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Gut Check: Can the U.S. Meet a Public Health Challenge More Complex Than Smoking?

Poor fitness and nutrition are undermining kids' performance in school. Does the U.S. have what it takes to meet a public health challenge more complex than smoking?
Poor fitness and nutrition are undermining kids’ performance in school. Does the U.S. have what it takes to meet a public health challenge more complex than smoking?

Nearly 50 years ago, Americans smoked about 500 billion cigarettes a year. Non-smokers inhaled tar, nicotine, formaldehyde and scores of other toxins every time they entered a public space. Cigarette smoking was causing cancer, cardiovascular disease and pulmonary disorders, yet many smokers bought into the advertising myth that cigarettes – especially those with asbestos filters -- could actually keep them healthy.
Then in 1964, the U.S. Surgeon General’s office shattered the myth with its landmark Smoking and Health report. Public health researchers mobilized to convince millions of people that cigarette smoke is deadly. Since then, with the help of groups such as the American Cancer Society, the American Heart Association, the Campaign for Tobacco-Free Kids and Nicotine Anonymous, the smoking cessation movement has gained traction and millions of people have kicked the habit or simply never started. Remember those scary TV spots depicting little kids imitating their parents, right down to trying their cigarettes? The anti-smoking campaign has been particularly successful with young people: Where some 45 percent of young adults smoked in 1965, by 2009, less than 22 percent did (American Lung Association, Research and Program Services, Epidemiology and Statistics Unit, July 2011).
Fighting the Next War

Now, many educators and researchers are calling for a similar mobilization against another looming public health issue: the poor nutrition and lack of physical fitness among teenagers and children that is endangering the nation’s future by contributing to lower levels of academic achievement and seeding myriad long-term health problems. But the constellation of contributing factors this time around suggest that the anti-smoking campaign model may not be sufficient; that a new kind of education is in order, and that schools – as the place where young people spend most of their time – must be the focal point.

“Schools play a critical role in promoting the health and safety of young people and helping them establish lifelong healthy behavior patterns,” writes TC alumnus Howell Wechsler, Director of the Division of Adolescent and School Health at the National Centers for Disease Control and Prevention. Yet “despite increasing evidence of the effectiveness of school health programs and growing concerns over critical health problems affecting youth… most U.S. schools spend insufficient time on health education and physical education; fail to provide recommended levels of nursing and mental health services; commonly provide students with ready access to high calorie, low-nutrient foods and beverages; and generally fall short of the school health practices recommended by public health authorities.”

Among the most alarming statistics:

Two in three young Americans do not get enough physical activity.

Obesity among U.S. children has more than tripled since 1980, with one in six U.S. adolescents now qualifying as obese, according to a 2010 article in The New England Journal of Medicine.

The lifetime risk of type 2 diabetes is now more than one in three in the general U.S. population, with a steep rise in pediatric cases in recent years. Overall incidence is on pace to rise from 24 million people last year to twice that number by 2050.

Research confirms that avoiding such ills improves academic achievement.  For example, studies of hundreds of thousands of middle and high-school students conducted by the California Department of Education in 2002 found that physically fit youngsters posted significantly higher scores on math and reading tests, and those who met minimum fitness levels in three or more areas showed the greatest gains in academic achievement.

But the problem runs deeper than a simple one-to-one relationship between fitness and classroom performance.

In a special issue of The Journal of School Health this past October, Charles Basch, TC’s Richard March Hoe Professor of Health and Education, outlined seven major health issues – vision, asthma, teen pregnancy, aggression and violence, physical activity, breakfast, and inattention/hyperactivity -- that intertwine to limit the academic achievement of all students, but particularly that of low-income minority youth.

Basch, who has been invited to the White House as part of First Lady Michelle Obama’s Let’s Move initiative and has also met with U.S. Secretary of Education Arne Duncan, finds that:
Twenty percent of school-aged children do not eat breakfast. In a study of 1,151 low-income African-American second to fifth graders in New Jersey, 12 percent to 26 percent attended school on any given day without having eaten anything. Research has shown that eating a full breakfast is essential to children’s classroom performance.
More than one in five school-aged children suffers from visual problems. More than 90 percent of visual impairment cases among children ages 12 through 19 stems from uncorrected refractive error (nearsightedness, farsightedness, etc.)
In 2006 nine percent of children 18 and younger (6.8 million) still had asthma after diagnosis. Between 2001 and 2003, for youth between the ages of five and 14, average annual prevalence estimates were approximately 45 percent higher for black versus white children (12.8 versus 8.4), as were average annual estimates of asthma attacks (8.4 percent versus 5.8 percent).
One in three teen-age girls in the U.S. becomes pregnant.

