Ryaisa Armelin takes a "Save Half for Later" container to diners at Creole Restaurant. (Photo by Jacqueline Guzman)

Ryaisa Armelin, 18, stands beside the dim-lit bar at Creole Restaurant in East Harlem, wiping down a smooth, granite-colored tabletop as the midday rush dies down. She’s dressed head-to-toe in black; her apron shows a cartoonish figure of a plate and says, “Save Half for Later.” Posters and display cards with the same design, in English and Spanish, decorate walls and tables.

Armelin is between adding up checks and clearing tables, when a group of twentysomethings from the auction house around the corner walks in.

“Four for lunch?” Armelin asks, “I’ll be right there.”

Alana Celii, 25, and her co-workers have a seat while Armelin brings them menus.  After giving them a few minutes, Armelin takes the order and asks if they’d like to have half of the their meal now, and take the rest home.

Creole is one of 15 restaurants that has teamed up with the Mount Sinai School of Medicine’s Communities IMPACT Diabetes Center in a portion-control campaign called “Save Half for Later.” It’s an effort to combat ever-increasing cases of diabetes and obesity in East Harlem. The neighborhood has the highest rates of diabetes in Manhattan, with an estimated 1 in 6 adults living with the disease, according to the center. A contributor to the diabetes rate is obesity, which is also rising for a number of reasons, including the increasing size of food portions in restaurants.

The campaign has even expanded to Central Harlem, where 36 percent of adults were obese in 2009, according to the New York Department of Health and Mental Hygiene. On Wednesday, Sylvia’s Restaurant on Lenox Avenue held a portion-control event, becoming the first Central Harlem restaurant to officially join.

It’s a simple concept — eat less and save money. When dining out, the server asks the customer if he wants to “Save Half for Later.” Before bringing out the meal, the server offers to put half into a reusable plastic container — big enough for an entree and side dish —  that has the campaign’s logo on the lid. Then the diner takes the rest home to have for the next meal or even the next day, just as the name suggests. With “Save Half for Later,” the diner essentially gets two meals for the price of one.

“That’s my favorite part of it – saving your money,” Armelin says. A lot of people don’t have time to cook every day, she adds, “so why not split that in half?” Although servers must kindly offer a container to every customer, the decision to take it is ultimately the customer’s. “Sometimes people say ‘no thanks, I’m fine’ or ‘I’m really hungry today.’”

“It makes sense,” says Celii, who hadn’t heard of the program before. She and the three others have lunch at Creole every couple of weeks, but normally get their meals to go.

“Most people wouldn’t stop themselves midway through a meal,” admits Cory Hooper, 24, including himself. Self-control is difficult, he adds, especially with current portion sizes. Saving money “is a good incentive for people to participate and watch their health,” he says. “I would definitely do it.”

The program was launched last summer. Carolyn Zezima, director of the Food and Health Initiative for the Communities IMPACT Diabetes Center, explains that the group had to first carefully map out all restaurants in the area.

“Our interns pounded the pavement, hitting every restaurant,” Zezima says. The team surveyed and interviewed a number of owners of sit-down, local restaurants with hefty portions. They narrowed it down to those who shared a positive attitude toward healthy eating. Then the team presented the plan and trained the staffs on engaging the community.

“We want to empower the consumer to make decisions about their meals,” says Zezima. The point isn’t to dictate changing their eating habits, but to spread awareness and make healthier choices easier for them.

Although “Save Half for Later” is still in its early stages, restaurants have been receptive to the idea, says Zezima. At Cafe Ollin, Lydia Perez’s only compliant is that the containers are “not convenient for sandwiches.” Since their sandwiches tend to be thickly packed with ingredients, Perez finds fitting even half a sandwich into the container difficult.

Half of the portion is put in a container before enjoying the meal. (Photo by Jacqueline Guzman)

On the other hand, Ramon Duran, owner and operator of El Nuevo Caribeño, has accepted the program into his place wholeheartedly.

“It’s a contribution for the people, in order to maintain their health,” said Duran. He operates the restaurant, located on Lexington Avenue, that his father opened more than 20 years ago. He said that customers’ responses have been positive so far.

When they see the program’s poster hanging in the restaurant, they often ask about it. Duran figures that in a given week, all the plastic containers that the program delivers are gone.

“I want to see all my customers as healthy as they can be,” he says. “I want to see people happy and look good. If you look good, you feel good.”

