MUSKEGON, MICH. — Try one of these, says Patti Moran, a drug pusher who operates in a large, humid hut covered by a thick plastic tarp and smelling strongly of dirt. Accepting the dare, I pluck the lurid green item from her hand and put it my mouth. In just a few seconds, I start to feel its effects. I've just ingested a leaf pulled off a mustard plant growing at our feet, and I'm thoroughly enjoying the mild wasabi-like burn working its way up my sinuses.
The hut serves as a greenhouse, and it sits in the middle of a 2-acre microfarm right on the grounds of Mercy Health Hospital. It’s not an exaggeration to call this a drug factory: Soon, some of the patients leaving the hospital will come straight here, clutching a prescription from their clinicians for freshly harvested vegetables. Most of the patients will be diabetics or pre-diabetics, but they might also be at high risk for heart disease, or for knee replacement—ills that are exacerbated or even caused by excess weight and poor diets. The vegetable Rx, which doctors will begin adding to some patients' treatment plans in August, will be a small but important step toward reclaiming their health.
Moran’s prescription greenhouse is just one of a growing matrix of initiatives that are already starting to change attitudes and lifestyles in this rural, Middle American community. Muskegon County has struggled with job loss, large pockets of poverty, and the raft of health challenges that afflict a disproportionate number of American towns far from the coasts. Some of the biggest of these health challenges largely boil down to obesity—a problem that vexes the entire nation and has become particularly acute throughout the Midwest and South, especially in less affluent communities that, like Muskegon, are far from big cities.
What frustrates doctors and public-health experts about obesity is that we know how to fix it: Eat less and exercise more. But for the great majority of the roughly 200 million Americans who are overweight, it proves nearly impossible to keep that up for the years and decades required to have long-term health benefits. The reason is found all around us: Most Americans live where sugar- and fat-laden foods are ubiquitous and cheap, while healthy meals are neither; where the people around us tend to eat carelessly and eschew exercise; where everyone drives instead of walking and takes the elevator instead of stairs. Our communities exert a sort of gravity over our weight-related behavior, dragging us back to our old habits whenever we try to improve them.
But if communities are the problem, then perhaps they're the solution, too. Muskegon intends to find out. Embarrassed to be named the least healthy county in Michigan in 2011, Muskegon is trying something quietly radical: turning the small cluster of towns in the county into a multifaceted support network to help people make healthy changes that stick—like losing weight and keeping it off.
It’s one of a handful of similarly fitness-resistant communities across the U.S. in which a new approach is slowly taking hold. With roots in evidence-based medicine rather than diet fads, it's an approach that focuses help where it's needed, is driven by a broad coalition of community members, and looks to gradually grind out solutions by seeking tiny victories that can be aggregated and amplified. The goal is to form a web of interventions that successfully nudge, tempt, bribe and even scare people into sticking with new, healthier habits. The approach offers hope of accomplishing at the community scale what policymakers despair of getting done at the scale of an entire nation. These unflashy, slow-but-sure efforts are in their early stages and have received little attention in the press. But they are being carefully watched and nurtured by some influential national players.
One program, in particular, aims to thoroughly test that premise and turn towns like Muskegon into nationwide models for changes that work. Called The Way to Wellville, it was founded by the noted angel investor and futurist Esther Dyson. The project is assisting in the planned healthy-lifestyle transformation of five obesity- and health-challenged counties and cities across the country. Muskegon competed with more than three dozen other American communities to win a slot among the five Wellville pilot communities. Now, while most of what's happening in Muskegon is driven by the county itself, it's also getting a stream of crucial advice and feedback from a high-profile influencer and her team. That's a resource that wouldn't normally be accessible to a struggling rural community, and it could make enough of a difference to enable Muskegon to establish a badly needed precedent for success.
I visited Muskegon to get a look at how the project is coming together. It's far too early to gauge results. But I wanted to see what it's like when a community decides it needs a life-saving change in behavior—and decides to turn itself into an experiment.
