In Montana, efforts on childhood obesity focus on access to nutritious food and activities

In Missoula County, a program helps engage kids to play at recess. Up in Browning, an organization’s need-based food pantry provides healthy foods as part of the effort to combat health problems.

The two programs are examples of ways Montana communities have worked to address childhood obesity, a problem that affects Montana less severely than most of the country but still causes concern in the Big Sky state.

A 2006 report from the state of Montana pointed out that while obesity has increasingly become a problem for Americans, Montanans, with access to the outdoors and more active lifestyles, are relatively fit compared to other states.

“These include an abundance of beautiful outdoor recreation sites, a traditional heritage emphasizing physical activity, high rates of breastfeeding, and a population that is still among the most active in the nation,” the report states.

Still, the document flagged children as a priority, in part because of concerns that being overweight in childhood and adolescence indicates the likelihood of obesity as an adult. Being overweight can also cause children to develop Type 2 diabetes, asthma, hypertension, orthopedic complications and more.

Further, the report marked lower-income and Native children at higher risk.

Centers for Disease Control and Prevention data compiled in October 2020 by the Robert Wood Johnson Foundation found that Montana was one of eight states with lower obesity rates than the national rate, coming in at 10.6% compared to Kentucky at the highest in the nation at 23.8%.

While Montana looks good as a whole, data from the Montana Youth Risk Behavior Survey conducted by the Office of Public Instruction, which offers perhaps the most localized look, shows disparity between Native American children compared to white kids.

The most recent survey, from 2021, shows that about 8% of Native students surveyed identified themselves as “very overweight,” compared to nearly 4% of all students. About 54% of all students said they were about the right weight, compared to 46% of Native children. And nearly 59% of Native students said they were trying to lose weight, compared to 41% of all students surveyed.

Illustrating the disparity between income levels, county-wide body-mass index data from Missoula County collected in 2018 shows 16.3% of third graders attending low-wealth schools sampled were obese compared to 6.8% of those at high-wealth schools.

Dr. David Krainacker, who is board-certified in obesity medicine and practices at St. Peter’s Health in Helena, said he sees lots of children that are in households that fall below 400% of the federal poverty line.

“Those populations tend to have a higher percentage of kids that are overweight, as well as in the obese category, than those who are above that line,” he said. “There’s definitely a socio-economic impact, and that’s for a lot of reasons.”

Given its lower rates of childhood obesity compared to the rest of the country and acknowledging the increased risks for certain populations, much of the work to help improve the health of Montana’s kids has focused on access to nutritious foods and affordable ways to be active.

The 5-2-1-0 Let’s Move! program in Missoula County is one such effort in the state. The project’s mission is to build healthy kids and residents of all ages, no matter where they live, work, play or learn.

The program encourages kids to eat five fruits and vegetables a day, limit recreational screen time to two hours, engage in an hour of physical activity each day and drink no sweetened beverages.

Finding ways to help kids be active is a big part of senior community health specialist Peggy Schmidt’s job.

“We work on programs building partnerships and programs that give people access to physical activity and quality nutrition,” Schmidt said. “We have a real focus on health equity.”

In efforts to help kids meet the goal of 60 minutes of activity, Schmidt curates a calendar of free- and low-cost events where kids and families can get active.

The calendar has everything from bowling for $2 a lane and $2 for shoe rentals to free organized bike rides, practice sessions for a Hula club, farmers markets, yoga and more. Schmidt is constantly working to expand the events email list, and this summer an intern from United Way helped too by working with local doctors’ offices and dental clinics, faith-based organizations, collecting emails at community events, and social media.

Schmidt’s organization also piloted the Midday Move at Russell and Lowell elementary schools. 

During the pilot program, a YMCA employee went to Russell School three days a week from early February to late April. That position helped facilitate play, from engaging with kids that weren’t active to using a bag full of items like Frisbees, jump ropes and soccer balls.

Schmidt and a few nursing students collected data and observed the program. They found that 13% more kids were active at recess compared to before.

“Teachers said kids came in so much more ready to learn,” Schmidt said. Conflicts on the playground also were resolved more often and office discipline referrals went down 9%.

