Notes from the Editor-in-Chief
It is clear that the obesity epidemic is here. It is complex and pervasive in most developed countries. The stark contrast between the millions of people who are morbidly overweight and the undernourished is frightening; but as you will read in this issue, there is no simple way to rectify the equation.
In this issue of Healthcare Papers, we attempt to shed light on the complexities of the obesity issue as well as provide some strategies for moving ahead. In order to provide background, we engaged two experts on obesity and public policy. They are Suzanne Havala Hobbs, from the Department of Health Policy and Management, Gillings School of Global Public Health, and Neil Seeman, director, Health Strategy Innovation Cell, senior resident, Massey College at the University of Toronto, and adjunct professor, Health Services Management at Ryerson University.
In "Getting from Fat to Fit: The Role of Policy in the Obesity Disaster," Suzanne Havala Hobbs outlines the extent to which public health policy influences the life of individuals, specifically regarding weight management. She points out that being overweight was once a sign of affluence - a symbol of those fortunate enough to be employed in a less physically taxing environment. She then describes the current situation in which much of the world's population is experiencing health problems due to being overweight or obese - in the United States alone, two thirds of adults, about 134 million people, are overweight or obese and the percentage of overweight or obese children has risen, affecting 17% of individuals six to 19 years of age (National Center for Health Statistics 2007, cited in Hobbs).
Hobbs describes both simple and complex explanations for this trend. Simply put, she notes that individuals are consuming more calories than they are expending, which is easily done with the abundant availability of processed foods high in sugar, fat, sodium and calories and low in dietary fibre. Access to such foods, coupled with little physical activity, has resulted in substantial weight gain.
More complex explanations exist, and Hobbs outlines these from an ecological perspective. She notes the impact environmental factors play on our food choices, describing recent environmental changes, including changes in technology and social and family structures, that have worked against our ability to make healthy choices and that encourage a more sedentary lifestyle, less physical activity and more meals away from home. Hobbs also discusses inequities in socioeconomic status and unequal access to supportive healthcare services, noting that these may result in reduced access to proper recreational areas, markets for affordable fruits and vegetables and health professionals who are able to provide appropriate diet counselling.
Behind each of these factors lie government policies for agricultural subsidies and dietary guidance, as well as industry influence through the high production of processed foods and the proliferation of advertising for such foods. In addition to those issues affecting weight control, competing influential interests exist that make it difficult to find a solution that remedies our growing problem.
Without immediate and effective change, Hobbs notes that there will be a continued increase in health problems stemming from obesity, including "morbidity and mortality from high blood pressure, coronary artery disease, type 2 diabetes, osteoarthritis, some forms of cancer and other chronic degenerative disease and conditions (Flegal et al. 2005; Kaufman 2002; WHO 2002)." Such conditions are affecting younger and younger age groups, with the US Centers for Disease Control and Prevention reporting that, "in 2006, that one in 523 individuals under 20 years had diabetes (CDC 2008)," posing a risk for a shortened lifespan. The prevalence of such diseases also poses an economic risk, notes Hobbs, with the estimated cost of medical spending due to overweight and obesity at US$92.6 billion in 2002 (Finkelstein et al. 2003, cited in Hobbs).
Hobbs describes the problem as deserving immediate attention and discusses how recognition of the problem occurred as early as 1952 when the American Heart Association cited obesity as a risk factor for coronary artery disease. She notes a 1977 US Senate report, Dietary Goals for the United States(Nestle and Jacobson 2000, cited in Hobbs), that echoed that risk and how, in 1980, prevention and treatment of obesity was an "objective of the nation" (US Department of Health and Human Services 1980, cited in Hobbs). But despite the recognition of the problem, little has been done besides inadequate education efforts that do not take a holistic approach, which would include both education and a modification of our current food environment - a type of approach that Hobbs describes as being recognized as necessary by scientific and public health communities such as the US Department of Health and Human Services and the World Health Organization. Without such holistic approaches to this problem, obesity, Hobbs states, is a proxy for a widespread breakdown in the current healthcare system.
Hobbs examines determinants of health, which include environmental factors such as proximity to safe parks and recreation areas, sidewalks, bike paths and distance of employment; social conditions such as level of education and income; and individual biological and genetic factors and behaviours such as diet and exercise. She notes that despite economically developed nations benefiting from a high level of affluence, which seemingly should make it easier to create conditions supporting health, the United States has experienced a decades-long lack of success in reversing the obesity trend.
Hobbs then discusses the need for policies and subsequent interventions to be created with a focus on achieving optimal physical and social conditions for health. She also asserts the necessity of creating a values judgment to determine the appropriate role of government in enacting policies that promote health, noting that the Bush Administration has emphasized a diminished role for government and placed the responsibility on individuals.
Hobbs describes effective efforts to fight obesity as including policy actions that require political will and substantial abilities in and attention to four factors: (1) strategic management and planning, (2) fiscal leadership, (3) government accountability and transparency and (4) ethical leadership. Hobbs notes that effective large changes will need effort to generate political will and global co-operation, in addition to newly developed and effectively deployed leadership capacities within the senior public health workforce.
In "The Prevention Moment: A Post-partisan Approach to Obesity Policy," Neil Seeman advocates for a collaborative approach to fighting obesity. He defines post-partisanshipas "involving all sides early in contemplating problems to complex policy issues," noting that confronting obesity transcends political divisions.
