Proceedings of a Workshop

Leveraging Health Communication, Data, and Innovative Approaches for Sustainable Systems-Wide Changes to Reduce the Prevalence of Obesity

Proceedings of a Workshop—in Brief

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a virtual public workshop, Leveraging Health Communication, Data, and Innovative Approaches for Sustainable Systems-Wide Changes to Reduce the Prevalence of Obesity, on June 22, 2021. The workshop, the second in a series of three workshops to examine foundational drivers of obesity and sustainable systems-wide changes to reduce the prevalence of obesity, explored strategies for leveraging health communication and data-informed, innovative approaches. Participants in the workshop discussed how health communication might enhance the understanding and the use of current modeling and data-driven efforts to advance obesity solutions; they also explored innovative data and policy approaches for obesity solutions.

This Proceedings of a Workshop—in Brief highlights the presentations and discussions that occurred at the workshop and is not intended to provide a comprehensive summary of the information shared during the workshop.¹ The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the Roundtable on Obesity Solutions, or the National Academies.

Nicolaas (Nico) P. Pronk, president of HealthPartners Institute, chief science officer at HealthPartners, Inc., and adjunct professor of social and behavioral science at the Harvard T.H. Chan School of Public Health, explained that the roundtable’s strategic planning efforts completed during 2020 helped it coalesce around a systems-oriented approach to better understand the barriers and facilitators to implementing obesity solutions. These collaborative efforts by the roundtable members culminated in the development of a causal systems map of obesity drivers and solutions, he said, which formed a road map for action toward data-driven obesity solutions and innovative approaches.

Pronk highlighted the map’s three priority areas for action and solutions—structural racism, biased mental models and social norms, and effective health communication—and explained that these areas were identified primarily by using a framework developed by Donella Meadows that depicts potential places to intervene in a system as a taxonomy of system elements arranged by increasing effectiveness to create systems-wide changes.² Pronk pointed out that the framework’s increasingly deeper leverage points are the most difficult to change, but they also hold the most promise to affect systems-wide change because they represent the power to transcend the paradigms and mindsets out of which systems arise.

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OPERATIONALIZING HEALTH COMMUNICATION FOR OBESITY SOLUTIONS

The workshop’s first session featured Jeff Niederdeppe, professor in the Department of Communication, director of the Health Communication Research Initiative, and co-director of the Center for Health Equity at Cornell University. He discussed the role of health communication in sustainable systems-wide changes to reduce the prevalence of obesity.

Niederdeppe defined health communication as an interdisciplinary approach to the theory, research, and practice of (1) understanding when and how communication shapes population health, and, informed by that understanding, (2) developing effective communication to promote population health. He emphasized that health communication occurs at many different levels—interpersonally, within groups and networks; in health care organizations and between health care practitioners and people; in policy-making forums; in the mass media; online; within and between institutions; and in society as a whole. Therefore, health communication could be leveraged at multiple places as part of systems-wide strategies to reduce the prevalence of obesity.

Niederdeppe shared U.S. public opinion data from the past decade to convey that health communication has shaped the predominant societal perception that obesity is a personal problem to be solved primarily at the individual level. Multiple, powerful forces have contributed to this perspective, said Niederdeppe, including political groups that highlight individual responsibility, deregulation, and limited government; food and beverage industries that emphasize personal choice and self-regulation; and an entertainment industry that sells false images of the “ideal” body. Niederdeppe also remarked that there is an overemphasis on the medical definitions and health care costs associated with treating obesity. These forces occur within a broader context of structural racism, he maintained, that is embedded in discourse and policies that create obesogenic environments in communities of color through such mechanisms as economic oppression, zoning laws, and neighborhood segregation.

These forces and this context have also shaped public beliefs about how to address obesity and how people with obesity are viewed. For example, Niederdeppe reported that high levels of blame and stigma are directed toward people with obesity, and that substantial opposition has been mounted to systems-wide, evidence-based public policies designed to reduce its prevalence. Moreover, individual-level interventions to improve diet and promote physical activity are often emphasized in initial approaches to address obesity.

