Abstract
A few months later in May 2012, the Annual Report to the Nation on the Status of Cancer was released, and for the first time an analysis specific to obesity and physical inactivity was included. 2 Using data from the Centers for Disease Control's (CDC) National Program of Cancer Registries, and the National Cancer Institute's (NCI) Surveillance Epidemiology and End Results (SEER) program, researchers reported an overall reduction in cancer mortality. Specifically, over the time period of 1999–2008, mortality associated with most cancer types decreased, including mortality associated with the four most common cancers: lung, colorectal, breast, and prostate cancer. In addition, incidence rates for several types of cancer decreased, including lung, colorectal, stomach, prostate, and cervical cancers. Unfortunately, however, in this same time period there was an increase in the incidence of cancers known to be associated with excess weight and physical inactivity, including cancers of the esophagus, kidney, and pancreas. 2
For healthcare providers committed to improving the health and well-being of patients with obesity, the results of these two reports are disheartening. As clinicians, researchers, and academics, our work includes caring for patients before and after bariatric surgery, educating about the positive effects of good nutrition and increased activity, commitment to developing and implementing programs for individuals with obesity, supporting national campaigns such as “Let's Move,” and advocating for patients and the public through appropriate policy initiatives. Presented with the aforementioned data, it may seem as if our attempts to promote change are ineffective, if not futile.
Another headline from this same cancer report, however, provides hope; it reads: “Changes in cancer rates when health behaviors shift.” 3 This headline reflects the fact that this year's data show a statistically significant decrease in lung cancer incidence and mortality in women. Approximately 10 years ago, a statistically significant decrease in lung cancer incidence and mortality was realized in men, but this is the first year the decrease has been appreciated in women. According to researchers with the SEER program, this disparity is associated with differences in the smoking patterns of men and women between 1940 and 1960, but regardless, the key message is that smoking cessation efforts have been effective. In fact, another recently released study reports that since smoking cessation efforts began in 1964, almost 800,000 deaths have been prevented as a result of tobacco control initiatives, including increased public awareness, restrictions on public smoking, and policies associated with reduced access to cigarettes, such as age restrictions and excise taxes. 4
It is now almost 50 years since the first smoking cessation programs were initiated, but it is just recently that researchers are detecting population level changes. Given the known comorbidities associated with excess weight, such as diabetes, cardiovascular disease, and now the demonstrable increases in cancer, waiting 50 years to see an impact in obesity rates is not good enough. Nonetheless, the strategies and lessons learned from tobacco control efforts do present a good model. Not unlike the factors that influence smoking, the factors that influence obesity are complex, and understanding the individual, societal, and contextual factors that contribute to the complexity is critical.
The development of relationships between federal, state, and private agencies that was modeled during tobacco control initiatives translates nicely to obesity control efforts. In her guest editorial, Dr. Lisa Rowen highlights a recent statewide collaborative on childhood obesity that included Dr. William Dietz, the Director of the CDC's Division of Nutrition, Physical Activity, and Obesity (DNPAO). As you will read, the goal of the Summit was to encourage a statewide, interprofessional approach to address childhood obesity. DNPAO is a federal agency that aims to decrease obesity and obesity-related diseases through the support of state programs. Working with an agency such as this one assists healthcare professionals and researchers to navigate effectively the complex systems that influence obesity, obesity program development, and obesity-related policy. The newly formed North Carolina state chapter of NABN, which is also described in this issue of Bariatric Nursing and Surgical Patient Care, is another positive step in achieving meaningful and effective relationships between federal, state, and private agencies.
While tobacco control may serve as an effective road map in some aspects, the broad application of structures and policies that were effective for smoking prevention and cessation may not always directly translate to obesity. For example, policies and regulations that attempt to influence behavior, such as implementation of a sugar-sweetened beverage tax, may or may not have a similar impact. As advocates for the treatment and prevention of obesity, it is critical that research-based evidence supporting or refuting proposed practices and policies be understood and communicated appropriately. When high level evidence does exist, such as the evidence that supports bariatric surgery as an effective intervention for weight loss, 5 it is critical that this information also be articulated in a meaningful way to advocacy groups and policy makers. The relationships described above will facilitate and enable the collaborative strategies that are needed to impact practice, program development, and policy in a significant and evidence-based way.
Statistical modeling demonstrates that if obesity trends do not improve, the consequences will offset the positive public health effects achieved by smoking cessation. 6 Although, the most recent NHANES data demonstrate that obesity prevalence rates have not worsened in recent years, it is premature to claim that rates have stabilized. The urgency to decrease obesity and obesity-related disease is still profound, and recent reports support that health promoting policies and behaviors are effective. Tobacco control efforts can serve as a road map. However, it is also critical that obesity control programs and policies not just mirror those associated with tobacco control; unique factors specific to obesity must also be considered. A commitment to promoting only evidence-based policies and programs is crucial for success. Hopefully, by remaining steadfast in these efforts, we will see in the not too distant future a headline boasting of significant declines in obesity and obesity-related disease as a result of public health initiatives and health behaviors.