Many rural areas and reservations in Montana are classified as “food deserts,” meaning an area that doesn’t have access to fresh produce within 10 miles of a rural town.

The Rocky Boy Reservation, for example, has two convenience stores but no grocery stores. Most residents travel either 29 miles to Havre for food or 102 miles to Great Falls. The median household income on the Rocky Boy Reservation is $30,139. In the U.S., it’s $67,521, more than double.

High gas prices, limited access to a vehicle and the high cost of produce can also stand in the way of people trying to buy healthy foods. Fruits and vegetables also take longer to cook. If people work long hours or don’t have childcare, it can be increasingly hard to devote time to healthy meals.

Tescha Hawley, who is Aaniiih and Nakoda, runs Day Eagle Hope Project, an organization that helps rural Montanans navigate the health care system.

Hawley said the organization promoted healthy food at the youth rodeo by providing all children and their families with a bag of fresh produce from a nearby Hutterite colony. Hawley also provides fresh, local food to community members each month.

“As American Indian people, we have the worst health care in America,” Hawley said. According to a recent Indian Health Service report, past funding for the agency addressed about 48.9% of the health care needs for the population it serves.

According to a recent Indian Health Service report, when compared to the rest of the U.S. population, Native Americans have a lower life expectancy, and face high rates of diabetes and obesity.

The disparities, according to the report, “are a result of centuries of structural discrimination, forced relocation, reduced economic opportunities and chronic underfunding of health care.” Additional barriers to health and health care include historical trauma, discrimination and poverty.

“By eating healthy and living an active lifestyle, it cuts down on diabetes, it cuts down on cancer,” Hawley said. “If we can get people to eat healthier food and have access to quality produce, it’s huge.”

Even Hawley faces barriers when trying to get healthy food to the reservation.

“We can’t transport it in the winter,” she said. “The food will just freeze. We’re struggling to get adequate heating and cooling facilities so that we can do this in the wintertime.”

Danielle Antelope — executive director of FAST Blackfeet, a food access and sustainability organization — said about 67% of families on the Blackfeet Reservation experience some kind of food insecurity.

There are a few grocery stores in Browning on the reservation, but Antelope said rural communities, especially reservations, have higher food prices. When she went to the store in town the other day, a head of cauliflower was $12, and half a bag of grapes was $8. The next closest grocery store is two and a half hours away in Great Falls. But some families don’t have access to reliable transportation, and gas prices make the trip expensive.

“That’s food insecurity,” she said. “People are not going to buy healthy foods when they cost this much.”

Antelope said there are two other food assistance programs that serve the Blackfeet Reservation, but both are income-based, which can provide challenges for families.

When Antelope was growing up, for example, her single mother technically missed the income baseline for these food assistance programs by $6.

“Based on her income, that supposedly meant she could feed us healthy foods,” Antelope said. “But that was not the case. She chose cheaper foods that could get us full, like pizza and chicken nuggets.”

Antelope said when she and her siblings moved out of her mom’s house, they were “obese, overweight and mentally unhealthy.”

FAST Blackfeet offers a need-based pantry, rather than income-based. It also offers a mobile pantry to reach families who live rurally on the reservation. Antelope said between the two programs, the organization reaches well over 1,000 households each week.

The program is family- and community-based, and Antelope said a big piece is community education.

“We live in a community where we’re like, ‘Grandma had diabetes, mom had diabetes, so I’m going to get diabetes,’” she said. “We need people to recognize, well great-grandma didn’t have diabetes because she had traditional foods in her diet.”

Antelope said it’s important for people to understand the traumas that are linked with food insecurity.

“Oil, flour and sugar were all introduced to Native people through the ration system after the massacre of buffalo,” she said. “Our land loss relates to food insecurity. Our loss of cultural knowledge of harvesting and cooking is related. So, we’re on a mission to educate our community.”

While FAST Blackfeet doesn’t have programs specifically for children, Antelope said the family focus encourages children to get involved. Their pantry has juice boxes and healthy snacks available for children when they walk in. And when families take cooking classes, their children get excited about new food options.