Niederdeppe discussed the effects of communication interventions to promote individual behaviors such as diet and physical activity. Massive levels of exposure to messaging are needed to create change at a population level, he maintained, and even then, the effects of such messaging on behaviors tend to be small and short lived, with quickly waning effects when campaigns end. Furthermore, Niederdeppe went on, such communication interventions tend to widen inequity instead of reducing it, because populations that have difficulty implementing behavior changes as a result of economic, social, and structural factors are typically less likely to benefit from an infusion of health promotion messages.

Nonetheless, Niederdeppe stated that evidence indicates that strategic communication can promote systems-level thinking and interventions and increase public support for such evidence-based policies. Within obesity prevention, Niederdeppe referenced messaging efforts he worked on that increased public support for a penny-per-ounce tax on sugar-sweetened drinks, community-level strategies to reduce the number of food deserts, and restrictions on food and drink marketing to children.

Lastly, Niederdeppe highlighted three characteristics of effective communication strategies to promote health- and equity-focused, systems-level policy, starting with the first characteristic, which is the recognition that audiences are not monolithic and strategies should have multiple levels and multiple prongs. For example, a strategy might focus on engaging the public, either to persuade those potentially opposed to a proposed policy or to mobilize those already in support of it (e.g., to apply pressure to decision makers). Other strategies might focus on decision makers directly, to persuade them to support the proposed policy or to mobilize them to garner support and spur action among the decision makers already inclined to favor the policy.

The second characteristic of effective communication strategies, Niederdeppe continued, is that they start with the policy solution—not the health problem nor even the projected health impact of the proposed policy—and then work backward from there. Starting with the policy solution brings into play different kinds of values and beliefs that drive support or opposition to the policy, which may relate to the social impact, economic impact, or the institution and policy-making process of the proposed approach. Niederdeppe said that the third characteristic, to conclude his list, is that different messages may or may not resonate among different social groups, which emphasizes the importance of understanding diverse audiences’ perspectives prior to implementing communication strategies. Such understanding can help communicators anticipate how messages might resonate among different groups, which in turn helps differentiate strategies that aim to mobilize audiences in support of the policy from strategies that aim to persuade audiences who oppose it.

DATA-DRIVEN OBESITY SOLUTIONS AND INNOVATIVE APPROACHES IN EDUCATION AND HEALTH CARE

The workshop’s second session included two speakers who highlighted data-driven obesity solutions and innovative approaches in the context of education and health care.

Joseph E. Donnelly, professor of medicine and director of the Center for Physical Activity and Weight Management at the University of Kansas Medical Center, presented findings from a 15-year series of studies about increasing physical activity across school curricula. A primary reason to explore schools as a venue for increasing physical activity is that most school-age children are in school settings for 9 to 10 months of the year, Donnelly explained, and state mandates and school mission statements include a variety of health outcomes, including physical activity. In addition, schools offer a protected environment where children can play and be active under the supervision of an educated workforce at no additional cost, he continued. However, Donnelly acknowledged that schools have historically been sedentary (e.g., the traditional teaching paradigm is to “sit down and be quiet”). Nonetheless, Donnelly discussed how as fixtures of society, schools are well positioned to continue an intervention beyond a research study’s funding period.

Donnelly referenced growing evidence that suggests a relationship among physical activity, cardiovascular fitness, cognitive function, and academic achievement, which he believes is a “selling point” for administrators and teachers to add more physical activity into the classroom. This evidence base led to development of an intervention, Physical Activity Across the Curriculum (PAAC), that was explored in a 3-year randomized controlled trial of second- and third-grade students.

The premise of PAAC was to increase physical activity by using classroom teachers to integrate 10-minute periods of physical activity into a variety of existing lessons—without decreasing academic instruction time—for a total of 90 minutes across 1 week. PAAC was designed to appeal to school administrators and teachers as a fun, minimal intervention with the potential to enhance learning with no additional cost or teacher preparation time.

