C M Y KID NAME: Nxxx,2006-01-09,A,018,Bs-4C,E1 YELO MAG CYAN BLK 3 7 15 25 50 75 85 93 97

A18 N NATIONALTHE NEW YORK TIMES MONDAY, JANUARY 9, 2006

obese, who are at higher risk. It has a grow-ing population of Latinos, who get the dis-ease in disproportionate numbers, and ofAsians, who can develop it at much lowerweights than people of other races.

It is a city of immigrants, where new-comers eating American diets for the firsttime are especially vulnerable. It is alsoyielding to the same forces that have drivendiabetes nationally: an aging population, afood supply spiked with sugars and fats, anda culture that promotes overeating and dis-courages exercise.

Diabetes has no cure. It is progressiveand often fatal, and while the patient lives,the welter of medical complications it setsoff can attack every major organ. As manywar veterans lost lower limbs last year tothe disease as American soldiers did to com-bat injuries in the entire Vietnam War. Dia-betes is the principal reason adults go blind.

So-called Type 2 diabetes, the predomi-nant form and the focus of this series, iscreeping into children, something almostunheard of two decades ago. The AmericanDiabetes Association says the disease couldactually lower the average life expectancyof Americans for the first time in more thana century.

Even those who do not get diabetes willeventually feel it, experts say — in timespent caring for relatives, in higher taxesand insurance premiums, and in publicspending diverted to this single illness.

“Either we fall apart or we stop this,” saidDr. Thomas R. Frieden, commissioner ofthe New York City Department of Healthand Mental Hygiene.

Yet he and other public health officials ac-knowledge that their ability to slow the dis-ease is limited. Type 2 can often be post-poned and possibly prevented by eating lessand exercising more. But getting millions ofpeople to change their behavior, he said, willrequire some kind of national crusade.

The disease can be controlled throughcareful monitoring, lifestyle changes andmedication that is constantly improving,and plenty of people live with diabetes foryears without serious symptoms. But man-aging it takes enormous effort. Even amongAmericans who know they have the disease,about two-thirds are not doing enough totreat it.

Nearly 21 million Americans are believedto be diabetic, according to the Centers forDisease Control, and 41 million more areprediabetic; their blood sugar is high, andcould reach the diabetic level if they do notalter their living habits.

In this sedentary nation, New York isoften seen as an island of thin people whowalk everywhere. But as the ranks of Amer-ican diabetics have swelled by a distressing80 percent in the last decade, New York hasseen an explosion of cases: 140 percentmore, according to the city’s health de-partment. The proportion of diabetics in itsadult population is higher than that of LosAngeles or Chicago, and more than doublethat of Boston.

There was a pronounced increase in diag-nosed cases nationwide in 1997, part ofwhich was undoubtedly due to changes inthe definition of diabetes and in the waydata was collected, though there has contin-ued to be a marked rise ever since.

Yet for years, public health authoritiesaround the country have all but ignoredchronic illnesses like diabetes, focusing in-stead on communicable diseases, which killfar fewer people. New York, with its am-bitious and highly praised public health sys-tem, has just three people and a $950,000budget to outwit diabetes, a disease soon ex-pected to afflict more than a million peoplein the city.

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

Diabetes is “the Rodney Dangerfield ofdiseases,” said Dr. James L. Rosenzweig,the director of disease management at theJoslin Diabetes Center in Boston. As freshcases and their medical complications pileup, the health care system tinkers with newmodels of dispensing care and then forsakesthem, unable to wring out profits. Insurersshun 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 yearsfrom now people will look back and say:‘What were they thinking? They’re in themiddle of an epidemic and kids are watch-ing 20,000 hours of commercials for junkfood.’ ”

Of course, revolutionary new treatments

or a cure could change everything. Other-wise, the price will be steep. Nationwide, thedisease’s cost just for 2002 — from medicalbills to disability payments and lost work-days — was conservatively put by theAmerican Diabetes Association at $132 bil-lion. All cancers, taken together, cost thecountry an estimated $171 billion a year.

“How bad is the diabetes epidemic?”asked Frank Vinicor, associate director forpublic health practice at the Centers for Dis-ease Control. “There are several ways oftelling. One might be how many different oc-currences in a 24-hour period of time, be-tween when you wake up in the morning andwhen you go to sleep. So, 4,100 people diag-nosed with diabetes, 230 amputations in peo-ple with diabetes, 120 people who enter end-stage kidney disease programs and 55 peo-ple who go blind.

