Proceedings of a Workshop

Exploring Strategies for Sustainable Systems-Wide Changes to Reduce the Prevalence of Obesity

Proceedings of a Workshop—in Brief

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a virtual public workshop, Exploring Strategies for Sustainable Systems-Wide Changes to Reduce the Prevalence of Obesity, on April 8, 2021. The workshop, the first in a series of three workshops to explore this broad topic, provided a foundational introductory session for the series that covered the intersection of biased mental models, stigma, weight bias, structural racism, and effective health communications with obesity solutions. Additional sessions discussed the intersection of structural racism and obesity in the context of housing and education and the intersection of biased mental models, stigma, weight bias, and obesity in the context of workplace and health care settings.

Nicolaas (Nico) Pronk, president of HealthPartners Institute; chief science officer at HealthPartners, Inc.; and adjunct professor of social and behavioral sciences at the Harvard T.H. Chan School of Public Health, explained that the roundtable’s strategic planning efforts completed during 2020 helped it coalesce around a systems-oriented approach to better understand barriers and facilitators for implementing obesity solutions. He said these efforts culminated in the development of a causal systems map of obesity drivers and solutions, which forms a roadmap for action toward data-driven obesity solutions and innovative approaches. Pronk highlighted the roadmap’s three priority areas for action and solutions—structural racism and social justice, biased mental models and social norms, and effective health communications—and explained that these areas were identified primarily by using a framework developed by Donella Meadows that organizes potential places to intervene in a system by a taxonomy corresponding to the elements of a system from least to most effective.¹ He described that the framework depicts increasingly deeper leverage points in a system. Such leverage points are difficult to achieve, he admitted, but also represent increasing effectiveness to create systems-wide change.

This Proceedings of a Workshop—in Brief highlights the presentations and discussions that occurred at the workshop and is not intended to provide a comprehensive summary of information shared during the workshop.² It was prepared by the rapporteur as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual workshop participants and are not necessarily endorsed or verified by the Roundtable on Obesity Solutions or the National Academies, and they should not be construed as reflecting any group consensus.

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¹ Meadows, D. 1999. Leverage points: Places to intervene in a system. Hartland, VT: The Sustainability Institute.

² The workshop agenda, presentations, and other materials are available at https://www.nationalacademies.org/event/04-08-2021/exploring-strategies-for-sustainable-systems-wide-changes-to-reduce-the-prevalence-of-obesity-a-workshop-series--april-workshop (accessed June 17, 2021).

AN INTRODUCTION TO THE INTERSECTION OF BIASED MENTAL MODELS, STIGMA, WEIGHT BIAS, STRUCTURAL RACISM, AND EFFECTIVE HEALTH COMMUNICATIONS WITH OBESITY SOLUTIONS

The workshop’s first session featured speaker Camara Phyllis Jones, senior fellow at the Satcher Health Leadership Institute and the Cardiovascular Research Institute and adjunct associate professor at the Morehouse School of Medicine, who presented an allegory for understanding racism, discussed the adoption of a broader perspective for comprehending the obesity epidemic, described an analogy to illustrate levels of health intervention, and offered a perspective on commonalities between racism denial and the obesity epidemic.

Jones shared a story she developed to illustrate racism’s existence, based on an experience she had while eating in a restaurant as a first-year medical student. Noticing an “Open” sign hanging in the window, she realized that the sign was two-sided and read “Closed” to anyone on the opposite side, despite their desire to enter and eat. Jones proposed that racism structures “Open/Closed” signs in society, which she described as a “dual reality.” People inside the restaurant are potentially unaware that the opposite side of the sign has a different message, which she compared to the difficulty of recognizing a system of inequity among some whom she said the system privileges. Recognizing the existence of a two-sided sign (i.e., to name racism) is not scary but empowering, Jones maintained, and added that naming racism is essential but insufficient. She urged people to understand that racism is not only the sign creating a dual or multifaceted reality, but it is also a locked door that must be torn down.

