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To: BOARD OF SUPERVISORS
Contra
FROM: Mark DeSaulnier - �
- - Costa
DATE: January 24, 2006 • " _ County
SUBJECT: Child Obesity
SPECIFIC REQUEST(S)OR RECOMMENDATIONS)&BACKGROUND AND JUSTIFICATION
RECOMMENDATIONS
1. ADOPT a policy of promoting recommendations from the Centers for Disease Control and
Prevention and the National Institutes of Health against child obesity.
2. DIRECT Health Services staff to coordinate with and provide information to public school
districts within Contra Costa.County as to best practices for providing healthy and nutritious
cafeteria menus to children K through 12 as part of federally-required school wellness
policies.
3. DIRECT the Health Services,, Public Works, and Community Development Departments to
research and evaluate the most effective methods of restricting, in the County's General
Plan,,the number of new fast food restaurants within the County which may be constructed
and operated, in order ta help reduce instances of child obesity. DIRECT these departments
to report back on their findings to the Board of Supervisors.
4. DIRECT Health Services staff to coordinate a program for the voluntary participation of
restaurants within the County that would encourage all restaurants to list ingredients of their
dishes, in order of weight, and to make this information clearly available to patrons.
DIRECT Health Services to implement a"healthy restaurant"program for the County that
would award"healthy restaurant"designations to those establishments that offer a high
compliment of healthy and nutritious menu items.
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5. DIRECT the Health Services Department to provide information support and
encouragement to park and recreational facilities that want to voluntarily eliminate provision
of soft drink and junk food and replace with healthy alternatives.
6. DIRECT Health Services to work with staff at after school programs that want to voluntarily
provide healthy food options,physical education, and equipment for active play. DIRECT
Health Services to provide lists of low-cost healthy snacks, and training and equipment for
atter-school staff for activities that promote physical activity.
7. DIRECT Health Services to provide training to medical providers on standards of practice
that focus on effective patient education and counseling toprevent and treat childhood
%ape
obesity. DIRECT Health Services to provide or refer patients to appropriate health
education programs.
8. DIRECT Health Services to provide information to all schools in Contra Costa.about the
benefits.of participating in available federal school meal programs (including the School
Breakfast Program,National School Lunch Program, Summer Food Service Program, Fruit
and Vegetable Snack Program, and Child and Adult Care Food Program). DIRECT Health
Services to provide assistance with applications and implementation.
9. DIRECT Health Services Department to provide technical assistance and support to all
school districts in Contra Costa that are interested in exploring discontinuing exclusive soft
drink and fast food contracts as they expire, establishing alternative funding streams, and
providing healthy food and beverages on school campuses.
BACKGROUND:
According to the Centers for Disease Control and Prevention, the proportion of overweight
children ages 6 to 11 has skyrocketed in recent decades, from 7 percent in 1980 to 16 percent in
2002. Among those 12 to 19, the rate of obesity more than tripled, from 5 percent to 16 percent.
For these reasons, many health officials have called child obesity a pandemic.
Surveys and studies too countless to enumerate, speak of the many trends by which children have
become overweight in recent years. There are many contributing factors, including diet.
Currently, the biggest single source of calories in the American diet is the soft drink. The
average teenage boy, for example, will get 15 teaspoons of sugar a day from these drinks alone,
according to one report. And while soft drinks are frequently consumed, healthy alternatives like
milk too often go unconsumed. A diet such as this may also lead to other health problems like
diabetes.
The lack of exercise due to common sedentary habits such as lengthy television watching or
computer using has also escalated the prominence of child obesity. Exercise and athletics are
often relegated to the sidelines. The built environment also impedes physical activity because
our communities are designed for transportation by car. Bike riding and walking are either
unfeasible or unsafe.
And television makes an impression upon children in another, more subtle fashion. Advertising
impacts them. A child may see thousands of television commercials in any given year. It is
estimated that more than 90 percent of the ads targeted to this demographic consist of fast food,
soft drinks, candy or sugared cereals.
Schools play an extraordinarily significant role in the diet,health and weight of our children as
well. Kids consume two of their-daily meals-in some cases at school. The menu available to the
children of our county at their particular schools,therefore, takes on added importance, not only
in terms of nutrition,but also because of tree dietary lessons they learn and emulate outside of
class and will continue to retain later on as adults. The fact that roughly 50 percent of school
districts in the nation have contracts with soft-drink companies for the sale of such beverages on
school premises is not encouraging news.
In the 1970's,the proportion of a child's calories that originated from fast food was only two
percent. Today, it is ten percent. A 2002 survey even placed the percentage of children eating
fast food on any particular day at approximately thirty percent. Fast food consumption has
increased, in part,, due to the number of fast food restaurants that were constructed in the past 15
years and the availability and accessibility to such food choices.
Such are the contributing factors that help to explain why between 25 and 30 percent of
American children have excessive body weight today and why childhood diabetes has
skyrocketed in the past twenty years. Matters are not improving.
Educators are responding in part to the federal government's demand that virtually every school
system in the nation create a"local wellness,policy". Aimed at getting kids to exercise more and-
eat more nutritious food.,the plan,,required of all schools where lunchrooms get federal money,
must be in place by the start of the next school year. The law allows each system to develop its
own plan, based on the needs of its students and the facilities and resources available.
Innovative concepts are also being tried nationally to fight child obesity. The"Walking School
Bus", a program begun in Europe,works just like a car pool, and consists of a group of children
walking to school with one or more adults. It is a program supported by the Centers for Disease
Control and Prevention and the National Institutes of Health,which recently started a website
called"We Can!"to promote healthy activities for parents and children. The American Heart
Association too has recognized the grave problem of childhood obesity and is partnering with the
Nickelodeon network to reach children with a comprehensive health and wellness message.
Partnerships on many levels will be required to reverse the current trend. Contra Costa.County
can encourage such efforts by adopting a policy geared towards better nutrition and greater
exercise.
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Diabetes and Its Awful Toll Quietly Emerge as a Crisis New York Times gage I of 9
1;hC,N* dV 91ork rimeS
nytImi-e s.c om
January 9,2006
Bad]Blood
Diabetes and Its Awful Toll Quietly Emerge as a Crisis
By N.R.KLEDMLL.D
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 middlesaged man sprawled.,recuperating from a kidmv =Vjaj.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:diab tes.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 300,000 adult New Yorkers-more than one in every eight-now have diabetes, and city health officials
describe the problem as a bona fide widgnjiQ.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 dills.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 ooze.
i
Widiin a generation or so,doctors fear,a huge wave of new cases could overwhelm the public health system and engin
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 halL
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 AMS.or lung cancer.
In its most common fb=6 diabetes,wluch 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 hely i11.
Yet a close look at its surge in New York offers a disturbing glimpse of where the city,and the rest of the world,maybe
headed if diabetes remains unchecked.
The percentage of diabetics in the city is nearby 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 onewthird do
not know it.
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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
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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 bume are especially vulnerable. It is also
yielding to the same forces that have driven diabetes nationally: an aging population,a food supply spiced 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 Dives,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 Vietn=Warr.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 Amexicans for the fast time in more than a cenhuy.
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 singe illness.
"Either we fall apart or we stop this," said Dr.'Thomas R.Frieder,commissioner of the New York City Department of
Health and Mental Hygiene.
