Vaccines, boosters, and an array of medical advances have brought a sense of relief across the commonwealth as the threat from COVID-19 recedes.
Music lovers go to concerts, worshipers attend services, and travelers stand in line again at airports with the abandon they had before they'd ever heard of an animal market in Wuhan.
But another health crisis looms in Virginia. While we were social distancing, kids and teens not only grew restless, depressed, fearful and bored. They also grew more overweight and obese, according to preliminary studies and anecdotal evidence that doctors see in their clinics.
Already on an upward trend with nearly 15% of Virginia teens having obesity in 2019, doctors, dietitians and health experts are worried that the pandemic increased teen obesity rates. Many are waiting anxiously for the latest data from the Virginia Youth Survey, due within the next few weeks, to see the extent of the damage.
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And, while final numbers are not yet available, preliminary numbers suggest that the gains weren't just in teens, whose struggles during the pandemic have been well documented.
Some of the largest spikes in weight gain were in 3- to 5-year-olds, according to an unpublished study currently under peer review. In addition, spikes also occurred Latinx and Black youth from low-income households, groups already experiencing higher rates of obesity.
"The trends were there, and COVID accelerated them," said Dr. Catherine Varney, an obesity medicine specialist at the University of Virginia. Increased screen time, separation from friends, being at home alone while school was not in session, depression and anxiety are all contributors, Varney and others said. "We've got to turn this around for the kids."
With National Childhood Obesity Awareness Month underway, doctors, nutritionists and researchers who specialize in childhood obesity are worried. The human toll of obesity is well-documented -- type 2 diabetes, heart disease, joint disease, stroke and life spans shortened by up to eight years.
The financial costs are also devastating. Those who have obesity typically face twice the health care costs in a given year as those who do not have obesity. Societally, obesity nationally costs as much as $260 billion annually, by many estimates. In recent years, it has shown the potential to harm national security -- only two in five young adults are physically ready for basic training in the military, according to the Centers for Disease Control and Prevention.
But childhood obesity has a particularly disturbing consequence, experts said. It cheats children out of the joys of childhood and the potential for a happy future.
"We can't sit on our hands and not do something about this," Varney said.
Progress 'chipped away'
Dr. Jamie Zoellner, an obesity researcher in the department of public health sciences at the University of Virginia, was the principal investigator of the unpublished study on childhood obesity in Virginia that is currently under peer review.
"We have shared in a non-formal way that all of the progress we made in the past ten years was chipped away by COVID," she said.
That progress already was mixed across the country and within the state. For example, a 2021 study showed that almost 25% of Hispanic, non-Hispanic Black kids from low-income households at the beginning of the pandemic were obese, compared with 11.3% of non-Hispanic white youth who were in the highest income group. In Virginia, some of the highest rates of obesity are among the rural poor in the southwest part of the state.
That gap, while one of the biggest concerns of experts who study, prevent and treat obesity, is no surprise to people who work with children whose parents are poor.
"In a matter of days, your lower income people lost their childcare, two healthy meals a day for their kids, and sometimes their jobs," said Jessica Jones, a youth pastor who works to establish healthy lifestyles among the youth at her church in Lawrenceville.
Among the states, Virginia has ranked somewhere in the middle over the years that the CDC has tracked obesity data among children. But different areas of Virginia are affected more than others, according to the Virginia Department of Health. For example, rural western Virginia has higher rates of childhood obesity than northern Virginia.
And, different ethnic and racial groups have varying rates of obesity among children, with Latinx youth having the highest rates of obesity, followed closely by Black youth.
Those higher rates are not due to biological differences, experts said. They are related to lower income, lack of access to nutritious food, and a shortage of walkable and safe neighborhoods that these racial groups and ethnic groups experience — many of the same structural issues that plague people without money across the U.S.
That said, causes for obesity among children are varied and complex. Yes, it's about calories and energy expenditure, but not every body metabolizes calories in the same way.
On the calorie side, Virginia experts cite the mass production — and marketing — of high-calorie food that is cheap to produce and therefore more affordable to low-income people.
"And less expensive foods are also less healthy," said Dr. Mark DeBoer, professor of pediatrics in the division of pediatric endocrinology at UVa.
Another contributor to obesity is sugary drinks, which have no nutritional value but as many as 12 teaspoons of sugar per serving — and hundreds of millions of advertising dollars behind them each year to reach broad audiences, including children. A 12-ounce can of Coca-Cola or Pepsi, for example, has 10 teaspoons of sugar, according to the CDC.
A few U.S. cities, such as Berkeley, California, and Boulder, Colorado, levy a per-ounce excise tax on drinks sweetened with sugar, but no state taxes sugared drinks this way. Virginia does have gross receipt taxes on wholesalers who sell bottles of soda.
An inactive, screen-dependent lifestyle another contributor, said DeBoer.
"We have created a lifestyle where we avoid moving, we have little screens that entertain us, which also provides them (children) with an opportunity to eat while they're being entertained," said DeBoer.
Screen time also causes sleep problems, which also contribute to obesity.
Doctors also stress that genetics plays a role, which many people know all too well.
"You can have the same two people eat the same diet and watch one gain weight and the other not," said Varney. "This is all very complex, and there is no one treatment that works for everyone."
The shame and blame game of obesity
In addition, there are often ethnic and cultural barriers to overcome. Those who work in areas of high childhood obesity tailor the messaging to meet people where they are and within their cultural context and comfort, Jones and others said.
"So if you say to people in a rural area to exercise more, and there are no sidewalks to walk on, or you're telling this single mama with three kids to join a gym, and she barely has the money, that's not going to work," Jones said.
