Tucson Takes Charge of Diabetes
How the city fights type 2 diabetes
Where you live, and how you live, are everything when it comes to how healthy you are. Gwen Gallegos, FNP, CDE, who provides diabetes care and other services to people living on the border of Arizona and Mexico, sees that every day.
“Along the border, we have a lot of poverty. We have a lot of people who cross over from Mexico, like our day laborers. We have a lot of people who are undocumented, who do not qualify for any kind of medical support,” Gallegos says. “It’s a population that is so busy trying to survive, they don’t put a lot of value on preventative care. So a lot of our people don’t go to the doctor until they really start to feel some of the complications of diabetes.”
Income, education, environment, access to services: These are some of the “social determinants” of health, the factors outside the body that contribute to health. Coupled with physical risk factors, such as race and obesity, the social determinants of health can increase people’s risk for type 2 diabetes. When people, because they are poor, unable to see a doctor, and live with limited access to healthy food, face a greater risk for illness than others who are affluent, able to see a doctor, and have access to healthy foods, that’s a health disparity. And in the Tucson, Ariz., area, health disparities are everywhere. But people such as Gallegos are stepping forward to do something about it.
Tucson by the Numbers
The state’s “Arizona’s Diabetes Burden Report: 2011” shows a perfect storm of diabetes risk factors brewing in Tucson and much of the state. The state has a large Latino population (30.2 percent in 2012, according to the Census Bureau) and a relatively large American Indian population (5.3 percent). In counties with more young residents than average, the percentage of minorities is also larger. And these counties have higher percentages of people who lack health insurance, though the Kaiser Family Foundation reports that 120,000 Arizona residents enrolled in their state marketplace as part of the Affordable Care Act. In these counties, the percentage of people with diagnosed diabetes is also higher than the state’s average of 9 percent, according to the Centers for Disease Control and Prevention. In Pima County, where Tucson is the county seat, 10 percent of the population is diagnosed with diabetes, and in Santa Cruz County, just south of Tucson, the prevalence is 13 percent.
Arizona also ranks first in income inequality in the United States, according to the state report. Poverty levels correlate closely with racial and ethnic demographics there. White Arizonans are twice as likely as nonwhites to be enrolled in college and graduate from high school at a 75 percent rate, compared with 64 percent for Latinos. The National Center for Public Policy and Higher Education suggests that if all ethnic groups in Arizona had the same educational opportunities and earning power as whites, “total personal income in the state would be about $6.2 billion higher.”
The diabetes burden report also notes increasing obesity in Arizona. At 24.3 percent of the population, Arizona’s obesity burden is lower than the national average of 34 percent, but higher than that of other Western states. Obesity is a risk factor for developing type 2 diabetes.
The cost of diabetes is adding up in Arizona: In 2006, the most recent data available, there were 1,755 diabetes-related hospital stays per 100,000 people in Arizona, a rate about 10 percent higher than in other Western states, the state reported. Records show that 402 patients were discharged without complications, costing $1.45 million in hospital bills. And 10,447 patients were discharged with complications, costing $92 million. That’s a heavy burden on families, state and local governments, insurers, and hospitals when they aren’t reimbursed. So community members are taking steps to combat diabetes where they live.
The University of Arizona
“The problem with a lot of diabetes support services is they’re just not available,” explains Merri Pendergrass, MD, PhD, professor of medicine and endocrinology and the diabetes program director at the University of Arizona College of Medicine. The services exist—they’re just hard to get to, or they have business hours that don’t fit people’s schedules, or insurance doesn’t cover them. Or, in the case of preventive services, people are unaware of their risk for type 2 and don’t realize that making changes in weight, healthy eating, and physical activity may help them prevent or at least delay diabetes.
Pendergrass found that money and distance were big barriers: The rural poor in Arizona are extremely spread out over its 113,998 square miles. “People in these communities are seeing physicians, they do go to doctors, but they go less frequently and have [fewer] options for treatment,” Pendergrass says.
So instead of trying to bring people out to different diabetes prevention and treatment programs, Pendergrass and her team consolidated programs at the Pima County Public Works Building. Partnering with the local YMCA, the Pima Council on Aging, and other organizations, the university has created a diabetes treatment center in the same place residents can get birth certificates and Women, Infants, and Children (WIC) Program services.
The diabetes clinic includes physician visits for podiatry and nutrition services, from providers who volunteer their time. Outside the clinic, the Diabetes Prevention and Education Center draws people in. It includes a large demonstration and teaching kitchen, a classroom, and a gym-like performance assessment area where people learn about nutrition, diabetes risks and complications, and exercise—and work out, too. Every part of the program is free.
Dominique Henry, the diabetes program coordinator, says cooking demonstrations are the highlight of the program. She creates meal plans that are healthy, diabetes-friendly, and culturally relevant: She focuses on Mexican and Native foods. “We’re trying to cook things that the community can relate to and want to eat,” Pendergrass says. “We’re not [making] sushi here!”
Henry also bears in mind where people shop—these aren’t meals with boutique ingredients. “I try to shop at the grocery stores that are nearby and use ingredients that people can get in the area,” she says. “We are offering many of these classes in Spanish, and we’re hitting food banks, community centers, health fairs. We’re slowly getting these interested people to come in the door.”
