Health & Human Services

America Watches as Philadelphia Battles Obesity

The city, which is one of the nation’s poorest and most obese, is resorting to creative measures to get people to eat healthier. There are signs that its efforts are working.
August 2013

Happy Garden Chinese Restaurant sits at the corner of 27th and Eyre streets in North Philadelphia, occupying one of the many row houses that fill this section of the city. The restaurant’s register is protected by thick walls of Plexiglas, and customers slip cash through tiny slits. Happy Garden is one of more than 600 Chinese takeout restaurants in Philadelphia, many of them also located in low-income neighborhoods populated by minorities, especially African-Americans, who make up more than 40 percent of the city’s 1.5 million residents.

It’s the kind of place where strangers attract attention, and residents crowd around the restaurant’s front door to find out what the fuss is about. They’ll quickly tell you, with a distinct sense of Philly pride, that they were born a block from here. They recall the long-shuttered barber shops and laundromats that are now empty lots overgrown with weeds and littered with loose trash.

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Jeffrey Wakefield is one of the locals. He lives right next door to Happy Garden, taking care of his 80-year-old aunt. He’s pure Philadelphia -- “Lived here all my life” is how he introduces himself -- and on this rainy summer afternoon, he exudes the easygoing nonchalance that typifies the City of Brotherly Love. But Wakefield, 53, represents Philadelphia in another way: He’s an overweight diabetic. So is the aunt he lives with. So is his uncle. Here in America’s most obese and most diabetic major city, there are tens of thousands of Jeffrey Wakefields.

“My mom always told me, ‘You gotta watch what you eat when you’re young because you’ll pay for it when you get older,’” Wakefield recalls, and he has paid for it. He pulls up his beige polo shirt to show the scar where a doctor inserted a defibrillator to stabilize his irregular heartbeat a year ago. Wakefield says he had 10 operations in one year after he was diagnosed with diabetes in 2008.

“Why do you have to wait for a tragedy to happen before you do something about it?” he asks, not really expecting an answer. But it is a question that’s acquired a special meaning among nutritionists over the last 30 years as the obesity and diabetes epidemics have steadily grown. This June, the American Medical Association decided for the first time that obesity should be considered a disease. Of the 10 largest U.S. cities, Philadelphia has the most severe case.

Now its leaders are out to find a cure.

They’re willing to try almost anything, and that explains the changes in the kitchen at Happy Garden, where 50-year-old Zhongrui Yang has made his living for 10 years, serving dishes from his homeland. Yang is one of 206 Chinese takeout restaurant owners who are participating in a new city initiative to lower the amount of salt in their meals. Consuming too much sodium is one of the leading causes of high blood pressure, which is in turn one of the primary risk factors for heart disease and stroke. Almost half of African-American adults in Philadelphia already have high blood pressure. One likely culprit is the prevalence of Chinese takeout restaurants; Chinese dishes are particularly high in sodium because of their sauces and preparation methods.

So city officials saw a cause and its effect and crafted a first-of-its-kind plan to stop it. The Public Health Department recruited as many Chinese restaurants as possible, including Yang’s, to commit to reducing the amount of salt they served.

To help them do it, the city held free cooking classes from July 2012 to April 2013 to advise takeout chefs on how to change their recipes to contain less sodium while keeping their food flavorful with different herbs and spices. (A little more chili and garlic goes a long way, apparently.) Health officials also urged owners to give out fewer soy sauce packets, which are loaded with salt.

It’s making a difference. An initial city review of two popular dishes from 20 participating restaurants found that the sodium content had dropped 20 percent since the program started. Eventually, officials hope to gauge any resulting improvements in blood pressure and other health indicators. For his part, Yang seems glad to be helping his clientele, people like Jeffrey Wakefield, get healthy. The food tastes a little different, he admits, but he’s tried some new tricks he learned at the training sessions to keep his customers satisfied.

“I’m so proud that I can make a difference for the community,” Yang says through a translator. “Right now, it’s only a few people.But if everybody does it, it will be good for the whole community.”

In a city where 66 percent of adults and 40 percent of children are overweight or obese, you have to get creative -- and the Chinese takeout initiative is a perfect example of Philadelphia’s willingness to try something new. But it’s just a piece of the city’s overall plan to fight back against the epidemic. Being poor is one of the leading contributors to poor health, and Philadelphia is one of the nation’s poorest cities; one-quarter of its citizens are below the poverty line. So public health officials are trying to bring fresh produce -- apples, mangoes, pineapples, peas, radishes -- into some of its most destitute neighborhoods. They’re opening farmers markets next to subway stations and putting fruits and vegetables into neighborhood corner stores. (For now, the city’s signature cheesesteaks remain untouched.)

