In the first workshop’s final session, the workshop planning committee members shared their reflections on the workshop, engaged in a panel discussion of topics addressed, and responded to audience questions. The session was moderated by Angela Odoms-Young, associate professor and director of the Food and Nutrition Education in Communities Program and New York State’s Expanded Food and Nutrition Education Program in the Division of Nutritional Sciences at Cornell University.
REFLECTIONS
Carol Byrd-Bredbenner, distinguished professor of nutrition and director of the nutritional sciences graduate program at Rutgers University, began the reflection portion of the session by highlighting food insecurity as a contributing factor to obesity and a key barrier to reducing its prevalence. The COVID-19 pandemic has increased the prevalence of food insecurity, she observed, and has also widened the disparities in its prevalence among population subgroups. Actions to increase food security have focused on improving the U.S. food security safety net programs, she noted, and COVID-induced changes in those programs may provide insights into ways of removing participation barriers postpandemic.
As an example, Byrd-Bredbenner shared that the benefits of the Supplemental Nutrition Assistance Program (SNAP) were increased by 15 percent during the pandemic, and states were granted greater flexibility in managing their beneficiary caseloads. She called on researchers to evaluate the outcomes of these emergency measures and generate data that can support appeals to make the changes permanent.
Another example, Byrd-Bredbenner continued, is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which serves pregnant and lactating women and their children up to 5 years of age. WIC reaches about 55 percent of eligible recipients and has a steep dropout rate when children reach their first birthday, Byrd-Bredbenner observed, perhaps fueled in part by parents’ frustration over the challenges encountered in accessing options within the WIC food package for children between ages 1 and 4, as well as the requirement to appear in person with their children twice a year for recertification. Policy changes could require states to offer the full range of allowable WIC food package options, she suggested, and could offer more convenient (i.e., telehealth) delivery modes for the required visits.
The school-based components of the food safety net, Byrd-Bredbenner continued, include the National School Lunch Program (NSLP), School Breakfast Program (SBP), and Summer Food Service Program (SFSP). The NSLP reaches about 95 percent of schools, she stated, and she encouraged continuation of its widespread delivery. She cited as challenges with the program school schedules that give children insufficient time to sit down and eat lunch and
a cost burden that some parents face in paying for meals. Byrd-Bredbenner went on to note that the SBP is not available in many schools, and she called for expanding the program and increasing its accessibility. Making it no-cost for all children would remove the stigma many feel when participating in the program, she suggested, and scheduling it during—versus before—the school day would increase participation. As for the SFSP, Byrd-Bredbenner referenced a 2018–2019 participation rate of 1 in 7 eligible children, which she said was due mainly to the lack of school participation in the program or children’s lack of transportation to pick up food at a participating school. COVID-related changes allowed parents (instead of students) to pick up multiple days of meals at one time, a change that she urged maintaining postpandemic to make children’s participation more viable.
Beyond federal food programs, Byrd-Bredbenner highlighted small food outlets such as corner stores, which she pointed to as primary food retail venues for many people who live in urban areas and experience food insecurity. She suggested that such incentives as tax breaks or low-cost coolers could support these stores in offering a greater variety of perishable, healthy food options beyond what is required minimally to be a SNAP retailer.
According to Byrd-Bredbenner, the bottom line is that improving food security brings benefits beyond helping to prevent obesity and address health disparities. It also helps provide children enough nourishment so they can stay focused at school, alleviates parents’ stress about feeding their children, and improves employee health and reduces sick days.
Carlos Crespo, professor at Oregon Health and Science University and Portland State University School of Public Health and vice provost for undergraduate training in biomedical research at Portland State University, offered a series of comments, starting with an observation that weight stigma is often a short-term experience but can have lasting effects—not only health effects, he added, but also effects on occupational earnings and acquisition of wealth over time. Obesity is a community problem, he maintained, with determinants that are more sociopolitical than physiological, clinical, or biological in nature. Clinical solutions are narrow in scope, he continued, and he called for greater attention to and expenditures on the root causes of the problem. The COVID-19 pandemic’s universal reach increased societal awareness of social and political determinants of health, he observed, which he suggested exert a greater influence over some groups than others in terms of how they interact with their environments.
