[Paleopsych] NYT Diabetes Series

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NYT Diabetes Series

[Four articles and a later one on genes an diabetes. Being more Nietzschean 
than Mr. Mencken (I think), I have never been much interested in how the human 
body goes wrong, this in spite of my father, my mother's father, and my 
father's mother's father all having been physicians. I only repeat Mr. 
Mencken's observation that the botched state of the human body is proof of the 
Trinity, that man was designed by a committee.

[Still, all this medical knowledge shows the triumph of science.]

Diabetes and Its Awful Toll Quietly Emerge as a Crisis
http://www.nytimes.com/2006/01/09/nyregion/nyregionspecial5/09diabetes.html

Bad Blood
By N. R. KLEINFIELD

Begin on the sixth floor, third room from the end, swathed in
fluorescence: a 60-year-old woman was having two toes sawed off.
One floor up, corner room: a middle-aged man sprawled,
recuperating from a kidney transplant. Next door: nerve damage.
Eighth floor, first room to the left: stroke. Two doors down:
more toes being removed. Next room: a flawed heart.

As always, the beds at Montefiore Medical Center in the Bronx
were filled with a universe of afflictions. In truth, these
assorted burdens were all the work of a single illness: diabetes.
Room after room, floor after floor, diabetes. On any given day,
hospital officials say, nearly half the patients are there for
some trouble precipitated by the disease.

An estimated 800,000 adult New Yorkers - more than one in every
eight - now have diabetes, and city health officials describe the
problem as a bona fide epidemic. Diabetes is the only major
disease in the city that is growing, both in the number of new
cases and the number of people it kills. And it is growing
quickly, even as other scourges like heart disease and cancers
are stable or in decline.

Already, diabetes has swept through families, entire
neighborhoods in the Bronx and broad slices of Brooklyn, where it
is such a fact of life that people describe it casually, almost
comfortably, as "getting the sugar" or having "the sweet blood."

But as alarmed as health officials are about the present, they
worry more about what is to come.

Within a generation or so, doctors fear, a huge wave of new cases
could overwhelm the public health system and engulf growing
numbers of the young, creating a city where hospitals are swamped
by the disease's handiwork, schools scramble for resources as
they accommodate diabetic children, and the work force abounds
with the blind and the halt.

The prospect is frightening, but it has gone largely unnoticed
outside public health circles. As epidemics go, diabetes has been
a quiet one, provoking little of the fear or the prevention
efforts inspired by AIDS or lung cancer.

In its most common form, diabetes, which allows excess sugar to
build up in the blood and exact ferocious damage throughout the
body, retains an outdated reputation as a relatively benign
sickness of the old. Those who get it do not usually suffer any
symptoms for years, and many have a hard time believing that they
are truly ill.

Yet a close look at its surge in New York offers a disturbing
glimpse of where the city, and the rest of the world, may be
headed if diabetes remains unchecked.

The percentage of diabetics in the city is nearly a third higher
than in the nation. New cases have been cropping up close to
twice as fast as cases nationally. And of adults believed to have
the illness, health officials estimate, nearly one-third do not
know it.

One in three children born in the United States five years ago
are expected to become diabetic in their lifetimes, according to
a projection by the Centers for Disease Control and Prevention.
The forecast is even bleaker for Latinos: one in every two.

New York, perhaps more than any other big city, harbors all the
ingredients for a continued epidemic. It has large numbers of the
poor and obese, who are at higher risk. It has a growing
population of Latinos, who get the disease in disproportionate
numbers, and of Asians, who can develop it at much lower weights
than people of other races.

It is a city of immigrants, where newcomers eating American diets
for the first time are especially vulnerable. It is also yielding
to the same forces that have driven diabetes nationally: an aging
population, a food supply spiked with sugars and fats, and a
culture that promotes overeating and discourages exercise.

Diabetes has no cure. It is progressive and often fatal, and
while the patient lives, the welter of medical complications it
sets off can attack every major organ. As many war veterans lost
lower limbs last year to the disease as American soldiers did to
combat injuries in the entire Vietnam War. Diabetes is the
principal reason adults go blind.

So-called Type 2 diabetes, the predominant form and the focus of
this series, is creeping into children, something almost unheard
of two decades ago. The American Diabetes Association says the
disease could actually lower the average life expectancy of
Americans for the first time in more than a century.

Even those who do not get diabetes will eventually feel it,
experts say - in time spent caring for relatives, in higher taxes
and insurance premiums, and in public spending diverted to this
single illness.

"Either we fall apart or we stop this," said Dr. Thomas R.
Frieden, commissioner of the New York City Department of Health
and Mental Hygiene.

Yet he and other public health officials acknowledge that their
ability to slow the disease is limited. Type 2 can often be
postponed and possibly prevented by eating less and exercising
more. But getting millions of people to change their behavior, he
said, will require some kind of national crusade.

The disease can be controlled through careful monitoring,
lifestyle changes and medication that is constantly improving,
and plenty of people live with diabetes for years without serious
symptoms. But managing it takes enormous effort. Even among
Americans who know they have the disease, about two-thirds are
not doing enough to treat it.

Nearly 21 million Americans are believed to be diabetic,
according to the Centers for Disease Control, and 41 million more
are prediabetic; their blood sugar is high, and could reach the
diabetic level if they do not alter their living habits.

In this sedentary nation, New York is often seen as an island of
thin people who walk everywhere. But as the ranks of American
diabetics have swelled by a distressing 80 percent in the last
decade, New York has seen an explosion of cases: 140 percent
more, according to the city's health department. The proportion
of diabetics in its adult population is higher than that of Los
Angeles or Chicago, and more than double that of Boston.

There was a pronounced increase in diagnosed cases nationwide in
1997, part of which was undoubtedly due to changes in the
definition of diabetes and in the way data was collected, though
there has continued to be a marked rise ever since.

Yet for years, public health authorities around the country have
all but ignored chronic illnesses like diabetes, focusing instead
on communicable diseases, which kill far fewer people. New York,
with its ambitious and highly praised public health system, has
just three people and a $950,000 budget to outwit diabetes, a
disease soon expected to afflict more than a million people in
the city.

Tuberculosis, which infected about 1,000 New Yorkers last year,
gets $27 million and a staff of almost 400.

Diabetes is "the Rodney Dangerfield of diseases," said Dr. James
L. Rosenzweig, the director of disease management at the Joslin
Diabetes Center in Boston. As fresh cases and their medical
complications pile up, the health care system tinkers with new
models of dispensing care and then forsakes them, unable to wring
out profits. Insurers shun diabetics as too expensive. In Albany,
bills aimed at the problem go nowhere.

"I will go out on a limb," said Dr. Frieden, the health
commissioner, "and say, 20 years from now people will look back
and say: 'What were they thinking? They're in the middle of an
epidemic and kids are watching 20,000 hours of commercials for
junk food.' "

Of course, revolutionary new treatments or a cure could change
everything. Otherwise, the price will be steep. Nationwide, the
disease's cost just for 2002 - from medical bills to disability
payments and lost workdays - was conservatively put by the
American Diabetes Association at $132 billion. All cancers, taken
together, cost the country an estimated $171 billion a year.

"How bad is the diabetes epidemic?" asked Frank Vinicor,
associate director for public health practice at the Centers for
Disease Control. "There are several ways of telling. One might be
how many different occurrences in a 24-hour period of time,
between when you wake up in the morning and when you go to sleep.
So, 4,100 people diagnosed with diabetes, 230 amputations in
people with diabetes, 120 people who enter end-stage kidney
disease programs and 55 people who go blind.

"That's going to happen every day, on the weekends and on the
Fourth of July," he said. "That's diabetes."

One Day in the Trenches

The rounds began on the seventh floor with Iris Robles. She was
26, young for this, supine in bed. She wore a pink "Chicks Rule"
T-shirt; an IV line protruded from her arm. For more than a year,
she had had a recurrent skin infection. The pain overwhelmed her.
Then came extreme thirst and the loss of 50 pounds in six weeks.
In the emergency room, she found out she had diabetes.

She was out of work, wanted to be an R & B singer, had no
insurance. It was her fourth day in Montefiore Medical Center.
Her grandmother, aunt and two cousins have diabetes.

"I'm scared," she said. "I'm still adjusting to it."

Next came Richard Dul, watching news chatter on a compact TV. Now
64, he has had diabetes since he was 22. A month before, he had a
blockage in his heart and needed open-heart surgery. He was home
a few days, but an infection arose and he was back. Postoperative
infections are more common with diabetes. This was his 21st
straight day in the hospital.

Here, then, was the price of diabetes, not just the dollars and
cents but the high cost in quality of life.

Simply put, diabetes is a condition in which the body has trouble
turning food into energy. All bodies break down digested food
into a sugar called glucose, their main source of fuel. In a
healthy person, the hormone insulin helps glucose enter the
cells. But in a diabetic, the pancreas fails to produce enough
insulin, or the body does not properly use it. Cells starve while
glucose builds up in the blood.

There are two predominant types of diabetes. In Type 1, the
immune system destroys the cells in the pancreas that make
insulin. In Type 2, which accounts for an estimated 90 percent to
95 percent of all cases, the body's cells are not sufficiently
receptive to insulin, or the pancreas makes too little of it, or
both.

Type 1 used to be called "juvenile diabetes" and Type 2
"adult-onset diabetes." By 1997, so many children had developed
Type 2 that the Diabetes Association changed the names.

What is especially disturbing about the rise of Type 2 is that it
can be delayed and perhaps prevented with changes in diet and
exercise. For although both types are believed to stem in part
from genetic factors, Type 2 is also spurred by obesity and
inactivity. This is particularly true in those prone to the
illness. Plenty of fat, slothful people do not get diabetes. And
some thin, vigorous people do.

The health care system is good at dispensing pills and opening up
bodies, and with diabetes it had better be, because it has proved
ineffectual at stopping the disease. People typically have it for
7 to 10 years before it is even diagnosed, and by that time it
will often have begun to set off grievous consequences. Thus,
most treatment is simply triage, doctors coping with the
poisonous complications of patients who return again and again.

Diabetics are two to four times more likely than others to
develop heart disease or have a stroke, and three times more
likely to die of complications from flu or pneumonia, according
to the Centers for Disease Control. Most diabetics suffer
nervous-system damage and poor circulation, which can lead to
amputations of toes, feet and entire legs; even a tiny cut on the
foot can lead to gangrene because it will not be seen or felt.

Women with diabetes are at higher risk for complications in
pregnancy, including miscarriages and birth defects. Men run a
higher risk of impotence. Young adults have twice the chance of
getting gum disease and losing teeth.

And people with Type 2 are often hounded by parallel problems -
high blood pressure and high cholesterol, among others - brought
on not by the diabetes, but by the behavior that led to it, or by
genetics.

Dr. Monica Sweeney, medical director of the Bedford-Stuyvesant
Family Health Center, offered an analogy: "It's like bad kids. If
you have one bad kid, not so bad. Two bad kids, it's worse. Put
five bad kids together and it's unmanageable. Diabetes is like
five bad kids together. You want to scream."

The Caro Research Institute, a consulting firm that evaluates the
burden of diseases, estimates that a diabetic without
complications will incur medical costs of $1,600 a year -
unpleasant, but not especially punishing. But the price tag
ratchets up quickly as related ailments set in: an average
$30,400 for a heart attack or amputation, $40,200 for a stroke,
$37,000 for end-stage kidney disease.

One of the most horrific consequences is losing a leg. According
to the federal Agency for Healthcare Research and Quality, some
70 percent of lower-limb amputations in 2003 were performed on
diabetics. Sometimes, the subtraction is cumulative. One toe
goes. Two more. The ankle. Everything to the knee. The other leg.
Studies suggest that as many as 70 percent of amputees die within
five years.

Yet medical experts believe that most diabetes-related
amputations are preventable with scrupulous care, and that is why
the offices of conscientious doctors post signs like this: "All
patients with diabetes: Don't forget to bare your feet each
visit."

To witness the pitiless course that diabetes can take, simply
continue on the hospital tour. This one day will do. Dr. Rita
Louard, an endocrinologist, and Anne Levine, a nurse diabetes
educator, were making their way through the rooms at Montefiore.

Here was Julius Rivers, 58, on the sixth floor. Three years with
diabetes. He had been at home in bed when he saw a light like a
starburst and told his wife to take him to the emergency room.
His blood sugar was 1,400, beyond the pale. (A fasting level of
126 milligrams per deciliter is the demarcation point of
diabetes.)

This was his third trip to the hospital in seven months. At the
moment, he had a blood clot in his left leg. He had a heart
attack a few years ago. He was on dialysis. "Tuesday, Thursday
and Saturday," he said.

On the sixth floor was Mauri Stein, 58, a guidance counselor, a
diabetic for 20 years. She had been at a party recently and
"zoned out." Her words slurred. Foam appeared on her mouth. She
had had a mild stroke.

Now she tried to control her emotions, tried not to cry. She had
had repeated laser surgery on her eyes, and was effectively blind
in one. She had recovered from the stroke, but doctors had also
found a tumor on her heart and said it would need surgery.

"My feet burn," she said. "My toes burn all the time. My days of
wearing my pumps are over. I've gotten more cortisone shots in my
feet than I'm sure are legal."

She mentioned her brother, who lived in California. Diabetes had
ransacked his body - an amputation, kidney dialysis, heart
disease, blindness in one eye. He now resided in an
assisted-living center. He was 53.

Ms. Stein's husband walked in and sat on the bed. Six months ago,
he found out the same truth: he had diabetes.

This was one day in one hospital.

Inside the Incubator

Little about diabetes is straightforward, and to comprehend why
New York is such an incubator for the disease, it is necessary to
grasp that diabetes is as much a sociological and anthropological
story as a medical one. While it assaults all classes, ages and
ethnic groups, it is inextricably bound up with race and money.

Diabetes bears an inverse relationship to income, for poverty
usually means less access to fresh food, exercise and health
care. New York's poverty rate, 20.3 percent, is much higher than
the nation's, 12.7 percent.