Twenty-eight percent of adolescents report being bullied at school or on their way to it.
These problems are directly or indirectly responsible for a host of issues that affect ability to learn, Basch argues, including sensory perceptions, cognition, connectedness with school, absenteeism and dropping out. 

With such a tangled mass of health challenges, where to be begin? The best place may be in people’s heads, at the level of motivation. 

It Starts at the Table

“You can’t just give up food the way, theoretically, you can give up tobacco,” says Kathleen O’Connell, Isabel Maitland Professor of Nursing Education at TC.

As the founding director of TC’s new program in Diabetes Education and Management, O’Connell is keenly aware of notes how eating behaviors can lead to illness – and how, like smokers, people with diabetes often struggle to alter behaviors they know threaten their lives. Thus, the TC program trains care managers who understand the complex motivational issues involved, and who can create an individualized plan for each patient.

Isobel Contento, TC's Mary Swartz Rose Professor of Nutrition and Education, believes it is essential to address those same sorts of motivational issues in healthy people.

“When it comes to diets, there's plenty of evidence that knowledge alone doesn't change people's eating patterns," says Contento, the author of Nutrition Education: Linking Research, Theory and Practice. After all, it has been more than 40 years since Contento’s predecessor, TC Professor Emeritus Joan Dye Gussow, pioneered in sounding the call to eat fresh, pesticide-free, locally-grown produce. “Americans are well-informed, and at this point, the grocery stores are full of plenty of healthy foods. What people lack is the oomph to overcome barriers to changing their behavior. So the field needs behavioral, psychological and educational strategies, as well.

"This message seems simple,” Contento continues, “but it often involves making changes, and people often lack the confidence that they are capable of making those changes. They say, -'I don't like the taste,' or -'It's too hard to cook all that,' or, -'I can barely walk a block, let alone walk for an hour.’”

The most effective health strategy, according to Contento and her colleagues in TC’s Nutrition Education program, is to create a hands-on connection to healthy food and eating practices for children while they’re still relatively young. The program has developed a series of texts that do just that. Choice, Change & Control (C3) includes detailed lessons in which students measure the fat and sugar content of popular snacks and beverages (and often discover that a single portion contains more of both than the recommended maximum for an entire day). Students also investigate their own food and activity environments, learn how type 2 diabetes develops; and engage in other activities that teach them why and how to make changes in how they eat and live. In addition to C3, the Linking Food and the Environment (LiFE) series – Growing Food and Farm to Table & Beyond -- teaches children in grades four through six about “food webs,” agriculture, and the ecological impact of food choices. Students keep diet logs and do hands-on exercises involving cooking, eating and analyzing food.

Meanwhile, community-based food programs, many of them designed by TC professors, are making some inroads into New York City’s food deserts. Pamela Koch, TC Adjunct Associate Professor of Nutrition, is an evaluator for a program aimed at families in central Brooklyn called the New York City Food and Fitness Partnership. The area is home to high rates of asthma and diabetes, and the program – funded by the Kellogg Foundation – advocates for farmers markets, safe parks and healthier food choices in bodegas.
Long-time TC faculty member Toni Liquori founded School Food FOCUS, a national initiative that addresses food procurement in large school systems. The premise here is that more healthful food options in school cafeterias will help students achieve greater academic performance.
Liquori also developed the CookShop Program, a hands-on nutrition education program now administered by Food Bank For New York City, which teaches low-income children how to adopt a healthy diet on a limited budget.
But, as Contento readily attests, many people who are most at risk for poor health also face formidable external challenges to changing their diet and shopping habits. Here’s a biggie: If you don’t live near stores that sell fresh foods, you’ll have a tough time making them a regular part of your diet and your family’s diet.

