How do we fight back against obesity?

When Velveth Monterroso arrived in the USA from her hometown in Guatemala, she weighed exactly 10 stone. But after a decade of living in Oklahoma, she was more than five stone heavier and fighting diabetes at the age of 34. This friendly woman, a mother of two children, is a living embodiment of the obesity culture cursing the world’s wealthiest country. “In Guatemala it is rare to see people who are very overweight, but it could not be more different here,” she said. “I saw this when I came here.”

As soon as she arrived in the USA she started piling on pounds – an average of half a stone each year. In Guatemala she ate lots of vegetables because meat was expensive. But working from eight in the morning until eleven at night as a cook in an Oklahoma City diner, she would skip breakfast and lunch while snacking all day on bits of burger and pizza. Driving home she would often resort to fast food because she was hungry and exhausted after a 15-hour day slaving over a hot grill. If she and her husband Diego – also a cook – made it back without stopping, they would often gorge on whatever was available rather than wait to cook a decent meal.

Her lifestyle was no healthier when she stopped working after having her second child eight months ago. She was tired and her family encouraged her to drink lots ofatole – a heavily sweetened corn-based drink popular in central America – to aid the breastfeeding of her new daughter, Susie. Sugar levels in her body soared, and on top of her obesity she became pre-diabetic.

Velveth’s life was changed – and probably ultimately saved – when she took Susie for a medical check-up and was enrolled on a programme to curb obesity. Now she eats fast food just once a week, cooks more vegetables, has cut down the number of tortillas consumed at meals and exercises daily by walking up and down stairs for 20 minutes. Although still overweight, in just four months she has lost 16 of those pounds gained in America. “All my friends are impressed,” she told me with a smile. “I feel like I have so much more energy now. I can do the shopping and laundry, bathe the baby, and I’m not nearly so tired as before.”

Velveth is one beneficiary of a remarkable attempt to tackle obesity. For Oklahoma City has declared war on fat. First the mayor – realising he had become clinically obese just as his hometown was identified by a magazine as one of America’s most overweight cities – challenged his citizens to collectively lose a million pounds. But hitting that target was just the start: this veteran Republican politician then took on the car culture that shaped his nation and asked citizens to back a tax rise to fund a redesign of the state capital around people.

This unleashed an incredible range of initiatives, including the creation of parks, sidewalks, bike lanes and landscaped walking trails across the city. Every school is getting a gym. With the new emphasis on exercise, city officials spent $100 million creating the world’s finest rowing and kayaking centre in a Midwest town with no tradition of the sport beforehand. Overweight people are targeted at home and at work to alter their lifestyles, while data are used to discover the districts with the worst health outcomes so that resources can be poured in to change behaviour.

The experiment is unusual in terms of its ambition, breadth and cost, all of which take it beyond anything being attempted by other American cities in the fight against fat. The battle is being done with, rather than against, the fast food industry and soft drinks manufacturers, relying largely on persuasion instead of coercion through soda bans and sugar taxes. The city has been dubbed “a laboratory for healthy living”. Yet what makes the experiment quite so extraordinary is that it is being attempted in Oklahoma.

For the city is one of the nation’s most spread-out urban environments, covering 620 square miles, which means its 600,000 residents rely on cars; there are so many freeways they quip that “you can get a speeding ticket at rush hour”. Not only did the city not have a single bike lane, but also reputedly the highest density of fast food outlets in America, with 40 McDonald’s restaurants alone. It sits in a state seen as cowboy country filled with ultra-conservative Okies, symbolised by The Grapes of Wrath, John Steinbeck’s definitive 1930s novel about poor farmers driven away by drought and hardship. The economy collapsed again in the 1980s amid the energy crisis, with bank closures and another generation drifting away; then came the terrible 1995 bombing that killed 168 people.

