Diabetes and Its Awful Toll Quietly Emerge as a Crisis: PART 1 OF 3
By N. R. KLEINFIELD Published: January 9, 2006
Begin on the sixth floor, third room from the end, swathed in
fluorescence: a 60-year-old woman was having two toes sawed off. One
floor up, corner room: a middle-aged man sprawled, recuperating from a
kidney transplant. Next door: nerve damage. Eighth floor, first room to
the left: stroke. Two doors down: more toes being removed. As always,
the beds at Montefiore Medical Center in the Bronx were filled with a
universe of afflictions. In truth, these assorted burdens were all the
work of a single illness: diabetes. Room after room, floor after floor,
diabetes. On any given day, hospital officials say, nearly half the
patients are there for some trouble precipitated by the disease.
An estimated 800,000 adult New Yorkers - more than one in every eight
- now have diabetes, and city health officials describe the problem as
a bona fide epidemic. Diabetes is the only major disease in the city
that is growing, both in the number of new cases and the number of
people it kills. And it is growing quickly, even as other scourges like
heart disease and cancers are stable or in decline. Already, diabetes
has swept through families, entire neighborhoods in the Bronx and broad
slices of Brooklyn, where it is such a fact of life that people
describe it casually, almost comfortably, as "getting the sugar" or
having "the sweet blood."
But as alarmed as health officials are about the present, they worry
more about what is to come. Within a generation or so, doctors fear, a
huge wave of new cases could overwhelm the public health system and
engulf growing numbers of the young, creating a city where hospitals
are swamped by the disease's handiwork, schools scramble for resources
as they accommodate diabetic children, and the work force abounds with
the blind and the halt. The prospect is frightening, but it has gone
largely unnoticed outside public health circles. As epidemics go,
diabetes has been a quiet one, provoking little of the fear or the
prevention efforts inspired by AIDS or lung cancer.
In its most common form, diabetes, which allows excess sugar to build
up in the blood and exact ferocious damage throughout the body, retains
an outdated reputation as a relatively benign sickness of the old.
Those who get it do not usually suffer any symptoms for years, and many
have a hard time believing that they are truly ill. Yet a close look at
its surge in New York offers a disturbing glimpse of where the city,
and the rest of the world, may be headed if diabetes remains unchecked.
The percentage of diabetics in the city is nearly a third higher than
in the nation. New cases have been cropping up close to twice as fast
as cases nationally. And of adults believed to have the illness, health
officials estimate, nearly one-third do not know it. One in three
children born in the United States five years ago are expected to
become diabetic in their lifetimes, according to a projection by the
Centers for Disease Control and Prevention. The forecast is even b!
leaker
for Latinos: one in every two.
New York, perhaps more than any other big city, harbors all the
ingredients for a continued epidemic. It has large numbers of the poor
and obese, who are at higher risk. It has a growing population of
Latinos, who get the disease in disproportionate numbers, and of
Asians, who can develop it at much lower weights than people of other
races.
It is a city of immigrants, where newcomers eating American diets for
the first time are especially vulnerable. It is also yielding to the
same forces that have driven diabetes nationally: an aging population,
a food supply spiked with sugars and fats, and a culture that promotes
overeating and discourages exercise.
Diabetes has no cure. It is progressive and often fatal, and while
the patient lives, the welter of medical complications it sets off can
attack every major organ. As many war veterans lost lower limbs last
year to the disease as American soldiers did to combat injuries in the
entire Vietnam War. Diabetes is the principal reason adults go blind.
So-called Type 2 diabetes, the predominant form and the focus of this
series, is creeping into children, something almost unheard of two
decades ago. The American Diabetes Association says the disease could
actually lower the average life expectancy of Americans for the first
time in more than a century.
Even those who do not get diabetes will eventually feel it, experts
say - in time spent caring for relatives, in higher taxes and insurance
premiums, and in public spending diverted to this single illness.
"Either we fall apart or we stop this," said Dr. Thomas R. Frieden,
commissioner of the New York City Department of Health and Mental
Hygiene.
Yet he and other public health officials acknowledge that their
ability to slow the disease is limited. Type 2 can often be postponed
and possibly prevented by eating less and exercising more. But getting
millions of people to change their behavior, he said, will require some
kind of national crusade.
The disease can be controlled through careful monitoring, lifestyle
changes and medication that is constantly improving, and plenty of
people live with diabetes for years without serious symptoms. But
managing it takes enormous effort. Even among Americans who know they
have the disease, about two-thirds are not doing enough to treat it.
