[Paleopsych] NYT Magazine: Heavy Questions

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Heavy Questions
New York Times Magazine, 5.1.2
By ELIZABETH WEIL

The road changes just past the Starr County sign. The
shoulder disappears, the grass is left uncut and the
black-eyed Susans and big pink Texas sage have to compete
with the orange traffic cones set out by the border patrol.
Just two counties up from the Texas tip, where the flood
plains along the Rio Grande change to rolling hills and
eroding cliffs, Starr County, largely Mexican-American, is
one of the poorest counties in the nation. Fifty-nine
percent of its children live below the poverty level, and
in the strange new arithmetic of want, in which poverty
means not starvation but its opposite, it is also one of
the fattest.

In the colonias on the edge of Rio Grande City --
jerry-rigged neighborhoods that are home to many illegal
immigrants and lack adequate municipal services -- houses
that look as if they might fall down neighbor houses that
look like fortresses, a result of the boom-and-bust drug
economy. Little gorditos run around in juice-stained
diapers, and as the kids get older, they only get fatter.
By the time they are 4 years old, 24 percent of the
children are overweight or obese; by kindergarten, 28
percent; and by elementary school, 50 percent of the boys
are overweight or obese, along with 35 percent of the
girls. The concern is not just cosmetic. Overweight
children are at significantly greater risk for developing
Type 2 diabetes, and by early adulthood, hypertension,
heart disease, stroke, colon cancer, breast cancer,
gallbladder disease, arthritis and sleep apnea. ''Stop by
any time,'' said the local school district superintendent,
Roel Gonzalez, inviting me to visit. The child of migrant
farm workers, Gonzalez is perhaps the children's greatest
advocate and the community's greatest critic. ''I will take
you down the hall in any one of my schools, and you will
see most of the children aren't slim anymore; they're all
beefy. Kids are 30, 40 pounds overweight already, and
they're only in high school. We're basically walking time
bombs.''

The burden of childhood obesity is one created by adults
and borne by children, and while the problem is widespread
in America, there are few places where the children are
lumbering under the load the way they are in Starr County,
the point on the U.S. map where all the vectors that lead
to obesity form a tidy asterisk. Some reasons are clear and
well documented, but others are less transparent. According
to the Centers for Disease Control and Prevention's
National Health and Nutrition Examination Survey, rates of
childhood obesity are among the worst in the
Mexican-American population, and Starr County is 98 percent
Mexican-American. The U.S. Department of Health and Human
Services, among other sources, also shows that as
socioeconomic status falls, rates of childhood obesity
rise, and Starr County is desperately poor. Not only is
Starr County in Texas -- one of the fattest states in the
Union -- but it is also on the U.S.-Mexico border, the
fattest part of Texas. The overall effect is devastating:
almost half the adults in Starr County have Type 2
diabetes. A child is considered at risk if a close family
member -- mother, father, sibling, aunt, uncle -- has
diabetes, meaning virtually every child in Starr County is
at risk of contracting the disease.

Complicating matters, self-discipline is typically not a
hallmark of the school-age years. When you talk to children
about losing weight, ''you see a blank stare,'' Gonzalez
said. ''They hear you, but there's really not anything they
can do.'' Vans of well-meaning doctors regularly barrel
down from San Antonio and Houston, feeling the smooth
blacktop change to bumpy gravel as they near their
destination and knowing that if nothing changes soon, if
the children continue to put on ever more pounds, they will
be responsible for having watched over the first generation
of American children to have shorter expected life spans
than their parents.

