By Erica Hensley
MS Center for Investigative Reporting
The number of diabetes cases among adolescents has nearly doubled since 2001, according to a new study by the American Medical Association. Those numbers are expected to quadruple by 2050.
The average age of onset for Type 2 diabetes among children? About 14 – an age that was unthinkable decades ago for a disease associated with adults.
Spikes for Type 2 diabetes were highest among Black and Hispanic children. Some attribute the recent spike to COVID-19 – fueled by lockdowns and closed schools, which have reduced access to health care, healthy food, and places to exercise.
Researchers are seeing not only more new diagnoses, but worse cases that require acute hospital care. Nationwide and in Mississippi, pediatric hospitalizations for diabetes have surged.
Though Type 1 cases are still more prevalent among children, and have also increased recently, the rise has not been as sharp as Type 2 cases – suggesting practitioners should focus more on prevention, such as diabetes screenings at younger ages.
Type 2 diabetes used to be called “adult-onset diabetes” because it only developed with age – after a lifetime of high sugar intake and sedentary lifestyle – and was rarely seen in children.
But over the past two decades, new cases among children have exploded – rendering the old term moot, and setting up more and more kids for chronic complications for life. The earlier someone develops the condition, the more likely they are to see long-term health complications earlier in life, such as blindness, high blood pressure, limb amputations, and kidney failure, and to die younger.
Leaving a legacy in the state’s most diabetic county
An advocate for diabetes awareness, legendary Blues musician B.B. King never shied away from his Type 2 diagnosis. Playing sold-out arenas well until age 88, he openly discussed managing the disease, which causes the body to stop regulating sugar and insulin levels, and how changing his diet and routines helped him reduce reliance on meds.
In his hometown of Indianola, Mississippi, advocates and educators not only carry on his legacy at the B.B. King Museum, but also his heart for community activism. For the last six years, the museum has put on diabetes programming, including prevention classes for adults and wellness camps for kids, who are increasingly moving into the crosshairs of this deadly disease. The “Be Smart! Control Your Diabetes” initiative meets monthly and helps aging folks learn low-impact exercises, to cook healthier, and incorporate regular medical screenings.
With partners at Mississippi State University’s Extension Service, and state and county diabetes groups, the program serves about 40 people a month.
But in Sunflower County, the heart of the Mississippi Delta and home to Indianola, it’s an uphill battle. One in four adults has diabetes – the most of any county in Mississippi, which is the only state in the nation where every county is considered part of the “diabetes belt”. Too, 15% of the county lacks health insurance – meaning many folks are likely missing preventive health care and medical screenings. Overall, Mississippi has one of the highest rates of uninsured people and the state is one of 13 that have refused to expand Medicaid to people with low incomes.
A retired elementary school teacher in Indianola, Debra Bailey saw more and more young children diagnosed with Type 2. By 2010 when she retired, she had four third grade students with new cases.
“These are 7- and 8-year-olds who had to learn to give themselves shots during the school day,” Bailey said, adding that the school cafeteria had to completely overhaul its school lunch diet, too. “It’s one thing for an adult, but that’s scary for a child.”
Now pre-diabetic herself, but maintaining her A1C levels – a blood test that measures average blood sugar – she’s regularly attended the museum’s diabetes groups the past three years.
“When people hear they’re diabetic, they get all scared and think, ‘Oh, Lord, I have to take a shot and eat pills,’ but if you go to classes and educate yourselves, you learn it’s doable,” she said. “It doesn’t mean walking six miles a day, as long as you’re keeping active and moving around and monitor what you eat. But it is an ongoing progress to keep yourself healthy.”
Reducing the stigma and educating folks is the first piece to prevention, says Misty Clark-Johnson, educator coordinator at the museum.
“We do presentations and cooking classes, so they get a chance to taste new foods and see that it’s not so bad,” she said, adding Mississippi culture revolves around sharing meals – delicious, but unhealthy – and it’s hard to change those habits.
