William (Bill) Dietz, director of the Sumner M. Redstone Global Center on Prevention and Wellness at George Washington University’s Milken Institute School of Public Health, moderated a wide-ranging discussion with three of the leading figures in identifying and responding to the obesity epidemic in the United States: David Satcher, founding director and senior advisor to the Satcher Health Leadership Institute at the Morehouse School of Medicine, and 16th surgeon general and 10th assistant secretary for health of the United States; Jeffrey Koplan, vice president for global
health at Emory University and former director, Centers for Disease Control and Prevention (CDC); and Vice Admiral Vivek Murthy, 19th surgeon general. The topics they discussed included the labeling of obesity as an epidemic, the social determinants of health, comparisons with antismoking campaigns, and how momentum for dealing with a complex and difficult problem can be maintained. In their presentations, these speakers laid the groundwork for the discussions of specific settings and policy issues later in the workshop.
In response to a question from Dietz, Koplan noted that in the 1990s, the people who most noticed obesity in the United States were visitors from other countries. “You couldn’t travel anywhere without people saying to you, ‘What’s going on in your country?’” Then, in 1999, the Journal of the American Medical Association (JAMA) devoted an entire issue to obesity, including an article by Koplan and his colleagues that called attention to the spread of obesity during the previous decade (Mokdad et al., 1999). “I give JAMA and the American Medical Association a lot of credit, because they recognized the subject as important, and important in a long-range way,” said Koplan.
The article was the subject of some pushback as to whether it was appropriate to label the increase in obesity an epidemic, recalled Koplan. That reaction was “good for the cause,” he said, “because it permitted public health people and epidemiologists to say, ‘You’re damn right it’s an epidemic, and here’s why.’ It was an effective kickoff to introducing this to the press as a subject of interest and, of course, to professionals and the public as a subject of more than passing interest.”
In 2001 the Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity was released, offering recommendations for families, communities, schools, health care, media and communications, work sites, and the federal government (HHS, 2001). Satcher explained that it was the first call to action released during his time as surgeon general, and it was a relatively brief report. “We felt that if you’re dealing with an epidemic,” he said, “you’ve got to figure out a way to get people’s attention, and you’ve got to figure out a way to get people to act. And so we didn’t waste a lot of pages on discussing and explaining but got right to the point to say, ‘This is what we need to do.’” The report introduced the acronym CARE: C for communication, A for action, R for research, and E for evaluation. “We hoped that . . . we would motivate actions in all of those settings,” said Satcher.
Satcher cited what has happened in schools as the most important action since the release of the report. When he left government, he helped
found Action for Healthy Kids,1 a public–private partnership of more than 75 organizations dedicated to promoting health in schools. As he explained, “Our argument was that there were some kids who didn’t have safe places to play in their communities; they were not from homes where their parents understood the importance of nutrition or had access to good nutrition. But we felt that the schools should be the great equalizers in the sense that, at school, every child should have an opportunity to experience good nutrition and physical activity.” Although this vision has not yet been fully realized, he said, “we have made a lot of progress in the schools, . . . and we need to keep that going.”
In 2005, an Institute of Medicine committee chaired by Koplan released the report Preventing Childhood Obesity: Health in the Balance (IOM, 2005), which was followed up in 2007 by the report Progress in Preventing Childhood Obesity: How Do We Measure Up? (IOM, 2007). Koplan subsequently became chair of the Institute of Medicine Standing Committee on Childhood Obesity (the forerunner of the Roundtable on Obesity Solutions). These and other reports produced up to the present day have recommended multiple elements that work together: “a range of different players approaching this, a range of different approaches, multiple actions in a given community—even while we’re still determining which of them work better and how they work in concert with each other,” said Koplan. In addition, he reported that over the past decade foundations and other funders have been devoting large sums of money and energy to the issue. The Robert Wood Johnson Foundation, for example, initially dedicated $500 million to obesity prevention and treatment and then renewed that initiative. At the same time, Koplan continued, key voluntary health organizations in the country have made obesity a top priority, as have individual communities and states. These efforts still need to be better coordinated, measured, and evaluated, he said, “but we have some potential best practices out there, and we have enumerable examples from cities and some states.”
