9

Improving Communication About Body Weight

The fourth session featured two presentations highlighting the Trust for America’s Health (TFAH) and Robert Wood Johnson Foundation (RWJF) and their strategies for improving communication about body weight from a policy and public health perspective. Ihuoma Eneli moderated the session and led a panel and audience discussion afterward.

IMPROVING COMMUNICATION ABOUT BODY WEIGHT FROM A POLICY AND PUBLIC HEALTH PERSPECTIVE: TFAH

J. Nadine Gracia is the president and chief executive officer (CEO) of TFAH, a nonpartisan nonprofit organization that promotes health and ensures that health equity and prevention are foundational in policy making and supported by data and research to improve population health. Gracia gave the first presentation on how TFAH applies communications principles to inform its policy and advocacy efforts for obesity and chronic disease prevention.

Gracia provided an overview of TFAH’s advocacy goals to advance and translate evidence into laws and policies that protect and promote health and advance health equity. TFAH “makes the case” to policy makers with evidence-based policy recommendations, data, promising examples and spotlights, stories from the field, and media collaborations to help shape and shift the narrative to advance priorities.

However, Gracia noted, agencies and programs must have sufficient resources to be effective. TFAH also works to secure funding for critical public health investments at the federal level on emerging and long-standing

priorities, such as public health infrastructure, emergency preparedness, and obesity prevention. Gracia noted that TFAH informs and engages with policy makers (including Congress and the administration) on key public health priorities, leveraging windows of opportunity and advocating to ensure critical public health issues are addressed.

Gracia emphasized the importance of knowing and understanding the audience and their priorities to help inform policy advocacy strategies. She detailed that TFAH uses several levers for policy engagement in congressional meetings, offering technical assistance on legislation, hosting congressional briefings, and submitting comments in response to requests for information or regulatory actions. The organization informs and communicates with policy makers to understand their perspectives and priorities.

Gracia began by referencing the report The Impact of Chronic Underfunding on America’s Health System (TFAH, 2023), which outlined that over $4 trillion is spent annually on health, but that does not translate into positive health outcomes (Martin et al., 2023). Only a fraction (about 4–5 percent) is allocated to public health and prevention, and it shows (TFAH, 2022). The United States ranks the lowest in life expectancy compared to other high-income countries (Roser, 2020). Adequate investment in the public health system is critical when advocating for policies promoting healthy people and communities.

Gracia indicated that TFAH’s first report on obesity was derived from national priorities. Twenty years ago, the U.S. Surgeon General released a call to action on overweight and obesity to raise awareness among policy makers (HHS, 2001). In response, TFAH launched a report, F as in Fat, that highlighted the trends in obesity with data-supported strategies to address it.

Gracia noted that the “F” was intended to describe the failure of policy to address this public health issue and raise awareness. Although the title raised attention, it could also be misinterpreted and inadvertently stigmatize individuals living with obesity. It evolved in 2014 to The State of Obesity, recognizing the increased awareness and important progress made and highlighting the data, evidence, programs, and policies to promote optimal health and well-being.

Gracia highlighted that recent reports have included a special feature that elevate critical areas, including racial and ethnic disparities in obesity and advancing health equity; food insecurity and its connection to obesity; and the intersections of the COVID-19 pandemic, social determinants of health (SDOH), and obesity. The 2022 report focuses on food and nutrition insecurity among youth and families, the social and economic conditions that promote food insecurity, and creating policies and systems that promote healthy community conditions (TFAH, 2022).

Gracia shared some lessons that have informed TFAH’s approaches and recommendations. Although obesity is a public health issue, multisector

action and policy change are critical to progress. She noted key developments from the day’s workshop, such as recognizing obesity as a disease, a broader understanding of SDOH, prioritizing health equity by addressing the systemic inequities of structural and systemic discrimination and racism that contribute to health disparities, and further addressing weight-based stigma and discrimination.

Returning to TFAH’s communication strategies, Gracia indicated that advocating for obesity prevention policies can be positioned in different ways depending on the audience. It can be a national security issue about military readiness; studies have shown that only one in three military-age people meet the body mass index (BMI) eligibility cutoff determined by the Department of Defense. She continued that it can also be seen through the lens of health equity and nutrition security, and especially for the COVID-19 pandemic, which exacerbated inequities. Neighborhoods with more Black residents had fewer supermarkets and greater food insecurity, but transforming policy and systems is an opportunity to create healthy and resilient communities, she said.