Nearly 21 million Americans are believed to be diabetic, according to
the Centers for Disease Control, and 41 million more are prediabetic;
their blood sugar is high, and could reach the diabetic level if they
do not alter their living habits.
In this sedentary nation, New York is often seen as an island of thin
people who walk everywhere. But as the ranks of American diabetics have
swelled by a distressing 80 percent in the last decade, New York has
seen an explosion of cases: 140 percent more, according to the city's
health department. The proportion of diabetics in its adult population
is higher than that of Los Angeles or Chicago, and more than double
that of Boston. There was a pronounced increase in diagnosed cases
nationwide in 1997, part of which was undoubtedly due to changes in the
definition of diabetes and in the way data was collected, though there
has continued to be a marked rise ever since. Yet for years, public
health authorities around the country have all but ignored chronic
illnesses like diabetes, focusing instead on communicable diseases,
which kill far fewer people. New York, with its ambitious and highly
praised public health system, has just three people and a $950,000
budg!
et to
outwit diabetes, a disease soon expected to afflict more than a
million people in the city.
Tuberculosis, which infected about 1,000 New Yorkers last year, gets
$27 million and a staff of almost 400. Diabetes is "the Rodney
Dangerfield of diseases," said Dr. James L. Rosenzweig, the director of
disease management at the Joslin Diabetes Center in Boston. As fresh
cases and their medical complications pile up, the health care system
tinkers with new models of dispensing care and then forsakes them,
unable to wring out profits. Insurers shun diabetics as too expensive.
In Albany, bills aimed at the problem go nowhere. "I will go out on a
limb," said Dr. Frieden, the health commissioner, "and say, 20 years
from now people will look back and say: 'What were they thinking?
They're in the middle of an epidemic and kids are watching 20,000 hours
of commercials for junk food.' "
Of course, revolutionary new treatments or a cure could change
everything. Otherwise, the price will be steep. Nationwide, the
disease's cost just for 2002 - from medical bills to disability
payments and lost workdays - was conservatively put by the American
Diabetes Association at $132 billion. All cancers, taken together, cost
the country an estimated $171 billion a year. "How bad is the diabetes
epidemic?" asked Frank Vinicor, associate director for public health
practice at the Centers for Disease Control. "There are several ways of
telling. One might be how many different occurrences in a 24-hour
period of time, between when you wake up in the morning and when you go
to sleep. So, 4,100 people diagnosed with diabetes, 230 amputations in
people with diabetes, 120 people who enter end-stage kidney disease
programs and 55 people who go blind. "That's going to happen every day,
on the weekends and on the Fourth of July," he said. "That's diabetes."
One Day in the Trenches
The rounds began on the seventh floor with Iris Robles. She was 26,
young for this, supine in bed. She wore a pink "Chicks Rule" T-shirt;
an IV line protruded from her arm. For more than a year, she had had a
recurrent skin infection. The pain overwhelmed her. Then came extreme
thirst and the loss of 50 pounds in six weeks. In the emergency room,
she found out she had diabetes. She was out of work, wanted to be an R
& B singer, had no insurance. It was her fourth day in Montefiore
Medical Center. Her grandmother, aunt and two cousins have diabetes.
"I'm scared," she said. "I'm still adjusting to it."
Next came Richard Dul, watching news chatter on a compact TV. Now 64,
he has had diabetes since he was 22. A month before, he had a blockage
in his heart and needed open-heart surgery. He was home a few days, but
an infection arose and he was back. Postoperative infections are more
common with diabetes. This was his 21st straight day in the hospital.
Here, then, was the price of diabetes, not just the dollars and cents
but the high cost in quality of life. Simply put, diabetes is a
condition in which the body has trouble turning food into energy. All
bodies break down digested food into a sugar called glucose, their main
source of fuel. In a healthy person, the hormone insulin helps glucose
enter the cells. But in a diabetic, the pancreas fails to produce
enough insulin, or the body does not properly use it. Cells starve
while glucose builds up in the blood.
