Speakers in the workshop’s final session reflected on progress to date in addressing the obesity pandemic and discussed the lessons for obesity prevention and treatment efforts in the United States, especially with respect to reducing disparities. Bill Dietz, chair of the Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University, moderated the session. He mentioned that the workshop planning committee thought it important for this session to revisit physical activity, and for it to include representatives from organizations that fund prevention and treatment efforts.
James Sallis, distinguished professor emeritus of family medicine and public health at the University of California, San Diego, and professorial fellow at the Australian Catholic University, Melbourne, described global lessons for physical activity promotion in the United States. He began with a brief overview of disparities in prevalence, environments, and policies with respect to physical activity in the United States, displaying data on the differences among four ethnic groups in walking for transportation and leisure (see Figure 5-1). Few differences exist in walking for transport,
he remarked, but there are bigger differences in walking for leisure, with particularly lower levels among African Americans and Latinos. “Those are the disparities to pay attention to,” he urged.
Sallis declared that disparities in the “activity friendliness” of U.S. environments are location-specific. “It’s not one pattern across the country; it depends on where you are in the country,” he explained. He stressed that it is essential to have local data to understand disparities in the quality of environments in a particular city. There may also be disparities in policy implementation, he added, citing a study of differences in the implementation of federally funded bicycle and pedestrian projects. The study found that counties in the United States with persistent poverty or low educational status were less likely to obtain funding for or to implement such projects (Cradock et al., 2009).
Next, Sallis shared a series of international examples of physical activity initiatives that he said could “inspire and instruct us.” He provided examples for each of the four strategic objectives in the World Health Organization (WHO) Global Action Plan on Physical Activity.
Sallis first described ciclovias, “open street” practices aimed at creating active societies by closing miles of roads to cars and letting people take over the streets. Ciclovias were implemented in Bogotá, Colombia, for equity purposes, he explained, so that lower-income residents without cars could take advantage of the streets. This practice has become integrated into the culture in parts of Latin America, he observed, but in the United States is more limited in scope and frequency. “It’s not a part of our culture,” he observed. “It’s a special event that nobody pays much attention to.”
Next Sallis mentioned Brazil’s “academias de saude,” or “health academies,” which facilitate and encourage physical activity in public spaces. “In my mind,” he said, “that is creating a more active society, where everybody sees everybody else being active.” However, he added, organized physical activity in public spaces is “something that we don’t do very well here,” and he called attention to a journal supplement focused on reports and evaluations of those efforts in other countries (Giles-Corti et al., 2017).
Turning to the strategy of creating active environments, Sallis reported that Spain has banned cars from some city centers. “For me, this is paradise,” he quoted a resident of one of these cities saying in a newspaper headline. He encouraged making cities more bikable, noting that while 50 percent of all trips in the United States are bikable distances (up to 4 to 5 miles), the actual bike share of trips in cities is only 1 percent. He pointed to major cities around the world that have increased their bike share of trips through multilevel, multicomponent interventions over time (Pucher et al., 2010).
In the realm of creating active people, Sallis praised an enduring Canadian physical activity promotion initiative that began in 1971, called “ParticipACTION.” Through a media campaign and public–private part-
nerships to promote its messages, he reported, its aim to change social norms about physical activity has coincided with Canada being one of the few countries with a trend of increasing physical activity. He also mentioned Agita Mundo, a Latin American initiative to “massively mobilize” people to become active, as well as Finland’s requirement for 2 hours per day of physical activity in schools—“and they do better academically,” he noted about the latter.
Sallis then pointed to the Thai Health Promotion Foundation as a sustainably funded example of creating active systems, explaining that it collects taxes on alcohol and tobacco to fund initiatives that promote healthy behaviors. As a second example, he cited South Africa’s Bicycle Empowerment Network, which aims to alleviate poverty through promotion of bicycle use for commuting to jobs. According to data he shared from a recent study, lower-income households can save a considerable proportion of disposable income if they do not own cars and opt to use more active transport methods (Rachele et al., 2018).
Sallis closed by emphasizing that there are many good strategies for promoting physical activity around the world. He suggested that many of these strategies could be adapted, implemented, and evaluated in the United States given the necessary funding and political will for policy change.
According to Neena Prasad, director of the global obesity prevention and maternal and reproductive health program at Bloomberg Philanthropies, her organization works with leading advocacy and research organizations to raise awareness of obesity and to identify, implement, and evaluate effective obesity prevention policies in six low- and middle-income countries: Barbados, Brazil, Colombia, Jamaica, Mexico, and South Africa. Bloomberg Philanthropies is also supporting the evaluation of marketing and front-of-package labeling policies in Chile and sugary beverage taxes in some U.S. cities through an Evaluation Fund, she added.
