In 2012 the Institute of Medicine (IOM) released the report Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation (IOM, 2012a). Written by an expert committee in response to the epidemic of excess weight in America, the report evaluates obesity prevention strategies and offers recommendations for accelerating progress in obesity prevention. The report also articulates an ambitious vision: a “society of healthy children, healthy families, and healthy communities in which all people realize their full potential” made possible through “large-scale transformative approaches focused on multilevel environmental and policy changes” (p. 19).
The report identifies five critical environments in which reform is urgently needed to accelerate progress in obesity prevention:
1. environments for physical activity,
2. food and beverage environments,
3. message environments,
4. health care and work environments, and
5. school environments.
Each of these environments interacts with the others, creating a set of interconnected systems that can be changed only through engagement, leadership, and action among many groups and at many levels (see Figure 1-1).
1The planning committee’s role was limited to planning the workshop, and this workshop summary was prepared by the rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Institute of Medicine, nor should they be construed as reflecting any group consensus.
FIGURE 1-1 The Committee on Accelerating Progress in Obesity Prevention identified five interconnected environments in which engagement, leadership, and action are needed to accelerate progress in reducing obesity.
SOURCE: IOM, 2012a.
For each of these five environments, the report presents an overarching recommendation and a set of strategies and potential actions designed to achieve that recommendation. It also identifies relationships among the strategies and actions that could strengthen their overall impact. This systems approach enabled the authoring committee to identify synergies and potential unintended consequences while also highlighting and filling gaps in previous approaches to obesity prevention.
Accelerating Progress in Obesity Prevention (IOM, 2012a) acknowledges that the five environments identified above can differ substantially for individuals, families, and communities. A variety of characteristics linked historically to social exclusion or discrimination, including race, ethnicity, religion, socioeconomic status, gender, age, mental health, disability, sexual orientation or gender identity, geographic location, and immigrant status, can thereby affect opportunities for physical activity, healthy eating, health care, work, and education (IOM, 2012a). In many parts of the United States, certain racial and ethnic groups and low-income individuals and families live, learn, work, and play in places that lack health-promoting resources such as parks, recreational facilities, high-quality grocery stores, and walkable streets. These same neighborhoods may have characteristics such as heavy traffic or other unsafe conditions that discourage people from walking or being physically active outdoors. The combination of unhealthy social and environmental risk factors, including limited access to healthy foods and opportunities for physical activity, can contribute to increased levels of chronic stress among community members, which have been linked to increased levels of sedentary activity and increased calorie consumption.
To examine the role of these and other factors in health disparities and explore ways to counter and reverse their influence, the IOM’s Standing Committee on Childhood Obesity Prevention held a workshop in Washington, DC, on June 6-7, 2013, titled “Creating Equal Opportunities for a Healthy Weight.” Registered participants (see Appendix C for details), along with viewers of a simultaneous webcast of the workshop, heard a series of presentations by researchers, policy makers, advocates, and other stakeholders focused on health disparities associated with income, race, ethnicity, and other characteristics and on how these factors intersect with obesity and its prevention (see Box 1-1 for the statement of task for the workshop). In each of the five environments identified in Accelerating Progress in Obesity Prevention (IOM, 2012a), speakers discussed potential future research, policies, and actions that could lead to greater equity in opportunities to achieve a healthy weight. The workshop agenda and brief biographies of the speakers and moderators are presented in Appendixes A and B, respectively.
