Abstract
Reports of the increasing or high prevalence of obesity have become so commonplace as to seem like a permanent fixture of the health landscape—not only in the United States but abroad as well (Finucane et al., 2011; Flegal, Carroll, Kit, & Ogden, 2012; Lobstein, Baur, & Uauy, 2004; Ogden, Carroll, Kit, & Flegal, 2012). The importance and visibility of this issue have been enhanced by three interrelated events that occurred in May of this year: (a) the second Centers for Disease Control and Prevention (CDC) “Weight of the Nation” conference to assess progress and consider needed next steps for obesity prevention and control (Centers for Disease Control and Prevention, n.d.), (b) the release of Institute of Medicine (IOM) recommendations for a set of comprehensive strategies to accelerate progress in obesity prevention (Institute of Medicine, 2012), and (c) the premier of “The Weight of the Nation,” a documentary series on obesity, created by the Home Box Office Documentary Films division in partnership with the IOM and cosponsored by the CDC, the National Institutes of Health, Kaiser Permanente, and the Michael and Susan Dell Foundation, which is being widely disseminated in an effort to educate the public and mobilize action (Home Box Office Documentary Films, 2012). The IOM report stresses how much is at stake and the urgency of finding effective solutions (Institute of Medicine, 2012).
As health professionals and researchers, we are aware that we must find ways to alter this landscape and return the now normative, high population weight levels to lower levels that are “normal” in a physiological sense, that is, weight levels that are conducive to good long-term health and functionality. More than two thirds of adults and nearly a third of children in the United States are overweight or obese (Flegal et al., 2012; Ogden et al., 2012). We know that achieving healthy weights is important for both adults and children. We know that programs that can help people to prevent or reverse excess weight gain remain largely unavailable to the average person. And we know that achieving healthy weights is especially challenging in many ethnic minority, low-income, rural, or other socially disadvantaged populations, where the prevalence of obesity is higher and the circumstances for combating it are less favorable (Kumanyika et al., 2008).
From the findings of expert reports (Institute of Medicine, 2012; Kumanyika et al., 2008; White House Task Force on Childhood Obesity. Report to the President, 2010; World Health Organization, 2000), we know what has to be done to combat obesity, in general terms. We need to reorient everyday life so that people can readily find, want, and are directed toward healthful food choices and regularly choose to buy and eat healthier foods. This has major implications for food marketing (products, places available, promotions, and prices) that reaches the public. We need to reorient everyday life so that people both want and are obliged to get more physical activity in their daily routines, pursue active recreation, and spend less time sitting in front of screens. This has major implications for community design, transportation systems, school and workplace routines, community amenities, and parenting practices. Moreover, at the individual level, we need to ensure that adults, children, and adolescents develop social and psychological tools that help them navigate their environments in ways that support healthy weights. In combination, these processes for combating obesity are referred to as a “societal transformation.” The idea is not “social engineering,” which has negative connotations for societal and personal freedoms, but rather a vision of setting clear goals and facilitating the types of societal changes that will lead to achievement of those goals (Institute of Medicine, 2012; World Health Organization, 2000). In the United States, elements of a multifaceted, multi-stakeholder effort to generate such a societal transformation have been recommended, and efforts of this type are already underway nationally and in communities throughout the country (Institute of Medicine, 2012).
A Higher Bar for Research
The obesity crisis has raised the bar for obesity-related research—redefining this type of research to include not only etiologic studies or traditional weight loss trials but also studies of how to change policies and environments in ways that facilitate achievement of healthy weights. As explained in a 2010 IOM report that specifically addresses evidence needs for obesity prevention, there is a major gap between the types of evidence needed to inform decisions and the bulk of available scientific evidence about obesity (Institute of Medicine, 2010). While it is true that any study that adds to our knowledge about obesity may be useful in some way at some time, many studies that are of academic interest miss the mark with respect to providing evidence that is useful to policy makers and programmers. Relevant research questions to be asked include the following:
What strategies actually work in natural (as opposed to research) settings?
How does an intervention work, and what is needed to make it work?
