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10
Answering Questions About
Leadership, Prioritization,
and Assessment with a
Systems Perspective
Key Messages
• Leadership, in the case of the committee’s systems approach to accelerat-
ing obesity prevention, is a shared responsibility across sectors and levels,
and one that may not follow typical hierarchical or individual sector-based
approaches. It rests with all individuals, organizations, agencies, and sectors
that can influence physical activity and food environments.
• The committee did not give priority to any one recommended action or set
of actions above others. Rather, leaders are called on to identify priority
actions over which they have control, using systems thinking in their imple-
mentation efforts.
• A greater awareness of the potential catastrophic consequences of the high
rates of obesity, together with a common understanding that individuals
and groups in every sector and at every level must play a critical role in
prevention, will help catalyze the systemwide implementation of the com-
mittee’s recommendations.
• Resources will be required to effectively monitor the full impact of the com-
mittee’s recommendations and determine whether progress in obesity pre-
vention is accelerating.
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• The application of quantitative systems science to the examination of
complex public health problems, including obesity in particular, holds great
promise and offers enormous potential benefits.
T he unique perspective that a systems approach brings to the issue of obesity
is highlighted at the end of the previous chapters presenting the committee’s
recommendations (Chapters 5-9). For example, Chapter 7, on message environ-
ments, points out some of the important intrasector and cross-sector insights that
are gained by viewing these issues through a systems lens: “On their own, any one
of these actions might help accelerate progress in obesity prevention, but together,
their effect would be reinforced, amplified, and maximized. A social marketing
campaign on its own, without a decrease in young people’s exposure to food and
beverage marketing, would be less effective. Likewise, a shift in food and bever-
age marketing would be more powerful when accompanied by a vigorous social
marketing campaign.” Likewise, Supplemental Nutrition Assistance Program
(SNAP) Education (SNAP-Ed) would be much more effective if a sustained and
targeted social marketing campaign were initiated and there were significant
increases in food availability and affordability for SNAP recipients.
This unique perspective also influences the committee’s views on how leader-
ship, prioritization, and assessment should be handled. A theme that recurs through-
out this report is that each of the committee’s single recommendations, strategies,
and potential actions has the potential to accelerate progress in obesity preven-
tion, but that it is also important to view them as a whole system comprising the
five critical areas depicted in Figure 10-1. As illustrated in the figure, this chapter
addresses the important issues involved in the implementation of the committee’s
recommendations for accelerating progress in obesity prevention, using a simplified
systems perspective, by answering three important questions: How should leadership
be identified, defined, and exercised in response to the systems-oriented recommen-
dations presented in this report? How can the systems thinking represented in this
report guide the way a leader should approach implementation of the recommenda-
tions and the associated strategies and potential actions? What are the priorities on
which leaders should act within and among the five interacting critical areas?
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Engagement, Leadership, and Action
Individuals, Families, Communities, and Society
Message
Environments
School
Environments
Physical Food and
Activity Beverage
Environments Environments
Health Care
and Work
Environments
Assess Progress
FIGURE 10-1 Comprehensive approach of the Committee on Accelerating Progress in Obesity
Prevention.
This chapter also identifiesS-1 andindicators—complementary to the more
a set of 10-1
specific indicators in Chapters 5-9—that the committee recommends be used to
assess progress in the implementation of its recommendations as a whole, an
important step in effectively monitoring implementation and impact. The chapter
concludes with suggestions for future systems research in obesity prevention.
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DEFINING LEADERSHIP AND IDENTIFYING LEADERS
The issue of leadership is dealt with throughout this report. In Chapters 5-9,
the potential and obvious leaders for each of the committee’s recommendations are
identified and called upon to take immediate action to accelerate progress in obesity
prevention. These are typically the individuals, agencies, organizations, or sectors
that are traditionally seen as having the knowledge, control, and responsibility for
the particular environments, policies, and practices that must change. For example,
the recommendations, strategies, and potential actions in Chapter 6 (on food and
beverage environments) call on schools; the business community/private sector; non-
governmental organizations; federal, state, and local governments; the food and bev-
erage industry; and health care providers to take leadership on specific actions.
