Pat Higgins, who has type 2 diabetes and volunteers with the American Diabetes Association, has seen the diabetes population boom in Charlotte, N.C.



"In Charlotte alone, we have 165,000 people with diabetes," she says, in a city of about 750,000. "In the community, to 'have a little sugar,' everybody considered that to be normal. That's something you hear in the South in particular. I'm from the north [Chicago], and I didn't hear that before."



Charlotte is located on the edge of the "diabetes belt"—a geographic area of the United States where residents have a much higher risk of developing type 2 diabetes than people who live in other parts of the country. The ADA's Charlotte office serves several counties in the belt. Within the diabetes belt, 11.7 percent of the population has diabetes—in some counties, that percentage can reach 13 percent. The national average is 8.5 percent.



The diabetes belt spans counties in most of the Southern states and reaches up through Appalachia. And, in general, it's growing, according to the Centers for Disease Control and Prevention (CDC). New counties are added; we let out the belt another notch yet it cannot contain the strain. The geographic area affected closely mirrors the "stroke belt," and its population generally is more prone to developing not only diabetes but also other chronic diseases.



Amit Vora, MD, FACE, is a professor of endocrinology at the University of Tennessee–Knoxville and a practicing endocrinologist. In his practice, he sees how some of the risk factors for type 2 diabetes culminate in a kind of perfect storm. Vora cites an unhealthy food culture, few convenient or safe places to exercise, and an impoverished and poorly educated population—and all too often, he sees complications in patients who didn't get diabetes care early or regularly.



"I saw a patient who came in with an A1C of 13 [percent]," he remembers. "I said, 'Had you not been feeling well?' The patient said, 'Doctor, I haven't been to any doctor. I don't like to do that unless something's broken.' People just don't go to the doctor."

America's "diabetes belt" is a cluster of 644 counties in 15 states, mainly in the Southeast. At least 11 percent of residents in these counties have diagnosed diabetes, compared with 8.5 percent nationwide. The Centers for Disease Control and Prevention identified the belt to spur community leaders to prevent new cases of type 2 diabetes by working to reduce obesity through healthy eating and increased physical activity. Obesity is a risk factor for type 2. Some U.S. counties with high rates of diabetes aren't included in the belt because they are isolated from other diabetes hot spots.

Recipe for Disaster

Income, healthful food, access to health care, insurance coverage: All of these are social determinants of health—factors that can affect a person's well-being. And in the diabetes belt, they all play a part in the diabetes crisis.



Poverty is a huge factor in people's risk for type 2 diabetes. The states in which the highest percentages of residents live below the poverty line correlate with those in the diabetes belt almost exactly. These places often also have the lowest percentages of residents with health insurance and the fewest health care providers per capita—which means people aren't getting access to the care they need, says J. Nadine Gracia, MD, MSCE, director of the federal Office of Minority Health. This can be especially true in minority populations concentrated in urban centers in the South, as well as in rural areas throughout the diabetes belt.

POVERTY

At least 18 percent or more of the people in these states lived below the poverty line in 2011. The poverty line is the federal government's estimated minimum annual income for a person or family to have the necessities of life. In 2011, the poverty line for an individual was $10,890; for a family of four, $22,350.

"It's not just the health care system itself but also the broader social determinants of health," Gracia says. "It's these risk factors, and lower rates of exercise, and higher rates of obesity."



It's true that obesity, a risk factor for type 2 diabetes, is much more common in the diabetes belt than it is in the rest of the country. Most states in the belt have an obesity rate of more than 30 percent—outside the belt, only Indiana, Michigan, and Missouri have such a high percentage of obese residents.

OBESITY

In these states, 30 percent or more of people ages 18 and over were obese in 2011. Obesity is defined as having a body mass index (BMI) of 30 or higher.

