Systems and Obesity: Advances and Innovations for Equitable Health and Well-Being: Proceedings of a Workshop—in Brief (2022)

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Proceedings of a Workshop IN BRIEF March 2022 Systems and Obesity: Advances and Innovations for Equitable Health and Well-Being 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, “Systems and Obesity: Advances and Innovations for Eq- uitable Health and Well-Being,” on October 28–29, 2021. The workshop was the final in a series of three workshops to examine foundational drivers of obesity and discussed sustainable systems-wide changes that use three priority areas—biased mental models/social norms, structural racism, and health communication—to inform actionable priori- ties for individuals, organizations, and policy makers to reduce both the incidence and prevalence of obesity.1 The workshop sessions featured examples from across public health to explore ways to use data for systems change; how systems applications can address structural barriers to obesity; using policy for obesity solutions and nutrition secu- rity; and engaging multiple sectors for systems change. The workshop also included a session that examined patient– provider communication about obesity treatment and offered solutions to improve those communications. 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 information shared during the workshop.2 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 of Sciences, Engineering, and Medicine. Nicolaas (Nico) Pronk, president of HealthPartners Institute, chief science officer at HealthPartners, Inc., af- filiate professor of health policy and management at the University of Minnesota 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 barriers and facilitators for implementing obesity solutions. These efforts culminated in the development of a causal systems map of obesity drivers and solutions, he said, to guide the field toward data- driven obesity solutions and innovative approaches.3 Pronk highlighted the map’s three priority areas—structural racism and social justice, 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, which depicts potential places to intervene in a system as a taxonomy of 1 See https://www.nationalacademies.org/our-work/addressing-structural-racism-bias-and-health-communications-as-foundational- drivers-of-obesity-a-workshop-series (accessed January 10, 2022). 2 The workshop agenda, presentations, and other materials are available at https://www.nationalacademies.org/event/10-28-2021/ systems-and-obesity-advances-and-innovations-for-equitable-health-and-well-being-a-third-workshop-series-october-workshop (accessed January 10, 2022). 3 A formal publication on the roundtable’s systems map is forthcoming. 

system elements arranged by increasing effectiveness to create systems-wide changes.4 Pronk pointed out that the frame- work’s increasingly deeper leverage points are difficult to penetrate, but also hold the most promise to create systems- wide change because they represent the power to transcend the paradigms and mindsets out of which systems arise. USING DATA FOR SYSTEMS CHANGE: CONNECTING OBESITY AND ITS UNDERLYING DETERMINANTS The workshop began with two speaker presentations that discussed driving systems change by using data that con- nects obesity with its underlying determinants. Bruce Lee, professor of health policy and management at the City University of New York Graduate School of Public Health & Health Policy, framed his presentation around a series of examples describing what it would look like if society approached meteorology (i.e., forecasting the weather) the same simplistic way that it approaches obesity prevention and control. Although meteorology and obesity seem unrelated, he said, they are similar in that they both involve complex systems. First, Lee expected that it would be typical to use a single measure, such as temperature, to determine the weather. But that single metric fails to provide information about precipitation, humidity, or other aspects that affect how a person prepares for the weather. Similarly, Lee continued, it is insufficient to rely on single measures such as an individual’s body mass index (BMI) or the population prevalence of obesity to understand the broader set of complex, dynamic factors that contribute to obesity and how best to intervene. Second, Lee said that simple associations and correlations would be used to forecast the weather. To illustrate this point, Lee displayed a graph that tracked a decrease in the number of pirates with a rise in global temperatures. Lee noted that while there is a linear relationship between the two, the solution to climate change is not to train more pirates. The simple correlation association, he pointed out, does not necessarily imply a cause and effect relationship. Similarly, obesity prevention and control cannot rely on simple correlations and associations. He urged a combination of approaches, including top-down methods that scrutinize data for patterns and correlations in order to detect poten- tially important factors, and bottom-up methods that re-create systems to elucidate mechanisms of interest. Third, data collection would occur in isolation from other activities that help characterize a system’s interconnec- tivity. A better approach, Lee suggested, is to integrate data collection, systems mapping and modeling, and policies and interventions. Fourth, weather data would not be readily shared. In contrast, Lee explained that open data sharing about the multiscale, multilevel influences on obesity—from people’s genetics to their behavior to societal forces such as policies— would help paint a more complete picture of the broader system and reveal major forces driving the outcomes observed. Fifth, it would be assumed that weather conditions in one location are the same everywhere else. Citing his own research, Lee said that the effect of sugar-sweetened beverage warning labels on the prevalence of obesity varies by geographical location because of such factors as the distribution of stores and locations selling these products, as well as