Greater levels of physical activity were observed in PAAC intervention versus control schools, Donnelly reported, based on the direct observation of student behavior in response to teacher instructions using the SOFIT (System for Observing Fitness Instruction Time) tool. Average SOFIT-measured physical activity levels across intervention schools corresponded to energy-expending movements such as walking, hopping, and leaping, which Donnelly said could induce fitness and perhaps improve academic achievement. Although PAAC did not have an effect on students’ time spent on task, Donnelly shared his belief that the preponderance of evidence suggests that classroom-based physical activity does increase time spent on task. This outcome is particularly important to teachers, he noted, who tend to be concerned that integrating physical activity into classroom lessons will distract students from learning.

Donnelly suggested that a university curriculum to equip prospective teachers with the skills to encourage classroom-based physical activity would be a low-cost, effective strategy for promoting nontraditional physical activity in schools. Additional evidence to link physical activity and fitness with academic achievement would also help, he said, and would also support policy changes that could lead to more widespread dissemination of programs like PAAC.

Donnelly provided several suggestions for increasing physical activity in schools without decreasing academic instruction: increasing active time during physical education class and recess, providing access to physical activity before and after school, promoting active travel (i.e., walking, biking, or other nonmotorized transport) to school, providing physically active lessons, and using physical activity as a classroom management or behavior tool.

Donnelly ended his presentation by outlining a series of issues that have arisen from interventions that attempted to integrate physical activity throughout the school day: limited evidence about the effectiveness of teacher-led versus outside vendor–led efforts to increase physical activity; the standards, funding, and accreditation that prioritize academic learning over physical activity in school settings; the need for adequate training for teachers to design and deliver physical activity into academic lessons; and certain variations in educational settings (e.g., open classrooms, frequent moving between classrooms). Alternative settings such as boys and girls clubs and local parks and recreation facilities may be more suitable, Donnelly suggested, as they already have a culture of physical activity, follow structured schedules, and are subject to minimal if any academic governing entities that would shift the focus away from physical activity.

Patrick J. O’Connor, senior clinical investigator and co-director of the Center for Chronic Care Innovation at HealthPartners Institute, discussed the use of a data-driven, primary care–based clinical decision support tool to guide personalized and evidence-informed care for people with obesity and other chronic conditions. O’Connor began by affirming that primary care settings recognize the importance of intervening on systems-level factors that contribute to obesity, but that they also pursue individual-level approaches to address obesity at the patient level.

O’Connor explained that tremendous interindividual variation exists in the health benefits of the various approaches used to treat overweight and obesity—including lifestyle changes, Food and Drug Administration (FDA)approved medications, and metabolic bariatric surgery—and these approaches are influenced by such factors as age,

sex, baseline body mass index (BMI), and the number, duration, and severity of related comorbidities. These factors are among those included in a clinical decision support tool that O’Connor’s team developed to improve the quality of chronic disease care in adult patients with type 2 diabetes and a BMI greater than or equal to 25 kg/m². CV Wizard, a web-based tool, is linked to the electronic medical record (EMR) and uses algorithms to process a patient’s EMR data and any self-reported, lifestyle data in real time, he explained, to identify appropriate weight loss options for that patient. The tool has been in use for about 10 years, O’Connor said, primarily for the management of blood pressure, cholesterol, glucose, and tobacco use, and it will next be evaluated for its effect on weight trajectories, medication starts and metabolic bariatric surgical referrals, and patient-reported shared decision making (i.e., conversations about weight) and intent to lose weight.

O’Connor explained that an important element of the clinical decision support tool is its communication of the benefits and risks of appropriate weight loss options to the patient and the primary care clinician. Many clinicians and patients are often unaware of the potential (let alone patient-specific) benefits of FDA-approved medications and metabolic bariatric surgery for weight management, he reported, especially for patients with type 2 diabetes. The relative benefits of weight loss compared to improvements in other clinical domains depend on what type of weight loss treatment is under consideration, O’Connor explained, and he emphasized that optimal decision support tools will ideally address multiple clinical domains because at least four clinical issues are present in the average adult primary care encounter.

