ABOUT FIVE YEARS AGO, the schools of San Antonio, Texas, some of the most rapidly growing in the nation, confronted a troubling revelation: A new study by a local nonprofit health agency showed that, unless administrators acted to make substantial changes, there would soon be as many as 3000 type 2 diabetic children in the district's fifty elementary schools. The principal cause, the study had concluded, was excess body weight. Almost all of the children at risk had BMIs of greater than 27—they were already substantially overweight—and many had BMIs far in excess of 30, the cutoff for clinical obesity. Nearly as awful—at least to the men and women who ran the schools—was the implication that the San Antonio schools were themselves at least partly to blame for the trend. The study authors—all from the local Social and Health Research Center, headed by Dr. Robert Trevino—had found, among other things, that the school cafeterias were serving a menu laced with excess fats and sugars, that the food service staff had no idea about how to make fresh fruits and produce palatable to kids, that after-school care was bereft of any meaningful physical activity, and that teachers in the districts had few if any classroom materials for teaching sound nutrition and exercise practices. "We scared the hell out of them," says Trevino of the school district's reaction to his study. "They realized it was both the right thing to do and that it was in their self-interest to deal with it."
The annals of public health are chock-full of such momentary bureaucratic realizations—realizations that soon dim and fade as new and seemingly more urgent concerns wrinkle the public brow. The course that usually follows is as predictable as a Hollywood B movie: Posters inveighing against the evil get tacked up around the school. Memos go out to teachers, principals, and sometimes even parents. There follows a special "awareness" program, designed to change attitudes toward the problem and invite candid discussion. More pamphlets will be passed out. The PTA might receive a special report on the subject. An already overburdened principal will be assigned to head a committee to look into possible solutions. The issue will take its place alongside the others waiting in line, collecting administrative dust.
History, however, will in this case take due note: This is exactly what San Antonio did not do. Instead, the school district tried an aggressive and unconventional strategy that broke the mold of the traditional public health response to chronic disease. The first part of the strategy was to recognize that obesity and type 2 diabetes among its students was, first and foremost, a class issue. It wasn't something that, as most public health campaigns (often artificially) insist, affects everybody. "It's not a gene thing, it's a poverty thing," as Trevino says. That observation guided the district's allocation of resources—time, money, and expertise—and, as a result, made for a more targeted, efficient solution.
The second part of San Antonio's approach was even more controversial. Instead of focusing the main part of its efforts on the children themselves, the administration turned its attention to changing itself. "We didn't believe it was enough to put a few more dollars into a nutrition class and so to change some kids' attitudes and beliefs about food and health," says Trevino, who was put in charge of the effort. "We believed that you had to change their environment—their total school environment."
This Trevino and his staff did by devising an extensive series of lesson plans designed to change the health environments of targeted elementary schools. In the cafeteria, food service workers were tutored in state-of-the-art food preparation and food presentation schemes—all designed to increase the amounts of fruits and vegetables consumed and to lessen the amounts of added fats and sugars. Older students were drafted to monitor the eating habits of their younger schoolmates at lunchtime. In classrooms, students had new lesson plans designed to educate them about what choices they should make in the cafeteria setting—in essence, creating demand for the new cafeteria fare. Trevino also dedicated thirty-two new lesson plans to after-school care, where TV and video games had come to supplant physical activity as the recreational mainstay. The result was to transform the traditional after-school program into a highly popular "health club"—a place where child care met both traditional and nontraditional exercise and sports programs. There were even lesson plans for parents, principals, and school medical personnel.
A year later, the district assessed Trevino's intervention. In the cafeteria, there had been two dramatic improvements. Compared with a control group of schools that had not adopted the changes, the percentage of calories from fat dropped from an average of 34 percent to 30 percent—well in line with USDA guidelines—and the number of fruits and vegetables consumed per meal had more than doubled, from 1.2 to 2.5. The control group's fat content and fruit and vegetable consumption remained the same. Fitness scores, mainly aerobic capacity, also improved dramatically in the experimental schools, rising by 4.6 percent against the control group's rise of .8 percent. Most important, the average blood sugar measurement among the schools' type 2 diabetics had registered remarkable decreases—from 123 to 99; the kids in the experimental schools now had near-normal blood glucose counts.