Jones defined racism as

According to Jones, this definition of racism can be generalized to define any system of structured inequity. Many axes of inequity operate in society and intersect in individuals and communities, Jones observed, listing examples including age, gender, ethnicity, sexual orientation, disability status, and religion. These axes are risk markers for how opportunity is structured and value is assigned, she claimed, and some are also risk factors in the progression to poor health.⁴

Jones shifted to discuss obesity and weight perception, suggesting that the obesity epidemic has traditionally been characterized as a binary classification of individuals on either side of the body mass index cut point for obesity. She proposed that viewing the epidemic as a shift in population distributions of body mass would steer intervention strategies away from individual behavior-based tactics—where success depends on the perception of weight, motivation, and the availability of healthful resources—toward population-based strategies that modify the types of food and activity opportunities available in various settings, where success is influenced by leadership and political will.

Jones next described a cliff analogy to illustrate levels of health intervention. She listed strategies to prevent people from falling off the cliff and to care for them if they still fell—building a fence at the edge, installing safety nets halfway down the drop-off point, and stationing ambulances at the bottom—and compared these strategies to primary, secondary, and tertiary prevention, respectively. Better yet would be shifting people away from the cliff’s edge, she said, which she compared to addressing social determinants of health and the contexts of peoples’ lives that push or position them near the edge.

Jones acknowledged that the cliff analogy fails to address how health disparities arise. She offered three explanations: differences in the quality of care received in the health system; differences in access to preventive and curative health care services; and differences in life opportunities, exposures, and stresses that result in differences in underlying health status.^5,6,7 Exploring the drivers of these differences stimulates conversations about systems of power that can lead to differential circumstances, Jones explained, and described these systems as “social determinants of equity” (or inequity) or “systems of structured inequity.”

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³ Jones, C. P. 2003. Confronting institutionalized racism. Phylon 50(1–2):7–22.

⁴ Jones, C. P. 2014. Systems of power, axes of inequity: Parallels, intersections, braiding the strands. Medical Care 52(10 Suppl 3):S71–S75.

⁵ Phelan, J. C., B. G. Link, and P. Tehranifar. 2010. Social conditions as fundamental causes of health inequalities. Journal of Health and Social Behavior 51(Suppl):S28–S40.

⁶ Byrd, W. M., and L. A. Clayton. 2002. An American health dilemma: Race, medicine, and health care in the United States, 1900–2000. New York: Routledge.

⁷ IOM (Institute of Medicine). 2003. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press.

The three explanations for the existence of health disparities indicate that the cliff is three-dimensional, Jones pointed out, and that some of its areas might have slow or misdirected ambulances at the bottom and insufficient or missing fences or safety nets. These limitations, Jones continued, represent differences in access to and quality of care. At those parts of the cliff, she added, the population is usually pushed closer to the edge, which she likened to differences in opportunities and exposures. Because the cliff is three-dimensional, she cautioned that attempts to move people away from the cliff’s edge must avoid moving only some groups of people, which she said would worsen health disparities.

According to Jones, denying the existence of an uneven playing field and talking about diversity, equity, inclusion, cultural competence, disparities, and other similar terms without naming racism are different ways to deny its existence. She recapped what she perceives as four commonalities between racism denial and the obesity epidemic: (1) a narrow focus on individual attributes and behaviors that leads to (2) ignorance of systems and structures that contribute to the problem and therefore (3) the “invisibilizing” of solutions that would address those structures, leading to (4) indifference and inaction in the face of need.

THE INTERSECTION OF STRUCTURAL RACISM AND OBESITY

The workshop’s second session included two speakers who explored the intersection of structural racism and obesity, with a focus on housing and education.

Roland Thorpe, Jr., professor in the Department of Health, Behavior, and Society at Johns Hopkins University; deputy director of the Hopkins Center for Health Disparities Solutions and founding director of the center’s Program for Men’s Health Research; and co-director of Johns Hopkins University’s Alzheimer’s Disease Resource Center for Minority Aging Research, discussed the interplay of housing with structural racism and obesity.

