What should someone who can’t afford a gym membership and/or can’t exercise outside because of cold weather or safety concerns do?

Listen to Dr. Jennifer Ann Genuardi’s answer:

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Jennifer Ann Genuardi, MD is a staff physician at Bella Vista Health Center in Hunts Point, the Bronx affiliate of Urban Health Plan where she cares for the medically underserved as an internist and pediatrician. She is board certified in internal medicine and pediatrics. She received her bachelor’s degree from Georgetown University and completed her medical studies at the Georgetown University School of Medicine in Washington, D.C. Dr. Genuardi completed her residency in Internal medicine-Pediatrics in 2008 at Christiana Care and DuPont Children’s Hospital in Deleware. She then served as the Assistant Chief of Service for the Internal Medicine Program at Christiana while working in the Fast Track of DuPont’s ER and as a pediatric hospitalist at Christiana Care.

Dr. Jennifer Genuardi

Genuardi works at Urban Health Plan’s Bella Vista Health Center, where she treats many of Hunts Point’s diabetics. Her patients live in the poorest congressional district in the country. Health insurance isn’t comprehensive, and Medicaid coverage often lapses. Money is tight, so when medications or supplies aren’t covered by insurance, many go without.

After moving here last spring from Delaware, Genuardi has had to adapt to practicing medicine in the neighborhood.

“I definitely feel like in this setting I’m a lot more creative with my medicine choices,” she says. “A lot more of pushing things to the limit — not in a hazardous way — just sort of using everything I can.”

And for the clinic’s diabetic patients, one of the most important tools in managing the disease – glucometer test strips – is often very limited.

Those little test strips may not look important — but keeping careful track of blood glucose levels is the best way to tell if a diabetic’s treatment is working. A drop of blood on a test strip is read by a glucometer, which quickly produces a blood glucose reading. Results between 80 and 140 usually indicate controlled sugar levels, with higher readings often right after meals. If a diabetic keeps careful track of the results, his or her doctor can make a strong evaluation of how well the disease is being controlled. This could help determine what medications work best or what food triggers spikes in blood glucose. Once glucometer levels show the disease is well controlled, many patients are able to cut back on the number of glucometer readings each day.

But before a diabetic can reach that point, Genuardi recommends that newly diagnosed patients test their blood glucose levels at least three times a day, definitely in the morning, and before and after meals. But private insurance plans often limit the number of test strips per month, leaving only one or two strips for each day, say health care providers at the Urban Health Plan clinics. And that’s when doctors and patients have to get a bit creative. Sometimes it’s a guessing game, trying to figure out at what points during the day are the best times to use those precious test strips. Some diabetics have spikes in blood glucose first thing in the morning, while it happens for others right after meals.

And while it makes controlling the disease more difficult for diabetics and their doctors, it isn’t a big surprise to many that the test strips are limited.

“Yes, insurance companies will regulate the number of test strips given. Why? Because test strips are very expensive,” says Dr. Tom O’Brien, a primary care physician in Hunts Point.

And O’Brien is right. These things aren’t cheap. Each glucometer – and there are dozens – only operate with their corresponding test strips. At Duane Reade on Southern Boulevard, the price of a glucometer ranges from less than $20 to more $80. And with the more expensive glucometers come more expensive test strips.

A diabetic whose insurance has limited his or her supplies may look to buy extra test strips at retail price — and face some sticker-shock. The Accu-Chek Active glucometer costs $19.99, and 50 strips go for $32.99. Meanwhile, the One Touch Ultra Smart is priced at $82.99, and 50 of those strips will cost $57.99. A free glucometer may be easy to come by – just visit the One Touch website and fill out a short form to see if you qualify. But the retail price for that glucometer’s test strips works out to more than a dollar per strip, while a cheaper tester, like the Accu-Chek Active, might only run about 66 cents per strip.

While that might not sound so expensive, it adds up quickly. If a strip costs $1, and a patient buys three for each day, that’s nearly $100 each month. And according to the 2000 Census, the median household income in Hunts Point is $16,339. This leaves just about $1300 each month for all living expenses — meaning an extra $100 for test strips is simply not realistic for many diabetics in this neighborhood.

