Peer Counselors Can Help
To tackle diabetes among the Latino population in Hartford, community leaders could learn from the Third World, says Rafael Pérez-Escamilla.
Pérez-Escamilla, an associate professor of nutritional sciences and public health, has proposed that a network of peer counselors be formed to address some of the problems associated with diabetes among Latinos in the inner city. It's an idea that has been successful in addressing health-related issues in developing countries.
The bilingual, bicultural peer counselors Pérez-Escamilla envisages would act as liaisons with the health care system to improve access to and quality of care. They would also facilitate access to food assistance programs and other services, offer guidance on nutrition and physical activity, and provide support and encouragement to people with diabetes.
Pérez-Escamilla has been studying public health and nutrition issues among the Latino - mostly Puerto Rican - community in Hartford since 1994. He works closely with the Hispanic Health Council, a community health agency. This collaborative research, which included doctoral student Nurgul Fitzgerald, is part of a broad-based community nutrition program in Hartford that he has led over the past 10 years.
He says diabetes is a major public health problem. "This is a disease that has decimated the Puerto Rican community," he says. "Everyone has a close friend or relative that has lost a limb, been diagnosed with high blood pressure, or has kidney failure or heart disease because of Type 2 diabetes."
Type 2 diabetes, the most common form, is a condition in which glucose builds up in the blood instead of going into cells. The cells may be starved of energy and, over time, high blood glucose levels may damage the eyes, kidneys, nerves, or heart. In addition to therapeutic drugs, management of the disease relies largely on diet and physical activity.
The year-long diabetes study, funded by the U.S. Department of Agriculture, involved 200 middle-aged Latina women, 100 who had been diagnosed with diabetes, and 100 who had not.
The study's most surprising finding, says Pérez-Escamilla, was that there was little difference between the conditions of the two groups, suggesting that those who had not been diagnosed with diabetes were also at risk of contracting the disease, or may already have it without knowing it.
A large majority of those interviewed - more than 80 percent of both those who had diabetes and those who did not - were overweight or obese; most got little or no exercise; and many in both groups had a close relative with diabetes. All are risk factors for diabetes.
The study also found that people in both groups did not know how to use the food guide pyramid, and few understood food labels; yet knowledge of basic nutrition is important in managing diabetes.
Many are unable to afford sufficient high-quality food. More than 70 percent of both groups in the study relied on either food stamps or food pantries. Food insecurity contributes to obesity, which is one of the major causes of diabetes.
"Poor people tend to load up with cheap, high calorie, low nutritional value food," said Pérez-Escamilla. "Especially toward the end of the month, when food stamps may run out, food insecurity could involve people going without food for a day, or cutting the size of portions, or eating things that are loaded with calories and sodium."
Those who had diabetes were twice as likely as those without diabetes to have severe food insecurity, suggesting that a shortage of food may exacerbate the problem.
Less than half of each group ate lunch every day.
"It's really dangerous if you're using insulin and you skip meals," says Pérez-Escamilla. "Without sufficient food, the insulin can induce very negative effects."
Those who said they skip meals said it was either because they couldn't afford to eat, or because they "didn't feel like eating."
Close to half of people with diabetes reported symptoms of depression.
Although regular exercise is essential for controlling body weight and managing blood glucose, only 35 percent of study participants said they exercise regularly, and those with diabetes exercised less than those without.
Seventy percent of participants with diabetes described their health as fair or poor. Study participants with diabetes who received any medical care mostly received care for their diabetes from a generalist. Few had access to specialist care: nearly half of those with diabetes had never seen a dietician, for example.
Because they lack adequate health insurance, said Pérez-Escamilla, they rarely get referred. In addition, transportation to appointments was often a problem. Fifty percent of the people in the study didn't have a car.
"How can you manage a condition that depends so much on diet and physical activity," he says, "if you don't have money or access to adequate facilities for physical activity and health care?"
To help combat the problems, Pérez-Escamilla and his colleagues recommend a number of measures, including nutrition and diabetes education; promotion of physical activity; support for reducing alcohol intake and cigarette smoking; and ensuring referrals of diabetics to a dietician. Key among the recommendations is a proposal to form a network of peer counselors - paraprofessionals from the community who have experienced the condition and who would receive training, supervision, and compensation for their work.
The proposal, currently being considered by key decision-makers, would be only a partial solution. The bottom line, says Pérez-Escamilla, is poverty, and that's not easy to solve.
"The highest risk factor for health disparities is poverty," he says. "If people don't have access to decent paying jobs, it is very, very difficult to address the problem. People are not making enough for the minimum dietary quality they need or enough to have access to health care, and they don't have the minimum amount of infrastructure needed for physical activity. There is no magic wand."