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.