Proceedings of a Workshop—in Brief

Targeting Structures, Communications, and Beliefs to Advance Practical Strategies for Obesity Solutions

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 the virtual public workshop Shifting the Paradigm: Targeting Structures, Communications, and Beliefs to Advance Practical Strategies for Obesity Solutions on April 19, 2022. The workshop was the first in a series of three workshops to explore how to bridge evidence gaps within foundational drivers of obesity and translate knowledge toward actionable solutions. It examined the connections between obesity and structural racism, health communication, and biased mental models and social norms, as well as the interactions of these drivers with the evidence base and workforce, to uncover potentially practical strategies for intervention. Topics covered in the April workshop sessions included targeting academic and workforce structures that dismantle systemic racism while building an evidence base, the effect of communications on perceptions and the understanding of obesity, and strategies to change the conversation around representation in media and body image.

Christina Economos, New Balance chair in childhood nutrition and dean for research strategy at the Friedman School of Nutrition Science and Policy at Tufts University, explained that the workshop series builds on a strategic planning process the roundtable initiated in 2020. It took a systems-oriented approach to identify priority areas for obesity solutions, she said, which culminated in a causal systems map that depicts not only the drivers of obesity but also the evidence-based solutions to obesity. The map was used to determine three crosscutting priority areas that the roundtable has since pursued, including through a three-part workshop series in 2021—structural racism, biased mental models and social norms, and effective health communication—which Economos said were considered to be deep leverage points in the system that could bring about lasting, systems-wide change.

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.¹ The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.

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SHIFTING THE PARADIGM TO ADVANCE OBESITY SOLUTIONS

The workshop began with an introductory session that expounded on concepts presented in the introduction and further described the roundtable’s approach to organizing the workshop. Bruce Lee, professor of health policy and management at the City University of New York School of Public Health, listed several risks of not applying a systems approach to obesity and other systems problems. The development of “Band-Aids” that only address surface problems tends to occur, he explained, rather than sustainable solutions that address root causes. This leads to the manifestation of unintended consequences; missing secondary and tertiary effects; worsening of existing disparities and sometimes introducing new problems; expending time, effort, and resources through trial and error rather than targeting real solutions; and introducing multiple sources of bias.

Lee reiterated Economos’ introductory remarks about the importance of intervening on major leverage points in the system, which he said is a strategy to disrupt what he called a reinforcing loop. He illustrated this loop with a depiction of how major contributors to obesity tend to reinforce each other (Figure 1), noting that intervening on one or more of these factors can set off positive (or negative) effects that grow exponentially as they reverberate through the system.

The loop shows how structural racism—defined by the Aspen Institute as “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing, ways to perpetuate racial group inequity”²—can result in unbalanced workforces, which Lee cautioned could produce biased studies or data collection and ultimately a biased evidence base. This can lead to overly simplistic messages, he continued, which in turn affect health communication that go on to shape people’s mental models. Mental models affect how information is understood and interpreted and give way to social norms that reinforce the problem, such as structural racism, which perpetuates the cycle.³ Lee concluded by emphasizing the importance of changing the picture of obesity—how society views the problem, the makeup of its mental models, and how the problem is communicated—in order to achieve systems change.

TARGETING ACADEMIC AND WORKFORCE STRUCTURES THAT DISMANTLE SYSTEMIC RACISM WHILE BUILDING AN EVIDENCE BASE

The workshop’s second session featured four panelists who answered two questions. First, how did we get here: What are the structural processes of racism that produced the current workforce, and how does that affect evidence generation, funding offerings, and research prioritization? Second, what do we do about it: What practical solutions have been successful?

Daniel Aaron, Heyman Fellow at Harvard Law School and attorney at the U.S. Food and Drug Administration (FDA), offered five points in response to each question. For the first, he maintained that law has played a role in workforce racism. Law school has been described as a largely white space, he remarked, and one where discussing race and racial issues in the law is often viewed as unintellectual and sometimes even discouraged. This extraction of race and racism from

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legal education are manifested in Supreme Court outcomes, he said as an example, such as what he called the court’s taking a hard line on considering race by framing policies that remediate racial inequity as unconstitutional.

