Francine R. Kaufman Photo by S. Peter Lopez

Issue: Autumn 2005

Defying Diabesity

For years Francine Kaufman has watched the two-headed serpent of obesity and diabetes devour ever-younger and ever more prey. Now she’s fighting back with everything she’s got, including a tough-talking book that’s scaring people skinny.

By Gregory M. Vogel

In 1976, Francine Kaufman was a newly minted M.D., starting out as a pediatrics intern at Childrens Hospital Los Angeles. It was a different world back then. So many doctors and nurses smoked that cigarettes were sold in the hospital gift shop. And the chance of a child developing type 2 diabetes – then called “adult-onset” diabetes – was so remote, any such case would have been written up in a medical journal.

What a difference 30 years makes. Kaufman now heads CHLA’s pediatric endocrinology department. Smoking is no longer permitted anywhere in the hospital. And type 2 diabetes in children has become so common that one out of every three children born in the year 2000 is expected to develop diabetes in their lifetime.

“Diabetes has now become one of the most common diseases of childhood,” says Kaufman, who is also a professor of pediatrics at the Keck School of Medicine of USC. The simple explanation is that we’ve grown fat on too much junk food and too little exercise. Being overweight or obese greatly increases the odds of developing diabetes – having high blood sugar, which is dangerously toxic for organs and cells. And the earlier diabetes starts, the greater the risk of complications and an early death.

These days, Francine Kaufman is a doctor on a mission: To combat an epidemic of obesity and diabetes – a lethal combo called “diabesity.”

“Historically, this problem didn’t exist,” Kaufman explains by cell phone one Saturday afternoon in April. True, some people are genetically programmed for diabetes 2 even without being overweight. But “the bulk of people who get diabetes are people who have become obese, who are sedentary and have poor nutrition,” she says. “We know we can prevent diabetes. The irrefutable data points to the benefits of a healthy lifestyle and a healthy weight.”

Kaufman is on her way to the San Francisco airport, having flown up from L.A. that morning to speak at a seminar for health journalists organized by USC’s Annenberg School for Communication. A grueling schedule, but for Kaufman, dealing with diabesity is a 24/7 commitment, and she isn’t missing any chance to get the word out.

More than 18 million Americans suffer from diabetes. Another 41 million have pre-diabetes, often a harbinger of the full-blown disease. It’s the sixth leading cause of death, and according to the American Diabetes Association, it cost the nation $132 billion in 2002.

The disease has two major forms. Type 1 occurs when insulin-producing cells in the pancreas are destroyed by the body’s immune system. Formerly called “juvenile diabetes,” type 1 typically strikes children and young adults. But it accounts for only 5 percent of all diabetes.

The far more common type 2 diabetes strikes when the body can’t respond to the insulin being made. More than 80 percent of people with type 2 diabetes are overweight or obese. As a pediatrician, Kaufman worries most about the growing number of overweight kids with type 2 diabetes she sees.

To aim a spotlight on the problem, Kaufman wrote Diabesity: The Obesity-Diabetes Epidemic That Threatens America – and What We Must Do to Stop It. Published in March, the book takes a sober look at the realities of the disease.

The world is getting fatter (a condition that has been described as “globesity”), and forecasts are grim. Without intervention, 300 million people worldwide will have diabetes by 2020. As related problems like heart attack, stroke, kidney failure and blindness surge, whole healthcare systems could become overwhelmed. Some systems, especially in developing countries, may simply collapse.

Kaufman rejects simplistic explanations that put the blame on personal flaws like gluttony and laziness. Instead she blames the “toxic environment” created by modern living, which promotes overeating sugary and fatty junk foods, reinforces inactive lifestyles and focuses on “disease care” instead of preventative health care.

The nation’s flocks of young people with diabetes are simply canaries in a coal mine, she contends. Indeed, a 2005 study predicts the first decrease in American life expectancy in 200 years; it’s attributed to obesity-related diseases. “The clock is ticking,” Kaufman warns.