BMI distribution, differing by location. Sixth, the weather forecast would not be regularly updated over time, despite its highly dynamic nature. Lee indicated that decisions about obesity prevention and control also need to be informed by real-time surveillance data. Seventh, individuals would be singularly blamed for the weather. Lee urged consideration of external factors such as social determinants that influence the development of obesity. Eighth, single interventions would be expected to handle the weather. In contrast, multiple multiscale, layered, and integrated policies and interventions are needed to address the multifaceted contributors to obesity. Ninth, old technologies would be used to predict the weather. In- corporate advanced capabilities such as agent-based modeling and machine learning, Lee urged, as these can provide new insights about obesity prevention and control. Lastly, weather forecasting would be deemed overly complex and impossible to understand completely. Lee contended, “We have to start somewhere, even if initial efforts provide only partial solutions to the problem; the itera- tive nature of systems modeling will gradually enable better understanding and in turn, better solutions.” The second speaker, Ryan Masters, assistant professor of sociology and faculty associate of the Population Pro- gram and the Health and Society Program in the Institute of Behavioral Science at the University of Colorado Boulder, stated that characterizing the relationship between obesity and mortality risk at the individual level is a major chal- lenge, but it can be informed by examining population death rates from cardiometabolic diseases. He shared data indicating that since 1990, trends of decreasing death rates from cardiometabolic diseases among middle-to-older aged adults have begun to flatten,5 presumably driven by prolonged exposure to the rising 4 Meadows, D. 1999. Leverage points: Places to intervene in a system. Hartland, VT: The Sustainability Institute. 5 NASEM. 2021. High and rising mortality rates among working-age adults. Washington, DC: The National Academies Press. https://doi. org/10.17226/25976. 2 

obesogenic environment in the United States. When U.S. trends in cardiometabolic disease deaths are compared to those in other high-income countries, Masters pointed out that an “alarming widening” of the disparity between the United States and its peers has occurred since 2008–2009.6 According to Masters, he believes the disparity is an effect of changes in behavioral risk factors, including an increase in the prevalence of obesity, a slowdown in smoking reduction, and the indirect effect of the opioid epidemic. Despite the role of obesity-related mortality in fueling the gap, Masters emphasized the difficulty of empirically demon- strating that BMI classifications of obesity or other individual-level indicators of obesity translate into elevated mortality risk. Related to this challenge, Masters referenced a systematic review and meta-analysis indicating that mortal- ity rates were similar between populations with obesity and populations with low BMI, and also that individual-level mortality risk was lowest among people with BMIs in the overweight category;7 as well as a call for researchers to put forth better metrics than BMI to investigate the individual-level association between obesity and mortality.8 These pub- lications spurred a new era of proposed indices, Masters observed, that use measures of body size, shape, mass, and adiposity distribution to more accurately assess metabolic health and corresponding mortality risk. In Masters’ view, it may be more worthwhile to examine individuals’ cumulative duration of time spent in different BMI states, which is a key influence on one’s metabolic health. People who have been stable at normal weight BMIs exhibit more metabolically healthy profiles, he said as an example, than those who moved from a higher BMI category into the normal weight BMI category. After adjusting for a person’s lifetime history of being in different BMI states, Masters explained that the relationship between BMI and individual-level mortality risk shifts from a U-shape (with elevated risk at both underweight and very high BMI levels) to a nearly linear association where mortality risk rises as BMI rises. Current efforts seem to be shifting away from using BMI and toward new metrics, he observed, but he suggested comparing the payoffs for pursuing new metrics with those for pursuing new questions and designs for exploring associations. SYSTEMS APPLICATIONS TO ADDRESS STRUCTURAL BARRIERS TO OBESITY PREVENTION The second session of the workshop featured two speaker presentations that discussed systems applications to address structural barriers to obesity prevention. Soma Saha, executive lead of the Well Being in the Nation (WIN) Network, began by recounting her experi- ence mapping primary care patients’ environmental contexts as a way to explore community-level factors contributing to health outcomes. These exercises revealed that underresourced areas had higher rates of poor health outcomes (e.g., childhood obesity), and she said that these patterns were replicated in other locations across the country. The emergence of such widespread patterns indicates that an underlying system exists, Saha maintained, that propagates chronic, place-based inequities that cannot be explained by individual behaviors or even environmental factors. She remarked that racism is a transmissible illness that permeates not only one’s interpersonal experience but also the structures and systems of a society. Better understanding of this phenomenon could provide insights into why obesity outcomes have plateaued, she suggested, despite decades of U.S. efforts to slow and reverse its course. Saha discussed the Moving to Opportunity Program as an example of an effort that effected changes in obesity through structural change. Among women who moved from low- to higher-income neighborhoods, a 20 percent reduction in obesity was observed within 6 months, Saha reported, along with lower rates of severe obesity and diabetes, compared with a control group, 10 years later.9 These outcomes were only partly explained by neighbor- hood characteristics; Saha added that moving to more affluent areas decreased the women’s levels of allostatic stress, explaining the substantial differences observed in chronic disease development. Saha reviewed WIN Network’s theory of change, which proposes that the shape of people’s lives and their pre- dictive mortality from birth are determined in part by legacies of structural racism, colonialism, and economic inequal- ity that pervade current society. Policies can promote dignity and inclusion, she said, and affect whether people have the vital conditions necessary for well-being. On the other hand, policies can also promote trauma and exclusion that contribute to the experience of adversity and urgent needs, which in turn cause allostatic stress. 