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1
The Vision
Key Messages
• The Institute of Medicine’s (IOM’s) Committee on Accelerating Progress in
Obesity Prevention was charged with charting pathways to a timely resolu-
tion of the obesity epidemic in the U.S. population.
• The committee’s vision is for a successful, sustainable society that supports
obesity prevention and offers broad opportunities for everyone to lead a
healthy, productive life.
• Taking a systems perspective will accelerate the realization of this vision.
• Achieving this vision will involve mobilizing the population through engage-
ment and leadership at all levels—individuals, families, communities, and
society—and in all sectors.
• Targeted actions are needed to reduce the inequitable distribution of health
promotion resources and risk factors that contribute to health disparities in
low-income, minority, and other disadvantaged populations.
T he epidemic of obesity in the United States has major human and societal
costs, both now and for future generations. Obesity affects the entire child-
hood experience, predisposes adolescents to obesity in adulthood, and increases
the risk of chronic illness and reduced quality of life and success in adulthood.
Currently, a majority of U.S. adults and a substantial proportion of children and
adolescents have weight levels in the overweight or obese range (Flegal et al.,
2010; Ogden et al., 2010a). The percentage of people who are already obese
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translates to an estimated total of nearly 73 million adults and 12 million chil-
dren and adolescents (Ogden et al., 2010b,c), and those overweight are likely to
become obese if they gain weight over time. The United States is far from alone
in facing the challenges of this epidemic. Many aspects of the epidemic and its
causes reach across the globe. An estimated 1.5 billion adults worldwide are
overweight or obese (Finucane et al., 2011), and the World Health Organization
estimates that 35 million preschool children in developing countries and 43 mil-
lion preschool children worldwide are overweight or obese (de Onis et al., 2010).
However, the nature of the factors causing this epidemic is such that the search for
effective solutions must focus on specific drivers as they exist and operate within
countries, regions, and localities.
The purpose of this report, developed by the Institute of Medicine’s (IOM’s)
Committee on Accelerating Progress in Obesity Prevention, is to chart the path-
ways to a timely resolution of the obesity epidemic in the U.S. population. The
committee was tasked with formulating a coherent set of recommendations that, if
implemented, would be likely to significantly accelerate progress toward prevent-
ing obesity over the next decade, taking advantage, where possible, of favorable
emerging developments. The committee was tasked further with recommending
tangible, practical indicators with which to measure progress toward this goal.
Specifically, the committee’s charge was to review prior obesity-related recom-
mendations; consider relevant information on progress toward their implementa-
tion; develop principles to guide the selection of recommendations fundamental
to achieving progress in obesity prevention; and recommend potential indicators
that can act as markers of progress and can be readily evaluated through the use
of current databases and/or relatively simple measures or surveys. This report
responds to the challenges of this charge. The audience for the report includes
public policy makers at all levels; private-sector decision makers; leaders in other
institutions, including foundations, the education system, and professional and
community-based organizations and health agencies; and the public in general.
This chapter sets the stage by articulating the committee’s vision for success
(Box 1-1) and introducing concepts of a systems perspective and of engagement
and leadership as essential elements for achieving this vision. A clear vision is
essential to guard against thinking about obesity prevention in isolation from the
complex social and economic systems within which the determinants of obesity—
physical activity and eating patterns—are embedded. The committee’s vision imag-
ines what society would look like if obesity prevention were achieved effectively,
equitably, and sustainably. It allows for the identification of socially desirable
Accelerating Progress in Obesity Prevention
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BOX 1-1
A Vision for Success
The committee envisions a society of healthy children, healthy families, and
healthy communities in which all people realize their full potential and develop
the competencies required to interact successfully with their surrounding environ-
ments. There is an urgent need to employ large-scale transformative approaches
focused on multilevel environmental and policy changes within interconnected
systems to reduce the threat of obesity and sustain an enduring impact.
pathways for change and indicators for assessing whether initiatives undertaken
are on the right track before their longer-term effects can be fully evaluated.
Inherent in the committee’s vision is the belief that children and adults should be
able to satisfy their needs, be productive, and lead high-quality lives. Another criti-
cal common value expressed in the committee’s development of this vision is the
need for safeguards to ensure equity so that children and adults in communities
affected by social and economic disparities have opportunities to achieve a healthy
weight in the environments where they live, learn, work, and play.
The underlying logic of the committee’s vision is illustrated in Figure 1-1.