According to Stephanie Navarro Silvera, professor of public health at Montclair State University, a key message of the workshop was that the country’s deeply entrenched issues of race and racism cannot be addressed simply by encouraging good behaviors. She pointed out that racism often undermines efforts to access good health while simultaneously masking the structural inequalities that lead to health disparities and implying that
health problems are primarily behavioral in nature. Silvera appealed for structural solutions that include policy and political engagement strategies, as well as programmatic and intervention efforts. She declared that, although some policy topics appear to be disconnected from obesity, all policy is health policy and all politics are local. Thus she highlighted the importance of engaging with local government entities responsible for transportation, zoning, housing, and education policies, for example.
Silvera echoed prior speakers’ comments about the COVID-19 pandemic’s illumination and exacerbation of health inequities, and warned that because of structurally and socially mediated segregation, barriers in access to many occupations, and a higher risk of chronic disease in underresourced populations, disparities in obesity and chronic conditions are likely to worsen before they improve. As an example, she referenced the seven-fold mortality rate due to COVID-19 among Latinx men younger than age 65 compared with their age peers in other racial groups in New Jersey. She suggested that the far-reaching impact of this disparity on access of those men’s families to resources and how that impact may manifest through such conditions as obesity is as yet not understood. The loss of a family’s primary wage-earner is an economic insult to a household, she stressed, adding that the loss of a parent is traumatic for young children.
Melissa A. Simon, director of the Center for Health Equity Transformation at the Institute for Public Health and Medicine and George H. Gardner Professor of Clinical Gynecology in the Feinberg School of Medicine at Northwestern University, proposed that the prevalence of obesity in the United States represents the accumulation of decades of inequities rooted in structural and political racism that have promulgated harmful social, economic, and structural determinants of health. She offered the analogy of an apple tree bent toward one group of people, effectively favoring that group with the privilege and advantage of easier or even effortless access to its fruit (i.e., good health). Meanwhile, she continued, the apple tree is bent away from other groups that may never be able to reach the fruit. She urged increased awareness of the tree’s status of “fundamentally bent,” and appealed for efforts to unbend it. Health equity is not an outcome, Simon argued, but a process of ensuring that conditions of optimal determinants of health (e.g., access to health-promoting resources and culturally responsive health care and respect) are conferred on every person while acknowledging historical injustices, so that everyone has an opportunity to reach the fruit on the tree. She urged participants to examine the tree carefully to identify where it needs to be unbent.
PANEL AND AUDIENCE DISCUSSION
After presenting their reflections, the workshop planning committee members discussed structural considerations and potential solutions for
obesity and its root causes; potential solutions for addressing multiple drivers of obesity; effective, scalable, and sustainable solutions; taxation approaches; and the role of intersectionality in developing solutions.
Structural Considerations and Potential Solutions for Obesity and Its Root Causes
Byrd-Bredbenner emphasized consideration of “the cause of the cause” (i.e., upstream determinants of health) when determining how to remove barriers to health, and suggested that public education would increase awareness of structural root causes. At the same time, she appealed for attentiveness to downstream changes that could be implemented relatively quickly, such as making permanent the pandemic-induced increases in SNAP benefits. These increases give families about $95 extra per month, she noted, pointing to previous research showing that SNAP recipients reported that an extra $100 in monthly benefits would help them meet their monthly food needs. It will be interesting, she suggested, to evaluate the outcomes of the increased SNAP benefits in light of these data.
Simon reiterated that the phenotype of obesity reflects policies in sectors that appear unrelated to health, such as education and housing, and urged stakeholders to recognize these connections. She pointed out, for example, that health insurance is generally linked to employment, and that the COVID-19 pandemic left many people unemployed, with potential indirect effects on people’s ability to pursue and maintain health. She also encouraged structural and environmental policies promoting physical activity in various environments, as well as access to healthy food for all.