6 Ibid. 7 Flegal, K. M., B. K. Kit, H. Orpana, and B. Graubard. 2013. Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 309(1):71-82. https://doi.org/10.1001/ jama.2012.113905. 8 Ahima, R. S., and M. A. Lazar. 2013. The health risk of obesity – better metrics imperative. Science 341(6148):856-858. 9 Ludwig, J., L. Sanbonmatsu, L. Gennetian, E. Adam, G. J. Duncan, L. F. Katz, R. C. Kessler, J. R. Kling, S. T. Lindau, R. C. Whitaker, and T. W. McDade. 2011. Neighborhoods, obesity, and diabetes – a randomized social experiment. New England Journal of Medicine 365:1509-1519. https://doi.org/10.1056/NEJMsa1103216. 3 

This theory of change has led the WIN Network to shift to a structural approach to well-being, Saha ex- plained, that addresses people’s physical and mental health along with their social and spiritual well-being in a holistic way, as well as addressing underlying community conditions (e.g., food access and housing) and root causes (e.g., exclusionary zoning and other forms of structural racism) that perpetuate poverty and poor health. This approach to pursuing population health equity, Saha said, builds community assets and resilience and is a more efficient way to ad- dress health inequities than focusing solely on individual or even environmental determinants of health. The second speaker in the session, Rachel Godsil, cofounder and codirector of Perception Institute and distin- guished professor of law and chancellor’s scholar at Rutgers Law School, said that structural aspects are key barriers to accessing opportunities for healthy lifestyles and to having institutional policies and practices that can make a differ- ence. Using weight stigma as an example, she used the term intersectionality to help describe the dynamics of how people with obesity experience this bias. Obesity is experienced across multiple identity categories such as race, ethnic- ity, sexuality, and class, she explained, and the cumulative effect of the multiple forms of discrimination (e.g., racism, sexism, classism) that combine, overlap, or intersect in the experiences of marginalized individuals or groups is greater than the sum of its parts. Godsil voiced her opinion that broad-scale structural solutions to address obesity—those that recognize the roles of poverty, economic inequality, and other factors that hinder engagement in healthy lifestyle behaviors—are imperative but may be inadequate. She maintained that it is also critical to understand the ways in which the brain’s categorization of weight and body size affect the way people experience the world. One phenomena that results from this categorization is identity anxiety, which Godsil said people can experience in cross-group interactions when a person in the nondominant group is concerned that they may experience some form of discrimination or bias. For example, people with obesity fear that they may experience an interaction differently because of their body size. A second phenomena is implicit bias, which she said occurs when an individual, without conscious knowledge, has an attitude toward people or associates stereotypes with those people. A third is stereotype threat, which is the feeling that one’s identity is salient in a given environment. This can create a cognitive mindset where concern about conforming to the stereotype can lead to a greater likelihood of behaving in ways consistent with the stereotype. Health information that focuses on 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. Instead, Godsil suggested leading with possibilities of hope and aspiration that support shifts in behavior. Leading with evidence and solutions and countering misinformation are also important, Godsil added, to shift away from “blame and shame” narratives about people with obesity and to create conditions where people can see them- selves in a positive light and find hope in the possibilities for leading healthy lives. POLICY SOLUTIONS FOR NUTRITION SECURITY AND OBESITY The workshop’s third session included two speaker presentations that examined policy solutions for nutrition security and obesity. Sara Bleich, senior advisor for COVID-19 in the Office of the Secretary at the U.S. Department of Agriculture (USDA), highlighted USDA’s priorities that use federal nutrition assistance programs to improve health as the country aims to “build back better” in the wake of the COVID-19 pandemic. She explained that USDA is addressing food inse- curity—experienced by 1 in 11 U.S. adults, with a disproportionate effect on racial or ethnic minority, low-income, and rural or remote-dwelling populations—by promoting nutrition security, which it defines as consistent access, availabil- ity, and affordability of foods and beverages that promote well-being and prevent disease. One example is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides eligible mothers and their children (up to 5 years of age) with specialized nutrition resources and health care referrals. Only 57 percent of eligible women and their children are enrolled, Bleich noted, and said that a new initiative called WIC 390 (reflecting a $390 million investment via the American Rescue Plan [ARP] Act of 2021) will support out- reach, innovation, and modernization to improve program delivery and increase participation and benefit