One of the more contentious debates in modern public health, as it wrestles with relentlessly epidemic obesity and its protean consequences, is the role of personal responsibility.
At one end of the spectrum are those who believe that because we're in control of how we use our feet and forks each day, a simple matter of making good choices must trump all. At the other extreme are environmental determinists who feel we can never take better care of ourselves until the environment makes that the inescapable default; that only comprehensive policy changes will do. Mayor Michael Bloomberg's proposed ban on large sodas garners support from the latter camp, for instance.
The vitriol of this debate within the circles I travel is increasingly intense. We have, apparently, lost the ability to agree to disagree or to disagree with respect and civility. Taking cues from our political leadership—or groups of children with serious behavioral problems—we seem increasingly inclined to assume evil intent and cognitive deficiency among those who don't share our views. The problem with this, other than the hostility itself, is that we lose opportunities to meet in the middle.
This cultural conundrum has collided right into the cafeteria line of every public school in the country. So much so, that CBS News has recently declared school lunch a "battlefield." The combatants are just whom you would expect: Public health types arguing for improvements in school nutrition on one side, and an alliance of elements, including the industry profiting from the status quo, on the other, who contend that we "nutrition police" should just mind our own business—and certainly not mind theirs!
One way to test an ideology—such as the ideology of personal responsibility—is to see if it performs consistently well. With that in mind, imagine if we treated food, and food for thought, the same way. If we believe it makes sense to advocate for good nutrition, but then surround kids with enticing alternatives, I think it would only be fair to provide a comparably tantalizing array of alternatives to school attendance itself.
The scene I envision is this. Each morning, conscientious moms and dads around the country would wake up their kids and encourage them to go to school. Really responsible parents might even ensure that their children pack books, have a good breakfast, and get out the door on time. But once outside, on their own, the kids should encounter alternative ways to feed their curiosities, just as they encounter alternative ways to feed their appetites in the corridors and cafeterias of most schools around the country. Perhaps parked outside their home would be one bus to the circus, one to the water park, one to the zoo, one to a carnival, yet another to the mall, perhaps one to the ski slopes in winter, and one to the beach on warm days in spring. Oh, and one to school, too.
Naturally, none of the attractive options would be intended to replace school on a regular basis. In fact, each responsible vendor of daily diversions might go so far as to post a sign over the door of his or her bus: "This activity is fine on occasion, and can be part of a complete and healthy lifestyle." No one would be saying kids should go to the circus instead of school every day. We can all agree that, in general, school is the best option for our kids. But the occasional trip to the circus never hurt anybody, did it? And besides, we're not in the business of imposing the best option, are we? We can offer, even recommend, but we believe parents and kids should decide.
If you are a parent—as I am—perhaps you don't much like my idea of letting your child's education come down to a daily choice between school and more enticing alternatives. But that is exactly what we would do if we treated feeding the minds of our children the same way we approach feeding their bodies.
When it comes to feeding the minds of our children, we have established a decisive cultural position as the default: compulsory education, with particular standards. This does not preclude the exercise of personal responsibility by adults and children alike, which powerfully influences just how much benefit is derived from the education provided. But we don't offer kids a daily choice of going to school or the zoo, or rely on busy parents to overcome such temptations every day.
There is no reason why we can't pursue the same middle path of sense and reason when it comes to feeding our children's bodies. We have no evidence to suggest that today's average 8-year-old has less personal responsibility than counterparts of prior generations. Epidemic childhood obesity is about changes around the kids, not in the character of kids themselves.
There has been some real progress with school nutrition—including an upgrade in school nutrition standards at the federal level. There is dedicated attention to kid's nutrition from the First Lady, who held a 'state dinner' for kids at the White House this week.
Perhaps even more important are diverse local innovations around the country, some of which are described in the current issue of my journal, Childhood Obesity, dedicated to the subject.
But we have a long way to go before school food is consistently at a high standard. We have obstacles to overcome, such as food companies lobbying Congress to declare a slice of pizza a serving of vegetables because of the tomato sauce. What responsible parent thinks of a slice of pizza that way?
And there are even debates about what constitutes good nutrition for our kids—the latest example being an ad campaign against milk. But this effort is being conducted by a group that advocates for a vegan diet and, while laudable, should not be a tail that wags the dog. There is legitimate debate about the best variations on the theme of healthful eating. Let's help our kids get to that theme first, and worry about the details only after.
An overwhelming body of medical science, not to mention the meanest application of common sense, indicates that a healthy mind and healthy body are interdependent. We have evidence that this relationship is expressed in terms of school performance. A substantial number of articles in the peer-reviewed medical literature indicate that children eating relatively wholesome foods tend to have fewer behavioral problems than those eating a cornucopia of highly processed junk. We have evidence that academic performance tends to improve with physical activity during the school day as well.
There is that proverbial expression about leading horses to water. Yes, the horse must decide to drink. But there has to BE water in the trough—and that's not up to the horse, any more than it's up to the thirsty crops succumbing to the drought that's ravaging the Midwest this summer. Environmental factors can and do, quite handily, trump personal inclinations.
But when the environment provides opportunity, personal inclination must align to make use of it. Little good ensues from building "it" if no one does come.
We can and should do both. Feeding the bodies of our children well, just like feeding their minds well, requires both a supportive environment, and good choices. If we are to realize the aspiration of "sound mind, sound body" for our kids, it would help to hear the sound of sense both in arguments for good public policy, and personally responsible use of it.
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David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.