Favorable environments and behavioral settings positively influence individual,
family, and population expectations, norms, and behaviors related to physical
activity and healthy eating. Outcomes for individuals and society reflect decreased
obesity rates with commensurate improvements in the health and societal out-
comes highlighted in Chapter 2. Strategies and actions that drive overall environ-
ments in a health-promoting direction will be at the core of efforts to accelerate
progress in preventing obesity. The cross-cutting factors listed at the bottom of the
figure are a reminder that particular strategies and actions will affect individuals
and populations differently depending on their circumstances, resources, and out-
looks (IOM, 2007).
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20
Outcomes related to
Impact on home
Environments and
environments and behaviors
behavioral settings Impact on body weight obesity and health
Children grow and develop
People and families on a healthy trajectory
Government, industries,
change their personal People avoid excess
schools, and communities Adults avoid incremental
environments and weight gain or lose
undertake or support policies weight gain
behavior in response weight and maintain
or other strategies and
Children and adults avoid
to healthier weight loss
actions to change physical obesity-related health and
environmental options
and economic structures, psychosocial problems
institutions, and systems
Default options and cues to
choices in environments Population behavior Average weights in the
where children and adults and social norms population shift
live, work, and play are more reflect collective downward
likely to promote physical Societal costs of obesity
individual choices in
activity and healthy eating decrease
healthier Fewer people are
environments overweight or obese
Population quality of life
improves
Race/ethnicity; gender; socioeconomic status; residential area; and social, political, and historical contexts that influence
the baseline, opportunities, and responses to changes in environments for physical activity and eating.
FIGURE 1-1 The logic of populationwide obesity prevention.
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A SYSTEMS PERSPECTIVE
Several IOM reports and other prior analyses of potential solutions to the obe-
sity epidemic, relevant both to the United States and globally, have established the
inherent complexity of the problem (IOM, 2010). An impressive body of evidence
confirms that the drivers of the epidemic involve interactions among several com-
plex, ever-changing systems, including the food system, transportation systems,
community infrastructure, school systems, health care systems, and the intricate
behavioral and physiological systems that influence individual physical activity
and eating behaviors and body weight. Reflecting this complexity, a prior IOM
report calls for taking a systems approach to obesity prevention (IOM, 2010).
Specifically, that report explains how a systems approach is an evolution of and
expansion upon strategies already proposed or currently in use to prevent obesity.
It is an approach that focuses on the whole picture and not just a single element,
awareness of the wider context of any action, and an appreciation for interactions
among different components of the problem. Further details on how the current
committee took a systems approach can be found in Chapter 4 and Appendix B.
Building a society of healthy children, families, and communities will require
coordinated change at multiple levels—from individuals, to families, to commu-
nities, to society as a whole. Pathways for change to curb and then reverse the
epidemic of obesity involve core elements of the social fabric. The current environ-
ments in which eating and physical activity take place are the cumulative result of
decisions that have been made over several decades, in numerous societal sectors.
Many of those decisions have led—often inadvertently—to environments that run
counter to the achievement or maintenance of healthy weight (Huang and Glass,
2008; Popkin et al., 2005). Americans have adjusted to these current ways of
life and may strongly value many of the conveniences and pleasures they afford.
Approaches that are inconsistent with fundamental values and principles will be
undesirable and, ultimately, untenable.
Many initiatives needed for success in obesity prevention must occur through
changes in societal sectors or institutions that influence health, including ones
that are beyond the traditional health sector. Strategies must be carefully crafted
to ensure that they will align with the goals and processes of these other sectors.
Acceleration of obesity prevention will require reaching and engaging with mul-
tiple stakeholder groups. This need for action across a broad spectrum of society,
together with the evolution of the problem over several decades, suggests that
some time will be needed before solutions can be put in place and show effects.
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The committee’s focus was on how the process of change that is needed—and is in
many respects already under way—can be accelerated.
Two other elements are crucial for successful implementation of the com-
mittee’s recommendations to accelerate progress in obesity prevention utilizing a
systems perspective: (1) the engagement of individuals, families, communities, and
society and (2) the identification of leaders who can mobilize the changes needed
while reducing disparities in the risk for obesity.
LEVELS OF ENGAGEMENT TO MOBILIZE CHANGE
The concept of “engagement” conveys the importance of collaborative
approaches, “working with and through groups of people affiliated by geographic
proximity, special interest, or similar situations” (CDC, 1997, p. 9)—that is,
involving those affected by issues to address the issues that affect them. As
described in this section, engagement is required at all levels of the population and
across levels—individuals, families, communities, and the larger society—in order
to build capacity, accelerate progress in obesity prevention, and reduce disparities
in resources to ensure equity of impact in relation to the risk of obesity. The levels
are interdependent, and all are necessary to achieve impact. Although its delibera-
tions focused on strategies at the community and societal levels (see Chapter 3 for
more detail), the committee recognizes the interdependence of these broader levels
with the engagement of individuals and families. Every level of the population
must play an active role in the system. Their engagement, as detailed below, could
motivate a successful social movement for positive change.
