Description
The National Institutes of Health’s (NIH) National Heart, Lung, and Blood Institute (NHLBI) hosted a three-day virtual workshop titled “Advancing Interventions for Adult Obesity to Promote Health Equity: State of the Science and Research Opportunities” on October 18-20, 2022. The workshop was co-sponsored by NIH’s Office of Disease Prevention (ODP) and the Office of Behavioral and Social Science Research (OBSSR), in collaboration with the National Cancer Institute (NCI), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the National Institute of General Medical Sciences (NIGMS), the National Institute of Minority Health and Health Disparities (NIMHD), the Centers for Disease Control and Prevention (CDC), and the Department of Veterans Affairs (VA). Additionally, the independent, non-profit Patient-Centered Outcomes Research Institute (PCORI) participated as a collaborating organization. Two hundred and seven people registered for this workshop, and attendance ranged from one hundred and twenty (120) to two hundred and six (206) participants across the three days of the virtual workshop.
The objectives of the workshop were to: 1) convene members of the scientific research community to explore the evidence, knowledge gaps and research opportunities for effective and sustainable obesity prevention and treatment in adults from NIH-designated U.S. populations with health disparities; 2) identify research opportunities to improve health equity in adult obesity prevalence, and access to obesity treatment and prevention efforts for all groups in the United States; and 3) discuss the challenges as well as the resources, infrastructure, training, and scientific advancements that could contribute to reducing obesity prevalence and disparities.
The workshop agenda was organized into eight sessions during the first two days, during which thirty-five scientists and clinical investigators presented their findings, research gaps and opportunities, followed by panel discussions to address questions and comments. The third day consisted of summarizing discussions and outlining further research opportunities. The workshop sessions were moderated by the workshop co-chairs, speakers, and members of the Organizing Committee.
Background
Data from the National Health and Nutrition Examination Survey (NHANES) show that 41.9% of Americans had obesity in 2020, and 9.2% had severe obesity (Stierman et al., 2021). Adult obesity prevalence in the United States increased from 46.9% in 1999 to 58.1% in 2020 (Hu et al., 2023) and is higher in African Americans (49.9%) and Hispanics (45.6%) than in non-Hispanic whites (41.4%) and non-Hispanic Asians (16.1%) (Stierman et al., 2021). Obesity is associated with 78 different co-morbidities, and people with obesity often experience low self-esteem, depression, lower access to quality health care, and poorer health outcomes. Interventions to impact obesity-related health disparities need to address structural racism (external and internal biases) and social determinants of health, create partnerships that address upstream drivers, include pathways sensitive to cultural differences that are derived from engagement with populations with obesity, and apply proactive strategies to maintain equitable access and engagement with obesity treatment.
Discussions
After brief introductions and charge, the workshop focused on the following discussion topics:
Obesity Prevention and Treatment Through a Health Equity Lens and State of the Art Interventions to Reduce Health Disparities
Participants discussed the limited research specific to obesity disparities and health equity. An equity-focused framework was presented to guide future research design and formulation of obesity interventions that will lead to equitable impact. This framework illustrated potential policy and systems change interventions at multiple levels to increase healthy options and reduce deterrents, as well as individual and community resources and capacity. Two theoretical cases of patients with obesity with divergent outcomes were presented to demonstrate several health disparities and their impact on each patient’s ability to achieve a successful outcome. The cases emphasized the need to address the social determinants of health (SDOH) that significantly influence individual outcomes. Other speakers discussed key findings including outcomes of large-scale clinical trials with participants from two historically underserved populations, the potential of commercial weight loss programs as a referral resource for clinicians and employers and a rich data source for research, the need to expand access to safe and effective anti-obesity medications, and health disparities in bariatric surgery where underutilization is often driven by lower referral rates and disparate insurance coverage.
Research Gaps and Opportunities
- Documentation of specific pathways that link social determinants to health disparities as the basis for more focused interventions. Determine how social circumstances impact access, adherence, and long-term treatment in different groups.
- Develop theoretical models for policy, systems, and environmental change rather than only for behavioral change.
- Identify and understand key psychosocial variables, as well as patient and provider biases, that impact how patients navigate the healthcare system when seeking treatment for obesity.
- Facilitate wider dissemination and use of systems science approaches to build integrated and intersectional strategies that deliver personalized obesity treatment to those from disadvantaged backgrounds.
- Understand the health economics of allocating healthcare resources based on the need to eliminate health disparities in obesity and develop relevant funding models across institutes and agencies.
- Develop larger data sets and procure data from diverse populations to study the relationship between weight loss, weight regain, and health improvements in different racial and ethnic groups and/or across a variety of different clinical health outcomes.