Aaron’s second point in response to the first question was that nondiscrimination law is inadequate in preventing racism in the workforce and has led to the attrition of BIPOC—Black, indigenous, and people of color—from many institutions. He acknowledged that law is not the only solution to stopping discrimination, but asserted that it has provided an illusion of protection. His third point emphasized the power of corporations, which he said employ the majority of U.S. workers and also influence the foods that are produced and therefore consumed. Aaron’s fourth point was that a biology and genetics bias exists in many studies that mention race and that opining on biology has been perceived to be less political than opining on corporate power. Fifth, Aaron pointed out that people often study discrete issues without looking at the perspective of race or racism within that issue, and suggested that coming together intersectionally on obesity and racism studies would build a more durable, effective movement toward solving these problems.

For the second question about solutions, Aaron first suggested forming more alliances across identity groups and across disciplines in order to create more durable movements toward a nonracist workforce. His second point was to elevate lived experiences and voices at the ground level, and his third point was to promote demosprudence, which he described as a legal term for practicing law in a way that is responsive to social movements. Aaron’s fourth point was to support what he called race-conscious remedies, such as programs to remediate the legacy of racism and other historical injustices. Fifth, he echoed his earlier point about the importance of intersectionality.

Jacqueline Dejean, associate dean of research at the School of Arts and Sciences and associate dean of diversity and inclusion at the Graduate School of Arts and Sciences at Tufts University, expressed that society is experiencing a time of heightened racial awareness, accompanied by a commensurately heightened expectation of a new, authentic kind of justice that she indicated was possible if awareness becomes a launching point for systems change and the unearthing of new solutions.

Dejean recounted her efforts that began in 2017 to address racial disparities in research laboratory personnel at her institution by designing the VERSE program—Visiting and Early Research Scholars Experience—to provide underrepresented, undergraduate prescholars with substantive research experiences that enable them to become independent junior researchers who design and investigate their own research questions.

She recalled her application of John Kotter’s eight steps for change, as documented in his book Leading Change, to work toward dismantling barriers in institutions (Kotter, 1996). The first step is to create a sense of urgency, which she did (back in 2017) by starting conversations framed around the America Competes Act mandate, whereby she urged Tufts University to rise to a similar level as that of other nations that had already begun dismantling racial barriers in their institutions. The second step is building a guiding coalition, which she implemented by recruiting a small team, sharing her vision, and encouraging the team to help evolve it. This was step three, forming a strategic vision and initiatives.

As the small team earned buy-in and enlisted others within the institution, Dejean continued, the fourth step—enlisting a volunteer army—was achieved. This helped spread the vision and gather more people to enable action by removing barriers (in her institution’s case, it was insufficient funding opportunities to increase the number of students involved in research labs), which she listed as step five. Step six is to generate short-term wins, which Dejean said she implemented by celebrating her success in surpassing her goals for the number of faculty and students she recruited to participate in the program’s first year. These small wins contributed to step seven, sustaining acceleration, which she said she achieved by using those wins to accelerate the change process. Dejean explained that the eighth and final step

is to embed the change in the culture. Now 5 years out from starting the program, she reflected on the gradual emergence of students who had never had a vision for research or even recognized it as a career option but have now embraced new realms of education and experience that research has facilitated.

Michelle Ko, associate professor in the Department of Public Health Sciences at the University of California, Davis, discussed connections between institutional and structural racism in contemporary systems and inequities in the current workforce. She maintained that White supremacy is embedded in contemporary higher-education policies and processes; she supported her statement with findings from interviews conducted in 2019 and 2020 with 39 medical school admissions leaders. She reported that interviewees referenced a lack of leadership commitment to dismantling structural racism despite verbal affirmation of the topic’s priority. Another institutional barrier identified was an overemphasis on academic metrics, which she thought may be related to pressure on institutions to pursue high average test scores and grade-point averages because these metrics factor into rankings from influential entities such as U.S. News and World Report. A third barrier expressed was the influence of faculty, alumni, and local politicians and community leaders on admission decisions.