Yet he and other public health officials acknowledge that their ability to show 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 Axnericans are believed to be diabetic,according to the Centers for Disease Control,and 41 million
more are prediabetics their blood sugar is high,and could reach the diabetic level if they do not alter their living habits.
In this sedentary naiioza,New York is often seen as an island of thin people who walk everywhere.But as the yanks of
American diabetics have swelled by a distressing 80 percent in the last decade,New York has seen an explosion of cases:
X40 percent more, according to the city's health depailment. The proportion of diabetics in its adult population is higher
aiiathat of Los Angeles or Chicago,and more than double that of Boston.
There was a Pronounced increase in diagnosed cases nationwide in X997,part off'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 even since.
Yet dor 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 Rork,with its ambitious and highly praised public
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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. .
.sb§Xculosis,whicb, infected about ],,000 New Yorkers fast year,gets$27 million and a staff of almost 400.
Diabetes is "the Rodney Dangerfield of diseases,"said Dr.Janes L.Rosenzweig,the director of disease management at
the Jospin Diabetes Center in Boston.-As fresh cases and then 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.Frieder,the health commissioner,"anti say,20 years from now people will look back:
'4
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and say,: 'What were they thinking?They're int the middle of an epidemic and Ipids are watcbing 20,000 hours of
commercials for junk food.'
Of course,revolutionary new treatments or a cute could change everytbing. 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$1,32 billion.All cancers,taken together,cost the country an
estimated$171.billion a year,
"How bad is the diabetes epidemic?" asked Frank Vizuicor,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 m a 24-hour period of
time, between when you wake up inn 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,supmee 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 Montefloxe Medical
Center. Her grandmother,aunt and two cousins have diabetes.
"I'm scared," she said. "Pm 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 end 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 m qua.�ity 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 ia�sulin,or the pancreas makes too little of it,or both.
Type I 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 ii 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 obeli
and inactivity.This is particularly true in those prone to the illness.Plenty or tat,slothful people do not getediabetes. 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
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Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times gage 4 f 9
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 againand again,
Diabetics are two to four times more likely t1m others to developheart disease or have a stoke,and three times more
d%^likely to die of complications from or pneumonia,accordingto the Centers for Disease Control.Most diabetics surrer
now
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 pre =cy,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 golesterol =ong others
brought on not by the diabetes,but by the behavior that led to it,or by enetics.
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 kad,not so bad. Two bad kids,its 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 firmthat evaluates the burden of diseases,estimates that a diabetic without
complications will incur medical costs of$1,600 a year-unpleasant,but not especially Dunishin But the price tag
4V A %
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 kmee.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: "AU patients With diabetes:Don't forget to bare your feet each
visit." i
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 swburst 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 M* his left leg.He had a heart
attack a few years ago. He was on dialysis. "Tuesday,T'hursday and Saturday,"he said.
On the s L`Xth floor was Maur Stein, 53, 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=or on bier heart and said it
would need surgery. %^
"My feet baro," she said. "My toes bum all the time.My dav of weafing my pumps are over.I'vegotten more c i0sone
shots in my feet than rm sure are legal.
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She mentioned her brother,who lived in California.Diabetes had ransacked 1-ds body-an amputation,kidney dialysis,
heart disease,blindness in one eye.He now resided in an assisted-living center.He was 53.
Nis. Stein's husband waled in and sat on the bed. Six months ago,he found out the same tuth:he had diabetes.
This was one day in one hospital.
inside the Incubator
Little about diabetes is straightforward,,and to comprehend why New York its such an incubator for the disease,it is
necessary to grasp that diabetes is as much a sociological and anthropological stony 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 fess access to fresh food,exercise and health
care.New York's poverty rate,20.3 percent,is much bdgher than the nation's, ].2.7 percent.
' Akan-.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 oT 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 oneAenth 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 int lay 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 comer,the geese works perversely,causing them to accumulate
unhealthy quantities of fat.
But the velocity of new cases among X11 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."
0
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 thud of junior high schools require physical education at
all,the C.A.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 distfibution echoed demographic
patterns:Diabetes left only a light imprint on more a.ffluent,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.
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"New York is switching from a mommandopop type of environment to a chain-store type of environment, a proliferation of
fast food,even in high rent neigbborhoocis they haven't had access to before,like the East Village and Lower Manhattan,"
said Peter Muennig, an assistant professor of health policy and naa�nageznent 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.Friedm 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 zs on trying to better treat those who already have diabetes,an ambitious goal in its own fight. 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.
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Even the most basic step in controlling the disease-watching one's blood sugar-a is too much for many diabetics.Doctors
recommend that two to four times a year,patients take a so-called Alc 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 Ale 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 hazm you even if you never get it.Disease reverberates outward,
and ifthe 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 Associarion,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 ajob at a baked-bean factory M* 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.
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"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 goang 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, 'hese 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 lmourn to denigrate
advanced diabetics as"shipwrecks,"because they brave so many health problems and vir=lly live in the hospital,
Not only will the future mean too few beds and unsupportable drains on Medicaid and Medicare,W. Muennig said,but if
an emergency strikes-a a terrorist attach,an earthquake-the city health system's ability to respond maybe compromised
because all the beds will,be full of diabetics.
Most schools do not have full-tinge 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.
rf 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 econoxm*c trauma,"Mr. Muenwig 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-heading cause of death in New York to the fourth.It was
fifth, slightly behind stroke,in 2004.But the health depa=ent 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 tWrd,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 seen the disease's long tentacles. When she started,she 'saw
people in their 50's and 60's,hobbled the usual pxob�ezz�sof e:agbligs herniated discs,heart Now, every
y con "tions,
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."
e'en 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,,"
"Un Dominique and I've had diabetes for seven years."
"I'm Joseph and I've had diabetes for two months."
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Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New YorkTimes Page 8 of 9
The brisk introductions went on,the ritual start to the monthly meefmg of a support group called Sugar Babes Place.All
the members had diabetes.A.11 were children,
Sugar Babes is the idea of Dr.XoXaine 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 S.Another is 7.
Xt scares Dr. St. Louis.It scares many doctors who see the same thing,because they k-uow 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 linearfashion-today,one in
five New Yorkers age 65 and older have it-but the starting point used to be mostly intheir 5 0'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
0
a"failure-to-tluive" 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 failwre-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. Tow,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 ism. Some newer drugs can promote weight gain and thus elevate the risk of diabetes.Dr. Shapiro bias an autistic
patient who he feels needs the new medication.But since taking it,the young man has markedly put on weight and,at 1 8,
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 IS 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,
I"
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. 1.
I heard a horror story a few weeks ago.."Dr, Lorber said, "of a girl who was born dtd,got diabetes at 1 1 or 12 and went
blind from diabetes at 30.11
The C.D.C. has projected that a child found to have Type 2 diabetes at age 10 will see his life shortened by 1 9 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 then 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
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Diabetes and its Awful Toll Quietly Emerge as a Crisis-New York Times Page 9 0£9
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 waned thena,"If youx 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 Cable by the walk.No
rapt attention from Joseph,, 12,w'ho had begged not to come, until his mother puther 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 giurx
who was tang 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
1'V that the children might try.Last meeting,they held a jurnpwrope 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.
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East Meets West,Adding Pounds and Peril-New York Times Page 10f 1 0
�im ,�
91)t fur 0rk
rlyiim;e��-com
January 12,2006
Bad Blood
East Meets Westing
Add* Pounds and PeriX
By MARC SANaQffiA
May Chen is slender and healthy, a lively little girl whose parents left their nn-al 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 labEhc.