Patients with private insurance plans may face limitations on the number of strips and struggle to afford additional supplies. But some Medicaid patients who unknowingly allow their coverage to lapse are left without any strips, often for weeks at a time. And more than 14,200 residents of Bronx Community District 2, which includes Hunts Point and Longwood, are enrolled in the Medicaid program.

“You think ‘oh, I’m making progress with this patient,’ then for a month they can’t get anything,” says Genuardi. “It could be more like two or three months before they realize they have a lapse and then it takes 30 days to kick in, so that’s definitely very, very hard. It’s almost heartbreaking.”

In Hunts Point, this is where the local pharmacies often step up to the plate. Doctors at Bella Vista say they count on Boca Pharmacy, Point Pharmacy, and Sol’s Pharmacy to do what they can to work with the patients’ situations. It’s case-by-case, but some diabetics are offered the wholesale price for test strips or are allowed to make weekly payments, rather than one lump sum. Many pharmacists use a sliding scale, charging relative to patients’ incomes, rather than the expensive retail prices.

“A lot of times I’ll call the pharmacy and say ‘the patient has ten bucks and needs this medication, what can you do?’ and we’ll come up with something together,” says Genuardi.

While pharmacists do what they can to help, it’s a tough situation for them, too.

“Pharmacists recognize there are faults in the system and realize people can’t get everything they should get to take care of themselves,” says Selig Corman, director of the Pharmacists Society for the State of New York. “Sometimes [pharmacists] stretch things a bit, but it gets to the point where it’s serious money.”

Corman says that as the state reduces Medicaid reimbursements, pharmacists are feeling the pinch.

Just as it’s heartbreaking for doctors like Genuardi to watch a patient go without because of a Medicaid lapse, many neighborhood pharmacists find it hard to watch their long-time customers struggle.

“I think a lot of this is on the job experience and [pharmacists] trying to deal as best as they can with it, not wanting to break any laws but at the same time not trying to hurt the public because of administrative quirks,” says Corman.

And Corman knows from firsthand experience about the importance of each and every test strip. He’s a diabetic himself, and his doctor recommends that he test four times a day.

“If for some reason the blood sample isn’t enough or machine doesn’t register, you get some wasted strips in there,” he says. “I’m scrupulous when I take my own, but occasionally goof up.”

Wasted test strips — a problem all diabetics deal with — are just another added stress to the patients in Hunts Point. And while the test strip dilemma continues to disrupt compliancy among the area’s diabetics, health care providers stress that patients should ask for help. The clinics have strong relationships with the local pharmacies, and can help patients find deals on their medications and supplies. There are also some local medical supply companies, including Neighborhood Diabetes, that work with the underinsured. And for those with Medicaid questions, a Medicaid enroller visits the Urban Health Plan clinics weekly.

Even the companies that make those expensive test strips, like Harris Interactive, recognize that diabetics are struggling. Harris Interactive recommends that diabetics use Together Rx Access, Access 2 Wellness, Rx Assist, or Needy Medsto find affordable test strips.

On the untamed frontier that is diabetes in the South Bronx, a cowboy mentality goes a long way.

A McDonald's Quarter Pounder with cheese has 510 calories. (Photo by: Ernesto Andrade via Flickr)

The McDonald’s on Southern Boulevard in Hunts Point was packed on a recent Sunday afternoon. Two young women, both thin and in good shape, sat down in a booth with a tray full of food in the familiar orange and yellow wrappers: a cheeseburger (300 calories), a chicken wrap (340 calories), French fries (500 calories for a large) and sodas in paper cups (310 calories each).

“I don’t really pay attention,” said Arlene Jamiez, of the calories listed on the restaurant’s main menu board.

Her friend across the booth piped in.

“I don’t think everybody looks,” said Marian Suero. “You order what tastes good. After you eat it—that’s when you feel guilty.”

