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Race and place matter when it comes to diabetes

This article first appeared in the St. Louis Beacon, Nov. 20, 2010 - The genealogy bug first bit Anita Jenkins in the 1970s when she saw the television series "Roots." She takes pride in having traced her family's history at least as far back as antebellum days, and she hopes to turn to DNA to move even further back in time.

In the process of her search, however, she also turned up a family history of diabetes. She mentions this as she stands next to pictures of relatives that line the mantel above the living room fireplace in the family's two-story brick home on the north side. On this day the house is quiet, save for the hum of an air conditioner, on a bright summer afternoon. But she's in a gloomy mood as she introduces the faces in the photographs and talks about how diabetes has affected many of those lives.

"My mother had it," she begins, her shoulders sagging. "Her mother and father had it. Her sister had it. All but one of her six brothers had it. My sister has it. My daughter, who's 24, has had it since she was 14, and I've been dealing with it myself for 30 years."

The family suffers from type 2 diabetes. It results from an inability of the body to use insulin, a hormone that helps convert glucose or blood sugar into energy. In recent years, the disease has begun to affect a growing number of whites as well as blacks, health officials say, as Americans become overweight and obese, exercise less and consume unhealthy food.

This is also a pocket book issue. Controlling and preventing the disease would save lives and money. The nation spends an estimated $174 billion a year on diabetes-related care, and as recently as 2006, Missouri was spending $3 billion, a lot of the money going to address complications instead of prevention.

Diabetes hasn't been as devastating for many African Americans as it has for Jenkins, 54. But the disease continues to take a disproportionately heavy toll on blacks. The Missouri Foundation for Health said in a report last year that diabetes was the fifth leading cause of death for African-Americans in Missouri, and ranked as the eighth leading cause for whites.

In 2007, according to the Missouri Department of Health and Senior Services, 387,247 Missourians were estimated to have diabetes:   8.1 percent of all white Missourians; 11.5 percent of all African Americans in Missouri and 11.7 percent of Hispanics in Missouri.

A study by the Department of Health for the city of St. Louis reported a 2007 diabetes mortality rate of 51.1 per 100,000 population of African-Americans in the city, 27.6 per 100,000 of white city residents and 37.4 for all city residents.

African-Americans Endure More Amputations

A report by the Dartmouth Atlas Project notes that race and place not only affect the incidence of diabetes but influence treatment. In some instances, changes in a diabetic's blood vessels and nerves can result in ulcers. If they do not heal or result in other complications, doctors might recommend that the limb be amputated. The Dartmouth report noted that African-American Medicare patients lost legs to amputations at a rate nearly five times that of whites. The study suggested that factors beyond the health-care system -- such as poverty and health literacy -- may account for the disparity in amputations.

Like some other diseases, diabetes can be controlled and even prevented, and its causes stem from several factors. Aside from lack of physical activity and being overweight, diabetes is linked to a family history, as Jenkins knows all too well.

The Missouri Foundation for Health report also cites lower levels of vitamin D12 and higher levels of cortisol13, also known as a "stress" hormone, as being among factors affecting the prevalence of diabetes among African Americans. The report says cortisol output increases in relation to stress and contributes to heart disease, as well as diabetes.

Access To Supermarkets And Exercise Facilities Matters

The high incidence of diabetes among blacks is one more reminder that where people live makes a big difference in their health. In some instances, residents can help ward off diabetes itself and its side effects through exercise and diet. It's probably no accident that the prevalence of diabetes is higher in zip codes offering consumers the least access to safe public places to exercise and limited access to full-service supermarkets where they might buy fresh fruits and vegetables.

Public health officials point out that having access to these amenities won't necessarily mean all residents would take advantage of them, but they add that giving people convenient access to grocery stores, parks and playgrounds would make them more likely to use them to eat better and exercise more.

As a health risk, diabetes itself isn't the only problem. Equally troubling is the number of serious illnesses it can trigger: heart disease, vision problems and blindness, kidney failure and stroke.

Jenkins, a city worker who handles Medicaid billing issues, has experienced some of these problems. But she isn't one to think of the disease as a family curse. She blames her situation in part on her failure to make healthy choices in her life.

"Having this so long and not taking care of myself the way I should have contributed to my problems," she admits. "I know many things happened because I didn't follow what the doctors told me to do. And I tell my daughter not to go down the same path that I've gone down."

Jenkins thinks the problem for some African Americans boils down in part to culture and habits.

"How things taste is a big issue in my family," she says. "They like fried fish because it tastes better to them than baked fish, which is better for me. When you have people in the house who don't want to eat what you're supposed to, it's extremely hard to eat what I should."

Her problem is complicated by the cost of some medical supplies. She uses a hand-held meter into which she inserts a small plastic strip containing a drop of her blood to test her blood sugar. If the number is too high, it could mean she's consuming too much of the wrong food and may require her to inject insulin into her body.

"I must have a ton of those little meters. They're free, but I can't always afford the strips to use the machine. Sometimes I have to go without prescriptions because I can't afford the co-pays. I have no choice because I still have to keep my lights on, and my gas bill has to be paid."

Her health insurance covers part of the cost of the strips. Depending on which supplier is used, Jenkins says her out-of-pocket cost for the strips is about 50 cents each. They usually come in quantities of 50 or 100. It meant running through a box in less than a month when she was required to test her blood sugar five times a day. Meanwhile, Jenkins said her out-of-pocket costs for a three months supply of pills might run as high as $70. That has dropped somewhat recently since losing weight has meant taking fewer medications, she said.

Help Is Available

Jenkins praises efforts by the St. Louis Diabetes Coalition to show people things they can do to prevent and control the disease through diet and exercise. She adds that people need to find places to exercise even if they live in a north side neighborhood, as she does, where they might feel unsafe taking brisk walks on sidewalks or in parks in that part of town.

Jenkins has found help and support from work-based exercise and weight-loss programs. The city, she says, offers lots of options to promote wellness among its workers. One place she recommends for fellow workers is the gym at the St. Louis Police Academy downtown, which she says workers can use for $10 a month.

At one point, Jenkins decided it was too difficult for her to lose weight, so she underwent gastric surgery, which has helped her lose 135 pounds. It helped her fight diabetes, too, she says.

"Before the surgery, it was five shots of insulin a day. After the surgery, it then went down to one shot a day. I still take pills but nowhere the number that I took before."

The main thing Jenkins has learned about diabetes is to take nothing for granted. That includes limbs and eyesight. Because of the disease, she has had surgery to remove two toes, and she has had eye surgery because she says the disease has affected her vision.

"It's always something," she says of diabetes. "A lot of the time, I just don't feel well."

This story was written with the assistance of the Dennis A. Hunt Fund for Health Journalism, which is administered by the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism. Funding for health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.

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