Ko next shared her belief that diversity, equity, and inclusion cannot be accomplished unless there is a change in the foundation of schools as racialized organizations. She elaborated on this statement by sharing four themes emerging from interviews with approximately 30 people in positions created to promote diversity, equity, and inclusion in U.S. medical schools and academic medical centers. One theme is that wide variability exists in the roles (i.e., day-to-day duties and overall expectations) and the degree of support for achieving the role’s objectives. Another theme is a mismatch in investment and expectations (e.g., an individual might be expected to achieve certain outcomes but not given staff or volunteer support). Interviewees also said that they were asked to promote change in areas of the institution in which they did not have direct authority, such as faculty hiring or financial spending, and Ko noted that individuals in these positions typically had limited knowledge of existing scholarship and theory about effecting organizational change.

Ko’s last point was that structural racism in public health, health systems, and policy has ensured disproportionate COVID-19 effects on groups historically excluded from the health and research workforce, such that the challenges to their pursuits of careers in these fields have been compounded by increased financial insecurity and family caregiver responsibilities. In closing, she emphasized the importance of changing the people in the system concurrently with changing the system itself.

Eliseo Pérez-Stable, director of the National Institute on Minority Health and Health Disparities at the National Institutes of Health (NIH), stated that diversity in science and medicine is a demographic mandate as well as an inherent advantage to advance their missions. He asserted the importance of developing diverse clinical and biomedical scientific workforces, engaging underrepresented populations to participate in clinical research, and ensuring fairness and using intellectual capital with changing demographics. He warned that because racial and ethnic minorities now make up a significant portion of the U.S. population, the health and medical profession will be alienated from a large part of the population if it does not diversify.

Pérez-Stable discussed the “cultural taxation” that he said affects historically underrepresented minority people who are on university faculty (Pololi et al., 2013). They are often asked to serve on multiple committees to “represent” and satisfy university requirements for diversity and inclusion, he pointed out, and they are also asked to take responsibility for all diversity efforts. They receive excess mentorship requests from students, residents, and other faculty, yet also experience isolation and lack of community, discrimination, discomfort with the culture, and lower perception of relationships owing to being less able to relate to certain components of the culture.

Pérez-Stable suggested a series of steps that institutions could take to address diversity. One is leadership commitment to long-term, sustainable change with resources. Another is promoting and measuring organizational change by creating metrics to evaluate the institutional climate, a third is implementing unconscious bias training, and a fourth is tracking and promoting diversity by holistically reviewing admissions and hiring. He suggested that tracking applicants’ racial and ethnic identities, socioeconomic backgrounds, and national origins is a way to measure baselines. Lastly, he highlighted the value of connecting early-career faculty with mentors who have networks to create pathways of knowledge and further connections. On this note, he mentioned NIH’s Faculty Institutional Recruitment for Sustainable Transformation (FIRST) program, in which awardee institutions receive grant funding to hire annual cohorts of 6 to 10 faculty who commit to promoting diversity and sustaining cultures of inclusive excellence in the institution.

HOW COMMUNICATIONS CAN AFFECT PERCEPTIONS AND THE UNDERSTANDING OF OBESITY

The third session of the April 2022 workshop featured two presentations about the effect of communications on perceptions and understanding of obesity.

Laura Lindenfeld, executive director of the Alan Alda Center for Communicating Science and dean in the School of Communication and Journalism at Stony Brook University, framed her presentation around her views that (1) it is critical to adopt a systems-based understanding of, and approach to, communication about complex situations such as obesity, and (2) communication must be based in empathy.

