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HomeMy WebLinkAboutMINUTES - 01242006 - D.2 TO: BOARD OF SUPERVISORS 8E L FROM: Mark DeSaulnier Contra Costa DATE: January 24,2006 ., SQA COUTT- County SUBJECT: Child Obesity SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATIONS I. 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 to 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. CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER � SIGNATURE(S): ACTION OF BOARD ON PPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE ANIMOUS(ABSENT AND CORRECT COPY OF AN ACTION TAKEN YES. NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS OWN THE DATE SHOWN. ATTESTED JOHN SWEETEN,CLEI$0 OF THE B J ARD OF S ERVISORS AND COUNTY ADMINISTRATOR Contact: cc: BOS / CAO BY ,DEPUTY 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 after-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 to prevent and treat childhood obesity. DIRECT Health Services to provide or refer patients to appropriate health education programs. S. 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 the 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. j I 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. i 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. I 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. 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; Ken Lee, noted that some"fast-food"options are healthy foods; Addendum to D.2 January 24, 2006 Page 2 of 4 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 may be 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 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 Addendum to D.2 January 24, 2006 Page 2 of 4 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 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. Addendum to D.2 January 24, 2006 Page 2 of 4 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: REFER recommendations one through nine on the Board Order to the Family and Human Services committee for further study and report back to the Board of Supervisors. Further ADDED the following recommendations: 1)DIRECT the Family and Human Services Committee to respond to all the recommendations and identify any costs associated with the proposal; 2) REFER the recommendations to the Public Health Advisory Board,the Countywide Youth Commission, and the California Elected Women's Association for their comments and suggestions; 3)DIRECT that any recommendations for action to the Board of Supervisors should not result in any new net County cost. Jan -l3 - 2006 2:53Alm' SUPERVISOR MARK DE SAULNIER No.0454 P . 12 Diabetes and Its Awful Toll Quietly Emerge as a Crisis -New York Times page 1 of 9 O N&Rprk dimer; nyti.m.es.cdm January 9,2006 Bad Blood Diabetes and Its Awful Toll Quietly Emerge as a Crisis By N.R.KLEM-FIELI) 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,comer room: a middle-aged man sprawled,recuperating from ait l .Next door: nerve damage.Eighth floor,first room to the left. stroke. Two doors down: more toes being removed.Next room: a flawed heart. As always,the beds at Montefiore Medical Center in the Bronx were filled with a universe of afflictions.In truth, these assorted burdens were all the work of a single illness: diabetes.Room after room, floor after floor,diabetes. On any given day,hospital officials say,nearly half the patients are there for some trouble precipitated by the disease. An estimated 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 gpidgmic.Diabetes is the only major disease in the city that is growing,both in the number of new cases and the number of people it kills.And it is growing quickly,even as other scourges like heart disease and cancers are stable or in decline. Already,diabetes has swept through families,entire neighborhoods in the Bronx and broad slices of Brooklyn,where it is such a fact of life that people describe it casually,almost comfortably, as"getting the sugar" or having"the sweet blood." But as alarmed as health officials are about the present,they worry more about what is to come. Within a generation or so,doctors fear,a huge wave of new cases could overwhelm the public health system and engulf growing numbers of the young,creating a city where hospitals are swamped by the disease's handiwork, schools scramble for resources as they accommodate diabetic children, and the work force abounds with the blind and the halt. The prospect is frightening,but it has gone largely unnoticed outside public health circles. As epidemics go,diabetes has been a quiet one,provoking little of the fear or the prevention efforts inspired by AM or lung cancer. In its most common form,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 truly W. Yet a close look at its surge in New York offers a disturbing glimpse of where the city, and the rest of the world, may be headed if diabetes remains unchecked. The percentage of diabetics in the city is nearly a third higher than,in the nation.New cases have been cropping up close to twice as fast as cases nationally. And of adults believed to have the illness,health officials estimate,nearly one-third do not know it. One in three children born in the United States five years ago are expected to become diabetic in their lifetimes,according to a projection by the Centers for Disease Control and Prevention.The forecast is even bleaker for Latinos:one in every two. New York,perhaps more than any other big city,harbors all the ingredients for a continued epidemic.It has large http://www.nytimes.com/2006/01/09/n,vregion/nyregionspecial5/09diabetes.html?pagewauted=print 1/13/2006 Jan . 13 . 2036 2:54AM SUPERVISOR MARK DE SAULNIER No•0454 P . i3 Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times Page 2 of 9 numbers of the poor and obese,who are at higher risk.It has a growing population of Latinos,who get the disease in disproportionate numbers,and of Asians,who can develop it at much lower weights than people of other races. It is a city of immigrants,where newcomers eating American diets for the first time are especially vulnerable. It is also yielding to the same forces that have driven diabetes nationally: an aging population,a food supply spiked with sugars and fats,and a culture that promotes overeating and discourages exercise. Diabetes has no cure.It is progressive and often fatal,and while the patient lives,the welter of medical complications it sets off can attack every major organ. As many war veterans lost lower limbs last year to the disease as American soldiers did to combat injuries in the entire Vietnam War.Diabetes is the principal reason adults go blind. So-called Type 2 diabetes,the predominant form and the focus of this series,is creeping into children,something almost unheard of two decades ago.The American Diabetes Association says the disease could actually lower the average life expectancy of Americans for the first time in more than a century. Even those who do not get diabetes will eventually feel it,experts say-in time spent caring for relatives,in higher taxes and insurance premiums,and in public spending diverted to this single illness. "Either we fall apart or we stop this," said Dr.Thomas R.Frieden,commissioner of the New York City Department of Health and Mental Hygiene. Yet he and other public health officials acknowledge that their ability to slow the disease is limited.Type 2 can often be postponed and possibly prevented by eating less and exercising more.But getting millions of people to change their behavior,he said,will require some kind of national crusade. The disease can be controlled through careful monitoring,lifestyle changes and medication that is constantly improving, and plenty of people live with diabetes for years without serious symptoms.But managing it takes enormous effort.Even among Americans who know they have the disease, about two-thirds are not doing enough to treat it. Nearly 21 million Americans are believed to be diabetic, according to the Centers for Disease Control,and 41 million. more are prediabetic; their blood sugatt is high,and could reach the diabetic level if they do not alter their living habits. In this sedentary nation,New York is often seen as an island of thin people who walk everywhere.But as the ranks of American diabetics have swelled by a distressing 80 percent in the last decade,New York has seen an explosion of cases: 140 percent more, according to the city's health department.The proportion of diabetics in its adult population is higher thaa that of Los Angeles or Chicago,and more than double that of Boston. There was a pronounced increase in diagnosed cases nationwide in 1997,part of which was undoubtedly due to changes in the definition of diabetes and in the way.data was collected,though there has continued to be a marked rise ever since. Yet for years,public health authorities around the country have all but ignored chronic illnesses like diabetes,focusing instead on communicable diseases,which kill far fewer people.New York,with its ambitious and highly praised public health system,has just three people and a$950,000 budget to outwit diabetes, a disease soon expected to afflict more than a million people in the city. Tuberculosis,which infected about 1,000 New Yorkers last year, gets $27 million and a staff of almost 400. Diabetes is"the Rodney Dangerfreld of diseases,"said Dr.James L.Rosenzweig,the director of disease management at the Joslin Diabetes Center in Boston,-As fresh cases and their medical complications pile up, the health care system tinkers with new models of dispensing care and then forsakes them,unable to wring out profits.Insurers shun diabetics as too expensive.In Albany,bills aimed at the problem go nowhere. "I will go out on a limb,"said Dr.Frieden,the health commissioner,"and say,20 years from now people will look back http://www.nytimes.com/2006/01/09/nyregion/nyregionspecial5/09diabetes.html?pagewanted=print 1/13/2006 Jan - 18, 2006 8 :54AM SUPERVISOR DRK DE SAULNIER ho•0454 P, 14 , Diabetes and Its Awfiil Toll Quietly Emerge as a Crisis-New York Times Page 3 of 9 and say: 'What were they thinking?They're in the middle of an epidemic and kids are watching 20,000 hours of commercials for junk food.'" Of course,revolutionary new treatments or a cure could change everything. Otherwise,the price will be steep. Nationwide, the disease's cost just for 2002-from medical bills to disability payments and lost workdays-was conservatively put by the American Diabetes Association at$132 billion.All cancers,taken together,cost the country an estimated$171.billion a year. "How bad is the diabetes epidemic?" asked Frank Vinicor,associate director for public health practice at the Centers for Disease Control. "There are several ways of telling.One might be how many different occurrences in a 24-hour period of time, between when you wake up in the morning and when you go to sleep. So,4,100 people diagnosed with diabet_s,230 amputations in people with diabetes, 120 people who enter end-stage kidney disease programs and 55 people who go blind. "That's going to happen every day,on the weekends and on the Fourth of July,"he said. "That's diabetes." - One Day in the Trenches The rounds began on the seventh floor with Iris Robles. She was 26,young for this,supine in bed.She wore a pink "Chicks Rule"T-shirt; an IV line protruded from her arm.For more than a year,she had had a recurrent skin infection. The pain overwhelmedher.Then came extreme thirst and the loss of 50 pounds in six weeks. In the emergency room,she found out she had diabetes. She was out of work, wanted to be an R&B singer,had no insurance.It was her fourth day in Montefiore Medical Center.Her grandmother,aunt and two cousins have diabetes. "I'm scared,"she said. "I'm still adjusting to it." Next came Richard Dul,watching news chatter on a compact TV.Now 64,he has had diabetes since he was 22.A month before,he had a blockage in his heart grid 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 21 st straight day in the hospital. Here, then,was the price of diabetes,not just the dollars and cents but the high cost in quality of life. Simply put,diabetes is a condition in which the body has trouble turning food into energy. All bodies break down digested food into a sugar called glucose,their main source of fuel.In a healthy person, the hormone insulin helps glucose enter the cells.But in a diabetic,the pancreas fails to produce enough insulin,or the body does not properly use it. Cells starve while glucose builds up in the blood. There are two predominant types of diabetes.In Type 1, the immune system destroys the cells in the pancreas that make insulin. In Type 2,which accounts for an estimated 90 percent to 95 percent of all cases, the body's cells are not sufficiently receptive to insulin,or the pancreas makes too little of it,or both. Type 1 used to be called"juvenile diabetes" and Type 2 "adult-onset diabetes."By 1997,so many children had developed Type 2 that the-Diabetes Association changed the names. What is especially disturbing about the rise of Type 2 is that it can be delayed and perhaps prevented with changes in diet and exercise.For although both types are believed to stem in part from genetic factors,Type 2 is also spurred by obesi and inactivity.This is particularly true in those prone to the illness.Plenty of fat,slothful people do not get diabetes. And some thin,vigorous people do. The health care system is good at dispensing pills and opening up bodies,and with diabetes it had better be,because it has proved ineffectual at stopping the disease.People typically have it for 7 to 10 years before it is even diagnosed,and by http:/Avw%v.nytimes.com/2006/01/09/nyregiordnyregionspecial5/09diabetes.html?pagewanted=print 1/13/2006 Jan - 18 � 2006 8:55A(� SUPERVISOR (SARK DE SAULNIER No-0454 P. 15 Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times Page 4 of 9 that time it will often have begun to set off grievous consequences.Thus,most tzeatment is simply triage, doctors coping with the poisonous complications of patients who return again and again. Diabetics are two to four times more likely than others to develop heart disease or have a stroke,and three times more likely to die of complications from#Lu or pneumonia,according to the Centers for Disease Control.Most diabetics suffer nervous-system damage and poor circulation,which can lead to amputations of toes,feet and entire legs;even a tiny cut on the foot can lead to gangrene because it will not be seen or felt. Women with diabetes are at higher risk for complications in pregroncy,including miscarriages and birth defects.Men run a higher risk of impotence.Young adults have twice the chance of getting gum disease and losing teeth. And people with Type 2 are often hounded by parallel problems-high blood pressure and high cholesterol, among others -brought on not by the diabetes,but by the behavior that led to it,or byeE netics. Dr.Monica Sweeney,medical director of the Bedford-Stuyvesant Family Health Center,offered an analogy: "It's like bad kids. If you have one bad kid,not so bad. Two bad kids,it's worse.Put five bad kids together and it's unmanageable. Diabetes is like five bad kids together.You want to scream." The Caro Research Institute,a consulting firm that evaluates the burden of diseases,estimates that a diabetic without complications Nvill incur medical costs of$1,600 a year-unpleasant,but not especially punishing. But the price tag ratchets up quickly as related ailments set in: an average$30,400 for a heart attack or amputation,$40,200 for a stroke, $37,000 for end-stage kidney disease. One of the most horrific consequences is losing a leg.According to the federal Agency for Healthcare Research and Quality, some 70 percent of lower-limb amputations in 2003 were performed on diabetics. Sometimes, the subtraction is cumulative. One toe goes.Two more.The ankle.Everything to the knee.The other leg. Studies suggest that as many as 70 percent of amputees die within five years. Yet medical experts believe that most diabetes-related amputations are preventable with scrupulous care,and that is why the offices of conscientious doctors post signs like this: "All patients with diabetes:Don't forget to bare your feet each visit." To witness the pitiless course that diabetes can take,simply continue on the hospital tour.This one day will do.Dr.Rita Louard,,an endocrinologist, and Anne Levine,a nurse diabetes educator,were making their way through the rooms at Montefiore. Here was Julius Rivers,58,on the sixth floor.Three years with diabetes.He had been at home in bed when he saw a light like a starburst and told his wife to take hire to the emergency room.His blood sugar was 1,400,beyond the pale. (A fasting level of 126 milligrams per deciliter is the demarcation point of diabetes.) This was his third trip to the hospital in seven months.At the moment,he had a blood clot in his left leg.He had a heart attack a few years ago.He was on dialysis. "Tuesday,Thursday and Saturday,"he said. On the sixth floor was Mauri Stein, 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 tumor on her heart and said it would need surgery. - "My feet burn,"she said. "My toes burn all the time.My days of wearing my pumps are over.I've gotten more cortisone shots in my feet than.I'm sure are legal." http://www.nytimes.conV2006/01/09/nyregion/nyregionspecial5/09diabetes.html?pagewanted=print 1/13/2006 Jan - i8. 