Addressing Structural Racism, Bias, and Health Communication As Foundational Drivers of Obesity

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Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of...
Emily A. Callahan, Rapporteur
Roundtable on Obesity Solutions
Food and Nutrition Board
Health and Medicine Division
Copyright National Academy of Sciences. All rights reserved.

Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings...
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This workshop was supported in part by the Academy of Nutrition and Dietetics;
Alliance for a Healthier Generation; American Academy of Pediatrics; American
Cancer Society; American College of Sports Medicine; American Council on
Exercise; American Society for Nutrition; Blue Shield of California Foundation;
General Mills, Inc.; Intermountain Healthcare; The JPB Foundation; The Kresge
Foundation; Mars, Inc.; National Recreation and Park Association; Nemours Chil-
dren’s Health; 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; Stop & Shop; Wake
Forest Baptist Medical Center; Walmart; WW International; and YMCA. Any
opinions, findings, conclusions, or recommendations expressed in this publication
do not necessarily reflect the views of any organization or agency that provided
support for the project.
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Addressing structural racism, bias, and health communication as foundational drivers
of obesity: Proceedings of a workshop series. Washington, DC: The National Academies
Press. https://doi.org/10.17226/26437.

Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: ...
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PLANNING COMMITTEE ON ADDRESSING STRUCTUAL

RACISM, BIAS, AND HEALTH COMMUNICATION
AS FOUNDATIONAL DRIVERS OF OBESITY1
ANGELA M. ODOMS-YOUNG (Co-chair), Associate Professor and

Director, Food and Nutrition Education in Communities Program
and New York State Expanded Food and Nutrition Education
Program, Cornell University
NICOLAAS (NICO) PRONK (Co-chair), President, HealthPartners
Institute; Chief Science Officer, HealthPartners, Inc.
JAMY D. ARD, Professor, Department of Epidemiology and Prevention
and Department of Medicine, Wake Forest School of Medicine;
Co-director, Atrium Health Wake Forest Baptist Weight
Management Center
CAROL BYRD-BREDBENNER, Distinguished Professor of Nutritional
Sciences and Director, Graduate Program in Nutritional Sciences,
Department of Nutritional Sciences, Rutgers University
CARLOS J. CRESPO, Professor, Oregon Health and Science University
and Portland State University School of Public Health; Vice Provost,
Portland State University
STEPHANIE A. NAVARRO SILVERA, Professor, College of Education
and Human Services, Department of Public Health, Montclair
State University
MELISSA A. SIMON, Vice Chair for Research, Department of Obstetrics
and Gynecology; Director, Center for Health Equity Transformation at
the Institute for Public Health and Medicine; and George H. Gardner
Professor of Clinical Gynecology, Feinberg School of Medicine,
Northwestern University
SUSAN Z. YANVOSKI, Co-director, Office of Obesity Research and
Senior Scientific Advisor for Clinical Obesity Research, National
Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health
1 National Academies of Sciences, Engineering, and Medicine planning committees are solely
responsible for organizing the workshop series, identifying topics, and choosing speakers. The
responsibility for the published Proceedings of a Workshop rests with the workshop rappor-
teur and the institution.


ROUNDTABLE ON OBESITY SOLUTIONS2
NICOLAAS (NICO) PRONK (Chair), HealthPartners Institute and

HealthPartners, Inc., Bloomington, Minnesota
CHRISTINA ECONOMOS (Vice Chair), Tufts University, Boston,
Massachusetts
IHUOMA ENELI (Vice Chair), American Academy of Pediatrics,
Columbus, Ohio
SHARON ADAMS-TAYLOR, The School Superintendents Association,
Alexandria, Virginia
KATIE ADAMSON, YMCA of the USA, Washington, DC
JAMY D. ARD, Wake Forest University, Winston-Salem, North Carolina
HEIDI MICHELS BLANCK, Centers for Disease Control and Prevention,
Atlanta, Georgia
JEANNE BLANKENSHIP, Academy of Nutrition and Dietetics,
Washington, DC
DON W. BRADLEY, Duke University, Durham, North Carolina
JAMIE BUSSEL, Robert Wood Johnson Foundation, Princeton, New Jersey
MICHELLE I. CARDEL, WW International, Gainesville, Florida
DEBBIE I. CHANG, Blue Shield of California Foundation, San Francisco,
California
JENNIFER FASSBENDER, Reinvestment Fund, Philadelphia, Pennsylvania
AMENDA FISHER, Walmart, Bentonville, Arkansas
TODD GALATI, American Council on Exercise, San Diego, California
ALLISON GERTEL-ROSENBERG, Nemours Children’s Health System,
Washington, DC
MARJORIE A. INNOCENT, National Association for the Advancement
of Colored People, Baltimore, Maryland
JOHN JAKICIC, University of Pittsburgh, Pittsburgh, Pennsylvania
ELIZABETH A. JOY, Intermountain Healthcare, Salt Lake City, Utah
SCOTT I. KAHAN, The George Washington University, Washington, DC
PETER T. KATZMARZYK, Pennington Biomedical Research Center,
Baton Rouge, Louisiana
CATHERINE KWIK-URIBE, Mars, Inc., Germantown, Maryland
THEODORE KYLE, The Obesity Society, Pittsburgh, Pennsylvania
LISEL LOY, Bipartisan Policy Center, Washington, DC
MONICA V. LUPI, The Kresge Foundation, Troy, Michigan
KELLIE MAY, National Recreation and Park Association, Ashburn, Virginia
2 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables
do not issue, review, or approve individual documents. The responsibility for the published
Proceedings of a Workshop rests with the workshop rapporteur and the institution.
vii

STACY MOLANDER, Partnership for a Healthier America,

Washington, DC
MYETA M. MOON, United Way Worldwide, Alexandria, Virginia
STEPHANIE A. MORRIS, SHAPE America, Reston, Virginia
JOSEPH NADGLOWSKI, JR, Obesity Action Coalition, Tampa, Florida
MELISSA NAPOLITANO, The George Washington University,
Washington, DC
PATRICIA NECE, Obesity Action Coalition
MEGAN NECHANICKY, General Mills, Inc., Minneapolis, Minnesota
COURTNEY P. PAOLICELLI, Food and Nutrition Service, U.S. Department
of Agriculture, Alexandria, Virginia
BARBARA PICOWER, The JPB Foundation, New York, New York
LESLIE PLATT ZOLOV, Novo Nordisk, Plainsboro, New Jersey
SUE P. POLIS, National League of Cities, Washington, DC
AMELIE G. RAMIREZ, Salud America!, San Antonio, Texas
GORDON REID, Stop & Shop, Gordon, Massachusetts
SYLVIA ROWE, SR Strategy, LLC, Washington, DC
LAURIE STRADLEY, Alliance for a Healthier Generation, Asheville,
North Carolina
KRISTEN R. SULLIVAN, American Cancer Society, Decatur, Georgia
SUSAN Z. YANOVSKI, National Institute of Diabetes and Digestive and
Kidney Diseases, National Institutes of Health, Bethesda, Maryland
Health and Medicine Division Staff

HEATHER DEL VALLE COOK, Roundtable Director
MARIAH BRUNS, Senior Program Assistant (starting January 2022)
ZARIA FYFFE, Senior Program Assistant (through July 2021)
CYPRESS LYNX, Research Associate
AMANDA NGUYEN, Program Officer
ANN L. YAKTINE, Food and Nutrition Board Director
MEREDITH YOUNG, Research Associate (through January 2022)
Consultant
WILLIAM (BILL) H. DIETZ, The George Washington University,
Washington, DC
viii

Reviewers
This Proceedings of a Workshop was reviewed in draft form by indi-

viduals chosen for their diverse perspectives and technical expertise. The
purpose of this independent review is to provide candid and critical com-
ments that will assist the National Academies of Sciences, Engineering, and
Medicine in making each published proceedings as sound as possible and
to ensure that it meets the institutional standards for quality, objectivity,
evidence, and responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
KIMBERLY GUDZUNE, The Johns Hopkins University

PETER KATZMARZYK, Pennington Biomedical Research Center
STEPHANIE A. NAVARRO SILVERA, Montclair State University
Although the reviewers listed above provided many constructive com-

ments and suggestions, they were not asked to endorse the content of
the proceedings, nor did they see the final draft before its release. The
review of this proceedings was overseen by MARIAN NEUHOUSER,
Fred Hutchinson Cancer Research Center. She was responsible for making
certain that an independent examination of this proceedings was carried out
in accordance with standards of the National Academies and that all review
comments were carefully considered. Responsibility for the final content
rests entirely with the rapporteur and the National Academies.
ix


Contents
1 INTRODUCTION 1
Introductory Remarks, 2
Organization of This Proceedings, 5
2
AN INTRODUCTION TO THE INTERSECTION OF
STRUCTURAL RACISM, BIASED MENTAL MODELS,
STIGMA, WEIGHT BIAS, AND EFFECTIVE HEALTH
COMMUNICATION WITH OBESITY SOLUTIONS 7
3
THE INTERSECTION OF STRUCTURAL RACISM
AND OBESITY 15
Housing Discrimination and Disparities, 17
Education, Segregation, and Structural Inequality, 19
Panel and Audience Discussion, 23
4
THE INTERSECTION OF BIASED MENTAL MODELS,
STIGMA, WEIGHT BIAS, AND OBESITY 25
Obesity Stigma at Work: Improving Inclusion and Productivity, 26
Health Care Systems Perspectives, 30
5
REFLECTIONS ON THE INTERSECTIONS OF
STRUCTURAL RACISM, BIASED MENTAL MODELS,
STIGMA, AND WEIGHT BIAS WITH OBESITY 35
Reflections, 36
xi

xii CONTENTS
6
OPERATIONALIZING HEALTH COMMUNICATION
FOR OBESITY SOLUTIONS 43
What Is Meant by Health Communication?, 45
Audience Discussion, 48
7
DATA-DRIVEN OBESITY SOLUTIONS AND
INNOVATIVE APPROACHES 51
Innovation in Education: Physical Activity across the
Curriculum, 52
Innovation in Health Care: Using Data to Guide Personalized,
Evidence-Based Care for Obesity Using a Clinical Decision
Support System, 55
8 INNOVATIVE POLICY SOLUTIONS 61

A Perspective from the Intertribal Agriculture Council, 62
A Perspective on Innovative Local Government Approaches, 64
9
REFLECTIONS ON EQUITY-CENTERED APPROACHES
TO REDUCING THE PREVALENCE OF OBESITY 69
Reflections on Equity-Centered Approaches to Reducing
the Prevalence of Obesity, 70
Panel Discussion, 74
10
LEVERAGING DATA FOR SYSTEMS CHANGE:
CONNECTING OBESITY AND ITS
UNDERLYING DETERMINANTS 79
How Data Science, Artificial Intelligence, and Other
Technological Approaches Can Help Address the Systems
Contributing to Obesity, 80
Mortality Consequences of the U.S. Obesogenic Environment, 82
11
SYSTEMS APPLICATIONS TO ADDRESS STRUCTURAL
BARRIERS TO OBESITY SOLUTIONS 89
A Structural Approach to Population Health Equity, 90
Structural Solutions for Obesity: Addressing Implicit Bias and
Stereotype Threat, 93

CONTENTS xiii
12
POLICY SOLUTIONS FOR NUTRITION SECURITY
AND OBESITY 99
USDA Priorities for Improving Nutrition Security, 100
Salud America!: Fueling Advocacy for Systems and
Policy Change for Latinx Health Equity, 103
13
A MULTISECTOR CONVERSATION ON SYSTEMS-LEVELS
CHANGES FOR OBESITY SOLUTIONS 109
Opening Reflections, 110
Panel Discussion with Members of the Roundtable on
Obesity Solutions, 113
Closing Remarks for Workshop Day One, 119
14
PATIENT–PROVIDER COMMUNICATION AROUND
OBESITY TREATMENT AND SOLUTIONS 121
The Ethical Dilemma of Implementing Recommendations, 122
The Effect of Obesity on Patient–Provider Communication, 126
Underutilization of Bariatric Surgery: Health Insurance Design,
Weight Stigma, and Patient–Provider Communication, 130
Identifying Gaps and Next Steps (Panel and Audience Discussion), 135
REFERENCES 143
APPENDIXES
A WORKSHOP AGENDAS 153

B ACRONYMS AND ABBREVIATIONS 161
C BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS
AND PLANNING COMMITTEE MEMBERS 163


Box and Figures
BOX
1-1 Workshop Series Statement of Task, 2
FIGURES
1-1 Causal systems map of obesity drivers and solutions, 4
1-2 Aggregation of Meadows’ system leverage points into four broad
types of system characteristics that interventions can target, 5
2-1 A cliff analogy to illustrate four types of health support strategies, 11

2-2 A cliff analogy to illustrate three explanations for the existence of
health disparities, 12
3-1 Racial/ethnic inequities in SARS-CoV-2 exposure and COVID-19

morbidity and mortality, 19
7-1 Theoretical model for improving health and academic

achievement, 53
9-1 Fundamental drivers of health inequity, 72

9-2 Interrelationships among core components of sustainable
systems-wide strategies for reducing the prevalence of obesity, 74
xv

xvi BOX AND FIGURES
10-1 Death rates from cardiometabolic diseases in midlife relative to the

rates in 1990, 83
10-2 Recent trends in cardiometabolic disease mortality, U.S. and peer
country averages, 84
11-1 Well Being in the Nation (WIN) Network’s theory of change, 91

11-2 Pathways to Population Health Equity framework, 92

Introduction
The Roundtable on Obesity Solutions, Health and Medicine Division,

National Academies of Sciences, Engineering, and Medicine, convened a
virtual workshop series to explore sustainable systems-wide changes with
the potential to reduce the prevalence of obesity. The series consisted of
three workshops held in 2021 (April 8, June 22, and October 28–29). The
overall goal of this workshop series was to examine data-driven solutions
and innovative approaches that leverage the connections among three foun-
dational drivers of obesity—structural racism, biased mental models and
social norms, and health communication—and hold promise for effecting
lasting systems change. The workshops explored opportunities for leverag-
ing these connections and their impact on other obesity drivers and solu-
tions across multiple levels and sectors of society, and aimed to identify
systems change applications and opportunities for the future (Box 1-1).1,2
The April workshop provided a level-setting introductory session for the
workshop series, covering the intersection of foundational drivers of obesity
and potential solutions. Additional sessions addressed the intersection of
1 The workshop series agendas, presentations, and other materials are available via https://www.
nationalacademies.org/our-work/addressing-structural-racism-bias-and-health-communications-
as-foundational-drivers-of-obesity-a-workshop-series (accessed January 10, 2022).
2 The planning committee’s role was limited to planning the workshop, and the Proceedings
of a Workshop has been prepared by the workshop rapporteur as a factual summary of what
occurred at the workshop. Statements, recommendations, and opinions expressed are those
of individual presenters and participants, and are not necessarily endorsed or verified by the
National Academies of Sciences, Engineering, and Medicine, and they should not be construed
as reflecting any group consensus.

2 ADDRESSING STRUCTURAL RACISM, BIAS, AND HEALTH COMMUNICATION
BOX 1-1
Workshop Series Statement of Task
Ad hoc planning committees will plan a series of two or three workshops

that will feature invited presentations and discussions to explore strategies for
sustainable systems-wide changes to reduce the prevalence of obesity. Building
on previous work on systems science approaches, health equity, and effective
health communication, the workshops will examine the connections between
drivers and solutions of obesity that have potential for lasting systems change,
including effective health communications, structural racism, and biased mental
models and social norms. The workshop series will also explore the ways to le-
verage these connections and their impact on other obesity drivers and solutions
across multiple levels and sectors of society.
Using diverse examples from across the public health field, workshop pre-
sentations could explore how these drivers interact with critical public health
issues (e.g., COVID-19) to synergistically enhance obesity solutions. Workshop
discussions will cover promising approaches, gaps in the evidence base, and the
challenges and opportunities for long-term, systems-wide strategies needed to
reduce the prevalence of obesity.
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. The June workshop ex-
amined strategies for leveraging health communication and data-informed,
innovative approaches for sustainable systems-wide changes to reduce the
prevalence of obesity. It explored how health communication might en-
hance the understanding and use of current modeling and data-driven ef-
forts to advance obesity solutions, as well as innovative data and policy
approaches. The October workshop considered means of advancing strate-
gies for sustainable systems-wide changes that leverage the three drivers of
obesity, which can inform actionable priorities for individuals, organiza-
tions, and policy makers seeking to reduce both the incidence and preva-
lence of obesity. The October workshop also included a session examining
patient–provider communication on obesity treatment and solutions for
improving those communications.
INTRODUCTORY REMARKS
Nicolaas (Nico) Pronk, president of HealthPartners Institute, chief sci-
ence officer at HealthPartners, Inc., affiliate professor of health policy and
management at the University of Minnesota School of Public Health, opened
each of the three workshops by welcoming participants and providing a

INTRODUCTION 3
brief overview of the Roundtable on Obesity Solutions, explaining that it

engages leaders and voices from diverse sectors and industries (e.g., aca-
demia, government, public health and health care, business, finance, media,
education, child care, philanthropy, nonprofit) to help solve the nation’s
obesity crisis. Through meetings, public workshops, reports, five innova-
tion collaboratives, and other workgroups, he continued, the roundtable
provides a venue for ongoing dialogue on critical and emerging issues in
obesity prevention, as well as treatment and weight maintenance. It applies
a policy, systems, and environmental change lens; focuses on sustainable,
equitable strategies for addressing obesity-related disparities; and explores
and advances effective solutions.
Pronk explained that the workshop series was designed to build on the
roundtable’s previous 2 years of work, during which it examined systems
science approaches, health equity, and effective health communication. He
summarized the roundtable’s strategic planning efforts, completed in 2020,
which he said were intended to inform future efforts in addressing obesity.
He highlighted the strategic planning activities that helped the roundtable
coalesce around a systems-oriented approach to better understanding bar-
riers to and facilitators for the implementation of obesity solutions, an
approach he said has informed its membership of actionable solutions
that support their organizational priorities. In this process, the roundtable
conducted group model-building exercises; gathered input via member
webinars; and disseminated new ideas and systems perspectives and ap-
plications through workshops, meetings, and publications. Infused in these
efforts were discussions that occurred during activities of the roundtable’s
innovation collaboratives and other workgroups.
The roundtable’s strategic planning activities culminated in the de-
velopment of a causal systems map of obesity drivers and evidence-based
solutions, Pronk said, intended to explore data-driven obesity solutions and
innovative approaches. This causal systems map illuminated three priority
areas for the roundtable to address during the next 3–6 years: structural
racism and social justice, biased mental models and social norms, and ef-
fective health communication (Figure 1-1).
Pronk explained that the three priority areas were identified by consid-
ering the roundtable’s mission and operating principles, along with a frame-
work, based on the work of prominent systems thinking scholar Donella
Meadows, illustrating the least and most effective leverage points at which
to intervene in a system (Meadows, 1999). The framework depicts increas-
ingly deeper leverage points, which Pronk acknowledged are progressively
more difficult to penetrate. Yet the deeper leverage points represent increas-
ing effectiveness in creating systems-wide change, he pointed out, because
they represent the power to transcend paradigms out of which systems arise
(Figure 1-2).

4
FIGURE 1-1 Causal systems map of obesity drivers and solutions.

NOTES: Yellow-highlighted areas indicate the roundtable’s priority obesity drivers. Blue-highlighted areas indicate the roundtable’s priority evidence-based solu-
tions. Red dots indicate potential solutions. Green boxes indicate the topics addressed in the workshop series. ACE = adverse childhood experience; CACFP = Child
and Adult Care Food Program; CDC = Centers for Disease Control and Prevention; EBT = electronic benefit transfer; ECE = early care and education; NSBP =
National School Breakfast Program; NSLP = National School Lunch Program; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
SOURCE: Presented by Nicolaas Pronk, April 8, 2021.
INTRODUCTION 5
FIGURE 1-2 Aggregation of Meadows’ system leverage points into four broad types of system
characteristics that interventions can target.
SOURCE: Presented by Nicolaas Pronk, April 8, 2021; Abson et al., 2017. Reprinted with
permission of Springer Nature.
The three focus areas are representative of the framework’s deeper

leverage points, Pronk clarified, adding that it is starting to introduce
these areas as opportunities for potential member action and solutions.
The conversation will be iterative, he emphasized, as it is fed back through
the activities of the full roundtable and its innovation collaboratives and
workgroups.
ORGANIZATION OF THIS PROCEEDINGS

This proceedings follows the order of the workshop agendas
(Appendix A), chronicling their sessions in individual chapters. Chapter 2
summarizes the introductory session from the April workshop, which laid
the foundation for the workshop series in focusing on the intersection of
obesity solutions with biased mental models, stigma, weight bias, structural
racism, and effective health communication. Chapters 3 through 5 report
on the remainder of the April 2021 workshop, which included sessions on
the intersections of obesity and structural racism (Chapter 3); obesity and
biased mental models, stigma, and weight bias (Chapter 4); and reflections
on the workshop (Chapter 5). Chapters 6 through 9 are dedicated to the
June 2021 workshop, which included sessions on health communication
(Chapter 6); data-driven obesity solutions and innovative approaches in
the education and health care contexts (Chapter 7); innovative policy

solutions, challenges, and opportunities (Chapter 8); and reflections on

the workshop (Chapter 9). Chapters 10 through 14 recount the October
2021 workshop, which included sessions on leveraging data for systems
change (Chapter 10), systems applications to address structural barriers to
obesity solutions (Chapter 11), policy solutions for nutrition security and
obesity (Chapter 12), multisector perspectives on systems-level changes
for obesity solutions (Chapter 13), and patient–provider communication
around obesity treatment and solutions (Chapter 14). Appendix B is a list of
acronyms used in this proceedings, and Appendix C contains biographical
sketches of the workshop series planning committee members and speakers
from the three workshops.

An Introduction to the Intersection

of Structural Racism, Biased Mental
Models, Stigma, Weight Bias, and
Effective Health Communication
with Obesity Solutions
Key Points from the Speaker Presentation (Workshop 1, Session 1)

Camara Phyllis Jones, Morehouse School of Medicine
• Racism has been defined as “a system of structuring opportu-
nity and assigning value based on the social interpretation of
how one looks (i.e., ‘race’), that (1) unfairly disadvantages some
individuals and communities, (2) unfairly advantages other in-
dividuals and communities, and (3) saps the strength of the
whole society through the waste of human resources.” Nam-
ing racism recognizes that a dual or multifaceted reality exists
for the affected individuals and communities, and empowers
and equips others to take action toward achieving a system in
which all people can know and develop to their full potential.
• This definition of racism can be generalized to define any
system of structured inequity. Many axes of inequity operate
in society (based on age, sex, sexual orientation, weight sta-
tus, disability status, or religion, for example) and intersect
in individuals and communities. These axes are purported to
be risk markers for how opportunity is structured and value
is assigned; some are also risk factors in the progression to
poor health.
• Health disparities may arise from differences in quality of care
received in the health system; differences in access to health
care, including preventive and curative services; and differences

in life opportunities, exposures, and stresses that result in dif-

ferences in underlying health status.
• Viewing the U.S. population’s trajectory of increased weight as
a shift in population distributions of body mass has implica-
tions for intervention strategies. Specifically, this view calls for
population-based strategies to shift the distribution of body
mass through social, policy, and environmental changes that
target the types of food and activity opportunities available
in such settings as neighborhoods, schools, and workplaces,
where success is influenced by leadership and political will.
• Four commonalities between racism denial and the obesity
epidemic are (1) a narrow focus on the individual that leads to
(2) ignorance of systems and structures that contribute to the
problem, therefore leading to (3) “invisibilizing” of solutions
that would address those structures, resulting in (4) indiffer-
ence and inaction in the face of need.
The first (April 2021) workshop began with an introductory session

that provided a foundation for the workshop series. Camara Phyllis Jones,
senior fellow at the Satcher Health Leadership Institute and Cardiovascular
Research Institute and adjunct associate professor at Morehouse School of
Medicine, presented an allegory for understanding racism, discussed the
adoption of a broader perspective for comprehending the obesity epidemic,
provided an analogy to illustrate levels of health intervention, and offered a
perspective on commonalities between race and weight status and between
racism denial and the obesity epidemic.
Jones began by sharing a story she developed to illustrate racism’s ex-
istence, titled “Dual Reality: A Restaurant Saga.” Based on an experience
she had as a first-year medical student, Jones’s story began with a group of
hungry medical students venturing into town for a meal after a long day
of studying. She and her friends had entered a restaurant, sat down and
ordered food, and begun eating when she noticed a sign in the restaurant
that caused her to have a startling revelation about racism. The sign read
“Open,” she explained, and she commented that she could have thought
no more about it and assumed that other hungry people could enter the
restaurant and order food as she and her friends had done. But because she
was aware of the two-sided nature of such signs, she continued, she realized
that the restaurant was now closed to anyone on the other side of the sign,
who despite their hunger would not be able to enter and eat.
Jones described that moment as critical to shaping her understand-
ing that racism structures “open/closed” signs in our society, which she

INTERSECTIONS WITH OBESITY SOLUTIONS 9
characterized as a “dual reality.” Those sitting inside the restaurant and

eating, she elaborated, look up and see the “Open” sign and are potentially
unaware that the opposite side of the sign has a different message. Jones
asserted that it is difficult for people to recognize a system of inequity that
privileges them, whereas individuals on the outside clearly see the “closed”
sign and are keenly aware of the two-sided nature of the system as they
look through the window and see others inside. For example, she went on,
it is difficult for White Americans to recognize White privilege and rac-
ism, and difficult for all Americans to recognize American privilege in the
global context.
Jones extended the allegory, explaining that people inside the restaurant
may wonder whether the two-sided sign (i.e., racism) really exists. It is dif-
ficult to know the answer to this question when one can see only “Open,”
she suggested, asserting that it is a privilege not to have to know. But when
those inside recognize the two-sided nature of the sign, they can no longer
wonder why those outside do not enter and sit down to eat. Knowledge of
the existence of the two-sided sign (i.e., naming racism) is not scary, but
empowering. Such knowledge does not compel those inside the restaurant
to act, she clarified, but it does equip them for action if they care about
those on the other side of the sign. As an example, she explained that the
people inside could inform the restaurant owner about those outside and
suggest that they be allowed to enter, or pass food out through the window,
or even try to tear down the sign or break down the door.
Jones expressed feeling encouraged that more people who are “born
inside the restaurant” have a sense of the two-sided nature of the sign
compared with a year ago. More people are saying the word “racism,” as
well as recognizing the terms “structural racism” and “systemic racism.”
She cautioned against proclaiming these terms but failing to act, thereby
slipping back into what she called a staunchly held societal “racism denial.”
Naming racism is essential but insufficient, and she urged the audience not
only to understand that racism is the sign creating a dual or multifaceted
reality, but also to recognize that the sign corresponds to a locked door that
must be broken down. “If we start acting, we will not forget why we are
acting,” Jones declared as she concluded her story.
Jones moved on to further characterize racism and link it to the obesity
epidemic, weight status, and discrimination. She described racism as “a sys-
tem of structuring opportunity and assigning value based on the social
interpretation of how one looks (i.e., what society calls ‘race’), that (1) un-
fairly disadvantages some individuals and communities, (2) unfairly advan-
tages other individuals and communities, and (3) saps the strength of the
whole society through the waste of human resources” (Jones, 2002). With
regard to her second named impact of racism, Jones suggested that the is-
sue of “unearned White privilege” is scarcely discussed in the United States

because it makes some people, particularly those living as White, uncom-

fortable. She urged leaning into such discomfort, proposing that “the edge
of our comfort is actually our growing edge.” She also urged society to raise
awareness of her third named impact of racism, such as through media sto-
rytelling and dinner table conversations, to instill a societal sense of urgency
around dismantling the system of racism and replacing it with a system in
which all people can know and develop to their full potential.
According to Jones, her definition of racism can be generalized to define
any system of structured inequity. She cited sexism as an example, charac-
terizing it as a system of structuring opportunity by assigning value based
on gender, and having the same three impacts described in her definition of
racism. Many axes of inequity operate in society and intersect in individuals
and communities, Jones said, giving the examples of ethnicity, Indigenous
status, and colonial history; weight status; labor roles and social class
markers; nationality, language, and immigration status; sexual orientation,
gender identity, and gender expression; disability status; geography; age;
religion; and incarceration history. 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 (Jones, 2014).
Shifting to discuss obesity and weight perception, Jones stated that the
U.S. obesity epidemic has traditionally been characterized as a binary clas-
sification of individuals on either side of the body mass index (BMI) cut
point for obesity. Overweight and obesity are considered characteristics of
“high-risk” individuals, she maintained, but suggested that understanding
distributions of BMI as characteristics of populations—given that shifts
in the population distribution of body mass drive the obesity epidemic—
would illuminate what action is needed.
Such a shift in perspective has implications for intervention strategies,
Jones continued, and she contrasted “high-risk” strategies with population-
based strategies. The former involve urging individuals to avoid weight gain
or lose weight by focusing on diet and physical activity, with success being
dependent on perception of weight, motivation, and availability of healthful
resources. The latter strategies, on the other hand, are aimed at shifting the
distribution of body mass at the population level toward lower values via
policy and environmental changes that target the types of food and activ-
ity opportunities available in such settings as neighborhoods, schools, and
workplaces, where success is influenced by leadership and political will.
Jones elaborated on intervention strategies by offering a cliff analogy to
explain levels of health intervention. Imagine that a person “fell off the cliff
of good health,” she began, and was met by an ambulance at the bottom
to whisk them to medical care. If society were concerned about others who
might encounter the cliff (i.e., if it cared about population or community
health), it might consider what supports to put in place in addition to the

ambulances at the bottom. Jones outlined potential support strategies,

along with their limitations: a net between the edge of the cliff and the
ground below, although some people might still fall through holes in the
net; a trampoline halfway down the cliff, although those who landed on it
might end up bouncing up and down, unable to get back to the top of the
cliff; and a fence at the edge of the cliff to prevent falls, although it would
have to be strong enough to resist heavy pressure from the population. A
fourth support strategy, she suggested, would be to move the population
away from the cliff’s edge. Jones likened the ambulance to acute medical
care and tertiary prevention, the net and trampoline to safety net programs
and secondary prevention, the fence to primary prevention, and shifting
the population away from the edge to addressing social determinants of
health and the contexts of peoples’ lives that push or position them into a
high-risk area (Figure 2-1).
Jones pointed out a critical limitation of the cliff analogy, which is
its failure to address how health disparities arise. She offered three expla-
nations for the existence of health disparities, which she explained may
FIGURE 2-1 A cliff analogy to illustrate four types of health support strategies.
SOURCE: Presented by Camara Phyllis Jones, April 8, 2021; Jones et al., 2009. Reprinted with
permission of Johns Hopkins University Press.

manifest according to such characteristics as racial/ethnic identity, weight

status, region, or immigration status. One explanation is differences in the
quality of care received in the health system; a second is differences in ac-
cess to health care, including preventive and curative services; and a third
is differences in life opportunities, exposures, and stresses that result in dif-
ferences in underlying health status (Byrd and Clayton, 2001; IOM, 2003;
Phelan et al., 2010). Returning to the cliff analogy, she pointed out that
these three explanations indicate that the cliff is three- (rather than two-)
dimensional, and that some parts of the cliff might have slow or misdi-
rected ambulances at the bottom, as well as insufficient or missing nets or
fences. These limitations, Jones continued, are representative of differences
in quality of care and in access to care, respectively. 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 (Figure 2-2).
Taking a step back, Jones explained that the analogy of a three-
dimensional cliff prompts such questions as how it became three-dimensional,
FIGURE 2-2 A cliff analogy to illustrate three explanations for the existence of health disparities.
SOURCE: Presented by Camara Phyllis Jones, April 8, 2021; Jones et al., 2009. Reprinted with
permission of Johns Hopkins University Press.

why differences in resources exist along the cliff face, and why differences
exist in the populations that are found at different points along the cliff
(Jones et al., 2009). When these questions come to the forefront, she said, it
stimulates conversations about systems of power that can lead to differen-
tial circumstances. She termed these systems of power “social determinants
of equity” (or inequity) or “systems of structured inequity.” According to
Jones, such systems include racism, sexism, heterosexism, capitalism, and
all of the systems associated with weight bias and discrimination.
Next, Jones expanded the cliff analogy to explain three dimensions of
health intervention. The dimension along the cliff’s edge is where preventive
and curative health services, such as the ambulance, net, and fence, are dis-
played. If this dimension is the only focus, she cautioned, even a universal
health care system may be overwhelmed by the need to serve everyone.
Jones urged moving into a second dimension of health intervention—
addressing such social determinants of health as adverse neighborhood
conditions and poverty—to move people away from the cliff’s edge. Failure
to recognize that the cliff is three-dimensional, she warned, risks moving
only some of the population away from the edge and thereby exacerbat-
ing health disparities. Jones emphasized the importance of acknowledging
and addressing the three-dimensional nature of the cliff. Doing so, she
suggested, leads to the third dimension of health intervention: addressing
social determinants of equity.
The cliff analogy and the framework it creates raise three questions,
Jones continued. First is why such a large proportion of U.S. health care
expenditures goes toward acute medical care and tertiary prevention. The
most cynical and apparent answer, she suggested, is that a great deal of
money is made on medical treatments and devices, pharmaceuticals, and
other such products and services. The more profound answer, however, is
that the United States is too narrowly focused on the individual and does
not recognize people’s health problems until they have already occurred.
This narrow focus prevents recognition of the proximity of populations to
the cliff’s edge as a health problem, Jones asserted, noting that such metrics
as income inequality and social cohesion are not used as health measures.
Jones went on to raise the second question: why certain populations are
so close to the edge of the cliff—why they engage in non–health-promoting
behaviors. This focus on individual behaviors, she proposed, renders sys-
tems and structures either invisible or seemingly irrelevant.
The third question, Jones continued, is why a problem exists with the
three-dimensional cliff. In her view, individuals may ask this question if they
are in relatively privileged positions and lack a strong sense of urgency to
help disadvantaged populations with whom they rarely come into contact.
Jones shared her belief that this point of view reflects an endorsement of
the “myth of meritocracy.” She acknowledged that most people who have

“made it” have indeed worked hard, but she suggested that this is not a
universal truth: that not everyone who has “made it” has worked hard,
and some who have worked hard “will never make it” because the playing
field is uneven, a situation perpetuated by systems of structural inequity.
According to Jones, denying the existence of an uneven playing field; rea-
soning that lack of hard work is why people have not “made it”; and
talking about diversity, equity, inclusion, cultural competence, disparities,
and other similar terms without naming racism are different ways of deny-
ing racism’s existence.
To conclude her presentation, Jones recapped what she perceives as
four commonalities between denial of racism and the obesity epidemic:
(1) a narrow focus on the individual that leads to (2) ignorance of systems and
structures that contribute to the problem, and therefore (3) “invisibilizing”
of solutions that would address those structures, leading to (4) indifference
and inaction in the face of need.
After her presentation, Jones answered a question from Pronk about
defining health equity in the context of obesity. She provided a three-part
definition that she said encompasses what health equity is, how it can be
achieved, and how it relates to health disparities. According to Jones, health
equity is not an outcome but a process by which society pursues assurance
of the conditions for optimal health for all people. She stressed that achiev-
ing health equity requires valuing all individuals and populations equally,
recognizing and rectifying historical injustices, and providing resources
according to need. She closed by asserting that health disparities will be
eliminated when health equity is achieved.

The Intersection of Structural

Racism and Obesity
Key Points from the Presentations of Individual

Speakers (Workshop 1, Session 2)
• Pathways through which housing discrimination operates and
structural racism influences housing disparities include physi-
cal housing conditions, housing affordability and stability, and
racial residential segregation. Segregation has been linked to
health via pathways of resource deprivation (differential ac-
cess to health-supporting resources) and risk exposure (greater
exposure to environmental toxins, hazardous products, and
concentrated poverty in the communities where segregated
populations tend to live). (Thorpe)
• Opportunities to reduce housing disparities include improving
housing affordability for people of color, providing people of
color with thriving wages, investing in underresourced com-
munities based on residents’ intentionally solicited input on
how best to make such investments, and forming cross-sector
partnerships to facilitate health equity in housing and com-
munities. (Thorpe)
• Legal segregation in housing has resulted from a series of Su-
preme Court decisions over the years. Racialized residential
patterns are a key contributor to resegregation and structural
inequalities in education, but the courts have declined to address
these connections meaningfully in recent decades. (Navarro)
15

• The Equal Protection Clause of the 14th Amendment was

a powerful tool in the past, but is now used to ensure that
institutions make race-blind decisions even when attempt-
ing to address racially mediated systemic problems. Fur-
thermore, school reform alone through such approaches as
schools of choice, voucher programs, and charter schools
fails to address the root problem of racialized residential
patterns. (Navarro)
The first workshop’s second session was dedicated to the intersection of

structural racism and obesity. Stephanie Navarro Silvera, professor of pub-
lic health at Montclair State University, moderated and provided opening
remarks, which were followed by presentations on housing and education
and a discussion with the session’s two speakers.
Silvera proposed that racism provides a social and institutional frame-
work for how people live, eat, and die. She likened it to an iceberg, sug-
gesting that most efforts to address racism chip away at the top of the
iceberg and appear to be making significant progress. But those efforts
do not penetrate the submerged, most dangerous portion of the iceberg.
Silvera explained two lenses through which she views issues of structural
inequality: large “P” policy, which includes broad federal, state, and local
laws that may or may not be specific to health (e.g., voting rights, housing,
education, and health care); and small “p” policy, which includes organi-
zational practices and policies that influence human behaviors, as well as
large “P” policy, through funding availability, enforcement, intention, and
equitability of policy application.
Silvera informed the audience that the session would explore the his-
tory of institutionalized racism in housing and education, and its influence
on current behaviors and food and activity environments. Inequities and
segregation persist in both residential environments and the educational
system, she observed, and are related to obesity because, for example,
geographic access to supermarkets in urban areas has been documented to
vary according to income and race (often both). According to Silvera, the
interconnectedness of housing’s impact on socioeconomic resources and
the corresponding impacts on education and occupation, and ultimately
health, manifest not only at an individual level but also at a generational
level. Circling back to her initial statement about racism, she stressed that
the environment into which one is born and the resources available affect
one’s health at birth and throughout the lifespan, as well as educational at-
tainment and income through a succession of interconnected systems that
influence how people live, eat, and die.