- Achieve substantial and sustained weight reduction by treating obesity with anti-obesity medications and surgical options.
- Review impact on health outcomes and engagement for programs involving partial subsidies, insurance coverage, treatments based on digital platforms, and other approaches that increase accessibility.
Addressing Obesity Disparities in High-Risk Populations and Intervening on Social and Structural Determinants of Health
Speakers discussed the need for more culturally adapted interventions and programs that address the intersectionality of multiple identities on obesity. Primary care approaches can be improved and made more accessible with increased utilization of electronic records and digital platforms, greater resources to educate patients and providers on pharmacotherapy treatment options, and increased training about biases and barriers to treatment of obesity as a disease. Increasing economic access to healthy foods, housing, and primary care promotes greater rates of engagement and adherence to interventions. Several examples of intervening on social determinants of health were discussed, including nutrition incentives, subsidies, produce prescriptions, and implementation of low-cost digital platforms to provide greater access and dissemination of programs. Community-based participatory research (CBPR) methods are associated with significant reach and retention of traditionally “hard-to-reach” populations. Speakers discussed the potential impact of neighborhood-level initiatives and public policies that focus on community health, as well as how community, economic, and lifestyle interventions affect the rates of successful outcomes. The impact of stigmas surrounding weight and race on overall health and accessibility to treatment was recognized as an underlying theme affecting access and adherence to interventions.
Research Gaps and Opportunities
- Develop and standardize metrics for the measure of impact of structural racism, stress, economics, and SDOH in studies to provide consistency in reporting of results and generation of larger datasets.
- Further investigate commercial determinants of health (strategies used by the private sector to promote products that are detrimental to health) within the broader scope of social determinants of health in communities.
- Design studies to learn more about the impact of intersectionality of multiple identities on obesity (e.g., racial/ethnic group and rural residence; racial/ethnic group and gender and/or sexual minority group, racial/ethnic group in persons living with disabilities).
- Develop therapeutic clinical trials with diverse approaches, as well as increased development and dissemination of culturally adapted and/or tailored interventions, to maximize utilization and engagement in programs and increase successful outcomes.
- Develop integrated platforms and methods that utilize digital and electronic medical records, patient portals, electronic scales, virtual clinic visit options, and other technologies to increase availability, and engagement and retention of patients in primary care settings.
- Develop tool sets to identify both barriers and facilitators (e.g., patient, provider, system) to guide equitable use of newer, highly effective weight management medications and programs in underserved patients and communities.
- Determine how obesity interventions can result in co-benefits to individuals and communities and identify equitable partnerships within communities to foster such interventions.
- Utilize technology, systems science, and neighborhood-level initiatives to increase access to healthy foods, dietary and nutritional education, and address gaps in social, economic, and other contributors to health disparities within and between communities.
Research Designs, Methods, and Use of Technology with Health Disparity Populations
Participants discussed the benefits of developing and utilizing various technologies to address health disparities and improve health outcomes related to obesity. The benefits of employing systems science methods, computer-aided programs, and artificial intelligence (AI) in the analysis of data can better account for inequities based on social, cultural, demographic, and geographical diversity that traditional methods often fail to address. Systems science can also simulate clinical and economic benefits of interventions and policies. Participants discussed how electronic health records (EHR) and community-based participatory research (CBPR) methods can adapt and tailor interventions to get the right treatment to the right person at the right time and identify specific investments to improve outcomes within under-resourced communities (e.g., infrastructure, expanded access to healthier foods, key partnerships). Results from additional studies found that incorporating online and digital weight management technologies and gamification strategies—delivered through primary care settings and integrated into health care delivery systems—are efficacious and can increase engagement and successful outcomes, particularly in populations with greater health disparities and resistance to traditional interventions. Such technologies may be lower in cost and more easily scaled and adapted to different populations or settings. Participants also acknowledged the potential discriminatory harm of AI that that may “bake in” racial/ethnic and gender bias.
Research Gaps and Opportunities
- Develop more artificial intelligence and computer-aided approaches to analyze complex, multi-layered sets of data on social and behavioral determinants of health while also evaluating the efficacies of obesity interventions, treatments, and policies.
- Increase training and research opportunities to develop more interdisciplinary researchers with experience using systems methods to address the various systems that affect obesity prevention and control.
- Develop methods and workflows to expand the use of electronic health records (EHR) to prescribe medications and surgery, collect data, document social and behavioral determinants of health, refer patients to obesity treatment programs, and enable direct outreach to patients without creating more work for primary care providers.