San Antonio's success points up one of the few bright patches in Fatland America: By and large, we already know what kind of basic health strategies work, at least when it comes to children, and, in many cases, what works for adults, when it comes to reducing both the incidence of obesity and its consequences. It was not always so. In a review published in 1978, researchers gloomily concluded that "clinically significant changes for obese children are rare. Follow-up data ... show consistently that subjects fail to continue losing weight or even maintain weight losses experienced during treatment." By 1994 the general wisdom on the subject had completely reversed itself, with one reviewer noting that "overall, treatments for childhood and adolescent obesity were found to produce medium sized treatment effects at posttest" with follow-ups showing that they "continue to maintain moderate results." Basic behavioral modification was the treatment of choice.
It is hardly surprising that the two most important behavioral changes involve food and exercise—less of one and more of the other. It is surprising, however, just how much of a difference such changes can make. Numerous recent studies—across large numbers of diverse Americans, as well as studies from other countries—show not only that the effects of type 2 diabetes can be substantially reduced through better eating and vigorous exercise, but that diseases like type 2 can actually be prevented by adopting such behaviors. In one study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases released in 2001, researchers from Massachusetts General Hospital recruited 3300 people with a condition known as impaired glucose tolerance—a kind of precursor to type 2 in which the body's ability to process sugar is slowed, but without any outward symptoms of disease. The subjects were then split up into three groups. One received a daily dose of metformin, a common pharmaceutical treatment for diabetes, along with basic dietary and exercise advice. A second group received a placebo along with the same advice. The third group got no drug, but instead received regular coaching on how to incorporate exercise into their daily schedules and how to best modify their diets. Three years later, the results were published. Among participants receiving the placebo, 11 percent developed diabetes. Among those receiving metformin, 7.8 percent developed the disease—a reduction of about one third. The big surprise was what happened among those who got no drug but who received in-depth coaching on diet and exercise. Among that group, only 4.8 percent developed diabetes—about half the rate of the control group. Among those in the coached group who were aged sixty or older, the drop in the disease rate was even more precipitous—nearly three quarters. In fact, in one third of the group, blood glucose levels returned to normal. The message was clear: Simple, consistent changes in diet and activity levels can dramatically alter an individual's metabolic destiny.
The key qualifier is the term "consistent." Getting that consistency comes with a price. In the case of the study that price was an investment in time and resources—weekly classes, coaches who followed a participant's progress, continuing medical and dietary monitoring by committed professionals. The question from a broader, policy-oriented point of view seems clear: How can we encourage such investments by large numbers of individuals, so that they become habit? The answer can be found in a number of programs that are dealing successfully with children who are either obese or at risk of becoming so. In other words, with the potentially obese adults of the future.
For twenty years, the trailblazer in the arena of childhood obesity treatment has been Stanford University's Leonard Epstein. A pediatrician and the head of the Stanford Pediatric Weight Control Program, Epstein pioneered the use of basic behavioral modification techniques, combined with a special diet and exercise program, to treat obesity in young children. The cornerstone of his approach is what he has dubbed the Stoplight Diet, which defines all foods by their calorie content and then divides them up into the three colors of the traffic light: red (for stop), yellow (for proceed with caution), and green (eat as one pleases). Children then count up the number of servings of each "color" so as to monitor their daily calorie count. This kind of clear, unambiguous division has been crucial, says Epstein. "It is our experience that some patients find looking for loopholes to be challenging and rewarding. As a result, it is better to leave little room for interpretation in defining dietary changes." He also notes that low-fat or diet versions of a normally high-calorie food should be avoided, so as to prevent continued exposure to such tastes.
As one might expect, Epstein is also concerned with increasing a child's physical activity, but his approach swerves from the predictable paths in two important ways. First, though Epstein believes that both structured exercise—sports and fitness programs—and lifestyle exercise—the "building in of a daily activity like walking to increase one's total expenditure"—can be critical to a child's success in maintaining a healthy weight, he also stresses the importance of activity choice. Children who are allowed to choose their own form of activity seem more likely to meet their daily calorie expenditure goals. Second, Epstein believes that reducing sedentary behavior may be more important than promoting physical activity itself. In a series of studies, Epstein and his colleagues at Stanford found that fat children who were either punished for sedentary activities or positively reinforced for decreasing TV viewing, playing computer and board games, or talking on the phone lost significantly more weight than peers who were simply reinforced for increasing physical activity. Epstein speculates about the reason, noting that the children in the decreased sedentary behavior group may have felt more personal control over being more active than those in the other group, who may have felt resentful toward parents who were pushing them into activity.