He outlines how each major US presidential candidate in 2008 promoted prevention-centred healthcare, signifying that the fight against obesity is not a one-sided political vantage but a problem that affects all citizens. From Democratic Senator Barack Obama's push for further fiscal resources allotted toward prevention efforts, to Republican Senator John McCain's focus on further educational efforts, to Democratic Senator Hillary Clinton's discussions about the costs associated with allowing poor dietary behaviours and physical inactivity to continue, Seeman shows how each major candidate for US president championed an agenda for improvements in the fight against obesity. He says that bringing members of all political viewpoints together is "not only smart policy but also smart politics," noting that post-partisanship is not political neutrality but, rather, a way to explore improvements in political dialogue and decision-making.
Seeman further addresses the need for post-partisanship as it applies to the fight against obesity. He explains 10 principles of post-partisanship (Satin 2007, cited in Seeman):
- Relationships are as important as convictions.
- Criticism needs to be well-balanced by self-criticism.
- There must be an overriding commitment to dialogue and deliberation.
- There must be an overriding commitment to diversity of opinions and perspectives.
- Compromise is not the only endgame.
- Be simultaneously creative and practical.
- Demonstrate a penchant for big ideas.
- Support a bias for action.
- Demonstrate concern with values and principles.
- Have a long-term vision.
Seeman describes carefully how each of the above principles relates to combating obesity. He discusses how building relationships must be done across all sectors and recognizes that the suggestion to 'involve industry' in partnerships to promote healthy lifestyles" has been on the table for some time. Seeman asserts that in order to make this happen, effort will need to be taken to identify which individuals within industry are decision-makers or key influencers. Additionally, there must be effort to determine how to help make the case for businesses.
Seeman explains the importance of different viewpoints coming together to create innovation - a result he says can only happen when multiple ideas are brought to one discussion. He explains that this discussion can result in bridging divides, which does not mean splitting differences. Such results can lead to creative and practical results. Seeman goes on to explain that large, actionable ideas are those that create change. He elaborates that big ideas are generally more "politically saleable" than smaller initiatives, and he discusses how such big ideas result in recognizable action.
Seeman also outlines how post-partisanship requires those involved to expose their own judgments and values to aid the process of policy formation. Such disclosure, Seeman says, allows individuals in the room to clearly understand others' viewpoints, resulting in group collaboration to make the results beneficial to all present and ultimately produce policies that will help reduce obesity rates.
Seeman discusses the principle of a "long-term vision" as being vital in the fight for weight management, noting that in obesity policy there is no short-term solution. Successful long-term policies, Seeman says, will include institution- and community-based interventions that promote healthy living, which he describes as including healthy eating habits, increased physical activity, attention to stress levels and decreased time spent in sedentary activity. He emphasizes the need for policy to have a multidisciplinary approach - one that can be reached through post-partisanship. He concludes that meaningful change is a function of legislative action and policy implementation. Education alone or roundtable calls to action do not take the fight against obesity to an appropriate level, but post-partisanship methods can result in meaningful change that will satisfy a diverse array of individuals.
With these two excellent papers as a backdrop, we have received many fine and diverse commentaries. Diane T. Finegood, Özge Karanfil and Carrie L. Matteson of the School of Kinesiology, Simon Fraser University, build upon the lead papers in terms of the ecological and complexity perspectives. They reinforce that "the obesity problem is often thought of as a simple problem of energy imbalance, with calorie intake exceeding energy expenditure. While there are still many people who believe the solution to the problem is as simple as telling people to reverse this balance for themselves, research demonstrates that energy balance is affected by a wide range of factors, from individual genetic and psychosocial factors, to local, regional and national government policies, to the behaviours of our close personal friends (Christakis and Fowler 2007, 2008; Glass and McAtee 2006; Institute of Medicine 2005; Kumanyika 2001)."
Professor Alan Shiell, AHFMR health scientist at the University of Calgary, presents ideas from a recent report by the UK Foresight team that outlines "system maps" to help understand the complex forces that influence an individual's weight. In responding specifically to the Seeman paper, he points out that in order to sell prevention we must not let policy makers take a route that may look good but has very little outcome. He underscores that leadership is required.
Trevor Silverstone, distinguished academic visitor, Department of Psychiatry, University of Toronto, believes the obesity issue should begin to be attacked in schools. He also asserts that more evidence-based research is essential.
Susan M. Heywood and Renee Deschamps, public health fellows with the Victorian Public Health Training Scheme, Latrobe University, Melbourne, discuss the role of public health professionals in obesity policy. They conclude that health professionals and policy makers have many opportunities on a daily basis to provide leadership for cross-sector policy solutions to the obesity epidemic and that professionals working outside the health arena can contribute to the success of cross-sector obesity policy.
Bruce Silverglade, director of legal affairs at the Center for Science in the Public Interest, in Washington, DC, advocates for a comprehensive public health program to fight obesity, and he describes this in some detail. Silverglade believes that we need to build public support for high-leverage government initiatives that are under way in several other countries.
The final commentary is by David Gratzer, a senior fellow at the Manhattan Institute. He suggests that politicians should toughen up their language and be more direct, quoting British politician David Cameron: "We talk about people being 'at risk of obesity' instead of talking about people who eat too much and take too little exercise. We talk about people being at risk of poverty, or social exclusion: it's as if these things - obesity, alcohol abuse, drug addiction - are purely external events like a plague or bad weather. Of course, circumstances - where you are born, your neighborhood, your school and the choices your parents make - have a huge impact. But social problems are often the consequence of the choices people make."
About the Author(s)
Peggy Leatt, PhD
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