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Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series (2022)

Chapter: 11 Systems Applications to Address Structural Barriers to Obesity Solutions

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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
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11

Systems Applications to Address Structural Barriers to Obesity Solutions

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

The second session of the third workshop featured two presentations that focused on systems applications to address structural barriers to obesity solutions. Stephanie Navarro Silvera, professor of public health at Montclair State University, moderated the session.

A STRUCTURAL APPROACH TO POPULATION HEALTH EQUITY

Soma Saha, executive lead of the Well Being in the Nation (WIN) Network, began her presentation by recounting a personal experience working in primary care. She had observed that optimal care at the clinical level improved diabetes outcomes but could not address community-level factors contributing to a marked increase in the community’s prevalence of diabetes. As Saha and her colleagues recognized that the community’s food and activity environments did not support healthy eating and regular physical activity, they began to construct geographic information systems maps of their patients’ environmental contexts. As a new method of analyzing patient data, Saha explained, this exercise revealed that areas of concentrated poverty also had higher rates of poor health outcomes, such as childhood obesity. Similar patterns emerged in maps of various major cities, she added, where considerable differences in average life expectancy existed depending on the zip code or neighborhood. Patterns of low-resource areas coinciding with worse health outcomes for their populations were replicated across the country.

According to Saha, the emergence of such widespread patterns indicates the existence of an underlying system that propagates chronic place-based inequities that cannot be explained by individual behaviors or such environmental factors as the existence of grocery stores. To support this point, she referenced a report documenting patterns of residential segregation that resulted in exclusionary zoning and policies (Davis et al., 2016). This situation precluded additional residential and business development in the segregated areas, she explained, which meant that its residents had to travel farther to get to work and that these municipalities had fewer tax revenues

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

to support schools and built environmental features (e.g., parks, sidewalks) that promote healthy behaviors. Saha underscored that racism is a transmissible illness that permeates an individual’s interpersonal experience as well as the structures and systems of a society. She argued that a better understanding of what this means could yield insight into why obesity outcomes have plateaued despite decades of efforts to slow and reverse its course in the United States.

Saha discussed the Moving to Opportunity Program as an example of an effort that effected changes in obesity through structural change. She explained that this randomized controlled trial, conducted in the mid-1990s, assigned 4,500 women with children living in public housing (where 40 percent or more of residents had incomes below the federal poverty line) to one of three groups: those given housing vouchers for neighborhoods with poverty levels below 10 percent, those given housing vouchers to use anywhere, and those given no vouchers (control group). Saha reported that among women who moved to more affluent neighborhoods, a 20 percent reduction in obesity was observed within 6 months, along with lower rates of severe obesity and diabetes (compared with the control group) 10 years later (Ludwig et al., 2011). She added that a follow-up study found that these outcomes were not fully explained by neighborhood characteristics (Zhao et al., 2014). Although the structural solution had led to changes in the resources available to those women who had moved, Saha observed, moving also had reduced their levels of allostatic stress, which had led directly to the substantial differences observed in the development of chronic disease.

Saha transitioned to discussing the WIN Network’s theory of change (Figure 11-1), which proposes that the shape of people’s lives and their predicted mortality from birth are determined in part by legacies of structural

Image
FIGURE 11-1 Well Being in the Nation (WIN) Network’s theory of change.
SOURCE: Presented by Soma Saha, October 28, 2021; Milstein et al., 2020. Reprinted with permission of the WIN Network.
Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

racism, colonialism, and economic inequality that pervade current society. Policies can promote dignity and inclusion or trauma and exclusion, she asserted, and the types of policies that exist affect whether people have the conditions necessary for well-being or experience adversity and urgent needs that cause allostatic stress. Over time, she said, this stress contributes to chronic health conditions and ultimately, struggling and suffering.