During the 2003-2004 school year, Peggy Visio, special
projects coordinator for the University of Texas Health
Science Center in San Antonio, made 13 trips to Rio Grande
City, the largest town in Starr County. Visio, who
specializes in diabetes prevention, worked previously with
Sioux Indians in South Dakota, and her university recently
received a grant from a private donor enabling her to start
a program in the Rio Grande Valley. Beginning last January,
Visio screened 2,931 elementary-school children, assuming
she'd find about 600 at high risk for diabetes. Instead she
found 1,172. Forty-five families volunteered to enroll a
child in her program, a combination of weekly nutrition and
exercise classes, plus two sessions of lab work to measure
each child's height, weight, blood pressure and blood sugar
and to examine each child for signs of diabetes. As part of
the project's design, half of the families met with Visio
and her staff in person, and half met via video link in
order to test the efficiency of telemedicine -- that is,
seeing a doctor, nurse or nutritionist remotely. (All
participants came to the lab in person.) Starr County has
15 physicians; the ratio of residents to doctors is 3,412
to 1. (The statewide ratio is 661 to 1.) There are no
behavioral therapists or pediatric dietitians in Starr
County. The nearest pediatric endocrinologist lives about
70 miles from Rio Grande City.

One of the first things Visio did when she started the
Diabetes Risk Reduction via Community-Based Telemedicine
program, or Dirrect, in Starr County was to analyze the
food served in the Rio Grande City Consolidated Independent
School District, where all children receive both free
breakfast and free lunch; so many qualified that it was
easier just to serve everybody. The food service is run by
Edna Ramon, who is 80 years old and began her job nearly
two generations ago when malnutrition, not obesity, was the
district's main problem. Ramon still talks about her
memories of the dry hair and bony hands she saw on the
children in the district in those early days. Visio
analyzed Ramon's menus and quickly established that with
breakfasts containing as many as 600 calories and lunches
with 800, every child was on track to gain at least nine
pounds during the school year. In addition, children were
drinking huge quantities of sugary drinks -- sodas, fruit
drinks and sports drinks -- which they bought from vending
machines and at convenience stores and also drank at home.
In the two months between her first two visits -- between
initially screening the children and starting the program
itself -- the children gained an average of two pounds.

Visio also found at the outset that 13 percent of the
prekindergarten and 18 percent of the kindergarten students
she screened had acanthosis nigricans, a disorder
characterized by dark, thick patches on the skin.
Acanthosis nigricans can signal insulin resistance, warning
of diabetes, a disease in which the body does not produce
or properly use insulin. Insulin, a hormone produced by the
pancreas, controls the level of sugar in the body and helps
the body use glucose as fuel. Excess fat tissue and
insufficient muscle, which come from a lack of exercise,
predispose a person to diabetes. Left untreated, diabetes
can lead to blindness and loss of limbs; many of the
children she found with acanthosis nigricans had never been
to a doctor.

Visio -- an intensely organized and practical 47-year-old
woman who makes spreadsheets of her own children's
after-school activities and who cooks meals on Sunday for
the entire week -- was deeply worried and deeply
frustrated. ''People who were supposed to be helping these
children'' -- school nurses, school food-service officials,
even parents -- ''were teaching them the wrong things. They
wanted to make the children happy by giving them what they
wanted. It was making the children sick.''

According to Nancy Butte, director of the Viva la Familia
Project at Baylor College of Medicine in Houston, 40 to 60
percent of the prevalence of childhood obesity in the
Hispanic population can be attributed to genetic factors.
''Much has been written about children who are
overweight,'' said Butte, explaining her study, ''but
little is known about why Hispanic children in particular
tend to be more at risk for obesity.'' Many believe that
there is, most likely, a set of genes that makes some
people more susceptible than others. Butte suggests that at
least part of the genetic component may be related to ''the
thrifty-gene hypothesis,'' the theory that some
combinations of chromosomes create a situation in which
cells are more inclined to store calories efficiently for
times of scarcity. Some researchers have speculated that
because many Mexican-Americans are descendants of American
Indian hunter-gatherers, who evolved to store fat more
easily for times of famine, those living a sedentary life
in modern westernized societies with access to fast food
may be more prone to gain weight.