African-Americans and Latinos, particularly Mexican-Americans and
Puerto Ricans, incur diabetes at close to twice the rate of
whites. More than half of all New Yorkers are black or Hispanic,
and the Hispanic population is growing rapidly, as it is around
the nation.

Some Asian-Americans and Pacific Islanders also appear more
prone, and they can develop the disease at much lower weights.
Asians constitute one-tenth of New York's population, more than
twice their proportion nationwide.

The nature of these groups' susceptibility remains under study,
but researchers generally blame an interplay of genetic and
socioeconomic forces. Many researchers believe that higher
proportions of these groups have a "thrifty gene" that enabled
ancestors who farmed and hunted to stockpile fat during times of
plenty so they would not starve during periods of want. In modern
America, with food beckoning on every corner, the gene works
perversely, causing them to accumulate unhealthy quantities of
fat.

But the velocity of new cases among all races has accelerated
significantly from just a few decades ago. Genetics cannot
explain this surge, because the human gene pool does not change
that fast. Instead, the culprit is thought to be behavior: faulty
diet and inactivity. Dr. Vinicor, of the Centers for Disease
Control, likes to use this expression: "Genetics may load the
cannon, but human behavior pulls the trigger."

Of the country's spike in diabetes cases over the last two
decades, C.D.C. studies suggest that about 60 percent stem from
demographic changes: a population increasingly comprising older
people and ethnic groups with a higher risk.

The studies ascribe the other 40 percent to lifestyle changes:
the fundamental shift that has people eating jumbo meals and
shunning exercise as if it were illegal. At every turn,
technology has made physical activity unnecessary or unappealing.
Gym class has largely been deleted from schools. Fewer than a
third of junior high schools require physical education at all,
the C.D.C. says.

On the whole, New York's corpulence is below the national
average, with 20 percent of adults qualifying as obese, compared
with 30 percent for the country, the C.D.C. says. But the figure
is much higher in poor areas like the South Bronx and East
Harlem.

When the health department studied diabetes in the city's 34
major neighborhoods, the distribution echoed demographic
patterns: Diabetes left only a light imprint on more affluent,
white areas like the Upper West Side and Brooklyn Heights. The
prevalence was about average in working-class Ridgewood, Queens,
and almost nil on the Upper East Side.

But that apparent immunity is weakening. Of those 34
neighborhoods, 22 already have diabetes rates above the national
average, and the numbers are rising all over as the city
continually remakes itself.

"New York is switching from a mom-and-pop type of environment to
a chain-store type of environment, a proliferation of fast food,
even in high-rent neighborhoods they haven't had access to
before, like the East Village and Lower Manhattan," said Peter
Muennig, an assistant professor of health policy and management
at Columbia.

If changes in daily living can bring on diabetes, they can also
delay it, though it is uncertain for how long.

A federal program studied people around the country at high risk
of getting diabetes, and concluded that 58 percent of new cases
could be postponed by shifts in behavior - most notably, shedding
pounds.

But Dr. Frieden, New York's health commissioner, says meaningful
prevention cannot be achieved at the city level. "I can urge
people until I'm blue in the face to walk and take the stairs and
eat less, and it won't make much difference," he said.

His emphasis is on trying to better treat those who already have
diabetes, an ambitious goal in its own right. Most primary care
doctors treat too many patients to provide the attention that
diabetics need, or to check for the disease, he said. Specialists
are scarce. And compliance among patients is notoriously poor.

Even the most basic step in controlling the disease - watching
one's blood sugar - is too much for many diabetics. Doctors
recommend that two to four times a year, patients take a
so-called A1c test, which gauges the average sugar level over the
prior 90 days and is more revealing than daily at-home
measurements.

But in 2002 , the health department found that 89 percent of
diabetics did not know their A1c levels. Of those who did,
presumably the most conscientious, four out of five had readings
over the level the American Diabetes Association says separates
well-controlled from poorly controlled diabetes.

The patients in the survey were not much better at knowing their
blood pressure and cholesterol, which are also crucial for
diabetics to control.

"Diabetes is an interesting beast," said Dr. Diana K. Berger, who
heads the diabetes division at the health department. "It's
probably one of the easier conditions to diagnose but one of the
hardest to manage."

Shortages and Shipwrecks

There is an underappreciated truth about disease: it will harm
you even if you never get it. Disease reverberates outward, and
if the illness gets big enough, it brushes everyone. Diabetes is
big enough.

Predicting the path of a disease is always speculative, but
without bold intervention diabetes threatens to hamper some of
society's most basic functions.

For instance, no one with diabetes can join the military, though
service members whose disease is diagnosed after enlisting can
sometimes stay. No insulin-dependent diabetic can become a
commercial pilot.

Shereen Arent, director of legal advocacy for the American
Diabetes Association, says she already fields 150 calls a month
from diabetics who complain that they are being discriminated
against in the workplace, double the number just a couple of
years ago. She mentioned a typical case, a man rejected for a job
at a baked-bean factory in Texas as a safety risk. "If this
continues," she said, "we're in big trouble."

Dr. Daniel Lorber is an endocrinologist in Queens who thinks a
lot about the disease's present and future. "The work force 50
years from now is going to look fat, one-legged, blind, a
diminution of able-bodied workers at every level," he said,
presuming that current trends persist.

As more women contract diabetes in their reproductive years, Dr.
Lorber said, more babies will be born with birth defects. Those
needy babies will be raised by parents increasingly crippled by
their diabetes.

"At a time when we are trying to shift health care out of
hospitals, with diabetics you don't have a choice," he said.
"Nursing homes are going to be crammed to the gills with amputees
in rehab. Kidney dialysis centers will multiply like rabbits. We
will have a tremendous amount of people not blind but with low
vision. And we have lousy facilities in this country for
low-vision problems. These people will not be able to function in
society without significant aid."

Cost pressures have been slashing the number of hospital beds,
and some exasperated doctors are known to denigrate advanced
diabetics as "shipwrecks," because they have so many health
problems and virtually live in the hospital.

Not only will the future mean too few beds and unsupportable
drains on Medicaid and Medicare, Mr. Muennig said, but if an
emergency strikes - a terrorist attack, an earthquake - the city
health system's ability to respond may be compromised because all
the beds will be full of diabetics.

Most schools do not have full-time nurses. Some public schools,
Ms. Arent said, try to turn away children with diabetes, even
though that is illegal. Others ban them from field trips and
sports teams. And this is now, when diabetes is still relatively
rare among children.

If trends continue, people will live through years blighted by
disability, then die too young. Diabetes is thought to shave 5 to
10 years off a life.

"Life expectancy usually decreases because there's a plague or
there's a massive economic trauma," Mr. Muennig said. "In this
case, we will see a decline in life expectancy due to a chronic
condition."

In 2003, diabetes vaulted past stroke and AIDS from the
sixth-leading cause of death in New York to the fourth. It was
fifth, slightly behind stroke, in 2004. But the health department
says it believes the actual toll is much worse because doctors
who fill out death certificates may ascribe the death to a
complication rather than to the diabetes at its root. Lorna
Thorpe, deputy health commissioner, combed through medical charts
and concluded that diabetes should be third, trailing
cardiovascular disease and cancer.

Laurie Raps is a claims representative for Social Security on
Staten Island, 31 years on the job. From her perspective,
interviewing people embarking on full-time disability, she has
seen the disease's long tentacles. When she started, she saw
people in their 50's and 60's, hobbled by the usual problems of
age: arthritis, herniated discs, heart conditions. Now, every
week, she gets diabetic after diabetic, people as young as 30.

In fact, a 2004 study by UnumProvident, a major provider of
disability insurance, found that the number of workers filing
claims for Type 2 diabetes doubled between 2001 and 2003.

"It's a double whammy," Ms. Raps said. "You don't have these
people working and paying into the system, and then you have
these people collecting from the system."

Ten years ago, Ms. Raps developed diabetes. Her husband has it.
Both her parents have it, their lives being washed away.

"When I look at the people who sit before me with disability
claims, I have to check the birth date in their records," she
said. "They look 10 or 20 years older. Diabetes does that. It
wears you down and wears you down. We're looking at a future of
people 10 or 20 years older in sickness than they are. What kind
of future is that?"

'A 15-Year-Old Is Immortal'

"I'm Linda and I've had diabetes for 13 years."

"I'm Dominique and I've had diabetes for seven years."

"I'm Joseph and I've had diabetes for two months."

The brisk introductions went on, the ritual start to the monthly
meeting of a support group called Sugar Babes Place. All the
members had diabetes. All were children.

Sugar Babes is the idea of Dr. Yolaine St. Louis, chief of
pediatric endocrinology at Bronx-Lebanon Hospital Center. When
she started practicing medicine 16 years ago, the only children
she saw with diabetes had Type 1.

Now, of Sugar Babes' 90 official members, roughly 40 percent have
Type 2. One is 8. Another is 7.

It scares Dr. St. Louis. It scares many doctors who see the same
thing, because they know it does not have to be. Type 2 was
supposed to be an old person's disease. Diabetes still increases
with age in an almost linear fashion - today, one in five New
Yorkers age 65 and older have it - but the starting point used to
be mostly in their 50's.

Dr. Alan Shapiro, a pediatrician with the Children's Health Fund
and Montefiore Medical Center who has spent 13 years ministering
to children in the South Bronx, said there was an easy way to
illustrate the change. When he began, there was a
"failure-to-thrive" clinic, meant to address the undernourished,
because so many children were dangerously thin and small.

"Now I don't think we hardly ever see a failure-to-thrive case,"
he said.

In the clinic's place is an obesity program. Dr. Shapiro never
saw children with Type 2 diabetes in his early years in medicine.
Now, the program has about 10 cases.

One concern he and fellow doctors have is the surge in children
who take antipsychotic drugs for anxiety and conditions like
autism. Some newer drugs can promote weight gain and thus elevate
the risk of diabetes. Dr. Shapiro has an autistic patient who he
feels needs the new medication. But since taking it, the young
man has markedly put on weight and, at 18, developed diabetes.

This extension of the disease to the young is where health care
professionals feel society and public policy have most glaringly
failed. Diabetes, they say, should never have gotten there.

There has been little research into the long-term impact of Type
2 diabetes on children. But doctors have a rough idea. The harsh
consequences that can accompany diabetes tend to arrive 10 to 15
years after onset.

If people contract diabetes when they are 15, 10 or even 5, they
may well start developing complications, not on the cusp of
retirement but in the prime of their lives.

There is a big difference between losing a limb at 21 and at 70.
There is a big difference between going on dialysis at 30 and at
65.

"I heard a horror story a few weeks ago," Dr. Lorber said, "of a
girl who was born deaf, got diabetes at 11 or 12 and went blind
from diabetes at 30."

The C.D.C. has projected that a child found to have Type 2
diabetes at age 10 will see his life shortened by 19 years.

"Imagine if kids were showing up at emergency rooms in cardiac
arrest," said Dr. David L. Katz, director of the Prevention
Research Center at the Yale University School of Medicine.
"Frankly, I think that's the next big thing. It's that dramatic.
If diabetes doesn't respect age, why should coronary disease?
Lord knows, I hope this never happens. But this is what keeps me
up at night."

Yet children can be the most reluctant to accept the truths of
their condition.

"A lot of them are in denial," Dr. St. Louis said. "They have
blood sugars of 300, 400, and they tell me right to my face they
don't have diabetes. 'You're wrong,' they say. 'I don't feel
anything.' I tell them what can happen down the road, and they
shrug. A 15-year-old doesn't care what's going to happen at 35 or
45. A 15-year-old is immortal."

The doctor was telling the Sugar Babes that everyone should have
two compact blood-sugar meters, one for home and one for school.
Then she warned them, "If your sugar is bad and you don't do
anything, you're going to be dropping down all over the Bronx."

Interest was tepid. Some children couldn't keep their eyes off
the waiting dinner arranged at a buffet table by the wall. No
rapt attention from Joseph, 12, who had begged not to come, until
his mother put her foot down. He moaned that he had schoolwork.

"Look at that," said Dorothy Morris-Swaby, a diabetes nurse
educator who worked with Dr. St. Louis, nodding at a girl who was
talking on her phone. "We're educating about diabetes, and she's
on her cellphone. Typical teenager."

As time ran out, hula hoops were brought out. Dr. St. Louis was
trying to identify activities other than video games and TV that
the children might try. Last meeting, they held a jump-rope
contest.

"They have 10,000 excuses why they can't do something," the
doctor said. "So you have to give them ideas and then hope."

The meeting wound up. The hoops were stashed away. Some of the
children stepped toward the buffet table and began to eat.

Living at an Epicenter of Diabetes, Defiance and Despair
http://www.nytimes.com/2006/01/10/nyregion/nyregionspecial5/10diabetes.html

Bad Blood
By N. R. KLEINFIELD

Santos Alicea tottered haltingly over to the art shop in East
Harlem, his legs screaming. The regulars knew what he was going
through. They always did - the diabetes was speaking. He
confirmed this with numerical rigor: 228, his nasty blood-sugar
reading this morning. Nods all around. They had ugly numbers,
too.

James De La Vega owned the art shop on Lexington Avenue, near
104th Street, and regarded the sidewalk out front as his living
room. There, with his friends and family, he shared a lot over
the years: Latino art and culture, the slow cadences of East
Harlem life, runs of hard luck. And diabetes.

Indeed, in East Harlem, it is possible to take any simple nexus
of people - the line at an A.T.M., a portion of a postal route,
the members of a church choir - and trace an invisible web of
diabetes that stretches through the group and out into the
neighborhood, touching nearly every life with its menace.

Mr. De La Vega, a 33-year-old self-styled "sidewalk philosopher"
whose murals and sidewalk chalk drawings are familiar
neighborhood ornaments, has a mother with diabetes. His
stepfather's case was confirmed in March. And a number of Mr. De
La Vega's friends who occupied his chairs or sat in the bordering
garden, well, they had it. Mr. De La Vega said he would probably
get it, too.

In East Harlem, in fact, it seems peculiar if you don't have it.