redemption among WIC-eligible women and their children. The ARP also includes investments in the Pandemic Electronic Benefits Transfer program, which Bleich said provides families an electronic debit card to purchase groceries for the value of the school meals missed owing to pandemic-related school closures. Since passage of the 2010 Healthy, Hunger-Free Kids Act, Bleich reported that foods consumed at schools have provided the best mean diet quality of any major U.S. food source. USDA plans to propose changes to update school meals in accordance with the Dietary Guidelines for Americans, 2020–2025, she indicated, and USDA may offer financial incentives to schools that go above and beyond the nutrition standards. Bleich stated that USDA has provided flexibilities, resources, and hands-on support to help schools adapt to new models of meals operation and weather a variety of unpredictable changes to the food supply. 4 

Next, Bleich highlighted the reevaluation of the Thrifty Food Plan—the foundation of the Supplemental Nutri- tion Assistance Program’s (SNAP) benefit calculations—which brought about the first permanent adjustment to SNAP benefits in 45 years. The revised plan budgets more money for recipients to purchase foods aligned with the latest dietary guidance, while accounting for shifts in the food market place. According to Bleich, the current presidential administration realizes that breaking down the cycle of racial inequity is a journey that begins with listening, which Bleich said USDA will accomplish by spending more time with program recipients— particularly those who have historically gone unseen and unheard—to understand how they interact with the programs and how the department can better meet their needs. Amelie Ramirez, director of Salud America! and professor of epidemiology and biostatistics at the University of Texas Health Science Center at San Antonio, shared Salud America!’s efforts to pursue health equity for Latinos. The inequities in income, education, housing, health, and other opportunities experienced by this population reflect resi- dential neighborhood disadvantages and wealth gaps, she explained, that are related to inequities in city planning and historical discriminatory practices such as redlining. Ramirez explained that the first phase of Salud America!’s work (2007–2012) created a research agenda on La- tino childhood healthy weight and built an evidence base from which to approach some of the systematic challenges. This current phase involves building a national digital network of health advocates and fueling them with culturally tai- lored and curated content, data, tools, and actions to activate systemic community changes that enable health equity. Salud America!’s multimedia digital communication infrastructure includes a website, social media platforms, and email campaigns, which Ramirez said are the channels it uses to share content designed to increase network mem- bers’ advocacy for grassroots systems and policy change. A goal is to enhance members’ self-efficacy and collective efficacy, two constructs within social cognitive theory, the framework underpinning Salud America!’s efforts. Ramirez highlighted one type of content, Salud Hero case studies that feature real Latino grassroots-change role models, as particularly valuable for increasing member self-efficacy. Ramirez described another type of content, digital action packs, which include topic-specific toolkits of tem- plate materials, sample emails, and frequently asked questions to help advocates make on-the-ground healthy system and policy changes. The action packs address strategies such as installing water bottle fountains in schools, establish- ing food pantries in schools attended by students who experience food insecurity, and identifying and supporting students who have experienced trauma. An evaluation of the organization’s digital communication structure and network activity found a strong relationship between the degree of engagement with Salud America!’s content and the likelihood of taking advocacy actions at the school, local, state, and federal levels. Lastly, Ramirez discussed Salud America!’s recent application of its model to systemic racism and discrimina- tion as root causes of obesity. It created new materials to stimulate conversation and share ideas to drive changes that increase social cohesion. These include action packs that help people identify their implicit biases and take steps to overcome them, as well as enable cities to adopt resolutions that racism is a public health crisis and commit to action. A MULTISECTOR CONVERSATION ON SYSTEMS CHANGE FOR OBESITY SOLUTIONS The fourth session of the workshop included three parts: reflections on the roundtable’s work from three speakers, perspectives on the workshop from five speakers, and a closing speaker for the first day of the workshop. Reflections on the Roundtable’s Past, Current, and Future Work Bill 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, said that the roundtable’s origins date back to 2005, when the National Academies published a consensus report called Prevent- ing Childhood Obesity and a follow-up report in 2007, Progress in Preventing Childhood Obesity: How Do We Measure Up? Also in 2007 the National Academies formed the Standing Committee on Childhood Obesity, which produced seven consensus reports and hosted eight workshops before evolving into the Roundtable on Obesity Solutions in 2014. Dietz explained that compared with the Standing Committee, the roundtable has a larger membership, rep- resenting a broader group of multisector stakeholders. The roundtable hosts workshops for ongoing public dialogue among leaders and voices from diverse sectors and industries and develops National Academy of Medicine (NAM) Perspectives that reflect on issues and opportunities for advancing obesity solutions.10 Dietz submitted that the round- table’s 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. 10 National Academies of Sciences, Engineering, and Medicine’s Roundtable on Obesity Solutions. Publications: Perspectives. https:// www.nationalacademies.org/our-work/roundtable-on-obesity-solutions/publications (accessed January 3, 2022). 5 