It’s an all-of-the-above strategy because the crisis in Philadelphia has become so acute. The city has positioned itself on the front lines in the battle against urban obesity, and the rest of the country will be watching. If we can do it here, the thinking goes, then maybe we can do it anywhere. But if we can’t, well, that’s a scary proposition for a nation where the obesity rate has risen by 30 percent in the last three decades.

If Philadelphia is the patient, then Giridhar Mallya, the public health department’s director of policy and planning, is the primary physician. He joined the city government at the behest of Donald Schwarz, the health commissioner, in 2008. Mallya had been practicing as a family doctor for three years, and he still speaks about Philadelphia’s citywide health problems with a soft voice and calm bedside manner that recall a pediatrician soothing a sickly child.

In March 2010, Mallya and Schwarz joined Mayor Michael Nutter to unveil the Get Healthy Philly initiative, the city’s long-term plan for getting its public health troubles under control, funded primarily through a two-year $15 million grant from the federal Centers for Disease Control and Prevention (CDC). It’s very broad in its scope, covering everything from smoking cessation programs to walkable communities and improved school lunches. But access to healthy foods is the cornerstone of the city’s treatment plan. Poor diet is the No. 1 driver of obesity and its related health conditions, and poor diet is mostly attributable to three things, known in the public health world as socioeconomic determinants: limited access to healthy food in poor communities, easy access to unhealthy food, and the high price of healthy foods even when they are available.

Mallya likes to cite one specific statistic that underlines Philadelphia’s challenges: The city’s low-income children visit a corner store once a day, on average, and with just one dollar, they can purchase about 350 calories in chips, candy or soda. “When people have very limited resources, but they’re surrounded by unhealthy options, then that’s going to translate into unhealthy behaviors,” he says. “So much of what affects people’s health are the environments they live in, and changing environments is really one of the things that government can do that not a lot of other entities can.”

And in the last three years, Philadelphia’s junk-food landscape has indeed changed. Indiana Joe’s, at the corner of Indiana Avenue and Gaul Street in the Port Richmond neighborhood, is one of 630 corner stores that agreed to participate in the Get Healthy Philly initiative. Sitting next to the refrigerator holding soda bottles and ice cream snacks in the store’s cramped retail space is another fridge stocked with pineapples and strawberries and tomatoes, displayed neatly in green mesh baskets. According to city estimates, more than 90 percent of the stores that joined the program have added fruits and vegetables to their shelves. The city partnered with the Food Trust, a Philadelphia-based nonprofit that has pioneered the healthy corner store concept, to help connect owners with healthy inventory as well as provide training and other support such as shelving and signage.

Howard McCrory, owner of Indiana Joe’s, is a lifelong resident of blue-collar Port Richmond. He grew up four blocks from the store that he’s owned for five years, and now lives directly above it. “Of course we’re conscious of it,” he says of his city’s status as the most overweight in the nation. When city officials approached him about joining the healthy corner store initiative, McCrory immediately took to the idea. “I like to think of it as a competitive advantage more than anything,” he says.

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McCrory recounts being frustrated watching diabetics come into his store daily, debate whether to purchase three sugary snack pies and then buy them anyway. Progress has been slow since he introduced sliced mangoes and heads of lettuce to his shelves -- on a recent afternoon, one obviously overweight customer ignores the healthy food fridge altogether and snatches a liter of Mountain Dew from the fridge -- but he’s seen some changes. Some of those customers who once debated whether to take home three snack pies will now take two pies and an apple instead. It’s an improvement, to be sure, even if a small one.

Corner stores, many of which have been neighborhood institutions for a generation, are a good way of testing whether simply introducing healthy food into a low-income community is enough to change people’s behavior. “Corner stores are already there,” says the Food Trust’s April White, a Philadelphian for nearly 20 years. “We have to think of them as not just creating the problem, but being part of the solution.” The city has installed new point-of-sale systems in some corner stores to capture sales data and assess whether there are noticeable changes in buying habits. No official stats are available yet, but anecdotal evidence is encouraging.

Four miles to the east, just outside the Frankford Transportation Center, a bus and subway hub, the city is experimenting with another access remedy: a farmers market where growers from nearby rural Pennsylvania can sell their goods to urban residents. Get Healthy Philly has helped the city open 10 new farmers markets since 2010, bringing the total run by the Food Trust to 25 across Philadelphia that serve areas home to 400,000 residents. Others are located near parks or bus connections -- places people will pass by even if they’re not looking to start a new diet. Even on a rainy summer afternoon, the market at the Frankford station attracts a steady stream of customers. They pick through the radishes, carrots and cherries that came from Oley Township, 60 miles to the west.

