Overfed but undernourished: not will power, but purchasing power, may determine who eats healthy foods.

In the land of plenty, Americans in growing numbers are obese. The reasons seem obvious--consuming too many calories, exercising too little to burn them away. Not necessarily so.

In low-income communities all across the country, the story is more complicated. The laws of thermodynamics haven't changed, but they're more difficult to apply when healthy foods are out of economic reach.

In lower socioeconomic areas, says Texas Commissioner of Agriculture Susan Combs, "There's a dearth of fruits and vegetables reasonably priced. Yet there's cheap fast food. It's certainly understandable why people opt for a burger for their 8-year-old kid."

Healthy choices are often unaffordable even when local markets stock fresh fruits, vegetables and other low fat, nutrient-dense foods. And it takes more time to prepare healthy, fresh foods, which may be difficult for many working poor families. These families also may need to learn what's healthy and how to prepare it.

Story after story reports the difficulties of locating, affording and preparing nutritious meals for those living at lower income levels.

In Boston, Robin Smith, a hospital worker, has only $30 to $40 a week to spend on groceries for herself and two daughters. That means she can afford the leaner cuts of meat only when they are on sale and fresh vegetables "once in a blue moon."

In Starr County, Texas, where 59 percent of children live below the poverty level, 24 percent of children are overweight or obese by age four, 28 percent by kindergarten, and by elementary school, 50 percent of boys and 35 percent of girls are overweight or obese. Almost half of the adults in the Star County, the poorest in Texas, have type 2 diabetes, and nearly every child is at risk for the disease because a close relative (parent, sibling, aunt or uncle) is already afflicted.

California farm worker Iris Caballero is overweight and diabetic, but cannot always afford the produce in the state's central valley, which also has some of the nation's highest poverty rates. During harvest season, when she works picking grapes and oranges, Caballero can find and purchase fruit in the local mini-market. In the winter, when work and fruits and vegetables are hard to find, Caballero depends on the cheapest food available to feed her family--potatoes, bread and tortillas.

Untreated diabetes caused the blindness of a 15-year-old student in Caballero's community, but served as the impetus for a free nutrition class for farm workers through the public health program. A rarity, the class offers information that takes into account limited budgets and lack of time while respecting culinary traditions. The local elementary school also offered a class for teachers on how to respond to high and low blood sugar emergencies.

Research reported in the January 2004 American Journal of Clinical Nutrition confirms that the highest obesity rates occur among people with the highest poverty rates and the least education. Moreover, the research confirms what Smith, Caballero and others like them have learned in practice: lower-calorie, high-nutrient foods cost more per calorie. As a result, many poor families are affected by "food insecurity," that is, the limited or uncertain availability of foods that are nutritionally adequate. These families may overeat to maximize caloric intake for their limited dollars when food is available. In the process, they sacrifice food quality for larger quantities, often resulting in obesity.

BAD FOR STATE BUDGETS

If being svelte was solely a cosmetic issue, policy concerns might not matter. Obesity, however, has a host of health and state budget consequences. About 50 percent of obese children become obese adults. In fact, we may be raising the first generation of American children to live sicker and die younger than their parents. People who don't maintain a healthy weight are at risk for a plethora of serious chronic conditions such as type 2 diabetes, heart disease, stroke, high blood pressure, cancer, and even gallbladder disease and arthritis.

The current impact on state budgets is staggering. It is estimated that in 2003, obesity carried a $75 billion price tag with half paid by taxpayers through Medicare (which covers older Americans with chronic conditions that may be related to obesity) and Medicaid (which primarily serves the poor, who are more likely to suffer from obesity). Estimated obesity-related medical expenditures ranged from $87 million in Wyoming, which included $15 million in Medicare expenditures and $23 million in Medicaid, to $7.7 billion in California, including $1.7 billion each in Medicare and Medicaid.

WHAT TO DO

Legislators are beginning to look not only at how to respond to obesity, but also how to prevent the conditions that contribute to it.

In Pennsylvania, two intertwined bipartisan legislative initiatives are aimed at making healthy foods more available in low-income communities. Spearheaded by Representative Dwight Evans, the Commonwealth's First Industries Fund, an economic stimulus program, now makes supermarkets eligible to receive $150 million in planning grants, loans and loan guarantees in order to promote urban and rural supermarket development.

