If managing diabetes is tough for city dwellers and suburbanites -- and it is -- then controlling it in rural areas can be an ordeal.

Problems include poverty, lack of healthy food and, worst of all, lack of doctors, pharmacists, dietitians, psychologists and diabetes educators.

"There is no public transportation," said Mona Counts, a Ph.D. and nurse practitioner who runs the Mount Morris Primary Care Center in southern Greene County. "There are no buses, taxis or trains."

Dr. Counts said many patients with low incomes rely on food banks, whose fare often is heavy on carbohydrates, salt and sugar, which worsen blood sugar, cholesterol and blood pressure levels and promote weight gain.

"It's just cheaper to have corn bread and beans," she said.

If back-country doctors are few, then rural endocrinologists specializing in diabetes care are almost nonexistent. Most rural counties are lucky to have one, and even then it can take months for an appointment. Children with type 1 diabetes can be forced to travel to Children's Hospital in Pittsburgh for routine appointments because pediatric endocrinologists are even rarer.

Battling diabetes in Pennsylvania's rural areas, where it's generally more prevalent than the state average, also can involve psychological hurdles. How does one change the lifestyles of people who take pride in resisting change?

These are the life-and-death questions experts are trying to answer in Western Pennsylvania, where diabetes is running rampant.

"There are 6,000 endocrinologists in the U.S., but try to get them to move to rural areas," said Dr. Linda Siminerio, executive director of the University of Pittsburgh Diabetes Institute.

The same holds true for other medical professionals in rural areas of Western Pennsylvania, where there is one physician for every 2,000 people and limited access to specialty care, Dr. Siminerio said. A study examining diabetes care in rural areas found that rural patients are less likely to receive blood tests, eye exams or cholesterol measurements than their urban counterparts.

As a result, she said of rural patients, "you are out there on your own."

No-show rates high

Education is considered key to controlling diabetes.

But in rural Western Pennsylvania, diabetes education programs, usually operated by county-seat hospitals, can represent the only oases of care. Even so, some rural residents still must trek 20 miles or more to attend weekly classes.

But many with type 2 diabetes -- formerly known as adult-onset -- are elderly, already have health problems and diabetes complications, and have little money for medications and supplies to treat their disease.

So fuel costs to attend classes can lower diabetes education on the priority list. Those without health insurance must pay some, if not all costs, of education, prompting even fewer to attend. Then subtract those who are reluctant to accept their diabetes diagnosis, or are not convinced they need help, especially if they've yet to experience symptoms or complications.

The result is no-show rates for diabetes education programs of 35 percent or higher, based on a survey of five programs in five rural counties in southwestern Pennsylvania. So thousands of rural residents with diabetes go without education, worsening the epidemic's impact.

Type 2 diabetes occurs when the body becomes insensitive to insulin, the hormone produced in the pancreas that allows glucose to enter cells and be used as energy. Type 1 involves an autoimmune response that kills insulin-producing cells in the pancreas.

Efficient control requires a nutritious diet, medications and exercise. Many patients must learn to give themselves insulin injections or use insulin pumps and regularly test blood glucose levels.

Keeping blood-glucose levels at or near normal levels helps prevent heart disease, stroke, renal failure, blindness and circulation problems that can lead to runaway infections and, sometimes, amputations.

But cost and distance represent dangerous bends in the rural road to diabetes management.

Diabetes educators, already scarce, are scarcer still in the hinterlands. There are only 30,000 diabetes educators registered with the American Association of Diabetes Educators.

"The problem is, people don't know who we are or where to find us," said Donna Rice, president of the American Association of Diabetes Educators.

For those reasons, the Diabetes Institute is working to deploy educators to rural areas.

Helping hand

Rural assistance is available through the Pittsburgh Regional Initiative Diabetes Education, or PRIDE -- a program initiated by the Diabetes Institute and University of Pittsburgh Medical Center with funding through U.S. Rep. John Murtha, D-Johnstown.

Formed in 2006, PRIDE's goal is providing comprehensive diabetes medical care throughout Western Pennsylvania, with an initial goal of establishing education programs in rural medical centers. The network collects data and helps diabetes education programs gain certification so they can receive reimbursement through health insurance plans. In that way, educators can spend more time with patients.

The Diabetes Institute now is working to place educators in rural primary care offices so patients can receive more immediate instruction closer to home. Diabetes educators are spending a day or two each month in doctors' offices in Fayette County, said Dr. Siminerio, a certified diabetes educator.

The institute also is working with pharmacists to help educate and assist people with diabetes. The prototype is Scott Drab, an associate professor at the University of Pittsburgh School of Pharmacy and director of the University Care Associates, a diabetes education clinic in Jeannette, Westmoreland County, that schools patients in diet and exercise and manages medication regimens with physician oversight. That center, in operation since 1991, has agreements with 36 physicians to provide services such as recommending drug or dosage changes, Dr. Drab said.

Creating a community of educators is necessary, Dr. Siminerio said, to bring an elusive epidemic under some control. But cost remains the big problem in diabetes education. Overruns already are more the norm than exception, prompting many programs to close.

Gary Weinstein, executive vice president of Washington Hospital, said its Diabetes Education & Management Center at the Cameron Wellness Center in South Strabane, Washington County, loses $100,000 to $300,000 a year. The program has been in operation for almost a decade.

The Diabetes Management Center at Butler Memorial Hospital in Butler also sustained losses in the fiscal year ending June 30. Melissa Allen, spokeswoman for the Butler Health System, said the program's revenues of $131,317 did not meet expenses of $183,231, creating an operating loss of $51,914 for the fiscal year ending June 30.

