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Fat City

Is there a way for a government to fight obesity? Chicago's new health commissioner is trying to figure that out.

At a health and fitness expo hosted by Chicago's Malcolm X College, Dr. Terry Mason is scolding a group of fellow African-American men about their diets, which he says contribute to obesity. "There is nothing soulful about soul food," he declares. "We sit down with trash from the innards of pigs, eating the nose and eating the snout, and we've got the NERVE to ask the Lord to BLESS this food and sanctify it." The audience stirs like a congregation preparing for redemption. "If I was the Lord, I'd strike the hell out of you bastards."

Nods and approving laughter ripple through the audience. Bouncing effortlessly from PowerPoint slides of clogged arteries to the Bible, Mason leads his listeners in reciting a verse from Genesis (1:29) to show that God wants them to eat more fruits and vegetables. And he concludes with a final admonition: "Brother, once you know better, it's on you to do better."

With communication skills like this, it's little wonder that Mason won Mayor Richard M. Daley's nod to be Chicago's health commissioner earlier this year. A former director of urology at Chicago's Mercy Hospital and head of a thriving private practice, Mason has won fans among public health advocates by promising to focus on obesity. On top of his medical credentials, he has a rare ability to bring a message about the importance of healthy eating and exercise to the common man- -a quality he has demonstrated over the past 12 years as host of "Doctor in the House," a call-in radio program on WVON, Chicago's leading African-American talk station.

But as he takes his first public-sector job, Mason finds himself confronting a difficult question: What exactly can government do about obesity? Traditionally, the problem has been seen as a private, individual concern--not a public one. But while Mason has mastered the gospel of personal responsibility in his years as a private doctor and celebrity, public health experts say much more will be required to conquer the obesity epidemic. To make good on his vow to shrink Chicago waistlines, they say, the city's top doctor may have to stretch himself in new and possibly unforeseen ways, taking on slow- moving bureaucracies, wading into planning fights and maybe doing battle with powerful business interests.


It's easy to see why he is concerned. The Centers for Disease Control and Prevention estimates that two-thirds of Americans are now either obese or overweight--a 75 percent increase from 15 years ago. What's more, 16 percent of children and teens are now considered overweight. The rate has doubled for children and tripled for teenagers since 1980.

Behind these figures lie a litany of obesity-related afflictions, ranging from soaring rates of stroke, heart disease and diabetes to gallstones, arthritis, sleep apnea, several types of cancer, depression and back pain. There is plenty of economic suffering, too: Analysts say obesity costs Americans $117 billion a year in medical expenses and lost productivity.

State and local governments have responded on a variety of fronts. At least 21 states have raised nutritional standards, or provided some nutritional guidance for food sold in school. Many others, including California, have banned the sale of junk food in school vending machines. At least 22 states have nudged schools to increase physical education and recess, and 11 have adopted legislation requiring that nutrition and physical education be covered in health courses. Arkansas Governor Mike Huckabee, who several years ago launched a program to screen Arkansas schoolchildren for their body mass index (a rough measure of the appropriateness of one's weight), recently established an awards program to recognize restaurants in the state that offer healthy options and post nutrition information on their menus. And Thomas R. Frieden, New York City's top health official, has asked city restaurateurs and food suppliers to eliminate partially hydrogenated vegetable oils, which contain relatively high levels of trans fat, from their kitchens.

But critics say politicians and health officials are mainly picking easy targets rather than devising comprehensive strategies that are likely to make a significant difference. "Policy makers largely understand that obesity is a serious issue, but only fairly minimal efforts have been undertaken to address it," says Trust for America's Health, a public health advocacy group, in a 2005 report titled, "F as in Fat: How Obesity Policies Are Failing in America."

Part of the problem is that while the basic cause of obesity is known--people are consuming more calories and burning fewer--the exact reasons for the recent rise in weight aren't clear. Nor is there much research showing which policies would be most effective in solving it. What's more, many lawmakers continue to believe obesity is a personal responsibility, not a social concern. Some 20 states have, for instance, enacted "common sense consumption acts" that prohibit individuals from suing food manufacturers and retailers for obesity- related damages. But even policy makers who believe obesity is a legitimate governmental concern find the problem vexing. Unlike the war on smoking, which involves getting people to change a single behavior, obesity arises from such a complex interplay of forces-- ranging from a relative decline in the price of sugars and fats to increased computer usage, and from a growing preference for eating in restaurants to urban design that makes people increasingly dependent on their cars. As a result, it's hard to know where to start.

