The Fat Trap
Could a simple after-school program be the answer to a national epidemic?
By Jessica Cohen

Juan Mendoza, a seventh grader at Fair Haven Middle School, used to be fat. Like most overweight kids in middle school, he endured his share of taunting. But as much as it bothered him, he didn’t know how to change his situation. “I used to just eat and not really care. I didn’t know why I was eating what I was eating,” he remembered. At the end of the school day, having skipped lunch and breakfast, Juan would hit the vending machines and stuff himself with unhealthy treats. On the way home local convenience stores lured him in with the promise of his favorite snack: Doritos. At home Juan’s family served him fried food; until last spring he had never even tried broccoli or cauliflower.

But in the fall of 2001, all of that changed. For 16 weeks Juan and 20 of his peers participated in an after-school program designed by Dr.
Margaret Grey, Assistant Dean of Research Affairs at Yale School of Nursing, and a team of colleagues. To Dr. Grey and her team, Juan is
representative of a national “epidemic of obesity” that has hit low-income and minority populations disproportionately hard. Though all
of America is getting heavier as a result of reduced physical activity and poorer nutritional habits, socio-economic factors often determine
who is most affected. It is a fact that the poorest people in this country are also the most overweight.

In this regard, New Haven is a prototypical American city. Statistics highlight the gaping health discrepancies that exist nation-wide between upper- and middle-class citizens and inner-city dwellers. While approximately 16 percent of American youth are obese, in New Haven, where 85 percent of students in public schools are either African American or Hispanic, and the majority eat state-subsidized free lunches, the numbers hover between 45 and 50 percent. 41 students participated in the 16-week program at Fair Haven and Sheridan middle schools. All of them were considered clinically obese and all but one of them were either African American or Hispanic.

Yale psychology professor and obesity expert Kelly Brownell likens the weight crisis to the early days of the hiv/aids epidemic. “Obesity is somewhat like hiv/aids was in that it is a stigmatized problem and so despite its dire consequences the public is slower to respond,” he explained. For the most part, poor people in America do not have access
to healthy food, cannot afford physically active lifestyles, and live in communities where obesity is commonplace. More troublesome, however, is the fact that obesity is the number one cause of Type 2 diabetes, one of the fastest growing diseases in America. In a statement issued last winter calling for changes in school lunch policies and the fast-food industry, Surgeon General David Satcher lamented, “The nation’s obesity epidemic has gotten so bad it soon may overtake tobacco as the leading cause of preventable deaths.”

For Juan, the program presented an opportunity to improve his health, to stop being teased about his size, and to become an exception to the
rule. A lot was at stake for Dr. Grey and her research team as well: If the program, one of the first of its kind, could reverse trends towards
obesity and, more importantly, Type 2 diabetes in Juan and his peers, despite their home and school environments, then it could be a viable answer to a national problem. But success will depend on the program’s ability to counter problems deeply engrained in American society.

Statistically, Latino males between the ages of six and twelve like Juan have the highest incidence of childhood obesity—clinically defined
by a ratio of height to weight above the 85th percentile. Childhood obesity has been linked to low self-esteem, altered body image,
decreased preferences for physical activity, and depression. The most alarming problem, however, and the one that Dr. Grey is most worried
about, is the direct connection to the early onset of Type 2 diabetes, a condition that impairs the body’s ability to use insulin. As a
result, fats and sugars are less effectively digested, causing high blood sugar levels. This can lead to reduced energy, high blood
pressure, heart disease, and kidney disease. In 1980, only 2 percent of Type 2 diabetes cases occurred in children between the ages of nine and 19. Now that figure has jumped to between 40 and 50 percent. The sharp rise in Type 2 diabetes in children is a troubling indicator of what is to come. “The problem here isn’t only health related,” explained Grey. “This health epidemic has huge societal implications. These kids will be suffering from complications in their 20s that we haven’t generally seen until much later in life—and this doesn’t have to be the case.” But if the over-arching goals of Grey’s course are of national significance, its classroom goals are surprisingly basic: nutrition, exercise, and coping skills.