When May watches cartoons in her family's apartment in Flushing,food Queens,the commercials tell her that junk food is
good -.the latest message from an industry that spends$ZO billion a year marketing to children.
When she strolls down Main Street, she walks a growing gantlet of -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 hagh-calorie American-
style treats, from chips to sweets,that are rapidly replacing tra�tional foods M* the local markets.
Children all over the world axe walling the same sort of obstacle course as obe and Type 2 diabetes increasingly strike
the young.
But to spend time with May Chen and the other children of inarmgrants in Flushing-at home in front of the TV,in the
places where they eat and buy food,in their schools m is to appreciate the everyday threat confronting a particularly
vulnerable group: the Asan-,Americans Who make up half the co smunity'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 frons Far Eastern nations like China, Korea and Japan,are acutely susceptible to Type 2 diabetes,
the most conunon fozm of the disease and the subject of this series.They develop it at faun 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 recentimmigrants'sudden collision with American culture. Many of them left places
Mg W
where factory and field work was strenuous,televisions were rare and adverfis* as 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 dieL high M* fat
and sugar,puts them in danger of getting Type 2 diabetes,which lzas been linked to obesity and inactivity,as well as to
heredity. (Type 1,which comprises only 5 percent to 1 0 percent of cases,is not associated with behavior,and is believed
to stern 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 embracm' g its foods and its sedentary
mw...v
pastimes,
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"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 immigration M. Suarez-Orozco, co.director of studies at New York University,
So far,that danger has not been fully realized.Flushing has only 1MV y 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.
Asad they say there is mounting evidence-including soaring diabetes rates in major cities in China,and ire other countries
40
10
with Chinese irxunigraats,,that New York will soon experience a s lar explosion as more Asiansarrive and have their
first encounters with Western ways,
The clash of cultures is Vividly apparent i.n,Flushing, one of the city's new Chinatowns.On streets like Roosevelt Avenue,i�runigramts
older still throng traditional Asian markets,with their signs in Chinese,and dine at noodle shops where
0
windows fog with steam.Their children,however,are increasingly lured by fast food.Along x1.00-yard strip of
storefronts are a McDonald's,a Burger King",a Taco BelL a Pizza Hut,and a Joe's Best Burger.,
Even zn 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 govexnmen,t for its tepid response to the
crisis.
But in this country, where children are bombarded with much more food adv sing,many health experts say the
response has not been much stronger,
Yn 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.
Ia.1Vew York's City Hall, a former councilwoman who has been outspoken on childhood obesity,Eva S. Moskowitz,sees
similar apathy. "We have a massive problemon our hands she said. "There'is an utter lack of urgency to da .," o anvthineybout 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�.x�dungm- oneforducation,
y
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,M-alw;-n
colony of the sick. the daily choices that could mean the difference between a healthy city and a
A Melting dot,Boiling Fiercely
Incxedable,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 hips 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-m
old business consultant,as he steered.a cart through the Hong Kong Market on Main Street.
But at only 3 years old,hail twin daughters have already blazed their ownpath avAmerican food,,"he said. "I cannot stop "They both,like the
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He found the switch profoundly wnsettling-not because he saw health consequences,but because it had happened so fast.
"Only recently,they bred Coke and they loved that,"he said,as one twin fined 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 lswafi on. 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' -fly adopting the American diet go
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 Cbina'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 iminigrants: a mind-
boggling array of processed products,with added sugars and fiats 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 mops that still crowd
Flushing.The Hong Kang 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,Ran 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,fast,or vegetables."Now,faced with the ux�liur�ted 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 haat she does,too.It has made him a lithe
more conscious of what he consumes.But he has given up trying to control what his 1.6-year-old daughter,Vicky, eats.
"She would prefer American food,"he said. "Hex friends are go for pizza,she wants to go for pizza.It is normal.She
wands to do what her friends are doing."
The need to fit in is no less important for the fourth graders at Public School X20,where May Chen,the pigtailed 9-year-
old,
was the center of attention one afterntoon 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 bands 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," sand Professor Suarez.-Orozco of N.X.U.,who has spent the last five years studying the
lives of 400 immigrant families,with,a focus on Asi "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,pica and chicken nuggets.
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East Meets West,Adding Pounds and Peril-New York Tunes Page 4 of 10
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 charge their menus too drastically mid 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 fiuit.
'If It Is Delicious,I Love It'
A,sweet tooth is standard equipment on any child.But the sweetness diat 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 dor her friends at
Flushing High School,she wasn't looking at nutation labels.If she had,she Wight have noticed that nearly every purchase
she considered-the how-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 cora,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
chem 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 ase 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 abi,Uity to process sugar, and can promote faster fat growth than sweeteners derived from cane sugar.
What no one disputes,however,is ftt since the advent of the syrup,consumption of all sweeteners has soared; the
average American's intake has increase about 35 percent,according to the Federal Department of Agriculture. And a
2004 stud in The American Journal o�Clinacal Nutrition showed that tb�e rise of Type 2 diabetes since X980 had c�oseiYY
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 V"V"_Ilgrants from;China because of deep-seated attitudes they
have brought with them.
In many Chinese families,it is difficult to get parents and g=dparents 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 lir. Thomas
Tsang,medical director of the Charles B. Wang Community Health Center in Flushing.
%MW
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 feast 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."
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East Meets West,Adding Pounds and Peiil-New York Times Page 5 of 10
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 find 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 nest,
however, surprised his aunt,Cindy Chen.
"McDonald's,"she said."It was one of his durst words."
Neither fast food nog television was part of the Chens' life in Suzhou,a Chinese city where they struggled to find work
before moving to Flushing four years ago.
Now Henry and his family show up at feast 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 hovers 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-arts 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,M eturers 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 Duce-portly frame looks to have shed at least 30 pounds.The box for Hem-y'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 Flares 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 ion 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.McDo d'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 crested a different problem,according to many nutnidozusfis and
public health officials.Despite a sacrad here or a lower-fat oil there,they say,the food industry has done little to change
the basic unhealtb�fulness off'its best-seling 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 Ghana are keenly receptive to such claims because the Chinese have used foods to ewe 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.Jn New York,Professor Suarez-Orozco said, immigrant parents often
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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 Dong
Kong Market, a juice box caped Vita Chrysanthemum Tea promotes itself as a health drink for children,though
nutritionally it is little different from Snapple.
Ye Zhou, a six,tb,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 dies 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 ons-third more calories,carbohydrates and grams of fat than a typical hom=ade
one.
Even before the lates* t blitz of health messages;children were confused,the Henry J.Kaiser Family Foundation said in a
2004 report on childhood obesity.Ina 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.
dor 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�reeognizing the threat posed by obesity.Ike called the industry's new sales strategies
disingenuous. "To position themselves as headers 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 xestnichons on advertising to cbitldren,similau to limits in Australia, Canada and England.They are also
concerned about the increasing use ofthe 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 Judy
in Washington, the federal Trade Coission told food and advertising executives that it favored betting the industry
Police itself
A few companies have done just that-most notably ICraft foods,which decided fast January to curb its advertising of
ceztean products, like Oreos and fool-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 hong 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 hisfavorite foods were,his mother laughed.
"Look at hirr4" she said in a matter-of-fact way,as Tim is obviously overweight. "He likes his junk."
dwi.
