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Getting to Equity in Obesity Prevention: a New Framework

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Getting to Equity in Obesity Prevention: a New Framework DISCUSSION PAPER Getting to Equity in Obesity Prevention: A New Framework Shiriki Kumanyika, PhD, MS (Social Work), MPH, Dornsife School of Public Health, Drexel University January 18, 2017 High obesity prevalence persists as a major issue for societies globally (IOM, 2012; WHO, 2013). Chronic overweight and obesity have high health, social, and economic costs (Hammond and Levine, 2010), and the benefits of achiev- ing and maintaining healthy weight for overall health and well-being are well established (Horton, 2009; IOM, 2012; Wing et al., 2011; Zomer et al., 2016). Obesity in children and adolescents is of particular concern because it may compromise physical and psychosocial development and set the stage for early onset of adverse health effects that accumulate over a lifetime (IOM, 2005). Relevant to the topic of this discussion paper, obesity is also a health equity issue. Social disadvantage tends to intensify the exposure to obesity-promoting influences (Brave- man, 2009; May et al., 2013). The challenge of preventing and controlling obesity includes the need to assure that socially disadvantaged populations benefit from relevant public health interventions (IOM, 2013). Population-wide obesity and its health consequences car, in sedentary work environments that limit physical are linked to eating and physical activity patterns that activity, and where sedentary entertainment is readily have become ways of life in modern societies (IOM, available, affordable, and heavily promoted. 2012; Kumanyika et al., 2008; WHO, 2000). This is a Our communities are laden with obesity-promoting global problem, but one for which solutions must be influences that often overwhelm efforts of individuals tailored to national and subnational contexts (WHO, to control their weight. The current public health prior- 2000). Human physiologic systems for regulation of ity for transforming environments to be more support- food intake are well developed for responding to hun- ive of healthy eating and physical activity recognizes ger but poorly developed for curbing overeating, and this reality. Tables 1 and 2 list various types of obesity- they evolved when routine physical activity levels were promoting influences in daily living environments (mi- much higher than they are now. Thus, it is often said croenvironments) as well as factors farther upstream that from an evolutionary perspective widespread (macroenvironments). These tables are adapted from obesity reflects a natural response to an unnatural Preventing Childhood Obesity: Health in the Balance environment. On the energy intake side, this unnatu- (IOM, 2005). This report was among the earliest U.S. ral environment is characterized by ubiquitous, heav- efforts to shift the obesity intervention paradigm to- ily advertised, and highly palatable high-calorie foods ward public health approaches. The tables depict the and beverages and large portions of restaurant meals; spectrum of factors and environments that influence these all promote caloric overconsumption. On the en- eating and physical activity. The focus of this perspec- ergy output side, the unnatural environment is evident tive is on those factors that are amenable to modifica- in residential areas where cars are a common form of tion by altering existing public or private policies or by transportation or where mobility depends on using a establishing new ones. Perspectives | Expert Voices in Health & Health Care DISCUSSION PAPER Table 1| ExamplesType of of Environment: Environmental Food-Related Influences Influences on Food Intake, by Type of Environment Type of Environment: Food-Related Influences Size or Level of Environment Physical Economic Policy/Political Sociocultural Microenvironments • Location and type of • Locally imposed taxes • Family rules related • “Ethos” or climate (e.g., behavioral food stores • Vendor pricing to food purchasing related to food and settings such as • Vending machine policies and consumption eating in the home, homes, schools, and placement and • Financial support for • Food policies of local school, and communities) products health promotion schools and districts neighborhood • Point-of-purchase programs • Role models for eating information • Sponsorship of behaviors at home, in • Local food healthful food school, and in production policies and practices community settings (e.g., churches) Macroenvironments • Food production/ • Costs of food • National food and • Mass media influences (e.g., societal sectors • importing production, nutrition policies, on food selections and such as food and • Food manufacturing manufacturing, and regulations, and eating behaviors agriculture, education, • Food marketing