Interagency Collaboration: A Strategy for Obesity Policy Success

Abstract

The obesity epidemic has moved obesity policy to the forefront of the national healthcare agenda. Broad-based stakeholder and interagency involvement can lead to confusion regarding the role of nursing, and the focus and process of sound policies in obesity management.

While nursing is one of the most trusted and ethical of all professions, public perception is that nurses are largely absent in the policy arena. Nurses have a professional responsibility to advocate for clients in the policy process as well as in the clinical care of obese clients, including the removal of barriers to effective obesity management.

Societal norms policy focuses on secondary and tertiary interventions while devaluing primary interventions through nonsustainable reimbursement levels, and a lack of integration of evidence-based obesity management in interdisciplinary healthcare educational curricula serves as a barrier to effective obesity policy.

Empowered with knowledge of the policy process and interagency collaboration, nurses must maintain an ongoing relationship with their elected officials as active participants in the policy process. The NABN is an important stakeholder in educating and supplying nurses to fill this important policy gap.

It is a well-known fact that obesity has reached epidemic proportions in United States.^1,2 Sedentary lifestyles, poor nutrition choices, and societal norms enforcing these unhealthy choices have converged to create what the Centers for Disease Control and Prevention (CDC) has termed an “obesogenic society.”³

As the United States has become increasingly obesogenic, concerted efforts of numerous governmental and special interest groups have kept the issue of obesity at the forefront of the national healthcare agenda,^1,2,4–9 moving obesity to an area of increased priority on the agenda platform for numerous stakeholders. Diverse stakeholder involvement in the obesity policy process has lead to an increasingly politicized and confusing collaborative in regard to who is advocating for clients living with the chronic illness of obesity. Nurses have a professional obligation to understand and to participate in the policy process.¹⁰

The purpose of this article is to discuss interagency collaboration as an effective strategy for obesity policy success. Historical evolutions in health policy are discussed, stressing the importance of nursing participation in each step. Barriers to successful obesity policy are discussed in light of multiple and emerging stakeholders. Finally, interagency collaboration is discussed as a strategy to ensure a voice for all stakeholder interests while amplifying the voice and the needs of the consumer living with obesity.

Evolution of Obesity Policy

Obesity is a complex chronic illness that is best addressed through population-based healthcare policy.^11,12 However, obesity policy has evolved through an inconsistent policy process influenced by stakeholders with political or economic interests that impact the direction of obesity policy.^12–14 Nurses are natural policy advocates on behalf of clients challenged with obesity.¹⁰ For example, childhood obesity has reached epidemic proportions, tripling in incidence over the past 20 years.¹⁵ Numerous stakeholders have been involved in policies addressing childhood obesity including public education systems, the vending industry, and the healthcare and insurance industries. Nurses with expertise in the management of obesity have been key participants as healthcare representatives. Each stakeholder brings its own normative values and ideas that must be addressed in the context of the policy process.¹⁶

Fit Families NC was a study committee for childhood overweight and obesity in North Carolina (hereafter, NC) that was commissioned by the NC Health and Wellness Trust Fund, a trust fund created in 2000 by the NC General Assembly to receive 25% of NC's share of the master tobacco settlement agreement payments.¹⁵

The study commission had broad stakeholder involvement including health, education, industry, city and county government, research, faith-based organizations, and public member involvement to bring about the best recommendations to address childhood obesity.¹⁵ This process involved legal accountability involving the lieutenant governor and the General Assembly, and hierarchical, political, and professional relationships. The purpose of the study was to evaluate the causes and status of obesity among the state's children and to recommend policy initiatives to the general assembly and relevant organizations to address this serious health issue. This broad-based stakeholder approach requires policy actors representing numerous grassroots, professional, and governmental agencies to work together in a coordinated fashion to address childhood obesity in NC.

