Doctors try to discover why more Latinos are being diagnosed with Type 2 diabetes

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When her doctor told her she was a borderline diabetic, Rose Morales took the warning seriously. The 50-year-old Ventura woman had seen what diabetes had done to her relatives.

Her grandfather lost his sight then died from diabetes at age 62.

"My uncle, he's on insulin. My aunt was a diabetic. My dad's on medication (for diabetes) too," she said.

The Morales family knows about the research. Latinos are 1.5 times more likely to develop Type 2 diabetes than non-Latino white adults. They also know Latinos are twice as likely to die of complications from diabetes than non-Latinos.

Now, researchers are trying to figure out why.

Type 2 diabetes in all Americans has become a code red emergency in the United States, with people of color topping the list as the most vulnerable. More than 10 percent of the country's Latino population has diabetes. In Ventura County, the number of Latinos with diabetes is actually slightly lower than the national average, according to the California Diabetes Program, but it has nearly doubled in four years — from 3.8 percent In 2005 to 7.5 percent in 2009.

Type 2 diabetes typically develops in adults, but doctors are seeing an alarming number of cases in Latino children. If current trends in childhood obesity go unchecked, one out of every two Latino children born in the year 2000 will develop it, according to the Centers for Disease Control and Prevention.

The American Diabetes Association last month applauded first lady Michelle Obama's childhood obesity campaign called Let's Move! America's Move for a Healthier Generation. Obesity is a major cause of diabetes, so Obama is pushing to get kids to get up from the computer and the TV and get moving.

Diabetes can lead to amputation, heart attack, stroke, blindness, kidney disease and death. It develops when the body doesn't make enough insulin, or if the cells in the pancreas have been working so hard, they effectively give up and ignore the insulin.

The quest to reverse this crisis involves a multi-layered investigation, beginning at a genetic level and branching into the psychological, cultural, social and economic factors that may be paving the way toward obesity, and ultimately, diabetes.

"Type II diabetes is a difficult disease to study because it's clearly got a genetic component, but it's also got a lifestyle component," said Richard Watanabe, a researcher with of the USC Department of Preventive Medicine at Keck School of Medicine

Refine the target

Watanabe, who has a doctorate in exercise science, and two colleagues from his department are credited with the recent discovery of 13 genetic variations that may provide insight into Type 2 diabetes.

The 13 genetic variations were identified in 46,000 people of Northern European descent, but Watanabe feels certain similar variations exist in people of Mexican descent.

To find out, Watanabe and four of his colleagues recently collected DNA samples and other biological markers from 2,200 people from Southern California. All 2,200 have both parents born in Mexico as well as three out of four of their grandparents.

Finding the genetic center of activity for the disease helps researchers refine the target for new drugs to treat it, he said.

Dr. Esteban Gonzalez Burchard, an associate professor at UC San Francisco, studies why certain diseases affect certain ethnic populations. In the case of Mexican Americans, the propensity to develop Type 2 diabetes may be linked to something called the "founder effect."

"That's when someone with a diseased gene comes to a new world, mates with the native population, and all their progeny will have that combo," he said.

In the case of those native to Mexico 500 years ago, the founder population was a small group of European men: the Spanish conquistadors.

"It's possible that all the folks that came over on those boats could have brought certain genetic factors," he said.

Then come modern times, creating the right situation for these genes to get switched on and create a problem. Mexicans come to America and begin to gain weight then develop diabetes.

There can be all sorts of genetic reasons why Latinos get diabetes, but it can't be disentangled from lifestyle, economics and environment, Burchard said.

"I think the strongest predictor of health outcomes is socioeconomics."

'They have all kinds of stressors'

The Ventura County Public Health Department has a diabetes case management unit, overseen by nutritionist Selfa Saucedo, which is following about 40 clients, mostly Latinos ranging in age from 14 to 70.

Saucedo said even if clients want to diet and exercise, sometimes environmental and socioeconomic issues get in the way.

"They have all kinds of stressors, including medical access, no transportation, children experiencing issues at school," Saucedo said.

Parents who live in rough areas know parks could be riddled with gangs, and the streets with guns, so they will keep the kids safely inside in front of the TV or computer.

Dr. Catarina Castañeda, whose parents immigrated to California from Mexico, is now a family practice physician in Santa Paula. She understands the difficulties immigrants face when trying to exercise and eat right.

"Because of socioeconomic reasons, we usually lived in less safe places," she said. "Once it got to be dusk we were in the house."

Castañeda sees a lot of Type II diabetes at the Santa Paula Clinic, which is part of the Ventura County Public Health chain of clinics. Many of those she sees were not obese in Mexico but are now having trouble. Castañeda suspects it may be because they were accustomed to eating a high energy, high carbohydrate diet in Mexico but were able to work off the calories.

"In Mexico you're much more dependent on public transportation," she said. "You walk where you need to go, and you're more active in your daily activities."

Mexicans who live in rural areas are likely to get plenty of exercise with their daily routines, Castañeda said, such as doing laundry by hand and hanging it in the sunshine.

After immigrating to the U.S. Castañeda's father developed Type 2 diabetes, too. She tells her patients she is also at risk.