Satcher cited as one of the most influential experiences he has had since leaving government working with the World Health Organization’s Commission on Social Determinants of Health. The 24 commissioners traveled all over the world, and everywhere they beheld how “the social determinants of health stood out in terms of the impact that they were having on health and health outcomes.” Concentrating on the social determinants
of health “is where we’re going to make the greatest difference,” Satcher asserted.
The commission’s final report emphasized that changing the social determinants of health will require changes in policy (CSDH, 2008). Schools and communities are particularly promising targets of such changes, Satcher suggested. He gave the example of the City of Louisville, which changed zoning laws to expand access to fresh fruits and vegetables. Similarly, he said “we can never justify having a situation in which every child doesn’t have access to a safe place to be physically active.” He cited a report produced by Action for Healthy Kids demonstrating that children who are active and well nourished learn better and are more prepared for school (Action for Healthy Kids, 2004). According to Satcher, if schools were aware of this finding, they would be less likely to cut funding and time for physical education. “We still haven’t [reached] the point where all schools value physical activity and good nutrition, but we’re moving in the right direction,” he said. Additional scientific research on this and other contributors to the obesity epidemic, he added, could foster needed policy changes.
Murthy said that when he became surgeon general he wanted two values—prevention and health equity—to drive everything his office did. But he quickly realized that discussions of health equity can make people uncomfortable. Such conversations, he said, “force us to confront the fact that people who are like us and who deserve the same opportunity to lead a healthy life are not afforded that opportunity.” He gave the analogy of a family in which two of three children have access to healthy food, physical activity, and health care, while the third child does not. No family would shower all of its love and resources on two children while neglecting a third, he argued, “but we don’t do that with societal inequities, because we don’t necessarily feel that sense of the family and community.” Overcoming that lack of connection requires rebuilding a sense of community, he argued, so that people empathize with what others are experiencing and have a vested interest in the outcomes and well-being of others. The United States has “the potential for diversity and understanding but too often ends up segregated and excluded,” he asserted, with entire groups of people being siloed in separate parts of towns and invisible to other groups. “If we want equity to be a focus,” he said, “we have to recognize that equity is not just a policy priority; it’s a value that reflects who we are as a country. For that reason, it has to be a part of how we evaluate our success. It has to be a part of how we train our medical and public health professionals. It has to be a part of what we track in terms of the research that we do when we’re evaluating whether programs work or don’t work.”
What was once seen as a U.S. problem is now a worldwide problem, Koplan observed. Some of the highest rates of obesity in preteen boys are in Italy and in Greece, he noted, and such countries as England and
Germany have widespread adult obesity. He argued that this represents an opportunity for the United States to learn from other countries. Scotland, for example, has placed a heavy emphasis on social determinants in its health policies, he observed. It has sought to provide safe, attractive, and accessible places for people to be physically active, he continued, and housing, transportation, and schools are incorporated in the country’s health program in a seamless way. “We’re going to need to go in that direction,” he said, even if it requires seeking to reverse the loss of a sense of mutual responsibility and community in the United States.
According to Murthy, “We spend a lot of money on health care in this country, but we don’t invest a lot of it in health promotion and disease prevention.” Furthermore, he noted, funding that affects public health is segregated into sectors, such as transportation, housing, public health, and health care. But the sectors need to work together, he argued, to build healthy communities, and without more flexible funding, the issue of who pays for the initial up-front investment will always be contentious. Recently, he explained, the Centers for Medicare & Medicaid Services has been funding demonstration projects aimed at moving toward a model of community-wide prevention funding, while accountable care organizations have been moving away from fee-for-service payment models to paying for desired health outcomes. “We’re going to need to change overall our funding in communities and tie funding to collaboration if we want a multisector approach that addresses the social determinants of health,” Murthy argued.
During the discussion session, Shiriki Kumanyika, research professor for community health and prevention at Drexel University and founder and chair of the African American Collaborative Obesity Research Network, raised the issue of unintended consequences of implementing public health interventions. She referred to evaluations finding that certain interventions could widen disparities by exacerbating issues in low-income communities. She hypothesized that restrictions on marketing of food could fall into that category. When public health measures force an unhealthy product from an affluent community, for example, it may remain or become even more widely promoted in less advantaged communities, especially where the product is still popular and affordable, and disparities could increase as a result. Koplan added that the same thing happens internationally, with unhealthy products moving to other countries or toxic chemicals being produced and stored abroad. “There is a pattern in multiple areas of public health in which items that are toxic, either by ingestion or by exposure or by addiction, get shifted onto vulnerable communities,” he said.