Societal-Level Engagement
Prevention of obesity at the societal level requires supports for child health
and development, including food, education, and family life. The health of the
public is ultimately a collective responsibility, and the fear of engendering political
opposition through bold and widespread action can stand in the way of positive
change in the nation’s current physical activity, food, and other environments that
influence individual behavior and choice. Awareness, will, and action on the part
of the public and the business community/private sector, as well as government at
all levels, must increase if the necessary changes are to occur.
Population behavior is influenced by several societal subsystems, including the
economy, the political system, social institutions, and culture (de Silva-Sanigorski
and Economos, 2010). To influence behavior on a broad societal level, multiple
Accelerating Progress in Obesity Prevention
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subsystems must be targeted, and communities can be seen as important social
forces in the process of change. As the broader society develops strategies to tackle
the obesity epidemic, it will be able to draw on lessons learned from a range of
successful social change efforts, such as those designed to increase breastfeeding
rates, seat belt use, smoking cessation, and recycling (Economos et al., 2001). As
described by de Silva-Sanigorski and Economos (2010, pp. 57-58) “key elements
identified from these past successes include
• recognition that there was a crisis;
• major economic implications associated with the crisis;
• a science base including research, data, and evidence;
• sparkplugs, or leaders who can work for their cause through their knowl-
edge, competence, talents, skills, and even charisma;
• coalitions to move the agenda forward and a strategic, integrated media
advocacy campaign;
• involvement of the government at the state level to apply regulatory and
fiscal authority, and at the local level to implement change;
• mass communication that includes consistent positive messages supported
by scientific consensus and repeated in a variety of venues;
• policy and environmental changes that promote healthy lifestyle behaviors;
and
• a plan that includes many components which work synergistically.”
Community-Level Engagement
Community engagement is a powerful vehicle for bringing about environ-
mental and behavioral changes that will improve the health of the community
and its members. It often involves partnerships and coalitions that help mobilize
resources and influence systems, change relationships among partners, and serve
as catalysts for changing policies, programs, and practices (CDC, 1997). As
described later in this report, the recognition of social, cultural, and environmental
factors influencing obesity has motivated a shift to community-level strategies for
health promotion, with the understanding that change at this level will encourage
and sustain individual-level behavior change. There is no consistent definition of a
“community”; however, experience suggests that it may be defined as “a group of
people sharing a common goal, interest, or identity—for example, culture, social,
political, health, economic interests or a particular geographic association” (Bell
et al., 2010, p. 233). Within the field of community health, this broad definition
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gives way to two subclassifications of community: “communities of identity”
(shared ethnicity, religion, illness) and “communities of location” (towns, cities,
distinct neighborhoods) (Campbell and Murray, 2004; Israel et al., 2003).
Geographically defined communities hold diverse resources, ranging from
the institutional (including worksites, places of worship, schools, and service and
information providers), to the interpersonal (including peer networks, coalitions,
and task forces), to community leaders and policy makers. Communities have
their own history, social norms, traditions, and knowledge. These assets contrib-
ute points of leverage and resistance, intersections that spark strongly positive
or negative reactions. Community-based interventions aim to apply community
assets purposefully and efficiently to address an issue the community would like
to resolve (Issel, 2009). Communities differ in their readiness or pre-existing
capacity to address a given issue, such as obesity prevention, and those seeking
to catalyze change in a community must employ different strategies for different
readiness levels.
Community coalitions can be developed and supported to encourage the deep
and meaningful engagement and organization of community members to real-
ize systemic change at the local level (National Opinion Research Center, 2011).
When people create or are involved in developing programs or policies, they value
them more (Huang and Story, 2010). The formation of local, community-based
coalitions can improve the reach and rate of information exchange nationally or at
the societal level (Butterfoss et al., 1993).
Family/Household- and Individual-Level Engagement
The need for a major emphasis on change at the societal and community levels
stems from the fact that many determinants of both voluntary and routine eating
and physical activity behaviors are outside of the direct control of individuals and
families. However, the ultimate success of changes at these levels depends on the
extent to which the changes reach and are adopted and sustained by individuals
and families. As described by Finegood (2011, p. 228), “given the heterogeneous
nature of individuals and their environments, it is impossible to take individuals
out of the solution equation.” This suggests it is important to consider the rela-
tionship between individuals/families and their environment to find effective
solutions to obesity (Brownell et al., 2010). Engagement with individuals is foun-
dational for achieving broad social action on obesity prevention in many ways.