The report also introduces new ways to think about leadership. For example,
Chapter 1 identifies and calls on another set of leaders—individuals, families,
communities, and the larger society—for engagement, involvement, and action at
multiple levels, pointing out that these levels are interdependent, and all are neces-
sary to achieve impact. Their engagement can lead to, and is a prerequisite for, the
exercise of leadership at these different levels. The initial discussion in Chapter 1
also highlights the importance of taking collaborative approaches, involving those
affected by an issue in addressing the issues that affect them, and reducing dispari-
ties in racial/ethnic minority and low-income communities through “robust and
long-term community engagement and civic participation among these disadvan-
taged populations.” In addition, the chapter deals with the issue of responsibility,
which is an important component of leadership, suggesting a new way to view
personal responsibility—as a collective responsibility of the public and private sec-
tors, and all those involved in each sector, to act to improve physical activity and
nutrition environments. Chapter 3 includes some insights from systems thinking
into new ways in which leaders can be identified or act, including the concepts of
“facilitative leadership,” which is “not necessarily located at any particular level
or organization and is likely to encourage bottom-up solutions and activities”;
“local creativity,” which involves “mechanisms for local people to design locally
relevant activities and solutions” and not “rigid requirements for activities
imposed from outside the area”; and the possibility of “the visibility of obesity as
an explicit policy goal or concern for nonhealth organizations. . . .”
A major premise that underlies all the points made above is that leadership in
the case of the committee’s systems approach to accelerating obesity prevention is
a shared responsibility across sectors and levels, and one that may not follow typi-
cal hierarchical or individual sector-based approaches. In the committee’s view, the
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problem of obesity is so complex and so embedded in Americans’ everyday lives,
culture, and physical environments that only integrated, systemic, cross-sector
approaches to the problem will succeed. The committee’s systems approach to
accelerating progress in obesity prevention calls on all individuals, organizations,
agencies, and sectors that do or can influence the environments that control physi-
cal activity and food consumption to assess and begin to act on their important
roles as leaders in prevention. Some traditional leaders may turn away from their
logical or designated roles in helping to solve this problem, but other organiza-
tions that have previously been concerned with obesity prevention may increase
their efforts or broaden the scope of their activities, and many other less likely,
unexpected, or less well-known candidates for leadership may step forward to
address issues in sectors where they are stakeholders or have influence. For exam-
ple, the broad articulation of the committee’s system of recommendations will sup-
port ongoing organizational activity by groups such as county-level Cooperative
Extension agencies that have nutrition expertise and strong community ties, while
also encouraging many more leaders to identify themselves as important and will-
ing actors, such as local banks that invest in community development or small
businesses and faith-based organizations that provide services to their communi-
ties and congregations.
I MPLEMENTATION
Leaders who are identified and called upon by this report to act and who seek
to carry out their designated roles, or leaders who self-identify—whether a group
of mothers of young children concerned about the foods available in their com-
munity or an environmental specialist who sees the connections between her work
on clean air and the importance of making physical activity a routine part of life—
will share the moment of saying to themselves, “I can do something about this,
and I want to play a role.” From that point on, thinking about their role with a
systems lens can guide their actions in new directions. They may consider various
sectors, recommendations, strategies, and actions and find themselves on the sys-
tems “map” (as presented in Appendix B), figuratively or literally. However, they
will act with new foresight—examining how what they plan to do will intersect
with other actions that may be taken or are being taken already in various sectors.
They will examine actions by others, in their critical area or in the other four
critical areas that are part of the whole system, that will help accelerate what they
are attempting to accomplish. They may also see potential actions by others that,
if taken, could advance them more rapidly toward their goals. This in turn may
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lead them not only to implement actions they have already identified, but also to
encourage others, sometimes in different sectors, to act in new ways that support
their own efforts.