2006 85AM SUPERU(SOR MARK DE SAULNfER No.0454 P- 16 Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times Page 5 of 9 She mentioned her brother,who lived in California.Diabetes had ransacked his body-an amputation,kidney dialysis, heart disease,blindness in one eye.He now resided in an assisted-living center.He was 53. Ms. Stein's husband walked in and sat on the bed. Six months ago,he found out the same truth:he had diabetes. This was one day in one hospital. Inside the Incubator Little about diabetes is straightforward, and to comprehend why New York is such an incubator for the disease,it is necessary to grasp that diabetes is as much a sociological and anthropological story as a medical one. While it assaults all classes,ages and ethnic groups,it is inextricably bound up with race andmoney. Diabetes bears an inverse relationship to income,for poverty usually means less access to fresh food, exercise and health care.New York's poverty rate,20.3 percent,is much higher than the nation's, 12.7 percent. African-Americans and Latinos,particularly Mexican-Americans and Puerto Ricans,incur diabetes at close to twice the rate of whites.More than half of all New Yorkers are black or Hispanic, and the Hispanic population is growing rapidly, as it is around the nation. Some Asian-Americans and Pacific Islanders also appear more prone,and they can develop the disease at much lower weights_Asians constitute one-tenth of New York's population,more than twice their proportion nationwide. The nature of these groups'susceptibility remains under study,but researchers generally blame an interplay of genetic and socioeconomic forces.Many researchers believe that higher proportions of these groups have a"thrifty gene"that enabled ancestors who farmed and hunted to stockpile fat during times of plenty so they would not starve during periods of want. In modem America,with food beckoning on every cower,the gene 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." Of the country's spike in diabetes cases over the last two decades,C.D.C. studies suggest that about 60 percent stem from demographic changes:a population increasingly comprising older people and ethnic groups with a higher risk. The studies ascribe the other 40 percent to lifestyle changes: the fundamental shift that has people eating jumbo meals and shunning exercise as if it were illegal.At every turn,technology has made physical activity unnecessary or unappealing. Gym class has largely been deleted from schools.Fewer than a third of junior high schools require physical education at all,the C.D.C.says. On the whole,New York's corpulence is below the national average,with 20 percent of adults qualifying as obese, compared with 30 percent for the country,the C.D.C.says. But the figure is much higher in poor areas like the South Bronx and East Harlem. When the health department studied diabetes in the city's 34 major neighborhoods,the distribution echoed demographic patterns:Diabetes left only a light imprint on more affluent,white areas like the Upper West Side and Brooklyn Heights. The prevalence was about average in working-class Ridgewood,Queens,and almost nil on the Upper East Side. But that apparent immunity is weakening. Of those 34 neighborhoods,22 already have diabetes rates above the national average,and the numbers are rising all over as the city continually remakes itself. http://www.nytimes.corr/2006/01/09/nyregion/nyregionspecial5/O9diabetes.html?pagewanted=print 1/13/2006 Jan - 18. 2006 8:5WA' SUPERVISOR DARK DE SAULNIER No,0454 P. 11 Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times Page 6 of 9 "New York is switching from a mom-and-pop type of environment to a chain-store type of environment,a proliferation of fast food,even in high-rent neighborhoods they haven't had access to before,like the East Village and Lower Manhattan," said Peter Muennig, an assistant professor of health policy and management at Columbia. If changes in daily living can bring on diabetes,they can also delay it,though it is uncertain for how long. A federal program studied people around the country at high risk of getting diabetes,and concluded that 58 percent of new cases could be postponed by shifts in behavior-most notably,shedding pounds, But Dr.Frieder,New York's health commissioner,says meaningful prevention cannot be achieved at the city level. "I can urge people until I'm blue in the face to walk and take the stairs and eat less,and it won't make much difference,"he said. His emphasis is on trying to better treat those who already have diabetes,an ambitious goal in its own right. Most primary care doctors treat too many patients to provide the attention that diabetics need, or to check for the disease,he said. Specialists are scarce.And compliance among patients is notoriously poor. ' Even the most basic step in controlling the disease-watching one's blood sugar- is too much for many diabetics.Doctors recommend that two to four times a year,patients take a so-called Al c 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 Alc levels.Of those who did, presumably the most conscientious,four out of five had readings over the level the American Diabetes Association says separates well-controlled from poorly controlled diabetes. The patients in the survey were not much better at knowing their blood pressure and cholesterol,which are also crucial for diabetics to control. "Diabetes is an interesting beast," said Dr.Diana K.Berger,who heads the diabetes division at the health department. "It's probably one of the easier conditions to diagnose but one of the hardest to manage." Shortages and Shipwrecks There is an underappreciated truth,about disease: it will harm you even if you never get it.Disease reverberates outward, and if the illness gets big enough,it brushes everyone.Diabetes is big enough. Predicting the path of a disease is always speculative,but without bold intervention diabetes threatens to hamper some of society's most basic functions. For instance,no one with diabetes can join the military,though service members whose disease is diagnosed after enlisting can sometimes stay.No insulin-dependent diabetic can become a commercial pilot. Shereen.Arent,director of legal advocacy for the American Diabetes Association, says she already fields 150 calls a month from diabetics who complain that they are being discriminated against in the workplace,double the number just a couple of years ago. She mentioned a typical case,a man rejected for a job at a baked-bean factory in Texas as a safety risk. "If this continues,"she said,"we're in big trouble." Dr.Daniel Lorber is an endocrinologist in Queens who thinks a lot about the disease's present and future. "The work force 50 years from now is going to look fat,one-legged,blind,a diminution of able-bodied workers at every level,"he said, presuming that current trends persist.- As more women contract diabetes in their reproductive years,Dr.Lorber said,more babies will be born with birth defects. Those needy babies will be raised by parents increasingly crippled by their diabetes. http://,,ww.nytimes.com/2006101/09/nyregiotVnyregionspecial5/09diabetes.html?pagewanted=print 1/13/2006 Jan . 18. 2006 8:56AM SUPERVISOR DARK DE SAULNIER Nc -0454 P- 13 Diabetes and Its Awful Toll Quietly Emerge as a Crisis -New York Times Page 7 of 9 "At a time when we are trying to shift health care out of hospitals,with diabetics you don't have a choice," he said. "Nursing homes are going to be crammed to the gills with amputees in rehab.Kidney dialysis centers will multiply like rabbits. We will have a tremendous amount of people not blind but with low vision.And we have lousy facilities in this country for low-vision problems. These people will not be able to function in society without significant aid." Cost pressures have been slashing the number of hospital beds,and some exasperated doctors axe known to denigrate advanced diabetics as"shipwrecks,"because they have so many health problems and virtually live in the hospital. Not only will the future mean too few beds and unsupportable drains on Medicaid and Medicare,Mr.Muennig said,but if an emergency strikes-a terrorist attack,an earthquake-the city health system's ability to respond may be compromised because all the beds will be full of diabetics. Most schools do not have full-time nurses.-Some public schools,Ms.Arent said,try to turn away children with diabetes, even though that is illegal.Others ban them from field trips and sports teams.And this is now,when diabetes is still relatively rare among children. If trends continue;people will live through years blighted by disability,then die too young. Diabetes is thought to shave 5 to 10 years.off a life. "Life expectancy usually decreases because there's a plague or there's a massive economic trauma,"Mr.Muennig said. "In this case,we will see a decline in life expectancy due to a chronic condition." In 2003,diabetes vaulted past stroke and AIDS from the sixth-leading cause of death in New York to the fourth.It was fifth, slightly behind stroke,in 2004.But the health department says it believes the actual toll is much worse because doctors who fill out death certificates may ascribe the death to a complication rather than to the diabetes at its root.Lorna Thorpe,deputy health commissioner,combed through medical charts and concluded that diabetes should be third,trailing cardiovascular disease and cancer. Laurie Raps is a claims representative for Social Security on Staten Island,31 years on the job.From her perspective, interviewing people embarking on full-time disability,she has seen the disease's long tentacles.When she started, she saw people in their 50's and 60's,hobbled Uy the usual problems of ages,herniated discs,heart conditions.Now, every week,she gets diabetic after diabetic,people as young as 30. In fact, a 2004 study by UnumProvident,a major provider of disability insurance, found that the number of workers filing claims for Type 2 diabetes doubled between 2001 and 2003. "It's a double whammy,"Ms.Raps said. "You don't have these people working and paying into the system,and then you have these people collecting from the system." Ten years ago,Ms. Raps developed diabetes.Her husband has it.Both her parents have it,their lives being washed away. "When I look at the people who sit before me with disability claims,I have to check the birth date in their records,"she said. "They look 10 or 20 years older.Diabetes does that.It wears you down and wears you down.We're looking at a future of people 10 or 20 years older in sickness than they are.What kind of future is that?" 'A 15-Year-Old Is Immortal' "Dm Linda and I've had diabetes for 13 years." "I'm Dominique and I've had diabetes for seven years." "I'm Joseph and I've had diabetes for two months." httpJ/www.nytimes.00m/2006/01/09/nyregion/nyregionspecial5/09diabetes.html?pagewanted=print 1/13/2006 Jan . l8 . 2006 3 :57H SUPERVISOR MARK DE SAULNIER No. 0454 P- 19 Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times Page 8 of 9 The brisk introductions went on,the ritual start to the monthly meeting of a support group called Sugar Babes Place.All the members had diabetes.A11 were children. Sugar Babes is the idea of Dr. Yolaine St.Louis,chief of pediatric endocrinology at Bronx-Lebanon Hospital Center. When she started practicing medicine 16 years ago,the only children she saw with diabetes had Type 1. Now,of Sugar.Babes'90 official members,roughly 40 percent have Type 2. One is 3.Another is 7. It scares Dr. St.Louis.It scares many doctors who see the same thing,because they kmow it does not have to be.Type 2 was supposed to be an old person's disease.Diabetes still increases with age in an almost linear fashion-today,one in five New Yorkers age 65 and older have it-but the starting point used to be mostly in their 50's. Dr.Alan Shapiro,a pediatrician with the Children's Health Fund and Montefiore Medical Center who has spent 13 years ministering to children in the South Bronx,said there was an easy way to illustrate the change.When he began,there was a"failure-to-thrive" clinic,meant to address the undernourished,because so many children were dangerously thin and small. "Now I don't think we hardly ever see a failure-to-thrive case,"he said. In the clinic's place is an obesity program.Dr. Shapiro never saw children with Type 2 diabetes in his early years in medicine. Now,the program has about 10 cases. One concern he and fellow doctors have is the surge in children who take antipsychotic drugs for anxiety and conditions like uta ism. Some newer drugs can promote weight gain and thus elevate the risk of diabetes.Dr. Shapiro has an autistic patient who he feels needs the new medication.But since taking it,the young man has markedly put on weight and,at 18, developed diabetes. This extension of the disease to the young is where health care professionals feel society and public policy have most glaringly failed.Diabetes,they say,should never have gotten there. 4 There has been little research into the long-term impact of Type 2 diabetes on children.But doctors have a rough idea. The harsh consequences that can accompany diabetes tend to arrive 10 to 15 years after onset. If people contract diabetes when they are 15, 10 or even 5,they may well start developing complications,not on the cusp of retirement but in the prime of their lives. There is a big difference between losing a limb at 21 and at 70.There is a big difference between going on dialysis at 30 and at 65. "I heard a horror story a few weeks ago,"_Dr.Lorber said, "of a girl who was bornelf,got diabetes at 11 or 12 and went blind from diabetes at 30." The C.D.C. has projected that a child found to have Type 2 diabetes at age 10 will see his life shortened by 19 years. "Imagine if kids were showing up at emergency rooms in cardiac arrest,"said Dr. David L.Katz, director of the Prevention Research Center at the Yale University School of Medicine. "Frankly,I thunk that's the next big thing. It's that dramatic. If diabetes doesn't respect age,why should coronary disease?Lord knows,I hope this never happens.But this is what keeps me up at night." Yet children can be the most reluctant to accept the truths of their condition. "A lot of them are in denial,"Dr.St.Louis said. "They have blood sugars of 300,400,and they tell me right to my face they don't have diabetes. 'You're wrong,'they say.'I don't feel anything.'I tell them what can happen down the road,and http://www.nytimes.corn/2006/01/09/nyregion/nyregionspecial5/09diabetes.html?pagewanted=print 1/13/2006 Jan . 18. 2006 2 :57AM SUPERVISOR MARK DE SAULNIER No-0454 P . 20 Diabetes and Its Awful Toll Quietly Emerge as a Crisis-New York Times Page 9 of 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 warned them,"If your sugar is bad and you don't do anything,you're going to be dropping down all over the Bronx." Interest was tepid. Some children couldn't keep their eyes off the waiting dinner arranged at a buffet table by the wall.No rapt attention from Joseph, 12,who had begged not to come, until his mother put her foot down.He moaned that he had schoolwork. "Look at that,"said Dorothy Morris-Swaby,a diabetes nurse educator who worked with Dr. St. Louis,nodding at a girl who was talking on her phone. "We're educating about diabetes, and she's on her cellphone.Typical teenager." As time ran out, hula hoops were brought out.Dr. St.Louis was trying to identify activities other than video games and TV that the children might try.Last meeting,they held a jump-rope contest. "They have 10,000 excuses why they can't do something,"the doctor said. "So you have to give them ideas and then hope." The meeting wound.up.The hoops were stashed away. Some of the children stepped toward the buffet table and began to eat. Copyright 2006The New York Times Company I Home I Privacy Policy I SearchI Corrections I XML I Help I Contact Us I Work for Us http://www.nytirnes.com/2006/01%09/nyregion/nyregionspecial5/OMabetes.html?pagewanted=print 1/13/2006 Jan . i8 . 2006 9 2SAM SUPERVISOR MARK DE SAULNIER No 0455 P. 2 East Meets West,Adding Pounds and Peril-New York Times Page 1 of 10 nyt:im; s.cora January 12,2006 Sad Blood East Meets West, .Adding Pounds and Peril By MARC SA 1DJ1A May Chen is slender and healthy,a lively little girl whose parents left their rural Chinese village just a decade ago in search of a better life.But at age 9,still in pigtails,she is already coming face to face with the forces that many say are making America fat and Tabetic. When May watches cartoons in her family's apartment in Flushing,Queens,the commercials tell her that junk food is good food-.the latest message from an industry that spends$10 billion a year marketing to children. When she strolls down Main Street,she walks a growing gantlet of fast-food restaurants,many of them built with the help of government loans. At her public school,the city sells sugary Snapple in vending machines to raise money.But it does not pay for a full. physical education program, so May's fourth-grade class has gym just once a week,in violation of state law. And when she and her friends gather for snacks, she basks in their approval as she produces the high-calorie American- style treats, from chips to sweets,that are rapidly replacing traditional foods in the local markets. Children all over the world are walking the same sort of obstacle course as obesand Type 2 diabetes increasingly strike the young. But to spend time with May Chen and the other children of immigrants in Flushing-at home in front of the TV,in the places where they eat and buy food,in their schools-is to appreciate the everyday threat confronting a particularly vulnerable group:the Asian-Americans who make up half the community's population. It is also to understand what alarms health authorities about the future of New York,a city of immigrants where Asians are the fastest-growing racial group. Asians,especially those from Far Eastern nations like China,Korea and Japan,are acutely susceptible to Type 2 diabetes, the most common form of the disease and the subject of this series.They develop it at far lower weights than people of other races, studies show;at any weight, they are 60 percent more likely to get the disease than whites. And that peril is compounded by recent immigrants'sudden collision with American culture. Many of them left places where factory and field work was strenuous,televisions were rare and advertising was limited. They may speak little English and have poor access to medical caze. Many have never even heard of diabetes,much less the recent scientific studies showing that a Western die high in fat and sugar,puts them in danger of getting Type 2 diabetes,which has been linked to obesity and inactivity, as well as to, heredity.