Negotiating Diabetes

Barbara Goldoftas

In the United States, we typically associate type 2 diabetes with over-eating. But it turns out that this chronic disease—and its causes—are far more complex.

While at a conference several years ago, Clark environmental scientist and IDCE Professor Barbara Goldoftas first learned that overweight could co-exist with persistent hunger. “I was looking for a study site where I could do a project on type 2 diabetes, and I heard from a colleague that overweight was emerging in some rural populations in Nicaragua that also endured seasonal hunger,” she recalls.. “Even though people didn’t have enough to eat for several months every year, they had started to become overweight. I figured that if there were so many people who were overweight, there also would be type 2 diabetes. I decided to go and find out. What I couldn’t have imagined was just how much diabetes there actually was.”

Today, type 2 diabetes is the primary cause of hospitalization and second leading cause of death in Nicaragua. Goldoftas, now in year two of her research, focuses on the environmental and social determinants of the disease in Estelí, a rural and primarily agricultural province in the northern uplands of Nicaragua.

“We’ve found a great deal of interest in and concern about the disease,” she says, and willingness to collaborate. In order to gain access to the rural communities and work with the government health clinics that serve each town, Goldoftas partnered with the Ministry of Health of Nicaragua (MINSA). She also collaborated with ASDENIC, a development nongovernmental organization in Estelí whose staff ran the study, and with the local nursing school. “I couldn’t do it alone,” says Goldoftas, whose research is funded by Clark University’s Mosakowski Institute of Public Enterprise.

In addition to MINSA and ASDENIC, to develop a study that would be appropriate for Nicaragua, she consulted with the National Autonomous University of Nicaragua (UNAN) medical schools in Managua and Léon, the Pan-American Health Organization, and others. They conducted a community-based, epidemiologic case-control study exploring different hypotheses for the sudden rise in type 2 diabetes. The research team also conducted focus groups with type 2 diabetics and their families to understand their experiences with the disease and the changes they would be willing to make to manage or prevent it.

The results of the case-control study so far show some key differences between the type 2 diabetics and non-diabetics who were studied in Estelí. Compared with non-diabetics, the diabetics were much more likely to have reported eating sweets and drinking soda frequently when they were children. There was some evidence that the diabetics ate more fried food when young than the non-diabetics, and also that eating fruit, beans, and rice during childhood was “protective.” In addition, the diabetics reported more exposure to fertilizers and, to some extent, pesticides when they were younger. Other results focus on the experiences of the diabetics. For example, diabetics reported having difficulties making the changes the doctors and nurses had recommended, particularly in terms of being able to afford the medications and diet. Further, the majority of diabetics surveyed thought that type 2 diabetes was at least partially caused by stress, and they overwhelmingly believed that it was preventable—which may prove critical to future interventions.

For Goldoftas, this work has a personal dimension. Type 2 diabetes runs in her family, and she was diagnosed years ago as pre-diabetic. “My experience dealing with the unrelenting dietary restrictions makes it easier for me to empathize with what people with type 2 diabetes experience day to day,” she says. “I understand how hard it can be to decipher and follow medical advice, how hard it can be to negotiate the restrictions in social situations, how hard it can be to always be the one who has to say no.”

In Nicaragua, the next step is to work with MINSA to build on the research results and develop interventions at the family and community levels. Goldoftas heads back to Estelí in spring 2015 to continue her work. “My hope is that the research will not just help families negotiate this serious disease, but will also help communities find ways to support diabetics and their families—and ultimately stem the rise of this punishing but preventable disease.”