Time dor Gym! O.K.,Time's Up!
"Two fingers in the aix!"the teacher aides shouted at the more than 100 children squig in the auditorium seats.
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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 1030 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 sugax waiting to be bumed off.
Finally the doors opened, and the students scampered out to the playground,a parking lot zinged by achain-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 fluee had a chance before a bell summoned them
back inside for lunch.
Nay'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
a of
stay ivas�de and watch movies.
- recess and physical,education are treated like luxuries in the New York City schools. Though half the grade schooners 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 minimtun amount of physical education mandated by state
law, two bouts a week. She has a single gym cuss each week,for 50 minutes.
She is among the lucky ones.More than half the city's?00 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 gyne 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 repots 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 I 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 budgetfMphysical
education was slashed to protect other academic programs.But New York's plight is not much worse than the rest of the
country's.
Evert as the health authorities pronounced obesity a national epidemic,daily participation in gym classes dropped to ZS
percent in 2003 from 42 percent in 199 1,according to the Centers for Disease Control and Prevention. And the Bush
admuustration 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 fir=oe exercise programs that many have turned to food compaxuies dor help.McDonald's is
offering curriculums and undisclosed swans to 3 1,000 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 ate 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 ttaxee 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 groats,and several children
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were winded,but few broke a sweat.
Naz. 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
of
Bloomberg administration created the Office of Fitness and Physical education. Its director,Loi,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 progrmn by the end of this school year in every grade school with a physical education teacher,including May's.
She conceded it 'vas merely a first step. "fit 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 woticed:The Assembly actually debated
r�a
a bili 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 govenment officials, and it
was short-lived.The debate,and the bili,died in mocking laughter.
The story of that bili, known as A5664,is a lesson in the ways of Albany-and the apathy that diabetes expel 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 shaxp learning
curve. When.he was elected the previous fall-the first Asian-American voted into state office in New Rork-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 commtunity,Mr.Meng said,he
became fiwtrated with the ignorance and inaction he discovered.
In April,he organized and led the fist 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 dill would require all restaurants to prominently post the amounts of calories,fix and salt in each menu item.It was
hardly a radical notion.Many fast-food es had.already begun listing calorie counts in restaurants and on Web sites,
and months latex 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 pi�z2a
or a Starbucks cazamel 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 SS.
"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 Sflyer,iland 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
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years,it was opposed by the food industry,which contributed more than$4 million to legislative and gubematorial
campaips between X999 and 2005,according to state records.
And diabetes had hardly caught fire as a pressing health issue.The Patald 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 comp up for a full Assembly vote.But
on rune 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 W. 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:"Z 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
_ n1a],;e it to the floor of either house unless they are assured passage.Mr. Ortiz's five other bills to fight obesity had
languished in cozxmittees.
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 bili came up dor 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 Lowg 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 ow to standard menu items.
"What about the weekly specials?"Nix.Conte asked.
Laughter rose in the chamber. Daniel J.O'Donnell.,a fellow Democrat from Manhattan,kept it going. "Z watch people
who work at McDonald's,and they don't measure how much salt they put on fries,"he said. "Do you expect these 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 srna11 restaurants.
As the time for debate waned,Joel M.Millet,a Republican from Poughkeepsie,rose to state his position. "I did not
develop this physique by eating healthy,"Mr. Miller,a stout mai,said to guffaws*.-.X.colleague conopleted the joke by
bringing him a generous plate of cookies.
"The bottom line is,it is not going to matter," Mr. Miller said. "Weare fooling and deluding ourselves."
W. Ortiz made one last plea. "When-we hook 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 adds."
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.
At
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Before the tally could be completed,Mr.Ortiz stood and delivered the final word: I would like to say,with a lot of
passion,Z withdraw this bill."
Comvriaht 2006Th New York Times ComuanY Home I Priya Policy ( Search I Qrrectons I rXMLI Hemel � Contact Us ( Work for Us
1
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abetes.htxnl?pagewanted=print 1/13/2006
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In the Treatment of Diabetes,Success Offen Does Not Pay New York Times gage I of 10
1Bo&$-***rn��
nylimes.corn
January 11,2006
Bad Blood
In the Treatment of Diabetes, Success Often does Not Pay
By LAN MINA
Witli much optimism,Beth Israel Medical Center in Manhattan opened its new di&b es center in March X999.Miss
Amenca,Nicole Johnson Baker,herself a diabetic,showed up for promotional pictures,wearing her insulin pump-
In
one phots,she posed with a mean dressed as a giant foot-a comical if daze.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 teabment.They would be boot camps
for diabetics,who struggle daily.to reduce the sugar levels in their blood.The centers would teach thein 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'hype 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 chxonie
diseases like diabetes but by treating their many complications.
Insurers,for example,will open refuse'to pay$150.for a diabefic 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 M:idexmc 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 great them,"said Dr.Matthew
E.Fink,a fo president of Beth Israel.
Ten months after the hospital's center was founded,it had h orrhaized more thou$1.1 million.And the hospital gave its
director,Dr. Gerald Benistein, 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 stcugbX�ng 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 taldng pills.
Type 2,the subject of this series,has been linked to obesity and inactivity,as well as to heredity. (Type 1,which
4
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compri0
ses 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 Yorles 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 criti cal diabetes cake-because lower pay has dawn too few doctors to the specialty.And
insuxers limit diabetes benefits for fear they will draw the sickest,most exTensive 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 cage 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, "oz 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 Iszael's center bred to tum diabetic lives around from their base of operations: a
classroom and three adjoining offices on the seventh floor of Fie, an Hall,a hospital building on East 17th Street.
The stark,white-walled classroom did not hook 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 waling blood sugar was," she told therm, "axed then try to explain why itis 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 lddney failure,blindness,heart disease.amputations-a challenging sate 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.
"Mow, come ora,,"she said,ruffling the fabric of a black gabardine pantsuit she had not wom since slimmer days,years
earlier.
"Don't Yall notice 24 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
dor an interruption than a success story.
Like many Type 2 diabetics,Ms. Hanimond had been wamad 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 sown the door,until her next appointment
a year later.
"The center was a totally different experience,"Ms. Hammond said. "What they did wozked because they taught me how
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to dead 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
woks to create insulir, a hormone needed to process sugar. Why it is important to leave four fours between meals so
insulin can finish breaking down the sugar. She counted the gxams 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 Alc 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 si�ntgle-handedly
to reverse a disease with,the gaffe force of popular culture behind it.
Type 2 diabetes grows hand in glove with,obesity, and America is becom'�r�g fatter.Undoubtedly,many of these diabet"es
are often their owe worst enemies. Some do not exercise. Others view salad as a foreign substance and,life 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 brick their fmgers to test their blood several tunes 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.,
"Thin of it this way," said Dr.Berger%,"An average person spends less than.03 percent of their entire life meeting with a
cliniciau. The rest of the time they're being bombarded with all the societal influences that mace 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 speeiatisis,studies show.
0%
For those under specialty care,there is often little coordination of treatment,and patients end up Ping-Ponging between
their appointments with little sense o#'their prognosis or of how to take control of their condition.
Consequently, ignorance prevails. 0f X2,000 obese people in a X999 federal study,more than half said they were never
told to curb their weight,
fewer than,40 pement of those with newly diagnosed diabetes receive any follow-up, according to another study.In New
York City, officials say,newly 9 out of 10 diabetics do not know their A I c 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
&*& 0
accessible and adequate health care,most diabetics suf�ex senus complications that could have been prevented.