Statement of Task
An ad hoc committee will plan a 2-day public workshop that will examine childhood obesity prevention through the lens of working to achieve health equity. Workshop presentations and discussions involving researchers, policy makers, advocates, and other stakeholders will focus on income, race, and ethnicity, and how these factors intersect with childhood obesity and its prevention. The workshop will feature invited presentations and discussions concerning the key obesity prevention goals and recommendations outlined in the 2012 IOM report Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation related to physical activity, healthy food access, food marketing and messaging; and the roles of employers, health care professsionals, and schools. Workshop attendees will explore the health equity issues in each of these critical aspects of obesity prevention, while discussing potential future research, policy, and action in each area that could lead to equity in opportunities to achieve a healthy weight. The committee will plan and organize the workshop, select and invite speakers and discussants, and moderate the discussions. An individually authored workshop summary will be prepared by a rapporteur. The designated rapporteur will not be a member of the committee and no committee members will be used in the development of the workshop summary.
The Standing Committee on Childhood Obesity Prevention was formed in 2008 to serve as a focal point for national and state-level policy discussions about obesity prevention. It comprised national leaders in public health, public policy, medicine, nutrition, physical activity, pediatrics, obesity prevention, the social and behavioral sciences, biostatistics, and epidemiology. During its existence, it guided the selection and refinement of focused topics on obesity prevention to be examined through workshops, public briefings, and studies conducted by separately appointed ad hoc committees.
The workshop summarized herein was the last formal activity of the standing committee. A new phase of obesity work was initiated at the IOM with the formation of the Roundtable on Obesity Solutions, which is intended to engage leadership from an even broader range of sectors, including public health, health care, and health insurance; the food industry; the entertainment, sports, and recreation industries that influence physical activity; government; philanthropy; diverse nonprofit organizations; the financial sector; and academia. The goal of the roundtable is to foster ongoing cross-sector dialogue on critical and emerging policy and research issues and to accelerate and sustain progress in obesity
prevention and care through a focus on implementation challenges and successes.
The standing committee’s chair, Shiriki Kumanyika, associate dean for health promotion and disease prevention and professor of epidemiology at the University of Pennsylvania’s Perelman School of Medicine, dedicated the workshop to Antronette K. Yancey, M.D., M.P.H.,2 associate professor of health services at the University of California, Los Angeles, and a member of the standing committee, who died of lung cancer at age 55 shortly before the workshop. A college athlete, fashion model, poet, and inventor of Instant Recess®—short activity breaks in which anyone can participate at any time—Yancey was a pioneer and a national leader in introducing physical activity into all settings and among all groups. Box 1-2 at the end of this chapter contains a remembrance of Yancey written by Kumanyika.
During her opening remarks at the workshop, Kumanyika laid the groundwork for the discussion to follow. She began by defining health equity as the principle underlying a commitment to reducing disparities in health and its determinants (Braveman et al., 2011). In other words, health equity represents social justice in health because it focuses on eliminating differences in health that are associated with the systematic social disadvantages that affect some population groups. Disparities are not just differences, Kumanyika emphasized. They reflect unfair circumstances that result in worse health outcomes.
Systematic, avoidable health differences can adversely affect many different socially disadvantaged groups, including those distinguished by (Braveman et al., 2011):
• race or ethnicity, skin color, religion, language, or nationality;
• socioeconomic resources or position;
• sexual orientation or gender identity; and
• age, geography, disability, illness, political or other affiliation, or other characteristics that are associated with discrimination or marginalization or that determine position in a social hierarchy.
Kumanyika identified several broad issues that need to be considered in addressing disparities that affect obesity. Disparities can result from higher exposure to a certain type of risk, greater sensitivity to that risk, or circumstances associated with greater resistance to change, each of which calls for a different approach to risk reduction (Braveman, 2009). Ethnicity and socioeconomic status are both risk factors. Both are characterized by great heterogeneity, yet they also overlap, Kumanyika pointed out, in that poverty rates are much higher among many ethnic minority groups than in the general population (Macartney et al., 2013). In addition, the actions of parents and other adults clearly influence the risk of childhood obesity, as does the broader social context (IOM, 2005). Each of these factors plays a role in conceptual frameworks that can be used to address obesity prevention.
