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Welcome to the Obesity Dialogue

May 30, 2013

The Journal blog is happy to report that the subject of obesity has made it to the pages of the Journal of Socio-Economics, in a recent paper by  John F. Tomer. This is a salutary example of cross-disciplinary dialogue, more of which we would like to see in journals outside those of health and medicine. Dr. Tomer is a professor of economics at Manhattan College, and in his paper he argues that the scale and complexity of the obesity problem require not only government efforts, but a social movement. He also says that to fully understand the obesity epidemic one must look beyond health science alone, and consider the many external and internal factors that influence an individual’s choice of diet and life patterns.

A slightly different version of this perspective was expressed over a decade ago by Jeffery Sobal in the International Journal of Epidemiology. “To fully understand the globalization of obesity, epidemiologists need to move beyond biology and beyond behaviors to examine collective social, economic, and political structures and cultural changes rather than focusing only on individual physiology and personal characteristics. Global values, corporations, and politics transform the material conditions of life so that children and adults eat more and are less active, leading to global increases in obesity.”

More recently, the Organization for Economic Cooperation and Development (OECD) referred to “obesogenic environments,” including physical, social and economic. An OECD report on obesity and the economics of prevention declares, “…obesogenic environments have contributed to higher obesity rates over the past 30 years by exerting powerful influences on people’s overall calorie intake, on the composition of their diets and on the frequency and intensity of physical activity at work, at home and during leisure time.  The reality is that every step of the process is conditioned not just by public health concerns, but by history, culture, the economic situation, political factors, social inertia and enthusiasm, and the particularities of the groups targeted.”

Readers of this blog don’t need reminding that the AJPM has consistently broadcast the importance and credibility of transdisciplinary research, with papers that report on the evidence for important links between policy, the built environment and health, or that illustrate how public health is successfully collaborating with non–health sectors in efforts to combat obesity. The Journal routinely publishes articles on research to test new ideas and develop new models of the factors influencing children’s diet, physical activity, and obesity, including environmental, social (family and peer), and psychological, while other study topics identify the biological and behavioral mechanisms of obesity development. A cursory review of multidisciplinary articles published since 2005 located 16, of which the following are representative:

In his paper, Professor Tomer refers to technological change—what he calls the infrastructure of obesity—as causal, along with an individual’s intangible capital (personal and health) that plays a significant role in decision-making. He calls for a socioeconomic transformation to reverse negative behaviors, and he suggests the necessity of a social movement led by groups who understand the magnitude of the health threat. “The needed efforts are not just those of government; they include efforts of communities, grass-roots groups, individuals, and food businesses.”

Tomer’s recommendations for broad stakeholder engagement are also consistent with OECD initiatives. Curbing obesity is a leading public health priority in OECD countries, where it is reported that many governments are embracing comprehensive strategies and involving multiple communities and groups.  Perhaps New York Mayor Michael Bloomberg can take belated validation for his attempt to regulate sugary beverages from recent European interest in the use of taxes on foods rich in fat and sugar, with several governments including Denmark, Finland, France, and Hungary passing new legislation in 2011.

Tomer’s analysis might also be seen in the context of the nutrition transition, a term referring to a series of adverse changes in diet, physical activity and health that often accompany economic development. It describes a shift from a high prevalence of under-nutrition to a situation where nutrition related non-communicable diseases (NR-NCDs) predominate. This pattern is typical in middle-to low- income countries of the world, and results from increased consumption of unhealthy foods and higher prevalence of overweight and obesity.  It is graphically presented in the figure below.

Tomer blog figure2

The Nutrition Transition (adapted from Kearney, 2010)

Professor Tomer’s paper cites the smoking and tobacco control movement, described by Constance A. Nathanson in her 1999 comprehensive assessment, “Social Movements as Catalysts for Policy Change: The Case of Smoking and Guns” in the Journal of Health, Politics, Policy and Law.  Nathanson argues that the success of health-related social movements is associated with (1) the articulation of a socially (as well as scientifically) credible threat to the public’s health, (2) the ability to mobilize a diverse organizational constituency, and (3) the convergence of political opportunities with target vulnerabilities.

Whether the obesity epidemic has the requisite ingredients for a successful social movement remains to be seen.  The OECD is skeptical, remarking that it took 30 years for tobacco control to move from information campaigns to smoking bans, and pointing out that there are many other ways in which the conditions which led to the assault on tobacco being relatively successful are absent when considering the much more complicated issue of controlling obesity.  (OECD Healthy Choices Session 2 Paris October 2010.)  The bad news is that in the U.S., recent progress in reducing tobacco use has slowed.  Tobacco use remains the leading cause of preventable death, causing more than 440,000 deaths annually and resulting in $193 billion in health-related economic losses each year—$96 billion in direct medical costs and $97 billion in lost productivity (CDC, 2008).

In thinking about the possible similarities between the two health crises, it struck me that tobacco use is widely understood by the general public to be deadly.  Data from thousands of studies documented the overwhelming and conclusive biologic, epidemiologic, behavioral, and pharmacologic evidence that tobacco use kills people. Yet obesity seems to lack a catalyzing shock to trigger a collective sense of urgency.

With that in mind, I asked Professor Tomer if obesity might not be misunderstood by the average person as a “benign” chronic disease, troubling and unfortunate certainly, but not terminally hazardous. In other words, are people not sufficiently afraid, and could fear be an appropriate, perhaps even the best catalyst for action?

Professor Tomer commented that healthcare professionals are certainly aware that obesity is a major health problem, and he thinks a large percentage of the population shares this awareness.  But he also says that it might be true that certain segments of the population are in denial about obesity as a significant health risk. The statistics make that clear.

With respect to a catalyst for action, he says, “I am not sure that fear is the motivation that is most useful to get people to take anti-obesity action.  Ideally, people should develop the positive motivation to live a healthy life in many dimensions:  eating, exercise, social life….  Of course, there are some people who will not take necessary action until they hit bottom and become severely obese with many serious ailments.”

The OECD concludes that tackling chronic diseases through interventions aimed at modifying lifestyle risk factors is possible and cost-effective, and are likely to decrease health inequalities within countries into the bargain. Lifestyles should not be viewed merely as the result of “independent preferences” (in the language of the standard economic model) because choices are often influenced, even constrained, by environmental conditions, including social structures, cultural and political conditions, physical and economic environments.  In particular, studies suggest that our body weight, well-being, loneliness and our ability to stop smoking are hugely influenced by the people we associate with, and to a degree far higher than we typically accept.

Given that 34% of American adults are obese, I asked Professor Tomer if this doesn’t present an enormous challenge in efforts to change the eating habits of children. He agreed: “It is an enormous challenge, and it is a challenge that is worldwide.  Obesity rates are rising throughout the world, and some industrial countries have rates nearly as high as the U.S.  Although it does not manifest the same way in every country, there are similar socio-economic aspects in all countries, including challenges related to lifestyle changes, such as coping with two adult earners in the family and lack of time for food preparation, among many other issues.

—Michael Lytton, AJPM Blog Editor

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