There are two predominant types of diabetes. In Type 1, the immune
system destroys the cells in the pancreas that make insulin. In Type 2,
which accounts for an estimated 90 percent to 95 percent of all cases,
the body's cells are not sufficiently receptive to insulin, or the
pancreas makes too little of it, or both. Type 1 used to be called
"juvenile diabetes" and Type 2 "adult-onset diabetes." By 1997, so many
children had developed Type 2 that the Diabetes Association changed the
names. What is especially disturbing about the rise of Type 2 is that
it can be delayed and perhaps prevented with changes in diet and
exercise. For although both types are believed to stem in part from
genetic factors, Type 2 is also spurred by obesity and inactivity. This
is particularly true in those prone to the illness. Plenty of fat,
slothful people do not get diabetes. And some thin, vigorous people do.
The health care system is good at dispensing pills and opening up
bodies, and with diabetes it had better be, because it has proved
ineffectual at stopping the disease. People typically have it for 7 to
10 years before it is even diagnosed, and by that time it will often
have begun to set off grievous consequences. Thus, most treatment is
simply triage, doctors coping with the poisonous complications of
patients who return again and again.
Diabetics are two to four times more likely than others to develop
heart disease or have a stroke, and three times more likely to die of
complications from flu or pneumonia, according to the Centers for
Disease Control. Most diabetics suffer nervous-system damage and poor
circulation, which can lead to amputations of toes, feet and entire
legs; even a tiny cut on the foot can lead to gangrene because it will
not be seen or felt.
Women with diabetes are at higher risk for complications in
pregnancy, including
miscarriages and birth defects. Men run a higher risk of impotence.
Young adults have twice the chance of getting gum disease and losing
teeth.
And people with Type 2 are often hounded by parallel problems - high
blood pressure and high cholesterol, among others - brought on not by
the diabetes, but by the behavior that led to it, or by genetics. Dr.
Monica Sweeney, medical director of the Bedford-Stuyvesant Family
Health Center, offered an analogy: "It's like bad kids. If you have one
bad kid, not so bad. Two bad kids, it's worse. Put five bad kids
together and it's unmanageable. Diabetes is like five bad kids
together. You want to scream." The Caro Research Institute, a
consulting firm that evaluates the burden of diseases, estimates that a
diabetic without complications will incur medical costs of $1,600 a
year - unpleasant, but not especially punishing. But the price tag
ratchets up quickly as related ailments set in: an average $30,400 for
a heart attack or amputation, $40,200 for a stroke, $37,000 for
end-stage kidney disease.
One of the most horrific consequences is losing a leg. According to
the federal Agency for Healthcare Research and Quality, some 70 percent
of lower-limb amputations in 2003 were performed on diabetics.
Sometimes, the subtraction is cumulative. One toe goes. Two more. The
ankle. Everything to the knee. The other leg. Studies suggest that as
many as 70 percent of amputees die within five years. Yet medical
experts believe that most diabetes-related amputations are preventable
with scrupulous care, and that is why the offices of conscientious
doctors post signs like this: "All patients with diabetes: Don't forget
to bare your feet each visit."
To witness the pitiless course that diabetes can take, simply
continue on the hospital tour. This one day will do. Dr. Rita Louard,
an endocrinologist, and Anne Levine, a nurse diabetes educator, were
making their way through the rooms at Montefiore.
Here was Julius Rivers, 58, on the sixth floor. Three years with
diabetes. He had been at home in bed when he saw a light like a
starburst and told his wife to take him to the emergency room. His
blood sugar was 1,400, beyond the pale. (A fasting level of 126
milligrams per deciliter is the demarcation point of diabetes.) This
was his third trip to the hospital in seven months. At the moment, he
had a blood clot in his left leg. He had a heart attack a few years
ago. He was on dialysis. "Tuesday, Thursday and Saturday," he said.
On the sixth floor was Mauri Stein, 58, a guidance counselor, a
diabetic for 20 years. She had been at a party recently and "zoned
out." Her words slurred. Foam appeared on her mouth. She had had a mild
stroke. Now she tried to control her emotions, tried not to cry. She
had had repeated laser surgery on her eyes, and was effectively blind
in one. She had recovered from the stroke, but doctors had also found a
tumor on her heart and said it would need surgery. "My feet burn," she
said. "My toes burn all the time. My days of wearing my pumps are over.
I've gotten more cortisone shots in my feet than I'm sure are legal."
She mentioned her brother, who lived in California. Diabetes had
ransacked his body - an amputation, kidney dialysis, heart disease,
blindness in one eye. He now resided in an assisted-living center. He
was 53. Ms. Stein's husband walked in and sat on the bed. Six months
ago, he found out the same truth: he had diabetes. This was one day in
one!
hospital.