M
This grim reality persuaded hospital officials in the 1990's to by something different. The new centers would provide the
tricks for changing behavior and the methods of tracking complications that were lacking from most tate.
Instead of having noshed conversations with harried p rimary care physicians,patients would discuss their weights and
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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,directoTof 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 dian 60 percent of the
center's patients'
who were tested had their blood sugar under conizol. 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 lik-e we had momentum," said Jane Seley,the center's nurse
practitioner. "end it wasn't backwards momeiztum."
Failure for Profit
From the outset, everyone knew diabetes centers were financially risky ventures.That is why Beth Israel took a distinctive
approach before sixang$1.5 million into its plan.
0
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 hospitaYs fo president.
The other centers that opened took similaz precautions.
The St.Luke'swJoslin 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 rats the center.
Mount Sinai Hospital's diabetes center hired an accounting fim to calculate just how many bypass surgeries, lam
cra1 �and other profitable procedwres the center would have to send to tlae hospital to offset the cost of keeping the
center running,said Dz.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 asprofitable as acute care
because insurers,and consumers,do not want to pay as much for care that is not urgent,according to Dr.Amold 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 toad,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,here is less willingness to pay,which undercuts prices and profits,
Dr.Milstein explained.
"There is a lesser sense of mann,associated with slow-moving threats,so prices and profits dor 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 marguial 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 moneymalc4uag surgeries."
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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.
Mn 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 threesinch plastic monster with a puff of fluorescent hair.Mx.13errie took more than$20 m
I 'd*
Troll 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 amillion-doll.ar grant from a company that males 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'cuter 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 fo er 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 lawyand 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 wkht it cost to have me to do the paperwork to get the reimbursement," she said.
Beth Israel was not alone in this predic ent.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,tWs 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 refixed 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 Haat analyzes their sugar levels.
Each stip 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.
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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,Mx. 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 Nor. Schonfeld's doctor,Dr.Goland. She held up a manila folder thick
with letters that she had sent to his insurer explaining Mr. Schonfel&s case.Nor. Schonfeld had his own pile of letters: the
0
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 night.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-tisk case than Sidney,"Dr. Goland said.
"hough 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 thein supplies.
In Indiana,hospital workers organized Diabetes,Ringo 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 stoles test strips and sullies.
In fast Harlen-4 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 scare 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 S'maaSchool off'Medicine, "that
patients who could not afford the strips for them blood monitor were buying cheaper strips that were incompatible and that
were giving false reads.'
At feast they knew they had the dis=e. 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 kmown 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 hirci to start walking two miles a day,he did that,too.but her instructions to test his blood at feast twice a
day were not as easy to follow.
W. Schonfeld runs out of strips even though he tries to plan ahead by ordering extras,said Kathy Person,his nurse. "The
insuarance 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 Centex has afull-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.
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Although a recent federal study found that an increasing number of health insurers coven 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.
Oil was a businessman for more than 40 years," said Mac. 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 toms 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,during 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 choke 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 foix er urance 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 dear they
will attract the chronically ill.
In a 2003 survey, 87 percent of health inswrance actuaries queried by Mr.Xnutson said that if they were to ianprove
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.Largs employers,many of which devise and finance their own employee health
plans,know that their allotted reserves are j eoparclized if too much of their work force is seriously ill.Last year,for
example, aural-Mart executive suggested in an internal memo that the company could reduce costs by discouraging
unhealthy people from applying dor work.
Even when urers are simply third-party admuustxatozs,processing claims but not covering the actual medical expenses,
they try to keep claims down by attracting healthier patients to their plans,I*.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 tb,euc health care through private
health maintenance organizations that operate under govermnent 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.
dor 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.hoz each additional session of nutritional
counseling,he said,an insurer must account for the likely cost of luring sick patients away from its competitors.
Mir. 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 tympany found that two-thirds
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off'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,"Mac.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 cake 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 stip 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 scare money savers for health insurers since they might eliminate or
forestall expensive diabetes complications down the goad. But many insurers do not think that way.They figure that
• complicadons 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 bait.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 uxance about evexy six years.
"It's perverse," W.Knutson said. "But it's the reality of there being a wear business case for quality when it comes to
handling chronic care."
'Jerry,We Meed 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 Tan.41,2000,he had a bounce in his step,and it Look him Half that time,he recalled.
He had a good stony 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 tum 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 adrniaaisbrators explained that the hospital was ruining 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 bee n 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
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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 stzil.+;e of lightning.They had come to Dr.B ernstein 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 overwb,eLned clinks; general practitioners with too little tne; 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 dower-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,meedles.
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 deny in this epidemic," Dr.Bernstein said. "The inhaler is a promising
breakthrough.but its 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,phan=eutical tympanies have
good reason to focus they attention on the more than$10 billion market in controlling the disease's complications.
But thew is only so much the drugs can do, they add,if they are not accompanied by the soil 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 AmericaB 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 fries7)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 reixnbwsent 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 oare. Even with then demise,many hospitals,clinics
and endocrinology practices say they are providing cost-effective,quality treatment
"?he care we provide now is on the pax with what was offered before,"said Dr.Leonid Poretsky,who became director of
Beth Israel's endocrinology division after the diabetes program closed. "Themain difference is that we are financially
viable because half of our patients are not diabetic."
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These facilities,though,often fund fhexnselves 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 foer 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 bead 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 goys to the podiatrist once a year,but
she said she could not ren ember 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 monaings 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.
-------------
Couyright 2006The New York Tlmes CompHome Privacv Policv ( Search ( Corrections � �XM L f Helo � Contact Us Work for Ua
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ffile ft. ork 6 m
nytimle$.coren
January 10,2006
Bad Blood
Living at an Epicenter of Diabetes, Defliance and Despair
By N.R.KLETNETELD
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 spealzng.He confurned 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 ftiends.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 fast Harlem, it is possible to take any simple nexus of people-the line at an A.T.M.,a portion of postal
route,the members of a church choir- and trace an invisible web of diabetes that stretches through the group and out mato
the neighborhood,touching nearly every life with its menace.
Mr. De La Vega, a 33-year-odd self--styled"sidewalk philosopher" whose murals and sidewalk chalk drawings are familiar
neighborhood oxnatnents,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 fonn. 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 all comforts:a piece of cake,a couple of beers, a
daybff from sticking oneself with needles.
That behavior is all the.more evident.in fast Harlem,,a tty 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 Last 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,fast 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 ppidemig,a place where,as health officials warn of a worsening crisis,you
can see the ruins the disease has already wrought.
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Most of the afflicted people in East Harlem have'ape 2 diabetes,the focus of this series,which has been linked to
obesi 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 dei Barrio,which celebrates Latin culture. Early on,it was the repository of Russian Jewish,Irish and Italian
i�unigrants,congealiuc�g into the city's hub of Italian liFe; after World War II,a Puerto Riean�influx converted it into
Spanish Harlem.
Recently,there has been an uptick in Mexican,Domimcan and Asian arrivals.,and stirrings of gentrification. But the core
population that has been its ballast for ahalf-century is being eroded by forces as powerful as real estate values and
immigradon waves: a deviously complicated disease,poverty and simple human frailty.
