Nancy Rivera once had a blood sugar level more than four times the normal range, a danger zone that could have landed her in a coma. The 48-year-old mother of four has type 2 diabetes, a fast-growing affliction among Latinos. (Margarita Persico photo)
Fortunately, Nancy Rivera now sees the light. She now knows the dangers of diabetes.
“I was a walking time bomb … waiting to explode,” says Rivera, a 48-year-old mother of four who was diagnosed with type 2 diabetes.
She had all the symptoms: she was overweight, constantly tired and always thirsty. Her blood sugar level was over 500, more than quadruple a normal blood glucose reading, which should typically fall between 80 and 120. She could have been in a coma.
According to the American Diabetes Association (ADA), Rivera is one of nearly 24 million diabetics in the United States, a number expected to double in four decades. As a Latina, she is part of the nation’s fastest growing ethnic group — one that’s also being diagnosed with diabetes and its many complications at nearly twice the rate of the general population.
Even though type 2 diabetes is associated with the elderly, it is now being diagnosed in younger people, including children and adolescents. One in every three Americans and one in every two Hispanic females born in the United States after 2000 are at lifetime risk of diabetes, according to a 2008 Center for Disease Control and Prevention (CDC) report.
Worse, it is estimated that 5.7 million people are unaware that they have diabetes, according to the ADA.
“Diabetes is … probably one of the most challenging problems that is going on right now in the Latino community in terms of health,” says Dr. Alexander Green, associate director of the Disparities Solutions Center at Massachusetts General Hospital (MGH) in Boston.
The numbers have driven many health organizations to start diabetes initiatives and outreach interventions. For example, MGH started the Disparities Solutions Center nearly four years ago to seek answers to persistent racial and health disparities. One of their projects is the Diabetes Initiative, started in Chelsea in part because of the Boston suburb’s high population of Latinos — 48 percent, according to the last census.
Green says nearly 50 percent of the initiative’s diabetic patients are Latinos.
The problems are clear.
“If [patients] don’t have education in Spanish, for example, they may not be able to understand diabetes as well,” Green says.
At MGH’s Chelsea HealthCare Center, where Rivera is a patient, Spanish-speaking diabetes coach Eddie Horta works with patients to take control of their diabetes. As a liaison between doctor and patient, he tries to figure out what barriers the patient is facing and tries to devise solutions — within a patient’s budget or health care plan.
Some physicians have learned that patients may not be able to afford their medications, but are too embarrassed to say as much.
“Some are on a fixed income or get paid only when they work,” says Dr. Enrique Caballero, director of the Latino Diabetes Initiative at the Harvard-affiliated Joslin Diabetes Center. “They don’t have the luxury to take a day off to go to the doctor … because that may cost them money.”
Another problem is the cost of “eating healthy” and the relative lack of stores that sell healthy foods in communities of color. To close that gap, Joslin’s Latino initiative sent two of its health officials and several patients to a local supermarket where they shopped for healthy foods on a budget.
“Sometimes healthier foods are more expensive, but not all the time,” says Caballero. “So even within a limited budget, people can make better choices. And so now we go exactly to where people buy the food and teach people how to do that in a better way.”
Latino patients, though, face more than economic barriers.
Diabetes runs in Rivera’s family.
“I have two [younger] brothers that are diabetic, my mom is diabetic, my [step]dad is diabetic, my grandmother was diabetic,” says Rivera, a patient access representative at Boston Medical Center.
Rivera was diagnosed with gestational diabetes 22 years ago during her last pregnancy. She still was able to give birth to a 10-pound baby. Now, she says she worries for that daughter, who is now struggling with her weight.
“The reason for that is a combination of genetic and lifestyle issues,” says Caballero. “We know that, unfortunately, in the Latino population, insulin doesn’t work as well, and that is what is called insulin resistance. And the prevalence of insulin resistance is higher in Latinos than in the white population.”
Caballero, a Latino himself, says that lifestyle factors — such as poor diet and lack of participation in physical activities — can greatly affect the probability of Latinos developing diabetes. Rivera agrees.
“My grandmother ate anything she wanted because she said she was going to die anyway, and she was going to die happy,” says Rivera, who admits having “the same attitude” at times, even though her grandmother died of renal failure at the age of 78.
For Rivera, her biggest obstacles are carbohydrates and foods containing a lot of fat. She doesn’t like sweets, but says she loves pork loin and “pasteles” — stove top cakes made from root vegetables and plantains, usually filled with meats and wrapped in banana leaves. Until last month, she explains, her typical breakfast was “sausage, home fries, eggs, [and] toast.”
Bad diets coupled with lack of exercise exacerbate the problem. Studies have shown that “Latinos engage less frequently in physical activity than … the white population,” according to Caballero.
But that’s not an easy problem to fix. Many patients do not have facilities in their neighborhoods where they can exercise. And, as Caballero points out, many Latinos live in neighborhoods where violence is prevalent. When he tells his patients to go out for a walk, for instance, some say they fear for their lives.
“Are you crazy? I could get killed,” he recalls a patient telling him.
But exercise is critical to higher survival rates — as is cultural comfort.
“One example of our culturally oriented activities is that we just created a pilot [program] of salsa dancing,” Caballero says. “Many of our patients said they … didn’t like to run or jog, but that they would dance.”
As a result, Caballero and his team hired a salsa instructor for a monthly meeting at a Jamaica Plain church.
“We all get together with the patients, and we dance for a little bit. And we take that opportunity to also convey some educational messages of what to do with their diabetes, how to improve their care,” says Caballero.
This year, Rivera says she wants to lose weight. She says she wants to be around to spend time with her grandkids; to celebrate her granddaughter’s “quinceañera,” or 15th birthday, and her daughter’s wedding next year.
According to Caballero, patients like Rivera should be extra careful and stick to their plans, in part because Latinos can develop more complications if their diabetes remains untreated.
“I don’t think we can only blame the patient,” Caballero says. “I think that the other piece here is that we as health care providers may not have the skills or the information sometimes to provide good care to this population.”
Rivera says she is controlling her diabetes now by watching her diet and following her doctor’s advice. She is taking insulin, and the result is a blood sugar level that now ranges between 155 and 165. It’s still not perfect, but it’s much better than before.
“I have two angels watching over me,” Rivera says, referring to her medical doctor and nurse practitioner. “They never gave up on me, even though I would give up on myself.”
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