The women’s sentiments seem to confirm what some researchers are discovering: that posting the caloric content on restaurant menus does not necessarily mean people will pay attention to it, and if they do, it still might not change what they decide to eat.

The 2008 law, which requires chain restaurants in New York City to post nutritional information on menu boards, is just one of a number of food policies enacted by the City in recent years. But are these policies effective? Studies of the menu labeling requirement, as well as the growing number of New Yorkers who are obese and diabetic, suggest that such tactics might not be working to curb the growing prevalence of diet-related illnesses like those that plague this neighborhood in the South Bronx.

Hunts Point, and nearby Mott Haven to its west, has become a microcosm for a health pandemic that’s sweeping the nation. A quarter of the residents in the South Bronx are obese, and the area has the highest proportion of diabetic adults in all of New York City –17 percent of the population, according to the Department of Health.

A study published in October in the journal Health Affairs, the first real look at the impact of the calorie rule in New York, showed that people in low-income neighborhoods like the South Bronx are actually eating slightly more now than they were before the law was passed.

Other studies, including data recently released from the Department of Health, are more optimistic, and most public health advocates argue that informing consumers about the food they’re eating can’t possibly be a bad thing.

“Menu labeling is capitalism—letting the purchaser know what the labeler knows,” said Steven Gardner, a lawyer for the Center for Science in the Public Interest, a consumer advocacy group based in Washington, DC.

“Give me information, and I’ll react.”

As director of litigation, Gardner has spearheaded high-profile lawsuits against fast food giant KFC for their use of artery-clogging cooking oil, and chain restaurant Denny’s for not disclosing that some of it’s meals contain more than an entire day’s worth of sodium (KFC eventually stopped using trans-fat oils, while the Denny’s case was dismissed in a New Jersey court last month).

If it were up to Gardner, labeling would go even further than just calorie postings: he’d like to see restaurants openly disclose their use of things like trans fat, list their sodium contents and be held accountable for their marketing practices.

While most menu-labeling laws are not that stringent, they appear to be a growing trend. Dozens of states and counties continue to introduce legislation similar to the one implemented in New York, and provisions in the Senate’s health care reform bill could make labeling a nationwide policy.

The Menu Education and Labeling (MEAL) Act , introduced last spring by Senator Tom Harkin of Iowa and Congresswoman Rosa DeLauro of Connecticut, would require all restaurants and vendors nationwide with 20 or more locations to post information on the calories, sodium, saturated and trans fat, and carbohydrates in products.

“Overweight, poor nutrition and diet-related diseases are public health threats of the first order,” Senator Harkin said in a press release in May. “It is time to take preventive action and give consumers the tools that they need to take better control of their diet and health.”

WHAT’S FOR DINNER?

If menu labeling does indeed help some people, as the health department’s data claims and as most health advocates will argue, then why is it that neighborhoods with disproportionate health problems—like the South Bronx or South Los Angeles—seem to be the least affected by the rule?

“It’s possible that with the economy the way it is, price might be trumping menu labeling in some instances,” said Christina Roberto, a researcher at the Rudd Center for Food Policy and Obesity at Yale.

The neighborhoods of Hunts Point and Mott Haven make up one of the poorest congressional districts in the country, and 31 percent of the population in the Bronx lives below the federal poverty line, according to census data.

The area has been pegged by the health department as a “food desert,” or neighborhood where supermarkets that sell fresh foods are scarce in proportion to the population. While nearly every block has a bodega, the stores supply relatively few fruits and vegetables.

Until this year, food stamps were not accepted at the local farmer’s market—despite the fact that nearly 60 percent of residents in the district are on some kind of public assistance. And in a landscape littered with all kinds of fast food choices, it’s can be easy to see how tempting the dollar menu at a McDonald’s or Burger King can look compared to buying pricier fruits and vegetables.

Knopf says that even patients who do their own cooking and shopping often make unhealthy choices based on what’s cheap.

“The price is huge,” she said. “What’s cheap and what’s on sale is all the junk and all the stuff that’s horrible for diabetics.”

Jhack Sepulveda, a nutritionist at the Albert Einstein School of Medicine in the Bronx, agreed.

