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Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
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7

Power Dynamics and Community as Complex Systems

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
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The second session of the July workshop explored power dynamics and communities as complex systems in relation to obesity. Stephanie A. Navarro Silvera, professor of public health at Montclair State University, and Rodney Lyn, dean of the School of Public Health and professor in the Department of Health Policy and Behavioral Sciences at Georgia State University, comoderated a panel discussion with three speakers, and then facilitated a discussion and question-and-answer period with workshop attendees.

Lyn noted that the session would explore questions about how power is typically situated in the community context; who has influence and authority to modify systems, environments, and policies; and how means of engaging with communities to intervene on obesity are informed by the fact that communities are complex systems. The topics of power and access to power can seem distal to conversations about obesity, Silvera acknowledged, and she explained that the Roundtable has been exploring these types of deeply embedded leverage points and how they could positively affect multiple aspects of health and health outcomes. According to Silvera, it is essential when one thinks about how to create neighborhoods and communities that promote health to consider who has access to the political and social power necessary to determine how to make changes and what those changes should look like. She maintained that for proposed solutions to be equitable and effective, all members of society across race, gender identity, body size, and a host of other characteristics must be at the table of power.

THE IMPORTANCE OF UNDERSTANDING AND ADDRESSING STRUCTURAL RACISM

Angela Odoms-Young, associate professor and director of the Food and Nutrition Education in Communities Program in the Division of Nutritional Sciences at Cornell University, highlighted the importance of understanding and addressing structural racism as a pathway to obesity solutions. She underscored that thinking about solutions requires one to understand the past, which informs both the present and the future. With that, she noted that Cornell University is located on the traditional homelands of the Gayogohó:nǫ' (the Cayuga Nation), who are members of the Haudenosaunee Confederacy, an alliance of six sovereign Nations with a historical and contemporary presence on that land.

Odoms-Young explained that communities encompass many complex adaptive systems, including small- to large-scale systems (e.g., families, neighborhoods) and a variety of domain-specific systems (e.g., housing, employment, schools). In her view, it is important to understand the complex interaction among these systems and their relationships to influences on obesity (Aspen Institute, 2016; Auspos and Cabaj, 2014). Communities are shaped by the characteristics of these systems, she asserted, including their

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
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multiple, diverse actors, emergent and self-organizing behavior, and nested and overlapping nature. According to Odoms-Young, systemic inequality, including racism, is a threat to community health and well-being through such practices as displacement, exclusion, segregation, and exploitation.

Odoms-Young discussed racism as a root cause of disparities in obesity and health and urged a deeper understanding of the relationships through which racism and power exert these effects (Aspen Institute, 2016; Guess, 2006; Krieger, 2008; Williams and Mohammed, 2013). She described racism as a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate inequity, superiority, and inferiority among racial groups. Institutional and individual practices may create and reinforce oppressive systems of race relations, she maintained, whereby people and institutions engaging in discrimination adversely restrict, by judgment and actions, the lives of those against whom they discriminate. Odoms-Young pointed to the long history of systems of oppression in the United States and globally, noting that these systems often manifest in racism and colorism whereby dimensions of the country’s history and culture have allowed privileges associated with “Whiteness” and disadvantages associated with “color” to endure and adapt over time. As an organized system, she elaborated, racism is based on the premise of categorization and ranking of social groups into races, which then became the basis for devaluing and disempowering certain groups and differentially allocating desirable societal opportunities.

Racism occurs at several levels within the fabric of society, Odoms-Young posited, from internalized racism (one’s private beliefs and biases about race and racism) and interpersonal racism (occurring within interactions between individuals) to institutional racism (occurring within institutions and systems of power) and structural racism (racial bias among institutions and across society) (Jones, 2000). She noted that racism sometimes goes unseen because it is embedded in society, which she said is important to recognize when discussing interventions and power. She shared several additional definitions that relate to power: social power (access to resources that enhance one’s chances of getting what one needs to lead a comfortable, productive, and safe life); privilege (unearned social power, accorded by the formal and informal institutions of society to all members of a dominant group); and discrimination (unequal allocation of goods, resources, and services).

