The fourth session of the third workshop included reflections from members of the Roundtable on Obesity Solutions on the roundtable’s past, current, and future work and additional member perspectives on the workshop, which were followed by a final speaker who provided closing remarks for the first day of the workshop: Nicolaas Pronk, president of HealthPartners Institute, chief science officer at HealthPartners, Inc., and affiliate professor of health policy and management at the University of Minnesota School of Public Health.
OPENING REFLECTIONS
William Dietz, consultant to the Roundtable on Obesity Solutions and chair of the Sumner M. Redstone Global Center on Prevention and Wellness at the Milken Institute School of Public Health at The George Washington University, reviewed the roundtable’s origins and history. The National Academies’ engagement with obesity began in 2005 when the then-Institute of Medicine (IOM) (now the Health and Medicine Division) published the consensus report Preventing Childhood Obesity (IOM, 2005), funded by the Robert Wood Johnson Foundation (RWJF). A follow-up study evaluating progress in preventing childhood obesity was published in 2007, which prompted the IOM to establish a Standing Committee on Childhood Obesity.
The Standing Committee was funded by RWJF from 2007 to 2013, Dietz continued, during which time it produced seven consensus reports and hosted eight workshops. An additional enhancement of the IOM’s engagement with obesity that occurred during the Standing Committee’s tenure came in 2010, he recounted, when the IOM collaborated with HBO Documentary Films to produce a four-part video series called The Weight of the Nation. In Dietz’s view, this series solidified recognition of the role the National Academies could play in addressing childhood obesity.
Dietz pointed out that, in addition to the continuity of funding invested in the Standing Committee, another source of continuity was the long-standing service of certain members. The first chair of the Standing Committee was Jeff Koplan, who had previously directed the Centers for Disease Control and Prevention (CDC) and chaired the committees that produced the first two IOM consensus reports on childhood obesity. Shiriki Kumanyika was one of the first members of the Standing Committee, Dietz added, and went on to succeed Koplan as chair before becoming one of the charter members of the Roundtable on Obesity Solutions.
Dietz went on to report that in 2013, the Standing Committee evolved into the Roundtable on Obesity Solutions, which maintains a larger membership than the Standing Committee and represents a broader group of multisector stakeholders. Instead of producing consensus studies, he explained, the roundtable hosts workshops (19 to date) and develops National Academy of Medicine (NAM) Perspectives papers (24 to date) that reflect on issues and opportunities in advancing obesity solutions. Dietz submitted that, because the roundtable provides a venue for public, ongoing dialogue among leaders and voices from diverse sectors and industries, its current focus on structural racism, bias, mental models, and health communication is sound, but it faces the challenge of inspiring the members to take action.
Dietz highlighted a new NAM venture, a funding investment called the Grand Challenge on Climate Change, Human Health, and Equity, a multiyear global initiative to improve and protect human health, well-being, and equity by working to transform systems that both contribute to and are impacted by climate change. He relayed the initiative’s emphasis on the “triple threat” of structural racism, climate change, and the COVID-19 pandemic, calling these important considerations for charting the roundtable’s next steps.
In Dietz’s opinion, one of the areas the roundtable did not consider extensively in its model-building activities was how the model is embedded in climate change issues and how solutions for climate change may also help solve obesity (Swinburn et al., 2019). A related question, he continued, is how the roundtable might fit its priorities of structural racism, biased mental models, and health communication into the broader context of
climate change and point to common solutions for both. Finally, Dietz wondered what metrics could be used to assess the roundtable’s effectiveness in advancing these three priority areas, as well as the consistency between its actions and the NAM’s Grand Challenge on Climate Change, Human Health, and Equity.
Shiriki Kumanyika, emeritus professor of epidemiology at the University of Pennsylvania Perelman School of Medicine, research professor in the Department of Community Health & Prevention at the Dornsife School of Public Health at Drexel University, and Food and Nutrition Board liaison to the roundtable, followed Dietz in reflecting on the roundtable’s work.