Communicating evidence-informed, personalized estimates of benefits and risks of weight management options is challenging, O’Connor acknowledged. These challenges stem from the need to tailor the communication to the many factors that influence a patient’s capacity to understand information. He emphasized the importance of considering a patient’s numeracy and health literacy levels and clinical status, as well as their personal and cultural perspectives on eating, weight, and medical treatments.

In summary, O’Connor maintained that the use of clinical decision support tools to manage overweight and obesity could promote uptake of effective weight management strategies. Directing tools to both patients and providers is key, he reiterated; that way both parties are informed about the estimated individual-level benefits and risks of weight management strategies and can engage in shared decision making. For adults with type 2 diabetes and obesity, O’Connor proposed that framing weight management options as treatments for type 2 diabetes (versus obesity) may motivate more serious consideration of such options by some clinicians and patients. The effect of a decision support tool on the quality of care could be maximized if combined with another intervention, he suggested, such as gamification, incentives, or active outreach to patients with registry-based case management.

INNOVATIVE POLICY SOLUTIONS

The third session of the workshop featured two speaker presentations that discussed innovative policy solutions and policy opportunities and challenges.

Colby D. Duren, director of policy and government relations at the Intertribal Agriculture Council (IAC), discussed the council’s work and approach to policy innovation. The IAC was established in 1987 in the wake of the farm financial crisis, which he said disproportionately affected tribal producers. In recognition of the inequities these producers experienced, the IAC was directed to provide them with direct assistance and support, as well as to support policy developments. Tribal producers were not included among the original stakeholders in the U.S. Department of Agriculture’s (USDA’s) foundational policies, Duren said, and the IAC continues to advocate for access to the funding and support available through USDA programs.

Duren pointed out that because USDA is not structured around the realities of tribal agriculture, the IAC works to have a voice in the making of agriculture policy as early as possible. He reminded workshop attendees that as sovereign governments, tribes have a unique and direct nation-to-nation relationship with the federal government and are continuous stakeholders in its programs, which warrants consulting tribes prior to and during the creation of federal policies.

Duren discussed recent progress in including tribes in federal farm policies, focusing on the formation of the Native Farm Bill Coalition. The coalition was born out of a research and data-gathering effort leading up to the 2018 Farm Bill that engaged the Indigenous Food and Agriculture Initiative at the University of Arkansas to produce an extensive report called Regaining Our Future. The report reviewed the history of tribal agriculture and suggested opportunities for the Farm Bill’s policies to serve tribal producers. The IAC used the report to engage tribal organizations across the country, Duren said, who then worked together to develop and distribute materials to drive conversation about the report and advocate for its suggested policy changes. The Native Farm Bill Coalition now includes 17 national tribal organizations, 3 allied organizations, and represents more than 170 tribes.

Duren next described the challenges that the coalition faced when trying to effectively translate the report to policy makers so they could understand how the proposed policy changes would benefit tribal producers. Stakehold-

ers of federal government programs often use shorthand phrases and acronyms to communicate program data, which he said had to be broken down and supported with additional context to help convey the data’s meaning. In many cases, few data were available to describe the effect of federal programs on tribal producers and communities, but using stories to provide decision makers with tangible illustrations of how proposed policies would benefit tribal stakeholders on the ground helped to provide additional, valuable support for policy change.

Duren relayed that the coalition was able to help secure 63 tribal-specific provisions in the 2018 Farm Bill. In his view, one of the most important wins was the extension of tribal self-governance, which he described as the ability for tribal governments to contract with the federal government to administer and manage a program to help serve its citizens as well as build their capacity for ongoing work. One way that authority manifests is in the Food Distribution Program on Indian Reservations, he noted, a commodity food assistance and purchasing program that allows distribution sites to contract with and purchase food from Native producers.

