Or so the headlines said. Too bad they’re not exactly accurate. Last week the Board of Supervisors voted to ban restaurants from giving out toys with kids’ meals that don’t meet certain nutritional standards. This decision has received a fair amount of media attention and riled up the “personal responsibility” activists. Ironically, the ban’s reach is very limited, since it only affects restaurants located within the unincorporated areas of Santa Clara County. The ordinance also doesn’t have a lot of tooth: the fine is $250 for the first offense, $500 for the second, and no more than $1000 for subsequent violations.

The requirements for food are: 

• <200 calories in a single food item; <485 calories for a meal
• <480 mg sodium in a single food item; <600 mg sodium for a meal
• <35% of calories from fat
• <10% of calories from saturated fat
• <10% of calories from added sweeteners
• <0.5 g of trans fat

The requirements for drinks are:

• <120 calories
• <35% of calories from fat
• <10% of calories from added sweeteners
• no artificial sweeteners 
• no caffeine

Despite all the ruckus that this ban has caused, my friends from my public health days (who are, by the way, still in the very thick of this work) are actually pretty underwhelmed by the ordinance. In fact, I think most people living in this area will probably forget all about this soon. 

Let’s be clear: foods that do not meet these limits are not being banned or explicitly curbed in any way. Restaurants just can’t give away toys (or other incentive items) with foods that don’t meet these criteria. This was an attempt to ban a certain kind of marketing directed at children, the kind that most public health professionals believe is responsible for kids getting addicted to foods with lots of fat, sugar, and salt. People who oppose the ban say that it is parents’ responsibility, not the government’s, to decide what their kids eat. But clearly, the choice has never been easy for parents. 

The tension between personal freedom and policies to promote the public health is greatest when it comes to controlling obesity. We tend to attribute a person’s overweight to their unhealthy behaviors and choices. It’s their fault, we think (mostly to ourselves in private). If only all the fat smokers in the country would get on a treadmill, forgo the extra-large orders of bacon-covered cheese fries, and finally give up the cigarettes and booze, we could solve our obesity problem once and for all. If only parents would just stop being so self-involved and pay more attention to what their kids are eating. If only we could all take personal responsibility for our health.

It’s very American to emphasize personal responsibility. Individualism is the core of the American culture and identity. I’m all for personal responsibility, but we can’t continue to ignore the environmental and cultural obstacles to making healthy choices. Let me share with you my personal understanding of how hard it is to eat well when you don’t have a lot of money or resources.

Growing up poor in Vietnam meant that our family ate lots of leafy, green vegetables and that my childhood entertainment consisted of playing outdoors. There is even a perception in my culture that eating out often and sitting idle in a café or restaurant is improper. People familiar with a more modern Vietnam might dispute my claim that this is a cultural perception, but I make it in reference to my mother, who tells stories about how shy or embarrassed she used to feel sometimes when eating at roadside stands. 

When my family moved here, we continued to eat mostly in the same way, although our meals would contain a lot more meat than before. My mother cooked most of our meals, but she worked full-time and went to school in the evenings, so there were many nights when we made ourselves ramen or, oops, ate fast food. Throughout most of my childhood in the United States, my family received bags of groceries from the local food bank. These bags often came with a lot of bad food: a box of candy bars, mass-produced muffins, juice powders. My siblings and I happily gobbled up all this “food”. 

To be fair, food banks and programs like WIC or SNAP have gotten much better about providing low-income families with fresh produce and cutting out the junk. However, I don’t know how long those innovations will last, since funding is always volatile.

It’s hard to make healthy choices when most of the options in front of you are not healthy. What these crazy public health Big Brothers are trying to do is change how we think about food, how we interact with food. Last year, I was involved in organizing a pre-medical enrichment program for high school students, and the medical students I was working with insisted that it was no big deal that we were giving the kids pizza and soda for lunch. Yes, there was water and salad. Yes, most of the kids took some salad and about half chose water instead of soda. But by providing pizza as the main course and making soda available, we enabled unhealthy choices. We did not have an even playing field for the healthy and unhealthy choices: we made the unhealthy choice the attractive and easy one. 

The result of my wrangling over these relatively minor details was that I felt guilty for being uptight. These were future physicians who dismissed my concerns about the food that we were offering. Sometimes I wonder what hope we have at all if physicians can’t even agree that there needs to be policies in place to promote healthy decision-making. Let me just tell you: yes, it is a. Big. Deal. What food you make available to people is what they will eat. If you provide muffins and cake at your meeting, people will eat muffins and cake. If you besiege poor neighborhoods with liquor stores and fast food joints…

Factor in how stressed out and busy Americans are these days, and we are making it nearly impossible for people to make the right food choices. In one study, subjects were asked to memorize a number, walk down the hall, and report the number. One group of subjects got 2 digits and the other had 7, which is the average maximum number of items that you can keep in working memory. In the hallway, they were stopped and asked to choose a snack: chocolate cake or fruit salad. The seven-digit subjects overwhelming chose cake (something on the order of 80%). It appeared that with the rational part of the brain busy, the emotional part ended up controlling the decision-making. It’s THAT easy for us to end up making the wrong choices about what to eat. 

Parents still have the responsibility to choose what their kids will eat. Honestly, I doubt that the parents who were feeding their kids fast food all the time will now stop doing so because toys were banned from certain kinds of meals. But for those parents who were trying and struggling to say no, it is now a little bit easier to do so.

In the end, personal responsibility is easy to prescribe but difficult to enforce. We can’t go on expecting people to do the right thing for their health when doing the right thing is so damn hard. There is also a collective responsibility when it comes to issues of public health. Humans have evolved this far because we formed tribes, villages, and entire civilizations. Responsibility does not lie only with individuals. 

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