June 16, 2010

The Battle for Healthy Children

As the U.S. prepares to attack childhood obesity, Tufts experts pitch in

By Helene Ragovin

On a rainy afternoon inside Boston’s Oliver Wendell Holmes Elementary School, a small girl with a serious expression is engaged in a battle with a carrot.

Grasping the vegetable in one hand and a box grater in the other, she brings the two together, clumsily at first—after all, until a little while ago, she didn’t even know what a box grater was. Now she has figured out how to steady the grater, and rubs the carrot intently across the grates, picking up speed and confidence, until, triumphant, she shows off a small, colorful mound of shreds.

At Boston’s Oliver Wendell Holmes Elementary School, learning healthy food habits is lesson number one when Friedman School students visit. Photo: Joanie Tobin

The carrot, along with a cornucopia of other vegetables and some red beans, will be used to make “protein pitas.” It’s part of a project called Jumbo’s Kitchen, in which Friedman School students run hands-on healthy cooking classes for Boston school kids.

The struggle between the girl and the carrot is emblematic of a larger battle to change the eating and activity habits of America’s kids as the nation grapples with a decades-old epidemic of childhood obesity.

Now the White House has taken up the banner. In February, Michelle Obama launched the first national effort to combat weight gain in kids, an obesity prevention campaign called Let’s Move. It uses an approach called community-based intervention, in which schools, government, public health resources, youth services and other agencies, along with children and their families, are all called upon to help change unhealthy behaviors.

“About 10, 20 years ago, all [obesity prevention] efforts were aimed at the individual, with the thinking, ‘If we can just get this kid to eat the right foods and do a lot of exercise, we’ll be all set,’ ” says Virginia Chomitz, N85, N92, a senior scientist at the Institute for Community Health in Cambridge, Mass.

“As we’ve gotten wiser and started to look around at children, we realized they’re just one cog in the wheel,” Chomitz says. “If they live in an area where they can’t walk to school, either because of safety or because it’s too far; if they don’t have an opportunity to be active; if there are no after-school programs or their school doesn’t offer recess; if school lunches aren’t very healthy; if parents are not providing good meals; if there are no grocery stores in the neighborhood—it’s very hard for that child to do the right things.”

In developing Let’s Move, the first lady took several cues from a Friedman School project, the seven-year-old community intervention in Somerville, Mass., known as Shape Up Somerville, that resulted in children gaining less weight than their peers in other cities.

Dozens of other communities are doing similar things. Chomitz, for example, recently released the results of a three-year community-based healthy weight intervention called Healthy Living Cambridge Kids, which found modest reductions in obesity and improvements in fitness levels among that city’s public school students.

Shaping Up the U.S.

But as encouraging as community anti-obesity programs have been, researchers caution that the childhood obesity crisis is far from being solved, and that millions of children still face serious health risks.

“The sweeping, contextual piece around this is that in this nation, childhood obesity rates are very high and have been skyrocketing for decades,” says Chomitz. “Although it looks like [those rates are] starting to stabilize, nothing that has been done to date has been all that effective.”

Last year, when Michelle Obama was looking for scientists to advise her on childhood nutrition, Christina Economos, N96, was an obvious choice.

Economos, the holder of the New Balance Chair in Childhood Nutrition at the Friedman School, was the creator and force behind Shape Up Somerville, mobilizing restaurants to highlight healthy menu choices, schools to teach more about nutrition and the city to paint new crosswalks to encourage children to walk to school. Now Economos is helping adapt the Somerville model for programs across the country, in locations as varied as the Central Valley of California and the Mississippi Delta.

A vital component in the success of Shape Up Somerville, Economos says, is that it was designed with the specific needs of that community in mind. For instance, Somerville is a fairly compact and walkable city, yet it lacks green space—so while developing walk-to-school and bike-to-school programs was not difficult, it was more challenging to find ways to promote other outdoor activities. In a more rural area, where open spaces are abundant but schools are far apart, a walk-to-school program may be impractical.

The program was also devised to mesh with the city’s demographics. Materials distributed in the schools, for example, were presented in four languages: English, Spanish, Portuguese and Haitian Creole.

“You want to be creating healthy alternatives while maintaining the cultural preferences in every community,” Economos says.

Shape Up Somerville was also successful because it had staff and funding—something that can be difficult when municipal finances are tight, Economos says. “A lot of communities rely on volunteers, who can show up and have lots of great ideas, but to really transform a community and create the environment and policy changes that were realized in Somerville, it takes dedicated, paid staff. And when there are a lot of competing economic pressures, programs like this are often the first to go.”

A federal initiative like Let’s Move could give communities the tools to address some of these issues, she says. For instance, Let’s Move intends to involve pediatricians throughout the country to reinforce anti-obesity messages at well-child visits. It could bolster efforts by the USDA to abolish “food deserts”—areas that lack supermarkets and other places to purchase fresh foods—and to improve the school meals program. “It will be how national change occurs over the next few years,” Economos says.

Overweight but Malnourished

Some recent data from the National Health and Nutrition Examination Survey indicates the childhood obesity rate may have plateaued. “It looks like things are sort of at a standstill,” Economos says. “Nevertheless, there are still 32 percent of children between the ages of 2 and 18 who are overweight or obese. If you go to Somerville or the Mississippi Delta, you’ve got 45 to 50 percent of kids overweight or obese. There are real pockets where it’s quite different, and it’s related to poverty.”