“That’s going to happen every day, on theweekends and on the Fourth of July,” hesaid. “That’s diabetes.”

One Day in the TrenchesThe 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 re-current skin infection. The pain over-whelmed her. Then came extreme thirstand the loss of 50 pounds in six weeks. In theemergency room, she found out she had dia-betes.

She was out of work, wanted to be anR & B singer, had no insurance. It was herfourth day in Montefiore Medical Center.Her grandmother, aunt and two cousinshave diabetes.

“I’m scared,” she said. “I’m still adjustingto it.”

Next came Richard Dul, watching newschatter on a compact TV. Now 64, he hashad diabetes since he was 22. A month be-fore, he had a blockage in his heart andneeded open-heart surgery. He was home afew days, but an infection arose and he wasback. Postoperative infections are morecommon with diabetes. This was his 21ststraight day in the hospital.

Here, then, was the price of diabetes, notjust the dollars and cents but the high cost inquality of life.

Simply put, diabetes is a condition inwhich the body has trouble turning food intoenergy. All bodies break down digested foodinto a sugar called glucose, their mainsource of fuel. In a healthy person, the hor-mone insulin helps glucose enter the cells.But in a diabetic, the pancreas fails toproduce enough insulin, or the body does notproperly use it. Cells starve while glucosebuilds up in the blood.

There are two predominant types of dia-betes. In Type 1, the immune system de-stroys the cells in the pancreas that makeinsulin. In Type 2, which accounts for an es-timated 90 percent to 95 percent of all cases,the body’s cells are not sufficiently recep-tive to insulin, or the pancreas makes too lit-tle of it, or both.

Type 1 used to be called “juvenile diabe-tes” and Type 2 “adult-onset diabetes.” By1997, so many children had developed Type2 that the Diabetes Association changed thenames.

What is especially disturbing about therise of Type 2 is that it can be delayed andperhaps prevented with changes in diet andexercise. For although both types are be-lieved to stem in part from genetic factors,Type 2 is also spurred by obesity and inac-tivity. This is particularly true in thoseprone to the illness. Plenty of fat, slothfulpeople do not get diabetes. And some thin,vigorous people do.

The health care system is good at dis-pensing pills and opening up bodies, andwith diabetes it had better be, because it hasproved ineffectual at stopping the disease.People typically have it for 7 to 10 years be-fore it is even diagnosed, and by that time itwill often have begun to set off grievous con-sequences. Thus, most treatment is simplytriage, doctors coping with the poisonouscomplications of patients who return againand again.

Diabetics are two to four times more like-ly than others to develop heart disease orhave a stroke, and three times more likelyto die of complications from flu or pneumo-nia, according to the Centers for DiseaseControl. Most diabetics suffer nervous-sys-tem damage and poor circulation, which canlead to amputations of toes, feet and entirelegs; even a tiny cut on the foot can lead togangrene because it will not be seen or felt.

Women with diabetes are at higher riskfor complications in pregnancy, including

miscarriages and birth defects. Men run ahigher risk of impotence. Young adults havetwice the chance of getting gum disease andlosing teeth.

And people with Type 2 are often houndedby parallel problems — high blood pressureand high cholesterol, among others —brought on not by the diabetes, but by the be-havior that led to it, or by genetics.

Dr. Monica Sweeney, medical director ofthe Bedford-Stuyvesant Family Health Cen-ter, offered an analogy: “It’s like bad kids.If you have one bad kid, not so bad. Two badkids, it’s worse. Put five bad kids togetherand it’s unmanageable. Diabetes is like fivebad kids together. You want to scream.”

The Caro Research Institute, a consultingfirm that evaluates the burden of diseases,estimates that a diabetic without complica-tions will incur medical costs of $1,600 ayear — unpleasant, but not especially pun-ishing. But the price tag ratchets up quicklyas related ailments set in: an average$30,400 for a heart attack or amputation,$40,200 for a stroke, $37,000 for end-stagekidney disease.