INTERSECTION OF STRUCTURAL RACISM AND OBESITY 17
HOUSING DISCRIMINATION AND DISPARITIES

Roland Thorpe Jr., professor in the Department of Health, Behavior,
and Society at The 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 codirector of the uni-
versity’s Alzheimer’s Disease Resource Center for Minority Aging Research,
discussed the interplay of housing with structural racism and obesity.
Thorpe opened with a quote from a 2020 article in The Atlantic,
“Sometimes racial data tell us something we don’t know. Other times we
need racial data to confirm something we already seem to know.”1 From
Thorpe’s perspective, this quote inspires conversation about the broader
systems that influence reality and also highlights that sometimes sufficient
data exist to confirm a problem, which in turn propels action toward
solutions.
Thorpe described pathways through which housing discrimination op-
erates and through which structural racism influences housing disparities.
The first is physical housing conditions, such as lead in a home. The second
is housing affordability and stability, he continued, adding that a higher
rent burden (i.e., a higher proportion of income spent on housing) has
been linked to hypertension and poor self-rated health, and also consumes
financial resources that otherwise could go toward health-related expenses.
He explained that housing instability encompasses such outcomes as being
behind on rent or mortgage payments, frequent moves, homelessness, evic-
tion, foreclosure, displacement, and overcrowding. The third pathway is
residential racial segregation, which he identified as a fundamental deter-
minant of health, but one that has garnered little discussion with regard to
its impact on housing.
Thorpe expounded on two pathways linking residential racial segrega-
tion to health: resource deprivation and risk exposure. Noting that segrega-
tion creates differential access to health-supporting resources, he pointed
to associations between segregation and lower availability of full-service
restaurants and supermarkets; fewer opportunities to access high-quality
medical care; and fewer health clinics, physicians, and pharmacies (Bower
et al., 2014; Gaskin et al., 2012a,b; LaVeist, 2011; Morland et al., 2002;
Morrison et al., 2000). Moving on to the risk exposure pathway, Thorpe
explained that segregation creates differentials by race in the health risk
profiles of communities in which Black people and other minorities often
live. Exposure to environmental toxins (e.g., lead paint in a home) often is
greater in highly segregated areas, he stressed, as is the targeted availability
1 https://www.theatlantic.com/ideas/archive/2020/04/coronavirus-exposing-our-racial-
divides/609526 (accessed January 11, 2021).

of such hazardous products as tobacco, alcohol, and illegal drugs. He added

that highly segregated areas are typically characterized by concentrated
poverty, which tends to lead to high crime, low-quality housing, and a
stressful environment.
Racial segregation in the United States distinguishes how people ex-
perience this country, Thorpe declared. He noted that minorities tend to
live in more geographically distinct communities compared with Whites,
which impacts housing. Not only does racial segregation lead to differential
environmental and social risk exposures that exist within a long-standing
system of structural racism, but other discriminatory practices, such as
redlining, have perpetuated housing disparities. Thorpe highlighted the
Homeowners Loan Act of 1933, whose objective was to help refinance
nonfarm home mortgages at risk of foreclosure. This was to be accom-
plished by creating a Home Owners’ Loan Corporation (HOLC) to buy
upside-down mortgages from banks and issue low-interest, federally backed
15-year amortized home mortgage loans that would reduce homeowners’
monthly payments. Banks would not issue loans to homeowners in certain
areas in the city, he continued, which were designated with red lines on
HOLC maps and corresponded to the areas where large proportions of
Black people lived. The result was that Black Americans were systemati-
cally denied these loans, illustrating the point with the high proportion of
redlined areas on a 1930 HOLC map of Macon, Georgia. He next showed
a recent map of Macon, pointing out that even though the Fair Housing Act
of 1968 outlawed redlining, the areas categorized as declining or hazardous
on this map correspond to the previously redlined areas. Most (91 percent)
of the redlined neighborhoods continue to be inhabited predominantly by
minorities and 73 percent of these neighborhoods are low to moderate
income (Jan, 2018). Most White people live in the neighborhoods catego-
rized as “best” or “desirable,” he continued, which correspond directly to
the areas designated as such in the 1930 HOLC map.
Turning to the potential influence of structural racism on diseases
including obesity, Thorpe next presented a conceptual framework of path-
ways through which neighborhoods shaped by structural racism may con-
tribute to racial/ethnic inequities in SARS-CoV-2 exposure and COVID-19
morbidity and mortality (Figure 3-1) (Berkowitz et al., 2021).
He cited attributes of low-resource neighborhoods—including pollu-
tion, limited walkability, lower-quality housing stock, low access to nutri-
tious foods, less accessible health care, and overpolicing and crime-related
stress—and pointed out that those attributes are also potential contributors
to obesity. He added that during the COVID-19 pandemic, the same neigh-
borhoods tended to have limited ability to practice social distancing because
of crowded housing conditions, had fewer resources that were open and
accessible, and had limited protective social environments.

FIGURE 3-1 Racial/ethnic inequities in SARS-CoV-2 exposure and COVID-19 morbidity

and mortality.
SOURCE: Presented by Roland Thorpe Jr., April 8, 2021; Berkowitz et al., 2021. Reprinted
with permission of Taylor & Francis Ltd.
The problems of structural racism, housing disparities, and obesity are

at the systems level and are inextricably linked, Thorpe stressed, but he ar-
gued that these problems can be addressed with new, different approaches.
He ended his presentation by listing four opportunities for achieving greater
equity in health and health care for vulnerable populations, with an empha-
sis on reducing housing disparities. The first is improving housing afford-
ability for people of color, perhaps through zero-interest loans. The second
is providing people of color with not just living but thriving wages, a
concept he noted is currently undefined but a ready topic for discussion.
The third is investing in underresourced communities based on residents’
meaningfully solicited inputs on how best to make those investments. The
fourth is forming cross-sector partnerships to facilitate health equity in
housing and communities.
EDUCATION, SEGREGATION, AND STRUCTURAL INEQUALITY

J. Alexander Navarro, assistant director of the University of Michigan
Center for the History of Medicine, discussed connections among institution-
alized racism, housing, and segregation in the U.S. education system. One
cannot understand inequality in education, he proposed, without understand-
ing the role played by the courts in resegregating the country’s schools during

the past 70 years. The role of these court decisions is also important in the
context of spatial U.S. geographic and residential patterns that reflect decades
of legal segregation in housing. Segregation in education is described more
accurately by the phrase “de jure” rather than “de facto,” he pointed out,
because it is the result of legal segregation in housing versus an occurrence
that exists in reality but lacks legal recognition.
Navarro reviewed a series of court cases he sees as key influences on
education in the United States. In Brown v. Board of Education (1954), he
began, the Supreme Court ruled that school segregation is unconstitutional,
a decision that overturned the Plessy v. Ferguson (1896) ruling upholding
the constitutionality of racial segregation under the “separate but equal”
doctrine. In the Brown decision, the Court ruled that separate facilities are
inherently unequal and therefore violate the Equal Protection Clause of the
14th Amendment. The following year, the Court’s Brown II (1955) ruling
that school districts must desegregate “with all deliberate speed” placed
responsibility for desegregation with local school boards. Although griev-
ances are typically redressed immediately in cases of civil rights violations,
he explained, this clause was problematic because it left room for school
districts to resist desegregation. Many places refused to desegregate or did
the bare minimum, Navarro recounted, which he described as evident based
on the poor state of desegregation into the 1960s.
Navarro moved on to discuss Green v. New Kent County (1968), which
he characterized as possibly the most important of the cases he would be
discussing. Virginia had strongly resisted integration efforts even after the
Brown decision, he noted for context, and began to relent only after pas-
sage of the 1964 Civil Rights Act tied federal funding to desegregation.
Prior to the 1968 ruling, New Kent County students could choose to attend
the county’s (previously all-)White school or (previously all-)Black school
under a “freedom of choice” plan. Students could change schools only after
sending paperwork to a state-run board; otherwise they were automatically
assigned to the school they had attended previously. Despite this adminis-
trative requirement, several hundred Black students opted to transfer to the
White school. Once there, Navarro continued, they faced opposition and
harassment, and a resulting court case made it to the Supreme Court. The
Court ruled that the freedom of choice plan was ineffective; that “the time
for mere ‘deliberate speed’ has run out”; and that school boards have an af-
firmative duty to dismantle and eliminate racially unitary school systems, a
component of the ruling that Navarro characterized as critically important.
Swann v. Charlotte-Mecklenburg (1971) was a turning point, according
to Navarro, because the Supreme Court ruled that district courts can use
three powerful tools to influence school district policies: (1) racial quotas
can be used as a starting point for the development of integration plans;
(2) courts can redraw district lines as an interim corrective measure; and

(3) courts can mandate and enforce busing plans for school districts to facili-
tate transportation of both Black and White students to opposite-race schools
for integration purposes. This third provision was widely unpopular, Navarro
explained, because of the burden it placed on students who were bused long
distances (many of whom were Black). He also noted that this was the last
time the Supreme Court was unanimous on a school segregation case.
Navarro next pointed to San Antonio v. Rodriguez (1973), which
stemmed from the practice in Texas of deriving school district funding
mainly from local property taxes and guaranteeing only a small proportion
of that funding from the state. According to Navarro, this practice 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 discrimi-
nated against children living in poverty. The district court agreed with the
school district, but the Supreme Court struck down the lower court’s deci-
sion in ruling that (1) a federal, constitutional right to education does not
exist; therefore (2) unequal school funding is not illegal; and (3) poverty
does not make for a suspect class—that is, courts cannot view people who
are poor as subjects of discrimination because of poverty itself. Navarro
explained that this case set the stage for considering school segregation in
light of residential housing and therefore funding patterns, and a rapid shift
in segregation in education followed.
The following year, Milliken v. Bradley (1974) featured a plaintiff’s
allegation that de facto school segregation in Detroit resulted from de jure
housing policies. This was the first time a plaintiff had attempted to link
segregation with housing policies, he pointed out, and the district court
agreed that policies influencing geographic and residential housing pat-
terns had contributed to school segregation. The district court ordered
Detroit schools and 53 adjacent suburban school districts to desegregate,
Navarro said, which was realistically achievable only by busing suburban
children into the city and vice versa because of the way housing patterns
had developed. But the Supreme Court disagreed with forced busing across
school district lines, despite having ruled 3 years earlier (Swann, 1971) that
districts could impose busing to facilitate integration. The Supreme Court
suggested that the racial makeup of school districts resulted from housing
patterns and not policies, Navarro elaborated, and that children in the
suburbs could not be forced to bus across county lines to desegregate a dif-
ferent (i.e., the city of Detroit’s) school system. According to Navarro, this
essentially meant that a Detroit-only desegregation plan was the only solu-
tion, but he questioned the feasibility of that approach given that Detroit
at the time was rapidly becoming a majority Black city.
Navarro fast-forwarded to 1991 to review Oklahoma City Schools
v. Dowell, a case that spanned a decades-long series of events in which

Oklahoma City attempted desegregation via neighborhood zoning and then

busing. After integration was achieved in the late 1970s, the busing man-
date was removed, and resegregation ensued, yet a district court ruled that
any segregation had resulted from neighborhood housing patterns, not from
school district discriminatory practices. The Supreme Court agreed that
because the school district had complied with the original desegregation
plan and the vestiges of de jure segregation had been removed, schools did
not need to continue with court-mandated desegregation plans. According
to Navarro, the ruling effectively communicated that school segregation
based on racialized housing patterns was legal. In light of this decision, he
maintained, school resegregation has increased dramatically since 1991.
Navarro discussed a final case, Parents Involved in Community Schools
v. Seattle (2007), which developed as a result of the practice of using race as
a tiebreaker for admission to competitive high schools in Seattle, intended
to ensure some level of diversity in those schools. The Supreme Court
agreed with the parents that the practice was unconstitutional and that
students cannot be classified on the basis of race despite diversity goals.
Furthermore, the Court ruled that because Seattle was never under a deseg-
regation order, the state had no compelling interest in using race for school
admission. In short, he said, this ruling indicated that segregation based on
housing patterns was not illegal.
Navarro shifted to describing the current state of school segregation,
referencing data indicating that more than half of U.S. students attend a
racially concentrated school (García, 2020; Schaeffer, 2021). Racialized
poverty is a “double whammy” for students of color, he contended, be-
cause poor students of color fare worse than poor White students. Students
of color are twice as likely to live in poverty as their White counterparts,
he pointed out, and are at least five times as likely to live in an area of
concentrated poverty, with associated negative social and health effects
(Creamer, 2020; Kneebone and Holmes, 2016; National Equity Atlas,
2019). Even though school integration has been recognized as one of the
best paths to achieving racial equity, he asserted, school resegregation has
accelerated in recent decades, and he reiterated that it is tied directly to
residential segregation.
Navarro cited as a key issue to keep in mind that the Equal Protection
Clause of the 14th Amendment has become a double-edged sword. It was a
powerful tool in the past, he observed, but he believes it has become weap-
onized and now ensures that institutions can make race-blind decisions even
when attempting to address racially mediated systemic problems. In addi-
tion, he argued, the courts do not reliably provide remedies as they did for
plaintiffs between the late 1950s and early 1970s. The connections between
racialized residential patterns and school segregation are well known, he
maintained, but he stressed that the courts have routinely refused in recent

decades to address these connections in a meaningful way. He reiterated

his assertion that “de facto” school segregation is a misnomer, and that
the phenomenon instead results from legal segregation and residential pat-
terns. These conditions were initially bolstered by Jim Crow–era policies, he
added, and have been fueled more recently by policies that privilege private
capital, private development, and urban renewal programs that he asserted
are aimed at affluent populations and seek to protect White sensibilities
regarding “who gets to live where.”
Finally, Navarro shared his belief that school reform alone is a dead
end. He contended that such programs as schools of choice, voucher pro-
grams, and charter schools fail to address the root problem, characterizing
them as conservative, “pseudo free market approaches” to public educa-
tion. He contended that introducing competition among schools does not
work because public education is not a commodity, and treating it as such
feeds into the notion that de facto school segregation results from market
forces and from who buys homes in which neighborhoods and communi-
ties. In closing, he argued for viewing public education as infrastructure
rather than as a commodity.
PANEL AND AUDIENCE DISCUSSION

Following the two presentations summarized above, Silvera moderated
a discussion with the speakers, which was followed by a round of audience
questions. Topics addressed included ideas for effecting systemic change by
intervening on root causes, such as housing and education, and by promot-
ing multisector involvement and community engagement.
Effecting Systemic Change by Intervening on Root Causes

Silvera observed that racialized segregation in housing and education
are so deeply entrenched that they may not be recognized as consequences
of policies, and she asked the speakers for suggestions about where to
intervene to address the root causes of these issues. Thorpe suggested that
it is necessary first to acknowledge the existence of structural racism, and
then to apply both federal-level and local municipality–level approaches
simultaneously to address political determinants of health.
Navarro predicted that the current Supreme Court, with its conserva-
tive makeup, is unlikely to produce a court-based solution to these issues
any time soon. He agreed with Thorpe that both federal and local ac-
tions are important. He cited housing voucher programs and the Internal
Revenue Service’s low-income housing tax credit program as examples of
federal programs that are ineffective in addressing structural inequality in
housing because they focus on keeping people in high-poverty areas instead

of moving them to high-opportunity areas. He suggested examining local

zoning and housing ordinances, which he said have racial implications
regarding “who gets to afford to live where,” and cautioned against incen-
tivizing gentrification that displaces current inhabitants. He appealed for
increasing access to capital for communities of color, alleging that these
populations have been denied access to the home-buying market under
racialized policies operating under the guise of other issues, such as using
credit score as a proxy for race.
Effecting Systemic Change through Multisector

Involvement and Community Engagement
Addressing a participant’s question about who is responsible for driv-
ing changes to address structural racism, Thorpe called out people who
are in positions that maintain the structures involved, such as government
officials and corporate decision makers. In terms of obesity solutions, he
mentioned building grocery stores in food deserts as a way to both address
food insecurity and provide employment for community residents, as well
as using government or corporate capital to fund schools in establishing
urban gardens that can be used to teach students while producing fresh
produce for the community. Silvera underscored her belief that all policy
is health policy given the multisectoral influences on health, and that all
politics are local, which is the level at which she said policy has a direct
impact on individuals and communities.
Navarro observed that when cities undergo urban renewal, much of
that capital is directed to large developers and corporations. He proposed
allocating a proportion of capital to community-based organizations owned
and operated by residents, who he said typically lack the connections
needed to secure a seat at the table when capital is being distributed. Silvera
agreed and emphasized the value of amplifying community voices to better
understand challenges and cocreate solutions that will be a good fit for the
community, such as ensuring that foods provided to improve food access
are culturally and ethnically appropriate.
Thorpe built on Silvera’s statement about health in all policies, point-
ing out that sectors tend to work in silos, but that partnering on seemingly
unrelated but interconnected issues could leverage expertise and resources
to achieve greater benefit relative to working independently. Navarro men-
tioned the Flint water crisis as an example of a health issue with broader
systemic influences, stemming from a decades-earlier White flight out of
Detroit, the city’s deindustrialization, and remaining residents’ loss of water
access due to unpaid water bills. These events made such a crisis inevitable,
he contended, rather than the result of a series of unforeseen consequences.

The Intersection of Biased

Mental Models, Stigma,
Weight Bias, and Obesity

• Weight-based stigma in employment appears to pervade every
stage of the employment cycle, including recruitment and selec-
tion, the development of employee relationships and well-being,
progression and promotion, employment retention, and unem-
ployment. These disadvantages are compounded by an obesity
wage penalty, which affects women more than men. (Bevan)
• Well-intentioned workplace health promotion programs with
a nutrition, exercise, or weight management component may
inadvertently reinforce obesity stigma and make people with
obesity reluctant to participate. (Bevan)
• Weight-related biases among members of the health care system
become embedded in the system’s structures and form weight-
related barriers for patients navigating the system. (Norris)
• It is important to recognize the experiences of patients with
excess weight—such as weight-related discrimination, weight
bias–induced limitations on employment and educational at-
tainment, mistrust of care, impaired cognitive processing due
to the additional psychosocial stress, and other comorbidities—
and provide them with high-quality care, respectful treatment,
empathy, compassion, support, and hope. (Norris)
25

Carlos Crespo, professor at Oregon Health and Science University

and Portland State University School of Public Health and vice provost for
undergraduate training in biomedical research at Portland State University,
moderated the first workshop’s third session. The session’s two speakers
discussed the intersection of biased mental models, stigma, weight bias, and
obesity, with a focus on workplace and health care settings.
In his introductory remarks, Crespo suggested that to guide their ac-
tions, people rely on mental models, which he likened to behavioral short-
cuts or algorithms. He suggested that these algorithms are as good as the
assumptions and biases on which they are based, which therefore inform
a person’s actions, even subconsciously. Consequently, he argued, decon-
struction of those assumptions and biases is important. Weight biases exist
at the individual, institutional, and structural levels, he continued, where
they become negative attitudes that are based on distorted beliefs. These
attitudes and beliefs permeate multiple types of settings, he added, and
provide the foundation for organizational norms. Those norms in turn
lead to stereotypes that negatively impact the lives of people with obesity,
he elaborated, such as through stigma, exclusion, and discrimination, and
ultimately, health inequities. He reiterated the call to deconstruct and elimi-
nate weight bias as an essential step in rewriting the narrative at all levels.
OBESITY STIGMA AT WORK:

IMPROVING INCLUSION AND PRODUCTIVITY
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. He elaborated
on two specific challenges—the obesity “wage penalty” for women, and the
sometimes inadvertent internalization of weight stigma in worksite health pro-
motion efforts. He also offered suggestions for ways in which employers and
health care providers could improve work outcomes for people with obesity.
Bevan suggested that among people who characterize obesity solely as
an individual issue of willpower and eating and activity habits, weight bias
may be the last “acceptable” form of stigma and discrimination. Almost
half (45 percent) of UK employers say they are less inclined to recruit
candidates who have obesity, and people who have obesity experience
lower starting pay, less hiring success, and lower coworker ratings of job
performance and ability (Bevan, 2019). They are frequently regarded as
having less willpower and resilience, he continued, and are less likely to be
perceived as able leaders or as having career potential. Women with obesity,
Bevan reported, are less likely to get customer-facing jobs and fare poorly in
the “aesthetic labor market,” a term he explained refers to settings where
appearance may be deemed more important than competence.

BIASED MENTAL MODELS, STIGMA, WEIGHT BIAS, AND OBESITY 27
Bevan next referenced a literature review indicating that employment

discrimination and stigma appear to be more common among women
than men, with women being 16 times more likely to report weight-related
employment discrimination (Bajorek and Bevan, 2020). These authors also
found that 25 percent of women with overweight and obesity reported
experiencing job discrimination because of their weight, and 54 percent
reported being subjected to weight-based stigma from coworkers or col-
leagues (Bajorek and Bevan, 2020). These experiences are rarely challenged
in workplaces, Bevan observed, and are instead regarded as outside the
mainstream of diversity and inclusion practices and policies.
According to Bevan, research suggests that weight-based stigma in
employment pervades every stage of the employment cycle, including re-
cruitment and selection, the development of employee relationships and
well-being, progression and promotion, employment retention, and un-
employment. For people with obesity, the weight-based challenges at each
stage influence their employment outcomes.
Bevan then turned to discussing the obesity wage penalty, the first
of two specific challenges he would address. He reported that a 2016 re-
view conducted by the UK government identified a 10 percent wage gap
between people with obesity and those with average weight. Neither the
contributors to this finding nor the direction of causality was explored, but
he referenced prior research on employment that identified links among
social determinants of health (including poverty and employment), health
inequalities, and obesity (Marmot, 2020). Moreover, living with obesity is
linked not only to lower wages and employment discrimination, but also
to lower household income throughout life because of gaps in education,
as well as poorer health (Lee et al., 2019). Elaborating on social determi-
nants of health, he explained that they have been referred to as “the causes
of the causes of ill health,” where the first type of “causes” encompasses
the conditions in which people are born, grow, live, and work, while the
second type consists of health risk factors such as smoking and poor diet
(Walker, 2021).
Bevan cited “overwhelming” evidence of the greater effects of the
wage penalty on women than on men, and said his group is studying
its causes and impact. He reported that the average gap is estimated at
9–13 percent. He added that this gap is not just in annual earnings (Bajorek
and Bevan, 2020). Rather, strong evidence suggests that living with obe-
sity from childhood to adulthood is associated with an earning disparity
throughout the life course. Bevan gave the example of a study finding
that females who had obesity at age 16 had 34 percent lower household
incomes at age 42 compared with women of normal weight in the same
age cohort (Black et al., 2018). Bevan listed additional research findings:
women’s earnings peak at a body mass index (BMI) of 20–22 and decrease

as BMI increases (one study detected a 4 percent drop in income within

4 years after a 1-point increase in BMI); mothers who have obesity earn
almost 7 percent less than mothers of average weight (one study measured a
7.6 percent decline per child among single mothers with obesity); and older
women with BMI > 40 kg/m2 are more likely to have extended periods of
sick leave and to leave employment early, after controlling for age and other
health factors, with stigma and discrimination hypothesized as playing a
role (Linaker et al., 2020).
Bevan moved on to review four proposed explanations for the wage
penalty. First is the explanation of human capital differences, which pur-
ports that women with obesity have lower educational attainment and
limited work experience and experience occupational segregation into oc-
cupations with less prestige (i.e., work that is lower paid, lower skilled, and
lower status). A second explanation is life-course barriers: that women with
versus those without obesity find it more difficult to shed the health and ed-
ucation inequalities of childhood and adolescence and risk living in lower-
income households because they are less likely to marry or cohabit. The
third health differences explanation, Bevan continued, suggests that women
with obesity have more health conditions and comorbidities that affect their
ability to find and retain work, leading to reduced functional capacity, in-
creased use of sick leave, and elevated risk of premature withdrawal from
the labor market for health reasons. A final explanation is stigma. Bevan
explained that according to this view, women with obesity are subject to
systemic discrimination in the job market and workplaces. As a result, they
are relegated to low-paying jobs for which they may be overqualified and
in which opportunities for job and pay progression are constrained while
negative stereotypes and weight-based stigma are normalized.
The conclusion from some of this evidence, Bevan summarized, is that
the multiple employment disadvantages already experienced by women
with obesity in the labor market are being compounded by a pervasive
wage penalty in a tangible way, established for many in adolescence and
continuing throughout adulthood. He reviewed the projected effect of the
wage penalty at the national level in the United Kingdom on annual earn-
ings per woman, based on average earnings and a prevalence of obesity of
30 percent: a 2 percent wage penalty = a 500-GBP (Great British pound)
reduction; a 5 percent wage penalty = a 1,250-GBP reduction; a 9 percent
wage penalty = a 2,250-GBP reduction; and a 13 percent wage penalty = a
3,250-GBP reduction. At a macroeconomic level, these reductions translate
to 2.3, 5.75, 10.35, and 14.95 billion GBP per year, respectively (Bajorek
and Bevan, 2020).
Bevan turned to the second challenge to be addressed in his presenta-
tion: that well-intentioned workplace health promotion programs with a
nutrition, exercise, or weight management component may inadvertently

reinforce obesity stigma by reinforcing the belief that overweight and

obesity can be resolved through efforts, driven mainly by an individual’s
willpower, to eat less and move more (Bajorek and Bevan, 2020). As a re-
sult, some people with obesity may internalize the stigma they experience
in society, Bevan explained, or make them reluctant to participate in such
workplace programs or access support, advice, or even psychosocial help
from which they might otherwise benefit (Täuber et al., 2018). He pointed
out further that encouraging competition or using incentives can produce
negative outcomes for some workers, mainly those with obesity (Quintiliani
et al., 2010).
In closing, Bevan outlined actions that governments, employers, the
media, and health care professionals can take to reduce obesity stigma. He
suggested that governments can be more intentional in considering social
determinants of health, such as employment, when attempting to address
health inequities, and can classify obesity as a disease so as to open more
health care pathways for resources to address it. He also proposed designat-
ing people with obesity as a protected class to help empower employers to
protect them. He added that employers could modify their human resources
processes to reduce the risk of stigma and discrimination by including
obesity more explicitly in the design, implementation, and evaluation of
diversity and inclusion programs and policies. He reiterated the call for
workplace health promotion programs to avoid reinforcing stigma and to
involve employees in their design. He suggested further that health care
professionals could do more to consider employment outcomes as a clinical
outcome of care and to be cognizant of obesity comorbidities—particularly
mental health comorbidities—as a barrier for workers. Finally, Bevan ar-
gued that the media could promote people-first language, use appropriate
images, and avoid oversimplifying the causes of obesity in favor of descrip-
tions that highlight their complexity.
Bevan offered a few comments about COVID-19, prefaced by an ac-
knowledgment of the elevated risk of poor COVID-19 outcomes for people
who have obesity, which he said has amplified stigma for some people.
He urged vigilance in preventing this situation from exacerbating existing
health and social inequalities, noting that some employers are not managing
the return to physical workplaces with sensitivity to weight issues. Although
an employer’s desire to conduct a risk assessment among its workforce
is prudent, Bevan said, it is important to avoid characterizing obesity as
a burden.
In summary, Bevan reiterated that the labor market and workplaces
are arenas in which much of the intersectionality of obesity’s drivers and
consequences plays out. Work is both an economic and a social act, he
maintained, and many challenges associated with inequalities in social de-
terminants of health become manifest in work settings.

HEALTH CARE SYSTEMS PERSPECTIVES

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 the perspectives of health care systems
on obesity and suggested how those perspectives could be improved going
forward. He prefaced his remarks by defining three key terms:
• Weight bias: negative attitudes toward and beliefs about others

because of their weight
• Obesity stigma: a social sign or label affixed to an individual who
experiences prejudice because of excess weight
• Weight-based discrimination: enactment of weight bias and stigma
in any discipline or sector
Norris continued by conveying the narratives about eating less and

moving more are commonly heard by patients with obesity. To a patient,
he pointed out, these narratives make weight loss and management sound
simple, but they may also convey that health professionals believe obesity
is self-imposed, so they have no obligation to help the patient find evidence-
based treatments. In reality, Norris suggested, the journey for many patients
has been anything but simple; he urged mindfulness of the challenges faced
by people living with obesity.
To illustrate the reality of bias and stigma experienced in health care
by patients with excess weight, Norris shared the results of a survey of
more than 100 postgraduate trainees in professional health disciplines (Puhl
et al., 2014). For example, 50 percent reported that their peers tend to have
negative attitudes toward patients with obesity. However, only 1 percent
agreed with the notion that if a person develops obesity, it is that person’s
own fault, so it is acceptable to make jokes about their weight, and just
3 percent agreed that it is acceptable to make jokes about patients with
obesity. Yet despite the reportedly wide unacceptability of this behavior,
Norris pointed out, other results of this survey indicate that it is pervasive
in health care settings: 40–65 percent of respondents reported that they had
heard or witnessed negative comments, jokes, or derogatory humor about
patients with obesity from professors or instructors, health care provid-
ers, students, or residents. He added that about one-third of respondents
said they felt frustrated with patients with obesity; a similar percentage
expressed the view that patients with obesity can be “difficult to deal with”;
and 13 percent reported a dislike for treating patients who have obesity.
With regard to respondents’ perceptions of patients with obesity, Norris
continued, 21 percent saw no difference between patients with obesity and
those with normal weight; 18 percent stated the view that patients with obesity

tend to be lazy; 33 percent said patients with obesity lack motivation to make
lifestyle changes; and 36 percent reported that patients with obesity are often
noncompliant with treatment recommendations. On the other hand, Norris
said it was encouraging that 95 percent of respondents said it is important to
treat patients with obesity with compassion and respect, although only 27 per-
cent reported that treating patients with obesity is professionally rewarding.
Finally, Norris pointed out what he characterized as a disconnect
whereby 80 percent of respondents expressed confidence in providing qual-
ity care to patients with obesity, yet only 57 percent said they felt profes-
sionally prepared to treat patients with obesity effectively. These results
have been replicated in a few other surveys of 600–800 providers, he
added, referencing one survey in which physicians expressed their general
sentiments that patients with obesity are noncompliant, lazy, lacking in self-
control, weak willed, unsuccessful, and dishonest (Puhl and Heuer, 2009).
These views, Norris said in summary, indicate how the health care system
interfaces with many patients with respect to weight.
Norris observed that although physicians say they want to do the best
for their patients, they may harbor implicit biases that hinder achieving that
goal. He referenced research suggesting a high level of anti-Black implicit
bias and a strong antifat bias among physicians and researchers (Alegria
Drury and Louis, 2002; Merrill and Grassley, 2008). According to Norris,
bias plays out in ambivalence about treatment roles, less time spent with
and less discussion with patients, more ascribing of negative symptoms
to patients, less intervention, and reduced preventive health services and
exams (Puhl and Heuer, 2009; Sabin et al., 2012).
Biases among members of the health care system become embedded
in the system’s structures, Norris argued, and form weight-related barriers
for patients navigating the system. He explained, for example, that patients
with obesity may receive unsolicited advice about losing weight or inappro-
priate comments about their weight, or experience disrespectful treatment
or inaccessible equipment and facilities because of their weight (Puhl and
Heuer, 2009).
Norris reviewed the negative consequences of weight bias for patients,
listing shame and guilt, anxiety, depression, poor self-esteem, and body dis-
satisfaction, all of which can lead to unhealthy weight control practices. He
added that weight bias also negatively affects access to obesity treatment,
educational attainment, employment opportunities, employment earnings,
and quality of health care, ultimately leading to inequities in patient care
(Puhl and Heuer, 2009). He explained that experiences of weight-based
discrimination amplify psychosocial stress, which in turn triggers a realloca-
tion of neuronal activity in the brain that leads to poor cognitive processing.
For patients, he continued, this pathway initiated by structural biases can
lead to suboptimal clinical outcomes as a result of internalized fear, shame,

guilt, poor self-esteem, anxiety, depression, mistrust of the health system,

and inability to remember and implement health advice. Based on the way
this bias operates, Norris maintained, health professionals tend to think of
the patient and wonder, “What did you do to yourself?” A more appropri-
ate question, he suggested, is, “What did society do to you?,” which he
said takes social determinants of health and structural biases into account.
Norris next offered strategies for countering bias and discrimination
based on weight, starting with overcoming unconscious or implicit bias.
Bias is universal and manifests differently for each person, he asserted, add-
ing that recognition of one’s potential for bias is a first step. He encouraged
clinical settings to treat patients as individuals and with empathy, care, and
respect instead of relegating them to particular categories to which labels
and personal attributes are automatically assigned. To unravel the institu-
tionalization of bias, Norris urged examining and revising health system
policies and practices that perpetuate structural biases. He encouraged
health care providers to recognize their roles as community resources and
leaders for health equity. To not get involved is to choose to be passive, he
stressed, which he equated with choosing to perpetuate structural biases
and health disparities.
Norris urged that when caring for patients with excess weight, provid-
ers recognize their experiences with weight-related discrimination, weight
bias–induced limitations on employment and educational attainment, mis-
trust of care, impaired cognitive processing from the additional psychoso-
cial stress associated with their condition, and other comorbidities. What
patients need, he stressed, is high-quality care, respectful treatment, empa-
thy, compassion, support, and hope—not judgment, ire, or lecture. Such
care builds trust, he said, and could reduce patients’ psychosocial stress and
resulting strains on cognitive processing. Norris ended his remarks with a
quote from Sri Sathya Sai Baba: “Before you speak, think—Is it necessary?
Is it true? Is it kind? Will it hurt anyone? Will it improve on the silence?”

Following their presentations, the two speakers engaged in a moderated
discussion and answered participants’ questions. They covered the role of
policy in addressing weight bias, medical education on caring for patients
with obesity, sector-specific differences in the obesity wage gap, and work-
site health promotion programs and weight stigma.
The Role of Policy in Addressing Weight Bias

Crespo began the discussion by asking the speakers to comment on
the role of policy in addressing weight bias. Bevan replied that under

European law, employers must treat obesity as a protected characteristic

and make reasonable adjustments to accommodate any associated impair-
ments among employees. He supported a shift in emphasis from individual
behavior change to policy interventions, recognizing the roles of obesogenic
environments1 and health inequalities in contributing to the development
of obesity.
Norris remarked that laws and policies reflect the conscience of society,
and suggested examining and modifying policies that may inadvertently
promote weight bias and discrimination. It is easier to do this at the local
institutional level, he acknowledged, where structures could be established
to promote good behavior rather than demean negative behavior.
Medical Education on Caring for Patients with Obesity

Asked about medical training in caring for patients with obesity, Norris
affirmed that a one-size-fits-all weight management plan is not the answer.
The current emphasis in medical education is on individualized care, he ex-
plained, which involves shared decision making between clinician and patient
to determine what changes and interventions would be best suited to the
patient’s goals, lifestyle, and resources. Patients have a sense of the barriers
to change they may encounter, he elaborated, and sharing those barriers helps
clinicians tailor recommendations and determine when to refer patients to
other colleagues or specialists who can help them pursue the goals.
Norris also posited that a common health care perspective is to overes-
timate the ability of clinical recommendations on lifestyle changes to impact
weight loss. The reason is that weight gain results from multiple factors,
some structural and societal in nature, which he explained are difficult to
overcome with health care providers’ lifestyle change recommendations. He
urged providers to be mindful of where they are intervening along the spec-
trum of factors that influence weight (i.e., mainly on relatively downstream
factors) so they will have a realistic sense of their interventions’ potential
to make a difference.
Sector-Specific Differences in the Obesity Wage Gap

Bevan reported that his group had observed the wage gap to be ampli-
fied in lower-skilled, lower-paid jobs in such sectors as hospitality and retail
that are often customer facing, compared with professional white-collar
roles. He added that the wage gap is an issue predominantly among females
in these sectors.
1 “Obesogenic environment” is defined as “an environment that promotes gaining weight
and one that is not conducive to weight loss” (Swinburn et al., 1999).

Worksite Health Promotion Programs and Weight Stigma

Bevan commented on the design of worksite health promotion initia-
tives, noting that U.S. employers generally bear the high financial burden of
health care costs and are therefore incentivized to improve their employees’
health. For example, employers may conduct health risk assessments and
collect biometric measures, which he argued can reinforce stigma if not
messaged carefully. In the United Kingdom, he said, worksite health promo-
tions tend to fall into two categories: those that help the employer compete
in the labor market by offering a benefit to employees but are rarely evalu-
ated in terms of health outcomes, and those that aim to reduce psychosocial
risk and musculoskeletal strain through a more methodological approach
that assesses and mitigates workplace risks, and measures such outcomes
as serious absenteeism, presenteeism, and labor productivity. In both cases,
Bevan contended, organizations make the mistake of regarding ill health
of any kind as a burden and a risk to mitigate instead of focusing on what
people can still do despite living with a chronic disease or condition. The
latter perspective is more positively framed, he asserted, and is a step to-
ward undermining stigma and discrimination.

Reflections on the Intersections

of Structural Racism, Biased
Mental Models, Stigma, and
Weight Bias with Obesity

• Improving food security brings benefits beyond helping to
reduce the prevalence of obesity and addressing health dispari-
ties. It helps provide children with adequate nourishment so
they can stay focused at school, alleviates parents’ stress about
feeding their children, and improves employee health and re-
duces sick days. (Byrd-Bredbenner)
• Weight stigma is often a short-term experience but can have
long-lasting effects, not only on health but also on occupa-
tional earnings and acquisition of wealth over time. (Crespo)
• Racism often undermines efforts to access good health while
simultaneously masking the structural inequalities that lead
to health disparities and implying that health problems are
primarily behavioral in nature. (Silvera)
• The prevalence of obesity in the United States reflects an ac-
cumulation of decades of inequities, rooted in structural and
political racism, that have promulgated harmful social, eco-
nomic, and structural determinants of health. Health equity
is the process of ensuring that conditions of optimal determi-
nants of health are conferred on every person while acknowl-
edging historical injustices. (Simon)
35

In the first workshop’s final session, the workshop planning commit-

tee members shared their reflections on the workshop, engaged in a panel
discussion of topics addressed, and responded to audience questions. The
session was moderated by Angela Odoms-Young, associate professor and
director of the Food and Nutrition Education in Communities Program and
New York State’s Expanded Food and Nutrition Education Program in the
Division of Nutritional Sciences at Cornell University.
REFLECTIONS
Carol Byrd-Bredbenner, distinguished professor of nutrition and di-
rector of the nutritional sciences graduate program at Rutgers University,
began the reflection portion of the session by highlighting food insecurity
as a contributing factor to obesity and a key barrier to reducing its preva-
lence. The COVID-19 pandemic has increased the prevalence of food inse-
curity, she observed, and has also widened the disparities in its prevalence
among population subgroups. Actions to increase food security have fo-
cused on improving the U.S. food security safety net programs, she noted,
and COVID-induced changes in those programs may provide insights into
ways of removing participation barriers postpandemic.
As an example, Byrd-Bredbenner shared that the benefits of the Supple-
mental Nutrition Assistance Program (SNAP) were increased by 15 percent
during the pandemic, and states were granted greater flexibility in manag-
ing their beneficiary caseloads. She called on researchers to evaluate the
outcomes of these emergency measures and generate data that can support
appeals to make the changes permanent.
Another example, Byrd-Bredbenner continued, is the Special Supplemen-
tal Nutrition Program for Women, Infants, and Children (WIC), which serves
pregnant and lactating women and their children up to 5 years of age. WIC
reaches about 55 percent of eligible recipients and has a steep dropout rate
when children reach their first birthday, Byrd-Bredbenner observed, perhaps
fueled in part by parents’ frustration over the challenges encountered in access-
ing options within the WIC food package for children between ages 1 and 4,
as well as the requirement to appear in person with their children twice a year
for recertification. Policy changes could require states to offer the full range
of allowable WIC food package options, she suggested, and could offer more
convenient (i.e., telehealth) delivery modes for the required visits.
The school-based components of the food safety net, Byrd-Bredbenner
continued, include the National School Lunch Program (NSLP), School Break-
fast Program (SBP), and Summer Food Service Program (SFSP). The NSLP
reaches about 95 percent of schools, she stated, and she encouraged continua-
tion of its widespread delivery. She cited as challenges with the program school
schedules that give children insufficient time to sit down and eat lunch and

REFLECTIONS ON INTERSECTIONS 37
a cost burden that some parents face in paying for meals. Byrd-Bredbenner
went on to note that the SBP is not available in many schools, and she called
for expanding the program and increasing its accessibility. Making it no-cost
for all children would remove the stigma many feel when participating in the
program, she suggested, and scheduling it during—versus before—the school
day would increase participation. As for the SFSP, Byrd-Bredbenner referenced
a 2018–2019 participation rate of 1 in 7 eligible children, which she said was
due mainly to the lack of school participation in the program or children’s
lack of transportation to pick up food at a participating school. COVID-
related changes allowed parents (instead of students) to pick up multiple days
of meals at one time, a change that she urged maintaining postpandemic to
make children’s participation more viable.
Beyond federal food programs, Byrd-Bredbenner highlighted small food
outlets such as corner stores, which she pointed to as primary food retail
venues for many people who live in urban areas and experience food inse-
curity. She suggested that such incentives as tax breaks or low-cost coolers
could support these stores in offering a greater variety of perishable, healthy
food options beyond what is required minimally to be a SNAP retailer.
According to Byrd-Bredbenner, the bottom line is that improving food
security brings benefits beyond helping to prevent obesity and address
health disparities. It also helps provide children enough nourishment so
they can stay focused at school, alleviates parents’ stress about feeding their
children, and improves employee health and reduces sick days.
Carlos Crespo, professor at Oregon Health and Science University
and Portland State University School of Public Health and vice provost for
undergraduate training in biomedical research at Portland State University,
offered a series of comments, starting with an observation that weight
stigma is often a short-term experience but can have lasting effects—not
only health effects, he added, but also effects on occupational earnings and
acquisition of wealth over time. Obesity is a community problem, he main-
tained, with determinants that are more sociopolitical than physiological,
clinical, or biological in nature. Clinical solutions are narrow in scope, he
continued, and he 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 groups
than others in terms of how they interact with their environments.
According to Stephanie Navarro Silvera, professor of public health at
Montclair State University, a key message of the workshop was 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 while simultaneously masking
the structural inequalities that lead to health disparities and implying that

health problems are primarily behavioral in nature. Silvera appealed for

structural solutions that include policy and political engagement strate-
gies, as well as programmatic and intervention efforts. She declared that,
although some policy topics appear to be disconnected from obesity, all
policy is health policy and all politics are local. Thus she highlighted the
importance of engaging with local government entities responsible for
transportation, zoning, housing, and education policies, for example.
Silvera echoed prior speakers’ comments about the COVID-19 pan-
demic’s illumination and exacerbation of health inequities, and warned that
because of structurally and socially mediated segregation, barriers in access
to many occupations, and a higher risk of chronic disease in underresourced
populations, disparities in obesity and chronic conditions are likely to
worsen before they improve. As an example, she referenced the seven-fold
mortality rate due to COVID-19 among Latinx men younger than age 65
compared with their age peers in other racial groups in New Jersey. She
suggested that the far-reaching impact of this disparity on access of those
men’s families to resources and how that impact may manifest through such
conditions as obesity is as yet not understood. The loss of a family’s primary
wage-earner is an economic insult to a household, she stressed, adding that
the loss of a parent is traumatic for young children.
Melissa A. Simon, director of the Center for Health Equity Transforma-
tion at the Institute for Public Health and Medicine and George H. Gardner
Professor of Clinical Gynecology in the Feinberg School of Medicine at North-
western University, proposed that the prevalence of obesity in the United
States represents the accumulation of decades of inequities rooted in structural
and political racism that have promulgated harmful social, economic, and
structural determinants of health. She offered the 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 that may never be able to reach the fruit. She urged increased aware-
ness of the tree’s status of “fundamentally bent,” and appealed for efforts to
unbend it. Health equity is not an outcome, Simon argued, but 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 on every person while acknowledging historical injustices, so
that everyone has an opportunity to reach the fruit on the tree. She urged par-
ticipants to examine the tree carefully to identify where it needs to be unbent.