Childhood obesity policy was moved onto the national agenda through the work of First Lady, Michelle Obama.^6,9 This political move provided the necessary fulcrum to galvanize obesity policy. However, recent obesity policy trends have shifted from population-focused policies, which emphasized prevention, to individual policy interventions through increased insurance premiums for those diagnosed with obesity and increased taxation for calorie-dense foods.^12,17 The policy focus shifts from prevention to punitive when individual policy interventions utilize societal-normative values where obesity is considered a result of deficient willpower rather than a chronic medical condition.¹²

Nurses have become natural client advocates, entrepreneurs, key stakeholders, and political activists in the evolving obesity policy arena, advocating for population-focused interventions. Nurses have a professional obligation to advocate for clients in the policy process as well as in the clinical care of obese clients.¹⁰

Barriers to Successful Obesity Policy

It is an interesting paradox to consider the role of nurses in the policy process. As opportunities for involvement in the policy arena increase, public perception is that nurses are largely absent in the policy arena.

Absentee nurses

Nurses are consistently ranked among the most trusted, ethical, and honest of professionals. In a Gallup Poll survey among 1,504 opinion leaders including insurance, corporate, health services, government, industry, and university faculty, respondents identified significant barriers that prevent nurses from fully participating as leaders in health and health care.¹⁸ Nurses were not perceived as important decision makers or revenue generators compared with doctors, and do not have a single voice on national issues. Despite these barriers, nurses were viewed as important stakeholders and decision makers in health policy. As obesity policies continue to emerge, nurses have a professional obligation to participate and to advocate for clients in the policy process.

Health professionals

The unique focus of the nursing profession posits nurses as natural advocates for clients in a multidisciplinary setting. Nurses can provide the unifying thread that focuses on what is in the best interest of the obese client. However, there is a need for all healthcare professionals to provide focused primary, secondary, and tertiary education for clients' challenges with obesity. In one study conducted by the Veteran's Health Administration (VHA),¹⁴ many VHA clinicians did not provide weight management services for obese clients. Poor integration of obesity care into interdisciplinary educational curricula and the lack of information provided by the VHA to clinicians and patients about weight management services were identified as barriers. Nurses can be leaders in setting policy to ensure the integration of obesity management content in interdisciplinary curricula.

Societal norms

Interdisciplinary teams and diverse stakeholders all bring unique professional, industry, and societal norms—all with potential competing interests in regard to obesity policy and management. It is vital to ensure that the client remains the focus of policy initiatives. Policy leaders must collaborate with other stakeholders at various levels, keeping the public health goal of elimination of obesity as the central focus. Individual stakeholders must ensure that they do not weigh the advancement of their cultural norms as more important than that of the collaborative group.¹⁶ For example, recent policies focused on individual intervention rather than population-based policy have resulted in higher insurance premiums for those diagnosed with obesity.^11,13 This amplifies the influence of the insurance industry's perception that causality and management of obesity are driven by deficient willpower and the cosmetic effects of bariatric interventions.^12,13

Reimbursement

Societal norms and stakeholder influences continue to influence reimbursement for obesity management. Individual- rather than population-level intervention policies dictate reimbursement levels for obesity management.¹⁷ Nurses along with the Obesity Action Coalition and other key stakeholders successfully advocated for obese clients for Medicaid and Medicare coverage of bariatric interventions.¹⁹ Despite this policy success, there remains a need for a policy shift from secondary and tertiary management of obesity to primary prevention at the aggregate population level. Reimbursement policies supporting primary prevention efforts are needed for all clinicians. Interdisciplinary education systems, funding priorities, and workforce demographics should reflect this focus.¹²

Interagency Collaboration

It has been previously established that nurses are perceived as valuable policy leaders and participants.¹⁸ A rapidly evolving healthcare environment with increasing globalization necessitates a shift from the traditional concept that nursing is only a caring profession in the applied sciences with obligations only in the realm of direct clinical care. “Nurses are highly trusted sources of health care information, but as we look to reform our health system, our nation is not taking advantage of all that nurses have to offer,” said Risa Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation.¹⁸ Opportunities exist for nurses to advocate for consumer-focused obesity policy through the collaborative efforts of interagency policy processes. Interagency collaboration is a voluntary effort by more than one agency to work together to share resources and responsibilities to achieve a common goal.²⁰