Pennsylvania's Fresh Foods Financing Initiative, the second effort led by Evans, provided $10 million in state seed money that was matched by $30 million raised from other sources to create a public-private partnership. The initiative's goal is to make nutritious foods more available, but benefits have also included the creation of 258 jobs and development of a huge supermarket that opened in Philadelphia last September. Evans envisions direct health benefits for his constituents.

"As an African-American legislator, I'm very concerned about the issues of diabetes and cancer," he says. "Bringing quality food outlets to inner-city neighborhoods is a way to encourage healthy nutrition choices to fight those diseases. It's also an economic engine driver--it builds businesses, it generates jobs, it transforms communities. All of those things are part of this initiative."

SCHOOLS--A PLACE TO START

Other states are considering policies to encourage better food choices, especially in schools. Texas Commissioner Susan Combs notes there were 7,000 diabetes-related amputations last year in her state. And children are showing signs of the disease at age 8 of 9; some 15-year-olds already have type-2 diabetes. If these unhealthy trends continue, says Combs, coupled with an aging population and population growth, "from the most cold-blooded economic standpoint, the medical costs will break the state." She has become a strong advocate of making healthy foods available in all schools.

In Combs' view, the state stands in loco parentis during the school day and is responsible for setting a good example by offering only healthy food. "Your state makes them go to school. You must do them no harm while they're in your care," says Combs.

It is Combs' job to set the state's standards for the school breakfast and lunch program. She has exceeded the federal guidelines and instituted rules for Texas schools that eliminate all "competitive foods'--those that compete with healthy choices offered in school breakfast and lunch programs. She touts the economic benefits of this for the state, explaining that if there was 100 percent participation in the school lunch program, Texas would increase its federal share of school nutrition funds by $562 million statewide. Her office also provides training on how to fundraise for revenues that may be lost when competitive foods aren't sold at school.

Combs has talked with Kraft, Cadbury Schweppes, Nestle, Coke and other "agribusiness" executives in an effort to persuade them to offer healthier fare for students. She tells them the public wants smaller portion sizes and fewer calories and says that "everybody is offering healthier," in part, because of concerns about liability.

There is no doubt that the availability of healthy choices encourages healthy lifestyles. Dr. Risa Lavizzo-Mourey, president and CEO of The Robert Wood Johnson Foundation perhaps sums it up best. "Obesity rates are highest in communities afflicted by poverty. Families in these communities simply don't have the same opportunities to make healthy choices as families in other neighborhoods. They don't have grocery stores that stock affordable fresh fruits and vegetables. There aren't enough sale places for kids to play or programs that teach kids physical activity. We must remove these barriers. We want to encourage legislators to be visible, vocal champions of policies that promote nutrition and physical activity."

A SMORGASBORD OF IDEAS

Other options being considered by legislators, although by no means an exhaustive list, include:

* California legislation passed in 2003 requires the State Department of Health Services to develop and distribute if funds are available a brochure educating at-risk pregnant women and new parents about preventing chronic disease by eating a diet rich in fruits and vegetables and staying active every day.

* California also passed legislation that restricts the fat, sugar and calories of competitive foods sold in elementary schools.

* An Illinois resolution adopted in 2003 urges the U. S. Department of Agriculture to update and improve the nutritional quality of all food packages covered by WIC and to update nutritional labeling and nutrient targets to reflect current science at least every 10 years.

* Illinois requires non-invasive diabetes screening for school children and training in diabetes management for at least three employees at each school that has a student with diabetes. The legislation recognizes that diabetes is more prevalent in underserved populations.

* Washington state enacted legislation last year to require the state's school directors association, with the Office of the Superintendent of Public Instruction, the Department of Health, and others to develop a model policy regarding access to nutritious foods and opportunities for exercise. Each school district's board of directors is to establish its own policy by this August.

For more information go to www.ncsl.org/health/childhoodobesity.htm, www.ncsl.org/ programs/health/vending.htm and www.ncsl.org/programs/health/publichealth/foodaccess/ index.htm.

Amy Winterfeld tracks health issues at NCSL.