We have the tools for treatment, he said, and now is the time to implement them in such a way that many people can benefit. He noted that a great deal of progress has been made on the treatment side, but there is a need to make more progress on the prevention side.

A NUTRITION PERSPECTIVE

Nutrition is fundamental to health and well-being, yet it is difficult to manage for countless Americans, said Sims. He asked Angela Odoms-Young, Cornell University, to answer a number of questions about nutrition: “What advances have been made in nutrition over the last decade? What are we doing better today than we have in the past? And what actions can be taken to strengthen the role of nutrition in order to prevent and manage obesity?” Odoms-Young said that there have been big successes in nutrition over the last decade, including revised guidelines for school lunches and updates to food assistance programs. What is needed moving forward, she said, is societal change. People do not live in nutrition studies; they live in neighborhoods in the real world.

There has been a move away from the focus on individual responsibility and toward a focus on upstream factors, community-level interventions, and policies that can affect obesity. This shift from “what you do to what we do” is very important, she said. Sims agreed that there is remarkable value in focusing on making changes in community practices that are associated with health. Looking at the obesity systems map (Figure 2-3), many factors are difficult for an individual to manage but can be addressed with the aggregated power of a community.

A PHYSICAL ACTIVITY PERSPECTIVE

Like nutrition, physical activity is fundamental to health and well-being, said Sims. Across our communities, both intentional and incidental physical activity seem to be on the decline. Sims asked Laurie P. Whitsel, American Heart Association and the Physical Activity Alliance, about how to encourage and facilitate physical activity as an important component of obesity prevention and management. Just before the COVID-19 pandemic, responded Whitsel, the physical activity community came together in Washington, D.C., to talk about how to bring the community together to speak with one voice on national policy and systems change. Over the course of the next year, key organizations—the National Coalition for Promoting Physical Activity, the National Physical Activity Alliance, and the National Physical Activity Society—and individuals met weekly to bring together the physical activity community and form the non-profit Physical Activity Alliance.

The Physical Activity Alliance includes the National Physical Activity plan, which is the road map for implementing the U.S. Physical Activity Guidelines for Americans and has a memorandum of understanding with the U.S. Department of Health and Human Services to support implementation of these guidelines as well as the Centers for Disease Control and Prevention’s Active People, Healthy Nation initiative. As an example of its efforts, Whitsel highlighted the “It’s Time to Move” work that her group is doing to integrate physical activity assessment, prescription, and referral into health care delivery.

One of the barriers that clinicians reported was a lack of measures for physical activity in electronic health records (EHRs). To address this barrier, the alliance set a goal of creating standardized measures nationally and getting them added to all EHRs. It worked with HL7 International, an organization that conducts measure standardization, and developed an implementation guide that standardized assessment, prescription, and referral for physical activity. Next, said Whitsel, the alliance worked with the Office of the National Coordinator, which is responsible for the interoperability of health data. Through this work, physical activity assessment was incorporated into the U.S. Core Data for Interoperability, which is the core data required in all EHRs. However, Whitsel cautioned that this does not mean that all clinicians will necessarily use these measures.

The Physical Activity Alliance is now working with key organizations and partners to develop quality and performance measures that will incentivize clinicians, health systems, and payers to incorporate physical activity into their clinical workflow and patient care. The group is also working on other barriers in clinical care, such as payment for supervised exercise therapy, as well as coordinating with workplace health promotion. For example, said Whitsel, the Physical Activity Alliance has a chief executive officer pledge to create leadership role modeling and a social movement for the importance of healthy levels of physical activity and fitness for all U.S. employees. While addressing obesity is not an easy task, said Whitsel, working together in collaboration and coordination makes it possible.