Melissa Clark, director for population health at the National Human Genome Research Center, suggested that the scope of data on disparities in obesity should go beyond race and ethnicity. Many factors affect the health of population groups, she asserted, such as maternal and paternal nutri-
tion, access to supermarkets, and safe neighborhoods. Presenting statistics in terms of race and ethnicity can be instructive, she said, but can mask other social determinants of obesity. She argued that presenting statistics in terms of such indicators as poverty, access to groceries, and zip codes could provide much more useful information than that gleaned from ethnic and racial categorizations.
The panelists drew several parallels between efforts to combat obesity and tobacco control, in which considerable progress has been made over the last half century, observed Koplan, often driven by reports from surgeon generals. However, tobacco control is a more direct problem than obesity prevention and treatment, he pointed out. The toxic effects of tobacco are widely accepted, he noted, and commercial sources of tobacco are readily identifiable, whereas the commercial products that contribute to obesity are more benign in normal doses. “I’m not apologizing for all things that are ingested,” he said, but “it’s a much more complex issue to deal with.”
Nevertheless, Koplan asserted, the tobacco control campaign demonstrates how much is possible. A few decades ago, he said, the idea that people would not be able to smoke in the workplace was inconceivable, as was the idea that taxes could be much greater than the cost of making cigarettes. These steps were labeled “wishful thinking,” he observed, yet since then they have been implemented, and he credited them with helping to cut the rate of smoking in the United States in half. People have to “demonstrate the stamina to get with [the fight against obesity] and stick with it, and it has to take place no matter what political party is in power, no matter what else is going on,” he said. “Tobacco has done that and has done it successfully. . . . We have to employ a similar level of energy.”
According to Satcher, the tobacco campaign also demonstrated how the promotion of healthful models can cause best practices to spread. In 1990, for example, California was the first state to establish a comprehensive statewide tobacco control program, which included banning smoking in public places (Office of Smoking and Health, 2001). Between 1988 and 1997, the state saw a decrease in lung cancer incidence among women, while other regions experienced an increase, a finding Satcher worked to disseminate widely. Today many states and cities have outlawed smoking in public places. “We need to do a better job of highlighting successful models if we’re going to make real progress,” Satcher asserted.
Murthy drew a contrast with the tobacco campaign, warning against “picking a bad guy” and “saying this person is responsible for everything” with regard to obesity. For example, he said, while the practices of the food and beverage industry could be better, businesses have stepped up to
improve health through the Partnership for a Healthier America and other endeavors. Also, he suggested, part of the effort to shift the products and services offered includes working to shift demand as well as supply. However, he argued that efforts to increase demand for more healthful foods must be paired with lowering prices because “[healthful options] are far out of reach for far too many people.”
Koplan observed that stigmatizing people who are overweight or obese is not acceptable, but as with tobacco, “there also is a problem in normalizing it.” “There has to be an interplay,” he said, “where people are compassionate and understand that this is a health problem, not a cosmetic or aesthetic issue . . . and it has to be something that we work to diminish.”
Murthy has been a leader in the effort to promote physical activity, particularly walking. Step It Up!: The Surgeon General’s Call to Action to Promote Walking and Walkable Communities (HHS, 2015) was released in September 2015. In traveling around the country as surgeon general, Murthy has heard that time for physical activity is disappearing from schools and that communities today have fewer places for children to play than in the past.
“We live in a world that often believes that complex problems can only be met with complex, expensive solutions,” Murthy said. “[But] every now and then there are some simple elements that can be part of the solution that are accessible for people to take, and walking happens to be one of them.” He pointed out that an average of just 22 minutes of brisk activity, when performed consistently, can lower a person’s risk of diabetes by 30 percent while also lowering the risk of cardiovascular disease and sudden death (HHS, 2015). “I guarantee you that if I created a taken-once-daily medication that lowered your risk of diabetes by 30 percent, I would probably do quite well,” he said. “But people are used to the idea of taking pills to improve their health and less necessarily inclined to believe that lifestyle change is worth the investment.”