Opportunities exist at the grassroots, state, and national levels for interagency collaboration on obesity policy initiatives. Interagency collaborators include but are not limited to obese clients, community representatives, nurses, physicians, nutritionists, social workers, the National Association of Bariatric Nurses, the Obesity Action Coalition, primary and secondary education systems, universities, insurance industries, vendors of bariatric equipment, hospitals, public health systems, and elected officials.

Effective interagency collaboration can make a positive policy impact when leaders are well versed in their field and demonstrate a commitment to participate in a collaborative effort. This requires intentional effort to place interagency objectives and consumer interests ahead of individual stakeholder agendas.¹⁶

The federal government is in the best position to force interagency accountability. Intricate governmental relationships and limits on the reach of the federal government, however, create challenges in holding nongovernment agencies accountable for government-sanctioned objectives.²¹

Identification of childhood obesity as a national health agenda has provided the fulcrum to motivate interagency collaboration.⁶ Federal resources have been aligned through the Department of Health and Human Services to coordinate key stakeholders committed to the goal of eliminating childhood obesity. An example of state-level interagency collaboration is noted in the work of the North Carolina Nurse's Association's (NCNA) Obesity Task Force. Nurses are collaborating with local, state, and national health special interest groups, policy makers, and legislators to support obesity awareness and the promotion of programs to decrease childhood, adolescent, and adult obesity.²² Working on local, state, and national levels, the NABN continues to lead in collaborating with key stakeholders at all levels as clinical and policy experts in the management of obesity issues. The bariatric nurse coordinator brings expertise that is critical to institutional and broader policy initiatives regarding obesity management.

The NABN offers a wealth of resources important to interagency collaboration for obesity policy. Through collaboration with the advocacy program of Obesity Action Coalition,² nurses must maintain an ongoing relationship with their elected officials. The importance of this interagency collaboration cannot be understated. There are currently 39 nurses serving in state legislatures.⁸ These nurses are valuable resources as they bring a nursing perspective to the policy process. There are 10 states with at least one nurse serving in their state legislature. These nurses have clearly embodied the importance of interagency collaboration. With 40 states and the District of Columbia without nursing representation in the legislature, there is much work to be done.

Conclusion

An increasingly obesogenic United States has kept the issue of obesity at the forefront of the national healthcare agenda.^1,2,4–9 While one of the most trusted and ethical of all professions, public perception is that nurses are largely absent in the policy arena. Nurses have a professional responsibility to advocate for clients in the policy process as well as in the clinical care of obese clients.¹⁰ Barriers that impede the obesity policy process include societal norms suggesting that causality and management of obesity are driven by deficient willpower and the cosmetic effects of bariatric interventions rather than medical diagnoses,^12,13 policy focus on secondary and tertiary interventions while devaluing primary interventions through nonsustainable reimbursement levels,¹⁸ and a lack of integration of evidence-based obesity management in interdisciplinary healthcare educational curricula.¹⁴

Interagency collaboration is a necessary process required to achieve success in the obesity policy arena.²⁰ Working on local, state, and national levels, the NABN continues to lead in collaborating with key stakeholders at all levels as clinical and policy experts in the management of obesity issues. Empowered with knowledge of the policy process and interagency collaboration, nurses must maintain an ongoing relationship with their elected officials. Nurses are an untapped resource in the obesity policy process. The NABN is an important stakeholder in educating and supplying nurses to fill this important policy gap.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

U.S. Office of the Surgeon General. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. www.surgeongeneral.gov/topics/obesity/calltoaction/fact_vision.htm. 2009 September 1.

