Bad food is easier to come by than good in too many places. Here junk fare is sold right outside a school.
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But inner cities are only part of the problem. Despite the image we might have of the abundance and open spaces of the countryside, Americans living in isolated rural communities also tend to have few places to walk and play and few convenient options for decent food. "You have to drive miles and miles to find a grocery store," says Jan Probst, who directs the South Carolina Rural Health Research Center at the University of South Carolina. Indian reservations are often the most extreme example of this rural nutritional isolation. The Pine Ridge reservation is nearly 3,500 sq. mi. (9,000 sq km)--more than half the size of Connecticut--but there are just a handful of stores in the area that sell fresh produce. And with average income well below the poverty line, even Pine Ridge families who have access to the good stuff can't afford to buy it. "When you have families on a limited income, it gets difficult to make that decision to eat well," says Bonnie Holy Rock, an Oglala Sioux from Pine Ridge. Holy Rock is the field-site coordinator for Bright Start, a University of Minnesota--sponsored program to reduce child obesity and diabetes on Pine Ridge. "What do you have to eliminate to buy fresh fruit and vegetables?" she asks.
And if you think rural kids at least spend more time outside, working off the extra calories they consume every day, think again. Country life isn't what it looked like on Lassie. "You say rural, and you think kids are on the farm, lifting hay bales," says Probst. "But they don't do that anymore." What they do is the same thing other kids do, which is to say they spend more and more time inside, in front of a screen--even more so since their homes are a lot likelier than those of suburban kids to lie next to a four-lane interstate or some other decidedly unsuitable place to play. "Kids need a support system for activity," says David Hartley, director of the Maine Rural Health Center. "And in rural areas, too often they don't have that."
Other cultural factors, harder to define, could influence the geography of obesity as well. Yancey, an African-American woman, points out that being overweight isn't looked down on as much in the black community as it is in the white community and that extremely high levels of adult obesity among African Americans--31.2% of black men and 51.6% of black women are classified as obese--may have shifted social norms. (Race isn't an absolute determinant, though--largely African-American Mississippi and overwhelmingly white West Virginia both have high obesity levels.) The same could be true among Hispanics, especially recently arrived immigrants, according to Amelie Ramirez, director of the Institute for Health Promotion Research at the University of Texas Health Science Center. "There's a perception in the community that a chubby baby is a healthy baby," she says.
Fighting the Fight
So if an obesogenic environment is responsible for our national weight problem, how can we fix our surroundings so we fix our health? "We have to realize that we're not going to get anywhere in getting people to eat healthy and be more physically active until we create an environment that supports that," says James Hill, director of the Center for Human Nutrition at the University of Colorado Health Sciences Center.
One place to begin that transformation is in schools, since that's where children spend much of their waking lives--and ingest up to 50% of their daily calories. Here, Arkansas--a state that has had one of the nation's highest rates of childhood obesity--is in the vanguard. Led by Joseph Thompson, director of the Arkansas Center for Health Improvement, the state in 2004 began tracking the BMI of more than 400,000 children, sending home confidential health reports to parents. BMI is an imperfect metric since it often mistakes a stocky or muscular kid for an obese one, but as a quick way to spot weight problems it can reveal a lot. Officials also eliminated junk-food vending machines in all elementary schools--a policy that's becoming more common around the U.S.--and added half an hour of daily physical education to the school curriculum. The plan has had its critics, but Thompson knows that without help, children in Arkansas--poor, relatively rural--face a lifetime struggle against obesity.
"This is not a disease that will be solved with medicines or vaccines," says Thompson. "A social movement has to solve this." So far, the interventions seem to be working--after years of increase, obesity rates among children in Arkansas have leveled off.
Arkansas isn't the only state trying to tackle childhood obesity. In 2003, California led the way by banning sugary sodas from public schools and was soon followed by states across the country, with the result that the major soft-drink companies agreed to withdraw all high-calorie sodas from schools by 2009. In Arizona, the Pima tribe of Native Americans, which has some of the highest obesity levels in the world, is growing school gardens in the desert to supply cafeterias with fresh vegetables and reconnect kids to a traditional cuisine. Today at least 17 states have set nutritional standards for school meals that are stricter than those demanded by the U.S. Department of Agriculture.
As part of its fight against childhood obesity, the Robert Wood Johnson Foundation is seeding local initiatives like the Healthy Schools Program, which will provide on-site support for more than 8,000 schools by 2010, improving access to healthy food and increasing opportunities for students to exercise. Last year 16 states supported policies to improve physical-education classes, which have been cut back severely in recent years, and just this month Florida governor Charlie Crist signed a bill requiring physical-education programs in the state's elementary schools. Denver has renovated more than 50 school playgrounds, significantly increasing children's activity levels, and towns and cities elsewhere have launched similar efforts to make it easier for kids to be active. "If you build a park or playground, people will come," says James Sallis, a professor of psychology at San Diego State University and the director of the Active Living Research initiative.
But the school day has to end, and when it does, too many kids emerge into a world in which their food choices begin with Arby's and end with Wendy's. There are groups working to get different foods blooming in the nutritional desert, however. One of the most successful is the Food Trust in Philadelphia. Begun as a produce market in Philadelphia's Reading Terminal, the trust sponsors farmers' markets throughout the city, taking fresh fruits and vegetables to neighborhoods that lack them. The group is also working to improve the selection of corner stores and bring back supermarkets to poor neighborhoods that have lost them over the years.