The Communities IMPACT Diabetes Center says that many affected residents are unaware they have diabetes because they have never been tested. The agency is concerned that if nothing is done to educate residents about making healthier food choices, poor eating habits could lead to diabetes in their children. By the time those children grow up, the cases of obesity could increase and the rates for diabetes could even jump to 1 in 2 diabetic adults in East Harlem.

The program is now entering a new phase, Zezima says. Case managers have been assigned to each restaurant and will follow up on their performance and send them more containers as needed. Plans to add more Central Harlem restaurants, like Sylvia’s, are also under way. Lolita’s on West 113^th Street is already training staff on approaching customers. A similar take-out version of “Save Half for Later” would also aim to teach children to make healthier choices at home.

Word of mouth is slowly getting residents to save half their meal. Wednesday’s event at Sylvia’s has drawn instant attention to the center’s effort. Tren’ness Woods-Black, vice president of communications and Sylvia’s granddaughter, tells the press that joining the campaign is “in line with what we do whenever we’re given the opportunity to empower the community and make them healthy.”

“It’s definitely catching on,” said Zezima, “we’re really excited about it.”

Proportion of residents with diabetes in U.S., New York City and uptown neighborhoods. (By Medina Roshan).

Half a dozen diabetes patients gathered in a classroom uptown one recent morning to discuss why keeping blood sugar levels between 70 and 150 is so vital.

The Naomi Berrie Diabetes Center at Columbia University Medical Center offers diabetes education classes, along with nutrition counseling and other programs, for a community beset with diabetes. “We are here like a GPS,” educator Martin Ovalles told the class. “We guide you where to go.”

Some who attended were among the estimated 10.7 percent of residents in Harlem, East Harlem, Washington Heights and Inwood with diabetes, compared to the city’s average of 9.7 percent, according to the city health department.  A health department survey released last year shows that diabetes disproportionately affects low-income neighborhoods, as well as black and Hispanic populations, all characteristic of uptown neighborhoods.

Uptown residents also face several additional risk factors for the disease, which some public health experts are calling a nationwide epidemic: poor diet, obesity, heredity and sedentary lifestyles.

Vanessa Castillo, a patient at the center, was shocked when her doctor diagnosed her, at 14,  with Type 2 diabetes.  “I was like me? Diabetes?,”recalled Castillo, now 22,. “For me, it was an old people’s disease.”

Her disease was discovered when she consulted a doctor about darkened skin around her neck, a condition known as acanthosis nigricans that is an indicator of diabetes.

Education is at the core of the problem, said nurse Patricia Kringas,  also a research coordinator and certified diabetes educator at the Berrie Center.

“Diabetes is a disease of management,” she said.

Type 1 diabetes occurs when the pancreas produces an insufficient amount of the insulin hormone, which regulates blood sugar in the body. Insulin resistance occurs with Type 2 diabetes, whereby the body is unable to process glucose to be metabolized for energy, Kringas explained.

With childhood obesity rates rising, Type 2 is no longer seen only in older adults. “Now more and more, you are finding it with younger people,” Kringas said.

Genetics also plays a role, she added. In Castillo’s family, her mother and several of her aunts have the disease, and two  grandparents died from complications of diabetes.

Poor diet choices are another major contributing factor.

About 60 percent of the patients that nutritionist Ericka Arrecis sees at the Berrie Center are uptown residents. Many are of  Dominican background and eat high-carbohydrate diets, she said, including starchy cassava, a traditional mainstay of Dominican cuisine. That makes healthy eating challenging.

But misperceptions about the disease and its management, and about which foods contain the right types of carbohydrates for diabetics, are widespread, Berrie staff members said, particularly among immigrant populations.  Some patients mistakenly believe that diabetes results from eating a lot of sugar or that being heavier means being healthy.

In fact, Ovalles said that his own mother, who lives in the Dominican Republic, complains that his sons, 9 and 11, are too thin; she asks him to send them to her for the summer so she can help them gain weight.

But even when patients understand how to manage the disease, Arrecis says, they complain about the cost of healthier foods, and about being unable to afford fresh vegetables or whole grains. “The diabetic diet is more expensive,” she acknowledged.

Castillo and her family frequently deal with this issue. “You just take whatever is cheaper,” she said of her family’s shopping habits. “Usually the cheaper stuff is the fattier food.”

Experts agree that socioeconomic factors contribute to the problem. “Diabetes to me is to me one more manifestation of social and economic inequity,” said Marilyn Aguirre-Molina, a professor of public health at the City University of New York..