Obesity Action Coalition. Overview. 2010. www.obesityaction.org/aboutus/overview.php. 2010 February 21.

Centers for Disease Control and Prevention. Obesity and Overweight: Topics. 2010. www.cdc.gov.jproxy.lib.ecu.edu/obesity/index.html. 2010 September 5.

White House. Childhood Obesity Task Force Unveils Action Plan: Solving the Problem of Childhood Obesity within a Generation. www.whitehouse.gov/the-press-office/childhood-obesity-task-force-unveils-action-plan-solving-problem-childhood-obesity/. 2010 June 28.

Department of Health and Human Services. Let's Move. Rockville, MDAuthor2010. www.letsmove.gov. 2010 February 20.

White House. Presidential Memorandum: Establishing a Task Force on Childhood Obesity. 2009. www.whitehouse.gov/the-press-office/presidential-memorandum-establishing-a-task-force-childhood-obesity. 2010 February 20.

Thomas

, Rickabaugh

. Bariatric nurse coordinator: Carving out a new role in bariatrics. Bar Nurs Surg Pat Care, 2009; 3:63.

U.S. House of Representatives. House Press Gallery. 2010. www.house.gov/daily/hpg.htm. 2010 September 5.

White House. First Lady Michelle Obama Launches Let's Move: America's Move to Raise a Healthier Generation of Kids. 2009. www.whitehouse.gov/the-press-office/first-lady-michelle-obama-launches-lets-move-americas-move-raise-a-healthier-genera/. 2010 February 20.

10.

Lowery

. Obesity, bariatric nursing, and the policy process: The connecting points for patient advocacy. Bar Nurs Surg Pat Care, 2009; 4:133.

11.

Bodenheimer

. High and rising health care costs. Part 3: The role of health care providers. Ann Int Med, 2005 June 21 142,12 Part 1:996–1002.

12.

Lowery

. Obesity policy spotlight: New trends in obesity policy. Bar Nurs Surg Pat Care, 2009; 4:325.

13.

Acs

, Lyles

, Stanton

. Obesity, Business and Public Policy. Northampton, MA: Edward Elgar, 2007.

14.

Forman-Hoffman

, Little

, Wahls

. Barriers to Obesity Management: A Pilot Study of Primary Care Clinicians. BMC Family Practice, 2010. www.ncbi.nlm.nih.gov.jproxy.lib.ecu.edu/pmc/articles/PMC1525170/. 2010 September 4.

15.

North Carolina Health and Wellness Trust Fund. Childhood Obesity in North Carolina: A Report of Fit Families in NC: A Study Committee for Childhood Overweight and ObesityRaleigh: Author2006.

16.

Edmondson

. DHS casts a wide net: Maritime-security strategy takes a step toward interagency cooperation. J Comm, 2005; 15.

17.

Kersh

, Morone

. Obesity, courts, and the new politics of public health. J Health Polit Policy Law, 2005; 30:839–868.

18.

Robert Wood Johnson Foundation. Groundbreaking New Survey Finds That Diverse Opinion Leaders Say Nurses Should Have More Influence on Health Systems and Services. 2010. www.rwjf.org/pr/product.jsp?id=54488. 2010 September 6.

19.

Obesity Action Coalition. Medicare Releases New Rules for Weight-Loss Surgery. www.obesityaction.org/advocacy/medicare/medicarenewrules.php. 2010 September 6.

20.

Thomas

. Public management as interagency cooperation: Testing epistemic community theory at the domestic level. J Pub Admin Res Theory, 1997; 7:221.

21.

Conlan

, Posner

. Intergovernmental Management for the 21st Century. Washington, DC: Brookings Institution Press, 2008.

22.

North Carolina Nurses Association. NCNA, the Professional Association for All Registered Nurses in NC: NCNA Obesity Task Force. 2010. www.ncnurses.org/comm_spp.asp. 2010 September 7.