Butte has embarked on a five-year program of intensive
metabolic and physiological testing, taking blood samples
from Hispanic children and their parents, scrutinizing how
children metabolize calories and analyzing body
composition. She explained that the self-reported data she
collected did not show great differences in calorie intake
between children who were obese and children who weren't.
But as Butte notes, ''We know they have to be eating
more,'' and everyone tends to underestimate how many
calories they eat. In order to assess how individuals
actually metabolize what they consume, Butte is also
gathering data in a ''room calorimeter,'' an extreme
measure that involves a sealed chamber equipped with a bed,
toilet, sink, desk, TV, CD player and telephone, where
children spend up to 24 hours. Here, caloric intake, as
well as how much oxygen a child breathes and how much
carbon dioxide she exhales, can be precisely recorded.

Outside factors are not helping, either. Throughout
America, high-calorie fast food is cheaper than food that's
good for you. Starr County has its share of franchises,
including McDonald's, Dairy Queen, Jack in the Box and
Burger King. What's more, in the Rio Grande Valley, as
elsewhere, children are not getting enough exercise, a fact
linked by some to the general indifference to exercise
along with the misapprehension of risk: the risk of, say,
letting your kid run around the neighborhood versus the
risk of encouraging a sedentary life by keeping her home.

''If you look at the probability of something that's in the
headlines -- that your kid is abducted -- the probability
of that happening to your child is very low, though
certainly it's a terrible thing,'' said Deanna Hoelscher,
director of the Human Nutrition Center at the University of
Texas's School of Public Health at Houston. ''But if it
happens, everybody hears about it, so the perception is
that the risk is very high. However, the probability of
your kid being overweight right now is very high, because a
lot of kids are overweight. So you have to balance things
out. Though of course, providing safe places for children
to play would alleviate parents' fears.''

While to date few have studied them, the sociological
underpinnings of childhood obesity in Hispanic communities
seem to operate on three levels: inside Hispanic -- and
American -- culture as a whole, inside specific communities
like Starr County and inside families. Visio's most
rewarding work has been inside individual families; as she
puts it, ''I've got to get to that home, that mom, that
family, that grandmother. Get inside that child's world.
The child doesn't have the money to buy groceries.''

One afternoon she met with Cristen Gonzalez, who was 9
years old, and Cristen's mother, Gracie, a schoolteacher in
Rio Grande City, to discuss the situation at home. Two
months before, Christen started Visio's program. At that
time, Cristen, the oldest of three children, was well into
the overweight range. Cristen has a small, sweet voice, is
on the elementary-school drill team and wants to rescue
animals when she grows up. She also wants to be a good
girl, and in the context of Visio's program, with its focus
on healthful food and weekly nutrition and exercise
classes, her mother was concerned. ''She's been obsessing
about the program,'' whispered Gracie, who was also hoping
to lose weight. Cristen drew quietly at a folding table.
''This week especially, she's been so self-conscious. I
can't have it anymore.''

Guilt is a major problem in dealing with childhood obesity
-- the guilt parents feel in denying their children food or
inadvertently making them self-conscious about their
weight, the guilt children try to instill in their parents
in order to get what they want. Gracie, by all rights, has
a lot to feel proud about. The Gonzalez family is strong,
loving, disciplined and intact. Gracie and her husband both
have good jobs in the school district; they don't eat much
fast food, going out for only one meal a week, lunch after
church on Sunday; and they are still married -- and that
puts them way ahead of most families in the county, where
jobs and structured families are scarce. Once, a few years
ago, when a friend of Cristen's came to sleep over, the
little girl saw Gracie in the kitchen and begged her to
make her spaghetti; people rarely cooked in her house. The
girl also found it exotic that Cristen had a bedtime; she
was used to falling asleep around midnight from sheer
exhaustion.

Still, life for the Gonzalezes was not so easy. Three kids
plus two working parents did not leave Gracie time each
week to plan menus and shop carefully for groceries, which
Visio explained she should do. So harried was Gracie that
she sometimes caught up on paperwork while her children ate
dinner. This meant, to Visio's eyes at least, that Cristen
was more or less having to tackle her weight problem alone.