Some families find it more convenient and economical to pick up dinner from the McDonald’s dollar menu rather than locate a grocery store that provides nutritious and affordable choices, she said. Uptown, “The food sources are atrocious,” Aguirre-Molina added. “They have lots of fast food, which I called fields of fat.”

According to a report from the East and Central Harlem District Public Health Office, two in three food stores in those neighborhoods are bodegas, many of which don’t offer healthy foods. For example, leafy green vegetables are available in just three percent of bodegas there, compared to 20 percent on the Upper East Side. “There has to be ways of bringing in supermarkets and other stores,” Aguirre-Molina said.

Furthermore, uptown neighborhoods are not conducive to physical activity, she added, especially when parents are concerned for their children’s safety.“Playgrounds in some of these areas are a disaster,”she said.

One uptown neighborhood responding to the growing problem is East Harlem, which Mt. Sinai School of Medicine researcher Euny Lee calls the epicenter of diabetes and obesity in the city.

Lee is the project manager of a study called the East Harlem Partnership for Diabetes Prevention, started to help pre-diabetic adults from developing full blown diabetes. Pre-diabetes occurs when people have higher than normal blood glucose levels that aren’t high enough to be classified as diabetes.

A participatory research program, the project involves several uptown community organizations in organizing workshops designed to help participants lose weight. “We’re trying to see if the workshops are a successful way of preventing diabetes,” Lee said.

While she said she can’t provide conclusive data from the study, still in progress, Lee has noticed a trend in participants’ ages. “Participants that we screen are a younger cohort,” she said.  “It’s not like they are senior citizens.”

Other city programs include the Healthy Bodegas Initiative, which encourages shopkeepers to provide healthier foods like fruits, vegetables and low-fat milk in exchange for help with advertising and permits to sell on sidewalks.

Castillo, learning about her disease, still struggles to eat well and remain active, she said.

Her blood sugar is higher than it should be and she also suffers from high blood pressure. Her doctor recently prescribed insulin injections, a prospect she is nervous about because she is afraid of needles.

“I don’t like pain,” she said.

Still, Castillo said she can’t complain because she has not felt ill since being diagnosed. Her goal, she said, is to get her diabetes under control.

Tiffany Denise, facilitator of Hip Hop H.E.A.L.S., leads a health session at Thurgood Marshall Academy in Harlem. (Photo by Dewi Cooke)

They know the ingredients of a bottle of Coke and can describe the difference between empty calories and nourishing ones. But it’s Chris Brown who really speaks to them.

When MC Easy AD plays Brown’s bass-heavy “Transform Ya”, the fourth graders of Thurgood Marshall Academy Lower School on West 151^st street can’t contain themselves.

That’s just what AD – Adrian Harris, half of the pioneering hip-hop duo the Cold Crush Brothers – and his partner Tiffany Denise hope for. “Do you know dancing is great exercise?” Denise tells the group of 50 wriggling students seated on the floor of their school’s cafeteria. “When we dance, we burn calories.”

Hip-hop is the key to engaging students, she says. “They love the latest stuff, as long as it’s hot and fly and they can move to it.”

It’s a routine the pair run in schools around New York every week. Since starting in Harlem 18 months ago, the city-funded Hip Hop H.E.A.L.S (Healthy Eating and Living in Schools) project has taught 12,000 local schoolchildren about nutrition and health.

But it’s more than another anti-obesity program for kids. The brainchild of Harlem Hospital’s Dr. Olajide Williams, the project’s lesser-known aim is to use children as a way to funnel information on nutrition, diabetes and heart disease to at-risk parents.

And its sister program – Hip Hop Stroke, which laid the ground work for Hip Hop H.E.A.L.S. when it started in 2007 – just landed a $3.7 million grant from the National Institute of Neurological Disorders and Stroke to test that strategy. The five-year project,  led by Williams, will look at how well parents and grandparents grasp the messages children and grandchildren bring home, about stroke awareness and prevention.

“I call it child-mediated health communication,” Williams says. “It’s an approach that I think is innovative and I think it’s a potential vehicle for additional health communication in disadvantaged communities.

“It’s very hard to penetrate the home fabric of individuals in disadvantaged communities because there’s so many competing interests,” he continues. Survival is the primary objective for many of the families the program serves, mostly at public schools in low-income neighborhoods.