- Examine different intervention designs (e.g., Sequential Multiple Assignment Randomized Trial (SMART), BestFIT) to develop rules on how and/or when to alter treatment to produce clinically significant weight loss and successful outcomes.
- Investigate the mechanisms of previously successful workplace-based initiatives, including those used to deter use of alcohol, tobacco, and sugar-sweetened beverages, and how such initiatives could benefit obesity treatments.
- Expand the use of “Citizen Science” and other CBPR approaches to collect data and input directly from the community to address the unique obesity, diet, and physical activity inequities.
- Explore the implementation of online and digital technologies to increase reach, engagement, and success in programs for the treatment and prevention of obesity.
- Evaluate strategies to minimize or eliminate potentially discriminatory bias in algorithms.
Innovative Dietary Interventions and Obesity Prevention and Treatment in Special Populations
Data were presented that illustrated the considerable cost of overweight, obesity, and diet-related diseases among American adults—an estimated $1.1 trillion lost every year in preventable healthcare spending and productivity (Fallah-Fini et al., 2017). Several initiatives and pilot programs to address obesity-related health inequities have already been proposed and implemented including medically tailored meals (MTMs) and produce prescriptions; home visiting programs to educate women about healthy eating and active living; and integrating community with scientific knowledge to change systems and structures that have historically perpetuated obesity and weight gain. Existing research shows that culturally adapted dietary interventions can be effective in changing behavioral patterns, supporting positive lifestyle changes, and lowering the risk of severe cardiovascular disease events. Focus on the local food environment and traditional foods of a region benefit interventions that promote healthy food choices and influence decision-making and behavioral change. Participants discussed the challenges that exist in translating the initial success of some approaches into programs that can be successfully implemented across diverse populations. They also acknowledged that more attention is needed on how policy and advocacy efforts can better support obesity treatments. Biases (e.g., cultural, racial/ethnic, health history, sexual or gender identity) within existing research approaches must also be recognized and addressed to reduce inequities and close gaps in successful outcomes.
Research Gaps and Opportunities
- Identify key barriers to implementing Food is Medicine (FIM) interventions for healthcare systems and federal and private payors.
- Determine the optimal duration, dose, and cost-effectiveness of FIM interventions for different health conditions.
- Increase the scientific knowledge that measurably impacts lifestyle behavior change interventions by shifting from a focus on individual mechanisms of change to strategies that account for social and cultural networks in which individuals are embedded. Such networks strongly influence health-related attitudes and behaviors, which in turn affect reach and sustainability.
- Investigate how individual and coexisting root cause inequities across gender, racial/ethnic group, sexual/gender identity, etc. impact weight gain and quantify the impact of unmet social needs on the prevention and treatment of obesity.
- Determine the impact of innovative technologies on the reach and uptake of interventions.
- Identify specific barriers to the uptake of weight gain prevention interventions and evaluate meaningful methods of stakeholder engagement.
- Develop evidence-based methods and leverage community assets to change structures and systems that perpetuate obesity and weight gain in diverse populations.
- Determine the effects of time restricted eating and intermittent fasting approaches in various racial/ethnic and other populations that experience health dispartities.
Cross-Cutting Themes
- Social and Structural Determinants of Health
- Develop new frameworks, theories, and models to facilitate more inclusive research of different social, political, economic, and environmental systems.
- Identify and measure impact of specific barriers such as insurance reimbursement and cost of interventions, availability and accessibility of foods and safe activity spaces, and education and resources around pharmacological and surgical treatments.
- Direct research with the understanding that obesity is influenced by many different social, political, economic, and environmental factors.
- Translational and Implementation Research
- Understand the mechanisms of successful outcomes and how to implement and adapt to diverse populations.
- Create equity-minded tools to measure the impact of policy, environment, and culture on health outcomes.
- Understand and address how foundational data sets used in systems science-based approaches may contain inherent racial or other biases, which may skew results, make them non-transferrable, and impact translational and implementation interventions.
- Identify the roles of employers, health plans, care delivery systems, and community partners in the implementation of research initiatives and interventions.
- Understand barriers to increasing utilization of effective medical and surgical treatments and develop interventions to overcome those barriers, particularly in communities that have been traditionally underserved or disadvantaged.
- Community Partnerships
- Build and rebuild trust in communities, health care, and science by facilitating community engagement and collecting information from diverse populations that are traditionally underserved and underrepresented in research.
- Recruitment and retention of researchers from diverse populations should also be prioritized to enhance trust and community engagement.
- Support more development of community-based participatory research (CBPR) methods to increase community engagement and develop interventions that are adapted to the diversity of a community.