Visio asked Gracie what her past week was like.

''Crazy,'' she replied. ''So crazy. My husband had to take
care of his parents, and my little Anthony'' -- who is 5 --
''lost his two front teeth running into his best friend's
head. I walked out of a staff meeting to get here. I've
barely had time to eat.''

Visio pressed her, ''Have you been sitting down for meals
together at night?'' The Journal of Adolescent Health has
reported that families that eat together consume healthier
food.

Gracie smiled and shook her head. ''Haven't had time.''


''Do you think this weekend you can make menus again, go
shopping?''

''Next week.''

''Cristen needs you -- you just told me, she's obsessing on
the program.''

''Don't make me feel worse,'' Gracie said. ''I already feel
bad enough.''

Cristen looked up from her drawing again.

''Twenty minutes, just 20 minutes,'' Visio said. ''Everyone
has 20 minutes. I'm sorry to tell you this, Gracie, but if
you're not sitting down to meals together and showing her
you eat just like you're telling her to, you're putting it
all on her.''


Across town at the John and Olive Hinojosa Elementary
School, on an unpaved road beside one of the colonias, 50
second and third graders in red-and-white uniforms spent
phys-ed class having a dance party under a big gazebo. It's
rare to see children in Rio Grande City being so active
outside. The average high temperature is above 87 degrees
for nine months of the year, and even in the cooler months,
the north wind blows fiercely across the Rio Grande plain.
Despite the day's heat, the dance party was a grand
success, the kids jumping and shaking and feeling confident
and comfortable. But paradoxically, that confidence can
create its own problems. Sometimes, explained Olga Smedley,
the principal, that self-certainty gives the children the
upper hand in dealings with their parents. Starr County has
three bridges to Mexico, and countless places for
unofficial crossings. Some women who live in the area
arrived from Mexico pregnant in order to have American-born
children. As a result, many parents are trying to raise
children in a country where they aren't supposed to be.

''A lot of these parents give in to their kids too much,''
said Smedley, a pretty and trim mother of three who grew up
in the Rio Grande City area and does her best to resist her
chubby 6-year-old's relentless requests for shrimp scampi.
The upended power dynamics can lead parents to cede
authority to children and lead children to bully their
parents. ''These children threaten their parents,'' Smedley
said. ''They say: 'If you spank me, or if you do this, I'm
going to call child protective services. I'm going to call
the police.' '' Smedley explained that the kids are just
being kids, but the parents, perhaps feeling vulnerable,
capitulate. ''Who's in control?'' Smedley asked, her eyes
widening and her frustration apparent. ''I told the parents
-- it's because you're allowing it.''

The odd power dynamic affects food choices as well. After
Visio trimmed back the fat and sugar from the school lunch
and breakfast menus -- no more breakfasts of sugar-coated
cereals and a bag of cookies; in fact, cookies are no
longer served, and cereals are low in sugar -- many
teachers were pleased. But the children, not surprisingly,
were not happy, a feeling they expressed by staging
lunchroom protests and hanging signs outside some
cafeterias that read ''No more diet'' and ''We want to eat
cool stuff -- pizza, nachos, burritos, cheese fries.''
Visio expected as much from the kids, but what caught her
short was how much the children's hounding got to their
parents, and how often those parents caved to their
children's shortsighted, unhealthful wishes. ''We have one
morbidly obese girl, and since we changed the menus, her
mother has been stuffing her backpack with three bags of
chips and three candy bars, every day,'' Visio said. ''This
is in addition to a full breakfast and lunch. Some of these
parents are just afraid to say no. They love their
children, but their children have them convinced that if
they eat a healthy diet, they will starve.''

The issues affecting the Hispanic child-obesity epidemic
have been the hardest to talk about, and Roel Gonzalez, the
school superintendent, has appointed himself the man for
the job. ''I know we always hear sad stories about
different groups of people, but this is one group that's
very sad,'' Gonzalez said over breakfast one morning.