distribution laws, including food • General consumer medical, government, • Federal nutrition • Taxes, pricing labeling trends in food and public health, or labeling guidelines policies, subsidies • Food industry eating health care) • Wage structure and standards and other factors that practices influence personal • Regulations and and household guidelines on income advertising to children Source: Adapted from Swinburn et al., 1999; IOM, 2005 Table 2| Examples of Environmental Influences on Physical Activity, by Type of Environment Type of Environment Size or Level of Environment Physical Economic Policy/Political Sociocultural Microenvironments • Sidewalks and • Cost of gym • Family rules about • “Ethos” or climate (e.g., behavioral footpaths memberships television watching related to physical settings such as • Cycle paths • Budget allocations for • Family rules about activity and inactivity in homes, schools, and • Public transportation recreation centers or household chores the home, school, and communities) • Street lights walking and cycling • Restrictions on neighborhood • Recreational facilities paths bicycle or pedestrian • Role models for and clubs • Funding for improved traffic physical activity and public transportation • Zoning for protection inactivity in the home, • Sponsorship of of green spaces school, and physical activity- • Building codes neighborhood related health promotion • Influences on household income and time expenditures Macroenvironments • Automobile industry • Public transport • State-level policies on • Mass media influences (e.g., societal sectors funding and physical education in on physical activity and such as food and subsidies schools inactivity agriculture, education, • General consumer medical, government, trends patterns of public health, or physical activity and health care) inactivity Source: Adapted from Swinburn et al., 1999; IOM, 2005 Page 2 Published January 18, 2017 Getting to Equity in Obesity Prevention: A New Framework A General Framework for Obesity Prevention Potential targets for interventions in these settings in- in the United States clude the types of foods available in neighborhoods and settings such as schools, child care facilities, or The 2012 Institute of Medicine (IOM) Committee on worksites; food prices; advertising and promotion of Accelerating Progress in Obesity Prevention (APOP) (2) unhealthy foods and beverages; public transporta- (IOM, 2012) developed strategies and action plans that tion; traffic patterns, air quality, and other aspects of have become a reference point for current U.S. obesity neighborhood safety and quality; and access to parks prevention efforts with both children and adults. The and recreational facilities. These factors are difficult to APOP study committee reviewed hundreds of recom- change. mendations for preventing obesity and arrived at five The APOP framework also highlights the roles of en- recommendations, 20 accompanying strategies for gagement and leadership in effecting changes in these implementing these recommendations, and a number environments. Environments related to healthy eating of potential action steps for each strategy (IOM, 2012). and physical activity are not only a part of the fabric of Taken together, the recommendations, strategies, and everyday life, they also reflect processes that are use- action steps form a comprehensive strategy to foster ful to communities in other ways and are, therefore, obesity prevention in key environments or “settings.” protected by a combination of public policies, com- The approach was grounded in a systems perspec- mercial interests, and public preferences. For example, tive to encourage actions within and across settings school policies may limit time for physical education in that were complementary and could be mutually favor of more time for academics. Community design reinforcing (Figure 1). practices that are efficient for automobile transporta- Characteristics of the settings in the APOP frame- tion and suburban living may take priority over con- work define the overall context for choice options, figurations that make it possible for children to walk to motivations, and actions regarding eating and nearby schools. physical activity for individuals and communities. Figure 1 | Comprehensive approach of the Committee on Accelerating Progress in Obesity Solutions. Source: IOM, 2012. Published January 18, 2017 NAM.edu/Perspectives Page 3 DISCUSSION PAPER Health Equity Considerations contexts influence the feasibility and relevance of in- terventions designed to improve options for healthy We continue to observe substantially higher obesity eating and active living, stating in the opening chapter prevalence in U.S. racial/ethnic minorities compared to of the report: white populations. For example, in National Health and Nutrition Examination
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