ANYONE WHO READS the titles in the checkout stand knows there are plenty of faddish options for people hoping to trim some weight: Cut out carbs! Fast twice a week! Be a part-time vegetarian! Eat like a caveman! These sorts of claims have been around for more than a century—the low-carb craze alone dates back to the 1800s. And they have continued to be wildly unsuccessful against the aggregate public-health problem of obesity. Eleven years ago, only two states had obesity rates higher than 31 percent. Today, exactly half the states have obesity rates of 31 percent or higher. Most of the rest aren't far behind.
It seems the more we know as a society about what it means to eat well and exercise, the fatter we get. The message isn't complicated—eat less junk food, more fruits and vegetables, move around—but it barely registers as background noise in the heartland communities that most need to hear it. Some communities were almost literally up in arms when Michelle Obama tried to get them to add an apple to their kids' school lunch plates.
In Muskegon, as in any community, food can't be separated from culture. I'm reminded of that fact when I sit down with Juan and Nancy Gardiola as they enjoy a hearty lunch at Carmen's Cafe. Their table affords big plate-glass views of the flat, pleasantly drab streets of Muskegon, which are dotted here and there with almost-hip coffee shops and upscale stores, but also with abandoned warehouses and vacant lots. Nancy, 55, is working on a giant hot dog smothered in fixings, and Juan, 63, is tucking into a loaded hamburger, each embedded in thick buns and snugged up against impressive piles of fries.
Not exactly health food. And, unfortunately, the affable Gardiolas need all the health help they can get. Nancy, who works at a former battery manufacturer nearby that now repackages Chinese-made batteries, has had three operations on her back; Juan, a retired industrial machine technician, has had three heart attacks. Juan gets free care at a VA hospital, but one of his heart attacks landed him at a local ER that left him with a $2,000 bill; lately, his blood-pressure readings have been varying wildly. Nancy has health insurance but has no idea what her health stats are. That's because with a $3,000 annual deductible, she avoids routine care or checkups. "I'm afraid to see the doctor because of how much it will cost me," she says. Neither of them exercises, though Juan says he does work around the yard.
The food and the chatter is altogether different at the Rotary Club meeting at the Holiday Inn across town. Here lunch is a big salad bar and tub of white-meat chicken. At the podium, tucked in among the high-school leadership awards and new member introductions, the action includes Green Apple awards to two members for achieving healthier lifestyles. But the talk here among members isn't about their own fitness. The Green Apple program was started to get members interested in a much bigger, more ambitious one: a plan to get the entire county healthier through lifestyle change—including people like the Gardiolas, as well as the thousands who couldn't afford to eat at Carmen's, let alone join the Rotary Club.
The Rotary Club may not get a lot of attention in Boston or San Francisco, but in Middle America it's a concentration of local influence, bringing together leaders from business, schools, religious congregations, government and health care systems. It's not a bad choice for driving a communitywide effort. In particular, the Muskegon Rotary Club's "1 in 21" program emerged from the shame and worry that came with the release of the 2011 rankings of county health in Michigan, a state that is itself not terribly high on health lists. The program defined itself through a goal of getting Muskegon recognized as the healthiest county in the state by 2021—that is, No. 1 by '21.
I sit in on a meeting of the 1 in 21 leadership, attended by nearly two dozen of the many project champions that come from every segment of Muskegon life. One of the more forceful members is Jim Fisher, a fit-looking 71-year-old who runs a scrap-metal-recycling business. Fisher, who was president of the Rotary Club at the founding of 1 in 21, explains how his own healthy-lifestyle conversion 10 years ago inspired him to work to get the county into shape. "We're trying to create a movement that will keep ratcheting up the message until everyone wants to do something about it," he says.
The ratcheting happens not through any big action on the part of 1 of 21, but rather through many modest ones by different groups in the area. The 1 in 21 program serves to set overall goals and coordinate the effort, via meetings like the one I attend. "We have a shortage of resources in this county," says Jamie Hekker, the nominal head of the program, as well as an official at the county public health department. "But a bunch of us met and said, 'Here's what we got, what can we put together?'”