After presenting their reflections, the workshop planning committee
members discussed structural considerations and potential solutions for

obesity and its root causes; potential solutions for addressing multiple
drivers of obesity; effective, scalable, and sustainable solutions; taxation
approaches; and the role of intersectionality in developing solutions.
Structural Considerations and Potential Solutions

for Obesity and Its Root Causes
Byrd-Bredbenner emphasized consideration of “the cause of the cause”
(i.e., upstream determinants of health) when determining how to remove
barriers to health, and suggested that public education would increase
awareness of structural root causes. At the same time, she appealed for
attentiveness to downstream changes that could be implemented relatively
quickly, such as making permanent the pandemic-induced increases in
SNAP benefits. These increases give families about $95 extra per month, she
noted, pointing to previous research showing that SNAP recipients reported
that an extra $100 in monthly benefits would help them meet their monthly
food needs. It will be interesting, she suggested, to evaluate the outcomes
of the increased SNAP benefits in light of these data.
Simon reiterated that the phenotype of obesity reflects policies in sec-
tors that appear unrelated to health, such as education and housing, and
urged stakeholders to recognize these connections. She pointed out, for ex-
ample, that health insurance is generally linked to employment, and that the
COVID-19 pandemic left many people unemployed, with potential indirect
effects on people’s ability to pursue and maintain health. She also encour-
aged structural and environmental policies promoting physical activity in
various environments, as well as access to healthy food for all.
Silvera underscored voting rights as a key issue with downstream im-
plications for health and noted an uptick in recent state-level efforts to
modify voting laws. She also urged greater awareness of state-level poli-
cies and decision makers in general, suggesting that most people are less
familiar with the officials who represent them at the state level than at the
federal level. Local policies are most closely related to people’s daily lived
experiences, Silvera argued, and she encouraged attendance at city council
and school board meetings to learn what policies are under consideration.
Improving the health of communities is better accomplished when decision
makers listen to community voices, she suggested, instead of presuming to
know what changes need to be made.
Exploring Potential Solutions for Addressing Multiple Drivers of Obesity

According to Crespo, making one’s voice heard in government decision
making is critical. Silvera endorsed Thorpe’s suggestion of a thriving wage
and raised the topic of reparations, acknowledging that it is a challenging

and controversial issue, but one she believes merits an honest conversa-
tion as a means of providing resources to people who have experienced
historical injustices. She also urged that conversations about race and rac-
ism include Latinx, Asian American, and Indigenous populations, which
she said are often discussed and represented in data at the aggregate level,
masking the diversity of experiences and outcomes that often exist within
those communities.
Simon pointed out that physician training is disease focused, with
little emphasis on health promotion and wellness. Incorporating more
of the latter perspective, she suggested, would help physicians do a bet-
ter job of counseling patients on such lifestyle topics as nutrition and
physical activity.
Byrd-Bredbenner reiterated Silvera’s earlier comment about engaging
communities. She pointed to community-based participatory research as a
core public health strategy for gaining understanding of community per-
spectives on solutions.
Effective, Scalable, and Sustainable Solutions

Crespo admitted that it is difficult to identify a solution for reducing the
prevalence of obesity that has demonstrated promise, scalability, and sus-
tainability. Nonetheless, he highlighted advances in identifying risk factors
and evidence-based solutions and suggested that the present challenge is
implementation. Silvera agreed and stressed the importance of cross-sector
collaboration in implementing community-wide solutions. As an example
of situations in which obesity and other chronic health conditions are distal
to people’s daily realities, she observed that residents of low-income com-
munities may expend most of their energy figuring out how to pay their
bills. Unless such acute, everyday stressors are addressed, she argued, it will
be challenging to make progress on obesity.
Building on that point, Byrd-Bredbenner recounted her experience de-
veloping a program intended to deliver education about nutrition and
physical activity to families. When participating families were asked what
topics would most improve their quality of life, they requested content on
building stronger families and managing stress. The program had to adapt
its intended content, she explained, to address what families considered to
be their pressing needs.
Asked about the optimal time to begin nutrition education, Byrd-
Bredbenner said she would like to see it integrated in multiple settings
throughout the life course, from educational institutions starting with pre-
school, to WIC and SNAP touchpoints, to grocery stores and food labels.
She urged that current efforts to educate the public about nutrition evolve
to reflect the latest evidence and encourage broader uptake.

Taxation Approaches
A participant suggested that taxation lies at the intersection of obesity,
structural racism, poverty, and community self-determination, among other
issues, and panelists discussed how to approach stakeholders’ conflicted
perspectives on the topic. Taxation is a difficult policy proposition, Crespo
began, generally viewed as a punitive measure and opposed by powerful
industries that represent the taxed products. He suggested considering the
opposite angle of lowering prices for products that are being encouraged.
Byrd-Bredbenner agreed about the philosophical and administrative com-
plexities of taxation policies, and Silvera cautioned against their unintended
consequences, particularly for low-income communities that lack access to
healthier options. Linking the discussion to the broader topic of encourag-
ing policies that promote equity, she reiterated the significance of knowing
and engaging with one’s local and state representatives, advocating for
solutions, empowering other community members to raise their voices, and
getting involved with local decision-making bodies.
The Role of Intersectionality in Developing Solutions

Silvera proposed that addressing the needs of people who have the most
layers of disadvantage will benefit all people. She reiterated the importance
of making space in all environments and communities for disadvantaged
groups, including individuals with physical or developmental disabilities,
and amplifying their voices so their needs can be heard. Crespo reminded
participants to focus not just on the various intersecting characteristics but
on the dignity of the person in which those characteristics occur.


Operationalizing Health Communication

for Obesity Solutions
Key Points from the Speaker Presentation

(Workshop 2, Session 1)
Jeff Niederdeppe, Cornell University
• The view that obesity is a personal problem to be solved pri-
marily at the individual level is shaped by multiple, powerful
forces. These forces and viewpoints shape how the public and
policy makers think about whether and how best to address
rates of obesity.
• Communication campaigns to promote health behavior changes
tend to move the needle on the targeted behaviors, but their
effects wane quickly when the messages end. These campaigns
also tend to increase rather than reduce inequity because popu-
lations that have difficulty implementing behavior changes as
a result of economic, social, and structural factors are often
less likely to benefit from the infusion of health promotion
messages.
• Effective health communication strategies (1) recognize that
audiences are not monolithic, (2) center on the policy solution
instead of the health problem, and (3) seek to understand di-
verse audiences’ perspectives before communication strategies
are implemented.
43

The second (June 2021) workshop began with a session that provided
a high-level perspective on health communications and how they relate to
data-driven and innovative approaches for achieving sustainable systems-
wide changes to reduce the prevalence of obesity. A presentation on the
topic was followed by a moderated discussion and question-and-answer
period with participants. Angela Odoms-Young, associate professor and
director of the Food and Nutrition Education in Communities Program and
New York State Expanded Food and Nutrition Education Program in the
Division of Nutritional Sciences at Cornell University, offered introductory
remarks prior to the presentation.
Odoms-Young explained that because obesity is a condition associ-
ated with a multitude of genetic, behavioral, and environmental factors,
the development of effective solutions requires a nuanced and strategic
approach that reflects this complexity. She pointed out that people under-
stand and perceive the world through mental models, and these mental
models influence their perceptions of the relevance of efforts to address
obesity and its determinants. She added that people’s mental models shape
how they simplify complexity and what connections and opportunities
they see with respect to obesity’s causes and consequences, and under-
standing these models can therefore point toward promising population-
level solutions.
Odoms-Young emphasized the value of discussing what is known and
believed about obesity and how that information is communicated, re-
ceived, processed, and internalized. She maintained that these processes
shape beliefs about sustainable systems-wide changes and solutions for re-
ducing the prevalence of obesity. She offered examples of several questions
that reflect this observation:
• How do public policies concerning obesity reflect the complexity

of what is known about its causes and effects?
• How do public perceptions of obesity and people who have obesity
lead to public support for or opposition to specific types of obesity-
related policies and programmatic interventions?
• How do public health narratives and framings reinforce or combat
obesity stigma and weight bias?
• How do anti-Black or anti-Indigenous narratives coexist with
thinking related to obesity stigma, and how can obesity solu-
tions align with narratives of social justice, antiracism, and
liberation?
• What strategies work for equitably engaging communities and
supporting community-driven leadership in communication about
obesity and its solutions?

OPERATIONALIZING HEALTH COMMUNICATION 45
WHAT IS MEANT BY HEALTH COMMUNICATION?

Jeff Niederdeppe, professor in the Department of Communication,
director of the Health Communication Research Initiative, codirector of
the Center for Health Equity, and associate dean for faculty development
in the Jeb E. Brooks School of Public Policy at Cornell University, discussed
the role of health communication in the context of sustainable systems-wide
changes to reduce the prevalence of obesity.
According to Niederdeppe, health communication is an interdisciplin-
ary approach to the theory, research, and practice of (1) understanding
when and how communication shapes population health and, informed
by that understanding, (2) developing effective communication to promote
population health. He emphasized that health communication occurs at
many different levels—interpersonally, within groups and networks, in
health care organizations and between health care practitioners and people,
in policy-making forums, in the mass media, online, within and between
institutions, and in society as a whole. He suggested, therefore, that health
communication could likewise be leveraged at multiple levels as part of
systems-wide strategies for reducing the prevalence of obesity.
Niederdeppe discussed how health communication has shaped public
understanding of obesity. In one survey focused on the extent to which
Americans view a variety of actors as responsible for addressing obesity in
the United States, 88 percent and 87 percent of respondents, respectively,
named individuals and parents (in the context of childhood obesity); fewer
respondents named other actors, including health care providers (57 percent),
the food and beverage industry (53 percent), schools (50 percent), and gov-
ernment (23 percent) (Wolfson et al., 2015). Niederdeppe noted that these
data are from 2012, but that more recent data echo those findings.
According to Niederdeppe, the view that obesity is a personal problem
to be solved primarily at the individual level is shaped by multiple power-
ful forces. These forces include political groups that highlight individual
responsibility, deregulation, and limited government; the food and drink
industries, which emphasize personal choice and self-regulation with little
if any oversight; and an entertainment industry that sells false images of the
“ideal” body. Niederdeppe also pointed to an overemphasis on the medi-
cal definitions and health care costs associated with treating obesity. These
forces operate within a broader context of structural racism, he maintained,
which is embedded in discourse and policies that generate obesogenic envi-
ronments in communities of color through such mechanisms as economic
oppression, zoning laws, and neighborhood segregation.
According to Niederdeppe, these forces and this context have also
shaped public beliefs about how to address obesity and the ways in which
people with obesity are viewed. He pointed out, for example, that high

levels of blame and stigma are directed toward people with obesity, and that
systems-wide, evidence-based public policies designed to reduce prevalence
of obesity have garnered substantial opposition. He added that individual-
level interventions to improve diet and promote physical activity are often
emphasized in approaches for addressing obesity.
Building on his point about the emphasis on individual-level behav-
iors, Niederdeppe discussed the effects of communication interventions to
promote behaviors related to diet and exercise. He stressed that massive
amounts of exposure to messaging are needed to create change at a popula-
tion level, and even then, the effects of such messaging on behaviors tend
to be small and short lived. As an example, he shared results of a study
examining percentage changes in grocery store sales of products high in
trans fats occurring around the time of the release of a widely publicized
report on the dangers of trans fat consumption (Niederdeppe and Frosch,
2009). The researchers observed a substantial reduction in purchases of
such products immediately and up to a week after the report’s release, and
then a steady diminishing of those effects 2 and 3 weeks later as media cov-
erage of the issue subsided. This kind of pattern is consistently reproduced
in communication campaigns, Niederdeppe observed.
Niederdeppe went on to assert that communication interventions tend
to increase rather than reduce inequity. He cited as an example messaging
about tobacco use, for which investments of hundreds of millions of dollars
have been made. Referencing data on the prevalence of cigarette smoking,
he pointed to similar rates among population subgroups with various levels
of educational attainment in the 1960s, but widening gaps in rates among
the same subgroups during the following several decades (Drope et al.,
2018). Such patterns of widening inequity occur repeatedly, he explained,
because populations that have difficulty implementing behavior changes as
a result of economic, social, and structural factors are typically less likely
to benefit from an infusion of health promotion messages.
Niederdeppe shifted to the final portion of his presentation, in which
he discussed the emerging evidence base on the effects of communication
interventions focused on promoting systems-level changes to reduce the
prevalence of obesity and on spurring other structural changes to promote
population health. According to Niederdeppe, strategic communication can
promote systems-level thinking and interventions and increase public sup-
port for such evidence-based policies. With respect to obesity prevention, he
referenced messaging efforts in which he had been involved that increased
public support for a penny-per-ounce tax on sugar-sweetened beverages,
community-level strategies for reducing the number of food deserts, and
restrictions on food and drink marketing to children.
Niederdeppe next highlighted three characteristics of effective com-
munication strategies, starting with the recognition that audiences are

not monolithic. In effective strategies, he explained, the objective of creating

environments that promote health and social equity is often accompanied
by a focus on promoting evidence-based, systems-level policies at various
levels across sectors and involves multiple strategic elements. A strategy
might, for example, focus on engaging the public, either to persuade those
potentially opposed to a proposed policy or to mobilize those who already
support it, such as by applying pressure on decision makers to enact it.
Other strategies might focus on decision makers directly, Niederdeppe
continued, whether to persuade them to support the proposed policy or to
mobilize and spur action among those already inclined to favor it. Strategies
that target a particular group spill over to other groups, he acknowledged,
but he stressed that effective communication strategies are tailored to the
specific groups they are intended to reach.
Niederdeppe turned to the second characteristic of effective commu-
nication strategies: that they center the policy solution, not the health
problem. When public health researchers generate evidence supporting the
health-promoting potential of a policy or intervention, he remarked, they
typically develop a communication strategy that focuses on the projected
health impacts. In his experience, Niederdeppe observed, this is often an
ineffective strategy at best or a counterproductive one at worst, a point he
illustrated by showing a picture of a billboard featuring a close-up photo
of a concerned physician, with text urging viewers that childhood obesity is
not to be taken lightly. Not only does that message medicalize the problem,
he explained, but it also fails to account for the possibility that other less
stern, more hedonistic messages may be contending for attention in the
same public information environment—in this example, a second billboard
positioned immediately below the first one advertising fast food.
Starting with the policy solution and working backwards allows differ-
ent kinds of values and beliefs to come into play. In some cases, he elabo-
rated, values and beliefs about the social impact, the economic impact, or
the institution and process associated with developing a particular systems-
level policy drive support for or opposition to the policy. Health impacts
play a role at times, he conceded, but he cautioned against assuming that
they always drive policy support or opposition, even though public health
and medical actors may emphasize those impacts in their communications.
Finally, Niederdeppe cited as a third characteristic of effective com-
munication strategies recognition that different messages may or may not
resonate among different social groups. He reported results of a study of
parents who reported annual household incomes of less than $40,000 in
which the researchers assigned various levels of strength to different mes-
saging strategies designed to boost support for increasing prices on sugary
drinks according to the racial/ethnic identity of respondents (Cannon et al.,
2022). A message focused on supporting community efforts to improve

children’s health had similar appeal across the three racial/ethnic groups, he
observed, whereas a message about standing up to the sugary drink industry’s
targeting of Hispanic/Latinx children was perceived to be stronger among
Black and Hispanic/Latinx parents versus White parents. When the message
was about standing up to the sugary drink industry’s targeting of children
from lower-income families, however, its appeal increased among White
parents. Niederdeppe emphasized the principle conveyed by this example:
the importance of understanding the perspectives of diverse audiences before
implementing communication strategies to promote evidence-based health
policies. Understanding this principle can help communicators anticipate
how their messages will resonate among different groups, he asserted, which
in turn helps differentiate strategies aimed at mobilizing audiences who sup-
port a policy from strategies aimed at persuading audiences who oppose it.
AUDIENCE DISCUSSION
Following his presentation, Niederdeppe responded to two questions
about communication strategies for systems-wide changes to reduce the
prevalence of obesity.
Challenges to Effective Communication about

the Need for Systems-Wide Changes
In response to Odoms-Young’s question about the biggest challenge to
effective communications on the need for systems-wide changes to reduce
the prevalence of obesity, Niederdeppe offered two thoughts. He pointed
out, first, that there will always be groups that are resistant to proposed
changes in systems, institutions, or structures, particularly when those
changes are perceived as threatening power structures and economic in-
terests. He called for recognizing these “often powerful and well-funded
forces,” noting that they may be a moving target depending on the policy
or intervention being proposed. He added that they often dramatically out-
spend public health efforts to promote structural changes to address obesity
on countermessages opposing the changes.
Niederdeppe’s second thought was that the creative and innovative
nature of some systems-level changes means they may not initially have the
strongest possible evidence for implementation. Policies are implemented
differently across communities, he elaborated, where they may have dif-
ferent parameters or make different compromises based on a particular
community’s needs and interests. As a result, he explained, a policy that
has been tailored to a particular community may not have the same effect
in a different setting. He urged a willingness to try innovative and promis-
ing solutions, even though they may not yet have been thoroughly studied.

Communication Strategies to Change the Perception of Obesity’s Origin

A participant suggested that shifting the perception of obesity from
having a behavioral origin to being a disease state could alter the bias and
stigma directed at people with obesity and increase support for treatment.
Niederdeppe agreed that it is important to shift society’s perception of obe-
sity away from a problem that is primarily personal in nature, but appealed
for framing it as a broader societal problem with a medical component. He
cautioned against “overmedicalizing” the problem, explaining that people
usually think of treating clinical problems with medical treatments focused
on individual bodies, whereas obesity’s drivers go beyond the realm of
health care.


Data-Driven Obesity Solutions

and Innovative Approaches
Key Points from the Presentations of Individual Speakers

• Most children spend a substantial portion of the year in school
settings, which offer a protected environment where they can
play and be active under the supervision of an educated work-
force at no additional cost. University curriculum designed to
equip future teachers with the skills to encourage classroom-
based physical activity could be a low-cost, effective strategy for
promoting nontraditional physical activity in schools. (Donnelly)
• Additional evidence to clarify the relationships among physical
activity, cardiovascular fitness, cognitive function, and aca-
demic achievement would help promote nontraditional physi-
cal activity in schools and support policy changes that could
lead to wider dissemination of programs for integrating physi-
cal activity into the school day. (Donnelly)
• Clinical decision support tools directed at patients and clini-
cians in primary care and other settings have the potential to
promote the uptake of effective weight management strategies,
such as Food and Drug Administration (FDA)–approved medi-
cations and metabolic bariatric surgery. Individual benefits
from these strategies vary greatly, depending on such factors
as age, sex, baseline body mass index (BMI), and the presence
and duration of comorbidities. (O’Connor)
51

• Communicating evidence-informed, personalized estimates of

the benefits and risks of weight management options to pa-
tients and clinicians in a concise, understandable way is chal-
lenging, but promotes shared decision making. (O’Connor)
The second session of the June 2021 workshop featured two presenta-
tions highlighting data-driven obesity solutions and innovative approaches
in the contexts of education and health care. Panel and audience discussions
about these presentations followed. Carlos Crespo, professor at Oregon
Health and Science University and Portland State University School of
Public Health and vice provost for undergraduate training in biomedical
research at Portland State University, moderated the session.
In his introductory remarks, Crespo observed that although data play a
critical role in science, they have limitations and do not work alone to change
behavior. He cited emerging challenges to data use, such as the proliferation
of artificial intelligence approaches based on profiles that could perpetuate
intrinsic and extrinsic bias. He added that, although the field of precision
medicine is also expanding, over- and underrepresentation are seen in the
racial, ethnic, and anthropometric groups that are included in many of the
clinical trials and biospecimen banks used to produce precision medicine
guidelines. Crespo urged transparency about such limitations when leverag-
ing data in systems-level solutions to reduce the prevalence of obesity.
INNOVATION IN EDUCATION: PHYSICAL

ACTIVITY ACROSS THE CURRICULUM
Joseph E. Donnelly, professor of medicine and director of the Divi-
sion of Physical Activity and Weight Management, Department of Internal
Medicine at the University of Kansas Medical Center, presented findings
from a 15-year series of studies focused on increasing physical activity
across school curricula.
Donnelly began by listing several reasons to explore the school setting
as a venue for increasing physical activity. First and foremost is that most
school-age children are in these settings for 9–10 months of the year. State
mandates and school mission statements encompass a variety of health
outcomes, including physical activity, Donnelly continued, and research
conducted in the past one to two decades has begun to explore potential re-
lationships between physical activity and academic achievement. He stressed
that the physical infrastructure of schools provides a protected environment
where children can play under the supervision of an educated workforce

DATA-DRIVEN OBESITY SOLUTIONS 53
(i.e., teachers) that is generally respected for its authority, at least among
elementary students. This workforce is already salaried to educate students,
Donnelly pointed out, and physical activity can therefore be integrated at
no additional (salary) cost. Finally, he noted that schools are entrenched in
society and may be better positioned than other, less permanent settings to
continue an intervention beyond a research study’s funding period.
Participation in schools is historically sedentary, Donnelly maintained,
with students often experiencing long bus rides and what he called the
traditional teaching paradigm of “sit down and be quiet,” which he said
discourages movement during the off-task periods of the school day. He
contended that in most cases, dedicated recess and physical education peri-
ods fail to provide adequate energy expenditure to protect against adiposity
or promote fitness, a failure he attributed to challenges with equipment,
space, and lack of teacher encouragement and guidance.
Donnelly presented a theoretical model of the connections among
physical activity, improved health, and academic achievement (Figure 7-1),
which he said can help build support for integrating physical activity into
the school day. This model led to the development of an intervention called
Physical Activity Across the Curriculum (PAAC), which Donnelly’s group
explored in a 3-year randomized controlled trial of physical activity and
academic achievement for students in second and third grades.
Donnelly explained that the premise of PAAC was to increase physical
activity by using classroom teachers to integrate it into existing lessons.
He clarified that this did not imply a decrease in academic instruction time
and that the physical activity was not intended to be delivered as a break
in the academic agenda. The intervention’s primary aim was to reduce in-
creases in BMI, he recounted, and its secondary aims were to (1) determine
associations between physically active lessons and academic achievement,
and (2) describe time on task, a variable expected to be associated with
academic achievement.
FIGURE 7-1 Theoretical model for improving health and academic achievement.
SOURCE: Presented by Joseph E. Donnelly, June 22, 2021; Donnelly and Lambourne, 2011.
Reprinted with permission of Elsevier.

Turning to describe the conceptual framework for PAAC, Donnelly ex-

plained that it was a minimal intervention in that it did not set out to diffuse
change throughout the school environment. He added that other intervention
characteristics, such as the promise of enhanced learning with no additional
cost or teacher preparation time, were designed to appeal to school adminis-
trators and teachers. It was important that PAAC be easily perpetuated and
replicated in schools, Donnelly continued, and for it to be fun for teachers
and students. Most students follow teacher directions to participate in class-
room lessons, he pointed out, in contrast with recess, where they can choose
to engage in sedentary behavior for the duration of the period.
Donnelly next described the PAAC approach, which was to integrate
10-minute periods of physical activity into a variety of academic lessons
for a total of 90 minutes across the week, ideally distributed across morn-
ing and afternoon instruction times each day. This guidance quickly de-
teriorated, he admitted, into simply encouraging teachers to integrate the
90 minutes/week of physical activity whenever and however it was best for
them and their classroom dynamics.
Greater levels of physical activity were observed in PAAC intervention
versus control schools, Donnelly reported, based on direct observation of
student behavior in response to teacher instructions using the SOFIT (Sys-
tem for Observing Fitness Instruction Time) tool. Average SOFIT-measured
physical activity levels across intervention schools corresponded to such
energy-expending movements as walking, hopping, and leaping, which
Donnelly asserted could induce fitness and perhaps improve academic
achievement. Although PAAC did not have an effect on students’ time
spent on task, he pointed to the preponderance of evidence suggesting
that classroom-based physical activity does increase time spent on task.
This outcome is particularly important to teachers, he noted, who tend to
be concerned that integrating physical activity into classroom lessons will
distract students from learning.
Donnelly suggested that a university curriculum designed to equip fu-
ture teachers with the skills to encourage classroom-based physical activity
is the most low-cost, effective strategy for promoting nontraditional physical
activity in schools. Such training is virtually nonexistent at the university
level, he observed, but would help minimize the burden on teachers of
integrating physical activity by providing guidance on how to incorporate
simple movements into lessons. He argued that additional evidence linking
physical activity and fitness with academic achievement would also help pro-
mote nontraditional physical activity in schools and support policy changes
that could lead to more widespread dissemination of programs like PAAC.
Shifting back to the challenge of increasing physical activity in schools
without decreasing academic instruction, Donnelly provided several sugges-
tions. He described increasing children’s physically active time during physical

education class and recess as an obvious approach and then listed other
ideas, including providing access to physical activity before and after school,
promoting active travel (i.e., walking, biking, or other nonmotorized transport)
to school, providing physically active lessons, and using physical activity as a
classroom management or behavior tool. He expressed skepticism about the
level of school support for integrating physical activity, referencing data from
the 2016 School Health Policies and Practices Survey indicating that relatively
few U.S. school districts require schools to provide regular classroom physical
activity breaks (CDC, 2017). Around one-third to one-half of districts recom-
mend such breaks, he noted, suggesting that the probability of policy change
is low in the absence of a requirement.
In the final portion of his presentation, Donnelly raised a series of is-
sues that have emerged from interventions aimed at integrating physical
activity throughout the school day. One such issue is that limited evidence
is available to inform whether teacher-led or outside vendor–led efforts are
more effective in increasing classroom physical activity because most studies
have taken the latter approach. Donnelly identified as a second issue that
school settings prioritize academic learning, which unlike physical activity
is tied to state standards and consequences related to funding and accredi-
tation. A third issue, he continued, is that teachers cannot reasonably be
expected to design, organize, and incorporate physical activity into lessons
without adequate training. In that scenario, he asserted, school principals
are unlikely to hold teachers accountable for delivering physical activity as
intended, and teachers are unlikely to react favorably to the directive to add
another daily task. He acknowledged that these issues may generate doubt
as to whether schools are good settings for promoting physical activity and
that certain variations in educational settings (e.g., open classrooms, fre-
quent moving between classrooms) may not be conducive to pursuing this
goal. In such cases, he suggested, alternative settings such as boys and girls
clubs and local parks and recreation facilities may be more suitable, as they
already maintain a culture of physical activity, follow structured schedules,
and are subject to minimal if any academic governing entities that would
shift the focus away from physical activity.
INNOVATION IN HEALTH CARE: USING DATA TO GUIDE

PERSONALIZED, EVIDENCE-BASED CARE FOR OBESITY
USING A CLINICAL DECISION SUPPORT SYSTEM
Patrick J. O’Connor, senior clinical investigator and codirector of the
Center for Chronic Care Innovation at HealthPartners Institute, discussed the
use of a data-driven approach to guide personalized and evidence-based care
for people with obesity. He drew on his experience with a clinical decision
support tool that was developed for patients with chronic health conditions.

O’Connor began by affirming that primary care settings recognize the

importance of intervening on systems-level factors that contribute to obesity,
but that they also pursue approaches to address obesity at the patient level.
He agreed that prevention of obesity is critical, but pointed out that solutions
are also needed for people who already have obesity. Care and clinical man-
agement of people with overweight and obesity are far from optimal (Fang
et al., 2021), he observed, not only for obesity but also for other chronic
conditions, such as type 2 diabetes, hypertension, and high cholesterol.
To provide context for his discussion of the clinical decision support
tool, O’Connor reviewed various strategies used to treat overweight and
obesity and their average effects on weight loss. Lifestyle changes and
interventions are clearly indicated and important for any patient with a
weight-related condition, he began, but he pointed out that the impact
of these approaches on weight varies among individuals and in the best
cases is about a 5 percent weight loss over 1 year, on average. Several
FDA-approved medications have been approved for longer-term treatment
among people with BMIs greater than 27 kg/m2, he continued, and can help
patients achieve a 5–15 percent weight loss at 1 year. The proportion of
eligible people who use these medications is quite small, he acknowledged,
despite their potential to effect substantial decreases in weight when com-
bined with lifestyle changes. A third level of treatment is metabolic bariatric
surgery, which O’Connor reported is effective—leading to average weight
losses of about 30 percent of weight at 1 year postsurgery among patients
with BMIs greater than 35 kg/m2—but used infrequently. He added that
many patients regain substantial amounts of weight in the years after bar-
iatric surgery.
O’Connor then elaborated on the impact of bariatric surgery on coro-
nary artery disease and mortality. Among people with BMIs greater than
35 kg/m2 and type 2 diabetes, he reported, the surgery is associated with
coronary artery disease event rates (assessed 7 years postsurgery) that are
substantially lower (2.3 percent) than the rates for matched patients not
having undergone the surgery (4.2 percent) (Fisher et al., 2018). In another
study of outcomes in surgical patients and matched controls, the percentage
of people who died 12 years after surgery was around 20 percent for surgi-
cal patients and 30 percent for controls (Arterburn et al., 2015).
Despite these positive outcomes for surgical patients on average, O’Connor
emphasized the tremendous magnitude of individual variation in benefits from
bariatric surgery. To illustrate this point, he referred to an analysis that pre-
dicted a gain of 6 quality-adjusted life years in a 40-year-old female with a
BMI of 40 kg/m2 and newly diagnosed type 2 diabetes that did not require
exogenous insulin, but a potential small loss of quality-adjusted life years
in a 68-year-old male with long-standing type 2 diabetes and poor glucose
control, other comorbidities, and a BMI of 55 kg/m2 (Arterburn et al., 2015).

O’Connor explained that research using data from hundreds of thousands of

patients has identified factors that can help predict the benefits in individual
patients. These factors include age, sex, baseline BMI, presurgical hemoglobin
A1c level, presence of comorbidities, length of time since diabetes diagnosis,
and use of insulin to control diabetes.
O’Connor transitioned to describing the data-driven, primary care–
based clinical decision support tool his team developed to improve the
quality of chronic disease care in adult patients with type 2 diabetes and
BMIs greater than 25 kg/m2. The web-based tool is linked to the patient’s
electronic medical record (EMR) and uses algorithms (based on evolving
clinical guidelines and FDA actions) to process the patient’s EMR data
and any self-reported lifestyle data in real time to identify appropriate
weight-loss options for that individual. O’Connor added that the next step
for this tool is to promote a shared decision-making process by communi-
cating the benefits and risks of each appropriate weight loss option to both
the patient and the primary care clinician.
This nonproprietary clinical decision support tool has been in use for
about 10 years, O’Connor recounted, and now serves around 3 million
patients in 12 medical groups across 10 states. It has been used primarily
for management of blood pressure, cholesterol, glucose, and smoking, he
relayed, and will next be evaluated in relation to obesity decision support.
Specifically, he elaborated, his team will evaluate the effect of the tool
on weight trajectories, FDA-approved weight-loss medication starts and
metabolic bariatric surgical referrals, and patient-reported shared decision
making (i.e., conversations about weight) and intent to lose weight.
O’Connor then listed the questions typically asked about a given treatment
by patients being treated for obesity, which revolve around anticipated amount
of weight loss and how long the loss will persist, whether it will eradicate their
diabetes and for how long, and whether they will be able to stop taking any
of their medications. They also ask about the risks of medications or surgery;
insurance coverage; and how the treatment will impact their risks for longer-
term outcomes, such as quality of life, longevity, heart attack, and stroke.
According to O’Connor, a concise format is the best way to present
clinicians with information useful for shared decision making. He observed
that primary care clinicians are generally rushed and unaware of the po-
tential (let alone patient-specific) benefits and risks of bariatric surgery
and medications to treat obesity. To illustrate this observation, he pointed
out that current diabetes guidelines suggest that all patients with diabetes
and certain levels of obesity consider bariatric surgery, but nothing in the
guidelines suggests the characteristics of patients who are likely to have
substantial versus small benefits from the surgery. Accurate estimation
of benefits for a given patient will be difficult without a decision support
tool, O’Connor maintained, perhaps with the exception of bariatricians

(clinicians specializing in bariatric surgery), who work in weight-loss cen-

ters and not typically in primary care.
O’Connor stressed the importance of tailoring the information commu-
nicated to patients according to their numeracy and health literacy levels and
considering their personal and cultural perspectives on eating, weight, and
treatments. Many patients strongly resist suggestions for surgery or additional
medications, he noted, and weight is often an emotionally loaded issue. He
then showed screenshots of the clinical decision support tool’s graphic interface
for patients, pointing out the use of colored symbols to prioritize the health pa-
rameters (e.g., weight, blood pressure, cholesterol, or glucose) and/or behaviors
(e.g., tobacco use) for which improvements are expected to yield the greatest
benefit for an individual patient. The relative benefits of weight loss and im-
provements in other clinical domains depend on what type of weight-loss treat-
ment is under consideration, O’Connor explained, and he emphasized that
optimal decision support tools address and compare benefits across multiple
clinical domains. The tool has an additional tab for clinicians, he added, with
more information about the estimated risks and benefits of specific options.
O’Connor provided several summary points with regard to the use of
clinical decision support tools to manage overweight and obesity, which he
predicted could promote uptake of effective weight management strategies.
Directing tools to both patients and providers is key, he began, so that both
parties are informed about the estimated potential individual-level benefits
and risks of various weight management strategies and can engage in shared
decision making. For adults with type 2 diabetes and obesity, O’Connor
proposed that framing weight management options as treatments for dia-
betes (versus obesity) could motivate more serious consideration of such
options by some clinicians and patients. He suggested that the impact of a
decision support tool on quality of care could be maximized if combined
with other strategies, such as the use of gamification, incentives, or active
outreach to patients with registry-based case management.
Lastly, O’Connor highlighted several challenges to the clinical manage-
ment of obesity. Many clinicians and patients underestimate the effective-
ness and safety of FDA-approved medications and bariatric surgery for
weight management, he observed, especially for patients with type 2 diabe-
tes. If they had a more accurate view of the potential positive outcomes of
these options, he suggested, many more people with obesity could benefit.
At the same time, he acknowledged that communicating evidence-informed
personalized estimates of the benefits and risks of weight management
options is challenging because of the need to tailor such communications
to the many factors that influence an individual patient’s capacity to un-
derstand information. Finally, O’Connor urged attention to ensuring that
informatics-driven quality improvement strategies, including clinical deci-
sion support tools, improve health equity.


Following the two speaker presentations, Crespo moderated a discus-
sion with Donnelly, O’Connor, and workshop participants. The speakers
responded to questions about opportunities to increase classroom-based
physical activity, changes in participation in physical activity as school-
children age, intensive behavioral therapy for children who have obesity,
prioritizing clinical actions in the presence of multiple comorbidities, and
the availability of clinical decision support systems.
Opportunities to Increase Classroom-Based Physical Activity

Donnelly stated that a school’s culture is the most important factor
in increasing classroom-based physical activity. A low-cost, efficient way
to change the culture, he reiterated, is to include integration of physical
activity into classroom lessons in the curriculum of teacher preparation
programs across colleges and universities so that prospective teachers will
expect to carry out this strategy and feel equipped to do so. Donnelly
clarified that the goal of classroom-based physical activity is to expend
energy, which can be accomplished through simple movements and instruc-
tions; complex motor tasks or sports-related movements are unnecessary.
He acknowledged that teachers would likely need at least minimal guidance
on how to adapt activities for students with special needs.
Changes in Participation in Physical Activity as Schoolchildren Age

Donnelly explained that as grade level increases, changes occur in the
types of physical activity that are promoted and selected. He pointed out
as an example that the typical approach with elementary school students
tends to break down as children enter middle school, as they become self-
conscious about doing silly movements that could cause them to sweat
or could be difficult to perform in clothing or shoes that may have been
selected with fashion rather than comfort in mind. Recreational and sports
activities are typically promoted among older children, but Donnelly ob-
served that data indicate a decrease in physical activity as children age
despite the shift in activities offered.
Intensive Behavioral Therapy for Children Who Have Obesity

A participant asked how to advance the U.S. Preventive Services Task
Force recommendation that children (older than 6 years of age) with obesity
be offered or referred to intensive counseling and behavioral interventions
to promote improvements in weight. O’Connor referenced efforts to engage

these children and their families in intensive behavioral therapy programs,

noting a low completion rate despite free and relatively easy access to a care-
fully designed, sophisticated intervention. He noted that it is unclear whether
the key barrier is families’ lack of time or parent–child conflicts, but he sug-
gested that improving engagement in the intervention is an important step.
Prioritizing Clinical Actions in the Presence of Multiple Comorbidities

O’Connor addressed the question of how to prioritize clinical actions
for patients who have obesity along with multiple comorbidities. He ex-
plained that algorithms can be designed so that a patient’s current weight,
blood pressure, and cholesterol values can be input into the American
College of Cardiology/American Heart Association’s risk calculator1 or
other cardiovascular risk calculator (along with a few other key factors)
to estimate a patient’s 10-year risk of heart disease or stroke as a reference
point. The calculation can then be rerun to forecast the potential impact on
that risk of decreasing certain values, and that information can be used to
prioritize treatment options and discuss them with patients.
Availability of Clinical Decision Support Systems

O’Connor stated that the tool he had discussed is web based and scalable
and is available to health care systems at a cost that covers such expenses as
installing the tool at the recipient site. In terms of potential for the tool to
interface with a learning health care system,2 he explained that if the tool com-
municates with the EMR and provides decision support at the point of care,
the data can be deidentified and archived in a way that provides a roadmap for
identifying care improvement opportunities. As an example, he said that data
could be used to identify how many of a physician’s patients with diagnosed
hypertension had been treated with blood pressure–lowering medications,
how many had their blood pressure under control, and how many whose
blood pressure was uncontrolled received a second drug. These kinds of data
could also be compared among providers, he added, so as to target learning
interventions to those with the most room for improvement. In addition, the
data could be used to examine outcomes by specific patient characteristics to
identify subgroups of patients who experience disparate outcomes.
1 https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate (accessed January 12,
2021).
2 https://nam.edu/programs/value-science-driven-health-care/learning-health-system-series
(accessed April 21, 2022).

