Combating diabetes

People living with diabetes in San Joaquin County may have cause for concern: The county ranks worst in the state for deaths caused by diabetes. Medical officials say the lack of education and resources are to blame.

STOCKTON - The most important space in Dr. Kwabena Adubofour's East Main Clinic & Stockton Diabetes Intervention Center is the education room. Before patients enter, they pass a poster that declares: "It's never too early to prevent diabetes."

Much has been written about San Joaquin County's poor outcomes concerning diabetes and other chronic diseases. It might be easy to assume that not much is being done since the county continues to hover at or near the bottom of many lists, showing little to no improvement. But that is not the case.

Type 2 diabetes, a complex disease that generally develops in adulthood and accounts for up to 95 percent of all diagnosed cases, has a strong scientific connection to obesity. It is a condition marked by high levels of blood glucose resulting from defects in insulin production, insulin action or both, according to the California HealthCare Foundation. Left untreated, diabetes can lead to serious complications, including blindness, kidney damage, lower-limb amputations and premature death.

Hospitalization is the most expensive treatment option. It can usually be prevented by eating healthy foods, regular physical activity and taking prescribed medications. Where you live, what you know and your ability to access medical care play a critical role in remaining healthy.

For many people, having diabetes and living in San Joaquin County is a deadly combination. The county ranks worst in California for deaths caused by diabetes.

Education is key

As the only full-time physician practicing in southeast Stockton - one of the poorest neighborhoods in San Joaquin County - Adubofour sees a never-ending stream of adults with Type 2 diabetes. After almost 15 years, he's become a nationally recognized expert on their plight.

As one county public health official described him, Adubofour is "our medical champion for diabetes care and treatment."

Adubofour sees only three ways to break the cycle and rein in the epidemic of overweight and obese children at high risk.

"No 1 is education, No. 2 is education and No. 3 is education," Adubofour said without missing a beat.

Cultural shift

About 200 health educators and others who come in regular contact with kids, pregnant women and parents of young children in the county have had two training sessions with Dr. Nick Yphantides of San Diego, an acclaimed advocate primarily concerned with childhood obesity and family wellness. Yphantides told them:

"If you want to be an agent of change, it has to start with changing yourself." Stop smoking, start eating healthier foods, get active.

The collaboration of private and public health agencies that brought him to Stockton hope his lead-by-example message will plant a seed of change in the culture of despair that has gripped the area for too long. Eventually, it is hoped his message will result in a cultural shift leading to better overall health outcomes countywide.

In 2009, more than 31 percent of kids 2 to 4 years old were overweight or obese, based on their Body Mass Index. For those from 5 to 19, a staggering 40 percent were considered overweight or obese.

This condition puts these kids at serious risk for cardiovascular, endocrine, gastrointestinal, orthopedic, psychological and pulmonary conditions, according to the California Medical Association Foundation. Already, these risks have led to epidemic rates of Type 2 diabetes as well as high cholesterol, depression, low self-esteem, asthma and sleep apnea, based on survey data for the county.

The most staggering statistic of all is the death rate.

San Joaquin County ranks worst among all 58 California counties with an age-adjusted death rate of 35.2 people per 100,000. Compare that with the state average of 21.1 per 100,000.

"The mistake is that we are treating this as a disease that only affects one individual, when we should be treating it as a disease of families," Adubofour said.

"We should be handling it the way we handle tuberculosis. It's a genetic disorder, it runs in families, it is a very dangerous disease - it's the No. 1 cause of blindness, the No. 1 cause of heart disease and the No. 1 cause of kidney failure. Whatever information that is provided to the patient should be spread to the family," he said.

"The same aggressive approach ought to be brought to bear at the advent of diabetes."

Once the patient is identified, locate the immediate family and bring them in, he said. Adubofour said he has his male patients bring in their wives or mates in order to hear what nutritional and lifestyle changes need to be made for improvement.

Adubofour believes there's another step that needs to be taken.