Prasad explained that the organization pursues national policy change in four priority areas—fiscal measures, marketing restrictions, front-of-package warning labels, and healthier schools—to improve food environments so that healthier options are the default. She added that these four priorities were chosen in consultation with leading scholars and are revisited regularly, although they have remained relatively consistent over the past 6 years. According to Prasad, the organization’s largest investment is in tobacco control, and it is applying lessons from that arena to obesity prevention. “It’s not a perfect parallel,” she said, “but there are important similarities.”
Bloomberg Philanthropies supports policy change by funding advocacy, mass media, and research activities, Prasad continued, and then evaluates
policy implementation. To explain why the organization takes a regulatory approach, she contrasted rates of progress toward reducing consumption of sugary beverages for voluntary industry-coordinated initiatives and regulatory initiatives (Keybridge, 2018; Public Health England, 2018). The regulatory initiatives made a bigger impact in a shorter period of time, she reported. She emphasized her organization’s commitment to evidence-based policy advocacy and shared examples of research that supports policy initiatives, such as modeling of the impact of a sugary beverage tax on diabetes and cardiovascular disease.
A large proportion of Bloomberg Philanthropies’ resources goes toward public awareness campaigns, Prasad continued, which are usually coupled with policy campaigns. Based on the experience with tobacco control, she elaborated, “we tend to go for hard-hitting graphic campaigns.” She shared an awareness-raising video that aired in conjunction with a sugary beverage tax campaign, reporting that pre- and posttesting indicated a positive impact on viewers’ understanding of the causes and consequences of consuming sugary beverages, as well as their expectations of what their governments should be doing to protect them in this regard. Prasad asserted that grassroots activity and public buy-in are important because “often when policy makers know the public is on their side, they are more willing to take those risks” to support a policy campaign. In addition, she stressed, keeping an issue in the news and maintaining its sense of urgency creates and softens the ground for policy action.
Prasad went on to discuss Bloomberg Philanthropies’ support for coalition-building activities, highlighting coalitions in South Africa, Brazil, and Mexico that she said have engaged numerous diverse, credible organizations to advocate for shared interests. If policy is instituted, she added, the organization supports evaluation postimplementation to assess its impact (e.g., Colchero et al., 2016, 2017; Guerrero-Lopez et al., 2017; Silver et al., 2017). She noted that after Mexico adopted a sugary drink tax in 2014, a number of other countries followed suit. “We are optimistic that this is soon going to become a public health norm,” she said.
To wrap up, Prasad underscored that Bloomberg Philanthropies wants to accelerate the growth of the evidence base for “what works” in obesity prevention. She stated that the organization wants to achieve the implementation of diverse policies in its six focus countries, evaluate the early impact of policies in both its focus and nonfocus countries, and construct the beginnings of a policy package that any country can begin to adopt.
The World Bank focuses on obesity as an economic issue, said Meera Shekar, global lead for nutrition with the World Bank’s health, nutrition,
and population global practice. She warned that it is only a matter of time before obesity overwhelms the health sector and the economy in countries across the globe, pointing out that the problem affects low-, middle-, and high-income countries. She also explained that as a country’s per capita income increases, the burden of overweight and obesity shifts to the poor. Echoing the workshop’s earlier discussion about the double burden (see Chapter 2), she noted that mapping a country’s overweight and obesity alongside stunting helps determine which strategies to pursue.
Shekar briefly mentioned nine country case studies of health promotion strategies and policies that the World Bank is reviewing to determine scalability in different conditions. These include fiscal and regulatory policies, she said, as well as education, media, and transportation strategies and traditional nutrition interventions. She then highlighted key milestones in global action on obesity and previewed a number of forthcoming reports. However, many reports on noncommunicable diseases fail to focus on overweight and obesity, and “that’s something I think we might try and fix,” she noted.
The World Bank has invested considerable funding in efforts to address undernutrition, Shekar continued, but while awareness of the obesity problem is increasing, concrete action at scale in this area remains elusive. She suggested that while the World Bank contributes money, what is more useful is its power to convene high-level national leaders and decision makers, as well as ministries of finance, and reach them with messages and evidence. In addition, she maintained, mobilizing domestic resources is critical to change the financing landscape for any of these issues.
Shekar then turned to the World Bank’s new Human Capital Project, which, she said, will accelerate more and better investments in people globally. She characterized this as a major shift from the World Bank’s reputation as a “hard infrastructure bank.” The project, she explained, will include a Human Capital Index to make the case for investment in the human capital of the next generation, focusing on health and education; improve measurement and provide analysis to support investments in human capital formation; and support early adopters, and ultimately all countries, in preparing national strategies that accelerate progress on human capital.