ALSO AT THE MEETING is a smallish woman with darting dark eyes and a near-constant look of bemusement, and whose body language suggests she's torn between pitching into the conversation and slinking into the background. This is Esther Dyson, the well-known high-tech angel investor, and one of a small number of people in the world who can credibly list "futurist" on their CVs. It's easier to picture Dyson flying over Muskegon between alternate-coast meetings at Google and iRobot than eating at the Holiday Inn here, where the hot company in town was bowling-ball manufacturer Brunswick until it closed down the factory a few years ago. But Dyson is personally, if not financially, invested right up to those darting eyeballs in Muskegon, as well as in the four other moderately sized, moderately struggling cities across the U.S. that compose the Wellville lineup.
Dyson's involvement in biotech startups led to an interest in health, which in turn led to the realization that getting the obesity problem under control would probably do more for population health than any series of breakthrough drugs. Too smart and pragmatic to slide into the cesspool of fad solutions, Dyson followed the trail of science-backed obesity approaches to what others have tended to see as a dead end: It's frustratingly hard to get people to change their eating and exercise habits. (Dyson herself eats like each mouthful is being graded by a nutritionist and swims most mornings, leaving her with the wiry build of a Manhattan yoga instructor.) But there's one proven way out of the dead end: As Weight Watchers and weight-loss clinics run by medical centers like those at Duke and Northwestern universities have demonstrated, people are much more likely to make the changes and stick with them if they're willing to embed themselves in a supportive environment. Could an ordinary community be turned into a sort of real-life weight-loss clinic, so that the embedding happens automatically?
Dyson formed the Way to Wellville project in 2014 and quickly realized that the chances for effecting change were small if the communities in the project didn't have the motivation and means to make it all work. So she asked cities to compete to be selected. Forty-two did. Muskegon's middling size of 170,000 was one selling point in making the cut. "Foundations usually fund programs in big cities with big problems, like Newark," she says. "But we can make a bigger difference in a city like Muskegon."
The Wellville communities get expertise, encouragement, connections and organizational support from the Wellville team. "Things happen when someone's in charge, and there's a plan and a budget," explains Dyson, who tends to speak in irregular bursts, like she's emitting data packets. "We can help provide clarity of goals, and business discipline." The communities get no actual money from Wellville, and Dyson insists that's a big part of the point: Anti-obesity efforts are usually grant-driven, and grants dry up, along with project impact and opportunity to scale. Dyson pushes her communities to figure out how their efforts will be financially sustainable.
As a result, Dyson and her Wellville team don't actually run anything in Muskegon. But they help 1 in 21 coordinate and inform the various efforts that have sprung up in the community to foster healthier lifestyles and cut obesity. The efforts are wide-ranging. For starters, Muskegon is trying to connect as many people as possible to the local health care system. Fully on board is Mercy Health, the main health care provider in Muskegon County and the dominant provider in West Michigan. Mercy spends some $4 million a year in the area placing health care workers in the Muskegon community to provide outreach services, a program called the Community Health Project.
Many of these services are focused on identifying and helping people who need health-related lifestyle changes, including bringing them into the system for care, and providing education in the community. "We're changing our internal culture to learn what we have to do with patients to move the needle for their all their health needs," says Roger Spoelman, a Muskegon resident who is the CEO of the West Michigan Region for Mercy Health's parent organization, Trinity Health. Spoelman adds that any investment made in fending off obesity and the attendant risks in obesity and heart disease are likely to pay off in reduced long-term health costs—and hospitals are increasingly being paid by health care plans not for providing more treatment but for keeping patients healthier and cutting costs. In fact, U.S. government and other studies have repeatedly shown that healthy-lifestyle coaching programs cost about $7,000 a year per patient less than treating unhealthy-lifestyle patients, and return to the health care system $2,600 per patient more than they cost within 14 months.
To make sure more people can be touched by the health care system, the community formed a coalition called Access Health to negotiate a full health care-coverage plan with Mercy Health for those who can't afford other plans, costing $120 a month. An integral part of the plan, which currently covers some 1,200 people, is requiring obese and other participants with lifestyle-related health risks to attend coaching programs similar to the Y's. "Regular health care-plan providers don't want to touch this population," says Access Executive Director Jeff Fortenbacher. "But by focusing on prevention, our program keeps patients from costing the system nearly as much as they would if they showed up sick at the emergency department door." Mental health is covered by another program, Resilience Muskegon, which was formed to identify and offer support to people who suffered any of a range of childhood traumas, and to link that support to help in overcoming the unhealthy lifestyles that may have come out of it.