“Food choices here are based on cultural preference and affordability,” he said.

Sepulveda is the lead dietician on the Hispanic Community Health Study

Study of Latinos (HCHS/SOL) , a nationwide study examining the health of Hispanic populations.

A healthy lifestyle is harder in low-income neighborhoods, Sepulveda says, where families might not have the time and resources that people in wealthier neighborhoods do.

STICKER SHOCK

Everyone knows fast food is bad for you, so why should anyone be surprised by how many calories are in a Whopper? If you drop into a Burger King, you’ve probably already resigned yourself to a high-calorie, high-fat meal.

“Everything sweet has a lot of calories in it,” shrugged one patron at a Hunts Point Baskin Robbins, as she pondered which flavor ice cream to order. “I don’t really even think about it.”

But many nutrition experts say it’s not that simple.

“Myself, as a dietician who has gone to school for this for years and years, even I’m surprised by the calorie count,” Knopf said. Posting the nutritional information can help clear up confusion for consumers who might mistakenly think they’re picking a healthier option.

The classic example: a Caesar salad.

“People who don’t eat any vegetables at all, that’s like their first foray into vegetables,” Knopf said. “They think they’re making a healthier choice, and I hate to shoot them down, but it often has a lot more calories in it than even a hamburger. The dressing, and if they get the extra crispy chicken in it instead of the real chicken, it’s even more fattening.”

Another purpose of calorie labeling is not just to get the consumer to order healthier, but to get retailers to offer healthier.

“It has the potential to get restaurants to reformulate foods,” said Roberto, of the Rudd Center. “Anecdotally, you hear a lot of, ‘Oh my God, I walked into Starbucks, and the muffin had this many calories, I can’t eat there anymore – it’s like that shaming.”

Many chains have already responded to health policy’s nudging: Starbucks now uses 3 percent milk as their standard in coffee drinks, instead of whole; KFC introduced Kentucky Grilled Chicken as an alternative; kids meals at places like McDonald’s and Burger King now offer milk or juice instead of soda and apple slices in place of fries.

“I think if restaurants are taking initiatives, and making these changes on their own, then that’s great,” Roberto said. An article she published this month in the American Journal of Public Health added further credit to the idea of menu labeling.

The study examined the way people ate under three different circumstances: a first group of diners was presented with a regular menu, the second was given a menu with calorie information listed, and a third had menus that contained both the caloric content of the food, plus a label stating the recommended daily caloric intake for an average adult.

The last group, with the recommendation label on their menus, consumed an average of 250 fewer calories than both of the other groups. Even the diners with just the calorie information showed little difference from the group that had none.

“The take home message is that you need to put that contextual menu on the label,” Roberto said. The postings will be the most effective when used in combination with other health policies that encourage education about nutrition, she said.

Elbel, from the NYU/Yale study, made the same conclusion, but insists we shouldn’t throw in the towel on menu labeling just yet.

“People can make solid arguments that even if there’s not a huge response, it’s still worth doing. We don’t have to prove that exit signs are effective, but we still have them everywhere,” he said.

“I think it just means that we don’t know yet if we can rely on labeling to be the by and end-all. This isn’t going to be enough. This just reaffirms that we’re going to have to do other things as well.”

Data collected by New York City’s Department of Health is telling: nearly half the population characterizes their health as fair or poor, the death rate is 35 percent higher than the rest of the city, the hospitalization rate for heart disease is 50 percent higher, and 17 percent of the population has diabetes, double the rate for New York City overall.

Home to 800 industrial businesses and two detention centers, this heavily Latino neighborhood where almost half the population is at or below the poverty level, has some of the greatest shortages of health care providers in the city. It also has some of the highest rates of uninsured. More than one-third of the population lacks health insurance or went without it at some point within the past year. For residents suffering from diabetes, this lack of access to care compounds the difficulties in managing their disease, and for some has proven deadly.

Less than 10 miles away, on the affluent Upper East Side of Manhattan, which has the lowest rate of diabetes in the city and highest percentage of insured, the number of health care providers dwarfs Hunts Point.