Innovative Policy Solutions

• As sovereign governments, tribes have a unique and direct
nation-to-nation relationship with the federal government and
are continuous stakeholders in its programs. Therefore, it is im-
portant to provide tribal stakeholders equitable opportunities
to engage in policy initiation, development, implementation,
and assessment. (Duren)
• Relatively few data are available to describe the impact of
federal programs on tribal producers and communities, but us-
ing stories can provide additional, valuable support for policy
change by giving decision makers tangible illustrations of how
proposed policies would benefit people on the ground. (Duren)
• The New York City Department of Health has pioneered in-
novative policy approaches for addressing overweight and
obesity, several of which have been replicated by other local
jurisdictions and propelled to the national level. (Bassett)
• Education and willpower are insufficient to confront the
rising tide of inexpensive, calorie-dense offerings in the cur-
rent food environment; it is critical also to improve the
availability and accessibility of healthy food choices for all
populations. (Bassett)
61

The third session of the June 2021 workshop featured two presenta-
tions on innovative policy solutions and policy opportunities and chal-
lenges, which were followed by a panel discussion and question-and-answer
period with workshop participants. Stephanie Navarro Silvera, professor
of public health at Montclair State University, moderated the session and
provided opening remarks.
Silvera reiterated comments she had made during the first workshop
to distinguish between large “P” and small “p” policies. Large “P” policies
include broad federal, state, and local laws that may be specific to health
(e.g., access to universal health care) or not specific to health yet potentially
can influence health outcomes (e.g., policies related to voting rights, hous-
ing, and education). These policies often influence small “p” policies, she
explained, which include organizational practices and policies such as those
that govern workplaces or school food systems. Small “p” policies can
also influence large “P” policies, she added, through funding availability,
enforcement, attention, and equitability of policy application.
Silvera elaborated on the equity aspect of policy development, urg-
ing consideration of who (i.e., which individuals and populations) is and
is not involved in decisions related to defining a problem and determining
potential solutions to address it. When some populations are outside of that
“circle of power,” she suggested, their absence influences the language used,
the data that are collected and prioritized, the interpretation of those data,
and ultimately the details of the policy developed. She added that excluded
populations may be historically disenfranchised, and that exclusion from
the policy cycle omits their voices from both policy development and assess-
ment; therefore, their perspectives on a policy’s impact (whether positive or
negative) are also absent. Silvera closed her remarks with a quote from Mikki
Kendall: “We have to be willing to embrace the full autonomy of people who
are less privileged and understand that equity means making access to op-
portunity easier, not deciding which opportunities those individuals deserve.”
A PERSPECTIVE FROM THE INTERTRIBAL

AGRICULTURE COUNCIL
Colby D. Duren, director of policy and government relations at the
Intertribal Agriculture Council (IAC), discussed the council’s work and
approach to policy innovation. He explained that the IAC was established
in 1987 in the wake of the farm financial crisis, which disproportionately
affected tribal producers. In recognition of the inequities these producers
experienced, the IAC was directed to provide them with direct assistance
and support, as well as to support relevant policy developments.
Tribal producers were not envisioned as original stakeholders in
the U.S. Department of Agriculture’s (USDA’s) foundational policies,

INNOVATIVE POLICY SOLUTIONS 63
Duren maintained, and the IAC continues to advocate for tribal producers’
access to the funding and support available through USDA programs. One
approach to this end involves technical assistance agents who work directly
with tribal producers to illuminate producer’s concerns and their challenges
in accessing programs, funding, or other opportunities. The IAC reviews
this feedback, Duren added, and determines whether the issues can be ad-
dressed through USDA or need to be elevated to Congress.
Duren referenced recent progress toward including tribes in federal
farm policies, noting that tribes were mentioned in the Farm Bill for the first
time in 1990. He pointed out that because USDA is not structured around
the realities of tribal agriculture, the IAC works to have a voice in the
process of agricultural policy making as early on as possible. He reminded
participants that as sovereign governments, tribes have a unique and direct
nation-to-nation relationship with the federal government and are continu-
ous stakeholders in its programs, a status that warrants consulting tribes
prior to and during the creation of federal policies.
Duren described the formation of the Native Farm Bill Coalition, which
started as a research and data-gathering effort leading up to the 2018 Farm
Bill. That effort engaged the Indigenous Food and Agriculture Initiative at the
University of Arkansas, he recounted, to produce an extensive report titled
Regaining Our Future (Hipp and Duren, 2017). The report reviewed the
history of tribal agriculture and suggested opportunities for the Farm Bill’s
policies to serve tribal producers. The IAC used the report to engage tribal
organizations across the country, Duren continued, which worked together
to develop and distribute dissemination materials aimed at spurring conversa-
tion about the report and advocating for its suggested policy changes. Duren
added that the Native Farm Bill Coalition now includes 17 national tribal
organizations and 3 allied organizations and represents more than 170 tribes.
Duren next described challenges faced by the coalition in effectively
translating the report to help policy makers understand how the proposed
policy changes would benefit tribal producers. He observed that stakehold-
ers in federal government programs often use shorthand phrases and ac-
ronyms to communicate program data, which he said had to be translated
and supported with additional context to help convey the data’s meaning.
In many cases, he noted, few data were available to describe the impact of
federal programs on tribal producers and communities, which he identified
as an impediment to building a compelling case for change. Duren high-
lighted the importance of using stories to help fill data gaps and to provide
decision makers with tangible examples of how proposed policies would
benefit people on the ground. He maintained that, even in the presence of
abundant data and sound analyses indicating a proposed policy’s effective-
ness, clear examples of a policy’s practical benefits for constituents can have
a unique impact.

Returning to 2018, Duren relayed that the coalition was able to help
secure 63 tribal-specific provisions in that year’s Farm Bill. One of the
most important wins was the extension of tribal self-governance, which he
described as the ability for tribal governments to contract with the federal
government to administer and manage a program designed to serve its
citizens. According to Duren, one way that authority manifests is the Food
Distribution Program on Indian Reservations (FDPIR), a commodity food
purchasing program that allows distribution sites to contract with and
purchase food from local producers. This has a double benefit, Duren ex-
plained, as it gives program recipients the opportunity to access foods that
are traditional to their region while also helping local producers build their
capacity by connecting them with a federal government program. Duren
reported that the IAC has been working on implementation of the Farm
Bill’s provisions, which he said is at least half the battle (the other half being
enactment/passage) in achieving a policy’s intent.
Duren ended his remarks by underscoring the importance of ensuring
tribal representation from the initiation of policy through its development,
implementation, and assessment. He reiterated that tribal producers have
historically been in a reactive position because they have been excluded from
this process, which he said left them “trying to fit the square peg of tribal
agriculture into a round policy hole.” Even if tribal stakeholders are able
to advocate successfully for adjustments to proposed or enacted policies,
Duren observed they are still subject to a program that may not be as help-
ful as it could be for the people it is intended to serve. In closing, he stated
that the IAC will continue to build relationships that help tribal stakehold-
ers achieve equitable opportunities through early and deep engagement in
policy initiation, development, implementation, and evaluation.
A PERSPECTIVE ON INNOVATIVE LOCAL

GOVERNMENT APPROACHES
Mary T. Bassett, director of the François-Xavier Bagnoud (FXB) Center
for Health and Human Rights at Harvard University and FXB professor of
the practice of health and human rights at the Harvard T.H. Chan School
of Public Health, reflected on her tenure as deputy health commissioner
(2002–2009) and health commissioner (2014–2018) in New York City
(NYC). According to Basset, the position of the NYC Department of Health
on equity during those years was that “a rising tide would raise all boats.”
In other words, she clarified, a specific equity lens did not exist because a
policy initiative that would advance the availability of and ability to make
healthy food choices was expected to be good for everyone.
Bassett explained that the NYC Department of Health’s various policy
approaches were aimed at countering the rising prevalence of overweight,

obesity, and diabetes among the city’s residents. She acknowledged that
these approaches were innovative, but said they seemed like common sense
in light of available data on the city population’s rates of overweight, obe-
sity, and diabetes, as well as the structural context that had affected the
way people obtained food and were prompted to consume calories from
purchased and prepared foods. Bassett highlighted wide variation at the
neighborhood level—mainly by race, ethnicity, and income—in the preva-
lence of these conditions and of self-reported consumption of calorie-dense
foods and sugar-sweetened beverages. To her, it seemed clear that the rising
prevalence of adverse health indicators could not be attributed to individual
choices alone, which she said led to the Department of Health’s realization
that improving the availability and accessibility of healthy food choices is
at least as important as educating people about making healthy choices—if
not more so.
Bassett went on to describe several policy approaches pioneered by
the NYC Department of Health, beginning with its 2006 requirements
for chain restaurants to post calorie information on their menus and for
all restaurants to remove trans fats from most of their menu offerings. In
2008, she continued, the city used executive authority to establish nutrition
standards for snacks and beverages purchased by the city and brokered an
agreement to remove sugary beverages from public school vending ma-
chines. Arguably the most well-known action taken by the Department of
Health was its 2012 attempt to limit the serving size of sugar-sweetened
beverages in food service establishments, Bassett recalled, a measure that
was highly contested and ultimately overturned in the courts. She noted
that prior policies had also faced legal challenges, usually on the basis of
federal preemption or corporate free speech, but had nonetheless prevailed.
In 2015, the Department of Health instituted warning labels on chain res-
taurant menu items containing more than the daily recommended intake
of sodium. Local jurisdictions followed NYC’s lead in adopting some of
these policies, Bassett said, which subsequently garnered national attention.
She cited two examples: calorie posting in chain restaurants as part of the
Patient Protection and Affordable Care Act of 2010, and Food and Drug
Administration actions to lower trans fat and sodium content across the
food supply.
More action at the national level is critical, Bassett asserted, given
limits to the power of local authorities to make healthy choices available
to their residents. She expressed the hope that future actions would target
ultraprocessed foods, which she said are low cost and readily available
and furnish a majority of the calories in U.S. diets. In her view, more than
information, education, and individual willpower will be required to con-
front the rising tide of inexpensive, calorie-dense options in the current
food and beverage environment.


Following their presentations, Duren and Bassett responded to ques-
tions from workshop participants about the development of inclusive
food policies, approaches for building support for public health policy ap-
proaches, taxation as a potential obesity solution, distribution of benefits
from USDA funding and programs, and issues of preemption.
The Development of Inclusive Food Policies

Duren urged those advocating for food policies that would benefit
Indigenous populations and other communities of color to include re-
searchers and data representative of those populations in those efforts. He
also believes it would be valuable for federal dietary guidance to include
examples of healthy foods representing the diverse cultures of people who
live in the United States. To illustrate these points, he recounted that when
tribal stakeholders participated in policy development and advocacy efforts
related to the FDPIR, the result was an increase in program recipients’
access to more healthy and traditional food options.
Approaches for Building Support for Public Health Policy Approaches

According to Bassett, an increasingly common yet misguided approach
for addressing obesity is to modify the individual instead of the environ-
ment. Treating people with obesity is important, she clarified, but she
argued that the condition’s high prevalence warrants population-level ap-
proaches as well. The trajectory of the prevalence of overweight, obesity,
and type 2 diabetes in the United States is associated with changes in the
country’s food environment, she observed, and she called for more robust
federal action to shift the composition of the nation’s food supply. She
pointed out that social movements have driven community-grown strate-
gies, such as those focused on increasing neighborhood availability of
healthy food and promoting urban agriculture. She contrasted such efforts
with “top down” approaches—i.e., larger-scale policy changes—that the
NYC Department of Health pursued.
In response to a question about guidance for the upcoming genera-
tion of change makers, Bassett urged advocating for regulation of the
large industrial complexes that she said control the food system, and for
providing data that can build the case for restructuring the food produc-
tion landscape to support a healthier food supply. According to Duren, the
current environment is fertile for making changes on a large scale in light
of technologies for rapidly disseminating messages with the potential for
broad reach. On that note, he emphasized the importance of a consistent,

accurate stream of data and information for inclusion in daily news cycles
about a proposed policy and its potential benefits for the intended recipi-
ents. He urged youth to be bold in making their voices and stories heard,
which he claimed is particularly impactful when they speak about how a
proposed policy would affect them.
Taxation as a Potential Obesity Solution

Bassett voiced her support for the concept of taxes on sugary drinks
but also acknowledged their mixed associations with consumption de-
pending on geographic area, as well as the disproportionate burden of
taxation on people with low incomes (although she also noted that these
populations are often exposed to disproportionate levels of marketing for
such beverages).
Duren reminded participants that tribes, as sovereign governments, re-
tain their own taxation authority, and tribal governments sometimes impose
taxes on certain activities that occur within their jurisdictional boundaries,
reservation boundaries, or a business in which they are engaged. With re-
spect to economic activity on tribal lands, he continued, tribes provide and
finance services for which they do not necessarily have a standard or estab-
lished tax base because tribal citizens are also citizens of their states and the
United States. This situation, he maintained, creates the potential for dual
taxation if tribal governments decide to issue taxes on the same services or
goods that are taxed by the state and/or federal government. From a tribal
perspective, Duren suggested, a federal tax on a particular item or activity
would be construed as relinquishing a tribal government’s taxation author-
ity for that item or activity. Tribal stakeholders want to ensure that tribal
governments retain authority to make taxation decisions that affect their
tribes, he elaborated, and that they receive the tax revenues and determine
how to use them for the benefit of their citizens. According to Duren, while
tribes may be able to negotiate agreements with state governments to split
revenues from excise taxes on certain items or services, this arrangement
depends on a tribe’s relationship with its state government.
Benefit Distribution from USDA Funding and Programs

Asked for his opinion on ending farm subsidies, Duren said the IAC
does not have a firm stance on this issue, but took a broader perspective to
raise the issue of benefit distribution from USDA funding and programs.
Noting that the majority of Coronavirus Aid, Relief, and Economic Security
Act funding went to White, male, large-scale producers, he appealed for
more equitable access to USDA programs. Referring specifically to farm
subsidies, he suggested examining what kinds of products are more or less

likely to receive support and considering that degree of likelihood in rela-

tion to the characteristics of producers of those products. This perspective
reflects a wider lens, he explained, that is oriented to reshaping USDA
programs and support structures to better serve all types of producers in
today’s landscape and promote the production of foods more aligned with
current dietary guidance. An example of such innovation, he continued, is
to invest in strong local food structures that lift up both producers—who
would never be able to compete in a large-scale food processing market—
and consumers in a community.
Issues of Preemption
In Bassett’s view, preemption—when a state passes a law that takes
precedence over local law—is a worrying development because it means
that innovations in local jurisdictions, which may go further than the state
is willing to go, can be rolled back by preemption. The only recourse is
legal action to overturn laws that preempt local authority, she said, and
she cited preemption along with corporate freedom of speech as two key
arguments used to oppose such public health approaches as taxes on sugary
drinks and marketing restrictions on unhealthy foods and beverages. Silvera
added that this issue relates to voting rights as an upstream determinant
of health because eligibility to vote in state elections can influence who is
elected to state government and what policies they support, which may
relate to preemption.
Tribal governments are similar to local governments, said Duren, in
that they want to retain power and authority over the laws that govern their
jurisdictions and the people who live there. He reiterated the importance
of ensuring representation of the voices of people who will be affected by a
policy during the policy development process. Government’s role is to pro-
tect public interests, he maintained, and because corporations must operate
within the laws passed by the government, changes could be made to those
laws to better protect the public.

Reflections on Equity-Centered
Approaches to Reducing the
Prevalence of Obesity
Key Points from the Keynote Presentation (Workshop 2, Session 4)

Sarah de Guia, ChangeLab Solutions
• Disparities related to health and obesity cannot be addressed
adequately without attending to underlying health inequities,
which are typically driven by upstream, systems-level factors.
• Five fundamental drivers of inequity are structural racism and
discrimination, income inequality and poverty, disparities in
opportunity, disparities in political power, and governance
that limits meaningful participation. These co-occurring, over-
lapping drivers shape places, social environments, and living
conditions, as well as individuals’ daily experiences and per-
spectives in those settings.
• Equity-centered frameworks and strategies both enhance
and transcend policy, systems, and environmental change ap-
proaches to improving public health. An equity-centered strat-
egy for reducing health inequities addresses social and political
pressures or promotes policies designed to change social de-
terminants of health, applying a people-centered approach to
identifying and prioritizing interventions that will most benefit
underserved populations.
• Community engagement in policy development builds social cap-
ital, increases community cohesion, fosters confidence and trust
in government, and builds on community strengths and assets.
69

The fourth and final session of the June 2021 workshop featured a key-
note speaker who offered reflections on the workshop and discussed equity-
centered approaches for reducing the prevalence of obesity. Her remarks
were followed by a panel discussion during which three of the workshop
speakers answered questions from the audience. Melissa A. Simon, direc-
tor 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,
moderated the session.
REFLECTIONS ON EQUITY-CENTERED APPROACHES

TO REDUCING THE PREVALENCE OF OBESITY
Sarah de Guia, chief executive officer of ChangeLab Solutions, ex-
plained that ChangeLab Solutions is a national, nonpartisan, nonprofit
organization that uses the tools of law and policy to advance health equity
at the national, state, and local levels. Its interdisciplinary team of lawyers,
planners, analysts, and other professionals works with community organi-
zations, governments, and anchor institutions to develop and implement
equitable policy solutions. According to de Guia, a focus of the organiza-
tion is on demystifying law and policy, which she described as two power-
ful tools that are often inaccessible to the public yet hold strong potential
both to help undo historical harms that affect large numbers of people and
to engage change makers in the policy process. As ChangeLab works to
connect stakeholders across sectors, she elaborated, a goal is to increase
their understanding of equity issues and their ability to address them. She
explained that ChangeLab pursues this goal by strengthening stakeholders’
leadership and capacity through training and technical assistance designed
to help them leverage policy and legal tools that elevate practical, evidence-
based, and community-centered solutions and successes.
As de Guia chronicled ChangeLab’s history, focusing on its efforts
related to obesity prevention, she explained how the organization’s pivot
to focus on fundamental drivers of health inequity has played out in its
legal and policy solutions. The idea for ChangeLab Solutions arose in the
mid-1990s, she recounted, when states had begun to win lawsuits against
tobacco companies and found themselves with additional resources to
support prevention of tobacco use. ChangeLab operated primarily as a
provider of technical and legal assistance to local health departments in
California, helping them use innovative legal and policy interventions—
such as land use and zoning regulations, taxation, and First Amendment
and consumer law—for tobacco control. According to de Guia, ChangeLab
urged health departments to consider policy, systems, and environmental
changes instead of the usual educational and outreach approaches, and

EQUITY-CENTERED APPROACHES 71
in the early 2000s began applying this perspective and its lessons from
tobacco control to the topic of obesity prevention. She described initial ef-
forts as being focused on downstream drivers of obesity, such as access to
healthy foods and opportunities to be physically active, and as involving
technical assistance as well as communication strategies to build the case
for environmental change. In 2008, she continued, ChangeLab received a
grant that enabled it to scale its policy and legal analysis efforts in obesity
prevention to the national level. Yet despite the organization’s progress in
addressing school environments and promoting healthy environments in
other places, de Guia recalled, health disparities persisted and even widened
among Black people, Indigenous people, other people of color, and low-
income communities.
As ChangeLab considered how to integrate equity into its law and
policy frameworks, de Guia reported, three resources, among many others,
provided compelling data and evidence to support shifting its focus fur-
ther upstream. The first was a framework for increasing equity in obesity
prevention (Kumanyika, 2019), which is built on the premise that dispari-
ties related to health and obesity cannot be addressed adequately without
attending to underlying health inequities (which are typically driven by
upstream, systems-level factors). This framework, de Guia explained, in-
cludes policy solutions that incorporate traditional, downstream public
health interventions, but also highlights the role of community engagement
in the development of policies and practices. In addition to informing poli-
cies, she maintained, such engagement helps build social capital, increase
community cohesion, build confidence and trust in government, and build
on community strengths and assets. The second resource was an article on
structural racism and health inequities in the United States (Bailey et al.,
2017), which de Guia described as defining the systemic nature of struc-
tural racism and making the connection between historical racist laws and
the policies and pathways that have led to disparities. The third resource
was a trauma-informed approach (CDC, 2018) that encourages awareness
of the impact trauma can have on communities and emphasizes principles
of safety; trustworthiness and transparency; peer support; collaboration;
empowerment; and cultural, historical, and gender issues.
In 2019, ChangeLab published A Blueprint for Changemakers, which
posits that a focus on drivers of health inequities is critical for address-
ing health adequately and that unjust laws and policies are powerful risk
factors for poor health given their historical perpetuation of racism, dis-
crimination, and segregation. A Blueprint for Changemakers, de Guia
elaborated, urges pursuing health equity by addressing five fundamental
drivers of health inequity: structural racism and discrimination, income
inequality and poverty, disparities in opportunity, disparities in political
power, and governance that limits meaningful participation (Figure 9-1).

FIGURE 9-1 Fundamental drivers of health inequity.

SOURCE: Presented by Sarah de Guia, June 22, 2021. Graphic from ChangeLab Solutions,
2019, used with permission. Design by Black Graphics.
As described in A Blueprint for Changemakers, these five co-occurring,

overlapping drivers shape places, social environments, and living con-
ditions, as well as individuals’ daily experiences and perspectives in
those settings.
According to de Guia, ChangeLab’s recognition of these drivers has led
it to adopt equity-centered frameworks and strategies that both enhance
and go beyond its policy, systems, and environmental change approaches
to improving public health. She explained that an equity-centered strategy
for reducing health inequities addresses social and political pressures or
promotes policies designed to change social determinants of health, apply-
ing a people-centered approach to identifying and prioritizing interventions
that will most benefit underserved populations. A Blueprint for Change-
makers offers several frameworks and approaches that spotlight people
and communities most affected by injustice—for example, a “health in all
policies” approach to government; ongoing, deliberate community engage-
ment processes; and emphasis on local solutions. To highlight ChangeLab’s
equity-oriented approach to changing policies, systems, and environments
to reduce disparities in the prevalence of obesity while supporting and en-
gaging communities most affected by structural barriers, de Guia offered
three examples.
The first example was a systems change effort that applied a trauma-
informed lens to an analysis of food policies in the U.S. Department of Ag-
riculture’s (USDA’s) Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC). The goal, de Guia explained, was to develop
policy recommendations that might not be identified in a traditional public
health analysis. Food insecurity is associated with traumatic experiences

that affect children’s development and health, de Guia pointed out; more-
over, food assistance programs such as WIC are potential points of inter-
vention to prevent trauma and retraumatization among individuals and
families. According to de Guia, ChangeLab’s participant-centered approach
and policy scan revealed that some WIC policies offer more generous food
allowances for women who breastfeed fully or partially than for those who
do not, although the policy does not necessarily consider that barriers to
breastfeeding may be beyond a family’s control. She added that ChangeLab
also found that few exceptions exist within WIC food packages for families
of different cultural groups; de Guia asserted that a trauma-informed lens
would seek to preserve WIC participants’ sense of control and choice. If
these participants were invited to provide feedback on the program’s ad-
ministration, she argued, their suggestions could improve its effectiveness
and even identify community assets, such as stores offering cultural foods,
that could be considered for inclusion in food packages.
With her second example—an effort to enact taxes on sugary drinks in
Berkeley, California—de Guia highlighted advocates’ innovative approach
that involved engaging community youth. The first step was to inform
young people about the contribution of sugary drinks to diabetes, and then
to alert them to such structural issues as targeted advertising of sugary
drinks to Black and Latinx communities. Community members were also
asked for ideas on how to spend revenues from taxes on sugary drinks,
de Guia recalled, and an advisory board was formed to help distribute
the funds. This example illustrates key components of the Kumanyika
framework,1 de Guia pointed out; the change effort deters harmful products
while also fostering community engagement and capacity.
The third example offered by de Guia also featured a community-
centered approach, which grew out of a New Jersey documentary demon-
strating how community assets could transform local structures and systems
to enhance food security. ChangeLab identified legal barriers that communi-
ties needed to surmount in order to create and expand urban agriculture,
farmers’ markets, and community gardens, de Guia said.
Shifting to reflect on the workshop presentations and discussions, de
Guia offered a simple graphic (Figure 9-2) highlighting communications,
data, community engagement, and equitable policy solutions, which she
proposed are core, interrelated components in advancing efforts to reduce
the prevalence of obesity.
The public and policy makers are two important audiences for com-
munications, de Guia observed. She suggested framing messages with a
1 The equity-oriented obesity prevention action framework is intended to assist in selecting
or evaluating combinations of interventions that incorporate considerations related to social

disadvantage and social determinants of health (Kumanyika, 2019).

FIGURE 9-2 Interrelationships among core components of sustainable systems-wide strategies

for reducing the prevalence of obesity.
SOURCE: Presented by Sarah de Guia, June 22, 2021. Reprinted with permission.
lens of fairness and justice, highlighting practices that drive disparities, and
offering corresponding policy solutions. Communities want to see their as-
sets and strengths uplifted in policy solutions, she maintained, instead of
hearing only alarm bells and lectures about the problem.
According to de Guia, building intentional, deep relationships with
communities engages them as cocreators—rather than mere recipients—of
policies, which in turn increases the likelihood of developing optimal solu-
tions for their needs. Such relationships also enhance policy evaluation by
meaningfully soliciting community members’ experiences with and feedback
on a policy—information that de Guia termed “community-defined data.”
Stating that she was energized by the potential opportunities to engage
schools and clinical settings in obesity prevention in new ways, de Guia under-
scored the value of multisector collaboration. She urged public health stake-
holders to learn other sectors’ languages and to frame communications in a
way that invites collaboration. She also urged mindfulness of potential biases
in data sources and data collection methods, cautioning against introducing
bias into such seemingly neutral tools as artificial intelligence and algorithms.
PANEL DISCUSSION
Following de Guia’s presentation, Simon moderated a discussion with
three of the second workshop’s speakers: Colby Duren, director of policy
and government relations at the Intertribal Agriculture Council (Chapter 8);

Jeff Niederdeppe, professor in the Department of Communication, director

of the Health Communication Research Initiative, and codirector of the
Center for Health Equity at Cornell University (Chapter 6); and Patrick
O’Connor, senior clinical investigator and codirector of the Center for
Chronic Care Innovation at HealthPartners Institute (Chapter 7). Panelists
discussed topics that included laying the foundation for a successful com-
munication strategy, using big data and clinical decision support tools,
addressing climate change through agricultural policy, navigating gaps in
data, implementing public health infrastructure initiatives that relate to
obesity, and communicating about COVID-19 and obesity.
Laying the Foundation for a Successful Communication Strategy

In response to Simon’s question about successful two-way communica-
tions, Niederdeppe drew a contrast between interpersonal communication,
in which exchange and feedback (both verbal and nonverbal) are available
to enhance effectiveness, and organizational or community communication,
in which the lack of direct feedback from various audiences creates a chal-
lenge. He cautioned that a communication strategy to achieve buy-in for a
proposed policy will face an uphill battle if those at whom the policy is tar-
geted have not been engaged in its development. He appealed for taking an
inclusive approach to articulating shared goals and cocreating policies, ex-
plaining that including all stakeholders at the outset enables communication
strategies to better reflect the interests of different groups and organizations.
Using Big Data and Clinical Decision Support Tools

O’Connor replied to Simon’s question about big data challenges and
considerations by highlighting limitations of the data available in clinical
decision support tools. These technologies are restricted to data that are
included in an easily retrievable form in electronic medical records or other
related big data systems, he explained, which are largely devoid of patient-
reported outcomes, let alone information about the patient’s personal val-
ues and beliefs. According to O’Connor, it is a major challenge to obtain
this type of data and incorporate it securely into clinical datasets so it can
inform clinical decision making. Reiterating his presentation’s emphasis on
shared decision making, he said a communication gap often exists between
providers and patients because providers may have difficulty presenting
information in a way that patients understand. He pointed out as well
that providers tend to lack the training and skills that are often needed to
counsel patients about health behavior change (e.g., smoking cessation) so
that the potential benefits identified by clinical decision support tools can
be achieved.

Addressing Climate Change through Agricultural Policy

Duren focused on climate change in his response to Simon’s question
about additional outcomes that could be addressed through agricultural
policy. Taking a broader perspective, he noted that large-scale entities often
develop policies in silos, which results in approaches that are limited to
their own departmental and issue area realms. A more inclusive approach,
he suggested, would be to ensure representation of a broader group of
stakeholders in policy initiation and development. One of the first hear-
ings on climate change held by the agriculture community did not include
producers of color, he recalled, who could have indicated how potential
solutions would impact their communities and contributed their own ideas
for solutions to serve their communities’ needs.
Duren highlighted as a further challenge that an issue initiative undertaken
by a federal department may be discontinued when a new administration with
different priorities takes control. This happened several years ago when the
U.S. Department of the Interior’s Bureau of Indian Affairs allocated funding
for tribes to formulate climate change actions and plans, he recounted, until
the subsequent administration decided not to continue the program.
Duren encouraged those considering large-scale changes to address
such issues as climate change to adopt a perspective that considers the issue
in the context of the entirety of a government department’s programs. As
an example, he pointed to USDA, whose provision of funding to producers
is contingent on certain requirements. Duren suggested that those require-
ments could be adapted to empower producers who want to venture into
an innovative practice such as regenerative agriculture.
Navigating Gaps in Data

A participant asked panelists what they should do if data they need are
not available. In the clinical context, replied O’Connor, provider–patient
conversations can elicit patient priorities and guide shared decision making
about behavior change and other treatment options. Such an exchange can be
difficult in the face of communication barriers related to culture or language,
he pointed out, and even more so if a patient’s conception of a health condi-
tion deviates from a Western biomedical perspective. He added that most
EMR systems have a patient portal where information can be exchanged
between patient and provider, but at present, this pathway is often limited to
one-way sharing of laboratory results and visit summary notes with patients.
Enabling patients to self-report their beliefs, values, and preferences and
provide information about symptoms or lifestyle, he argued, would greatly
expand the scope of clinical decision support systems. Simon pointed to the
concept of a learning health care system designed to enable a patient’s prefer-
ences and values to drive the clinical care team’s learning.

In Niederdeppe’s experience, data are rarely available at a level needed to

predict the outcomes of systems-level changes. A wide range of relevant data
with a high degree of confidence related to effects on health, economic, social,
or equity outcomes may be needed, he elaborated, and he echoed Duren’s call
to solicit the input of a broad, diverse group of stakeholders to identify some
of those potential effects based on their lived experiences. He also stressed the
importance of consistent evaluation of systems change interventions to assess
their implementation and compile lessons that can be applied the next time a
similar intervention is implemented in a different community.
Implementing Public Health Infrastructure

Initiatives That Relate to Obesity
A participant asked whether any public health initiatives in the U.S.
Congress’s infrastructure bill have the potential to influence the prevalence
of obesity. Duren responded that the final provisions and specific language
of the bill are still uncertain, but from his perspective, an important public
health support would be to improve access to potable water in homes and
other community settings. A more tangential yet relevant public health
support would be to increase access to broadband, he suggested, which
would provide opportunities for telemedicine and support the building of
additional health facilities in rural areas and throughout Indian country.
Communicating about COVID-19 and Obesity

Niederdeppe shared two observations about health communication re-
garding COVID-19 and obesity. First, he stated that mixed messages from a
government agency about what is considered evidence-based practice result
in public confusion in the short term and erosion of trust in public health
institutions in the longer term. He added that the perception of mixed mes-
sages may be accurate, particularly if messages have been politicized, or
less accurate, if changing guidance reflects an evolving evidence base used
to inform best practice.
This issue reflects a broader communication challenge, Niederdeppe
said in introducing his second observation: that complex, dynamic concepts
cannot always be distilled into simple, definitive messages and that doing so
may risk causing public distrust in the longer term. He referenced the exam-
ple of face mask guidance early in the COVID-19 pandemic, recounting the
shift in public messaging that paralleled emerging science but was perceived
by many to represent an abrupt turnaround. Niederdeppe encouraged those
responsible for health communication to raise awareness that science is a
process that results in an evolving understanding of the truth—and thus in
the evolution of public health guidance—as the evidence base grows.

To respond to Simon’s follow-up question about whether the emphasis

on protecting others as the public health rationale for mask wearing was in-
congruent with the individualistic culture of the United States, Niederdeppe
observed that public health messaging is often based on fear and defaults to
the concept of “protect yourself.” He urged improvements in communicat-
ing the value of individual actions in influencing collective benefits.
O’Connor asked Niederdeppe for advice on how to improve provider–
patient communication. Niederdeppe suggested striking a balance between
talking and attentive listening, offering qualitative explanations of risks
and benefits that are typically provided in quantitative terms, and consid-
ering how to provide communication opportunities outside of the clinical
encounter with the primary care provider.
O’Connor addressed the final question from a participant, who asked
about the role of obesity treatment in relation to efforts to change systems
to reduce the prevalence of obesity. According to O’Connor, it is important
to pursue both as part of a holistic approach to addressing the root causes
of the problem, and the most effective way to combat the obesity epidemic
may be to coordinate public health, environmental policy, public policy,
and clinical approaches.

10
Leveraging Data for Systems Change:

Connecting Obesity and Its
Underlying Determinants

• Advanced technological capabilities that involve data science,
systems modeling, and artificial intelligence can provide impor-
tant new insights for understanding and addressing the systems
that drive obesity. For example, a computational simulation
model can integrate multiple complex and dynamic measures
to simulate intervention effects. (Lee)
• Although the problem of obesity could be deemed overly com-
plex and impossible to understand completely, it is important
to start somewhere—even if initial efforts provide only partial
solutions. The iterative nature of systems modeling will gradu-
ally connect obesity and its underlying determinants, allowing
for systems change. (Lee)
• Trends of decreasing death rates from cardiometabolic dis-
eases have flattened in the United States, driven presum-
ably by prolonged exposure to the rising U.S. obesogenic
environment. Nonetheless, characterizing the relationship
between obesity and mortality risk at the individual level is
challenging. (Masters)
79

• Instead of moving away from body mass index (BMI) to pursue

new metrics and indices for investigating the individual-level
association between obesity and mortality, it may be more
worthwhile to examine individuals’ cumulative duration of
time spent in different BMI states, which is a key influence on
metabolic health and long-term outcomes. (Masters)
The third (October 2021) workshop began with a session focused on

driving systems change by leveraging data that connect obesity with its
underlying determinants. Carlos Crespo, professor at Oregon Health and
Science University and Portland State University School of Public Health
and vice provost for undergraduate training in biomedical research at
Portland State University, moderated the session.
HOW DATA SCIENCE, ARTIFICIAL INTELLIGENCE, AND

OTHER TECHNOLOGICAL APPROACHES CAN HELP
ADDRESS THE SYSTEMS CONTRIBUTING TO OBESITY
Bruce Y. Lee, professor of health policy and management at the City
University of New York School of Public Health, discussed opportunities
for data science, systems modeling, artificial intelligence, and other types of
technological approaches to improve how the complex systems that drive
obesity are understood and addressed.
Lee offered a series of examples to illustrate what it would look like if
society approached meteorology and weather forecasting in the same sim-
plistic way that it approaches obesity prevention and control. Although these
areas may seem unrelated, he pointed out that they both involve complex
systems. These examples, he suggested, demonstrate the need to account for
the entire system of factors when addressing the obesity epidemic.
First, Lee highlighted the need to consider a suite of indicators when
trying to understand a complex system. Applying his analogy with meteo-
rology, he pointed out that using a single measure, such as the temperature,
to understand the weather would be inadequate because it would exclude
information about such variables as precipitation and humidity that affect
how a person prepares for the day’s weather. Similarly, Lee continued, it is
insufficient to rely on single measures, such as an individual’s body mass
index (BMI) or the population prevalence of obesity, to understand the
broad set of factors that contribute to obesity and how best to intervene.
He referenced a computational model that accounts for not only an indi-
vidual’s BMI but also the person’s chronic health condition(s) to estimate
specific disease outcomes and associated costs. This model can then be used

LEVERAGING DATA FOR SYSTEMS CHANGE 81
to estimate specific disease outcomes and costs that could be prevented by

helping the patient transition from a BMI category of overweight or obesity
to one of normal weight (Fallah-Fini et al., 2017). Multiple complex and
dynamic measures provide a more complete picture of what is happening
with a patient, he reiterated, compared with single measures.
Second, Lee explained the need for a combination of bottom-up and
top-down approaches. In this example, he asked what would happen if
simple associations and correlations were used to forecast longer-term
changes in the weather. He shared a graph charting an increase in global
average temperatures that has occurred over time alongside a decrease in
the number of seafaring pirates. Lee pointed out that, although an associa-
tion exists between global average temperatures and numbers of pirates,
this association does not demonstrate that decreases in the number of
pirates have caused the increases in global temperatures. He argued that
top-down methods that involving scrutinizing data for patterns and correla-
tions to detect potentially important factors should be used in combination
with bottom-up methods that re-create systems to elucidate mechanisms
of interest.
Third, Lee described the need to integrate data collection across differ-
ent parts of a system. If a meteorologist collected data on barometric pres-
sure but did not examine those data in the context of other measures and
dynamics in the environment, many insights about the system’s interconnec-
tivity would be missed. Data collected to support obesity prevention often
occur in isolation from other activities focused on the same goal, which may
result in mischaracterizing the system. A better approach, Lee suggested, is
to integrate data collection, systems mapping and modeling, and policies
and interventions to gain a holistic understanding of what is happening.
Such insights can guide and prioritize subsequent data collection and in-
tervention design, he added, which in turn generate more information that
can be used to update maps and models in a circular, iterative process that
gradually yields better solutions.
Lee’s fourth example focused on the importance of open data shar-
ing. He asked the audience to think about the problems that would occur
if weather data were not readily shared from location to location and
people thus could not understand weather patterns in different parts of the
country. Lee maintained that open sharing of data about the factors and
processes that affect obesity at various scales and levels—genetics, physiol-
ogy, individual behavior, social environments, physical environments, and
societal forces such as policies—would help paint a more complete picture
and reveal major forces driving the outcomes observed.
In his fifth example, Lee explained the value of understanding the varia-
tions among different locations. In meteorology, he said, it is illogical to
assume that weather conditions in one location are the same everywhere,

as it is well known that weather varies geographically. The same is true with
the obesity epidemic, he contended. Referring to a study by his group, Lee
discussed how the effects of warning labels on sugar-sweetened beverages
on the prevalence of obesity were found to vary by geographic location,
reflecting differences in the environments studied (Lee et al., 2018).
Sixth, Lee discussed the importance of data surveillance systems that
provide real-time updates. He asked the audience to imagine what it would
be like if weather forecast systems were not regularly updated over time.
In the same way that weather systems are based on immediately available
information, Lee continued, decisions about obesity prevention and control
need to be informed by real-time surveillance data because many of obe-
sity’s contributing factors shift regularly.
Lee’s seventh example emphasized that external forces matter. He asked
the audience to imagine what would happen if individuals were to be sin-
gularly blamed for the weather. Thus he urged consideration of external
factors, such as social determinants, that influence an individual’s develop-
ment of obesity.
In his eighth example, Lee underscored the need for multilevel interven-
tions. Addressing the obesity epidemic effectively, he argued, will require
multiple multiscale, layered, and integrated policies and interventions that
address the multifaceted contributors to obesity.
Ninth, Lee urged the use of new, innovative technologies to understand
and address complex systems, asking, what if society were to rely on old
technologies to understand weather patterns? Clearly, he said, using old
technologies to predict the weather would not provide the most accurate
understanding of what weather to expect. Lee urged the use of advanced
technologies, such as agent-based modeling and machine learning, to ad-
dress the obesity problem, as they can provide new insights about obesity
prevention and control.
Lastly, Lee asserted that the overly complex nature of problems should
not prevent society from making concerted efforts to address them. Despite
the fact that meteorology is complex and difficult to understand completely,
he stressed the importance of not allowing these challenges to discourage
people from trying. “We have to start somewhere,” he argued, “even if
initial efforts provide only partial solutions to the problem. The iterative
nature of systems modeling will gradually enable better understanding and
in turn, better solutions.”
MORTALITY CONSEQUENCES OF THE

U.S. OBESOGENIC ENVIRONMENT
Ryan Masters, assistant professor of sociology and faculty associate
of the Population Program and the Health and Society Program in the

Institute of Behavioral Science at the University of Colorado Boulder,

discussed efforts to estimate the mortality consequences of the U.S.
obesity epidemic. This issue can be approached at the population level
by examining death rates from cardiometabolic diseases, he explained,
which are the greatest contributor to poor trends in U.S. life expec-
tancy. At the individual level, on the other hand, he pointed out that
characterizing the relationship between obesity and mortality risk is a
major challenge.
Masters began by reviewing recent trends in cause-specific mortality
at the population level. He shared data indicating that among several age
groups of middle- to older-aged adults, trends of decreases in death rates
from cardiometabolic diseases since 1990 have begun to stall. This flatten-
ing of death rates began sooner after 1990 among people in their 40s and
50s compared with people in their early 60s, he noted, and was more pro-
nounced in all age groups among women compared with men (Figure 10-1).
The latter differential, he explained, is thought to be related to differential
exposures to the U.S. obesogenic environment.
According to cohort-based trends in average rates of mortality from
cardiometabolic diseases, Masters elaborated, both Black and White men
and women born in the early 20th century experienced steady reductions in
those rates. These decreases were reversed among those born in the 1950s,
1960s, and 1970s, he relayed, with the increasing mortality from cardio-
metabolic diseases presumably being driven by prolonged exposure to the
rising U.S. obesogenic environment. When U.S. trends in cardiometabolic
disease mortality are compared with those in other high-income countries,
Masters pointed out, an “alarming” widening of the difference between the
United States and its peers can be seen to have occurred since 2008–2009
(Figure 10-2). This gap is suspected to be linked to obesity-related deaths,
he noted, but has not been formally analyzed.
FIGURE 10-1 Death rates from cardiometabolic diseases in midlife relative to the rates in
1990.
SOURCE: Presented by Ryan Masters, October 28, 2021 (data from NASEM, 2021).
Reprinted with permission.