According to Kumanyika, the roundtable represents a significant paradigm shift in how the National Academies addresses obesity. Whereas the National Academies previously convened consensus committees to respond to specific statements of task that were most relevant to specific audiences, she explained that the roundtable engages a broader group of multisector actors who are committed to translating the science into action. This model is transformative in that it links academics and action, she maintained, noting that the nonacademic roundtable members have kept the group accountable for addressing actionable, real-world contributions to obesity solutions.
The roundtable’s deep dive into systems thinking is another paradigm shift, Kumanyika suggested, because it represents a “coming of age” in declaring that obesity is not a discipline-specific issue. Obesity solutions cannot be developed in silos, she argued, because of the interconnected nature of its etiology. In addition to the subsystems in the obesity realm, she elaborated, other systems that are related to obesity, such as those involved in the issues of climate change and food insecurity, come together in a focus on systems thinking. This focus has opened the door for broader perspectives, she observed, and automatically incorporates a global perspective because the issues are global in nature, with social equity as a common thread.
The roundtable is now well recognized, Kumanyika said in concluding her remarks, as a fully mature group that is empowered to take action. Given its multisector engagement in ongoing discussion, she pronounced that the roundtable is well equipped as a platform for generating ideas and translating them into real-world action.
Pronk was the final roundtable member to share his reflections on the group’s work. He suggested that addressing obesity from a systems thinking perspective requires stepping back and creating a larger worldview. The roundtable previously called for multi- and cross-sector partnerships, he recounted, and he affirmed that the urgency for such partnerships continues. He reiterated the caution against siloed thinking and urged recreating alliances that can facilitate appreciation for the involvement of many sectors in public health endeavors. Pronk shared his belief that at the same
time, it would benefit the roundtable to slow down and engage in holistic, solution-oriented thinking with a long-term horizon.
An appropriate response to the need for action, Pronk suggested, is to prioritize key systems actors who can achieve major impact in the short term while reducing the risk of unintended consequences that sometimes result from acting too soon. He proposed that immediate actions might be best focused on increasing the scalability or sustainability of existing programs known to be effective. He proposed a shift toward a paradigm whereby shared values generate energy and excitement for participants, alongside significant community benefit.
Pronk elaborated on this concept of shared values by describing an example of three key sectors—public health, health care, and business and industry—organizing around a framework of shared values including equity, harm prevention, ethical principles, science, and practical wisdom as they pursue policy or programmatic initiatives. As an example of a multisector systems change initiative, he mentioned providing health insurance coverage for obesity prevention and treatment options, such as bariatric surgery, in a way that yields benefits for all stakeholders (health plans, employers, and government).
Following the above three sets of comments, Pronk asked Dietz and Kumanyika what opportunities the roundtable should leverage or prioritize in terms of next steps. Dietz referenced The Lancet global syndemic work that proposed the existence of “triple duty” or “quadruple duty” solutions addressing the synergistic interactions among climate change, undernutrition, and obesity.1 Equity must be addressed throughout those solutions, he added, because low-income, underserved people suffer most from climate change. He suggested that applying a similar lens would identify priorities with multiple beneficial effects. Kumanyika echoed Pronk’s guidance to proceed carefully, but cautioned that an overly slow pace might not foster transformative change. She appealed for transforming the systems that perpetuate obesity, contending that action sooner rather than later is needed to disrupt them.
PANEL DISCUSSION WITH MEMBERS OF THE ROUNDTABLE ON OBESITY SOLUTIONS
Following the reflections from Dietz, Kumanyika, and Pronk, five members of the Roundtable on Obesity Solutions offered perspectives on the workshop and shared thoughts and ideas about systems-level obesity solutions.
___________________
1 Syndemic is the presence of two or more disease states that adversely interact with each other, negatively affecting the mutual course of each disease trajectory and enhancing vulnerability, and that are made more deleterious by experienced inequities (Sharma, 2017).
