Tipping the Scale

In the U.S., one out of every three adults and an estimated 17 percent of children and adolescents are obese, according to the Centers for Disease Control (CDC). As obesity rates climb to an historic high, the condition and its complications result in 240,000 premature deaths and medical costs of approximately $147 billion annually. Experts now predict that the up-and-coming generation of American children will be the first to have a shorter life expec­tancy than their parents.Faced with this grim reality, two communities in the greater Boston area are partnering with Massachusetts General Hospital in a massive effort to shape up — pledging to combat the obesity epidemic as the life-or-death battle it’s fast becoming on their streets.

Chelsea and Revere, coastal cities bordering each other just north of Boston, face many of the challenges common to America’s working-class, urban culture: poverty, unemployment, substance abuse and high population density. (Chelsea, the smallest city in Massachusetts, is also one of the most densely populated places in the country). That is all paired with an extraordinarily high rate of population turnover due to waves of immigrant and refugee groups settling in the cities temporarily before relocating else­where. And as with so many other public health issues making national headlines, the country’s obesity problem is hitting especially hard in Chelsea and Revere. Though Massachusetts ranks as the fourth-leanest state in a national poll, the two cities boast obesity rates that rival Mississippi’s, the “fattest” state in the U.S.

“Five or 10 years ago, obesity wasn’t a health issue that concerned the average person or the majority of caregivers,” says Jeffrey Collins, MD, medical director for the Massachusetts General Hospital Center for Community Health Improvement and of the Urgent Care Center at the MGH Chelsea HealthCare Center. “But in the past few years, Mass General has recognized that the communities we serve are overwhelmed by the problem and scared for the future of their families.”

Dr. Collins admits that they have good reason to be frightened. Obesity, he explains, is a health condition linked to a whole host of chronic — even life-threatening — problems, from asthma and coronary artery disease to depression, infertility and cancer. Complicating matters further is the fact that many healthcare providers feel ill-equipped to address the issue effectively in the short time they have with each patient.

“From the outset,” he says, “we knew that a team approach had the best chance of success in changing obesity trends in Chelsea and Revere.”

Team Revere

What Dr. Collins calls the “team approach” is taken very seriously by residents in Revere. In 1996, Revere was reeling from a generations-old substance abuse scourge that culminated in twice the state’s average rates of drug-related hospitalization and death. Community leaders and concerned citizens decided to fight back, led and supported at each step in the process by experts from the MGH Revere HealthCare Center. By 1997, Kitty Bowman, MEd, of the Mass General Center for Community Health Improvement, convened a coalition — called Revere Community Awareness, Resources and Education to Prevent Substance Abuse (CARES) — comprising police, government and school officials, local business owners, physicians and church leaders, parents, teenagers and other community members who had a stake in changing the drug culture in Revere and helping teens make smarter, healthier choices. Fewer than 15 years later, Revere CARES is a nationally-recognized, award-winning coalition that is seeing results, with alcohol, tobacco and drug use declining at unprecedented rates. In short, in Revere, the coalition approach is one that works.

“The Revere CARES model has taught everyone involved that sustainable change doesn’t happen from the top down,” says Joan Quinlan, director of the Center for Community Health Improvement (CCHI) at Mass General. “Real change happens when organizations like Mass General put resources toward empowering communities to take control of a problem.” In the experience of Ms. Quinlan and her colleagues at CCHI, a community like Revere lacks the resources — not the commit­ment — to effect positive, lasting change. Families eat poorly because it’s better than not eating anything at all; kids opt to stay indoors when playing outdoors is unsafe.

In 2009, Ms. Bowman, now coalition director, and Sylvia Chiang, MPH, launched the Revere Food and Fitness Initiative, an extension of the CCHI-led Revere CARES program, headquar­tered at the MGH Revere HealthCare Center. The Food and Fitness Initiative coalition, which brings many of the same people to the table who achieved so much in the fight against substance abuse, is patterned after those efforts in many ways. Significantly, as with Revere CARES, the new coalition is focusing primarily on Revere’s youth.

To target Revere’s kids in the short-term, the group is taking steps to adopt and implement an improved nutrition and physical education curriculum while making healthier snacks available to children throughout the school day. The coalition is helping their schools develop and expand clubs and events that promote physical activity, such as the Revere High School Dance Team, while advocating for the commu­nity to participate in the Safe Routes to School Project, encouraging daily walking and biking among youth.

Longer-term plans include the expan­sion of school-based health centers; negotiations to provide healthier breakfast, lunch and snack options to children through the public schools year-round; and an overhaul of school physical activity requirements.

“We’re working to increase kids’ access to healthy foods and to increase opportunities for physical activity, but also to decrease hunger,” says Ms. Bowman. Fighting obesity and hunger simultaneously in a single community might seem counterintui­tive, but experts agree that the two conditions often go hand-in-hand.

“Most meals available to families living on small incomes consist of high-calorie, low-nutrient foods and sugary drinks,” says Ronald E. Kleinman, MD, physician-in-chief at MassGeneral Hospital for Children. “And, too many children binge on these kinds of foods after 10 to 12 hours of not eating anything.” Because of such conditions, it is now common to see children who are overweight, obese or undernour­ished at age five, according to Dr. Kleinman, many of whom will experi­ence developmental delays and might expect to live with these conditions and their complications for decades.

An essential step toward restoring a proper balance to the health of Revere’s children is the transformation of their city into one that gives healthy choices pride of place. It’s a colossal task, Ms. Bowman admits, but it’s one the coalition believes is necessary and realistic. In fact, thanks in part to a Massachusetts state grant awarded to the City of Revere through the Mass in Motion (MiM) program, the Food and Fitness coalition is off to a running start. The group launched a farmer’s market — which they managed for the first two years and still support — to make fresh local produce available on a weekly basis at Revere Beach.

As of summer 2010, the coalition is working to create an “urban trail” in the city and an incentive program for small bodegas that sell fresh fruit and vegeta­bles near the storefront, as well as to develop an “adopt-a-park” initiative to clean and beautify outdoor recreational spaces. Additionally, police and city officials are working to provide better lighting in parks and along the Revere beachfront so that residents feel safe enough to take advantage of available open spaces.

The focus on Revere’s youth is moti­vated by a number of factors. First, because of new state regulations requiring school children to have their Body Mass Index (BMI) — a statistical measure used to correlate healthy weight based on height — recorded annually, it will simply be easier for the coalition to measure the progress of younger community members at regular intervals. Second, the group feels strongly that youth BMIs will be a good indicator of Revere’s progress overall. Third, and most importantly, mobilizing citizens around their children, the coalition predicts, will bring an appropriate sense of urgency to the challenging work ahead.

“Building an effective coalition is like weaving a web, drawing on the exper­tise and resources of everyone around you,” says Ms. Bowman of the work being done out of the MGH Revere HealthCare Center. “To any single group or person, this problem might seem impossibly overwhelming. But as a team, and with the knowledge that the health of Revere’s kids is at stake, you can really make things happen.”