That fact could be chalked up to a few causes. For one, the traditional Southern diet is high in carbohydrate and fat. "The South has never had the best eating habits, but we do have the best food," says Stewart Perry, a former chairman of the board of the ADA and current volunteer in Lexington, Ky. Perry, 56, has lived with type 2 diabetes for more than 20 years. "I grew up eating chicken and dumplings, and fried apple pies, and it's not particularly healthy."



Historically, says Andrew S. Rhinehart, MD, FACP, CDE, BC-ADM, of Abingdon, Va., many people living in the diabetes belt worked in manual labor on farms and in coal mines (indeed, the U.S. census still finds that many states in the diabetes belt have high percentages of rural residents). Today, he says, "we're all desk jockeys."



Even formerly physically active jobs have been made easier, and thus less calorie-burning, than they were in the past. Rhinehart recalls telling a patient he wasn't active enough. The man told Rhinehart he was a farmer. "Then his wife said, 'Honey, you sit on a tractor all day,' " Rhinehart says. "It's not like the old days."



And the way our bodies work may still be tied to our ancestral lifestyles. The "thrifty gene" hypothesis speculates that, as a means of survival, human beings evolved to hold on to fat and store it. But now, with more nutrient-dense (and sometimes unhealthy) foods readily at our disposal and a much less active lifestyle, those fat-storing genes work against us to pack on pounds.

Nowhere to Turn

A large swath of the diabetes belt comprises states that have both the most and the least rural populations in the country. While that might seem like a contradiction, living in either an urban center or a rural setting can limit a person's access to health care. Several states in the diabetes belt rank among those with the fewest physicians per capita in the nation. And these populations often don't have good access to safe places to exercise. Rhinehart says he once asked an Appalachian patient about her exercise plan. It wasn't going great, she said, because she lived on a winding, mountainous road with no shoulder—walking there was out. She lived 45 minutes from the closest high school, so getting to that gym or track was a no-go. And she was afraid to work out in her own yard, she said, because she had seen bears there in the past. That's a lot stacked against someone who just wants to get in a 30-minute walk every day.



There's also the matter of food security, defined by the U.S. Department of Agriculture as "access by all people at all times to enough food for an active, healthy life." More than 17 percent of the populations of diabetes-belt states Alabama, Arkansas, Georgia, Mississippi, North Carolina, and Texas have food insecurity. That has an impact on people's wallets and their health, says Edward Gregg, PhD, chief of the Epidemiology and Statistics Branch in the CDC's Division of Diabetes Translation.

FOOD INSECURITY

Households that are "food insecure" do not have "access by all people at all times to enough food for an active, healthy life," as defined by the federal government. The national average of food insecurity from 2009 to 2011 was 14.9 percent. In these states, at least 16.5 percent of households are "food insecure."

"The cheaper foods tend to be more dense and less healthy foods," Gregg says. "If you go to high-risk rural areas, there are fewer options for people, combined with less awareness and less education. The way we eat and the way we move are embedded in our culture, and those can be difficult to shift."



But more than anything, Gregg says, poverty is the No. 1 risk factor for type 2 diabetes, statistically speaking. From there, the risks pile up: If you don't have access to fresh, healthful foods, you buy what you can. The cheaper something is, the more plentiful it becomes in your diet. Living in poverty usually means less access to education, which leads to fewer opportunities for jobs that pay well and provide health insurance. If you can't afford insurance, going to the doctor becomes even more expensive—and so on and so forth. It's a vicious cycle.



And if diabetes is something you grow up surrounded by—especially in some families, where "a touch of sugar" is seen as no big deal—it can be hard to find the motivation to take preventive measures against type 2 yourself, says Rhinehart. "In some families, it's so prevalent, it's [considered] inevitable," he says. "[People think], 'That's going to happen to me no matter what I do.' "

Turning the Tide?

Making diabetes education and prevention accessible to residents of the diabetes belt is no small task. It takes action on personal, neighborhood, and national levels.



