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1
Background and Rationale
I
n 1995, Shiriki Kumanyika, now associate dean of health promotion
and disease prevention and professor of epidemiology at the University
of Pennsylvania Perelman School of Medicine, began reading a report
from the British Recreation Department about building a network of bicy-
cle paths in the United Kingdom. The rationale for the network was that
families needed to spend more time together. The report did not mention
obesity, but Kumanyika immediately realized that such a network would
have an incidental co-benefit for prevention of childhood obesity by getting
children to engage in more physical activity. Thus a public policy interven-
tion designed for one purpose could serve another.
This concept—that interventions not directly premised on health could
have the beneficial side effect of supporting obesity prevention—was the
motivation behind a workshop organized by a planning committee1 com-
posed of Kumanyika and four other members of the Institute of Medicine’s
Committee on Childhood Obesity Prevention. The workshop was funded
by the Robert Wood Johnson Foundation,2 which has a major commitment
to reversing the epidemic of childhood obesity by 2015. Held in Wash-
1 The planning committee’s role was limited to planning the workshop. This summary was
prepared by the workshop rapporteurs and Institute of Medicine (IOM) staff as a factual
summary of what occurred at the workshop. Statements, recommendations, and opinions
expressed are those of individual presenters and participants, and are not necessarily endorsed
or verified by the IOM or the National Research Council, and they should not be construed
as reflecting any group consensus.
2 For more information about the Robert Wood Johnson Foundation, see http://www.rwjf.
org/.
1
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2 ALLIANCES FOR OBESITY PREVENTION
ington, DC, on October 20, 2011, the workshop was titled Alliances for
Obesity Prevention: Finding Common Ground.
The organizers chose the title carefully, Kumanyika explained in her
opening remarks. The term “partnership” had been considered; however,
that term can be interpreted in many different ways and often is applied
to public-private partnerships, which were not the focus of the workshop.
The planning committee preferred the term “alliances” because it better
expressed the focus of the workshop—to explore potential relationships
involving seemingly disparate nonprofit or government organizations that
may have common ground relevant to obesity prevention. Core obesity
prevention groups (e.g., public health departments) are likely to form alli-
ances to the extent that they expect obesity prevention co-benefits to accrue
as another organization or sector pursues its primary, non-obesity-focused
goals. This allows both groups to leverage each other’s strengths to achieve
mutual benefits. Thus, alliances can form between organizations that have
different objectives but have identified issues of mutual interest on which
they can work together, even if only for a finite period of time, to achieve
a discrete goal.
The workshop had three objectives, as described in its statement of task
(see Appendix C):
• to hear from organizations, movements, and sectors with the
potential to be allies for obesity prevention, and to identify com-
mon ground and engender dialogue among them;
• to discuss whether and how to develop innovative alliances that
can synergize efforts and resources, accelerate progress, and sustain
efforts toward obesity prevention; and
• to learn from other initiatives that have benefited from forming
alliances to synergize efforts and resources and accelerate progress.
It should be noted that, given limitations of both time and scope, the work-
shop could not address all issues related to alliances for obesity prevention.
SOCIAL MOVEMENTS AND OBESITY PREVENTION
The chair of the workshop planning committee, Thomas Robinson,
Irving Schulman Endowed Professor in Child Health at the Stanford Uni-
versity School of Medicine, has worked extensively on alliances between
organizations to prevent childhood obesity, and he elaborated on the ratio-
nale for the workshop. Robinson also observed that strategies for the pre-
vention of obesity may encompass environmental-, policy-, interpersonal-,
or individual-level interventions. The ultimate pathway for all of these
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3
BACKGROUND AND RATIONALE
approaches is that they rely on changing behavior; if an intervention fails
to change behavior, it does not produce the desired effects.
Behavioral change depends on two types of motivation. One is motiva-
tion to adopt the new behavior and achieve a particular outcome, which
Robinson terms outcome motivation. The other is motivation to partici-
pate in the intervention itself, which Robinson calls process motivation
(Robinson, 2010a). The medical and public health communities tend to
focus on outcome motivation. They emphasize the risks of obesity, type 2
diabetes, hyperlipidemia, hypertension, cardiovascular disease, and can-
cer (Robinson, 2010a). “Those are the things that we try to persuade the
public or patients to pay attention to as motivators to change behavior,”
Robinson said.
However, research on motivation in children as well as in adults points
to an entirely different set of powerful motivating forces. These include
fun, choice, control, curiosity, challenge, cooperation, competition, social
interaction, sense of accomplishment, peer approval or disapproval, and
parental approval or disapproval. These factors, rather than the ultimate
outcome of the behavior, are more likely to predict whether a child or an
adult will persist at a task or participate in the process of behavioral change
(Lepper et al., 2008; Robinson and Borzekowski, 2006). None of these fac-
tors is specific to health. Robinson’s question, then, is whether an interven-
tion to change a health-related behavior needs to look, feel, sound, smell,
or taste like health education. Does the intervention need to have anything
to do with health, given that the things that motivate people to change their
behaviors often have little or nothing to do with outcomes?
These questions have led Robinson to examine what he calls “stealth
interventions.” Stealth does not imply deception or manipulation, he said.
Rather, the intervention has an effect on physical activity or diet but is
centered on a different aspect of motivation (Robinson, 2010a). In other
words, although the intervention may target changing obesity, the partici-
pant is not motivated by an outcome such as losing weight or being more
active but instead is focused on other motivating aspects of the process.