Epstein has since delineated a number of other elements critical to childhood weight loss programs. They are, in toto, clear, concise, and demanding. Parents must play an active role in treatment, but not necessarily as "co-patients." Rather, they are best used as monitors and enlightened authority figures. They are best left out of specific counseling and exercise sessions, leaving children in a less inhibited arena in which to learn and play. For the first eight to twelve weeks of the program, children should receive weekly follow-up sessions with a counselor; monthly follow-up sessions should continue for the next six to twelve months. In essence, parents are charged with changing the environment that encourages obesity. High-calorie foods should be removed from the home. The number of meals eaten outside the home should be drastically reduced. The soup pot or the casserole dish should be left in the kitchen, not set on the table family style, so as to increase the effort required for additional portions. TVs should be removed from bedrooms. Children should be taught to monitor their body weight, to set reasonable weight loss goals not to exceed one pound a week, and, when required, to enter into a written contract with their parents, with each side carefully delineating their responsibilities in the weight loss effort.
All of which may sound somewhat draconian to the ears of a generation raised to believe that, when it comes to food, personal choice and individual autonomy should trump traditional parental authority. Yet Epstein, unlike a generation of diet gurus who tried to separate control and children's eating habits, can show consistent and healthy results from his approach. Ten years after onset of treatment, some 30 percent of his patients were no longer obese, with 33.5 percent maintaining at least a 20 percent weight loss. His message is unequivocal: Parents must take back control of the table.
Dr. Francine Kaufman, head of the pediatric endocrinology department at Los Angeles's bustling Children's Hospital, has for the last few years successfully woven together some of Epstein's concepts with some of her own to deal with the city's growing problem of childhood type 2 diabetes. Once a week for eight weeks, a group of fifteen or so children, usually accompanied by one parent, file into her department for a two-hour "Kids and Fitness" program. Many come referred by pediatricians, others by school nurses and social services. After a weekly weigh-in, the children and their parents part, the latter to a waiting room, the former to a large conference room. For the next hour, the children are led through a variety of physical activities, ranging from calisthenics to running games to a smaller version of volleyball. "What's amazing is how uninhibited the kids are when the adults are gone and they are just around a bunch of other overweight kids," says Marsha MacKenzie, who runs the program for Kaufman. "The other day we had to laugh, because we asked them what game they would like to play, and a group of them yelled out 'Dodgeball!' Which, of course, they would never do at school, because they are the ones who usually get singled out to be bashed by the ball because they are a natural target for bullies."
For the second hour of Kaufman's program, parents are reunited with their child for a session of nutrition education. It is, to be frank, a troublesome undertaking. During the three sessions I attended, it was not unusual to witness a parent walk into the class eating french fries from McDonald's or sipping a thirty-two-ounce Big Gulp Coke from the local convenience mart. "We have to start from ground zero," says MacKenzie. "It's easy to pass judgment and say, people should know this and people should act this way, but the fact of the matter is that few doctors—let alone parents—know the basics of good nutrition."
MacKenzie and her staff focus each week's discussion on one element of a typical food label—on its fat content, added sugars, calories, portion sizes. Children must then choose from a lineup of typical popular foods, from Cheetos to Cap'n Crunch, and calculate out loud whether it is a good food or a bad food, based on the nutrition information they are studying that week. In a lesson about portions, for example, children were asked first to pour out what they considered one portion. They were then asked to read out loud what the label indicated was one portion, and then to pour out that amount on a small weighing scale. In most cases, the estimated serving size was at least three times the label serving size. "That drives the point home, both for the kids and the parents," says MacKenzie. But it also drives home how much educating needs to be done all over the city.
Schools have long offered tremendous promise as possible battlegrounds against childhood obesity. After all, more than 95 percent of American youth between the ages of five and eighteen are enrolled in school. Though school authority has been whittled down substantially over the years, the institution, by sheer dint of its daily presence, still exerts enormous influence on the lives of its subjects. In the early 1980s the Yale obesity expert Kelly Brownell undertook a small-scale intervention at public schools in Fort Myers, Florida, using nutrition education, physical activity training, changes in food service, and behavior modification techniques with a group of overweight children. The students were able to achieve and sustain a notable weight loss of 15 percent. At the time, many hailed the Brownell approach as a possible new standard in the treatment of childhood obesity.