This theory of change has led the WIN Network to shift to a structural approach to well-being, Saha explained, that balances its efforts to build and support resilient, thriving people. What this means, she elaborated, is addressing their physical and mental health (pathway 1) along with their social and spiritual well-being (pathway 2) in a holistic way, and addressing underlying community conditions such as food access and housing (pathway 3), as well as root causes such as exclusionary zoning and other forms of structural racism (pathway 4). The combination of these efforts is expected to improve the systems in many communities that serve as a “down escalator” toward poverty and poor health (Figure 11-2).

Saha shared a few examples of this structural approach to pursuing population health equity. In Rhode Island, she reported, clinical community teams are stratifying people with diabetes in terms of COVID-19 risk, physical health risk, mental health risk, and social risk to determine how best to address those domains of well-being holistically. This effort involves connecting with community-based organizations and public health departments to coinvest in improving access to resources and advancing policies with the potential to mitigate root causes of poverty. At MetroHealth in Cleveland,

Image
FIGURE 11-2 Pathways to Population Health Equity framework.
SOURCE: Presented by Soma Saha, October 28, 2021; Saha et al., 2017. Reprinted with permission.
Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

Saha continued, people’s downstream needs are addressed by providing high-functioning primary care; “midstream” issues are addressed by increasing pay for front-line health care staff and building hiring pipelines from zip codes with poor health outcomes; upstream issues are addressed by partnerships to infuse STEM (science, technology, engineering, and mathematics) curricula into schools; and root causes of poverty are addressed by financing business development in disenfranchised communities.

Saha ended her presentation with an example from Texas, where links were uncovered among COVID-19 cases, child poverty, COVID-19–related unemployment, and health status. Investments in emergency and recovery supports were made in a way that advances long-term, equitable recovery and resilience, she explained, such as building the capacity of community assets to distribute healthy foods and making these foods available in local shops. The Methodist Health Care Ministries went even further to help interrupt the cycle of intergenerational poverty, she added, by expanding Medicaid and investing in internet access, computers, and digital literacy for communities in greatest need.

To end her remarks, Saha asserted that this kind of broader thinking that addresses root causes is a more efficient way to address health inequities compared with focusing solely on individual or even environmental determinants of health.

STRUCTURAL SOLUTIONS FOR OBESITY: ADDRESSING IMPLICIT BIAS AND STEREOTYPE THREAT

Rachel Godsil, cofounder and codirector of Perception Institute and distinguished professor of law and chancellor’s scholar at Rutgers Law School, discussed implicit bias and stereotype threat as key areas to address as part of structural solutions to obesity. She began by submitting that one of the primary obstacles to developing structural solutions is the need to deal with the multiple facets and dimensions of the challenges faced by people with obesity. Discussion of structural challenges is therefore critical in dialogues about structural solutions, she maintained, if the conditions under which people lack the opportunity to lead healthy lives are to be fully addressed.

Godsil stressed that structural factors are key barriers to accessing healthy lifestyles and to having institutional policies and practices that support healthy behaviors. As an example of a structural factor that shapes people’s opportunities, she cited weight stigma that results in a host of negative health outcomes for people with obesity and challenges their attempts to become healthy and achieve their potential. She pointed out that the adverse effects of weight stigma manifest in both educational and health care settings, where institutional policies and practices fail to recognize how it affects obesity outcomes. Godsil called this process a “negative cyclical

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

phenomenon” that is a combination of the structural dimensions that shape people’s opportunities and the institutional policies and practices that shape the way people experience institutions. When interpersonal encounters of people with obesity are added to the mix, she said, experiences of discrimination create a compounding health effect, leading to a noticeable change in individual beliefs and behaviors with regard to obesity.

Godsil referenced the term “intersectionality” as she explained that obesity is a challenge experienced across multiple identity categories, such as race, ethnicity, sexuality, and class. When several identity categories experience inequities, she said, the cumulative effect of the multiple forms of discrimination experienced by people with intersecting identities is greater than the sum of its parts (i.e., the individual experiences of each form of discrimination). Thus, she maintained, understanding intersectionality sheds light on what needs to be understood to create healthy lifestyle opportunities for people with obesity that are consistent with their sense of self.