Lindenfeld shared her perspective that communication is both an act of conveying meaning and a system that shapes the interrelationships of different communities, institutions, and stakeholders such as scientists and health care professionals. This system can be viewed as operating on top of the system of drivers that contribute to obesity challenges, she suggested, and added that part of the communication infrastructure that is critical to problem solving at the systems level is the ability to craft powerful forms of collaboration through empathy and engagement. Empathy calls for engaging directly with individuals and institutions that are entrenched in the systems involved in the problem, she explained, in order to understand and appreciate the vantage point from which others experience and approach communication, rather than assuming that one’s own lived experience is universal. Empathy is not synonymous with sympathy, she clarified, and requires dignity and respect for others but not necessarily agreement. Lindenfeld also called for the integration of community engagement into research design and processes in order to understand perspectives, values, attitudes, and needs, and build trusting partnerships before conducting research.

Lindenfeld discussed three areas of communication interventions to strengthen linkages between the production of knowledge and action, which she said could spur meaningful change in addressing obesity. The first area is science communication: it should include training programs that help scientists and health care professionals develop the critical ability to accurately and effectively communicate science in order to support decision making. Lindenfeld described her own organization’s training program, which she said is unique because of its principles from improvisational theatre. She explained that this approach invites trainees to embrace the challenges of working across cultures and contexts with a creative lens and to practice genuine, responsive listening through empathy.

The second area is interdisciplinary collaboration. Challenges such as obesity call for strong interdisciplinary collaboration, yet she contended that interventions and training programs rarely focus on targeting changes in communication to better prepare teams to work together. A growing body of literature on team science, she said, offers powerful insights into strategies for creating more productive team collaboration.

The third area is approaching partnerships and engagement from the perspective of understanding community needs and authentically integrating community members into all stages of the research

process to ensure that it centers their needs and values. In her view, humility and empathy are critical foundations for partnerships, collaboration, and engagement in the pursuit of obesity solutions. Lindenfeld encouraged attendees to consider building more interdisciplinary project teams that include communication researchers who can help establish relationships and mutual trust between each field’s researchers and communities so knowledge is coproduced, which she said promotes more useful and meaningful research outcomes for the intended recipients.

Neal Baer, a showrunner, television writer and producer, physician, author, and lecturer at Harvard Medical School and the Yale School of Public Health, discussed the power of storytelling to change the way people think about problems and solutions. He focused on advertisements, which he said are a form of storytelling that deserve attention based on their ubiquity in society and their ability to affect people’s decisions about what to eat and drink.

To preface his sharing of a soda advertisement video to explain its use of storytelling, Baer described soda as the hub of a corporate wheel, with its spokes connected to health effects (e.g., a causal link between consumption and development of chronic diseases such as obesity), environmental impacts (e.g., related to the volume of plastic waste it produces), jobs, advertising, philanthropy, taxes, government subsidies, and legal issues. A product’s effect on health and obesity is only one aspect of the system, he pointed out, and the exploration of the other aspects is needed to understand the product’s comprehensive impact and why addressing only the health effects may not gain much traction.

Baer played a soda advertisement video that he said seems simple and lighthearted on the surface, but it is embedded with deep layers of meaning that influence the intended audience’s decisions to consume the product. The advertisement tells a story that connects the product to positive attributes related to Latino culture, he explained, as it features a variety of people from Latino backgrounds who are asked to share their family names and the values they connect to being a person who bears the name. Attributes related to pride, hard work, and faith are shared, and eventually the people in the ad visit a food truck distributing soda cans that have tattoos of Latino surnames on their sides. The people then press the cans to their arms, wrists, and necks to tattoo their bodies with their family surname, and the ad ends by encouraging viewers to share the product with others. Baer applied the causal loop diagram that Lee shared in the first session (see Figure 1) to analyze how characteristics of the advertisement map back to the drivers of obesity. The power of the story is that the ad does not explicitly talk about the soda, but the actors are drinking it throughout the commercial, and it is thus associated with the cultural values expressed throughout the ad. It is tough for obesity solutions to compete, he admitted, with this kind of compelling, poignant storytelling.