In addition, these leaders may identify ongoing actions that work against what
they are attempting to accomplish. This may lead them to change their strategies
or work toward removal of the barriers in their or other sectors. They will also
want to make sure that what they are planning to do does not have any obvious
adverse consequences, and if there are additional positive consequences (side ben-
efits) of what they are attempting, they will want to let others know about them
in order to enlist additional support within or across sectors.
Finally, these leaders will want to examine their efforts over time with an eye
to what others in their or other sectors are doing as it relates to their goals and
how things may be changing overall. They also may want to communicate their
actions, goals, and views to others who are working in their or other sectors to
implement related changes. Examination of current or potential actions of others
within the system and the development of creative, coordinated intra- or cross-
sector relationships can lead to more effective efforts and greater opportunities
for success. Some leaders, because of their roles, capacities, and broader influence,
will choose to focus on an examination of what is happening in the whole system,
within and across sectors and critical areas, and will act to understand and influ-
ence changes throughout the system.
PRIORITIES
Implicit in the preceding discussion of leadership and implementation is the
assumption that individual leaders will determine which recommendations, strate-
gies, and potential actions are their priorities or that those who choose to follow
their lead will play a major role in determining these priorities. These leaders will
likely start from where they have the most influence and likelihood of success, a
decision that will result from a unique assessment of a range of variables. This
follows naturally from the committee’s systems perspective and definition and
identification of leaders as described above, and from its approach to selecting rec-
ommendations, strategies, and potential actions as laid out in Chapter 4. The com-
mittee selected five major recommendations among hundreds of possibilities, with
associated strategies and potential actions, for accelerating obesity prevention in the
next decade. These are the committee’s priorities for action. Beyond that prioritiza-
tion, the committee did not go further, as it saw the implementation (or continuing
implementation) of the entire system of recommendations, to the greatest extent
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possible, as the overarching priority. The committee did not give priority to any
action or set of actions above any others, but rather envisioned leaders within sec-
tors, and others, stepping up to implement different aspects of the system.
THE PUBLIC HEALTH CRISIS AS MOTIVATOR AND CATALYST
FOR IMPLEMENTATION
This report describes the public health crisis of obesity in stark terms. It points
out that almost one-third of children and two-thirds of adults in the United States
are overweight or obese. In certain demographic groups, rates reach even higher
levels. There are devastating health and social consequences for individuals—the
great potential for illness, disability, and early death; social ostracism; discrimination
in employment and income; depression; and an overall poor quality of life for many
millions. Some estimate that one-third of all children born today (and one-half of
Latino and black children) will develop type 2 diabetes in their lifetime, and that
obesity may lead to a generation with a shorter life span than that of their parents.
As this report points out, the estimated cost of obesity-related illness based on
data from the Medical Expenditure Panel Survey for 2000-2005 is $190.2 billion
annually (in 2005 dollars), which represents 20.6 percent of annual health care
spending in the United States (Cawley and Meyerhoefer, 2011). The U.S. economy
already struggles today to cope with health care spending; this struggle will grow
progressively more difficult as today’s obese children mature.
Because of its views on leadership in accelerating obesity prevention, where
that leadership resides, and how it is identified, the committee does not name or
recommend one agent, leader, or “commission” to catalyze or lead the implemen-
tation of its system of recommendations for obesity prevention. Rather, it sees
potential for many leaders across sectors and levels, from individuals working for
improvements in physical activity at home and in their communities to federal
agencies acting to prevent the negative effects of marketing on children’s risk of
obesity. The committee sees the primary catalyst for activation of its system of
recommendations as a heightened awareness of the potential catastrophic conse-
quences of the high rates of obesity in the United States for quality of life and the
national budget, and a common understanding of the critical role that must be
played by individuals in every sector and at every level.