Duren ended his remarks by acknowledging the current administration is engaged and supportive of racial equity and inclusion; however, he underscored the importance of ensuring tribal representation from the initiation of policy through its development, implementation, and assessment. He reiterated that tribal producers have historically been in a reactive position because they were excluded from these processes, which he said presented them with the challenge of “trying to fit the square peg of tribal agriculture into a round policy hole.” Even if tribal stakeholders are able to successfully advocate for adjustments to proposed or enacted policies, Duren said that they are still subject to programs that may not be as helpful for them as they could be.

Mary T. Bassett, director of the François-Xavier Bagnoud (FXB) Center for Health & Human Rights at Harvard University and the FXB Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health, reflected on her tenure as deputy health commissioner (2002–2009) and health commissioner (2014–2018) in New York City (NYC).

Bassett explained that the NYC Department of Health’s various policy approaches aimed to counter the rising prevalence of overweight, obesity, and diabetes among its residents. Though these approaches were innovative, she said they seemed like common sense in light of available data on the city’s rates of overweight, obesity, and diabetes, as well as the structural context that had affected the way people obtained food and prompted the increased consumption of calories from purchased and prepared foods. Bassett highlighted wide neighborhood-level variation, mainly by race, ethnicity, and income, in prevalence of these health conditions and of self-reported consumption of calorie-dense foods and sugar-sweetened beverages. She noted it seemed clear that the rising prevalence of adverse health indicators could not be attributed to individual choices alone, which she said led to the Department of Health’s realization that improving the availability and accessibility of healthy food choices is at least as—if not more important than—educating people about making healthy choices.

Bassett highlighted several policy approaches pioneered by the NYC Department of Health, beginning with its 2006 requirements for chain restaurants to post calorie information on their menus and for all restaurants to remove trans fats from most of their menu offerings. In 2008, the city used executive authority to establish nutrition standards for snacks and beverages purchased by the city and brokered an agreement to remove sugary beverages from public school vending machines. Arguably the most well-known action taken by the Board of Health was its 2012 attempt to limit the serving size of sugar-sweetened beverages in food service establishments, Bassett recalled, which was highly contested and ultimately overturned in the courts. She noted that prior policies had also faced legal challenges, usually on the basis of federal preemption or corporate free speech, but had prevailed. In 2015, the Board of Health instituted warning labels on chain restaurant menu items containing more than the daily recommended intake of sodium. Local jurisdictions followed NYC’s lead in designing some of these policies, Bassett said, which subsequently gained national attention. She listed two examples: calorie posting in chain restaurants as part of the Patient Protection and Affordable Care Act passed in 2010, and FDA actions to lower trans fat and sodium across the food supply.

More action at the national level is critical, Bassett asserted, given limits to local authorities’ power to make healthy choices available to their residents. In her view, it will take more than information, education, and individual willpower to confront the rising tide of inexpensive, calorie-dense options in the current food and beverage environment.

REFLECTIONS ON THE WORKSHOP AND EQUITY-CENTERED APPROACHES TO REDUCE THE PREVALENCE OF OBESITY

The fourth and final session of the workshop featured a keynote speaker who offered reflections on the workshop and discussed equity-centered approaches to reducing the prevalence of obesity.

Sarah de Guia, chief executive officer of ChangeLab Solutions, explained that ChangeLab is a national, nonpartisan, nonprofit organization that uses the tools of law and policy to advance health equity at national, state, and local levels. Its team of interdisciplinary staff works with community organizations, governments, and anchor institutions

to develop and implement equitable policy solutions. This is achieved by strengthening stakeholders’ leadership and capacity through training and technical assistance to leverage policy and legal tools that elevate practical, evidence-based, community-centered solutions.