Solving the problem won’t be easy. She proposes taking a “holistic” approach, everything from changing school lunch menus to changing laws. Lobbying lawmakers is an unusual step for a doctor to take. But Francine Kaufman is an unusual doctor.

“Fran has no fear of anything,” says USC colleague Tom Buchanan, an expert in type 2 diabetes who directs the Keck School’s General Clinical Research Center. “She looks at a problem, decides what needs to be done and figures out how to do it. She has no limits to the number of things she’ll get accomplished. If it means going to Sacramento, she’ll do it; getting involved nationally, she’ll do it; spending time at summer camp or creating an educational DVD, she’ll do it.”

The indefatigable Kaufman always has time for her patients, though. “I’ve been with her at meetings internationally, and she’s always getting paged, all over the world,” Buchanan says. “She responds immediately. She’s their doctor, all the time.”

Colleagues marvel at the way Kaufman juggles her roles as a pediatrician, teacher, administrator, researcher, writer, inventor, mother, wife and public health advocate. She seems to have more energy than a teenager.

Dynamic Duo Kaufman (left) and colleague Anne Peters are both superstars at USC’s Keck School. Each published a major self-help book this spring tackling the diabetes epidemic. Photo by Mark Harmel

“She’s extraordinary,” says Keck School clinical professor Anne Peters, who directs the USC Westside Center for Diabetes and whose own book on the prevention and treatment of diabetes was published in April by Hudson Street Press. “Fran probably sleeps less than any other person I know. She can go back and forth to the East Coast twice in a week, and all that while she’s doing 16,000 other things simultaneously. Her ability to multi-task is unbelievable.”

Peters and Kaufman co-direct the Keck Diabetes Prevention Initiative, a two-year, $2 million joint USC-CHLA project funded by the W.M. Keck Foundation. The initiative, which seeks to identify factors that contribute to decisions about diet, physical activity and health care within the East Los Angeles and South Los Angeles communities, also involves other USC graduate schools, including the USC Annenberg School for Communication, the School of Policy, Planning, and Development and the School of Social Work.

In her personal life, Kaufman “walks the walk” – literally – to stay fit. She stays slender thanks to morning hikes with her husband Neal and their dog Islet (named after the body’s insulin-producing cells). At work, she takes the stairs, never the elevator. She favors fresh fruits and vegetables, and avoids junk food, but admits to enjoying an occasional Oreo. The secret to not gaining weight, she says, is maintaining energy balance – that is, not consuming more calories than you burn.

And Kaufman burns plenty. At Childrens Hospital, she sees all kinds of patients – overweight kids with diabetes; kids with thyroid cancer; kids with growth problems, bone diseases and hormone imbalances. She chairs and participates in multiple studies funded by the National Institutes of Health. She writes grant applications, publishes research articles, teaches, speaks at international meetings and oversees the diabetes prevention program that she and her staff created, called KidsNFitness.

Then there are her side projects: volunteering as medical director at Camp Chinnock, a summer camp for kids with diabetes in the San Bernardino mountains. Leading a Los Angeles County task force on youth fitness. Participating in a White House summit on the health of schoolchildren. Producing a video game that teaches kids how to cope with diabetes. She even invents products, like the insulin dosage sliding scale. And the ExtendBar, a snack that releases carbohydrates slowly, protecting patients with diabetes from dangerous hypoglycemia. For that invention USA Today affectionately dubbed her the “Betty Crocker of Diabetes” (Kaufman developed the recipe in her own kitchen).

In 2002 she was president of the American Diabetes Association. Secretary of Health and Human Services Tommy Thompson presented her with the ADA “Women of Valor” lifetime achievement award.

Yet Kaufman is quick to share credit with colleagues; she cites fellow diabetologists Peters, Richard Bergman, Michael Goran and Buchanan. In fact, researchers and clinicians from the Keck School and CHLA are coming together in new ways in response to the diabesity epidemic. “We have closer scientific ties,” Buchanan explains. “There used to be more of a separation. [CHLA] took care of type 1, and [the Keck School] took care of type 2. But that’s not true anymore. What the parents used to get, their kids are getting now.”