Months spent in the easy company of the shop's dozen or so
regulars reveal something more than just the insidiousness of
Type 2 diabetes, the disease's most common form. Those months,
and conversations, disclose with relentless consistency the human
behavior that makes dealing with Type 2 often feel so futile -
the force of habit, the failure of will, the shrugging defeatism,
the urge to salve a hard life by surrendering to small comforts:
a piece of cake, a couple of beers, a day off from sticking
oneself with needles.

That behavior is all the more evident in East Harlem, a gritty
neighborhood where problems back up on people like fallen
dominoes.

For as bad as diabetes is in New York, it is staggeringly worse
in East Harlem. Precise numbers are hard to ascertain, but the
prevalence of the disease, factoring in an estimate for
undiagnosed cases, has fluctuated in recent city health
department surveys between 16 percent and 20 percent, as many as
one in five adults.

People in East Harlem die of diabetes at twice the rate of people
in the city as a whole. Diabetes-related amputations are higher
than in any other part of New York. For hospitalizations linked
to diabetes, East Harlem is the third-worst neighborhood. It has
the largest percentage of obese people, whose weight makes them
more susceptible to Type 2.

The fact that East Harlem is roughly 90 percent Hispanic and
black, groups believed to have a genetic predisposition to the
disease, explains part of the problem. There are also other
factors: bad food habits, little exercise, rampant poverty and,
according to health officials, poor access to medical care.

In East Harlem, then, you're in the teeth of an epidemic, a place
where, as health officials warn of a worsening crisis, you can
see the ruins the disease has already wrought.

Most of the afflicted people in East Harlem have Type 2 diabetes,
the focus of this series, which has been linked to obesity and
inactivity, as well as to heredity. (Type 1, which comprises only
5 percent to 10 percent of diabetes cases, is not associated with
behavior, and is believed to stem almost entirely from genetic
factors.)

East Harlem is not just any neighborhood. It is the fabled home
of Rao's, the always-booked Italian restaurant, and El Museo del
Barrio, which celebrates Latin culture. Early on, it was the
repository of Russian Jewish, Irish and Italian immigrants,
congealing into the city's hub of Italian life; after World War
II, a Puerto Rican influx converted it into Spanish Harlem.

Recently, there has been an uptick in Mexican, Dominican and
Asian arrivals, and stirrings of gentrification. But the core
population that has been its ballast for a half-century is being
eroded by forces as powerful as real estate values and
immigration waves: a deviously complicated disease, poverty and
simple human frailty.

'Then I Started Cheating'

The sun was piercing, and the light banged off the side of the
art shop. The air was stippled with fragrances of fried meat.
Crammed inside the claustrophobic interior were assorted
paintings, decorated mugs, greeting cards and other oddments.
Elsie Matos, Mr. De La Vega's mother, sat out front, her dark
hair in a ponytail. The two of them still lived together. She was
56 and worked in the office at a local public school.

She discovered her diabetes coincidentally, as many do, nine
years ago. A boil on her left thigh refused to heal. A blood test
told her what she didn't want to know. Her fasting blood-sugar
reading was nearly triple the 126 milligrams per deciliter that
defines the illness.

She was no stranger to the complexities of diabetes. A few years
ago, an East Harlem coalition fighting the disease enlisted her
son to sketch some pithy warnings. He did this for brochures; and
he scattered chalk drawings across the sidewalks of East Harlem,
depicting his barefoot mother in a sun dress and hoop earrings,
beseeching people: "Eat well and exercise!" "Test your blood for
sugar!" "Check and protect your feet!"

It turns out that the woman in his sketches was a version of Ms.
Matos that had ceased to exist. She was no longer that thin. And
like most people burdened with the disease, whether they lived in
East Harlem or Chelsea or Jamaica, Queens, she toggled back and
forth between obeying its dictates and ignoring them.

When she got the diagnosis, the doctor told her to shed 100
pounds. With a crash diet she did just that, slimming down to
150. She stayed thinner for a year.

"Then I started cheating," she said. "Sandwiches. Frankfurters. I
didn't care. I didn't think it would matter."

She was put on pills. Those who have diabetes usually suffer from
related conditions, especially high blood pressure and high
cholesterol, and often swallow 8 to 10 pills a day. Ms. Matos had
high cholesterol and asthma.

She was warned that she had to control her lust for calorie-rich
food, that taking pills was not enough. Doctors like to say that
patients can eat their way through the pills. And a cruel truth
of diabetes care is that many oral medications prompt weight
gain. Oral diabetes drugs also tend to lose effectiveness. They
sometimes work for a few years, then have to be teamed with other
drugs. Anyone who has diabetes long enough is likely to find
herself on insulin.

Ms. Matos frowned at her stomach. She said she was 165 or 170
pounds, still too much. "The doctor said if I didn't diet, I'd
have to take the insulin," she said. "I don't want the needle."

Despite that dreaded prospect, she had difficulty satisfying the
disease's persistent needs. Among widespread chronic conditions,
diabetes is arguably the most arduous to control.

Diabetics not only need to take an array of drugs, but must also
prick themselves one to four times a day to check their blood
sugar, keeping a log of the results, and then adjust their eating
habits according to the readings. Blood-sugar meters are much
improved from years ago, when they had to be plugged in and
warmed up for an hour. But some diabetics skip the readings,
filling in fake numbers to show their doctors.

For many Type 2 diabetics, doctors say, a half-hour of daily
exercise and the loss of as little as 10 to 15 pounds can make a
big difference in their health. Still, that can be a formidable
challenge.

Understandably, people talk about wanting to take a vacation from
diabetes, but it grants no time off.

Ms. Matos often found herself succumbing to a lifestyle
guaranteed to make her sicker. Until it has been in the system
for a long time, diabetes doesn't hurt. In East Harlem, what
doesn't hurt is often ignored.

She pointed out that many people in her world were stressed out
and depressed. There are other serious health issues, like asthma
and H.I.V., the signposts of many poor neighborhoods. Their
cobbled-together lives drain residents of their resolve. And so
they cede diabetes the upper hand and eat what tastes good to
them to counteract the gravity of unhappiness.

So if diabetes didn't cause her pain, as it didn't most of the
time, then Ms. Matos dismissed it as a problem for another day.

"Listen, if I want to eat a piece of cake, I'm going to eat it,"
she said. "No doctor can tell me what to eat. I'm going to eat
it, because I'm hungry. We got too much to worry about. We got to
worry about tomorrow. We got to worry about the rent. We got to
worry about our jobs. I'm not going to worry about a piece of
cake."

Ms. Matos gave a feeble glance at a shopper mulling the mugs and
T-shirts. She carried her glucose meter around, but didn't like
to use it regularly, especially when she was with friends, a
vanity of hers. "It's embarrassing to check your blood in front
of people," she said. It irked her, this machine laying a claim
on her.

Diabetes, then, had worn her out. She was quite direct about
that. "I hate it," she said. "I hate diabetes. I'm tired of
checking my blood three times a day." She tidied up some
merchandise.

"You get used to it, but you know what?" she said. "You don't get
used to it."

Society of the Sick

First Raul Rivera parked his bike, then he slid into a chair. A
shadow fell over his face. The street was characteristically
cacophonous. The door to the art shop was agape.

Diabetes hadn't visited him yet, but his stomach was expanding,
and that gave him pause. He knew what diabetes did. It made you
somebody else.

He was 50 and lived with his mother. She was 66, and after more
than a dozen years with diabetes had been hit by its full-court
press. Kidney dialysis three times a week. Open-heart surgery.
Dependent on a wheelchair. Legally blind. It was Mr. Rivera who
had to inject her with insulin twice a day. "She's black and blue
from all the needles," he said. Lately, she had been in the
hospital more than out.

Mr. Rivera, after a back injury, quit his job as a parking
attendant 15 years ago. He had no income or insurance. He had not
been to a doctor in several years. Last time he saw one, he was
told he had high cholesterol and given medication. He didn't take
it. He didn't like pills. "That's me," he said.

Juan Concepcion, 57, Mr. De La Vega's stepfather, materialized.
He had been a truck mechanic, until he became disabled by
rheumatoid arthritis. In March, he spent 12 days in the hospital
after nearly passing out, and his diabetes became bleakly clear.
Ten years ago, his father died of diabetes. "He kept taking
sugar," Mr. Concepcion said. "He kept drinking beer. He was a
stubborn guy. They cut one leg at the ankle. Then they took the
other above the knee."

He stared unblinkingly into the distance. "I felt I was too
strong for it," he said.

He drew on a cigarette, ashes fluttering in the air. He knew he
should quit. Smoking is especially bad for diabetics. "I check my
blood every morning and every night," he said. "I'm supposed to
do it four times, but sometimes my fingers hurt and I don't do it
as often." He was trying to lose weight. "I loved my coffee with
three sugars. My Pepsi, Coke, beer." He was given a book about
diabetes by a doctor. "But I didn't go deep into the book,
because it makes me lose my mind," he said. "I'm going to do it
slowly. But I know, this is a killing machine."

He shook his head. "Everywhere you go here, someone tells me they
have diabetes. I'll go into a store and ask for coffee, no sugar.
They say, 'Oh, you have diabetes?' "

He was having trouble figuring out how to fit the disease's
maxims into his life. "I'm trying to give up beer," he said. "I
would drink at 7 at night until 3 in the morning, watched boxing
and baseball, drinking beer. I drank 15 or 20 beers in a night."

He had been avoiding his drinking buddies. "I have friends who
have diabetes and they continue drinking," he said. His doctor
told him to avoid stress. "How do you do that, not put worries in
your head?" he asked. "I have to go on living. I've always been a
fast guy."

Across East Harlem, there is a great range in response to the
disease: some diabetics embrace the daily regimens that now frame
their lives, many others constantly struggle to. Doctors say the
will to fight the disease is often eroded by its psychological
toll.

Sitting with these men and women whose lives were pervaded by
diabetes, one couldn't escape feeling that they shared a dark
cosmic joke - that diabetes was too much to master at the
individual level in a world that had become so hospitable to it.

Mr. Concepcion said: "Everything about this neighborhood, the
pollution in the air, it all makes you sick. Don't get me wrong,
we love this place, we love Spanish Harlem. But it does stuff to
us. Now it's giving us all diabetes."

Mr. De La Vega nodded. "We love eating trash," he said. "We grew
up eating McDonald's, and I still find myself eating candy and
chocolate cake."

People got huffy about their doctors. "Mine tells me, 'Lose
weight, exercise more,' " Ms. Matos said. "Let him live my life
and see."

Mr. Rivera said: "You know what I think? I think there's a cure.
We're the poor, so they don't want to give it to us."

Mr. Concepcion rubbed his forehead. "Since I got the diabetes,
maybe twice a week I sit down and pray," he said. "Because if I
don't take care, I'm going to go down the drain. I put myself in
God's hands."

Mr. Rivera bathed Mr. De La Vega with an odd look: "Did Mike have
diabetes? The guy who passed away?"

Mr. De La Vega said, "Yeah, he had it."

"He was, like, 300 pounds."

"He would brag about eating a pint of ice cream every night."

"He used to eat six pork chops in one sitting. Then he would
drown them down with a quart of Budweiser. What was he when he
died?"

"Fifty-four."

"You know Bigwig? He's 42. He just found out he has diabetes.
Like, two weeks ago."

New Rhythms, Old Patterns

Bigwig pulled up a chair beneath a thicket of light. The streets
were puddled from morning rain. His real name was Luis Hernandez.
His job was route supervisor for a produce company. He was a
veteran member of the art-shop crowd, and now a new admission to
its diabetic subset.

His vision had been getting a little blurred - he'd look at a
paper and it was like 3-D vision; one morning he woke up and one
eye wouldn't focus - and a physical found the source. "When they
told me, it was like somebody punched me in the gut," he said.

His diabetic mother died in 2004, at 59. She had done little to
address her condition. She continued to smoke and eat generously.

He was confused. He said his doctor put him on pills and
suggested avoiding juice or sweets, but didn't tell him much
more.

He weighed 252 when he got the news. He had cut it to 245. He
knew it should be lower. But he found it excruciatingly hard to
adopt a new rhythm of life, particularly since it was less
appealing than the one he had.

Bigwig had to go. Maria Calderon stopped by to visit Elsie Matos.
Give her a moment. Ms. Matos was waiting on a young woman torn
between two T-shirts.

Yes, Ms. Calderon had it, too. Seven years since the diagnosis.
She was 69. She was 210 pounds, and had been told to lose weight.
"I didn't think it was important," she said.

Then, more than a year ago, a solution presented itself, and it
was the worst kind. Her grandson was killed in a holdup over a
car.

Devastated, she lost her will and her appetite. She shed 60
pounds. Now she was gaining again, six pounds in a month.

"How can you worry about your health when you don't know where
you're going to live next week?" she said.

She watched Ms. Matos help the customer. "We are the poor
people," she said. "We only get the crumbs. I used to advocate a
lot. I got tired. I don't do it anymore. I'm not tired in my
heart. I'm tired in my body."

She said to Ms. Matos: "I have a friend, she's diabetic and
everything else. She takes 52 pills a day. She has everything in
the book. When she calls, she wants to talk for 99 hours. I say:
'My sister's calling. I've got to get off.' "

Ms. Matos said: "What, 52 pills? She's nuts."

Frank Gonzalez had something to say. He was 77, compact, peppy.
He used to work as a security guard at a hospital, had clocked 16
years with diabetes.

When things were not going well, as they weren't now, you could
see the fanned-up embers in his eyes. Hear his speedy voice:
"Diabetes is the worst disease I've ever seen. You can't trust
it. Two weeks ago, I got all messed up. You know why? I've got
two machines. One gave me a reading of 150. The other machine
gave me 130. I said this can't be. So I changed the batteries on
both machines. You've got to keep an eye on your machines."

He went on. "Diabetes is something you have to look at from all
sorts of angles. It takes a long time to find out the real truth.
And you know what? You never find out the real truth."