With respect to oppression (i.e., when a dominant social group, also known as an agent group, knowingly or unknowingly abuses a target group), Odoms-Young continued, race often comes to mind first, but, she observed, individuals and groups can be oppressed on the basis of other characteristics, such as sex, gender identity, sexual identity, physical ability, or weight. Oppression can occur in layers when multiple oppressed

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

identities are present, she added. She used the term “intersectionality” to describe this occurrence, defining that term as the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping, interdependent systems of discrimination or disadvantage.

Odoms-Young referenced a 2017 National Academies report that examines racial discrimination in pathways to treatment and impact outcomes (NASEM, 2017). She identified one pathway as disparate treatment that occurs on the basis of race and disadvantages a racial group. She cited as a second pathway disparate impact, which she defined as treatment on the basis of inadequately justified factors other than race that disadvantages a racial group. She gave as an example the overrepresentation of certain populations in the criminal justice system, which she described as an impact of disparate treatment. Odoms-Young also described another study outlining potential pathways of racism and health (Williams and Mohammed, 2013). According to these authors, she reported, racism, biology, and geographic origin are among the basic causes of health, and certain physiological responses to different exposures are part of the pathway to health outcomes.

Odoms-Young next highlighted a paper by Dhurandhar and colleagues (2021) on the key causes and contributors of obesity, which suggests that potential causes of and contributors to obesity occur both inside and outside a person and that many of these pathways can be impacted by racism. An example is obesogens, which are synthetic chemicals such as pesticides, food additives, plasticizers, and cosmetic or pharmaceutical additives, that cause weight gain by altering lipid homeostasis to promote adipogenesis and lipid accumulation and alter hormonal regulation of appetite and satiety, which may affect energy intake (Dhurandhar et al., 2021). Odoms-Young called attention to exposure to environmental chemicals as a potential cause of obesity and to evidence suggesting that racial/ethnic inequalities exist in beauty product–related chemical exposures, industrial pollution (e.g., air, water, soil), and agricultural exposures (based on employment) (James-Todd et al., 2016). She also highlighted factors influencing energy intake and expenditure as contributors to obesity and suggested that gendered racism (intersecting systems of oppression based on race and gender)1 is associated with poor mental health, anxiety, and depression, which in turn may affect dietary preferences, food consumption, sleep, and regional distribution of adipose tissue.

Odoms-Young turned to discussing the concept of power and appealed for embedding this concept into discussions of health equity. Power can be defined, she said, as the ability to act or produce an effect (including

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1 For more information on gendered racism, visit https://blogs.cdc.gov/healthequity/2022/10/06/gendered-racism-among-women-of-color/ (accessed January 24, 2023).

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

with respect to one’s own future); legal or official authority, capacity, or right; possession of control, authority, or influence over others; and political control or influence. Multiple definitions of health equity exist as well, she observed, and they tend to be comparative in that they centralize Whiteness and its privilege versus that of another group. This perspective can lead to the perception of certain groups as behaviorally inferior and lacking in agency. There is a difference, she pointed out, between equitable access to food assistance and equitable access to the income/wealth needed to purchase food.

Odoms-Young referenced an extensive literature on building power, pointing in particular to a primer on community power, place, and structural change from the University of Southern California’s Dornsife Equity Research Institute (Pastor et al., 2020). According to the primer,

community power is the ability of communities most impacted by structural inequality to develop, sustain, and grow an organized base of people who act together through democratic structures to set agendas, shift public discourse, influence who makes decisions, and cultivate ongoing relationships of mutual accountability with decision makers that change systems and advance health equity. (Pastor et al., 2020)

Odoms-Young reiterated that it is important to understand the complex interaction among community systems and their relationships to influences on obesity. Also important, she maintained, is understanding how historical, contemporary, and recurring “shocks,” both acute (e.g., natural disasters or racialized violence) and chronic (e.g., disinvestment, racial segregation) can influence a community’s risk for obesity.