(Type 1,which comprises only 5 percent to 10 percent of cases,is not associated with behavior,and is believed to stem almost entirely from genetic factors.) Many recent Chinese immigrants have come from places where food was scarce, and experts say some view fat as a trophy of wealth and status.Their children try to fit into their new country by embracing its foods and its sedentary pastimes. http://www.nytimes.conV2006/01/12/nyregion/nyregionspecial5/12diabetes.htrnl?pagewanted=print 1/13/2006 Jan . 18. 2006 9:21A14' SUPERVISOR MARK DE SAULNIER No.0455 P . 3 East Meets West,Adding Pounds and Peril-New York Times Page 2 of 10 "When they give you the visa to the United States in Shanghai,Fujian or Beijing,they should stamp a clear warning: danger to your health,"said Marcelo M. Suarez-Orozco,co-director of immigration studies at New York University. So far,that danger has not been fully realized.Flushing has only half as many diabetics as the New York neighborhoods where the disease has made its deepest inroads. City epidemiologists say they have limited data on its spread among Asians. But they do know that 14 percent of Asian children in New York are obese,more than twice the rate among their parents. And they say there is mounting evidence-including soaring diabetes rates in major cities in China,and in other countries with Chinese immigrants-that New York will soon experience a similar explosion as more Asians arrive and have their first encounters with Western ways. The clash of cultures is vividly apparent in Flushing,one of the city's new Chinatowns. On streets like Roosevelt Avenue, older immigrants still throng traditional Asian markets,with their signs in Chinese,and dine at noodle shops where windows fog with steam.Their children,however,are increasingly lured by fast food.Along a 100-yard strip of storefronts are a McDonald's,a Burger King,a Taco Bell,a Pizza Hut,and a Joe's Best Burger. Even in China, the number of obese people has tripled since 1992 to 90 million,as Western food has become popular and prosperity has made it possible to eat more.The World Health Organization has warned that Asia faces a"tsunami"of diabetes in the coming decade, and health officials have assailed the Chinese government for its tepid response to the crisis. But in this country, where children are bombarded with much more food advertising,many health experts say the response has not been much stronger. In Washington, money for school gym programs is measured in the millions,while billions are spent on subsidies for those who produce food sweeteners. In Albany,where the restaurant and food industries are generous campaign donors,bills to raise awareness of nutrition and diabetes have been dismissed or derided. In New York's City Hall,a former councilwoman who has been outspoken on childhood obesity,Eva S. Moskowitz,sees similar apathy. "We have a massive problem on our hands,"she said. "There is an utter lack of urgency to do anything about it." And in Flushing,where the Small Business Administration has lent$4.6 million in the last decade to spur fast-food franchises,the community health center has trouble finding money for diabetes education. Here, for anyone who cares to look,are the people left to fend for themselves: a new generation that will soon fill New York's schools and workplaces,making the daily choices that could mean the difference between a healthy city and a colony of the sick. A Melting Pot,Boiling Fiercely Incredible,,Li Li kept repeating,simply incredible. For 14 years, ever since he moved to Flushing from Canton,China,he has hewed to the same diet that his ancestors ate for hundreds, if not thousands,of years. "Chicken,frog,duck,all very fresh-that is what we like," said Mr.Li, a 40-year- old business consultant,as he steered a cart through the Hong Kong Market on Main Street. But at only 3 years old,his twin daughters have already blazed their own path away from history. "They both like the American food,"he said. "I cannot stop that." http://www.nytimes.com/2006/01/12/nyregion/nyregionspecial5/l2diabetes.html?paoewanted=print 1/13/2006 Jan . 18, 2006 9 . 210' SUPERVISOR DARK DE SAULNIER ho-0455 P. 4 East Meets West, Adding Pounds and Peril-New York Times Page 3 of 10 He found the switch profoundly unsettling-not because he saw health consequences,but because it had happened so fast. "Only recently,they tried Coke and they loved that,"he said, as one twin tried to grab a package of candy. "They won't drink tea anymore. Can you believe it?They will not drink tea." It was a classic scene from the well-known story of American immigration: the children of newcomers eagerly assuming the ways of their new world, and rejecting the old. But a rite of passage that used to take most immigrant families a generation or two-fully adopting the American diet- has accelerated for Asians,said James L. Watson,a Harvard anthropologist who has studied their response to fast food. Many have moved in just a few years from villages to China's increasingly Westernized cities and then to the United States,he said,quickly abandoning traditional foods. "Everything is happening at warp speed,"Dr.Watson said. "The melting pot may have been simmering in the past,but now it is raging." And the American diet they are taking up is far different from what it was for earlier generations of immigrants: a mind- boggling array of processed products,with added sugars and fats that can turn these unfamiliar foods into seductive pleasures. Even the store Mr.Li was shopping in is a startling departure from the small produce and poultry shops that still crowd Flushing.The Hong Kong Market,which opened in 1996,is a meeting spot for old and new: a huge supennarket that stocks Chinese versions of processed American foods. One shopper,Sian Kang Qiu, 43,an artist who moved from a coastal village in the province of Guangdong six years ago, said his family's eating had changed radically. "At home we would shop in the open market,"he said. ""There was not so much packaged food.We would eat maybe two meals a day.Rice with something on the side,fish or vegetables."Now,faced with the unlimited choices here, they eat a far broader diet,with many treats. l Mr.Qiu's mother has.Type 2 diabetes,and recently his younger sister learned that she does,too.It has made him a little more conscious of what he consumes. But he has given up trying to control what his 16-year-old daughter,Vicky,eats. "She would prefer American food,"he said."Her friends are going for pizza,she wants to go for pizza.It is nonnal.She wants to do what her friends are doing." The need to fit in is no less important for the fourth graders at Public School 120,where May Chen,the pigtailed 9-year- old,was the center of attention one afternoon as snack time rolled around. May's parents co-own a sushi restaurant,but she had come to school with a bag of all-American snacks:a shiny blue can of Lay's Stax potato chips and a package of neon-orange Cheetos Puff's. She.passed out chips to her friends,and in no time hands were stretched out all over the classroom. No one gave a second glance to the steamed dumplings that a classmate,Annie Wu,had brought from home. "There is a kind of shame issue," said Professor Suarez-Orozco of N.Y.U.,who has spent the last five years studying the lives of 400 immigrant families,with a focus on Asians."The kids feel if they bring food from home, some ethnic dish, they are seen as not as cool and not with it." School is one place where good eating habits can be taught.Yet at P.S. 120, fats, sugars and calories figure heavily in cafeteria fare:burgers,pizza and chicken nuggets.. http://www.nytimes.com/2006/01/12/nyregion/nyregionspecial5/12diabetes.html?pagewanted=print 1/13/2006 Jan . l8 . 2066 0 28AM SUPERVISOR DARK DE SAULNIER t`o.0455 P. 5 East Meets West,Adding Pounds and Peril-New York Times 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 change their menus too drastically and risk a drop in sales that would reduce those reimbursements. And at the end of each school day,the trash baskets at P.S. 120 are filled with the compulsory fiuit. 'If It Is Delicious,I Love It' A sweet tooth is standard equipment on any child.But the sweetness That satisfies it is no longer limited to cookies and candy. When 18-year-old Jin Yang dashed into a Key Food supermarket one rainy afternoon to buy food for her friends at Flushing High School,she wasn't looking at nutrition labels.If she had,she Haight have noticed that nearly every purchase she considered-the low-fat yogurt,the basil vinaigrette and even the chicken noodle soup she ended up buying- shared the same major ingredient:high-fructose corn syrup,a sweetener first derived from com in the 1960's. Underwritten by roughly$40 billion in federal subsidies paid to corn growers in the past 10 years alone,it is now so cheap that it has all but replaced cane sugar as the sweetener of choice in processed foods. The syrup has been singled out by many health experts as one of the chief culprits in the rise of obesity.Its inexpensiveness,they say,has helped soda producers create the larger portions that have led to overconsumption.It is so versatile,they say,that it now shows up in many foods that would not have been sweetened at all in the past. There is wide disagreement among scientists over some studies indicating that high-fructose corn syrup can hinder the body's ability to process sugar, and can promote faster fat growth than sweeteners derived from cane sugar. What no one disputes,however,is that since the advent of the syrup,consumption of all sweeteners has soared; the average American's intake has increase about 35 percent,according to the Federal Department of Agriculture. And a 2004 study in The American Journal of�Clinical Nutrition showed that the rise of Type 2 diabetes since 1980 had closely paralleled the increased use of sweeteners,particularly coma syrup. Food industry officials say there is nothing wrong with the syrup as long as people eat it in moderation. But Jin, who carne here just a year ago from rural northeastern China,said she had never even heard of the sweetener-or diabetes, for that matter.Thin and healthy,she subjects each food purchase to only one test. "If it is delicious,"she said,"I love it." Moderation may also be a foreign concept to many new immigrants from China because of deep-seated attitudes they have brought with them. In many Chinese families,it is difficult to get parents and grandparents,who were raised during the deadly famines and deprivations of the 1950's to stop overfeeding their children. "Increased girth is an indicator of wealth," said Dr. Thomas Tsang,medical director of the Charles B. Wang Community Health Center in Flushing. But any extra weight is dangerous for Asians, research shows,because of their susceptibility to Type 2 diabetes.For example,a 5-foot-9 Japanese man who weighs 156 pounds-and who may never develop the sort of belly that is a warning sign for the disease-is twice-as likely as a white man that size to become diabetic. Because of that,Dr.Tsang said he believed that the number of Asian diabetics is underestimated;he has recently diagnosed at least a dozen new cases among his longtime patients. "It's astounding,"he said. "And it puts a lot of pressure on us to educate them." http://www.nytimes.com/2006/01/12/nyregion/nyregionspecial5/12diabetes.html?pagmanted=print 1/13/2006 r� Jao . 18 . 2006 9 28AI�i SUPERVISOR MARK DE SAULNIER No .0455 P. 6 East Meets West,Adding Pounds and Peril-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 tend to avoid doctors, and some Chinese people will not test their blood sugar. "My own mother has diabetes,"the doctor said,"and she will not draw her own blood. She believes blood is the life essence and should not be lost." Selling Frosted Flakes and Fitness At age 3,Henry Chen is learning his first words in English. "Mother"was first,followed by"father." What came next, however, surprised his aunt,Cindy Chen. "McDonald's,"she said. "It was one of his first words." Neither fast food nor television was part of the Chens' life in Fuzhou,a Chinese city where they struggled to find work before moving to Flushing four years ago. Now Henry and his family show up at least once a week at McDonald's.At home,he perches on the sofa to watch Nickelodeon.By his aunt's estimate,he spends as much as 30 hours a week in front of the TV-more than double the average for a child in China,according to data collected for The New York Times by AGB Nielsen Media Research.Like a human Spongel3ob,he soaks up ads for Pop-Tarts and Lucky Charms. There is nothing new about the marketing of food to children,with all of its cartoon characters and free toys. According to a study released in May by the Grocery Manufacturers Association,the average child watches 4,900 food commercials a year. What is new,though,is the message that child-and his parents-are hearing. Ronald McDonald now snowboards,and his once-portly frame looks to have shed at least 30 pounds.The box for Henry's Happy Meals reads,"A game of tag keeps me happy and fit." In,one commercial,a woman does a victory jig when she finds out her Lay's potato chips are low'-fat.A Frosted Flakes ad shows children running around a soccer field with Tony the Tiger. "Without a doubt, the food industry,while not moving away from convenience,has begun to push health as the main driver of food packaging and promotion," said Don Montuori,publisher of Packaged Facts,which does consumer research for food companies. The companies say they are doing their part to combat obesity by offering lower-calorie,lower-fat choices,and encouraging children to exercise.McDonald's sponsors track events for young runners,and Coca-Cola has created the Tiger Woods Foundation to promote children's sports. But what would seem to be welcome news has simply created a different problem,according to many nutritionists and public health officials. Despite a salad here or a lower-fat oil there,they say,the food industry has done little to change the basic unhealthfulness of its best-selling products.And by making the link to fitness,they say,the companies are telling children that all of those foods are good for them. New immigrants from China are keenly receptive to such claims because the Chinese have used foods to cure illnesses and promote general health for thousands of years,said Dr.Watson,the Harvard anthropologist.One cure for a cough, for instance, involves duck gizzards,apricot kernels and watercress. A variety of foods are thought to improve brain function. Many Chinese people have replaced those traditional foods with processed foods,Dr. Watson said,and have little idea what is in them. Still, the faith in food persists: for instance,he said,there is a widespread perception in China that eating at McDonald's can somehow make you smarter.In New York,Professor Suarez-Orozco said, immigrant parents often http:/Iwww.nytimes.conV2006/01/12/nyregion/nyregionspecial5/12diabetes.html?pagewanted=print 1/13/2006 Jan . l2- 2006 9:29AIV SUPERVISOR MARK DESAULNIER ho, 0455 P. 7 East Meets West,Adding Pounds and Peril-New York Times Page 6 of 10 reinforce that connection by rewarding academic achievement with a McDonald's meal. And many Chinese companies have adopted the same kind of health pitches as their American counterparts.At the Hong Kong Market, a juice box called Vita Chrysanthemum.Tea_promotes itself as a health drink for children,though nutritionally it is little different from Snapple. Ye Zhou, a sixth grader whose parents arrived from China shortly before she was born,said she tried to eat right,and knew that some.foods were unhealthful. On this day she had come to the McDonald's on Main Street to try the new Premium Crispy Chicken Breast Sandwich,drawn by the ads that touted the "energy" packed in the meal,which includes French fries and a soda. How, she was asked,did it compare nutritionally with the stir-fried chicken and rice her mother made at home? "They taste different," she said. "But one is not healthier than the other." Actually,the fast-food meal has at least one-third more calories,carbohydrates and grams of fat than a typical homemade one. Even before the latest blitz of health messages;children were confused,the Henry J.Kaiser Family Foundation said in a 2004 report on childhood obesity.In a 1997 study it cited,fourth and fifth graders were asked which of two foods-say, corn flakes or frosted flakes-was more healthful;the children who watched the most TV were the most likely to pick the less nutritious one. For more than two decades,Dr.Daniel S.Acuff helped hone food ads aimed at children as a marketing consultant to companies like Coca-Cola and Nestle.But about two years ago,he said,he stopped consulting on products he did not consider nutritious after recognizing the threat posed by obesity.He called the industry's new sales strategies disingenuous. "To position themselves as leaders in providing healthy food for children is nonsense,"he said. He and others- including the American Academy of Pediatrics and the American Psychological Association-have called for tighter restrictions on advertising to children,similar to limits in Australia,Canada and England.They are also concemed about the increasing use of the Internet and video games to sell food. But repeated attempts to enact such strictures in the United States have failed for three decades, and at a meeting last July in Washington, the Federal Trade Commission told food and advertising.executives that it favored letting the industry police itself. A few companies have done just that-most notably Kraft Foods,which decided last January