He went home, a couple of blocks away, to take a blood-sugar
reading. He opened a hallway closet, wedged full of supplies -
test strips and lancets and pill bottles and batteries. Most, but
not all for diabetes. He showed a bottle: Viagra. Opened it and
smiled: half-full.

He inserted a strip into his machine. He swabbed his ring finger
with alcohol, then pricked it with a lancet. The machine counted
down 45 seconds. The reading: 152. High. He stared balefully at
the number.

"It could be I've been sitting too much," he said. "I should be
out and walking. I don't know, I was going to do the cleaning."

A Geography Lesson

A few things to notice. On Third Avenue, around the corner from
the art shop, a banner outside McDonald's proclaimed, "$1 Menu."
Down the way, plastered on Burger King, "New Enormous Omelet
Sandwich. It's Huge." At KFC, a sign boasted, "Feed Your Family
for Under $4 each."

The art-shop gatherers sometimes talked about 96th Street, the
tangible southern divide of a neighborhood and of a disease. Go
north of 96th Street and you enter a constricted world laden with
poverty. Go south and you find promise and riches, thin not fat,
the difference between East Harlem and the Upper East Side, the
difference between illness and health.

Go north and the chances of bumping into a diabetic are maybe 20
times greater than if you go south. For the Upper East Side,
according to the health department, has the lowest prevalence in
the city, about 1 percent.

In East Harlem, people sometimes have to choose between getting
their diabetes medication and eating. They sometimes share their
pills, cut them in half and take half-dosages. They improvise.
Everywhere blare the signals that the best meal is the biggest
meal.

Nutritious food exists, but it isn't easy to find. Dr. Carol R.
Horowitz, an assistant professor at Mount Sinai School of
Medicine, heads an East Harlem coalition trying to improve
diabetes care. She oversaw a study several years ago that tracked
the availability of diet soda, low-fat or fat-free milk,
high-fiber bread, fresh fruit and fresh vegetables in food stores
in East Harlem and the Upper East Side.

Stores on the Upper East Side were more than three times more
likely than those in East Harlem to stock all five items. It did
not seem to matter that East Harlem has more than twice as many
food stores per capita as its wealthier neighbor to the south.

Diet on the Down Low

All the same, it was worth asking: Why not stop with the
doughnuts and fried calories and eat salads, drink diet soda?

James De La Vega laughed. "We've got cultural differences," he
said. "Here, for a guy to eat a salad, he's a wimp. He'll eat a
big portion of rice and beans and chicken. The women can't be
chumps, either. A woman can eat a salad but has to eat it on the
low. She has to do it quiet. They make fun of you: What are you,
a rabbit?"

What's wrong with an orange?

Mr. De La Vega said: "Oranges are messy. You dirty your teeth."

Uncontrolled diabetes is a forced death march. Literature handed
out in the community underscores this.

Knowledge alone, though, is never enough to change behavior,
particularly in an overwhelmed neighborhood. Chocolate cake may
be a risk, but it tastes so good on a bleak day. What stops that?

Mr. De La Vega said: "People ultimately feel powerless about a
lot of things. People think about bigger things. They think about
survival. Kids grow up fighting in the streets, so you want to
raise big, strong kids. So you give them three pork chops, a nice
tall glass of soda to make them strong. You realize, some of
these people go to prison, and they have to be strong. They eat
and they eat. Nobody teaches them about diabetes."

"I have two nieces," Ms. Matos said. "They're 24. I call them the
sumo wrestlers. They eat everything."

Mr. De La Vega said: "A lot of people eat on the streets. I eat
breakfast on the street and lunch on the street, and sometimes
dinner. I have hot dogs. I had two today."

His mother said, "If you drink a diet soda and a man is watching,
he'll say, 'Why you drinking that?' "

Mr. De La Vega said: "Nobody here goes out and gets an apple.
They get cake. People here associate diet as unhealthy. If you're
dieting, then you're sick. You look at the people on the streets,
they're heavy. That's the way we grow up here."

Mr. De La Vega was silent, listening to the boom box. He said:
"Around here, if you make it to 40, you think, hey, I'm lucky, I
made it to 40. You have to understand, the philosophy out here is
we're going to die from something."

Young and Unconcerned

At times the art-shop regulars pondered what diabetes meant for
the neighborhood's young. They surveyed the pudgy children
sauntering past and shook their heads.

And so, a not uncharacteristic East Harlem story. A couple of
blocks away, on East 102nd Street, lived Xiomariz Downs. She was
15, sweet and polite. She weighed 287 pounds. She lived with her
mother, Olga Pagan, her grandmother, her brother, her sister and
two cousins in an apartment not intended for that many people.
Someday, she said, she wants to be a missionary or a beautician.

On a Thursday, after school, she was in sweatpants at the Bally
gym near her home, her second day in an attempted fitness
regimen. Her grandmother had enrolled her.

At the start of last year, when she was still 14, she was found
to have Type 2 diabetes. It happened this way: She had gotten
horribly depressed. Her mother had lupus, and had had two
strokes. School had been going badly; Xiomariz was failing math,
English, science and history. She made a feeble attempt to cut
her wrists. She spent a week in a hospital and the diabetes
revealed itself.

Doctors had been hectoring her for years, saying that if she
didn't lose weight she was going to end up with diabetes. But she
didn't feel sick. She wasn't worried about what might happen at
40. She was a teenager, with teenage hauteur, living in the now.

Again she was told to diet. Her mother said Xiomariz was "on the
see-food diet - every food she sees, she eats." Her mother felt
frustrated: "I want her to go live with her father and have him
knock some sense into her - literally." He, too, had diabetes.

Xiomariz didn't mind her weight. "I feel my weight makes me look
like me," she said. "So I don't have to look like those skinny
people."

Not long after starting, in fact, she quit the gym - too much
time and too much money.

She didn't comprehend the terror of the disease. "I know you
can't pass it like kissing someone or something," she said.

Some mornings, rushing, she neglected to take her pills. She had
stopped checking her sugar. She said she had lost the meter.

Was she worried about her diabetes?

She moved her head from side to side. "Sometimes I forget I have
it," she said. "It's not that big a deal."

What other disease would she compare diabetes to? She thought a
moment, and found the answer. She said, "A cold."

Veterans, and War Stories

Santos Alicea had not been by the art shop in days. He was
usually around so often that he seemed part of the décor. Now,
here he was again, scraping somnolently along behind his walker.
He had just gotten out of the hospital. Doctors had removed his
right eye. The usual reason around here: diabetes. He got the
disease 20 years ago, at 47. He used to work in a laundry and as
a security guard, until he had a heart attack.

He plopped down onto the brick ledge beside the art shop. "I'm
killing time," he said. He gave a craggy grin.

He settled his walker before him. "The circulation is no good in
my legs," he said. He rubbed them.

He unabashedly admitted that good management of his diabetes
often seemed like a drama of grand futility. "I got 200 this
morning," he said, reciting his latest reading. "Not good. Maybe
I ate the wrong thing. I had rice and beans last night. It was
good."

He was talking to Jose Castro, 52, a squat man with a grizzled
face, worlds of feeling in his eyes. "I got it, too," he said.
"Yeah, I got the diabetes."

The diagnosis came six years ago. Was he monitoring his sugar?

"I check once a day or every two days."

How was it?

He laughed. "Been a little high," he said. "I started eating
Frosted Flakes. What can I say? I like them. You can't always be
eating things without sugar. Sometimes, you have to take a
chance."

He used to deliver flowers, but stopped a few years ago after
having a liver transplant. Besides insulin, he took 10 pills a
day.

He took a drag on a cigarette. He said he was working on
quitting. His method, he said, was to sleep a lot. "Sometimes, I
sleep all day," he said.

He bore a visible scrape on his left arm. His circulation was bad
and he sometimes saw double. "I'll be watching TV and I'll see
two images," he said. "I have to wink to see the show."

He had fainting spells, falls. Thus his bruised left arm. He
showed another mark on his right arm and one above his eye.

"The other day, I took my blood count and it was 40," he added.
"My son took me to the hospital. They said I may have forgotten
to take my insulin. I don't know. I don't remember."

He used to keep a log of his readings, but quit. Why?

"I don't know," he said. "So many things you have to do. It gets
boring."

A mariachi band arrived in the garden and began to play. Mr.
Alicea and the others tapped their feet.

As New York got ready for its evening routines, Mr. Alicea tired,
his eyelids sailing down, and he returned to his two-room
apartment across the street. His furniture was plain. Bare bulbs
protruded from the ceiling. Mr. Alicea shared the place with his
older brother, Pedro.

He, too, had diabetes. His vision was poor, his circulation was
not good, he had asthma, he had a weak heart. A while ago, he had
fallen and broken his arm and hit his head, and had not been
himself since. "He's like a baby," Mr. Alicea said. "He's
supposed to use insulin, but he doesn't like the needle."

He didn't like to prick his finger to check his sugar level, so
he had no idea what it was. Pedro didn't go out much. No scale
was needed to judge that he was obese. He watched TV, one more
soap.

A home attendant helped care for them. She had dinner on the
stove, cream of tomato soup. The dining table was shoved against
the wall. Resting on it was a box of corn flakes and a container
with doughnuts.

The phone rang. Santos spoke briefly. "My daughter," he said when
he hung up. He said she lived in the Bronx, and worked as a
waitress near Yankee Stadium. "Yes, my daughter," he repeated.
"She has diabetes."

Racing Against the Blade

There is no way to talk about diabetes without talking about
money, because they are interwoven. The story with Fernando
Salicrup was the foot and the money.

Go see him, Mr. De La Vega had said. He'll tell you something
about diabetes.

He was an artist, too, 58. He did computer-assisted art, printed
out his efforts on a big Epson printer in the back of his
apartment.

He got the diagnosis 20 years ago. His mother and grandmother
died of diabetes complications. "They told me about diet and
exercise," he said. "But you're a young man, and you don't
listen. I didn't take it very seriously."

He had no insurance, either, and so he took his medication when
he could afford it, tested himself when he could afford it.

He got a drink. He walked slowly, with a cane. He told the story.
Nearly two years ago, overseas for an art exhibit, he twisted the
big toe on his right foot on the cobblestone streets. It became
infected. When he finally got to see a doctor, the toe had to be
removed, along with two others. The infection spread, and he lost
the final two.

"All the things you take for granted, you have to give up," he
said. "Dancing. You have to plan things out, take things slow.
It's not just that they operate on your toes. Your veins aren't
working properly. You don't have feel."

He was worried about his vision. An artist without eyes, that was
tough to imagine. He mentioned a sad case, a jazz drummer he
knew. He had diabetes and had to have a hand amputated. His hand,
his livelihood.

When he had the amputations, Mr. Salicrup was in the hospital a
month and a half, amassing medical bills he put at more than
$300,000. It was an amount in some ways laughable to him, because
he expected never to pay it off in this lifetime, but at the same
time he knew it was a serious matter. He gave something each
month, and it constricted his life, hanging over him like a
sentence. He had since acquired insurance, for which he paid
stiff premiums.

"You make choices," he said. "Instead of buying sneakers, you
stay with what you're wearing. I've got to stay ahead of the
blade."

He massaged his leg. Diabetics, often with subdued feeling in
their legs, don't realize they have cuts until irreversible
infections set in. Doctors caution that they should check their
feet daily, using a mirror if they can't see past their stomachs.
That they never go around barefoot. That even abrasive socks can
lead to an infection. That a simple toenail-clipping mishap can
escalate into an amputation.

Five toes gone, Mr. Salicrup didn't want to lose more. He did his
best, he said, to tame his illness. He never cut the toenails on
his left foot. He paid a podiatrist. He still had a hard time
wrapping his mind around that: Here he was, a grown man, paying
somebody else to clip his nails.

One Fewer Shop, One More Ghost

The city seemed caught in overcooked air. The art-shop regulars
were out, the usual byplay. A gaunt man was selling Gillette
razors out of a backpack: $7. Interested, Santos Alicea dug out
some bills and took one.

Mr. Alicea mentioned that another diabetic had died the other
day. A massive heart attack, and the man became one more diabetes
ghost to haunt the neighborhood.

Elsie Matos was displeased with her blood sugar. It was
mercilessly high.

Raul Rivera, wearing a smudged T-shirt, began watering the
garden's plants, swishing the spray back and forth. How was his
mother? Bad, he said. Very bad.

Bigwig said that he had shed some weight, was getting used to
one-and-a-half spoonfuls of sugar on his corn flakes instead of
four. But also, he had stopped taking his diabetes pills, not
wanting to get too used to them, not knowing if that was right or
wrong.

James De La Vega's art shop closed at the end of August. Word
arrived that the space would become a hot-dog place. Mr. De La
Vega moved down to the East Village.

The regulars frowned on the displacement. "Just what the
diabetics need," Ms. Matos said. "Hot dogs."

In the Treatment of Diabetes, Success Often Does Not Pay
http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html

Bad Blood
By IAN URBINA

With much optimism, Beth Israel Medical Center in Manhattan
opened its new diabetes center in March 1999. Miss America,
Nicole Johnson Baker, herself a diabetic, showed up for
promotional pictures, wearing her insulin pump.

In one photo, she posed with a man dressed as a giant foot - a
comical if dark reminder of the roughly 2,000 largely avoidable
diabetes-related amputations in New York City each year. Doctors,
alarmed by the cost and rapid growth of the disease, were getting
serious.

At four hospitals across the city, they set up centers that
featured a new model of treatment. They would be boot camps for
diabetics, who struggle daily to reduce the sugar levels in their
blood. The centers would teach them to check those levels, count
calories and exercise with discipline, while undergoing prolonged
monitoring by teams of specialists.

But seven years later, even as the number of New Yorkers with
Type 2 diabetes has nearly doubled, three of the four centers,
including Beth Israel's, have closed.

They did not shut down because they had failed their patients.
They closed because they had failed to make money. They were
victims of the byzantine world of American health care, in which
the real profit is made not by controlling chronic diseases like
diabetes but by treating their many complications.