But the Brownell approach fell victim to the cultural politics of the 1980s, namely, the fear that fat children undergoing such treatment would be stigmatized by their peers. Although it is true that some stigmatizing occurs when any group is singled out for special treatment, this objection—and it was voiced widely and vehemently throughout the decade—ignored the most basic truism about fat and stigmatization: The best way to prevent it is to avoid becoming obese in the first place. As the influential—and, it should be noted, very politically sensitive— International Journal of Obesity worried in a review of school programs in 1999, "It is interesting that few studies on school-based treatment of obesity were identified after 1985 ... Greater awareness of the stigma attached to participating in school-based treatments may have decreased enthusiasm for the programs, even though they appear to be effective [emphasis mine]."
Yet the "decreased enthusiasm" seems to be limited to the adults. A more recent survey, based on in-depth interviews with sixty-one overweight adolescents from large inner-city schools, indicated not only that children want such programs, but that they are willing to put up with their possible social ramifications if such a program "was undertaken in a supportive and respectful manner, offered fun activities, was informative, was sensitive to the needs of overweight youth and did not conflict with other activities."
Such interest by children has helped launch a new generation of school-based interventions. One of the most promising involves preventive screening. In a study by the University of Houston and Baylor College, scholars looked at how a child's weight in, say, kindergarten would predict that child's chances of becoming obese at a later age. Researchers collated the weights and BMIs of 1013 Mexican American children in a Texas school district. They then tracked the children as they progressed through the system. They found that a kindergarten BMI was highly predictive of obesity at later dates. A child with a low kindergarten BMI of 16.5, for example, would have only a 21 percent chance of becoming obese by fifth grade. A kindergartner with a BMI of 20.9, however, would have a 70 percent chance of becoming an obese fifth grader, while a kindergartner with a BMI of 23.7 would have a 91 percent probability of becoming obese.
While the Houston-Baylor study provides schools with one way to assess a child's relative risks, a program in San Jose, California, has carved a potential path toward reducing both current and future obesity rates. The impetus for it flowed from both theoretical and practical concerns. Researchers from Stanford's Departments of Pediatrics and Medicine had long theorized that if sedentary behaviors like TV-viewing and video game–playing were linked to increased obesity, then programs that taught children to reduce such activities might lead to reductions in adiposity. Meanwhile, teachers and parents in the San Jose School District, aware of increasing obesity rates, were looking for ways to deal with the issue. They decided to give the Stanford researchers access.
To find out if their hypothesis held, the researchers recruited 192 third- and fourth-grade students from two socioeconomically matched schools. One school was assigned to implement a program to reduce TV and video game use, the other was not. The means of the intervention was simple: Limit access to TV sets and game machines, teach children to budget their use, then teach them how to become more selective viewers and players. This the researchers sought to inaugurate and support through traditional classroom instruction. Teachers in the intervention school were trained to administer eighteen specialized lessons, each thirty to fifty minutes in length, taught during regular school hours during the first two months of the school year. The first few lessons taught the students how to monitor and report their own TV and game use, followed by a "TV Turnoff." The TV Turnoff challenged children to watch no TV and play no video games for ten days. After the turnoff, students were told to budget their viewing to seven hours per week. The last lessons sought to increase students' ability to be selective, "intelligent viewers," and to become advocates for reducing the use of such media among their peers. At home, each student TV was equipped with an electronic TV time manager, which logged and measured TV time through the use of a personal code, without which the set would not operate.
The results of the intervention surprised even its most enthusiastic and optimistic supporters. After seven months, TV use in the intervention group was down by one third, compared to the control group. Video game use and viewing of videocassettes were down as well. While not an anticipated outcome, the intervention group also "significantly reduced the frequency of children eating meals in a room with a television turned on." And, most important, children in the intervention group, in the words of the researchers, "had statistically significant relative decreases in BMI, triceps skinfold thickness, waist circumference, and waist to hip ratio." The results did not change with ethnicity or level of parental education.
The success of the San Jose experiment posed an intriguing question for its authors. Why did the children lose weight? After all, there were no reports that children had dramatically increased high-level activity when not watching TV, and when they were watching TV their level of snacking matched that of their more sedentary control group. Three answers emerged. One, children in the intervention group snacked less in toto. Two, they had been exposed to dramatically fewer advertisements for high-calorie foods. And three, they likely sought out and engaged in more low-intensity activity. Whatever the cause, the Stanford researchers concluded, reducing TV, video game, and video use "may be a promising, population-based approach to help prevent childhood obesity."