Nonetheless, physical activity or dietary changes are beneficial side effects
of the intervention.
The ideal situation is to target behaviors that are motivating in them-
selves. For example, Robinson and his colleagues have used ethnic dance to
work with pre-adolescent girls (Robinson et al., 2010). “Physical activity
and obesity never enter the lexicon,” he said. “It’s about the costumes, it’s
about the music, it’s about learning about your cultural heritage, it’s about
the importance of doing dances that your parents did when they were grow-
ing up in Mexico.” Another example involves overweight children on sports
teams. These children tend not to join sports teams, but they may be much
more likely to do so if they are joining a league that is just for overweight
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4 ALLIANCES FOR OBESITY PREVENTION
kids. The attractions that accompany team sports—teamwork, competition,
coaches, uniforms—are highly motivating, and weight loss can be an ancil-
lary benefit. Thus one study of team sports for overweight children found
that body mass index (BMI) declined in the intervention group compared
with a control group even when the controls received nutrition and health
education (Weintraub et al., 2008).
A prominent challenge is to produce effects of greater magnitude than
are currently observed with such stealth interventions. In a search for
motivations that cause more dramatic and sustained changes in behavior,
Robinson has focused on social and ideological movements (Robinson,
2010b), loosely defined as groups of people or organizations that focus
on specific common issues, often to effect change. The classic example
is religious movements, in which people with strong religious beliefs can
sustain behaviors that differ markedly from social norms. Other social and
ideological movements that could have an effect on obesity include
• environmental sustainability/climate change;
• food justice/urban agriculture;
• food safety;
• community safety, beautification, and traffic reduction;
• human rights/social justice;
• anti-globalization/nationalism;
• animal protection;
• anti-consumerism;
• violence and crime prevention;
• cause-related fundraising;
• energy independence; and
• national security/anti-terrorism.
As an example, Robinson cited the adolescent girls he sees in his pedi-
atric practice who are vegetarians, despite pressures from their parents or
communities. They are able to sustain these behaviors over time because of
their strong beliefs, which may be based on preventing animal cruelty or
protecting the environment.
Robinson also highlighted cause-related fundraising, which often has
an altruistic component. An example is Team in Training, through which
people raise money for the Leukemia & Lymphoma Society3 by training
to participate in half-marathons, 10-kilometer races, triathlons, and other
sporting events. “There are people who [can’t] walk around a track when
they start, who train over a series of months and end up being able to run
a half marathon,” Robinson observed.
3 For more information about the Leukemia & Lymphoma Society, see http://www.lls.org/.
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5
BACKGROUND AND RATIONALE
People have many reasons for joining a social movement. They may
make a rational choice in that they see the benefits of joining the movement
as greater than the risks. Joining a movement may help form or define an
identity, whether a self-identity, a social or collective identity, or a public
identity. People may be attracted by the possibilities for social interaction,
which provides social support and, especially for stigmatized groups, can
enhance feelings of efficacy and performance. Joining a social movement
may help people avoid personal failure by exchanging personal responsi-
bility for collective responsibility. Finally, emotional responses can be a
powerful motivator.
As an example of this last factor, Robinson described an experiment
he conducted at Stanford with a class called Food and Society. The course
covers agricultural policies, labor issues, consumerism, animal rights, ani-
mal welfare, environmental issues, and other topics related to food and
agriculture that are not necessarily directly related to nutrition and health.
When the eating behaviors of students who took this class were compared
with those of students who took classes on obesity or public health nutri-
tion, the former students were found to have changed their eating behaviors
significantly more than the latter students (Hekler et al., 2010).
Social movements have the potential to influence public policy through
the mobilization of families, governments, markets, and civil society,
Robinson observed. In turn, new norms, laws, or regulations can further
promote individual change, creating a self-reinforcing feedback loop of
change.
Piggybacking obesity prevention on existing social movements makes
it possible to leapfrog the difficult process of starting a social movement
from scratch, Robinson concluded. There are many examples of such move-
ments, as illustrated by the workshop presentations, and they are already
proving to be highly motivating to segments of the population (Robinson,
2010b). They have the potential to produce dramatic and sustained changes
in behavior, and these behavioral changes can be magnified through changes
in norms and public policy. Teaming with existing social movements can
create many new allies, resources, and strategies for the obesity prevention
movement.
ORGANIZATION OF THIS SUMMARY
Chapter 2 examines a particular alliance in more detail. Mission: Read-
iness4 is an initiative led by a group of retired military leaders to enhance
military preparedness by reducing obesity and increasing fitness among
potential recruits. This initiative has been part of an unexpected alliance,
4 For more information on Mission: Readiness, see http://www.missionreadiness.org/.
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6 ALLIANCES FOR OBESITY PREVENTION
several workshop participants noted, that can attract attention to and gen-
erate change for obesity prevention.
Chapters 3 and 4 summarize the presentations and subsequent discus-
sions of two panels. The first panel looked at groups and programs focused
on food and nutrition; the second looked at groups and programs focused
on physical activity and the built environment. Together, these two panels
represented a sizable list of potential allies in the effort to prevent childhood
obesity, and pointed toward a much larger list.
Chapter 5 examines the conditions necessary for alliances to form and
endure, while Chapter 6 describes some of the more practical aspects of
building and maintaining alliances.
Finally, Chapter 7 summarizes the closing observations about work-
shop themes made by a member of the Committee on Childhood Obesity
Prevention.