Insurers, for example, will often refuse to pay $150 for a
diabetic to see a podiatrist, who can help prevent foot ailments
associated with the disease. Nearly all of them, though, cover
amputations, which typically cost more than $30,000.

Patients have trouble securing a reimbursement for a $75 visit to
the nutritionist who counsels them on controlling their diabetes.
Insurers do not balk, however, at paying $315 for a single
session of dialysis, which treats one of the disease's serious
complications.

Not surprising, as the epidemic of Type 2 diabetes has grown,
more than 100 dialysis centers have opened in the city.

"It's almost as though the system encourages people to get sick
and then people get paid to treat them," said Dr. Matthew E.
Fink, a former president of Beth Israel.

Ten months after the hospital's center was founded, it had
hemorrhaged more than $1.1 million. And the hospital gave its
director, Dr. Gerald Bernstein, three and a half months to direct
its patients elsewhere.

The center's demise, its founders and other experts say, is
evidence of a medical system so focused on acute illnesses that
it is struggling to respond to diabetes, a chronic disease that
looms as the largest health crisis facing the city.

America's high-tech, pharmaceutical-driven system may excel at
treating serious short-term illnesses like coronary blockages,
experts say, but it is flailing when it comes to Type 2 diabetes,
a condition that builds over time and cannot be solved by surgery
or a few weeks of taking pills.

Type 2 , the subject of this series, has been linked to obesity
and inactivity, as well as to heredity. (Type 1, which comprises
only 5 percent to 10 percent of cases, is not associated with
behavior, and is believed to stem almost entirely from genetic
factors.)

Instead of receiving comprehensive treatment, New York's Type 2
diabetics often suffer under substandard care.

They do not test their blood as often as they should because they
cannot afford the equipment. Patients wait months to see
endocrinologists - who provide critical diabetes care - because
lower pay has drawn too few doctors to the specialty. And
insurers limit diabetes benefits for fear they will draw the
sickest, most expensive patients to their rolls.

Dr. Diana K. Berger, who directs the diabetes prevention program
for the City Department of Health and Mental Hygiene, said the
bias against effective care for chronic illnesses could be seen
in the new popularity of another high-profit quick fix: bariatric
surgery, which shrinks stomach size and has been shown to be
effective at helping to control diabetes.

"If a hospital charges, and can get reimbursed by insurance,
$50,000 for a bariatric surgery that takes just 40 minutes," she
said, "or it can get reimbursed $20 for the same amount of time
spent with a nutritionist, where do you think priorities will
be?"

Back in the Pantsuit

Calorie by calorie, the staff of Beth Israel's center tried to
turn diabetic lives around from their base of operations: a
classroom and three adjoining offices on the seventh floor of
Fierman Hall, a hospital building on East 17th Street.

The stark, white-walled classroom did not look like much. But it
was functional and clean and several times a week, a dozen or so
people would crowd around a rectangular table that was meant for
eight, listening attentively, staff members said.

Claudia Slavin, the center's dietitian, remembers asking the
patients to stand, one by one.

"Tell me what your waking blood sugar was," she told them, "and
then try to explain why it is high or low."

People whose sugars soar damage themselves irreparably, even if
the consequences are not felt for 10 or 20 years. Unchecked,
diabetes can lead to kidney failure, blindness, heart disease,
amputations - a challenging slate for any single physician with a
busy caseload to manage.

One patient, Ella M. Hammond, a retired school administrator,
recalled standing up in the classroom one day in 1999.

"Has anyone noticed what's different about me?" Ms. Hammond
asked.

Blank stares.

"Now, come on," she said, ruffling the fabric of a black
gabardine pantsuit she had not worn since slimmer days, years
earlier.

"Don't y'all notice 20 pounds when it goes away?" she asked.

Ms. Slavin, one of four full-time staff members who worked at the
center, remembers laughing. There were worse reasons for an
interruption than a success story.

Like many Type 2 diabetics, Ms. Hammond had been warned
repeatedly by her primary care doctor that her weight was too
high, her lifestyle too inactive and her diet too rich. And then
she had been shown the door, until her next appointment a year
later.

"The center was a totally different experience," Ms. Hammond
said. "What they did worked because they taught me how to deal
with the disease, and then they forced me to do it."

Two hours a day, twice a week for five weeks, Ms. Hammond learned
how to manage her disease. How the pancreas works to create
insulin, a hormone needed to process sugar. Why it is important
to leave four hours between meals so insulin can finish breaking
down the sugar. She counted the grams of carbohydrates in a bag
of Ruffles salt and vinegar potato chips, her favorite, and
traded vegetarian recipes.

After ignoring her condition for 20 years, Ms. Hammond, 63, began
to ride a bicycle twice a week and mastered a special sauce,
"more garlic than butter," that made asparagus palatable.

She also learned how to decipher the reading on her A1c test, a
periodic blood-sugar measurement that is a crucial yardstick of
whether a person's diabetes is under control.

"I was just happy to finally know what that number really meant,"
she said.

Many doctors who treat diabetics say they have long been
frustrated because they feel they are struggling single-handedly
to reverse a disease with the gale force of popular culture
behind it.

Type 2 diabetes grows hand in glove with obesity, and America is
becoming fatter. Undoubtedly, many of these diabetics are often
their own worst enemies. Some do not exercise. Others view salad
as a foreign substance and, like smokers, often see complications
as a distant threat.

To fix Type 2 diabetes, experts agree, you have to fix people.
Change lifestyles. Adjust thinking. Get diabetics to give up
sweets and prick their fingers to test their blood several times
a day.

It is a tall order for the primary care doctors who are the sole
health care providers for 90 percent of diabetics.

Too tall, many doctors say. When office visits typically last as
little as eight minutes, doctors say there is no time to retool
patients so they can adopt an entirely new approach to food and
life.

"Think of it this way," said Dr. Berger. "An average person
spends less than .03 percent of their entire life meeting with a
clinician. The rest of the time they're being bombarded with all
the societal influences that make this disease so common."

As a result, primary care doctors often have a fatalistic
attitude about controlling the disease. They monitor patients
less closely than specialists, studies show.

For those under specialty care, there is often little
coordination of treatment, and patients end up Ping-Ponging
between their appointments with little sense of their prognosis
or of how to take control of their condition.

Consequently, ignorance prevails. Of 12,000 obese people in a
1999 federal study, more than half said they were never told to
curb their weight.

Fewer than 40 percent of those with newly diagnosed diabetes
receive any follow-up, according to another study. In New York
City, officials say, nearly 9 out of 10 diabetics do not know
their A1c scores, that most fundamental of statistics.

In fact, without symptoms or pain, most Type 2 diabetics find it
hard to believe they are truly sick until it is too late to avoid
the complications that can overwhelm them. The city comptroller
recently found that even in neighborhoods with accessible and
adequate health care, most diabetics suffer serious complications
that could have been prevented.

This grim reality persuaded hospital officials in the 1990's to
try something different. The new centers would provide the tricks
for changing behavior and the methods of tracking complications
that were lacking from most care.

Instead of having rushed conversations with harried primary care
physicians, patients would discuss their weights and habits for
months with a team of diabetes educators, and have their
conditions tracked by a panel of endocrinologists,
ophthalmologists and podiatrists.

"The entire country was watching," said Dr. Bernstein, director
of the Beth Israel center, who was then president of the American
Diabetes Association.

By all apparent measures, the aggressive strategy worked. Five
months into the program, more than 60 percent of the center's
patients who were tested had their blood sugar under control.
Close to half the patients who were measured had already lost
weight. Competing hospitals directed patients to the program.

"For the first time in my 23 years of diabetes work I felt like
we had momentum," said Jane Seley, the center's nurse
practitioner. "And it wasn't backwards momentum."

Failure for Profit

From the outset, everyone knew diabetes centers were financially
risky ventures. That is why Beth Israel took a distinctive
approach before sinking $1.5 million into its plan.

Instead of being top-heavy with endocrinologists, who are
expensive specialists, Beth Israel relied more on nutritionists
and diabetes educators with lower salaries, said Dr. Fink, the
hospital's former president.

The other centers that opened took similar precautions.

The St. Luke's-Joslin diabetes center, on the Upper West Side,
tried lowering doctors' salaries, hiring dietitians only part
time and being aggressive about getting reimbursed by insurers,
said Dr. Xavier Pi-Sunyer, who ran the center.

Mount Sinai Hospital's diabetes center hired an accounting firm
to calculate just how many bypass surgeries, kidney transplants
and other profitable procedures the center would have to send to
the hospital to offset the cost of keeping the center running,
said Dr. Andrew Drexler, the center's director.

Nonetheless, both of these centers closed for financial reasons
within five years of opening.

In hindsight, the financial flaws were hardly mysterious, experts
say. Chronic care is simply not as profitable as acute care
because insurers, and consumers, do not want to pay as much for
care that is not urgent, according to Dr. Arnold Milstein,
medical director of the Pacific Business Group on Health.

By the time a situation is acute, when dialysis and amputations
are necessary, the insurer, which has been gambling on never
being asked to cover procedures that far down the road, has
little choice but to cover them, if only to avoid lawsuits,
analysts said.

Patients are also more inclined to pay high prices when severe
health consequences are imminent. When the danger is distant,
perhaps uncertain, as with chronic conditions, there is less
willingness to pay, which undercuts prices and profits, Dr.
Milstein explained.

"There is a lesser sense of alarm associated with slow-moving
threats, so prices and profits for chronic and preventive care
remain low," he said. "Doctors, insurers and hospitals can
command much higher prices and profit margins for a bypass
surgery that a patient needs today than they can for nutrition
counseling likely to prevent a bypass tomorrow."

Ms. Seley said the belief was that however marginal the centers
might be financially, they would bring in business.

"Diabetes centers are for hospitals what discounted two-liter
bottles of Coke are to grocery stores," she said. "They are not
profitable but they're sold to get dedicated customers, and with
the hospitals the hope is to get customers who will come back for
the big moneymaking surgeries."

Indeed, former officials of the Beth Israel center said they
anticipated that operating costs would be underwritten by the
amputations and dialysis that some of their diabetic patients
would end up needing anyway, despite the center's best efforts.
"In other words, our financial success in part depended on our
medical failure," Ms. Slavin said.

The other option was to have a Russ Berrie.

Mr. Berrie, a toymaker from the Bronx, made a fortune in the
1980's through the wild popularity of a product he sold, the
Troll doll, a three-inch plastic monster with a puff of
fluorescent hair. Mr. Berrie took more than $20 million of his
doll money and used it to finance the diabetes center at Columbia
University Medical Center in memory of his mother, Naomi, who had
died of the disease. The center was also helped by a
million-dollar grant from a company that makes diabetes drugs and
equipment.

Even with its stable of generous donors, even with more than
10,000 patients filing through the doors each year, the Columbia
center struggles financially, said Dr. Robin Goland, a
co-director. That, she said, is because the center runs a deficit
of at least $50 for each patient it sees.

Without wealthy benefactors, Beth Israel's center had an even
tougher time surviving its financial strains.

Ms. Slavin said the center often scheduled patients for multiple
visits with doctors and educators on the same day because it
needed to take advantage of the limited time it had with its
patients. But every time a Medicaid patient went to a diabetes
education class, and then saw a specialist, the center lost
money, she said. Medicaid, the government insurance program for
the poor, will pay for only one service a day under its rules.

The center also lost money, its former staff members said, every
time a nurse called a patient at home to check on his diet or
contacted a physician to relate a patient's progress. Both calls
are considered essential to getting people to change their
habits. But medical professionals, unlike lawyers and
accountants, cannot bill for phone time, so more money was lost.

And the insurance reimbursement for an hourlong diabetes class
did not come close to covering the cost. Most insurers paid less
than $25 for a class, said Denise Rivera, the secretary for the
center.

"That wasn't even enough to pay for what it cost to have me to do
the paperwork to get the reimbursement," she said.

Beth Israel was not alone in this predicament. Dr. C. Ronald
Kahn, president and director of the Joslin Diabetes Center in
Boston, the nation's largest such center, with 23 affiliates
around the country, said that for every dollar spent on care, the
Joslin centers lost 35 cents. They close the gap, but just
barely, with philanthropy, he said.

"So you have the institutions, which are doing much of the work
in dealing with this major health epidemic, depending on
charity," he said. "In the long run, this is definitely not a
tenable system."

Plastic Strips and Red Tape

Sidney Schonfeld was not a patient at Beth Israel, but he ran
into his own set of financial obstacles in trying to manage his
disease.

"Controlling my condition isn't that hard," said Mr. Schonfeld,
82, a retired businessman from Washington Heights. "The hard part
are the things outside my control, like getting the test strips
and the medicines."

Test strips are not complicated pieces of medical equipment. They
are inch-long pieces of plastic with tiny metal tabs that
diabetics use to measure the sugar in their blood. After pricking
their finger, diabetics place a drop of blood on the strip and
then insert it into the side of a handheld meter that analyzes
their sugar levels.

Each strip costs only about 75 cents, but many diabetics are poor
and, over the course of a year, those who test their blood
frequently, as instructed, will spend more than $500 on strips.

Mr. Schonfeld, like many diabetics, is supposed to test his blood
at least twice a day so he can make adjustments to his diet and
medications that can ward off serious complications. But many
insurers cover only one strip per day unless a patient obtains
written justification from a doctor. Even with letters from his
doctor, Mr. Schonfeld has had a tough time getting insurers to
pay for his strips, his doctor and nurse said.

"Fighting the disease is only half of this job," said Mr.
Schonfeld's doctor, Dr. Goland. She held up a manila folder thick
with letters that she had sent to his insurer explaining Mr.
Schonfeld's case. Mr. Schonfeld had his own pile of letters: the
rejection notices he got back.

Dr. Goland says that Mr. Schonfeld has good reason to be
vigilant. His mother lost her left foot to Type 2 diabetes. She
died several months later after gangrene spread to her right. Mr.
Schonfeld's six uncles and aunts on his mother's side had the
disease. Three of them underwent amputations. His son, Gary, is
also diabetic.

"You can't get a more textbook high-risk case than Sidney," Dr.
Goland said.