Captain Heidi Michels Blanck, chief of the Obesity Branch in the Division of Nutrition, Physical Activity and Obesity in the National Center for Chronic Disease Prevention and Health Promotion at the CDC, focused her remarks on leveraging data for systems change. She described how the CDC’s Clinical and Community Data Initiative (CODI, previously known as the Childhood Obesity Data Initiative) uses existing information technology in new ways to link individuals’ data across clinical and community sectors to create local data that can help researchers better evaluate multiple interventions and understand differential effects by root causes.
CODI’s data assets and inputs include data from individual-level electronic health records (EHRs), clinical and community interventions, community-based organizations, and federal programs, as well as from geographic information systems. Its infrastructure allows communities to analyze these data in a way that links health behaviors, interventions, and outcomes to social determinants of health and other factors, such as community services. Blanck gave the example of data on an individual child from the child’s EHR, which through CODI can be linked with data from a community-based organization (e.g., parks and recreation), as well as community data indicating the child’s neighborhood safety and access to healthy food and physical activity opportunities. This layering of data from different levels provides a broad picture of what the child experiences in the neighborhood and community, and can help researchers evaluate the impact of services, policies, and programs.
CODI data remain with local practitioners, Blanck clarified, and do not go to the CDC. CODI links individuals’ EHRs in existing information systems while protecting personally identifiable information. To preserve privacy while linking records, Blanck explained, information is encoded in a secure, private format behind each organization’s firewall before sharing occurs (a process called data hashing), and CODI then uses the hashed data to link records across settings and information systems. Bringing together the sectors of public health, health care, and community-based organizations through technology services holds promise, she said in closing, for enabling better understanding of root causes.
Jamie Bussel, senior program officer at RWJF, reviewed the evolution of the Foundation’s work in the obesity arena. Over the past two decades, she began, RWJF has deepened its understanding of the immense complexity of the obesity epidemic and of the multifaceted, systemic, equity-centered approaches that are warranted to address it properly.
Bussel explained that RWJF’s obesity prevention efforts helped shape its overall vision for a culture of health, which in the past few years has focused more intensely on the need for systems-wide, structural changes to address the root causes of health inequities. She asserted that the achievement of enduring change will depend on long-term commitments to holistically
addressing upstream, interconnected community conditions, such as housing, employment, poverty, food access, and structural racism, that contribute to obesity but can be transformed to support health and well-being.
Bussel listed a few highly regarded peer-reviewed journal articles by public health leaders and experts that emphasize the importance of and possibilities for transformative social change to address obesity. In 2019, Kumanyika proposed an equity-oriented obesity prevention action framework, contending that obesity prevention interventions should be linked to strategies that account for or indirectly address social determinants of health (Kumanyika, 2019). Later that year, the Lancet Commission report The Global Syndemic of Obesity, Undernutrition, and Climate Change highlighted the urgent need for sustainable solutions for achieving both healthy weight and a healthy ecosystem for the planet’s survival (Swinburn et al., 2019). And in December 2020, Kumanyika and Dietz coauthored a paper asserting that population-wide obesity cannot be solved without far-reaching restructuring of current systems (Kumanyika and Dietz, 2020).
Bussel admitted that broad systems-wide strategies for addressing obesity will be complex and controversial, but she argued that such strategies are fitting in the context of the COVID-19 pandemic’s illumination of the stark health and social inequities in the United States. It is not a coincidence, she maintained, that the disparities that increase the risk of obesity also increase risk of contracting and dying from COVID, and she added that these disparities stem from policies, decisions, and disinvestment that put certain Americans, especially people of color, at risk for poor health outcomes.
Bussel ended by invoking a sense of hope, suggesting that the country is at a “watershed moment” in its history given the intersection of the COVID-19 pandemic, devastation from the economic downturn, and the inspirational movement around racial justice. Policies that truly change the nature of communities are on the horizon, she predicted, and she stressed that a window of opportunity exists around the widespread sense of urgency to change the trajectory of children’s health and well-being.