If the corner store initiative is slightly passive, simply bringing healthy food to disadvantaged communities, then the farmers markets are pushing the issue a little more aggressively. In July 2010, the city introduced the Food Bucks program to encourage low-income people who receive food stamps to spend their money at farmers markets. For every $5 that food stamp recipients spend at a market, they receive a $2 coupon in return. The impact has been substantial: Food stamp spending at the markets has quadrupled since the program started, and customers have reported consuming more fruits and vegetables after they began frequenting the markets. One farmer at the Frankford market says that 40 percent of her sales are paid for with food stamps. The extra nudge, it seems, is working.

“There has been a real dearth of shopping markets, so these have become hubs for the community,” says Nicky Uy, a senior associate with the Food Trust, which is also helping to oversee the Food Bucks program. “Now this is how people do their grocery shopping.”

A hundred miles up the New Jersey Turnpike, New York City Mayor Michael Bloomberg has garnered considerably more media attention for his public health crusade than the folks in Philadelphia. Much of that attention, of course, has been criticism aimed at measures, such as a ban on large sodas, which are seen as government overreach. Though Philadelphia’s public health crusade is similarly sweeping, Mallya and his team appear glad to avoid the comparison.

They point out that participation in all of the major Get Healthy Philly initiatives -- the corner store, the farmers markets and Chinese takeout programs -- is voluntary. But there could still be a move toward more restrictive policies; Mayor Nutter in June joined other mayors in calling for the federal government to prohibit people from buying soda with food stamps, and the city plans to change its food procurement rules to steer its purchases toward healthy food. Philadelphia is also petitioning the federal Food and Drug Administration to allow the city to keep more stringent menu-labeling rules for chain restaurants than the Affordable Care Act requires.

But the general lack of draconian (or Bloombergian) policies could help explain the noticeable lack of criticism aimed at Get Healthy Philly. “These things that are more controversial on the surface get more coverage, but then at the same time, New York and other jurisdictions are also engaging industries in a collaborative way, asking: What can you do to make your products healthier but still maintain a profit?” Mallya says. “Initiatives that are educational, that are programmatic, that are more focused on regulations, we need all those things if we’re going to have an effect.”

The obesity and diabetes epidemics are daunting enough to demand a variety of approaches. A 2012 report found that the city’s various programs, including the healthy corner stores and farmers markets initiatives, had reduced the number of low-income residents without easy access to healthy food by 61,000. But the same report concluded that more than 300,000 poor Philadelphians still lacked such access.

Any good news, it seems, is tempered by the scale of the city’s challenges. Obesity among Philadelphia schoolchildren declined by 5 percent from 2006 to 2010, according to a September 2012 study published by the CDC. But over the same period, adult obesity continued to rise, as did rates of hypertension and diabetes among adults.

Get Healthy Philly is seen as the city’s best chance to reverse these trends for good -- and it could be a symbol for the nation as a whole. Public health advocates are increasingly turning their eyes to Philadelphia, anxious for any opportunity to translate its success elsewhere. “The birthplace of our nation’s liberty is becoming a cradle of good health by implementing policies strong enough to overcome the barriers to health that many of our cities face,” James Marks and Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation wrote of the program last fall. They pointed to recent estimates that keeping obesity at 2010 levels could save the nation $550 billion in health-care costs over the next 20 years. “Philadelphia is pointing the way to a path for doing just that.”

From the sixth floor of city hall, Mallya tries to put his city’s programs in a historic context. He references the sanitation improvements of the 20th century and their resulting positive influence on public health and the drop in deaths from infectious diseases. What’s the analogous treatment for obesity and the chronic diseases that now kill most Americans? Philadelphia is trying to find out, and at the same time, trying to impart onto street corners citywide the sense of urgency that permeates the health department’s offices.

“There’s been this epidemiologic shift in this last century in terms of what kills people,” Mallya says. “Almost everyone has an aunt, a sister, a parent who’s suffered from obesity and diabetes in some way. That makes it much more real.”

So city officials keep spreading the word. From Happy Garden to Indiana Joe’s to the Frankford farmers market, this new mentality is seeping into every corner of the city. No idea is too far-fetched, no effort too small. But it’s not just about a new set of policies; it’s about changing the lifelong habits of a city that’s grown to be our most obese. People like Jeffrey Wakefield and Zhongrui Yang and Howard McCrory have to continue to be involved in Get Healthy Philly for it to have the kind of impact that its advocates are hoping to make.

But even there, signs of hope periodically emerge. On that June afternoon outside Happy Garden, two neighborhood residents -- older and overweight African-American men like Wakefield -- ventured out into the rain to ask what attracted the group of unfamiliar faces to their corner. After learning about the Chinese takeout initiative and the city’s other efforts to combat obesity, they ask a public health official for his business card so they can find out what they can do to help. Maybe it was just an impulsive move and they’ll never call.

But maybe they will.

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