Inside the Incubator
Little about diabetes is straightforward, and to comprehend why New
York is such an incubator for the disease, it is necessary to grasp
that diabetes is as much a sociological and anthropological story as a
medical one. While it assaults all classes, ages and ethnic groups, it
is inextricably bound up with race and money. Diabetes bears an inverse
relationship to income, for poverty usually means less access to fresh
food, exercise and health care. New York's poverty rate, 20.3 percent,
is much higher than the nation's, 12.7 percent.
African-Americans and Latinos, particularly Mexican-Americans and
Puerto Ricans, incur diabetes at close to twice the rate of whites.
More than half of all New Yorkers are black or Hispanic, and the
Hispanic population is growing rapidly, as it is around the nation.
Some Asian-Americans and Pacific Islanders also appear more prone, and
they can develop the disease at much lower weights. Asians constitute
one-tenth of New York's population, more than twice their proportion
nationwide. The nature of these groups' susceptibility remains under
study, but researchers generally blame an interplay of genetic and
socioeconomic forces. Many researchers believe that higher proportions
of these groups have a "thrifty gene" that enabled ancestors who farmed
and hunted to stockpile fat during times of plenty so they would not
starve during periods of want. In modern America, with food beckoning
on every corner, the gene works perversely, causing them to accumulate
unhealt!
hy
quantities of fat.
But the velocity of new cases among all races has accelerated
significantly from just a few decades ago. Genetics cannot explain this
surge, because the human gene pool does not change that fast. Instead,
the culprit is thought to be behavior: faulty diet and inactivity. Dr.
Vinicor, of the Centers for Disease Control, likes to use this
expression: "Genetics may load the cannon, but human behavior pulls the
trigger." Of the country's spike in diabetes cases over the last two
decades, C.D.C. studies suggest that about 60 percent stem from
demographic changes: a population increasingly comprising older people
and ethnic groups with a higher risk. The studies ascribe the other 40
percent to lifestyle changes: the fundamental shift that has people
eating jumbo meals and shunning exercise as if it were illegal. At
every turn, technology has made physical activity unnecessary or
unappealing. Gym class has largely been deleted from schools. Fewer
than a third of jun!
ior high
schools require physical education at all, the C.D.C. says.
On the whole, New York's corpulence is below the national average,
with 20 percent of adults qualifying as obese, compared with 30 percent
for the country, the C.D.C. says. But the figure is much higher in poor
areas like the South Bronx and East Harlem.
When the health department studied diabetes in the city's 34 major
neighborhoods, the distribution echoed demographic patterns: Diabetes
left only a light imprint on more affluent, white areas like the Upper
West Side and Brooklyn Heights. The prevalence was about average in
working-class Ridgewood, Queens, and almost nil on the Upper East Side.
But that apparent immunity is weakening. Of those 34 neighborhoods, 22
already have diabetes rates above the national average, and the numbers
are rising all over as the city continually remakes itself.
"New York is switching from a mom-and-pop type of environment to a
chain-store type of environment, a proliferation of fast food, even in
high-rent neighborhoods they haven't had access to before, like the
East Village and Lower Manhattan," said Peter Muennig, an assistant
professor of health policy and management at Columbia. If changes in
daily living can bring on diabetes, they can also delay it, though it
is uncertain for how long.
A federal program studied people around the country at high risk of
getting diabetes, and concluded that 58 percent of new cases could be
postponed by shifts in behavior - most notably, shedding pounds.
But Dr. Frieden, New York's health commissioner, says meaningful
prevention cannot be achieved at the city level. "I can urge people
until I'm blue in the face to walk and take the stairs and eat less,
and it won't make much difference," he said. His emphasis is on trying
to better treat those who already have diabetes, an ambitious goal in
its own right. Most primary care doctors treat too many patients to
provide the attention that diabetics need, or to check for the disease,
he said. Specialists are scarce. And compliance among patients is
notoriously poor. Even the most basic step in controlling the disease -
watching one's blood sugar - is too much for many diabetics. Doctors
recommend that two to four times a year, patients take a so-called A1c
test, which gauges the average sugar level over the prior 90 days and
is more revealing than daily at-home measurements.
But in 2002 , the health department found that 89 percent of
diabetics did not know their A1c levels. Of those who did, presumably
the most conscientious, four out of five had readings over the level
the American Diabetes Association says separates well-controlled from
poorly controlled diabetes. The patients in the survey were not much
better at knowing their blood pressure and cholesterol, which are also
crucial for diabetics to control. "Diabetes is an interesting beast,"
said Dr. Diana K. Berger, who heads the diabetes division at the health
department. "It's probably one of the easier conditions to diagnose but
one of the hardest to manage."