"People keep asking me what is the one thing, the critical pressure point," notes Katherine Kaufer Christoffel, professor of pediatrics and preventive medicine at Northwestern University and medical and research director of the Consortium to Lower Obesity in Chicago Children (CLOCC). "I don't think there is one. Obesity is a perfect storm, where a myriad of things all turned the wrong way at the same time. Interfering with the complex cascades that lead to rising obesity requires that we intervene at all levels, from the sub- cellular to the societal."


While government is struggling to find its way, nonprofit organizations and civic groups have rushed in to take on the problem. "Foundations are knocking on our door asking us how they can help," notes Erica Salem, Chicago's assistant health commissioner. "I have never seen anything like it." Chicago's CLOCC has gained national recognition as a model nongovernmental initiative. Launched four years ago, it now has 1,100 members representing more than 500 organizations. Pursuing what the national Institute of Medicine calls an "ecological" approach, it seeks to address as many of the individual, family, community and societal factors that underlie obesity as it can--all at the same time.

In messages aimed at individuals, CLOCC proposes a simple formula: 5- 4-3-2-1-Go! People should eat five servings of fruit or vegetables a day, drink four cups of water, consume three servings of low-fat dairy products, spend two hours or less sitting in front of a computer or television screen, and get one hour or more of physical activity. It also catalogs where individuals can find help for themselves or others to overcome obesity. Its list of programs and groups that are involved in influencing how Chicagoans eat and exercise runs 385 pages. "We have endeavored to get across the point that everybody has a role to play," says Matt Longjohn, the executive director.

At the community level, CLOCC works with civic groups to encourage the establishment of community gardens and farmers' markets, help distribute healthy food to the poor, organize "walking school buses" (parents who escort groups of children so they can walk safely to and from school), and explore ways to make their neighborhoods more pedestrian- and bike-friendly. And it has delved into the broader policy arena, too. It persuaded the Illinois legislature to create a Food Systems Policy Council, which brings together a range of state agencies to seek ways to improve the availability and affordability of locally grown fresh produce. It pushed successfully to require a public-private Early Learning Council to focus on ways to increase physical activity and improve nutrition and nutrition education in schools. And it won amendments giving parents and community members more of an opportunity to comment on requests from schools to waive state physical education requirements; traditionally, waivers have been granted very liberally.


Meanwhile, Chicago's city government hasn't exactly taken the lead in dealing with obesity, but it has weighed in on the issue in some areas. The lack of supermarkets--and hence fresh fruit and vegetables- -in low-income neighborhoods has been a particular concern. When the city council learned that supermarket chains routinely impose deed restrictions on properties that they sell in order to prevent the new owners from operating grocery stores on the sites, it moved to prohibit the practice.

The city planning department has hired a "farm forager" to explore how the city can attract more truck farmers to farmers' markets and perhaps broker partnerships in which large-scale farmers would provide fresh produce to city institutions that have meal programs. One interested buyer is the city's Department on Aging.

Several city agencies are reassessing their own programs to see if they can do more to combat obesity. The Department of Parks, for instance, borrowed accelerometers--devices that look like pagers and can measure a wearer's physical activity--from CLOCC to assess whether kids get enough exercise in its after-school programs.

Chicago also has acquired almost 300 acres of new parkland since 1998--more than it did in the previous half century. And officials say the city's basic planning strategy--to concentrate development around transit stations, increase population density and encourage mixed commercial and residential land use--all could help combat obesity by enabling people to get out of their cars and walk more.

Anti-obesity activists, however, say the city could do much more. They are particularly frustrated with the city's public schools. The system's health officer ranks so low in the bureaucracy that CLOCC won't invite him to join the organization. Most elementary schools say they don't even have enough time in the day to provide recess, but the administration has negotiated away its control of the issue: Under the teachers' contract, schools can lengthen the day to provide time for recess only if teachers vote to authorize it.

The school system has a significant opportunity to influence students' diets since it serves 17 million meals a year (more than any Chicago institution except McDonald's). But it has outsourced its meal service to private vendors. Outsourced means out-of-mind, say critics.

A few schools have moved aggressively to deal with obesity. The Namaste Charter School on the city's southwest side provides an hour of physical education a day to its kindergarten, first- and second- grade students. Each morning, children are led in exercises designed to help them not only physically but mentally as well.

The school also teaches nutrition in its classes and gives students a chance to practice what they learn about healthy eating at a lunchtime salad bar, which is stocked with items such as cottage cheese, turkey, carrots, green beans and fresh fruit. On a unit basis, the food costs more than what regular schools pay, but the charter school gets by on the same budget as other schools because its portion sizes are smaller. These innovations have attracted national attention but not in the Chicago school system. "I have never had another principal call me to talk about what we are doing," says principal Allison Slade.


