COVER STORY : AT RISK : Ranked as the Third Leading Cause of Death by Disease, Diabetes Strikes People of Color at an Alarmingly High Rate.

IT STARTED AS JUST A SMALL SORE ON HIS HEEL, nothing to worry too much about.

Twelve days later, the sore had worsened into a gangrene-infected ulcer. And soon after, diabetic Adan Monterrosa lay in a hospital bed, his left ankle and foot amputated.

“I had the thought that nothing would happen because it didn’t bother me,” Monterrosa, 46, of South-Central, said as he sat in his hospital bed on a recent afternoon at Rancho Los Amigos Hospital in Downey.

The loss of a limb is always horrible, but what makes Monterrosa’s tale--and the stories of uncounted thousands of other diabetics like him--even more tragic is that it possibly could have been avoided.

In Central Los Angeles, minimal access to medical care and lack of awareness of the potentially serious consequences of unchecked diabetes is taking its toll on segments of the population already genetically predisposed to the disease.

With regular checkups, doctors can often catch early symptoms of diabetes that patients may overlook and can inform them of how to curb its progression. But because many do not have the means to get preventive care or wait too long before they do, diabetes among people of color is often more devastating than it needs to be.

Diabetes ranks high among illnesses affecting those in minority communities. Ranked as the third leading cause of death by disease, diabetes strikes people of color at an alarmingly high rate. Genetic makeup and environmental factors contribute to the extreme consequences of the disease among minorities, but poor diet, stress and sedentary lifestyles--all correctable, to some degree--exacerbate the problem.

“Historically, diabetes has been recognized as being in the majority population, with the insulin-dependent and kids,” said Dr. Don Garcia of the Community Health Foundation of East Los Angeles’ Bell office and a member of a statewide steering committee on treating diabetes at the local level. “But there has been a rude awakening that diabetes has changed. It is no longer just among Europeans and juveniles, but it is an ethnic disease that has besieged communities of color.”

More than 14 million people nationwide have diabetes, half of whom are undiagnosed and most of whom are minorities, according to the American Diabetes Assn. The federal Centers for Disease Control estimates that Native Americans have diabetes at a rate five times greater than whites. The rate among Latinos and Asian Americans is three times greater than whites, and African Americans have a rate twice as high as whites.

In Los Angeles County, more than 700,000 people are afflicted with diabetes, according to the diabetes association. Latinos suffer the highest incidence rate, with one in seven having diabetes. One in 10 Asian Americans, one in 13 African Americans and one in 19 whites have the disease.

“Diabetes is a dangerous disease because initially there are no symptoms. It’s just something that creeps up on you slowly,” said Dr. Luz Medina of the Community Health Foundation of East Los Angeles.

Diabetes prevents the body from making insulin, a hormone that converts the sugar in food into energy. Instead, the sugar collects in the blood and urine, stalls body functions and hardens arteries.

Diabetes also contributes to increased health problems among people afflicted with other illnesses, leading to a change of lifestyle or--at the other extreme--kidney or heart failure, blindness, amputation and death.

People of color, especially Latinos, are increasingly being found to have diabetes in their late 30s and 40s, an especially young age, health officials say.

“With Latinos being diagnosed with diabetes earlier, that means they’re walking around with the disease longer and that puts them more at risk of suffering the complications of diabetes),” said Marta Miyar of the American Diabetes Assn.’s Los Angeles chapter.

Monterrosa was diagnosed with diabetes 19 years ago at age 27 in his native El Salvador. As far as Monterrosa knows, he is the only one in his family with diabetes. He never knew anyone else who had the disease until he came to the United States 12 years ago.

Although he carefully watched his diet and took his insulin daily, Monterrosa made only sporadic visits to his doctor and waited until he had severe problems before he sought treatment. By then, it was too late to save his leg.

Most people wait until they have noticeable infections or feel too sick to go to work before they see doctors, Medina said. If a person then ends up with a diagnosis of diabetes, “it’s so far gone they have problems with their vision or have to have an amputation,” she said.

Though diabetes is a common disease, most people do not know very much about it. Some shrug off the disease as a nuisance rather than a serious condition, and others equate it with an early demise.

In reality, many diabetics live with the disease for years without severe complications.

There are two types of diabetes: Type 1, which requires insulin, and Type 2, which is non-insulin-dependent. Health officials say research on diabetes has shown that 90% of diabetics are non-insulin-dependent.

Another 4% develop gestational diabetes, which affects pregnant women. Though gestational diabetes goes away when a baby is born, it is a warning signal that there could be a diagnosis of diabetes in the future. One result in gestational diabetes is giving birth to an infant weighing about 10 pounds or with a deformed nervous system or limbs, Medina said.