Shortages and Shipwrecks
There is an underappreciated truth about disease: it will harm you
even if you never get it. Disease reverberates outward, and if the
illness gets big enough, it brushes everyone. Diabetes is big enough.
Predicting the path of a disease is always speculative, but without
bold intervention diabetes threatens to hamper some of society's most
basic functions.
For instance, no one with diabetes can join the military, though
service members whose disease is diagnosed after enlisting can
sometimes stay. No insulin-dependent diabetic can become a commercial
pilot.
Shereen Arent, director of legal advocacy for the American Diabetes
Association, says she already fields 150 calls a month from diabetics
who complain that they are being discriminated against in the
workplace, double the number just a couple of years ago. She mentioned
a typical case, a man rejected for a job at a baked-bean factory in
Texas as a safety risk. "If this continues," she said, "we're in big
trouble." Dr. Daniel Lorber is an endocrinologist in Queens who thinks
a lot about the disease's present and future. "The work force 50 years
from now is going to look fat, one-legged, blind, a diminution of
able-bodied workers at every level," he said, presuming that current
trends persist.
As more women contract diabetes in their reproductive years, Dr.
Lorber said, more babies will be born with birth defects. Those needy
babies will be raised by parents increasingly crippled by their
diabetes. "At a time when we are trying to shift health care out of
hospitals, with diabetics you don't have a choice," he said. "Nursing
homes are going to be crammed to the gills with amputees in rehab.
Kidney dialysis centers will multiply like rabbits. We will have a
tremendous amount of people not blind but with low vision. And we have
lousy facilities in this country for low-vision problems. These people
will not be able to function in society without significant aid."
Cost pressures have been slashing the number of hospital beds, and
some exasperated doctors are known to denigrate advanced diabetics as
"shipwrecks," because they have so many health problems and virtually
live in the hospital. Not only will the future mean too few beds and
unsupportable drains on Medicaid and Medicare, Mr. Muennig said, but if
an emergency strikes - a terrorist attack, an earthquake - the city
health system's ability to respond may be compromised because all the
beds will be full of diabetics. Most schools do not have full-time
nurses. Some public schools, Ms. Arent said, try to turn away children
with diabetes, even though that is illegal. Others ban them from field
trips and sports teams. And this is now, when diabetes is still
relatively rare among children.
If trends continue, people will live through years blighted by
disability, then die too young. Diabetes is thought to shave 5 to 10
years off a life. "Life expectancy usually decreases because there's a
plague or there's a massive economic trauma," Mr. Muennig said. "In
this case, we will see a decline in life expectancy due to a chronic
condition."
In 2003, diabetes vaulted past stroke and AIDS from the sixth-leading
cause of death in New York to the fourth. It was fifth, slightly behind
stroke, in 2004. But the health department says it believes the actual
toll is much worse because doctors who fill out death certificates may
ascribe the death to a complication rather than to the diabetes at its
root. Lorna Thorpe, deputy health commissioner, combed through medical
charts and concluded that diabetes should be third, trailing
cardiovascular disease and cancer.
Laurie Raps is a claims representative for Social Security on Staten
Island, 31 years on the job. From her perspective, interviewing people
embarking on full-time disability, she has seen the disease's long
tentacles. When she started, she saw people in their 50's and 60's,
hobbled by the usual problems of age: arthritis, herniated discs, heart
conditions. Now, every week, she gets diabetic after diabetic, people
as young as 30. In fact, a 2004 study by UnumProvident, a major
provider of disability insurance, found that the number of workers
filing claims for Type 2 diabetes doubled between 2001 and 2003. "It's
a double whammy," Ms. Raps said. "You don't have these people working
and paying into the system, and then you have these people collecting
from the system."
Ten years ago, Ms. Raps developed diabetes. Her husband has it. Both
her parents have it, their lives being washed away. "When I look at the
people who sit before me with disability claims, I have to check the
birth date in their records," she said. "They look 10 or 20 years
older. Diabetes does that. It wears you down and wears you down. We're
looking at a future of people 10 or 20 years older in sickness than
they are. What kind of future is that?"
