Tackling Obesity Across Multiple Levels

Complex problems require equally complex solutions. Modern society has found ways to combat the plight of infectious agents that once posed the greatest threat to human life (Cutler, Deaton, & Lleras-Muney, 2006, pp.99-100). Our reward? A dramatically increased life expectancy, often fraught with years of pain, illness and disability at the hands of chronic health threats. Cancer, heart disease, diabetes and renal failure represent highly prevalent ailments in modern developed countries. An increasingly mechanized and technological society contributing to a largely sedentary lifestyle, along with a readily available caloric surplus creates an imbalance that leads to a condition known to be a risk factor for each of these disease states: obesity.

The most difficult aspect of weight control is that it is not intuitive. Without the proper environment, instruction and/or modelling, the plentiful calorie-dense food options engineered by modern science to appeal to biological cravings for sugar and fat can easily disrupt the delicate balance of the energy budget. Add to this the fact that everyone comes from a unique background with a unique understanding of and perspective on nutrition and fitness, and it becomes clear that one size does not fit all when it comes to solving the obesity riddle.

Backholer et al. (2014, p.e45) propose a two-dimensional model for directing change. One dimension consists of micro- versus macro- environmental factors, encompassing the home environment (micro level) up to the national level (macro) and beyond. The second dimension addresses the degree to which individuals are empowered to implement change or maintain current practices. Agency, on one end, gives full autonomy to the individual to choose among available options, while structural approaches provide regulations that dictate paths that must be followed.

Figure 1: Backholer et al., 2014, p.e45

This model attempts to provide a framework that will allow for maximization of improvements in obesity levels across all populations by offering multiple methods of attacking this issue. Socioeconomically disadvantaged groups tend to experience proportionally less benefit through health initiatives that allow for individual choice (Backholer et al., 2014, p.e45). Given this knowledge, the starting point when attempting to elevate overall health through the application of this model would be to institute structural changes such as policies expanding mandatory gym classes or -as instituted in New Brunswick a decade ago- restricting the sale of food and drinks that lack any recognizable nutrients within the public school system (Department of Education, 2008, p.2). The added environmental dimension to this model allows influencers to determine the level at which this policy should be implemented. As the environmental scope expands toward the macro end of the spectrum, so too grows the number of individuals impacted by a particular policy, and thus the total effect it may have on the overall population. To clarify: if the above policies were implemented at the national level, all schools within that scope would be forced to comply, meaning all students across the country would benefit. The total effects would be lessened by moving to the provincial, district or individual school level, respectively. These progressively less inclusive environments could be used to create further policies that are more directly applicable to the subtle regional differences that may require greater focus to address optimally. For example: the school board from a region where temperatures are consistently low enough to prevent children from safely playing outside during recess may orchestrate structured physical activities inside a gymnasium during such times to supplement the activity level required for optimal development rather than leave the children in a more cumbersome classroom. Alternatively, policy-makers within regions facing a scarcity of affordable fresh vegetables may subsidize a program that provides free nutritious lunches for all students a set number of days per week to ensure access to essential nutrients.

Ball (2015, p.3) likens prospective positive behavioral modifications to climbing a mountain. The analogy suggests that those with lower socioeconomic standing must start their climb to the top of the mountain from further down than would more privileged groups (Ball, 2015, p.3). Structural interventions, then, could be thought of as taking a chairlift to the halfway point; it offers the greatest assistance to those furthest from the top, thereby narrowing the range of climbers starting out. To expand on this analogy, after getting off the chairlift, those from higher socioeconomic backgrounds will have greater support systems -akin to a less steep and arduous journey to the top. Conversely, those without the education, social support network and monetary resources lack the tools to simplify their task, creating a steeper climb toward health. Thus, while policies close the gap, agentic influences (behavioral choices) dictate who will complete the journey.

By again incorporating the micro-macro environmental scale, interventions can be approached from the individual through to the national level for strictly agentic changes as well as across limitless agento-structural gradations along the behavioral continuum. Agency dependent initiatives would include those for which there is no direct penalty for non-compliance but also no direct incentive to act (public service announcement boasting the benefits of exercise or highlighting nutrient dense foods), while intermediate (agento-structural) offerings would be optional as well, but with the addition of incentives or removal of barriers to facilitate uptake (such as food banks or the construction of hiking trails or bike lanes throughout a city).

Due to the non-discrete nature of the agency/structural variable in this model, the possible interventions that may be applied to it are endless. Therefore, to effectively utilize it to combat the obesity issue within a society, a careful evaluation would need to be employed to ensure that it is effectively addressing issues relevant to that population. With some planning however, the flexibility of this model allows its operator to make it as comprehensive or generic as desired.

Resources

Backholer, K., Beauchamp, A., Ball, K., Turrell, G., Martin, J., Woods, J., & Peeters, A. (2014). A Framework for Evaluating the Impact of Obesity Prevention Strategies on Socioeconomic Inequalities in Weight. American Journal of Public Health, 104(10), e43. https://doi.org/10.2105/AJPH.2014.302066

Ball, K. (2015). Traversing myths and mountains: addressing socioeconomic inequities in the promotion of nutrition and physical activity behaviours. The International Journal of Behavioral Nutrition and Physical Activity, 12, 142. https://doi.org/10.1186/s12966-015-0303-4

Cutler, D., Deaton, A., & Lleras-Muney, A. (2006). The Determinants of Mortality. Journal of Economic Perspectives, 20(3), 97–120. Retrieved from https://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.20.3.97

Department of Education. (2008). 711A - Handbook to Policy 711 Healthier Eating and Nutrition in Public Schools. Retrieved from www.healthcanada.gc.ca/