Kathy Hosig, director of the Center for Public Health Practice and Research at Virginia Tech, said that even using certain words, such as obese or obesity, can lead people to feel shame. When those words were mentioned at a community get-together, the negative reaction was immediate.
"They would step back and put their hands over their abdomens," Hosig said.
Complicating the treatment of obesity are long-held views that people who have obesity are lazy or lack will power.
"There's certainly a widespread stigma," said Michael Parsons, director of programs for the Virginia Foundation for Health Youth. Many parents contacted for this article did not want to talk for fear of exposing their children to bullying, they said.
The Virginia Foundation for Healthy Youth, funded by the Master Settlement Agreement with tobacco companies in 1999, is the state agency responsible for funding childhood obesity programs. It receives 8.5% of the MSA allotment that goes to Virginia each year, Parsons said in an email.
Individual people should not be singled out, Parsons said. Treatment and prevention should be done with community support, with people pulling together to help kids.
"We want to do this alongside families, not doing things to people, but with people," Parsons said.
Turning the tide
Toward that goal, hundreds of adults and dozens of programs across the state are working to reverse the trends, including in school systems across the state.
Hosig, for example, oversees $500,000 grant from the CDC to test prevention techniques in Petersburg. As part of that grant, program coordinators and community leaders in Petersburg are working with retailers, food banks and corner stores in town. The program opened a fresh food market at the Petersburg Public Library. She said he is encouraged by the response, she said.
Other programs bring together parents, churches and other places of worship, schools and after-care programs together to help inform adults who take care of kids about how to make healthy choices.
Many are community programs across the state to educate kids and parents about healthier choices, such as choosing water instead of soda or sweet tea, choosing whole grains and vegetables instead of packaged food, and being more active instead of sedentary.
The kids at Jones's church in Lawrenceville eat it up, she said. She believes one reason the kids like the learning so much is that classes on healthy choices are taught by adults in the church.
"Our babies get taught by faces they know," said Jones.
The church also offers exercise and dance programs to get kids moving.
In Charlottesville and other cities, VFHY has partnered with YMCAs to help increase activity among kids. It also utilizes peer volunteers in schools to promote water as a healthy beverage.
Schools across the commonwealth are also working to curb the trend. Many have fresh vegetable gardens so kids can learn where food comes from. Cafeterias have re-evaluated their offerings. And physical education teachers are committed to showing that physical activity is fun.
While the educational and community components are important, many said that slowing down childhood obesity will take more than information and education. That can mean medical care and oversight from experts trained in obesity. It also means policy changes, some said.
UVa opened the interdisciplinary Children's Fitness Clinic 2003, bringing together pediatricians, dietitians, endocrinologists and exercise experts for comprehensive treatment of children with obesity. As with the community programs across the state, the clinic always involves the parents, teaching them substitutes for snacks — including how to choose less expensive and less perishable fruit, such as apples, instead of something that won't last long in the refrigerator, such as raspberries.
"Parents are really eager, but often frustrated," said Dr. Christine Burt Solorzano, director of the clinic and a pediatric endocrinologist. They have often tried so many things that they are at their wits' end by the time their children are patients at the clinic.
A mother of a 14-year-old, who asked to be identified by her first name only to prevent her daughter from being bullied, knows that feeling. Elizabeth became overweight in her teens and became an adult with obesity.
She has learned healthy eating patterns — she works in health care — but obesity for her and her teenager seems to be more genetic than anything else.
"She doesn't eat Twinkies or drink lots of soda or eat ice cream," said Elizabeth. But during the pandemic, her daughter took to her bedroom and hid from the world. In the process, Elizabeth estimates that her daughter gained 40 pounds.
"I tried so hard so she wouldn't have to go through it, too," she said, fighting tears. "It makes you feel like a failure as a parent."
Having gone through her own overweight and obesity conditions, Elizabeth said she knows the basics — move more, eat less. But it doesn't always work, she said. And when it doesn't, there's not a lot of help.
"I try to help her, but the system is not set up to help us," she said.
Many experts said they think that public policies and systems need to change. Zoellner cites the United States Preventive Services Task Force 2017 study that showed that 52 hours of interventions — in other words, meeting once a week for a year with a counselor, therapist or dietitian — yielded results in children with obesity. But that high standard is nearly impossible for families to meet, much less those with low income and no transportation, she said.
"It's really hard to get parents to adhere, and to find time and transportation when they don't have money," she said.
Such findings are disappointing, Zoellner said. She isn't about to give up, she said, but the results do lead her to believe that policy makers will have to step in to stem the childhood obesity trends in Virginia. She and others cite the biggest public health success in U.S. history — a turnaround in smoking and tobacco usage — as an example of the role that legislators can play. Higher cigarette taxes and municipal smoking bans slowly brought down rates of cigarette smoking, the number one cause of preventable death in the U.S.
In addition to possible legislation to limit the sales of sodas and sweets in schools, others call for more research and better training in medical schools on obesity to change attitudes and to reverse the trend lines. Perhaps above all, some said, a little bit of compassion and understanding for kids who struggle with obesity would help.
"I'd just love to see us working on the whole stigma thing," said Elizabeth. "I know we've got our cancers, Lou Gehrig's disease (ALS), but kids with obesity deserve our concern, too."
UVa's Varney agrees that there's a lot of work to do. For her, one of the most pressing needs is for Congress to approve reimbursements for treatment of obesity for a broader range of specialties, and also to approve reimbursement for FDA-approved medication that can be useful in many children.
"We can't sit on our hands and not do something about this," Varney said. "We're kidding ourselves if we think it's going to get any better on its own. We've seen what happens in with adults. Now is the time to do something to help the kids."