At the Visalia Oak Health Center, doctors know all about diabetic patients even before examining them.
A computer tracking system alerts doctors to a patient's health needs. They know if the patient is due for a foot exam to check for nerve damage, an eye test to look at blood vessels or laboratory work to measure blood-glucose levels.
It doesn't matter if the patient is there for something else -- a cough, cold or backache. The diabetes registry tells the doctor what diabetes care the patient needs.
"The goal is to prevent the progression of diabetes complications," said Erik Persell, a physician's assistant.
This is the type of program that could help bring the diabetes epidemic under control, health experts say. But the high cost of expanding programs has been a barrier. The very scope of the problem is daunting.
Diabetes is a societal disease. The fight can't be confined to treating one patient at a time. It's a battle against obesity, poverty, a doctor shortage, urban sprawl -- factors found in abundance in the Valley.
"We've got to make people realize this is not simply just poor eating behaviors, poor lifestyle choices," said Rudy Ortiz, a UC Merced professor who studies obesity and diabetes. "There are issues in the workplace, in the community, in the schools that all contribute to this."
And everyone agrees more needs to be done. If things don't change, one-third of the children born in 2000 will develop the disease sometime in their lives. That puts thousands of 9-year-olds needlessly at risk of heart attack, stroke, blindness and amputations later in life.
Sounds hopeless. But each small step helps. In the waiting room
At least 25% of the patients seen at the Visalia clinic are diabetic. And half of patient visits are related to diabetes, said Dr. Christopher Rodarte, the medical director.
Diabetes requires doctors, physician assistants, diabetes educators, nutritionists, psychologists -- and the patient -- working together to keep a patient's blood-sugar levels under control, he said.
Family HealthCare Network, which runs the Visalia clinic, spent nearly $50,000 on the computerized diabetes registry. The system replaces a manual registry that was time-consuming and often out of date.
The registry has had concrete success:
--A comparison of diabetes patients before and after the computer tracking found that 61%, up from 25%, had received a pneumonia vaccine. This is important because diabetes patients are more at risk of pneumonia.
--Sampling suggests that nearly half of patients, up from 20%, received a retinal screening to detect eye problems. Diabetes is the leading cause of new cases of blindness among adults in the United States.
Not enough money
So far most diabetes-prevention programs have been accomplished on a shoestring budget, advocates say. That's despite evidence that prevention programs save money.
Foot-care programs to prevent amputations reduce a diabetic's health-care costs by about $900 over five years, according to a federal report in 2000. Blood-pressure screenings to decrease the risk of heart attack and stroke save $900 over a diabetic's life.
Overall, every $1 spent training people to take care of their diabetes saves up to $8.76 in health-care costs, the report concluded.
But funding for diabetes prevention in California has been lacking for some time, said Lisa Murdoch of the American Diabetes Association.
The California Diabetes Program is charged with reducing the prevalence of the disease. Its $1 million annual budget is entirely funded by the federal Centers for Disease Control and Prevention.
The program has nine full-time employees and two who are part-time. One part-time health-promotion specialist works in the Fresno area.
The program has tried to distribute the people to get as much coverage statewide as possible, said Linda Rudolph, deputy director for the state's Center of Chronic Disease Prevention and Health Promotion. Rudolph is responsible for the program.
"We're doing the best that we can do given the economic challenges that the state is confronting," Rudolph said.
The diabetes association worries that low-income diabetics could be hurt by California's budget crisis, Murdoch said. California could tighten eligibility rules and limit services under Medi-Cal, the federal-state insurance plan for the poor.
Ortiz, the UC Merced professor, helped write a legislative report last month that outlines a plan to fight obesity and diabetes in California. But it counts on funding that has not been secured.
Among its recommendations: Increase meal reimbursements for schools that provide fresh fruits and vegetables to students for breakfast and lunch, and increased financial support for students enrolled in public-health degree programs.
Ortiz, an assistant professor of physiology and nutrition, recognizes the obesity and diabetes report he co-authored is hitting legislators' desks at a bad time. But he hopes legislators will take its recommendations to heart.
A simple plan
Agencies must look at new ways to prevent diabetes, said Dr. Dean Schillinger, who runs the California Diabetes Program. For example, he is trying to capitalize on simple technology to reach diabetics.
He is trying to get a grant for a telephone self-management support system that would be operated out of the University of California at San Francisco. Diabetics would have access to a nurse or diabetes care manager by telephone. The easy access would help them manage their disease better, Schillinger said.
A Medi-Cal managed-care health plan and a private foundation currently pay for such a program in San Francisco County, he said.
Other seemingly simple remedies can make a huge difference.
An influential 2002 study of 3,234 people with elevated blood-glucose levels showed blood-sugar levels can be brought under control if a patient loses 5% to 7% of body weight.
Participants accomplished this with a few changes: eating less fat, keeping track of what they ate, learning to handle stress, and finding time to be physically active, among others. They also exercised at least 150 minutes a week.
The exercise and weight loss were far more effective than taking pills that control blood-sugar levels, the study found.
They also save money. The state task force report says a 10% improvement in physical activity and weight could save California nearly $13 billion a year.
Another answer is to provide diabetes-education classes.
Studies in the United States and abroad have demonstrated that diabetics who have been educated about their disease do better. Their blood-sugar levels showed improvement, and they lost more weight.
But without widespread public education, many Valley residents continue to dine at fast-food outlets, eating high-fat, high-carbohydrate diets that promote weight gain and diabetes.
According to a 2007 retail-food survey by a California health advocacy group, Fresnans are more than six times as likely to be able to find a hamburger at a fast-food restaurant than to find broccoli at a grocery store or farmers market.
A foot exam
At the Oak clinic, diabetes patient Beverly Beach beamed as she walked out of an examination room recently.
The physician assistant had examined her feet for sores -- which can be a sign of diabetes-related nerve damage.
"I'd never had that done," she said.
Beach, 59, of Visalia was diagnosed with diabetes more than a year ago.
She changed her diet and takes pills every day to control her blood sugar.
The doctor's visit this month was the first she had had in a year.
She and her husband own a welding business, and they don't have health insurance.
The physician's assistant made an appointment for an eye test, she said. It has been a year since she had one, and she is due for another.
She likes knowing her doctor is keeping tabs on her diabetes. "I'm happy with the care," she said.
She'll return every three months now for follow-up exams, she said.
Across the clinic's hall, physician assistant Erik Persell wants a psychologist to see a diabetic patient.
She is showing signs of depression.
He is sold on the computer-tracking system, he said.
This month, he sent a patient for an eye exam. Turns out she had eye damage from diabetes.
"We caught the problem," Persell said, "and now we can get her into a specialist."
It was another small step in the right direction.
The reporters can be reached at banderson@fresnobee.com or (559) 441-6310 and natalya@gmail.com To see more of The Fresno Bee, or to subscribe to the newspaper, go to http://www.fresnobee.com Copyright (c) 2009, The Fresno Bee, Calif. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.
Copyright (C) 2009, The Fresno Bee, Calif.