables in community gardens, and the city received a grant to create a farmer's market. Another aspect of the project was to establish a nutrition and walking club. "We call it 'the walking club,'" Bogle said, "but that's really a misnomer. The participants meet on Saturdays for a sort of cheerleading meeting, and they have an educational aspect of the meeting where they learn about healthy foods, how to enhance recipes to make them low-fat, low-salt, and low-sugar, but still tasty." The project is very heavily community-based. "A big part of our success is because we involved the community leadership from the start," Bogle said. "Instead of saying, 'We want you to participate in this study,' we said, 'What kind of needs does your city have? These are what we see, but how would you like us to help?'" The walking club emerged from the city's suggestions. Although it was understood that exercise improves health, Marvell had no city gym available for residents to exercise. The intense heat precluded walking during daylight hours much of the year, and there were few safe, lit areas available for walking after dark. Bogle said the research initiative helped light and renovate an existing walking trail for the city, and it started group-based walking activities to encourage utilization of the new resource. Although their ages range from teens to seniors, the majority of the participants are older African American adults. Other parts of the project will involve a modified version of the DASH (Dietary Approaches to Stop Hypertension) eating plan for the community, recommended by the National Institutes of Health, as well as a workplace nutritional intervention and a body mass index-lowering plan for the Marvell School District. Bogle said the organization would continue to work with the community and evaluate the results of the Marvell project for some time in the hopes that it can transplant the lessons learned to other resource-hungry towns. "Just waking them up to the need to take care of their health and showing them how to do that is a major step, even if it's a small one," Bogle said. Health Before Wealth Similarly, on September 28, the Delta Regional Authority announced another concentrated diabetes-reduction effort for the area. Rex Nelson, alternate federal co-chairman of the eight-state organization and former communications director for Gov. Mike Huckabee, said that while it's unusual for what is primarily an economic development organization to get into the healthcare arena, the board determined that having a healthy workforce was a prerequisite to fostering any kind of sustainable economic development. "We've got to do human development before we can advance in any other area," Nelson said. "We started with diabetes because the epidemic is nationwide, but it is even greater in the 240 counties and parishes we serve than it is anywhere else in the country." Nelson said the sedentary lifestyle is the major reason diabetes is flourishing in the Delta. "It's a caricature, of course, but it's almost safe to say that the average Delta citizen is sitting on the couch, has a rib in one hand and a cigarette in the other hand," Nelson said. "You've frankly got to change that lifestyle. You've got to get people up and exercising, get them eating very differently than they ate or their parents ate or their grandparents ate in this part of the country, and get them to give up smoking." Called Healthy Delta, the project involves three steps: a media blitz spreading diabetes information, a 24-hour diabetes call center that directs residents to testing and treatment resources in their area and follows up with them for three months to see if they have accessed care, and a database that tracks patients' progress as they move through the system. Haircuts and Hymnals As additional funding becomes available, a certain part of the program will be targeted specifically to minority communities. Nelson said the Delta Regional Authority has hired an expert in minority outreach, a man who helped get Ray Nagin reelected mayor of New Orleans this year by working with African American churches and neighborhoods. "He's taught me a lot about reaching minorities," Nelson said. "You go through churches; you go through barbershops, through beauty shops. We're going to try some nontraditional methods to get the message to people who might not get it otherwise, people who would not necessarily respond to the television ads we have up and who would never see a Web site, but who would work through their health fairs sponsored by their church and so forth and get some testing." The Arkansas Minority Health Commission is also promoting Southern Ain't Fried Sundays, a program that disseminates diabetes information through minority churches. The commission developed a cookbook with healthier Southern-style recipes. It holds a potluck at the church using the recipes in the cookbook and give copies of the book to the members. Those who cook the meals also receive a Southern Ain't Fried apron and everyone takes home refrigerator magnets and Bible bookmarks with the symptoms of diabetes, heart attack and stroke for future reference. "We targeted 10 counties and we hoped to get one church in each county," Smith said. "We ended up so far with 133 churches in 21 counties. It's very, very popular." Smith said another new program the commission is co-sponsoring with the American Cancer Society helps people become more physically active at church. "They bring in an expert from Memphis to train trainers to help church members exercise," she explained. "I think if they just put on some gospel music and move around for a bit every day of the week, that would help a lot of people." Family Matters Hispanic populations also benefit from a more nontraditional approach to diabetes care. In September, the CDC recommended engaging entire Hispanic families and communities in diabetes prevention and management. "One of the things we've learned is that if you want to get more people in the Hispanic community involved in health promotion activities, it's vital to focus on the entire family," said Guadalupe X. Ayala, PhD, MPH, research director at the San Diego Prevention Rescue Center, in a CDC press release. CDC-sponsored research in Hispanic-centric prevention in other states includes teaching relatives to help diabetics in their family manage the disease and prevent it in themselves by eating well and staying active, and creating walking clubs for adults and soccer leagues for disadvantaged children. Bogle said that although she was not aware of diabetes-related nutritional research published on Arkansas' Hispanic population, she knew that in Texas' lower Rio Grande Valley, a Hispanic-dense area, studies showed that diabetes rates greatly increased as Hispanics' diets became more Westernized. "Traditionally, they bake, grill, or boil a lot of foods, but the American way of cooking Mexican food is to fry everything and cover it with extra fats," she explained. "Hispanics' traditional diet is limited in nutritional variety, but much healthier than what we do to it." Conversely, she pointed out, Asian Americans, who have drastically lower obesity and diabetes rates, have a diet rich in a variety of vegetables and whole grains. "We could learn something there," she said. The Huckabee Factor Smith, Bogle, and Nelson all agree that Gov. Huckabee's well-known story of taking his diabetes and lifestyle choices into his own hands has benefited the state, and particularly the state's minority children, citing in particular his efforts to provide healthy choices and anti-obesity programs in public schools. "The doctor scared Mike Huckabee by telling him he was probably in his last decade of life," Nelson said. "And I know it goes against the grain to tell physicians it's time to start scaring people, but when it comes to diabetes, we've reached that point in this country. We spend such a huge amount of our healthcare budget on treating the effects, and we've got to move toward preventive care." Smith said: "The Governor's done a lot to raise awareness of diabetes in this state and I think the state of Arkansas is making tremendous progress as it relates to diabetes, but we just can't do enough for our people. I don't want another person to have to find out about diabetes like my family did." For more information, visit www.healthydelta.com and www.arminorityhealth.com. ie. November 2006 Tags:NoneBookmark:
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