Louisville:
This city's Broadway displays its own array of neon signs -- two dozen fast-food restaurants, as diverse as McDonald's and the local Indi's -- beckoning along a 2.8-mile corridor bookended by low-income neighborhoods on the front lines of a multimillion-dollar battle against obesity.
The street symbolizes one of many hurdles facing officials here working to put a severely overweight population on a diet. After all, Kentucky is where Colonel Harland Sanders first made his famous fried chicken and a hotel invented the Hot Brown, a turkey-bacon sandwich drowning in Mornay sauce.
In many ways, Louisville's experience in fighting obesity is little different from that of a dieter stepping on and off a scale. Successes on one front are countered by setbacks on another, and signs that the needle has moved overall are slight and mostly anecdotal.
More than six in 10 people in metro Louisville are still considered seriously overweight, in a state that ranks seventh in the nation for obesity. The rates continued to rise through 2008, while the percentage of the population reporting any physical activity outside of work fell despite public campaigns advocating more walking and biking.
More recent developments underscore the tug of war over food and weight. On one hand, KFC has announced plans for its first nonfried menu, alongside leaflets listing the calorie, fat and salt content of its entire line (as required by the new federal health act).
Behind the scenes, its corporate parent, Yum Brands, was quietly lobbying the state government to turn Kentucky into one of the few states that allow the use of food stamps in its restaurants, which include Pizza Hut and Taco Bell, according to documents unearthed by The Courier-Journal newspaper in Louisville.
"It turns my stomach, the push for using food stamps for fast-food purchase," said Dr. Adewale Troutman, director of the public health practice at the University of South Florida. "It makes the unhealthy option the easier one."
As director of the Louisville health department until last fall, Dr. Troutman presided over a campaign that has come to involve nearly every city agency, from the mayor's office to the sewer department.
The city's efforts to combat obesity, how and where it is spending money to fight it are instructive at a time when federal dollars are becoming more scarce and budgets are pinched. Cities are increasingly vying for nonprofit and government financing now available as concerns about the obesity epidemic have been underscored by Michelle Obama and others.
To obesity warriors, trying to assess how best to spend the money and demonstrate progress may not be clear for 10 years or more, prompting calls for patience.
"The changes to our physical and social environments that have contributed to the epidemic were gradual and have had decades to gain momentum," said Risa Lavizzo-Mourey, chief executive of the Robert Wood Johnson Foundation. "We have to expect that this won't be a quick fix."
The foundation began its fight against obesity here in 2003 with a grant that, among other things, helped establish the city's first bicycle lane and ensured that the redevelopment of a low-income housing project included small "pocket" parks, improved traffic patterns and wider and safer sidewalks.
Based on that early progress here and elsewhere, the foundation announced in 2007 that it would spend $500 million to try to reduce childhood obesity rates. Louisville received about $400,000, bringing the foundation's total investment here to nearly $740,000. It also leveraged its private grants to receive almost $8 million from the Centers for Disease Control and Prevention.
In some of the low-income neighborhoods, there are small signs that awareness of obesity as a problem has increased.
For instance, a local corner store in the Smoketown neighborhood has begun selling plastic tubs of cut fruit as snack food, and orange traffic cones and tape protect freshly poured concrete curb cuts aimed at making walking easier.
At the Presbyterian Community Center's annual pre-Christmas breakfast, the demand for eggs now outstrips that for bacon -- though whether the change can be chalked up to new neighborhood eating habits or the recent arrival of several Somali families is anyone's guess.
"It's kind of become a movement," Bill Gatewood, the center's executive director, said. "We still have a long way to go, but you do see some changes."
Another example of how Robert Wood Johnson money has come into play is the St. Peter Claver Community Garden, formerly an abandoned lot that has a waiting list for its plots and is used by the nearby middle school.
The foundation's $13,500 investment was supplemented with money from, among others, the sewer department, which allocated $30,000 for a pavilion and to help pay for an education program on obesity. It helped that the foundation made its first grant when Jerry Abramson, then the mayor, had begun to worry that obesity was lowering Louisville's attractiveness.
"For businesses, a healthy work force is more productive and less costly, so it became a competitiveness issue," Mr. Abramson said. "Every city was offering tax incentives, every city was offering real estate deals but not every city had the weight problem we do."
Mr. Abramson also began the Mayor's Healthy Hometown Movement, to engage the city's agencies to reverse the obesity rate.
"The grant made us think about the problem differently, that it's not just about smart growth, it's not just about transportation, it's not just about parks or better nutrition, it's about all of those things and more," said Mary Lou Northern, senior adviser to Louisville's current mayor, Greg Fischer.
Today, sidewalks in downtown Louisville bear labeled routes of exactly a mile to encourage walking. Bicycle lanes line streets, whose lights have countdown mechanisms to enhance rider and pedestrian safety.
The Transit Authority of River City has added bike racks to its buses and is working to better link bus routes to its Frederick Law Olmsted parkways, which in turn are being connected to a 100-mile walking and biking loop around the city that has attracted more than $100 million in federal and private money.
Robert Wood Johnson's money also has drawn in other nonprofit players. The YMCA of Greater Louisville, for example, is helping corner store owners in low-income neighborhoods to add fresh fruits and vegetables to their product mix.
"I got so sick of seeing chips, chips, chips go out our door," said Julie Kader, a former special education teacher who now owns the Smoketown Dollar Plus, where the Y's Healthy in a Hurry program began in January 2009.
Her sales of fresh fruits and vegetables ranged from $200 to $800 a month, picking up sharply after the state began allowing the use of food stamps for fresh produce, according to the Y's estimates. Profitability has been mixed, and the Y is working to adjust the program in the four stores where the program operates now.
"We're one for three out of the first three stores," said R. Stephen Tarver, the Y's executive director. "Like the merchants involved, we've learned a lot."
If Smoketown represents some successes, the California neighborhood exemplifies the challenges. One of the Y-supported stores there closed. Efforts to establish a community garden have foundered in unresolved lot ownership and tax lien issues.
"This traditionally is a poorer, more underserved area, with a lot of transients, so neighborhood groups are weak, unlike in Smoketown, which has a strong community network," said Michael Dean, a California resident and coordinator of the California Collaborative, an umbrella organization for nonprofit groups, churches and businesses operating there.
City officials working in California are encouraged by what has happened just three miles east in the Shawnee neighborhood. Today it has a community garden, a Y-supported corner store and a brand-new community health center supported by other donors.
"We got busy," said Monica Brown, the new association's director of neighborhood transformation.
Ms. Brown has lost 30 pounds, in part by eating the beets, green beans, lettuce and other greens she raises on her plot in the local community garden. "I walk in the morning, and I try to drink water, which is hard because I'm a Coke girl," she said.
Jasimine Mays and Ashley Joslin, both 19, were among a group of teenagers who participated in a walkability survey of Shawnee last summer.
"There are sidewalks that are all gone or just half there, no curb cuts and a lot of abandoned houses," Ms. Mays said. "Until we did the walkability survey, I had just thought that was the way it was supposed to be."