In Dietz’s opinion, one of the areas that the roundtable did not consider extensively in its model-building activi- ties was how the model relates to climate change issues. He referenced a new NAM venture and funding investment, the Grand Challenge on Climate Change, Human Health, and Equity. This is a multiyear global initiative, Dietz explained, to address the “triple threat” of structural racism, climate change, and the COVID-19 pandemic by transforming systems to promote human health, well-being, and equity. He wondered what metrics could assess the roundtable’s effectiveness in advancing its priorities of structural racism, biased mental models, and health communication, and how those three areas might fit into the broader context of climate change and point to common solutions that address both. Shiriki Kumanyika, research professor in the Department of Community Health & Prevention at the Dornsife School of Public Health at Drexel University and a charter member of both the Standing Committee and the roundta- ble, observed that the roundtable represents a significant paradigm shift in how the National Academies addresses obe- sity. Whereas the National Academies previously convened consensus committees to respond to specific statement of tasks that were most relevant to specific audiences, Kumanyika 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 said, noting that the nonacademic roundtable members have kept the group loyal to addressing actionable, practical contributions to obesity solutions. The roundtable’s deep dive into systems thinking was another paradigm shift, Kumanyika suggested, because it represented a “coming of age” in declaring that obesity is not a discipline-specific issue. Obesity solutions cannot be developed in siloes, she maintained, because of its interconnected etiological origins. This systems focus has opened the door for broader perspectives, she observed, and automatically incorporates a global perspective because the is- sues are global in nature, with social equity as a common thread among them. Pronk was the final roundtable member to share his reflections on its work. To address obesity from a sys- tems thinking perspective, Pronk suggested that it is necessary to step back and create a larger worldview. He urged continued multi- and cross-sector partnerships and appealed for stakeholders to slow down and engage in holistic, solution-oriented thinking with a long-term horizon. An appropriate response to the need for action, he suggested, is to prioritize key systems actors who can create a major effect in the short term, while reducing the risk of unintended consequences that sometimes result from acting too soon. He proposed that the immediate responses would be best focused on increasing scalability or sustainability of existing programs that are known to be effective. He appealed for a shift toward a paradigm where shared value generates energy and excitement for participants, alongside significant community benefit. Pronk elaborated on this concept of shared value 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, Pronk mentioned providing health insurance coverage of obesity prevention and treatment options, such as bariatric surgery, in a way that provides benefit for all stakeholders (health plans, employers, and government). Perspectives from Roundtable Members Captain Heidi Blanck, chief of the Obesity Branch in the Division of Nutrition, Physical Activity and Obesity in the Na- tional Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention, described CDC’s Clinical and Community Data Initiative (CODI; previously known as the Childhood Obesity Data Initia- tive) as an effort that uses modern technology to combine data from multiple scales and layers, enabling individual data across clinical and community sectors to be linked. As an example, Blanck explained that clinical systems capture data on an individual child, and CODI enables it to be linked with community data about the child’s neighborhood safety and access to healthy food and physical activity opportunities. This layering of data from different levels pro- vides a bigger picture of the child’s environmental experiences and can help researchers evaluate the effect of services, policies, and programs and understand what is and is not working. Blanck noted that CODI data remain with local practitioners, and individual privacy is preserved while linking records through a process called data hashing. Bringing together the sectors of public health, health care, community-based organizations, and technology services is promis- ing, she said in closing, for being able to better understand root causes. Jamie Bussel, senior program officer at the Robert Wood Johnson Foundation, reviewed the evolution of the foundation’s work in the obesity arena. Over the past 2 decades, she began, the foundation has deepened its un- derstanding of the immense complexity of the obesity epidemic and of the multifaceted, systemic, equity-centered approaches that are necessary to properly address it. Enduring change will depend on long-term commitments to holistically address upstream, interconnected community conditions, Bussel asserted, such as housing, employment, poverty, food access, and structural racism, that contribute to obesity but that can be transformed to support health 6 

