The Bigger Picture Campaign recently brought a giant "Diabetes can" to Thurgood Marshall High School in San Francisco. Youth Speaks

A local doctor tries to raise awareness about the social causes of Type 2 diabetes, in his community and others.

At high school assemblies, the team from the Bigger Picture Campaign, a diabetes-prevention program run out of San Francisco, always begin their presentation with a video called "Sole Mate."

It starts out as a loving ode to feet, with images of dancing baby feet, basketball-playing feet, skateboarding feet flashing across the screen as a young poet recites in the background: "This foot, that has tasted the grass of Humboldt between my toes and the beaches of Hawaii, you were a friend to lean on. And now I'll never be able to stand on my own two feet again."

The last image is of a diabetes-related foot amputation in progress.

The Bigger Picture Campaign was founded in 2011 by Dean Schillinger, a primary-care doctor at San Francisco General Hospital and former chief of the Diabetes Prevention and Control Program for the California Department of Health. He'd become increasingly frustrated by the growing number of Type 2 diabetes patients he was seeing.

"It's just overwhelming. We're doing one battle at a time, one patient at a time," Schillinger says. "I was hoping to create a movement that would change the conversation about diabetes away from blame-and-shame to the social drivers of the epidemic."

According to an analysis from the Centers for Disease Control and Prevention (CDC), in the year 2008, 23 percent of teenagers in the U.S. had either diabetes or pre-diabetes, up from 9 percent in 1999. Even more alarming, a 2014 CDC report concluded that 40 percent of Americans born in the year 2000 are likely to develop Type 2 diabetes over the course of their lifetime, despite the fact that it is largely preventable. For people of color, that figure increases to 50 percent.

When Schillinger met Erica Sheppard, he saw his chance to raise awareness about diabetes in a whole new way. At a fundraiser for the arts organization Youth Speaks, Schillinger watched as Sheppard, then 19, performed her slam poem "Death Recipe," which poignantly recounts how diabetes has ravaged her family and describes her struggles with obesity. ("It's like smacking on Sour Patch Kids /  While walking my aunt to dialysis.")

Inspired by the idea of directly engaging the next generation of potential diabetics—teenagers—Schillinger and the Center for Vulnerable Populations at San Francisco General Hospital teamed up with Youth Speaks to create the Bigger Picture Campaign. It uses a combination of writing workshops, video PSAs created by young people, and school visits to raise awareness about the disease and shift the focus of prevention efforts.

Dean Schillinger (UCSF Center for Vulnerable
Populations)

Schillinger knows that if you want to get through to adolescents about diabetes, you have to stop lecturing them about eating fruits and vegetables and start getting them fired up about the social causes of the disease. And there's plenty to get fired up about.

"People who live in congested, racially segregated communities have a number of factors stacked against them in terms of maintaining a healthy weight and preventing and controlling diabetes," says Monica Peek, a diabetes expert at the University of Chicago. "If you're in a neighborhood that has fewer grocery stores and more McDonalds, the easiest choice is something that's not the healthiest choice." Plus, Peek notes, communities with higher rates of crime often lack safe spaces to play and exercise.

There's also evidence that food companies specifically market unhealthy foods to young people of color. A report from the Yale Rudd Center for Food Policy & Obesity found that in 2010, African American teens saw 90 percent more ads for sugar-sweetened beverages than white teens, even after accounting for levels of television viewing.

This is no small thing: a 2007 study published in the American Journal of Public Health found that drinking one or two sugary drinks per day increases the risk of type-2 diabetes by up to 25 percent.

The Bigger Picture videos, which have received about a million views, touch on these issues. In "Product of His Environment," Joshua Merchant depicts an eighth-grade boy living in a violent neighborhood who has nothing in his house to eat except sugary cereal. Poet and performer Monica Mendoza captures her Mexican-American family's reliance on soda in "A Taste of Home." She wrote the poem just days before finding out her mother is pre-diabetic.

The program's videos and performances are personal; they're relatable to young people living in urban areas most hard hit by the diabetes epidemic. What's more, they're just really good.

"I've seen the poets perform their pieces multiple times, and every time it gives me shivers," says Christina Goette of the San Francisco Department of Health. "It evokes this visceral reaction, which is much more powerful than a piece of paper with information on it."

In addition to the PSAs, the Bigger Picture brings poet-performers into Bay Area high schools. So far they've presented to more than 2,400 students, and they hope to increase that to 10,000 by the end of the 2014-2015 school year. And their message is getting across. Prior to the assemblies, only 34 percent of students polled cited environmental causes as influencing type-2 diabetes risk. After the assemblies, 83 percent did.

To expand the Bigger Picture's reach, Schillinger is pursuing funding to spend two years working closely with specific schools while tracking key health indicators. He also plans to replicate the program throughout California.

In the meantime, the health departments in San Francisco, Alameda, and Sonoma counties have already adopted the Bigger Picture's messaging for their own initiatives to reduce sugar-sweetened beverage consumption. Their joint efforts may result in concrete policy changes: Both San Francisco and Berkeley had soda tax measures on the ballot this week.

Schillinger draws parallels between the Bigger Picture's methods and those waged by the wildly successful anti-smoking campaign, Truth, which gained momentum through youth empowerment and effective marketing. Tackling diabetes, he says, isn't all that different.

"This is a social problem. This is a public health problem," Schillinger says. "As long as we talk about it as the lazy fat kid who's eating Oreos, we're going to go nowhere."

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