CROSS-SECTOR APPROACHES

A hallmark of the roundtable is its cross-sector membership and its systems orientation, said Sims. He asked Parekh to comment on how cross-sector approaches can be used to address obesity. While many sectors have been very active in the obesity fight, said Parekh, one has not been involved to the extent it should be: the health care sector. “Where are the health plans and the purchasers and the hospitals and the provider groups?” asked Parekh. Parekh called out poor diet as the leading risk factor for mortality in the United States, and health care organizations ought to prioritize

obesity as a top issue to tackle. There are many opportunities and incentives for the health care sector to partner with CBOs, the business community, and other key players to spread the word about the importance of addressing obesity and about evidence-based interventions that can be used. For example, nonprofit hospitals have billions of dollars in tax exemptions to provide community benefit; this is a prime opportunity for hospitals to work with the community to tackle obesity, he said. Parekh expressed hope that the health care sector will soon give obesity the attention it deserves.

STRUCTURAL INTERVENTIONS FOR NUTRITION

Noting that the work of Odoms-Young has focused on structural determinants of dietary behaviors and related health outcomes in traditionally underserved communities, Sims asked her to discuss what types of structural-level nutrition programs could be expanded or accelerated to help improve health in these communities. “Food and nutrition are embedded in all of life,” said Odoms-Young, and poor health outcomes related to nutrition are a symptom of the broader inequities that exist within society. When thinking about nutrition, the focus is often exclusively on what a person is putting in their mouth instead of looking at the whole person. There are a number of factors that affect the body, from stress to adverse childhood experiences to obesogens. The disparities in these factors are “not one thing, they’re everything.” When thinking about social and structural determinants, said Odoms-Young, it is critical to look at the whole person and at all the exposures and risk factors that they encounter day to day.

Structural oppression is multilevel and bidirectional, and it affects individual exposure. Instead of thinking about how to counsel an individual to eat certain things or not eat certain things, we need to think about manipulating and improving structures that are linked to dietary outcomes. Odoms-Young said that in her work on structural determinants, she has heard communities saying that they are “tired of the down story.” They do not want to only hear about structural oppression but want to hear about joy and resilience in their communities. Structural interventions can be focused on challenges, but also on assets, she said. Structures affect people in different ways, and there is a need to understand these differences and how structures affect the people who are the most vulnerable or who have the most exposure to structural disadvantage.

ENCOURAGING PHYSICAL ACTIVITY

Sims noted that the Olympics—which were starting around the time of this symposium—serve as inspiration for physical activity. He asked Whitsel how to make the most of the excitement of events like this while

also building sustainable systems for physical activity. She said that the Olympics are inspiring and bring attention to physical activity and sports in the moment, but that we need to focus on evidence-based policy and systems change to facilitate sustainable support for physical activity over time. “Let’s catalyze the opportunity and interest that come with the Olympics,” she said, and use it to build a movement of influencers, organizations, employers, and schools that are making physical activity a priority.

Whitsel said that she has been closely following the work of Euan Ashley, a researcher involved in the Molecular Transducers of Physical Activity Consortium. He is building a molecular map to explain why physical activity and exercise are beneficial for health and has said that “exercise could be the most potent medicine that we could prescribe.” Whitsel said that the consortium is finding that exercise has profound effects on systems of the body that we normally would not think of as being related, such as the adrenal gland. This work will inform policy and systems change work, she said, by demonstrating the value of incorporating physical activity and movement into our daily lives.

There are also opportunities to encourage physical activity through influencers, said Whitsel. Young people are incorporating physical activity into their lives, not just for physical health but also for mental health and well-being. They share what they are doing on social media, and this attention can be used as a catalyst for other efforts. There has been great progress in nutrition in school, with updated nutrition standards for school meals, but there is a long way to go to make the same progress in physical activity. Funders are pulling out of this area, she said, and there is a vacuum in schools in terms of a commitment to comprehensive school physical activity programs. Building a movement for physical activity and incorporating physical activity into the discussion of obesity will take commitment across the private and public sectors, said Whitsel.

MOVING FORWARD

Several speakers at the symposium noted that there is a need for a new consensus report on obesity, said Sims. He asked panelists to briefly identify the topics for which it would be most beneficial to have a consensus document in order to make progress in the prevention and management of obesity. Odoms-Young responded that we need more information on “the how.” There is evidence that structural oppression and other structural determinants are associated with obesity, but more research is needed on the pathways by which they make an impact. “We need more of this understanding … in order to know where to “tweak” things,” she said. Odoms-Young also said that there is a need to hear the voices of those with lived experience and to listen when they come up with solutions. Rather

than inviting them into our rooms, “maybe we need to be out of the room” meeting them where they already are. Whitsel agreed with the need to incorporate lived experience and to meet people where they are and added that addressing obesity can only be accomplished through collaborative, coordinated work across settings.

