The New York Times
January 9, 2006


By N. R. Kleinfield

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

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

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

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

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

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

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

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retains an outdated reputation as a relatively benign sickness of the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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"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

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

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

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

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

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

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

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

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

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

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

"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

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

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

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

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

"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

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

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

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

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

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

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

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

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

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

'A 15-Year-Old Is Immortal'

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"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

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 2006 The New York Times Company