State still seeks winning strategy against childhood obesity

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For a decade, Washington has been fighting for your life.

Yet you might not even know this because it's been a quiet battle, a fight designed to work its way into the fabric of your life.

It's about your weight — or, more important, the weight of your children.

In this battle, state and local agencies have spent millions. They've enlisted hundreds of local groups and engaged key national experts. Traveled the country for ideas, tested promising new approaches and won coveted grants. They've devised a multifront attack covering everything from breast-feeding to gym classes to meals in senior housing. In the past two years, they've stepped up the effort.

Through it all, agencies and experts have pinned a lot of hopes on a relatively new concept in obesity-fighting: creating "access." The idea is to ensure that everyone, especially kids, has access to healthy food and recreation. Yet those in charge say it's really a big experiment; it will be at least a decade before we know whether it's working.

"We have a crisis we're trying to address," explains James Krieger, the doctor with Public Health-Seattle & King County who's in charge of one of the major grants. Officials have to act based on the best information available, he says, even if it's not a sure thing.

So far, the results are discouraging. A push to put more fresh produce in poor neighborhoods' corner stores, for instance, is struggling. And recent studies suggest the proliferation of farmers markets has done little to change diets or behavior. The number of overweight and obese kids continues to climb.

In other words, we might be spending a whole lot of money on efforts that miss the mark.

Shifting tactics

The way experts look at weight control has changed dramatically in the past decade or so.

With good reason, says Donna Johnson, one author of the state's anti-obesity plan. Now a researcher at the University of Washington, she spent years as a dietitian working with people who were overweight.

She didn't like what she saw: Traditional weight-loss programs seemed to make a lot of people feel worse. There were the food logs, in which clients documented every shameful morsel. And the weigh-ins — those humiliating moments on the scale, recorded, charted and scrutinized.

"This was not a way toward sanity," she realized.

Besides, it wasn't working.

Adults had been pudging out for years, but by the late 1990s, the U.S. Centers for Disease Control noticed something even more alarming: Kids were rocketing up the weight charts, too.

As Johnson explains, Americans long have gained weight as they aged; with so many kids now starting off 10, 20, 30 percent or more overweight, they'd likely be heavy adults. Doctors say that puts them at higher risk of debilitating — yet preventable — disease.

This is why everyone from Krieger to Michelle Obama is so focused on childhood obesity.

Meanwhile, public-health officials noticed something else: The well-to-do are less likely to be overweight than the poor. So, much of the recent anti-obesity work has focused on poorer communities.

As Adam Drewnowski, one of Johnson's colleagues, likes to say, "Obesity in America is an economic issue."

The problem, he says, is the world around us.

For one thing, junk food is relatively cheap and available on every corner. Healthier foods aren't. In general, poorer neighborhoods aren't teeming with produce-filled grocery stores. This, experts say, illustrates the problem of "access." The idea has especially taken hold here. In a survey last year of leaders in Washington's obesity battle, only 29 percent agreed with the statement "everyone has access to healthy food." People in poverty, Drewnowski says, are also especially short on other things it takes to maintain a healthy lifestyle: time, education and money. So in 2000, when Johnson and others began writing the state's first Nutrition & Physical Activity Plan, they came up with a theme: "Make the healthy choice the easy choice."

Broader approach

They had another new concept. Instead of focusing on individuals, they would aim at society itself. In time, experts hoped, healthy behaviors would become routine.

This broader, societal approach has a lot to do with efforts to get kids to cook or grow their own vegetables. It's part of the reason Auburn school-cafeteria ladies are getting scratch-cooking lessons. It's why you're hearing about "food deserts" and "healthy vending machines."

It's also what's pulling millions of dollars into Washington. Last year, the CDC awarded King County $15.5 million in stimulus money to fight obesity. The W.K. Kellogg Foundation gave $1.7 million, to be used over several years. The U.S. Department of Health and Human Services kicked in $9.5 million. The list goes on.

The idea of the healthy corner store is a big part of the CDC and Kellogg grants.

The thinking is, if it was as easy to find veggies as chips there, families would buy the good stuff, skip the bad.

It's sort of an "if you build it, they will come" model, and it's what progressive communities are doing coast-to-coast. Store owners, nonetheless, took some convincing. Proprietors had concerns about a lack of shelf space and refrigeration, about suppliers and what to stock. But by fall 2009, the county had enlisted its first healthy corner store: Super 24 in Delridge. Featured in The Seattle Times and other media outlets, it sounded good. The problem is, it didn't work.

Within months, the store owners, Sam and Bhim Singh, had given up. They still stock a few fresh things that have a long shelf life, like onions and potatoes. But they had been stocking those long before the county got involved.

People simply didn't buy the new produce, Sam Singh says. "We would spend $200 on vegetables and make only $10."

Officials say they have learned valuable lessons. Maybe they didn't spend enough time selling the idea.

In any case, they've budgeted another $1.8 million in hopes of enlisting at least 25 stores. Three have signed on.

Those in charge say the effort is worthwhile, pointing to a study of a similar program in Baltimore.