- Address the potential impact of neighborhood-level initiatives that focus on community health. For example, engage key commercial, retail, workplace, and infrastructure partnerships to address access to healthy foods, improve marketing schemes of healthy food within communities, incentivize employer buy-in to health initiatives, and improve accessibility to active spaces.
- Methods and Measurement
- Develop and validate standardized methods to measure the impact of structural racism, stress, economics, and SDOH in studies to provide consistency in results reporting.
- Design interdisciplinary systems science methods to examine intersectionality of multiple identities and SDOH and to quantify impacts of unmet social needs.
- Consider the historical causes of inequities and how they contribute to current disparities when developing new approaches.
- Expand use of artificial intelligence and electronic health records to develop and adapt interventions tailored to an individual while considering and addressing potential biases in aggregate data sets.
- Include in the analytical framework more diverse populations, particularly those from traditionally understudied and underserved communities, including American Indians, African Americans, immigrants, pre- and postpartum mothers, men, and individuals with sexual and gender differences.
Participants ranked categories of research priorities as follows, acknowledging that they were integrated and could be incorporated into a systems science approach:
- Social and structural determinants of health
- Multi-level obesity interventions
- Translational and implementation research
- Foster community partnerships and engagement
- Systems science approaches
- Health services and cost-effectiveness research
- Improved measurement
- Policy and economic intervention evaluation
Selected References
Fallah-Fini S, et al. The Additional Costs and Health Effects of a Patient Having Overweight or Obesity: A Computational Model. Obesity. 2017 Oct;25(10):1809-1815. https://doi.org/10.1002/oby.21965
Gittelsohn J, Lee-Kwan SH, Batorsky B. Community-Based Interventions in Prepared-Food Sources: A Systematic Review. Prev Chronic Dis. 2013 Oct 21;10:E180. https://doi.org/10.5888/pcd10.130073
Greene M, et al. Nutrition Interventions Addressing Structural Racism: A Scoping Review. Nutr Res Rev. 2022 Jan 13:1-53. https://doi.org/10.1017/S0954422422000014
Hu G, Ding J, Ryan, DH. Trends in obesity prevalence and cardiometabolic risk factor control in US adults with diabetes, 1999–2020. Obesity. 2023 Jan 25. https://doi.org/10.1002/oby.23652
Kumanyika SK. Getting to Equity in Obesity Prevention: A New Framework. NAM Perspectives. 2017. https://doi.org/10.31478/201701c
Kumanyika SK. A Framework for Increasing Equity Impact in Obesity Prevention. Am J Public Health. 2019 Oct;109(10):1350-1357. https://doi.org/10.2105/AJPH.2019.305221
Lee BY, et al. A Systems Approach to Obesity. Nutr Rev. 2017 Jan; 75(suppl 1):94-106. https://doi.org/10.1093/nutrit/nuw049
Mangione CM, Nicholson W, Davidson KW. Addressing Gaps in Research to Reduce Disparities and Advance Health Equity: The USPSTF Incorporation of the NASEM Taxonomy on Closing Evidence Gaps in Clinical Prevention. JAMA. 2022 Nov 8;328(18):1803-1804. https://doi.org/10.1001/jama.2022.19154
Stierman B, et al. National Health and Nutrition Examination Survey 2017–March 2020 Prepandemic Data Files Development of Files and Prevalence Estimates for Selected Health Outcomes. National Health Statistics Reports. 2021 Jun 14; 158: 1-10. http://dx.doi.org/10.15620/cdc:106273
Workshop Organizing Committee and Leadership:
Workshop Co-Chairs
- Jamy D. Ard, M.D., Wake Forest School of Medicine
- Monica Baskin, Ph.D., University of Pittsburgh School of Medicine
NIH Co-Leads