'Then Z Started Cheating'
The sun was piercing,and the light banged off the side of the art shop.The air was stippled with fragrances of dried meat.
� Crammed inside the elaustrophobic interior were assorted pftv A&A&A, S,decorated mugs,greeting cards and other oddments.
Elsie Matcys,Mr.De La Vega's mother,sat out front,her dark bair 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,Wane 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-sugai reading was nearly trifle the 126 milligrams per
deciliter that defines the illness.
She was no stmge.r 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 died this for brochures; and he scattered chalk drawings across the
sidewalks of East Harlem,depicting his barefbot 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 mss.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'hex to skied 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 cage.I didn't think it would matter."
She was put on pills. Those who have diabetes usually suffer from related conditions,especially high,blood pregM and
high cholesterol., and often swallow 3 to 10 pills a day.Ms. Matos had high cholesterol and asthma.
She was warned that she bead to control her lust for calorie-rich food,that taking pills was not enough.Doctors like to say
that patients can eat thein 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 1,65 or 170 pounds, still too much. "The doctor said it I didnt,diet,
I'd have to take the insulin,"she said."I don't want the needle."
got
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 roux tunes a day to check their
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blood sugar,keeping a log of the results,and then adjust their eating habits according to the readings. Bloodr-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,ahalf-hour of daily exercise and the loss of as little as 10 to 1.5 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 g=anteed 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 HJN•, 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 tuxes 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 fxom all the needles,"he said.Lately,she had
been in the hospital more than out.
Mz.
Rivera,after a back injury,quit los 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 be 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,bus father died of diabetes. "He kept kin sugar,"Mr. Concepcion said. "He kept drinking
bier.He was a stubborn guy. They cut one leg at the ankle.Then they took the ether above the kmee.pi
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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. Soroking is especially bad for diabetics. "1
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 males me dose 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. Z drank- 15 or 20 beers in a
night.of
... •He had been avoiding his druIdn1g 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,thence is a great range in response to the disease:some diabetics embrace the daily regimens that now
fiame 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
WCk cosmic joke-that diabetes was too much to master at the individual level in a world that had become so hospitable to
�t.
Mir'. Concepcion said: "Everything about this neighborhood,the pollution in the air,it all makes you sick.Don't get me
wrong,we dove this place,we love Spanish Harlem.But it does stuff to us.Now its giving us all diabetes."
e
W. De La Vega nodded. "We dove eating trash,"he said. "We grew up eating McDo d!s, and I still find myself eating
candy and chocolate cake."
People got huffy about their doctors. "Mane tells me, 'Lose weight,exercise more,'"Nis. Matos said. "Let him live my life
and.see."
Mir.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."
Nor. Concepcion tubbed his forehead.."Since I got the diabetes,maybe twice a week Y 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."
Nix.Rivera bathed Naz.De La Vega with an odd hook: "Did Mike have diabetes?The guy who passed away?"
W. De La Vega said,"Yeah,he had.it"
"die was,like,3 00 pounds."
"He would brag about eating a pint a 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-fowr."
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Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 5 of 10
"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 moaning rain.Has zeal name was Luis
Hemandez. His job was route supernisor for a pro.duce 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 hook at a paper and it was like 3-D vision;one rooming he woks up and
one eye wouldnft focusm 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 tom between two T-shirts.,
Yes,Ms. Calderon had it,too. Seven years since the diagnosis. She was 69. She was 2 10 pounds,and had been told to
dose weight. "I didn't think it was important,"she said.
Then,naoace than.a year ago, a solution presented.itself,and it was the worst Idnd.Her grandson was killed in a holdup
over a car.
a
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 whew you're going to live next week?" she said.
Shy watched Ms.Gatos help the customer. "We are the poor people," she said. "We only get the crumbs.I used to
advocate a dot. I got tired.I doWt 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 everyting else.She takes 52 pills a day. She has everything in
the book.When she calls, she wants to talc for 99 hours.I say:'may sister's calling.I've got to get off.'"
NJs.Matos said: "What,52 pus?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 week5 ago,Z got all messed up.You know
why?I've got two machines.One gave me a reading of 150.The othEx machine gave me 13 0. 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 zeal
truth. And you know what?You never find out the real txuth."
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Living at an Epicenter of Diabetes,Defiance and Despair New York Tunes Page 6 of 10
He went home, a wuple of blocks away,to take ablood-sugaz reading.He opened a lway 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 wallCing. Z don't know,I was going to do the
cleaning."
- A Geography Lesson
A few things to nonce. On Third Avenue,around the comer from the art shop,a banner outside McDoaald's proclaimed,
"$I 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 eat-shop gatherers sometimes talked about 96th Street,the tangible southem divide of a neighborhood and of a
disease.Go north of 96th Street and you enter a constricted word laden with poverty.Go south and you find promise and
riches,thin not fat,the difference between East Harlem and the Upper Fast Side,the difference between illness and
health.
Go north and the chances of bumping into a diabetic are maybe 20 tunes 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 thea pills,cut them in half and take half-dosages. They improvise. Everywhere blare the sigmas that the best meal is
the biggest meal.
Nutrifious 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 duet soda,low-fat or fat,-free naik high.,fiber bread,fresh fruit and fresh vegetables in food
stores in East Harlem and the Upper East Side,,
9
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 z y food stores per capita as its wealthier neighbor to
the south.
Diet on the Down,Jow
All the same,it was wortb,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 be and chicken.The women can't be chumps,either.A woman can earl a salad but has to eat it
on the how. She has to do it quiet. They make fun of you:What are you, a rabbit?"
What's wrong with an ormge?
Mr.De La Vega said: "Oranges arc.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 c�enge behavior,particularly in an overwhelmed neighborhood.Chocolate
cake may be a risk, but it tastes so good on a bleak day. What stops ftt?
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Living at an Epicenter of Diabetes,Defiance and Despair-New Yofk Times Page 7 0f 10
Mr.De La Vega said: "people ultimately feed 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 tali 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."
"Z have two nieces," Ms.Matos said. "They're 24.I call them the swno 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.Y had two today."
His mother said,"If you drink a diet soda and a man is watching,he'll say,'Why you drinking that?' "
Mx.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.'Mat's the way we grow up here."
Mx.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 somtetking."
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 pnrolIed 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 u us 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.
1#0
Doctors had been hectoring her for years,saying that if she didift,lose weight she was going to end up with diabetes. But
she didn't feed sick. She wasn't worried about what nought 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: "Z waist her to go live with her father and have him knock some sense into her-literally."He, too,
had diabetes.
Xiornafiz didn't mind her weight. "I feed my weight makes me look like me," she said. "So I don't have to look like those
sldnny 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. "Z know you can't pass it like Idssing 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.
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Living at an Epicenter of Diabetes,Defiance and Despain-New York Times Page 8 of 10
Was she wozxied about her diabetes?
She moved her head from side to side. "Sometimes Y forget Y have it," she said.."It's not that big a dead."
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 pact of the decor.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 laundxy and as a security guard,until be had a heart attack.
He plopped down onto the brick ledge beside the art shop. "I'm Iduing time,"he said.He gave a craggy glin.
He settled his walker before him. "The circulation is no good in my legs,"he said.He rubbed them.
Ele unabashedly admitted that good management of his diabetes often seemed like a drama of grand futility. "I gat 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, Y 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 Flares.What can Z say?I like theme.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 insuI4 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,"be said.