“But we show them that you can manage and control diabetes through exercise and eating better, like cooking healthier foods with spices, to get away from salt intake. Especially during the holidays when food is everywhere and so good.”
And more so than ever before, those trends are trickling down to children across the region.
In Mississippi, more children are overweight or obese and live in poverty than anywhere else in the country, and 15% of their parents have Type 2 diabetes – behind only West Virginia. More younger adults develop Type 2 in Alabama than any other state. In Georgia, Type 2 cases are growing at a faster rate than the rest of the country.
Together, these three states buckle the diabetes belt, where more young people are on track to live with diabetes than ever before – a threat to not only their health and livelihood, but also the healthcare infrastructure overall in a part of the country where safety nets are slim and generational poverty rampant.
How we got here
Dr. Foluso Fakorede says the dual diabetes and obesity epidemic creates the biggest health challenge the nation faces – and social determinants of health, such as poverty and lacking access to healthy food and health care, only make it worse.
That epidemic has spanned decades, devastating places like Mississippi, where the social determinants are the worst, said the Delta cardiologist, who works to help diabetes patients save their limbs. Black Southerners see the highest rate of diabetes-related amputations – expensive, preventable, and often primitive surgeries – in a part of the country where lack of insurance and other barriers to care are high.
Mississippi has the fewest physicians per capita in the U.S. as well as the fewest trained to treat diabetes, despite being the state with the highest rate of diabetes risk, Fakorede said, noting increasing trends among youth. With that in mind, “How do we tackle this problem?” It’s worse for children here – there are only three pediatric endocrinologists in the state, according to 2020 data from the Office of Mississippi Physician Workforce.
Even before the pandemic saw increased Type 2 cases and hospitalizations, trends have showed the influx of youth cases has been a long-time coming, exacerbated by school closures and lockdowns.
New research from the Centers for Disease Control and Prevention shows that the monthly rate of increase in weight gain among kids nearly doubled during the COVID-19 pandemic compared with a pre-pandemic period.
In Shaw, Mississippi, a rural town of 2,000 residents that splits across Sunflower and Bolivar counties, advocates say food deserts and poverty stretch limited resources and create auxiliary impacts across the Delta.
“Folks flood into Cleveland to do grocery shopping,” said Chiquikta Fountain, executive director of Delta Hands for Hope, a nonprofit in Shaw that focuses on healthy food distribution for the community. Her background is in school policy, both in and out of the classroom – including the cafeteria.
“Kids were coming home from school starving. I mean, just literally raiding the refrigerator after school, and parents had two concerns: They’re coming home hungry and on the verge of starving, that means that they’re not functioning to the capacity that they should because their little brains and bodies are not getting any type of nutrition,” she said, adding kids weren’t eating school-provided lunches because of quality concerns – leading some students to protest the cafeteria meals.
Schools have historically struggled to prioritize healthy lunches, and 605 schools across the nation don’t have a full-time nurse on staff to help the growing number of students who need help managing diabetes meds during the day. Southern states are the least likely to have a full-time school nurse – creating a perfect storm across the region among food deserts and poverty, where families tend to rely on cheaper, but less healthy, fast and pre-packaged food full of sugar, fats, and carbohydrates.
Too, many parts of the rural region struggle with physical inactivity, where families lack access to safe exercise opportunities, like playgrounds, lighted walking paths, or affordable gyms. In Mississippi, 38% of adults report not exercising at all or lacking exercise activity – the most of any state. For kids, those opportunities usually come at school, but when school shuts down, even the option to eat a meal or get a few minutes of exercise evaporates.
That’s where Delta Hands for Hope came in. During the pandemic, the group pivoted their normal youth programming to provide emergency food pantry and soup kitchen meals. Now that school is back, the group has pivoted again to focus on weekend care packages – chock full of local fruits and veggies. But many folks aren’t familiar with fresh food and don’t know how to prepare it, Fountain says.