Kumanyika briefly summarized several of the frameworks that can be used to analyze disparities relevant to obesity prevention and develop potential solutions. One such framework identifies differential exposures, differential vulnerabilities, and differential consequences in the context of social stratification (Diderichsen et al., 2001). Each of these differences among individuals and groups provides an opportunity for intervention.
Another framework, known as the ANGELO (Analysis Grid for Environments Linked to Obesity) framework, divides the environment into microenvironments (“settings”) and macroenvironments (“sectors”), separately for nutrition and physical activity (Swinburn et al., 1999). It then prompts for analyses of the physical, economic, policy, and sociocultural influences within these settings and sectors. In the sociocultural environment, for example, it asks, for both the micro- and macroenvironment, “What are the attitudes, beliefs, perceptions, values, and practices?” This framework has been used to analyze what makes a community high risk (Yancey et al., 2004) and to develop community action plans (Simmons et al., 2009).
Finally, Kumanyika mentioned a framework developed by the African American Collaborative Obesity Research Network that can be used to engage communities in analyzing their environments (AACORN, 2013). It divides influences on eating habits, physical activity, and body weight into the domains of historical and social factors, culture and
mindset, and environments to navigate. Conversations with communities enable community members to recognize and articulate the effects of environments on health, wellness, and quality of life.
Targeted solutions to the obesity problem are needed, said Kumanyika, because solutions with an equivalent impact on all populations will not close existing gaps. Solutions for the general population that fail to target high-risk populations could increase or fail to decrease the disparities that were the focus of the workshop. Even if obesity prevalence in minority populations and those of low socioeconomic status were to decrease, the disparity relative to the white and higher-income populations could remain, Kumanyika stated. For example, disparities could worsen if an approach were less appealing, less feasible, or less effective for high-risk groups.
This failure to close existing gaps is apparent in some of the otherwise encouraging reports of declining obesity prevalence in children. In Mississippi, childhood obesity has declined somewhat in white children but has only leveled off in black children (Center for Mississippi Health Policy, 2012). In New York City, obesity has decreased among all children (in kindergarten through eighth grade) but has declined less among blacks, Hispanics, and students in high-poverty schools (CDC, 2011a). While any decline in childhood obesity is welcome news, the persistence of such disparities is a reminder of how much remains to be done.
Kumanyika left the workshop participants with two broad questions to inform their discussions:
1. What does “accelerating progress” mean in creating equal opportunities for a healthy weight, given that “accelerating” means not just working to create equal opportunities but speeding up progress toward that goal?
2. Which of the recommendations of Accelerating Progress in Obesity Prevention (IOM, 2012a) are the most important for making progress in creating equal opportunities, and how can their implementation be tailored for maximum effectiveness?
Meeting the challenge of achieving equity will require both transforming inequitable environments, including those associated with physical activity, foods and beverages, and messaging, and targeting
critical settings, including schools, worksites, and health care institutions. These targets for action reflect the structure of both Accelerating Progress in Obesity Prevention and the workshop.
Following the opening session, the workshop was divided into six panels. Each panel focused on one of the five environments identified in Accelerating Progress in Obesity Prevention, with health care and work environments being split into two separate panels. Thus, the workshop covered the following six subjects, each of which is treated in a separate chapter of this summary:
1. physical activity (Chapter 2),
2. foods and beverages (Chapter 3),
3. workplaces (Chapter 4),
4. health care (Chapter 5),
5. messaging (Chapter 6), and
6. schools (Chapter 7).
In each panel session, a member of the standing committee introduced the strategies described in Accelerating Progress in Obesity Prevention for achieving progress in the respective environment. A speaker then presented a case study of a program or initiative that embodied those strategies. A subsequent speaker broadened the discussion by considering policy issues or other topics associated with the environment. Finally, the standing committee member led a moderated intrapanel discussion in which the speakers responded to questions from the moderator.
