The May 2009 workshop brought together policy makers, advocates, researchers, program staff, and others seeking to understand how community environments affect the prevalence of obesity and to develop community-based policies and programs built on this understanding. The Institute of Medicine (IOM) staff and planning committee organized the workshop around three interrelated panels: the first comprised representatives of community-based programs who discussed the information they need to move ahead; the second involved staff of research and advocacy organizations that provide a link between communities and policy makers; and the third consisted of decision makers who explained how community perspectives affect policies in their jurisdictions. After each series of presentations, the audience was invited to ask questions and make comments. These discussions reflected the broad background of attendees, including urban planners, nutritionists, activists, and researchers. (See Appendix A for the workshop agenda, Appendix B for biographies of the planning committee, IOM staff, and the presenters, and Appendix C for a complete list of the workshop attendees.)
Approaches that involve a wide range of partners—including neighborhood groups, government agencies with a range of missions, and businesses—characterize many of the promising efforts discussed throughout the workshop sessions. As many speakers noted, a paradigm shift that recognizes the role of the community environment in obesity prevention is
emerging, but is far from universally accepted. Other common messages that emerged during the day were highlighted in the workshop’s closing remarks and are summarized below:
The diversity of community efforts represents both a strength and a drawback. It sparks innovation and empowers people to work toward their own better health. However, this diversity also complicates efforts to measure impact and build the strongest possible evidence base. The field must grapple with this dichotomy to achieve the ultimate outcomes of improved health and a reduction in obesity rates.
Obesity-related policy must occur “in all places” to form a long-term movement toward better health. The development of comprehensive frameworks for community efforts to create healthy environments is under way. The need persists to educate, convince, and inform key players and decision makers in other sectors that health and health policy are their allies in changing the shape of community environments for the better.
Communication is key to this work. Communication is needed to develop a common understanding of obesity prevention and to articulate the shift from individual interventions to environmental change in combating the obesity epidemic. Differences in expectations and professional paradigms can lead to a breakdown in communication. Dialogue on how different sectors view evidence, for example, can help bridge these divides. The importance of communication also relates to how best to present research and other evidence to draw the attention of policy makers.
The question remains whether a set of data should be collected consistently across communities. Some divergence of opinion arose about the use of body mass index (BMI) data in community-based interventions, yet no recommendation for an alternative has emerged. Another issue voiced by several speakers is whether assembling the entire chain of evidence—from environmental interventions, to changes in food and physical activity behaviors, to changes in BMI—is necessary for every intervention. Moreover, many community residents have expressed that they do not want to serve constantly as the subject of research studies that lead to no visible improvement.
Community knowledge is an essential building block in reducing childhood obesity. Community knowledge is the cultural context. Local information about the population and knowledge about what programs are more likely to work or have been shown to work help form and set policy priorities for communities and dif-
ferent contexts, from soccer fields in Santa Ana to green carts in New York City. Ongoing engagement of neighborhoods and residents strengthens leadership and power within communities, which in turn helps create and sustain change.
COMMUNITY VOICES AND EVIDENCE
As Marion Standish, Director of Healthy Environments for the California Endowment, observed in her opening remarks, community experience is part of the overall effort to understand what does and does not work, and how well it works, in combating obesity. Despite the power of community experience, researchers and policy experts have found it difficult, according to Standish, “to articulate the ‘hows’ and ‘whys’ of that experience and how it should inform and influence our work.” The Endowment supported this workshop, she said, to detail community experiences and better use those experiences to inform policy and research and build a body of evidence.
“Often we think we have a good policy. It passes, but it doesn’t work in a community. The value of community eyes and community voices … is an immeasurable asset in the work that we do.”
Loel Solomon, National Director of Community Health Initiatives and Evaluation for Kaiser Permanente, reminded workshop participants and audience members of the statement of Goethe often cited in IOM publications: “Knowing is not enough; we must apply. Willing is not enough; we must do.” Those words, he said, set the stage for the workshop. Credible evidence is essential, but “what we really are about,” he said, “is changing our environments, changing our communities so people are healthier.” He described a complementary IOM study cofunded by Kaiser Permanente to develop a framework for how evidence on obesity prevention is developed and translated into action (A Framework for Decision-Making for Obesity Prevention: Integrating Action with Evidence). Planning for that study affirmed that end users’ perspectives are vital because the social context for decision making is larger than the development of credible evidence. Solomon described a challenge presented to the steering committee for the framework to “reinvent” the abbreviation RCT (which traditionally stands for “randomized controlled trial”), with R standing for “relevant,” C for “communicate,” and T for “timely.” These three attributes, as much as the rigor of a study’s design, are what communities and policy makers take into account in their obesity prevention efforts.
As demonstrated in projects funded by The California Endowment, The Robert Wood Johnson Foundation, Kaiser Permanente, and others,
evidence does play a role at key junctures in community change processes. In planning, evidence is used to determine what has worked elsewhere. It improves programs as they are under way, and can be a vital tool for influencing policy change and decision makers. At the same time, however, Solomon stressed the importance of recognizing that different audiences and different kinds of decisions require different levels of evidence.
For instance, community groups find useful many tools that do not adhere to accepted cross-experimental design; an example is PhotoVoice, in which community members document their experience and viewpoints through photography. In contrast, the Congressional Budget Office is debating the kinds of evidence it needs to generate what have been termed “scorable savings” for prevention. As highlighted in the workshop, policy makers draw on different levels of evidence depending on the issue under consideration and the myriad of other issues competing for resources and attention. Solomon urged the IOM, as well as workshop participants, to play a role in determining what constitutes evidence to support change.
“It is really important for us to hold to the fact that different audiences and different kinds of decisions require different levels of evidence.”
This report follows the organization of the workshop. Chapter 5 summarizes the presentations of community-based representatives and the discussion that followed. Chapters 6 and 7 highlight the presentations of nonprofit organizations and policy makers and ensuing discussions, respectively. Chapter 8 summarizes the closing remarks of representatives of two foundations that have supported many community-level programs. It should be noted that consensus recommendations were not sought during the course of the workshop, and thus are not presented in this report.