Drawing on other liberation approaches and methodologies, Odoms-Young suggested applying a “liberation nutrition research lens” to promote understanding of race as a social construct, as well as understanding and targeting of social and structural drivers of behavior. That lens can help change narratives, she asserted, so that people can engage in their own solutions to problems or participate in advocacy to support policy solutions. She concluded with an illustration of the nuances distinguishing equality, equity, and justice. Justice, she stated, requires fixing systems to offer equal access to both tools and opportunities at both individual and community (population) levels.

COMMUNITY EMPOWERMENT IN HARLEM

Curtis L. Archer, president of the Harlem Community Development Corporation, discussed efforts to empower Harlem’s community members to choose healthy lifestyle behaviors. He recalled that most of the land and

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

buildings in an undesirable commercial corridor of New York City gradually evolved into what is now called “Restaurant Row.” The restaurants that tended to open in the community, however, were large chain fast food establishments, which Archer said are more likely than mom and pop restaurants to survive in the area. In the absence of a supermarket, a large number of bodegas and delis also populated the Harlem community, he said, until a large chain supermarket opened there in the early 1990s. He pointed out, however, that the existence of the new supermarket did not guarantee that residents would stop frequenting the community’s numerous fast food restaurants, which he attributed to the convenience of fast food, as well as a lack of education about how to correct unhealthy patterns of behavior.

According to Archer, these concerns have not been a focus of many of the area’s elected officials or community-based organizations, but he has observed growing recognition of the need for change. He highlighted the work of community-based organizations such as the Harlem Children’s Zone and Harlem Congregations for Community Improvement, which he said have developed learning opportunities and resources to empower youth and entire households to adopt lifelong healthy eating and activity habits by changing the community culture.

Archer noted that although a Whole Foods Market recently opened in Harlem, the price point of some of its healthful food offerings was prohibitive to many community residents. “They did not feel that Whole Foods was built for them,” he said, and they were reluctant to enter the store. Archer reported that the store worked to raise awareness of the more reasonable price points of its 365 brand and began offering classes on healthy eating, and more community residents have since visited the store. He added that healthy eating is now included in the curriculum of some community-based organizations’ programming, reflecting growing recognition that such education could help curtail the proliferation of diet-related comorbidities in Harlem.

According to Archer, notwithstanding these positive efforts to address the role of diet in the development of chronic disease, this is still an “uphill battle.” He cited a lack of coordinated effort on the part of food and beverage companies to provide meaningful support to promote healthy eating and active living, noting that these companies tend to have philanthropic divisions but have not committed to stopping the marketing of unhealthy foods in the community. Harlem is inundated with advertisements for fast food restaurants, he observed, whereas advertisements for fruits and vegetables are scarce. He remarked that one of the community’s elected officials asked the CEO of a major food company to stop targeting Harlem’s young people with sugary beverages and instead to advertise the company’s more healthful beverages.

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

Archer highlighted the occurrence of a significant change in Harlem’s demographic during his tenure in the community, whereby more residents with more disposable income have moved into the area. These newer residents tend to want more choices and different choices from those historically offered in the community, he observed, and he suggested that this shift offers hope for changing community members’ lifestyle patterns. He reiterated that even with the introduction of healthier choices, it is also necessary to provide education and shift the culture in order to realize meaningful shifts in dietary risk factors for obesity and other chronic diseases.

COMMUNITY POWER BUILDING IN THE CALIFORNIA ENDOWMENT’S BUILDING HEALTHY COMMUNITIES INITIATIVE

Anthony (Tony) Iton, senior vice president for programs and partnerships at The California Endowment (TCE), discussed the organization’s Building Healthy Communities (BHC) initiative. He began by sharing three popular paradigms about key factors that shape health: one’s genetic makeup, behavioral choices, and medical transactions (i.e., the frequency and quality of medical services). These paradigms are individual frames that inform how a health care provider interacts with a patient, he suggested, terming this “micro health.” These paradigms are accurate, he clarified, but are insufficient to address what he called “macro health” (i.e., population-level problems).

