Fixing Obesity, Between Little Rock and Hard Places

When the annual ‘F as in Fat’ report was issued a week or so ago by the Trust for America’s Health and the Robert Wood Johnson Foundation, it gave us an encouraging, albeit modest, dose of good news. For the first time in a long time, obesity rates had leveled off rather than risen almost everywhere in the country.

This hint of progress provides some timely evidence that our efforts in this area can make a difference. It’s clearly no cause for confetti or champagne, any more than the recent news from CDC that early childhood obesity rates declined ever so slightly in less than half the sites monitored in a national survey. We should be reading these signs as if they declared “there are miles to go, but it truly is possible to get there from here!” No one should be thinking they say anything remotely like: “mission accomplished.”

Even so, obesity rates holding steady is certainly better than the previous trend of relentless increases. But one state, and one state only, was left out of even this tepid claim to celebration. Obesity rates rose yet again in Arkansas.

So, it’s an interesting time to be confronting the obesity epidemic in Arkansas- where the confluence of factors responsible for its trends- from poverty, to high rates of illiteracy, to rural isolation- may make it seem that all effort is squeezed between the proverbial rock and a hard place. Or, more geographically, between Little Rock, near the center of the state, and all the hard places that surround it.

As fate would have it, I am just back from Little Rock, where I addressed my usual topics- the peril of rampant obesity and chronic disease to adults and children alike, and our potential to turn this toxic tide with better use of feet and forks- at both the Arkansas Children’s Hospital, and the Clinton School of Public Service. At the latter event, I was privileged to address, among others, the First Lady of Arkansas, Ginger Beebe- along with the many newly minted Clinton School students, eager to convert youthful energy and fresh ideas into public service. The devotion of bright young people to public service and public health is cause for the brightest of hopes if anything is.

But then again, we must acknowledge that Arkansas- home though it may be to Hope, and a President from there- is indeed a very hard place to fix all the broken elements of public health. While high everywhere, obesity rates, along with the associated toll of chronic disease, are especially high and hard to fix where poverty prevails. The color-coded CDC maps that show obesity trends over time have highlighted the singular challenge of the southern and Gulf Coast states for decades.

We live in an obesigenic world. We are awash in highly processed, hyperpalatable, energy-dense, “betcha’ can’t eat just one” kinds of foods, and the aggressive marketing of them. These are hard to resist, but all the more so in areas where fresh produce is scarce, supermarkets may not exist, TV may be the predominant source of information, and fast food restaurants may rival the population of mailboxes.

Similarly, those populations- such as the rural poor of Arkansas- who most desperately need the benefits of exercise - are least likely to have linear parks, well maintained playgrounds, home exercise equipment, or any possibility of joining a gym. And, of course, the oppressive heat and humidity of the southern states discourages outdoor activity for much of the year, just as cold does in winter in upper Michigan, where obesity rates are also very high.

Given that a sizable majority of all adults in the U.S. (along with a large and growing proportion of the global population) are overweight or obese, there is a pretty good chance that you are personally familiar with the struggle of weight control in a modern environment that conspires against it. So I probably have no need to tell you that weight control is challenging, even for those who are well educated, have access to gyms and fresh produce, and can afford these. Few if any of those living in the places where obesity is hardest to fix will read this column, because many such households lack Internet access and even computers, and many such folks have limited literacy. The rest of us, then, can certainly understand how difficult weight control must be in not only a food desert, but an information desert, too. We can talk all we want about personal responsibility, in other words, but at some point we simply have to acknowledge: there is just no way to lift yourself up by your bootstraps when you don’t have, and can’t afford, boots.

But I set off to Little Rock convinced we could prevail (eventually) in spite of it all, and I return- buoyed by the good energy of all the dedicated people I met there- even more so. In public health training, we remind one another routinely: think globally, act locally. Global thinking, and local action, can help fix the broken aspects of health in Arkansas and its neighbors.

For example, my trip to Little Rock was sponsored by HealthTeacher, a company specializing in innovative approaches to health education. With support from the Arkansas Children’s Hospital, HealthTeacher is introducing health programming into public schools throughout the state. The goal of this programming is “health literacy,” enabling the kids to make informed decisions about factors affecting their health. HealthTeacher is also helping to introduce a physical activity program, GoNoodle, to the schools of Arkansas.

Public health programming has long demonstrated that if we could reach kids effectively, they could help us reach their parents. Schoolchildren have championed the causes of seatbelt use, smoke detector maintenance, and even smoking cessation. In our own work, my colleagues and I seen that if we teach food label literacy to kids in school, they can teach it to their parents. And we have evidence that when people use that knowledge to trade up their groceries to better nutrition, they can reduce their risk of obesity and chronic disease- and maybe even lose over 100lbs!

The immediate concern raised about this is that more nutritious food costs more, but in fact, that’s just a little bit true, and quite a bit urban legend; we have data to prove it. When people have food label literacy, they can often find more nutritious foods that don’t cost more.