Joseph Nadglowski, president and chief executive officer of the Obesity Action Coalition (OAC), maintained that better progress toward obesity solutions will come from factoring in the lived experience of people with obesity and thinking about systems that will work for and not against them. He reported that the OAC has begun applying lessons learned from the roundtable’s systems mapping efforts, which integrate structural racism, biased mental models and norms, and health communication. First, he said, the OAC is partnering with the NAACP, the National Action Network, and the National Hispanic Medical Association, among others, to address systemic racism and obesity through policy changes designed to improve access to obesity care for people from diverse communities. Weight bias and other
social norms about obesity are key barriers to obesity care, he asserted, referencing Godsil’s comments (Chapter 11) about reframing weight bias with a positive frame. Future roundtable meetings would be helpful, he suggested, to explore how this latter objective could be delivered.
In terms of communications, Nadglowski pointed out that obesity advocacy organizations are constantly assessing the way they communicate about obesity. He said that they question, for example, whether their messages are contributing to misunderstandings about obesity by being presumptuous, overly simple, or too narrowly focused on a single issue or data point. Catastrophizing the issue at the expense of people living with obesity is also a risk, he commented, noting that the roundtable’s work has highlighted the importance of messaging effectively.
Megan Nechanicky, nutrition manager for General Mills North America Retail, spoke as a representative of the food industry. The starting point for this industry, she said, is using a consumer lens to understand consumer problems and how it can help solve them. She recounted visiting consumers in their homes before the COVID-19 pandemic to listen and understand the challenges they faced to healthy eating. She found that among shoppers with low incomes, for example, the top concern is having enough food to feed themselves and their families, followed by having flexible, basic food staples on hand. They often would give the example of ground beef, Nechanicky recalled, because it forms a foundation for many different meals. Asked to describe the characteristics a healthy meal, she continued, they would cite balance (i.e., inclusion of foods from the major food groups), filling, and tasty, and many would use the example of a chicken pot pie.
As for General Mills’ nutrition strategy, Nechanicky said its focus is on nutrient density and dietary patterns. She highlighted the potential of innovation to make healthy foods more convenient and better tasting, to drive reformulation that improves the nutrient profile of foods, and to make healthy foods more accessible and affordable. She ended her remarks by stressing the food industry’s potential to help improve nutrition security.
Susan Yanovski, codirector of the Office of Obesity Research and senior scientific advisor for clinical obesity research at the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (NIH), proposed strategies that NIH could use to accelerate obesity solutions in light of its focus on biomedical and behavioral research. One such strategy would be to support research to evaluate new programs and policies. She suggested that the resulting evidence base could guide policy makers and funders in their allocation of limited resources. As an example of this kind of support, Yanovski cited an NIH rapid response funding opportunity that supports investigators over a short period of time so they can collect baseline data before a new policy or program is implemented. Another way NIH could accelerate obesity solutions, she continued, would be
by informing strategies for the dissemination and implementation of efficacious interventions.
According to Yanovski, the NIH UNITE initiative indicates that NIH recognizes the critical role of such factors as systemic racism that lie upstream of biomedical outcomes of interest. The purpose of this initiative, she clarified, is to identify actions that can help eliminate structural racism and racial inequities throughout the biomedical research enterprise. She also pointed to the NIH Common Fund, which is supporting transformative research to address health disparities and advance health equity.
The first funding opportunity announcements from the UNITE initiative were released in fiscal year 2021, Yanovski continued. She explained that this funding will provide support for highly innovative translational research projects that purport to prevent, reduce, or eliminate health disparities and advance health. Eleven grants were recently awarded in that cycle, she reported, amounting to $58 million over 5 years, adding that several of the awards were targeted to minority-serving institutions. As an example of a funded grant application, she described a cluster randomized trial of concentrated investment in Black neighborhoods to address structural racism as a fundamental cause of poor health.2 This study will deliver a suite of place-based and financial well-being interventions, she observed, at the community, organizational, and individual household levels. Another example of funded research is the Harlem Strong Mental Health Coalition, a multisector, community-engaged collaborative for system transformation.3 According to Yanovski, health insurers will work with a network of community-based organizations, medical providers, and behavioral health providers, with a long-term goal of developing a sustainable model for task-sharing mental health care that will be embedded in a coordinated comprehensive network of services, including primary care, behavioral and mental health care, social services, and other community resources.