Thorpe described three pathways through which housing discrimination operates and through which structural racism influences housing disparities. One pathway is physical housing conditions, such as lead in a home; a second is housing affordability and stability, the latter encompassing outcomes such as being behind on rent or mortgage payments, frequent moves, homelessness, eviction, foreclosure, displacement, and overcrowding; and a third is residential racial segregation, which Thorpe labeled a fundamental determinant of health.

Thorpe expounded on two pathways linking residential segregation to health: resource deprivation and risk exposure. Segregation creates differential access to health-supporting resources, he indicated, and greater exposure to environmental toxins (e.g., lead paint in a home) often exists in highly segregated areas, as does the targeted availability of hazardous products such as tobacco, alcohol, and illegal drugs. Highly segregated areas are typically characterized by concentrated poverty, he continued, which tends to lead to high crime, low-quality housing, and a stressful environment.

Racial segregation can lead to different environmental and social risk exposures, Thorpe continued, that exist in a long-standing system of structural racism. Other discriminatory practices perpetuate housing disparities, he added, such as redlining, whereby banks would systematically deny the low-interest loans created by the Home Owners’ Loan Act of 1933 to homeowners in certain areas of a city. These areas were designated on maps with red lines, he explained, and corresponded to the areas where large proportions of Black people lived.

Moving on to the potential influence of structural racism on diseases including obesity, Thorpe described a conceptual framework of pathways through which structurally vulnerable neighborhoods—those shaped by structural racism and more likely to be inhabited by people of color—may contribute to racial or ethnic inequities in SARS-CoV-2 exposure and COVID-19 morbidity and mortality.⁸ He listed the characteristics of such neighborhoods—including pollution, limited walkability, lower-quality housing stock, low access to nutritious foods, less accessible health care, and overpolicing and crime-related stress—and pointed out that those attributes are also potential contributors to obesity. During the COVID-19 pandemic, Thorpe went on, the same neighborhoods tended to have limited ability to socially distance amid crowded housing conditions, had fewer resources that were open and accessible, and had limited protective social environments.

The problems of structural racism, housing disparities, and obesity are at the systems level and are inextricably linked, Thorpe emphasized, but they can be addressed with new, different approaches. He offered four opportunities for achieving greater equity in health and health care of vulnerable populations, with an emphasis on improving housing disparities: improving housing affordability for people of color; providing people of color with not just living wages but thriving wages; investing in underresourced communities based on residents’ meaningfully solicited inputs

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⁸ Berkowitz, R. L., X. E. K. Michaels, and M. S. Mujahid. 2020. Structurally vulnerable neighbourhood environments and racial/ethnic COVID-19 inequities. Cities & Health.https://doi.org/10.1080/23748834.2020.1792069.

as to how best that may be accomplished; and forming cross-sector partnerships to facilitate health equity in housing and communities.

J. Alexander Navarro, assistant director of the University of Michigan Medical Center for the History of Medicine, sharing remarks that related to the previous presentation, discussed the connections among housing, institutionalized racism, and segregation in the U.S. education system. To understand inequality in education, he proposed that one must understand the role that courts of law have played in resegregating the country’s schools during the past 70 years. The role of court decisions is also important, he continued, in the context of spatial geography, residential patterns, and housing discrimination in the United States. He stated his belief that segregation in education is more accurately described by the phrase de jure rather than de facto, meaning it results from legal segregation in housing versus being an occurrence that exists in reality but lacks legal recognition.

Navarro reviewed a series of Supreme Court cases that he considers key influences on education in the United States. In Brown v. Board of Education (1954), the Court ruled de jure school segregation unconstitutional, he began, declaring that separate facilities are inherently unequal and therefore a violation of the Equal Protection Clause of the 14th Amendment. The Brown II (1955) ruling that school districts must desegregate “with all deliberate speed” placed responsibility for desegregation with local school boards, which Navarro said was problematic because it left room for school districts to resist desegregation.