The man behind the transformation is Mick Cornett, a former television sportscaster who became mayor in 2004. Three years later he was flicking through a fitness magazine when he noticed his city had been given the unwanted accolade of having the worst eating habits in the USA and was prominent on a list of the nation’s most obese populations. This coincided with his own reluctant acceptance, after checking his personal details on a government website, that at almost 16 stone he was obese.

“This list of obesity affected me as mayor, and when I then got on the scales it affected me personally. I have always exercised and I remember thinking that I did not eat between meals, yet I was eating 3,000 calories a day. As mayor people are always wanting to meet with you, so it was not unusual to have a business breakfast, then a lunch with someone, then a function dinner. And in between there can be events with snacks and cookies.”

Cornett’s response was to start losing weight by watching what he ate; today he is almost three stone lighter. But he also began to think about the issue, wondering why America was ignoring such a massive problem. His eventual conclusion was that this was because no one had any real solutions to the crisis. At the same time, the mayor began to look afresh at the culture and infrastructure of his city, realising how the extent of reliance on cars had alienated human beings from enjoying and using their own urban environments.

His first step was to challenge citizens to join him on a diet. Using his flair for publicity after 20 years in television, he announced that he wanted Oklahoma City to lose one million pounds, doing so standing in front of the elephant enclosure at the local zoo on New Year’s Eve, aware of the media focus on diets in the days after the festive excess. He persuaded a healthcare magnate to fund an information website called This City Is Going On A Diet – and was relieved over the following days as local papers backed his campaign and the national media praised it rather than poking fun at fat Okies.

Churches began setting up running clubs, schools discussing diet, companies holding contests to lose weight; chefs in restaurants competed to offer healthy meals. More importantly for the mayor, people across the city began discussing a crisis spiralling out of control. Almost one-third of adult Oklahomans are obese, while the state ranks among the worst in fruit consumption and has one of the lowest life expectancies in America. Diabetes rates nearly doubled in a decade. Perhaps most alarmingly, more than one in five children aged 10 to 17 suffer from obesity and almost one-third of pre-school infants are overweight.

Dr Ashley Weedn, medical director of a specialist child obesity clinic that opened three years ago in Oklahoma City, told me they were seeing ‘incredible’ cases of four-year-olds with high cholesterol and children consuming five times the daily sugar allowance in soft drinks alone. “We are even coming across kids with joint problems usually associated with much older people because of the strain on their legs, which we are seeing as early as six. This can involve surgery because of the pressure on bones leading to abnormal growth, which can lead to misshapen limbs.”

Despite some flak from doctors, Cornett decided from the start to work with the food and drink industry. So the soft drinks sector sponsors health programmes to fight obesity, and the mayor even posed with the boss of Taco Bell in one of the chain’s outlets to publicise a low-fat menu; indeed, he keeps one of the company’s promotional cut-outs in his office and proudly showed it to me when we met. “Even when I lost weight I would go to a fast food place, although I might have a bean burrito without sour cream,” he told me. “I could not stop people going to them, but I could try to make them more discerning with their orders. You can’t totally change people’s habits.”

In January 2012 the city hit the mayor’s million-pound target – 47,000 people had signed up, losing on average more than 20 pounds apiece. An admirable achievement, with the campaign proving a clever way to raise awareness. But for all the publicity, Cornett’s ambitions had grown way beyond that original simple stunt: now he wanted to remake his huge metropolis by remoulding it around people in place of cars. Or as he explained it, “putting the community back in the community”. Yet although these days hailed as an urban visionary, he readily admits there was no ‘grand plan’ at the outset.

Oklahoma City has been a sprawling place since the day it was founded with a land grab in 1889, when thousands of settlers raced from a gunshot to stake out their land. Like most US cities, it is criss-crossed with thunderous multi-lane freeways and developed around the car. Pedestrians and cyclists were largely ignored, with few pavements and no bike lanes. When Cornett began the first of his record-breaking four terms as mayor in 2004 the city was still emerging from the economic collapse of the 1980s; he was lucky to inherit the legacy of a predecessor who understood the need to create a nicer living environment to attract families and professionals, and who did so by building a new canal and sports arenas.