'A 15-Year-Old Is Immortal'
"I'm Linda and I've had diabetes for 13 years." "I'm Dominique and
I've had diabetes for seven years." "I'm Joseph and I've had diabetes
for two months." The brisk introductions went on, the ritual start to
the monthly meeting of a support group called Sugar Babes Place. All
the members had diabetes. All were children. Sugar Babes is the idea of
Dr. Yolaine St. Louis, chief of pediatric endocrinology at
Bronx-Lebanon Hospital Center. When she started practicing medicine 16
years ago, the only children she saw with diabetes had Type 1. Now, of
Sugar Babes' 90 official members, roughly 40 percent have Type 2. One
is 8. Another is 7. It scares Dr. St. Louis. It scares many doctors who
see the same thing, because they know it does not have to be. Type 2
was supposed to be an old person's disease. Diabetes still increases
with age in an almost linear fashion - today, one in five New Yorkers
age 65 and older have it - but the starting point used to be mostly in
thei!
r 50's.
Dr. Alan Shapiro, a pediatrician with the Children's Health Fund and
Montefiore Medical Center who has spent 13 years ministering to
children in the South Bronx, said there was an easy way to illustrate
the change. When he began, there was a "failure-to-thrive" clinic,
meant to address the undernourished, because so many children were
dangerously thin and small. "Now I don't think we hardly ever see a
failure-to-thrive case," he said.
In the clinic's place is an obesity program. Dr. Shapiro never saw
children with Type 2 diabetes in his early years in medicine. Now, the
program has about 10 cases. One concern he and fellow doctors have is
the surge in children who take antipsychotic drugs for anxiety and
conditions like autism. Some newer drugs can promote weight gain and
thus elevate the risk of diabetes. Dr. Shapiro has an autistic patient
who he feels needs the new medication. But since taking it, the young
man has markedly put on weight and, at 18, developed diabetes. This
extension of the disease to the young is where health care
professionals feel society and public policy have most glaringly
failed. Diabetes, they say, should never have gotten there.
There has been little research into the long-term impact of Type 2
diabetes on children. But doctors have a rough idea. The harsh
consequences that can accompany diabetes tend to arrive 10 to 15 years
after onset. If people contract diabetes when they are 15, 10 or even
5, they may well start developing complications, not on the cusp of
retirement but in the prime of their lives. There is a big difference
between losing a limb at 21 and at 70. There is a big difference
between going on dialysis at 30 and at 65. "I heard a horror story a
few weeks ago," Dr. Lorber said, "of a girl who was born deaf, got
diabetes at 11 or 12 and went blind from diabetes at 30." The C.D.C.
has projected that a child found to have Type 2 diabetes at age 10 will
see his life shortened by 19 years. "Imagine if kids were showing up at
emergency rooms in cardiac arrest," said Dr. David L. Katz, director of
the Prevention Research Center at the Yale University School of
Medicine. "Fra!
nkly, I
think that's the next big thing. It's that dramatic. If diabetes
doesn't respect age, why should coronary disease? Lord knows, I hope
this never happens. But this is what keeps me up at night."
Yet children can be the most reluctant to accept the truths of their
condition.
"A lot of them are in denial," Dr. St. Louis said. "They have blood
sugars of 300, 400, and they tell me right to my face they don't have
diabetes. 'You're wrong,' they say. 'I don't feel anything.' I tell
them what can happen down the road, and they shrug. A 15-year-old
doesn't care what's going to happen at 35 or 45. A 15-year-old is
immortal."
The doctor was telling the Sugar Babes that everyone should have two
compact blood-sugar meters, one for home and one for school. Then she
warned them, "If your sugar is bad and you don't do anything, you're
going to be dropping down all over the Bronx."
Interest was tepid. Some children couldn't keep their eyes off the
waiting dinner arranged at a buffet table by the wall. No rapt
attention from Joseph, 12, who had begged not to come, until his mother
put her foot down. He moaned that he had schoolwork.
"Look at that," said Dorothy Morris-Swaby, a diabetes nurse educator
who worked with Dr. St. Louis, nodding at a girl who was talking on her
phone. "We're educating about diabetes, and she's on her cellphone.
Typical teenager."
As time ran out, hula hoops were brought out. Dr. St. Louis was
trying to identify activities other than video games and TV that the
children might try. Last meeting, they held a jump-rope contest. "They
have 10,000 excuses why they can't do something," the doctor said. "So
you have to give them ideas and then hope." The meeting wound up. The
hoops were stashed away. Some of the children stepped toward the buffet
table and began to eat.
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