Godsil went on to discuss civil rights solutions, explaining that weight is not a protected class under federal civil rights statutes even though weight stigma is a powerful form of bias. By contrast, she elaborated, exhibiting bias toward other identity categories is viewed as inconsistent with egalitarian values. Although people who have disabilities with respect to experiencing obesity may find protection under the Americans with Disabilities Act, Godsil called this protection insufficient. She noted that state and local civil rights laws are emerging to protect people from weight-based discrimination, both as individuals and as members of broader groups who are negatively affected by the structural environment.

Godsil expressed her opinion that broad-scale structural solutions to address obesity—those that recognize the roles of poverty, economic inequality, and other factors as barriers to engaging in healthy lifestyle behaviors—are imperative, but may be inadequate. It is also critical, she argued, to understand how the brain’s categorization of weight and body size affects the way people experience the world. Godsil shared three phenomena that result from such categorization.

The first is identity anxiety, which Godsil said people can experience in cross-group interactions. This phenomenon is often discussed in the form of racial anxiety, which occurs when people in nondominant groups are concerned that they may experience discrimination or bias. Identity anxiety comes into play with respect to weight stigma, she elaborated, when people fear that they may experience an interaction differently because of their body size—for example, that they might not be invited to participate in endeavors that involve physical activity because of the organizer’s bias toward people with obesity. This anxiety may be exacerbated, Godsil noted, in the presence of multiple differences between people in the dominant and nondominant groups.

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

A second phenomenon is implicit bias, Godsil continued, which occurs when an individual holds without conscious knowledge an attitude toward people with a certain identity or associates stereotypes with those people. Implicit bias affects body language and moment-by-moment evaluative behavior, Godsil explained, and is a major influence on how people with obesity experience health care, employment, educational, and other institutions in society.

A third phenomenon identified by Godsil is stereotype threat, which occurs when people feel that their identity is salient in a given environment. According to Godsil, this phenomenon can create a cognitive mindset whereby a person’s concern about conforming to a stereotype can actually lead to a greater likelihood of behaving in ways consistent with that stereotype. She asserted that feeling as though they are being seen through the lens of negative stereotypes that result from a belief that obesity is a problem of personal will is an enormous impediment to people’s ability to initiate health-promoting behaviors.

In Godsil’s view, the conditions that create stereotype threat also perpetuate narrative schemas. She asserted that the broad narrative schema that “racial equity doesn’t matter” is supported by a set of smaller-scale narratives that can also exist in relation to weight. She cited examples of these smaller narratives, which include the notion that individual acts, rather than systemic issues, drive the problem; a belief that bias is conscious and intentional; a focus on self-determination and meritocracy to effect change; and promotion of limited government. Godsil cautioned that embracing these narratives would eliminate a host of structural possibilities for addressing the root causes of obesity. Structural options must be on the table, she maintained, given that the present conditions in many communities stem from a history of differential treatment as a result of government and institutional policies.

Godsil explained further that when discussions of a particular problem emphasize existing disparities, support for structural solutions to that problem is lower. Health information that emphasizes racial health disparities may activate stereotype threat, she elaborated, undermining the affected group’s sense of possibility and increasing allostatic load and other adverse psychological responses. This phenomenon creates challenges in addressing conditions in which overlap exists between race/ethnicity and health outcomes, she maintained, and she stressed the importance of documenting such disparities so that solutions can be targeted and tailored for different population groups.

Instead of leading with disparities in considering solutions for obesity-linked health conditions, Godsil suggested leading with possibilities for hope and aspiration. She believes this approach is far more likely to be effective in supporting shifts in behavior both for the community of concern

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

and in terms of broader political support for the issue of interest. She referenced a study of efforts to increase turnout among voters of color, reporting that materials emphasizing higher voting rates among Whites depressed turnout among voters of color, whereas materials emphasizing how people in the community were engaging—“Your neighbors vote, so should you!”—increased their turnout.

