Four decades after the beginning of the global obesity epidemic, awareness of the threat of obesity to the population’s health and well-being can be seen in a plethora of national reports and strategic plans from various countries, however, conversion to action remains mainly unrealised (Swinburn et al., 2011). Posing the question: Why?
Divergent beliefs exist about what drives and sustains obesity, consequently, substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail.
The determinants of obesity and its solutions are complex, however, many of these debates have become entrenched in overly simple dichotomies that present seemingly competing perspectives. Examples of such dichotomies include: individual versus environmental causes, government regulation versus industry voluntary codes, top-down versus bottom-up drivers for change, evidence-based versus lobby-responsive policy and making and prioritisation of treatment versus prevention. Genuine progress lies beyond the impasse of these entrenched dichotomies. Therefore, an urgent rethinking of causes, enablers, and barriers to change is required to begin to make a difference in the global obesity epidemic (Kleinert & Horton, 2015).
This narrative previews papers in The Lancet’s 2015 Series on Obesity, which provides an opportunity for such a rethinking. Papers in the series identify high priority actions on key obesity issues and challenge some of the entrenched dichotomies that dominate thinking about obesity and its solutions.
In the first paper of the series, Roberto and colleagues (2015) challenge the false dichotomy that obesity is driven by either personal choice or environment influence, and suggest that the two competing perspectives be merged to show the reciprocal relationship between individual person and environment. Roberto and colleagues (2015) discuss that obesity must be reframed to acknowledge that individuals will bear some responsibility for their health, yet, on the other hand, environmental factors exploit biological, psychological, social and economic vulnerabilities, making it easier for individuals to consume unhealthy products. A vicious cycle is then created in which preferences and demands for unhealthy food are not only shaped by the environment, but lead to environmental changes. Thus, this cycle makes it difficult for people to act in their long-term self-interest, yet Roberto and colleagues (2015) comment it can be broken by regulatory action from governments and joint efforts from industry and civil society to create healthier food environments.
The second paper by Hawkes and colleagues (2015) also challenges the dichotomy between a traditional public health-based perspective (which identifies food systems, food environments, and food industry as leading causes of obesity) and an individual-based perspective (which argues that consumer demand drives unhealthy food consumption because the market simply delivers what consumers want). Hawkes and colleagues (2015) discuss that the learning, expression, and reassessment of food preferences in the context of individual’s environments are important elements in understanding how food polices work. Indicating that effective food policy actions are tailored to preference, behavioural, socio-economic, and demographic characteristics of the individuals they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions.
The paper by Huang and colleagues (2015) challenges the false dichotomy that either top-down (e.g. government) or bottom-up (e.g. grassroots) solutions are needed. Public health officials and political leaders tend to focus on top-down solutions (i.e. polices that can be passed down to alter the environment and improve health). Although, the passage of policies is pivotal, there is a need to mobilise policy from the bottom-up. The paper emphasises that public mobilisation is needed to enact obesity prevention and to mitigate reaction against their implementation. Huang and colleagues (2015) focus on bottom-up strategies that view people as active agents who can change their environments, not as passive recipients of information and change as top-down strategies do.
Closing the series is a paper by Swinburn and colleagues (2015), who focus on a shift from a responsibility to an accountability framework (diminishing arguments about who is to blame for obesity), which involves multiple actors of varying degrees of power over one another to ensure each other’s performance. Swinburn and colleagues (2015) propose a four step accountability framework (take the account, share the account, hold to account, and respond to the account). The framework identifies multiple levels for change, including innovative application of quasi-regulatory approaches which hold some promise to overcoming the impasse of the debate of whether to use regulatory or voluntary policies.
In conclusion, overall this Lancet series offers the reader an understanding of why conversion to action has remained mainly unrealised. However, by rethinking obesity, major areas (e.g. fundamental framing of the issues, food policies and societal movement for change) for potential progress have emerged. The papers in this series, challenge dichotomies, seek improved ways to move forward by understanding interactions, synergies, alternative frames, and different pathways within the complexity of obesity (Swinburn et al., 2015). Ultimately, we now need to turn this progress into serious strides to reverse the tide in the global obesity epidemic.
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