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In Gittelsohn’s intervention, healthy eating messages will soon go beyond store boundaries. A cartoon about nutrition and exercise featuring an Apache family will run in local newspapers. And Gittelsohn is lining up a local musician who will write and perform songs for the radio that blend messages about nutrition with cultural themes. “All of this needs to be reinforced repeatedly,” says Gittelsohn. “It’s not enough to be using just one pamphlet or just one poster.”

To gauge whether the interventions are succeeding, the researchers are keeping a log of sales data for each store and conducting home interviews. They are also monitoring the weight of a subgroup of  women to determine whether the project reduces obesity levels.

Gittelsohn is currently developing Healthy Stores programs for Baltimore and Hawaii. If these first projects prove successful, the model could be applied on a larger, even national, scale.  But changing people’s behavior is not easy, as Gittelsohn learned in an earlier attempt to reduce childhood obesity called the Pathways Project .

Pathways met with both successes and disappointments. The School’s program, which involved seven American Indian reservations starting in 1993, aimed to reduce childhood obesity by at least 5 percent. But by the end of the intervention, though the children knew significantly more about good nutrition and exercise, their obesity rates had not declined. 

Caballero now concludes that focusing on schools is not enough. After school, children can all too easily plop down in front of the TV and stuff themselves with potato chips. Effective programs must involve the family, workplace, and community—strategies the Healthy Stores researchers are now trying to implement.

Public health authorities have an ambitious goal: to reduce the prevalence of obesity among U.S. adults from 31 percent to less than 15 percent by the year 2010.

But how to get there?

Nutrition scientists use the term “nutrition transition” to refer to dietary changes that occur as societies develop. Barry Popkin, a professor of nutrition at the University of North Carolina, has outlined these progressive stages in The Nutrition Transition: Diet and Disease in the Developing World, which he and Caballero co-edited.

People begin as hunter-gatherers, relying on a low-fat animal and plant-based diet. (Meat from free-roaming animals is low in fat.) They battle high rates of infectious disease but rarely suffer chronic diseases (stage 1). They then developed a less varied diet that spawns nutritional deficiencies such as kwashiorkor, scurvy, pellagra, and beriberi (stages 2 and 3). Later, technology reduces physical labor and make possible a diet rich in fat, sugar, and processed foods. Society then suffers high rates of heart disease, cancer, diabetes, and other degenerative diseases (stage 4). Americans and other industrialized societies are in this stage.

 Finally, in the next stage, people become more aware of how a healthy diet prevents degenerative disease. They exercise more and live longer, healthier lives, with less heart disease, cancer, and diabetes.

No society has yet advanced to stage 5. And finding the way there is an experiment. But it is an experiment we must attempt, says Caballero. “With  64 percent of the population overweight, we face a serious social danger. We need to do what we have to to reduce that threat.” 

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