Population health is political with a small “p,” Iton said, referring not to partisan politics but instead to the struggle over the allocation of limited and precious social goods. These include health-protective resources such as access to parks, potable drinking water, and a neighborhood grocery store. Such resources are allocated in political decision-making processes, he explained, whereby communities that lack collective political power are less likely to have an equitable share. Therefore, he reasoned, the goal is to build power at the individual, family, and community levels.

Iton shared a framework that he said has helped guide how TCE has shifted from a technocratic to a democratic understanding of health (Figure 7-1). A group of public health practitioners in the Bay Area Regional Health Inequities Initiative developed the framework, he recounted, because prior tools were insufficient for addressing the latest challenges. The framework’s right half, representing a medical model, illustrates downstream drivers of health—genetics, individual risk factors and behaviors, and health care access. The health care delivery system spends an enormous amount of time managing the consequences of upstream conditions, he continued, which led the initiative to focus on opportunities to intervene on those conditions to try to lessen the burden in downstream clinical settings.

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
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FIGURE 7-1 A framework for health equity.
NOTE: Adapted by the Alameda County Public Health Department from the Bay Area Regional Health Inequities Initiative, Summer 2008.
SOURCE: Presented by Tony Iton, July 25, 2022. Iton and Shrimali, 2016. Reprinted with permission from Springer Nature.

Iton explained that the framework’s left half, representing a socioecological model, illustrates three categories of upstream drivers of health—discriminatory beliefs, institutional power, and social inequities. He described discriminatory beliefs as the “isms” in the United States that shape the behavior of institutions and individuals to drive apartheid and segregation, resulting in inequities when people are separated from opportunities. Institutional power, he continued, includes the role of corporations and other businesses, government agencies, and schools in establishing policies that influence health outcomes, he continued, while social inequities encompass the conditions in such places as neighborhoods and workplaces that affect health. Iton added that the framework recognizes that upstream buffers such as family and culture can mitigate negative upstream influences to help communities and individuals thrive despite adverse conditions.

Iton suggested that the two halves of the framework could be thought of as inequities and disparities, conditions and consequences, or democratic and technocratic strategies. He explained that TCE organized its upstream strategies into three categories that each align with a component in the left

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

half of the framework: place (social inequities), policy (institutional power), and narrative (discriminatory beliefs). He elaborated that “place” refers to the communities in which many historical inequities manifest, “policy” refers to systems that steer resources toward favored communities and away from other communities, and “narrative” refers to both historical and present beliefs that shape those policies. The goal of TCE’s work, Iton said, is to build a critical mass of social, political, and economic power in people who are “closest to the pain” (i.e., on the front lines of experiencing health inequities) in order to reshape narratives and lead to more equitable policy.

Iton expounded on the BHC program, which he described as an ecological approach to improving population health in California. TCE spent more than $1 billion on the program over a period of about 12 years, he remarked, with the aim of influencing drivers of social determinants of health. Such drivers are often referred to as political determinants of health, he added, because they are politically controlled. BHC believes that health is created in communities—not health care spaces—which Iton said begs the question of how to create, protect, and sustain health in communities. BHC aims to optimize the physical, social, economic, services, and political environments in communities, he said, so that these environments will promote positive health outcomes.

In presenting BHC’s theory of change, Iton explained that improving health status requires improving the opportunity environment so that the environments in which people live are conducive to well-being. Changing the opportunity environment calls in turn for policy and systems changes, which he termed “macro-level work,” to fundamentally undo structural racism that manifests in the physical segregation of people from opportunity. To influence policies, he insisted, the inputs into policy processes must be changed—in other words, it is “absolutely critical” to build power.

Iton described building a stronger ecosystem of power and the ability to control the narrative using a graphic known as the “power flower,” which has the concept of organizing and base building as its central ecosystem and six supporting and complementary types of organizations as its petals (Figure 7-2). All six petals must be robust, he said, for a community to be able to exercise power effectively.

