For at least two decades, Arkansas has been among the heaviest states in the nation: By 2000, the state's obesity rate was 20% to 24% and rising. Appalled, in 2003 then-Arkansas Gov. Mike Huckabee — who had been diagnosed with Type 2 diabetes and famously went on to shed more than 100 pounds — became a champion for healthy lifestyles in his home state.
He signed into law a sweeping piece of legislation targeting childhood obesity. Over the next few years, he launched the Healthy Arkansas Initiative, aimed at helping overweight and obese adults improve their physical well-being.
With broad efforts and the support of an impassioned governor, the state seemed poised to make serious progress. Eyes of obesity experts around the U.S. trained on Arkansas, waiting to see the results — and what lessons it held for tackling obesity nationwide.
Since then, Huckabee appears to have regained much of the weight he had lost, a stark reminder of how difficult it is to slim down and stay that way. And although Arkansas officials remain committed to fighting the state's weight problem, they've found that it is, and will be, an uphill battle.
When Arkansas Act 1220 was signed into law in 2003, it was one of the most expansive pieces of legislation targeting childhood obesity in the nation, said Dr. Martha Phillips, an assistant professor in the department of psychiatry at the University of Arkansas for Medical Sciences, who has helped lead efforts to study the law's effects.
It restricted access to vending machines in elementary schools, created an advisory committee to make recommendations about nutrition and physical activity to the state Legislature, asked school districts to set up committees overseeing the health needs of children and families, and — most controversially — implemented body mass index screenings of students, sending the results home to families as part of their report cards, and later as a separate letter.
It was the right approach, said Roberta Friedman, director of public policy at the Yale Rudd Center for Food Policy and Obesity — adjusting what children are exposed to at school rather than attempting to transform their behavior.
According to a recent evaluation of the law conducted by the University of Arkansas for Medical Sciences and funded by the Robert Wood Johnson Foundation, an organization devoted to public health, schools in Arkansas look much different now. Between 2004 and 2009, the number of students who reported that they had access to vending machines dropped from 64% to 23%, and the percentage of school districts with policies prohibiting the sale of junk food increased from 37% to 67%.
But those involved in evaluating the bill say that while schools have changed, behaviors of students and their families largely have not.
"Have we seen an increase in physical activity, healthy eating, healthy diets? No," Phillips said.
According to the recent evaluation, which Phillips co-wrote, in 2009 parents reported modifying recipes to make them more healthful about 2.1 times a month, down a little from 2.3 in 2004. The average number of times that families said they ate fast food each month increased from 5.9 to 6.6 during that same period.
Results of the BMI screenings, which are published annually by the nonpartisan Arkansas Center for Health Improvement, show that the percentage of overweight and obese children has remained stubbornly and exactly at 38% from 2005 to 2009.
Students' BMI screenings and reports were implemented, policymakers say, to help parents understand the severity of their children's weight problems. They also would enable the law's effects to be studied. But many parents resisted; some were worried that students would be tested using calipers or that they would be teased or go on unnecessary diets.
"There were quite a few parents that opposed it," said Valerie Beshears, lead nurse for Arkansas' Fort Smith public school district. "We would get notes back saying, 'I don't want this done.'"
Beshears says objections have largely waned, and evaluations showed that weight-based bullying and dieting among students hasn't increased. But the practice remains a subject of debate in the medical community.
In 2005, the U.S. Preventive Services Task Force, an independent panel of medical experts, reported that there wasn't enough evidence against or in favor of BMI screenings in children to render them necessary. And specialists in the field of eating disorders still worry that the screenings could be a trigger pushing those with predispositions to anorexia, bulimia or binge eating over the edge.
"In every school district, there is going to be somebody with that predisposition who they are nudging towards an eating disorder," said Lynn Grefe, president and chief executive of the National Eating Disorders Assn.
Children aren't the only people targeted by Arkansas' efforts. As part of a focus on adults, the Arkansas Coalition for Obesity Prevention was formed, bringing together groups committed to improving public health by such measures as increasing access to healthy foods and helping residents become more physically active.
Arkansas designated much of the revenue from a recent tobacco tax increase for health improvement efforts, such as joint use agreements that allow communities have access to school fitness facilities. And for several years, more than 11,000 state employees have participated in a program in which they track their intake of fruits and vegetables, physical activity and tobacco use and get three extra vacation days a year in return.
But just as with children, the state's obesity stats haven't improved. According to the Centers for Disease Control and Prevention, in 2009, 30.5% of Arkansans were obese, a number that has gone up steadily: from 15%-19% in 1993, to 20%-24% in 2000, to the current rate.
Friedman said that expecting behavior and obesity rates to change quickly through legislative efforts isn't realistic.
"There is this assumption that a bill like [Arkansas Act 1220] is a sort of magic bullet … you focus on the school environment and you change it and it's going to mean automatic weight loss," she said. "What I see it as, is one piece of what needs to be going on."
Parents and children must become informed about healthy living, she said; environments near schools must change, offering healthier options in stores and corner markets that students may pass walking to and from school; marketing of junk food to children must be scaled back.
"You can educate kids in school about the problems with drinking too many sugary, sweet beverages and eating too many snacks," she said, "but if they then walk into the hallway to see vending machines with ads all over them selling soda and selling candy, it's such a mixed message that it's hard to say how well the education can then work."
Though the future of obesity in Arkansas — and the entire U.S. — seems uncertain, those who have invested their energy there said they aren't giving up hope.
"I want to be the first state that has clearly showed we have reversed the epidemic," Arkansas Surgeon General Joe Thompson said. "And I think we have the pieces in place to do that."