Gracia turned the discussion to TFAH’s priorities to adequately fund obesity prevention and public health programs. For example, she pointed to Centers for Disease Control and Prevention (CDC), which receives 31 cents per person for evidence-based obesity prevention programs, such as its effective State Physical Activity and Nutrition program (CDC, 2023; grants.gov, 2018). Gracia explained that the consequence is that funding is only sufficient for 16 states; the other 34 states and the U.S. territories are excluded. CDC program funding has been stagnant and not kept pace with the magnitude of obesity (CDC, 2023).

Gracia highlighted that TFAH reports demonstrate the data for overweight and obesity at the population level and inform policy makers that it is a complex, multifaceted issue in need of addressing. Broader community conditions, such as issues of poverty, health insurance coverage, participation in Supplemental Nutrition Assistance Program (SNAP), and examining the proportion of the eligible population that is participating, provide a more comprehensive picture of structural drivers of obesity for policy makers.

Gracia ended by revisiting the notion of seizing the moment to inform the administration’s priorities. The school meal programs, for example, stem from the 1946 National School Lunch Act to the 2010 Healthy and Hunger-Free Kids Act and aim to improve school nutrition standards and increase access to healthy school meals to reduce obesity, especially for children living in households with low incomes. Gracia urged participants to leverage the opportunity and momentum created by the Biden–Harris administration’s National Strategy on Hunger, Nutrition, and Health (White House, 2022) to advocate and educate policy makers on obesity prevention and treatment, emphasizing SDOH.

A NEW NARRATIVE ON CHILDHOOD OBESITY

Jennie Day-Burget was the second speaker and presented on the progression of narratives about obesity at RWJF, where she is the senior communications officer. She shared that RWJF is building a national culture of health, rooted in equity, to provide all people with opportunity for health and well-being no matter who they are, where they live, or how much money they have.

Day-Burget opened by indicating that RWJF is shifting away from individual responsibility and blame for obesity and working to change policies and the environment. Recently, she said, it has learned about the inadvertent impact of words and acknowledges the prevailing narratives on childhood obesity that have unintentionally contributed to and exacerbated anti-fat bias in children. Feelings of shame, sadness, and embarrassment have been found to be connected to terms such as “fat” and “weight problem” among children. Although “epidemic” and “disease” are found in the media and doctor’s offices, raising the profile of the health impacts of obesity, the same language has led to toxic connections between bodies with obesity and diseases (Kyle and Puhl, 2014; Puhl et al., 2017).

In the past, Day-Burget said that TFAH and RWJF cobranded the report, F as in Fat. The goal of the title was to use shock language to garner media attention to spark a conversation about policy and system changes to address obesity prevention. She explained that by doing so and focusing on the deep and persistent disparities of childhood obesity rates, the report called attention to a public health challenge faced by many communities. However, it did not describe the positive attributes of those same communities; although it received plenty of media coverage, it caused harm.

Day-Burget outlined the steps that RWJF has taken to improve the narrative about obesity. The foundation has launched an annual report, the State of Childhood Obesity, telling families’ stories and sharing personal narratives to animate the data. She continued that RWJF no longer focuses on obesity-rate data and instead promotes the perspectives of the community thought leaders and emphasizes systems-level solutions that could improve the built environment for better health. She added that RWJF has also shifted to using people-first language, not blaming individuals, and refocusing on systems change.

Day-Burget turned to discuss media and childhood obesity. To better understand the impact of the COVID-19 pandemic on such narratives, RWJF analyzed popular media outlets (e.g., Twitter) and coverage on obesity, stigma, and bias. The goal was to understand how obesity and weight stigma were depicted in the media through language and the primary messengers. Although the findings showed a regression to individual

responsibility and blame, other results showed progress. The media began shifting to positive language, emphasizing a shift in cultural norms. Unfortunately, she said, findings also showed that social media used traditional language about obesity. With high engagement rates, social media promotes purposefully offensive, negative discussions about weight.