Many of the concerns he described are true of American
culture as a whole and crystallized in Starr County. ''The
attitude here is hoard as much as you can right now,
because there might not be tomorrow.'' Some health care
researchers who are studying obesity and diabetes among
Hispanics talk about an undercurrent called fatalismo --
the belief that there's little you can do to alter your own
destiny, so why not live for today? ''But we have to
change,'' Gonzalez said. ''We don't have more time. This is
something we need to get on now, but we're going to go
slowly. Like my dad says, if you're in a hurry, go slow,
and I'm in an awful hurry.''

Gonzalez grew up in Starr County, left for a time to work
in upstate New York and Washington and now every morning
puts on a suit and heads to Che's, the restaurant
downstairs in Rio Grande City's one elegant old border
hotel, where we met one day. Gonzalez sees himself as the
children's advocate in the ''Lean on Me'' tradition, the
stalwart authority figure, the local boy made good. ''The
kids are not negotiable,'' he said in his husky, urgent
voice, stopping often to greet every customer who walked in
by name. ''You can have my parking space, my office, I
don't care, but I will never negotiate the kids. Those
children's lives are my responsibility. Not only
academically -- their lives physically are in my hands.''

Gonzalez has decided that the children deserve not only
positive change -- when Visio approached Gonzalez about
revising the breakfast and lunch menus for the kids in her
diabetes program, he instructed her to alter menus for the
entire district -- but also to hear adults speak the truth
about the particular problems in their community. In the
past year, he set up salad bars for all the teachers (''the
teachers have to model it, because kids idolize their
teachers, and if they don't, they're bad teachers''). He
also hired Rey Ramirez, a local Hispanic athlete -- a Texas
track and field champion -- to try to get his town
physically active again. As a farmhand, Gonzalez's father
never had to seek out exercise, but Gonzalez himself, like
a lot of his neighbors, is packing a few extra pounds. He
understands what the children are up against. ''Out here
it's 110 degrees at 6 in the afternoon, and not very many
people want to go outside and play. Myself, I get up every
morning and walk. I get up at 4:45 a.m. or 5, and it's
hard. Some mornings, I just want to stay in bed. If it's so
hard for me, I can only imagine what it's like for a
child.''

Gonzalez also talked about how attitudes toward
self-reliance have changed significantly in the course of a
single generation. He told a story I heard several times
from people over 40 in Rio Grande City. ''When I went to
school they gave you colored coupons,'' he said. ''The blue
one meant you paid for your lunch. The white one was a
reduced price. The pink one was free, and you didn't want
to be seen with the pink one. People would tear you
apart.'' Now government assistance is a major part of the
fabric of society. In addition to free meals for their
children in school, many adults in Starr County receive
food stamps, health care and utility and housing subsidies.
Much of this is beneficial, of course, but Gonzalez also
explained that it has contributed to eroding the old norms.
A while back, for instance, Gonzalez caught a girl smoking
marijuana. ''I told her that's not what I would call normal
behavior for a girl of 12, and she said, 'It's normal in my
house.' It's normal in my house. We've got to change what's
normal.''

The parents in Gonzalez's community are as loving as you'll
find anywhere, but, as Gonzalez explained, there is an
inclination to overempathize or overcompensate with their
children. This is happening across cultures and classes
throughout the country. Children are indulged and are obese
everywhere, but the conditions in Starr County aggravate
the problem. His term to describe this is ''pobrecito
syndrome,'' an affliction of parents and other adults,
passed down to youngsters, part fatalismo and part a
communal throwing up of the hands. Pobrecito means ''poor
little thing,'' and ''the pobrecito syndrome,'' Gonzalez
said, occurs when parents ''feel sorry for their child and
they're doing the best they can but -- they're just so
sorry and they really do nothing. All they do without
intending to is perpetuate the problem, and so it
continues.'' Or to put it another way, some parents can
have bad habits -- regarding food, drugs, exercise,
financial responsibility -- that they want to change, or
say they want to change, but can't. ''Basically, it's an
addiction. We just can't get the parents off the TV, and we
can't get them to stop eating fast food. We can't get them
to do anything. And the kids aren't going to get off the TV
if the parents don't get off the TV. It's going to be a
long, hard battle, because it's very hard to reach the
child if the parent is entrenched.''