One of the most horrific consequences islosing a leg. According to the federal Agen-cy for Healthcare Research and Quality,some 70 percent of lower-limb amputationsin 2003 were performed on diabetics. Some-

times, the subtraction is cumulative. Onetoe goes. Two more. The ankle. Everythingto the knee. The other leg. Studies suggestthat as many as 70 percent of amputees diewithin five years.

Yet medical experts believe that most di-abetes-related amputations are preventablewith scrupulous care, and that is why the of-fices of conscientious doctors post signs likethis: “All patients with diabetes: Don’t for-get to bare your feet each visit.”

To witness the pitiless course that diabe-tes can take, simply continue on the hospitaltour. This one day will do. Dr. Rita Louard,an endocrinologist, and Anne Levine, anurse diabetes educator, were making theirway through the rooms at Montefiore.

Here was Julius Rivers, 58, on the sixthfloor. Three years with diabetes. He hadbeen at home in bed when he saw a light likea starburst and told his wife to take him tothe emergency room. His blood sugar was1,400, beyond the pale. (A fasting level of 126milligrams per deciliter is the demarcationpoint of diabetes.)

This was his third trip to the hospital inseven months. At the moment, he had ablood clot in his left leg. He had a heart at-tack 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 “zonedout.” Her words slurred. Foam appeared onher mouth. She had had a mild stroke.

Now she tried to control her emotions,tried not to cry. She had had repeated lasersurgery on her eyes, and was effectivelyblind in one. She had recovered from thestroke, but doctors had also found a tumoron her heart and said it would need surgery.

“My feet burn,” she said. “My toes burnall the time. My days of wearing my pumpsare over. I’ve gotten more cortisone shots inmy feet than I’m sure are legal.”

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

Ms. Stein’s husband walked in and sat onthe bed. Six months ago, he found out thesame truth: he had diabetes.

This was one day in one hospital.

Inside the IncubatorLittle about diabetes is straightforward,

and to comprehend why New York is suchan incubator for the disease, it is necessaryto grasp that diabetes is as much a sociolog-ical and anthropological story as a medicalone. While it assaults all classes, ages andethnic groups, it is inextricably bound upwith race and money.

Diabetes bears an inverse relationship toincome, for poverty usually means less ac-cess to fresh food, exercise and health care.New York’s poverty rate, 20.3 percent, ismuch higher than the nation’s, 12.7 percent.

African-Americans and Latinos, partic-ularly Mexican-Americans and Puerto Ri-cans, incur diabetes at close to twice therate of whites. More than half of all NewYorkers are black or Hispanic, and the His-panic population is growing rapidly, as it isaround the nation.

Some Asian-Americans and Pacific Is-landers also appear more prone, and theycan develop the disease at much lowerweights. Asians constitute one-tenth of NewYork’s population, more than twice theirproportion nationwide.

The nature of these groups’ susceptibilityremains under study, but researchers gen-erally blame an interplay of genetic and so-cioeconomic forces. Many researchers be-lieve that higher proportions of these groupshave a “thrifty gene” that enabled ancestorswho farmed and hunted to stockpile fat dur-ing times of plenty so they would not starveduring periods of want. In modern America,with food beckoning on every corner, thegene works perversely, causing them to ac-cumulate unhealthy quantities of fat.

But the velocity of new cases among allraces has accelerated significantly fromjust a few decades ago. Genetics cannot ex-plain this surge, because the human genepool does not change that fast. Instead, theculprit is thought to be behavior: faulty dietand inactivity. Dr. Vinicor, of the Centersfor Disease Control, likes to use this ex-pression: “Genetics may load the cannon,but human behavior pulls the trigger.”

Of the country’s spike in diabetes casesover the last two decades, C.D.C. studiessuggest that about 60 percent stem fromdemographic changes: a population in-creasingly comprising older people and eth-nic groups with a higher risk.

The studies ascribe the other 40 percent tolifestyle changes: the fundamental shiftthat has people eating jumbo meals andshunning exercise as if it were illegal. At ev-ery turn, technology has made physical ac-tivity unnecessary or unappealing. Gymclass has largely been deleted from schools.Fewer than a third of junior high schools re-quire physical education at all, the C.D.C.says.

On the whole, New York’s corpulence isbelow the national average, with 20 percentof adults qualifying as obese, compared with30 percent for the country, the C.D.C. says.But the figure is much higher in poor areaslike the South Bronx and East Harlem.