and well-being. She admitted that broad systems-wide strategies will be complex and controversial, but she sug- gested they are fitting in the context of the COVID-19 pandemic’s illumination of stark health and social inequities in the United States. Bussel ended by invoking a sense of hope, suggesting that the country is at a “watershed moment” given the intersection of the COVID-19 pandemic, devastation from the economic downturn, and invigorated move- ment around racial justice. Policies that truly change the nature of communities are on the horizon, she predicted, and she urged participants that a window of opportunity exists around the universal sense of urgency to change the trajec- tory of children’s health and well-being. Joe Nadglowski, president and chief executive officer of the Obesity Action Coalition (OAC), appealed for obesity solutions to factor in the lived experience for people with obesity and to develop communications that neither oversimplify nor catastrophize the issue. He said that OAC has already begun applying learnings from the roundtable’s systems mapping efforts in addressing structural racism, biased mental models and norms, and health communica- tion in its work. For example, OAC is partnering with the National Association for the Advancement of Colored People (NAACP) and other organizations to address systemic racism and obesity through policy changes to improve access to obesity care for people from diverse communities. With regard to biased mental models and norms, he suggested that future roundtable meetings would be helpful to explore a positive reframing of weight bias. Megan Nechanicky, nutrition manager for General Mills North America Retail, said that the food industry seeks 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. As an example, when talking to shoppers with low incomes, she said their top concern was having enough food to feed themselves and their families, followed by having flexible, basic food staples such as ground beef. Asked to describe a healthy meal, she continued, they mention balanced (i.e., inclusion of foods from the major food groups), filling, and tasty. As for General Mills’ nutrition strategy, Nechanicky said that its focus is on nutrient density and dietary patterns. She highlighted the potential of innovation to make healthy foods more convenient and tasty, to drive reformulation that improves the nutrient profile of foods, and to make healthy foods more accessible and affordable. She ended her remarks by conveying the food industry’s potential to help improve U.S. 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 for NIH to accelerate obesity solutions in light of its focus on biomedical and behavioral research. One way is to support research to evaluate new programs and policies, she suggested, which helps build an evidence base to guide policy makers and funders as they allocate their limited resources. Another way is to inform strategies to disseminate and implement efficacious interventions. According to Yanovski, the NIH UNITE initiative indicates that NIH recognizes the critical role of factors such as systemic racism that may be considered as upstream of biomedical outcomes of interest. The purpose of NIH UNITE is to identify actions to end structural racism and racial in- equities throughout the biomedical research enterprise. The first cycle of UNITE initiative funding was awarded in 2021 and provides support for highly innovative translational research projects that purport to prevent, reduce, or eliminate health disparities and advance health. Additional funding initiatives for transformative research to address health dis- parities and advance health equity is planned for fiscal year 2023. 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, pro- fessor of general medical sciences in the School of Medicine, professor of biomedical engineering in the Case School of Engineering, and professor, Jack, Joseph and Morton Mandel School of Applied Social Sciences at the Case Western Re- serve University School of Medicine, delivered final remarks to close the first day of the workshop. Hovmand recalled key milestones leading up to the field’s current focus on systems approaches to obesity solutions, which he described as a paradigm shift over the past 2 decades in terms of the remarkable reframing of the issue. He noted that his collaboration with the roundtable began in 2019, and an early draft of its systems map had recognized that addressing structural rac- ism and health equity would be important components, even before the COVID-19 pandemic’s declaration and the rise in social and racial justice activity in the United States. Systems change is difficult without corresponding changes in the mental models underlying them, he suggested, and he proposed that if a lens of structural racism, health equity, and racial equity is front and center, then community members will think differently about the meaning of systems change. Building on Pronk’s comments about the pace of change, Hovmand pointed out that on one hand, the luxury of time to wait for data to accumulate does not exist, but on the other hand, there is risk of losing people if movement occurs before support has been built (especially for controversial policies). There are evidence-based interventions that are ready to be scaled now and improved in terms of reach and equity, he said, and he suggested that these be pur- sued in parallel with building capacity for systems-oriented, community-driven solutions. 7 

In Hovmand’s experience, the systems language provides a bridge in that systems concepts are not new to people with lived experience of adverse conditions, but the systems language is a way of expressing those concepts for people who have different experiences so that they can develop structural empathy and be part of the solutions. He concluded his remarks by echoing Lee’s point about the importance of studying complex systems. It is easy to get overwhelmed by the complexity, he admitted, but he asserted that new technologies and methods for under- standing systems, and the new appetite for the importance of doing so, is an asset to developing and scaling obesity solutions. PATIENT–PROVIDER COMMUNICATION AROUND OBESITY TREATMENT AND SOLUTIONS The second day of the workshop was dedicated to a final session that explored issues of patient–provider communica- tion around obesity treatment. The first speaker in the session, Hunter J. Smith, Chief of Preventive Medicine for the U.S. Army Medical Research Directorate—Africa, reviewed the U.S. Preventive Services Task Force (USPSTF) recommendation for childhood obesity and discussed ethical issues associated with its implementation. The recommendation was issued in 2017, he began, and advises clinicians to “screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.” Such