Thirty-five percent of residents in Hunts Point reported that they lacked a personal doctor, compared to 18 percent of residents on the Upper East Side. Primary care doctors are important to overseeing the management of diabetes, but patients often need a host of specialists as well, since the disease can lead to vision loss and blindness, amputations, skin disorders, heart disease, and depression.

Federally funded clinics, including Urban Health and Hunts Point Multi-Service Center, have proven critical for the neighborhood, but workers say they are overrun with clients.

Dr. Thomas O'Brien
(photo: Sophie Coocke)

Thomas O’Brien, who has run a non-profit clinic in the neighborhood for 14 years, talks about the challenges to maintaining a practice, and why there is a severe shortage of doctors.

He also explains diabetics’ need for specialists and describes the difficulties for patients in obtaining needed services.

In the past 30 years, rates of obesity have increased in the United States.  However, current patterns of obesity indicate that poor and minority groups experience the highest obesity rates in the country.  For example, research shows that obesity rates are higher among adults with lower incomes and lower education levels.^1,2 A similar pattern is seen in young people; childhood obesity rates are higher among low-income families.^3,4

Differences also exist by race and ethnicity.  For adults, the largest differences are found among women. In fact, obesity rates among non-Hispanic Black women are almost twice as high as those for non-Hispanic White women. The obesity prevalence for Mexican American women falls between these two groups.⁵ Likewise, Mexican American boys and non-Hispanic Black girls have the highest rates of obesity, while non-Hispanic White girls have the lowest.⁵ The table below lists the 2003-2004 obesity rates for each group.

Source: Ogden, 2006.⁵

References:

(1) Drewnowski A, Darmon N. The economics of obesity: dietary energy density and energy cost. Am J Clin Nutr. 2005;82(1):265S-273.

(2) Drewnowski A, Specter S. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79(1):6-16.

(3) Wolfe WS, Campbell CC, Frongillo EA,Jr, Haas JD, Melnik TA. Overweight schoolchildren in New York State: prevalence and characteristics. Am J Public Health. 1994;84(5):807-813.

(4) Haas JS, Lee LB, Kaplan CP, Sonneborn D, Phillips KA, Liang S. The association of race, socioeconomic status, and health insurance status with the prevalence of overweight among children and adolescents. Am J Public Health. 2003;93(12):2105-2110.

(5) Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555.

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Lauren Dinour, MPH RD CDN is a Registered Dietitian and Nutrition Consultant in NYC. Currently a Public Health doctoral student at the CUNY Graduate Center, Lauren received a bachelors degree in Nutritional Sciences from Cornell University and a Masters degree in Public Health Nutrition from Hunter College. Since completing her dietetic internship at New York-Presbyterian Hospital/Cornell Medical Center, she has worked with physical rehabilitation and elder care nutrition in several Manhattan institutions. In addition, Lauren’s passion for obesity prevention has allowed her to work on several public health projects with the NYC Department of Health, Head Start, and other community-based organizations.

Fast food will always be a part of our culture, and a lot of times it may be the only food that you have access to. Limiting the amount of fast food you eat has to be a conscious decision. For example, limit yourself to eating fast food only once a week if you were previously eating it daily. If going to the fast food restaurant is the only option, then try to make a healthy choice – order the grilled chicken sandwich instead of the hamburger or get a fruit or salad as a side instead of fries. It also helps to have healthy fast options available to you – such as a granola bar or a piece of fruit – so you aren’t tempted to run into the local McDonald’s or Burger King.

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Amanda Marsh is the lead dietitian at St. Luke’s Surrey Place rehabilitation center in St. Louis. Mo. Amanda began her career New York Presbyterian hospitals including the Columbia University Medical Hospital and Morgan Stanley’s Children’s Hospital in New York City. During this time, she worked with children and adults diabetics. She left NY Presbyterian to work as a health coach in preventative health care at EHE, International before moving to Missouri and landing her current job. Amanda received her B.S. in Food, Nutrition, and Dietetics from Illinois State University in her hometown of Chicago.