to curb its advertising of certain products, like Oreos and Kool-Aid, to children under 12.The move raised eyebrows both in the food industry and in public health circles because of its implicit suggestion that there are bad foods.The industry has long maintained that there are no bad foods,only bad habits-like overeating. Tim Wong is only 10,but he had no problem polishing off a large dinner platter from the adult menu one afternoon at the KFC on Main Street in Flushing.He had asked his mother to take him and his 6-year-old sister,Tiffany, so they could try "the new stuff'on the menu. "I see the new items on television and I want them,"he said. When he was asked what his favorite foods were,his mother laughed.. "Look at hien," she said in a matter-of-fact way,as Tim is obviously overweight. "He likes his junk." Time for Gym! OX,Time's Up! "Two fingers in the air!"the teacher aides shouted at the more than 100 children squirming in the auditorium seats. http:/Avww.nytimes.corn/2006/01/12/nyregion/nyregionspecial5/l2diabetes.html?pagewanted=print 1/13/2006 Jan - 18, 2006 9: 29AM' SUPERVISOR MARK DE SAULNIER No-0455 P. 8 East Meets West, Adding Pounds and Peril-New York Times Page 7 of 10 Two fingers held high is the way students at May Chen's school signal that they are sitting quietly enough to be let out for recess.It was 10:30 a.m.,less than two hours after they had been served a breakfast that included chocolate milk, a doughnut and a juice box-at least 400 calories and 47 grams of sugar waiting to be burned off. Finally the doors opened, and the students scampered out to the playground, a parking lot ringed by a chain-link fence. Several boys ran around like mad.In a makeshift game of keep-away,May and some other girls tossed around a bag of cheese snacks., . They had to play fast.Twelve girls were lined up to jump rope,but only three had a chance before a bell summoned them back inside for lunch. May's recess had lasted eight minutes. It was,as always, the only recess for the day, and fortunately the weather was mild. On cold or rainy days,the children stay inside and watch movies. - Recess and physical education are treated like luxuries in the New York City schools. Though half the grade schoolers are overweight and roughly one in four are obese,the city did little until last year to promote one of the best antidotes: exercise. May,like most schoolchildren in the city,does not get even the minimum amount of physical education mandated by state law,two hours a week. She has a single gym class each week,for 50 minutes. She is among the lucky ones.More than half the city's 700 elementary schools have no usable outdoor play space, according to a 2003 survey by the City Department of Education.May's school has only one gym teacher for its 1,000 students,but roughly one in seven elementary schools in the city have no teacher dedicated to physical education. And although P.S. 120 has a functioning gym,many elementary schools do not, according to reports by the City Council and the State Assembly.Even those that have gyms often use them for classes or meetings.There has been no standardized testing of student fitness in more than a generation. ti The sad state of the school gym class is a legacy of the city's fiscal crisis in the 1970's,when the budget for physical education was slashed to protect other academic programs.But New York's plight is not much worse than the rest of the country's. Even as the health authorities pronounced obesity a national eMidemic,daily participation in gyre classes dropped to 28 percent in 2003 from 42 percent in 1991,according to the Centers for Disease Control and Prevention. And the Bush administration recently proposed cutting Physical Education Program grants to schools by more than one-quarter, to$55 million,though Congress rejected the proposal. Schools are so desperate to finance exercise programs that many have turned to food companies for help.McDonald's is offering curriculums and undisclosed sums to 31,000 schools across the country to improve physical education through an effort called Passport to Play;every piece of program literature that children see will carry the company's golden-arches logo. Two years ago, even as New York's health department was assigning a team to improve the treatment of diabetics,the city signed a deal with Snapple that made its fruit drinks the only beverages,besides water,sold in school vending machines. A 12-ounce can of Snapple contains 170 calories and 40 grams of sugar,as much as most colas.The calories in three cans -the amount many students drink every day-would take at least three hours to walk off. The 29 fourth graders in May Chen's class have gym directly after lunch,and their stomachs were full this day with chicken nuggets.They did not change into gym clothes.The teacher,Bruce Adler,started them off with calisthenics, moving quickly to situps and three leisurely laps around the basketball court.There were groans,and several children http://www.nytimes.com/2006/01/12/nyregion/nyregionspecial5/12diabetes.html?pagewanted=print 1/13/2006 Jan . 18. 2006 9 : 30Alm' SUPERVISOR DARK DE SAULNIER No-0455 P- 9 East Meets West,Adding Pounds and Peril-New York Times Page 8 of 10 were winded,but few broke a sweat. Mr. Adler, 55,said the school could really use a second teacher,recalling how different things were when he was growing up in Yonkers. Students there had at least three gym classes a week,he said. New York school officials say they are adding more physical education teachers each year.And two years ago,the Bloomberg administration created the Office of Fitness and Physical Education. Its director,Lori Rose Benson,has begun a program called Physical Best,which will track students'fitness,charting progress for each school. She said she hoped to start the program by the end of this school year in every grade school with a physical education teacher, including May's. She conceded it was merely a first step. "It is very difficult to reverse a culture that existed for 20 to 30 years,"she said. Tilting at Golden Arches At least two unthinkable things happened in Albany in the past year. One made headlines: The Legislature passed a budget on time.The other went unnoticed:The Assembly actually debated a bill that tried to address, in some small way, the leap in obesity and Type 2 diabetes. It was a rare moment of attention for a cause that has drawn little more than lip service from government officials, and it was short-lived.The debate,and the bill,died in mocking laughter. The story of that bill, known as A5664,is a lesson in the ways of Albany-and the apathy that diabetes experts say is blocking any effective response to the epidemic. The lesson was an abrupt one for Assemblyman Jimmy Meng of Flushing,who had already embarked on a sharp learning curve. When he was elected the previous fall-the fust Asian-American voted into state office in New York-diabetes was nowhere near the top of his list of health issues. But as he became more aware of the disease's threat to children and young adults in his comimnity,Mr.Meng said,he became frustrated with the ignorance and inaction he discovered. In April, he organized and led the first march in Queens to raise money and awareness in the battle against diabetes.And he agreed to support legislation by a fellow Assembly Democrat,Felix Ortiz of Brooklyn. The bill would require all restaurants to prominently post the amounts of calories, fat and salt in each menu item.It was hardly a radical notion.Many fast-food chains had already begun listing calorie counts in restaurants and on Web sites, and months later McDonald's would decide to print nutritional data right on its wrappers. But Mr. Ortiz felt those moves were only a start. Who knew how many calories were in a slice of the neighborhood pizza or a Starbucks caramel macchiato? His passion for the issue-this was just one of six bills he introduced in the 2004-5 session to fight obesity and diabetes- was fed by his own loss.His mother died of the disease when she was only 58. . "Everything was caused because she did not take care of her weight,"he said. In Albany,the path from legislation to law is thomy,and Mr.Ortiz brought along his own set of hurdles.He was hardly an insider within the Democratic conference,which is controlled by Speaker Sheldon Silver, and some of his bills were considered odd. One would have made it a crime for a person not to come to the aid of another in trouble. The restaurant labeling bill looked like another loser. It had no support from the Democratic leadership. Although it was backed by the American Diabetes Association,which has spent$9,000 lobbying New York lawmakers in the past few http://www.nytimes.conV2006/01/12/nyregion/nyregionspecial5/12diabetes.html?pagewanted�print 1/13/2006 Jaa , i8- 2006 9.30AIA' SUPERVISOR DARK DE SAUL1`!ER Ao.0455 P. 10 East Meets West, Adding Pounds and Peril-New York Times Page 9 of 10 years,it was opposed by the food industry,which contributed more than$4 million to legislative and gubernatorial campaigns between 1999 and 2005,according to state records. And diabetes had hardly caught fire as a pressing health issue.The Pataki administration is investing$9 million this year to encourage physical activity among children,but the state has not moved to limit the sale of unhealthful snacks in schools,as a half-dozen other states have. Only S1.9 million of the$100 billion state budget goes directly to diabetes prevention and control,roughly the same amount spent to fight anorexia and bulimia. Two months after the Health Committee approved Mr. Ortiz's bill,it had still not come up for a full Assembly vote.But on June 22, as the legislative session wound down,the bill found its moment. Many members were in a hurry to leave town.As evening approached,Mr. Ortiz spotted Mr. Silver,chased him down a corridor and cornered him outside the speaker's office, in a space where legislators often horse-trade in whispers. Mr. Ortiz,however,was shouting:"I get the same excuse every year!" He wanted his bill debated and voted on by the full Assembly-an unusual request in Albany,where measures rarely _ make it to the floor of either house unless they are assured passage.Mr.Ortiz's five other bills to fight obesity had languished in committees. If a bill this mild could not succeed in New York,Mr. Ortiz argued,what hope was there for more sweeping measures? Mr. Silver relented.And when the bill canoe up for a vote,near midnight,Mr. Ortiz had the floor. "This is about the future of our children," he said. When he stopped,the sarcasm began. James D.Conte, a Long Island Republican,said his family owned a burger restaurant.What would happen,he asked, in the case of all-you-can-eat buffets? Mr. Ortiz said the law would apply only to standard menu items. "What about the weekly specials7"Mr.Conte asked. Laughter rose in the chamber. Daniel J.O'Donnell,a fellow Democrat from Manhattan,kept it going. "I watch people who work at McDonald's,and they don't measure how much salt they put on fries,"he said. "Do you expect there to be a shaker lesson?" Mr.Ortiz said he guessed that employees were adequately educated. An hour went by.A few colleagues defended the measure. Others argued that enforcing it would be a nightmare, and that the costs would hurt small restaurants. As the time for debate waned,Joel M.Miller, a Republican from Poughkeepsie,rose to state his position. "I did not develop this physique by eating healthy,"Mr.Miller, a stout man„said to guffaws.Azcolleague completed the joke by bringing him a generous plate of cookies. "The bottom line is,it is not going to matter,"Mr. Miller said. "We are fooling and deluding ourselves." Mr. Ortiz made one last plea. "When Nve look at the rate of diabetes in our state,"he said,"and when we look at this bill, we should remind ourselves that the decision we make here tonight will make an impact on our kids." The result was clear as soon as the voting began.The yes votes showed up on,an electric signboard in green,the no votes in red. Within minutes,the.board was glowing red. titlp://www.nytimes.com/2006/01/12/nyregion/nyregionspecial5/12diabetes.html9pagewanted=print 1/13/2006 Jan - 18. 2006 9:30AM SUPERVISOR (SARK 4E SAULNIER 1`!0.0455 P . I1 East Meets West, Adding Founds and Peril-New York Times Page 10 of 10 Before the tally could be completed,Mr.Ortiz stood and delivered the final word: "Z would like to say,with a lot of passion,Z withdraw this bill." CopyrioM riv 2006ThA Now York Times Company ! Home ! Pa y Pogcy I Search 1 Corrections 1 rXML , Heli 1 Contact Us 1 Work for Ua t http://w w,nytimes.com/2006/01/12/nyregion/nyregionspecials/12diabetes.html?PaRewanted=print 1/13/2006 Jan , l8, 2006 9:81AM SUPERVISOR MARK DE SAULNIER No-0455 P. 12 In the Treatment of Diabetes, Success Often Does Not Pay-New York Times page I of 10 Clic Xcty Mork Ulm$ nytimes.com January 11,2006 Bad Blood In the Treatment of Diabetes, Success Often Does Not Pay By LAN�A With much optimism,Beth Israel Medical Center in Manhattan opened its new di&bgles center in March 1999.Miss America,Nicole Johnson Baker,herself a diabetic,showed up for promotional pictures,wearing her insulin pump. In one.photo,she posed with a man dressed as a giant foot-a comical if dark reminder of the roughly 2,000 largely _ avoidable diabetes-related amputations in New York City each year. Doctors, alarmed by the cost and rapid growth of the disease,were getting serious. At four hospitals across the city, they set up centers that featured a new model of treatment.They would be boot camps for diabetics,who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels,count calories and exercise with discipline,while undergoing prolonged monitoring by teams of specialists. But seven years later,even as the number of New Yorkers with Type 2 diabetes has nearly doubled,three of the four centers,including Beth Israel's,have closed. They did not shut down because they had failed their patients. They closed because they had failed to make money.They were victims of the byzantine world of American health care,in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications. Insurers,for example,will often refuse'to pay$150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though,cover amputations,which typically cost more than$30,000. Patients have trouble securing a reimbursement for a$75 visit to the nutritionist who counsels there on controlling their diabetes.Insurers do not balk,however,at paying$315 for a single session of dialysis,which treats one of the disease's serious complications. Not surprising,as the epidemic of Type 2 diabetes has grown,more than 100 dialysis centers have opened in the city. "It's almost as though the system encourages people to get sick and then people get paid to treat them,"said Dr.Matthew E.Fink,a former president of Beth Israel. Ten months after the hospital's center was founded,it had hemorrhaged more than$1.1 million.And the hospital gave its director,Dr.Gerald Bernstein, three and a half months to direct its patients elsewhere. The center's demise, its founders and other experts say,is evidence of a medical system so focused on acute illnesses that it is struggling to respond to diabetes,a chronic disease that looms as the largest health crisis facing the city. America's high-tech,pharmaceutical-driven system may excel at treating serious short-term illnesses like coronary blockages,experts say,but it is.flailing when it comes to Type 2 diabetes,a condition that builds over time and cannot be solved by surgery or a few weeks of taking pills. Type 2,the subject of this series,has been linked to obesily and inactivity,as well as to heredity.(Type 1,which http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/l ldiabetes.html?pagewanted=print 1/13/2006 Jai • 18. 