Green v. County School Board of New Kent County (1968) was prompted by the Virginia county’s freedom of choice plan, he continued, under which students could submit paperwork to a state-run board to indicate their decision to attend the county’s traditionally white school or traditionally Black school. The freedom of choice plan was ruled ineffective for achieving integration; the Supreme Court also ruled that school boards have an affirmative duty to dismantle and eliminate racially unitary school systems.

Swann v. Charlotte-Mecklenburg Board of Education (1971) was a turning point, according to Navarro, because it granted district courts three powerful tools to influence school district policies: (1) use racial quotas as a starting point to develop integration plans, (2) redraw district lines as an interim corrective measure, and (3) mandate and enforce bussing plans to facilitate transportation of both Black and white students to opposite-race schools for integration purposes.

Navarro next pointed to San Antonio Independent School District v. Rodriguez (1973), which stemmed from Texas’s practice of deriving school district funding primarily from local property taxes. This resulted in major disparities in school district funding, which led the San Antonio Independent School District to argue that children have a fundamental, constitutional right to education and that the Texas funding plan discriminated against children living in poverty. The Supreme Court ruled that a federal, constitutional right to education does not exist; therefore, unequal school funding is not illegal and the courts cannot view people who are poor as subjects of discrimination in and of poverty itself.

Milliken v. Bradley (1974) was the first time a plaintiff attempted to link de facto school segregation with de jure housing policies. The district court agreed and ordered schools in its jurisdiction to desegregate, which Navarro said was feasible only by bussing because of the way housing patterns had developed. The Supreme Court disagreed with forced bussing and suggested that the racial makeup of school districts resulted from housing patterns, not policies.

Board of Education of Oklahoma City v. Dowell (1991) spanned a decades-long series of events in which Oklahoma City attempted desegregation via neighborhood zoning and then bussing. After achieving integration in the late 1970s, Navarro recounted, the bussing mandate was removed and resegregation ensued. The Supreme Court ruled that because the school district had complied with the original desegregation plan and the vestiges of de jure segregation had been removed, schools need not continue with court-mandated desegregation plans. According to Navarro, the ruling effectively communicated that school segregation based on racialized housing patterns is legal. School resegregation has since increased dramatically (and is tied directly to residential segregation), he observed, referencing data indicating that more than of half of U.S. students attend a racially concentrated school.⁹

Navarro discussed a final case, Parents Involved in Community Schools v. Seattle School District No. 1 (2007), which developed as a result of Seattle schools’ practice of using race as a tiebreaker for admission to competitive high schools, which was intended to promote the schools’ diversity. The Supreme Court ruled the practice unconstitutional, he reported, and that students cannot be classified on the basis of race despite diversity goals. In short, Navarro summarized, this ruling indicated that segregation based on housing patterns is not illegal.

In his final points, Navarro emphasized that the Equal Protection Clause of the 14th Amendment was a powerful tool in the past, but he said he believes it has become weaponized and now ensures that institutions make race-

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⁹ EdBuild. 2019. 23 billion.https://edbuild.org/content/23-billion (accessed June 7, 2021).

blind decisions even when attempting to address racially mediated systemic problems. In addition, he maintained that although connections between racialized residential patterns and school segregation are well known, the courts have routinely refused in recent decades to meaningfully address them. Finally, he shared his belief that school reform alone through programs such as school of choice, voucher programs, and charter schools are a dead end because they fail to address the root problem.

THE INTERSECTION OF BIASED MENTAL MODELS, STIGMA, WEIGHT BIAS, AND OBESITY

The workshop’s third session included two speakers who discussed the intersection of biased mental models, stigma, weight bias, and obesity, with a focus on workplace and health care settings.