FIGURE 10-2 Recent trends in cardiometabolic disease mortality, U.S. and peer country
averages.
SOURCE: Presented by Ryan Masters, October 28, 2021 (data from NASEM, 2021).
Reprinted with permission.
Masters transitioned to discussing work by Acosta and colleagues

(2022) that examined drivers of this widening gap between the United States
and its peer countries. The primary hypothesis is that the gap is an effect
of changes in behavioral risk factors, he explained, including an increase in
the prevalence of obesity, a slowdown in smoking reduction, and an indi-
rect effect of the opioid abuse epidemic. At a more granular level, Masters
shared additional data from Acosta and colleagues (2022) indicating that
prior to the gap’s widening, both the U.S. male and female populations had
begun catching up to peer countries (the convergence period) in terms of
cardiovascular disease death rates before they started falling behind again
(the divergence period). According to Lee, the convergence was due primar-
ily to faster rates of reduction in deaths from ischemic heart disease in the
United States versus peer countries, while the divergence was driven by U.S.
increases in hypertensive diseases and stroke.
Shifting to discuss the specific causes generating these trends, Masters
characterized trends in obesity-related deaths as prominent and highly
concerning. The U.S. disadvantage (compared with peer countries) in terms
of obesity-related mortality has widened over the past one to two decades.
Essentially, Masters observed, obesity-related mortality has driven the
increasing gap in cardiometabolic disease–related mortality between the
United States and other high-income countries over this period. However,
Masters added, it has been difficult to demonstrate empirically that the
mortality consequences of having BMIs in the obesity category or other
individual-level indicators of obesity translate into elevated mortality risk.

Related to this challenge, Masters referenced two key events in 2013:

the first was publication of a systematic review and meta-analysis indicat-
ing that mortality rates were similar between populations with obesity
and populations with low BMIs, and that individual-level mortality risk
was lowest among people with BMIs in the overweight category (Flegal et
al., 2013); the second was a call for researchers to identify better metrics
than BMI for investigating the individual-level association between obesity
and mortality (Ahima and Lazar, 2013). Masters expounded on the latter,
relaying the authors’ observation that both individuals with low BMIs and
with BMIs in the obesity category exist on the low end of mortality risk
as well as the high end. The difference in mortality risk is believed to be
an outgrowth of differences in individuals’ metabolic health profiles, he
continued, with low mortality risk reflecting such indicators as greater fit-
ness and normal insulin and blood sugar levels, and higher mortality risk
reflecting such indicators as chronic illness, sarcopenia, lower fitness, and
inflammation. These observations spurred a new era of proposed indices,
Masters noted, that use measures of body size, shape, mass, and adiposity
distribution to assess metabolic health and mortality risk more accurately.
In Masters’s view, instead of pursuing new indices of body composition,
it may be more worthwhile to examine individuals’ life-course exposures to
high or low BMIs. Whether an individual is metabolically healthy or not,
he elaborated, can sometimes be associated with that person’s cumulative
duration of time spent in different BMI states. To illustrate this point, he
reported that about 22 percent of respondents to the National Health and
Nutrition Examination Survey with BMIs in the normal weight category at
the time of the survey had had BMIs in the overweight or obesity category
a decade prior. Similarly, many respondents with higher BMIs had been
classified as having BMIs in the normal weight category 10 years previously.
Masters observed that people who have been stable at BMIs in the normal
weight category exhibit more metabolically healthy profiles (i.e., they are
less likely to report having hypertension, diabetes, or hyperlipidemia, for
example), compared with those who moved from higher BMIs to BMIs in
the normal weight category. He added that people who have only recently
developed high BMI levels are in better metabolic health than those who
have lived with high BMIs for longer periods of time.
Masters explained that, after adjusting for a person’s lifetime history of
being in different BMI states, the relationship between BMI and individual-
level mortality risk shifts from a U-shape (where risk is elevated at both
underweight and very high BMI levels) to a nearly linear association where
mortality risk rises as BMI rises (Berrington de Gonzalez et al., 2010; Pro-
spective Studies Collaboration, 2009). This finding raises the question, he
proposed, of whether it is best to pursue better metrics or to pursue better
research designs and understanding of lifetime exposures to different weight

states and body types. For population health, Masters suggested collect-
ing measures early and often across individual and cohort life courses to
observe trajectories and durations of time spent in different body shapes,
sizes, and adiposity distributions. Current efforts appear to be shifting away
from BMI and toward new metrics, he observed, but he believes it is worth
considering the payoff for pursuing new metrics compared with that for
pursuing new questions and designs with which to explore associations.

Following their presentations, Lee and Masters answered questions
about barriers to implementing obesity solutions; obesity, life expectancy,
and mortality risk; and the relationship between health care spending and
life expectancy.
Barriers to Implementing Obesity Solutions

A participant commented that evidence-based obesity solutions take a
long time to develop (e.g., to satisfy concerns about rigor and replication in
different environments) and to implement (e.g., to change complex political
and economic systems), and asked Lee what else impedes the implemen-
tation of solutions. Lee cited three obstacles that he said reflect broken
underlying systems. First was that different disciplines and sectors operate
in silos. Lee acknowledged that deep, sector-specific understanding of an
issue can be helpful, but stressed that obesity is not a discipline-specific is-
sue and called for more efforts that cut across disciplines and sectors. As
a second obstacle, Lee referenced the truism, “perfect is the enemy of the
good,” arguing that instead of waiting for optimal conditions, efforts must
start somewhere. Third, Lee urged reframing obesity as a systems problem
instead of an individual problem, noting that inaccurate framing will not
lead to the types of solutions needed to make population-level differences.
Obesity, Life Expectancy, and Mortality Risk

Masters answered a participant’s questions about the relationship be-
tween obesity and the recent decrease in U.S. life expectancy, as well as the
role of the duration of obesity exposure. He reiterated that trends of in-
creased U.S. life expectancy have flattened since 2010. Compared with peer
countries’ trends in life expectancy, he continued, the United States has been
diverging away since at least the 1980s. At the population level in the United
States, he observed, the link between the rising prevalence of obesity and the
causes of death most responsible for the stall in life expectancy is increas-
ingly clear, although it has not been fully demonstrated in a convincing way.

Masters added that the field does not yet have robust measures or
data designs to capture lifetime exposure to or indicators of time spent at
high BMIs or other individual-level metrics of obesity. He clarified that the
study designs he espoused in his presentation would require longitudinal
follow-up of large cohorts, which is costly because datasets need to be large
enough and to represent a sufficient duration of time to enable observation
of individual-level trajectories and long-term outcomes.
Another participant asked Masters whether any long-term studies had
followed a cohort from childhood to examine the relationship between
duration of exposure to obesity and mortality. Masters replied that the
National Longitudinal Study of Adolescent to Adult Health (Add Health)
cohort will probably be a solid indicator of the health consequences of
an extended duration of time spent in the U.S. obesogenic environment
because its members have been exposed to that environment since first
enrolling in the study (as adolescents in 1994–1995). He expressed hope
that, as the cohort ages, this dataset will yield the data needed to inform
how exposure to the U.S. obesogenic environment affects mortality risk.
Relationship between Health Care Spending and Life Expectancy

Crespo asked Lee to comment on why the United States spends more
money on health care than peer countries do yet has inferior life expectancy
outcomes. Lee suggested that this is an example of a single measure failing
to tell the full story, and offered three explanations for the complex rela-
tionship between health care spending and life expectancy outcomes. First,
health care spending includes administrative and other costs that do not
go directly toward patient care, and evidence suggests that administrative
costs are rising more rapidly than costs associated with patient care. A sec-
ond issue is the need to separate costs for treatment from costs for disease
prevention and risk factor mitigation, Lee continued, noting that evidence
supports the value of investing in the latter. Third, Lee argued that to un-
derstand the mismatch between health care spending and life expectancy,
one must pay attention to the characteristics of patients on the receiving
end of different types of spending. Disparities exist in the demographics of
patients who can access health care resources, he observed, and these dis-
parities contribute to different health outcomes among population groups.


11
Systems Applications to Address

Structural Barriers to Obesity Solutions

• According to the Well Being in the Nation Network’s theory of
change, the shape of people’s lives and their predicted mortal-
ity from birth are determined in part by legacies of structural
racism, colonialism, and economic inequality that pervade
current society. These systemic conditions propagate chronic,
place-based inequities that cannot be fully explained by indi-
vidual behaviors or environmental factors. (Saha)
• An approach to population health equity that addresses peo-
ple’s physical, mental, social, and spiritual well-being in a ho-
listic way while addressing underlying community conditions
(e.g., food access and housing) and root causes (e.g., exclusion-
ary zoning) that perpetuate poverty and poor health builds
the capacity of community assets and resilience, and is a more
efficient way to address health inequities relative to focusing
on individual or environmental determinants of health. (Saha)
• Broad-scale structural solutions to address obesity are im-
perative, but may be inadequate unless they consider how the
brain’s categorization of weight and body size affects the way
individuals experience the world. This categorization may lead
to such phenomena as identity anxiety, implicit bias, and ste-
reotype threat. (Godsil)
89

• Health information that emphasizes racial health disparities

can undermine the affected group’s sense of possibility and
increase their allostatic load and other adverse psychological
responses. Leading with possibilities of hope and aspiration
that shift away from “blame and shame” narratives about
people with obesity creates conditions whereby people can see
themselves in a positive light, which in turn fosters healthful
changes. (Godsil)
The second session of the third workshop featured two presentations

that focused on systems applications to address structural barriers to obe-
sity solutions. Stephanie Navarro Silvera, professor of public health at
Montclair State University, moderated the session.
A STRUCTURAL APPROACH TO POPULATION HEALTH EQUITY

Soma Saha, executive lead of the Well Being in the Nation (WIN)
Network, began her presentation by recounting a personal experience
working in primary care. She had observed that optimal care at the clinical
level improved diabetes outcomes but could not address community-level
factors contributing to a marked increase in the community’s prevalence
of diabetes. As Saha and her colleagues recognized that the community’s
food and activity environments did not support healthy eating and regular
physical activity, they began to construct geographic information systems
maps of their patients’ environmental contexts. As a new method of analyz-
ing patient data, Saha explained, this exercise revealed that areas of con-
centrated poverty also had higher rates of poor health outcomes, such as
childhood obesity. Similar patterns emerged in maps of various major cities,
she added, where considerable differences in average life expectancy existed
depending on the zip code or neighborhood. Patterns of low-resource areas
coinciding with worse health outcomes for their populations were repli-
cated across the country.
According to Saha, the emergence of such widespread patterns indicates
the existence of an underlying system that propagates chronic place-based
inequities that cannot be explained by individual behaviors or such envi-
ronmental factors as the existence of grocery stores. To support this point,
she referenced a report documenting patterns of residential segregation
that resulted in exclusionary zoning and policies (Davis et al., 2016). This
situation precluded additional residential and business development in the
segregated areas, she explained, which meant that its residents had to travel
farther to get to work and that these municipalities had fewer tax revenues

SYSTEMS APPLICATIONS 91
to support schools and built environmental features (e.g., parks, sidewalks)

that promote healthy behaviors. Saha underscored that racism is a transmis-
sible illness that permeates an individual’s interpersonal experience as well
as the structures and systems of a society. She argued that a better under-
standing of what this means could yield insight into why obesity outcomes
have plateaued despite decades of efforts to slow and reverse its course in
the United States.
Saha discussed the Moving to Opportunity Program as an example of
an effort that effected changes in obesity through structural change. She ex-
plained that this randomized controlled trial, conducted in the mid-1990s,
assigned 4,500 women with children living in public housing (where
40 percent or more of residents had incomes below the federal poverty line)
to one of three groups: those given housing vouchers for neighborhoods
with poverty levels below 10 percent, those given housing vouchers to use
anywhere, and those given no vouchers (control group). Saha reported that
among women who moved to more affluent neighborhoods, a 20 percent re-
duction in obesity was observed within 6 months, along with lower rates of
severe obesity and diabetes (compared with the control group) 10 years later
(Ludwig et al., 2011). She added that a follow-up study found that these
outcomes were not fully explained by neighborhood characteristics (Zhao
et al., 2014). Although the structural solution had led to changes in the re-
sources available to those women who had moved, Saha observed, moving
also had reduced their levels of allostatic stress, which had led directly to
the substantial differences observed in the development of chronic disease.
Saha transitioned to discussing the WIN Network’s theory of change
(Figure 11-1), which proposes that the shape of people’s lives and their pre-
dicted mortality from birth are determined in part by legacies of structural
FIGURE 11-1 Well Being in the Nation (WIN) Network’s theory of change.
SOURCE: Presented by Soma Saha, October 28, 2021; Milstein et al., 2020. Reprinted with
permission of the WIN Network.

racism, colonialism, and economic inequality that pervade current society.

Policies can promote dignity and inclusion or trauma and exclusion, she
asserted, and the types of policies that exist affect whether people have
the conditions necessary for well-being or experience adversity and urgent
needs that cause allostatic stress. Over time, she said, this stress contributes
to chronic health conditions and ultimately, struggling and suffering.
This theory of change has led the WIN Network to shift to a structural
approach to well-being, Saha explained, that balances its efforts to build
and support resilient, thriving people. What this means, she elaborated, is
addressing their physical and mental health (pathway 1) along with their
social and spiritual well-being (pathway 2) in a holistic way, and address-
ing underlying community conditions such as food access and housing
(pathway 3), as well as root causes such as exclusionary zoning and other
forms of structural racism (pathway 4). The combination of these efforts
is expected to improve the systems in many communities that serve as a
“down escalator” toward poverty and poor health (Figure 11-2).
Saha shared a few examples of this structural approach to pursuing
population health equity. In Rhode Island, she reported, clinical community
teams are stratifying people with diabetes in terms of COVID-19 risk, physi-
cal health risk, mental health risk, and social risk to determine how best to
address those domains of well-being holistically. This effort involves con-
necting with community-based organizations and public health departments
to coinvest in improving access to resources and advancing policies with the
potential to mitigate root causes of poverty. At MetroHealth in Cleveland,
FIGURE 11-2 Pathways to Population Health Equity framework.

SOURCE: Presented by Soma Saha, October 28, 2021; Saha et al., 2017. Reprinted with
permission.

Saha continued, people’s downstream needs are addressed by providing

high-functioning primary care; “midstream” issues are addressed by increas-
ing pay for front-line health care staff and building hiring pipelines from zip
codes with poor health outcomes; upstream issues are addressed by partner-
ships to infuse STEM (science, technology, engineering, and mathematics)
curricula into schools; and root causes of poverty are addressed by financing
business development in disenfranchised communities.
Saha ended her presentation with an example from Texas, where links
were uncovered among COVID-19 cases, child poverty, COVID-19–related
unemployment, and health status. Investments in emergency and recovery
supports were made in a way that advances long-term, equitable recovery
and resilience, she explained, such as building the capacity of community
assets to distribute healthy foods and making these foods available in local
shops. The Methodist Health Care Ministries went even further to help
interrupt the cycle of intergenerational poverty, she added, by expanding
Medicaid and investing in internet access, computers, and digital literacy
for communities in greatest need.
To end her remarks, Saha asserted that this kind of broader thinking
that addresses root causes is a more efficient way to address health inequi-
ties compared with focusing solely on individual or even environmental
determinants of health.
STRUCTURAL SOLUTIONS FOR OBESITY:

ADDRESSING IMPLICIT BIAS AND STEREOTYPE THREAT
Rachel Godsil, cofounder and codirector of Perception Institute and dis-
tinguished professor of law and chancellor’s scholar at Rutgers Law School,
discussed implicit bias and stereotype threat as key areas to address as part
of structural solutions to obesity. She began by submitting that one of the
primary obstacles to developing structural solutions is the need to deal with
the multiple facets and dimensions of the challenges faced by people with
obesity. Discussion of structural challenges is therefore critical in dialogues
about structural solutions, she maintained, if the conditions under which
people lack the opportunity to lead healthy lives are to be fully addressed.
Godsil stressed that structural factors are key barriers to accessing
healthy lifestyles and to having institutional policies and practices that sup-
port healthy behaviors. As an example of a structural factor that shapes
people’s opportunities, she cited weight stigma that results in a host of
negative health outcomes for people with obesity and challenges their at-
tempts to become healthy and achieve their potential. She pointed out that
the adverse effects of weight stigma manifest in both educational and health
care settings, where institutional policies and practices fail to recognize how
it affects obesity outcomes. Godsil called this process a “negative cyclical

phenomenon” that is a combination of the structural dimensions that shape

people’s opportunities and the institutional policies and practices that shape
the way people experience institutions. When interpersonal encounters of
people with obesity are added to the mix, she said, experiences of discrimi-
nation create a compounding health effect, leading to a noticeable change
in individual beliefs and behaviors with regard to obesity.
Godsil referenced the term “intersectionality” as she explained that
obesity is a challenge experienced across multiple identity categories, such
as race, ethnicity, sexuality, and class. When several identity categories ex-
perience inequities, she said, the cumulative effect of the multiple forms of
discrimination experienced by people with intersecting identities is greater
than the sum of its parts (i.e., the individual experiences of each form of dis-
crimination). Thus, she maintained, understanding intersectionality sheds
light on what needs to be understood to create healthy lifestyle opportuni-
ties for people with obesity that are consistent with their sense of self.
Godsil went on to discuss civil rights solutions, explaining that weight
is not a protected class under federal civil rights statutes even though weight
stigma is a powerful form of bias. By contrast, she elaborated, exhibit-
ing bias toward other identity categories is viewed as inconsistent with
egalitarian values. Although people who have disabilities with respect to
experiencing obesity may find protection under the Americans with Dis-
abilities Act, Godsil called this protection insufficient. She noted that state
and local civil rights laws are emerging to protect people from weight-based
discrimination, both as individuals and as members of broader groups who
are negatively affected by the structural environment.
Godsil expressed her opinion that broad-scale structural solutions
to address obesity—those that recognize the roles of poverty, economic
inequality, and other factors as barriers to engaging in healthy lifestyle
behaviors—are imperative, but may be inadequate. It is also critical, she
argued, to understand how the brain’s categorization of weight and body
size affects the way people experience the world. Godsil shared three phe-
nomena that result from such categorization.
The first is identity anxiety, which Godsil said people can experience in
cross-group interactions. This phenomenon is often discussed in the form
of racial anxiety, which occurs when people in nondominant groups are
concerned that they may experience discrimination or bias. Identity anxi-
ety comes into play with respect to weight stigma, she elaborated, when
people fear that they may experience an interaction differently because of
their body size—for example, that they might not be invited to participate
in endeavors that involve physical activity because of the organizer’s bias
toward people with obesity. This anxiety may be exacerbated, Godsil noted,
in the presence of multiple differences between people in the dominant and
nondominant groups.

A second phenomenon is implicit bias, Godsil continued, which occurs

when an individual holds without conscious knowledge an attitude toward
people with a certain identity or associates stereotypes with those people.
Implicit bias affects body language and moment-by-moment evaluative
behavior, Godsil explained, and is a major influence on how people with
obesity experience health care, employment, educational, and other institu-
tions in society.
A third phenomenon identified by Godsil is stereotype threat, which
occurs when people feel that their identity is salient in a given environ-
ment. According to Godsil, this phenomenon can create a cognitive mindset
whereby a person’s concern about conforming to a stereotype can actu-
ally lead to a greater likelihood of behaving in ways consistent with that
stereotype. She asserted that feeling as though they are being seen through
the lens of negative stereotypes that result from a belief that obesity is a
problem of personal will is an enormous impediment to people’s ability to
initiate health-promoting behaviors.
In Godsil’s view, the conditions that create stereotype threat also per-
petuate narrative schemas. She asserted that the broad narrative schema
that “racial equity doesn’t matter” is supported by a set of smaller-scale
narratives that can also exist in relation to weight. She cited examples of
these smaller narratives, which include the notion that individual acts,
rather than systemic issues, drive the problem; a belief that bias is con-
scious and intentional; a focus on self-determination and meritocracy to
effect change; and promotion of limited government. Godsil cautioned that
embracing these narratives would eliminate a host of structural possibilities
for addressing the root causes of obesity. Structural options must be on the
table, she maintained, given that the present conditions in many communi-
ties stem from a history of differential treatment as a result of government
and institutional policies.
Godsil explained further that when discussions of a particular problem
emphasize existing disparities, support for structural solutions to that prob-
lem is lower. Health information that emphasizes racial health disparities
may activate stereotype threat, she elaborated, undermining the affected
group’s sense of possibility and increasing allostatic load and other adverse
psychological responses. This phenomenon creates challenges in address-
ing conditions in which overlap exists between race/ethnicity and health
outcomes, she maintained, and she stressed the importance of documenting
such disparities so that solutions can be targeted and tailored for different
population groups.
Instead of leading with disparities in considering solutions for obesity-
linked health conditions, Godsil suggested leading with possibilities for
hope and aspiration. She believes this approach is far more likely to be ef-
fective in supporting shifts in behavior both for the community of concern

and in terms of broader political support for the issue of interest. She
referenced a study of efforts to increase turnout among voters of color,
reporting that materials emphasizing higher voting rates among Whites
depressed turnout among voters of color, whereas materials emphasizing
how people in the community were engaging—“Your neighbors vote, so
should you!”—increased their turnout.
Leading with evidence and solutions and countering misinformation
are also important, Godsil continued, to shift away from “blame and
shame” narratives about people with obesity. As an example of framing an
intervention in positive terms, she described a culturally tailored program
for managing hypertension among Native Hawaiians and Pacific Islanders
by promoting physical activity through hula dancing (Kaholokula et al.,
2017), which reported that greater reductions in systolic blood pressure
were observed among the intervention group compared with the control
group. Godsil attributed this result to the program’s promotion of the po-
tential for positive change, which she said created conditions for people to
see themselves in a positive light and improved their self-efficacy for change.

Following their presentations, Saha and Godsil answered questions about
investing in higher-poverty communities, changing narratives to foster sys-
tems change, and the effects of framing communications around disparities.
Investing in Higher-Poverty Communities

Silvera began the discussion by recalling the Moving to Opportunity
intervention’s finding that moving women from higher- to lower-poverty
neighborhoods reduced obesity rates. Relocating required the women to
leave social and structural supports they may have established, she ob-
served, and she asked Saha about ideas for investing in higher-poverty
communities. Saha cited such initiatives as Purpose Built communities that
integrate mixed-income housing with a stabilization lens, which she ex-
plained are less about moving people and more about investing in changing
the conditions of a place so people can retain their community supports
while having other conditions vital to thriving.
Changing Narratives to Foster Systems Change

Silvera recounted Godsil’s suggestion to approach obesity solutions
through a lens of hope and build on existing strengths, and asked her
whether the changes that need to occur at the individual level can also be
considered systems change if they effect systems outcomes. According to

Godsil, research supports the notion that there is a systems dimension to

how groups are seen and that perception affects how individuals experience
everyday moments. She reiterated the need to shift the current narrative
about the assumed causes of obesity and characteristics of people with obe-
sity, which she said causes them to be seen through a lens of weight stigma.
She stressed that this lens is a structural condition in that it assigns negative
stereotypes to a category of people, and that these stereotypes are reinforced
as they are perpetuated in society (e.g., in media and in policy making).
When people with obesity experience discrimination based on other char-
acteristics such as race/ethnicity or class, Godsil observed, it compounds
their experience of negative weight-based stereotypes, undermines their
self-image, and makes it difficult for them to engage in healthful behaviors.
Saha concurred and suggested that another important narrative to change
is that structural conditions are intractable barriers. Structural conditions
are diagnosable, treatable, and curable, she maintained, because they come
from structures, policies, and systems that can be unpacked and changed.
Effects of Framing Communications around Disparities

A participant asked Godsil whether leading with disparities activates
stereotype threat when communications are targeted to children. Research
suggests that such communications can activate stereotype threat, Godsil
replied, if the children are seen as a stigmatized group, whereas when com-
munications about an issue are targeted to groups that are not stigmatized,
leading with disparities can evoke a sense of moral urgency. She reiterated
Saha’s comment about the value of framing structural barriers as tractable
in order to view individuals through a lens of possibilities.


12
Policy Solutions for Nutrition

Security and Obesity

• The Biden-Harris Administration’s U.S. Department of Ag-
riculture (USDA) is leveraging federal nutrition assistance
programs to improve health by promoting nutrition security.
Nutrition security is defined as having consistent accessibil-
ity, availability, and affordability of foods and beverages that
promote well-being and prevent (and if needed, treat) disease,
particularly among racial/ethnic minority, lower-income, and
rural and remote populations. (Bleich)
• USDA is supporting nutrition security by improving the
Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC), Pandemic Electronic Benefits Transfer
(P-EBT) program, school meals programs, and Thrifty Food
Plan—the foundation of Supplemental Nutrition Assistance
Program (SNAP) benefit calculations. Priority areas include
increasing participation among eligible Americans and tackling
barriers to accessing nutritious and safe foods. (Bleich)
• Salud America! is pursuing health equity for Latinx by grow-
ing a national digital network of health advocates and fueling
them with culturally tailored and curated content, data, tools,
and actions to activate systemic community changes. (Ramirez)
99

• Salud America! aims to enhance network members’ self-efficacy

and collective efficacy to pursue on-the-ground healthy system
and policy changes. An internal evaluation found a strong
relationship between the degree of member engagement with
Salud content and the likelihood of taking advocacy actions at
the school, local, state, and federal levels. (Ramirez)
The third session of the third workshop featured two presentations

that examined policy solutions for nutrition security and obesity. Angela
Odoms-Young, associate professor and director of the Food and Nutri-
tion Education in Communities Program and New York State’s Expanded
Food and Nutrition Education Program at Cornell University, moderated
the session.
USDA PRIORITIES FOR IMPROVING NUTRITION SECURITY

Sara Bleich, senior advisor for COVID-19 in the Office of the Secretary
at the U.S. Department of Agriculture (USDA), opened her remarks by
stating that the COVID-19 pandemic has placed extraordinary stress on
American families. According to U.S. Census data, 1 in 11 adults report
food insecurity, a condition that strains worker productivity, health care
spending, and military readiness (U.S. Census Bureau, 2022). Bleich added
that food insecurity has disproportionate impacts on racial and ethnic mi-
nority, low-income, and rural and remote-dwelling populations.
Bleich proposed that these circumstances offer a unique opportunity for
the country to build back better—to, for example, recover from the pan-
demic, pursue racial equity, rebuild the economy, address impacts of climate
change, provide open markets and fair trade, and reinvigorate a competitive
workforce. According to Bleich, USDA is supporting the pursuit of these
goals by leveraging federal nutrition assistance programs to promote nutri-
tion security. She explained that nutrition insecurity starts early in life and
can result in diet-related chronic diseases that place financial strain on fami-
lies and health care systems, and also negatively impact national security.
To tackle both food and nutrition insecurity, Bleich said, USDA is working
to strengthen its programs and remove barriers to participation to ensure
consistent accessibility, availability, and affordability of foods and bever-
ages that promote well-being and prevent (and if needed, treat) disease for
all eligible individuals and families, with a particular focus on racial/ethnic
minority, lower-income, and rural and remote populations.
Bleich highlighted positive outcomes among participants in the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC),

POLICY SOLUTIONS 101
which provides eligible mothers and their children (up to 5 years of age)
with specialized nutrition resources and health care referrals. As examples
of these outcomes, she cited improved birth weights, lower infant death
rates, and fewer premature births (USDA, 2013, 2021a,b). She added
that updates to WIC food packages implemented in 2009 were linked to
increased consumption of whole grains, fruits, and vegetables and were
correlated with a downward trend in obesity in a significant sample of
preschool children (Andreyeva et al., 2012; Lu et al., 2016; Schultz et al.,
2015; Zenk et al., 2014). Yet while WIC has been shown to be a powerful
public health intervention to reduce racial disparities and maternal and
child health outcomes, Bleich observed, only 57 percent of eligible women
and their children are enrolled (USDA, 2021c).
Bleich reported that increasing WIC enrollment is a goal of a new ini-
tiative called WIC 390, supported by a $390 million investment in the pro-
gram via the American Rescue Plan Act of 2021 (P.L. 117-2). She explained
that this historic investment in WIC will be used for outreach, innovation,
and modernization to improve program delivery and boost participation
and benefit redemption among WIC-eligible women and their children.
She added that USDA is also preparing to update WIC food packages to
incorporate recommendations from a 2017 National Academies report
(NASEM, 2017) and to align the program with the latest edition of the
Dietary Guidelines for Americans (P.L. 101-445).
The American Rescue Plan also includes investments in children’s health
through the Pandemic Electronic Benefits Transfer (P-EBT) program, which
Bleich said provides families with an electronic debit card with which to
purchase groceries for the value of the school meals missed as a result of
pandemic-related school closures. These benefits are also available to younger
children in certain Supplemental Nutrition Assistance Program (SNAP)
households. Most states extend the P-EBT program into the summer months
to fill the gap in school meal access, Bleich noted. She referenced the findings
of a recent study indicating the program has a measurable impact on food
insecurity, decreasing food hardship for low-income children by 33 percent
in the week following issuance of the benefits (Bauer et al., 2020).
Bleich transitioned to reflecting on improvements in the nutritional
quality of school meals since implementation of the Healthy, Hunger-Free
Kids Act of 2010 (P.L. 111-296). She cited one analysis showing that dur-
ing the past decade, school meals became the most nutritious food source
for American children (Liu et al., 2021). She also referenced other analyses
finding that school meals prepared under the updated nutrition standards
contained higher proportions of vegetables, whole grains, and dairy foods
and lower proportions of refined grains and empty calories relative to prior
school meals (Hager and Turner, 2016; Johnson et al., 2016; Kinderknecht
et al., 2020; USDA, 2021d).

Bleich acknowledged that changing children’s eating habits can be

challenging, and schools may face obstacles to improving nutrition, but she
assured participants that incremental changes can make a difference in the
long run. USDA plans to propose changes that would update school meals
in accordance with the 2020–2025 Dietary Guidelines for Americans, she
reported, and will work with schools to implement the changes on reason-
able timelines and maintain taste appeal. She added that the Biden-Harris
Administration is considering financial incentives for schools to adopt prac-
tices that go beyond the meal standards, such as limiting added sugar, using
more local and culturally appropriate foods, and sourcing ingredients from
disadvantaged producers. She noted that USDA will evaluate the impact
of any incentives on school meal participation, educational outcomes, and
overall well-being.
Bleich observed that school nutrition professionals have remained com-
mitted to preparing and serving nutritious meals to the nation’s children
during the pandemic, and stated that USDA has provided flexibilities, re-
sources, and hands-on support to help them adapt to new models of operation
and weather unpredictable changes to the food supply (USDA, 2022). As a
recent example, she reported that USDA provided more than a billion dollars
of funding assistance in fiscal year 2021 to help schools respond to supply
chain disruptions as part of a comprehensive set of investments designed to
address challenges in American agriculture (USDA, 2021e,f).
Bleich went on to discuss the reevaluation of the Thrifty Food Plan,
which she called one of the most exciting and potentially high-impact
efforts to improve nutrition security (USDA, 2021g). Because the Thrifty
Food Plan is the foundation of SNAP benefit calculations, its reevaluation
brought about the first permanent adjustment to SNAP benefits since that
program’s introduction 45 years ago. Prior to the reevaluation, Bleich
observed, nearly 9 out of 10 SNAP participants reported struggling to
achieve a healthy diet, with the cost of healthy foods cited as the most
common roadblock (Bleich and Fleischhacker, 2020). The revised plan
budgets more money for recipients to purchase foods aligned with the
latest edition of the Dietary Guidelines for Americans and accounts for
shifts in the food marketplace. According to Bleich, this is a step in the
right direction toward ensuring that Americans of all backgrounds can
afford healthy food, although she acknowledged that USDA recognizes
the need to do much more to ensure the fair and equitable application of
its nutrition assistance programs.
Bleich ended her presentation by stating that the Biden-Harris Admin-
istration realizes that breaking the cycle of racial inequity is a journey that
begins with listening. Thus, she said, spending more time with program
recipients will help USDA understand how they interact with the programs
and how it can better meet their needs, particularly for those who have

historically gone unseen and unheard. The ultimate result, Bleich maintained,
will be to help narrow disparities and accelerate progress toward equity.
SALUD AMERICA!: FUELING ADVOCACY FOR SYSTEMS

AND POLICY CHANGE FOR LATINX HEALTH EQUITY
Amelie Ramirez, director of Salud America! and professor of epidemi-
ology and biostatistics at the University of Texas Health Science Center at
San Antonio, shared Salud America!’s efforts to pursue health equity for
Latinx.1 She began by noting that almost 18 percent of the U.S. population
is Latinx—making this the largest minority population in the country—
adding that the health inequities faced by this population relative to non-
Hispanic White peers existed prior to the COVID-19 pandemic. Multiple
conditions have contributed to these inequities, Ramirez stated, including
higher rates of poverty and uninsurance; less access to early education; less
stable housing; less safe neighborhood streets and transit options; fewer safe
places to play; and disproportionate exposure to pollution, food deserts and
swamps, and such adverse childhood experiences as racism and discrimina-
tion. According to Ramirez, these conditions reflect residential neighbor-
hood disadvantages and wealth gaps that in turn are related to inequities
in city planning and such historical discriminatory practices as redlining.
The first phase of Salud America!’s work spanned 2007–2012, Ramirez
recounted, and was focused on creating a research agenda on healthy weight
among Latinx children and funding 20 grantees to conduct pilot research
on the agenda’s topics. She explained that this work established a research
base from which to approach some of the systemic challenges that are being
addressed in Phase 2 of the organization’s work. The work in this phase
involves building a digital network of advocates and fueling them with cul-
turally tailored and curated content, data, tools, and actions with which to
activate systemic community changes that can enable health equity.
Ramirez elaborated on the process used to build the national digital
network of Latinx health advocates, which she said includes more than
400,000 community leaders, parents, health care workers, and school
personnel across the United States. She described how Salud America!
built a multimedia digital communication infrastructure comprising a
website, social media platforms, and an email campaign framed around
its equity data and solutions. Within this infrastructure, she explained,
the organization develops content designed to support network members’
advocacy for grassroots systems and policy changes by enhancing their
self-efficacy—two constructs in social cognitive theory that lie at the heart
of Salud America!’s efforts.
1 https://salud-america.org (accessed April 11, 2022).

Ramirez next described three steps in the network’s process for digital
content curation. First, a team of four curators searches for content by
topics. Second, after interviewing people who are working to improve
health and equity in communities, the team crafts that information to
provide easy-to-consume content featuring resources, policies, and heroes
of change. The content is tailored to resonate with Latinx cultural values
and residents of the geographic location where it is delivered, Ramirez
observed. Third, the content is connected with audiences by being dis-
seminated in readily downloadable and sharable forms, free of charge, via
websites (blogs, videos, searchable infographics), email, social media, and
in-person meetings. According to Ramirez, these materials are frequently
used to build a case for systems and policy changes at the local level, along
with Salud Hero case studies featuring real Latinx grassroots-change role
models. Ramirez emphasized the importance of the case studies by list-
ing five ways in which they increase self-efficacy among Latinx viewers:
(1) they demonstrate mastery as they describe how the role models gained
experience by taking on a new challenge and succeeding; (2) they provide
role models to emulate; (3) they produce social persuasion by promoting
engagement, amplifying feelings of empathy, and motivating viewers to act;
(4) they produce psychological responses; and (5) they help viewers visual-
ize future success and believe that it is achievable.
Ramirez next described Salud America!’s digital action packs, which
are topic-specific toolkits of template materials, sample emails, and FAQs
to help advocates make on-the-ground healthy systems and policy changes.
She noted that technical assistance and coaching via phone or online are
available for each action pack from the Salud America! curators who are
experts in their topics.
Ramirez shared a few examples of how the action packs can support
change in Latinx communities. In one case, a fifth grader and her teacher in
San Antonio created an action pack modeled after their success in adding
a water bottle fountain at their school, which improved children’s access
to clean water during the school day and provided an alternative to sugary
drinks. Another action pack described by Ramirez helped establish food
pantries in schools attended by students who experience food insecurity.
This pack included a guide to help school personnel work through the
logistics of starting a school food pantry, such as accepting contributions
from local stores and discretely redistributing them to students in need. In
a third example, Ramirez recounted the development of a “trauma-sensitive
school” action pack to help school personnel talk to their leadership about
trauma, build support strategies for students who experience trauma, and
create a system for identifying and supporting traumatized students. She
referenced a similar program called Handle with Care, which helps schools
coordinate with local police departments and receive alerts when police

encounter children at crime scenes. Schools can then provide immediate

support to their students who have experienced trauma, she explained, as
well as understand why a child might be exhibiting certain behaviors.
Ramirez next highlighted Salud America!’s Health Equity Report Card,
which generates local data on housing, transit, health care, food access,
and other topics. Network members use these data to advocate for healthy
changes in their communities, she explained, and nonprofits have also used
the report card to apply for community improvement grants.
In addition to content resources, Ramirez continued, Salud America!
developed a crosstalk network called “SaludTues Tweetchats,” a live, in-
teractive discussion on the Twitter social media platform. These chats, held
once a month for 1 hour each, focus on various health-related topics. Salud
America! partners with large organizations that are experts in the chat’s
topics, Ramirez said, which helps expose more than 6 million Twitter ac-
counts to the messages during that hour. She noted that a network analysis
of the chat network found it to be a connecting node for large organiza-
tions, health groups, individual advocates, and key influencers (Ramirez
et al., 2021). According to Ramirez, an internal evaluation of the organiza-
tion’s digital communications structure and network activity found a strong
relationship between the degree of engagement with the content offered and
likelihood of taking advocacy action at the school, local, state, and federal
levels. She added that another external evaluation of Salud America! found
that its digital communications network had resulted in 275 policy wins
in the areas of Latinx child health and general public health (Calloway
et al., 2018).
In the final portion of her presentation, Ramirez discussed Salud’s re-
cent application of its model to systemic racism and discrimination as root
causes of obesity. She explained that racial and ethnic discrimination, such
as differential treatment or underestimation of abilities by school person-
nel, impacts educational attainment and in turn future educational, health,
social, and career opportunities for people of color. Lower educational
attainment among Black and Latinx students is linked to increased risk of
institutionalization, she added, along with poor physical and mental health
and reduced lifetime earnings and economic potential (Mroczkowski and
Sánchez, 2015).
Salud’s goal is a more cohesive culture for health equity, which Ramirez
described as one in which everyone works individually and as a group to
ensure that each person has a fair opportunity for health and wealth, as
well as equitable access to basic resources required to achieve those goals.
To that end, Salud has created new materials designed to increase social
cohesion, which Ramirez said represents a society’s capacity to ensure
the long-term physical and psychological well-being of its members. A
cohesive society is an inclusive one that values individuals’ backgrounds,

she maintained, and is devoid of significant disparities in health, wealth,

and income. In Ramirez’s view, intergroup contact, peer modeling, targeted
social media messages, and awareness-provoking interventions can improve
social cohesion and compassion toward minority and impoverished groups.
She explained that Salud’s action pack to help counteract stereotypes—the
“Find Out If You Have Implicit Bias” pack—helps users identify their im-
plicit biases—defined as stereotypes that operate beyond one’s conscious
control and affect understanding of and decisions about others—and take
steps to overcome them. She also described another action pack designed
to help communities adopt resolutions that declare racism to be a public
health crisis and commit to specific actions for addressing it. In closing,
Ramirez stated that Salud’s materials are intended primarily to stimulate
conversation and provide ideas for using information to drive change.

A panel discussion with Bleich and Ramirez followed their presenta-
tions. The two speakers answered questions about USDA efforts to improve
nutrition security, opportunities for food retailers to advance nutrition
security, and Salud America!’s lessons learned and future vision.
USDA Efforts to Improve Nutrition Security

Bleich recapped two components of USDA’s multipronged strategy for
addressing nutrition security: (1) reevaluation of the Thrifty Food Plan,
which addresses cost and practical barriers to SNAP participants choos-
ing a nutritious diet; and (2) increasing WIC benefits for the purchase of
fruits and vegetables by more than threefold, a temporary increase to boost
recipients’ purchasing power for those foods. She added that USDA and
external researchers will evaluate the impact of these and other program
and policy changes.
Bleich also reiterated that the federal government is working on pro-
posed updates to regulations governing WIC food packages to incorporate
recommendations from the above-referenced 2017 National Academies
report (NASEM, 2017) and align the packages with the 2020–2025 Dietary
Guidelines for Americans. The updates also include administrative revisions
or clarifications for food package requirements. Bleich estimated that the
proposed updates would be published in spring 2022, with public com-
ments invited via regulations.gov.
Lastly, Bleich noted that USDA’s efforts to prioritize food and nutri-
tion security are being undertaken in parallel with efforts to promote racial
equity. She urged stakeholders to capitalize on this federal momentum to
make a difference in people’s lives.