He bore a visible scrape on his left ann.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 ann.lie showed another nnark on his right arm and one above his eye.
"The other day, 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.Z don't remember."
He used to keep a dog of his readings,but quit.Why?
"I don't know,"he said."So many dfings you have,to do. It gets boxing."
A mariachi band arrived in the garden and began to play.IS4r.Alicea and the others taped their feet.
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Living at an Epic-enter of Diabetes,Defiance and Despair-New York Tunes Page 9 of 10
As New York got ready for its evening routines,Mt.Alicea tired,his eyelids sailing down,and he xetuarned to Ips two-
room apaTtzaent across the street. His furniture was plain.Bare bulbs protruded fiom the ceiling.Mx. Alicea shared the
place with his oder 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. "de's dike 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.Pedxo didn't go out zan;uch.No
scale was needed to judge that he was obese.He watched TV,one more soap.
A,home attendant helped care for theme. She had dinner on the stove, cream of tomato soup.The dining table was shoved
against the walk. Resting on it was a box of com 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 tallying 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 di "Theyabetes complications. "They told nae about dietand exercise," he said. "But you're a young man,and you don't listen.I didn't take it very seriously."
s
He had no insurance,either,and so he took his medication when he could afford it,tested self when he could afford it.
He got a drink.Fle waked 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 be ally got to see a doctor,the
toe had to be removed,along with two others.The infection spread,and he lost the final two.
"Ali 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 woxkxng properly.You don't have feel."
He was wozfied about his vision, An axtitst without eyes,that was tough to imagine.He mentioned a sad case,a jazz
drunmer 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 birn,because he expected never to pay it off in this lifetime,
but at the same lime 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 paid6fiff premiums.
"You male choices,"he said. "Instead of buying sneakers,you stay with what you're wearing.I've got to stay ahead of the
blade." 06
He massaged his leg.Diabetics,often with subdued fee g in their begs,don't realize they have cuts until irreversible
infections sit 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-
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clipping mishap can escalate into an amputation.
Five toes gone,Mr. Salicrup didn't wane 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:dere he was,a
grown m.an,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 miiati was selling
Gillette razors out of a backpack: $7. Interested,Santos Alicea dug out some bills and took one.
Mx.Alicea mentioned that another diabetic had died the other day.A massive heart attack, and the man became one more
diabetes ghost to haunt the neighborhood.
Elsie Matos was displeased with her blood sugar.It was mercilessly high.
- Raul Rivera, wearing a smudged T-shirt,began watering the garden's plants, swishing the spray back and forth. How was
his naother?.Bad,he said.Very bad.
Bigwig said that he had shed some weight,was getting used to one-and-a-half spoonfuls of sugar on his aona flares
instead of dour.But also,he had stopped taldng his diabetes pills ,not wanting to get too used to them,,not knowing if that
was night or wrong.
James De La Vega's art shop closed at the end of August.Word arrived that the space would become ahot-dog place.Mx.
De La Vega moved down to the East Village.
The regulars frowned on the displacement. "Just what the diabetics need,"Ms. Matos said. "Hot doffs."
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J HN-24-200b 10:
C A L I F 0 R N i A
SINCE
IQD$
ASSOCIATION
January 24,2006
Contra Costa County Board of Supervisors
Supervisor Nark DeSaulnier
2425 13isso Lane, Suite 110
Concord, CA 94520
RE: Item #D.2 - Reciuest for Continuance,
Dear Super-visor DeSaulnier,
On behalf of the California Restaurant Association, r am asking for a continuance of the
above item. The California restaurant Association is the largest and longest serving non-
profit restaurant trade association in the nation. Representing the restaurant and hospitality
industries since 1906, CRA is proudly made up of more than 22,000 foodservice
establishments in the Goldin State.
The restaurant industry has a Longstanding commitment to promoting healthy
lifestyles, which can be best obtained through balance and moderation in diet,
combined with physical activity. Healthy options have always been available on
restaurant menus everywhere. Although 76 percent of meals are eaten at home, when
individuals do tine out, California's 81,000 restaurants are responding to consumer
demand with ex-ren more menu options.
The California Restaurant Association was not made aware of this study and would
Tike to participate in the hearing as well as work with the Board of Supervisors on an
issue that is very important to our association.
For these reasons, we respectfully request a continuance of this item.
Thank you dor your consideration.
Sincerely,
Johnnise Foster Downs
Director of Local Government Affairs
California restaurant Association
CC: All members of the Board
TOTAL P.��
CALIFORNfA
ASS OC«T10N
70: Clerk of the Board From: johnnise Faster Downs
Luca!Government Affairs Director
Californio Restaurant ASsadCltion
Phone:946.431.2720
Fax.:416.447.6182
Idowns@calrestorg/
www.calrest.orq
Fax: 925.335.1913 Pages 2
(Induft Cave
Phone: 925.335-1900 Date: 1124l2006
Re: item Q.2--Request for a Continuance CC:
D Urgent El For Review D Please Comment ❑Please Reply CJ Please Recycle
92nfi.dentiality Note. This facsimile transmission contains information from the California Restaurant ASSOGation that may
be confidential or privileged.The information is intended to be for the use of the individual or entity named above. If you
are not the intended recipient, please be aware that any diSClosure. Copying,distribution or u52 4f the Contents of this
information is prohibited. If you have received this electronic transmission in error, please immediately notify us by
telephone at(800)765-4842- Thank you.
• Comments:
pear Clerk of the Board
Attached is a letter tO the board of Supervisors requesting a continuance for Item D.2 directing the
Health Services Department to establish a comprehensive program to combat childhood obesity.
Thank you for your consideration.
Please feel free to call or send an email with any questions.
;ahnnise Foiter Downs
Local Ojovertimer+t Affairs Director
California Restcxuratit Association
Phone:916.c131.2T20
Fax:916.447.618Z
jdowns@calrest.org 1 www.calrest.org
I i
ADDENDUM TO ITEM D.2
January 24, 2006
On this day, the Board of Supervisors considered directing the Health Services
Department to establish a comprehensive program to combat childhood obesity, and
taking related actions.
Supervisor DeSaulnier introduced this item,noting that he will include three more
recommendations at the advice of Chair Gioia. 1) Direct Family and Human Services to
respond to all recommendations and 'identify costs associated with this proposal,with a
condition that no General Fund money is used; 2)Refer to the Public Health Advisory
Board for comments and suggestions and 3)Refer this item to the Youth Commission for
comments and suggestions.
Supervisor DeSaulnier said he and his staff would work with Drs. Wendel Brunner and
William Walker to coordinate and provide information to school districts within Contra
Costa County.
Dr. Wendel Brunner,,Director of Public Health,made the point that additional funding
will be available through grants from other organizations for these types of programs.
Supervisor DeSaulnier advised he would meet with Dr. Richard Jackson, former Public
Health Officer for the State of California, again on February 2, 2006 to see how Contra
Costa County could be involved in this proposal.
Dr.Walker stated the goal of the program was a major initiative for the County not only
to include obesity,but also diabetes and other health disparities. He noted that diabetes,
mortality and morbidity impact the Latino and African-American populations in Contra
Costa County. He went on to say if the County could get a strategic plan together they
would be in line to do this with outside funding, and not utilize County General Fund.