In an address delivered at TC last spring, the celebrated health and fitness guru Dr. Ian Smith (MA ’93) amplified that point, calling it  “ironic and embarrassing in a country with an abundance of food” that, for example, half the population of Detroit and more than a fifth of Chicago’s population live in such “food deserts.” These people increasingly subsist on fast food restaurants and convenience store offerings, positioning a generation of low-income Americans of color for vastly increased risk of heart attack, stroke, diabetes and cancer.  And those are just the most obvious consequences. Malnutrition at age three produces increased hyperactivity and aggressive behavior by age eight, Smith said, lower IQ in eleven-year-olds, and increased motor activity and conduct disorders in 17-year-olds.

Ironically, convenience store food prices are higher than those in supermarkets, so poor people are paying more for unhealthier food. Combating that problem requires intervening on the ground, at the most grassroots level. For example, the Laurie M. Tisch Illumination Fund, a New York City foundation headed by TC Board of Trustees Vice Chair Laurie M. Tisch, is working to increase the number of food cart vendors who sell fresh produce in food deserts. Cooperating with Montefiore Hospital, the Illumination Fund has supported a free blood pressure program that includes a coupon for a food-cart purchase. The Fund also has produced a cookbook by celebrity chefs.

More broadly, the food industry itself has contributed to unhealthy eating by playing on what Contento describes as humans’ biological predisposition, or “coding,” to like sweet foods. Popular writers on food such as Marion Nestle and Michael Pollan have written about manufacturers that have a stake in producing “addictive” foods high in non-nutritive sugar, salt and fat. Contento herself has called attention to manufacturers that sponsor “wellness” drives featuring foods with dubious nutritional value and that fund “studies” minimizing health concerns associated with their goods. And to ensure that breakfast cereals, beverages, snacks and other processed foods find a market, the industry spends up to $10 billion a year on advertising – much of it aimed at children.

“Children get three hours a week, on average, of ads for food,” Contento says. And, unless they attend what is still a fairly small number of schools using curricula like the ones developed by TC, “they get about four hours a year of nutrition education.”

Muscle Matters

Parents who are informed about nutrition can at least try to take matters into their own hands at home. They’re facing tougher odds, though, when it comes to physical fitness, because kids spend most of their time in school – and at a growing number of schools, physical education is a thing of the past. 

According to a survey released in October by the American Alliance of Health, Physical Education, Recreation and Dance (AAHPERD), fewer than 20 percent of K-12 schools nationwide provide their students with opportunities to engage in physical activity before, during or after school. Along with art, music and even history, both the study and the pursuit of exercise are being squeezed out of the school day because of deep budget cuts and a heavy emphasis on language arts and math, the two subjects most heavily tested for compliance with federal No Child Left Behind legislation.

To Stephen Silverman and his colleagues in TC’s Movement Science and Education/Kinesiology program, that’s plain wrong-headed thinking. 

“You cannot improve academic achievement, well-being or health without a focus on physical activity and physical education,” says Silverman, Professor of Education, Chair of the College’s Department of Biobehavioral Sciences and AAHPERD 2011 Alliance Scholar. “That’s just so clear.”

At the physiological level, research has shown that aerobic activity improves cognitive performance by increasing the number of capillaries in the brain and thus facilitating the transport of oxygen and the removal of waste products such as carbon dioxide. There is also accumulating evidence that the cerebellum, an area of the brain once thought to govern only motor skills, may also play an important role in spatial learning, associative skills, and language processing, and that development in each area may reinforce the others. 

On a behavioral level, studies have shown that physical education and activity can boost students’ cognitive skills, contribute to overall health and wellbeing, and instill a life-long appreciation for staying fit.

Silverman, who studies how students learn physical skills and develop positive attitudes and confidence about being physically active throughout their lives, says most K-12 physical education programs don’t cultivate such a combined focus. And while trained physical education teachers are professional, skilled and well prepared, some public school physical education programs that have survived budget cuts nevertheless save money by using by non-expert teachers.

“If we want children to be skilled and engaged in physical activity, we have to teach it right,” Silverman says. Teachers should choose the curriculum carefully and develop a sequence of instruction, so that children learn in small steps, in one-on-one or small-group settings, where they can feel successful. “In this way, they will develop skill and better attitudes.”

