One by one, the diabetic patients reluctantly stepped on the scale in the basement of a South Los Angeles clinic. Nearby, a nurse scribbled numbers on a chart.
Camara January, 31, her round face framed by a sparkly headband, held her breath. The number stopped at 245 pounds. "That's not good," January said. Tracy Donald, 45, stepped up. Just under 240 pounds. "That is wrong," she said. Ramon Marquez, 62, tall and clean-shaven, methodically took off his watch, his cap and his shoes. 170 pounds. Ramon strips down to almost nothing, the others jokingly complain.
They are among those who come each month to the To Help Everyone (T.H.E.) Clinic, hoping to finally gain the upper hand on their diabetes, a disease wreaking havoc on their bodies — and their community. Several have been hospitalized. Some have seen relatives die from complications. All have struggled to manage blood sugar levels that spike and plummet to ominous extremes.
A chronic illness that can lead to heart attacks, blindness and kidney failure, diabetes is exploding across the United States and raising enormous obstacles to the Obama administration's drive to control costs and reform the healthcare system. In California alone, the disease costs taxpayers and businesses roughly $24 billion annually. One in seven California residents has diabetes — a 32% increase in the last decade.
"This is a train going in the wrong direction," said Dean Schillinger, a UC San Francisco Medical School professor and medical officer at the California Diabetes Program, run by the university and the state public health department.
Community health centers like T.H.E. Clinic are a crucial front line in the federal government's war against diabetes. They're charged with slowing the advance of the disease, which disproportionately affects poor patients whose care may be taxpayer-funded.
To do so, clinics must get millions of patients to change deeply ingrained eating habits, embrace regular exercise regimens and better manage their health to avoid unnecessary hospitalizations.
Many low-income, urban patients struggle with the willpower challenges afflicting diabetes sufferers everywhere. But their struggle is often complicated by limited understanding of the links between lifestyle and blood sugar levels, along with fewer safe, affordable and convenient options for healthy activities and fresh food.
"The approach of telling people they need to lose weight and exercise is clearly not working," said Martha Funnell, past chairwoman of the National Diabetes Education Program.
Like her mother and grandmother, 17-year-old Charnay Winbush has diabetes. She injects herself with insulin five times a day and wears a bracelet identifying her illness. But Charnay often tells people she isn't diabetic.
Without her injections, she feels weak and tired. When her blood sugar levels climb, she gets extremely thirsty and can't stop sweating. One incident sent her to the emergency room this summer. "I was scared," she said.
Doctors at T.H.E. Clinic tell Charnay she needs to lose weight, but she continues to gain. She keeps small bags of candy in the refrigerator next to her insulin. Counting calories brings unwelcome memories of math class, she says. The only exercise she likes is playing virtual tennis or bowling.
The diabetes battle permeates almost every aspect of T.H.E Clinic's routine. Patients are greeted in the waiting room by television programs about the disease. They are routinely tested for it, counseled about how to prevent it and referred to nutritionists and diabetic education groups to manage it.
Research shows such efforts can produce results. Patients surrounded by support and education programs do better at controlling their blood sugar, eat more healthfully and use their medication as recommended.
At the Saturday session, retired nurse Emily Moore handed out a soul food cookbook with healthy recipes. Patients shared about their favorite types of exercise. One woman said she liked dancing to disco music, another announced she was going to Zumba classes.
The sessions began as a diabetes education class but soon morphed into a less formal support group, said M.D. Donnell, education manager at T.H.E. Clinic. Patients say they come for the snacks, the nutrition advice and the camaraderie. James Hicks, whose leg was amputated after a diabetes-related infection, said he serves as a cautionary tale for others. "You never want to get this far," he said.
Despite the intense focus, a quarter of the clinic's diabetic patients haven't brought the disease under control, records show. Cynthia Francis, a physician assistant, dispenses sober warnings along with hope. "You have to be real with them," she said. "You have to tell them that managing their disease is a life-or-death situation."
Stephen Carter, a laid-off security director, is among those struggling to keep his diabetes in check. He cut out fried food, joined a gym and charts his blood sugar levels. But sticking to his diet and exercising regularly is "an incredible challenge," he said. "It's really, really hard to break habits you've had for 50-some odd years."
Gabrielle Guzman tries to get the dangers and warnings to sink in, but she knows they often don't.
Her small nutritionist's office at the clinic is decorated with oversized food labels and pictures of fruits and vegetables. "There is no diet that will do what healthy eating does," one sign reads. She pulls out bags of chips and soda cans to show obese and overweight patients the calorie content of their favorite foods. She schools them on nutrition labels and presses them to keep diaries of what they eat.
Sometimes, she tries to scare patients into taking better care of themselves, or their pre-diabetic children.
Angelica Fortunato and her preteen daughter, both overweight, sat down with Guzman one afternoon in the summer. Fortunato said she, her parents and her siblings all have diabetes, and she didn't want her daughter to suffer the same burden. "I'm really concerned about her going through what I'm going through," she said.
Sternly, the nutritionist warned Fortunato that the entire family had to commit to eating healthier. She encouraged the girl to help herself by avoiding soda and exercising. "It's hard to be a little kid when you are not little," Guzman said.
Three months later, Guzman was worried after Fortunato missed a follow-up appointment. The girl is at risk of becoming a diabetic adult, she said. "If she doesn't change her eating habits now, she's not going to change them later," she said.
When Guzman called, she said Fortunato explained she was going elsewhere for medical care after her insurance coverage changed.
Most patients want to live healthier lives, Guzman said. But even some with horrible complications from diabetes can struggle to understand and manage the disease.
Carlos Sanchez, 55, ignored his diabetes for nearly 15 years, rarely going to the doctor and failing to keep up with his medication. Then last February he developed a sore on his foot that wouldn't go away. After feeling weak and nauseated for days, Sanchez went to the Harbor-UCLA Medical Center emergency room, where doctors told him his diabetes was out of control and his leg would have to be amputated because of a related infection.
One recent afternoon, Sanchez, a former cook, sat in the shade outside the house where he lives with his brother and used his good leg to kick a soccer ball to his nephew. "Two points for me!," he yelled when he got a shot past the boy. "After this happened to me, I said, 'My life has to continue,'" he said.
Sanchez said he now takes his illness seriously, but he also admitted he fails to check his blood sugar regularly. During a clinic visit, Sanchez proudly noted he'd been using crutches instead of a wheelchair to stay strong. Francis, the physician assistant, praised his efforts but said his blood sugar level was still too high. "You're going to need better control," she said. "You can do this."
The next month, Sanchez's blood sugar level had improved, but he still was having trouble understanding the consequences of his diet. In a session with Guzman, he stressed that he was trying to avoid sugar. But Guzman grew concerned as he described what he'd eaten the previous day: cereal, eggs and tortillas, a pear, pizza, chicken wings and cinnamon bread.
"It's not just sugar," Guzman said, explaining what foods diabetics must limit. "It's fruit, milk, bread, potatoes and cereal.... You have to watch your carbs."
About the same time, Sanchez received something that lifted his spirits and could help him better balance activity with what he eats: a prosthetic leg.
"I feel like I am born again," he said.
Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School of Journalism.