Cross-Sector Responses to Obesity: Models for Change: Workshop Summary (2015)

1

Introduction¹

Obesity affects 17 percent of children and adolescents and almost 36 percent of adults in the United States. Conservative estimates suggest that obesity now accounts for almost 20 percent of national health care spending (IOM, 2012). Until the obesity epidemic is reversed, obesity will continue to drive rates of chronic diseases such as heart disease, stroke, type 2 diabetes, and certain types of cancer (IOM, 2012).

For more than a decade, the Institute of Medicine (IOM) has made a major commitment to obesity prevention. This commitment has led to 10 consensus reports offering policy recommendations; more than a dozen workshop publications; and approximately 50 other briefs, action guides, infographics, and publications in this area.

In 2014, the IOM created the Roundtable on Obesity Solutions to engage leadership from multiple sectors in responding to the obesity crisis. Through meetings, public workshops, background papers, and other activities, the roundtable fosters an ongoing dialogue on critical and emerging issues in obesity prevention and treatment and weight maintenance while enhancing and accelerating the discussion, development, and implementation of solutions.

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¹The planning committee’s role was limited to planning the workshop. This workshop summary was prepared by the rapporteur as a factual account of what occurred at the workshop (see Appendix A for the workshop agenda). Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Institute of Medicine. They should not be construed as reflecting any group consensus.

In its first workshop, which was held in January 2014 and is summarized in The Current State of Obesity Solutions in the United States: Workshop Summary (IOM, 2014), the roundtable examined initiatives in seven areas that could contribute to obesity prevention:

• early care and education,
• schools,
• worksites,
• health care institutions,
• communities and states,
• the federal government, and
• businesses and industry.

In its second workshop, which was held on September 30, 2014, and is summarized in the present report, the roundtable explored ways in which these and other sectors can work together to achieve more progress than would be possible with any sector working on its own. (Box 1-1 lists the goals of the workshop.) Many sectors have recognized the need for action, and successful examples of cross-sector collaborations exist. Yet a number of barriers must be overcome before such cross-sector initiatives can be scaled up and replicated. Continued efforts to partner and develop shared goals and initiatives across sectors are key to the prevention and control of obesity. The composition of the roundtable’s membership, which comprises representatives from public health, health care, government, the food industry, education, philanthropy, the nonprofit sector, and academia, makes it an ideal venue in which to discuss such collaboration.

THE NEED FOR CROSS-SECTOR APPROACHES

Making progress on a major problem such as obesity requires scalable and sustainable solutions that reach a large proportion of the population over a long period of time, said Nico Pronk, chair of the planning committee for the workshop and vice president for health management and chief science officer at HealthPartners, Inc., in his opening remarks at the workshop. Large-scale, transformative approaches focused on multilevel and interconnected environmental and policy changes are needed, Pronk continued. In particular, changes are required in many of the environments in which people interact, including schools, the messaging environment, the environment that influences physical activity, the food and beverage industry, and the health care and work environments. Furthermore, because these environments are affected by activities that occur simultaneously across multiple sectors, an explicit focus on cross-sector work is essential.

“What do we mean by sector or cross-sector work?” Pronk asked. A sector can be many different things: an industry or market sharing common characteristics, a distinct part or branch of a nation’s economy or society, a sphere of activity such as education, or an area of the economy in which businesses share the same or related products or services. These various definitions of the word “sector” must be considered in any cross-sector approach to preventing obesity, said Pronk.

Regardless of how they are defined, sectors are distinct from each other, but they are “very much interdependent when the objective is to produce something meaningful,” Pronk said. For this reason, cross-sector work calls for going beyond normal partnering or day-to-day transactional behaviors and connecting with institutions, disciplines, and bodies of knowledge in new ways. Forging these new connections in turn requires recognizing shared goals, shared ownership, shared decision making, shared burdens, and shared rewards. “This joining together will allow for synergies that move us beyond what any person or group can accomplish alone,” said Pronk.

Pronk suggested that the intentional pursuit of collaborative approaches built on mutual respect and trust leads to solutions that last. Joint planning, the pooling of resources, the evaluation of outcomes across sectors, and other collaborative actions can take account of and recognize separate mandates and responsibilities while enabling collaboration toward a common goal. In some cases, this cross-sector work involves alliances of seemingly disparate nonprofit or government organizations that share the common goal of obesity prevention. In other cases, cross-sector work is more informal but still enables the leveraging of disparate strengths to achieve mutual benefits. Whatever the arrangement, Pronk observed, “shared ownership,

transparency in decision making, mutual respect and trust, and an authenticity in purpose and process are important attributes of such approaches.”

ORGANIZATION OF THE WORKSHOP AND THIS SUMMARY

The workshop began by addressing four cross-cutting issues important to cross-sector work and then turned to a series of five case studies representing cross-sector collaboratives at different levels of organization—regional and tribal, county, state, and national. The workshop structure is depicted in Figure 1-1.

As illustrated in Figure 1-1, the workshop planning committee identified the following four cross-cutting issues important to cross-sector work that formed the basis for the first four presentations at the workshop²:

• health equity,
• sustainability,
• leadership, and
• measurement.