Parekh reiterated his earlier point that the health care sector needs to take more of a leadership role and be part of ongoing cross-sectoral collaborations. Another area in which work is needed is policy, systems, and environmental change to support physical activity and nutrition. He noted that this approach has been neglected over the last few years, and he hoped that it would pick up, particularly at the community level. Finally, Parekh said that there is a need for urgent action. The work of the roundtable has been very important over the last 10 years, but it will be more important over the next 10 years, given what we know and where we are with obesity, health outcomes, and health care costs.

OPPOSING INTERESTS

In groups of people like the participants at this symposium, Kumanyika said we are “singing to the choir.” However, in other groups, there may be individuals who have very different priorities and approaches. She gave an example of meeting a public health professional who worked in transportation; he wanted to get people off the streets, while she wanted to get people on the streets to exercise. Kumanyika invited panelists to comment on these types of conflicts and opposing incentives. Whitsel said that it is challenging but important to get out and talk to new audiences, organizations, and sectors to see if there are areas for collaboration. She noted that sometimes these audiences use different language—such as the health information technology sector—but they are receptive to messages about the importance of obesity when it is communicated clearly.

Whitsel urged the audience to have conversations with people and in places that are outside of their comfort zone. Odoms-Young agreed that there are different priorities, even within the public health world. For example, someone might feel that obesity is not nearly as big of a problem as mental health, violence, or human immunodeficiency virus (HIV). However, she argued that the structural determinants of health affect nearly all health outcomes. While some might disagree on the specific issue that needs to be addressed, there are opportunities to collaborate on policies and programs to address upstream causes of multiple outcomes.

SYSTEMS OF ACCOUNTABILITY

A participant noted that there are currently systems in place or under development to hold the health care system accountable for outcomes. For example, the Healthcare Effectiveness Data and Information Set is a set of measures to assess the quality and performance of health plans. The health care system is the “recipient of people’s lived lives,” said the participant; that is, the health care system often deals with downstream outcomes rather than upstream causes. Is it possible, he asked, to put the burden of accountability on those involved with upstream determinants of health? For example, if the obesity rate stays high and there is evidence that it is due to ultra-processed foods, could the food industry be held accountable through regulations or tax incentives or disincentives? This could cause the industry to change their advertising practices to promote more whole, fresh foods rather than processed foods. Whitsel said that holding industry accountable for upstream causes of health outcomes can be done and gave the example of the tobacco industry. The food industry is more challenging, she said, because it is not as clear-cut as tobacco.

There are times when industry needs incentives or tax structures for motivation to offer healthier options. The physical activity industries, in most cases, can be an important ally. However, Whitsel said that she worries that both the food and physical activity industry sometimes push products that may not be safe, healthy, or based on evidence, which can undercut the credibility of health promotion work. For example, the Internal Revenue Service (IRS) updated its guidance to allow people to use their tax-exempt Health Savings Accounts or Flexible Savings Accounts to pay for gym memberships to treat a disease or condition with a letter of medical necessity. There was a company that was writing automated letters of medical necessity outside of the guidance for people, which raised red flags for the IRS. “We may lose that benefit when companies do this kind of behavior,” said Whitsel. It is necessary and important to work with industry, she said, but depending on the issue or public policy lever it can be challenging.

Parekh added that there are policy approaches that can be used to incentivize or disincentivize industry behaviors, such as sugar-sweetened beverage taxes or rules on front-of-label packaging. This is a space that needs to be watched carefully over the next few years, he said. Parekh cautioned that the 2024 Supreme Court decision that overturned Chevron may complicate what federal agencies can do.¹ “We need to think about all the levers that are out there,” including legislation, tax policy, and regulations, that can be used to drive improvements in population health.

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¹ Loper Bright Enterprises v. Raimondo, 603 U.S. ___ (2024).

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