Most health-insurance providers that fund diabetes education follow the Medicare model and pay for 10 hours of education in the year of diagnosis, then two hours of education for each subsequent year. Most hospitals accept patients regardless of their ability to pay. Typical cost is $60 for each half-hour or $1,200 for the 10-hour program.

The common method of gauging diabetes control is an A1C test, which provides an average of blood-sugar levels over a period of months. A1Cs typically drop closer to normal levels after patients receive education. But keeping track of long-term results is difficult.

In a survey of local programs, average AIC levels dropped from about 8.5 to 7 percent.

"We're good cheerleaders," said Karen Harouse-Bell, a dietitian and diabetes educator with Excela Health at Latrobe Hospital in Westmoreland County. Educators there take a firm approach to overcome patients' reluctance to manage their diabetes.

"We tell them where they are going, what path they are on and the end results," she said, noting that such "results" can include complications and death. "That's why the average A1C dropped to 7. We consider that a success."

The ADA recommends that people with diabetes lower their A1C to 7, with normal ranging from 4 to 5.9. The American College of Endocrinology recommends A1C levels below 6.5.

But basing success on AIC is not enough, Dr. Siminerio and Ms. Rice agree. Reducing blood pressure and cholesterol, among other medical benchmarks of good health, also are necessary. But the key to control is behavior change and that can be difficult, given rural lifestyles and jobs.

Coal miners, for example, have trouble taking medicine and testing blood sugar while on the job, especially if they work underground, Ms. Harouse-Bell said. Farmers, too, often are reluctant to take time to test their blood, eat properly or take medications.

One patient, she said, spent his day on a ladder working on machinery. He was forced to remove his insulin pump because excess heat from equipment spoiled the insulin.

Diabetes compliance

Washington Hospital's diabetes education program has been described as a prototype, even if it does lose money.

It operates from a new building it shares with the metabolism and endocrinology practice of Dr. Ralph Schmeltz, a clinical professor at the University of Pittsburgh School of Medicine.

Rural doctors in Washington County say it helps patients learn about medications, how to give insulin injections and use blood-glucose testing machines and insulin pumps, along with providing a primer on nutrition, carbohydrate-counting and exercise.

Anyone doubting that type 2 diabetes is a rural epidemic need only speak with Dr. Fred Landenwitsch of Claysville Family Practice in western Washington County. On the day he talked to an interviewer, he said he had made three diabetes diagnoses.

"There is certain disbelief," Dr. Landenwitsch said. "Then they are frightened that they will have to be on insulin."

Insulin, typically taken by injection, is a volatile treatment regimen because it can cause blood sugar levels to dip to dangerously low levels. But often insulin is necessary for control.

"The science of diabetes is the same if you are in a rural or city setting, but the art of medicine changes in those settings," said Dr. Janine K. Rihmland, also of Claysville Family Practice.

She, Dr. Landenwitsch and Dr. John Six said they prescribe lifestyle changes rather than a battery of medications after diagnosis. If they do prescribe a medication, it is for one month, which means the patient must return for a second appointment to get a refill. That appointment will include a new round of suggestions.

Dr. Rihmland said some rural residents have problems finding a place to exercise. Country roads are dangerous places to walk. Gymnasiums and health centers are rare.

"Believe me, there are challenges. We try to get them to buy into therapy. We have good educational information and the wellness center is a nice resource."

But 15 percent of their patients have no health insurance. Only two-thirds of the people they refer to Washington Hospital's program actually enroll.

Government-funded programs to attack the epidemic with technology may be one salvation.

"Why can't we beam in an endocrinologist?" Dr. Siminerio said. "Or they can have consultation with them on computer. Beam them in. We can do that. We are trying to explore these things."

If PRIDE's goal is providing educators in rural areas, the CERMUSA program funded through Mr. Murtha gives patients a way to communicate with physicians by computer.

CERMUSA -- the Center of Excellence for Remote and Medically Under-Served Areas based at St. Francis University in Loretto, Cambria County -- is helping people of limited incomes who have "fallen through the cracks" of the healthcare system, said Camille Wendekier, a "tele-health" development specialist and registered nurse with CERMUSA.

In a Fayette County pilot study, CERMUSA provided people with blood-glucose testing supplies and placed modems at libraries and hospitals to send readings to physicians. The sheer act of sending test results to doctors inspired tighter control, without additional charge or effort. Only about 60 percent of Pennsylvanians with diabetes test their blood sugar daily, according to state Department of Health statistics.

Fayette's challenge

Fayette County can claim the largest obstacles to reining in the diabetes epidemic.

Cheryl Roberts, a diabetes educator who helped establish Uniontown Hospital's education program last November, said 11 percent of the population has diabetes, with the largest rate of amputations in the nation.

In western Pennsylvania, Washington, Indiana, Venango and Clarion counties also have "significantly higher" mortality rates from diabetes, compared with the state rate.

Fayette County, whose population of 150,000, has only 36 primary care physicians and one endocrinologist, Dr. Jill Felder of Shadyside, who visits the county once a week.

Ms. Roberts said the county population generally is older with lower incomes, with no public transportation and fewer places to buy fresh fruits and vegetables. Many people without insurance decide not to attend education classes. The result is a 35-percent no-show rate.

"The biggest challenge is getting the population to realize they can make changes," Ms. Roberts said. "There are things we can do."