4

Study Approach

Key Messages

  A systems perspective informed the committee’s approach to developing its recommendations and identification of indicators with which to measure progress toward their implementation.

  Guiding principles were developed to inform the committee’s decisions, including its critical review of prior obesity-related recommendations and identification of relationships and synergies among them.

  The committee identified five critical areas of focus necessary to accelerate progress in obesity prevention—the physical activity, food and beverage, message, health care and work, and school environments—that are linked as an interrelated system.

  For each critical area, the committee identified goals, recommendations, strategies, and potential actions with the greatest potential reach and impact on preventing obesity as outlined in the committee’s guiding principles, based on research evidence and the current level of progress in each area.

  The identification of indicators of progress in implementing the committee’s recommendations took into consideration (1) how well an indicator links to the goal of accelerating progress in obesity prevention, (2) its cost, (3) its availability in existing sources or ease of development in cases where sources are lacking, and (4) its ability to measure progress over the next decade.

As discussed in Chapter 1, the committee was tasked with developing a set of recommendations that, if implemented, would be likely to significantly



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4 Study Approach Key Messages • A systems perspective informed the committee’s approach to developing its recommendations and identification of indicators with which to measure progress toward their implementation. • Guiding principles were developed to inform the committee’s decisions, including its critical review of prior obesity-related recommendations and identification of relationships and synergies among them. • The committee identified five critical areas of focus necessary to accelerate progress in obesity prevention—the physical activity, food and beverage, message, health care and work, and school environments—that are linked as an interrelated system. • For each critical area, the committee identified goals, recommendations, strategies, and potential actions with the greatest potential reach and impact on preventing obesity as outlined in the committee’s guiding principles, based on research evidence and the current level of progress in each area. • The identification of indicators of progress in implementing the committee’s recommendations took into consideration (1) how well an indicator links to the goal of accelerating progress in obesity prevention, (2) its cost, (3) its availability in existing sources or ease of development in cases where sources are lacking, and (4) its ability to measure progress over the next decade. As discussed in Chapter 1, the committee was tasked with developing a set of recommendations that, if implemented, would be likely to significantly 115

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accelerate progress in obesity prevention over the next decade, along with recom- mendations for tangible, practical indicators with which to measure progress. This chapter first describes the general approach used by the committee to identify critical recommendations for accelerating progress. It then outlines the committee’s proposed approach to assessing the progress of these recommendations, including indicators for measuring progress, as well as the need to create a research frame- work based on the committee’s general approach. Before proceeding, a note on terminology is in order. In reviewing previous obesity-related recommendations as part of its charge, the committee found that a variety of terms were used to frame the advice provided, including “recommenda- tions,” “strategies,” “actions,” and “interventions.” In this report, the committee uses the terms “goals,” “recommendations,” “strategies,” and “(potential) actions” to denote levels of increasing specificity (see Box 4-1 for definitions). BOX 4-1 A Note on Terminology Goals are the desired outcomes if recommendations are successfully • implemented. Recommendations encompass the broad actions that need to be imple- • mented and the responsible actors. Strategies are specific means of implementing the recommendations. • (Potential) actions are activities that can help to implement the strategies. • In general, the term “recommendations” is used in the report to denote this full set of terms, whether describing previous work or that of the committee. Accelerating Progress in Obesity Prevention 116

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THE COMMITTEE’S GENERAL APPROACH This section describes the approach used by the committee to formulate its recommendations for accelerating progress in obesity prevention, including the systems perspective that informed its deliberations and the development of a set of guiding principles. A Systems Perspective As noted in previous chapters, a systems perspective informed every aspect of the committee’s approach to its task, including the development of its vision; identification of the need to engage individuals, families, communities, and society to catalyze change; integration of knowledge about the current environment; development of guiding principles; review of prior recommendations; formulation of recommendations, strategies, and actions with the greatest potential to acceler- ate progress in obesity prevention; and identification of indicators of progress. Systems thinking helped the committee identify areas in which change is needed and how actions taken in these areas can work synergistically to make the greatest impact on obesity prevention. Appendix B provides additional detail on the com- mittee’s use of a systems perspective. Guiding Principles As described in Chapter 2, obesity has imposed substantial social, health, and economic burdens on the U.S. population. The epidemic is a startling setback to major improvements in child health in the past century. Obesity has many causes; individual energy imbalance is influenced by environmental, cultural, and societal factors (e.g., food policies, the built environment, cultural norms) that ultimately affect personal decisions about physical activity and food intake. Exposure to these influences, both positive and negative, varies by subpopulation, with result- ing disparities in the prevalence of obesity. An urgent need exists to accelerate progress toward obesity prevention because prevention is a more sustainable population-based solution than treatment. Prior recommendations for obesity prevention have been proposed, but their fidelity and degree of implementation and integration have not been thoroughly evaluated. Informed by a systems perspective as described above; a vision of what society would look like if obesity prevention were achieved (as detailed in Chapter 1); and an understanding of the complex social, political, and economic environment (as 117 Study Approach

