As a society, we often blame weight problems on poor eating habits and a lack of willpower. But when families have neither access to nutritious food nor the resources to buy it, healthy meals are a luxury they can’t afford.

Gena L. Lewis, a pediatrician at Children’s Hospital and Research Center in Oakland, CA, should know: many of the children she sees every day are both overweight and chronically hungry. GreatSchools caught up with Lewis and asked her to talk about childhood obesity and how parents and educators can make a difference.

First: stop thinking of weight as a personal choice

Can you explain the link between poverty and obesity? I’m not sure it’s well understood.

I think you’re right, because it’s a difficult concept to understand.

We tend to think about weight as a personal choice: we assume that people make the choice to eat healthy food or to eat junk food. In reality, in this country, it costs more to eat healthy food than it does to eat junk food.

Fast food is easily accessible and it’s filling, but there are many more fat calories than in fresh fruit and vegetables. But fresh fruit and vegetables cost more. Many families don’t have the money to make healthy food choices. So they buy bulk processed food so their kids don’t go hungry. I see that in my practice all the time.

The accessibility factor is huge: families living in poverty often don’t have access to markets that sell fresh produce. When I’m working with medical residents, I ask them to drive through the neighborhoods where our families live. In East Oakland, for example, there are no markets for fresh fruits and vegetables, there are only liquor stores, payday lenders, and corner convenience stores. My patients tell me that when they can find fruit in the convenience stores, it’s often old and moldy. Many don’t have cars, they walk or take the bus. After work they rush to get their kids from childcare. They don’t have time or easy access to large supermarkets outside the neighborhood.

This comes as a shock to people who live in areas with ready access to big grocery stores that offer lots of fresh fruits and vegetables. In poorer neighborhoods, you aren’t going to see that kind of diversity of food options.

So access is a huge issue, and money — how much it costs to buy healthy food — those two issues get in the way of families being able to make healthy food choices.

Hungry and overweight

What about the kids you see in your practice who are hungry and also struggling with weight issues?

Unfortunately, I have many patients in this situation; it’s a problem I see every day. All the pediatricians I work with are dealing with this issue, and it’s really scary to us.

One of my patients is a morbidly obese teenager. She has many other health problems — diabetes, chronic back pain, reflux, joint pain. These are problems you’d expect to see in a middle-aged person with weight problems. She weighs over 300 pounds.

Her mom tries to buy the right kind of foods. She really wants to do the right thing, but by the end of month she’s running out of money. This mom is incredibly frustrated: she wants her daughter to be healthy, but she feels like she doesn’t have any option but to make bad choices. At the end of the month, it’s often a question of eating unhealthy food or going hungry.

There’s a lot of judgment in this country about weight, and some people might say, well, if this girl is morbidly obese, it might do her good to go without a few meals. In fact, the opposite is true: skipping meals causes your body to hold on to weight. When you skip meals, your body’s metabolism feels threatened with starvation. People with weight issues shouldn’t skip meals. You need to let your metabolism know that your body can afford to lose weight by eating regular meals.

Better bad choices

How should families facing these kinds of economic challenges tackle weight issues?

I’m a realist, so if healthy food isn’t an option, I encourage families to make better bad choices. For example, I counsel patients to avoid soda and juice if they only have a little money to get through the end of the month. If it’s a choice between buying a bottle of cola or a loaf of white bread, I advise them to choose the white bread. It isn’t a great option, but it has more nutrients and better calories than soda or juice.

I encourage parents to look for foods that are good value. We talk a lot about reading labels and looking for cheap food that has lots of fiber and protein. For example, beans and legumes have more nutrients than white potatoes or Top Ramen noodles, they’re cheap, and they’re also more filling and nutritious. Dense processed carbohydrates are the worst in terms of nutrients. They give your blood sugar a quick spike, and then you’re hungry again. That’s why sugared cereal is not a good choice for breakfast. If you give that to kids they’ll soon be hungry again. Oatmeal will stick with them a lot longer.

I tell patients to check labels and to look for foods with over three grams of fiber and five grams of protein. In some cases, it’s possible to find food that’s better for you and cheaper than junk food, even if it’s not fresh fruits and vegetables.

Talking about weight

Kids who are overweight face a lot of teasing and bullying in school. How should parents talk about how to treat kids with weight issues? Should they point out the connection between poverty and weight?

Teasing and bullying is a huge issue for kids with weight issues. Some of my patients are so ashamed that they don’t even want to tell me about the bullying they face at school, and they don’t tell their parents.

There’s research showing that kids who are overweight get shunned more than kids with other disabilities. One study, for example, found that when kids were  picked for games, obese children were picked last, after the child with the cleft palate or the child in a wheelchair. This indicates that kids are getting the message that you should have empathy for children with disabilities, but not for kids struggling with weight issues.

I think it’s important for parents to talk to kids about weight, and how you treat kids with weight issues, but how you talk about it depends on the child’s age. I don’t think parents should raise the poverty issue with young children, because this could confuse them. When kids are in high school, yes, I think it’s important to educate kids about all kinds of social inequities.

With younger kids, I think it’s better to keep it general. Parents need to explain that everyone is different, and that this is okay. If a child says something negative about an overweight child, it’s important for parents to convey the message that the overweight child is a special, wonderful child in his or her own way. The parent can ask, “I wonder how that child feels about everyone picking on him? How would you feel if you were in that situation?” The same way you would talk to your child about how it might feel to be in a wheelchair.

I want all kids to get the message that they can feel good about themselves and good about their bodies. Even if someone has tried to shame them, I want them to have the confidence to still feel good about themselves.

It’s important for parents and teachers to talk to their own children and to students about ways they think they are great. Every child needs to find at least one thing she thinks is great about herself — something that has nothing to do with how she looks. What’s important is what’s inside you, how you act toward other people, how you work and play. Educators talk about this when addressing issues of skin color. It would be great if we could do this about diversity of body type, too. Because once your community is accepting, it’s much easier to make a positive change. It’s really hard to change if you feel badly about yourself.

I see more teachers talking about nutrition and healthy food, and I think they can have an important impact. Just like the issue of seat belts: kids hear all the time that it’s important to buckle up, and they get it, they point it out if an adult is driving without a seat belt.  This is beginning to happen with nutrition and food issues. These ideas are percolating through the general culture. Educators can play a huge role in decisions kids will make later on.