Stumping for a Cause Kaufman blitzed network and cable news, local television and radio to get the word out. “We have to change schools. We have to change the workplace,” she told CNN’s Wolf Blitzer. Photo courtesy of Francine Kaufman

With the publication of Diabesity, Kaufman is more than ever on the go. She has appeared on the “CBS Morning Show,” been interviewed on CNN, been reviewed and quoted by Jane Brody in the New York Times, featured in USA Today and been a guest on PBS’s “Tavis Smiley Show.” Meanwhile, the book is winning praise from public health officials, obesity specialists, even journalists. (On the back, a quote from CNN’s Wolf Blitzer: “Francine Kaufman will save lives.”)

The book’s effect is already tangible. Dominique De Clerck, nursing supervisor in CHLA’s Division of Research Immunology/ Bone Marrow Transplant, now wears a pedometer to make sure she gets the recommended 10,000 steps a day for fitness. “I really think Fran is right,” she says of Kaufman’s wake-up call to America. De Clerck lends her copy of Diabesity to friends and tries to motivate overweight patients. She’s even asked Kaufman to address CHLA nurses during Nurse Recognition Week – typically celebrated with fatty treats like cookies, pancakes and pizza. “This should be the first place where we have more healthy things,” De Clerck says.

Kaufman’s book covers every aspect of diabesity, from genetic heritage to super-sized portions. But this is no typical self-help book: It’s a moving, first-person account of Kaufman’s own experiences and the impact of diabesity on people she knows. Diabesity “turned out to be more personal than I thought it was going to be,” she acknowledges. “It made me a little nervous and scared at the beginning. Why would I want to reveal things about myself and my family? But it just kept coming.”

The reader learns about Kaufman’s occasional battles with the “powers that be,” arguing with her own hospital’s administrators over selling candy in the gift shop and serving doughnuts at staff meetings. And perhaps most importantly, Kaufman gets us in touch with her patients’ lives.

“As a doctor, you listen to stories all day long,” she says. “Intimate things that a person might not tell anyone else. You hear about their greatest pleasures and greatest fears. Then you watch their stories unfold, with all their disasters and triumphs.”

Over the years, Kaufman started writing down the most poignant stories until she had a drawer full – a chronicle of the diabesity epidemic, first in pencil on legal pads, then in blue ballpoint, then printed on dot-matrix pages with perforated edges, and most recently on laser paper. She realized these true stories could show the public what diabesity is really like.

“If I can’t get someone to see the face of this disease, it’s abstract. And then who cares?” she says.

There’s Tanesha, a teenage diabetic who weighed 267 pounds at only 5 feet 3 inches – and whose obese grandmother was in denial about her own neglected diabetes. And Henry, an out-of-shape 12-year-old who regularly stuffed his face with federally subsidized school breakfasts of fried eggs, bacon and biscuits; lunches of hot dogs, fries and cupcakes; plus fatty, sugary snacks. And Gordon, a teenager who sums up his prospect of never-ending blood tests and insulin shots in two words: “Diabetes sucks!”

Kaufman’s own childhood was deeply affected by diabetes. When she was 9, her beloved Grandma Sadie was taken to the hospital and diagnosed with diabetes. After that, everything changed: there would be no more candy in the house – which was hard for Sadie, who had owned a candy store. No cookies, no more of her mother’s delicious chocolate cake. Instead, there would be an endless parade of syringes, insulin injections and blood tests. “In that instant, I hated diabetes,” Kaufman writes. “I hated diabetes because it made my grandmother sick and I was worried she would die…. I didn’t know exactly what this disease was, but I vowed to get back at diabetes some day.”

That vow stuck with her. Her physician father encouraged Kaufman to become a doctor. After graduating from Chicago Medical School, she and her husband came to CHLA as residents in pediatrics. In 1980, she joined the USC medical faculty at CHLA as a clinical pediatrician with a special interest in endocrinology.