CHANGING THE CONVERSATION AROUND REPRESENTATION IN MEDIA AND BODY IMAGE

The fourth and final session of the April 2022 workshop discussed the marketing landscape and barriers and opportunities to address bias, stigma, and the inequities associated with obesity.

Rebecca Pearl, assistant professor in the Department of Clinical and Health Psychology and Social and Behavioral Sciences at the University of Florida College of Public Health and Health Professions, stated that society blames obesity mostly on individual choices, primarily poor diet and failure to exercise, attributed to the person with obesity’s presumed lack of self-control and laziness; meanwhile, thinness is valued and associated with good moral character.

Pearl referenced data indicating that despite increased attention over the past decade to topics such as body shaming, weight bias, and stigma, negative implicit attitudes related to body weight have increased over time (Charlesworth and Banaji, 2019). Negative weight-related attitudes are problematic from ethical, social justice, and public health lenses, Pearl said, because they contribute to negative body image and weight stigma and discrimination (Neumark-Sztainer, 2006; Pearl et al.,

2015, 2020; Pearl and Puhl, 2018; Tomiyama et al., 2016). Weight bias and stigma have been linked to negative effects on access to health care and quality of care received, she explained, as well as to both psychological and physiological stress on the affected individuals. These sources of stress combine and promote coping mechanisms such as engaging in unhealthy behaviors that further contribute to poorer health-related quality of life and increased risk for chronic disease beyond weight-related risks (Pearl et al., 2020).

Pearl turned to the topic of body image in the media and emphasized the potential of news stories to help shift the narrative by highlighting the complexity of the contributors to obesity and the effects of weight stigma and discrimination. In addition to shifting the content of news stories, she also called for them to carry images that depict people with obesity engaging in health-promoting behaviors instead of stereotypical unhealthy behaviors. When the public sees the former types of images, Pearl explained, they report less negative attitudes toward the people depicted. She shared guidelines for media portrayals of individuals affected by obesity, which include publicly available image galleries.^4,5

Pearl highlighted social media for its giving voice to diverse individuals to participate in and lead conversations from which they may have previously been marginalized or excluded (Cha et al., 2022; Cohen et al., 2019; Fioravanti et al., 2021; Pearl, 2020; Puhl, 2022; Webb et al., 2019; Zavattaro, 2021). Positive body image content is present in social media spaces and appears to have positive short-term effects on mood and body images, she reported, and she suggested that social media can also be used to elevate activism and correct misinformation.

Pearl concluded her remarks by observing that increasing diversity in body sizes shown in the media does not necessarily achieve full representation of all bodies in the United States. She highlighted the importance of including people with diverse lived experiences when creating content to avoid inadvertent stigmatization, and she emphasized the importance of appreciating that weight intersects with other identities and represents a variety of intersecting experiences.

Ginny Levine, managing director of marketing for the U.S. Tennis Association (USTA), offered reflections on the marketing landscape. She discussed her perspective that Generation Z will be a force of change for increasing representation in media, shared examples of USTA’s efforts in this vein, and highlighted a sample of brands that she would position at the forefront of changing the conversation about representation.

Media ideals of thinness have persisted for generations, Levine observed, and she suggested that this theme in media and marketing has led to “image conditioning,” inflating a false sense of reality and fueling biases that have become entrenched in society. Nonetheless, her outlook is that positive shifts in marketing and media are forthcoming and hold potential to improve perceptions and conversations about obesity.