Children and adults, particularly caregivers, make decisions about their own phys-
ical activity and eating behaviors on a daily basis; they may also make decisions
Accelerating Progress in Obesity Prevention
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that affect other people’s physical activity and food choices and environments,
have responsibility for organizing the context in which people make such decisions
(Finegood et al., 2010; Thaler and Sunstein, 2009), and take civic actions that
influence policy makers. If individuals are engaged in the effort to accelerate obe-
sity prevention, success is more likely to be achieved (Bar-Yam, 2004).
Building the awareness and will within households to influence the home envi-
ronment and family dynamics positively with respect to physical activity and food
choices is an essential part of changing the overall system. The reasons to foster
will and action within households across the United States are especially clear in
relation to prevention of obesity in children. Children learn to assimilate their
parents’ health-related behaviors at a young age (Perryman, 2011). Furthermore,
parents act as decision makers for their children in the areas of physical activity
and nutrition. An estimated 66 percent of the caloric intake of children and ado-
lescents occurs within the home (Poti and Popkin, 2011). Parents also serve as role
models for their children, helping to shape physical activity values and behaviors,
providing a sense of portion control and nutrient balance, and building related
skills. For example, limiting children’s television time, using parental controls, and
disallowing television in the bedroom can help reduce exposure to the marketing
of unhealthy food products and reduce sedentary behavior.
Society benefits if all families have the social and material resources to raise
their children to be healthy, educated, and productive members of their communi-
ties and nation. A healthy home environment can begin before conception with
strong maternal nutrition, supported by other family members (IOM, 2005). It
can prevent rapid early infant weight gain from ages 0 to 4 months, which has
been shown to be a risk factor for childhood obesity (Birch and Davison, 2001;
Stettler et al., 2003). And a healthy home environment can reach parents, grand-
parents, and extended family members, supporting a life-course perspective on
obesity prevention.
The skill base for healthy living has eroded, however, and many people need
support on parenting, cooking, and media use (Golan and Crow, 2004). Moreover,
the resources available to parents to meet their children’s needs vary considerably.
While the value of creating the optimal healthy environment for children is clear,
society has largely left this responsibility to individual families, even though the
financial or political resources to affect changes in major corporate interests, gov-
ernment programs, or policy generally are not available to individuals or individual
families (Prilleltensky, 2010). For families to be able to raise healthy, well-educated
children, communities and societal structures must assist in providing access to
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opportunities for physical activity, healthy food, and adequate health care and
other social services that support health (Scarr, 1996).
Reducing Disparities: Equity of Impact in Relation to Risk
Not all individuals, families, and communities are similarly situated with
respect to environments that influence food and physical activity. A variety of
characteristics historically linked to social exclusion or discrimination, such as
race or ethnicity, religion, socioeconomic status, gender, age, mental health, dis-
ability, sexual orientation or gender identity, geographic location, and immigration
status, are known to influence health status. In its 2011 Action Plan to Reduce
Racial and Ethnic Health Disparities, the Department of Health and Human
Services (HHS) highlights that health disparities “are closely linked with social,
economic, and environmental disadvantage” and “are often driven by the social
conditions in which individuals live, learn, work and play” (HHS, 2011, p. 1).
As described in Chapter 2, the burden of obesity is notably greater in racial/
ethnic minority and low-income populations. A high level of community engage-
ment and carefully targeted approaches will be particularly important to acceler-
ate obesity prevention in such communities. In many parts of the United States,
racial/ethnic minority and low-income individuals and families live, learn, work,
and play in neighborhoods that lack sufficient health-protective resources, such as
parks and open space, grocery stores, walkable streets, and high-quality schools
(Adler et al., 2007; Iton et al., 2008). Additionally, community-level risk fac-
tors, including freeways, incinerators, ports, heavy industry, and other sources
of noxious pollution, often are concentrated in these same places (Adler et al.,
2007). This relative absence of health-promoting resources and disproportionate
concentration of unhealthy risk factors contributes to increased levels of chronic
stress among individuals experiencing these conditions (Iton et al., 2008), and this
chronic stress is in turn associated with increased levels of sedentary activity and
increased calorie consumption (Adler et al., 2007).