Juan remembers the beginning of the class as being extremely challenging. “Almost everything I learned was new and it was hard to
change the kind of food I ate.” At the second session of the class, students were asked to talk about the kinds of foods they consume and
think of why they might choose those foods. While choosing foods based on taste, cost, and convenience was familiar to the students, thinking
about nutrition was not. High-sugar and high-fat foods are ubiquitous, regularly appearing in advertisements and promotions, while messages
about nutrition are more obscure. According to Brownell, “the economics of food are the reverse of what they should be. Unhealthy food is easy, cheap, everywhere, and tastes good.” The students’ diets at the beginning of the course reflected this. “Their diets were high-fat,
high-carb and low-protein. They were drinking close to a liter of soda a day and didn’t know that it was a problem,” said Diane Berry, one of the primary researchers.

During the first few weeks, the nutritionist for the course, Pamela Galasso, tried to give the students tools and information that they
could use when making choices about food. “I had to present them with a new way of talking to get them thinking about and actively participating in more meals,” said Galasso. The approach Galasso used was holistic. Rather than focus on diet and weight-loss, she tried to emphasize small changes that students could make. She presented them with “culturally competent” food guide pyramids that included foods that the students typically ate, such as rice and beans, and taught them some mnemonic devices to help them make decisions about food.
Among the devices were phrases like “diet: Deprived Individuals Eat Too much”—a reminder not to skip meals—and “soda: Stop Options Decide Act”—encouraging careful decision making when choosing a beverage. Though these strategies may seem simple, for students who didn’t know that “four tennis balls” of rice was too much, they were welcome tools. Each week Juan made goals for the next week’s class based on what he had learned: “Sometimes it was to add more vegetables or to eat some breakfast. I would try to eat less high fat food.” The course gave Juan clear messages about food and nutrition—messages that were not often reinforced at home or at school.

Unfortunately, processed, high-fat, and high-calorie food is just as prevalent in schools as it is in homes and stores. Students on subsidized school lunch programs do not have many options when choosing what to eat. School lunches, though financed by the government and required to meet certain standards, are often high in fat and light on fruits and vegetables. “The government policies are confused,” explained Grey. “There are rules and regulations regarding school lunches. But in places like New Haven, where many of the meals are subsidized, the stuff they get free or cheap are the high fat choices.” In a recent study only 20 percent of schools met all the government’s nutritional requirements. “Lots of times I didn’t like the school lunch,” Juan said, “and so I would buy a soda or a candy bar or maybe both.” Juan’s decision to skip school meals and buy food from the vending machines was not unusual. “Lots of these kids are eating two meals a day at school. If the school lunch doesn’t appeal to them, they turn to the vending machines. They have very limited healthy options,” said Berry. Schools across the country have lined their hallways with candy-stocked vending machines and filled their cafeterias with à la carte fast-food chains as a way to make money. Nationwide, vending machines account for approximately $750 million annually in extra funds for schools. The profits are substantial and help pay for additional programs and facilities, but they come at a high price.

Many students in the class come from families and communities where obesity and diabetes have become standard. In order to break the cycle of obesity and its related health problems, the class had to address the larger context in which these children were living. Though the
program told the kids to eat more vegetables and more of “nature’s candy”—fruit—one look into a small inner-city grocery makes it clear that these things are not so easy for families to provide. “Many of the families have to take two buses to get to a good grocery store, and the
stores nearby might have one or two sorry looking heads of iceberg lettuce to choose from,” explained Grey. So one Saturday morning Galasso gathered about a dozen students and mothers at a big grocery store nearby and showed them healthy and cost-effective options. “I
taught them how to use what was in season and showed them the nuts and bolts of reading food labels.” Halfway through the program, the researchers found that parents had altered their shopping to include more healthy choices, which was something the parents attributed to
their children’s participation in the program. Juan’s family incorporated much of what he learned into their daily lives. “I would tell my family so that we could adjust what we were doing. My family has cut down on sweets and fats and instead of frying foods they steam hem.” Everyone in his family lost weight, but Juan put it best when he said, “I think my family feels better.”

Fewer than half of American school children have daily opportunities to engage in structured physical activity. At Fair Haven Middle School, Juan has gym only twice a week. He doesn’t play sports, and he couldn’t say whether there is a football team or a basketball team at his school. Inner city schools often lack the time and space for effective physical education. Exercise was not part of the daily routine for many of the children enrolled in the after-school intervention program.

