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In Bush's oil-rich Texas, the children of the poor don't starve - they just get fatter

Starr County is one of the poorest districts in America. Like the 'refugees' of New Orleans, many of its citizens are part of an invisible, immigrant underclass - they don't own cars, have health insurance or much money, but what they can afford is fast food and sugary drinks. Elizabeth Weil joins the health workers fighting the tide of chronic illness that threatens a whole generation of children

Sunday October 9, 2005
The Observer


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 per cent 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 - ramshackle neighbourhoods that are home to many illegal immigrants and lack adequate municipal services - houses that look as if they might fall down neighbour 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 four years old, 24 per cent of the children are overweight or obese; by kindergarten, 28 per cent; and by elementary school, 50 per cent of the boys are overweight or obese, along with 35 per cent 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, gall bladder 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 any more; 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 US 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 per cent Mexican-American. The US 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 US-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 has diabetes, meaning virtually every child in Starr County is at risk of developing the disease.

When you talk to children about losing weight, 'you see a blank stare', Gonzalez said. 'They hear you, but there's really nothing they can do.' Vans of well-meaning doctors regularly barrel down from San Antonio and Houston, feeling the smooth blacktop change to bumpy gravel, knowing that 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 specialises in diabetes prevention, worked previously with Sioux Indians in South Dakota, and her university recently received a grant enabling her to start a programme 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 enrol a child in her programme, 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. 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 behavioural therapists or paediatric dieticians in Starr County.

One of the first things Visio did when she started the Diabetes Risk Reduction programme was to analyse the food served in the Rio Grande City schools, where all children receive 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 when malnutrition was the district's main problem. Ramon still talks about her memories of the dry hair and bony hands she saw on local children in those days. Visio analysed Ramon's menus and quickly established that with breakfasts containing as many as 600 calories and lunches 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 which they bought from vending machines and at convenience stores and also drank at home. In the two months between her first two visits the children gained an average of two pounds.

Visio also found at the outset that 13 per cent of the pre-kindergarten and 18 per cent of the kindergarten students she screened had acanthosis nigricans, a disorder characterised by dark, thick patches on the skin that can signal insulin resistance, warning of diabetes, a disease in which the body does not produce or properly use insulin. Insulin 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, which, left untreated, can lead to blindness and loss of limbs; many of the children with acanthosis nigricans had never even been to a doctor.

Visio - an intensely organised 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 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 per cent of the prevalence of childhood obesity in the Hispanic population can be attributed to genetics. '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.' Many believe that there is 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' - that some people's chromosomes cause cells to store calories efficiently for times of scarcity, possibly relevant because many Mexican-Americans are descendants of American-Indian hunter-gatherers, who evolved to store fat more easily for times of famine.

Butte has embarked on a five-year programme of intensive testing, taking blood samples from Hispanic children and their parents, scrutinising how children metabolise calories and analysing 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 metabolise 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, calorific intake, as well as how much oxygen a child breathes and how much carbon dioxide is exhaled, 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, due to the general indifference to exercise along with the misapprehension of the risk attached to letting your kid run around the neighbourhood.

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 nine years old, and Cristen's mother, Gracie, a schoolteacher in Rio Grande City, to discuss the situation at home. Two months before, Cristen started Visio's programme. 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 programme, with its focus on healthy food and weekly nutrition and exercise classes, her mother was concerned. 'She's been obsessing about the programme,' 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 any more.'

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 instil 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 five] 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 programme.'

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

'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 six-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."'

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 - many teachers were pleased. But the children were not happy and staged lunchroom protests, 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 unhealthy 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. 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.

'The attitude here is, hoard as much as you can right now, because there might not be tomorrow.' Some healthcare 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?

In the past year, Gonzalez has set up salad bars for all the 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. He understands what the children are up against. 'Out here it's 110 degrees at six in the afternoon, and not very many people want to go outside and play. It's hard.'

The parents in Gonzalez's community are as loving as you'll find anywhere, but, as Gonzalez explained, there is an inclination to overempathise or overcompensate with their children. 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. 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 realises 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 have 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 kindergarten child 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.'

In her pink terry tank top and shorts, Cristen stopped by the Rio Grande health centre to be weighed and measured by Visio's team before heading to a pool party for the drill team. By 9am, the morning was scorchingly hot already, and in line at the health centre in front of Cristen stood a boy in a dark blue T-shirt and dark blue pants named Alfredo. Daniel Hale, a paediatric 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 analyser scale, where Alfredo registered 171 pounds and 46 per cent body fat.

'The problem is,' Hale said after the boy left, 'there's very little we in the public-health community can do. We don't have very much control over what children eat and we're not in people's homes, where kids are taking part in the major sedentary behaviour, known as television watching. And here in South Texas, where you can get an X-treme 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 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 twenties, 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 programme. 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.'