Is back to school better or worse than pandemic eating, couch surfing at home?
By Gabriella Fuster, Donovan McClain, Melissa Noda and Julianne Hill
As young people returned to the classroom this fall, they faced the dual challenges of undoing unhealthy eating and exercise habits developed during virtual learning and searching for healthy food choices in the cafeteria---issues especially pronounced for kids of color.
Obesity in children climbed during the pandemic-- increasing by 1.7% from 2019 to 2020 in 2 to 17-year-olds, according to a study in Pediatrics. Non-white children in the study, who were already at greater risk for obesity pre-pandemic, saw the biggest increases, with the racial gap in obesity rates widening from a 10% to 11% difference to a 13% to 14% difference.
The study--which included patients at the Children’s Hospital of Philadelphia--also found that the poorer the children were, the more likely they were to be obese. Obesity is a known risk factor for many diseases, including cancer, heart disease and COVID.
“In lower income groups you tend to see obesity more,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “It can be genetic for people overall, but it tends to be a manifestation of diet, exercise.”
The increasing rates of diabetes among children started even before the pandemic, says Dr. Janis Orlowski, chief healthcare officer at the Association of American Medical Colleges.
A February 2020 Centers for Disease Control and Prevention (CDC) study found that diabetes increased among people younger than 20 years old between 2002 and 2015 (4.8 % type 2 diabetes and 1.9% type 1). “It’s really of concern that we are seeing so many kids with a new onset of diabetes,” said Orlowski, a nephrologist.
Remote learning created extra challenges. Unlike attending in-person classes when access to food is limited to lunchtime, food was available all day for most children at home.
“We see a lot more snacking than you would in a child that was attending school,” said Rocio Garcia, a pediatric dietician at the Miami Transplant Institute.
Physical education opportunities were limited during quarantine, and many students sat for five to eight hours a day in front of computers without even the minimal physical activity they’d get from walking between classes in school.
“Going back to school is definitely a benefit for our children. Many children were sedentary during the height of the pandemic,” said Dr. Suzette Oyeku, a pediatrician who is chief of The Children's Hospital at Montefiore’s division of Academic General Pediatrics in New York City. “Some parents were definitely trying to incorporate some regular exercise, some school curriculums had exercise as part of their programs, but many schools did not."
For some, just getting to and from school creates a pattern of regular physical activity.
“Normally when you go to school...you're out running around the playground and you often walk to school--at the very least you have to walk to the bus and back carrying your backpack all over the place,” said Benjamin, an internal medicine physician and former health secretary of Maryland.
Back to school
Now, with most children attending school in person, school cafeterias are again providing free breakfasts and lunches. In 2019, the National School Lunch Program served more than 29.4 million children daily.
But sometimes those meals are not the most nutritious. A recent study of families in San Joaquin Valley, California, which has a largely Latino population, found some low-income parents continue packing their kids’ lunches because of unhealthy offerings at school, such as corn dogs.
“The school meals are not so good,” said Garcia. “I know they've made little changes, such as baking instead of frying and the type of fries they're using, serving more fruit, making more salads available, cutting down on soda. But they're still a work in progress.”
Broadening the menu to include a variety of options is important, as is portion control.
“It's okay to eat pizza. It's not a sin,” Garcia said. “It's the amount and how often.”
While making school lunches more balanced is important, Orlowski said it takes an entire community to create substantial change. “There has to be attention on the part of parents and on the part of educators and community leaders to really emphasize an improvement in the school diet,” she said.
Solutions beyond schools
Whether or not a young person eats well and exercises enough depends on a lot more than just where and how they attend school, of course. Neighborhood factors ranging from the safety and quality of housing, whether there are enough safe, green places to play, and what types of foods are available and accessible have a profound influence on health.
“It turns out that about 80% of what makes you healthy actually occurs outside the doctor's office,” Benjamin said.
Many non-white people live in food deserts, low-income areas with little access to full service grocery stores, limiting easy access to affordable fresh fruits and vegetables and other healthy food options. Often the easiest place to buy food is a corner store.
“Unfortunately fruits and vegetables can be expensive if you don't know where to shop,” Garcia said. “What's going to be available in these smaller stores, it’s going to tend to be more processed, unhealthy.”
To reduce obesity, teaching students about good nutritional choices is vital.
“A lack of education makes us go for what's available that tends to be cheaper, such as fast food,” Garcia said. “(Education) is the only way where you're going to learn about which [better] foods to choose, what portions to serve for the different age groups.”
Inclusivity also plays a role. “As we look at school cafeterias’ meals, we really need to be culturally and ethnically sensitive so that kids learn how to eat foods that are within their family,” said Orlowski.
Oyeku says those in health care need to take a “culturally humble” approach to conversation with families “to get a sense of their view in terms of how they view the weight.”
In some families, Oyeku said, chubby cheeks on children are considered a sign they are healthy. In particularly low-income households, parents may also forgo meals for themselves to feed their children - a scenario that can lead kids to eat too much high-calorie, starchy foods.
Oyeku has faced a similar challenge when showing patients pictures of plates with recommended portions.
“The challenge was the actual visual did not look like any food that they regularly eat,” she said. “You want try to co-design the intervention or strategy for healthier eating and weight loss together.”
Solutions need to reflect families’ living situations and priorities, as a 2019 review of five failed programs to prevent weight gain in African-American and Hispanic children in the journal Pediatrics found. Children and their parents had bigger worries - including neighborhood violence and food insecurity - than weight and waistlines.
Hospital-based food pantries and food prescriptions are among the health care-related solutions. At Oyeku’s hospital in the Bronx, there’s a food pantry on campus called Project Bravo, to which doctors can send patients, Oyeku said. Prescriptions offered in a variety of similar programs around the U.S. are typically for coupons or vouchers that can dramatically reduce the cost of fruits and vegetables.
But getting people and their children to want to eat healthy food is another matter.
Oyeku, the daughter of a Nigerian-born father and a mother from Guyana, has personal experience when it comes to the cultural challenges of healthy eating: she’s been working to introduce palatable and healthier options into her own diet. Rice, for example, was essential.
So she reduced carbohydrates, started walking more and added a “desk cycle” where she can pedal intermittently during her work day.
“A meal wasn’t a meal in my family without rice so I switched to brown rice, quinoa, couscous and increased my vegetable intake,” Oyeku said. “I understand the struggles our families face to remain physically active and healthy so I try to meet them where they are.”