Opportunities for Food Retailers to Advance Nutrition Security

Federal nutrition assistance programs work through several important
partners, Bleich pointed out, and she stressed that food retailers can play a
significant role in promoting nutrition security. For example, she said, they
can work to strengthen supply chains so consumers do not encounter empty
shelves when they walk into a store. Small corner stores could also play a
role, Ramirez suggested, if given assistance in upgrading the healthfulness
of the foods they make available to their community.
Salud America! Lessons Learned and Future Vision

Ramirez stated that Salud America! has found social media to be an
effective communication channel, as well as an example of how easily both
accurate information and misinformation or disinformation can be rapidly
distributed. She noted that the organization must be careful about the
individuals and organizations with which it partners and how their mes-
sages are disseminated, and also wishes to help youth distinguish truthful
information. The network became the go-to source for Latinx information
at the height of the COVID-19 pandemic, Ramirez added, because of its
reputation for sharing quality information.
Ramirez confirmed that Salud America! is open to collaborating with
other stakeholders interested in advancing health equity to help maintain
its network’s momentum. The organization is intent on increasing collective
efficacy, she reiterated, so as to empower individuals to come together in
pursuit of more equitable communities. Ramirez stressed that Latinx want
better access to basic resources, which has been impeded by inequitable
laws and other structural barriers. She closed by suggesting that Salud will
need an advisory committee to help guide its vision for expanding its reach.


13
A Multisector Conversation
on Systems-Levels Changes
for Obesity Solutions

• It is worthwhile to consider how structural racism, biased mental
models, and health communications might fit within the broader
context of efforts to address climate change, potentially pointing
to solutions for both obesity and climate challenges. (Dietz)
• To address obesity from a systems thinking perspective, it is
important for multi- and cross-sector partnerships to balance
the need for action and the value of slowing down to engage in
holistic, solution-oriented thinking with a long-term horizon.
(Pronk)
• The Centers for Disease Control and Prevention’s (CDC’s)
Clinical and Community Data Initiative uses existing infor-
mation technology in new ways to link individual data across
clinical and community sectors to create local data that can
help researchers better evaluate multiple interventions and un-
derstand differential effects by root causes. (Blanck)
• The achievement of enduring change hinges on long-term com-
mitments to holistically addressing upstream, interconnected
community conditions in such areas as housing, employment,
poverty, food access, and structural racism that contribute to
obesity but can be transformed to support health and well-
being. (Bussel)
109

• The lived experiences of people with obesity are an important

consideration for obesity solutions, as are communications
that do not oversimplify or catastrophize the issue and perhaps
reframe weight bias positively. (Nadglowski)
• The U.S. food industry can help improve nutrition security
by innovating to make healthy foods more convenient and
better tasting, reformulating its offerings to improve their nu-
trient profile, and making healthy foods more accessible and
affordable. (Nechanicky)
• The National Institutes of Health can help accelerate obesity
solutions by supporting research to evaluate new programs and
policies. The resulting evidence base can guide policy makers
and funders as they allocate their limited resources, and inform
strategies for disseminating and implementing efficacious inter-
ventions. (Yanovski)
• The current focus on systems approaches to obesity solutions
represents a remarkable reframing of the issue over the past
two decades. (Hovmand)
The fourth session of the third workshop included reflections from

members of the Roundtable on Obesity Solutions on the roundtable’s
past, current, and future work and additional member perspectives on the
workshop, which were followed by a final speaker who provided closing
remarks for the first day of the workshop: Nicolaas Pronk, president of
HealthPartners Institute, chief science officer at HealthPartners, Inc., and
affiliate professor of health policy and management at the University of
Minnesota School of Public Health.
OPENING REFLECTIONS
William Dietz, consultant to the Roundtable on Obesity Solutions
and chair of the Sumner M. Redstone Global Center on Prevention and
Wellness at the Milken Institute School of Public Health at The George
Washington University, reviewed the roundtable’s origins and history.
The National Academies’ engagement with obesity began in 2005 when
the then-Institute of Medicine (IOM) (now the Health and Medicine
Division) published the consensus report Preventing Childhood Obesity
(IOM, 2005), funded by the Robert Wood Johnson Foundation (RWJF).
A follow-up study evaluating progress in preventing childhood obesity
was published in 2007, which prompted the IOM to establish a Standing
Committee on Childhood Obesity.

MULTISECTOR CONVERSATION ON SYSTEMS-LEVELS CHANGES 111
The Standing Committee was funded by RWJF from 2007 to 2013,

Dietz continued, during which time it produced seven consensus reports
and hosted eight workshops. An additional enhancement of the IOM’s
engagement with obesity that occurred during the Standing Committee’s
tenure came in 2010, he recounted, when the IOM collaborated with HBO
Documentary Films to produce a four-part video series called The Weight
of the Nation. In Dietz’s view, this series solidified recognition of the role
the National Academies could play in addressing childhood obesity.
Dietz pointed out that, in addition to the continuity of funding in-
vested in the Standing Committee, another source of continuity was the
long-standing service of certain members. The first chair of the Standing
Committee was Jeff Koplan, who had previously directed the Centers for
Disease Control and Prevention (CDC) and chaired the committees that
produced the first two IOM consensus reports on childhood obesity. Shiriki
Kumanyika was one of the first members of the Standing Committee, Dietz
added, and went on to succeed Koplan as chair before becoming one of the
charter members of the Roundtable on Obesity Solutions.
Dietz went on to report that in 2013, the Standing Committee evolved
into the Roundtable on Obesity Solutions, which maintains a larger mem-
bership than the Standing Committee and represents a broader group
of multisector stakeholders. Instead of producing consensus studies, he
explained, the roundtable hosts workshops (19 to date) and develops Na-
tional Academy of Medicine (NAM) Perspectives papers (24 to date) that
reflect on issues and opportunities in advancing obesity solutions. Dietz
submitted that, because the roundtable provides a venue for public, ongoing
dialogue among leaders and voices from diverse sectors and industries, its
current focus on structural racism, bias, mental models, and health com-
munication is sound, but it faces the challenge of inspiring the members to
take action.
Dietz highlighted a new NAM venture, a funding investment called the
Grand Challenge on Climate Change, Human Health, and Equity, a mul-
tiyear global initiative to improve and protect human health, well-being,
and equity by working to transform systems that both contribute to and
are impacted by climate change. He relayed the initiative’s emphasis on the
“triple threat” of structural racism, climate change, and the COVID-19
pandemic, calling these important considerations for charting the round-
table’s next steps.
In Dietz’s opinion, one of the areas the roundtable did not consider
extensively in its model-building activities was how the model is embedded
in climate change issues and how solutions for climate change may also
help solve obesity (Swinburn et al., 2019). A related question, he continued,
is how the roundtable might fit its priorities of structural racism, biased
mental models, and health communication into the broader context of

climate change and point to common solutions for both. Finally, Dietz won-
dered what metrics could be used to assess the roundtable’s effectiveness
in advancing these three priority areas, as well as the consistency between
its actions and the NAM’s Grand Challenge on Climate Change, Human
Health, and Equity.
Shiriki Kumanyika, emeritus professor of epidemiology at the Univer-
sity of Pennsylvania Perelman School of Medicine, research professor in the
Department of Community Health & Prevention at the Dornsife School of
Public Health at Drexel University, and Food and Nutrition Board liaison
to the roundtable, followed Dietz in reflecting on the roundtable’s work.
According to Kumanyika, the roundtable represents a significant para-
digm shift in how the National Academies addresses obesity. Whereas the
National Academies previously convened consensus committees to respond
to specific statements of task that were most relevant to specific audiences,
she explained that the roundtable engages a broader group of multisec-
tor actors who are committed to translating the science into action. This
model is transformative in that it links academics and action, she main-
tained, noting that the nonacademic roundtable members have kept the
group accountable for addressing actionable, real-world contributions to
obesity solutions.
The roundtable’s deep dive into systems thinking is another paradigm
shift, Kumanyika suggested, because it represents a “coming of age” in de-
claring that obesity is not a discipline-specific issue. Obesity solutions can-
not be developed in silos, she argued, because of the interconnected nature
of its etiology. In addition to the subsystems in the obesity realm, she elabo-
rated, other systems that are related to obesity, such as those involved in the
issues of climate change and food insecurity, come together in a focus on
systems thinking. This focus has opened the door for broader perspectives,
she observed, and automatically incorporates a global perspective because
the issues are global in nature, with social equity as a common thread.
The roundtable is now well recognized, Kumanyika said in concluding
her remarks, as a fully mature group that is empowered to take action.
Given its multisector engagement in ongoing discussion, she pronounced
that the roundtable is well equipped as a platform for generating ideas and
translating them into real-world action.
Pronk was the final roundtable member to share his reflections on the
group’s work. He suggested that addressing obesity from a systems think-
ing perspective requires stepping back and creating a larger worldview. The
roundtable previously called for multi- and cross-sector partnerships, he re-
counted, and he affirmed that the urgency for such partnerships continues.
He reiterated the caution against siloed thinking and urged recreating
alliances that can facilitate appreciation for the involvement of many sec-
tors in public health endeavors. Pronk shared his belief that at the same

time, it would benefit the roundtable to slow down and engage in holistic,
solution-oriented thinking with a long-term horizon.
An appropriate response to the need for action, Pronk suggested, is to
prioritize key systems actors who can achieve major impact in the short
term while reducing the risk of unintended consequences that sometimes
result from acting too soon. He proposed that immediate actions might
be best focused on increasing the scalability or sustainability of existing
programs known to be effective. He proposed a shift toward a paradigm
whereby shared values generate energy and excitement for participants,
alongside significant community benefit.
Pronk elaborated on this concept of shared values by describing an
example of three key sectors—public health, health care, and business
and industry—organizing around a framework of shared values including
equity, harm prevention, ethical principles, science, and practical wisdom
as they pursue policy or programmatic initiatives. As an example of a mul-
tisector systems change initiative, he mentioned providing health insurance
coverage for obesity prevention and treatment options, such as bariatric
surgery, in a way that yields benefits for all stakeholders (health plans,
employers, and government).
Following the above three sets of comments, Pronk asked Dietz and
Kumanyika what opportunities the roundtable should leverage or prioritize
in terms of next steps. Dietz referenced The Lancet global syndemic work
that proposed the existence of “triple duty” or “quadruple duty” solutions
addressing the synergistic interactions among climate change, undernutri-
tion, and obesity.1 Equity must be addressed throughout those solutions, he
added, because low-income, underserved people suffer most from climate
change. He suggested that applying a similar lens would identify priorities
with multiple beneficial effects. Kumanyika echoed Pronk’s guidance to
proceed carefully, but cautioned that an overly slow pace might not foster
transformative change. She appealed for transforming the systems that per-
petuate obesity, contending that action sooner rather than later is needed
to disrupt them.
PANEL DISCUSSION WITH MEMBERS OF THE

ROUNDTABLE ON OBESITY SOLUTIONS
Following the reflections from Dietz, Kumanyika, and Pronk, five members
of the Roundtable on Obesity Solutions offered perspectives on the workshop
and shared thoughts and ideas about systems-level obesity solutions.
1 Syndemic is the presence of two or more disease states that adversely interact with each
other, negatively affecting the mutual course of each disease trajectory and enhancing vulner-
ability, and that are made more deleterious by experienced inequities (Sharma, 2017).

Captain Heidi Michels Blanck, chief of the Obesity Branch in the Divi-
sion of Nutrition, Physical Activity and Obesity in the National Center for
Chronic Disease Prevention and Health Promotion at the CDC, focused
her remarks on leveraging data for systems change. She described how the
CDC’s Clinical and Community Data Initiative (CODI, previously known
as the Childhood Obesity Data Initiative) uses existing information technol-
ogy in new ways to link individuals’ data across clinical and community
sectors to create local data that can help researchers better evaluate multiple
interventions and understand differential effects by root causes.
CODI’s data assets and inputs include data from individual-level
electronic health records (EHRs), clinical and community interventions,
community-based organizations, and federal programs, as well as from
geographic information systems. Its infrastructure allows communities to
analyze these data in a way that links health behaviors, interventions, and
outcomes to social determinants of health and other factors, such as com-
munity services. Blanck gave the example of data on an individual child
from the child’s EHR, which through CODI can be linked with data from
a community-based organization (e.g., parks and recreation), as well as
community data indicating the child’s neighborhood safety and access to
healthy food and physical activity opportunities. This layering of data from
different levels provides a broad picture of what the child experiences in the
neighborhood and community, and can help researchers evaluate the impact
of services, policies, and programs.
CODI data remain with local practitioners, Blanck clarified, and do
not go to the CDC. CODI links individuals’ EHRs in existing information
systems while protecting personally identifiable information. To preserve
privacy while linking records, Blanck explained, information is encoded in
a secure, private format behind each organization’s firewall before sharing
occurs (a process called data hashing), and CODI then uses the hashed data
to link records across settings and information systems. Bringing together
the sectors of public health, health care, and community-based organiza-
tions through technology services holds promise, she said in closing, for
enabling better understanding of root causes.
Jamie Bussel, senior program officer at RWJF, reviewed the evolution of
the Foundation’s work in the obesity arena. Over the past two decades, she
began, RWJF has deepened its understanding of the immense complexity
of the obesity epidemic and of the multifaceted, systemic, equity-centered
approaches that are warranted to address it properly.
Bussel explained that RWJF’s obesity prevention efforts helped shape its
overall vision for a culture of health, which in the past few years has focused
more intensely on the need for systems-wide, structural changes to address
the root causes of health inequities. She asserted that the achievement of
enduring change will depend on long-term commitments to holistically

addressing upstream, interconnected community conditions, such as hous-

ing, employment, poverty, food access, and structural racism, that contribute
to obesity but can be transformed to support health and well-being.
Bussel listed a few highly regarded peer-reviewed journal articles by
public health leaders and experts that emphasize the importance of and
possibilities for transformative social change to address obesity. In 2019,
Kumanyika proposed an equity-oriented obesity prevention action frame-
work, contending that obesity prevention interventions should be linked
to strategies that account for or indirectly address social determinants of
health (Kumanyika, 2019). Later that year, the Lancet Commission report
The Global Syndemic of Obesity, Undernutrition, and Climate Change
highlighted the urgent need for sustainable solutions for achieving both
healthy weight and a healthy ecosystem for the planet’s survival (Swinburn
et al., 2019). And in December 2020, Kumanyika and Dietz coauthored
a paper asserting that population-wide obesity cannot be solved without
far-reaching restructuring of current systems (Kumanyika and Dietz, 2020).
Bussel admitted that broad systems-wide strategies for addressing obe-
sity will be complex and controversial, but she argued that such strate-
gies are fitting in the context of the COVID-19 pandemic’s illumination
of the stark health and social inequities in the United States. It is not a
coincidence, she maintained, that the disparities that increase the risk of
obesity also increase risk of contracting and dying from COVID, and she
added that these disparities stem from policies, decisions, and disinvest-
ment that put certain Americans, especially people of color, at risk for poor
health outcomes.
Bussel ended by invoking a sense of hope, suggesting that the country
is at a “watershed moment” in its history given the intersection of the
COVID-19 pandemic, devastation from the economic downturn, and the
inspirational movement around racial justice. Policies that truly change
the nature of communities are on the horizon, she predicted, and she
stressed that a window of opportunity exists around the widespread sense
of urgency to change the trajectory of children’s health and well-being.
Joseph Nadglowski, president and chief executive officer of the Obesity
Action Coalition (OAC), maintained that better progress toward obesity
solutions will come from factoring in the lived experience of people with
obesity and thinking about systems that will work for and not against
them. He reported that the OAC has begun applying lessons learned from
the roundtable’s systems mapping efforts, which integrate structural racism,
biased mental models and norms, and health communication. First, he said,
the OAC is partnering with the NAACP, the National Action Network, and
the National Hispanic Medical Association, among others, to address sys-
temic racism and obesity through policy changes designed to improve access
to obesity care for people from diverse communities. Weight bias and other

social norms about obesity are key barriers to obesity care, he asserted, ref-
erencing Godsil’s comments (Chapter 11) about reframing weight bias with
a positive frame. Future roundtable meetings would be helpful, he suggested,
to explore how this latter objective could be delivered.
In terms of communications, Nadglowski pointed out that obesity
advocacy organizations are constantly assessing the way they communi-
cate about obesity. He said that they question, for example, whether their
messages are contributing to misunderstandings about obesity by being
presumptuous, overly simple, or too narrowly focused on a single issue or
data point. Catastrophizing the issue at the expense of people living with
obesity is also a risk, he commented, noting that the roundtable’s work has
highlighted the importance of messaging effectively.
Megan Nechanicky, nutrition manager for General Mills North America
Retail, spoke as a representative of the food industry. The starting point for
this industry, she said, is using a consumer lens to understand consumer
problems and how it can help solve them. She recounted visiting consumers
in their homes before the COVID-19 pandemic to listen and understand the
challenges they faced to healthy eating. She found that among shoppers with
low incomes, for example, the top concern is having enough food to feed
themselves and their families, followed by having flexible, basic food staples
on hand. They often would give the example of ground beef, Nechanicky
recalled, because it forms a foundation for many different meals. Asked to
describe the characteristics a healthy meal, she continued, they would cite
balance (i.e., inclusion of foods from the major food groups), filling, and
tasty, and many would use the example of a chicken pot pie.
As for General Mills’ nutrition strategy, Nechanicky said its focus is
on nutrient density and dietary patterns. She highlighted the potential of
innovation to make healthy foods more convenient and better tasting, to
drive reformulation that improves the nutrient profile of foods, and to make
healthy foods more accessible and affordable. She ended her remarks by
stressing the food industry’s potential to help improve nutrition security.
Susan Yanovski, codirector of the Office of Obesity Research and se-
nior scientific advisor for clinical obesity research at the National Institute
of Diabetes and Digestive and Kidney Diseases of the National Institutes of
Health (NIH), proposed strategies that NIH could use to accelerate obesity
solutions in light of its focus on biomedical and behavioral research. One
such strategy would be to support research to evaluate new programs and
policies. She suggested that the resulting evidence base could guide policy
makers and funders in their allocation of limited resources. As an example
of this kind of support, Yanovski cited an NIH rapid response funding op-
portunity that supports investigators over a short period of time so they can
collect baseline data before a new policy or program is implemented. An-
other way NIH could accelerate obesity solutions, she continued, would be

by informing strategies for the dissemination and implementation of effica-

cious interventions.
According to Yanovski, the NIH UNITE initiative indicates that NIH
recognizes the critical role of such factors as systemic racism that lie up-
stream of biomedical outcomes of interest. The purpose of this initiative,
she clarified, is to identify actions that can help eliminate structural racism
and racial inequities throughout the biomedical research enterprise. She
also pointed to the NIH Common Fund, which is supporting transformative
research to address health disparities and advance health equity.
The first funding opportunity announcements from the UNITE initiative
were released in fiscal year 2021, Yanovski continued. She explained that
this funding will provide support for highly innovative translational research
projects that purport to prevent, reduce, or eliminate health disparities and
advance health. Eleven grants were recently awarded in that cycle, she re-
ported, amounting to $58 million over 5 years, adding that several of the
awards were targeted to minority-serving institutions. As an example of a
funded grant application, she described a cluster randomized trial of con-
centrated investment in Black neighborhoods to address structural racism
as a fundamental cause of poor health.2 This study will deliver a suite of
place-based and financial well-being interventions, she observed, at the com-
munity, organizational, and individual household levels. Another example of
funded research is the Harlem Strong Mental Health Coalition, a multisector,
community-engaged collaborative for system transformation.3 According to
Yanovski, health insurers will work with a network of community-based
organizations, medical providers, and behavioral health providers, with a
long-term goal of developing a sustainable model for task-sharing mental
health care that will be embedded in a coordinated comprehensive network
of services, including primary care, behavioral and mental health care, social
services, and other community resources.
Lastly, Yanovski informed participants that a suite of funding initiatives
for transformative research to address health disparities and advance health
equity is planned for fiscal year 2023. The NIH Common Fund held a se-
ries of listening sessions in October and November 2021, she said, where
stakeholders shared ideas for innovative approaches to this type of research
that actively involve community members in the process.
Following the remarks from the five Roundtable members, Pronk posed
a question to each to elicit additional insights on systems approaches for
obesity solutions. He began by asking Blanck whether she could identify
systems approaches that state or local public health agencies can leverage
to address obesity. She pointed back to CODI as an example of utilizing
2 https://reporter.nih.gov/project-details/10413510 (accessed January 28, 2022).

3 https://reporter.nih.gov/project-details/10414696 (accessed January 28, 2022).

technology that other sectors are using—e.g., the financial services industry’s
application of the technology for enabling privacy for online banking—and
applying it to public health. She stressed that a great deal of investment
and partnering with other sectors will be required for local and state public
health departments to leverage natural experiment research and implement
multidisciplinary research tools to meet their data needs. She also empha-
sized the need for ample data to enable disaggregation of information so
the needs of diverse identity groups can be better characterized.
Pronk next asked Bussel how the COVID-19 pandemic influenced
RWJF’s strategy for addressing obesity. She replied that the pandemic il-
luminated the critical need to address the social side of health, giving the
example of the difficulty of isolating for people who work in low-wage
jobs with no paid sick leave or who live in crowded housing. She confirmed
that the pandemic has reaffirmed the Foundation’s focus on addressing root
causes of health and social inequities, such as long-standing discrimina-
tory policies and systems, with the goal of helping to create a country that
allows everyone a fair, just opportunity to live the healthiest life possible.
Pronk moved on to ask Nechanicky what the pandemic highlighted for
the food industry in terms of the role it could play in addressing health in-
equities. She responded that the pandemic has vividly displayed the fragility
of the U.S. food supply chain, and explained that its stability depends on the
consistent operation of food production facilities that employ many people
on the front lines. Through the pandemic, she elaborated, both large and
small food manufacturers came to realize how critical they are in providing
food for people around the world, and she called on the industry to apply
its resources and capacity to address food and nutrition insecurity. She ar-
gued that the case for such a strategy for improving the affordability and
accessibility of healthier products could be made from a business standpoint.
Pronk directed a question to Nadglowski about how an individual with
obesity might respond to the roundtable’s focus on foundational drivers of
obesity. From his perspective, Nadglowski said, the roundtable’s causal sys-
tems map removes the individual from the center of blame and recognizes
the host of other factors contributing to obesity. This approach is hopeful in
his view, and he said he looked forward to communicating with the public
about the systems nature of obesity to help them understand its complexity
and to relieve the sense of shame and blame often experienced by people
living with obesity.
Finally, Pronk asked Yanovski how research funders can best facili-
tate solution-oriented research that reflects and values communities. She
suggested greater involvement of stakeholders and communities at all
stages of research, such as by seeking their input when identifying pri-
orities and goals, designing research studies, recruiting participants, and
developing understandable consent forms that are relevant to the potential

research volunteers. Community stakeholders are rarely involved in confer-

ence planning and grant application review, she pointed out, and suggested
that they could be included in the process of drafting manuscripts to dis-
seminate research findings.
CLOSING REMARKS FOR WORKSHOP DAY ONE

Peter Hovmand, Pamela B. Davis M.D. Ph.D. Professor of Medicine at
the Center for Community Health Integration, professor of general medical
sciences in the School of Medicine; professor of biomedical engineering in
the Case School of Engineering; and professor of social work (secondary
appointment) in the Jack, Joseph and Morton Mandel School of Applied
Social Sciences at the Case Western Reserve University School of Medicine,
delivered final remarks to close the first day of the workshop.
Hovmand began by recalling key events leading up to the roundtable’s
focus on systems approaches to obesity solutions. They4 explained that
the first time they remembered hearing systems approaches and obesity
prevention discussed at the same conference was in 2000, in the context of
applying a syndemics framework to disease prevention. Almost a decade
later (2009), they continued, a group of multisector experts was invited
to a meeting to consider systems approaches to prevention of childhood
obesity, which served as the starting point for a comparative modeling
network funded by NIH, RWJF, and others. Despite multisector repre-
sentation at that meeting, Hovmand thought at the time that sectors were
still positioned against each other and not thinking about obesity from a
systems perspective.
Hovmand contrasted that perception with conversations held during
the past year and at this workshop, which they described as a paradigm
shift in terms of the remarkable reframing of the issue. They noted that their
collaboration with the roundtable’s group model-building exercises began
in 2019, and components of its systems map (Figure 1-1 in Chapter 1) be-
gan to emerge in early 2020. Even though this work occurred prior to the
COVID-19 pandemic and the rise in activities to promote social justice and
combat systemic racism following George Floyd’s death, Hovmand contin-
ued, the authors of the map recognized that addressing structural racism
and promoting health equity would be important components. Hovmand
noted that these themes have been raised in some of their recent work to
map other systems, and observed that a new shift in thinking has been the
idea of understanding the role of biased mental models and implicit bias.
Describing some of the work they have done in Cleveland, Ohio,
Hovmand shared a community member’s contribution at a recent event—that
4 Hovmand uses the pronouns “they,” “them,” and “their.”

it is difficult to change systems unless the mental models underlying them

are also changed. If the focus is simply on reforming the systems, they
elaborated, it will not change the thinking. In contrast, they proposed that
if a lens of structural racism, health equity, and racial equity is at the fore-
front, the meaning of systems change will be different. This point brought
Hovmand to the notion of collective action, which they suggested goes
beyond simply convening multiple sectors to activating double- and triple-
duty solutions that address multiple complex problems at multiple scales.
Hovmand highlighted several opportunities that result from taking
a systems approach, the first of which is being able to identify common
structures across national and global regions that provide insight into a
system’s underlying structural racism and the impact of colonialism. They
commended efforts to learn from innovative solutions being implemented
globally and to translate them across contexts. They identified as a second
opportunity recognizing that implicit bias reflects systemic racism, which
they said was proposed in a recent paper implying that if individual-level
implicit bias can be measured, it can be changed, but that change will
not endure unless larger systemic or structural changes occur (Payne and
Hannay, 2021). According to that paper, only larger-scale change will shift
the associations that people accumulate over time.
Building on Pronk’s comments about the pace of change and the unin-
tended consequences that could result from moving too quickly, Hovmand
called for balance. On the one hand, they pointed out, the luxury of time to
wait for data to accumulate does not exist, but on the other hand, there is the
risk of losing people if movement occurs before support is built (especially
for controversial policies). Some evidence-based interventions are ready to
be scaled now and improved in terms of reach and equity, they observed,
and they suggested that interventions be pursued in parallel with building
capacity for community-driven solutions from a systems perspective.
In Hovmand’s experience, systems language provides a bridge in that
systems concepts are not new to people with lived experience of adverse
conditions, and systems language is a way of expressing those concepts for
people who have had different experiences so they can develop structural
empathy and be part of the solution. To enable such collaboration, Hovmand
proposed a focus on supporting and sustaining investment at multiple scales
from multiple levels (e.g., neighborhood, school, community, national, and
global), given the multifaceted contributors to the obesity epidemic.
Hovmand concluded their remarks by echoing Lee’s point about the
importance of studying and understanding complex systems. It is easy to
get overwhelmed by the complexity, they admitted, but they encouraged
participants to regard new technologies and methods for understanding
systems and the new appetite for the importance of doing so as an asset in
developing and scaling obesity solutions.

14
Patient–Provider Communication around

Obesity Treatment and Solutions

• Clinicians who want to implement the 2017 U.S. Preventive
Services Task Force recommendation on childhood obesity
face communication and ethical challenges when the resources
to implement the recommendation are not readily available
and/or accessible for their patients. Inequitable access to scree
ning and preventive interventions for childhood obesity across
populations creates and exacerbates disparities in health out-
comes among groups. (Smith)
• Multiple challenges to obesity care exist in health care set-
tings, giving rise to differential health care experiences for
patients with obesity that can affect the treatment received. At
the same time, clinicians can play a positive role in a patient’s
health care experience, and would benefit from training to
enable them to reduce weight bias and apply evidence-based
communication and counseling approaches for health behavior
change. (Gudzune)
• Bariatric surgery is underutilized in the United States despite
its effectiveness in treating obesity. This underutilization re-
flects issues of health insurance coverage and benefit designs,
weight bias and stigma, and patient–provider communication.
121

Until these issues are adequately addressed, health care provid-

ers can have their greatest impact on the delivery of evidence-
based obesity treatment by using shared decision making in
their consultations with patients who have obesity. (Sarwer)
The fifth and final session of the third workshop comprised three
presentations exploring issues of patient–provider communication around
obesity treatment. Jamy Ard, professor in the Department of Epidemiology
and Prevention and the Department of Medicine at Wake Forest School of
Medicine, moderated the session.
THE ETHICAL DILEMMA OF IMPLEMENTING

RECOMMENDATIONS
Hunter Jackson Smith, chief of preventive medicine for the U.S. Army
Medical Research Directorate—Africa, reviewed the U.S. Preventive Ser-
vices Task Force (USPSTF) recommendation for childhood obesity, patient–
provider communication challenges and ethical issues associated with the
recommendation’s implementation, and systems-wide methods for addressing
inequities in the implementation of childhood obesity recommendations.
Smith set the stage by reporting trends in the U.S. prevalence of child-
hood obesity, which has quadrupled over the past 50 years to the current rate
of 19.3 percent of children and adolescents, with an additional 16.1 percent
who qualify as overweight (Fryar et al., 2020). He emphasized that the
prevalence of obesity varies by several factors, such as socioeconomic group
and racial/ethnic population; for example, the prevalence of obesity for
children and adolescents aged 2–19 years is around 25 percent for African
American and Hispanic children (males and females), 15 percent for non-
Hispanic White females, and 5 percent for Asian American females (Fryar
et al., 2020). According to Smith, the consequences of childhood obesity
manifest in the short term as conditions related to metabolic syndrome,
such psychological problems as anxiety and depression, and low self-esteem
and self-reported quality of life. Over the longer term, he said, they manifest
in a greater likelihood of having obesity as an adult, which is associated
with increased risk of such serious conditions as heart disease, type 2 dia-
betes, and cancer (CDC, 2021).
Having set this context Smith presented the 2017 USPSTF recom-
mendation, which advises clinicians to “screen for obesity in children
and adolescents six years and older and offer or refer them to compre-
hensive, intensive behavioral interventions to promote improvements in

PATIENT–PROVIDER COMMUNICATION 123
weight status.” The recommendation was assigned grade B, which Smith

explained represents that the group concluded with moderate certainty that
screening for obesity is of moderate net benefit in this population. Based
on the evidence reviewed, he said, the USPSTF defined “comprehensive,
intensive behavioral intervention” to mean at least 26 contact hours over a
2- to 12-month period. He added that interventions with at least 52 contact
hours yielded even greater weight loss and improvements in metabolic risk
factors, and that adherence to either the 26–contact hour or 52–contact
hour intervention ranged from 65 to 95 percent (O’Connor et al., 2017).
Smith explained that the interventions reviewed consisted of multiple com-
ponents, such as the targeted behavior changes and the theories of change
underlying the intervention, that varied by study; they also involved multi-
disciplinary teams of providers, such as pediatricians, exercise physiologists,
dietitians, psychologists, and social workers.
Smith pointed out that it is beyond the USPSTF’s scope and mission
to integrate such issues as cost and population-based implementation con-
siderations into its deliberations on whether to recommend a preventive
treatment or screening modality. Nonetheless, he said, the USPSTF recog-
nized that children and their families may have limited access to effective,
intensive behavioral interventions for obesity. This issue of access gives rise
to several communication challenges for clinicians who want to implement
the USPSTF recommendations, he explained, but are aware that resources
for doing so are not readily available and/or accessible for all of their
patients. As examples, he pointed out that the nearest location for such
services may be a long distance from the patient’s home, or accessing the
services may be cost prohibitive or logistically challenging for the patient’s
family. Clinicians must therefore navigate a space within common-sense
clinical advice but outside the evidence, he maintained, as they determine
how to guide patients and their parents. He noted that they could provide
general advice for improving eating and activity habits, but added that no
evidence base exists to support the ability of such guidance to result in a
meaningful impact on weight.
Smith then compared the USPSTF’s recommendations for childhood
obesity screening and adolescent depression screening. In 2009, he said,
it issued a grade B recommendation for screening 12- to 18-year-olds for
depression only when systems are in place and accessible to ensure accu-
rate diagnosis, effective treatment, and appropriate follow-up. However,
he pointed out, that guidance was updated in 2016 to recommend the
implementation of screening provided diagnosis, treatment, and follow-up
systems are in place without requiring that they be accessible. Smith char-
acterized the updated guidance as a significant shift from saying that screen-
ing should be conducted only when those services are accessible. Part of
the rationale for the change, he elaborated, was the acknowledgment that

regardless of the accessibility of optimal services, there is an inherent merit

and value in diagnosing and offering counsel for adolescents with depres-
sion and providing whatever interventions are available, even if they lack
an evidence base in the primary care setting. A similar case could be made
for the screening of childhood obesity, Smith suggested, so that regardless
of the services available, it may be valuable to inform patients and their
parents of the seriousness of the obesity diagnosis and advise that they
pursue a sustained behavioral intervention.
Smith shifted to discuss ethical issues in three areas—research, screen-
ing, and implementation—in which gaps exist between the USPSTF recom-
mendation and the status quo. Beginning with research, Smith highlighted
the need for longer-term studies to evaluate maintenance of weight loss
after completion of a behavioral intervention, noting that current evidence
has followed patients up to only 1 year following intervention. More
evidence is also needed, he argued, regarding what constitutes clinically
important health benefits, as well as the amount of weight loss associated
with those benefits. Studies addressing behavioral interventions in diverse
populations and in children aged 5 years and younger are also needed, he
suggested, to determine whether preventive interventions and screening
modalities are effective for all groups or more tailored recommendations
are warranted. Smith highlighted the National Institutes of Health UNITE
initiative (see Chapter 13) as an example of a research effort to address
the ethical gaps related to diversity and racial equity that he predicted will
impact implementation.
Moving on to the screening gap, Smith proposed that core criteria
for a good screening tool include the existence of an accepted treatment
for patients who screen positive for the condition of interest, as well as
the availability of facilities for diagnosis and treatment of that condition
(Andermann et al., 2008). He reiterated that the lack of or only minimal
access to an accepted treatment raises concern about the consequences of
screening. This concern leads in turn, he argued, to the question of whether
clinicians should recommend preventive interventions to their patients—
based on USPSTF guidance—if patients have limited or no access to them
despite their proven effectiveness.
Systematic inaccessibility of treatment becomes an issue for disadvan-
taged groups, Smith maintained, and can exacerbate existing disparities.
He highlighted this issue as an exemplar of the difference between health
equality and health equity. Equality, he stated, is achieved by offering ev-
eryone the same service, but such parity is insufficient when people need
different solutions to resolve disparities—an issue of equity. Moreover,
he said, equality exists when all children are referred to intensive behav-
ioral counseling, but equality alone may not be sufficient for patients for
whom those services are largely inaccessible—likewise an issue of equity.

Thus equality is meaningful only if accompanied by equity. If justice and

equity are public health imperatives, Smith maintained, then efforts to
achieve equitable distribution and accessibility of interventions are critical
for addressing childhood obesity in an ethical manner.
Smith has observed a lack of urgency on the part of many clinicians and
parents to address a positive screening for obesity, despite its health, quality
of life, and social consequences. He drew a contrast with the response to
screening results for other health conditions, where clinicians automatically
feel compelled to refer a patient to the appropriate next step for interven-
tion, however costly or difficult to access it may be. According to Smith,
the lack of urgency to address a positive screening for obesity could reflect
findings of public opinion polls that Americans do not generally perceive
obesity to be a major problem for them or their family (Berry et al., 2018;
Cyr et al., 2016; Roper Center, 2020), or maybe a response to a normalizing
of excess weight in society.
Moving on to the gap in implementation of the USPSTF recommenda-
tion on screening for childhood obesity, Smith highlighted two questions:
Who is responsible for ensuring that the USPSTF recommendations are
implemented equitably, and how can we best fill the gaps in access for dis-
advantaged populations who are most afflicted by childhood obesity? These
questions, he suggested, evoke fundamental considerations about defining
the ethical responsibilities of states and governments for the well-being of
their children. If health care is deemed a basic right, he continued, what
does this right entail, and who is charged with protecting it? After such
bodies as the USPSTF identify effective preventive actions, Smith argued,
universal implementation must be ensured—particularly where the need is
greatest—to avoid exacerbating disparities.
Creative solutions will be key in responding to implementation chal-
lenges, Smith proposed, citing as examples collaboration with community
programs and the use of technology to enable telehealth opportunities.
He urged clinicians to emphasize screening, documenting, and offering
interventions and counseling as feasible in the meantime, but asserted that
addressing core issues is a precursor to reaching the next level of progress.
Some communities may be unable to offer evidence-based interventions,
he acknowledged, but may be able to spotlight the issue and provide
alternative, less resource-intensive options, recognizing possible gaps in the
evidence for their effectiveness. Looking further upstream, Smith promoted
the value of targeting social determinants to address childhood obesity,
arguing that children deserve to reach adulthood with the ability to pursue
their goals unencumbered by the physical and mental impairments result-
ing from obesity. He reiterated that lack of equitable access to childhood
obesity screening and preventive interventions across populations creates
and exacerbates disparities in health outcomes among groups.

AUDIENCE DISCUSSION
Following Smith’s presentation, Ard asked him whether different types
of research and evidence need to be available before further childhood
obesity recommendations are developed. Smith replied that although more
evidence is desirable, it is unreasonable to wait for perfect data, and that
failure to act on the available evidence would be a disservice to patients.
Once a baseline of evidence for a particular intervention has been estab-
lished, he suggested, the next step is to apply more robust and nuanced
research methods to examine its effectiveness for various subpopulations
and contexts.
Next, a participant asked Smith for his opinion on the potential for
telehealth and remote patient monitoring to facilitate access to treat-
ment. Smith maintained that telehealth is a key means of facilitating
equitable implementation of childhood obesity counseling, particularly
in rural locations that lack obesity specialists. He observed that the
COVID-19 pandemic had improved people’s comfort and familiarity
with telehealth modalities.
Another participant asked whether shared decision making could help
bridge the gap between an evidence-based recommendation that seems
unattainable and the need to act. Smith wholeheartedly agreed that shared
decision making is a good alternative in these cases. A benefit of shared
decision making is being able to engage more deeply and meaningfully
with patients, he added, which enables a shared understanding of the kinds
of common-sense solutions that can be pursued when the optimal solution
is inaccessible.
THE EFFECT OF OBESITY ON PATIENT–PROVIDER

COMMUNICATION
Kimberly Gudzune, medical director of the American Board of Obesity
Medicine and director of the Healthful Eating, Activity & Weight Program
at The Johns Hopkins University, reviewed evidence on how health care
professionals’ attitudes, communications, and behaviors may differ for
patients with obesity and proposed potential strategies for improving these
patients’ health care experience.
Gudzune began by observing that multiple challenges to obesity care
exist in health care settings. She cited the examples of incomplete insur-
ance coverage for evidence-based treatments (e.g., behavioral weight-loss
counseling, antiobesity medications, bariatric procedures) and medically
induced causes contributing to obesity or impaired treatment (e.g., medica-
tions that promote weight gain) (Apovian et al., 2015; Kushner, 1995; Tsai
et al., 2006).