The BHC initiative chose 14 communities throughout California, Iton explained, that represent the state’s geographic and demographic diversity. TCE’s belief was that the greatest resource for unleashing power lay within the human capital in those communities. It organized community members around a hub—a table where people came together to share meals. Invitees included “systems players” representing schools; health systems; human services systems; and other community physical, social, and economic environments that support health, such as mayors, police chiefs, and health department leaders. Also invited were community organizers

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
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FIGURE 7-2 Types of organizations within the power-building ecosystem.
SOURCE: Presented by Tony Iton, July 25, 2022. Dornsife Equity Research Institute (2019). Reprinted with permission.

and community residents who were close to the pain but also to the beauty of the communities. TCE provided meals, transportation, translation, and child care, and facilitated the formation of human relationships around the table, Iton recounted, creating an opportunity for community residents to exercise power and influence directly over systems leaders and help them understand the lived experience of people in the community. Fundamentally, Iton reported, the initiative’s budget was spent on building resident power and organizing communities so that residents could exercise more power over decision makers and hold them accountable.

Iton explained that to guide targets for community change, TCE gave the hubs a basic framework with a menu of options from which to select, or allowed communities to create their own priorities. TCE facilitated a concept it called “collaborative efficacy,” which he described as bringing people together to break down silos and enhance coordination and human relationships. BHC also invested in youth leadership and youth organizing, which Iton called “the rocket fuel of change” in communities; leveraged private capital to build grocery stores; and worked with health insurers

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

and banks to create investment funds for enhancing physical environments. Lastly, BHC worked to change the predominant narrative in communities that some people were valuable and others were less valuable, a racist narrative that needed to be changed to one of belonging for all people. The “basic recipe” for the work, he said in summary, is that it is about power, policy, and narrative.

In the final part of his presentation, Iton shared a BHC case study from Fresno, California, that illustrates building community power to participate in political decision making. He shared redlining maps of the city, noting that its northern area is mainly White, while its southern and eastern areas are mainly Black and Latino, and have a variety of immigrant populations. He observed that geographic differentials exist by race, wealth, income, educational attainment, and cancer risk.

Fresno’s BHC hub had prioritized access to parks, noting disparities in park condition and accessibility between the northern and the southern and eastern parts of the city. Accordingly, Iton said, the community organized a “One Healthy Fresno” campaign called “parks for all,” and one of the campaign’s initial activities was to update the city’s parks master plan. An investigation of the city’s own data had revealed a wide disparity in per capita park space, he recounted, whereby North Fresno had 4.62 park acres per 1,000 residents, while South Fresno had 1.02 park acres per 1,000 residents (Dyett & Bhatia Urban and Regional Planners, 2014). Iton described how community residents organized a campaign to advertise those data, as well as data from the Trusts for Public Land that ranked Fresno 94th out of 100 cities in the United States for parks (a measure that took into account quality of, access to, and maintenance of parks). The residents held press conferences, earned media attention, and lobbied to advertise the data on banners placed on buses and bus shelters. The City of Fresno denied the campaign organizers the opportunity to display the bus banners, Iton said, because they thought the content was too political and controversial. He explained that this denial turned out to be a positive thing because it triggered an enormous amount of local, national, and even international media attention and energy.

At this point, Iton continued, the Fresno BHC parks campaign recognized that it needed more resources for the city. The campaign established a ballot initiative and collected enough signatures to place a parks measure, “Measure P,” on the ballot. Although the measure received 52 percent of the vote, Iton said, key individuals and organizations in the city’s power structure (e.g., the mayor, police chief, fire chief, Chamber of Commerce, and Taxpayer’s Association) insisted that a two-thirds majority was needed. The issue went to appellate court, the Fresno BHC residents won, and the Supreme Court declined to hear the case. According to Iton, this was a huge victory for the people of South Fresno, who won what was estimated at the

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

time to be about $38 million a year in parks revenue from a 3/8-cent sales tax. The actual figure is almost $60 million a year, he noted, and estimates suggest that over the measure’s 30-year duration, nearly $2.2 billion will have been allocated for parks and park infrastructure in Fresno.