Jim Hill, at the University of Colorado Health Sciences Center, has come to a similar conclusion about larger interventions. As he and John Peters note in a recent issue of Obesity Reviews, "The challenge in changing the environment is not to 'go back in time,' but to engineer physical activity and healthy eating back into our lives in a way that is compatible with our socio-cultural value." As Peters and Hill see it, the challenge is to give everyday people the same cognitive tools—essentially a series of goads and rewards—that the more affluent always have had when it comes to managing weight. Hill and his colleagues have launched a program called "Colorado on the Move," a consortium of government agencies, private foundations, educational institutions, and business with one specific, measurable goal: to increase by 2000 steps a day the average number of steps the average Coloradan takes. To do so, they are underwriting the distribution of low-tech step counters around the state. Hill and his colleagues got the idea after comparing the average number of steps daily by an office worker (3000 to 5000) with the average number of steps by people in the National Weight Control Registry (11,000), the most successful single group to maintain weight loss after several years. Beginning with a modest 2000, Colorado on the Move could eventually encourage large numbers of citizens to take increasingly more steps per day. Already some six thousand people are enrolled in pilot programs.
One of the best ways to combat obesity would be to reinvest in traditional public school physical education. Unfortunately, taxpayers have not yet seen fit to do so. (In California in 2001, the legislature was unable to pass even modest legislation that would have funded the creation of written standards for all PE courses in the state.) There is the occasional nod and bow toward the need to "do something"—usually when the ever dismal state fitness test results are published every two years—but there is usually little if any follow-up. Many policy makers believe that today's parents have forever separated school and fitness, preferring either to ignore the subject altogether or to fill their kids' sports cravings through private programs. Unfortunately, that means permanent underfunding of public school PE—the only alternative for the less economically advantaged.
Still, a small core of educators, many of them young PE teachers in some of the nation's most underfunded school districts, have plunged ahead, crafting unique programs specifically targeted at reducing obesity and increasing overall fitness. One of them is Dan Latham, a PE instructor at West Middle School in blue-collar Downey, California. Latham is, in many ways, the kind of fellow that many principals dream about; he is engaging, well-spoken, energetic, and full of ideas—all of which he is convinced he can pull off. When he first arrived at West back in 1991, Latham was struck by how few resources his fellow PE teachers had at hand. "And I was also struck by, frankly, how fat the kids had become." By 1995, he recalls, after-school coaches were coming to him "saying, 'Look, I can't get enough kids to make a whole team anymore.'" Later, "we all got together and started talking, and it became clear right away what the enemy was—it was video games. We decided we had to find a way to make PE compete with Nintendo."
One day Latham had a brainstorm: What if they could create a gym that was one part video parlor and one part health club? He found a 2000-square-foot building on the school lot that was going unused and got the school principal to give him and his buddies permission to rehab it, with the condition that the project would not cost the district any money. Latham raised $50,000 from a local philanthropist for material costs; the labor was donated by "my coaching buddies." To equip the gym, Latham began acquiring stationary bicycles—the fancy kind used in many expensive high-tech urban health clubs. These he had wired into big video screens. On the screens appeared a number of competitive video games—which could only be played as long as the users kept on pedaling. "What we found startled us all—kids who, if you asked them to run a mile outside, would just sort of look at you and hide, they were crazy for it. I have a kid who used to weigh 310 pounds who has already dropped 50 pounds—he laughed and sweated his way through it." By 1999 Latham had raised more than $250,000. His center, which he has dubbed Cyberobics, can now accommodate up to fifty students at a time. "It's always packed," he says. It is also attracting notice. Last year, West Middle School registered big gains on the semiannual California fitness test. Students at West Middle School were number one among schools its size in the category of aerobic capacity. "Next we've gotta get that upper body strength back up," says Latham.
Perhaps the most controversial way to use schools to prevent obesity has been undertaken not by academics and health professionals, but by parents, teachers, and school administrators, who have in recent years fought a high-stakes guerrilla war with the fast-food companies that have come to dominate the school nutrition scene. The most tense battleground is that of soft drink pouring contracts, in which high schools are paid large sums of cash in exchange for an agreement to sell only one kind of soda, usually Pepsi or Coke. Also called exclusivity deals, these contracts can run into the seven-figure range—a great deal of money for any chronically hard-strapped school system. Nationally, there are thousands of such deals in place. They have, in fact, become the norm in most large school districts, with principals—and parents and administrators—justifying the consequent omnipresence of soda (and soda ads) on campus as a way to pay for athletic uniforms and a variety of after-school programs.