He was partly spurred into action by another of those lists loved by magazines, when his hometown was labelled worst for walking in the country. Cornett contacted a planning expert named Jeff Speck, who conducted a survey of the city that concluded it had twice as many car lanes as needed. The result was the dismantling of its one-way system, seen as encouraging faster driving, along with the start of a project to install hundreds of miles of pavements, parks, trees, bike lanes, sports facilities and on-street parking to create a ‘steel barrier’ between those thundering freeways and pedestrians.

The scale is impressive. The city’s downtown is being rebuilt, while next up is the creation of a 70-acre central park, since studies show people exercise more if close to green spaces. “The American healthcare crisis is an urban design problem,” argues Speck, author of a book called Walkable City. “The lack of attention to such issues has been a huge black hole. Data shows that physical health and obesity are tied much more to physical exercise than to diet. But what makes Oklahoma unique is their willingness to invest so generously, for which they must be commended.”

Cornett estimates about $3 billion has come from public funds, with up to five times that sum spent by the private sector riding his city’s renaissance. There was, for example, just one struggling hotel downtown at the turn of the century; today there are 15, and it was difficult to find a room at short notice. Remarkably, residents voted to pay for this redevelopment with a 1 cent rise on the local sales tax, which raises about $100m a year; other funds have been taken from tobacco settlements and rising income from property taxes as firms and people are attracted back. Oklahoma City currently has among the lowest unemployment in the country, which blows away the dusty Grapes of Wrath clichés.

The most unexpected part of the makeover can be found a few minutes’ walk from the city’s entertainment district of Bricktown, where one of the world’s finest rowing facilities has been created in the heart of the Midwest. This is a city that even the mayor’s chief of staff says was a “horrible” place when growing up. Yet what was once a dried-up river in a dilapidated ditch best avoided by decent folks at night is now a sparkling 3-mile stretch of water, fringed with lush landscaping, futuristic-looking boathouses, bike lanes and floodlights.

According to Shaun Caven, a 47-year-old Scotsman who led the gold-medal-winning British canoe and kayak team at the 2008 Olympics before moving to be head coach at the Oklahoma City Boathouse, this will be the best set-up in the world upon the completion of its $45m white-water course. There are even altitude training facilities in one of those high-tech boathouses. “People thought I was mad when I moved here – they said there’s no water, since the impression is of a bone-dry landscape,” said Caven. “But I liked the fact there was no history and the chance to start something from nothing.”

The river feels a long way from rowing’s upper-crust heritage: people on paddleboards and school parties on dragon boats share the water with US Olympic teams in training under the searing sun. Efforts are made to attract people from across society: 50 firms have joined a corporate rowing league, while eight local high schools have their own boats. Among those I met there was Bob Checorski, a 76-year-old sweating from his exertions after rowing an impressive 11,000 metres, who told me he began six years ago after losing his free gym membership at work. “I do it for relaxation rather than racing – although I did win a silver medal in a doubles race soon after joining, with a guy who’d had open-heart surgery,” he said. “Now I just go out and enjoy myself.”

But plush sports facilities, nice parks and pleasant sidewalks can only go so far in fighting a culture of rampant obesity; many people need encouragement, help and even prodding to alter lethal lifestyles. And Oklahoma has some of the highest mortality rates in the USA. So six years ago the city started poring over all available data to find its least healthy zip codes, discovering that some disadvantaged parts suffer five times as many deaths from strokes and cardiovascular conditions as wealthier areas. This led to the redirection of funds to places most in need.

“Obesity is the underlying cause of almost every chronic condition we have in Oklahoma,” said Alicia Meadows, Director of Planning and Development at Oklahoma City-County Health Department. “If you direct significant resources into areas of greatest health inequalities, we think you make the biggest difference.” They have an eight-strong team of outreach staff going to markets, sports events and even calling door-to-door in areas where data indicate people are in need of the most help. “We make it clear we don’t want to see their papers; we know many are undocumented. But their health impacts on the city’s health.”