Stephen Bevan, head of human resources research development at the Institute for Employment Studies in the United Kingdom, discussed obesity stigma and discrimination in the labor market and in worksites. Work is not only an economic act but also a social act, he maintained, and many challenges associated with inequalities in social determinants of health play out in work settings. He suggested that among people who characterize obesity solely as an individual issue of willpower over eating and activity habits, weight bias might be the last “acceptable” form of stigma and discrimination.

Bevan referenced UK data indicating that weight-based stigma is common in the workplace and pervades every stage of the employment cycle, including recruitment and selection, development of employee relationships and well-being, progression and promotion, employment retention, and unemployment. For example, 45 percent of UK employers say they are less inclined to recruit candidates with obesity, he relayed, and people with obesity have lower starting pay, less hiring success, and lower coworker ratings of job performance and ability.¹⁰ Employment discrimination and stigma appear to be more common among women than men, he noted, as women were 16 times more likely to report weight-related employment discrimination.¹¹ These experiences are rarely challenged in workplaces, Bevan observed, and are instead regarded as outside the mainstream of typical diversity and inclusion practices and policies.

Bevan discussed the obesity wage penalty, reporting that a 2016 review conducted by the UK government identified a 10 percent wage gap between people with obesity and people of average weight.¹² Additional evidence suggested that the wage penalty has a greater effect on women than men, he added, with the average gap estimated at 9–13 percent. Bevan reviewed four proposed explanations for this finding: human capital differences (i.e., women with obesity have lower education attainment and limited work experience, and experience segregation into occupations with less prestige); life course barriers (i.e., women with obesity find it harder to shed the health and education inequalities of childhood and adolescence); health differences (i.e., women with obesity have more health conditions and comorbidities that affect their ability to find and retain work); and stigma and discrimination (i.e., women with obesity face systemic discrimination in the labor market and workplaces). The conclusion from some of this evidence, Bevan summarized, is that the multiple employment disadvantages that women with obesity already experience in the labor market are being compounded by pervasive wage penalty in a tangible way, established for many in adolescence and continued throughout adulthood.

Bevan next highlighted potential unintended consequences of workplace health promotion programs. Well-intentioned programs with a nutrition, exercise, or weight management element may inadvertently reinforce obesity stigma, he explained, when they reinforce the belief that overweight and obesity can be resolved through an individual’s willpower over efforts to eat less and move more.¹³ This might cause some people with obesity to internalize the stigma they experience in society, Bevan explained, or make them reluctant to participate in workplace programs or access support, advice, or even psychosocial help.¹⁴

In closing, Bevan outlined actions that governments, employers, the media, and health care professionals can take to reduce obesity stigma. Bevan emphasized the need for inclusive and nonstigmatizing government legislation, workplace policies and programs, and media portrayal of people with obesity, as well as better recognition by health care professionals of the barriers people with obesity of working age face in the labor market.

Keith Norris, professor and executive vice chair for equity, diversity, and inclusion at the David Geffen School of Medicine at the University of California, Los Angeles, discussed health care systems’ perspectives on obesity and sug-

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¹⁰ Crossland Employment Solicitors. 2015. Employers’ attitude to obese candidates.https://www.crosslandsolicitors.com/site/crossland_news/Employer_survey_obese_candidates_2015_html (accessed June 7, 2021).

¹¹ Bajorek, Z., and S. Bevan. 2020. Obesity stigma at work: Improving inclusion and productivity. Brighton, UK: Institute for Employment Studies. https://www.employment-studies.co.uk/resource/obesity-stigma-work (accessed June 7, 2021).

¹² Bajorek Z., and S. Bevan. 2019. Obesity and work: Challenging stigma and discrimination. Brighton, UK: Institute for Employment Studies. https://www.employment-studies.co.uk/system/files/resources/files/526.pdf (accessed July 8, 2021).

¹³ Bajorek, Z. 2021. Weight stigma in employment.https://oen.org.uk/2021/05/26/weight-stigma-in-employment (accessed June 7, 2021).