Though the health care system asks diabetics to become rigorously
involved in daily management of their conditions, red tape and
the cost of drugs and supplies put self-management out of reach
for many patients. As a result, many diabetics either do without
or pay out of their own pockets. Some resort to other means to
get their supplies.

In Indiana, hospital workers organized Diabetes Bingo Night last
May to collect money for strips and supplies. In California,
F.B.I agents found that diabetics were buying stolen strips on
eBay. Last year, the agents charged a couple with mail fraud and
accused them of having sold $2.5 million worth of stolen test
strips and supplies.

In East Harlem, doctors at Mount Sinai were mystified by a number
of cases in 2002: patients came into the hospital asserting that
they had been testing themselves daily and were sure that their
blood sugar was under control. Hospital tests, however, showed
just the opposite.

"We finally figured out," said Dr. Carol R. Horowitz, an
assistant professor at the Mount Sinai School of Medicine, "that
patients who could not afford the strips for their blood monitor
were buying cheaper strips that were incompatible and that were
giving false reads."

At least they knew they had the disease. A third of diabetics do
not, in part because doctors do not screen as often as they
should, studies show. Since symptoms do not appear for 7 to 10
years on average, the effects of the elevated sugars begin to
build and become irreversible.

Mr. Schonfeld has known about his diabetes for more than 20 years
and prides himself on keeping it in check.

"I've seen what it can do," he said. "So I know better than to
ignore it."

When Dr. Goland told him to limit the chocolate mousse and
frankfurters, he did.

When she told him to start walking two miles a day, he did that,
too. But her instructions to test his blood at least twice a day
were not as easy to follow.

Mr. Schonfeld runs out of strips even though he tries to plan
ahead by ordering extras, said Kathy Person, his nurse. "The
insurance reps say they don't want the strips to end up on the
black market, so they don't let people preorder extras," she
said.

The Naomi Berrie Diabetes Center has a full-time staff member who
tries to do the clerical work associated with insurance coverage.
"Still, it's a struggle to keep up with the paperwork," Dr.
Goland said.

Some doctors simply do not have time and patients are left to
haggle with insurers - usually unsuccessfully - on their own.

Although a recent federal study found that an increasing number
of health insurers cover strips, few cover more than one a day,
according to strip manufacturers. In fact, a study last year by
Georgetown University found that insurance restrictions on strips
and other services for diabetics were reducing the quality of
care.

"I was a businessman for more than 40 years," said Mr. Schonfeld,
a former food importer. "What I just don't understand is how
these insurance companies can operate the way they do and keep
their customers."

Sick Patient? Expensive Patient

As it turns out, keeping customers who are diabetic is not the
goal of most health insurance companies, experts said. Avoiding
diabetics is actually more the point.

Understanding why, the experts said, requires an appreciation of
one of the crucial obstacles to better diabetes care.

Most insurers do not operate the way Mr. Schonfeld did in the
import business, luring additional customers by advertising a
good product at a fair price. Were they to operate in that
fashion, health plans looking to grow might advertise better
coverage for diabetics, such as a wide choice of blood-sugar
monitors.

But in the insurance business - and virtually all businesses
based on risk - the point is not to attract the most customers
but rather the best ones. As businesses, not charities, insurers
need to attract healthy customers, not sick ones, said David
Knutson, a former insurance executive who studies the industry's
economics for the Park Nicollet Institute, a health research
organization in Minneapolis.

As a result, experts say, insurance executives usually think
twice before bolstering their diabetes benefits, for fear they
will attract the chronically ill.

In a 2003 survey, 87 percent of health insurance actuaries
queried by Mr. Knutson said that if they were to improve coverage
with richer drug benefits or easier access to specialists, they
would incur financial problems by attracting the sickest, most
expensive patients.

"Insurers are as eager to attract the chronically ill as banks
are interested in loaning to the unemployed," Mr. Knutson said.
"The chances of losing money are simply too high."

Insurers are not alone in these concerns. Large employers, many
of which devise and finance their own employee health plans, know
that their allotted reserves are jeopardized if too much of their
work force is seriously ill. Last year, for example, a Wal-Mart
executive suggested in an internal memo that the company could
reduce costs by discouraging unhealthy people from applying for
work.

Even when insurers are simply third-party administrators,
processing claims but not covering the actual medical expenses,
they try to keep claims down by attracting healthier patients to
their plans, Mr. Knutson said.

Similarly, coverage for Medicaid recipients, though underwritten
by the government, can be subject to the same private-sector
pressures. More than 70 percent of Medicaid recipients in New
York now receive their health care through private health
maintenance organizations that operate under government contract.
These H.M.O.'s get the same annual flat fee from the government,
regardless of whether the patient is robustly healthy or
chronically ill, thus creating an incentive to attract the
healthiest customers.

For insurers, the high cost of attracting the sick is far from a
hypothetical problem, said David V. Axene, president of Axene
Health Partners, a consulting firm that advises these companies.
For each additional session of nutritional counseling, he said,
an insurer must account for the likely cost of luring sick
patients away from its competitors.

Mr. Axene cited an example from several years ago when, he said,
an insurer became puzzled about why a provider network that it
had set up at a Boston hospital was consistently over budget. Mr.
Axene's company found that two-thirds of the hospital's diabetics
had chosen to enroll in that network over others.

The reason? The insurer had mistakenly listed an endocrinologist
on its network's primary care physician list, he said.

"These patients no longer needed to get a referral to see the
endocrinologist, and with one visit they could get their general
and their diabetes needs filled," Mr. Axene said. Within months,
the network had redrafted its lists, dropping the
endocrinologist, he said.

Mohit Ghose, a spokesman for America's Health Insurance Plans, an
industry trade association, said insurers were working to improve
chronic care coverage. Many have created disease management
programs to track their sickest patients and pay bonuses to
doctors who show results in treating the chronically ill.

"Is there still a long way to go? Yes, definitely," Mr. Ghose
said. "But we're on the right track."

Some preventive measures would, at first glance, seem sure money
savers for health insurers since they might eliminate or
forestall expensive diabetes complications down the road. But
many insurers do not think that way. They figure that
complications are often so far into the future, insurance
analysts say, that many people will have already switched jobs or
insurers, or have even died, by the time they hit. As a result,
any savings from preventive measures will only go to their
competitors anyway, analysts say.

In fact, experts say, people generally change their health
insurance about every six years.

"It's perverse," Mr. Knutson said. "But it's the reality of there
being a weak business case for quality when it comes to handling
chronic care."

'Jerry, We Need to Talk'

It usually took Dr. Bernstein seven minutes to walk from his
office in Fierman Hall to the hospital president's office across
17th Street. On Jan. 4, 2000, he had a bounce in his step, and it
took him half that time, he recalled.

He had a good story to tell, and graphs and tables to back it up.
The Beth Israel center was an unqualified medical success. In
fact, patient loads were growing by 20 percent each month as its
reputation spread.

When he arrived, Dr. Fink, then the hospital's president, asked
the three other executives to take their seats. Dr. Bernstein
began talking before he had reached his chair.

"Things are really coming along well," he said as he handed out a
spreadsheet. "Patients are starting to turn their lives around."

Pausing, Dr. Bernstein looked around the table. He was struck by
an awkward silence.

"Jerry, we need to talk about what is happening at the hospital,"
Dr. Fink said. "We're going to have to close your program."

Dr. Bernstein cannot say which was more jarring: the news or the
way it arrived.

Numb, he kept his composure for 25 minutes, he said. The
administrators explained that the hospital was running a deficit.
The diabetes program was not helping matters.

"It was really not about the medicine but the business," Dr. Fink
said recently about the meeting. "That didn't make it any easier
to deliver the news, especially since I had been one of the main
advocates behind getting the center started."

After the meeting, as Dr. Bernstein walked back to his office, he
wondered where he would direct the program's 300 or so patients.
Still, he remained sympathetic to the hospital's plight.

"I was not of the belief that we should save the center only to
end up losing the hospital," he said.

For many of the patients, the news was a second strike of
lightning. They had come to Dr. Bernstein only after being cut
loose by the closing of the St Luke's diabetes center earlier
that year. Now they were being cut loose again, to drift back to
a life of limited care options: understaffed and overwhelmed
clinics; general practitioners with too little time; a city with
about 100 overbooked diabetes educators surrounded by 800,000
patients; and a shortage of endocrinologists, the specialists who
are often critical providers of diabetes care.

Since endocrinology is one of the lower-paying specialties, there
is a national shortage of such doctors. In New York, with its
armies of diabetics, patients must often wait months for an
appointment with one of fewer than 200 endocrinologists. The
poorest patients face the biggest problem, as only a fraction of
the specialists accept Medicaid.

Once the center had closed, Dr. Bernstein continued to teach at
Beth Israel, but he began to devote more and more time to a side
project. He was working on an inhaler that delivers insulin in
the form of a mist. The product is being developed by Generex,
and it is designed to appeal to patients who are reluctant to use
insulin because they do not like the idea of injections or
needles.

But the device will probably cost about 15 percent more than
traditional insulin and is likely to be too expensive for many of
the poorest diabetics, who are often the patients who need it
most because their illness is most severe.

"The center was a way to really make a dent in this epidemic,"
Dr. Bernstein said. "The inhaler is a promising breakthrough. But
it's mostly a business opportunity."

Other pharmaceutical innovations are likely to soften the toll of
diabetes for many patients in coming years, doctors said. With an
average diabetic spending more than $2,500 per year on drugs and
equipment, pharmaceutical companies have good reason to focus
their attention on the more than $10 billion market in
controlling the disease's complications.

But there is only so much the drugs can do, they add, if they are
not accompanied by the sort of changes in patient habits that the
centers fostered through education and monitoring.

Health economists suggest that if these preventive measures were
practiced on a wide scale, complications from diabetes would be
largely eliminated and the American medical system, and by
extension taxpayers, could save as much as $30 billion over 10
years. The experts disagree on what such an effort would cost.
(How much nutrition counseling does it take to wean the average
person from French fries?) Nonetheless, many of them believe the
cost would be largely offset by the savings.

Dr. Bernstein says the lone hope on the horizon is a restructured
reimbursement system that puts the business of chronic care on a
more competitive footing with acute care. Experts say this
restructuring could start if government insurance programs like
Medicaid began paying more for preventive efforts like education,
a move that the private sector would be likely to follow.

"Until we address the financing and the reimbursement structure,
this disease is going to rage out of control," Dr. Bernstein
said.

Not everyone believes the centers were the best answer to
diabetes care. Even with their demise, many hospitals, clinics
and endocrinology practices say they are providing
cost-effective, quality treatment.

"The care we provide now is on the par with what was offered
before," said Dr. Leonid Poretsky, who became director of Beth
Israel's endocrinology division after the diabetes program
closed. "The main difference is that we are financially viable
because half of our patients are not diabetic."

These facilities, though, often find themselves in the same
position the centers did: financing prevention efforts with
profits from the very kidney transplants and amputations that
preventive care is meant to deter.

It is tough to convince a former patient like Ms. Hammond that
the closing of the Beth Israel center was anything but a mistake.
She had started to make critical changes in her lifestyle after
just a few weeks there. She did not find out it had closed, she
said, until several months after the doors had shut, when she
called looking to sign up for a refresher class. She was starting
to fall back into old habits.

"I needed reminding," she said.

With the center gone, Ms. Hammond said she has had to try to
muddle through. She goes to the podiatrist once a year, but she
said she could not remember the last time she visited an eye
doctor. She has gained about 40 pounds.

Some days she wakes up and her blood sugar is high. Other
mornings she doesn't bother to check, she said.

"I couldn't get to where I was before," she said.

Two years ago, she said, she took a last look at that favorite
gabardine pantsuit she had once modeled for her class. Then, she
said, she gave it to her cousin.

East Meets West, Adding Pounds and Peril
http://www.nytimes.com/2006/01/12/nyregion/nyregionspecial5/12diabetes.html

Bad Blood
By MARC SANTORA

May Chen is slender and healthy, a lively little girl whose
parents left their rural Chinese village just a decade ago in
search of a better life. But at age 9, still in pigtails, she is
already coming face to face with the forces that many say are
making America fat and diabetic.

When May watches cartoons in her family's apartment in Flushing,
Queens, the commercials tell her that junk food is good food -
the latest message from an industry that spends $10 billion a
year marketing to children.

When she strolls down Main Street, she walks a growing gantlet of
fast-food restaurants, many of them built with the help of
government loans.

At her public school, the city sells sugary Snapple in vending
machines to raise money. But it does not pay for a full physical
education program, so May's fourth-grade class has gym just once
a week, in violation of state law.

And when she and her friends gather for snacks, she basks in
their approval as she produces the high-calorie American-style
treats, from chips to sweets, that are rapidly replacing
traditional foods in the local markets.

Children all over the world are walking the same sort of obstacle
course as obesity and Type 2 diabetes increasingly strike the
young.

But to spend time with May Chen and the other children of
immigrants in Flushing - at home in front of the TV, in the
places where they eat and buy food, in their schools - is to
appreciate the everyday threat confronting a particularly
vulnerable group: the Asian-Americans who make up half the
community's population.

It is also to understand what alarms health authorities about the
future of New York, a city of immigrants where Asians are the
fastest-growing racial group.

Asians, especially those from Far Eastern nations like China,
Korea and Japan, are acutely susceptible to Type 2 diabetes, the
most common form of the disease and the subject of this series.
They develop it at far lower weights than people of other races,
studies show; at any weight, they are 60 percent more likely to
get the disease than whites.

And that peril is compounded by recent immigrants' sudden
collision with American culture. Many of them left places where
factory and field work was strenuous, televisions were rare and
advertising was limited. They may speak little English and have
poor access to medical care.

Many have never even heard of diabetes, much less the recent
scientific studies showing that a Western diet, high in fat and
sugar, puts them in danger of getting Type 2 diabetes, which has
been linked to obesity and inactivity, as well as to heredity.
(Type 1, which comprises only 5 percent to 10 percent of cases,
is not associated with behavior, and is believed to stem almost
entirely from genetic factors.)