Day-Burget illustrated the self-reflection at RWJF by sharing its study on the language of structural racism and health over 14 months to understand how to engage audiences in discussion about structural racism and health and possibly act. The results generated a formula of three parts to engage persuadable audiences to communicate about obesity and weight, particularly with structural racism as the underlying system: a shared, values-based ideal statement, positive vision and problem statement, and call to action and unity statement. RWJF applied this formula to a script for social media influencers on summer hunger that begins with a shared value statement:

Day-Burget noted that the same communications principles can help to depict structural racism in health through a static image (see Figure 9-1).

Day-Burget ended by reiterating RWJF’s commitment to examine and continuously improve its approach to create narratives for better communication about childhood obesity that promotes unity and refrains from perpetuating stigma and harm.

PANEL AND AUDIENCE DISCUSION

Eneli thanked the presenters for sharing practical strategies and complimented their organizations and leadership for their bravery in recognizing missteps with good intentions. Eneli then led a moderated discussion with questions from the audience for Gracia and Day-Burget about lessons learned for effective and trustworthy communication with communities.

Lessons Learned: Effective Communication Factors

Eneli began with a question for Gracia and Day-Burget. Thinking about TFAH and RWJF’s policies and initiatives, which have had the most success in terms of the communication strategies? Are there tips that the audience could apply in their work?

Day-Burget responded first and said that shifting from personal responsibility to policy systems and the environment for obesity prevention refocused the RWJF narrative that consumers can only choose options that they have. It acknowledges individual responsibility and the system and has been well received. One surprise, she said, was the backslide observed in their research during the pandemic, emphasizing that progress is fragile.

Gracia shared that TFAH found an effective communications strategy that goes beyond simply data points to describe barriers and why they

may exist. It created new dialogues using person-first language and provided greater context that humanizes the discussion. During the pandemic, messages on food insecurity were effective because so many families and communities were at risk and a broader understanding existed of the connection between access to nutritious foods and the risk for obesity. Gracia continued that the narrative shifted to ensure that communities and families have access to resources and opportunities to be healthy and highlighted success stories. Sharing on-the-ground experience humanizes the data points and has been critically important in understanding the need for equitable access to affordable, healthy food and economic opportunities, she said.

Eneli followed up with a question for Day-Burget and RWJF. Did the study identify societal factors that led to backsliding? Day-Burget replied that it did not but that research at RWJF tested messages on SNAP participants, focusing on the concept that a hand up is not a handout. A campaign with storytelling, media partnerships, and work with Mathematica promoted evidence-based research about the impact of potential changes to SNAP on families was powerful and effective.

Lessons Learned: Effectively Using Data in Messaging

An audience member commented that they had been advocating for expanding nutrition services through Medicaid in DC and struggled with data access. Do TFAH or RWJF have state-by-state policies on Medicaid?

Gracia highlighted one of TFAH’s policy recommendations is expanding access to health care coverage, including Medicaid expansion in remaining states. Gracia responded that these data need to be disaggregated to improve completeness for public health and health care. It is paramount to have access to robust data to make informed decisions and ensure resources are equitably allocated to communities. Day-Burget added that RWJF is working to expand Medicaid on the state level. It is moving away from data disparities and narratives and toward contextualizing data. RWJF’s research showed that leading with these narratives about families and children can be harmful.

Lessons Learned: Trust and Communication

A final question from the audience was about trust and communication: “How do TFAH and RWJF handle miscommunication in social media?”

Day-Burget began by stating that RWJF is monitoring social media, trying to figure out what to do about misinformation and disinformation, although she emphasized the lack of an easy solution. It is also undertaking organizational reflection about past messaging campaigns that unintentionally harmed children and their families.

Gracia added that TFAH is actively engaged in work on countering misinformation, particularly during the COVID-19 pandemic. In 2020, TFAH launched the Public Health Communications Collaborative with the de Beaumont Foundation and CDC Foundation, offering messaging guidance and resources to state and local health departments and health officials. Its website has a misinformation tracker that guides users on how or whether to respond.

Misinformation and disinformation are ongoing issues in public health. Gracia emphasized the importance of earning trust for effective communication, building authentic and meaningful partnerships with trusted messengers from local communities, and listening to and learning about individual and community concerns so that messages are pertinent, tailored, and nonjudgmental.