Such was the initial justification of most members of the Sacramento school board last year when they considered a lucrative pouring contract from Pepsi. Over a five-year period, the soft drink behemoth promised to pay the board $2.5 million in return for the exclusive right to sell and advertise Pepsi products on Sacramento public school campuses. "Frankly, it was such a done deal that when it came before us, it was expected to be fast-tracked to approval," recalls Michelle Masoner, a thirteen-year veteran of the school board. But then, after reflection, "it did not feel right to me. After all, we already had some vending machines on campuses, and many parents, and myself as a parent with kids in the district, had always felt conflicted about that. I came to believe that this contract would hook us into something long-term that we should not be selling." An associate on the board, Manny Hernandez, soon came to feel the same way. "We looked closely at the contract and saw that we were locking the kids into a long-term cycle that would be skewed to the worst nutritional situation rather than the best."
But first Masoner and Hernandez had to convince their fellow board members, who were not wont to give up the $2.5 million in free operating funds. "We decided that we had to make the health case, in very clear terms," Masoner says. At the next board meeting, her fellows heard testimony from the county coroner, who noted that arterial streaking and early signs of bone disease were being seen in children as young as ten years old. The head of the regional dental association presented epidemiological data indicating that, as he put it, "our area has the worst dental health record in the state." At the next meeting, the board unanimously rejected Pepsi's offer.
But the board did not stop there. The inquiry into the pouring contract had made them curious. And concerned. They decided to look into just how much junk food was present on campus. "What we found was stunning," Masoner says. "Candy and pop were everywhere. In almost any classroom in the district, you could find kids with soda and candy at their desk. Teachers were actually using them as a reward." Presenting all of this at a subsequent meeting, the board voted to present its principals with an ultimatum: They would have ten years to eliminate all high-sugar and high-fat foods from their campuses. The initial reaction was predictably truculent, but, say Masoner and Hernandez, the principals have more than risen to the occasion. By the end of winter break, they had already met the board's first incremental mandate of providing as much bottled water on campus as soda. "The kids were telling us they loved it," says Hernandez.
Even when the contracts themselves go unchallenged, the pouring contract disputes are increasingly fueling a new wave of parental activism. The target is junk food advertising in schools, which in recent years has become ubiquitous. The most common comes in the form of "sponsored educational materials": nutrition curriculum by McDonald's; math lessons using Tootsie Rolls and Domino's Pizza wheel graphics; reading texts that teach first graders to start out by recognizing logos from Pizza Hut and M&Ms. There is even a nutrition guide put out by McDonald's that teaches kids with diabetes how to calculate the number of diabetic "points" (the system advocated by the American Diabetes Association) in a typical McDonald's meal.
In an era when many school districts can't keep up with demand for basic texts, free supplemental materials are hard to turn away. But that is increasingly what is happening, says Andrew Hagelshaw, head of Berkeley's Center for Commercial-Free Public Education. "We are seeing hundreds of groups across the country take this issue on," he says. "The key is the parents. It's like a sleeping giant has been roused. Once they find out this has been happening right under their noses, they are unstoppable. They don't buy the notion that school is about educating consumers. It isn't. It's about educating citizens."
What can be done on a national level? Certainly obesity, with its $100 billion a year (and growing) price tag in health services, justifies some involvement by the government, or at least by large national organizations. Concern about it is now well established. On the day after the September 11, 2001, attacks, one of the few nonwar stories to break through was one about the latest obesity statistics (the national rate had jumped again—to 26 percent). A few weeks later, the army released its latest fitness study, with its own alarming obesity numbers. How can America capitalize on this growing awareness?