Many recent Chinese immigrants have come from places where food
was scarce, and experts say some view fat as a trophy of wealth
and status. Their children try to fit into their new country by
embracing its foods and its sedentary pastimes.

"When they give you the visa to the United States in Shanghai,
Fujian or Beijing, they should stamp a clear warning: danger to
your health," said Marcelo M. Suarez-Orozco, co-director of
immigration studies at New York University.

So far, that danger has not been fully realized. Flushing has
only half as many diabetics as the New York neighborhoods where
the disease has made its deepest inroads. City epidemiologists
say they have limited data on its spread among Asians.

But they do know that 14 percent of Asian children in New York
are obese, more than twice the rate among their parents. And they
say there is mounting evidence - including soaring diabetes rates
in major cities in China, and in other countries with Chinese
immigrants - that New York will soon experience a similar
explosion as more Asians arrive and have their first encounters
with Western ways.

The clash of cultures is vividly apparent in Flushing, one of the
city's new Chinatowns. On streets like Roosevelt Avenue, older
immigrants still throng traditional Asian markets, with their
signs in Chinese, and dine at noodle shops where windows fog with
steam. Their children, however, are increasingly lured by fast
food. Along a 100-yard strip of storefronts are a McDonald's, a
Burger King, a Taco Bell, a Pizza Hut, and a Joe's Best Burger.

Even in China, the number of obese people has tripled since 1992
to 90 million, as Western food has become popular and prosperity
has made it possible to eat more. The World Health Organization
has warned that Asia faces a "tsunami" of diabetes in the coming
decade, and health officials have assailed the Chinese government
for its tepid response to the crisis.

But in this country, where children are bombarded with much more
food advertising, many health experts say the response has not
been much stronger.

In Washington, money for school gym programs is measured in the
millions, while billions are spent on subsidies for those who
produce food sweeteners.

In Albany, where the restaurant and food industries are generous
campaign donors, bills to raise awareness of nutrition and
diabetes have been dismissed or derided.

In New York's City Hall, a former councilwoman who has been
outspoken on childhood obesity, Eva S. Moskowitz, sees similar
apathy. "We have a massive problem on our hands," she said.
"There is an utter lack of urgency to do anything about it."

And in Flushing, where the Small Business Administration has lent
$4.6 million in the last decade to spur fast-food franchises, the
community health center has trouble finding money for diabetes
education.

Here, for anyone who cares to look, are the people left to fend
for themselves: a new generation that will soon fill New York's
schools and workplaces, making the daily choices that could mean
the difference between a healthy city and a colony of the sick.

A Melting Pot, Boiling Fiercely

Incredible, Li Li kept repeating, simply incredible.

For 14 years, ever since he moved to Flushing from Canton, China,
he has hewed to the same diet that his ancestors ate for
hundreds, if not thousands, of years. "Chicken, frog, duck, all
very fresh - that is what we like," said Mr. Li, a 40-year-old
business consultant, as he steered a cart through the Hong Kong
Market on Main Street.

But at only 3 years old, his twin daughters have already blazed
their own path away from history. "They both like the American
food," he said. "I cannot stop that."

He found the switch profoundly unsettling - not because he saw
health consequences, but because it had happened so fast.

"Only recently, they tried Coke and they loved that," he said, as
one twin tried to grab a package of candy. "They won't drink tea
anymore. Can you believe it? They will not drink tea."

It was a classic scene from the well-known story of American
immigration: the children of newcomers eagerly assuming the ways
of their new world, and rejecting the old.

But a rite of passage that used to take most immigrant families a
generation or two - fully adopting the American diet - has
accelerated for Asians, said James L. Watson, a Harvard
anthropologist who has studied their response to fast food. Many
have moved in just a few years from villages to China's
increasingly Westernized cities and then to the United States, he
said, quickly abandoning traditional foods.

"Everything is happening at warp speed," Dr. Watson said. "The
melting pot may have been simmering in the past, but now it is
raging."

And the American diet they are taking up is far different from
what it was for earlier generations of immigrants: a
mind-boggling array of processed products, with added sugars and
fats that can turn these unfamiliar foods into seductive
pleasures.

Even the store Mr. Li was shopping in is a startling departure
from the small produce and poultry shops that still crowd
Flushing. The Hong Kong Market, which opened in 1996, is a
meeting spot for old and new: a huge supermarket that stocks
Chinese versions of processed American foods.

One shopper, Jian Kang Qiu, 43, an artist who moved from a
coastal village in the province of Guangdong six years ago, said
his family's eating had changed radically.

"At home we would shop in the open market," he said. "There was
not so much packaged food. We would eat maybe two meals a day.
Rice with something on the side, fish or vegetables." Now, faced
with the unlimited choices here, they eat a far broader diet,
with many treats.

Mr. Qiu's mother has Type 2 diabetes, and recently his younger
sister learned that she does, too. It has made him a little more
conscious of what he consumes. But he has given up trying to
control what his 16-year-old daughter, Vicky, eats.

"She would prefer American food," he said. "Her friends are going
for pizza, she wants to go for pizza. It is normal. She wants to
do what her friends are doing."

The need to fit in is no less important for the fourth graders at
Public School 120, where May Chen, the pigtailed 9-year-old, was
the center of attention one afternoon as snack time rolled
around.

May's parents co-own a sushi restaurant, but she had come to
school with a bag of all-American snacks: a shiny blue can of
Lay's Stax potato chips and a package of neon-orange Cheetos
Puffs. She passed out chips to her friends, and in no time hands
were stretched out all over the classroom.

No one gave a second glance to the steamed dumplings that a
classmate, Annie Wu, had brought from home.

"There is a kind of shame issue," said Professor Suarez-Orozco of
N.Y.U., who has spent the last five years studying the lives of
400 immigrant families, with a focus on Asians. "The kids feel if
they bring food from home, some ethnic dish, they are seen as not
as cool and not with it."

School is one place where good eating habits can be taught. Yet
at P.S. 120, fats, sugars and calories figure heavily in
cafeteria fare: burgers, pizza and chicken nuggets.

In the last two years, the Bloomberg administration has made some
changes: hiring an executive chef to make food in all schools
more nutritious; installing salad bars at many schools, including
P.S. 120; and cutting the fat and calories in some of the most
popular items. At lunch, every student gets a banana or an apple
- a requirement that schools must meet to receive federal
reimbursements.

But schools, critics say, are reluctant to change their menus too
drastically and risk a drop in sales that would reduce those
reimbursements. And at the end of each school day, the trash
baskets at P.S. 120 are filled with the compulsory fruit.

'If It Is Delicious, I Love It'

A sweet tooth is standard equipment on any child. But the
sweetness that satisfies it is no longer limited to cookies and
candy.

When 18-year-old Jin Yang dashed into a Key Food supermarket one
rainy afternoon to buy food for her friends at Flushing High
School, she wasn't looking at nutrition labels. If she had, she
might have noticed that nearly every purchase she considered -
the low-fat yogurt, the basil vinaigrette and even the chicken
noodle soup she ended up buying - shared the same major
ingredient: high-fructose corn syrup, a sweetener first derived
from corn in the 1960's.

Underwritten by roughly $40 billion in federal subsidies paid to
corn growers in the past 10 years alone, it is now so cheap that
it has all but replaced cane sugar as the sweetener of choice in
processed foods.

The syrup has been singled out by many health experts as one of
the chief culprits in the rise of obesity. Its inexpensiveness,
they say, has helped soda producers create the larger portions
that have led to overconsumption. It is so versatile, they say,
that it now shows up in many foods that would not have been
sweetened at all in the past.

There is wide disagreement among scientists over some studies
indicating that high-fructose corn syrup can hinder the body's
ability to process sugar, and can promote faster fat growth than
sweeteners derived from cane sugar.

What no one disputes, however, is that since the advent of the
syrup, consumption of all sweeteners has soared; the average
American's intake has increased about 35 percent, according to
the Federal Department of Agriculture. And a 2004 study in The
American Journal of Clinical Nutrition showed that the rise of
Type 2 diabetes since 1980 had closely paralleled the increased
use of sweeteners, particularly corn syrup.

Food industry officials say there is nothing wrong with the syrup
as long as people eat it in moderation.

But Jin, who came here just a year ago from rural northeastern
China, said she had never even heard of the sweetener - or
diabetes, for that matter. Thin and healthy, she subjects each
food purchase to only one test. "If it is delicious," she said,
"I love it."

Moderation may also be a foreign concept to many new immigrants
from China because of deep-seated attitudes they have brought
with them.

In many Chinese families, it is difficult to get parents and
grandparents who were raised during the deadly famines and
deprivations of the 1950's to stop overfeeding their children.
"Increased girth is an indicator of wealth," said Dr. Thomas
Tsang, medical director of the Charles B. Wang Community Health
Center in Flushing.

But any extra weight is dangerous for Asians, research shows,
because of their susceptibility to Type 2 diabetes. For example,
a 5-foot-9 Japanese man who weighs 156 pounds - and who may never
develop the sort of belly that is a warning sign for the disease
- is twice as likely as a white man that size to become diabetic.

Because of that, Dr. Tsang said he believed that the number of
Asian diabetics is underestimated; he has recently diagnosed at
least a dozen new cases among his longtime patients. "It's
astounding," he said. "And it puts a lot of pressure on us to
educate them."

The Wang Center has hired three diabetes nurse educators and a
nutritionist in the last two years. But the effort to prevent,
diagnose and treat the disease is hobbled, Dr. Tsang said, by
cultural barriers. Asian immigrants who are in the country
illegally tend to avoid doctors, and some Chinese people will not
test their blood sugar.

"My own mother has diabetes," the doctor said, "and she will not
draw her own blood. She believes blood is the life essence and
should not be lost."

Selling Frosted Flakes and Fitness

At age 3, Henry Chen is learning his first words in English.
"Mother" was first, followed by "father." What came next,
however, surprised his aunt, Cindy Chen.

"McDonald's," she said. "It was one of his first words."

Neither fast food nor television was part of the Chens' life in
Fuzhou, a Chinese city where they struggled to find work before
moving to Flushing four years ago.

Now Henry and his family show up at least once a week at
McDonald's. At home, he perches on the sofa to watch Nickelodeon.
By his aunt's estimate, he spends as much as 30 hours a week in
front of the TV - more than double the average for a child in
China, according to data collected for The New York Times by AGB
Nielsen Media Research. Like a human SpongeBob, he soaks up ads
for Pop-Tarts and Lucky Charms.

There is nothing new about the marketing of food to children,
with all of its cartoon characters and free toys. According to a
study released in May by the Grocery Manufacturers Association,
the average child watches 4,900 food commercials a year.

What is new, though, is the message that child - and his parents
- are hearing.

Ronald McDonald now snowboards, and his once-portly frame looks
to have shed at least 30 pounds. The box for Henry's Happy Meals
reads, "A game of tag keeps me happy and fit." In one commercial,
a woman does a victory jig when she finds out her Lay's potato
chips are low-fat. A Frosted Flakes ad shows children running
around a soccer field with Tony the Tiger.

"Without a doubt, the food industry, while not moving away from
convenience, has begun to push health as the main driver of food
packaging and promotion," said Don Montuori, publisher of
Packaged Facts, which does consumer research for food companies.

The companies say they are doing their part to combat obesity by
offering lower-calorie, lower-fat choices, and encouraging
children to exercise. McDonald's sponsors track events for young
runners, and Coca-Cola has created the Tiger Woods Foundation to
promote children's sports.

But what would seem to be welcome news has simply created a
different problem, according to many nutritionists and public
health officials. Despite a salad here or a lower-fat oil there,
they say, the food industry has done little to change the basic
unhealthfulness of its best-selling products. And by making the
link to fitness, they say, the companies are telling children
that all of those foods are good for them.

New immigrants from China are keenly receptive to such claims
because the Chinese have used foods to cure illnesses and promote
general health for thousands of years, said Dr. Watson, the
Harvard anthropologist. One cure for a cough, for instance,
involves duck gizzards, apricot kernels and watercress. A variety
of foods are thought to improve brain function.

Many Chinese people have replaced those traditional foods with
processed foods, Dr. Watson said, and have little idea what is in
them. Still, the faith in food persists: for instance, he said,
there is a widespread perception in China that eating at
McDonald's can somehow make you smarter. In New York, Professor
Suarez-Orozco said, immigrant parents often reinforce that
connection by rewarding academic achievement with a McDonald's
meal.

And many Chinese companies have adopted the same kind of health
pitches as their American counterparts. At the Hong Kong Market,
a juice box called Vita Chrysanthemum Tea promotes itself as a
health drink for children, though nutritionally it is little
different from Snapple.

Ye Zhou, a sixth grader whose parents arrived from China shortly
before she was born, said she tried to eat right, and knew that
some foods were unhealthful. On this day she had come to the
McDonald's on Main Street to try the new Premium Crispy Chicken
Breast Sandwich, drawn by the ads that touted the "energy" packed
in the meal, which includes French fries and a soda.

How, she was asked, did it compare nutritionally with the
stir-fried chicken and rice her mother made at home?

"They taste different," she said. "But one is not healthier than
the other."

Actually, the fast-food meal has at least one-third more
calories, carbohydrates and grams of fat than a typical homemade
one.

Even before the latest blitz of health messages, children were
confused, the Henry J. Kaiser Family Foundation said in a 2004
report on childhood obesity. In a 1997 study it cited, fourth and
fifth graders were asked which of two foods - say, corn flakes or
frosted flakes - was more healthful; the children who watched the
most TV were the most likely to pick the less nutritious one.

For more than two decades, Dr. Daniel S. Acuff helped hone food
ads aimed at children as a marketing consultant to companies like
Coca-Cola and Nestle. But about two years ago, he said, he
stopped consulting on products he did not consider nutritious
after recognizing the threat posed by obesity. He called the
industry's new sales strategies disingenuous. "To position
themselves as leaders in providing healthy food for children is
nonsense," he said.