Lastly, Yanovski informed participants that a suite of funding initiatives for transformative research to address health disparities and advance health equity is planned for fiscal year 2023. The NIH Common Fund held a series of listening sessions in October and November 2021, she said, where stakeholders shared ideas for innovative approaches to this type of research that actively involve community members in the process.
Following the remarks from the five Roundtable members, Pronk posed a question to each to elicit additional insights on systems approaches for obesity solutions. He began by asking Blanck whether she could identify systems approaches that state or local public health agencies can leverage to address obesity. She pointed back to CODI as an example of utilizing
___________________
2https://reporter.nih.gov/project-details/10413510 (accessed January 28, 2022).
3https://reporter.nih.gov/project-details/10414696 (accessed January 28, 2022).
technology that other sectors are using—e.g., the financial services industry’s application of the technology for enabling privacy for online banking—and applying it to public health. She stressed that a great deal of investment and partnering with other sectors will be required for local and state public health departments to leverage natural experiment research and implement multidisciplinary research tools to meet their data needs. She also emphasized the need for ample data to enable disaggregation of information so the needs of diverse identity groups can be better characterized.
Pronk next asked Bussel how the COVID-19 pandemic influenced RWJF’s strategy for addressing obesity. She replied that the pandemic illuminated the critical need to address the social side of health, giving the example of the difficulty of isolating for people who work in low-wage jobs with no paid sick leave or who live in crowded housing. She confirmed that the pandemic has reaffirmed the Foundation’s focus on addressing root causes of health and social inequities, such as long-standing discriminatory policies and systems, with the goal of helping to create a country that allows everyone a fair, just opportunity to live the healthiest life possible.
Pronk moved on to ask Nechanicky what the pandemic highlighted for the food industry in terms of the role it could play in addressing health inequities. She responded that the pandemic has vividly displayed the fragility of the U.S. food supply chain, and explained that its stability depends on the consistent operation of food production facilities that employ many people on the front lines. Through the pandemic, she elaborated, both large and small food manufacturers came to realize how critical they are in providing food for people around the world, and she called on the industry to apply its resources and capacity to address food and nutrition insecurity. She argued that the case for such a strategy for improving the affordability and accessibility of healthier products could be made from a business standpoint.
Pronk directed a question to Nadglowski about how an individual with obesity might respond to the roundtable’s focus on foundational drivers of obesity. From his perspective, Nadglowski said, the roundtable’s causal systems map removes the individual from the center of blame and recognizes the host of other factors contributing to obesity. This approach is hopeful in his view, and he said he looked forward to communicating with the public about the systems nature of obesity to help them understand its complexity and to relieve the sense of shame and blame often experienced by people living with obesity.
Finally, Pronk asked Yanovski how research funders can best facilitate solution-oriented research that reflects and values communities. She suggested greater involvement of stakeholders and communities at all stages of research, such as by seeking their input when identifying priorities and goals, designing research studies, recruiting participants, and developing understandable consent forms that are relevant to the potential
research volunteers. Community stakeholders are rarely involved in conference planning and grant application review, she pointed out, and suggested that they could be included in the process of drafting manuscripts to disseminate research findings.
CLOSING REMARKS FOR WORKSHOP DAY ONE
Peter Hovmand, Pamela B. Davis M.D. Ph.D. Professor of Medicine at the Center for Community Health Integration, professor of general medical sciences in the School of Medicine; professor of biomedical engineering in the Case School of Engineering; and professor of social work (secondary appointment) in the Jack, Joseph and Morton Mandel School of Applied Social Sciences at the Case Western Reserve University School of Medicine, delivered final remarks to close the first day of the workshop.