The schools are another prime target for intervention, since obesity now tends to take hold in childhood. The county has brought in a health coordinator to help remake its food offerings, and it consults with Mercy Health for advice and ideas. County Superintendent John Severson has personally been involved in the efforts, and he recognizes that it takes more than simply replacing less-healthy food with a healthier version. "It's hard to get to get kids to make an extreme change in what they eat," he says. "So we're just trying to expose them to healthier food that's also fun." One healthy item that's been a hit: smoothies. Another program sends 900 students from low-income families home every night with healthy suppers in bags.
Virtually everyone in the obesity field agrees that reliable lifestyle-change advice has to be made available out in the community, and not just in hospitals and doctors' offices. The local YMCA has played a lead role here, spinning off its workout facilities and focusing instead on providing a coaching program aimed at the 39 percent of the Muskegon County population that's pre-diabetic. (Pre-diabetes risk tracks so closely with obesity that the two are regarded as nearly equivalent by the medical community in terms of how they're addressed.) The Y delivers its yearlong program at more than 20 sites in the community, with participants typically losing 5 percent to 7 percent of their body weight in the first 16 weeks—after that, the focus is on maintaining that loss. Studies show that nearly 60 percent of pre-diabetic participants in programs like the Y's avoid progressing to diabetes. In addition, some 650 schoolchildren enrolled in the Y's 2016 summer program addressing obesity and healthy lifestyle, the largest attendance of any Y in the state offering the program. "A fitness center is a commodity," says Bruce Spoelman, who runs the Muskegon Y (and who is the brother of Mercy Health's Roger Spoelman). "Lifestyle coaching is a way to have a bigger impact and fill a greater need."
And there's access to healthy food. As Juan Gardiola puts it: "I might eat more vegetables, but they'd have to be good food, not something boiled from a can." Getting higher-quality healthy food has been a challenge for many in Muskegon, which a few years back was declared a food desert, according to USDA standards. But a program called Healthy Muskegon has been moving toward making fresh produce available to everyone in the county, by helping small farmers in the region get their products to farm stands and local restaurants and other institutions, as well as by assisting in starting community gardens and setting up healthy-food delivery vans. The program is also running the "prescription food" program on Mercy's campus, which is starting in August on a pilot basis. Patients with a prescription will not only get fresh-grown food, they'll also get a free cooking class at the local community college. "We're going to measure what these patients eat, how it makes them feel, and what happens to their health numbers," says Moran. "That way we can figure out which foods are the most popular and also do the most good." The program is currently capable of growing enough food to handle a few hundred patients, and when more patients join in the program will recruit local farmers to help supply the produce.
Exercise is covered a number of ways, too. The massive Lakeshore Fitness Center at Muskegon Community College already works with some health care plan providers to offer free visits to covered members, and is negotiating to get more plans on board. It's also gearing up to be certified as a medical fitness center, so patients can be given prescriptions for fitness sessions covered by insurance. In addition, a variety of groups around the county have embarked on programs to create, maintain and promote safe walking, running and biking paths, and to spruce up and highlight building stairways so more people will choose them over elevators. One counseling center even provides exercycle-like attachments to some of the chairs in its waiting area.
THE MUSKEGON COMMUNITY'S earnestness and breadth of buy-in is impressive. But is there much reason to think the changes will work in turning obesity trends around, given how stubborn a problem obesity has proved so far?
Muskegon is betting on an approach that, in one sense, is a proven winner: Study after study has backed the notion that by far the best route to long-term weight loss is lifestyle changes aimed at reducing calorie consumption and increasing physical activity through education and personal support. (Surgery and drugs can be effective as well, but carry outsize costs and risks.)
But extending this sort of approach throughout an entire community is a new challenge. Community behavior-change efforts, if they make ripples at all, tend to appear as either controversies or nuisances—sugar or junk-food taxes, or vegetable subsidies, or requiring calorie counts at restaurants. Such isolated efforts can be mildly helpful if properly implemented, but in and of themselves typically have little or no impact on long-term behavior change. What makes the Muskegon approach so potentially important is that it is one of the first efforts to bombard the population with an ongoing, broad stream of effective opportunities, nudges and supports. "Whatever door someone in Muskegon walks through, we want that person to be reminded of what they need to do, and to get encouragement to do it," says Fortenbacher.