The physical activity training part of the program did not demand that the students engage in formal, rigorous exercise. Instead, it was designed to help students change their lifestyles. Berry explained the
strategy: “We spent a lot of time talking about sedentary and non-sedentary activities and brainstorming ways to cut down on time spent sitting in front of the TV or computer and thinking of other things to do.” By reinforcing the value of any kind of physical
activity—be it actual exercise or just active behavior—the teachers hoped to help the students modify their own environments.

Physical activity was Juan’s favorite part of the program: “I liked it best when we played outside and danced for a long time in the music room.” During one class, the students were told that they were on the new Survivor series “Getting Back to Basics in Activity” and that they had to use three random props to design and perform a ten- to fifteen-minute routine. The props were everyday household items—canned
goods, towels, chairs, as well as affordable items such as tennis balls, jump ropes, and basketballs. Through this process, the students
learned to create games and activities for themselves. Most often during the physical activity portion of the class, however, the
students were simply asked to do something active, whether it was dancing to hip-hop cds (everyone’s favorite) or simply taking a walk
with one of the exercise teachers. Many of the children whose neighborhoods do not have big parks to play in or community sports teams to play on had long ago given up on physical activity. “They see things as skinny or fat, couch potato or marathon runner, so we tried to introduce a middle ground,” Grey said.

Hip-hop dance routines, forced acronyms, and weekly worksheets seem too simple to be a viable solution to a national health problem of such depth and scale. But these simple solutions may, in fact, be a foundation upon which to build a national response. After twelve
months, nearly all of the students in the program had stabilized their glucose tolerance, and their insulin metabolism had improved. In addition, students’ behaviors changed dramatically: They consumed fewer calories, had greater dietary knowledge, became more active and,
perhaps most surprisingly, helped their families change their patterns of behavior, suggesting a “trickle down” effect from the school into the entire community.

With the results confirmed, Dr. Grey and her research team have been approached by school systems across the country asking for advice and information about the program. While eager to share the information, Dr. Grey is also quick to explain that it was a pilot study and that
the full-scale trial she is currently working on will provide more substantial and perhaps more accurate answers. The next study will take place in four New Haven middle schools and will be incorporated into the regular school day.

One of the driving beliefs behind the program is that schools are the perfect place to begin addressing problems that plague entire
communities. One teacher quoted in the proposal for the study said, “We as teachers need to expand our knowledge base and understand the benefits of good nutrition and physical activity. We are in the perfect position to reach young people in our schools and promote healthy
lifestyles.” The hope is that this information, provided at the most basic levels, will eventually change larger community patterns. “Dr. Grey’s program is innovative in that it focuses on prevention at all,” explained Brownell. “There is very little else currently being done to
prevent this societal problem.” Connecticut is among the few states starting to address actively the discrepancy in health that is
prevalent among its citizens. Dr. Grey’s program is at the forefront of research in the field, and politicians around the state have begun to
take note. State Senator Toni Harp has incorporated the health concerns at hand into her political agenda. With Senator Harp’s push,
Connecticut is one of only six states whose efforts to promote nutrition and physical activity have been awarded funding by the national Centers for Disease Control. Harp founded and co-chairs the Coalition to Fight Childhood Obesity in New Haven and was a key promoter of a resolution passed last April by the Connecticut general assembly concerning nutrition in public schools. One of the most important reasons for adopting the resolution was “to assist in the reduction and prevention of obesity and non-insulin-using (Type 2) diabetes in children.” On a small scale, these solutions look promising.

If Juan and his family were able to reverse the trends in their life, and if four New Haven schools adopt active prevention program, does this mean that the epidemic can be managed? The most significant obstacle in the way of large-scale change seems to be that Juan lives in a community where obesity is the most natural path. Solutions are presented to children who live in a fat-saturated world. Brownell’s hope, however, is that the sort of action demonstrated by Harp and Grey will be noticed. “Ultimately the people and the government are in a position to do something similar regarding obesity as they have recently done with tobacco.” Juan’s success could be evidence that the problem can be solved, but until the obesity-reinforcing infrastructure of society is torn down, Juan’s will be an uphill march.

Juan Mendoza is a pseudonym.

Jessica Cohen, a senior in Timothy Dwight College, is managing editor for TNJ.