After the second, fourth, and sixth panels, a standing committee member led a “town hall” session in which the speakers answered questions from the audience, followed by public statements from audience members. Responses from speakers to questions are integrated into the synopses of their talks in this workshop summary. The statements from workshop participants are presented in Appendix D.
In the final session of the workshop, a speaker discussed the systems perspective that is a prominent feature of Accelerating Progress in Obesity Prevention (IOM, 2012a). A systems approach emphasizes the inherent complexity of a problem, recognizes the wider context of any action to address it, investigates interactions among the components of
the problem and potential solutions, and seeks solutions that move the system as a whole in positive directions. This talk is summarized in Chapter 8.
Also during the final session of the workshop, Kumanyika described several prominent issues that arose repeatedly during the workshop. This section combines those issues with topics identified by other workshop participants to provide a brief introduction to the major themes of the workshop. These themes should not be viewed as consensus conclusions or recommendations of the workshop participants; rather, they point to the wide range of topics discussed and viewpoints expressed during the workshop.
• The social and environmental factors that contribute to health disparities generally also act to increase weight among high-risk populations.
• Population-oriented approaches are needed for obesity prevention initiatives in high-risk communities.
• Cross-sector linkages can produce win-win situations.
• Evaluations can demonstrate what has and has not worked, but should account for the fact that change takes time.
• The activities of and examples set by adults in many sectors are essential to preventing childhood obesity.
The following subsections are a continuation of the issues discussed at the workshop, and should not be seen as consensus conclusions or recommendations.
• Civil rights laws provide an opportunity to reverse overt discrimination, such as the lack of public parks and recreational facilities in disadvantaged communities.
• Realizing the potential of parks and other facilities to reduce health disparities requires proximity, quality, safety, and promotion of their use.
• Better understanding of the features of parks and other facilities that increase physical activity would enable these features to be incorporated into future facilities.
Foods and Beverages
• Straightforward measures such as eliminating sugary drinks from schools, promoting the drinking of tap water, and providing calorie information to consumers can improve food and beverage environments for members of high-risk populations.
• A combination of media campaigns, menu labeling laws, school nutrition policies, and incentives for food and beverage outlets has the demonstrated ability to reduce childhood obesity.
• If funding levels for programs that act to prevent obesity are reduced, the high-risk populations they serve will be negatively affected.
• The number of workplace wellness programs has been growing with employers’ increasing recognition that such programs can reduce medical spending, absenteeism, and worker turnover.
• Approaches aimed at improving the health of employees are most effective when they are tailored to the needs, belief systems, and histories of particular groups.
• The costs of wellness programs that generate large health benefits can be kept low.
• Much more needs to be learned about how to prevent obesity through primary care. In the context of the health care system, obese individuals are an underserved group.
• Although community-based care has much to offer many overweight and obese individuals, the heaviest individuals are likely to need additional medical intervention and more intensive supervision.
• Engagement and adequate preparation of a broad range of health care providers will be essential in dealing with obesity, as well as other chronic conditions.
• Message environments in many ethnic minority and low-income communities are dominated by advertisements and other promotions for high-calorie foods and beverages to a significantly greater extent than is the case in white and higher-income communities.
• Obesity prevention messages can counter at least some of the unhealthy messaging to which people are exposed, but need to be sustained given the ubiquity of food and beverage advertising and the time required to change behaviors.
• The four Ps of marketing—product, price, place, and promotion— all need to be understood in greater detail to counter the unhealthy effects of today’s message environments.
• Disparities in schools reflect broader inequities in society and contribute to health disparities.
• Food service departments can be central to the efforts of schools to improve nutrition for students.
• Out-of-school programs can complement and augment the efforts of schools to encourage healthy eating and physical activity.
• Cross-sector linkages can take advantage of connections within broader systems to produce win-win outcomes.
• Developing a systems understanding requires both broad studies of societal forces and detailed examinations of specific issues and populations.
• Given that changing a complex system can take time, both short- and long-term evaluations may be required to judge the effectiveness of actions taken.