This work is political, Iton said in summary, as major obstacles in the status quo infrastructure oppose the interests of low-income people, especially those of color. Changing that dynamic, he asserted, calls for building power to participate in political decision making at the local, regional, and state levels.

PANEL AND AUDIENCE DISCUSSION

Following their presentations, the three speakers engaged in a moderated discussion and answered participants’ questions. They first commented on the links between the session topic and obesity, and then discussed the role of implementation science research in understanding and shifting power, the power of changing narratives, ensuring that obesity solutions benefit all people, health care providers’ involvement in community and policy efforts, opposition to Fresno’s Measure P, and responding to differing views about determinants of health.

Links between Community Power Dynamics and Obesity

In response to Lyn’s question about how the relationship of each speaker’s content to obesity, Odoms-Young replied that obesity is embedded in the broader context of structural racism. She suggested that gaps remain in understanding of the full scope of pathways through which structural racism can impact obesity across the life course, particularly with respect to the effect of exposures early in life.

Archer pointed out that from his perspective as a community development professional, it is important to note that Harlem is the third most popular destination for international tourism in New York City. Yet compared with tourist hubs such as midtown Manhattan or Wall Street, he observed, Harlem has more fast food restaurant chains and fewer supermarkets, and he questions whether this concentration of unhealthy foods and lack of healthier options is intentional.

Iton pointed to the connection between obesity and access to parks/recreation. He recounted that TCE formerly had an initiative focused on obesity, but that it shifted that framing after recognizing that drivers of obesity were also driving other chronic disease outcomes that disproportionately affected certain neighborhoods in California. Those patterns of distribution of obesity and chronic disease burden led to the idea that zip code may matter more than genetic code to one’s health, Iton continued,

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

because the patterns observed were not fully explained by health behaviors or even access to health care. They were explained, however, by accounting for political power and the marginalization of communities that Iton contended are a result of segregation. He asserted that U.S. policies have been intentionally designed to separate certain people from opportunities—including parks and infrastructure—and to drive the health outcomes seen today. To undo this, he contended, will require a change of inputs into political systems.

The Role of Implementation Science Research in Understanding and Shifting Power

Odoms-Young shared her view that implementation science offers a promising opportunity to examine emerging paradigms about structural and social determinants of health and their role in disease outcomes relative to that of biological and behavioral influences. She submitted that understanding traditional theories and frameworks focused on the role of health behaviors is helpful for establishing a baseline from which to inform exploration of broader influences on health. She urged action to understand implementation at the community and even national and international levels and suggested that an implementation science approach can shed light on the effectiveness of interventions at multiple levels.

The Power of Changing Narratives

Narrative is “incredibly powerful,” Iton maintained, because narrative shapes policy, and policy creates conditions. He observed that people often pursue efforts to change policies and suggested that these endeavors are limited absent concurrent efforts to shift narratives. Iton outlined an “A, B, C” framework that TCE developed and has used to guide communities in changing narratives around, for example, undocumented people, formerly incarcerated people, and boys and men of color. “A” is for agency, which he explained is community-level power; “B” is for belonging, which he described as the ability to have one’s story heard and valued in the community; and “C” is for conditions of opportunity, such as social or political determinants of health, which Iton said can be changed through policy.

According to Iton, two fundamental narratives exist in the United States about Americans as a people: a dominant, White supremacist narrative about who belongs and has the greatest legitimate claim to the instruments of government, and a second narrative about America as a place for liberty, freedom, and optimizing of human potential, whereby anyone is an American if they contribute to structuring society to optimize opportunity. The second narrative is a hopeful one, he said, because it recognizes the strength of diversity.