With this mix of promising starts, disappointing gaps and unknowns, how can Terry Mason, the city's new health commissioner, best contribute to the effort to reduce obesity? He can, of course, add a strong voice to the chorus urging people to improve their eating and exercise habits. But public health advocates say government is uniquely able to contribute in another way: It can change the environment in which people make unconscious, daily decisions about such behaviors. And that, experts say, may be crucial. As the long, sad story of failed diets and abandoned resolutions to get more exercise demonstrate, relying on individuals to change by willpower alone doesn't have a good track record.

"Someone like Mason has to be collaborative and collegial, with a diversity of partners," says Michael Erickson, director of the Institute of Public Health at Georgia State University. "But he also has to know what his authority is and where he can regulate, and he has to take action that people will find unpopular." Erickson, who headed the federal Centers for Disease Control's tobacco program from 1992 to 2000, says the war on smoking owes much of its success--just 21 percent of Americans now smoke, half as many as in 1965--to the fact that government not only warned people about the dangers of smoking but also backed up those warnings with regulations such as bans on smoking in public places. Unfortunately, he says, government increasingly seems reluctant to use its regulatory powers. "Government has morphed into being a facilitator of public-private partnerships," he says. "It's less regulatory and more collaborative. But you can't leave the regulatory aspects behind."

So far, Mason seems most comfortable when addressing personal behavior--not in wielding power. When it comes to policy, he has played mostly an inside game during his first months in office, dealing with internal staffing and planning issues. But he has waded into the bureaucratic thicket and come away with a significant victory: He won school officials' support for a plan to establish an office of school health to be housed in the health department. He also has formed partnerships with other city departments, including the planning department. And he says he's open to using his regulatory authority--provided he has proof that it will make a difference. "In God we trust," he says. "All others must have data."


Some Chicagoans would like to see Mason join the effort to make the city more pedestrian- and bicycle-friendly. "We have a strong ethic in the Midwest that everybody should be able to drive from point A to point B and park right in front," notes Benet Haller, director for urban design in the Department of Planning and Development. That attitude, Haller says, repeatedly thwarts the department's efforts to make Chicago a more pedestrian-friendly city. Drivers oppose efforts to increase housing density for fear it will lead to parking shortages, for instance, and businesses insist on surrounding their buildings with parking lots rather than locating on the sidewalk where they would be more welcoming to people on foot. The issue is politically radioactive, says Haller, who adds that he would welcome the health commissioner's support.

Perhaps even more eager for an alliance with Mason is the Chicagoland Bicycle Federation. It is working with the city to close a few miles of city streets one day this summer for bicyclists and pedestrians, a first step toward a goal of closing 68 miles of city streets on Sundays. The group's ultimate goal is to make it much easier for people to bicycle city streets every day. To do that, it would deliberately slow down automobile traffic by making changes such as reducing the size of lanes and intersections--another politically explosive idea. "We need to broaden our base of support, and public health is a big piece of that," says Rob Sadowsky, the federation's executive director.

If Mason isn't ready to take on Chicago's commuters, he could do battle with a smaller, though still powerful constituency: restaurant owners. Earlier this year, the Center for Science in the Public Interest, a national advocacy group, tried to persuade him to push for a city ordinance requiring restaurants to post nutritional information on their menus. Americans now spend almost half of their food dollars away from home, and restaurant meals often have more calories than food cooked at home. But the restaurant industry wouldn't swallow the center's proposal easily.

Nationwide, it has formed an organization, the Center for Consumer Freedom, to fight what it describes as efforts by "food cops" to "take away the fundamental freedom to control what we eat and drink." The battle surely would rage in Chicago, where restaurants proudly market fat-inducing products. The Big Downtown restaurant, for instance, boasts on its menu, "We Make No Small Burgers," while a nearby Bennigan's restaurant offers desserts such as "Death by Chocolate."

Mason has declined to join that fight for now, noting that Chicago has just gone through a bruising battle to ban smoking in public places, including restaurants. Margo Wootan, director for nutrition policy for the Center for Science in the Public Interest, doesn't fault the health commissioner's political judgment, but she warns that he won't solve the obesity problem merely by encouraging people to eat less and exercise more. "Of course, personal behavior is a part of the solution," she says. "But most of the major problems to public health haven't been overcome by government wagging its finger at people and asking them to act individually."

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