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detailed in Chapters 2 and 3), the committee developed the following principles to guide its deliberations and decisions: 1. Bold, widespread, and sustained action will be necessary to accelerate progress in obesity prevention. 2. Priority and targeted actions must drive cultural and societal changes to improve environments that influence physical activity and food intake options. 3. Cultural and societal changes are needed to address obesity, and a systems approach must be taken when formulating obesity prevention recommenda- tions so as to address the problem from all possible dimensions. 4. Solutions to the obesity epidemic must come from multiple sources, involve multiple levels and sectors, and take into account the synergy of multiple strategies. 5. Obesity prevention recommendations should be based on the best available scientific evidence as outlined in the Locate Evidence, Evaluate Evidence, Assemble Evidence, Inform Decisions (L.E.A.D.) framework (IOM, 2010). 6. The cost, feasibility, and practicality of implementing prior and further rec- ommendations must be considered. 7. Unintended consequences of obesity prevention efforts must be considered. 8. Obesity prevention recommendations should incorporate ongoing evalu- ation of progress toward achieving benchmarks and of the need for any course corrections. 9. Recommendations to accelerate progress in obesity prevention must include an assessment of the potential for high impact, the reach and scope of potential effects, the timeliness of effects, the ability to reduce disparities and promote equity, and clearly measureable outcomes. Approach to the Development of Recommendations From the outset, a key aspect of this study was the tension between the reality that complementary interventions in multiple areas are needed and the fact that evidence and decisions about specific interventions often are generated without consideration of the larger systemic context. Therefore, the committee evaluated all potential recommendations for their potential impact on obesity based both on their theoretical or documented effects on physical activity or eating and on their potential links to other recommendations. The committee’s step-by-step approach to the development of recommendations, which was informed throughout by the Accelerating Progress in Obesity Prevention 118

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guiding principles outlined above, is depicted in Figure 4-1, described below, and discussed in greater detail in Appendix B. Identification, Grouping, Organization, Review, and Filtering of Prior Recommendations and Identification of Gaps As a first step, the committee was charged with reviewing previous obesity- related recommendations. To this end, the committee identified approximately 800 recommendations to review, as shown on the left of Figure 4-1. It then grouped and organized these recommendations and developed a process for reviewing and filtering them. The committee identified prior recommendations with the greatest reach and potential impact on obesity prevention, and prioritized them using the best available scientific evidence according to the L.E.A.D. framework, a frame- work that was developed to inform decisions on obesity prevention, integrating research evidence into a broader policy context (IOM, 2010). In this process, the committee took into consideration the progress made in implementing the recom- mendations, their ability to be evaluated or measured to assess progress or impact, the timeliness of their effects, any unintended consequences, their potential to reduce disparities in the risk of obesity, and the feasibility and practicality of their implementation. Throughout the process, gaps were identified and considered in formulating the committee’s final set of recommendations. The process of locating, evaluating, and assembling the evidence is further detailed in Appendix B. Identification of Linkages Among Filtered Recommendations As recommended by the L.E.A.D. framework, the committee’s approach included identifying relationships among recommendations and implementing strategies with the most promise to accelerate progress in obesity prevention and determining whether they could work together to make a larger impact. This pro- cess was informed by guidance from an expert in systems modeling and centered Review and Filter Prior Develop Recommendations, Determine Identify, Group, and Recommendations Identify Existing Measures of Organize Prior to Accelerate Gaps, and Identify Progress Recommendations Progress Linkages FIGURE 4-1 Overview of committee’s approach to identifying recommendations to accelerate progress in obesity prevention. 4-1 only 119 Study Approach

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around whether the recommendations and strategies of interest required, would enhance, or would be enhanced by any of the others under consideration. A quali- tative tool—a systems map—was developed as an aid to visualizing and better understanding the interconnectedness of the recommendations and strategies and other factors that could improve or act as barriers to their implementation. The results of this effort included the identification of five critical areas of focus for this study (see Figure 4-2) • physical activity environments, • food and beverage environments, • message environments, • health care and work environments, and • school environments. Message Environments School Environments Physical Food and Activity Beverage Environments Environments Health Care and Work Environments FIGURE 4-2 A simplified systems map illustrating the interconnectedness of the five areas of focus of the Committee on Accelerating Progress in Obesity Prevention. Accelerating Progress in Obesity Prevention 120