Elementary school students tend to have good attitudes about physical education and physical activity, Silverman said, but that those attitudes typically decline—particularly among girls—during middle and high school. It doesn’t help that many physical education programs push kids, regardless of skill level, into group activities or competitive athletics without giving them proper instruction on technique and skill acquisition. Silverman himself has found that the types of competitive activity in many schools—such as in-class scrimmages, in which the instructor stops the play to give players feedback; or full-size games, which don’t allow enough time for each student to practice skills at his or her own pace—are not as effective as individual instruction, with frequent feedback and adjustment of tasks. 

The point isn’t that schools are missing the chance to develop future professional athletes, Silverman says, but rather that all people are capable of learning physical education “in ways that make them enjoy it.”

In fact, fostering positive attitudes toward physical education is critical even among highly skilled students, Silverman said. “If students are skilled and fit, but leave physical education with poor attitudes, they may not use the skill or participate in regular physical activity.” Citing his own and other studies, he said that teaching methods that do not engender positive attitudes toward physical activity produce a “lack of learning” that students acutely sense and that robs them of motivation. 

Taking Action
With unprocessed and affordable foods often hard to find, especially in inner city “food deserts,” some food analysts are trying to educate policy makers on the link between healthy lifestyle habits and academic achievement.
“We have this momentum from the First Lady [Michelle Obama], who is saying, ‘Good nutrition habits are a priority for our schoolchildren,’” says Ellie Krieger, a TC-trained dietician and host of the Food Network’s Healthy Appetite. Krieger testified in April 2010 before the House Committee on Agriculture about the relationship between low income families and health issues such as diabetes and obesity.
Similarly, John Allegrante, Professor of Health and Education and TC’s Deputy Provost, has, over the years, led delegations of students from his Social Policy and Prevention course to Washington each February to advocate for higher funding levels at the U.S. Centers for Disease Control and Prevention and other federal agencies focused on health. The trips are targeted to the National Health Education Advocacy Summit, a two-and-a-half day annual conference that Allegrante co-founded and helped launch when he served as the President of the Society for Public Health Education. The event represents organizations working on health issues that include tobacco control, adolescent health, diet and physical activity, hypertension and the elimination of health disparities.

Such public health efforts are critically important – but ultimately, many food and fitness educators believe that what’s really needed is a commitment at the highest levels of government and education – the Department of Education, the Department of Health and Human Services and the National Education Association, for starters – to improve students’ academic achievement by fixing the food and activity deficits in children’s lives. What better point of delivery for these healthier students programs than schools?
In his recent report in The Journal of School Health, TC’s Charles Basch provides recommendations that will help schools advocate for a coordinated nutrition, fitness and educational system with the goal of producing better learners. Among them:
  • Align federal, state and local policies to form a coherent national agenda to close the achievement gap.
  • Incorporate the available school health guidelines proposed by many federal and nongovernmental organizations into the educational mission. A sampling of groups includes: the CDC’s Division of Adolescent and School Health; the Association for Supervision and Curriculum Department; the Health Resources and Services Administration; the National Registry of Evidence-Based Programs and Practices; the Office of Juvenile Justice and Delinquency Prevention, and Find Youth Info.
  • Institute the roles of school health coordinator and school health council to integrate health promotion into the fundamental mission of the school.
  • Develop a set of metrics by which to assess which areas in the school heath program are effective.
Undeniably, the health problems that plague the typical U.S. classroom did not arrive overnight. Nor can they be solved overnight. 
Educators note that it took nearly five decades to make smoke-free environments both the norm in the work place and more and more the rule in public indoor gathering places – and the battle continues. Only in July 2011 did some 500 U.S. universities enact 100 percent smoke-free policies. It could take even longer, to reform nutrition and physical activity attitudes in schools and communities – but there are hopeful signs that change is starting to happen. Several TC researchers point to the elimination of trans-fats from New York City restaurants as the beginning of a campaign to reduce the number of unhealthy food options in New Yorkers’ diets.
Or as the old saying goes: a journey of a thousand miles begins with a single step. At least we’re moving.

By Barbara Finkelstein

Published Thursday, Nov. 3, 2011


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