2006 9: 31A64 SUPERVISOR f4RK OE SAULNIER No- 0455 P, 13 In the Treatment of Diabetes, Success Often Does Not Pay-New York Times Page 2 of 10 comprises only 5 percent to 10 percent of cases,is not associated with behavior,and is believed to stem almost entirely from genetic factors.) Instead of receiving comprehensive treatment,New York's Type 2 diabetics often suffer under substandard care. They do not test their blood as often as they should because they cannot afford the equipment.Patients wait months to see endocrinologists%who provide critical diabetes care-because lower pay has drawn too few doctors to the specialty.And insurers limit diabetes benefits for fear they will draw the sickest,most expensive patients to their rolls. Dr.Diana K.Berger,who directs the diabetes prevention program for the City Department of Health and Mental Hygiene, said the bias against effective care for chronic illnesses could be seen in the new popularity of another high-profit quick fix: bariatric surgery,which shrinks stomach size and has been shown to be effective at helping to control diabetes. "If a hospital charges,and can get reimbursed by insurance,$50,000 for a bariatric surgery that takes just 40 minutes,"she said, "or it can get reimbursed$20 for the same amount of time spent with a nutritionist,where do you think priorities will be?" ,back in the Pantsuit Calorie by calorie,the staff of Beth Israel's center tried to turn diabetic lives around from their base of operations: a classroom and three adjoining offices on the seventh floor of Fierman Hall,a hospital building on East 17th Street. The stark,white-walled classroom did not look like much. But it was functional and clean and several times a week,a dozen or so people would crowd around a rectangular table that was meant for eight,listening attentively,staff members said. Claudia Slavin,the center's dietitian,remembers asking the patients to stand,one by one. "Tell me what your waking blood sugar was," she told them, "and then try to explain why it is high or low." People whose sugars soar damage themselves irreparably, even if the consequences are not felt for 10 or 20 years. Unchecked,diabetes can lead to kidney failure,blindness,heart disease,amputations-a challenging slate for any single physician with a busy caseload to manage. One patient,Ella M.Hammond,a retired school administrator,recalled standing up in the classroom one day in. 1999. "Has anyone noticed what's different about me?"Ms. Hammond asked. Blank stares. "Now, come on,"she said,ruffling the fabric of a black gabardine pantsuit she had not wom since slimmer days,years earlier. "Don't y'all notice 20 pounds when it goes away?" she asked. Ms. Slavin,one of four full-time staff members who worked at the center,remembers laughing.There were worse reasons for an interruption than a success story. Like many Type 2 diabetics,Ms.Hammond had been warned repeatedly by her primary care doctor that her weight was too high,her lifestyle too inactive and her diet too rich.And then she had been shown the door,until her next appointment a year later. "The center was a totally different experience,"Ms.Hammond said. "What they did worked because they taught me how http://www.nytimes.com/2006/01/1l/nyregion/nyregionspecial5/lldiabetes.html?pagewanted=print 1/13/2006 Jan - 18 - 2006 9:21 AM' SUPERVISOR DARK DE SAULNIER No- 0455 P 14 In the Treatment of Diabetes, Success Often Does Not Pay-New York Times _ , Page 3 of 10 to deal with the disease, and then they forced me to do it." Two hours a day,twice a week for five weeks,Ms.Hammond learned how to manage her disease. How the pancreas works to create insulin, a hormone needed to process sugar. Why it is important to leave four hours between meals so insulin can finish breaking down the sugar.She counted the grams of carbohydrates in a bag of Ruffles salt and vinegar potato chips, her favorite, and tradedvegetarian 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 single-handedly to reverse a disease with the gale force of popular culture behind it. Type 2 diabetes grows hand in glove with obesity,and America is becoming fatter.Undoubtedly,many of these diabetics are often their own worst enemies.Some do not exercise. Others view salad as a foreign substance and,like smokers, often see complications as a distant threat. To fix Type 2 diabetes,experts agree,you have to fix people. Change lifestyles.Adjust thinking. Get diabetics to give up sweets and prick their fingers to test their blood several times a day. It is a tall order for the primary care doctors who are the sole health care providers for 90 percent of diabetics. Too tall,many doctors say.When office visits typically last as little as eight minutes, doctors say there is no time to retool patients so they can adopt an entirely new approach to food and life. "Think of it.this way," said Dr.Berger'. An average person spends less than.03 percent of their entire life meeting with a clinician, The rest of the time they're being bombarded with all the societal influences that make this disease so common." As a result, primary care doctors often have a fatalistic attitude about controlling the disease.They monitor patients less closely than specialists,studies show. For those under specialty care,there is often little coordination of treatment, and patients end up Ping-Ponging between their appointments with little sense of their prognosis or of how to take control of their condition. Consequently, ignorance prevails. Of 12,000 obese people in a 1999 federal study,more than half said they were never told to curb their weight. Fewer than 40 percent of those with newly diagnosed diabetes receive any follow-up, according to another study.In New York City, officials say,nearly 9 out of 10 diabetics do not know their Alc scores,that most fundamental of statistics. In fact,without symptoms or pain,most Type 2 diabetics find it hard to believe they are truly sick until it is too late to avoid the complications that can overwhelm them.The city comptroller recently found that even in neighborhoods with accessible and adequate health care,most diabetics suffer serious complications that could have been prevented. This grim reality persuaded hospital officials in the 1990's to try something different. The new centers would provide the tricks for changing behavior and the methods of tracking complications that were lacking from most care. Instead of having rushed conversations with harried primary care physicians,patients would discuss their weights and http://viww.nytimes.conV2006/01/1l/nyregion/nyregionspecia15/1ldiabetes.html?pagewanted=print 1/13/2006 Jan- 18. 2006 9: 32Ak' SUPERVISOR DARK DE SAULNIER No.U455 N . I � In the Treatment of Diabetes, Success Often Does Not pay-New York Times Page 4 of 10 habits for months with a team of diabetes educators,and have their conditions tracked by a panel of endocrinologists, ophthalmologists and podiatrists. "The entire country was watching," said Dr.Bernstein,.director of the Beth Israel center,who was then president of the American Diabetes Association. By all apparent.measures,the aggressive strategy worked.Five months into the program,more than 60 percent of the . center's patients who were tested had their blood sugar under control. Close to half the patients who were measured had already lost weight. Competing hospitals directed patients to the program. "For the first time in my 23 years of diabetes work I felt like we had momentum," said Jane Seley,the center's nurse practitioner. "And it wasn't backwards momentum." Failure for Profit From the outset, everyone knew diabetes centers were financially risky ventures. That is why Beth Israel took a distinctive approach before sinking SL5 million into its plan. Instead of being top-heavy with endocrinologists,who are expensive specialists,Beth Israel relied more on nutritionists and diabetes educators with lower salaries,said Dr.Fink, the hospital's former president. The other centers that opened took similar precautions. The St.Luke's-Joslin diabetes center, on the Upper West Side,tried lowering doctors'salaries,hiring-dietitians only part time and being aggressive about getting reimbursed by insurers,said Dr.Xavier Pi-Sunyer,who ran the center. Mount Sinai Hospital's diabetes center hired an accounting firm to calculate just how many bypass surgeries, kidney =splarits and other profitable procedures the center would have to send to the hospital to offset the cost of keeping the center running,said Dr.Andrew Drexler,the center's director. Nonetheless,both of these centers.closed for financial reasons within five years of opening. In hindsight,the financial flaws were hardly mysterious,experts say. Chronic care is simply not as.profitable as acute care because insurers, and consumers, do not want to pay as much for care that is not urgent,according to Dr.Arnold Milstein, medical director of the Pacific Business Group on HealdL By the time a situation is acute,when dialysis and amputations are necessary,the insurer,which has been gambling on never being asked to cover procedures that far down the road,has little choice but to cover them,if only to avoid lawsuits, analysts said. Patients are also more inclined to pay high prices when severe health consequences are imminent.When the danger is distant,perhaps uncertain,as with chronic conditions,there is less willingness to pay,which undercuts prices and profits, Dr.Milstein explained. "There is a lesser sense of alarm associated with slow=moving threats,so prices and profits for chronic and preventive care remain low," he said. "Doctors,insurers and hospitals can command much higher prices and profit margins for a bypass surgery that a patient needs today than they can for nutrition counseling likely to prevent a bypass tomorrow." Ms.Seley said the belief was that however marginal the centers might be financially,they would bring in business. "Diabetes centers are for hospitals what discounted two-liter bottles of Coke are to grocery stores," she said. "They are not profitable but they're sold to get dedicated customers, and with.the hospitals the hope is to get customers who will come back for the big moneymaking surgeries." http://`www,.nyt*unes.com/2006/01/1 I/nyregion/nyregionspecial,5/1 ldiabetes.html?pagewanted=print 1/13/2006 Jan , 12. 2006 9:32AM SUPERVISOR MARK DE SAULNIER No-0455 P. 15 In the Treatment of Diabetes,Success Often Does Not Pay-New York Times Page 5 of 10 Indeed,former officials of the Beth Israel center said they anticipated that operating costs would be underwritten by the amputations and dialysis that some of their diabetic patients would end up needing anyway,despite the center's best efforts. "In other words,our financial success in part depended on our medical failure,"Ms. Slavin said. The other option was to have a Russ Berrie. Mr.Berrie,a toymaker from the Bronx,made a fortune in the 1980's through the wild popularity of a product he sold,the Troll doll,a three-inch plastic monster with a puff of fluorescent hair.Mr.Berrie took more than$20 million of his doll money and used it to finance the diabetes center at Columbia University Medical Center in memory of his mother,Naomi, who had died of the disease.The center was also helped by a million-dollar grant from a company that makes diabetes drugs and equipment. Even with its stable of generous donors,even with more than 10,000 patients filing through the doors each year,the Columbia center struggles financially, said Dr.Robin Goland,a co-director.That, she said,is because the center runs a deficit of at least$50 for each patient it sees. Without wealthy benefactors,Beth Israel's center had an even tougher time surviving its financial strains. Ms. Slavin said the center often scheduled patients for multiple visits with doctors and educators on the same day because it needed to take advantage of the limited time it had with its patients, But every time a Medicaid patient went to a diabetes education class,and then saw a specialist,the center lost money,she said.Medicaid, the government insurance program for the poor,will pay for only one service a day under its rules. The center also lost money,its former staff members said, every time a nurse called a patient at home to check on his diet or contacted a physician to relate a patient's progress.Both calls are considered essential to getting people to change their habits.But medical professionals,unlike lawyers and accountants,cannot bill for phone time,so more money was lost. And the insurance reimbursement for an hourlong diabetes class did not come close to covering the cost.Most insurers paid less than$25 for a class,said Denise Rivera,the secretary for the center. "That wasn't even enough to pay for whoa it cost to have me to do the paperwork to get the reimbursement," she said. Beth Israel was not alone in this predicament.Dr. C.Donald Kahn,president and director of the Joslin Diabetes Center in Boston,the nation's largest such center,with 23 affiliates around the country,said that for every dollar spent on care,the Joslin centers lost 35 cents. They close the gap,but just barely,with philanthropy,he said. "So you have the institutions,which are doing much of the work in dealing with this major health epidemic,depending on charity,"he said. "In the long run,this is definitely not a tenable system" Plastic Strips and Red Tape Sidney Schonfeld was not a patient at Beth Israel,but he ran into his own set of financial obstacles in trying to manage his disease. "Controlling my condition isn't that hard," said Mr.Schonfeld,82,a retired businessman from Washington Heights. "The hard part are the things outside my control,like getting the test strips and the medicines." 'rest strips are not complicated pieces of medical equipment.They are inch-long pieces of plastic with tiny metal tabs that diabetics use to measure the sugar in their blood.After pricking their finger,diabetics place a drop of blood on the strip and then insert it into the side of a handheld meter that analyzes their sugar levels. Each strip costs only about 75 cents,but many diabetics are poor and,over the course of a year,those who test their blood frequently,as instructed,will spend more than$500 on strips. http://WNVW.nydmes.conV2006/01111/nyregiou/nyregionspecial5/1 ldiabetes.html?pagewanted=print 1/13/2006 Jan - 19. 2036 9:33AM SUPERVISORAARK DE SAULNIER No-UON ii In the Treatment of Diabetes,Success Often Does Not Pay-New York Times Page 6 0£10 Mr. Schonfeld,like many diabetics,is supposed to test his blood at least twice a day so he can make adjustments to his diet and medications that can ward off serious complications.But many insurers cover only one strip per day unless a patient obtains written justification from a doctor.Even with letters from his doctor,Mr. Schonfeld has had a tough time getting insurers to pay for his strips,his doctor and nurse said. "Fighting the disease is only half of this job," said Mr. Sehonfeld's doctor,Dr.Goland. She held up a manila folder thick with letters that she had sent to his insurer explaining Mr. Schornfeld's case.Mr. Schonfeld had his own pile of letters: the rejection notices he got back. Dr. Goland says that Mr.Schonfeld has good reason to be vigilant.His mother lost her left foot to Type 2 diabetes. She died several months later after gangrene spread to her right.Mr.Schonfeld's six uncles and aunts on his mother's side had the disease. Three of them underwent,amputations.His son,Gary,is also diabetic. "You can't get a more textbook high-risk case than Sidney,"Dr. Goland said. Though the health care system asks diabetics to become rigorously involved in daily management of their conditions,red tape and the cost of drugs and supplies put self-management out of reach for many patients. As a result,many diabetics either do without or pay out of their own pockets. Some resort to other means to get their supplies. In Indiana,hospital workers organized Diabetes Bingo Night last May to collect money for strips and supplies.In California,F.B.I agents found that diabetics were buying stolen strips on eBay.Last year,the agents charged a couple with mail fraud and accused them of having sold$2.5 million worth of stolen test strips and supplies. In East Harlem,doctors at Mount Sinai were mystified by a number of cases in 2002:patients came into the hospital asserting that they had been testing themselves daily and were sure that their blood sugar was under control.Hospital tests,however,showed just the opposite. "We finally figured out,"said Dr. Carol R Horowitz, an assistant professor at the Mount Sinai School of Medicine, "that patients who could not afford the strips for their blood monitor were buying cheaper strips that were incompatible and that were giving false reads." At least they knew they had'the disease. A third of diabetics do not,in part because doctors do not screen as often as they should,studies show. Since symptoms do not appear for 7 to 10 years on average, the effects of the elevated sugars begin to build and become irreversible. 1V1r. Schonfeld has known about his diabetes for more.than 20 years and prides himself on keeping it in check. "I've seen what it can do,"he said. "So I know better than to ignore it." When Dr. Goland told him to limit the chocolate mousse and frankfurters,he did. When she told him to start walking two miles a day,he did that,too.But her instructions to test his blood at least twice a day were not as easy to follow. W. Schonfeld runs out of strips even though he tries to plan ahead by ordering extras,said Kathy Person,his nurse. "The insurance reps say they don't want the strips to end up on the black market, so they don't let people preorder extras,"she said. The Naomi Berrie Diabetes Center has a full-time staff member who tries to do the clerical work associated with insurance coverage. "Still,it's a struggle to keep up with the paperwork,"Dr.Goland said. Some doctors simply do not have time and patients are left to haggle with insurers-usually unsuccessfully-on their own. http://www.nytimes.com/2006/01/lI/nyregion/nyregionspecial5/lldiabetes.html?pagewanted=print 1/13/2006 Jan. l2 . 2006 9: 33AM .. SUPERVISOR DARK DE SAULNIER No -0455 P. 18 In the Treatment of Diabetes,Success Often Does Not Pay-New York Times Page 7 of 10 Although a recent federal study found that an increasing number of health insurers cover strips,few cover more than one a day,according to strip manufacturers.In fact,a study last year by Georgetown University found that insurance restrictions on strips and other services for diabetics were reducing the quality of care. "I was a businessman for more than 40 years," said Mr. Schonfeld,a former food importer. "What I just don't understand is how these insurance companies can operate the way they do and keep their customers." Sick Patient? Expensive Patient As it turns out,keeping customers who are diabetic is not the goal of most health insurance companies,experts said. Avoiding diabetics is actually more the point. Understanding why,the experts said,requires an appreciation of one of the crucial obstacles to better diabetes care. Most insurers do not operate the way Mr. Schonfeld did in the import business,luring additional customers by advertising a good product at a fair price. Were they to operate in that fashion,health plans looking to grow might advertise better coverage for diabetics,such as a wide choice of blood-sugar monitors. But in the insurance business-and virtually all businesses based on risk-the point is not to attract the most customers but rather the best ones.As businesses,not charities,insurers need to attract healthy customers,not sick ones,said David Knutson, a former insurance executive who studies the industry's economics for the Park Nicollet Institute,a health research organization in Minneapolis. As a result,experts say,insurance executives usually think twice before bolstering their diabetes benefits, for fear they - - will-attract the chronically ill-.