Framework for Prevention and Perspectives on Addressing Health Disparities
DR. KUMANYIKA: Contrary to Dr. Koplan’s feelings about physical education, I loved physical education, but we had to wear green bloomers. Anybody here who is old enough knows what I mean. The rest of you, you are just lucky that you came along after the green bloomer phase.
It is nice to have a chance to give some perspectives on the report and to discuss where I think our challenges lie. These are challenges that are implied in the report and perhaps left open for the community to address as efforts to combat obesity in youth move forward. If we are going to realize the potential that is in this report, I see three challenges ahead of us.
My perspective is that we are in the honeymoon phase now. We have created a report that has made a lot of people happy. There have been some criticisms of it, but it is good to see people say, “Now we have the full story all together, and we are ready to go forward.” But there are going to be some challenges.
Dr. Koplan gave an excellent overview of our situation, so this will be a quick summary of what I think we have actually accomplished by creating the report. We emphasized in the report a population health perspective. We need a broad base of intervention in the population at large to succeed in stopping this epidemic. This is not a medical problem that is going to be solved by the doctors, and everybody else can forget about it. On the very first page of this report, the high-risk groups are mentioned, the ethnic minority populations: African Americans, Hispanics, Native Ameri-
cans, and children in low-income families. There are groups in the population that have more than their share of this problem, and any solution we implement has to especially address these populations.
After reading the report, many people have said, “We know all these things, but where do we start? How do we get our arms around a problem this big?” We offer an ecological model to not only interpret the problem, but to manage the complexity of the problem as well. We lay out the layers that are global or national in their influence on the obesity problem by influencing the environments in which choices are made about eating and physical activity. The ecological model can show how everything filters down and relates to the balance of energy at the base of the problem. What we have to ultimately affect in growing children is the balance of energy going in and energy going out.
We have offered the ecological model as a useful tool, and I think it really is helpful as a way of thinking about how it all fits together. We also included in the report the concept of social transformation, not social reform. We are not going to turn society upside down, but if this action plan on childhood obesity is going to succeed, it is going to both require and drive changes in social norms. In that sense, even though we talk about the solution playing out in the long term, we don’t back away from the idea that we are talking about social change. Again, we are not talking about a technical solution that can be kept in a box and that is going to flow out and spill over and affect everybody.
By analyzing the efforts made in the past to increase automotive safety, to recycle wastes, and control tobacco use, we learned that, indeed we can accomplish widespread changes and transformations.
We took an inclusive approach, which Dr. Koplan called a “collegial approach.” We avoided trying to determine who was to blame by spreading the responsibility for the problem and its solutions as widely as possible across society. Yes, there are some obvious players here, but all sectors of society contribute to the causes of obesity. So, we all have to be a part of the solution.
To show how you to go about thinking through these different environments in the ecological model, we use two levels.
There is the micro level, or micro environment, which encompasses the behavioral settings in which people actually make choices and live. Next, there are the macro environments, which control the micro environments. These include the physical, the economic, the policy or political, and the social or cultural environments.
This is from Boyd Swinburn1 and his colleagues in Australia and New Zealand, the ANGELO model, which is an analysis grid of influences and stands for an Analysis Grid for Environments Linked to Obesity. The idea helps us to organize the environmental influences is where the environment is affecting the problem of childhood obesity. The solutions, then, will be different depending on which environment you examine. If you put the problem in the physical environment, the solutions are going to be different from those found in the economic environment. Policy and political environments are different from social and cultural environments, which often can’t be changed directly but require changes in social norms.
In the micro environment, for example, the policy makers are the parents. There are lots of policies and rules in the home that affect how children eat and whether they are active. There are many examples in the report of how the different environmental factors become operational when you start thinking about where to intervene. And, of course, all the factors are related.
The ecological model is being used globally to help find where we have leverage or where the low-hanging fruit is. Is there something going on in one of these environments that we can use to influence the obesogenic environment?
As I said, there are three challenges I want to point out. The first one deals with private sector issues, and I put here a “committee of dreamers.” We have been criticized the most by health advocates and policy analysts, observers who think that we were naive
and too optimistic because we did not ask for regulatory solutions or because we did not try to force changes to happen tomorrow.