He and others - including the American Academy of Pediatrics and
the American Psychological Association - have called for tighter
restrictions on advertising to children, similar to limits in
Australia, Canada and England. They are also concerned about the
increasing use of the Internet and video games to sell food.

But repeated attempts to enact such strictures in the United
States have failed for three decades, and at a meeting last July
in Washington, the Federal Trade Commission told food and
advertising executives that it favored letting the industry
police itself.

A few companies have done just that - most notably Kraft Foods,
which decided last January to curb its advertising of certain
products, like Oreos and Kool-Aid, to children under 12. The move
raised eyebrows both in the food industry and in public health
circles because of its implicit suggestion that there are bad
foods. The industry has long maintained that there are no bad
foods, only bad habits - like overeating.

Tim Wong is only 10, but he had no problem polishing off a large
dinner platter from the adult menu one afternoon at the KFC on
Main Street in Flushing. He had asked his mother to take him and
his 6-year-old sister, Tiffany, so they could try "the new stuff"
on the menu. "I see the new items on television and I want them,"
he said.

When he was asked what his favorite foods were, his mother
laughed.

"Look at him," she said in a matter-of-fact way, as Tim is
obviously overweight. "He likes his junk."

Time for Gym! O.K., Time's Up!

"Two fingers in the air!" the teacher aides shouted at the more
than 100 children squirming in the auditorium seats.

Two fingers held high is the way students at May Chen's school
signal that they are sitting quietly enough to be let out for
recess. It was 10:30 a.m., less than two hours after they had
been served a breakfast that included chocolate milk, a doughnut
and a juice box - at least 400 calories and 47 grams of sugar
waiting to be burned off.

Finally the doors opened, and the students scampered out to the
playground, a parking lot ringed by a chain-link fence. Several
boys ran around like mad. In a makeshift game of keep-away, May
and some other girls tossed around a bag of cheese snacks.

They had to play fast. Twelve girls were lined up to jump rope,
but only three had a chance before a bell summoned them back
inside for lunch.

May's recess had lasted eight minutes.

It was, as always, the only recess for the day, and fortunately
the weather was mild. On cold or rainy days, the children stay
inside and watch movies.

Recess and physical education are treated like luxuries in the
New York City schools. Though half the grade schoolers are
overweight and roughly one in four are obese, the city did little
until last year to promote one of the best antidotes: exercise.

May, like most schoolchildren in the city, does not get even the
minimum amount of physical education mandated by state law, two
hours a week. She has a single gym class each week, for 50
minutes.

She is among the lucky ones. More than half the city's 700
elementary schools have no usable outdoor play space, according
to a 2003 survey by the City Department of Education. May's
school has only one gym teacher for its 1,000 students, but
roughly one in seven elementary schools in the city have no
teacher dedicated to physical education.

And although P.S. 120 has a functioning gym, many elementary
schools do not, according to reports by the City Council and the
State Assembly. Even those that have gyms often use them for
classes or meetings. There has been no standardized testing of
student fitness in more than a generation.

The sad state of the school gym class is a legacy of the city's
fiscal crisis in the 1970's, when the budget for physical
education was slashed to protect other academic programs. But New
York's plight is not much worse than the rest of the country's.

Even as the health authorities pronounced obesity a national
epidemic, daily participation in gym classes dropped to 28
percent in 2003 from 42 percent in 1991, according to the Centers
for Disease Control and Prevention. And the Bush administration
recently proposed cutting Physical Education Program grants to
schools by more than one-quarter, to $55 million, though Congress
rejected the proposal.

Schools are so desperate to finance exercise programs that many
have turned to food companies for help. McDonald's is offering
curriculums and undisclosed sums to 31,000 schools across the
country to improve physical education through an effort called
Passport to Play; every piece of program literature that children
see will carry the company's golden-arches logo.

Two years ago, even as New York's health department was assigning
a team to improve the treatment of diabetics, the city signed a
deal with Snapple that made its fruit drinks the only beverages,
besides water, sold in school vending machines. A 12-ounce can of
Snapple contains 170 calories and 40 grams of sugar, as much as
most colas. The calories in three cans - the amount many students
drink every day - would take at least three hours to walk off.

The 29 fourth graders in May Chen's class have gym directly after
lunch, and their stomachs were full this day with chicken
nuggets. They did not change into gym clothes. The teacher, Bruce
Adler, started them off with calisthenics, moving quickly to
situps and three leisurely laps around the basketball court.
There were groans, and several children were winded, but few
broke a sweat.

Mr. Adler, 55, said the school could really use a second teacher,
recalling how different things were when he was growing up in
Yonkers. Students there had at least three gym classes a week, he
said.

New York school officials say they are adding more physical
education teachers each year. And two years ago, the Bloomberg
administration created the Office of Fitness and Physical
Education. Its director, Lori Rose Benson, has begun a program
called Physical Best, which will track students' fitness,
charting progress for each school. She said she hoped to start
the program by the end of this school year in every grade school
with a physical education teacher, including May's.

She conceded it was merely a first step. "It is very difficult to
reverse a culture that existed for 20 to 30 years," she said.

Tilting at Golden Arches

At least two unthinkable things happened in Albany in the past
year.

One made headlines: The Legislature passed a budget on time. The
other went unnoticed: The Assembly actually debated a bill that
tried to address, in some small way, the leap in obesity and Type
2 diabetes.

It was a rare moment of attention for a cause that has drawn
little more than lip service from government officials, and it
was short-lived. The debate, and the bill, died in mocking
laughter.

The story of that bill, known as A5664, is a lesson in the ways
of Albany - and the apathy that diabetes experts say is blocking
any effective response to the epidemic.

The lesson was an abrupt one for Assemblyman Jimmy Meng of
Flushing, who had already embarked on a sharp learning curve.
When he was elected the previous fall - the first Asian-American
voted into state office in New York - diabetes was nowhere near
the top of his list of health issues.

But as he became more aware of the disease's threat to children
and young adults in his community, Mr. Meng said, he became
frustrated with the ignorance and inaction he discovered.

In April, he organized and led the first march in Queens to raise
money and awareness in the battle against diabetes. And he agreed
to support legislation by a fellow Assembly Democrat, Felix Ortiz
of Brooklyn.

The bill would require all restaurants to prominently post the
amounts of calories, fat and salt in each menu item. It was
hardly a radical notion. Many fast-food chains had already begun
listing calorie counts in restaurants and on Web sites, and
months later McDonald's would decide to print nutritional data
right on its wrappers.

But Mr. Ortiz felt those moves were only a start. Who knew how
many calories were in a slice of the neighborhood pizza or a
Starbucks caramel macchiato?

His passion for the issue - this was just one of six bills he
introduced in the 2004-5 session to fight obesity and diabetes -
was fed by his own loss. His mother died of the disease when she
was only 58.

"Everything was caused because she did not take care of her
weight," he said.

In Albany, the path from legislation to law is thorny, and Mr.
Ortiz brought along his own set of hurdles. He was hardly an
insider within the Democratic conference, which is controlled by
Speaker Sheldon Silver, and some of his bills were considered
odd. One would have made it a crime for a person not to come to
the aid of another in trouble.

The restaurant labeling bill looked like another loser. It had no
support from the Democratic leadership. Although it was backed by
the American Diabetes Association, which has spent $9,000
lobbying New York lawmakers in the past few years, it was opposed
by the food industry, which contributed more than $4 million to
legislative and gubernatorial campaigns between 1999 and 2005,
according to state records.

And diabetes had hardly caught fire as a pressing health issue.
The Pataki administration is investing $9 million this year to
encourage physical activity among children, but the state has not
moved to limit the sale of unhealthful snacks in schools, as a
half-dozen other states have. Only $1.9 million of the $100
billion state budget goes directly to diabetes prevention and
control, roughly the same amount spent to fight anorexia and
bulimia.

Two months after the Health Committee approved Mr. Ortiz's bill,
it had still not come up for a full Assembly vote. But on June
22, as the legislative session wound down, the bill found its
moment.

Many members were in a hurry to leave town. As evening
approached, Mr. Ortiz spotted Mr. Silver, chased him down a
corridor and cornered him outside the speaker's office, in a
space where legislators often horse-trade in whispers. Mr. Ortiz,
however, was shouting: "I get the same excuse every year!"

He wanted his bill debated and voted on by the full Assembly - an
unusual request in Albany, where measures rarely make it to the
floor of either house unless they are assured passage. Mr.
Ortiz's five other bills to fight obesity had languished in
committees.

If a bill this mild could not succeed in New York, Mr. Ortiz
argued, what hope was there for more sweeping measures?

Mr. Silver relented. And when the bill came up for a vote, near
midnight, Mr. Ortiz had the floor. "This is about the future of
our children," he said.

When he stopped, the sarcasm began.

James D. Conte, a Long Island Republican, said his family owned a
burger restaurant. What would happen, he asked, in the case of
all-you-can-eat buffets?

Mr. Ortiz said the law would apply only to standard menu items.

"What about the weekly specials?" Mr. Conte asked.

Laughter rose in the chamber. Daniel J. O'Donnell, a fellow
Democrat from Manhattan, kept it going. "I watch people who work
at McDonald's, and they don't measure how much salt they put on
fries," he said. "Do you expect there to be a shaker lesson?"

Mr. Ortiz said he guessed that employees were adequately
educated.

An hour went by. A few colleagues defended the measure. Others
argued that enforcing it would be a nightmare, and that the costs
would hurt small restaurants.

As the time for debate waned, Joel M. Miller, a Republican from
Poughkeepsie, rose to state his position. "I did not develop this
physique by eating healthy," Mr. Miller, a stout man, said to
guffaws. A colleague completed the joke by bringing him a
generous plate of cookies.

"The bottom line is, it is not going to matter," Mr. Miller said.
"We are fooling and deluding ourselves."

Mr. Ortiz made one last plea. "When we look at the rate of
diabetes in our state," he said, "and when we look at this bill,
we should remind ourselves that the decision we make here tonight
will make an impact on our kids."

The result was clear as soon as the voting began. The yes votes
showed up on an electric signboard in green, the no votes in red.
Within minutes, the board was glowing red.

Before the tally could be completed, Mr. Ortiz stood and
delivered the final word: "I would like to say, with a lot of
passion, I withdraw this bill."

Gene Increases Diabetes Risk, Scientists Find
http://www.nytimes.com/2006/01/16/science/16gene.html

By NICHOLAS WADE

Scientists have discovered a variant gene that leads to a sizable
extra risk of Type 2 diabetes and is carried by more than a third
of the American population.

The finding is being reported today in the journal Nature Genetics
by researchers at Decode Genetics, a company in Reykjavik, Iceland,
that specializes in finding the genetic roots of human diseases.
Decode Genetics first found the variant gene - one of many
different versions that exist in the human population - in
Icelanders and has now confirmed the finding in a Danish and an
American population.

An immediate practical consequence of the discovery, said Decode's
chief executive, Kari Stefansson, would be to develop a diagnostic
test to identify people who carry the variant gene. If people knew
of their extra risk, they would have an incentive to stay thin and
exercise, he said.

Diabetes, a disease in which damaging amounts of sugar build up in
the blood, with risk of blindness and loss of limbs, affects 20.8
million Americans, according to the Centers for Disease Control and
Prevention. An estimated 800,000 adult New Yorkers - more than one
in every eight - now have diabetes, and city health officials have
expressed concern about its growing incidence.

Type 2 diabetes, the predominant form, is typically diagnosed in
adults and adolescents, though it is creeping into younger age
groups. The Type 2 kind accounts for up to 95 percent of all
diagnosed cases, according to the centers.

Because people carry two copies of every gene, one inherited from
each parent, the risk conferred by the new gene depends on whether
one or two copies of it have been inherited. The estimated 38
percent of Americans who have inherited a single copy have a 45
percent greater risk of Type 2 than do unaffected members of the
population. The estimated 7 percent who carry two copies are 141
percent more likely to develop the disease, according to the Decode
researchers, who were led by Struan F. A. Grant.

What scientists call the "population-attributable risk" of the new
variant is 21 percent, which means that if all the variant genes in
the population were erased, so would be 21 percent of diabetes
cases.

The finding is "a beautiful piece of work and as convincing as any
initial publication could be," said David Altshuler, a medical
geneticist at Massachusetts General Hospital, who has in the past
taken issue with certain aspects of Decode's claims.

"In terms of the epidemiological risk of diabetes, this is by far
the biggest finding to date," he said, just after hearing a lecture
on the finding by Augustine Kong, Decode's chief statistician.
Diabetes is thought to be caused by a variety of different genes,
each conferring a risk for the disease. Because most of the
variants exert a minor effect, they are hard to detect, and many
claims to have found diabetes-causing genes have turned out to be
unfounded.

"This has turned out to be the disease that has been the most
difficult for geneticists to crack, probably because of the large
environmental contribution," Dr. Stefansson said.

The new variant identified by Decode was of a somewhat obscure gene
that had not been suspected of having any involvement in diabetes.
The gene, designated TCF7L2, is one that controls the activity of
other genes. Its role may include setting the level of a hormone
that acts along with insulin to control blood sugar levels.

Discovery of the TCF7L2 gene could be therapeutically helpful, Dr.
Stefansson said, because it identified a major biochemical chain
reaction or pathway through which the disease developed. Several
different genes, and their protein products, are involved in the
pathway that sets the level of the companion hormone. Any of these
genes and proteins are potential targets for new drugs.

Dr. Altshuler, of Massachusetts General, agreed. "Being directed
down that pathway is very helpful," he said, though he added that
the process of developing better treatments might take a decade or
two.

While Type 2 diabetes is more common in African-Americans, Latinos,
American Indians, and Asian-Americans, Dr. Stefansson said more
studies were needed to see whether there were significant
differences in the variant gene's distribution among races.

He said he could not yet say if the genetic variant was more common
in African-Americans and so might explain their greater burden of
Type 2 diabetes. But he noted that the variant was ancient, having
arisen before the dispersal of modern humans from Africa some
50,000 years ago, and would probably be found to exist to varying
degrees in all populations.