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The waiting room in William Yule's office is full by the time he arrives each morning.
Throughout the day, Yule sees dozens of patients, bouncing between four sparsely decorated examining rooms on such a tight schedule that he often has no time for lunch.
But Yule is no doctor. He's a prosthetist who fits limbs on recent amputees, and business is booming for one reason: diabetes.
"There's no such thing as a slow day," says Yule, of Hanger Prosthetics & Orthotics Inc. in Downey, as he helps a client adjust her new right leg. "It can be hard because you can't help thinking a lot of these people don't need to be here."
As more Americans become obese and 1.5 million of them are diagnosed with diabetes each year, a growing number are confronting one of the most brutal consequences of the disease: suffering amputation of a limb or two.
The number of amputees in the U.S. has grown to 1.9 million, up nearly three-quarters of a million people over the last decade, according to federal statistics. About 60% of those are diabetes-related. (By contrast, as of April, the number of soldiers serving in Afghanistan and Iraq who have had a limb, hand or foot amputated is 630.)
While public health experts are ramping up efforts nationwide to reverse the trend, it is leading to a boom in the long-sleepy prosthetics industry, which experts say hasn't seen a sales increase like this since its modern inception on the Civil War battlefields.
Sales of prosthetics have jumped from $340 million in 1996 to nearly $600 million last year, according to estimates based on federal data.
The industry's growing profile has even caught Hollywood's eye. The Discovery Channel aired a 10-part series on a Fairfax, Va., prosthetics shop last year called "Rebuilt: The Human Body Shop," and a prosthetist was prominently featured in the first season of Showtime's "Dexter." (He was a serial killer who — DVD spoiler alert — was killed in the final episode.)
Although the industry has begun to consolidate, most manufacturers and sellers in the field remain small to medium-sized companies and mom-and-pop shops that are adapting to their growing businesses.
Five years ago, Life-Like Prosthetics, a Torrance clinic that creates artificial limbs, saw two or three patients a day but now fits an average of eight patients daily, manager and former owner Carlos Sambrano said.
Sambrano, who sold the shop to a larger San Diego company in the fall, said as many as 70% of his clients had diabetes, versus a quarter when he entered the business three decades ago, when most amputations resulted from car accidents and cancer.
The company moved into a 6,000-square-foot warehouse in 2004, doubling its size, and its biggest struggle today is finding qualified employees. "I've been looking to fill one of my spots since October," Sambrano said.
Peter Rosenstein, executive director of the American Academy of Orthotists and Prosthetists, said the industry's labor shortage had worsened in recent years. By some estimates, it will need 100% more workers over the next decade.
Since 2003, Congress has given the organization $4 million in grants to heighten awareness of the specialty at high school and junior college job fairs and for public awareness campaigns that are set to start this summer on television, radio and the Internet.
"We tell kids, 'You can make a good living doing this,' " Rosenstein said. "A lot of them think it's cool."
Diabetes is a metabolic disease in which the body doesn't produce enough insulin. Because diabetics have reduced circulation in their limbs, an estimated 5 of every 1,000 diabetics eventually suffer an amputation, usually of a leg. As many as half of the amputees lose two limbs.
Lilia Portales, a 67-year-old from San Bernardino, had her left leg amputated below the knee more than a year ago.
The mother of 14 and grandmother of six lost her left leg after a small cut on one of her toes developed an infection that grew so severe that doctors had to cut her toe off. When that didn't help, they removed the other toes, then her leg up to the knee.
Portales says she didn't leave her house very often at first and, tearing up to a reporter's question, acknowledges going through bouts of depression in recent months.
During a therapy session, Yule of Hanger Prosthetics tried to get Portales to walk the length of the room on her new leg with the aid of two assistance bars, promising that she would eventually be able to dance again.
"Right now, I'll be happy if I get to the grocery store more often," she said.
To capitalize on the market boom, manufacturers are introducing an unprecedented number of artificial sockets and limbs, many aimed at older and overweight users rather than the younger patients who have traditionally been the focus for new products.
Some have sensors in the feet that clock how fast a user is moving, how much they weigh and whether the foot is on an incline so it can adjust accordingly. Other products such as the C-Leg and a bionic knee called the Rheo are so advanced that some amputees use them to run marathons.
Other products are now available for obese patients. Typically, patients over 250 pounds have had a hard time getting a prosthetic, but some newer models can accommodate patients weighing as much as 350 pounds.
Prices of artificial limbs cost $2,500 to $50,000 depending on how advanced they are. Insurers pay for most products, although some have started to balk as reimbursement claims have risen.
In response, three states, including California, passed laws in the last two years requiring insurers to boost coverage. In total, six states now have such laws and several others are considering similar measures.
"We joke that whenever they have a pill to cure diabetes we are all going to be out of business," said Eric Robinson, president of Fraser, Mich.-based College Park Industries, which recently introduced an advanced foot called the TruStep.--