The Chair asked for public opinion and the following people spoke:
Kathy Lafferty, Cambridge Community Center, said obesity is a critical issue for
children and emphasized the importance of parent education;
Ken Hambrick,resident of Walnut Creek, said this is not a concern the Board
should be addressing and suggesting leaving this issue to parents and schools;
Jack Weir,,resident of Pleasant Hill, said it is time for the Board of Supervisors to
concentrate on getting their fiscal house in order;
Blanca Campos, Concord resident, said she is proud of the program Cambridge
Community Center offers and said that serving healthy foods will not break their
budget. She hopes the County will provide more funding and other resources.
Ms. Campos urged the Board to encourage the WIC program to provide healthier
alternatives;
Addendum to D.2
January 24, 2006
Page 2 of 4
Ken Lee,noted that some"fast-food"options are healthy foods;
Bonnie Wolf, described seeing children with diabetes and said she is thankful the
Board is initiating this program;
Roland Katz,,Public Employees Union, Local 1 encouraged the Board to move
forward with this proposal as it has the support of both Doctors Walker and
Brunner.
Supervisor Piepho said she understands the referral to Family and Human Services
Committee but has concerns about the cost. She elaborated that the Board Order
describes promotion, coordination,provision,research and evaluation, and said these are
all tasks that County staff maybe expected to provide and fulfill, Supervisor Piepho said
she agrees with the importance of this issue but expressed concerns about associated
costs. She referred to a letter from the California Restaurant Association expressing their
concerns and suggested including them either by direct invitation or by making them
aware of when the committee meets. She also said this proposal could have an impact on
small businesses and fast-food restaurant franchises in the County as well as the jobs they
provide to constituents. Supervisor Piepho noted working with the schools is a valuable
partnership. She also suggested partnering with Contra Costa Television. Supervisor
Piepho encouraged leverage of funding sources but does not think it should be done to
the exclusion of current services the County is strained to provide. Supervisor Piepho
said the cost estimate should be evaluated before returning to the Board.
Supervisor Uilkema said to limit the number of fast-food restaurants within the County
may be a land use, zoning and a general plan amendment issue and suggested that this
matter be referred to Community Development for their response. Supervisor Uilkema
said she would like to see greater involvement not only with the Restaurant Association
but also with the Chambers of Commerce within the County. She suggested staff work
with schools to develop healthier cafeteria lunches; encourage restaurants to print
ingredients; and help parks and recreation sites cut contracts with junk food and soft
drink distributors in favor of more healthy alternatives. She conceded the proposal needs
to be refined to get to a point where the goals are clearly identified. She commented that
federal meal programs have standards already, saying, "If we are already qualifying for
programs then I would like to know how it interrelates with this or what changes are
going to be made within the meal program that we currently have available, to assure the
federal funding that is part of this proposal is something we can tap into." She expressed
concern,that she does not wish the County to be precluded from grants or in any way be
prevented from accessing the funding the County already has. Supervisor Uilkema
referred to recommendation Number 9 and said"We are asking the Health Services
Department to provide technical support and support for school districts. I would like to
II
Addendum to D.2
January 24, 2006
Page 3 of 4
know whether the Health Services Department has the resources to do this and I would
also like this directed to the Contra Costa Health Committee where two members of this
board serving on that committee could find out the inner relationship between CCHP—the
Health Plan and the HSD and whether any of our efforts are going to be diluted."
Supervisor Uilkema said the County needs a strong financial foundation to help promote
issues such as this. Supervisor Uilkema suggested the Committee return to the Board
with defined responsibilities of the school district, including how they would contribute
to the funding and the training. Supervisor Uilkema said she did not want to dilute the
workforce tasks or lose focus. She suggested the Retail Association be involved, and
requested an estimated cost for carrying out such a program. Supervisor Uilkema said
her final recommendation would be to see available grants for programs and the
likelihood of achieving those grants so the proposed program could be implemented
without any impact to the General Fund.
Supervisor Glover said he understands the fact this proposal is going to a committee and
thinks some refinement within those recommendations are something that he would like
to work on. He went on to say he recognizes the fact no General Fund would be used in
terms of this effort. Supervisor Glover said one of the County's core responsibilities is to
provide health care and went on to suggest partnering with other agencies through health
care and through corporate America to work together to combat the problem. He added
"If we think about the money the County uses for treatment each year with the various
diseases that are contracted because of obesity I think it is proper that this Board starts to
take a look at that particular problem." Supervisor Glover said he is confident that
through the leadership of Drs. Walker and Brunner the County will come up with some
partnerships to address this problem that could also lessen costs for treatment of various
diseases.
Chair Gioia stressed it is important to remember most of the County's health issues are
related to nutrition and diet and advised that this is a role of the Public Health
Department. Chair Gioia added all the recommendations in this proposal will be
researched and evaluated by Family and Human Services, and felt confident that this is
the best way to approach this. He pointed out he would not support or approve any item
before the item is thoroughly analyzed with plenty of opportunity for public input.
Chair Gioia explained the role of the Public Health Department is to educate and spoke of
the former Public Health Officer for the State of California Dr. Richard Jackson who
continually talks about saving taxpayers billions of dollars by addressing the issue of
obesity in the early years by educating the public. He went on to say the taxpayers in his
District agree this proposal is an investment. Chair Gioia said he met with the Regional
Director of the United States Department of Agriculture who suggested increasing food
stamp availability increases people's nutrition,health and education. He noted his
intention in seeking the funding that exists and concurred the Board should be conscious
Addendum to D,,2
January 24, 2006
Page 4 of 4
of the County's fiscal situation but reiterated this should not exclude the County from
spending time on worthy issues, and said he would support the proposal.
Supervisor Uilkema suggested adding CEWA, the California Elected Women's
Association at the state level and reported they have had made several recommendations
throughout the state. She thinks this would be a good reference.
Supervisor Glover announced there would be a Youth summit taking place within the
next month or so,, and said he feels this would be a good workshop for the Youth summit
to take on.
Supervisor DeSaulnier made a motion to incorporate all the Board members concerns.
He noted as a member of the California Restaurant Association(as a restaurateur) for the
last 30 years, he is sensitive to the issues around food service and the hospitality industry.
Supervisor DeSaulnier said he agrees with Supervisors Piepho and Uilkema about
including to include the California Restaurant Association in the recommendations, and
commented the restaurants can be part of the solution and not the problem. He said we
should be sensitive to our budgetary issues but, on the other hand, this epidemic will cost
both nationally as well as our County. Supervisor DeSaulnier made a motion to include
all the recommendations and incorporate the comments of all the Supervisors including
the outreach to communities suggested including the California Restaurant Association,
the Chambers of Commerce and the California Elected Women's Association and to be
specific that it should incur no new net County cost to any Department, either
Community Services,Health Services or Public Works.
Chair Gioia noted the referrals to Family and Human Services,the Public and
Environmental Health Advisory Board, the Youth Commission and the California
Elected Women's Association,with the inclusion of no net County cost and incorporating
as some guidance the comments of the various Supervisors. He noted there would be
plenty of opportunity for further discussion there and when it comes back to the Board.
The Board of Supervisors took the following action by unanimous decision with none
absent:
REFERRED recommendations one through nine on Board Order to: Family and Human
Services, Public Health Advisory Board, the Youth Commission, and the California
Elected Women's Association for their comments and suggestions; DIRECTED that this
proposal should not cause the County to incur any new net costs, and DIRECTED this
item be returned to the Board for a review of committee comments and suggestion.