Dr. Heather Nichols works with Castañeda at the Santa Paula Clinic and helped found Si Se Puede, a free six-week clinic for obese kids and their families. About half of the kids she saw at the medical clinic were overweight, many developing diabetes in elementary school.

Santa Paula is about 70 percent Latino. Nichols notes its main streets are lined with fast food restaurants and says it is not a fitness-friendly town.

"The town is not very walkable," she said. "I walk to work once or twice a week and I find it difficult myself."

Santa Paula Community Services Director Brian Yanez disagreed with Nichols' assessment of the city's walkability but agreed the city is in need of more green spaces.

"We're in desperate need of park space, open space," he said.

In comparison, Westlake Village is surrounded with open space, horse trails and bike trails, including the Santa Monica Mountains National Recreation area. Less than 5 percent of that city's population is Latino.

Healthy food vs. cultural cuisine

Her struggle with the scale was no mystery to Rose Morales.

"I started to diet but I didn't stick with it," Morales said. "My whole family, we're so used to eating Latino foods like tacos and enchiladas, chili con carne, and tortillas, and all that stuff," she said.

Certainly some of the foods popular in the Mexican American culture are not helpful for weight loss, but it can't be blamed on traditional diet alone, physicians say.

Fast food and what's called the "built environment"— structures and roads built by humans — may be as much a contributor to obesity as any Mexican food.

Rose Morales' daughter, Alicia Morales, said she used to be guilty of relying on the convenience of fast food for her son, Isaiah, 4. She is a single mom with two jobs who commutes to Los Angeles to attend graduate school.

"My brother said, ‘You know what's sad? That your son knows what McDonald's is at 2 years old,'" Alicia Morales said. "Him telling me that got me upset. I knew I had to make a change."

A 2008 UCLA report on obesity showed people who live near an abundance of fast-food restaurants and convenience stores are more likely to be obese and have diabetes.

The problems largely poor and Latino neighborhoods face were reflected in a 2007 Ventura County Public Health survey, which focused on La Colonia and Durley Park in Oxnard, the city of Santa Paula, and Ventura Avenue. None of the areas had farmers markets. Durley Park and Santa Paula each had one grocery store. The other two area, none.

"Imagine if you are a family of five and you are the mother of that family and you have to take two buses to get to the supermarket?" said Andreina Millan, a dietician with Joslin Diabetes Center at the Harvard University Medical Center. "And how are you going to carry those things home?"

Latinas more at risk

Latinas face an even greater burden when it comes to obesity and diabetes. In 2007, 73 percent of Mexican American women in the U.S. were obese or overweight as compared with 61.6 percent of non-Latino females, according to The Office of Minority Health. And Latinas are more prone to develop Type 2 diabetes.

Alicia Morales was not specific about the number on the scale but says she has always been overweight.

"I've always been able to carry my weight pretty well," she said. "It wasn't until after I had him (her son) that I put on more weight, and it scared me."

Latinas are especially at risk for developing gestational diabetes, according to the CDC. And if they do, they are then more likely to be diagnosed with Type 2 diabetes later on.

Pepperdine University researcher Cooker Perkins is particularly interested in what happens to Latinas during pregnancy and up to a year postpartum. Through questionnaires, blood panels and other tests, she hopes to find out why they are more likely to develop gestational diabetes.

"We are trying to understand better the differences between these groups," Perkins said. "We want to ask them, what are your sleep patterns, are you breast-feeding, are you active? What is your basal metabolic rate, your blood profile?"

Latino families tend to be larger, which means more pregnancies for Latinas and more risk of being overweight and getting diabetes.

"There's a biological plausible link between pregnancies, having more children and potentially putting yourself at risk for being overweight," Perkins said.

Perkins' hope is to isolate causes for weight gain before and after pregnancy and develop a way to intercede.

Public Health officials say they will make diabetes detection and management a priority this year, and are developing workshops to help.

The Morales family members are doing their part. Three times a week, Rose gets together with her sister and a friend and they work out on the treadmill.

"We all decided we were going to exercise together as a family and keep each other accountable," she said.

Alicia Morales now carves out time to cook as many healthy meals as she can for Isaiah. She also enrolled him in Si Se Puede.

If more Americans of all ethnicities don't make the sort of changes the Morales family has, diabetes and pre-diabetes will cost the U.S. economy $336 billion per year by 2034. Diabetes cost the U.S. more than $174 billion in 2007. Factor in pre-diabetes, gestational diabetes and those who are undiagnosed and it rises to $218 billion, according to the Lewin Group, a healthcare policy research and management consulting firm.

For Rose Morales, the cost would be much greater. Her kids lost their dad — her husband— six years ago, at the age of 54. He was stubborn, she said, and wouldn't follow doctors' orders about his failing heart. She is all her kids and grandkids have left.

"I have to be the vessel in this family," Morales said, her eyes filling with tears. "If I don't do it for me, I'll do it for them."

This article was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism. Kim Lamb Gregory received a journalism fellowship from the school to explore the question of why Latinos are at twice the risk for diabetes as other ethnic groups.