- Laurie Friedman Donze, Ph.D., NHLBI
- Charlotte Pratt, Ph.D., M.S., R.D, FAHA, NHLBI
Workshop Planning Committee
- Tanya Agurs-Collins, Ph.D., M.S., R.D., NCI
- Jamy D. Ard, M.D., Wake Forest School of Medicine
- Monica Baskin, Ph.D., University of Pittsburgh School of Medicine
- David Berrigan, Ph.D., M.P.H., NCI
- Brook Belay, M.D., M.P.H., CDC
- Andrea Brandau, MPP, Patient-Centered Outcomes Research Institute
- Susan M. Czajkowski, Ph.D., FABMR, NCI
- Laurie Friedman Donze, Ph.D., NHLBI
- Crina Frincu, Ph.D., NIGMS
- Bramaramba Kowtha, M.S., RDN, LDN, NIH ODP
- Robert J. Kuczmarski, Dr.P.H., NIDDK
- Leah M. Lipsky, Ph.D., M.H.S., NICHD
- Priscah Mujuru, Dr.P.H., M.P.H., RN, COHN-S, NIMHD
- Linda Nebeling, Ph.D., M.P.H., RD, FAND, NCI
- Cathie Plouzek, Ph.D., PMP, DASM, U.S. Department of Veterans Affairs
- Charlotte Pratt, Ph.D., M.S., R.D, FAHA, NHLBI
- Deborah Young-Hyman, Ph.D., NIH OBSSR
- Dan Xi, Ph.D., NCI
Workshop Participants:
Workshop Speakers and Moderators
- Tanya Agurs-Collins, Ph.D., M.S., R.D., NCI
- Jamy D. Ard, M.D., Wake Forest School of Medicine
- Heather Baer, Sc.D., Brigham & Women's Hospital
- Monica Baskin, Ph.D., University of Pittsburgh School of Medicine
- David Berrigan, Ph.D., M.P.H., NCI
- Brook Belay, M.D., M.P.H., CDC
- Gary Bennett, Ph.D., Duke University
- Loneke Blackman Carr, Ph.D., R.D., University of Connecticut
- Susan M. Czajkowski, Ph.D., FABMR, NCI
- Jessica Yelena Breland, Ph.D., VA Palo Alto Health Care System
- Carmen Byker-Shanks, Ph.D., RD, Gretchen Swanson Center for Nutrition
- Tiffany L. Carson, Ph.D., M.P.H., FTOS, Moffitt Cancer Center
- Caitlin Caspi, Sc.D., University of Connecticut
- Lisa S. Chow, M.D., University of Minnesota
- Kristen Cooksey Stowers, Ph.D., University of Connecticut
- Wendy Demark-Wahnefried, Ph.D., R.D., University of Alabama
- Evan Forman, Ph.D., Drexel University
- Gary Foster, Ph.D., Weight Watchers International
- Amanda Fretts, Ph.D., M.P.H., University of Washington
- Joel Gittelsohn, Ph.D., Johns Hopkins University
- David Goff, M.D., Ph.D., NHLBI
- Lisa Goldman Rosas, Ph.D., M.P.H., Stanford University
- Stephanie Goldstein, Ph.D., Brown University
- Debra Haire-Joshu, Ph.D., Washington University
- Melanie Jay, M.D., M.S., New York University
- Shaneeta Johnson, M.D., MBA, FACS, FASMBS, ABOM, Morehouse School of Medicine
- Namratha Kandula, M.D., M.P.H., Northwestern University
- Thomas Keyserling, M.D., M.P.H., University of North Carolina, Chapel Hill
- Ania Jastreboff, M.D., Ph.D., Yale University
- Peter Katzmarzyk, Ph.D., FACSM, FTOS, FAHA, Pennington Biomedical Research Center
- Bramaramba Kowtha, M.S., RDN, LDN, NIH ODP
- Shiriki Kumanyika, Ph.D., M.P.H., University of Pennsylvania
- Bruce Y. Lee, M.D., City University of New York
- Kristina Henderson Lewis, M.D., M.P.H., SM, Wake Forest University
- Michelle Martin, Ph.D., University of Tennessee
- Dariush Mozaffarian, M.D., Dr.P.H., Tufts University
- Priscah Mujuru, Dr.P.H., M.P.H., RN, COHN-S, NIMHD
- Linda Nebeling, Ph.D., M.P.H., RD, FAND, NCI
- Robert L. Newton, Jr., Ph.D., Louisiana State University
- Angela Odoms-Young, Ph.D., Cornell University
- Emily Panza, Ph.D., Brown University
- Rebecca Pearl, Ph.D., University of Florida
- Eliseo Perez-Stable, M.D., NIMHD
- Nico P. Pronk, Ph.D., M.A., FACSM, FAWHP, HealthPartners Institute
- Carmen Samuel-Hodge, Ph.D., M.S., RD, LDN, University of North Carolina, Chapel Hill
- Fatima Cody Stanford, M.D., M.P.H., MPA, MBA, FAAP, FACP, FAHA, FAMWA, FTOS, Harvard / Massachusetts General Hospital
- Laura Schmidt, Ph.D., University of California, San Francisco
- Nancy Sherwood, Ph.D., University of Minnesota
- Bonnie Spring, Ph.D., Northwestern University
- Deborah Young-Hyman, Ph.D., NIH OBSSR
- Rena Wing, Ph.D., Brown University