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These five areas constitute those in which major reforms are necessary to accelerate progress in obesity prevention: access to and opportunities for physical activity; widespread reductions in the availability of unhealthy food and bever- age options and increases in access to healthier food and beverage options at affordable, competitive prices; an overhaul of messages that surround Americans (through marketing and education) with respect to physical activity and food consumption; expansion of the obesity prevention support structure provided by health care providers, insurers, and employers in every health care and workplace setting; and schools being made a major national focal point for obesity preven- tion. Appendix B provides the committee’s detailed systems map, along with discussion of its development and interpretation; Chapters 5-9 each contain a simplified systems map (similar to Figure 4-2) highlighting the area addressed in that chapter. While a Venn diagram such as that in Figure 4-2 cannot illustrate the many and diverse interactions and feedback loops revealed by a systems map (as presented in Appendix B), it does reflect the critical areas of concern and their interrelationships. Development of Recommendations The final step was to formulate a recommendation in each of the five areas outlined above and to articulate the goal associated with each of these recommen- dations. The committee identified three to five strategies for each recommenda- tion that, if acted upon, would have the greatest potential reach and impact on preventing obesity, based on research evidence and the current level of progress in each area, with guidance from the L.E.A.D. framework. For each strategy, the committee then devised a set of actions that would be likely to make a positive contribution to the implementation of that strategy based on research evidence or, where evidence is lacking or limited, have a logical connection with the strategy’s implementation. The committee’s stepwise approach to the development of rec- ommendations, goals, strategies, and potential actions is illustrated in Figure 4-3. Chapters 5 through 9, respectively, present the committee’s recommendations and goals in the five focus areas, the associated strategies and actions, the supporting research evidence, and the current level of progress in each area. As described earlier in this chapter, the committee determined that accelerating obesity prevention will require synergy among various strategies and actions that, although important in themselves, would yield even greater benefit through com- plementary effects and mutual positive feedback. Box 4-2 provides an example to illustrate how action in a particular area might enhance or be enhanced by action 121 Study Approach

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Comprehensive Approach (5 Critical Areas of Focus) Recommendations and Associated Goals Strategies for Achieving the Recommendations Actions for Implementing the Strategies FIGURE 4-3 The committee’s stepwise development of goals, recommendations, strategies, and 4-3.eps potential actions. in other areas, previewing some of the strategies recommended in the critical area of school environments and linkages identified in the systems map (see Chapter 9 and Appendix B). Finally, the committee considered the important role of two issues—leadership and prioritization—in the implementation of its recommendations and the accel- eration of progress in obesity prevention over the next decade (see Chapter 10). ASSESSMENT OF PROGRESS Recommending potential indicators that can act as markers of progress in obesity prevention was one aspect of the committee’s charge. Moreover, the com- mittee believes that, to accelerate progress in obesity prevention, it is critical to identify and track progress in achieving each of the recommended strategies included in this report, as well as the overarching goal of reducing the prevalence and incidence of obesity and overweight. The committee’s charge clearly stated that indicators of progress should be capable of being evaluated readily through the use of existing databases and/or measures or surveys that could be developed and implemented quickly in cases where existing sources failed to exist. For purposes of this report, the committee defined an indicator of progress as “an objective measure that can be used to assess the effect of, or association with, a given strategy in accelerating progress toward obesity prevention.” In identifying potential indicators of progress, the committee considered the following key factors • the extent to which existing and/or potential indicators were linked with the overarching goal of accelerating progress in obesity prevention and/or with the individual strategies tied to each recommendation, Accelerating Progress in Obesity Prevention 122

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BOX 4-2 Example of Linkages Among the Committee’s Recommendations Consider a school district that would like to implement actions to improve its students’ physical activity and food environments. Chapter 9 describes the committee’s three strategies for implementing its recommendation related to school environments—making schools a focal point for obesity prevention: (1) require quality physical education and opportunities for physical activity in schools; (2) ensure strong nutritional standards for all foods and beverages sold or provided through schools; and (3) ensure food literacy, including skill development, in schools. Individually, the implementation of these evidence- based strategies will be important to prevent obesity, but they can most likely make a larger impact on accelerating obesity prevention by working together. Furthermore, it will be important for school districts to understand how these changes will influence, reinforce, or even be affected by other strategies that are implemented (or not implemented) outside of school. If schools invest in sports fields and open spaces as opportunities for students to participate in physical activity during the school day, not only will the activity level of the students be increased, but also will that of their families and others in the com- munity if these spaces are available to them. That is, investing in and allowing joint use of the physical environment at the school will reinforce opportuni- ties for activity for students after school and may encourage their families and other community members to make physical activity routine. Additionally, these school-based strategies support strategies in a variety of other areas. For example, physical education and physical activity in schools will contribute to making physical activity an integral and routine part of life (another critical recommendation). Also, food literacy in schools can help reduce overconsump- tion of sugar-sweetened beverages (a recommended strategy for food and beverage environments). This example illustrates how the committee’s full set of recommendations and strategies support each other as a system for prevent- ing obesity, increasing overall effectiveness from multiple directions and among multiple actors. The systems map in Appendix B provides additional linkages among and across the committee’s critical recommendations and related strategies. 123 Study Approach