The physical environment of a clinic may propagate stigma, Gudzune

continued, if appropriately sized equipment and devices are unavailable to
accommodate patients of all sizes. Although subtle, she said, such environ-
mental factors can signal to patients with obesity that they are unwelcome
and unable to be treated. As another challenge she pointed to clinicians’ lack
of time to perform obesity care services—assuming they are even trained to
provide them—as well as a broader problem of clinicians themselves serv-
ing as a source of stigma for patients with obesity (Gudzune et al., 2012;
Kushner, 1995; Mastrocola et al., 2020; Puhl and Brownell, 2001).
Gudzune elaborated on clinicians’ biased attitudes toward patients
with obesity, which she characterized as pervasive and persistent over time.
According to surveys conducted on different continents as far back as 1969,
she reported, clinicians associate obesity with poor hygiene, lack of adherence
to recommendations, and dishonesty. Primary care physicians tend to believe
that patients with obesity are less likely to follow medical advice, benefit from
counseling, or adhere to medications, attitudes that Gudzune suggested may
subtly influence their treatment recommendations (Foster et al., 2003; Hebl
and Xu, 2001; Huizinga et al., 2009, 2010; Klein et al., 1982; Maddox and
Liederman, 1969; Puhl and Heuer, 2009).
Gudzune maintained that in the context of these challenges, patients
with obesity often have health care experiences that can negatively affect
the treatment they receive. She gave several examples of these negative ef-
fects, beginning with patients’ avoidance of or delay in health care seeking.
One study found that more than half of patients with obesity reported
canceling an appointment because of anxiety about being weighed (Alegria
Drury and Louis, 2002), Gudzune relayed, while another study found that
patients with obesity delayed cancer screening tests because they feared
being treated disrespectfully or otherwise stigmatized (Amy et al., 2006).
In many cases, she added, patients with obesity have higher risks for ad-
verse health outcomes, which heightens the importance of their prompt
engagement in care.
A second example of these negative effects, Gudzune continued, is
impaired continuity of care. Patients with obesity are 37 percent more
likely to “doctor shop,” she reported, noting that some people engage in
doctor shopping as a result of weight-stigmatizing experiences, such as the
perception that their primary care provider has judged them on the basis of
their weight (Gudzune et al., 2014b). They also have a 68 percent greater
incidence of going to the emergency department although they are not at
increased risk of hospitalization (Gudzune et al., 2013), which according
to Gudzune indicates that they are accessing the emergency department for
concerns that instead could have been brought to a primary care provider
if they had a continuous relationship with one. Gudzune stressed how im-
portant it is for providers to understand a patient’s prior experience with

weight stigma in health care settings so they can promote a welcoming

environment that fosters continuity of care.
Gudzune moved on to a third example—undermining communication—
which she described using data comparing incidence rates of physician
communication behaviors (during typical primary care visits) with patients
who have overweight and obesity and those with normal weight. These
data showed nonsignificant differences by patients’ body weight for medi-
cal data gathering (e.g., collecting information about medical history) and
education/counseling (e.g., how to take a medication), as well as data
gathering and education/counseling on lifestyle topics. Gudzune questioned
the equitability of the counseling outcomes, however, given that patients
with overweight and obesity may warrant more counseling, particularly
for lifestyle behavior changes. Among patients with versus those without
overweight or obesity, she highlighted a significantly lower incidence of
physicians’ emotional rapport building (e.g., developing a connection be-
tween patient and provider, including exhibiting empathy, which Gudzune
identified as critical for successful behavioral counseling).
As a fourth example Gudzune cited the influence of a patient’s weight
on a clinician’s decision making and care. Gudzune pointed out that cli-
nicians may avoid performing exams for patients with obesity if they
encounter technical difficulty or lack the proper equipment, adding that
diagnostic plans may differ for patients with versus those without obesity
(e.g., physicians tend to prescribe more tests and to spend less time in the
room with these patients) (Campbell et al., 2009; Ferrante et al., 2006;
Hebl and Xu, 2001). This differential treatment extends to clinicians’ lower
likelihood of counseling patients about weight loss, she continued, for such
reasons as perceiving limited efficacy or futility of obesity treatment, feeling
unprepared with respect to training, having limited time and reimbursement
for services, and ranking weight-loss counseling low on the list of multiple
issues to address during a care visit (Fogelman et al., 2002; Foster et al.,
2003; Gudzune et al., 2012; Kristeller and Hoerr, 1997; Kushner, 1995).
Lastly, Gudzune mentioned effects on patient outcomes. She shared
one example in which lower rates of cancer screening (mammography, pap
smear, colonoscopy) were observed for patients with overweight or obesity
compared with those with normal weight. She added that greater degrees
of obesity were associated with lower rates of screening (Maruthur et al.,
2009a,b, 2012).
Gudzune shifted to highlighting opportunities for clinicians and health
care settings to play a positive role for patients with obesity. Among par-
ticipants in a behavioral weight-loss trial, she reported, higher ratings of
the helpfulness of the primary care provider’s involvement were associated
with greater weight loss in primary care, as was combining population
health management with an online obesity care program. She added that

discussing weight loss with patients in a way that they do not perceive as
judgmental is associated with achieving clinically significant weight loss
over 1 year, and that, contrary to some assumptions, non-Hispanic Black,
Hispanic, and Asian patients want to have weight-related discussions with
their clinicians (Baer et al., 2020; Bennett et al., 2015; Gudzune et al.,
2014a; Lewis et al., 2016).
Gudzune pointed out that evidence-based communication and counsel-
ing approaches such as the 5A’s framework and motivational interviewing
are associated with improvements in patient willingness and confidence with
respect to changing their health behaviors, and are applicable in a variety of
clinical settings (Alexander et al., 2011; Cox et al., 2011; Gallagher et al.,
2021; Jay et al., 2010, 2013; Pollak et al., 2010; Washington Cole et al.,
2017; Welzel et al., 2021). She suggested that, because clinicians can readily
be trained in these techniques, and many clinicians may already be familiar
with them, their regular use could change care for patients with obesity.
Gudzune ended her presentation with a list of ideas for addressing
weight bias in health care settings, with the caveat that most are untested
yet pragmatic based on relevant available evidence. One is to alter the
clinic environment to provide chairs and medical equipment that can
accommodate patients of any size, which she said could be facilitated
by providing financial support or incentives for facilities to cover the
expenses involved. Another idea, she suggested, is to provide sensitiv-
ity training to improve awareness of how clinician attitudes can impact
patients with obesity, in combination with additional research to design
and evaluate such trainings. A similar idea, she continued, is to increase
empathy and positive affect among clinicians through perspective-taking
exercises, and another is to increase their awareness of weight bias and
help them examine their explicit and implicit attitudes (Alberga et al.,
2016; Phelan et al., 2015). Gudzune added that interventions to address
clinician barriers might include providing education—from medical school
through board certification and in continuing medical education—on the
multifaceted contributors to weight gain and loss; conducting training
on evidence-based counseling techniques; leveraging electronic health
records to support counseling; and improving access by advocating for
coverage of evidence-based obesity treatments with insurers, employers,
and government agencies.
AUDIENCE DISCUSSION
Gudzune answered a few questions following her presentation. First,
Ard asked how race concordance affects patient–provider discussions about
obesity. Gudzune responded by explaining that race concordance can be an
important factor in how conversations play out; for example, having race

as a common shared experience can make it easier to bring up a topic like

weight in a way that is well received. On the other hand, she suggested,
race-discordant scenarios may increase the likelihood of the topic being
sidestepped because of concern about offending the other party or not
understanding how that person perceives weight or obesity. These reasons
for avoiding the topic are understandable, she said, but at the same time,
some studies suggest that non-Hispanic Black, Hispanic, and Asian patients
want to discuss obesity treatment options. She added that race discordance
may play a role in some cases in which these conversations do not take
place. Gudzune also pointed out that, while race-concordant relationships
can help, another solution is to empower the current clinician workforce to
initiate these conversations with patients of all backgrounds. She suggested
that further research could help inform strategies for approaching different
populations in a way that is both sensitive and engaging.
A participant asked whether efforts for system change would be ampli-
fied by physician demand for referral mechanisms to connect patients with
providers who have expertise in obesity medicine. While acknowledging
this possibility, Gudzune maintained that two other aspects are important:
first, that a comprehensive network of qualified obesity care providers is
on the receiving end of the referral, and second, that insurance coverage is
available to facilitate patient access to those services.
Asked to share her thoughts on the intersectionality of income, socio-
economic status, and weight and stigma in obesity treatment and health
care settings, Gudzune suggested that race can be another layer in this
dynamic. She called for equipping health care systems so they do not ex-
acerbate disparities—for example, by increasing the equity of Medicaid
coverage, which varies by state, for obesity treatments.
UNDERUTILIZATION OF BARIATRIC SURGERY:

HEALTH INSURANCE DESIGN, WEIGHT STIGMA,
AND PATIENT–PROVIDER COMMUNICATION
David B. Sarwer, associate dean for research and director of the Center
for Obesity Research and Education at Temple University College of Pub-
lic Health, discussed access to care and insurance coverage for bariatric
surgery, along with the potential benefits of a shared decision-making ap-
proach for engaging patients in obesity treatment.
Sarwer began by reviewing the prevalence of extreme (also known as clini-
cally severe) obesity in the United States (body mass index [BMI] ≥ 40 kg/m2),
which he called a “subepidemic” embedded within the country’s broader obesity
epidemic. He noted that nearly 12 percent of women and almost 7 percent of
men are in this weight category, which he said translates to an individual’s hav-
ing approximately 100 pounds of excess weight. He added that the prevalence

of extreme obesity is highest among non-Hispanic Blacks (13.8 percent) (Hales

et al., 2020). He reported further that as of 2016, more than 32 million U.S.
adults had either class II or III obesity (BMI 35–39.9 kg/m2) (Campos et al.,
2020), making them potential candidates for bariatric surgery.
Sarwer elaborated on bariatric surgery procedures in the United States,
which approximately 256,000 Americans undergo annually (ASMBS,
2021). He pointed out that this figure represents only 1 in 100 individuals
who meet BMI criteria for the procedures (≥ 40 kg/m2 or 35–40 kg/m2 in
the presence of an obesity-related comorbidity), and only 25 percent of
those who have the surgery are Hispanic or African American despite the
higher prevalence of extreme obesity in these populations (ASMBS, 2021).
Sarwer pronounced this a profound health disparities issue, maintaining
that the underutilization of bariatric surgery reflects issues of health insur-
ance coverage and benefits design, weight bias and stigma, and patient–
provider communication (Sarwer et al., 2021).
Insurance coverage for bariatric surgery procedures has expanded over
the past decade, Sarwer reported, and as of 2018, coverage was provided
by Medicare, 49 state Medicaid programs, 43 state employee programs,
individual and small-group insurance markets in 23 states, and more than
90 percent of commercial insurers (ASMBS, 2018; Gebran et al., 2020).
He added that insurance coverage varies by state and sometimes by region,
which he said can create logistical complications for patients who reside at
the intersection of different states or metro areas and seek care in a different
area from where they live.
Sarwer emphasized that the existence of insurance coverage does not
necessarily mean easy access to bariatric surgery. He highlighted several
barriers to access, such as the major effort required to prepare the required
documentation to seek insurance approval for a procedure. Time and re-
sources are also required to satisfy precertification criteria for a procedure
(e.g., completing 3–6 months of preoperative medical weight management
[MWM]). Sarwer explained further that several studies have suggested
that patients complete an average of eight separate visits to the institution
performing the bariatric surgery prior to the procedure, with the intent
of preparing them for optimal outcomes. A related barrier is patient cost
sharing, which he clarified encompasses the costs of such expenses as visit
copays, transportation or parking fees, and child care costs that accumulate
during a bariatric surgery experience. Sarwer shared a personal anecdote on
this topic, recalling that he used to assume that patients were disinterested
or disengaged if they failed to attend presurgery visits, whereas in reality
their absence may have reflected social determinants of health, such as
financial or logistical constraints (Gasoyan et al., 2019; Tewksbury et al.,
2017). Telehealth has tremendous potential, he suggested, to help reduce
some of these barriers to obesity care.

Sarwer moved on to relay key findings from three studies examining

relationships between insurance plan design and utilization of bariatric
surgery, based on data from southeastern Pennsylvania during 2014–2018
(Gasoyan et al., 2020, 2021). During this period, he observed, rates of bar-
iatric surgery increased nationally among African Americans and Hispanic
Americans. Individuals with preferred provider organization (PPO) and fee-
for-service insurance plans within the private insurance category had greater
odds of undergoing the surgery relative to those with private health mainte-
nance organization (HMO) plans. Similarly, among Medicare beneficiaries,
those with Medicare Advantage PPO plans versus those with Medicare
Advantage HMO plans had greater odds of undergoing the surgery. And
individuals with traditional Medicare (Parts A and B) fee-for-service plans
had lower odds of undergoing the surgery compared with beneficiaries of
Medicare Advantage HMO plans. Sarwer cited data suggesting that preop-
erative MWM requirements are a barrier to care, as patients with versus
those without that requirement were less likely to have the surgery within
a year. He added that neither preoperative MWM nor cardiology and pul-
monary clearances were associated with a reduction in inpatient health care
utilization in the first postoperative year.
Sarwer next described implications of these findings, first for providers
and patients. First, he maintained that it is time to reconsider insurance-
mandated precertification requirements for bariatric surgery. As an exam-
ple, he suggested that preoperative MWM may be necessary and helpful for
only a subset of patients—those who have not already exhausted diet- and
activity-related approaches to weight loss. Second, he appealed for reorga-
nizing care around the patient instead of around the demands of insurance
companies or specific clinics. He reiterated the potential of telemedicine to
address barriers to completion of preoperative assessments and engagement
in postoperative care. As for implications for payers, he argued that it is
time to apply to bariatric surgery value-based insurance design that con-
siders cost savings over the patient’s life postsurgery. According to Sarwer,
payers would achieve higher return on investment if utilization of bariatric
surgery increased among patients with BMI ≥ 40 kg/m2 and type 2 diabetes,
and he suggested that patient out-of-pocket costs be based on the clinical
value of a specific bariatric procedure. Some employers already incorporate
bariatric surgery into their self-administered benefit plans, he noted, using
a value-based insurance design. For instance, MGM Resorts International
saw good clinical outcomes after offering an incentive for its employees
who underwent weight-loss surgery: $5,000 in reimbursed copays after
2 years and another $5,000 to cover such procedures as excess skin removal
after 4 years (Fendrick and Sonnad, 2012).
Sarwer moved on to discuss weight stigma as another major barrier to
bariatric surgery. Weight stigma is ubiquitous in the general population,

he maintained, and is a well-established barrier to all forms of obesity treat-

ment. It is associated with psychosocial distress, he added, with 50 percent
of these patients meeting criteria for a psychiatric diagnosis (Hatzenbuehler
et al., 2009), as well as with weight gain, increased waist circumference,
elevated levels of C-reactive protein, and poor glycemic control (Pearl et al.,
2017). He observed that internalized weight bias, whereby individuals
absorb stigmatizing beliefs because of their own perceived failings, can be
associated with increased odds of metabolic syndrome (Pearl et al., 2017).
To reduce weight-biased attitudes, Sarwer advocated for educating the
public (and specifically health care providers) about the multifactorial con-
tributors to the development of obesity, an understanding that he said chal-
lenges common assumptions that weight is exclusively within an individual’s
behavioral control (Pearl and Lebowitz, 2014). Trainings that allow medical
students to interact with standardized patients with obesity appear to hold
some promise, he noted, for increasing empathy and confidence in delivering
treatment (Kushner et al., 2014). He suggested that future research target
the relationships among race; weight stigma; and patient–provider commu-
nication about obesity treatment, including bariatric surgery.
Sarwer ended his presentation by discussing shared decision making
as it relates to navigating a patient’s options for obesity treatment. Shared
decision making, he explained, is a process whereby patient and provider
actively share information and work collectively to come to a treatment
decision that meets the patient’s needs (McCaffery et al., 2010). Sarwer
highlighted the importance of connecting patients with the education and
support they need to make decisions and participate in their own care,
including expressing their values and preferences for treatment (Hawley
and Morris, 2017).
When applied to patients with clinically severe obesity, Sarwer pro-
posed, shared decision making should start with the patient and provider
overseeing or coordinating medical care. A thorough review of the patient’s
weight history and history of weight-loss efforts is critical, he added, and
should be conducted in a forthright yet respectful manner to avoid the
patient’s feeling blamed for a lack of sustained success with previous treat-
ments. Shared decision making that extends to all members of the multi-
disciplinary care team is useful, he continued, in discussing the benefits and
limitations of different surgical interventions for a particular patient, as well
as options for the delivery of postoperative care.
Sarwer pointed out that the idealized vision of shared decision making
does not explicitly recognize the personal, interpersonal, and community
characteristics that affect a patient’s capacity to engage. Racial, ethnic, and
cultural minorities in particular may have limitations with language, commu-
nication skills, and medical literacy (Hawley and Morris, 2017). Individuals
from underrepresented groups may be skeptical or distrustful of health care

providers whom they perceive as not understanding their lived experiences.

The result, Sarwer said, can be to default to the traditional, hierarchical
provider-as-expert approach to communication, which in turn can strain
the relationship and lead to deferred or atypical care (Smith et al., 2009).
Sarwer stressed the importance of provider efforts to develop rapport and
empathy with patients, and cautioned that provider biases about which pa-
tients are most likely to take an active role in their care may impact provider
engagement in shared decision making (Williams et al., 2008). He expressed
enthusiasm about the potential for new decision support tools to facilitate
and enhance shared decision making in obesity and bariatric care.
To summarize, Sarwer reiterated that bariatric surgery produces greater
and more enduring weight losses relative to lifestyle modification and
pharmacotherapy, but remains profoundly underutilized for reasons related
to health care policy and delivery, as well as individual-level beliefs and
experiences. He called for strategies for minimizing internalized weight
bias and stigma, which he suggested could be addressed most effectively
by education to create a new culture of understanding among medical stu-
dents and other health professionals about the disease of obesity. Finally, he
urged providers to identify novel strategies for ensuring that patients with
clinically severe obesity and related morbidities are informed of the most
appropriate treatments available to them.
AUDIENCE DISCUSSION
Following Sarwer’s presentation, Ard asked him to share his perspective
on how people perceive surgical treatment in initial discussions about obe-
sity treatment options. Sarwer replied that he believes misinformation about
the risks of bariatric surgery is widespread, and he referred to anecdotes
about health care providers who say they do not recommend bariatric sur-
gery because they have heard about a patient who died or ended up in the
intensive care unit following a bariatric procedure. He acknowledged that
bariatric procedures are not risk free, but asserted that for most patients,
risks for severe adverse outcomes are relatively low and outweighed by the
potential benefits. He added that it can be a challenge to steer conversa-
tions away from misinformation in a way that is productive for changing
the beliefs and attitudes of the misinformed party.
A participant asked Sarwer for suggestions for motivating employers to
provide insurance coverage or related benefits that would encourage their
employees to pursue bariatric surgery. Sarwer posited that such decisions
are easier for large than for small employers because the latter are typically
less able to negotiate with insurance companies. Thus, he said, they face
the dilemma of absorbing or passing on to employees the extra costs of
providing bariatric surgery coverage for their workforce.

Another participant remarked that preferences for body shape and size
vary by ethnic identify and self-identity, and asked Sarwer how to balance
those preferences with medical recommendations for bariatric surgery.
Evidence indicates that body image improves postsurgery for a majority
of patients, Sarwer reported, but he acknowledged that in his experience,
some patients have expressed concern that they or their spouse or romantic
partner would be dissatisfied with their appearance postsurgery. He pointed
out that when 60–90 minutes can be dedicated to preoperative counseling
visits, such concerns can be further discussed. He added that the challenge
of shorter preoperative visits is another reason why it is important for all
members of multidisciplinary obesity care teams to be trained in handling
such concerns, or at least to be able to direct patients to another colleague
with the appropriate expertise.
IDENTIFYING GAPS AND NEXT STEPS

(PANEL AND AUDIENCE DISCUSSION)
The session concluded with a panel and audience discussion focused
on identifying research gaps and next steps for improving patient–provider
communication around obesity treatment, as well as access to treatment
for all patients. Smith, Gudzune, and Sarwer discussed a range of topics
that included initiating conversations with patients about obesity treatment,
discussing the impact of social determinants on obesity, communicating the
long-term nature of treatment, promoting shared decision making, integrat-
ing synergistic clinical care models, novel settings for weight management
strategies, ideal coverage scenarios for obesity treatment, and key priorities
for improving patient–provider communication about obesity.
Initiating Conversations with Patients about Obesity Treatment

Ard opened the discussion by asking the panelists for practical tips on
broaching the topic of obesity treatment with patients. Sarwer replied that
conversations about weight are expected when patients visit a clinic that
specializes in obesity, but suggested that providers who are not obesity
specialists are often on solid ground in discussing the health consequences
of excess weight. At the same time, he continued, patient perceptions about
their body image and appearance may be stronger motivators than health
improvements for them to address their weight. Patients often find greater
satisfaction in dropping a clothing size, he said to illustrate this point, than
in lowering their hemoglobin A1c level.
Gudzune urged providers to consider the appropriate timing for initi-
ating discussion of the topic of weight. In her experience, weight stigma
can be reinforced for patients when they present for a visit or complaint

not directly related to obesity and the provider brings weight into the
discussion—even if the complaint may be alleviated by weight loss—or
mentions weight fleetingly at the end of the visit. She proposed that in these
situations, the provider ask the patient about returning for a future visit
to discuss weight loss as a strategy for addressing the problem. This fram-
ing asks the patient for permission to discuss weight, she explained, and it
also conveys that the provider perceives the topic to be important enough
to warrant its own visit. Even when weight is a planned discussion topic,
Gudzune urged providers to first understand how patients perceive their
weight before launching into their recommendations. This context helps
set the stage for a better patient–provider partnership, she maintained, by
aligning expectations and helping the provider provide appropriate treat-
ment recommendations. Smith echoed Gudzune’s advice and shared his
view that asking patients how they feel about their weight status is a way
both to introduce the topic and to discover a patient’s level of readiness and
willingness to pursue weight loss.
Integrating the Impact of Social Determinants

of Health in Patient Conversations
In Smith’s view, introducing social determinants of health in conversa-
tions with patients who have obesity has value in helping to change the
pervasive U.S. perspective that obesity is a completely self-inflicted condi-
tion. Individual behaviors play a role, he clarified, but social determinants
of health also have a large role in a person’s obesity status, as well as a
range of other domains of well-being. He suggested talking with patients
about how to work together to overcome challenges within their built and
food environments.
Sarwer agreed that social determinants of health are a fundamental
concept regardless of disease condition, but submitted that for obesity, so-
ciety tends to blame the individual. He recounted some of his conversations
with patients with obesity, in which he said it resonated with them when he
suggested that the condition is a logical consequence of living in an envi-
ronment that is engineered to minimize physical activity and is replete with
readily accessible unhealthy food choices. A person has to mount a valiant
effort in such an environment, he suggested, not to gain excess weight. The
concept of mindfulness may also have traction, he added, in helping people
become more engaged in the moment when making food choices.
Gudzune built on Smith’s and Sarwer’s points in proposing that discuss-
ing the genetic heritability of obesity can help patients minimize self-blame.
It is illuminating for many patients to recognize, she said, that they face
a deck that is not stacked in their favor when a genetic predisposition is
combined with an environment that favors weight gain, although it often

takes multiple conversations for this concept to sink in when the willpower
perception is deeply ingrained. She shared that in her practice, she invites
patients to describe the positive and negative aspects of their environments
in terms of influences on weight management. They usually identify some
positive aspects and resources, she recounted, which gives way to a joint
discussion about how to leverage those resources. This exchange helps
start what she called a “positive snowball” that she believes is important
for countering feelings of hopelessness or ambivalence that can easily arise
in some situations.
Communicating the Long-Term Nature of

Obesity Management to Patients
Ard pointed out that obesity is a chronic disease that is likely to relapse
if treatment stops, and asked panelists how to help set patients’ expecta-
tions about its long-term nature. Sarwer urged repetition and affirmed the
value of delivering a consistent message that cuts through the clutter of
background noise about weight. He stressed that, after giving behavioral
recommendations to a patient, providers should follow up on those recom-
mendations at the subsequent patient visit, arguing that failure to do so
sends a message that the recommendations were unimportant.
Gudzune called attention to a societal misperception that weight loss
is a temporary experience, whereas in reality it is often a chronic, relaps-
ing experience whether the treatment approach is lifestyle modification,
pharmacotherapy, or surgery. Weight-loss stories highlighted in the media
often show dramatic, seemingly instant losses, which she said does not give
patients realistic expectations about the progress and timeline of typical
weight-loss journeys. These kinds of portrayals reinforce self-blame and in-
ternalization of stigma, she asserted, suggesting that patients might instead
feel affirmed by their smaller victories if portrayals were more accurate.
Smith agreed that media portrayals of weight-loss success stories often
fail to convey the tremendous effort that goes into achieving a substantial
weight reduction. As a result, people may quickly become depressed or
disenchanted with the gradual process of losing and maintaining weight. He
suggested comparing obesity to other types of chronic relapsing conditions,
such as chronic pain, to help convey the message that persistent effort is
required to achieve and maintain weight loss.
Promoting Shared Decision Making

Smith suggested, first, that providers consider the various shared
decision-making approaches and philosophies that exist and then choose a
decision-making tool that corresponds to the approach they want to pursue.

Second, he said it is helpful to gather information resources that patients

can use to make a decision about obesity treatment. Readily available re-
sources can help guide patients in their decision making, he elaborated, so
they are not starting with an open-ended Google search. Gudzune added
that it is also important to understand a patient’s usual and trusted—and
mistrusted—sources of information, which she suggested helps providers
know how to tailor conversations with individual patients. She also urged
the health care community to be engaged in communications and popular
media to increase the public’s exposure to credible voices that can help raise
societal awareness of obesity issues.
In Sarwer’s view, a provider’s approach to shared decision making de-
pends on the clinical context. He contended that shared decision making
is easier for providers in obesity-specific practice settings because patients
know what they are getting into. In these situations, he maintained, the key
focus is on building rapport with patients and communicating the evidence
with both authority and empathy. For providers in primary care settings
who are unsure of how best to treat a patient with obesity, Sarwer said,
providing an evidence-based referral to another provider with the appro-
priate expertise is “the greatest gift” they can give to that patient. Another
member of the treatment team may be able to step in, he remarked, add-
ing that nonphysician, non–doctoral-level providers can also be trained to
provide effective weight management counseling.
Integrated Synergistic Clinical Care Models

The three speakers agreed that reliance on comprehensive obesity treat-
ment programs is insufficient and that multilayered approaches are impera-
tive to address the systemic factors that contribute to the development of
obesity and propagate weight stigma. Gudzune reiterated that a relatively
easy win in this space is to adjust the physical clinic environment so that
waiting room chairs, exam tables, and scales, for example, can readily ac-
commodate people of all body sizes. This relatively simple, common-sense
strategy still requires financial capital or other incentives to achieve, she
pointed out, suggesting that quality and equity of care are rationales for
this investment. Gudzune also argued that engaging different types of pro-
viders would help achieve a more integrated clinical care model. An alert
could be programmed to appear in a patient’s electronic health record, she
said as an example, when a certain threshold has been reached in terms of
prescriptions for weight-gain–causing medications. Doing so would facili-
tate bringing pharmacists into decision-making processes, she observed, to
discuss potential medication alternatives.
Sarwer agreed that pharmacists could play a more active role in obe-
sity management and suggested that nursing and social work professionals

could also participate. These professionals often work in community set-

tings and may even conduct home visits, he pointed out, giving them the
opportunity to discuss patients’ specific lifestyle habits.
Novel Settings for Weight Management Strategies

Gudzune urged stakeholders to consider embedding weight manage-
ment strategies in settings that are widely accessible, even in places where
people typically would not think about receiving health care services. She
pointed to pharmacies located in supermarkets as an example of a common
setting for reaching people in the context of their everyday lives. From there
they could be triaged into a more focused setting within the community
for their specific health conditions, she added, facilitated by partnerships
with the pharmacy and other community entities that provide care. Smith
echoed the importance of diversifying the environments in which patients
can receive care, adding that not all patients can access specialized clinical
weight management programs.
Sarwer built on Gudzune’s idea about leveraging pharmacies and sug-
gested that the field of obesity care needs champions who can approach
potential funders to discuss such investments as housing weight manage-
ment clinics in pharmacies or piloting programs that train pharmacists to
deliver lifestyle modification interventions. He shared his view that obesity
does not lend itself to philanthropic investment as much as do other dis-
eases, perhaps in part because of bias and stigma, and speculated as to
whether a celebrity endorsement would help maximize the reach of treat-
ment solutions.
Envisioning an Ideal Coverage Scenario for Obesity Treatment

Asked to envision the components of a comprehensive health plan
that would include coverage of obesity treatment for children and adults,
Gudzune espoused coverage for three primary categories of intervention:
lifestyle/behavioral counseling, pharmacotherapy, and surgical procedures.
She stressed the importance of having multiple options for patients within
each type of intervention, describing an example scenario whereby a plan
would cover behavioral counseling in primary care settings, but this treat-
ment would become inaccessible if the provider were not trained to offer
that service. She suggested that partnerships with evidence-based com-
mercial weight-loss programs could be additional avenues for lifestyle
solutions. With regard to pharmacotherapy, she explained that coverage
for a single agent—particularly if that agent can be prescribed for only
3 months, for example—is insufficient to address the long-term nature of
most weight management efforts; she also highlighted that Medicare does

not cover antiobesity medications. With respect to surgical procedures,

Gudzune maintained that it is important to have an evidence base to sup-
port their coverage. She indicated that bariatric surgery has solid supporting
evidence, but that emerging minimally invasive techniques, such as intragas-
tric balloons, have less evidence. She explained that the latter techniques are
important for patients who have contraindications to pharmacotherapy or
bariatric surgery but have a medical need to lower their body weight, such
as to prepare for an organ transplant or knee surgery. In Gudzune’s view, a
lack of options for these people creates a persistent sense of hopelessness.
Smith and Sarwer agreed with Gudzune that an ideal coverage scenario
would include various treatment modalities, multiple specialties, and mul-
tiple options within those specialties. Smith appealed for another layer of
coverage to reduce the practical and financial barriers to accessing care for
obesity, such as transportation, child care, and time off from work. Sarwer
proposed that coverage also could include incentives that promote healthy
lifestyle behaviors, such as purchasing fruits and vegetables and gym mem-
berships, though he acknowledged that such provisions would be challeng-
ing to substantiate with evidence and to implement.
Improving Patient–Provider Communication about Obesity

The panelists’ final comments highlighted key priorities for improving
patient–provider communication about obesity. Smith reiterated his empha-
sis on discussing the influence of social determinants of health on obesity
status. The evidence base in this area is still developing, he conceded, and
consists predominantly of relatively short-term studies that modified single
aspects of an environment. These studies tend to produce modest results,
he observed, and he asserted that research examining the effects of modify-
ing multiple determinants of health over a longer time period would more
likely observe greater impact. Such studies are challenging and expensive
to conduct, he admitted, but would help build an evidence base about the
synergistic benefits that would likely result from a focus on multiple inter-
connected determinants.
Gudzune focused on the need to train both future and practicing clini-
cians in how to treat obesity. She called for more robust research on how to
tailor training for the next generation of clinicians, pointing out that some
evidence indicates that training can exacerbate weight bias in certain situa-
tions. She observed that many medical students and residents are interested
in providing better treatment for obesity, but their supervising clinicians
sometimes have attitudes and biases that impede them from obtaining ap-
propriate training. Gudzune argued that this observation points to a need
to find ways of supporting both upcoming and practicing clinicians at the
right level.

Sarwer echoed his earlier comments about the importance of empha-

sizing the chronic nature of obesity treatment, stressing that, regardless
of modality, the duration of obesity treatment is similar to treatment for
other chronic diseases, such as diabetes or hypertension, not a quick fix of
3–6 months. Sarwer’s second point was that many unanswered questions
remain about the 20–30 percent of patients who fail to respond well to
bariatric surgery. More research is needed, he asserted, to better inform the
field about how to care for those patients. Lastly, he envisioned an ideal
scenario of comprehensive obesity care centers where multidisciplinary
professionals would converge to provide holistic, patient-centered care. In
closing, he argued that the prevalence and severity of obesity truly warrant
this kind of approach.


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Appendix A
Workshop Agendas
Exploring Strategies for Sustainable Systems-Wide Changes to

Reduce the Prevalence of Obesity: A Virtual Workshop
April 8, 2021
AGENDA
SESSION ONE—AN INTRODUCTION
10:00 AM The Roundtable on Obesity Solutions’ Strategic Planning

Process and Systems Map: A Brief Overview
Nicolaas P. Pronk, HealthPartners Institute, Chair of the
10:10 An Introduction to the Intersection of Biased Mental Models,

Stigma, Weight Bias, Structural Racism, and Effective
Health Communications with Obesity Solutions
Camara Phyllis Jones, Morehouse School of Medicine
10:30 Moderated Discussion and Q&A
153

SESSION TWO—THE INTERSECTION OF STRUCTURAL RACISM

AND OBESITY
10:40 Remarks from Session Moderator

Stephanie A. Navarro Silvera, Montclair State University
10:45 Housing
Roland J. Thorpe Jr., Johns Hopkins Bloomberg School of
Public Health
11:00 Education
J. Alexander Navarro, University of Michigan Center for the
History of Medicine

Session Moderator: Stephanie A. Navarro Silvera
11:45 Break
SESSION THREE—THE INTERSECTION OF BIASED MENTAL

MODELS, STIGMA, WEIGHT BIAS, AND OBESITY
12:00 PM Remarks from Session Moderator

Carlos J. Crespo, Oregon Health and Science University and
12:05 Worksite
Stephen Bevan, Institute for Employment Studies
12:20 Health Care

Keith C. Norris, David Geffen School of Medicine, University
of California, Los Angeles

Session Moderator: Carlos J. Crespo
1:00 LUNCH BREAK
SESSION FOUR—WRAP-UP REFLECTIONS PANEL
1:30 Panel Discussion

Session Moderator: Angela M. Odoms-Young, University of
Illinois Chicago

APPENDIX A 155
Panelists:
• Carol Byrd-Bredbenner, Rutgers University
• Carlos J. Crespo, Oregon Health and Science University and
• Stephanie A. Navarro Silvera, Montclair State University
• Melissa A. Simon, Northwestern University Feinberg School
of Medicine
2:30 ADJOURN WORKSHOP
Data and Innovative Approaches for Sustainable Systems-Wide Changes

to Reduce the Prevalence of Obesity: A Second Workshop in the Series
June 22, 2021
AGENDA
SESSION ONE—OPERATIONALIZING HEALTH COMMUNICATIONS

FOR OBESITY SOLUTIONS
10:00 AM Welcome

Angela Odoms-Young, University of Illinois Chicago
10:15 What Do We Mean by Health Communications?

Jeff Niederdeppe, Cornell University
SESSION TWO—DATA-DRIVEN OBESITY SOLUTIONS AND

INNOVATIVE APPROACHES

Carlos J. Crespo, Oregon Health and Science University and
10:45 Innovation in the Education Context

Joseph E. Donnelly, University of Kansas Medical Center

11:00 Innovation in the Health Care Context

Patrick J. O’Connor, HealthPartners Institute
11:45 Break
SESSION THREE—INNOVATIVE POLICY SOLUTIONS
12:00 PM Remarks from Session Moderator

Stephanie A. Navarro Silvera, Montclair State University
12:05 Innovative Policy Solutions

Colby D. Duren, Intertribal Agriculture Council
12:20 Policy Challenges and Opportunities

Mary T. Bassett, Harvard University
1:00 LUNCH BREAK
SESSION FOUR—KEYNOTE REFLECTIONS AND SPEAKER PANEL
1:30 Workshop Reflections

Sarah de Guia, ChangeLab Solutions
1:55 Audience Q&A with Speaker Panel

Session Moderator: Melissa A. Simon, Northwestern University
Feinberg School of Medicine
Panelists:
• Colby D. Duren, Intertribal Agriculture Council
• Jeff Niederdeppe, Cornell University
• Patrick J. O’Connor, HealthPartners Institute
2:30 Closing Remarks

Angela Odoms-Young, University of Illinois Chicago
ADJOURN WORKSHOP

APPENDIX A 157
Systems and Obesity: Advances and Innovations for Equitable

Health and Well-Being: A Third Workshop in the Series
Sessions 1–4
October 28, 2021
10:00 AM – 2:45 PM ET
DAY ONE AGENDA
10:00 AM Welcome
SESSION 1—LEVERAGING DATA FOR SYSTEMS CHANGE:

CONNECTING OBESITY AND ITS UNDERLYING DETERMINANTS
Session Moderator: Carlos J. Crespo, Oregon Health and Science University

and Portland State University
10:10 Presenters
• Bruce Y. Lee, City University of New York
• Ryan Masters, University of Colorado Boulder
SESSION 2—SYSTEMS APPLICATIONS FOR ADDRESSING

STRUCTURAL BARRIERS TO OBESITY
Session Moderator: Stephanie A. Navarro Silvera, Montclair State

University
11:00 Presenters
• Somava Saha, Well Being in the Nation Network
• Rachel D. Godsil, Perception Institute
11:45 Break

SESSION 3—UTILIZING POLICY FOR OBESITY SOLUTIONS AND

NUTRITION SECURITY
Session Moderator: Angela Odoms-Young, Cornell University
12:00 PM Presenters
• Sara N. Bleich, U.S. Department of Agriculture
• Amelie G. Ramirez, Salud America!
1:00 LUNCH BREAK
SESSION 4—A MULTISECTOR CONVERSATION ON SYSTEMS

CHANGE FOR OBESITY SOLUTIONS
Session Moderator: Nicolaas P. Pronk, HealthPartners Institute, Chair of

the Roundtable on Obesity Solutions
1:30 Opening Reflections

• William H. Dietz, The George Washington University
• Shiriki K. Kumanyika, Drexel University
• Nicolaas P. Pronk, HealthPartners Institute
Panel Discussion with Members of the Roundtable on

Obesity Solutions
• Captain Heidi M. Blanck, Centers for Disease Control
and Prevention
• Jamie B. Bussel, Robert Wood Johnson Foundation
• Joseph Nadglowski, Jr., Obesity Action Coalition
• Megan Nechanicky, General Mills, Inc.
• Susan Z. Yanovski, National Institutes of Health
2:30 Closing Remarks

Peter S. Hovmand, Case Western Reserve University

APPENDIX A 159
Session 5
October 29, 2021
1:00 PM – 4:00 PM ET
DAY TWO AGENDA
SESSION 5—PATIENT–PROVIDER COMMUNICATION AROUND

OBESITY TREATMENT AND SOLUTIONS
1:00 PM Welcome
Jamy D. Ard, Wake Forest School of Medicine, Session
Moderator
1:05 The Ethical Dilemma of Implementing Recommendations

Captain Hunter J. Smith, Johns Hopkins Berman Institute
of Bioethics
1:25 Audience Q&A
1:35 The Effect of Obesity on Patient–Provider Communication

Kimberly A. Gudzune, The Johns Hopkins University
1:55 Audience Q&A
2:05 Weight Bias, Provider Communication, and Barriers to

Obesity Treatment
David B. Sarwer, Temple University
2:25 Audience Q&A
2:35 Identifying Gaps and Next Steps

• Kimberly A. Gudzune, The Johns Hopkins University
• David B. Sarwer, Temple University
• Captain Hunter J. Smith, Johns Hopkins Berman Institute
of Bioethics
4:00 ADJOURN WORKSHOP


Appendix B
Acronyms and Abbreviations
AI artificial intelligence
BMI body mass index
CDC Centers for Disease Control and Prevention

CODI Clinical and Community Data Initiative
EFNEP Expanded Food and Nutrition Education Program

EMR electronic medical record
FDA U.S. Food and Drug Administration

FDPIR Food Distribution Program on Indian Reservations
GIS geographic information systems
HOLC Home Owners’ Loan Corporation
IAC Intertribal Agriculture Council

IOM Institute of Medicine
MWM medical weight management
NAM National Academy of Medicine

NHANES National Health and Nutrition Examination Survey
161

NIH National Institutes of Health

NSLP National School Lunch Program
OAC Obesity Action Coalition
PAAC Physical Activity Across the Curriculum

P-EBT Pandemic Electronic Benefit Transfer
RWJF Robert Wood Johnson Foundation
SBP School Breakfast Program

SNAP Supplemental Nutrition Assistance Program
USDA U.S. Department of Agriculture

USPSTF U.S. Preventive Services Task Force
WIC Special Supplemental Nutrition Program for Women, Infants,

and Children
WIN Well Being in the Nation

Appendix C
Biographical Sketches of
Workshop Speakers and Planning
Committee Members
Jamy D. Ard, M.D., is professor in the Department of Epidemiology and

Prevention and the Department of Medicine at Wake Forest School of
Medicine. He is also codirector of the Atrium Health Wake Forest Baptist
Weight Management Center, directing medical weight management pro-
grams. Dr. Ard’s research interests include clinical management of obesity
and strategies to reduce cardiometabolic risk using lifestyle modification.
In particular, his work has focused on developing and testing medical
strategies for the treatment of obesity in special populations, including
African Americans, those with type 2 diabetes, and older adults. Dr. Ard
has participated in several major National Institutes of Health–funded mul-
ticenter trials, including Dietary Approaches to Stop Hypertension (DASH),
DASH-Sodium, PREMIER, and the Weight Loss Maintenance Trial. His
work has been published in numerous scientific journals, and he has been
a featured presenter at several national and international conferences and
workshops dealing with obesity; he has served on several expert panels,
guideline-development committees, and editorial boards. Prior to joining
the faculty at Wake Forest in 2012, Dr. Ard spent 9 years at the University
of Alabama at Birmingham in the Department of Nutrition Sciences. He
received an M.D. and completed internal medicine residency training at the
Duke University Medical Center.
Mary T. Bassett, M.D., is director of the François-Xavier Bagnoud (FXB)