“We need to appeal to hearts, minds, a sense of justice, power, and money.... We can’t just be technocrats. We have to understand the field we are working in.” —Shiriki Kumanyika
Antronette “Toni” K. Yancey, M.D., M.P.H.: A Remembrance November 1, 1957-April 23, 2013
Toni Yancey was a force to be reckoned with on many fronts. At the time of her death, she was a tenured professor at the University of California, Los Angeles (UCLA) Fielding School of Public Health and co-director of the UCLA Kaiser Permanente Center for Health Equity. She had also just released the second edition of her book of poetry, An Old Soul with a Young Spirit: Poetry in the Era of Desegregation Recovery, published on April 30, 2013. A gifted and successful scholar, mentor, and public health practitioner and advocate and a creative writer who used poetry and the spoken word to reach diverse audiences with her keen insights on issues of concern for public health, she accomplished more in her too-brief 55 years than many of us can dream to accomplish in our lifetime.
The name Antronette K. Yancey will surface readily in any review of the evidence on the importance of physical activity for health or the need to try harder to address disparities in chronic disease based on race/ethnicity and socioeconomic status. Dedicating this workshop to Toni is a fitting and timely way to pay homage to this great colleague and friend. Toni was a valued colleague on the Standing Committee on Childhood Obesity Prevention. She would have been here on the stage with us had it been within her power. Many who knew or knew of Toni will remember their shock upon learning that this seemingly invincible icon of health and physical fitness, a nonsmoker, had been diagnosed with lung cancer. But we will also remember that she continued to be a role model and spokesperson for striving to remain active and fit during the subsequent fight for her life. Her energy, spirit, and wisdom will be missed within the public health academic and practice communities and in communities at large that were touched in some way by her efforts.
We will remember Toni in many ways. Perhaps most vivid will be the unforgettable image of an engaging, 6'2" tall black woman who would appear at the front of the room at a National Institutes of Health meeting, Institute of Medicine meeting, workplace, school, or other venue to tempt (or perhaps to dare) those assembled to join her in a 10-minute physical activity break. As an avid proponent of taking short physical activity breaks to incorporate physical activity into daily routines, she might say—not really with apology—that she
could not see why we always had a coffee or snack break but had difficulty finding time for a little activity. This became her trademark—eventually named Instant Recess®—disseminated through a book (Instant Recess: Building a Fit Nation 10 Minutes at a Time), a website, and partnerships with sports organizations and businesses and supported by research studies. The concept was deceptively simple: using prerecorded breaks that could be played for groups of people to follow along—children or adults of any level of fitness, in any clothing, and in any setting. But as Toni knew, the concept is far from simple in that it challenges deeply entrenched social norms of sedentary behavior at work, at school, and even at home.
Toni will long be remembered for putting her credentials, reputation, and personal credibility on the line to challenge these norms—for walking the talk. The concept caught on and has attracted many followers and proponents to the movement she sought to spark. She spread the word in diverse communities while also traveling in leadership circles that led her to count First Lady Michelle Obama and former President Clinton among her supporters. Following the news of her death, as a tribute and to amplify her message, colleagues and supporters organized a nationwide Instant Recess® on May 7, garnering support from more than 100 organizations and with massive participation.
Woven throughout Toni’s efforts to make a difference in population health was her persistent advocacy within academic and professional circles for a greater focus on the science of addressing health disparities. We spoke often about her frustration with the dearth of research on ways to reduce the excess risks of cardiovascular diseases and cancer in communities of color and with the difficulty of keeping these issues on the research agenda and giving them priority. Her legacy includes the many research studies and reviews she generated in an attempt to fill this void and to identify solutions.
Toni Yancey was wise beyond her years. Close examination of her academic and creative writing reveals remarkable insights that will continue to inform efforts to create equal opportunities for achieving a healthy weight. Toni’s legacy above all is the inspiration to fight for health justice.