Policymaking and the Obesity Epidemic: Giving Up Power to Build Power

Rajiv Narayan, MSc, offers his thoughts on the special series on obesity published in The Lancet and what changes are necessary to fight the disease.

Policymaking is hard. It relies on a precarious alignment of constellations, the stars of which range from the whims of elected officials to the strength of research to the coverage of media to the consensus of advocates to the demands of the public. Folks who study public health policy strain to conceive of which policies are most effective, and moreover, how to get them from idea to implementation. What if that work, as well as the outcomes desired, could benefit from sharing the burden?

The Lancet published its first special collection on obesity in 2011. The panel of experts sought to collect a sprawling set of threads that represented different aspects of obesity management into a more tightly woven fabric of strategies. Their key messages included a call for government leadership, an indictment of “business as usual” and “assumptions about speed and sustainability of weight loss,” and an endorsement of the “systems approach” to handling multiple sectors of influence.

No one seriously thought 2011 would be the year when we finally and collectively turned the corner on obesity, but the passage of time has given many an opportunity for reflection.

In February, executive editor Sabine Kleinert, MD, PhD, and editor-in-chief Richard Horton, BSc, MB, FRCP, FMedSci, of The Lancet introduced the 2015 special collection on obesity with the premise that “little progress has been made …” The second special collection includes papers promising a new paradigm. Taken together, they deconstruct dichotomies, propose new frameworks where others have fallen short and target traditional actors with fresh approaches.

Two papers stand out among the rest in their prescriptions to policy researchers who seek to make real change. The first, authored by Huang et al, outlines a veritable arsenal of tactics and strategies to mobilize public support for anti-obesity policies.1 The second, authored by Brownell and Roberto, speak directly to researchers who want to influence policymakers.2 Both papers successfully make the case for researchers to actively collaborate with actors far beyond their institutional walls — some literal and others made from the isolating mortar of expert credentials. To be sure, that’s a bold task.

Huang et al organize a set of guidelines that can engineer citizen “demand” for obesity reduction policies that may be on their own unappealing — a tax on added sugars, for example — or unachievable without mass buy-in. These guidelines include targeted messaging to different groups, increased overall media advocacy to compete with industry marketing, engaging and encouraging citizen protest, publicizing the costs of obesity to society and investing resources in shaping a receptive political environment via political staffing, lobbying and think tank issue education.

Brownell and Roberto expand on that last point in their commentary by invoking the tactics of strategic science, in which researchers collaborate directly with the policymaking world to tailor-make an evidence base that can be mobilized to educate lawmakers, provide support for key proposals and proactively frame conversations about cost-effectiveness and economic impact in a “feedback loop.” Their strategy opens the research process to policy leaders in a way that seeks to increase buy-in and ownership.

These methods of increasing political pressure carry a long history and evidence base. Should the obesity policy community be able to organize and execute, it’s very possible that the changes they seek would gain more traction. These are all important premises to recognize because it’s important to distinguish between improving outcomes and empowering communities. The history of policy makes clear that the former can be accomplished without the latter, and so the concern is that even “bottom-up” approaches to cultivate demand still operate from a position that privileges and retains the power of researchers and policymakers.