But of course, some nutritious foods do cost more, and here’s where global thinking could come in handy. We could combine nutrition guidance with financial incentives for those most in need, such as SNAP beneficiaries, so that the more nutritious the food, the less it costs. If these incentives are provided by those currently paying the disease care bills- federal and state governments, as well as private insurers- there is an opportunity to help poor people choose better food on their way to better health, and save a whole lot of money into the bargain. There are many such win-win opportunities on the way to health; we can save money, even while improving, and saving, lives.

There are ways to fit physical activity into the daily routines of children and adults alike; and organizations like my own non-profit foundation make such programming available for free. Where there is reluctance to exercise in conventional ways, non-conventional approaches may be the answer. Tom Robinson at Stanford University has shown, for instance, that for tween and teen African American girls with little interest in dodge ball, dance may be the ideal exercise. All movement is good movement, so we can tailor the prescription accordingly. There are ways to get the kids and adults of Arkansas moving, and the best way to know the best ways is…to ask. As graduates of the Clinton School of Public Service fan out across the state, I anticipate they will do exactly that.

The faith-based community is strong in Arkansas, as it is throughout the rural south, and there are opportunities there. My lab has been involved in peer-to-peer programming before, working with churches here in CT. We are currently working on a program that will use church kitchens to produce not just dinners the congregation can love, but dinners that love everybody back- by promoting health. Arkansas would be a great place to test a program where church kitchens are used to help teach families how to prepare delicious, nutritious, economical, convenient meals at home. We can all learn to love food that loves us back.

Working through schools, churches, and perhaps PSAs, we can change attitudes about health. True, people struggling with poverty have other priorities. But we can help people understand that whatever other challenges each day may bring, diabetes is unlikely to make them any easier. Good health is one of the resources we need most to meet and overcome life’s difficulties. Little by little, we can update the way we show love- with neighbor helping neighbor choose nutritious food or go for a walk (or dance), rather than sharing oversized portions of all the wrong foods and speeding one another’s next trip to the ER. Everyone who acquires a bit of health related insight and skill power can say thanks by paying it forward.

With the right programming, we can make the state’s clinicians a more effective part of the solution. We can engage the state’s supermarkets. We can empower and inspire teachers. We can work with chain restaurants. We can nudge choices toward the better in cafeterias, at almost no cost. We can sow community gardens, and reap the related benefits.

And since we can beat the influx of technology that has played a role in reducing our physical activity, we can join with it for good. Even households that don't have computers increasingly do have smart phones, and more and more programming can reach more and more of the population via apps. Free apps to support health literacy and healthy behaviors can be used by Arkansas to reach even its hard-to-reach families.

And, of course, to some extent we should consider that a rising tide lifts all boats. Imagine if the middle class throughout the country rebelled against junk food, and refused any longer to grow the bodies of children and grandchildren we love out of junk? If there were no junk in the food supply, there would be no junk on the shelves of mini-marts in rural areas either. If we can improve the food supply at large, the pickings in so-called food deserts may still be comparatively slim, but what’s there will be better.

I have written before about the array of practical strategies needed to fix epidemic obesity, and turn the tide of chronic disease. I generally liken the effort to the construction of a levee: every good effort is a sandbag in the levee, and we need many such good efforts. No one sandbag can stop a flood, but enough of them certainly can. I believe we can aggregate programs to protect our health the way we aggregate sandbags into a levee that protects our homes. We need programming to facilitate good use of both forks and feet in all the places that influence our diet and activity patterns: work, school, church, home, food service, media, cyberspace, and whatever I’ve left out. We need programming to address the needs of the severe obesity already established. Everything that isn’t part of the solution, is part of the problem. The levee metaphor is helpful because it makes the daunting task far more manageable: no one of us can fix it all, but every one of us with good will and a strong back can stack a bag of sand. No one program will get us to the prize, but in the unity of our efforts, there is the strength to get it done.

Fixing obesity in Little Rock won’t be easy, and between there and the rest of Arkansas are many places where it will certainly be harder still. But few worthwhile things are easy. When they matter enough, we do them anyway.

I was privileged to be in rooms full of people passionate about the challenges in Arkansas, and prepared to work hard. They fully appreciate, as I do, that for such promises as more years in life, more life in years to be kept, we all have miles to go, and must commit to the journey, however arduous. Everyone around me, from new student to veteran clinician to First Lady, seemed realistic about the challenges, and was lacing up their hiking boots accordingly.

I was proud to be in such company. And so I return from my visit to Arkansas knowing that it is home not only to Little Rock and many hard places for health promotion– but home to Hope as well; mine included.

-fin

Dr. David L. Katz; author of the forthcoming 'Disease Proof'

https://www.davidkatzmd.com/

www.turnthetidefoundation.org

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