Pulling large numbers of people into these efforts, and getting those who do participate to change their habits, is a slow slog that's barely getting started. So admits Jim Fisher, the otherwise gung-ho former Rotary Club president. "Getting to be No. 1 in health in Michigan by 2021 is looking like it might be a little ambitious," he says.
But the approach has garnered enough credibility to have spilled beyond the Way to Wellville project to other struggling communities. Scranton, Pennsylvania, for example, has been similarly pulling together resources in a concerted effort to reduce obesity and boost lifestyle-related health, with assistance from Geisinger Health System, the dominant hospital system in Pennsylvania. One Geisinger-run program there provides diabetes patients with a full array of ongoing lifestyle-improvement consultations and services at no cost, including the free weekly provision of enough healthy food for every meal, every day—not just for the patient, but for the patient's family, too.
Most patients lose 20 to 40 pounds on the Geisinger program, which is adding 50 new patients every month and is likely to be scaled up. "As a big health care provider, we have more clout and resources than others in the community to make these things happen," says Geisinger CEO David Feinberg. "With a $41 million budget for food in our system, we can afford to give away some of it." Diabetes patients are, of course, a sweet spot in this sort of intervention, with Geisinger saving about $7,000 a year per patient on lowered treatment costs. But Feinberg says the hospital system plans to roll out a range of programs and services that will ultimately directly impact some 76,000 people in the Scranton area.
Technology, meanwhile, is positioned to further drive the growth of community-based lifestyle-change programs, and a handful of startups have moved into the space. A Phoenix-based company called Solera works with some 1,300 organizations that provide coaching directly to people in the community, helping them to get reimbursed by health insurance companies, Medicare and Medicaid. "Delivering these programs through physicians in the hospital overburdens the medical system," says Solera founder and CEO Brenda Schmidt. "But community providers have trouble integrating into the referral and payment system and getting access to patient health care data. That's what we can help with."
Phrql, a startup based in Pittsburgh, is doing roughly the same, but it is targeting solo dietitians who provide coaching right in supermarkets. "You shouldn't have to go to a hospital to get nutritional info any more than you should have to there for exercise," says CEO Paul Sandberg. "Better to get it right where people are making their food decisions." Phrql-connected dietitians have coached some 100,000 consumers, who are losing an average of half a pound a week—just the sort of gradual weight loss recommended by experts. Other high-tech startups are making it even easier for the obese and overweight to get into community programs, by creating virtual communities and offering personalized coaching and monitoring online. Omada Health in San Francisco has placed more than 90,000 people into online groups matched by location, interests and health needs. Dyson thinks enough of Omada to have invested.
Muskegon and other communities trying similar approaches aren't yet far enough along to prove these programs hold the key to solving the obesity crisis at scale. But moving slowly isn't a sign of trouble—it's a key characteristic of the approach. "We're going for culture change, and it can take generations to get all the way there," says Fisher. "We're focusing on process," he says.
Even aside from the truism that a long journey has to start somewhere, there's reason to believe that the slow going could give way to rapid acceleration when participation reaches a critical mass. That's in part because there's a network effect in behavior change—if enough people change their behavior, the people around them are far more likely to change theirs, too. What's more, notes Dyson, growing participation among her Wellville communities might give her enough leverage in a year or two to approach big food companies to get them to offer healthier menus in those communities, which could further accelerate change. "We want to get to a point where Wal-Mart and PepsiCo and McDonald's can actually make more money by selling stuff that's good for people," she says. The goal is to take it from a web of nudges and start-up firms to a philosophy that's simply woven into American business and life.
After all, even Carmen's offers a veggie burger. Someday, the Gardiolas may learn to love it.
David H. Freedman is co-founder and Executive Editor of Global HealthCare Insights Magazine, and a contributing editor at The Atlantic. His most recent book is "Wrong: Why Experts Keep Failing Us."