In many communities, “the ability to step outside our door and take a walk after dinner is often not that easy,” Murthy pointed out, noting that in neighborhoods that are not safe, people can risk being the victims of crime if they go for a walk. He therefore has been calling attention to the structural factors that impact walking. His office has been working with city planners, local elected officials, and others to help them understand that making communities walkable is “a very powerful public health intervention.”
Koplan also advocated for policy changes that promote physical activity in communities and that are tied to funding. He suggested creating a
range of incentives to promote physical activity, citing the example of creating incentives for developers to build or renovate sidewalks. He argued that such measures can have benefits down the road. “When that gets done, housing values go up; it benefits the builders; it benefits the community as a whole; it benefits the tax base. Doing the right thing can also sometimes play into economic growth and enhancement of other areas of life.”
Incentives are the critical factor, agreed Satcher. He gave the example of major businesses that had created incentives for employees to quit smoking and saw tobacco use among their employees fall dramatically. But in addition to incentives, he called for investments in what he identified as the leading social determinants of health—education, income, and safety.
As an example of an incentive, Murthy cited a walking competition among the clinicians at Brigham and Women’s Hospital in Boston. People initially said they would never have the time to compete, but soon they were finding time to take 20,000 to 30,000 steps per day. Because the incentives were aligned with the culture of the hospital, people incorporated walking into their everyday life. For example, physicians would meet for walks rather than coffee. “The idea of taking a walk with somebody and conversing is a subtle but powerful shift,” Murthy observed. “It’s part of the cultural change that can drive behavior change.” Similarly, Koplan said, physically active video games and other activities done in front of screens may not be perfect, but they can allow physical activity to take place.
Finally, Eduardo Sanchez, deputy chief medical officer for the American Heart Association, raised the issue of loose dogs, which in many ways act as a proxy for the lack of safety that can deter people from walking. Citing the city of Dallas as an example, he noted that, in some neighborhoods, loose dogs act as a powerful force against walking, reducing not only physical activity but also social cohesion.
The challenge for obesity prevention and treatment, Koplan argued, is to maintain momentum with a problem that took time to develop, has many contributing factors with uncertain and interacting effects, strikes disadvantaged groups the most, and will take time to solve. Murthy agreed, noting that people can tire of being reminded about the obesity epidemic. Their response can be, “We know it’s a problem, but stop trying to take my chips away.” Three things are necessary if people are to sustain their efforts in an epidemic, he continued: they need to believe that the issue is directly relevant to them; they need to see evidence of progress; and they need to have a sense of clear agency, “that there are things they can do in their day-to-day lives that will make an impact.” All three of these things were present in the tobacco campaign, he argued. With the sense of agency,
for example, “at the very basic level, you could choose to quit. At another level, you could talk to family members you love about quitting. At yet another level, if you’re a local elected official, you could think about passing clean indoor air laws and know that that would have an impact on the health of your community.” So as Koplan had suggested, the challenge with obesity is that it is an epidemic with multiple causes that will not have a quick fix. Rather, Murthy asserted, it will require a long-term commitment and engagement of the public.
Government warns people about many threats—such as the Zika virus, obesity, and prescription opioids—“and sometimes, with all of that, people can feel overwhelmed, and they tune out,” said Murthy. One approach is to engage people in communities to help change the environment, which is “a powerful avenue through which we can impact the choices that people make,” he suggested. Changing the environment is not always easy, he acknowledged, and families may be busy and short of resources, including time. Changing the environment also often requires having difficult conversations with people who do not want to change. But Murthy has been encouraged by seeing what is possible, and he cited the example of a group of mothers who succeeded in removing advertising for unhealthy foods from the schools their children attended. “They didn’t necessarily have a lot of money; they didn’t have a whole lot of training; they were not public health experts,” he said. “These were grassroots mothers who care deeply about their kids, and that was actually their most powerful asset.” People often underestimate how much change is possible, he observed. “If we can help them see examples of progress, and help them learn from other communities how to make their voices heard, that could be incredibly powerful.”
Murthy continued by pointing out that people have a hunger to learn from others. “If I go to Birmingham and they know I was in Chicago the day before,” he noted, “they’ll often say, ‘We know that Chicago has had problems with obesity. What are they doing about it? Can we learn something from them?’” Great things are happening at the grassroots level, he observed. The challenge is to connect communities so they can learn from each other; to provide advocates with the resources they need to make their work collaborative and sustainable; and to enable them to see their progress, giving them a sense of hope.
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