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• cost, • the availability of an existing indicator or the ease of an indicator’s develop- ment, and • the ability to measure progress in the given strategy over the next decade. A multilevel framework for developing the indicators of progress was devel- oped. This framework (Figure 4-4) was designed to ensure that relevant and mea- surable indicators would be identified at multiple levels. Referring to Figure 4-4, four levels of indicators of progress are used in this report. Overarching indicators focus on tracking progress in reducing the inci- dence and prevalence of obesity and overweight. These indicators are assumed to be the data that most clearly measure progress toward obesity prevention. Primary indicators focus on measuring progress in factors most closely related to energy balance, the physiologic precursor to obesity. These indicators are those Overarching Reduce Reduce incidence incidence and and prevalence prevalence of of obesity overweight ENERGY BALANCE Primary Increase Reduce Energy Energy Intake Expenditure Examples include Foundational Process Improve Increase Reduce Improve food Increase access street-scale quality school overconsumption of Improve and beverage to physical community physical sugar-sweetened food labeling marketing activity design education beverages practices Examples include advocacy, coalition and community capacity-building, education, advancing science, and reports 4-4.eps FIGURE 4-4 Framework for developing indicators of progress in accelerating obesity prevention. Accelerating Progress in Obesity Prevention 124

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most closely related to higher energy expenditure (increased physical activity) and lower energy intake (lower caloric consumption)—the two components of energy balance. If achieved, they should affect the overarching indicators of accelerating progress in obesity prevention. Process indicators are more distal and relate to policies and environmental strategies designed to result in increasing the likelihood of energy balance. Examples include increasing the proportion of states and municipalities that adopt policies promoting enhancements to the physical and built environment that sup- port increased physical activity. Finally, foundational indicators relate to actions even further upstream that influence the broader dynamics involved in accelerating progress in obesity pre- vention (e.g., adoption of federal legislative and regulatory policies to increase domestic production of fruits and vegetables). Foundational indicators also relate to actions designed to specifically address health disparities for population subgroups disproportionately affected by obesity, physical inactivity, or excess caloric intake (e.g., reduced consumption of sugar-sweetened beverages among populations with higher rates of consumption of such beverages, including non-Hispanic blacks, Mexican Americans, and lower-income individuals). The committee carefully reviewed each recommended strategy against exist- ing data sources to identify indicators of progress at each level of the above framework. Additionally, the committee held a public workshop in March 2011 to obtain input on potential indicators and to identify areas in which systems for tracking progress on a given indicator are clearly needed. Because of the committee’s emphasis on accelerating progress in obesity prevention nation- wide, the focus was on identifying national data sources as the primary sources for proposed indicators that currently exist. As indicated in the committee’s charge, however, indicators do not yet exist for many of the strategies recom- mended in this report. Therefore, it was necessary to identify new indicators that must rely heavily on commercial data or require the development of new data sources. The proposed indicators (both existing and new) are identified after each recommended strategy (throughout Chapters 5 through 9) and for the system of recommendations (near the conclusion of Chapter 10). Additionally, because many of the proposed indicators do not yet exist, the committee has identified this as an area in which additional work is clearly needed moving forward (see Chapter 10). Finally, in conjunction with the identification of indicators of progress, the committee believes an important opportunity exists to create a research frame- 125 Study Approach

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work that would further the committee’s systems approach. At the conclusion of Chapter 10, the committee offers a brief discussion of quantitative systems-science methodologies that could be used to further test and refine the set of recommen- dations in this report and in turn facilitate future decisions that may be necessary to address this dynamic, complex problem. SUMMARY In accordance with its charge, the committee drew on approximately 800 prior obesity prevention recommendations to identify critical areas for interven- tion that are fundamental to accelerating progress against the obesity epidemic. This process involved reviewing the evidence that supports these interventions, evaluating potential interventions according to a set of guiding principles, determining what indicators could be used to assess progress related to these interventions, and using a systems perspective to understand the potential for these actions to influence each other and drive change. The committee identi- fied five critical environments for intervention: physical activity environments, food and beverage environments, message environments, health care and work- place environments, and school environments. These areas serve as the basis for the committee’s five recommendations and respective goals, along with specific strategies and potential actions for implementation, as detailed in Chapters 5 through 9. When reading these next five chapters, it is important to remember that each recommendation, strategy, and potential action has positive potential to accelerate obesity prevention. However, the committee also emphasizes that its recommendations should be viewed together as a system, taking into account the potential for combined impacts (or synergies) and recognizing likely positive and negative interactions and feedback loops. REFERENCE IOM (Institute of Medicine). 2010. Bridging the evidence gap in obesity prevention: A framework to inform decision making. Washington, DC: The National Academies Press. Accelerating Progress in Obesity Prevention 126