On the largest scale, the U.S. Department of Health and Human Services has launched a "disparity action plan" that promotes community-based interventions to help people achieve better health. The department's Office of Minority Health offers community transformation grants for programs that attempt to reduce the burden of chronic disease, says Gracia. Health and Human Services also is funding ongoing research to better understand why disparities exist in the health of different racial or ethnic groups, in order to reduce them, she adds. In 2011, the ADA partnered with the Office of Minority Health to promote a community-driven effort to reduce disparities.

NO HEALTH INSURANCE

On average, 16 percent of Americans did not have any form of health insurance in 2010–2011. In these states, 18 percent or more of residents were uninsured.

And on a governmental level, Gracia says, the Affordable Care Act, also known as Obamacare, is making a huge difference for those who want access to health care but who were previously locked out of insurance plans because of their preexisting health conditions, including diabetes. But that alone won't shrink the diabetes belt, she says. "It can't be done by the government alone, but it also can't be done by the health care industry alone," Gracia adds.



To be effective, diabetes prevention needs to be local, at the community level. Perry says he can see this firsthand. His mother, father, and other relatives also have type 2 diabetes, which he calls "the family curse." Perry has dedicated himself to raising diabetes awareness locally and nationally. "You have to start recognizing the problem and building communities around that problem," he says. "We've got to get out to the people where the problem is. It's going to take government leaders to step up and say, 'This is important.' "



Rhinehart suggests that communities strive together to be healthier, which can take civic planning. For example, in designing buildings, architects "have to hide the elevators and escalators," he says, to increase the odds of people taking the stairs instead. Cities and towns need to build walking and biking trails that are safe to use.



Of course, projects like these cost lots of money, not just to design and build but to maintain. Yet consider this: In 2012, the cost of diabetes in the United States was more than $245 billion ($176 billion in direct medical costs and $69 billion in reduced productivity), according to the ADA's "Economic Costs of Diabetes in the U.S. in 2012," published this year.



On an individual level, Rhinehart says reaching those at risk—especially while they're young—and educating them are keys to reducing the number of people who develop type 2 diabetes. One effective method, he says, is the Diabetes Prevention Program, which brings people with prediabetes to meet one-on-one with health care providers. Participants aim to lose 7 percent of their body weight in 16 weeks through changing what they eat and increasing their physical activity. The program has been supported by the ADA, and the YMCA has offered it at many facilities. "We're not talking about getting down to your high school game weight, just a 5 to 7 percent loss," Rhinehart says. "What we have to do is take that next generation and make it a healthy generation."



Vora, the Tennessee endocrinologist, also says health care providers are where "the rubber meets the road" when it comes to preventing type 2 diabetes. Just talking about diabetes care and prevention, he says, can have a huge impact. He likened the hush-hush nature of diabetes management in the past to erectile dysfunction: "We didn't talk about it until the Viagra commercials. But [now] it's OK to bring it to the doctor's attention."



Reaching people where they are, before they even meet with a doctor, can also help raise awareness and get people moving in a healthy way. The ADA does this through several of its programs for high-risk populations, such as Live Empowered: Learning to Thrive With and Prevent Diabetes, designed for African American church congregations. "We can't change poverty a whole bunch, but attitudes, and seeking care, will probably change," Vora says. "Education, increasing the awareness of the problem, will only help."



Raising awareness, Perry believes, is the first step in breaking down the diabetes belt. And to do that, he says, people need to get fired up about stopping diabetes, as they are for fighting cancer or AIDS. "I want to see this disease put down," Perry says. "Think about polio: People got behind [research and education, and now polio is rare]. We can show people how to prevent their diabetes from getting worse and how to prevent themselves from getting [type 2] diabetes if they're one of those 79 million people with prediabetes."

FEWEST PHYSICIANS

Nationally, there was an average of 25.7 physicians per 10,000 people in 2008. In these states, there were fewer than 21 physicians per 10,000 residents, making it more difficult to get access to health care.