Type 1 diabetes almost exclusively affects whites, who make up about 5% of all diabetics, and has a greater link to environmental conditions--such as lifestyle--than to genetics, said Dr. Francis Rhie, a specialist in Orange County.

However, a significant number of people of color, primarily Latinos, are also afflicted with Type 1 diabetes, said Dr. Adira Zeidler of the Los Angeles County-USC Medical Center. People can be diagnosed with Type 1 diabetes without any prior history of the disease in their family, said Zeidler, who is conducting a study among Latino diabetics to determine if Type 1 diabetes, which is insulin-dependent, can be prevented.

Most Type 2, non-insulin-dependent diabetics have a history of diabetes in their family, Zeidler said. Most minorities with diabetes are non-insulin-dependent and control the disease with a strict diet and glucose pills to help their bodies produce more insulin.

“A genetic susceptibility puts you at risk,” said Dr. James Gavin, president of the American Diabetes Assn. “But there are some strong environmental influences to give rise to diabetes in urban areas: obesity, diets high in simple sugar and fat, cigarette smoking, stress, low social economic status and a sedentary lifestyle.”

There is no clear understanding of why ethnic and racial groups are more predisposed to diabetes than whites, researchers say. Immigrants are being diagnosed much more frequently with diabetes as they assimilate to sedentary lifestyles and high-fat diets common in the United States.

Latinos have high levels of diabetes because of their shared ancestry with Native Americans, Gavin said. Korean Americans, Southeast Asian immigrants and Japanese Americans have the greatest prevalence of diabetes among Asian Americans--about whom there is little statistical information on diabetes’ effects, said Julie Masumoto, a consultant who has done studies on diabetes.

Diabetes is the eighth leading cause of death among Asian Americans and Pacific Islanders, she said.

For a number of Asian Americans and Latinos, cultural myths aggravate the problems and consequences of diabetes. Many believe diabetes can be cured with home remedies such as herbal teas, special potions or vitamins, or by eating cactus plants. And then there are those who believe that if there’s no pain, there’s no problem.

African Americans and Korean Americans are prone to hypertension, and--in addition to diabetes--they are at risk of getting kidney disease or diabetic retinopathy, which can lead to blindness. Diabetes is the leading cause of new blindness in the nation and is responsible for 8% of legal blindness, Gavin said.

The combination of obesity and diabetes is a major problem among African Americans and Latinos. Women in these communities are especially susceptible, suffering from the highest death rates from diabetes related to obesity, health officials said.

“The more overweight you are the greater the likelihood of getting diabetes, especially if you’re older,” said Miyar.

James Martin of the Community Health Foundation explained that treating diabetes in overweight people is hard because insulin cannot always affect their bodies properly because of the extra fat.

Amputations are common among diabetics because the disease accelerates hardening of arteries and causes poor circulation, frequently affecting the feet, said Dr. Richard Chambers, an orthopedist and co-chief of the diabetic-amputation ward at Rancho Los Amigos Hospital.

Eight years ago, Refugia Ostoich, 52, went to a doctor about a foot problem. She left his office diagnosed with diabetes.

“I didn’t know much about diabetes. I had a sister and brother who had it, but didn’t really know what it would do to me,” said Ostoich, a retired nursing attendant who lives in Mid-Wilshire.

What it did was lead to the eventual amputation of three toes three years ago and a piece of bone in her foot last month.

“It started so small I didn’t think anything of it at first. But in no time it just got worse,” said Ostoich. “Luckily, I only lost a few toes.”

Chambers and his colleague, Dr. Vikram Kamdar, said diabetics often lose feeling in their feet so they are more apt to ignore pain or think a problem such as a sore or an infection will disappear.

“All of a sudden, patients will say they’re really tired, are drinking and urinating a lot and don’t know why,” added Medina, of Community Health Foundation. “Or else they’ll come in with some kind of an infection--athlete’s foot, jock itch, recurring yeast infection. When we do tests, we find that a lot of these people are diabetic.”

Except for some extreme complications that require hospitalization, diabetics can monitor their sugar levels with special machines and can give themselves insulin.

Seated at her desk in the accounting office of Yes Clothing Inc. on Washington Boulevard early one morning, Margarita Santinilla spread open her bright purple medicine pack complete with needles, insulin vials, alcohol pads and a pocket calculator-sized machine to test her blood glucose level for her daily insulin injection.

With a quick prick to a finger and a drop of blood on a small strip of paper, she tested her glucose level: 193, a little high because of a late dinner the night before.

Blood sugar levels should be held at about 70 to 120 milligrams per cubic centimeter of blood. Some diabetics on first diagnosis have had levels over 300, which could result in diabetic coma.