The committee also sees the issue of funding the numerous changes that may
be involved in implementing its recommendations as related to its concepts of moti-
vator and catalyst and to the potential consequences for funding of taking a sys-
tems perspective. Experience in the politics of democracy shows that if an issue is
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truly understood as potentially catastrophic by citizens and their leaders, calls and
support for change will emerge, and resources to engage in the battle will become
more available. In addition, leaders will emerge at many levels, and their existing
assets often will be brought into action or redeployed for new actions. Taking a
systems perspective can help identify and open up new resources for funding from
unexpected sources, and new assets that can support the cost of change can be dis-
covered that would not otherwise be apparent. In addition, actions within a system
can lead to alliances with individuals and sectors engaged in efforts that contribute
significantly to obesity prevention but whose focus is related to another aspect of
health or some other social outcome. The resources that can flow from these alli-
ances have the potential to sustain obesity prevention efforts.
ASSESSMENT OF PROGRESS
Once implemented, the recommendations, strategies, and actions proposed
in this report will be even more useful if they are evaluated to determine their
individual and collective impact. While the recommendations included herein are
based on the best evidence available to the committee as it prepared this report,
new evidence will emerge and new evaluation research will be needed to fully
examine the impact of the committee’s individual and collective recommendations.
However, such research will not happen without a sustained commitment on the
part of decision makers to providing the resources necessary to support the work
of monitoring the extent to which progress in obesity prevention is truly accelerat-
ing, as well as the impact of individual recommendations and the system of rec-
ommendations included in this report.
Using the framework developed in Chapter 4, the committee identified over-
arching (or system-level) indicators that focus on tracking progress toward reduc-
ing the incidence and prevalence of obesity and overweight in the United States.
These indicators are intended for use in evaluating progress toward the adoption
of the full system of strategies and actions described in Chapters 5 through 9.
The committee also identified a foundational indicator focused on the broader
dynamics of accelerating progress in obesity prevention, encompassing actions far-
ther upstream from obesity prevention that are important for the successful imple-
mentation of all the recommended strategies and actions.
Notably, throughout the process of identifying indicators of progress, it
became apparent to the committee that in many cases, national data sources do
not yet exist for many of the proposed indicators. This is clearly an area of need
going forward. More work is required to develop systems with which to monitor
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progress on the recommendations and strategies included in this report. Clearly
not all of the systems for monitoring progress will be based on federally funded
data sources. Rather, the committee envisions the need for a partnership among
federal agencies, state agencies, foundation sources, and commercial sources,
among others, to develop the systems necessary to monitor progress on the imple-
mentation of the committee’s recommendations.
Indicators for Assessing Progress in Obesity
Prevention with a Systems Perspective
Overarching Indicators
• Reduction in the proportion of adults who are obese.
Source for measurement: NHANES
• Reduction in the proportion of adults who are overweight.
Source for measurement: NHANES
• Reduction in the proportion of children and adolescents who are considered
obese.
Source for measurement: NHANES
• Reduction in the proportion of children and adolescents who are considered
overweight.
Source for measurement: NHANES
• Increase in the proportion of young children (aged 2-5) that are of normal
weight status.
Source for measurement: PNSS
• Increase in the proportion of adults who meet current federal physical activ-
ity guidelines.
Source for measurement: NHIS
• Increase in the proportion of children and adolescents who meet current
federal physical activity guidelines.
Sources for measurement: YRBS, NYPAANS (for adolescents); source needed
to measure proportion of children who meet current federal Physical Activity
Guidelines
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Foundational Indicator
• Increase in engagement, communication, and leadership among all sectors
to increase the development, implementation, and coordination of common
messages, processes, and strategies.
Source needed for measurement of indicator.
NOTE: NHANES = National Health and Nutrition Examination Survey; NHIS =
National Health Interview Survey; NYPAANS = National Youth Physical Activity
and Nutrition Survey; PNSS = Pediatric Nutrition Surveillance System; YRBS =
Youth Risk Behavior Survey.