Hovmand began by recalling key events leading up to the roundtable’s focus on systems approaches to obesity solutions. They4 explained that the first time they remembered hearing systems approaches and obesity prevention discussed at the same conference was in 2000, in the context of applying a syndemics framework to disease prevention. Almost a decade later (2009), they continued, a group of multisector experts was invited to a meeting to consider systems approaches to prevention of childhood obesity, which served as the starting point for a comparative modeling network funded by NIH, RWJF, and others. Despite multisector representation at that meeting, Hovmand thought at the time that sectors were still positioned against each other and not thinking about obesity from a systems perspective.
Hovmand contrasted that perception with conversations held during the past year and at this workshop, which they described as a paradigm shift in terms of the remarkable reframing of the issue. They noted that their collaboration with the roundtable’s group model-building exercises began in 2019, and components of its systems map (Figure 1-1 in Chapter 1) began to emerge in early 2020. Even though this work occurred prior to the COVID-19 pandemic and the rise in activities to promote social justice and combat systemic racism following George Floyd’s death, Hovmand continued, the authors of the map recognized that addressing structural racism and promoting health equity would be important components. Hovmand noted that these themes have been raised in some of their recent work to map other systems, and observed that a new shift in thinking has been the idea of understanding the role of biased mental models and implicit bias.
Describing some of the work they have done in Cleveland, Ohio, Hovmand shared a community member’s contribution at a recent event—that
___________________
4 Hovmand uses the pronouns “they,” “them,” and “their.”
it is difficult to change systems unless the mental models underlying them are also changed. If the focus is simply on reforming the systems, they elaborated, it will not change the thinking. In contrast, they proposed that if a lens of structural racism, health equity, and racial equity is at the forefront, the meaning of systems change will be different. This point brought Hovmand to the notion of collective action, which they suggested goes beyond simply convening multiple sectors to activating double- and triple-duty solutions that address multiple complex problems at multiple scales.
Hovmand highlighted several opportunities that result from taking a systems approach, the first of which is being able to identify common structures across national and global regions that provide insight into a system’s underlying structural racism and the impact of colonialism. They commended efforts to learn from innovative solutions being implemented globally and to translate them across contexts. They identified as a second opportunity recognizing that implicit bias reflects systemic racism, which they said was proposed in a recent paper implying that if individual-level implicit bias can be measured, it can be changed, but that change will not endure unless larger systemic or structural changes occur (Payne and Hannay, 2021). According to that paper, only larger-scale change will shift the associations that people accumulate over time.
Building on Pronk’s comments about the pace of change and the unintended consequences that could result from moving too quickly, Hovmand called for balance. On the one hand, they pointed out, the luxury of time to wait for data to accumulate does not exist, but on the other hand, there is the risk of losing people if movement occurs before support is built (especially for controversial policies). Some evidence-based interventions are ready to be scaled now and improved in terms of reach and equity, they observed, and they suggested that interventions be pursued in parallel with building capacity for community-driven solutions from a systems perspective.
In Hovmand’s experience, systems language provides a bridge in that systems concepts are not new to people with lived experience of adverse conditions, and systems language is a way of expressing those concepts for people who have had different experiences so they can develop structural empathy and be part of the solution. To enable such collaboration, Hovmand proposed a focus on supporting and sustaining investment at multiple scales from multiple levels (e.g., neighborhood, school, community, national, and global), given the multifaceted contributors to the obesity epidemic.
Hovmand concluded their remarks by echoing Lee’s point about the importance of studying and understanding complex systems. It is easy to get overwhelmed by the complexity, they admitted, but they encouraged participants to regard new technologies and methods for understanding systems and the new appetite for the importance of doing so as an asset in developing and scaling obesity solutions.