Levine explained that a relatively recent shift in marketing approaches has been driven by the coming of age of Generation Z—the first generation who has never experienced a world without the Internet, social media, and other technologies—and current world dynamics around climate concerns, the effects of the COVID-19 pandemic, and racial equity and social justice. Levine suggested that this environment gives way to generational characteristics such as being more politically aware, collaborative, multicultural, and likely to test current labels and demand representation (CM Group, 2022; Dentsu, 2022). She suggested that the combination of these global dynamics and these characteristics are forcing marketers to change their mindsets and accept an upcoming generation that is setting new standards for inclusion, reevaluating inequities, internalizing their self-worth, and pursuing mental health and well-being. If marketers embrace this, Levine maintained, “we can catapult the conversation” to change perceptions and norms about obesity.

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Levine discussed USTA’s initiative “The New and Next for Tennis” as an example of how marketers are reacting to Generation Z’s prompting of the marketing paradigm shift. Qualitative research indicated that people believed USTA (and by default, tennis) to be internal oriented, traditional, process heavy, complex, and slow to adapt, which she contrasted to a service-driven culture that is others oriented, empathetic, helpful, seamless, responsive, and communal. These findings led USTA to embrace a new service role definition and an aim to make tennis and USTA “open to all.” This is not merely a marketing campaign, she assured, but a gradual, significant shift in the way of operating. By elevating the diversity that exists through showing that people of all ages, shapes, sizes, and backgrounds already play and enjoy tennis, Levine explained that the stage is set for changing perceptions.

Levine turned to highlight several brands that she thinks are leaders in body diversity and representation: Dove’s Real Beauty campaign, which she said initiated the conversation and discussion about representing body diversity and also launched the era of brand purpose; Fenty Beauty, which carries a full range of makeup shades to suit people of every skin color; Blink Fitness, which showcases body diversity in its campaigns and leads with how exercise can make one feel, instead of focusing on how it can change physical appearance; and Old Navy, which has consistently promoted diversity in its styles, campaigns, and messages and has also eliminated plus size sections in its stores to address the subconscious bias that is perpetuated by isolating people with obesity to a certain physical area of the store.

CLOSING REFLECTIONS

Stella Yi, associate professor in the Department of Population Health, Section for Health Equity, at NYU Grossman School of Medicine, delivered a closing presentation. In addition to summarizing key points from each of the workshop’s four sessions, Yi also offered her observation of a few overarching themes that were conveyed. It is time to change how society views obesity, she said. Dismantling structural racism, communicating more effectively, and changing mental models, if addressed simultaneously, would ultimately change social norms and views on obesity held by researchers, public health providers, policymakers, and society.

The present society’s energy and enthusiasm around foundational drivers of obesity carries an exciting potential to drive changes in the current systems. This state also comes with a high level of expectation for carrying through some of these changes. Advancing obesity solutions calls for a focus on intersectionality and multisectoral collaboration, consideration of existing paradigms in institutions as well as social norms, and recognition that each person has one’s own identity and experience and deserves to be heard empathically and represented.

REFERENCES

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

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the 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 SARA J. CZAJA, Weill Cornell Medicine, and JOHN M. JAKICIC, University of Kansas Medical Center. 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; American Council on Exercise; Blue Shield of California Foundation; General Mills, Inc.; The JPB Foundation; Kresge Foundation; Mars, Inc.; MedTech Coalition for Metabolic Health; National Recreation and Parks Association; Nemours Children’s Health System; Novo Nordisk; Obesity Action Coalition; Partnership for a Healthier America; Reinvestment Fund; Rudd Center for Food Policy and Health; Robert Wood Johnson Foundation; SHAPE America; Society of Behavioral Medicine; Stop & Shop Supermarket Company; The Obesity Society; Wake Forest Baptist Medical Center; and Walmart.

STAFF: HEATHER COOK, AMANDA NGUYEN, CYPRESS LYNX, and MARIAH BRUNS, Food and Nutrition Board, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/04-19-2022/shifting-the-paradigm-targeting-structures-communications-and-beliefs-to-advance-practical-strategies-for-obesity-solutions-a-workshop.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Targeting structures, communications, and beliefs to advance practical strategies for obesity solutions: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26681.

Health and Medicine Division Copyright 2022 by the National Academy of Sciences. All rights reserved.