Looking more deeply at that study, however, the evidence was hardly convincing. University researchers who evaluated the program said there was just one statistically significant change in consumption: People were buying more cooking spray. At least, that's what the store owners thought. The study wasn't able to measure actual sales.

Beginning in 2008, the USDA and the Institute of Medicine (IOM) spent a year looking more broadly at the access issue. They each concluded it's unlikely that produce in minimarts, or even new full-service grocery stores, will make much difference in obesity rates.

"The supply of healthy food will not suddenly induce people to buy and eat such food over less-healthy options," the IOM report concluded.

After all, even those with the best access aren't eating their vegetables. Most of us get about half of what's recommended, research shows.

The reason for this is both intuitive and well-studied. Eating decisions are driven by taste. Then cost, Drewnowski says. Then convenience. "Health," he says, "is last."

"There are really two different issues," says Marlene Schwartz of the Yale Rudd Center for Food Policy & Obesity. "One is a lack of access to the healthy food. But the other is the overwhelming access to the unhealthy food. To only address one of those problems is really missing, I think, the opportunity to have a bigger impact."

Put it this way, she says: "No matter how beautiful the produce is, it's hard to compete with a brownie."

Searching for solutions

Remember that nearly three-fourths of the experts in a state survey believed access to healthy food was a problem?

In another state survey, this time of regular people, 95 percent said they didn't have a problem finding healthy fruits and vegetables.

In fact, the USDA calculated access using several statistical models, and each time found that this isn't the problem for the vast majority of Americans.

And those gardens and farmers markets that are so popular in the fight? The USDA report again said there is "little evaluation of their effectiveness in terms of changing shopping behavior, diet and diet-related outcomes for consumers."

It's not that there's anything inherently wrong with these things. But if the idea is to address obesity, we have to ask whether this is the best place to spend our money.

The USDA has given $276,000 to Washington State University to help 12 local schools create gardens. The county has $205,000 in grant money to help food-stamp recipients shop at farmers markets. It will help pay for benefit-card-reader machines for 45 farmers and eight markets. It's easy to see how it will help farmers because the machines will take debit and credit, too. But food-stamp users said in focus groups it's not really worth their while to shop at farmers markets when they have so little to spend, and when grocery stores offer more convenience.

Then there's the $1.8 million for healthy corner stores.

Johnson, the UW researcher, hasn't studied these programs, but is concerned about the big picture. "We don't want people to pour millions of dollars into something that doesn't work," she explains. "It leaves a really bad taste in the public's mouth."

Mixed results

So what's the solution? Eat less, move more, right? The problem is, there's so much we don't know.

We were told to drink low-fat milk; now studies show it's associated with weight gain in kids. Is there a cause and effect? The science isn't there yet.

We were told low-fat snacks are healthier than full-fat. Then we learned about the "SnackWell effect" — the tendency to eat more when food is labeled healthy or low-fat. Some believe lowering the cost of produce will get people to eat more of it. In one study, they wound up using their "extra" money to buy junk. It's not even clear that eating more fruits and veggies helps control weight. In some studies, it was actually connected with weight gain. Besides, we've eaten about the same amount of produce since the 1970s, yet continued to put on pounds.

Salad bars in schools? More mixed results.

How about putting calorie counts on menu boards? So far, studies haven't shown it changes eating habits. Still, grants are paying to put them up in local schools.

"I think some of these really idiosyncratic things — when you're sipping merlot, they sound really good," says Brian Wansink, a Cornell professor who oversaw the development of the USDA's 2010 Dietary Guidelines. "But in the normal world, there's just no evidence these things make any difference."

To be sure, Washington has a number of programs that seem promising. It has pushed hard to reduce the consumption of caloric beverages like soda and sports drinks, which study after study shows are closely linked with being overweight. In the past year, the county has run two anti-soda campaigns. Schools have put more water and sugar-free items in vending machines.

The state Department of Health says these efforts are starting to pay off. In its biannual survey of adolescents last year, the number of kids who said they drink two or more sodas a day dropped by half since 2002. More students reported getting the recommended amount of exercise — another goal of the anti-obesity efforts.

The county recently came up with healthy vending-machine guidelines, and places like community centers and Boys & Girls Clubs are working to get rid of the junk.

"A lot of the work we're doing in child care and schools is basically to establish Cheeto-free zones," Johnson says. "Inch by inch, we can kind of reclaim the territory for healthy eating."

None of these things is expected to do a lot in isolation. The idea is if we bombard 'em — improve phys ed and get kids to walk to school and teach them about food marketing and a bunch of other things — we'll create a healthy-eating culture, Krieger says.

Smoking changed from glamorous to gross, right? One day, advocates believe, kids will bike home from school and tell their parents they don't want corn chips.

The hurdles are large. Big Food, after all, makes Big Tobacco look puny.

This will all take time. And most of these projects are funded with the CDC grant, which ends next March. That's not even enough time for people to make changes in their behavior, much less lose weight, Krieger says.

"It's taken us 20 years or more to get to the point where we are now. I don't expect we're going to turn it around in a week or a month or a year."

But, he says, turn it around we will.

Maureen O'Hagan: 206-464-2562 or mohagan@seattletimes.com.