One way might involve expanded federal funding for safe public playgrounds and parks. There is a broad and potent constituency for such a measure, given that half of the nation's parents believe that their neighborhoods are not safe enough to let their children go outside and play. There is also the issue of pure economic equity. Recent studies in California and other states show that park and playground development has taken place disproportionately in new suburban areas, often at the expense of older—and poorer—urban centers. These same urban areas are increasingly the address of new immigrant communities who have yet to flex their political muscle on the most basic of health issues. What is needed is a revival of two older organizations, one governmental, the other private. The former would involve reinvigorating VISTA, an effective, if chronically underfunded, program that helped millions of urban Americans win basic housing and health benefits. During the 1970s and early 1980s, VISTA trained young college students to go out to poor communities and to teach residents how to organize themselves around such core issues. Another tack would focus on reviving the organizing groups of the Community Areas Foundation (CAF). Founded in the 1930s by the social activist Saul Alinsky, the CAF has successfully trained generations of urban activists on the fundamentals of how to empower local groups of citizens to demand what is their due. In the past, such groups have forced school boards to open more schools in underserved areas, pushed insurance companies to discontinue the practice of redlining, and turned back attempts to locate incinerators and toxic waste dumps in poor communities. Unfortunately, in recent years, many of the CAF groups have become bogged down in the ideological and personal antagonisms of the self-proclaimed "progressive" left. Their effectiveness has been muted, and will likely remain so until that old left dies and is replaced by a younger, more pragmatic leadership.
In California and around the nation, a perfect opportunity exists for such organizations to move the public fitness agenda forward. This is because almost every urban school district is, to one degree or another, out of compliance with state rules mandating minimal hours of physical education. California requires elementary schools to provide 100 minutes of physical education every two weeks. But few schools even come close to meeting the requirement, instead relying on recess and "unstructured playtime" to fulfill their obligations. In middle and high schools, required to provide 400 minutes every two weeks, the situation is even grimmer; studies have shown that as little as 20 percent of PE time is actually spent "in motion," the rest taken up with administrative work, suiting up, showering, and getting dressed for the next class. As one might expect, the situation degrades as the overall school performance degrades. Attempts to reduce class size in academic courses often translate into increases in PE class size. Average PE class size in Los Angeles stands at 55, with some schools logging as many as 85 kids per class. The recommended class size is 25. As the head of the Amateur Athletic Union of Los Angeles put it recently, "Someone needs to make parents aware that their children are not getting what they are entitled to, and to teach these parents how to get in the school board's face and demand what is theirs."
There is also what might be called the Americorps option. The federal program funnels newly minted college graduates into teaching and public service, providing a small but valuable support system for public schools. Yet almost all of its efforts have centered on aiding schools in the traditional academic areas graded on the SAT-9 examinations, the series of academic tests that have become the holy grail of most systems. What if it were expanded to target physical education and physical activity training? And what if the SAT-9 were broadened to include some form of fitness testing? This might seem a bit impractical, given the difficulties of so many districts in showing any progress with the most basic academic testing. A growing body of scientific and educational research, however, is documenting the connection between physical activity and mental acuity. And new studies are also documenting another link. The best academic scores among all high schools invariably match up with those displaying the best fitness scores.
We might also recast our traditional notions about food and exercise as separate pursuits toward the goal of good health. Instead, "we might start thinking of them as unified with one another," says Walter Willett, head of the Department of Nutrition at Harvard's School of Public Policy. Toward that end, Willett—the scholar who fought the USDA's ill-founded 1990 weight guidelines—has come up with an alternative food pyramid. Its principal distinction is that it defines weight control and exercise as the base of the pyramid. Without them—as uncomfortable as that might make parents, school administrators, and health professionals—all the healthy eating advice in the world will likely count for little, at least when it comes to obesity and the chronic disease it spawns. "And when I say exercise," adds Willett, "I mean vigorous exercise—enough to make you sweat!"
Then there are the "meta" approaches. Of these, the most controversial is the "fat tax." Put forth in 2000 by Yale's Kelly Brownell and Michael Jacobson at the Center for Science in the Public Interest, the proposal calls for state governments to enact small taxes on foods that are nutritionally unsound. The money would then be put into funds dedicated to promoting healthy eating and sound food choices. Despite the fact that the soft drink industry alone spends upward of $600 million annually to promote its trash (compared with the National Cancer Institute's paltry $1 million budget for promoting fruit and vegetable consumption), such promotional campaigns can be highly effective. A TV and radio campaign in Clarksburg, West Virginia, for example, encouraged shoppers to switch from higher-fat to lower-fat milk; after seven weeks, the market share for 1 percent and fat-free milk jumped from 18 to 41 percent—a change that Brownell and Jacobson note was sustained for more than a year.