Gradually, she realized that more and more of her patients were overweight and had diabetes. “I sort of watched this explosion occur in the midst of my career,” she recounts.

In the ’80s, fast food took over America, hitting hard in the low-income districts where many of Kaufman’s patients lived. From hash browns and soda pop for breakfast to burgers, pizza, fries and more soda for lunch, kids were eating themselves sick. Then came the super-size craze, with cheap, massive portions. As fast food ads saturated popular culture, kids demanded – and got – what they wanted. Meanwhile, their activity levels dropped as time spent watching TV and playing videogames increased. Many of Kaufman’s young patients were spending every afternoon and evening glued to a screen, not moving. Ordering them to get out and exercise wasn’t the answer. In some neighborhoods, she knew, it simply isn’t safe to play or walk around outside.

The result is that in 20 years, the number of overweight children has skyrocketed – and with it, diabetes. Cases have been reported in kids as young as 4.

Kaufman found herself irresistibly drawn into her young patients’ worlds – a connection that sometimes continues into their adulthood. “I get to be a participant in their lives,” she says. “I’ve gone through so much with them for so long, my goal is to become a partner with them in how they move forward.”

In examining the roots of the problem, Kaufman found social issues were just as important as dietary ones. She and her staff at CHLA developed the 12-week KidsNFitness program to teach youngsters about food labels, nutrition and portion sizes, and get them moving with exercises and dances. KidsNFitness is a research program too: The data shows improvements in weight, body-mass index, blood pressure, cholesterol and insulin.

It’s no secret that much of what kids consume at school can make them fat: Federally subsidized meals are often too high in calories and sugar. Schools also sell junk food in cafeterias, school stores and vending machines. But when Kaufman learned that soda companies were giving schools financial incentives to keep soda machines on campus, she threw herself behind the effort to “ditch the fizz.” She testified as a medical expert to the Los Angeles Unified School District board, urging a halt to soda sales in the school yard. After LAUSD superintendent Roy Romer revealed that he himself has diabetes, the board voted to make LAUSD America’s first major district to ban soda machines.

But Kaufman isn’t just fighting for her patients or the kid next door. She writes about visiting a health center in India serving 75,000 people with diabetes, and a children’s clinic in China with the barest of medical supplies. She takes politicians, HMOs, Medicare, Medicaid and large employers to task for not working harder to prevent the epidemic. She calls on government to reach out to disadvantaged communities.

Kaufman knows her zeal has taken its toll on her family. She’s grateful, she says, to her husband Neal for supporting her career, to her sons Adam and Jonah, who have worked as counselors at Camp Chinnock, and to Lance, her former patient and “extended” son.

Compared to other offices in her department, Kaufman’s is a modest, windowless room. Bookshelves line two walls, holding pictures of her family, the kids she’s taken care of at Camp Chinnock, and another summer camp in Ecuador. A photo of her mother, who made sure her family ate healthy food even when TV dinners were all the rage. Her father, who wanted her to be a doctor. Her sons celebrating their bar mitzvahs. A wedding photo of Lance and his bride.

Kaufman opens a drawer and takes out an old photo of Grandma Sadie and Grandpa Harry in front of their candy store in Chicago. The youthful Sadie is beautiful and slender, as she was in the years before weight gain and diabetes took their toll. She looks boldly at the camera – a strong woman capable of surviving poverty in Russia and the hardships of immigration to America.

“Sadie was the one who kept that family fed and alive,” Kaufman says proudly. “She was one tough chick.”

Fighting diabetes is tough, too. But Kaufman is optimistic: “We just have to keep pushing further until we have a tipping point, like we did with cigarettes. There are people all over working hard on this, not just a couple of us academics in some medical center. It’s a huge coalition of people, nonprofits and foundations. I think we’ve got a movement. And I’m very encouraged.”

Gregory M. Vogel is a freelance medical writer and branding consultant based in Los Angeles.