“If you’ve never been introduced to zucchini or squash or kale, you’re not going to gravitate towards that, or even try to find a way to cook it,” she said. “Even though it was free, they wouldn’t want it because it wasn’t something that they could necessarily make a meal out of that people in their household would eat.”
It’s been a challenge to constantly adapt during COVID, but Fountain keeps shifting to meet the needs of the community, including youth programming to instill the importance of healthy, local food to prevent future disease.
Fertile ground, but hungry homes
Of course, advocates point to the inherent irony that the diabetes belt map matches with the nation’s agriculture production maps. Amidst the most fertile soil in the country, more go hungry than anywhere else. But there’s more to those maps – obesity and poverty layer in, too, which tend to correlate with food deserts, where folks don’t have access to healthy, affordable foods nearby. The U.S. Department of Agriculture considers Mississippi the largest food desert in the country, where a higher percentage of people are considered food-insecure than anywhere else. Too, overlay the maps with states that have refused to expand Medicaid health insurance to those with low incomes, and it’s a near-perfect match to the diabetes belt.
Though agriculture is the largest industry in Mississippi, the state imports about 90% of food and sends most home-grown crops out of state. Alabama and Georgia have instituted state-led programs to keep healthy foods in-state, and launched “farm-to-school” programs to make sure young folks living in poverty can share in the access. In a report aimed at state policy makers, the Mississippi Food Policy Council says the state, where three in four students qualify for free school lunch, should take notes from neighboring states.
In 2021, Alabama’s legislature fostered greater coordination of farm-to-school programs, shared and made it easier for small purchases to be made from local farms, according to the report.
Georgia’s 2011 “Feed My School” program grew from a rotation of five to 19 schools each year to help bridge the gap in nutritional value and quality of food served in Georgia schools, while providing more local sales for community farms. Schools where at least 50% of students qualify for free and reduced meals get priority in the state program. By their second year participating, each school featured 75 to 100 percent Georgia-grown foods, according to the report.
Since 2002, Mississippi agriculture and education agencies have partnered to research and promote farm-to-school initiatives, with help from the U.S. Department of Agriculture’s Fresh Fruit and Vegetables Program. But just as the Type 2 diabetes cases have skyrocketed among children, the state program has seen declines.
For school year 2014-2015, schools ordered 32,927 cases of Mississippi products totaling over $1 million in sales to local farmers. By the 2017-2018 school year – the best recent year for the program according to Mississippi Department of Education that tracks the program – sales were down to 16,000 cases of produce totaling $622,000.
Cost and shipments vary depending on seasonal crops, farmers’ bandwidth, and schools’ needs, but the last three years have seen even further declines due to COVID-19 and longer rain seasons.
“I’m a product of Sunflower County, the town that I grew up in and the town that I work in are mirror images of each other,” said Fountain, of Delta Hands for Hope’s work. “If you do not grow up in a family or even in a community where agriculture and the importance of connecting with the land and earth was really instilled in you, farming wasn’t looked at as an attractive line of work. The whole purpose of upwardly mobile young people is going out to college for us to get a professional job,” usually far from Mississippi, she said.
But she sees that changing as more young people use their education to help grow their communities. And, too, she says, it’s an odd silver lining of the pandemic.
“I wish that those things were as valuable to me back then as they are to me now. But COVID has changed all of that and brought people back down to earth to let them see that while technology is great, what happens if all of those things shut down? Not to say that we need to live in the past, but I think that there are some things to learn from the past, as it relates to survival skills that just aren’t taught in school. Those things come from your family lineage passing that down to you or you seeing other people do that.”
This story was produced by the Mississippi Center for Investigative Reporting and funded in part by the Fund for Investigative Journalism. It was also produced in partnership with the Community Foundation for Mississippi’s local news collaborative, which is independently funded in part by Microsoft Corp. The collaborative includes MCIR, the Clarion Ledger, the Jackson Advocate, Jackson State University, Mississippi Public Broadcasting, and Mississippi Today.