Obesity Policy Streams,the Economy,and a Call for Nursing Leadership

Introduction

Agenda setting is defined as “the process of moving a problem to the attention of government so that solutions can be considered.” ¹ Obesity policy has received increasing prominence on the national agenda through the collective work of key stakeholders committed to the prevention, management, and treatment of obesity and its associated comorbid conditions.^2–6 Grim predictions regarding the constriction of national and state economies, however, threaten the public's perception and support of obesity as a national agenda item.

The purpose of this article is to illuminate policy streams impacting obesity policy and to identify methods for keeping obesity in the forefront of the national agenda. Trends in the economy, the public agenda, and the prevalence of obesity are discussed in context of obesity policy. Recommendations for the use of a public health model for obesity management are suggested, along with the necessity of nursing involvement in each step of the policy process.

The Economy

The nonpartisan congressional budget office (CBO) suggests a guardedly optimistic forecast for economic growth over the next decade. Constricting national and state budgets, coupled with historic national and state deficits, reinforce the hesitance of politicians to create new obesity programs or to expand existing programs. ⁷ Despite a blunting of the current recession, the CBO predicts that production and employment are likely to remain well below economic potential for several years to come. ⁸ These and other predictions have understandably focused the public's attention on the economy with emphasis on meeting the basic needs of the majority of Americans. A constricting U.S. economy serves as a distracter to public support of the obesity policy process and the political feasibility of comprehensive obesity policy. ⁹ Nurses with expertise in obesity management are needed to impact the policy stream.

Among the most trusted of professionals, nurses have been largely absent in policy-setting processes. ¹⁰ Understandably, the initial thought might be to question the relevance of the economy or public agendas to nursing. This author argues that it is vitally important for nursing to understand the impact of the economy on nursing and its impact on nursing's ability to advocate for obesity and bariatric issues.

As the healthcare delivery system continues to evolve, nurses are increasingly recognized as safe, effective healthcare providers with the appropriate competencies to address many healthcare management issues.^11–13 Economic detractors and incremental healthcare reform underscore the importance of nurses as policy leaders. Informing the policy process while educating the public regarding prevention and treatment of obesity and related conditions is vitally important in meeting current and future healthcare needs in a manner that reverses the physical and economic burden of obesity.^2,9,10,13

Public Agenda

The policy process is a dynamic process, evolving in response to multiple stakeholder preferences and input from public and political streams. ¹⁴ For example, First Lady Michelle Obama's Let's Move campaign has clearly solidified obesity policy as a national agenda item. ³ A recent poll by the Pew Research Center reveals a contrasting dynamic, however. Poll results detailed that the economy is listed as the public's number one agenda item for the President and Congress to address, but obesity barely made the list, coming in at number 19. ¹⁵ On the surface, this may appear problematic until one recognizes that obesity was never on the public's agenda prior to 2011.^15,16

Public opinion strongly influences the policy process, as politicians are constantly polling and attempting to read the trends of public opinion as they support or develop policies. ⁷ Current policy dynamics suggest an incremental approach to obesity policy, since the public attention is relatively low. As the economy improves, policy edicts would suggest that comprehensive obesity policies would stem from a predicted increased public focus on obesity policy. ¹⁴ Nurses must recognize and understand the importance of public agenda data, as well as advocate for continued movement and prioritization on the national political agenda. ¹⁵

Worsening Obesity Prevalence

As public perception increases regarding the need to move obesity higher on the public agenda, the importance of comprehensive and effective obesity policy cannot be understated. Inversely related to the declining U.S. economy, obesity rates have continued to climb over the past decade. For example, a report from the Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) demonstrated an alarming increase in obesity rates. Since 1991, obesity rates have consistently worsened to where there is now an obesity prevalence rate of >25% in two-thirds of the American states. ¹⁶ Moreover, while most adults reported a belief that childhood obesity is a serious problem, one third of those surveyed reported their children were at a healthy weight when, in fact, they were overweight or obese. ¹⁶ These prevalence rates suggest that current obesity policy is not working. The fact that obesity policy is now listed as one of the public's agenda items would suggest that we may be approaching the tipping point. Obesity may now be on the public policy agenda, but what will it take to actually move it toward a more comprehensive policy model that includes prevention, treatment, and follow-up?

Public Health Model

It has been well established that the public health model is an effective model for addressing, treating, and mitigating the effects of chronic health conditions through primary and secondary management.^7,17,18 The public health model moves the focus from the individual level to the population level, removing the punitive overtones to individual obesity management.^17–20 It is essential to ensure that obesity is framed in a manner that will continue to move the public perception of obesity up the agenda list. There is a need to educate the public about individual responsibility within the context of population issues related to obesity. Educational campaigns in mediums frequently accessed by the public must clearly make the connection between the individual ramifications and the population ramifications of obesity. ¹⁷ Nurses are uniquely positioned to impact obesity through primary prevention, secondary prevention, and tertiary disease management. Nurses working in public health, school health, primary care, and bariatric settings are key leaders with the potential to transform obesity management from the bedside to the boardroom.

Healthcare Reform and the Future of Nursing

Policy streams are participants and processes that affect the window of opportunity in setting political agendas. ¹ Policy streams are considered in three broad categories: policy stream, problem stream, and political stream.^1,7

Nurses are key actors in the obesity policy stream who directly impact the care of the obese client across the continuum of care. As clinical and administrative leaders in public health, school health, primary care, tertiary care, and bariatric surgical centers, nurses bring the leadership skill set required to interface between obese clients, the interdisciplinary teams, and those involved in the policy process.^11,13

An understanding of how the problem stream, the policy stream, and the political stream must be considered individually and collectively for convergence and a favorable result in obesity policy. ⁷ Nursing leadership in clinical, administrative, and policy arenas is critical in advocating for obesity policy that is patient-centered. ¹⁰ Successful navigation of all three policy streams is required to impact obesity policy positively.

Obesity Policy Streams

Obesity has now emerged as a new although distant priority on the public agenda. Providing leadership in the problem stream, policy stream, and political stream will optimize nurses' influence in obesity policy.

Conclusion

Obesity is a chronic illness at epidemic levels in the United States. Despite increased prominence on the national and public agendas, obesity prevalence rates continue to climb with resulting increases in human and economic burdens. While the national economy is clearly a higher priority on both the national and public agendas, nurses have an unprecedented opportunity to demonstrate leadership establishing comprehensive obesity policy. Nursing influence in the problem stream, policy stream, and political stream creates opportunities for nursing leadership to transform obesity policy from the bedside to the boardroom and finally to the halls of congress.