¹⁴ Tauber, S., S. W. Flint, and N. Gausel. 2020. Exploring responses to body weight criticism: Defensive avoidance when weight is seen as controllable. Frontiers in Psychology 11(598109):1–11.

gested how to improve those perspectives going forward. To illustrate the reality of stigma and bias that patients with excess weight experience in health care, Norris shared several findings from a survey of more than 100 postgraduate trainees in professional health disciplines. For example, 50 percent reported “my peers tend to have negative attitudes toward patients with obesity,” and despite nearly all respondents deeming it unacceptable to joke about a patient’s weight, many had heard or witnessed such humor from professors or instructors, health care providers, students, or residents.¹⁵ Other surveys found similar results, Norris said, indicating general sentiments among physicians and other health care providers that patients with obesity are noncompliant, lazy, lacking in self-control, weak willed, unsuccessful, and dishonest.¹⁶

Although physicians claim that they want to do the best for their patients, he observed, they may harbor implicit biases that hinder that goal. Norris said biases among members of the health care system become embedded in the system’s structures, and they form weight-related barriers for patients navigating the system. For example, patients with obesity may receive unsolicited advice about losing weight or inappropriate comments about their weight, he explained, or experience disrespectful treatment or inaccessible equipment and facilities because of their weight.¹⁷

Norris reviewed the negative consequences of weight bias for patients with obesity, explaining that experiencing weight-based discrimination amplifies psychosocial stress, which triggers a reallocation of neuronal activity in the brain and leads to poor cognitive processing. This pathway can lead to suboptimal clinical outcomes for patients, he continued, as a result of internalized fear, shame, guilt, poor self-esteem, anxiety, depression, mistrust of the health system, and inability to implement and remember health advice.

Finally, Norris offered strategies for countering bias and discrimination, starting by overcoming unconscious or implicit bias. Bias manifests differently for each person, he said, and recognition of one’s potential for bias is a first step. Norris encouraged clinical settings to recognize patients’ experiences with weight-related discrimination, weight bias-induced limitations on employment and educational attainment, mistrust of care, impaired cognitive processing from the additional psychosocial stress, and other comorbidities. Patients with obesity need high-quality care, respectful treatment, empathy, compassion, support, and hope, he emphasized—and not judgment, ire, or lecture. To unravel the institutionalization of bias, Norris urged examination and revision of health system policies and practices that could perpetuate structural biases.

REFLECTIONS

In the workshop’s fourth and final session, the members of the workshop planning committee shared reflections on the day’s presentations and discussions.

Carol Byrd-Bredbenner, distinguished professor of nutrition and director of the nutritional sciences graduate program at Rutgers University, highlighted food insecurity as a contributing factor to obesity and a key barrier to reducing its prevalence. The COVID-19 pandemic has increased the prevalence of food insecurity, she reported, to which the U.S. government has responded by effecting changes in the administration and delivery of some of its food security safety net programs to remove the barriers to participation. As an example, Byrd-Bredbenner shared that Supplemental Nutrition Assistance Program benefits were increased by 15 percent and states have been granted greater flexibility in managing their beneficiary caseloads. She called for researchers to evaluate the outcomes of these emergency measures in order to generate data to support appeals to make the changes permanent. She also highlighted several other federal food assistance programs—the Special Supplemental Nutrition Program for Women, Infants, and Children; the National School Lunch Program; the School Breakfast Program; and the Summer Food Service Program—and provided suggestions for increasing program participation rates and effectiveness. Byrd-Bredbenner also offered ideas for increasing healthy food options at small food outlets such as corner stores, which she said are primary food retail venues for many people who live in urban areas and experience food insecurity. The bottom line, she said, is that improving food security carries benefits beyond helping prevent obesity and addressing health disparities: it helps provide children enough nourishment to stay focused at school, alleviates parental stress about feeding their children, and improves employee health and reduces sick days.