During each two-day Hip Hop H.E.A.L.S. session, children watch cartoons and hear songs created especially for the project. They go home with DVDs, comic books and t-shirts. The program covers different themes, including fitness, but the growing interest in child obesity makes nutrition the most requested, Denise says. Students use “beat boxes”, electronic remote controls allowing them to answer on-screen quizzes such as “Where do calories come from?” and “Do you have a grown up at home who looks after you who smokes cigarettes?”.

At Thurgood Marshall this month, one student raises her hand to respond to the cigarette question. She tells the group that her aunt smokes, and “sometimes I tell her not to, and she throws the cigarettes away and now she stopped”. The class cheered. Then they danced to Aretha Franklin’s “Respect”.

“See, that’s the power of children I’m telling you about,” Williams says.

Harlem Hospital's community outreach service ran free health checks at a recent Latino community health fair on 145th st. (Photo by Dewi Cooke)

Gema Mosso was surrounded by children and balloons. Her stroller teetered under the weight of bags stuffed with health information and her two children wore colorful Mardi Gras beads handed out by a local HIV/AIDS prevention organization.

Mosso, a Mexican immigrant, was at the Hamilton Grange branch of the New York Public Library for a recent Latino health fair and had taken advantage of its offerings: She’d had her eyes tested and her son Edward’s feet checked. Soon, she’ll follow up with a doctor about Edward’s slightly crooked gait.

Uninsured but concerned about her children’s health, Mosso is exactly the person that community health fairs want to reach. A regular library visitor, she had heard about the fair – sponsored by the Harlem Dowling West Side Center for Child and Family Services – and had recruited two cousins and their three children to come along.

“I’m interested in anything regarding my kids and my kids’ well-being,” she said through an interpreter.

Demand for community health fairs – to test for everything from high blood pressure to breast cancer — is on the rise in Harlem, neighborhood organizations say, since the economic downturn took hold.

Naomi Griffin, director of community outreach at Harlem Hospital, said the hospital’s mobile outreach vans see about 2,500 people each year, sometimes visiting up to six sites on a weekend. The season for outreach work, formerly May to September,  now runs April to October.

“It’s an indicator that there is a need,” Griffin said. “We want to go out and assist the community to become more health care aware and know their status.”

Local non-profit groups have run such fairs, which also provide information about health, nutrition and low-cost health insurance, for years.

But despite city welfare officials’ recent City Council testimony that New York appears to be recovering from the recession at a stronger pace than the rest of the country, Lavater Harvin of West Harlem’s Ephesus Seventh Day Adventist Church said the economic downturn continued to have an impact.

Ephesus held its annual health fair last month when, despite a steady rain, around 40 people registered for free blood pressure  and diabetes tests. A mobile mammogram van was stationed at the church’s Lenox Avenue entrance, along with stalls offering nutritional advice, vegetarian cooking tips and podiatry check-ups. A group of about 20 joined in an aerobics class exercising to a rousing gospel soundtrack.

“We have a lot of people here that don’t have insurance, a lot of people that are out of jobs,” Harvin said. “Living in this neighborhood you see a lot of people in need.”

But Harlem Hospital’s Griffin acknowledged the outreach services can reach only those who want help and that follow-up appointments are left to patients themselves.

For this reason, Central Harlem Health Revival, a church-based coalition, hopes to track some who attended its annual health day last month. Revival coordinator Joanne Thigpen said that despite such efforts by community organizations, Harlem residents continue to have higher rates of obesity, stroke and heart disease than the city average, statistics show.

“Are we getting the right people in and are they getting the services they need?” Thigpen asked. “Let’s see how we can take them so they can actually get into the services. This is an underserved community.”

Upcoming:

Halloween Health Fair

Friday, Oct.  29, 10 a.m.-1 p.m.

Helen B. Atkinson Center, 85 W. 115th St.

New York State law is driving out the best podiatrists. (Photo by Zaheer Cassim)

New York State’s best podiatrists are moving to other states because of laws limiting them from working on the ankle, says an administrator from the largest and oldest podiatrist school located in Harlem.

Associate Dean of Student Services and Admissions Lisa Lee who works at New York College of Podiatric Medicine says: “New York State is losing its best trained podiatrists because it is so limited here. I’ve seen my best students leave.” Forty-four states in America allow for podiatrists to work on feet and ankles, while New York and five other states still lag behind. Lee says this is an outdated law but prevails because the orthopedics lobby is wealthier and hence has more sway with Congress.

In June, the state Senate passed a measure that will increase the scope of podiatry to ankles. The General Assembly will now vote on the issue. However, this may take some time explains podiatrist Eric Walter, who is also a member of New York Podiatric Medical Association. Walters says the association has been trying for more than six years to change this law and has seen some of his best residents leave New York during this period. “Our biggest nemesis is the orthopedic surgeons who feel like we don’t have the right training,” says Walters.