Laura Toeckes, nutrition director at Power School, said she’s noticed that children are more likely to try new foods before they hit about fifth grade.

“This is when kids are most impressionable,” Toeckes said, referencing children younger than fifth grade. “They may think, ‘Ew!’ but everyone is trying it, and then they’ll try it and actually like it. You have a greater success rate when they’re little.”

“If we expose them to it now, it may be a fun experiment for them,” Toeckes said. “It may be something they can learn to do more. If they try new foods now, the more likely they are to try something new in the future.”

Toeckes tries to make nutrition adventurous and fun for the children at Power School.

She tries to expose them to all kinds of local foods, like mangos, Flathead cherries, yellow watermelon and zucchini. And she always tries to pair a new food with a few fun facts.

“I don’t say, ‘Bananas have a lot of potassium,’” she said. “Because that wouldn’t be interesting to me when I was in second grade. Instead, I say, ‘A single banana is called a finger, and a bunch is called a hand.’ I think it engages them and makes it exciting. It opens their eyes, and hopefully, opens their willingness to try something new.”

Krainacker, the Helena doctor, uses an approach in his practice called “lifestyle medicine.”

While it involves exercise, diet is the primary pillar, and he works with his patients to focus on calories coming in, especially given how much physical activity it takes to burn off something like a bagel and cream cheese, which can clock in around 500 calories.

The work is important to help prevent some of the adult problems he’s now seeing in his young patients. Type 2 diabetes used to be known as an adult-onset disease, but now he’s seen it in kids as young as 8. Being overweight can also put children at a higher risk down the road for heart disease, joint problems, sleep apnea and at least 13 different kinds of cancer. For girls specifically, being an unhealthy weight can increase gynecological cancer risk.

Krainacker sees adults in their 30s who have never learned how to cook well and frequently bumps into a perpetuation that eating a healthy diet is expensive. He works with patients to help them understand how to better shop sales and reach for foods abundant and affordable in Montana, like rice, beans and lentils. He reminds patients “something good is always on sale.”

He provides new patients with three weeks of recipes for foods that are easy to prepare, convenient and inexpensive.

“My joke is people say it’s not convenient to eat healthy. What’s more convenient than an apple,” he said. “All you have to do is eat it. There’s no cooking involved.”

Still, Krainacker is cognizant of the challenges of focusing on numbers in a world where body image can create unhealthy situations, especially for children. The work with children, he said, is not about weight loss but weight stability — keeping a child at a weight and having them grow into it.

“Let’s be honest, for whatever reason it’s an age where we are extremely cruel to each other,” Krainacker said. While BMI is a convenient tool, he has a scale that also measures the percentage of body fat, which is a more accurate measurement, especially with kids.

Working parents with kids in school don’t always have the time to sit down and cook every day, he said, meaning it can be easier to pick up a meal from a fast food restaurant on the way home. Krainacker encourages families to prepare meals ahead of time by taking a couple of hours on the weekend.

“Use an Instant Pot, use a crock pot, make these meals way in advance,” Krainacker said. “Have them in the refrigerator (or) in the freezer. You come home and you have … a hot, nutritious meal in five minutes. You’re done (and) don’t have to wait in line at McDonald’s.”

Schmidt, in Missoula, echoed that fruits and vegetables can take more time to cook and, depending on location in the state, can be hard to access.

“It’s not that people are overweight because of some kind of failure on their part,” Schmidt said. “It’s the nutrition environment in which they live.”

Efforts in Missoula have moved away from the lens of obesity prevention in an effort to avoid stigmas around weight and body image. The pandemic forced a pause on the program that tested third graders and eventually the county might do it less frequently or switch to another metric, though all that is still in process.

The discussion for her work has shifted away from talking as much about obesity prevention to living a healthy lifestyle.

“In the ’80s, ’90s, 2000s, 2010s, it was such a big public health crisis and articles coming out telling you how unhealthy you are,” Schmidt said. “I just talk about getting people access to physical activity and quality nutrition.”