Written by: Uriyoán Colón Ramos, Assistant Professor at the Milken Institute School of Public Health of the George Washington University & Josiemer Mattei, Assistant Professor in the TH Chan Harvard School of Public Health.

November is Diabetes Awareness Month. We are participating in this worldwide campaign in order to promote awareness about what is diabetes, as well as prevention and treatment measures.

What is diabetes?

Diabetes is a disease that occurs when there are high levels of glucose, or sugar, in your blood. There are two types of diabetes: Type 1 and Type 2.  Type 1 Diabetes occurs when your body does not produce enough insulin, which helps the body control the levels of glucose. Type 1 Diabetes is also known as “insulin-dependent diabetes” or “juvenile diabetes,” since its onset tends to be in younger patients.Type 2 Diabetes occurs when the body is able to produce enough insulin, but is not able to use it properly.   

In Puerto Rico, approximately 63 out of 100,000 people die each year because of Type 2 Diabetes. In comparison, only 19 out of 100,000 non-Hispanic whites die each year because of Type 2 Diabetes.  Puerto Ricans in the island die twice as often because of diabetes compared to Puerto Ricans in the US. The prevalence of diabetes in Puerto Rico is also one of the highest in the US and Latin America. Approximately 1 out of every 6 people has diabetes, and many more are classified as “pre-diabetic.”

Why is the prevalence of diabetes so high in Puerto Rico?

Even though we are not entirely sure why prevalence of diabetes morbidity and rates of mortality are so high in Puerto Rico, we have various hypotheses. There are various factors that increase risk of Type 2 diabetes: obesity, unhealthful diet, lack of physical activity, older age, family history and ethnic origin. The coexistence of many of these factors in Puerto Rico can create the perfect storm.   

• Most of us are Hispanic and that alone increases the risk of diabetes. While this can be due to genetic predisposition, it doesn’t explain all of the cases of diabetes. This risk can be compensated for by following a healthy lifestyle.
• Obesity and overweight prevalence among adults is 68% (this means almost 7 in 10 people in Puerto Rico have diabetes).  These rates are very high and can help explain in part the high prevalence of diabetes because being overweight and obese can increase considerably your risk for diabetes.  Children in Puerto Rico can also be afflicted, since rates of overweight and obesity are between 20 -50% among kids.   
• Older age in Puerto Rico could be another factor to consider. Since the 1970’s, the young population (younger than 15 years of age) in Puerto Rico has been on a decline.  In 2006 there was a strong migratory movement of young people who moved away from the island.  This resulted in a larger portion of older people who stayed in the island.  As the population in Puerto Rico continues to age, and the older population becomes larger, we may expect rates of diabetes to increase.
• Our diet can improve considerably. Today, we don’t consumen the quantity of fruits and vegetables recommended by health officials. Surveys that have been conducted in the island show that we consume too much sugary drinks, such as juice and soda, baked good and processed meats. All of these food products are associated with an increased risk of diabetes. A study performed in the WIC program in Trujillo Alto reported that infants were consuming more fruit juices and sugary drinks that was is recommended.   
• Finally, we do very little physical activity– only 1 out of 13 people in Puerto Rico exercised at the recommended levels, according to a national survey. 
• It is important to note that those who suffer from Type 2 Diabetes may not present with typical symptoms right away, such as increased thirst or urinary frequency. During this time, the body slowly deteriorates due to the excess levels of glucose in blood. It is possible that in Puerto Rico the diagnosis for diabetes is coming too late, when complications are already present, and by that time it is more difficult to control the condition.  Also, even though more than 90% of the population has health care coverage, the infrastructure, quantity, and quality of preventive and treatment services against diabetes in our country has been limited.  Diabetes care in Puerto Rico has been found not to meet the recommendations established by the American Diabetes Association.

What can we do?

Several steps can be taken to prevent and control diabetes:

• Scientific studies show that having a diet high in fiber, fruits, vegetables and low in refined sugars, salt and saturated fats can prevent and control diabetes. For Puerto Ricans, this can be achieved by eating more beans, leafy greens, fruits, fish and drinking water instead of juice and soda while decreasing the consumption of processed meats, such as hot dogs and sausages.
• Exercising is also necessary: walking is a simple and effective way to exercise.
• Get informed and let others know: talk to your doctor about your diet and exercise patterns.
• Inform yourself and inform others: Speak with your doctor about your diet and exercise patterns and don’t wait until you are being prescribed medications for diabetes or pre-diabetes to do so.
• It is clear that diabetes is not a battle that can be won independently. It takes a lot of effort from oneself, one’s family and support system, good quality of medical care, infrastructure of government services and an environment which promotes healthy living.

Despite the high prevalence of diabetes in Puerto Rico, we have the opportunity to prevent and control it. It is up to each one of us to contribute a grain of sand (or better, fiber!) towards diabetes  prevention.

Additional Information:

Mattei J.Diabetes Mellitus. Encyclopedia of Immigrant Health. Publisher: Springer, US. Editors: Loue, S and Sajatovic M. Part 5: 542-546, 2012. DOI:10.1007/978-1-4419-5659-0_206

References - Academic Journals

Colón-Ramos U, et al.  Transnational Mortality Comparisons Between Archipelago and Mainland Puerto Ricans. J Immigr Minor Health. 2016 Jun 22.

Sinigaglia OE, Ríos EM, Campos M, Díaz B, Palacios C. Breastfeeding practices, timing of introduction of complementary beverages and foods and weight status in infants and toddlers participants of a WIC clinic in Puerto Rico. Springerplus. 2016 Aug 30;5(1):1437

Xu F, et al. Surveillance for certain health behaviors among States and selected local areas - behavioral risk factor surveillance system, United States, 2011. PubMed PMID: 25340985.

Colon-Ramos U, et al. Socio-demographic, behavioral, and health correlates of nutrition transition dietary indicators in San Juan, Puerto Rico. PubMed PMID: 24553760

Colon-Lopez V, et al. Behavioral correlates of fruit and vegetable intake in Puerto Rico: results from the Health Information National Trends Survey. Puerto Rico Health Sciences Journal. PubMed PMID: 24397217.

Colon-Ramos U, et al. The Association Between Fruit and Vegetable Intake, Knowledge of the Recommendations, and Health Information Seeking Within Adults in the U.S. Mainland and in Puerto Rico. Journal of Health Communication. PubMed PMID: 25204843.

Lin H, Bermudez OI, Tucker KL. Dietary patterns of Hispanic elders are associated with acculturation and obesity. The Journal of Nutrition. PubMed PMID: 14608089.