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

Archer reflected on his experience as a Black student entering a majority White institution when he began college at an Ivy League university, sharing that he went through “imposter syndrome” and felt as though he was not worthy to be there because of societal narratives he had internalized. He shared his belief that many people of color question their worth or whether they are deserving of such opportunities because of those narratives.

Ensuring That Obesity Solutions Benefit All People

Odoms-Young highlighted the importance of changing obesogenic environments, which she said affect people from all walks of life, although some individuals have greater exposure than others to structural and social barriers to health. Changing environments is also important for supporting individuals who receive pharmacologic or surgical treatment for obesity, she added, so that they are positioned to benefit fully from the positive outcomes that have been demonstrated to result from such treatments.

Archer confirmed that a shift in Harlem has occurred with respect to improved access to healthy food options but underscored that a gap remains in educating community members about the rationale for and benefits of purchasing and consuming those foods. According to Archer, a key challenge is that longtime Harlem residents believe that efforts to improve access to healthy foods and shift the community’s dietary patterns are not for them. He spotlighted an urban agriculture initiative called Harlem Grown that teaches young people how to grow produce and educates them on healthy eating. He described the initiative as “an oasis in the desert” and called for a more concerted effort by elected officials and community groups to collaborate and promote the message that fruits and vegetables and other healthy food choices are beneficial for everyone, not just the newcomers to the community.

Health Care Providers’ Involvement in Community and Policy Efforts

In response to an attendee’s question about how physicians in private practice can get involved in community and policy efforts, Iton urged them to “start where you are,” by which he meant that physicians who work as part of a group practice or health care system can work with their colleagues to identify policies and practices over which they have influence. As examples of opportunities to effect change, he cited decisions about whom to employ, how to structure career ladders in the organization, sourcing of materials and equipment, and service to the local community. Physicians employed in larger health institutions may have opportunities through their employers to participate in broader policy issues, he added, observing that “not everybody has to be testifying in Congress” in order to make an impact.

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×

Opposition to Fresno’s Measure P

Iton was asked why Fresno community leadership opposed Measure P (to improve access to park space for residents in underserved areas of the city) despite data clearly demonstrating inequities in access to park infrastructure. The majority of local budgets in California is dedicated to law enforcement (police) and fire resources, he explained, pointing out that the mayor who had taken office during the Fresno parks campaign was a former police chief who did not view parks as a priority. Iton described the situation as a typical example of individuals in the political infrastructure lobbying for resources to benefit their institutions.

Responding to Differing Views About Determinants of Health

An attendee referenced recent opposition to including such concepts as social determinants of health and critical race theory in the curriculum for taxpayer-funded education and asked how to respond to such barriers to efforts to advance education on structural drivers of health. Odoms-Young called for building power at the community level by developing messaging and solutions that speak to all community audiences. As a researcher, she explained, her strength is building an evidence base and mobilizing community members through community-based participatory research; she urged others to work within their scope of influence to build power.

Iton underscored that “racism affects all of us” and appealed for increasing awareness of its universal effects. Education about the social determinants of health and their political roots, he elaborated, is a way to convey that racism impacts everyone. As an example, he pointed to what he called racism’s “collateral damage” of negative health effects in White working-class people, who he observed are not the “intended targets” of racism.

Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
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Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
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Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
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Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
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Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 62
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 63
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
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Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 65
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 66
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 67
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 68
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 69
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 70
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 71
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 72
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 73
Suggested Citation:"7 Power Dynamics and Community as Complex Systems." National Academies of Sciences, Engineering, and Medicine. 2023. Translating Knowledge of Foundational Drivers of Obesity into Practice: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26942.
×
Page 74
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The National Academies Roundtable on Obesity Solutions hosted an April, July, and October, 2022 workshop series to explore the gaps in knowledge within the foundational drivers of obesity. Facilitating action will require improved health communication, deconstructing structural racism, and recognizing the biased mental models and social norms at odds with obesity solutions. Speakers discussed future research in evidence-based solutions and potential ways to translate current evidence into practice. This Proceedings of a Workshop summarizes the discussions held during the workshop.

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