Leading with evidence and solutions and countering misinformation are also important, Godsil continued, to shift away from “blame and shame” narratives about people with obesity. As an example of framing an intervention in positive terms, she described a culturally tailored program for managing hypertension among Native Hawaiians and Pacific Islanders by promoting physical activity through hula dancing (Kaholokula et al., 2017), which reported that greater reductions in systolic blood pressure were observed among the intervention group compared with the control group. Godsil attributed this result to the program’s promotion of the potential for positive change, which she said created conditions for people to see themselves in a positive light and improved their self-efficacy for change.

PANEL AND AUDIENCE DISCUSSION

Following their presentations, Saha and Godsil answered questions about investing in higher-poverty communities, changing narratives to foster systems change, and the effects of framing communications around disparities.

Investing in Higher-Poverty Communities

Silvera began the discussion by recalling the Moving to Opportunity intervention’s finding that moving women from higher- to lower-poverty neighborhoods reduced obesity rates. Relocating required the women to leave social and structural supports they may have established, she observed, and she asked Saha about ideas for investing in higher-poverty communities. Saha cited such initiatives as Purpose Built communities that integrate mixed-income housing with a stabilization lens, which she explained are less about moving people and more about investing in changing the conditions of a place so people can retain their community supports while having other conditions vital to thriving.

Changing Narratives to Foster Systems Change

Silvera recounted Godsil’s suggestion to approach obesity solutions through a lens of hope and build on existing strengths, and asked her whether the changes that need to occur at the individual level can also be considered systems change if they effect systems outcomes. According to

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

Godsil, research supports the notion that there is a systems dimension to how groups are seen and that perception affects how individuals experience everyday moments. She reiterated the need to shift the current narrative about the assumed causes of obesity and characteristics of people with obesity, which she said causes them to be seen through a lens of weight stigma. She stressed that this lens is a structural condition in that it assigns negative stereotypes to a category of people, and that these stereotypes are reinforced as they are perpetuated in society (e.g., in media and in policy making). When people with obesity experience discrimination based on other characteristics such as race/ethnicity or class, Godsil observed, it compounds their experience of negative weight-based stereotypes, undermines their self-image, and makes it difficult for them to engage in healthful behaviors. Saha concurred and suggested that another important narrative to change is that structural conditions are intractable barriers. Structural conditions are diagnosable, treatable, and curable, she maintained, because they come from structures, policies, and systems that can be unpacked and changed.

Effects of Framing Communications around Disparities

A participant asked Godsil whether leading with disparities activates stereotype threat when communications are targeted to children. Research suggests that such communications can activate stereotype threat, Godsil replied, if the children are seen as a stigmatized group, whereas when communications about an issue are targeted to groups that are not stigmatized, leading with disparities can evoke a sense of moral urgency. She reiterated Saha’s comment about the value of framing structural barriers as tractable in order to view individuals through a lens of possibilities.

Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×

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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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Suggested Citation:"11 Systems Applications to Address Structural Barriers to Obesity Solutions." National Academies of Sciences, Engineering, and Medicine. 2022. Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26437.
×
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The National Academies of Sciences, Engineering, and Medicine's Roundtable on Obesity Solutions convened a three-part workshop series that explored how structural racism, weight bias and stigma, and health communication intersect with obesity, gaps in the evidence base, and challenges and opportunities for long-term, systems-wide strategies needed to reduce the incidence and prevalence of obesity.

Through diverse examples across different levels and sectors of society, the workshops explored how to leverage the connections between these three drivers and innovative data-driven and policy approaches to inform actionable priorities for individuals, organizations, and policymakers to make lasting systems change.

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