But the trend in most state capitals, increasingly beholden to special interests, has been in exactly the opposite direction. There, soda and snack food lobbyists have made the elimination of such taxes a priority. In 1993 the ever-up-for-sale Louisiana legislature halved its existing soft drink tax in return for Coca-Cola's pledge to build a new bottling plant, then repealed it entirely in return for Coke building a bigger plant. At about the same time in Maryland, legislators caved in to threats from the Frito-Lay corporation not to erect a new plant there and repealed the state's snack food tax. The same story has been played out in ten other localities. If anything, these reversals serve notice to parents that the snack food industry will stoop to anything to protect its interests in maintaining their child's expanding belly, despite the medical consequences.
One might reasonably wonder, however, if the food industry might not take it upon itself to do something. It could re-size its portions. This would not require any major re-engineering for most of them. Many large snack food makers already have small-size lines in production, most of which are designed for the European market, where six to eight ounces of a soft drink have long been deemed sufficient as a portion (amusing as it may be to supersize-inclined American tourists). In recent years there has even been active consideration of introducing Euro-sizing into the United States. "But it is always held up by the basic marketing and market share imperative," says John Peters, a longtime obesity scholar who knows the food industry from the inside out. "The major players all know what could be done. But no one—no one—is going to take the first step. No one wants to take the big hit that the first to break ranks will inevitably take. They all know that, by and large, consumers are still stuck with nineteenth-century notions of 'more for less is better' in their heads."
One group of Americans has always known better than that. They are the rich, the more insightful and longer-living of whom have understood that the price of abundance is restraint; in their parlance, you can never be too rich or too thin. Yet today almost everyone in America is too rich in the fundamentals: Almost everyone has access to maximal cheap calories, and almost everyone has the opportunity to expend minimal calories. Such is the gift—and the challenge—of global capitalism, the principal legacy of Earl Butz and his war on inflation. That challenge may be one of the most difficult that modern society has ever faced. After all, overconsumption is an intuitive, rational act—at least on its face. Who wants higher food prices? Who wants to sweat? No one. Only when Americans feel the countervailing cost of being fat in their daily lives will they begin to undertake the necessary counterintuitive steps out of the obesity epidemic.
When that happens, watch out. For we need only look to previous eras to see what Americans are capable of when it comes to getting fit. In the late nineteenth century, social reformers in the mold of Jane Addams and Jacob Riis launched the playground movement, which drove hundreds of American cities to build safe, public recreation areas. Just before, German American immigrants proved extremely successful in planting a social institution known as the turnverein, or gym club, in many American communities. Often clustered around a hall and field, the turnvereins organized community members to meet on designated days of the week to exercise, dance, learn gymnastics, and practice a variety of other types of physical activity. At its peak, the movement reached far beyond its German immigrant origins to embrace a wide spectrum of the community. Before its demise in the 1920s and 1930s, due to assimilation, the turnverein had come to articulate a distinctly American view of fitness and citizenship. As one of its founders, Dr. Charles Beck, would write, there were great advantages to be derived by a republic from gymnastic exercises, "uniting in one occupation all the different classes of people and thus forming a new tie for those who, for the most part, are widely separated by their different education and pursuits of life."
There are already small—very small—signs that the nation's informal, experimental impulse is creating a new version of the public turnverein. By that I refer to the changing mode of the American Youth Soccer Organization. Until the last decade, the AYSO was largely a white, suburban phenomenon. But beginning in the early 1990s, the organization turned its efforts to cities, home to the country's burgeoning immigrant populations. The result has been an explosion of new members, and, as a result, a deeper penetration of the sport into the community. I need only spend a Friday evening on the practice field of my local middle school to witness this new phenomenon. All around the field, while boys and girls are running drills under the supervision of coaches, their waiting families are also at play. Papa teaches tiny Miguel how to skip rope. Mama jogs on the adjacent track. Brother José shoots hoops with a school friend over on the basketball court. The scene is re-created daily at hundreds of locations around the country. Instructively, all of this ancillary physical culture comes spontaneously. It is not the work of policy makers or recreation specialists but rather an expression of what happens when Americans take the time to move. My hope is that a variety of such responses might eventually become anchors for small but strategic new municipal investments in public fitness.
Until then, it pays to remember, perhaps while ordering that next supersized meal, that Dante put the gluttonous in the third circle of hell, where they were to endure "eternal, cold and cursed heavy rain." The slothful, one might consider as one cues up one's satellite dish, fared even worse; in the fifth circle they would "languish in the black slime" of the river Styx.
In the twenty-first century, we have put ourselves in the first circle of fat hell.
How we get out of that hell depends not upon prayer, but rather upon a new sense of collective will—and individual willpower.