LOOKING TO THE FUTURE: MOVING TO THE NEXT LEVEL OF
SYSTEMS ANALYSIS
As noted throughout the report and in Appendix B, a systems perspective con-
sistently guided the committee’s work, from the development of its vision to the
formulation of recommendations, strategies, and actions with the greatest poten-
tial to accelerate progress in obesity prevention. However, a systems approach
can provide additional opportunities for research and decision making. The com-
mittee’s use of a systems perspective in viewing solutions to preventing obesity
presents an important opportunity to create a research framework that takes
this approach into account. This section offers a short discussion of quantitative
systems-science methodologies that can be used to further test and refine the com-
mittee’s system of recommendations and in turn improve future decision making
on this dynamic, complex problem. As described in Chapter 4 (and presented in
further detail in Appendix B), the committee’s systems map serves many purposes,
providing important information both to the committee and to readers of this
report. In addition, it could in the future serve as a platform for the construction
of more quantitative dynamic models. This type of dynamic systems model would
enable the conduct of policy simulations exploring the impact over time of a sys-
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tem of recommended strategies and the impact of the five critical areas in which
action is needed on each other and on key outcomes of interest. Systems mapping
often is an important prerequisite for construction of such a quantitative model by
researchers.
Complex problems, such as obesity, typically have been approached using
correlation-based analytic methods (e.g., regression). These methods are useful for
identifying linear relationships, but are limited because of their inability to estab-
lish and test a web of interrelated causal relationships. While correlation-based
analytic methods can be valuable in providing detailed information about various
aspects of a problem, used alone they can be insufficient for understanding prob-
lems that are driven by interaction among a large number of factors. Moreover,
these conventional methods give limited insight into the mechanisms that underlie
observed relationships (Auchincloss and Diez-Roux, 2008; NIH, 2011b).
Systems-science quantitative methodologies enable investigators to examine
the dynamic interrelationships among variables at multiple levels of analysis (e.g.,
from individuals to society) simultaneously, often taking into account causal feed-
back processes among variables while also studying impacts on the behavior of
the system as a whole over time (Midgely, 2003). Such models that utilize data
(real or simulated) can incorporate knowledge about individual decision making
and biological effects as well as broader flows of information or distributions of
effect between factors to take into account the complex “real world” of interest
(Hammond, 2009). Systems-science quantitative modeling can even yield policy
and scientific insights when a randomized experiment is impractical, expensive, or
unethical. Examples of systems-science methodologies and their uses are provided
in Box 10-1.
Many systems modeling methods are not new and indeed are now used rou-
tinely in such fields as corporate management, economics, engineering, physics,
energy, ecology, and biology precisely because these methods add value relative to
alternative techniques or unaided decision making (NIH, 2011b). As appreciation
for the complexity of many problems in the public health sphere has grown, there
have recently been a number of calls to use systems science to examine public
health problems (Homer and Hirsch, 2006; Leischow et al., 2008; Mabry et al.,
2010; Madon et al., 2007; Milstein et al., 2007), including obesity in particular
(Auchincloss and Diez-Roux, 2008; Hammond, 2009; Huang and Glass, 2008;
NIH, 2011a).
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BOX 10-1
Examples of Systems-Science Methodologies and
Their Uses
Specific examples of systems-science methodologies include
• systems dynamics modeling (Homer and Hirsch, 2006; Sterman, 2006);
• agent-based modeling (Axelrod, 2006; Epstein, 2006; Miller and Page,
2007);
• discrete event simulation (Banks et al., 2010);
• network analysis (Scott, 2000; Wasserman and Faust, 1994);
• dynamic microsimulation modeling (Mitton et al., 2000); and
• Markov modeling (Sonnenberg and Beck, 1993).
These techniques, among others, are particularly well suited for
• understanding connections between a system’s structure and its behavior
over time;
• anticipating a range of plausible futures based on explicit scenarios for
action or inaction in certain areas;
• identifying unintended or counterintuitive consequences of interventions;
• evaluating both the short- and long-term effects of policy options; and
• guiding investments in new research or data collection to address critical
information needs.