“Whoa, well I’ll need to watch it a little today,” Santinilla, 42, said as she lifted her blouse, grabbed a fleshy part of her stomach and injected herself with the insulin.

“It’s a really tiny needle and it doesn’t really hurt,” she said matter-of-factly. “If I’m in a restaurant, I’ll just do it right there at the table,” Santinilla said, describing her twice-daily insulin injections.

Living with diabetes has not been a barrier, said Santinilla, who teaches bilingual courses on dealing with diabetes. Nor has it stopped Rita Bramasco, 38, of South-Central from caring for her six children and volunteering at her church. Bramasco takes four Glucotrol pills a day and watches her diet to control her diabetes.

Santinilla, who has a combination of Type 1 and Type 2 diabetes, takes small amounts of insulin and is hoping to start taking pills instead of the injections.

“What’s important is controlling your diet and staying away from fatty foods,” said Santinilla.

Judy Hancock, a registered dietitian and diabetes educator at the USC Ambulatory Health Care Center, said diabetics should cut down on the portions of food they eat or make other substitutions. For example, Asian Americans who are susceptible to diabetes should cut down on the amount of rice they eat or increase the amount of insulin they take.

“This is a disease that is controlled, not curable,” Hancock pointed out. “But if it’s controlled correctly, you can live a very, very long life.”

Diabetes at a Glance

Little is known in ethnic communities about a condition that is the third-largest cause of death by disease in the country and is responsible for thousands of deaths among minorities.

* What Is Diabetes?

The term diabetes encompasses two diseases: Type 1, in which the body does not produce insulin, and Type 2, in which the body has a normal or even above-normal production of insulin but does not respond to it efficiently. Insulin, a hormone produced by the pancreas, enables the body to use and store glucose, which is a term that applies to a wide range of natural sugars occurring in blood, honey, fruits and other parts of plants. It is the principal source of energy for humans and other organisms.

* How the Pancreas Works

Tiny cell clusters called islets of Langerhans secrete insulin. Islets comprise four types of cells. The most common, beta cells, are the insulin factories. The other cells secrete hormones that regulate the body’s insulin use.

* Cause of Diabetes

The cause is unknown. Researchers suspect that certain people inherit a tendency for developing Type 2 diabetes. Other factors such as obesity or stress may come into play. In Type 1 diabetes, some researchers believe that hereditary traits can trigger the body’s immune system during illness to mistakenly attack insulin-producing beta cells in the pancreas.

* Symptoms

A major symptom is excessive urination. Some other indications are chronic thirst, loss of appetite and strength, nausea and vomiting. If left untreated, the disease can cause blindness, kidney failure, strokes, heart failure, coma and death.

* Treatments

Carefully maintained diets are essential. Type 1 diabetics must have daily doses of insulin by injection. When the effect of insulin is so great that the level of blood sugar drops sharply, insulin shock occurs. A diabetic having this reaction may become weak or even unconscious. Many diabetics carry foods rich in sugar just in case. Primary treatment for Type 2 diabetes is a diet low in calories, but sometimes it is necessary to take insulin or oral drugs that reduce the level of blood glucose.

* Who Is at Risk

The disease is common in some families, but many diabetics have no known family history of the disease. Some minorities are at extremely high risk. One in 10 Latinos are affected. Among African Americans, the risk is 1 in 14. In the general population, the risk is 1 in 20. Latinos develop diabetes at a younger age. The disease in African Americans is more prevalent among older women, the elderly, people living alone and in families with low income. African Americans have a higher tendency toward obesity, a strong risk factor in Type 2 diabetes.

* Ethnic Groups and Diabetes

In Los Angeles County, nearly three-quarters of a million people have diabetes. The following is a breakdown among ethnic groups:

*NUMBER ETHNIC GROUP POPULATION WITH DISEASE PERCENT Native American 29,159 3,674 12.6% Latino 3,351,242 361,934 10.8% Asian 907,810 98,043 10.8% African American 934,776 65,434 7% Anglo 3,618,850 188,180 5.2% Other 21,327 1,109 5.2% TOTAL 8,863,164 718,374 8.1%

* People with Type 1 diabetes account for 10% of this figure SOURCE: American Diabetes Assn. Information based on adjusted 1990 census figures.

On the Cover

Adan Monterossa, 46, in his hospital room at Rancho Los Amigos Hospital in Downey.

Monterossa, a diabetic, had his left foot and ankle amputated after a small sore on his heel deteriorated into a gangrene-infected ulcer.

Many diabetics such as Monterossa wait to seek treatment until it is too late to save them from severe consequences. But with early diagnosis and proper care, the disease is manageable.