It’s also possible for overweight children to suffer from nutritional deficiencies.
“Certainly there are a lot of kids who are overweight and eating too many calories who still have micronutrient issues,” Economos says. “Vitamin D, iron, calcium, fiber—there are still a lot of foods they are not consuming, despite the fact that their calorie intake is high. We all know you can eat 3,000 calories of white bread and sugar-sweetened beverages, probably gain some weight, but lack a lot of important micronutrients.”

A study published this past February in the New England Journal of Medicine, which tracked thousands of Native American children for several decades, found that the heaviest youngsters were more than twice as likely as the thinnest to die before age 55.

“The things associated with childhood overweight—risk of cardiovascular disease, sleep apnea, depression, Type 2 diabetes—all these things we’re seeing more of, and it can only get better if we reverse those obesity rates,” Economos says.

School Lunch Revamp

A major goal of Let’s Move is to improve the nutritional quality of school lunches. Since many of the nation’s children, particularly those from low-income households, eat more than half of their daily calories at school, lawmakers, public health officials and even celebrity chefs have targeted school cafeterias in the fight against obesity.

“Here in Woonsocket, we potentially have control over the children for breakfast and lunch,” says Frances DeRuiter, N01, a registered dietitian and former chef who is food service manager in the economically depressed city along Rhode Island’s northern border.

DeRuiter is northeast district dietitian for Sodexo School Services, which, along with the two other major suppliers of school lunches, Chartwells Schools Dining Services and Aramark, has signed onto the Let’s Move initiative.

The food service companies have pledged to include more fresh fruit and vegetables, whole grains and legumes in meals for the federal school lunch program. Separately, the Obama administration is proposing legislation that would ban candy and sugary drinks from schools throughout the country; at least 11 states have already passed laws either banning junk food or encouraging the sale of healthier foods at public schools.

Rhode Island is one of the states that has beefed up its nutritional requirements for school lunches and instituted restrictions on snacks and vending-machine food. The requirements for the type and quantity of fruits, vegetables, whole grains and legumes included in Rhode Island school lunches now exceed federal standards.

Of course, the fickleness of young palates is also an important part of the equation. For example, DeRuiter talks about the attempts to introduce whole-grain bread in Woonsocket.

“Our bakery has formulated a bread that’s 60 percent whole wheat and 40 percent white, and the children are really eating it,” she says. “Before this, we had bread that was 70-30, and, honestly, the children were throwing the bread away. So this 60-40 is lighter and a bit sweeter, and the children are accepting it.”

She touts the success of the district’s new federally funded fresh fruit and vegetable program. At five elementary schools in Woonsocket’s low-income neighborhoods, the children get a mid-morning snack of an “unusual” fruit—think papayas, not bananas—or a fresh vegetable twice a week.

“That’s a wonderful way to make a difference in a child’s life, and it does translate into the community, into the home,” DeRuiter says. “The child goes home and says, ‘Oh mommy, I tasted a cantaloupe today—can you get one for us?’ ”

Chop, Stir, Eat, Learn

That “Hey, ma, look what I ate!” approach is exactly what drives Jumbo’s Kitchen, a partnership between Friedman School students; the Albert Schweitzer Fellowship, a nonprofit that works to address health disparities by developing leaders in public service; and DotWell, a community-based organization that runs after-school programs at several Boston public schools.

Once a week for 10 weeks, the student volunteers arrive at an urban school on a Friday afternoon, carrying mixing bowls, blenders, beans, carrots, cucumbers, lettuce—and even roasted garlic.

The idea is to teach kids the joys of fruits, vegetables and whole grains—without heavy-handed messages. “What we’ve learned is that kids love fruits and vegetables and being able to chop them up, eat them and become familiar with them,” says Dawn Undurraga, N10, the program coordinator and a 2009–10 Schweitzer Fellow.

For the Jumbo’s Kitchen kids who are chopping and stirring in the teachers’ lounge at the Holmes School, the consequences of being overweight are all around them. Twenty-four percent of the adults in their primarily African-American North Dorchester neighborhood are obese, according to 2005–06 data from the Boston Public Health Commission. Black residents of Boston have higher rates of overweight and obesity, and far higher hospitalization rates for heart disease and diabetes, than white or Asian Bostonians.

As a volunteer at Boston’s Martha Elliot Health Center, Undurraga works with teenagers who are already dealing with the consequences of weight-related ailments.

“We’re raising a whole generation of kids who have not had experiences in the kitchen and then are left to fast foods or whatever is easily accessible,” she says. “The point is to demystify the garlic press and the grater and the whisk and give the kids the feeling they know what these things are.”

Whether this newfound appreciation of fruits and vegetables will last for the long haul is unknown. But sometimes victories come in the short-term: earlier this semester, a child at another Jumbo’s Kitchen site, the Joseph Lee Elementary School, asked her mother to serve hummus and veggies at her birthday party.

Their efforts may not make a dent in the budgets of companies that make junk food, Undurraga says, “but maybe we’re getting a bit more vegetables in there.”

This article first appeared in the Spring 2010 issue of Tufts Nutrition magazine. 

Helene Ragovin can be reached at helene.ragovin@tufts.edu.

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