There are many factors that affect our health, from genetics to our own personal behaviors. Our health is also shaped by the condition of the world around us - factors such as where we live and where we go to school.
In public health circles these are called the social determinants of health. We may not personally have much control over some of these factors, but they can make a huge difference in our health and even our lifespan.
Higher rates of childhood obesity and childhood diabetes have put focus on schools and the role they play in the health of youngsters. Schools make a lot of decisions for kids - like the lunches they eat and recess they do or do not have.
But for schools grappling with expectations for higher test scores, health awareness sometimes falls by the wayside.
There are 550 or so kindergarten through sixth-graders at Jackson Elementary, in St. Paul's Frogtown neighborhood. They're just about all students of color, and 90 percent of them live in poverty. Given those demographics, Principal Patrick Bryan says a good 275 of them are on pace to develop diabetes, if they follow current trends.
A compelling reason, he said, to have personal health just as high up on the to-do list as reading, writing and arithmetic.
"Do we assume that a child knows how to think mathematically or do multiplication tables? No, they learn that from us," Bryan said. "We should assume that they do not have the knowledge in their heads of what necessarily makes for the healthy relationship between diet and exercise, rest and physical health."
Bryan finds one stat especially startling. A CDC report a few years ago said as many as one-in-two children of color born after 2000 will develop diabetes.
At Jackson, fat is fought with things like carrots and zucchini as the afternoon snack. Parents are encouraged to not bake cupcakes or send treats. Junk food is never a reward for doing something, and everyone even gets a few yoga lessons.
But the big change, made last year, was recess. It's now before lunch, not after. Bryan said that makes the kids hungrier and they eat more, meaning they don't leave the fruits and vegetables on the tray.
Recess itself is also different because it has structure. Before they can play, every student must do 30 jumping jacks, then run or speed walk two laps around the playground, even in the winter too.
Principal Bryan dons his shorts and sneakers every day to encourage kids, like fourth-grader Isiah, to keep running. "You can do how many laps you want until it's time for recess to end," Isiah said. He added he planned to do three laps that day, which would earn him extra credit because he was only supposed to do two.
In fact, in arranging to even interview Bryan, he told me to bring running shoes. It boosts energy, he said, which make afternoons less sleepy. He can't prove it but he thinks test scores improve, too, which is why everyone went running last springs on those mornings before standardized tests. Other problems don't pop up because of all the anxiety burned off, he said.
"Our disciplinary data has practically gone through the floor, meaning it has gone from being relatively higher to almost not being there at all," Bryan said.
But Bryan sees plenty of social determinants at play when these kids leave school. One idea behind social determinants is that even if you personally decide to make all the right, healthy decisions, society sometimes throws up walls to keep you from doing that.
Most Jackson Elementary students live in poverty. Bryan said parents, for example, often can't afford to go buy all those fresh ingredients at the store;fast food is cheaper.
"I can't give you hard data and say, yeah - my test scores are higher because they're running and learning about physical fitness and health and healthy diet and all that stuff," Bryan said. "But I tell ya', we're running a pretty good counter operation to fast food and couch-potato lifestyles that lead to childhood diabetes."
But even Jackson Elementary had to face the ultimate challenge in making these changes: money.
Funding health education
Ann Hoxie, who supervises health and wellness for the St. Paul School district, said Jackson and other schools probably would not have been able to do some of this stuff, except that a few grants helped pay for many of the changes.
Even within St. Paul, Hoxie said Jackson is an exception. There's so much pressure for schools to improve test scores that some, Hoxie said, have cut physical education and recess when scores decline to free up more time for classroom teaching.
"Some of what we're trying to say is 'you also need to make sure that some of the other things that make a whole child are there,' such as good nutrition and physical activity," Hoxie said.
For people studying these factors in society, this has been a key factor. Susan Egerter, co-director of the Center on Social Disparities on Health at the University of California, San Francisco, said she constantly hears from educators who have the desire to think about all things health -- they just don't have the money, or time.
"The danger there is people have so many things on their plate and, if budgets are an issue, they don't have the resources to even think about it," Egerter said. "So what we have to do is find ways, again, that can be low-cost solutions or no-cost solutions that really get people thinking about it."
Egerter also says it's important to just go to school. Some of her research suggests the higher degree you have, the healthier you are. Based on data on life expectancy, college graduates can expect to live at least 5 years longer than individuals who have not finished high school.
Back at Jackson Elementary, that aligns with what Principal Patrick Bryan is thinking. It's not enough, he said, for these kids to get accepted to college when they're older. They have to graduate.
But Bryan is also thinking short-term, like next spring, when the end of the school year causes kids' attention to wander. Bryan might just have them all run twice a day during those last weeks of school.