The persistence of concentrated health disparities in many American com-
munities is strongly influenced by the relative paucity of community-based health
improvement strategies focused on creating robust local participatory decision-
making processes. In any given community, the relative mix of these community-
level resources and risk factors is determined primarily through democratic local
and regional land use decision-making processes; consequently, organized partici-
pation in these processes influences where these community resources and risks
are located. Because of such factors as poverty, language barriers, and immigration
Accelerating Progress in Obesity Prevention
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status, low-income, minority, and other disadvantaged population groups often
are underrepresented and their concerns marginalized in these land use decision-
making processes (Iton et al., 2008). These groups are therefore less likely to ben-
efit from access to health-protective resources and more likely to live in proximity
to noxious land uses. To change this inequitable resource and risk distribution,
robust and long-term community engagement and civic participation among these
disadvantaged populations must occur.
LEADERSHIP
Responsibility for leading efforts to make the changes needed to prevent obe-
sity potentially rests with everyone that can influence physical activity and food
environments. There are obvious leaders that have traditionally been seen as hav-
ing the responsibility for making environmental and policy changes to influence
societal change, but the engagement of all individuals, families, communities, and
society, as described in the previous section, may identify another set of willing
and capable leaders whose actions will be necessary to achieve impact. Chapter 10
further details how taking a systems perspective helps define and identify leaders
and how these leaders should approach implementing the necessary changes.
THE ISSUE OF RESPONSIBILITY
The committee’s vision, its decision to take a systems perspective, and its belief
in the need for engagement and leadership at multiple levels and across multiple
sectors help inform the issue of who is responsible for addressing the epidemic
of obesity. Traditionally, obesity has been blamed on the failure of individuals to
exercise personal responsibility (Brownell et al., 2010; Leichter, 2003). In addition,
this view has been used as the basis for resisting government efforts—legislative
and regulatory—to address the problem. Recently, the discourse has been reframed
by Brownell and colleagues (2010) as a constructive approach to a controver-
sial issue. They assert that “personal responsibility can be embraced as a value”
(p. 378) by expanding its meaning to include such actions as improved school
nutrition, menu labeling, changes in industry marketing practices, and even such
controversial measures as taxes on foods and beverages that lead to the choice of
healthier items. Such an approach could bridge the divide between views based
on individual versus collective responsibility (Brownell et al., 2010). This train of
thought argues for making obesity prevention a political priority that reestablishes
the responsibility of the country—both the public and private sectors—to nurture
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and protect children, and to support the health priorities of the adults and families
who influence them and make the decisions that determine the overall physical
activity and food environments.
The committee’s recommendations (outlined in Chapters 5-9) have the poten-
tial to accelerate progress in obesity prevention by identifying changes that are
needed across all levels and sectors of society, but it is also important to view
them as a whole—an interrelated system of critical areas in which changes are
needed. The responsibility for implementing these changes is one that must be
shared. Engagement and leadership across all levels and sectors of the popula-
tion will be powerful vehicles for bringing about environmental and behavioral
changes that can improve the health of the population.
OVERVIEW OF THE REPORT
The next two chapters provide background on and fundamentals of the prob-
lem of obesity, including an assessment of the current problem and how, in gen-
eral, the problem is addressed at a population level. Chapter 2 describes the con-
sequences of obesity; reviews current trends of overweight and obesity and societal
trends that are drivers of excess weight gain at a population level; and outlines
advances in and barriers to implementing environmental and policy changes that
can help accelerate progress in obesity prevention. Chapter 3 describes the logic
of obesity prevention, including goals and key pathways and targets for change,
and explains the importance of taking a systems perspective on the problem.
Chapters 2 and 3 are particularly geared toward audiences unfamiliar with the
current situation regarding obesity and obesity prevention approaches from a
societal perspective, but they also highlight several current issues that required the
committee’s careful consideration in determining which strategies and actions to
recommend. Chapter 4 then presents the methodology used by the committee in
developing its recommendations. This chapter explains how the committee defined
the concept of accelerating progress in obesity prevention in order to screen and
evaluate the numerous interventions recommended in prior reports and to enhance
or choose among these interventions, and highlights the importance of viewing the
committee’s recommendations as an interrelated, synergistic system.
The remainder of the report presents the committee’s recommendations for
accelerating progress in obesity prevention. The committee identified five critical
action arenas—environments for change—for making progress in obesity preven-
tion. Chapters 5 through 9 present recommendations under five respective goals,
together with specific strategies, actions, and outcome indicators, in relation to
Accelerating Progress in Obesity Prevention
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these five environments: environments for physical activity (Chapter 5); food and
beverage environments (Chapter 6); message environments with respect to physi-
cal activity and healthy eating (Chapter 7); health care and work environments
(Chapter 8); and school environments (Chapter 9). Chapter 10 concludes the
report by addressing leadership and implementation, prioritization, and assess-
ment of the committee’s recommendations in the context of a systems perspective.
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