In what populations does it work, and how might it be adapted to fit other populations?
What types of outcomes are affected—not only the main targeted outcomes but also other effects, be they positive or negative?
If successful, how can interventions become permanent?
What sets of interventions, in combination, will be the most powerful?
In other words, to be of use for informing decisions about obesity prevention and control, we need much more research that is deliberately “solution oriented” (Robinson & Sirard, 2005) and that uses a systems perspective to view specific interventions within the applicable broader, complex contexts. Thus, generating evidence for solutions both requires and confirms the value of studies that draw on and integrate a wide array of information sources and use a range of pertinent research designs, including those that combine quantitative and qualitative methods.
In this issue of Health Education & Behavior, several articles exemplify the types of research approaches that are needed to meet this higher bar for answering obesity-related questions (Block et al., 2012; DeJoy et al., 2012; Hearst et al., 2012; Kaholokula et al., 2012; Pinard et al., 2012; Sosa, 2012). Two of these articles are process evaluations of large-scale efforts to change environments. Block et al. (2012) report results of an evaluation of a “seed-to-table” program that integrates gardening and cooking activities for 9- to 12-year-old children into primary school environments in Australia. The evaluation approach gives careful consideration to the different mechanisms whereby a program of this type might influence not only children’s food-related attitudes and behaviors but also a range of other child, family, teacher, and school outcomes. DeJoy et al. (2012) provide extensive detail on the success in implementing a 2-year trial conducted at 12 worksites of the Dow Chemical Company. The authors reflect on why things did or did not work as expected, how different aspects of the interventions were interrelated within the larger system, and what might need to be done differently to achieve better outcomes. Both these mixed-methods studies, as well as the Pinard study cited below, identify interesting differences between findings obtained with qualitative and quantitative data.
Two articles report pilot studies to evaluate individually oriented interventions in high-risk populations. Both used partnership approaches and peer educators to build in contextual and cultural relevance and potential sustainability. Pinard et al. (2012) piloted a family-oriented program for treatment of childhood obesity among low-income families in Southwest Virginia. Partners included a primary care practice, the local Cooperative Extension Service, and lay educators from the SNAP-ED (Supplemental Nutrition Assistance Program Education) Program. Quantitative and qualitative data were collected to estimate a range of outcomes, including program reach, representativeness, and implementation and perceptions of partners and clients regarding its utility and acceptability. Kaholokula et al. (2011) piloted a lifestyle weight maintenance program designed to reach Pacific Islander adults during the critical first 6 months after participation in a 3-month weight loss program. The study was conducted in partnership with five Pacific Islander community organizations. The added value of the community partnered and culturally tailored program over a telephone-based follow-up program using standard behavioral change techniques was identified using a randomized study design.
Other articles that focus on parental influences provide important insights for designing effective family-oriented interventions. Hearst et al. (2012) found that parental time demands and household rules about eating and screen time were associated with parent and child weight status. Finally, a systematic review by Sosa (2011) highlights the need for more theory-driven research to facilitate understanding of childhood obesity intervention perspectives that are relevant to Mexican Americans, related specifically to maternal knowledge and perceptions.
The Path Forward
The costs of a continuing high prevalence of obesity include the burdens on health, social functioning, and overall quality of life; health insurance and productivity costs to public and private sector employers; and the financial impacts and economic consequences associated with treatment of obesity-related disease and disability. Given the urgency of these obesity-related problems, the vision for obesity research going forward needs to be much more solution-oriented than has been the case to date. Such research will point to specific pathways for intervention, be clear as to why these pathways are promising and how they are expected to work, how they fit within more complex systems, what outcomes are targeted, and what other outcomes might be affected positively or negatively. Published research reports will include information not only about how well interventions actually work when tested in natural settings but also about what makes them work or not work and what segment of the targeted populations was reached. A better profile for the weight of the population is possible when policy makers and programmers can be informed and persuaded by sound recommendations supported by scientifically credible, relevant evidence. The studies highlighted here are promising in that they demonstrate what such evidence might look like for different questions, populations, and settings.