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REFERENCES
Auchincloss, A. H., and A. V. Diez-Roux. 2008. A new tool for epidemiology: The use-
fulness of dynamic-agent models in understanding place effects on health. American
Journal of Epidemiology 168(1):1-8.
Axelrod, R. 2006. Agent-based modeling as a bridge between disciplines. In Handbook
of computational economics. Vol. 2, edited by L. Tesfatsion and K. L. Judd.
Amsterdam (NL): North-Holland. Pp. 1565-1584.
Banks, J., J. S. Carson II, B. L. Nelson, and D. M. Nicol. 2010. Discrete-event system
simulation. 5th ed. Upper Saddle River, NJ: Pearson Prentice Hall.
Cawley, J., and C. Meyerhoefer. 2011. The medical care costs of obesity: An instrumental
variables approach. Journal of Health Economics 31(1):219-230.
Epstein, J. M. 2006. Remarks on the foundations of agent-based generative social sci-
ence. In Handbook of computational economics. Vol. 2, edited by L. Tesfatsion and
K. L. Judd. Amsterdam (NL): North-Holland. Pp. 1585-1604.
Hammond, R. A. 2009. Complex systems modeling for obesity research. Preventing
Chronic Disease 6(3):A97.
Homer, J. B., and G. B. Hirsch. 2006. System dynamics modeling for public health:
Background and opportunities. American Journal of Public Health 96(3):452-458.
Huang, T. T., and T. A. Glass. 2008. Transforming research strategies for under-
standing and preventing obesity. Journal of the American Medical Association
300(15):1811-1813.
Leischow, S. J., A. Best, W. M. Trochim, P. I. Clark, R. S. Gallagher, S. E. Marcus, and
E. Matthews. 2008. Systems thinking to improve the public’s health. American
Journal of Preventive Medicine 35(Suppl. 2):S196-S203.
Mabry, P. L., S. E. Marcus, P. I. Clark, S. J. Leischow, and D. Mendez. 2010. Systems
science: A revolution in public health policy research. American Journal of Public
Health 100(7):1161-1163.
Madon, T., K. J. Hofman, L. Kupfer, and R. I. Glass. 2007. Public health.
Implementation science. Science 318(5857):1728-1729.
Midgely, G. 2003. Systems thinking: Critical systems thinking and systemic perspectives
on ethics, power and pluralism. Vol. 4. Thousand Oaks, CA: Sage Publications.
Miller, J. H., and S. E. Page. 2007. Complex adaptive systems: An introduction to
computational models of social life. Princeton, NJ: Princeton University Press.
Milstein, B., A. Jones, J. B. Homer, D. Murphy, J. Essien, and D. Seville. 2007.
Charting plausible futures for diabetes prevalence in the United States: A role for
system dynamics simulation modeling. Preventing Chronic Disease 4(3):A52.
Mitton, L., H. Sutherland, and M. J. Weeks. 2000. Microsimulation modelling for
policy analysis: Challenges and innovations. New York: Cambridge University
Press.
391
Answering Questions about Leadership, Prioritization, and Assessment
OCR for page 392
NIH (National Institutes of Health). 2011a. Strategic plan for NIH obesity research:
A report of the NIH Obesity Research Task Force. NIH publication no. 11-5493.
Washington, DC: U.S. Department of Health and Human Services.
NIH. 2011b. Systems science. http://obssr.od.nih.gov/scientific_areas/methodology/
systems_science/index.aspx (accessed November 18, 2011).
Scott, J. 2000. Social network analysis: A handbook. 2nd ed. London: Sage
Publications.
Sonnenberg, F. A., and J. R. Beck. 1993. Markov models in medical decision making: A
practical guide. Medical Decision Making 13(4):322-338.
Sterman, J. D. 2006. Learning from evidence in a complex world. American Journal of
Public Health 96(3):505-514.
Wasserman, S., and K. Faust. 1994. Social network analysis: Methods and applications
New York: Cambridge University Press.
Accelerating Progress in Obesity Prevention
392