Several years ago, Gonzalez and his wife started a Subway
franchise in Rio Grande City in order to provide a quick,
affordable option to greasy fast food. It was one small
step -- like his current efforts to secure financing to
build an indoor pool and nice walking paths in town -- but
Gonzalez realizes the problems run much deeper. ''We have
drugs everywhere,'' he said. ''The cemeteries are full of
people who OD'ed. We have kids coming to school who've seen
a father or a brother shot, kids who are dealing with a
parent in prison.''

Still, when Gonzalez says he's been up all night thinking
about a kindergartner who weighs 90 pounds -- the average
for an American kindergartner is about half that -- it's
easy to believe him. ''We have to catch them between
kindergarten and second grade, because after that it gets
real hard,'' he told me. ''The ones that are slightly
obese, what we call 'chubbies,' at that stage they can
change. But once they get too big, it's next to
impossible.'' With so many children and parents overweight
or obese, there's little stigma attached to being fat.
Teasing about extra heft or gentle nudging to eat more
healthfully doesn't begin until the problem is quite dire.
''They think, I look good. They don't already see that
they're in the danger zone.'' Gonzalez slipped his suit
jacket back on to rush off to the high school for the day.
''These kids mean the world to me. We've got to make the
first move. If we ask the kids to make the first move,
we're going to lose the battle.''


In her pink terry tank top and shorts, Cristen stopped by
the Rio Grande health center to be weighed and measured by
Visio's team before heading to a pool party for the drill
team. By 9 a.m., the morning was scorchingly hot already,
and in line at the health center in front of Cristen stood
a boy in a dark blue T-shirt and dark blue pants named
Alfredo. Daniel Hale, a pediatric endocrinologist at the
University of Texas Health Science Center in San Antonio,
and one of the nation's leading experts on childhood
diabetes, looked at the blood pressure cuff and said to
Alfredo, ''I bet we need a little bit bigger one for you.''
Then he said to the boy, ''So, what have you been doing?''

Alfredo said, ''The kids all went to the pool on Friday,
but I didn't want to go, so I just stayed home.''

Hale measured him at 4 feet 11 inches, then he put him on
the body-composition analyzer scale, where Alfredo
registered 171 pounds and 46 percent body fat.

''The problem is,'' Hale said after the boy left, ''most of
the potential solutions rest either on very large changes
in public policy or very small changes that individuals and
families must make in the context of their own home.
There's very little we in the public-health community can
do. We don't have very much control over what children eat,
we don't have much control over safety, which affects where
children play, and we're not in people's homes, where kids
are taking part in the major sedentary behavior, known as
television watching. And here in South Texas, where you can
get an Extreme Gulp, which is 52 ounces of soda, and a bag
of chips for a dollar, and there aren't many outlets for
physical activity, the kids are at great risk. The biggest
problem is not that that kid doesn't feel comfortable
swimming. The biggest problem is that the long-term
consequences of an unhealthy lifestyle begin to accumulate
15 to 20 years after those lifestyles are initiated. When
these kids are in their 20's, the consequences are really
going to come home to roost.''

When it came to Cristen's turn, she weighed in at 10 pounds
less than two months before, when she started the program.
Her mother, Gracie, two younger lean children in tow, said
proudly: ''It wasn't until she started school that you
couldn't see her neck. Now you can see more of her neck.''

Cristen smiled and stood up for herself. ''I have to say,
I have a neck, and it's right here.''

Elizabeth Weil is an author of ''Crib Notes: A Random
Reference for the Modern Parent,'' published by Chronicle
Books.

http://www.nytimes.com/2005/01/02/magazine/02OBESITY.html