interventions are defined as including at least 26 contact hours over a 2- to 12-month period. Smith pointed out that it is beyond the USPSTF’s scope and mission to integrate concepts such as cost and population-based implementation considerations into its deliberations about whether to issue a particular recommen- dation, but it nonetheless recognized that children and their families may have limited access to effective, intensive behavioral interventions for obesity. This gives rise, he explained, to several communication challenges for clinicians who want to implement the USPSTF recommendations but are aware that resources to do so are not readily available or accessible for all of their patients. Smith discussed ethical issues in three areas—research, screening, and implementation—where gaps exist be- tween the USPSTF recommendation and the status quo. Beginning with research, he highlighted the need for longer- term studies to evaluate maintenance of weight loss after completing a behavioral intervention, noting that current evidence has followed patients up to 1 year following intervention. More evidence is also needed about what consti- tutes clinically important health benefits, he added, as well as the amount of weight loss associated with those benefits. Studies that address behavioral interventions in diverse populations and in children aged 5 years or younger are also needed to determine if preventive interventions and screening modalities are effective for all groups, or whether more tailored recommendations are warranted. Moving on to the screening gap, Smith highlighted that if minimal or no access exists for an accepted treat- ment for the condition of interest, it presents a concern about the consequences of screening for that condition. This leads to the question of whether clinicians should advise preventive interventions to their patients when limited or no access exists for such interventions, Smith said. He also observed what he perceived as a lack of urgency from many clinicians and parents to address a positive screening for obesity, despite the disease’s multifold consequences. In terms of the gap in implementation of the USPSTF recommendation, Smith highlighted two questions: Who is responsible for ensuring the USPSTF recommendations are implemented equitably? How can the gaps in access for disadvantaged populations who are most affected by childhood obesity be filled? He emphasized that lack of equitable access to childhood obesity screening and preventive interventions across populations creates and exacerbates dispari- ties in health outcomes between groups. Finally, Smith proposed creative solutions for responding to implementation challenges, such as collaborating with community programs and increasing capacity for telehealth opportunities. The second session speaker, Kimberly Gudzune, medical director of the American Board of Obesity Medi- cine and director of the Johns Hopkins Healthful Eating, Activity & Weight Program, discussed potential strategies to improve the health care experience for people with obesity. Multiple challenges to obesity care exist in health care settings, she began, such as incomplete insurance coverage for evidence-based treatments, medically induced causes contributing to obesity or impaired treatment (e.g., medications that promote weight gain), lack of appropriately sized clinic equipment and devices to accommodate patients of all sizes, lack of clinician time and training to perform obe- sity care services, and clinicians’ biased attitudes toward patients with obesity. In the context of these challenges, Gudzune described several factors that contribute to differential health care experiences for patients with obesity. These factors include avoidance or delay in seeking health care; impaired con- tinuity of care that results from a relatively high prevalence of “doctor shopping;” lower incidence of physician com- munication behaviors, such as emotional rapport building, with patients with overweight and obesity (compared with patients with normal weight); and weight-driven influences on clinician decision making and care practices, which extends to clinicians being unlikely to counsel patients about weight loss. Differential health care experiences can af- fect the treatment received. As an example, Gudzune reported that lower rates of cancer screening were observed for 8 

patients with overweight or obesity than patients with normal weight, with greater degrees of obesity associated with lower rates of screening.11 Gudzune reported that higher ratings of clinician helpfulness in a behavioral weight-loss intervention were associated with greater weight loss, and discussing weight loss with patients in a way that they do not perceive as judgmental is associated with achieving a clinically significant weight loss over a year.12 Gudzune ended by sharing ideas for addressing weight bias in health care settings, such as providing sensitiv- ity training, increasing awareness of weight bias, and examining explicit and implicit attitudes. She also mentioned ad- dressing clinician barriers by including training in evidence-based communication and counseling approaches, such as the 5 As framework (a model for behavior change) and motivational interviewing, which are associated with improve- ments in patients’ willingness and confidence to change health behaviors. David B. Sarwer, associate dean for research and director of the Center for Obesity Research and Education at Temple University College of Public Health, discussed bariatric surgery and shared decision making. As of 2016, more than 32 million U.S. adults were classified as having class II or III obesity (BMI 35–39.9 kg/m2),13 he said, making them potential candidates for bariatric surgery. Sarwer raised the concern that despite bariatric surgery being a highly effective treatment for obesity—often producing weight losses far greater and more durable than those seen with lifestyle modification and pharmaco- therapy—only about 1 in 100 patients who meet BMI criteria undergo these procedures.14 He said that the underuse of bariatric surgery reflects issues