There is perhaps no better demonstration of the historically unprecedented prosperity of the United States than that a major health concern of its poorest citizens is obesity. After all, for thousands of generations, one of humanity’s greatest challenges was to keep from starving. Today we inhabit a culture in which obesity—with all its attendant medical complications—is a large and growing health care problem, not least among children. But there is nevertheless disagreement about the problem’s cause, extent, and solution.
The Robert Wood Johnson Foundation (RWJF) is gravely concerned about childhood obesity, which it considers a pediatric crisis of epidemic proportions. RWJF is the nation’s largest foundation exclusively dedicated to health and health care, and it recently decided to confront the problem directly. It has committed $500 million over the next five years to halting the growth of childhood obesity by 2010, and to seeing its reversal by 2015.
“This is a health issue that is absolutely intertwined with our culture and society,” says Risa Lavizzo-Mourey, president of RWJF. “If we don’t do something, we are going to bear enormous health costs and other financial burdens—not to mention higher morbidity and early death in the next generations of kids.” Sally Pipes, president of the Pacific Research Institute, is less convinced. “My concerns with the attack on obesity—and childhood obesity in particular—surround tone, scope, and tactics,” she observes.
“Labeling America’s increasing girth as an ‘epidemic’ overstates the problem and, I believe, misrepresents our relationship to it.” Both Lavizzo-Mourey and Pipes acknowledge that the most alarming rates of increase are not among obese children per se, but rather among overweight children and children at risk of becoming overweight. Over the last 40 years, the percentage of overweight children between the ages of six and nineteen has tripled. Today, 17 percent of America’s children are overweight, with nearly a third at risk of becoming overweight. The rates trend higher still for Mexican-American boys and African-American girls.
Similarly disquieting is the fact that pediatricians are now treating a host of diseases—like high blood pressure and type 2 diabetes—that were once thought exclusively adult afflictions. Treating obese children is three times more expensive than treating children of normal weight. Worse, overweight and obese children stand an 80 percent chance of becoming overweight and obese adults—and face a future with a greater possibility of high cholesterol, high blood pressure, early-onset cardiac problems, liver abnormalities, depression, and stroke. If these developments continue, and if the correlation between early-acquired habits and lifelong health outcomes remains strong, then the cost of treating obesity in future decades could potentially skyrocket.
So far, RWJF has found that approaches focused on individual behavior have fallen short of effecting real change. “Changes to individual behavior are necessary—but not sufficient,” says Lavizzo-Mourey. “People live in environments that shape the choices they make on a daily basis. The environment either makes it easy or hard to make healthy choices. This is particularly true for children because they don’t create the environment they live in.” The foundation has accordingly focused on schools, households, neighborhoods, and industry practices. While some activists have proposed a fairly conventional set of regulatory responses, RWJF has led the movement for voluntary industry-wide reform. Towards that end, the foundation is the principal funder for the Alliance for a Healthier Generation, a collaboration with the American Heart Association and the William J. Clinton Foundation.
Among its major projects, the Alliance has worked with large beverage companies to fill school vending machines with low-calorie and nutritious beverages. The program intends to make good sense, economically as well as nutritionally. Brian Herr, the Alliance’s executive director, explains that because PepsiCo and Coca-Cola have similar product portfolios and readily substitutable products, it is financially viable for them to offer water, sports drinks, and low-calorie juices.
One year after the agreement, sales are tracking in the right direction. “There has been a 41 percent reduction in drink calories being shipped to schools and a 23 percent increase in water shipments,” says Lavizzo-Mourey. “Full calorie sodas are still the biggest sellers in schools, though they are on a rapid decline,” adds Herr. “Currently, 35 percent of the companies’ contracts are in compliance with the agreement with the beverage industry. Our goal is to reach 100 percent by the end of August 2009.”
But controlling consumption represents only one element in transforming the school environment. “Are we balancing the energy equation in schools?” asks Lavizzo-Mourey. In other words, how can school environments be structured so that children burn as many calories as they consume? Lavizzo-Mourey believes that one crucial way to balance the energy equation is by encouraging schools to provide more opportunities for physical exercise. There is plenty of room for improvement: the Center for Disease Control reports that two-thirds of high school students are not engaged in recommended levels of physical activity.
RWJF has thus added an extra $20 million to its initial $8 million contribution to Healthy Schools. Launched by the Alliance for a Healthier Generation in 2006, Healthy Schools helps schools whip themselves into shape. The program provides two primary services: online support to any school in the country, as well as an onsite support program that targets schools with the highest risks of obesity.
Healthy Schools customizes its plans to suit local conditions, and showcases participating schools’ work through recognition. “Schools own the effort from the very beginning,” says director Ginny Ehrlich. “As a result they feel more motivated and take steps that make them more comfortable and excited.” The RWJF grant has nearly doubled Healthy Schools’ capacity for onsite assistance. “In the first school year, 230 schools in 13 states were a part of our onsite support program,” says Ehrlich. “We will be working with over 1,200 schools in 34 states by the end of this school year.”
Pipes also favors school activities that promote exercise for children, but she prefers before- and after-school programs. “Implementing food and exercise regulations in schools has real costs,” she notes. “Some are apparent and quantifiable, but some can’t be anticipated and may resist quantification. As in all things, adding something will require subtracting something else.” “There is a tremendous opportunity for private philanthropy,” Pipes continues, “and many private foundations are already involved in helping children get more physical activity through after-school programs, particularly for those in lower-income neighborhoods.” She cites the Boys and Girls Clubs, the expansion of 4-H into the inner cities, and the William E. Simon Foundation’s support of the Sound Body Sound Mind fitness program for Los Angeles high schools.
The issue has already led a number of foundations to explore synergistic new ways to work together. The California Endowment, the W.K. Kellogg Foundation, the Nemours Foundation, and, of course, the Robert Wood Johnson Foundation are exploring how they can accelerate their work through joint grantmaking.
“We look at our work and see where there are opportunities to converge across multiple fields,” says Marion Standish of the California Endowment. Efforts to date have focused on providing less-affluent communities with better venues for physical activity and greater access to nutritious food. The initiative includes appealing to supermarkets to locate in low-income neighborhoods, improving the safety of public parks, and providing ample access to sidewalks.
Pipes, however, is skeptical of claims that poor children lack access to healthy food. She believes they have sufficient choices, but that they are not choosing healthy options. The problem, she claims, is not a lack of nutritious food, but a lack of demand for nutritious food.
“The same supermarkets that sell fried chicken and frozen pizzas offer salad bars and trays of sushi,” says Pipes. “The convenience stores that peddle bags of chips and soda pop also sell energy bars, bags of nuts, and bottled water. When fast food companies offer healthy choices, people pass them over for the more fatty fare.” Nor is it all that clear that healthy food is unaffordable. Pipes points to a recent USDA report on the cost of produce, which found that 86 percent of vegetables and 78 percent of fruit cost less than 50¢ a serving. “Consumers can meet the [department’s] recommendations of three servings of fruits and four servings of vegetables daily for as little as 64¢.”
Nevertheless, Pipes and Lavizzo-Mourey agree that foundations are uniquely placed to help American children lead healthier and more active lives. Foundations, Lavizzo-Mourey observes, enjoy a broader perspective than government or business, and can therefore tackle the comprehensive problems so difficult a health care challenge presents. “Government and private industry must be involved. But philanthropy plays the role as a neutral convener which rouses people from various walks of life,” concludes Lavizzo-Mourey. “It’s a powerful force when you have multiple foundations with varied perspectives and specialized expertise pushing forward with one effort toward a final goal.”
Clayton Broga is a publications associate at The Philanthropy Roundtable.