Carlos Crespo, professor at Oregon Health & Science University and the Portland State University School of Public Health, and vice provost for undergraduate training in biomedical research at Portland State University, observed that although weight stigma is often a short-term experience, it can have lasting effects on health, occupational earnings, and acquisition of wealth over time. Obesity is a community problem, he maintained, with determinants that

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¹⁵ Puhl, R. M., J. Luedicke, and C. M. Grilo. 2014. Obesity bias in training: Attitudes, beliefs, and observations among advanced trainees in professional health disciplines. Obesity (Silver Spring) 22(4):1008–1015.

¹⁶ Puhl, R. M., and C. A. Heuer. 2009. The stigma of obesity: A review and update. Obesity (Silver Spring) 17(5):941–964.

¹⁷ Ibid.

are more sociopolitical than physiological or biological in nature. Clinical solutions can be more narrow in scope, he continued, and called for greater attention to and expenditures on the root causes of the problem. The COVID-19 pandemic’s universal reach increased societal awareness of social and political determinants of health, he observed, which he suggested exert a greater influence over some population groups than others in terms of how they interact with their environments.

According to Stephanie Silvera, professor of public health at Montclair State University, a key message is that the country’s deeply entrenched issues of race and racism cannot be addressed simply by encouraging good behaviors. She pointed out that racism often undermines efforts to access good health care while simultaneously masking the structural inequalities that lead to health disparities and implying that health problems are behavioral in nature. Silvera appealed for structural solutions that include policy and political engagement strategies as well as programmatic and intervention efforts. She echoed prior speakers’ comments about the COVID-19 pandemic’s illumination and exacerbation of health inequities, and warned that because of structurally and socially mediated segregation, access to occupation, and higher risk of chronic disease, disparities in obesity and chronic conditions are likely to worsen before they improve.

Melissa Simon, vice chair for research in the Department of Obstetrics and Gynecology, director of the Center for Health Equity Transformation at the Institute for Public Health and Medicine, and George H. Gardner Professor of Clinical Gynecology in the Feinberg School of Medicine at Northwestern University, proposed that the prevalence of obesity in the United States is an accumulation of decades of inequities rooted in structural and political racism that have promulgated social, economic, and structural determinants of health. She offered an analogy of an apple tree bent toward one group of people, effectively favoring that group with the privilege and advantage of easier or even effortless access to its fruit (i.e., good health). Meanwhile, she continued, the apple tree is bent away from other groups who may never be able to reach the fruit. She urged increasing awareness of the tree’s status of “fundamentally bent” and appealed for efforts to unbend the tree. Health equity is not an outcome, Simon indicated, but rather a process of ensuring that conditions of optimal determinants of health (e.g., access to health-promoting resources and culturally responsive health care and respect) are conferred to every person, while acknowledging historical injustices, so everyone has an opportunity to reach the fruit. ◆◆◆

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Emily A. Callahan as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine.

The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for this published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Melissa A. Simon, Northwestern University, and Roland J. Thorpe, Jr., Johns Hopkins University. Leslie J. Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Society for Nutrition; Banner Health; Bipartisan Policy Center; Blue Shield of California Foundation; General Mills, Inc.; Intermountain Healthcare; The JPB Foundation; The Kresge Foundation; Mars, Inc., National Recreation and Park Association; Nemours; Novo Nordisk; Obesity Action Coalition; The Obesity Society; Partnership for a Healthier America; Reinvestment Fund; Robert Wood Johnson Foundation; SHAPE America; Society of Behavioral Medicine; University of Pittsburgh Medical Center; Wake Forest Baptist Medical Center; Walmart; WW International; and YMCA.

For additional information regarding the meeting, visit nationalacademies.org/obesitysolutions.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Exploring strategies for sustainable systems-wide changes to reduce the prevalence of obesity: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26260.

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Copyright 2021 by the National Academy of Sciences. All rights reserved.