- In ll In a 2003 survey, 87 percent of health insurance actuaries queried by Mr.Knutson said that if they were to improve coverage with richer drug benefits or easier access to specialists,they would incur financial problems by attracting the sickest,most expensive patients. "Insurers are as eager to attract the chronically ill as banks are interested in loaning to the unemployed,"Mr. Knutson said. "The chances of losing money are simply too high." insurers are not alone in these concerns.Large employers,many of which devise and finance their own employee health plans,know that their allotted reserves are jeopardized if too much of their work force is seriously ill.Last year,for example, a Wal-Mart executive suggested in an internal memo that the company could reduce costs by discouraging unhealthy people from applying for work. Even when insurers are simply third-party administrators,processing claims but not covering the actual medical,expenses, they try to keep claims down by attracting healthier patients to their plans,Mr.Knutson said. Similarly,coverage for Medicaid recipients, though underwritten by the government,can be subject to the same private- sector pressures.More than 70 percent of Medicaid recipients in New York now receive their health care through private health maintenance organizations that operate under government contract.These H.M.O:s get the same annual flat fee from the government,regardless of whether the patient is robustly healthy or.chronuically ill,thus creating an incentive to attract the healthiest customers. For insurers, the high cost of attracting the sick is far from a hypothetical problem,said David V.Axene,president of Axene Health Partners,a consulting firm that advises these companies.For each additional session of nutritional counseling,he said,an insurer must account for the likely cost of luring sick patients away from its competitors. Mr. Axene cited an example from several years ago when,he said, an insurer became puzzled about why a provider network that it had set up at a Boston hospital was consistently over budget.Mr. Axene's company found that two-thirds http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/l ldiabetes.html7pagewanted=print 1/13/2006 Jaa • 13 . 2006 9 : 3OM SUPERVISOR MARK DE SAULNIER No.U45N . IJ In the Treatment of Diabetes, Success Often Does Not Pay-New York Times page 8 of 10 of the hospital's diabetics had chosen to enroll in that network over others. The reason?The insurer had mistakenly listed an endocrinologist on its network's primary care physician list, he said. "These patients no longer needed to get a referral to see the endocrinologist,and with one visit they could get their general and their diabetes needs filled,"Mr.Axene said.Within months,the netwofk had redrafted its lists, dropping the endocrinologist,.he said. Mohit Ghose,a spokesman for America's Health Insurance Plans, an industry trade association,said insurers were working to improve chronic care coverage.Many have created disease management programs to track their sickest patients and pay bonuses to doctors who show results in treating the chronically ill. "Is there still a long way to go?Yes,-definitely,"Mr. Ghose said. "But we`re on the right track." Some preventive measures would,at first glance,seem sure money savers for health insurers since they might eliminate or forestall expensive diabetes complications drown the road.But many insurers do not think that way.They figure that complications are often so far into the future,insurance analysts say,that many people will have already switched jobs or insurers,or have even died,by the time they hit.As a result,any savings from preventive measures will only go to their competitors anyway, analysts say. In fact, experts say,people generally change their health insurance about every six years. "It's perverse,"Mr.Knutson said. "But it's the reality of there being a weak business case for quality when it comes to handling chronic care." 'Jerry,We Need to Talk' It usually took Dr. Bemstein seven minutes to walls from his office in FiermanHall to the hospital president's office across 17th Street. On Jan.4,2000,he bad a bounce in his step,and it took him half that time,he recalled. He had a good story to tell, and graphs and tables to back it up.The Beth Israel center was an unqualified medical success. In fact,patient loads were growing by 20 percent each month as its reputation spread. When he arrived, Dr. Fink,then the hospital's president,asked the three other executives to take their seats. Dr.Bernstein began talking before he had reached his chair. "Things are really coming along well,"he said as he handed out a spreadsheet."Patients are starting to turn their lives around." Pausing,Dr.Bernstein looked around the table.He was struck by an awkward silence. "Jerry,we need to talk about what is happening at the hospital,"Dr. Fink said. "We're going to have to close your program." Dr.Bernstein cannot say which was more jarring: the news or the way it arrived. Numb,he kept his composure for 25 minutes,he said-The administrators explained that the hospital was running a deficit. The,diabetes program was not helping matters. "It was really not about the medicine but the business,"Dr.Fink said recently about the meeting. "That didn't make it any easier to deliver the news,especially since I had been one of the main advocates behind getting the center started." After the meeting, as Dr.Bernstein walked back to his office,he wondered where he would direct the program's 300 or so http:Hwww,nytimes.coin/2006/01/11/nyregion/nyregionspecial5/1ldiabetes.html9pagewanted=Print 1/13/2006 Jan. 13� 2006 9:34Ah, SUPERVISOR DARK DE SAULNIER Wo-0455 P- 2U In the Treatment of Diabetes,Success Often Does Not Pay-New York Times Page 9 of 10 patients.Still,he remained sympathetic to the hospital's plight. "I was not of the belief that we should save the center only to end up losing the hospital,"he said. For many of the patients,the news was a second strike of lightning.They had come to Dr.Bernstein only after being cut loose by the closing of the St Luke's diabetes center earlier that year.Now they were being cut loose again,, to drift back:to a life of limited care options:understaffed and overwhelmed clinics; general practitioners with too little-time; a city with. about 100 overbooked diabetes educators surrounded by 800,000 patients; and a shortage of endocrinologists,the specialists who are often critical providers of diabetes care. Since endocrinology is one of the lower-paying specialties,there is a national shortage of such doctors.In New York,with its armies of diabetics,patients must often wait months for an appointment with one of fewer than 200 endocrinologists. The poorest patients face the biggest problem,as only a fraction of the specialists accept Medicaid. Once the center had closed,Dr.Bernstein continued to teach at Beth Israel,but he began to devote more and more time to a side project.He was working on an inhaler that delivers insulin in the form of a mist.The product is being developed by Generex,and it is designed to appeal to patients who are reluctant to use insulin because they do not like the idea of injections or needles. But the device will probably cost about 15 percent more than traditional insulin and is likely to be too expensive for many of the poorest diabetics,who are often the patients who need it most because their illness is most severe. "The center was a way to really make a dent in this epidemic,"Dr.Bernstein said. "The inhaler is a promising breakthrough.But it's mostly a business opportunity." Other pharmaceutical innovations are likely to soften the toll of diabetes for many patients in coming years, doctors said. With an average diabetic spending more than$2,500 per year on drugs and equipment,pharmaceutical companies have good reason to focus their attention on the more than$10 billion market in controlling the disease's complications. But there is only so much the drugs can do, they add,if they are not accompanied by the sort of changes in patient habits that the centers fostered through education and monitoring. Health economists suggest that if these preventive measures were practiced on a wide scale,complications from diabetes would be largely eliminated and the American medical system, and by extension taxpayers,could save as much as$30 billion over 10 years. The experts disagree on what such an effort would cost. (Flow 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 reimbursement system that puts the business of chronic care on a more competitive footing with acute care.Experts say this restructuring could_start if government insurance programs like Medicaid began paying more for preventive efforts like education, a move that the private sector would be likely to follow. "Until we address the financing and the reimbursement structure,this disease is going to rage out of control,"Dr. Bernstein said. Not everyone believes the centers were the best answer to diabetes ogre.Even with their demise,many hospitals,clinics and endocrinology practices say they are providing cost-effective,quality treatment. "The care we provide now is on the par with what was offered before," said Dr.Leonid Poretsky,who became director of Beth Israel's endocrinology division after the diabetes program closed. "The main difference is that we are financially viable because half of our patients are not diabetic." http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/1ldiabetes.html?pagewanted=print 1/13/2006 Jan . 12. 2006 9:35AM SUPERVISOR PARK DE SAULNIER No.0455 P . 21 In the Treatment of Diabetes, Success Often Does Not Pay-New York Times Page 10 of 10 These facilities,though,often find themselves in the same position the centers did: financing prevention efforts with profits from the very kidney transplants and amputations that preventive care is meant to deter. It is tough to convince a former patient like Ms.Hammond that the closing of the Beth Israel center was anything but a mistake. She had started to make critical changes in het lifestyle after just a few weeks there. She did not find out it had closed,she said,until several months after the doors had d shut,when she called looking to sign up for a refresher class. She was starting to fall back into old habits. "I needed reminding,"she said With the center gone,Ms.Hammond said she has had to try to muddle through. She goes to the podiatrist once a year,but she said she could not remember the last time she visited an eye doctor. She has gained about 40 pounds. Some days she wakes up and her blood sugar is high. Other mornings she doesn't bother tocheck,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. Copyright 2006The New York Times Company I Home I Privacy Policy I Search Corrections I !XML I Hero 1 Contact Us I Work for Us http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/lldiabetes.html?pagewanted=punt 1/13/2006 G OD -ci o © a ro co CL cn a s7.- GUS '. U N 0 cCD ) O ✓ O ' v -1&1 6) , civ . o tp O v v m to 'G UJ � a � d ✓ .D .� coo 6 cd .d =N � N . C-1. ©c O CL 0 pd7 cn v to � �•� � �? -CS ti co CD O O t3 rn o o N C 1 N co (DISco .a coo � 4 o il'a s, 2'o o m aCD w x o ' -4) 3 m z 46o 0 N _� CL C c o v o- o et o ;14 co 0- G4 i ccs CL Z Jan . 18 ?006 8: 4 9 A M SUPERVISOR DARK DE SAULNIER No.0454 N 1 Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 1 of 10 91je Nettr Mork Unnes nytirrta$.corn January 10,2006 Bad Blood Living at an Epicenter of Diabetes, Defiance and Despair By N.R.KLEINFIELD Santos Al.icea tottered haltingly over to the art shop in East Harlem,his legs screaming.The regulars knew what he was going through.They always did-the diabetes was speaking.He confirmed this with numerical rigor: 228,his nasty blood- sugar reading this morning.Nods all around.They had ugly numbers,too. James De La Vega owned the art shop on Lexington Avenue,near 104th Street, and regarded the sidewalk out front as his living room. There,with his friends and family,he shared a lot over the years:Latino art and culture,the slow cadences of East Harlem life, runs of hard luck.And diabetes. Indeed,in East Harlem,it is possible to take any simple nexus of people-the line at an A.T.M.,a portion of a postal route,the members of a church.choir- and trace an invisible web of diabetes that stretches through the group and out into the neighborhood,touching nearly every life with its menace. Mr.De La Vega, a 33-year-old self-styled"sidewalk philosopher"whose murals and sidewalk chalk drawings are familiar neighborhood ornaments,has a mother with diabetes.His stepfather's case was confirmed in March. And a number of Mr. De La Vega's friends who occupied his chairs or sat in the bordering garden,well,they had it.Mr.De La Vega said he would probably get it,too. In East Harlem, in fact,it seems peculiar if you don't have it. Months spent in the easy company of the shop's dozen or so regulars reveal something more than just the insidiousness of Type 2 diabetes, the disease's most common form Those months, and conversations,disclose with relentless consistency the human behavior that makes dealing with'Type 2 often feel so futile-the force of habit,the failure of will,the shrugging defeatism,the urge to salve a hard life by surrendering to small comforts:a piece of cake, a couple of beers, a day-off from sticking oneself with needles. That.behavior is all the.more evident in East Harlem,a gritty neighborhood where problems back up on people like fallen dominoes. For as bad as diabetes is in New York,it is staggeringly worse in East Harlem.Precise numbers are hard to ascertain,but the prevalence of the disease,factoring in an estimate for undiagnosed cases,has fluctuated in recent city health department surveys between 16 percent and 20 percent, as many as one in five adults. People in East Harlem die of diabetes at twice the rate of people in the city as a whole Diabetes-related amputations are higher than in any other part of New York.For hospitalizations linked to diabetes,East Harlem is the third-worst neighborhood. It has the largest percentage of obese people,whose weight makes them more susceptible to Type 2. The fact that'East Harlem is roughly 90 percent Hispanic and black,groups believed to have a genetic predisposition to the disease, explains part of the problem.There are also other factors:bad food habits, little exercise, rampant poverty and,according to health officials,poor access to medical care. In East Harlem, then,you're in the teeth of ane ip detnic,a place where,as health officials warn of a worsening crisis,you can see the ruins the disease has already wrought. http://nytimes.c-om/2006/O 1/10/nyregion/nyregionspecial5/10diabetes.html?pagewanted=print 1/13/2006 Jan . 18. 2006 8 : 49AM SUPERVISOR DARK DE SAULNIER No.0454 P. 3 Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 2 of 10 Most of the afflicted people in East Harlem have Type 2 diabetes,the focus of this series,which has been linked to obeljV and inactivity,as well as to heredity. (Type 1,which comprises only 5 percent to 10 percent of diabetes cases,is not associated with behavior, and is believed to stem almost entirely from genetic factors.) East Harlem is not just any neighborhood.It is the fabled home of Rao's,the always-booked Italian restaurant,and El Museo del Barrio,which celebrates Latin culture.Early on,it was the repository of Russian Jewish,Irish and Italian immigrants, congealing into the city's hub of Italian life; after World War II, a Puerto Rican influx converted it into Spanish Harlem. Recently,there has been an uptick in Mexican,Dominican and Asian arrivals,and stirrings of gentrification. But the core population that has been its ballast for a half-century is being eroded by forces as powerful as real estate values and immigration waves: a deviously complicated disease,poverty and simple human frailty. 