Health equity ensures that all communities are free from unnecessary, unjust, unfair, and avoidable differences in their health. If obesity prevention programs are to reduce the obesity burden equitably across the population, targeted solutions for those who experience the greatest obesity prevalence will be necessary in order to close existing gaps (IOM, 2013a). Today, communities of color and communities with low incomes are likely to have a higher prevalence of obesity than communities that are predominantly white or more affluent (IOM, 2013a). Chapter 2 addresses the importance of considering health inequities in the context of obesity and of designing cross-sector collaborations that lead to greater health equity.

Sustainability entails recognizing that obesity solutions need a vision if they are to have long-term impact. Grant-funded projects generally work well to identify promising practices, but these projects tend to be difficult to standardize and scale up to reach a population over prolonged periods of time. Chapter 3 looks at the importance of long-term financing strategies for cross-sector collaboratives and considers ways of ensuring that these efforts are supported adequately.

Leadership is critical both at the organizational level, to provide the vision required for progress, and at the local level, to enable implementa-

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²In addition to Nico Pronk from HealthPartners, Inc., the members of the planning committee for the workshop were Debbie Chang from Nemours, David Fukuzawa from The Kresge Foundation, Lisel Loy from the Bipartisan Policy Center, Amelie Ramirez from Salud America!, and Sylvia Rowe from SR Strategy, LLC.

FIGURE 1-1 The workshop examined initiatives at the regional and tribal, county, state, and national levels through the prism of four cross-cutting issues.
SOURCE: Pronk, 2014. Reprinted with permission.

tion of the actions required to realize that vision. Chapter 4 examines how leaders can be identified and engaged, the role established leaders can play in mobilizing and leveraging resources, and leadership structures necessary to engage stakeholders and empower people with authenticity and respect while building trust.

Measurement involves recognizing successes or understanding when intended outcomes are not being achieved. The IOM report Evaluating Obesity Prevention Efforts: A Plan for Measuring Progress describes the need to evaluate obesity prevention efforts appropriately, calls for the use of evaluation to inform and improve decision making, urges that tested interventions be identified and used, and recommends broad dissemination of the most promising approaches (IOM, 2013b). Chapter 5 explores evaluation and measurement of multisector efforts.

The discussions that followed the presentations on health equity, sustainability, leadership, and measurement were incorporated into Chapters 2–5, respectively, to enhance understanding of each of these cross-cutting issues and its importance to cross-sector work. In addition to these four cross-cutting issues, the planning committee identified the following five case studies representing cross-sector collaboratives at different levels of organization:

• the National Prevention Council,
• a statewide strategy for battling child obesity in Delaware,
• Cook County PLACE MATTERS (Chicago),
• PowerUp St. Croix Valley, and
• Sault Ste. Marie Tribe of Chippewa Indians.

In the second half of the workshop, panels of presenters described the barriers and challenges encountered and the lessons learned in establishing these initiatives.

In the sessions devoted to each of these case studies, panelists were asked to address how the four cross-cutting issues of health equity, sustainability, leadership, and measurement were reflected in the missions of these initiatives. They also considered several additional questions: What may be needed to accelerate movement forward in that cross-sector initiative? What are the core features or elements of the initiative that are necessary for scale-up and diffusion? What features need to remain flexible to allow for local adaptation? Chapters 6–10 summarize these panel presentations. A final chapter reports on the wide-ranging discussion that followed the presentation of the case studies. Appendixes B–F provide additional detail on each case study, submitted by the presenters prior to the workshop, posted online, and made available to the workshop participants. These appendixes provide the following information, presented through the lens of health equity, sustainability, leadership, and measurement:

• a description of the cross-sector model used,
• sectors included in the initiative,
• lessons learned from the initiative,
• barriers to establishing the initiative,
• what is needed to accelerate movement forward in the initiative’s cross-sector work,
• the core features or elements of the initiative that are necessary for scale-up and diffusion, and
• the features that need to remain flexible to allow for local adaptation.

REFLECTIONS OF THE WORKSHOP DISCUSSIONS

During the final session of the workshop, three individuals provided their perspectives on some of the messages that emerged from the presentations and discussions. These observations should not be seen as the recommendations or conclusions of the workshop participants as a whole, but they are presented here as reflections of the discussions that took place throughout the workshop.

• Work on obesity solutions will continue to occur within individual sectors, observed Russell Pate of the University of South Carolina. But expanded cross-sector approaches have the potential to deliver both dose and reach, which in turn can be more effective at decreasing obesity rates.
• Successful models of such approaches exist, as demonstrated by the programs discussed at the workshop. According to Pate, however, they need to be sustainable, which requires not just private support but also the backing of governmental policy, legislation, and funding.
• Although successful models exist, a unifying and compelling narrative around equity, obesity prevention, or health has not yet been developed, said Marion Standish of The California Endowment. She emphasized that clarity of goals is critical in scaling up models, enlisting community engagement, and holding programs accountable.
• Successful models need to be disseminated to and implemented in communities across the country, Standish added. Successful implementation in turn requires community capacity and the development of local leaders.
• Measures of the return on investment from cross-sector work on obesity, especially within the context of the Patient Protection and Affordable Care Act, can generate further support for such efforts, Standish said.
• Openness and optimism are needed to work across sectors successfully, said Maha Tahiri of General Mills, Inc., along with sustained dedication to the work among all partners, a deep knowledge of the communities in which partner organizations are working, and a commitment to keeping “health equity first in mind in everything we design.”

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