Silvera underscored voting rights as a key issue with downstream implications for health and noted an uptick in recent state-level efforts to modify voting laws. She also urged greater awareness of state-level policies and decision makers in general, suggesting that most people are less familiar with the officials who represent them at the state level than at the federal level. Local policies are most closely related to people’s daily lived experiences, Silvera argued, and she encouraged attendance at city council and school board meetings to learn what policies are under consideration. Improving the health of communities is better accomplished when decision makers listen to community voices, she suggested, instead of presuming to know what changes need to be made.
Exploring Potential Solutions for Addressing Multiple Drivers of Obesity
According to Crespo, making one’s voice heard in government decision making is critical. Silvera endorsed Thorpe’s suggestion of a thriving wage and raised the topic of reparations, acknowledging that it is a challenging
and controversial issue, but one she believes merits an honest conversation as a means of providing resources to people who have experienced historical injustices. She also urged that conversations about race and racism include Latinx, Asian American, and Indigenous populations, which she said are often discussed and represented in data at the aggregate level, masking the diversity of experiences and outcomes that often exist within those communities.
Simon pointed out that physician training is disease focused, with little emphasis on health promotion and wellness. Incorporating more of the latter perspective, she suggested, would help physicians do a better job of counseling patients on such lifestyle topics as nutrition and physical activity.
Byrd-Bredbenner reiterated Silvera’s earlier comment about engaging communities. She pointed to community-based participatory research as a core public health strategy for gaining understanding of community perspectives on solutions.
Effective, Scalable, and Sustainable Solutions
Crespo admitted that it is difficult to identify a solution for reducing the prevalence of obesity that has demonstrated promise, scalability, and sustainability. Nonetheless, he highlighted advances in identifying risk factors and evidence-based solutions and suggested that the present challenge is implementation. Silvera agreed and stressed the importance of cross-sector collaboration in implementing community-wide solutions. As an example of situations in which obesity and other chronic health conditions are distal to people’s daily realities, she observed that residents of low-income communities may expend most of their energy figuring out how to pay their bills. Unless such acute, everyday stressors are addressed, she argued, it will be challenging to make progress on obesity.
Building on that point, Byrd-Bredbenner recounted her experience developing a program intended to deliver education about nutrition and physical activity to families. When participating families were asked what topics would most improve their quality of life, they requested content on building stronger families and managing stress. The program had to adapt its intended content, she explained, to address what families considered to be their pressing needs.
Asked about the optimal time to begin nutrition education, Byrd-Bredbenner said she would like to see it integrated in multiple settings throughout the life course, from educational institutions starting with preschool, to WIC and SNAP touchpoints, to grocery stores and food labels. She urged that current efforts to educate the public about nutrition evolve to reflect the latest evidence and encourage broader uptake.
Taxation Approaches
A participant suggested that taxation lies at the intersection of obesity, structural racism, poverty, and community self-determination, among other issues, and panelists discussed how to approach stakeholders’ conflicted perspectives on the topic. Taxation is a difficult policy proposition, Crespo began, generally viewed as a punitive measure and opposed by powerful industries that represent the taxed products. He suggested considering the opposite angle of lowering prices for products that are being encouraged. Byrd-Bredbenner agreed about the philosophical and administrative complexities of taxation policies, and Silvera cautioned against their unintended consequences, particularly for low-income communities that lack access to healthier options. Linking the discussion to the broader topic of encouraging policies that promote equity, she reiterated the significance of knowing and engaging with one’s local and state representatives, advocating for solutions, empowering other community members to raise their voices, and getting involved with local decision-making bodies.
The Role of Intersectionality in Developing Solutions
Silvera proposed that addressing the needs of people who have the most layers of disadvantage will benefit all people. She reiterated the importance of making space in all environments and communities for disadvantaged groups, including individuals with physical or developmental disabilities, and amplifying their voices so their needs can be heard. Crespo reminded participants to focus not just on the various intersecting characteristics but on the dignity of the person in which those characteristics occur.
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