In closing, Shekar shared three ways for the World Bank to support obesity prevention and control efforts: maximize the potential of its multisectoral engagement (with the health, agriculture, transport, and fiscal sectors, for example); scale up promising policies and interventions; and leverage the range of World Bank instruments at all levels. At the global level, she elaborated, this might include advocating for the incorporation of obesity efforts into universal health care and poverty reduction efforts; at the country level, it might entail the use of policy instruments such as development policy operations. The latter initiatives come into play,
she explained, when the World Bank enters into an agreement to release resources to a government if the country implements designated policies. Lastly, Shekar reiterated that there are many lessons to be learned from the tobacco control movement—particularly its taxation strategy—and highlighted building broad alliances.
Reflecting on the day’s presentations, session moderator Bill Dietz applauded what he called a rich series of talks that had covered many topics and themes. He made a number of observations:
- Trends in obesity prevalence are parallel for men and women and for developed and developing countries, suggesting that the exposures that led to obesity were simultaneously distributed across the population.
- Health systems will be challenged by obesity and an ensuing wave of diabetes.
- As they face rapid urbanization, low-income countries may need to advocate for preservation of their activity-promoting built environments.
- It is important to be aware that some cultures have social norms that value obesity or at least do not consider it a problem.
- The globalization of the U.S. food supply has contributed to the obesity epidemic, and it was suggested that the health sector continue to establish trust with the food industry if a positive difference in the healthfulness of the food supply is to be made. According to the workshop’s presentations, it appears that a lack of trust between the two sectors is a bigger problem in Latin America than in the United States.
- It will not be possible to confront the racial and ethnic disparities in the development of obesity without confronting the inequities that lead to these disparities. Just as the consequences of adverse childhood experiences may not be fully expressed until adulthood, the consequences of these inequities may not manifest as disparities in obesity prevalence until later in life.
To conclude, Dietz maintained that sustainability is integral to the workshop’s discussions, given the relationship between the agricultural production and distribution system and the emission of greenhouse gases, for example. He challenged participants to consider sustainability in light of the interrelationships among undernutrition, obesity, and climate change. He cited a decision-making practice of the Iroquois Confederacy, a group
of several Native American tribes that controlled the northwest corner of the United States when the Europeans arrived. They considered how their decisions would affect people seven generations into the future, he said, and asked, “How do we ensure that our decisions are going to preserve the planet, planetary health, and the health of the population for the seventh generation?”
During the final discussion period, workshop participants considered the viability of fiscal strategies for helping to prevent and control obesity and the importance of evaluation.
Speakers touched on challenges and opportunities with respect to fiscal strategies for helping to address the obesity pandemic, such as taxes on unhealthy foods and financial incentives for healthy behaviors. Prasad said that although taxation is considered an effective strategy for tobacco control, her group has found discussion of earmarking of tax revenues for this purpose to be an unproductive conversation with ministries of finance. She pointed to promotion funds, such as the example from Thailand shared by Sallis, as another fiscal idea, one that is promising from a public health perspective. Shekar agreed that fiscal strategies can be promoted in conversations with ministries of finance, but urged the development of alternative, innovative financing sources. On that note, Sallis raised the idea of financial incentives for healthy behaviors such as walking or bicycling. He also suggested that health benefits could be realized if transportation budgets were reduced, quoting an economist from the Asian Development Bank who said that the cost to construct one freeway flyover could instead be used to build 800 miles of protected bike lanes. That would “revolutionize any city in this country, and one flyover would not be missed,” Sallis claimed.
The Importance of Evaluation
Rigorous evaluation of programs and “natural experiments” such as policy change, attendees observed, are critical to understanding a theory’s practical effectiveness and can help determine whether further investment in a particular strategy is worthwhile. One participant suggested that there may be surprises about the causal pathways for obesity, and Shekar reiterated that building evaluation into large-scale programming is critical. Prasad concurred and advocated for taking action based on the best available evidence rather than waiting to act. It is inevitable that there will be
some mistakes, she conceded, but “we can’t afford to wait to understand every aspect of this before we act.” Sallis agreed and added that the available evidence may not be definitive, but it is good fodder for hypotheses that could be tested. He questioned whether there have been enough interventions of sufficient magnitude to effect lasting change, and asserted, “The more I look into this, the more I see that we need to stimulate bold action, and then evaluate it.”
Bill Purcell concluded the workshop by stating that the Roundtable on Obesity Solutions will continue to explore the topic of global obesity and the implications for prevention and treatment efforts in the United States: “This is a conversation that we have been waiting to start for some time,” he said, and “I think . . . we’re at the beginning of that conversation.”
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