The New York State Society of Orthopaedic Surgeons has not denied this and says it will continue to oppose podiatrists wanting to work on the ankle, because the society says the podiatrists do not have adequate training. In a memorandum of opposition (PDF) to the measure, addressed to New York Legislature, the orthopedic society states that “training for orthopaedic surgeons and podiatrists are very different. Orthopaedic surgeons complete four years of medical school followed by five years of fellowship training. Podiatrists, by comparison, receive four years of graduate education followed by either a two-year or three-year residency.” This two- to three-year difference in training “is detrimental to patient care,” the letter says.

In the last 20 years, training in podiatry has become more rigorous. Residence has increased to three years from initially being a single year, so that new doctors can learn other skills, like surgery, and how to work with diabetic patients. The prevalence of diabetes, especially in poorer communities, has increased the demand for podiatrists.

Since the beginning of the recession more pre-med students have chosen podiatry as a profession. Lee says the podiatric school had a 15 percent increase in applicants over the last three years. She adds that more people are choosing podiatry over other forms of medical specializations. “Back in the early 2000s, I would say over 70 percent of our students, podiatry was a second choice after they couldn’t get into other medical programs,” she says. “But now I would say podiatry is a first choice for over 65 percent of our students.”

Third-year student Chioma Odukwe Enu, 29, worked as an administrator in the medical industry for several years before choosing podiatry. After receiving a master’s degree in molecular biology she decided to pursue a career in podiatry. She admits that in the past podiatrists were known to be the students who didn’t get into medical school, but this has changed. “You find as a trend now, kids are choosing podiatry,” she says. “Not saying I want to be in the medical field, but saying I want to be a podiatrist. It’s not so much that they didn’t get into medical school or they didn’t have the credentials to get into medical school because our credentials are pretty high, too.”

Enu says she doesn’t know if she is going to stay or leave New York after she graduates, but she implores her fellow students to get involved in the debate and make their voices known to the Legislature. She believes that if “other states like Connecticut or Washington, D.C., did it in order to increase their scope of practice so why shouldn’t New Yorkers step up?”

East Harlem has one of the highest rates of diagnosed diabetes in the city.  The Nourishing Kitchen*, a soup kitchen with a difference, is helping local residents eat well and lower their risk.

* Correction: This story originally included an incorrect link.

A Supermarket Need Index determined areas lacking access to fresh food. The dark green areas show FRESH Food store areas and light green shows additional areas where financial incentives may be available. (Map courtesy of NYC Department of City Planning)

Growing up in Harlem, Gail Brown got used to having limited access to fresh foods. She now shops at Fine Fare, a chain supermarket on Lenox Avenue and 116th Street, but still doesn’t see farm fresh or organic food. “I’m a little disgusted with this,” she said, pointing to the package of cellophane-wrapped chicken in her cart. “But this is the selection they had tonight.” Brown describes it as “second class food.”

Laura Purcell, who moved from the Upper West Side to central Harlem, also shops at Fine Fare when she needs something quick. For larger orders, “I tend to shop at Fairway,” she said, adding that she appreciated that store’s wider selection when she lived further downtown.

The City Planning Commission has voted to approve a fresh food program that offers incentives to develop supermarkets in targeted neighborhoods, including Central and East Harlem and Washington Heights. The City Council has until November 24 to review the proposal.

The Planning Commission developed a Supermarket Need Index last year to pinpoint areas with high levels of diet-related disease and limited supermarket access. The index showed that East and Central Harlem and Washington Heights needed better access to fresh food. New Yorkers living there and in Inwood are more likely to be obese and to have diabetes and other diet-related health conditions than other Manhattan residents, according to the New York City Department of Health and Mental Hygiene.

The FRESH program, short for Food Retail Expansion to Support Health, would allow businesses certified as “fresh” to be 20,000 square feet larger than the law currently permits. Such businesses would also benefit from reduced real estate taxes, sales tax exemptions and reductions in the amount of required parking.

A fresh-certified business would dedicate at least 6,000 square feet to selling groceries, according to the amendment, with 30 percent of that area designated for perishable foods like produce, meat and dairy products.

The FRESH program aims to improve the health of New Yorkers in “underserved areas,” according to a spokeswoman for the city’s Department of City Planning. The department also expects the program to generate new jobs for neighborhood residents.