When the health department studied dia-betes in the city’s 34 major neighborhoods,the distribution echoed demographic pat-terns: Diabetes left only a light imprint onmore affluent, white areas like the UpperWest Side and Brooklyn Heights. The preva-lence was about average in working-classRidgewood, Queens, and almost nil on theUpper East Side.

But that apparent immunity is weaken-ing. Of those 34 neighborhoods, 22 alreadyhave diabetes rates above the national aver-age, and the numbers are rising all over asthe city continually remakes itself.

“New York is switching from a mom-and-

Diabetes and Its Awful Toll Quietly Emerge as a Crisis

TODAY Diabetes, long viewed as a routine byproduct of old age, is emergingas the biggest health problem menacing New York City.

Driven in part by overeating and inactivity, diabetes has already strick-en an estimated one of every eight adult New Yorkers, a rate nearly one-thirdhigher than in the nation as a whole. It is finding new victims, and killingmany of them, faster than any other major illness — even as scourges likeheart disease, or all cancers taken together, have leveled off or fallen. If un-checked, it is expected to ensnare coming generations on an unheard-of scale:One in every three Americans born five years ago. One in two Latinos.

Yet a yearlong examination by The New York Times found an alarminglack of urgency about the threat among patients, doctors, insurers and evenpublic health authorities — partly because of the quirks of the disease, whichcan take years to show symptoms.

Those symptoms are dire. Diabetes allows sugar to build up in the blood,detonating a barrage of complications: kidney failure, strokes, decayinglimbs. Type 2 diabetes, the most widespread variety and the focus of this se-ries, increasingly afflicts children, who rarely got it a generation ago. It canoften be controlled, or possibly prevented, but many of those at risk — and themedical system that could help them — seem stymied by the effort and cost.

Diabetes is a global crisis. But for New York, a city of immigrants adopt-ing American lifestyles, the signs of the epidemic are chilling: crowded hospi-tals, swelling disability rolls and mounting costs that already touch everyone.

Claudette McCloggan, among the city’s 800,000 adult diabetics,at the Bedford-Stuyvesant Family Health Center.

ABOUT THE SERIES

The Stealth Epidemic

TOMORROW On the streets of East Harlem, a diabetic ground zero.WEDNESDAY A health care system avoids prevention and rewards failure.THURSDAY Among the next generation of victims: children of immigrants.

ONLINE: VIDEO, DISCUSSION AND MORE RESOURCESInterviews with experts and video reports from the placeswhere the fight against diabetes is being won, and lost, appearon the Web, along with reader forums and relevant links:nytimes.com/diabetes.

Continued From Page A1

2

4

6

8

2

4

6

A Local, National and Worldwide ScourgeRising diabetes rates in New York City, in the nation and around the world are alarming health officials. The World Health Organization estimates that 171 million people were living with diabetes in 2000, and that 266 million will have it in 2030.

Diabetes rates are climbing in New York City . . .

Nationally, diabetes is becoming more prevalent . . .

. . . with the South and East leading the way.

. . . and the burden is not shared equally among the city’s neighborhoods.

Percentage of adults reporting that they have diabetes

Age-adjusted prevalence of diagnosed diabetes, 2004

Age-adjusted prevalence of diagnosed diabetes

Worldwide, deaths from diabetes are expected to increase . . .

. . . especially among wealthier countries and as poorer countries develop.Estimated prevalence of diabetes, 2000

Estimated worldwide deaths from diabetes per 100,000 people

Percentage of adults reporting that they have diabetes

0 - 3%

4 - 6

7 - 9

10 - 12

13 - 15

4.8 - 6.0%

6.1 - 7.0

7.1 - 8.0

8.1 - 9.0

9.1 - 10.2

0.4 - 1.0% 1.1 - 3.0 3.1 - 5.0 5.1 - 7.0 7.1 - 16.71994-19951996-1997

1998-1999

2000-2001

2002

%

Sources: New York City Department of Health and Mental Hygiene; U.S. Centers for Disease Control and Prevention;World Health Organization

%

’80

’00 ’05 ’15 ’30

’85 ’90 ’95 ’00

5

10

15

20

25

30

1

3

5

James Bronzan/The New York Times