At the YMCA
Some Tucson residents already have prediabetes, elevated blood glucose levels that aren’t quite high enough to be diagnosed as diabetes. Making changes in eating patterns, losing weight, and getting more physical activity, are very effective in keeping prediabetes from progressing to type 2 diabetes. So Vivian Cullen, community outreach director at YMCA of Southern Arizona, and her staff set out to do something about it. They won a grant for diabetes prevention in 2010 and started the federally sponsored Diabetes Prevention Program, or DPP, early the next year.
Since then, nearly 350 people there have gone through the 16-week program, which offers weight-loss tips, exercise consultation, healthy-eating guides, and a support system for people who want to prevent type 2 diabetes. After the 16 weeks, participants are urged to take part in monthly sessions held around the city—and they do. Even years after the first session, DPP participants from 2011 still come to the monthly sessions for encouragement and refreshers. Four coaches, supervisors who guide participants through the Tucson program, are also program graduates.
The DPP has been implemented at YMCAs across the country, and Cullen loves it because she says it works with all ethnic groups. “The great thing about this program is you don’t have to get rid of your culture to be healthy,” she says. “It teaches you to be healthy and not throw away the burritos or the fry bread. Here in Tucson, we’ve made a special effort to work with [Latino and American Indian communities]. That’s why the program works.”
The program is also accessible. Participants are often referred to the program by their health care providers, but DPP staff do outreach in communities, in local neighborhoods, and at casinos around Tucson. Tuition is based on a sliding scale, and those who fall at or below the poverty line can get scholarships for the program. Plus, in Tucson (and in some other locations), people in the DPP get a free Y membership. “If we don’t put our skin in the game and allow them to use the facilities to become more active, that seems a little shortsighted on our part,” Cullen says.
On the Border
Gallegos, a nurse practitioner and diabetes educator with the Carondelet Health Network, reaches beyond Tucson to work along the U.S.-Mexico border, which is 60 miles south of the city. Because the population there is often transient, people can be tough to reach. So Gallegos works on both sides of the border to maximize outreach. The Carondelet Health Network in Arizona and El Rio Community Health Center clinics in Mexico partner together to offer diabetes care and prevention programs to underserved communities.
In the border towns of Nogales, Ariz., and Nogales, Mexico, many people are poor—which often leads to less preventive care and more dealing with diabetes complications, says Gallegos. “With diabetes, you [might not] feel any symptoms for many years,” she says.
In order to reach this population with diabetes, Gallegos and others, including the Mariposa Community Health Center in Nogales, Ariz., serve other needs and offer diabetes information as a bonus: A free meal program for seniors, for example, offers one healthy meal per day; while there, seniors can get blood pressure and blood glucose checked, and providers can review medications or advise on when to see a doctor. Another program, Vivir Mejor (Live Better), offers free diabetes education classes.
Getting people to class can be a challenge, Gallegos says, because “they’re fearful to go and seek assistance. We usually say they ‘fall through the cracks,’ but really it’s falling through a gorge.” So health leaders work to remove all barriers: Classes do not require registration or insurance. They’re held in the evenings. They’re held in Spanish. They’re meeting people where they are. And they work on people’s economic level. Diabetes is an expensive condition—really daunting if you’re uninsured. So Gallegos suggests tricks to make diabetes management easier and cheaper, such as using store-brand meters and test strips, and Regular and NPH insulin instead of expensive rapid-acting and long-acting formulations. These little changes can mean the difference for families on a tight budget.
And to foster a community of support, for the past 20 years Gallegos has hosted a cross-border support group for youth with type 1 diabetes and their families. The monthly meetings have helped children realize they’re not alone and parents share resources and experiences. “It’s one culture, just two nationalities,” she says.
The people who partake in the Tucson area’s community outreach programs—people of various backgrounds and socioeconomic situations—are learning plenty. The services and education help, yet caring for diabetes is still an everyday challenge.
Nick and Norma Drakovich, of Tucson, have attended nearly every class that Henry and her staff offer. Nick, 45, was diagnosed with type 2 diabetes a year ago. Norma, 46, was diagnosed with type 1 in 2005. In February, they learned of the Diabetes Prevention and Education Center and have been faithful attendees ever since. They say they’ve gained a wealth of knowledge, particularly from cooking classes. Are they cooking diabetes-friendly meals at home? “We’re starting to,” Nick says. “But that’s kind of our downfall. We’re not disciplined. We might do it for a day or a few, but then we get lazy and get into a bad habit.”
Norma says she’s trying to make exercise stick, even with her busy schedule. She works from 6:30 a.m. to 3 p.m., then goes to classes at 3 and 4:30 p.m. “It’s a long day.… I don’t want to go for a walk; I just want to relax.” But she knows it’s important to get moving. She has a friend at work to walk with, and they’re trying to stick to that plan.
And Nick and Norma are trying to foster the sense of community they get at class in their own home. “It does help that we’re both fighting the same fight,” Nick says. “We remind each other that we have a class or a program to go to later on tonight. That does help, to do those programs together.”
Similarly, Tucson is finding that diabetes is a multifaceted problem and the best way to tackle it is together.