Graphic: Income/education determine diabetes risk more than race CHARLESTON, W.Va. -- "West Virginia patients come into my office," Dr. Frank Schwartz said, "and they'll say, 'Yep, Mom had diabetes, and it caused her to go blind when she was 63. So when do you think I'll get diabetes?'"And I'll say, 'You don't have to get diabetes. You can prevent it.'"But it's like they didn't hear me. They'll say, 'But when do you think I'll get it? When do you think I'll go blind?'""And I'll say, 'You can cut your risk of diabetes in half if you exercise for a half hour three times a week and eat a reasonable diet,' and they'll say, 'I hope I won't lose my leg.'"It happens again and again," he said. "There's this very powerful cultural story line in Appalachia that says, if your grandma and your dad had sugar, you're going to have it, and there's not a thing you can do to stop it, and you'll go blind and your leg will be amputated, and your kidneys will shut down."It's completely untrue, but that doesn't seem to stop it. Before we can start preventing diabetes on a wide scale, we need to deal with that story. If people believe there's nothing they can do, they won't try to prevent it."Frank Schwartz, M.D., is an endocrinologist. He treats diabetes. He grew up in Parkersburg at a time when a kid "left the house in the morning and played all over town and didn't come back till supper. We walked two miles to school, so very few of us were heavy."Now he directs the diabetes/endocrine program at the Appalachian Rural Health Institute at Ohio University in Athens, where he treats a lot of West Virginians.He thinks a lot about the myths surrounding diabetes: Why is it so hard to convince people they can keep themselves from getting diabetes, even if their grandmother and mom had it?He also obsesses over a second question: "Why does Appalachia have a higher diabetes rate than most of the rest of the country?" The two questions are somehow connected, he thinks.Myth: Black people get diabetes because they're blackIn 2010, Marshall University professors Richard Crespo, Lawrence Barker and colleagues found, through analysis of Appalachian Regional Commission data, that people in distressed Appalachian counties get diabetes two years earlier than the national average."Distressed" means the average income and education levels are low, and services are scarce.Six years earlier, in 2004, Schwartz and his students basically found the same thing. They surveyed people in the 11 "Appalachian" Ohio counties located next to the West Virginia border. In those eleven counties, all of which qualify as "distressed," 11.3 percent of the people were diabetic, compared to the overall Ohio rate at the time of 7.2 percent. "They were in line with West Virginia, not Ohio," he said.Schwartz and students asked diabetics how old they were when they were diagnosed. Thirteen percent said they were under 21. "That's more than twice the national rate estimated by CDC," Schwartz said.How many West Virginia young people were diagnosed at a similar early age? "Nobody's ever asked, as far as I know," Schwartz said, "but it stands to reason that it would be happening."Somebody should find out," he said. "It's an established fact that people who make less money and have less education develop diabetes and heart disease more frequently, so you'll see more children with problems in distressed counties, too."West Virginia leads the nation in diabetes and obesity. Eighty percent of diabetics are obese. "Obesity is pushing the diabetes explosion," he said."Race is not causing it," he said. There's another myth, he said, that black people are genetically likely to be obese and get diabetes, so they are somehow responsible for the nation's diabetes problem. "That's not true."When I was a young doctor in Parkersburg, I'd go to national conferences, and experts would be saying diabetes rates were going up because American Indians and African Americans are genetically more disposed to get diabetes. And the West Virginia doctors would be sitting there saying, 'But we see those kinds of high rates at home, and we're 94 percent white.'""Back then, people assumed race was causing it," he said. "They weren't stopping to think that African Americans and American Indians also had less money and less education on the whole."Since then, a lot of research has shown that people who make less money and have less education are more likely to get diabetes, no matter what color they are. Just like people of any color who eat more calories than they burn off are more likely to gain weight. "In West Virginia, a high percent of white people have less money and education than the national average. A lot of white people are obese."West Virginians of any color who make $15,000 are twice as likely to get diabetes, compared with West Virginians of any color who make $50,000, according to the Centers for Disease Control. And people who went no further than high school are more than twice as likely to get diabetes than people who have college degrees."So how do we convince people they can keep themselves from getting diabetes, even if their grandmother and mom had it? Or if they're black and they've been told they'll probably get it."Some states are doing billboard and TV/radio ads to tell people they can prevent diabetes. West Virginia has not yet done so. "When you manage to get people past the story, good things often happen," Schwartz said. "Many people do just need good information. But information alone may not be enough."Unemployment and prescription drug abuse and diabetes all impact each other, he said. "We talk about each of these things as if they were separate," he said, "but they aren't. Where there are higher levels of poverty, illiteracy, tobacco use, unemployment and now prescription drug abuse, there are also higher levels of depression and chronic disease. It's all interconnected. "Communities have a part in this," he said. "If there's no grocery store, for instance, and the only food is at the Marathon that sells beer, chips and milk, it makes it harder for people to improve their diet." If there's no safe place for older people to walk or no gym where overweight children and teenagers can be active, that can make it harder to exercise, he said. "For a long time, we've assumed the medical establishment should somehow take care of chronic disease by itself. That's obviously not working. The problem has gotten too big, and it's becoming clear that this is something for whole communities to solve."Reach Kate Long at firstname.lastname@example.org or 304-348-1798.To find more information on the research referenced in this article, go to www.theshapewerein.wordpress.com."The Shape We're In" was written with the help of the Dennis A. Hunt Fund for Health Journalism, administered by the California Endowment Health Journalism Fellowships at the University of Southern California's Annenberg School for Communication and Journalism.