I like to think that if we were a committee of dreamers, we might also have been a committee of visionaries. We decided not to recommend new laws to force changes. We decided that the solutions have to be seen as win/win situations by a broad base in society, including the private sector. When you look at history, there was always a sector or sectors of industry that saw a profit in the changes that led to the healthier environment. That is why we laid out our recommendations in a more positive way. Time will tell if we were naive or visionary, and it is going to be incumbent upon us, we who think that this is a good plan, to make sure that the recommendations aren’t viewed as just something that bought a certain vested interest more time to avoid taking the steps they need to take.
The second challenge is the high-risk populations, and I think we need to apply this term both to the traditional minority populations and to the new immigrants arriving in this country. It is very clear that moving to this country is fattening for people. There is a report titled The Future of Our Children2 that shows that children of immigrants are heavier in succeeding generations and have the health problems that go along with obesity.
We have to think of the minority populations as they are now characterized as being at high risk. What are the factors that determine the excess risk? What is it about these factors? Is it quantitative factor? Do minority populations simply have more problems and fewer safe neighborhoods? Or are there qualitative differences in life in these communities that is driving the problem? These are important questions. But even if we think it is simply a higher-intensity version of the problem that we have in the mainstream community, the way that we go about changing it may be very different. For example, if you were in a low-income community and were finally able to afford fattening foods and beverages, you wouldn’t see the problem in the same way as somebody
Fuligni AJ, Christina C. Preparing Diverse Adolescents for the Transition to Adulthood. The Future of Our Children. 2004; 14(2):99–120. www.futureofchildren.org
who says that you are not supposed to have it. Or think of the low-income family that has been saving for three generations for a car or to find jobs in which the work was not physically intensive, the idea of running around in spandex or gym shorts exercising and to be healthy doesn’t make a much sense. We have to look at the different world views, the different life perspectives, that families in this communities might have.
The third challenge has to do with how the epidemic of childhood obesity is linked to the epidemic of adult obesity. I think we focused on children because the epidemic of childhood obesity was the only thing we could agree on where we would take action.
We have left latent this whole problem of obesity in adults. The questions that came to my mind were: Can we solve the problem in children without addressing the problem in adults? Or will our attempts to solve the problem in children inadvertently solve the problem in the adult population? One way or another, I think we have to have a plan for dealing with the obesity epidemic in the adult population at some point in the future. As I said, we are in the honeymoon phase.
It may be that the adult population will wake up and realize that this is going to affect their lives too, not just the children’s. There could be a backlash. I don’t think that we can assume that the adults who are targeted in all of these recommendations are going to not notice that their lives have to change too. We have to make sure we are ready for when that happens.
We talk about changing food programs, subsidies, reviewing subsidies, advertising, and building coalitions. Adults do all of these things. The recommendations are for children, but adults are in control of all of these things. Do we need an action plan for how to get adults to accept that doing this for children is something that is worth changing their own behavior?
What have we accomplished so far? If we ask this question jumping forward to 2010, I think the answer will depend on how well we meet these challenges in the area of the private sector, the high-risk populations, and the linked epidemics of children and adults. These are interrelated problems. Eighty percent of black women are overweight, and 50 percent are obese. Obesity is rising
faster in African American children than in the rest of the population.
So, in the very communities where we are talking about making a change in the children, the adults model the problem to an extreme degree, and their own behavior is going to have to be a part of the solution.
DR. KOPLAN: Thank you, Dr. Kumanyika. I think I would have enjoyed gym more if I had worn green bloomers.
Our next speaker, offering a slightly different perspective, is someone who has been active in the food industry for many years. He is currently the senior vice president for new growth platforms and chief innovation officer for PepsiCo. Brock Leach is responsible for identifying and developing new platforms for business growth beyond those already in PepsiCo’s operating units, and for building new capabilities to support innovative work in all divisions. He previously held the positions of president and CEO of Tropicana Products. He is a member of the national board of the YMCA and works for many children’s agencies in Florida. We are eager to hear him and glad he could join us.