'Then I Started Cheating' The sun was piercing,and the tight banged off the side of the art shop.The air was stippled.with fragrances of fried meat. Crammed inside the claustrophobic interior were assorted paintings,decorated mugs,greeting cards and other oddments. Elsie Matos,Mr.De La Vega's mother,sat out front,her dark hair in a ponytail.The two of them still lived together. She was 56 and worked in the office at a local public school. She discovered her diabetes coincidentally,as many do,nine years ago. A boil on her left thigh refused to heal. A blood test told her what she didn't want to know.Her fasting blood=sugar reading was nearly triple the 126 milligrams per deciliter that defines the illness. She was no stranger to the complexities of diabetes.A few years ago,an East Harlem coalition fighting the disease enlisted her son to sketch some pithy warnings.He did this for brochures; and he scattered chalk drawings across the sidewalks of East Harlem,depicting his barefoot mother in a sun dress and hoop earrings,beseeching people: "Eat well and exercise!" "Test your blood for sugar!" "Check and protect your feet!" It turns out that the woman in his sketches was a version of Ms.Matos that had ceased to exist. She was no longer that thin.And like most people burdened with the disease,whether they lived in East Harlem or Chelsea or Jamaica,Queens, she toggled back and forth between obeying its dictates and ignoring them. When she got the diagnosis,the doctor told*her to shed 100 pounds.With a crash diet she'did just that,slimming down to 150. She stayed thinner for a year. "Then I started cheating," she said. "Sandwiches.Frankfurters.I didn't care. I didn't think it would matter." She was put on pills. Those who have diabetes usually suffer from related conditions,especially high blood pressure and high cholesterol, and often swallow 3 to 10 pills a day.Ms.Matos had high cholesterol and asthma. She was warned that she had to control her lust for calorie-rich food,that taking pills was not enough Doctors like to say that patients can eat their way through the pills.And a cruel truth of diabetes care is that many oral medications prompt weight gain. Oral diabetes drugs also tend to lose effectiveness. They sometimes work for a few years,then have to be teamed with other drugs. Anyone who has diabetes long enough is likely to find herself on insulin. Ms.Matos frowned at her stomach.She said she was 165 or 170 pounds, still too much. "The doctor said if I didn't diet, I'd have to take the insulin," she said."I don't want the needle." Despite that dreaded prospect,she had difficulty satisfying the disease's persistent needs. Among widespread chronic conditions,diabetes is arguably the most arduous to control. Diabetics not only need to take an array of drugs,but must also prick themselves one to four times a day to check their http://nytimes.com/2006/01/10/nyregion/nyregionspecial5/1 Odiabetes.html?pagewanted=print 1/13/2006 Jan -,18- 2006 8 5WA ' SUPERVISOR MARK DE SAULNIER t~o 0454 P. 4 Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 3 of 10 blood sugar,keeping a log of the results,and then adjust their eating habits according to the readings. $food-sugar meters are much improved from years ago,when they had to be plugged in and warmed up for an hour..But some diabetics skip the readings, filling in fake numbers to.show their doctors. For many Type 2 diabetics,doctors say,a half-hour of daily exercise and the loss of as little as 10 to 15 pounds can make a big difference in their health. Still,that can be a formidable challenge. Understandably,people talk about wanting to take a vacation from diabetes,but it grants no time off. Ms.Matos often found herself succumbing to a lifestyle guaranteed to make her sicker.Until it has been in the system for a long time, diabetes doesn't hurt.In East Harlem.,what doesn't hurt is often ignored. She pointed out that many people in her world were stressed out and depressed.There are other serious health issues, like asthma and H13L, the signposts of many poor neighborhoods.Their cobbled-together lives drain residents of their resolve. And so they cede diabetes the upper hand and eat what tastes good to them to counteract the gravity of unhappiness. So if diabetes didn't cause her pain,as it didn't most of the time,then Ms.Matos dismissed it as a problem for another day. "Listen, if I want to eat a piece of cake,I'm going to eat it,"she said. "No doctor can tell me what to eat.I'm going to eat it,because I'm hungry.We got too much to worry about. We got to worry about tomorrow.We got to worry about the rent.We got to worry about our jobs. I'm not going to worry about a piece of cake." Ms.Matos gave a feeble glance at a shopper mulling the mugs and T-shirts. She carried her glucose meter around,but didn't like to use it regularly,especially when she was with friends,a vanity of hers. "It's embarrassing to check your blood in front of people,"she said.It irked her, this machine laying a claim on her. Diabetes,then,had worn her out.She was quite direct about that. "I hate it," she said. "I hate diabetes.I'm tired of checking my blood three times a day." She tidied up some merchandise. 1 "You get used to it,but you know what?" she said. "You don't get used to it." Society of the Sick First Raul Rivera parked his bike,then he slid into a chair.A shadow fell over his face.The street was characteristically cacophonous.The door to the art shop was agape. Diabetes hadn't visited him yet,but his stomach was expanding,and that gave him pause.He knew what diabetes did. It made you somebody else. He was 50 and lived with his mother. She was 66,and after more than a dozen years with diabetes had been hit by its full- court press.Kidney dialysis three times a week.Open-heart surgery.Dependent on a wheelchair. Legally blind.It was Mr. Rivera who had to inject her with insulin twice a day. "She's black and blue from all the needles,"he said.Lately,she had been in the hosRital more than out. Mr.Rivera,after a back injury, quit his job as a parking attendant 15 years ago.He had no income or insurance.He had not been to a doctor in several years. Last time he saw one,he was told he had high cholesterol and given medication.He didn't take it.He didn't like pills. "That's me,"he said. Juan Concepcion, 57,Mr.De La Vega's stepfather,materialized.He had been a truck mechanic,until he became disabled by rheumatoid adWitis.In March,he spent 12 days in the hospital after nearly passing out,and his diabetes became bleakly clear. Ten years ago,his father died of diabetes. "He kept taking sugar,"Mr. Concepcion said. "He kept drinking beer.He was a stubborn guy. They cut one leg at the ankle.Then they took the other above the knee." http://nytimes.com/2006/01/10/nyregion/nyregionspecial5/l Odiabetes.btml?pagetivanted=print 1/13/2006 Jan . 1-8 . 200.6 8 : 50AM SUPERVISOR DARK DE SAULNIER No. 0454 P. 5 Livirig at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 4 of 10 He stared unblinkingly into the distance. "I felt I was too strong for it,"he said. He drew on a cigarette,ashes fluttering in the air.He knew he should quit. Smoking is especially bad for diabetics. "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 makes me lose my mind,"he said. "I'm going to do it slowly. But I know,this is a killing machine." He shook his head, "Everywhere you go here, someone tells nae they have diabetes.I'll go into a store and ask for coffee, no sugar.They say,'Oh,you have diabetes?"' He was having trouble figuring out how to fit the disease's maxims into his life. "I'm trying to give up beer," he said. "I would drink at 7 at night until 3 in the morning,watched boxing and baseball, drinking beer. I drank: 15 or 20 beers in a night." He had been avoiding his drinking buddies. "I have friends who have diabetes and they continue drinking,"he said.His doctor told him to avoid stress."How do.you do that,not put worries in your head?"he asked. "I have to go on living.rve always been a fast guy." Across East Harlem,there is a great range in response to the disease:some diabetics embrace the daily regimens that now frame their lives,many others constantly struggle to. Doctors say the will to fight the disease is often eroded by its psychological toll. Sitting with these men and women whose lives were pervaded by diabetes,one couldn't escape feeling that they shared a dark cosmic joke-that diabetes was too much to master at the individual level in a world that had become so hospitable to it. Mr. Concepcion said: "Everything about this neighborhood,the pollution in the air,it all makes you sick. Don't get me wrong,we love this place,we love Spanish Harlem.But it does stuff to us.Now it's giving us all diabetes." e Mr.De La Vega nodded. "We love eating trash,"he said. "We grew up eating McDonald's, and I still find myself eating candy and chocolate cake." People got huffy-about their doctors. "Mine tells me; 'Lose weight,exercise more,'"Ms. Matos said. "Let him live my life and,see." Mr.Rivera said: "You know what I think?I think there's a cure.We're the poor,so they don't want to give it to us." Mr. Concepcion rubbed his forehead.."Since I got the diabetes,maybe twice a week I sit down and pray,"he said. "Because if I don't take care,I'm going to go down the drain.I put myself in God's hands." Mr.Rivera bathed Mr.De La Vega with an odd look: "Did Mike have diabetes?The guy who passed away?" Mr.De La Vega said,"Yeah,he had it" . "He was,like,300 pounds." "He would brag about eating a pint 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-four." http://nytimes.com/2006/01/10/nyregion/nyregionspecial5/l0diabetes.html?pagewanted=print 1/13/2006 Jan 18 . 2016 8: 51 AM' SUPERVISOR MARK DE SAULNIER No.0454 P. 6 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 morning rain.His real name was Luis Hernandez. His job was route supervisor for a produce company. He was a veteran member of the art-shop crowd,and now a new admission to its diabetic subset. His vision had been getting a little blurred-he'd look at a paper and it was like 3-D vision; one morning he woke up and one eye wouldn't focus-and a physical found the source. "When they told me,it was like somebody punched me in the gut,"he said. His diabetic mother died in 2004,at 59.She had done little to address her condition. She continued to smoke and eat generously. He was confused.He said his doctor put him on pills and suggested avoiding juice or sweets,but didn't tell him much more. He weighed 252 when he got the news.He had cut it to 245.He knew it should be lower.But he found it excruciatingly hard to adopt a new rhythm of life,particularly since it was less appealing than the one he had. Bigwig had to go. Maria Calderon stopped by to visit Elsie Matos. Give her a moment. Ms. Matas was waiting on a young woman torn between two T-shirts. Yes,Ms. Calderon had it,too. Seven years since the diagnosis. She was 69. She was 210 pounds, and had been told to lose weight. "I didn't think it was important,"she said. Then,more than.a year ago, a solution presented itself,and it was the worst kind.Her grandson was killed in a holdup over a car. Devastated, she lost her will and her appetite. She shed 60 pounds.Now she was gaining again,six pounds in a month. "How can you worry about your health when you don't know where you're going to live next week?"she said. Shq watched Ms.Matos help the customer. "We are the poor people," she said. "We only get the crumbs.I used to advocate a lot. I got tired.I don't do it anymore. I'm not tired in my heart. I'm tired in my body." She said to Ms. Matos: "I have a friend, she's diabetic and everything else. She takes 52 pills a day.She has everything in the book.When she calls,she wants to talk for 99 hours.I say: 'My sister's calling.I've got to get off.' " Ms.Matos said: "What,52 pills?She's nuts." Frank Gonzalez had something to say.He was 77,compact,peppy.He used to work as a security guard at a hospital,had clocked 16 years with diabetes. When things were not going well,as they weren't now,you could see the fanned-up embers in his eyes. Hear his speedy voice:"Diabetes is the worst disease I've ever seen.You can't trust it. Two weeks ago,I got all messed up.You know why?I've got two machines.One gave me a reading of 150.The other machine gave me 130. I said this can't be.So I changed the batteries on both machines. You've got to keep an eye on your machines." He went on. "Diabetes is something you have to look at from all sorts of angles. It takes a long time to find out the real truth. And you know what?You never find out the real truth." http://nytimes.conV2006/01/10/nyregion/nyregionspecial5/l Odiabetes.html?pagewanted=print 1/13/2006 J8- 2006 8 : 51AM SUPERV MR 1ARK DE SAULNIER ho,0454 P . 7 Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 6 of 10 He went home, a couple of blocks away,to take a blood-sugar reading.He opened a hallway closet,wedged full of supplies-test strips and lancets and pill bottles and batteries. Most,but not all for diabetes. He showed a bottle: Viagra. Opened it and smiled:half-full. He inserted a strip into his machine.He swabbed his ring finger with alcohol,then pricked it with a lancet. The machine counted down 45 seconds.The reading: 152.High.He stared balefully at the number. "It could be I've been sitting too much,"he said. "I should be out and walking. I don't know,I was going to do the Cleaning." A Geography Lesson A few things to notice. On Third Avenue,around the comer from the art shop,a banner outside McDonald's proclaimed, "S 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 art-shop gatherers sometimes talked about 96th Street,the tangible southern divide of a neighborhood and of a disease.Go north of 96th Street and you enter a constricted world laden with poverty.Go south and you find promise and riches,thin not fat,the difference between East Harlem and the Upper East Side,the difference between illness and health. Go north and the chances of bumping into a diabetic are maybe 20 times greater than if you go south.For the Upper East Side,according to the health department,has the lowest prevalence in the city,about 1 percent In East Harlem„people sometimes have to choose between getting their diabetes medication and eating.They sometimes share their pills,cut them in half and take half-dosages..They improvise. Everywhere blare the signals that the best meal is the biggest meal. Nutritious food exists,but it isn't easy to find.Dr.Carol R.Horowitz,an assistant professor at Mount Sinai School of Medicine,heads an East Harlem coalition trying to improve diabetes care. She oversaw a study several years ago that tracked the availability of diet soda,low-fat or fat-free milk,high-fiber bread,fresh fruit and fresh vegetables in food stores in East Harlem and the Upper East Side. Stores on the Upper East Side were more than three tunes more likely than those in East Harlem to stock all five items.It did not seem to matter that East Harlem has more than twice as many food stores per capita as its wealthier neighbor to the south. Diet on the Down Low All the same,it was worth asking:Why not stop with the doughnuts and fried calories and eat salads,drink diet soda? lames De La Vega laughed. "We've got cultural differences,"he said. "Here,for a guy to eat a salad,he's a wimp.He'll eat a big portion of rice and beans and chicken.The women can't be chumps,either.A woman can eat a salad but has to eat it on the low. She has to do it quiet.They make fun of you:What are you, a rabbit?" What's wrong with an orange? Mr.De La Vega said: "Oranges are.messy.You dirty your teeth." Uncontrolled diabetes is a forced death march.Literature handed out in the community underscores this. Knowledge alone,though,is never enough to change behavior,particularly in an overwhelmed neighborhood.Chocolate cake may be a risk, but it tastes so good on a bleak day. What stops that? http://nytimes.com/2006/01/10/nyregion/nyregionspecial5/10diabetes.htanl?pagewanted=print 1/13/2006 pan 18- 2 010 6 8 : 52AN' SUPERVISOR DARK DE SAULNIER N0-0454 P - 8 Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 7 of 10 Mr.De La Vega said: "People ultimately feel powerless about a lot of things.People think about bigger things.They think about survival.Kids grow up fighting in the streets, so you want to raise big,strong kids. So you give them three pork chops,a nice tall glass of soda to make them strong.You realize,some of these people go to prison, and they have to be strong.They eat and they eat.Nobody teaches them about diabetes." "I have two nieces,"Ms.Matos said."They're 24.I call them the sumo wrestlers. They eat everything." Mr.De La Vega said: "A lot of people eat on the streets.I eat breakfast on the street and lunch on the street, and sometimes dinner.I have hot dogs.I had two today." His mother said,"If you drink a diet soda and a man is watching,he'll say, 'Why-you drinking that?' " Mr.De La Vega said: "Nobody here goes out and gets an apple.They get cake.People here associate diet as unhealthy.If you're dieting,then you're sick. You look at the people on the streets,they're heavy. That's the way we grow up here." Mr.De La Vega was silent,listening to the boom box.He said: "Around here,if you make it to 40,you think,hey,I'm lucky,I made it to 40. You have to understand,the philosophy out here is we're going to die from something." Young and Unconcerned At times the art-shop regulars pondered what diabetes meant for the neighborhood's young.They surveyed the pudgy children sauntering past and shook their heads. And so,a not uncharacteristic East Harlem story.A couple of blocks away,on East 102nd Street,lived Xiomariz Downs. She was 15,sweet and polite. She weighed 287 pounds. She lived with her mother,Olga Pagan,her grandmother,her brother,her sister and two cousins in an apartment not intended for that many people. Someday,she said,she wants to be a missionary or a beautician. On a Thursday,after school, she was in sweatpants at the Bally gym near her home, her second day in an attempted fitness regimen.'Her grandmother had p rolled 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 IW—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. Doctors had been hectoring her for years,saying that if she didn't lose weight she was going to end up with diabetes. But she didn't feel sick. She wasn't worried about what might happen at 40. She was a teenager,with teenage hauteur,living in the now. Again she was told to diet.Her mother said Xiomariz was"on the see-food diet- every food she sees,she eats."Her mother felt frustrated: "I want her to go live with her father and have him knock some sense into her-literally."He, too, had diabetes. Xiomariz didn't mind her weight. "I feel my weight makes me look like me," she said. "So I don't have to look like those skinny people." Not long after starting,in fact,she quit the gym-,too much time and too much money. She didn't comprehend the terror of the disease. "I know you can't pass it like kissing someone or something,"she said. Some mornings,rushing,she neglected to take her pills. She had stopped checking her sugar. She said she had lost the meter. http://nytimes.com/2006/01/10/nyregion/nyregionspecial5/10diabetes.html?pagewanted=print 1/13/2006 J 3 . 