These outreach officials come from the same communities they seek to change. One is a mother-of-two from an impoverished Mexican background, who told me she used to know nothing about nutrition; now she has lost five stone and taken up kickboxing. I watched Dontae Sewell, another convert, lead a ‘Total Wellness’ class in a library, making self-deprecating jokes about scoffing burgers at barbeques as he explained the etiquette of healthy eating. “If your friends love you, they still gonna visit even if you just serve them vegetables,” he declared.

The lesson was good spirited, with lots of banter and little homilies alongside advice on when, what and where to eat. The class of 22 women and one man, mostly overweight and some clearly obese, had lost 200 pounds between them in five weeks. “We want to see our grandkids,” one middle-aged mother told me afterwards. Sewell, with a chunky silver cross around his neck, asked how many of the class ate at the table; just four raised their hands. Then he asked how many fast food outlets they passed on their way home from work. “Two dozen,” replied one woman. “Too many,” said another, laughing. “Don’t be too hard on yourselves,” said Sewell. “It’s about small changes and creating new habits.” Afterwards he confessed only about one-third stuck long term to their lifestyle changes.

The city has also built specialist ‘Wellness Campuses’ in its worst-afflicted areas, the first in a low-income, largely African-American area to the north-east of the city. The slick new building – filled with medical clinics, communal meeting rooms and kitchens for cooking demonstrations – sits in verdant grounds dotted with walking and bike trails. Patients at the private–public partnership can see specialists in everything from nutrition to domestic violence, taking home prescriptions for food boxes and soon even for running shoes and vests. The local soccer team is building its training ground beside the campus to encourage participation in sport.

There is no doubt Oklahoma City and its fat-fighting mayor deserve credit for their war against obesity, an inspiration to a country in which over two-thirds of the adult population are overweight and which has such a strong car culture. At the very least they have made their hometown a more pleasant place to live – so important given the struggle between cities for jobs and young professionals. Yet the key question is whether even such valiant and wide-ranging efforts can dent such a huge health problem, one needlessly killing so many people on the planet. After all,one Lancet study looking into three decades of global obesity found that not one of the 188 nations studied had managed to turn the tide on this crisis, which grows worse by the day.

There are signs of success, although Cornett is not making big claims. “All I will say is that my impression is we are going in the right direction.” He is sceptical about data on obesity, but health indicators seem to back him. In the lowest-income areas, which have the highest rates of diabetes and blood pressure problems along with the worst outcomes, they have cut key indicators by between 2 and 10 per cent in five years. Although Oklahoma men live almost six years less than the national average, the city has seen a 3 per cent fall in mortality rates. Yet for all this, the rise in obesity has slowed – down from 6 per cent a year to 1 per cent – but it is sadly still increasing.

No wonder many experts compare this struggle to the anti-smoking movement, which took several decades of campaigning, education and regulation to change societal behaviour. This was underlined to me the night before leaving Oklahoma City as I ate in a restaurant recommended by Cornett’s office. After a superb plate of pasta, I was offered desert and chose a “roasted pecan ice cream ball… smothered in chocolate sauce”. The waiter said that was a good choice, then asked if I wanted it “volleyball, softball or baseball sized”. I went for the smallest; it was delicious and absurdly filling. But a posh restaurant offering volleyball-sized portions of ice cream? As Cornett says, it is hard to change habits in the battle against obesity.

This article is published in collaboration with Mosaic Science. Publication does not imply endorsement of views by the World Economic Forum.

To keep up with the Agenda subscribe to our weekly newsletter.

Author: Ian Birrell is a columnist and foreign correspondent.

Image: An overweight woman sits on a chair in Times Square in New York. REUTERS/Lucas Jackson