of health insurance coverage and benefits design, weight bias and stigma, and patient– provider communication. Sarwer explained that despite expansion of insurance coverage for bariatric surgery procedures over the past decade, patients’ access may be hampered by extensive documentation requirements, precertification criteria such as 3 to 6 months of preoperative medical weight management, and costs of expenses that accumulate during a bariatric surgery experience such as visit copays, transportation or parking fees, and childcare expenditures. He proposed that telehealth has tremendous potential to help reduce some of these barriers to obesity care, as would reconsidering insurance-mandated precertification requirements and applying value-based insurance design that considers postsurgery lifetime cost savings. In discussing weight stigma, Sarwer called for reducing weight-biased attitudes by educating the public (and, specifically, health care providers) about the multifactorial contributors to the development of obesity, which he said challenges common assumptions that weight is exclusively within an individual’s behavioral control. Sarwer maintained that until issues of health insurance coverage and access and weight bias and stigma are ad- dressed, health care providers could show significant improvement in the delivery of evidence-based obesity treatment by using shared decision making in their consultations with patients with obesity. This is a process where both patient and provider actively share information and work collectively to come to a treatment decision that meets the patient’s needs and is aligned with his or her values and preferences for treatment. He continued by saying shared decision mak- ing that extends to all members of the multidisciplinary obesity care team is useful for discussing the benefits and limita- tions of different surgical interventions for a particular patient, as well as options for the delivery of postoperative care. Sarwer emphasized the importance of provider efforts to develop rapport and empathy with patients, and expressed enthusiasm at the potential for new decision support tools to facilitate and enhance shared decision making in obesity and bariatric care. Finally, he urged providers to identify novel strategies to ensure that patients classified with clinically severe obesity and related morbidities are informed of the most appropriate treatments available to them. ◆◆◆ 11 Maruthur, N. M., S. Bolen, F. L. Brancati, and J. M. Clark. 2009. Obesity and mammography: A systematic review and meta-analysis. Journal of General Internal Medicine 24(5):665-677; Maruthur, N. M., S. Bolen, F. L. Brancati, and J. M. Clark. 2009. The association of obesity and cervical cancer screening: A systematic review and meta-analysis. Obesity 17(2):375-381; Maruthur, N. M. S. Bolen, K. Gudzune, F. L. Brancati, and J. M. Clark. 2012. Body mass index and colon cancer screening: A systematic review and meta-analysis. Cancer Epidemiology Biomarkers & Prevention 21(5):737-746. 12 Baer, H. J., R. Rozenblum, B. A. De La Cruz, E. J. Orav, M. Wien, N. V. Nolido, K. Metzler, K. D. McManus, F. Halperin, L. J. Aronne, G. Minero, J. P. Block, and D. W. Bates. 2020. Effect of an online weight management program integrated with population health management on weight change: A randomized clinical trial. JAMA 324(17):1737-1746; Bennett, W. L., N.-Y. Wang, K. A. Gudzune, A. T. Dalcin, S. N. Bleich, L. J. Appel, and J. M. Clark. 2015. Satisfaction with primary care provider involvement is associated with greater weight loss: Results from the practice-based POWER trial. Patient Education Counseling 98(9):1099-1105; Gudzune, K. A., W. L. Bennett, L. A. Cooper, and S. N. Bleich. 2014. Perceived judgment about weight can negatively influence weight loss: A cross-sectional study of overweight and obese patients. Preventive Medicine 62:103-107; Lewis, K. H., K. A. Gudzune, H. Fischer, A. Yamamoto, and D. R. Young. 2016. Racial and ethnic minority patients report different weight-related care experiences than non- Hispanic Whites. Preventive Medicine Report 4:296-302. 13 Campos, G. M., J. Khoraki, M. G. Browning, B. M. Pessoa, G. S. Mazzini, and L.Wolfe. 2020. Changes in utilization of bariatric surgery in the United States from 1993 to 2016. Annals Surgery 271:201-209. 14 American Society for Metabolic and Bariatric Surgery. 2019. Estimate of bariatric surgery numbers, 2011-2019. https://asmbs.org/ resources/estimate-of-bariatric-surgery-numbers (accessed January 4, 2022). 9 

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Emily A. Callahan as a factual summary of what occurred at the meeting. The statements made are those of the author or individual meeting participants and do not necessarily represent the views of all meeting 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 institution. REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop— in Brief was reviewed by Carol Byrd-Bredbenner, Rutgers University, and Hunter Jackson Smith, U.S. Army Medical Research Directorate. 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 Cancer Society; American College of Sports Medicine; Ameri- can Council on Exercise; American Society for Nutrition; Blue Shield of California Foundation; General Mills, Inc.; Intermountain Healthcare; JPB Foundation; Kresge Foundation; Mars, Inc.; National Recreation and Parks Association; Nemours; Novo Nordisk; Obesity Action Coalition; Partnership for a Healthier America; Reinvestment Fund; Robert Wood Johnson Foundation; SHAPE America; Society of Behavioral Medicine; Stop & Shop Supermarket Company; The Obesity Society; University of Pittsburgh Medical Center; Wake Forest Baptist Medical Center; Walmart; and WW Inter- national. For additional information regarding the meeting, visit nationalacademies.org/obesitysolutions. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Systems and obesity: Advances and innovations for equitable health and well-being: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26498. Health and Medicine Division Copyright 2022 by the National Academy of Sciences. All rights reserved. 10