2006 8 : 52AI„ SUPERVISOR (SARK DE SAULN 0 No. 0454 P. 9 Living at an Epicenter of Diabetes,Defiance and Despair-New York Tinges Page 8 of 10 Was she worried about her diabetes? She moved her head from side to side. "Sometimes I forget I have it," she said.."It's not that big a deal." What other disease would she compare diabetes to?She thought a moment,and found the answer. She said, "A cold." Veterans,and War Stories Santos Alicea had not been by the art shop in days.He was usually around so often that he seemed part of the 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 laundry and as a security guard,until he had a heart attack. He plopped down onto the brick ledge beside the art shop. "I'm killing tinge,"he said.He gave a craggy grin. He settled his walker before him. "The circulation is no good in my legs,"he said.He rubbed them. He unabashedly admitted that good management of his diabetes often seemed like a drama of grand futility. "I got 200 this morning,"he said,reciting his latest reading. "Not good.Maybe I ate the wrong thing.I had rice and beans last night. It was good." He was talking to Tose Castro,52, a squat man with a grizzled face,worlds of feeling in his eyes. "I got it,too,"he said. "Yeah, I got the diabetes." The diagnosis came six years ago.Was he monitoring his sugar? "I check once a day or every two days." How was it? He laughed. "Been a little high,"he said. "I started eating Frosted Flakes. What can I say?I like them.You can't always be eating things without sugar. Sometimes,you have to take a chance." He used to deliver flowers,but stopped a few years ago after having a liver transplant. Besides insulin,he took 10 pills a day. He took a drag on a cigarette.He said he was working on quitting.His method,he said,was to sleep a lot. "Sometimes,I sleep all day,"he said. .. He bore a visible scrape on his left arm.His.circulation was bad and he sometimes saw double. "I'll be watching TV and I'll see two images, he said. "I have to wink to see the show." He had fainting spells,falls.Thus his bruised left arm.lie showed another mark on his right arm and one above his eye. "The other day,X took my blood count and it Was 40,"he added. "My son took me to the hospital. They said I may have forgotten to take my insulin.I don't know. I don't remember." He used to keep a log of his readings,but quit. Why? "I don't know,"he said."So many things you have.to do. It gets boring." A mariachi band arrived in the garden and began to play.Mr.Alicea and the others tapped their feet. http://nytimes.com/2006/01/1 0/nyregion/nyregionspecia.15/l0diabetes.html?pagewanted=print 1/13/2006 Jan - 12 . 2006 8:52AM SUPERVISOR DARK OE SAULNIER ho.0454 P . 10 Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 9 of 10 As New York got ready for its evening routines,Mr.Alicea tired,his eyelids sailing down,and he returned to his two- room apartment across the street.His furniture was plain.Bare bulbs protruded from the ceiling.Mr. Alicea shared the place with his older brother,Pedro. He,too,had diabetes.His vision was poor,his circulation was not good,he had asthma,he had a weak heart. A while ago, he had fallen and broken his arm and hit his head, and had not been himself since. "He's like a baby,"Mr. Alicea said. "He's supposed to use insulin,but he doesn't like the needle." He didn't like to prick his finger to check his sugar level, so he had no idea what it was.Pedro didn't go out much.No scale was needed to judge that he was obese.He watched TV,one more soap. A home attendant helped care for them. She had dinner on the stove,cream of tomato soup.The dining table was shoved against the wall.Resting on it was a box of corn flakes and a container with doughnuts. The phone rang. Santos spoke briefly. "My daughter,"he said when he hung up.He said she lived in the Bronx,and worked as a waitress near Yankee Stadium. "Yes,my daughter,"he repeated. "She has diabetes." Racing Against the Blade There is no way to talk about diabetes without talking about money,because they are interwoven.The story with Fernando Salicrup was the foot and the money. Go see him,Mr.De La Vega had said.He'll tell you something about diabetes. He was an artist, too,58. He did computer-assisted art,printed out his efforts on a big Epson printer in the back of his apartment. He got the diagnosis 20 years ago.His mother and grandmother died of diabetes complications. "They told me about diet and exercise," he said. "But you're a young man, and you don't listen.I didn't take it very seriously." He had no insurance,either,and so he took his medication when he could afford it,tested himself when he could afford it. He got a drink.He walked slowly,with a cane.He told the story.Nearly two years ago,overseas for an art exhibit,he twisted the big toe on his right foot on the cobblestone streets.It became infected. When he finally got to see a doctor,the toe had to be removed,along with two others..The infection spread,and he lost the final two. "All the things you take for granted,you have to give up,"he said. "Dancing. You have to plan things out, take things slow. It's not just that they operate on your toes. Your veins aren't working properly. You don't have feel." He was worried about his vision.An artist without eyes,that was tough to imagine.He mentioned a sad case,a jazz drummer he knew.He had diabetes and had to have a hand amputated.His hand,his livelihood. When he had the amputations,Mr.Salicrup was in the hospital a month and a half,amassing medical bills he put at more than$300,000.It was an amount in some ways laughable to him,because he expected never to pay it off in this lifetime, but at the same Time he knew it was a serious matter. He gave something each month,and it constricted his life,hanging over him like a sentence.He had since acquired insurance,for which he paid stiff premiums. "You make choices,"he said. "Instead of buying sneakers,you stay with what you're wearing.I've got to stay ahead of the blade." ` He massaged his leg.Diabetics, often with subdued feeling in their legs,don't realize they have cuts until irreversible infections set in. Doctors caution that they should check their feet daily,using a mirror if they can't see past their stomachs. That they never go around barefoot.That even abrasive socks can lead to an infection. That a simple toenail- http://nytimes.corn/2006/O1/10/nyregion/nyregionspecial5/1 Odiabetes.htznl?pagewanted=print 1/13/2006 Jan - 18. 2006 8 : 5 3 A M SUPERVISOR DARK DE SAULNIER No-0454 P. li Living at an Epicenter of Diabetes,Defiance and Despair-New York Times Page 10 of 10 clipping mishap can escalate into an amputation. Five toes gone,Mr. Salicrup didn't want to lose more.He did his best,he said, to tame his illness. He never cut the toenails on his left foot.He paid a podiatrist.He still had a hard time wrapping his mind around that:Here he was,a grown man,paying somebody else to clip his nails. One Fewer Shop*One More Ghost The city seemed caught in overcooked air.The art-shop regulars were out,the usual byplay. A gaunt man was selling Gillette razors out of a backpack: $7. Interested,Santos Alicea dug out some bills and took one. Mr.Alicea mentioned that another diabetic had died the other day.A massive heart attack,and the man became one more diabetes ghost to haunt the neighborhood. Elsie Matos was displeased with her blood sugar.It was mercilessly high. Raul Rivera, wearing a smudged T-shirt,began watering the garden's plants, swishing.the spray back and forth. How was his mother?.Bad,he said.Very bad. Bigwig said that he had shed some weight,was getting used to one-and-a-half spoonfuls of sugar on his corn flakes instead of four.But also,he had stopped taking his diabetes pills,not wanting to get too used to them,not knowing if that was right or wrong. James De La Vega's art shop closed at the end of Augusta Word arrived that the space would become a hot-dog place.Mr. De La Vega moved down to the East Village. The regulars frowned on the displacement. "Just what the diabetics need;" Ms. Matos said. "Hot dogs." Copyright 2O06The New York Times Company I Home I Privacy Polley I Search I Correctlons i XML I Help Contact Us Work for us http://nydmes.com/2006/01/10/nyregion/nyregionspecial5/10diabetes.html?pagewanted=print 1/13/2006 ter' �- ee��� 1Ci•�'7 i • C A L I FORNIA ASSOCIATION January 24, 2006 Contra Costa County Board of Supervisors Supervisor Mark DeSautnier 2425 Bisso Lane, Suite 110 Concord, CA 94520 RE: Item #D.2 - Request for Continuance Dear Supervisor DeSaulnier, On behalf of the California Restaurant Association, 1 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 Golden 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 dine out, California's 81,000 restaurants are responding to consumer demand with even more menu options. The California Restaurant Association was not made aware of this study and would like 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 for your consideration. Sincerely, Johnnise Foster Downs Director of Local Government Affairs California Restaurant Association CC: All members of the Board TOTAL P.©2 J � � CALIFORNIA T / r ASSOCIATION TO: Clerk of the Board From: Johnnise Foster Downs Local Covernment Affairs Director California Restaurant Association Phone:916.431.2720 Fax:916.447.6182 jdowns@cairest_org! www.cal rest.orct. Fax: 925.335.1913 Pages 2 (including Cover) Phone: 925.335.1900 Date: 1!2412006 Re: Item D.2--Request for a Continuance CC.- 0 C:❑Urgent Rl For Review 12 Please Comment ❑Please Reply D Please Recycle Confidentiality Note: This facsimile transmission contains information from the California Restaurant Association that may be confidential or privileged The information is intended to be for the use of the individual or entity named above. It you are not the intended recipient, please be aware that any disebsure, copying,distribution or use of 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. Dear 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. ;ohnnise Foster Downs Local Government Affairs Director California Restaurant Association Phone:976.ei3i.272o Fax:916.447.0182 jdowns@calrest.org i www,calrest.org tJl ` C a 911�OI2NI A' oz o ZHQ � � � .� o c 7a „t► � ,�► o, � o CON Q �► O a THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY, CALIFORNIA January 24,2006 Adjournment On this day the Board of Supervisors adjourned the meeting in memory of Pioneering environmental activist Jean Siri who died Friday of natural causes near her San Pablo home. She was 85. Siri was a persistent advocate of public access to East Bay parks and the eastern shore of San Francisco Bay, but she was equally determined to fight industrial pollution in West Contra Costa County and to build programs tc help the homeless. She was mayor of El Cerrito twice during the 1980s and a member of the East Bay Regional P directors from 1992 until her death. Born March 11, 1920, in Lakota,N.D., Siri graduated from Jamestown College with a degree in biology in 1942. She spent two years in the Navy and on Dec. 3, 1947,married William Siri, a nuclear physicist who became a famed mountaineer and president of the Sierra Club. Despite the towering figure her husband cut in the Bay Area during the formative years of modern environmentali spent seven years as a staff biologist at Lawrence Berkeley Laboratory, did not sit on the sidelines. She was part of an era when East Bay women played a particularly prominent role in fighting development arounc the Bay and on Mount Diablo. "Save the Bay was built by women and she was a good example of the kind of won accomplish things that men said were impossible,things like saving the Bay," said David Lewis, executive directc of Save the Bay. William Siri died in 2004. As a couple,the Siris were a powerhouse in the modern environmental movement as it was taking shape in the Ba Area during the 1950s, 1960s and 1970s. In the 1950s, Siri, Barbara Vincent and Lucretia Edwards formed a trio t battles to stop development along the Richmond shoreline. They also organized early efforts to fight for cleaner air around western Contra Costa's refinery and chemical plants. "They lived history, and they lived it well," said Susan Prather, an advocate of the homeless who in the 1980s teamed up with Siri and Fancheon Christner to form a group patterned after the earlier trio. "We made it our business to tell people about homelessness," Prather said. "Jean never stopped raising hell." Contra Costa Supervisor John Goia said even when he disagreed with her, Sin's blunt honesty was refreshing. "I think she just cared about improving the place in which she lived," Goia said. "You knew how she felt, and she meant it." THIS IS A MATTER FOR RECORD PURPOSES ONLY NO BOARD ACTION WAS TAKEN W Ems � lcr s�Di MISS lot UA { �FOfiNIA+. � 3R-t ► �. MS rC a '� CTS Was .� O � N � �� � � � � �•� N-y o N C�� M � � n +'A ',"� 'r .-t ""3-� D� `ems{ N •* N � d� � rq- :'� � LAd �a GiNtG toVr°o• � ��' � m ''G d �� Q N �. d O Gu' � a �O N " • y � r' O� �� i� 'r a � `°•° � � N w °coo ° °' ter• � �d a�' �� �•� �`oE `4 N • co CY� O ¢' � � O ~' P• co co ,-� p,w '� ty =,� T G • � `° ✓ � a,as ,-�� � a �"�� ° ° %' '' � °G :' o O `� 43 sv co r3 co d .t n cv r• ''. N oQ oo � w cao � r!> o. ,� �.•°'• � �' •ted '� �.� � C� CGw d° ",� R L'S O ✓'�a. r✓�tt" +-,��" �' ¢' c�i�•SCD o }V W t9 �'�p N n Q' Q+ N `'�• N O N (id O V' n .� V�] y� . (9 �" �. �+ �. rWS N`t3 ✓' `S pj UQ `y.;am.}e V N ✓ ^5� �/1 r' �". c� d N r' r•� O' p., `� "a� w'r• /� O ^ N •rG Nye C . Cl Olt '�' O � �' W � � ✓ pn� v' rd o �'+'� 'r� O' � fD '�' l N � � � � �d K � f. �• � o�- � G'" � ✓ O � � Q Cly '00, co �3• cmc G ° � G r io P cdo �0 uo co d `c e G eco c/� G' co m o CD o - m cNo y K3 c� U O G tto �• �-' a� co KS p' ¢• rot �d W G +t CP o ✓ ° � s °' a � °�H o �, o '°:�+ °py,. phi rn� 4 "d `� � �" N � � fit', a �.✓ r fi+ C� N u' a m And as the city started to ex perience a period of major ex- pansion Grimes adapted with it. Grimes and her husband had EP_,ITAP Hf ,* THE TIMES come to Pinole in 1956'and;she Elizabeth was already active.in the PTA' r= Beaty"Mae1,61 and the local League of"Women i Gnmesr� R # ua ° Voters chapter when discussion BORN` ® e began in 1960 about make g.the" June 28 _ city clerk-appointed,"I didn't be- 1924kPatter �" �� clerk lieve in that," Grimes said in s N �� ' 1989."I tried-to get.some native Ot DIEO Jan Gdme ° women, some sharp women to �17'infinole,,,11 run for the lob They wouldn t. N SURVIVORS Daughter Nancy So I ran myself Henderson of Antioch sonRoger . "She loved polittis,r said Dawn ,Grimes of Coupev�{Ie Wash{ason Abrahamson;who was hired by . Richaro Grimes of Pinole and3son Friends and family Grimes in 1985 as an assistant in Peter GnmesShe is'also suivroedd ? the city clerk's office She was a by 11�granddhildten and i6 reat remember her as a devout Re"ublican I;often told ,�rand'children 9 no-nonsense official Be she was on the wron side g SFS" �MIN Betty g 5_1 1Sj1' FdFngjand iier1 of the dais.,She"should have been Ion'to attend v to Ion' on, By Chris Treadway on the council. 1'16 8;p m Montlay Md�funeral�;t . TIMES STS WRITER Grimes was known for a no- �sennces at 1 p'K Tuesdayfat�., Betty Grimes;whose name nonsense attitude when it'came Cnnc Center Cfiapel ofi Wilson, ' was synonymous with city gov- : to city affairs. "They called her AAratzer Mo tuar es 455 24th St I ernment in Pinole,died Tuesday. the friendly barracuda;'.'said:her �Rlchrriond InteFnment�will�be held. She was 81. son Richard.Grimes cat GoldenGateeNahonai Cernetery'( 'I Grimes was Pinole's city clerk "She scared more than. a few on�Ttursdayy � for 38 years,first running for the reporters,' Abrahamson said".' then-elective office in 1960. But "She could be gruff in r at4re:but ; ' Jersey,where her_mother was a' her duties, especially in the be- deep inside she wasn't that,way, - ginning,covered much more. She was a teddy bear at heartw ! suffragette.During World War.II she enlisted in the,U.S. N'avy,, When she came into the of- Even city officials could.be a. lice,Pinole's population was just for it if Grimes thought.tliings',; serving as a captain's,yeoman.T, greater than 6,000 and govern- werent being done properly:;.:.,,;,- band - at the Navy xlandingas well as playing in;a,dance,,' ment was minimal, consisting I 'She wasn't afraid to.set,the primarily of a building inspector City Council straight at meetings,". equipment depot that temporar and "probably no more than ! said Abrahamson;who succeeded: Y occupied'Golden G..,I ells eight police officers,"said former Grimes before becoming,Pleasan`. in Albany. '` ' s' City Councilman Jack Meehan. ton's city clerk."When she'felt' . It was her'fust tune in th6 Bay There was no city manager the had conducted a meefin or Area, and that'was where Ste. and the city clerk was an Elected made a.decision ii appropriately_ metfuture husband Charles, Position that was part-rime and, she would.let them;know;:, paid little. Pinole's new City Hall:opened "She outranked my Dad,'!); "When she started,there was shortly before her retirement m Richard Grimes said.,:;_:! + just the old adobe building down- 1998,and the City,Council Cham' .j After•the war she returned to I town,"her.son,Richard Grimes hers were dedicated'in her named.. the East Coast and pursued mu- said. "There was no'foohng aiouiid sic as a livelihood,playing bass "She prepared budgets for the with Betty,"Puiole-Mayor.Betty_ and smgrng:,;with performing various departments,she was the Boyle said.."If she told you.some-, groups.But by...1947.she had'mar- finance director,she was the per- thing,that's the way,rt was:She ried and headed west;_settling in sonnel manager,"said Meehan. did an excellent job.She.kept the i.. El Cerrito be6'ie ovrng to Pinole "The city manager does all that council out of trouble ,. is I.1 Reach Chris Treadwa at stuff now.Betty was the de facto At the same time,those who: Y< < ctreadway@cctimes;com or city manager.I would say she co- knew Grimes knevr>she also had a ordinated the city.administration pla 510 264 2784:` r;,l.•; yful side "She laved to play for almost the next 30 years." jokes on people;". rahamson said. .It was a task she accomplished Born Betty.Williams,she was. while caring for four children on raised in a political family in New her own after her husband, -_ Charles,died in 1963."She raised four kids and paid off the house in 27 years, not 30," Richard Grimes said."'That's amazing,be- cause we.weren't easy." � N W N tll LIS' Qy �' 'r` ►`` ,¢ p 4 0 -0 0 .co 4 O oca0 -0 U M ONCl' E 4D 0 o N o `►- o N 5 C1 ul �Gt1 ti.. cC CL co Cd uy O � N -!3 0 13) CS ill 01 cn co U. 0 1.- -00) � O p 00) 0 ns s cd ed :► ai � �� � o a (k) o ui © C6 N' co .Q► co o s s7 moicocn . -a p p 4- © 0 CO O^ G to t0-1- U v N 0) N 0. 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