As de Guia chronicled ChangeLab’s history with an emphasis on its efforts related to the prevention of obesity, she explained how the organization’s pivot to focus on fundamental drivers of health inequities played out in its legal and policy solutions. When ChangeLab began in the mid-1990s, she recounted, it operated primarily as a technical and legal assistance provider to local health departments working on tobacco control in California. It urged the departments to consider policy, systems, and environmental changes instead of the usual educational and outreach approaches, and applied this lens to the obesity epidemic beginning in the early 2000s. Initial efforts focused on downstream drivers such as access to healthy foods and opportunities for physical activity, she said, later growing into national-level policy and legal analysis efforts to prevent obesity. Despite ChangeLab’s progress in addressing school environments and promoting healthy environments, de Guia recalled, health disparities persisted and even widened among Black people, Indigenous people, people of color, and low-income communities.

As ChangeLab considered how to integrate equity into its law and policy frameworks, it leaned on three resources that provided compelling data and evidence to support its shift to focus further upstream: a framework for increasing equity in the prevention of obesity,³ which purports that disparities related to health and obesity cannot be adequately addressed without considering underlying health inequities and engaging communities; an article on structural racism and health inequities in the United States that defined the systemic nature of structural racism and made connections between historical racist laws and policies and the pathways that led to disparities;⁴ and a trauma-informed approach,⁵ which encourages awareness of the effect that trauma can have on communities.

ChangeLab published a Blueprint for Changemakers in 2019, which posits that a focus on drivers of health inequities is critical for adequately addressing health. de Guia highlighted the document’s emphasis on pursuing health equity by addressing five fundamental drivers of inequity: structural racism and discrimination, income inequality and poverty, disparities in opportunity, disparities in political power, and governance that limits meaningful participation. These five co-occurring, overlapping drivers shape places, social environments, and living conditions, she pointed out, as well as individuals’ daily experiences and perspectives in those settings.

de Guia explained that ChangeLab’s recognition of these five drivers led it to adopt equity-centered frameworks and strategies that enhance and go beyond policy, systems, and environmental change approaches to improve public health. An equity-centered strategy to reduce health inequities addresses social and political pressures or policies for changing social determinants of health, she said, as it applies a human-centered approach to identifying and prioritizing interventions that will maximize benefits for disadvantaged populations.

Shifting to reflect on the workshop presentations and discussions, de Guia proposed that health communication, data, community engagement, and equitable policy solutions are critical and interrelated components to advance efforts to reduce the prevalence of obesity. She also underscored the value of multisector collaboration and urged public health stakeholders to learn other sectors’ languages and frame communication in a way that invites collaboration.

When communicating with the public and policy makers, de Guia suggested framing messages with a lens of fairness and justice, highlighting practices that drive disparities and offering corresponding policy solutions. Communities want to see their assets and strengths uplifted in policy solutions, she maintained, rather than hearing only alarm bells and lectures about the problem. Building intentional, deep relationships with communities engages them as co-creators—instead of merely recipients—of policies and increases the likelihood of developing optimal solutions for their needs. Such relationships also enhance policy evaluation by meaningfully soliciting community members’ experiences with and feedback on a policy, which she termed “community-defined data.” ◆◆◆

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DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Emily A. Callahan as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for this published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Jeff Niederdeppe, Cornell University, and Courtney P. Paolicelli, U.S. Department of Agriculture. Leslie J. Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Society for Nutrition; Blue Shield of California Foundation; General Mills, Inc.; Intermountain Healthcare; The JPB Foundation; The Kresge Foundation; Mars, Inc.; National Recreation and Park Association; Nemours; Novo Nordisk; Obesity Action Coalition; The Obesity Society; Partnership for a Healthier America; Reinvestment Fund; Robert Wood Johnson Foundation; Society of Behavioral Medicine; University of Pittsburgh Medical Center; Wake Forest Baptist Medical Center; Walmart; and WW International.

For additional information regarding the workshop, visit nationalacademies.org/obesitysolutions.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Leveraging health communication, data, and innovative approaches for sustainable systems-wide changes to reduce the prevalence of obesity: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26341.

Health and Medicine Division

Copyright 2021 by the National Academy of Sciences. All rights reserved.