Coordinating efforts

"We need to make sure we are all behaving ourselves in managing this disease. We need to have a countywide emphasis, replicating best practices all over San Joaquin County. We need funding for a newly invigorated local Diabetes Society that works in conjunction with the American Diabetes Association but places its emphasis on local concerns. We need to have a county diabetes coordinator," he said.

LaCresia Hawkins may be just the one to train that future coordinator. She is working with a small group of teenagers in southeast Stockton to help them recognize social and environmental problems that contribute to chronic poor health outcomes in their neighborhood.

While health educators take on the role of teaching about the importance of balanced nutrition and daily physical activity, Hawkins has inspired her kids to recognize problems in their physical environment that impact good health.

"No one person, family or business is fully responsible on their own. It really takes all of us as partners and treating each other as partners to make the changes necessary. ... There's still lots of work to be done," Hawkins said.

Lani Schiff-Ross agrees. The executive director of First 5 San Joaquin, the county's Children and Families Commission, said that lots of different approaches need to be undertaken to reach as many diverse residents as possible.

"A public-private partnership is the way to go," Schiff-Ross said. "Geographically based services are the most cost-effective, so agencies are not fighting over clients."

From feedback she has received, most people still want information on the basics: nutrition and physical activity.

"It's exciting to think this is what parents want, and they want it for a longer time. Sometimes they know it, but not how to implement good practices. Education gives them tools," she said.

One point has emerged from all the experts.

"If it's addressed as a family, it's more effective," Schiff-Ross said.

Building resources

Dr. Thomas Mahoney said it's all about resources.

"With limited health funding, we are going to have to rethink the way we look at health. In poor countries, the family members take care of their disabled family members. People should have access to safe sidewalks, safe paths, community gardens. That is going to have a huge impact on health. If we are not able to do that, all the money in the world won't help," said Mahoney, medical director at Stockton-based Community Medical Centers, a network of 12 medical, dental and school-based clinics serving almost 70,000 patients.

"Why can't we look at Stockton as being a cohesive community? Why can't we sit at a table and look at this, understand that we have limited resources and determine what's the best way of establishing policies, obtaining some funding, to address the whole?" Mahoney asked.

"For the most part, the people I know are interested in getting the community healthier. But we can't seem to see the forest for the trees. It's hard to see outside our four walls and look at partnerships. Hopefully, having even more collaborative programs working together is a hopeful sign. We need to be doing more community-oriented projects."

Bringing it together

Shené Bowie is in the process of making that happen. As program coordinator for Health Promotion and Chronic Disease Prevention for the county, Bowie knows all too well the disparities in programs that attempt to address unhealthy practices and environments. She is in the process of highlighting all the resources available with the goal of strengthening and broadening their impact.

"The efforts now under way in some communities and neighborhoods around the county need to be replicated elsewhere. Schools and after-school programs are the best places to reach children, because it's where you have their attention," Bowie said.

In addition to the University of California Cooperative Extension's well-established emphasis on nutrition education and physical activity lessons in after-school programs, the state funds the Harvest of the Month Program that school districts such as Manteca Unified use to integrate food lessons into regular curriculum.

Harvest of the Month also introduces fresh produce in the classroom for students to taste, and it sends menus, recipes and newsletters home for parents to follow.

Health Plan of San Joaquin, the publicly sponsored Medi-Cal managed-care health plan that serves more than 100,000 residents in San Joaquin, Stanislaus and Merced counties, brings together health educators from throughout the region to share best practices and to compile a quarterly schedule of community health-education programs covering diabetes, asthma, heart health and other topics.

Last summer, a proven program called Moms Taking Action was launched by public health with a dozen women trained as peer leaders.

"Their priorities are just to get their families fed with a healthy meal. We're getting the moms information on obesity and chronic disease and encouraging them to have conversations with other moms.

"Then we have them be advocates for their own health and their children's health. The goal is to reach 500 other moms by the end of this summer," Bowie said. "Moms Taking Action gets a few individuals together at the start who want to see change, then they create the social norm of change."

Contact reporter Joe Goldeen at (209) 546-8278 or Visit his blog at