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Ludwig's clinic at children's hospital, Optimal Weight for Life, offers a glimpse of the diversity of childhood obesity in the U.S. The clinic straddles the border between the wealthy neighborhood of Brookline and the poorer areas of Roxbury and Dorchester, and Ludwig's patients--black, white, Hispanic--are drawn from around the city. Ludwig's unique weight-control program focuses on the glycemic index of his patients' diets, attempting to reduce the sharp ups and downs in blood-sugar levels that he believes encourage children to overeat. That means cutting back severely on the highly processed carbohydrates that make up the backbone of the diet of too many kids. A first-time trip to the clinic includes a visit with a nutritionist, who listens as parents detail what a child has eaten over the past couple of days--and then informs them that almost all of it will have to go, to be replaced by lots of whole grains, fresh fruits and vegetables. "It can be challenging," says Suzanne Rostler, a top nutritionist at the clinic.
On a recent visit to Children's Hospital, 38-year-old Rachel (who, like many parents at this and other weight-loss clinics, prefers to use first names only with outsiders in order to protect her child's identity) listened to the changes she'd have to make in her 4-year-old son's diet and seemed a little daunted. "I'm still trying to process it all," she said a few days later. But Rachel's child is more fortunate than many of Ludwig's patients. The family lives in Brookline--in fact, right next to a Whole Foods store--so buying the healthy staples of a new and better diet wouldn't be that difficult. (Weaning her son off the snack food Pirate's Booty, she admitted, might be another story.) But not everyone is so fortunate, like a patient who visits soon after, an 11-year-old African-American girl. Her father works days, and her mother works nights; trying to find the time and budget to search out and prepare healthier food was clearly going to be harder for this family. "It's not impossible, but it's absolutely tougher for the family from the inner city where the parents are working two jobs," says Ludwig. "These are the trenches in the war against obesity."
For all the thousands of books published on obesity, body weight is the result of a pretty simple equation: calories taken in vs. calories expended. Over the past few decades, the entire American environment has become much more obesogenic, or obesity-supporting. Think of the ever increasing supply of fast-food outlets, where meal sizes have ballooned, or the fact that simple physical activity has been largely eliminated from the daily lives of children, who ride in cars where their grandparents might have walked and entertain themselves with an array of sedentary electronic pastimes that didn't even exist a generation ago. It shouldn't be surprising that many overfed, underactive kids lose the battle with their weight. "The environmental factors are much more compelling toward obesity than they were 30 years ago," says William Dietz, director of the division of nutrition and physical activity at the CDC.
It's the lack of good food choices that appears to play the greatest role in making poor kids fat, and the problem goes beyond parents' simply not having enough time away from the job to shop and cook. Often the healthiest foods--vegetables, fruits, whole grains--just aren't available. Many obese children live in what are called nutritional deserts, where there are few nearby supermarkets offering the produce nutritionists recommend. Instead, families may rely on corner delis and bodegas, which tend to stock fattening, processed food, in part for economic reasons: processed foodstuffs are cheaper and can sit on shelves indefinitely. (Between 1989 and 2005 the real price of fruits and vegetables rose 74.6%, while the price of fats fell 26.5%.) Supermarkets, where better choices are found, are three times as common in neighborhoods that are in the highest quintile of income as they are in communities in the lowest quintile. "What good is it to tell people they need to eat fresh produce if you have to take three buses to get apples?" asks Drewnowski. And if your parents are working long hours to pay the monthly bills, he notes, "making sure you have a salad at the end of the day is not the highest priority."
In Los Angeles' Pico-Union neighborhood, just west of downtown, you can see what kids and their parents are up against. Outside Union Avenue Elementary School in this mostly working-class Latino community, an army of street vendors selling potato chips, candy and ice cream has set up shop, waiting for schoolchildren to be released by the afternoon bell. Technically, it's against city ordinances for the vendors to operate near school grounds during the day, but no one is stopping them. Elizabeth Medrano--an activist with the Healthy School Food Coalition and the mother of a 9-year-old boy--tours the streets around the school, where nearly all the food options are found at a handful of liquor stores and bodegas. Each prominently displays candy and packaged snacks; only a few small retailers carry produce--and unappetizing produce at that. "Would you buy this?" she asks, pointing to a handful of bruised cantaloupes. "You walk in, and you see candy, soda and chips. Nothing healthy." It's no surprise that a recent study found that the obesity rate among fifth-, seventh- and ninth-graders in the 10 poorest communities in Los Angeles County was 32%, compared with 8% for the city's 10 wealthiest communities.
Another, often overlooked, factor is the simple matter of safety. Urban children should get at least one break in trying to stay healthy, since the greater density of city life makes it easier to walk to school, the park or just about anyplace else. But that advantage often evaporates in poorer neighborhoods, where recreational areas can be few and walking anywhere is perceived to be dangerous. Xuemei Zhu, a doctoral student at Texas A&M University, surveyed the neighborhoods of Austin and found that even in dense communities, parents often refused to allow kids to walk to school, fearing they would become victims of crime or traffic accidents. "In low-income neighborhoods, the walkability didn't matter," says Zhu. "Safety is the No. 1 factor influencing them." Antronette Yancey, a professor at UCLA's School of Public Health, sees the same phenomenon in her city. "Parents say they'd rather have a fat kid than a dead kid," she says.