Center for Health and Human Rights at Harvard University and the FXB
professor of the practice of health and human rights at the Harvard T.H.
Chan School of Public Health. She has dedicated her career to advancing
163

health equity. Prior to joining the FXB Center, Dr. Bassett served as New
York City’s Commissioner of Health from 2014 to 2018. She received her
M.D. from Columbia University’s College of Physicians and Surgeons, and
served her medical residency at Harlem Hospital Center. Dr. Bassett also
has a master’s degree in public health from the University of Washington,
where she was a Robert Wood Johnson Clinical Scholar.
Stephen Bevan, B.Sc., P.G.C.E., is head of human resources research devel-

opment at the Institute for Employment Studies (IES), with responsibility
for developing innovative new projects and programs with IES partners
and other collaborators. He returned to IES in April 2016 after spend-
ing 15 years as director of research and managing director at The Work
Foundation. Mr. Bevan has conducted research and consultancy on high-
performance work practices, employee reward strategy, performance man-
agement, staff engagement and retention, and “good work.” He has led a
number of national and international projects focusing on workforce health
and the impact of chronic illness on productivity and social inclusion, in-
cluding a major impact evaluation project for the Joint Work and Health
Unit. Mr. Bevan is an adviser to a number of government departments in the
United Kingdom, as well as employers and policy makers in Europe, Asia
Pacific, Australasia, and North America. He has received a special award
from Global Alliance of Mental Illness Advocacy Networks-Europe for
his contribution to the field of mental health and employment. He is a re-
viewer for several academic journals, including The Lancet. Mr. Bevan has
appeared in HR Magazine’s list of “Most Influential HR Thinkers” for the
past 10 years. He has been an honorary professor at Lancaster University
Management School since 2010.
Captain Heidi M. Blanck, Ph.D., M.S., is a U.S. Public Health Service of-
ficer and chief of the Obesity Branch in the Division of Nutrition, Physical
Activity, and Obesity in the National Center for Chronic Disease Prevention
and Health Promotion at the Centers for Disease Control and Prevention
(CDC). She oversees the CDC’s monitoring of state, territory, and tribal
obesity prevalence and key nutrition policies, environments, and behaviors.
Staff in the branch conduct surveillance, applied research, guidelines devel-
opment, and technical assistance for implementation of standards for early
care and education and food service venues. Staff also work with partners
to accelerate the use of electronic health records for obesity data and in-
creased access of pediatric weight management programs for low-income
families. Dr. Blanck has more than 22 years of experience at the CDC and
has authored more than 150 papers and reports in the areas of nutrition,
physical activity, obesity, and environmental exposures. She is senior advi-
sor to the agency’s Nutrition and Obesity Policy Research and Evaluation

APPENDIX C 165
Network of researchers and practitioners and a member of the National

Collaborative on Childhood Obesity Research, partnering with the U.S. De-
partment of Agriculture, the National Institutes of Health, and the Robert
Wood Johnson Foundation. Dr. Blanck received her master of science from
the University of Michigan and her Ph.D. from Emory University, where
she serves as adjunct professor.
Sara Bleich, Ph.D., is senior advisor for COVID-19 in the Office of the Sec-
retary at the U.S. Department of Agriculture (USDA). She is a policy expert
and researcher who specializes in diet-related diseases, food insecurity, and
racial inequality. She is on leave as a tenured professor of public health pol-
icy at the Harvard T.H. Chan School of Public Health, the Kennedy School
of Government, and the Radcliffe Institute for Advanced Study. Dr. Bleich
was also a White House fellow toward the end of the Obama Administra-
tion, where she worked at USDA as a senior policy advisor for food, nutri-
tion, and consumer services and with First Lady Michelle Obama’s Let’s
Move! initiative. She holds a B.A. in psychology from Columbia University
and a Ph.D. in health policy from Harvard University.
Jamie Bussel, M.P.H., is a senior program officer at the Robert Wood

Johnson Foundation. She is deeply committed to discovering, learning,
and exploring cutting-edge ideas with the potential to help build a culture
of health and ensure that all children and families have what they need to
thrive. Ms. Bussel currently leads the Foundation’s efforts to prevent child-
hood obesity, helping foster multidisciplinary partnerships and systems-level
change strategies to transform the health of people and places. A strong
believer in the impact of physical, social, and educational environments on
health, she hopes that her work will contribute to a healthier future for all
children. Ms. Bussel received a B.A. in English literature from the University
of Michigan and an M.P.H. in behavioral sciences/health education from
Rutgers University School of Public Health.
Carol Byrd-Bredbenner, Ph.D., R.D., is distinguished professor of nutri-

tion and director of the Nutritional Sciences Graduate Program at Rutgers
University. Her research focuses on elucidating the role of cognitive and
environmental factors on nutrition behaviors and health outcomes, and
developing recommendations for nutrition communications and health pro-
motion interventions. Currently, Dr. Byrd-Bredbenner is leading the innova-
tive childhood obesity prevention program HomeStyles, which motivates
parents to make quick, easy, evidence-based modifications to their home en-
vironment and lifestyle practices. Dr. Byrd-Bredbenner has published nearly
200 research articles and theory-driven, behaviorally focused nutrition cur-
ricula and intervention materials. She received the Helen Denning Ullrich

Award for Lifetime Excellence in Nutrition Education from the Society for
Nutrition Education and Behavior, and the Excellence in Nutrition Educa-
tion Award from the American Society for Nutrition. Dr. Byrd-Bredbenner
earned her doctoral degree at The Pennsylvania State University.
Carlos J. Crespo, Dr.P.H., M.S., is professor at the Oregon Health and Sci-
ence University and Portland State University School of Public Health, and
vice provost for undergraduate training in biomedical research at Portland
State University. Previously, he worked for the National Center for Health
Statistics at the Centers for Disease Control and Prevention (CDC), and
as a public health analyst for the National Institutes of Health (NIH). His
main areas of research include the epidemiology of physical activity in
the prevention of chronic diseases and research on minority health issues.
Dr. Crespo lists more than 100 publications and has been a contributing
author to five textbooks on minority health and sports medicine and more
than 20 government reports, including the Surgeon General’s Report on
Physical Activity and Health. He received the 1997 U.S. Secretary of Health
Award for Distinguished Service as part of the Salud para su Corazon cam-
paign, and in 2003 became a minority health scholar with the National
Institute of Minority Health and Health Disparities at NIH. Dr. Crespo is
a fellow of the American College of Sports Medicine and a member of the
editorial board of the journal Cities and Health. He graduated from the
Inter American University of Puerto Rico, has a master of science in sports
health from Texas Tech University, and a doctor of public health in preven-
tive care from Loma Linda University.
Sarah de Guia, J.D., is CEO of ChangeLab Solutions, a national orga-

nization that uses the tools of law and policy to advance health equity.
Previously, she was executive director of the California Pan-Ethnic Health
Network. Ms. de Guia has successfully accomplished passage of several
legislative, budgetary, and administrative efforts to further health equity,
including incorporating health equity into land use and planning regula-
tions, expanding language access provisions for limited English proficiency,
and improving the quality of health care for communities of color. Cur-
rently, she sits on the advisory committee for the Office of Health Equity
at the California Department of Public Health, the advisory council of the
Healthiest Cities and Counties Challenge, and the board of directors of the
CARESTAR Foundation. Ms. de Guia earned her law degree from Santa
Clara University School of Law and her bachelor’s degree in ethnic studies
from the University of California, Berkeley.
William (Bill) H. Dietz, M.D., Ph.D., is a consultant to the Roundtable on

Obesity Solutions and chair of the Sumner M. Redstone Global Center for

APPENDIX C 167
Prevention and Wellness at the Milken Institute School of Public Health at

The George Washington University. Previously, he was director of the Divi-
sion of Nutrition, Physical Activity, and Obesity in the Center for Chronic
Disease Prevention and Health Promotion at the Centers for Disease Con-
trol and Prevention (CDC). Prior to that, he was a professor of pediatrics
at the Tufts University School of Medicine and director of clinical nutrition
at the Floating Hospital of the New England Medical Center. Dr. Dietz has
been a counselor and past president of the American Society for Clinical
Nutrition, and past president of the North American Association for the
Study of Obesity. He served as a member of the advisory board to the In-
stitute of Nutrition, Metabolism, and Diabetes of the Canadian Institutes
for Health Research. Dr. Dietz has earned numerous awards, including a
Special Recognition Award from the American Academy of Pediatrics Pro-
visional Section on Obesity and the Outstanding Achievement Award from
the Georgia Chapter of the American Academy of Pediatrics. He has au-
thored more than 200 publications in the scientific literature and edited five
books, including Clinical Obesity in Adults and Children, and Nutrition:
What Every Parent Needs to Know. He is a member of the National Acad-
emy of Medicine. Dr. Dietz received his B.A. from Wesleyan University in
1966 and his M.D. from the University of Pennsylvania in 1970. After the
completion of his residency at Upstate Medical Center, he received a Ph.D.
in nutritional biochemistry from Massachusetts Institute of Technology.
Joseph E. Donnelly, Ed.D., is professor of medicine in and director of the

Division of Physical Activity and Weight Management at the University of
Kansas. He is a nationally recognized researcher in weight loss and mainte-
nance. Since 2000, he has received $60 million in grants from the National
Institutes of Health for his research to help combat obesity in children and
adults, including those with disabilities. Dr. Donnelly received his Ed.D. in
exercise physiology from West Virginia University.
Colby D. Duren, J.D., is director of policy and government relations for

the Intertribal Agriculture Council. Previously, he was director of the Indig-
enous Food and Agriculture Initiative (IFAI) at the University of Arkansas’s
Office of the Vice Chancellor for Economic Development. He has also
served as policy director and staff attorney for IFAI since 2017. Mr. Colby
has more than 13 years of experience in federal Indian law and policy,
with a specific focus on food, agriculture, nutrition, natural resources,
and economic development, including work on three Farm Bills. Prior to
joining IFAI, he worked as staff attorney and legislative counsel for the
National Congress of American Indians; for the Native American Rights
Fund Washington, DC, office; and for Olsson Frank Weeda Law. In 2016,
Mr. Colby was nominated by the Native American Bar Association of

Washington, DC, for its Significant Contribution in Indian Law Award

for his work on environmental issues in Indian Country. He was also rec-
ognized by the Intertribal Agriculture Council membership in December
2018 for his work supporting Tribal governments and Tribal producers in
the development of the 2018 Farm Bill. Mr. Colby earned his law degree
from the American University Washington College of Law in 2012 and his
bachelor of arts from Vassar College in 2006.
Rachel D. Godsil, J.D., is cofounder and codirector of the Perception

Institute and a distinguished professor of law and chancellor’s scholar at
Rutgers Law School. She collaborates with social scientists on empirical
research to identify the efficacy of interventions to address implicit bias,
racial anxiety, and stereotype threat, and regularly leads workshops and
presentations on these topics and more. Ms. Godsil is on the advisory board
for Research, Integration, Strategies, and Evaluation (RISE) for Boys and
Men of Color at the University of Pennsylvania’s Center for the Study of
Race and Equity in Education; the Systemic Justice Project at Harvard Law
School; and the Poverty and Race Research Action Council. She served as
chair of the New York City Rent Guidelines Board, as the convener for the
Obama campaign’s Urban and Metropolitan Policy Committee, and as an
advisor to the Department of Housing and Urban Development transition
team. Ms. Godsil was assistant U.S. attorney for the Southern District of
New York and associate counsel at the NAACP (National Association for
the Advancement of Colored People) Legal Defense and Educational Fund,
as well as an associate with Berle, Kass & Case and Arnold & Porter in
New York City. Additionally, she was Eleanor Bontecou professor of law at
Seton Hall University Law School, where she was named Researcher of the
Year in Law in 2003–2004. She has also taught at the law schools of the
University of Pennsylvania and New York University. Ms. Godsil received
a J.D. from the University of Michigan Law School.
Kimberly Gudzune, M.D., M.P.H., F.T.O.S., is medical director of the

American Board of Obesity Medicine and of the Healthful Eating, Activity
& Weight Program at Johns Hopkins Medicine, which offers comprehensive
services to support weight loss and manage chronic disease. She is board
certified in internal medicine and obesity medicine and was recognized as
a Top Weight Management Doctor by Baltimore Magazine in 2019, 2020,
and 2021. Dr. Gudzune is also an active researcher, focusing on how obesity
influences the health care experience, the efficacy of commercial weight-loss
programs, and how features of the built and social environment influence
diet and exercise habits among low-income, urban populations. Her re-
search has been featured in The New York Times and on National Public
Radio. Dr. Gudzune attended Tulane University in New Orleans, Louisiana,

APPENDIX C 169
where she received her doctor of medicine and master of public health. She
completed her training in internal medicine at the University of Maryland
Medical System. After residency, Dr. Gudzune engaged in additional weight
management training and completed a clinical research fellowship within
the Division of General Internal Medicine at the Johns Hopkins University
School of Medicine.
Peter S. Hovmand, Ph.D., M.S.W., is Pamela B. Davis M.D. Ph.D. Professor

of Medicine at the Center for Community Health Integration; professor of
general medical sciences in the School of Medicine, professor of biomedical
engineering in the Case School of Engineering; and professor of social work
(secondary appointment) at the Jack, Joseph and Morton Mandel School
of Applied Social Sciences at the Case Western Reserve University. Prior
to joining the Center for Community Health Integration, they founded
and led the Brown School’s Social System Design Lab at Washington Uni-
versity in St. Louis. Their research focuses on advancing methods for
understanding and preventing structural violence with a specific emphasis
on advancing knowledge on multilevel feedback systems. Over the last
25 years, Dr. Hovmand’s work has focused on innovations in applying
system dynamics group model building and formal modeling with com-
puter simulations to understand the structures underlying gender inequality,
structural racism, and social determinants of health more broadly across
a variety of outcomes, from pediatric obesity and interpersonal violence
to household air pollution and cancer. They authored Community Based
System Dynamics, led the creation of Scriptapedia (a knowledge commons
of group model building scripts), and cofounded/coled the System Dynam-
ics Society’s Diversity Committee and Structural Racism Special Interest
Group, and they currently serve as associate editor for System Dynamics
Review. Dr. Hovmand has a degree in electrical engineering and mathemat-
ics with an M.S.W. and Ph.D. from Michigan State University in interdisci-
plinary social sciences in social work and community ecological psychology
and cognate in women’s studies/feminist philosophy.
Camara Phyllis Jones, M.D., Ph.D., M.P.H., is senior fellow at the Satcher
Health Leadership Institute and Cardiovascular Research Institute, and
adjunct associate professor at Morehouse School of Medicine. Her work
focuses on naming, measuring, and addressing the impacts of racism on the
health and well-being of the nation. She is past president of the American
Public Health Association, a senior fellow at the Morehouse School of
Medicine, and an adjunct professor at the Rollins School of Public Health
at Emory University. While at Radcliffe College, Dr. Jones developed tools
to inspire, equip, and engage all Americans in a national campaign against
racism. For example, her allegories on “race” and racism illuminate topics

that are otherwise difficult for many Americans to understand or discuss.

Her toolbox will equip both children and adults to name racism, ask “How
is racism operating here?,” and organize and strategize to act. Dr. Jones
earned a B.A. in molecular biology from Wellesley College, an M.D. from
the Stanford School of Medicine, and an M.P.H. and a Ph.D. in epidemi-
ology from the Johns Hopkins School of Hygiene and Public Health. She
also completed residency training in general preventive medicine at Johns
Hopkins and in family medicine at the Residency Program in Social Medi-
cine at Montefiore Medical Center.
Shiriki K. Kumanyika, Ph.D., M.P.H., M.S., is emeritus professor of epide-

miology at the University of Pennsylvania Perelman School of Medicine and
research professor in the Department of Community Health & Prevention
at the Dornsife School of Public Health at Drexel University. Her interdis-
ciplinary background integrates epidemiology, nutrition, social work, and
public health methods and perspectives. The main themes in her research
concern prevention and control of obesity and other diet-related risk factors
and chronic diseases, with a particular focus on reducing health burdens
in Black communities. Dr. Kumanyika is founding chair of the Council
on Black Health (formerly the African American Collaborative Obesity
Research Network [AACORN]), a national network hosted by Drexel that
seeks to develop and promote solutions for achieving healthy Black com-
munities. She is past president of the American Public Health Association
and has served in numerous advisory roles related to public health research
and policy in the United States and abroad. She is a member of the National
Academy of Medicine. Dr. Kumanyika chaired the Standing Committee on
Obesity from 2009 until its retirement in 2013. She currently chairs the
National Academies of Sciences, Engineering, and Medicine’s Food and
Nutrition Board. Dr. Kumanyika received her M.S. in social work from
Columbia University, M.P.H. from The Johns Hopkins University, and
Ph.D. in human nutrition from Cornell University.
Bruce Y. Lee, M.D., M.B.A., is professor of health policy and management

at the City University of New York School of Public Health, where he is
executive director of PHICOR (Public Health Informatics, Computational,
and Operations Research), which he founded in 2007; he is also professor
by courtesy at the Johns Hopkins Carey Business School. He is a systems
modeler and a computational and digital health expert, writer, and journal-
ist, assisting a wide range of decision makers in health and public health.
Dr. Lee’s previous positions include associate professor of international
health at the Johns Hopkins Bloomberg School of Public Health, executive
director of the Global Obesity Prevention Center, director of operations
research at the International Vaccine Access Center, associate professor at

APPENDIX C 171
the University of Pittsburgh, senior manager at Quintiles Transnational,

researcher at Montgomery Securities, and cofounder of two companies.
He has been principal investigator for projects supported by a variety of
organizations and agencies, including the Bill & Melinda Gates Founda-
tion, the National Institutes of Health, the Agency for Healthcare Quality
and Research, the Centers for Disease Control and Prevention, UNICEF,
the Global Fund, and USAID. Dr. Lee also has served as a systems science
and modeling expert for numerous advisory boards and committees, such
as the National Academies of Sciences, Engineering, and Medicine com-
mittee on evaluating the Dietary Guidelines of America process. He has
authored more than 254 scientific publications and three books, and is a
senior contributor for Forbes. Dr. Lee received his B.A. from Harvard Uni-
versity, M.D. from Harvard Medical School, and M.B.A. from the Stanford
Graduate School of Business. He completed his internal medicine residency
training at the University of California, San Diego.
Ryan K. Masters, Ph.D., is assistant professor of sociology and faculty as-

sociate of the Population and Health and Society programs at the Institute
of Behavioral Science at the University of Colorado Boulder. His interests
include the examination of long-term trends in U.S. morbidity; chronic
diseases; and mortality rates, including the health consequences of the U.S.
obesity epidemic, especially as it relates to premature mortality among
the U.S. adult population. Dr. Masters has been involved in advancing
and testing new methodological approaches to studying period-based fac-
tors, such as health-promoting policies and new medical technologies, and
cohort-based factors, such as early-life disease exposure, related to adult
health. He holds a Ph.D. in sociology and demography from The University
of Texas at Austin.
Joseph (Joe) Nadglowski is president and CEO of the Obesity Action

Coalition (OAC)—a nonprofit organization formed in 2005 dedicated to
elevating and empowering those affected by obesity through education,
advocacy, and support. A speaker and author, Mr. Nadglowski is especially
passionate about access to treating obesity and tackling weight bias, as well
as sharing his own experiences with obesity. He has more than 20 years
of experience working in patient advocacy, public policy, and education.
Mr. Nadglowski is a graduate of the University of Florida.
J. Alexander Navarro, Ph.D., is assistant director of the University of

Michigan Center for the History of Medicine (CHM). A historian by
training, he has taught and conducted research on a wide range of top-
ics, including U.S.–Latin American history, U.S.–Southeast Asian relations,
Western labor history, 20th-century urban history, race and racism, and

issues of national identity. Since joining the CHM in 2005, Dr. Navarro
has focused much of his research on the historical, social, economic, and
political ramifications of the 1918 and 2009 influenza pandemics. He was
co–principal investigator and lead researcher on CHM’s landmark study of
the use of nonpharmaceutical interventions in the 1918 pandemic and on
CHM’s qualitative examination of school closures implemented during the
2009 pA(H1N1) influenza pandemic. Dr. Navarro is also co–editor in chief
of The American Influenza Epidemic of 1918-1919: A Digital Encyclopedia
and was responsible for researching and writing the site’s essays detailing
the experiences of 50 American cities during the deadly pandemic. He is
currently researching the interplay between territorial aggrandizement and
disease during the Mexican War, particularly among American troops, for
a forthcoming project. In addition to supervising CHM’s large research
projects, Dr. Navarro assists in developing its public programming and
managing its daily operations. He received his bachelor of arts in history
with honors from Rutgers University and his doctor of philosophy in his-
tory from the University of Michigan.
Megan Nechanicky, M.S., R.D., is nutrition manager for General Mills North
America Retail, where she provides strategic direction related to health and
wellness for business and research and development partners. She also works
externally with government, trade associations, and academic institutions to
position General Mills positively for future growth. When Ms. Nechanicky
first joined General Mills in 2014, she led health influencer communications
for some of General Mills’ largest brands, including Cheerios, Fiber One,
and Nature Valley. In this role, she delivered cutting-edge science, consumer
trends, and new product development and marketing to health influencers,
such as dietitians, physicians, nurses, and fitness professionals. Prior to Gen-
eral Mills, Ms. Nechanicky was the first dietitian to work at the President’s
Council on Sports, Fitness, and Nutrition, where she led nutrition- and
physical activity–related initiatives and events. She was also responsible for
the coordination of First Lady Michelle Obama’s Let’s Move! initiative to
end childhood obesity within a generation. Ms. Nechanicky served on the
federal steering committee to develop the U.S. Department of Health and
Human Services’ Physical Activity Guidelines Midcourse Report, coordi-
nating the communications strategy and report launch in 2013. She is a
registered dietitian and holds a bachelor’s degree in food marketing from
Saint Joseph’s University in Philadelphia, Pennsylvania, and a dual master’s
degree in exercise physiology and nutrition from San Diego State University.
Jeff Niederdeppe, Ph.D., is professor and director of graduate studies in

the Department of Communication and associate dean of faculty devel-
opment in the newly formed Jeb E. Brooks School of Public Policy at

APPENDIX C 173
Cornell University. He is director of Cornell’s Health Communication Re-

search Initiative and codirector of the Cornell Center for Health Equity.
Dr. Niederdeppe’s research examines the mechanisms and effects of mass
media campaigns, strategic messages, and news coverage in shaping health
behavior and social policy. He is committed to producing, catalyzing,
and disseminating innovative and rigorous research to support efforts to
achieve health equity. Dr. Niederdeppe has published more than 175 peer-
reviewed articles in communication, public health, health policy, and medi-
cine journals, and his work has been funded in recent years by the National
Institutes of Health, National Science Foundation, U.S. Department of
Agriculture, U.S. Environmental Protection Agency, Robert Wood Johnson
Foundation, and Town Creek Foundation. He received the Cornell College
of Agriculture and Life Sciences Research and Extension Award for Out-
standing Accomplishments in Science and Public Policy in 2019, the Early
Career Award from the Public Health Education and Health Promotion
Section of the American Public Health Association in 2016, and the Lewis
Donohew Outstanding Scholar in Health Communication Award from the
Kentucky Conference on Health Communication in 2014. He serves on
the editorial boards for nine journals in communication and public health.
Dr. Niederdeppe earned his Ph.D. from the University of Pennsylvania.
Keith C. Norris, M.D., Ph.D., is professor of medicine in the Division of

General Internal Medicine and Health Services Research at the University
of California, Los Angeles (UCLA) and codirector of UCLA’s Community
Engagement Research Program in the Clinical and Translational Science
Institute. Previously, he served as president of the Research Centers in Mi-
nority Institutions Program and as executive vice president for research and
health affairs and interim president at Charles Drew University. Dr. Norris is
an American Society of Hypertension specialist in clinical hypertension and
is board certified in internal medicine and nephrology. Funded extensively
by the National Institutes of Health, Dr. Norris has coauthored more than
400 articles in peer-reviewed journals, 25 textbook chapters, and more than
350 scientific abstracts; his work is often cited in the area of chronic kidney
disease and health disparities. He currently serves as editor-in-chief emeritus
of Ethnicity & Disease and on the editorial boards for the Journal of the
American Society of Nephrology and the Clinical Journal of the American
Society of Nephrology. Dr. Norris attended Howard University College of
Medicine, where he was inducted into the Alpha Omega Alpha medical honor
society. He received his doctorate in religious, spiritual, and metaphysical
philosophy from the College of Metaphysical Studies in Clearwater, Florida.
Patrick J. O’Connor, M.D., M.A., M.P.H., is senior clinical investigator and

codirector of the Center for Chronic Care Innovation at HealthPartners

Institute. Previously, he worked for 3 years on a Navajo reservation in

Arizona, where he researched diabetes and how to improve diabetes care.
With colleagues, Dr. O’Connor has developed a number of successful
strategies for improving chronic disease care in primary care settings; has
coauthored the Americans with Disabilities Act Standards of Diabetes
Care for 5 years; has published more than 250 peer-reviewed articles; and
has served on the editorial boards of several journals, including Annals
of Family Medicine and Diabetes Care. He has been a consultant to the
World Health Organization, Centers for Disease Control and Preven-
tion, Centers for Medicare & Medicaid Services (CMS), and National
Institutes of Health (NIH); has been visiting professor at many university
medical centers; and has reviewed many grants for NIH, CMS, Interna-
tional Diabetes Federation, Agency for Healthcare Research and Quality,
national research institutes in India and Ireland, and other organizations.
Dr. O’Connor has led or participated in more than 35 large, NIH-funded
grants; he has served on National Heart, Lung, and Blood Institute expert
committees that designed the Action to Control Cardiovascular Risk in
Diabetes (ACCORD) Trial, for which he also served as coinvestigator. He
now leads a new National Institute of Diabetes and Digestive and Kidney
Diseases–funded initiative to implement a clinical decision support system
for providing patients that have type 2 diabetes and their primary care
clinicians with accurate, patient-specific estimates of benefits and risks of
lifestyle, pharmacologic, and surgical treatment options related to obesity
management. Dr. O’Connor completed clinical training at Duke University
and an M.P.H. at the University of North Carolina at Chapel Hill.
Angela M. Odoms-Young, Ph.D., is associate professor and director of the

Food and Nutrition Education in Communities Program and the New York
State Expanded Food and Nutrition Education Program in the Division of
Nutritional Sciences at Cornell University. Before transitioning to Cornell
in 2021, she taught for 13 years at the University of Illinois Chicago in the
Department of Kinesiology and Nutrition. Dr. Odoms-Young’s research is
focused on public health, nutrition, and medicine, exploring the social and
structural determinants of dietary behaviors and related health outcomes
in low-income and Black and Latinx populations. She has authored more
than 200 academic publications, and has served on numerous advisory
committees and boards, including committees with the National Academies
of Sciences, Engineering, and Medicine Food and Nutrition Board, as well
as the Council on Black Health. Locally, she has been a board member at
the Greater Chicago Food Depository, American Heart Association Chicago
Metro Board, Grow Greater Englewood, and Blacks in Green. Addition-
ally, she serves currently as chair of the citywide Health Equity Advisory
Committee for the American Heart Association Chicago. Dr. Odoms-Young

APPENDIX C 175
received her B.S. in foods and nutrition from the University of Illinois
Urbana-Champaign and M.S./Ph.D. in community nutrition from Cornell
University. She completed a Family Research Consortium postdoctoral fel-
lowship at The Pennsylvania State University and the University of Illinois
Urbana-Champaign, as well as a Community Health Scholars fellowship at
the University of Michigan School of Public Health.
Nicolaas (Nico) P. Pronk, Ph.D., M.A., FACSM, FAWHP, is president of

the HealthPartners Institute, chief science officer at HealthPartners, Inc.,
full affiliate professor of health policy and management at the University of
Minnesota School of Public Health, and visiting scientist in social and be-
havioral sciences at the Harvard T.H. Chan School of Public Health. He fo-
cuses on connecting evidence of effectiveness with the practical application
of programs and practices, policies, and systems for measurably improving
population health and well-being. His work applies to the workplace, the
care delivery setting, and the community, and involves development of
new models to improve health and well-being at the research, practice, and
policy levels. His research interests include workplace health and safety,
obesity, physical activity, and systems approaches to population health and
well-being. Dr. Pronk served as cochair of the U.S. Secretary of Health and
Human Services’ advisory committee for developing Healthy People 2030,
and as a member of the Community Preventive Services Task Force. He is
founding and past president of the International Association for Worksite
Health Promotion and has served on boards and committees at the Na-
tional Academies of Sciences, Engineering, and Medicine; the American
Heart Association; the Health Enhancement Research Organization; and
others. He has published more than 400 articles, books, and book chapters,
and is an international speaker on population health and health promotion.
Dr. Pronk received his doctorate in exercise physiology at Texas A&M
University and completed his postdoctoral studies in behavioral medicine
at the University of Pittsburgh Medical Center at the Western Psychiatric
Institute and Clinic.
Amelie G. Ramirez, Dr.P.H., M.P.H., is director of Salud America! and

a professor of epidemiology and biostatistics at the University of Texas
Health Science Center at San Antonio, where she is also founding director
of the Institute for Health Promotion Research and associate director of
cancer prevention and health disparities at the Cancer Therapy & Research
Center. She conducts communications research and behavioral interventions
for reducing cancer and chronic disease, increasing screening rates and
clinical trial accrual, and improving healthy lifestyles among U.S. Latinx.
Salud America! The RWJF National Research Network to Prevent Obesity
Among Latino Children is building an evidence base, creating bilingual

multimedia content, developing the field of researchers, and empower-

ing communities to reverse the obesity epidemic among Latinx children.
Dr. Ramirez has been recognized with the Making a Difference Award
from Latinas Contra Cancer in 2014, as the White House “Champion of
Change” in 2011, and by her election to the National Academy of Medicine
in 2007. She is a member of the board of directors or the scientific advisory
board for Susan G. Komen, the Lance Armstrong Foundation, C-Change,
and others. She is a member of the San Antonio Mayor’s Fitness Council,
which has overseen implementation of healthy lifestyle programs that have
lowered local obesity rates. Dr. Ramirez earned her doctorate and master
of public health from the University of Texas Health Science Center.
Somava Saha, M.D., M.S., is executive lead of the Well Being in the Na-
tion (WIN) Network. She and her team led the process of developing the
WIN measures in partnership with the National Committee on Vital and
Health Statistics. Dr. Saha has dedicated her career to improving health,
well-being, and equity through the development of thriving people, orga-
nizations, and communities, and has worked as a primary care internist
and pediatrician in the safety net and a global public health practitioner
for more than 20 years. Previously, Dr. Saha served as vice president for
patient-centered medical home development at Cambridge Health Alliance
(CHA), where she led a whole-system transformation of leadership, care
delivery, workforce, and finances that garnered numerous national awards
and achieved breakthrough results in health outcomes and costs for a safety
net population. She served as codirector of leadership development at the
Harvard Medical School (HMS) Center for Primary Care, developing a
cadre of change leaders across the system. She continues as faculty at both
CHA and HMS. In 2012, Dr. Saha was recognized as one of ten inaugural
Robert Wood Johnson Foundation Young Leaders for her contributions to
improving the health of the nation. She has consulted with leaders from
across the world, including Guyana, Sweden, the United Kingdom, Singa-
pore, Australia, Tunisia, Denmark, and Brazil, and in 2016, she was se-
lected as a Leading Causes of Life Global Fellow. Dr. Saha received an M.D.
from the University of California, San Francisco and completed pediatrics
residency training at the Harvard Medical School.
David B. Sarwer, Ph.D., is associate dean for research and director of the
Center for Obesity Research and Education at Temple University College of
Public Health, where he is also professor in the Department of Social and
Behavioral Sciences. His research is focused on the etiology and treatment
of obesity, focusing on the psychosocial and behavioral aspects of extreme
obesity and bariatric surgery. He is currently leading a study, funded by the
National Institutes of Health/National Institutes of Diabetes and Digestive

APPENDIX C 177
and Kidney Diseases and the State of Pennsylvania, investigating the re-
lationship between psychosocial functioning and outcomes of bariatric
surgery. Dr. Sarwer also has a wealth of experience in the treatment of
obesity with lifestyle modification interventions and pharmacotherapy. His
more recent work in this area has focused on the adaptation and delivery
of weight-loss treatments in specialized medical settings, including primary
care, reproductive endocrinology, and oncology. Dr. Sarwer also maintains
an active program of research on the psychological aspects of physical
appearance and is currently involved in a project looking at the relation-
ship between traumatic brain injury, impulsivity, and substance misuse
in young adult athletes. He is founding editor-in-chief of Obesity Science
and Practice, and he serves as associate editor for both Health Psychology
and Obesity Surgery, as consulting editor for Plastic and Reconstructive
Surgery, and on the editorial boards of several other journals. In 2020, he
was coeditor of a special issue of the American Psychologist dedicated to
obesity. Dr. Sarwer received his B.A. from Tulane University, and his M.A.
and Ph.D. in clinical psychology from Loyola University Chicago.
Stephanie A. Navarro Silvera, Ph.D., M.S., C.P.H., is professor of public

health at Montclair State University. Previously, she worked as a nutrition
educator at the Special Supplemental Nutrition Program for Women, In-
fants, and Children at St. Joseph’s Medical Center in Paterson, New Jersey,
and as an epidemiologist at the Albert Einstein College of Medicine in
the Department of Epidemiology and Population Health. Dr. Silvera was
awarded the National Cancer Institute’s K01 Career Development Award
in 2009 to pursue her work on racial and ethnic disparities in health out-
comes. She has served on the board of the American Public Health Asso-
ciation Cancer Caucus, on the junior member and membership committees
of the American Society for Preventive Oncology, and on the academic
advisory board of the New Jersey Society for Public Health Education.
Dr. Silvera has been called upon by the New York and New Jersey media
to serve as an expert by interpreting and explaining the epidemiology of
the COVID-19 pandemic. She holds a bachelor of science in biology and
a master of science in nutritional sciences from Rutgers University, and a
doctorate in epidemiology from the Yale School of Medicine.
Melissa A. Simon, M.D., M.P.H., is George H. Gardner Professor of Clini-

cal Gynecology and vice chair of research in the Department of Obstetrics
and Gynecology at Northwestern University Feinberg School of Medicine.
She is also founder and director of the Center for Health Equity Transfor-
mation and the Chicago Cancer Health Equity Collaborative. Dr. Simon is
an expert in implementation science, women’s health across the lifespan,
minority health, community engagement, and health equity. She has been

recognized with numerous awards for her substantial contribution to ex-

cellence in health equity scholarship, women’s health, and mentorship, in-
cluding the Presidential Award for Excellence in Science, Mathematics, and
Engineering Mentoring. Dr. Simon is a former member and current consul-
tant to the U.S. Preventive Services Task Force. She is also a member of the
National Academy of Medicine (NAM), the NAM Leadership Consortium’s
Culture Inclusion and Equity Collaborative, and the National Academies’
Roundtable on the Promotion of Health Equity. She received her M.D. from
Rush Medical College and her M.P.H. from University of Illinois Chicago.
Hunter Jackson Smith, M.D., M.P.H., M.B.E., is currently the chief of pre-
ventive medicine for the U.S. Army Medical Research Directorate—Africa,
stationed in Kisumu, Kenya. He also serves as a subject matter expert for
the Department of Defense Medical Ethics Center and as adjunct assistant
professor for the Uniformed Services University in the Department of Pre-
ventive Medicine and Biostatistics. Dr. Smith is board certified in general
preventive medicine and public health. His research interests include obe-
sity, social determinants of health, bioethics, and epidemiology.
Roland J. Thorpe Jr., Ph.D., M.S., is professor in the Department of Health,

Behavior, and Society in the Johns Hopkins Bloomberg School of Pub-
lic Health (JHBSPH); founding director of the Program of Men’s Health
Research in and deputy director of the Hopkins Center for Health Dis-
parities Solutions; and codirector of the Johns Hopkins Alzheimer’s Dis-
ease Resource Center for Minority Aging Research. He also holds joint
appointments in the Division of Geriatric Medicine and Gerontology and
the Department of Neurology in the Johns Hopkins School of Medicine.
Dr. Thorpe is a social epidemiologist and gerontologist who has published
more than 240 peer-reviewed articles that have significantly contributed
to the understanding of how race, socioeconomic status, and segregation
influence the health and well-being of African Americans. His most recent
work focuses on improving the lives of Black men. Dr. Thorpe serves as
principal investigator on several National Institute on Aging–funded grants.
He participates in several training programs designed to develop underrep-
resented minorities at many career stages. Dr. Thorpe is a provost fellow in
the Office of the Vice Provost for Faculty Affairs, where he leads initiatives
in the Provost’s Postdoctoral Diversity Fellowship. He is a past recipient
of the Johns Hopkins School of Public Health Advising, Mentoring, and
Teaching Recognition Award; the inaugural annual 2018 Obesity Health
Disparities PRIDE Roland J. Thorpe, Jr. Mentoring Award; the 2020 Mi-
nority Issues in Gerontology Outstanding Mentorship Award; and the 2020
JHBSPH Dean’s Award of Distinction in Faculty Mentoring. He is also edi-
tor in chief of Ethnicity & Disease. Dr. Thorpe earned a bachelor’s degree

APPENDIX C 179
in theoretical mathematics from Florida A&M University, a master’s degree

in statistics, and a Ph.D. in clinical epidemiology with a graduate minor in
gerontology from Purdue University. He received postdoctoral training in
health disparities and gerontology from the Division of Geriatric Medicine
and Gerontology at the Johns Hopkins School of Medicine.
Susan Z. Yanovski, M.D., is codirector of the Office of Obesity Research

and senior scientific advisor for clinical obesity research at the National
Institute of Diabetes and Digestive and Kidney Diseases of the National
Institutes of Health. Her research interests include behavioral, medical,
and surgical approaches for obesity treatment in adults and children
and the study of binge eating disorder. Dr. Yanovski has published more
than 170 peer-reviewed papers and was a member of the expert panel that
developed the 2013 Guideline for the Management of Overweight and
Obesity in Adults for the American Heart Association, American College
of Cardiology, and The Obesity Society. She has served on the editorial
boards of the American Journal of Clinical Nutrition, Archives of Family
Medicine, and Eating Behaviors. Dr. Yanovski earned her medical degree
from the University of Pennsylvania Perelman School of Medicine. She
completed her residency and fellowship in family medicine at the Thomas
Jefferson University School of Medicine in Philadelphia, Pennsylvania,
and a postdoctoral fellowship in eating disorders research at the National
Institute of Mental Health.


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Emily A. Callahan, Rapporteur

Roundtable on Obesity Solutions

Food and Nutrition Board

Health and Medicine Division

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International Standard Book Number-13: 978-0-309-27599-6

Copyright 2022 by the National Academy of Sciences. National Academies of Sciences,

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022.

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The National Academy of Sciences was established in 1863 by an Act of

The National Academy of Medicine (formerly the Institute of Medicine) was

The three Academies work together as the National Academies of Sciences,

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Consensus Study Reports published by the National Academies of Sciences,

Proceedings published by the National Academies of Sciences, Engineering, and

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PLANNING COMMITTEE ON ADDRESSING STRUCTUAL

ANGELA M. ODOMS-YOUNG (Co-chair), Associate Professor and

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ROUNDTABLE ON OBESITY SOLUTIONS2

NICOLAAS (NICO) PRONK (Chair), HealthPartners Institute and

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STACY MOLANDER, Partnership for a Healthier America,

Health and Medicine Division Staff

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This Proceedings of a Workshop was reviewed in draft form by indi-

KIMBERLY GUDZUNE, The Johns Hopkins University

Although the reviewers listed above provided many constructive com-

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8 INNOVATIVE POLICY SOLUTIONS 61

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A WORKSHOP AGENDAS 153

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Box and Figures

2-1 A cliff analogy to illustrate four types of health support strategies, 11

3-1 Racial/ethnic inequities in SARS-CoV-2 exposure and COVID-19

7-1 Theoretical model for improving health and academic

9-1 Fundamental drivers of health inequity, 72

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xvi BOX AND FIGURES

10-1 Death rates from cardiometabolic diseases in midlife relative to the

11-1 Well Being in the Nation (WIN) Network’s theory of change, 91

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The Roundtable on Obesity Solutions, Health and Medicine Division,

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2 ADDRESSING STRUCTURAL RACISM, BIAS, AND HEALTH COMMUNICATION

Ad hoc planning committees will plan a series of two or three workshops

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brief overview of the Roundtable on Obesity Solutions, explaining that it

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