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Shifting the Paradigm to Advance Obesity Solutions

The April 2022 workshop began with a presentation expounding on concepts presented in the introduction to the workshop series (Chapter 1) and further described the roundtable’s approach to organizing the April workshop.

SETTING THE STAGE

Bruce Y. Lee, professor of health policy and management at the City University of New York Graduate School of Public Health and Health Policy and executive director of the university’s PHICOR (Public Health Informatics, Computational, and Operations Research) initiative and Center for Advanced Technology and Communication in Health, began by stating that obesity is a systems problem in need of systems solutions. Obesity is affected by and involved with not only biological and behavioral systems, he elaborated, but also social, economic, and environmental systems (Lee et al., 2017).

Lee listed several risks of failing to apply a systems approach to obesity and other systems problems. Without a systems approach, “Band-Aid” solutions, which address surface-level problems but are neither sustainable nor targeted to root causes, are often applied. Such approaches can have unintended consequences; miss secondary and tertiary effects; worsen existing disparities; expend time, effort, and resources on trial and error instead of targeting real solutions; and introduce multiple sources of bias. In short, said Lee, failure to apply a systems approach risks not solving the problem at all, and even worsening it and introducing new problems.

Lee reiterated Economos’s introductory remarks (Chapter 1) about the importance of identifying, examining, and intervening on major leverage points. Targeting these leverage points is a strategy for disrupting what he termed a reinforcing loop (Figure 2-1), which he illustrated with an image depicting how major contributors to obesity tend to reinforce each other.

Lee explained that this loop shows how structural racism can result in unbalanced workforces, which he cautioned could produce biased research and ultimately a biased evidence base. Such an evidence base can lead in turn to overly simplistic messages, he continued, which affect health communication intended to help shape people’s mental models. Mental models, he observed, collectively lead to social norms, such as structural racism, that reinforce the problem and perpetuate the cycle. Lee also pointed to the straight arrows in Figure 2-1—which he called spokes—leading from one contributor to another around the loop. He explained that because the contributors to obesity reinforce each other, intervening on one or more of them can initiate positive (or negative) effects that grow exponentially as they reverberate through the loop (i.e., the system).

Next, Lee outlined the April workshop’s three sessions and explained how they would collectively explore the seven obesity contributors illustrated in Figure 2-1. The first session would explore three of the contributors, examining academic and workforce structures that can dismantle systemic racism while building an evidence base. Lee highlighted the Aspen Institute’s definition of structural racism: “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity” (Aspen Institute, 2016).

The second session, Lee continued, would cover two more contributors—overly simplistic messages and health communication. As an example of an overly simplistic message, he shared a graph showing that an increase in global average temperatures has occurred over time alongside a decrease in the number of seafaring pirates. Although an

association exists between global average temperatures and numbers of pirates, he observed, this does not mean that a decrease in the number of pirates has caused the rise in global temperatures or that producing more pirates would help tackle global warming. Lee urged avoiding such overly simplistic messages, adding that health communication is critical for shaping messaging. Using the analogy of a tree falling in a forest, he suggested that if no one hears it, perhaps the tree has not garnered sufficient media attention or has a subpar social media presence. He pointed to the tree as a metaphor for information and health communication, explaining that if a particular scientific principle or understanding is not communicated accurately to decision makers and the public, it is as if that principle or understanding does not even exist.

The third session, Lee continued, would address the final two contributors illustrated in Figure 2-1—biased mental models and social norms. He explained that those contributors would be explored through discussion of representation in media and body image, emphasizing that mental models are important because they are the lenses through which an entity (an individual, a group of people, or an institution) views itself and everything else in its environment. According to Lee, an entity’s mental models affect how information is understood and interpreted, a perception that Lee explained affects the opportunities and solutions that the entity envisions for a given problem. He pointed out that mental models lead to social norms, defined as common standards within a social group regarding socially acceptable or appropriate behavior in particular social situations, the breach of which has social consequences (Chandler and Munday, 2016). Social norms can be powerful drivers of behavior, Lee stressed, even when they are not necessarily aligned with facts and the latest evidence.

Lee concluded by reiterating the importance of changing the picture of obesity—society’s view of the problem, the makeup of its mental models, and how the problem is communicated—in order to achieve systems change.

DISCUSSION

Following Lee’s presentation, he and Economos answered questions about breaking the cycle of the reinforcing loop of obesity contributors, body mass index (BMI) as a racist concept, and the role of weight stigma in driving the obesity epidemic.

Breaking the Cycle

In response to a question from Economos about how to find a tipping point at which the cycle of the reinforcing loop can be broken, Lee reassured participants that although obesity is the product of a complex system of many multilevel causes and contributors, “complex does not necessarily

mean complicated.” The strategy, he emphasized, is first to identify the key leverage points and then to work on more focused change. Recognizing that change will not happen overnight, he stressed that gradual movement toward positive change is a step in the right direction. He added that intervening on key leverage points can produce an impact that exceeds the investment, and he illustrated this point with the example of structural racism. According to Lee, obesity is just one manifestation of structural racism; therefore, targeting structural racism as a key contributor to obesity can have “reverberating” positive effects on both obesity and other manifestations of structural racism.

Is BMI Racist?

A participant asked Economos and Lee to share their perspectives on the claim that the use of BMI is racist. Economos began by explaining that BMI is used in population-level surveillance as a measure for examining the relationships between body mass and disease outcomes, and that BMI trend data can suggest patterns and advance understanding of these relationships. She contrasted this with the use of BMI at the individual level, suggesting that in this context, BMI should be treated as a guideline, with health care providers measuring individual body composition more precisely. BMI does not differentiate between fat mass and lean mass, she observed, whereas more sophisticated measurement techniques can better capture that distinction. Furthermore, she continued, health care providers can help identify a healthy weight for an individual based on other biological markers, medical history, and other important factors as part of a “whole person” approach. Economos does not necessarily believe BMI is racist, but she stressed that when guidelines are developed on the basis of data drawn mainly from individuals of one race, ethnicity, or other key characteristic, it is important to revisit those guidelines to evaluate how well they work for individuals of different backgrounds.

Lee pointed to a tendency to establish and focus on one measure, such as BMI, but cautioned that no one measure can capture the entirety of a system, and reliance on any single measure can lead to wrong conclusions and neglect key drivers and leverage points. He agreed with Economos that BMI is a helpful measure from a population standpoint, and called for a broader array of measures to better understand what is happening with weight status.

Weight Stigma

Economos replied to a participant’s question about how “fat shaming” may work to solidify obesity in today’s culture. Economos highlighted the focus of the Roundtable on Obesity Solutions’ Innovation Collaborative on

the lived experiences of individuals with obesity and raised concern about their experiences with weight stigma. She characterized this as a marked problem in one-on-one interactions when individuals are seeking help or advice in a medical or social services setting, stressing that discrimination or bias in those initial interactions can strongly influence a person’s likelihood of seeking further services. It is important to break that cycle in individual interactions, Economos maintained, as well as at the population level, such as by promoting media content that is free of weight bias.

By blaming the individual, Lee added, one overlooks the systems nature of the obesity epidemic and misses its true causal and contributing factors. Overlooking the systems aspect, he submitted, is one of the reasons why the obesity epidemic has persisted over the past few decades. Economos reiterated that the roundtable’s causal systems map (Figure 1-1) includes many other social drivers and social determinants of health, such as poverty, housing, employment, and stress, that are additional deep leverage points for changes in policy, systems, and structures.