Trimming the Fat: Making Healthy Populations

Question 1

Topic

Answer 1

Rising levels of Obesity have led to increasing concern that the next generation will be less healthy than their parents. The implications for health status, and health expenditures, have led to calls for remedial action. What are the alternatives, and who should be responsible for enacting them?

Question 2

Policy Issues Addressed

Answer 2

determinants of health, the concept of implementation and healthy public policy, framing, public/private roles responsibilities, policy instruments, and the roles of state/market

Question 3

What is Obesity?

Answer 3

• measured by Body Mass Index (BMI) which is a ratio of height and weight
• normal weight; BMI 18.5-24.9
• overweight; BMI 25-29.9
• Obese; BMI 30 and over
• considered both a health problem and a health risk factor
• associated with increased immediate and long-term effects such as heart disease, stroke, diabetes, cancer, bone and joint complications, poor mental health

Question 4

How Has Obesity Changed?

Answer 4

• changed over time (increased rates of obesity now vs. in the 1970s)
• different over space (prevalence is higher in some countries)
• different across the life course (obesity and overweight are higher as age increases
• costs to treat obesity have increased over time

Question 5

Framing (what is it?)

Answer 5

• mental structures that people use to provide categories and a structure to their thoughts
• how a potential hazard is processed? How a policy is perceived? how a policy is evaluated?
• demonstrates how the same set of facts can be used to present different messages
• how to best influence an outcome
• helps determine what stakeholders can participate

Question 6

Framing (lenses)

Answer 6

Perspectives on Burden:
- individual health
- population health
- health care system/ cost issue
- risk factor for other conditions or a risk factor in and of itself
- current and future risks

Combination of genetic factors, individual lifestyle behaviour, and/or environment within which people live
- e.g. built environment - compounded by the climate, weather, on how mobile individuals are

Access to fresh fruits and vegetables - complex dynamics involving the availability of of food and its price; this in turn relates to household income and household spending, and economic conditions

Question 7

Population Health

Answer 7

Unifying ‘force’ for health system interventions from “prevention and promotion to health protection, diagnosis, treatment and care” - and integrates and balances action between them

Health is influenced by “social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development and health services”

Inter-related conditions and factors that influence the health of populations across the life-course

Question 8

Demography and Population Health Geography

Answer 8

• is a branch of the social sciences concerned with the human population, its structure and change, and its relationship with the environment AND social and economic change
• includes things such as size, rates of growth, fertility, life expectancy and mortality
• Provides a lens which can help us understand observed trends and can help predict what will happen in the future

Question 9

Strategic Lenses

Answer 9

Target?
- entire population
- population currently at risk
- morbidly obese
- food producers
- consumers

Resolution is likely to need multiple stakeholders and approaches - ex. governments at multiple levels, social services, health promotion, etc.

Question 10

Types of environment

Answer 10

Natural Environment
Built environment
social environments

Question 11

What is the “built environment”

Answer 11

• research shows that the built environments in which we live, work and play have a direct impact on our health
• includes anything in our physical environment that is human-created such as buildings, parks, and neighbourhoods.

Question 12

Examples of built environments

Answer 12

• neighbourhoods
• homes
• workplaces
• schools
• shops and services
• sidewalks and bike paths
• streets and transit networks
• green spaces, parks and playgrounds
• buildings and other infrastructure
• food systems (the path that food travels from field to fork: the growing, harvesting, processing, transporting, marketing, consuming, and disposing of food)
• the built environment extends overhead in the form of electric transmission lines and underground in the form of waste disposal sites and subway lines and across the country in the form of highways

Question 13

Important considerations of built environment

Answer 13

• population density
• urban sprawl
• land use patterns
• pedestrian and cyclist safety
• climate
• access to food; deserts and swamps
• noise
• crime
• gentrification: taking an old house, renovating it, selling it to a younger population

Question 14

Opportunity structures

Answer 14

“…socially constructed and socially patterned features of the physical and social environment which may promote or damage health either directly, or indirectly through the possibilities they provide for people to live healthy lives.”

Question 15

Built Form is Important

Answer 15

• less obvious features of the built environment (parks; turf vs. natural grass)
• food deserts and swamps
• social and physical environments promote or damage health in multiple interconnected ways
• better community design can promote better health by improving access to healthy food and good public spaces to play, as well as making neighbourhoods more ‘walkable’
• paying attention to features of our community that we have not traditionally focused on will go a long way

Question 16

good policy should do what?

Answer 16

address every level of the social-ecological framework, including intrapersonal, interpersonal, physical environment, and public policy factors

Question 17

Criteria for Selecting Policy Alternatives

Answer 17

Effects; Effectiveness, unintended effects, equity

lead to:

Implementation; cost, acceptability, feasibility

and the cycle repeats

Question 18

Key Considerations when choosing a policy

Answer 18

• Costs; actual costs, opportunity costs, cost-effectiveness (and “whose costs?”)
• Role of the State
• What role does political ideology have in obesity policy?
• Note: Government turnover and implications this could have for long term policy change
• Individual and societal rights and the extent government should interfere with those rights (individualism vs. collectivism)

Question 19

Opportunity Costs

Answer 19

• “the true cost of something is what you give up to get it”
• How much good health would be lost if more money were allocated to this intervention rather than that one? What is the most productive investment, in terms of health, for any new resources?

Question 20

Types of Policies

Answer 20

• Redistributive policies: policies that impose costs or provide incentives to encourage certain individual and systems behaviours. e.g. taxation or subsidies
• regulatory policies: impose restrictions or inducements on defined individual and systems behaviours. e.g. sanctions
• “allocation” policies fund activities and strategies to produce longer-term health benefits for the population

Question 21

Policy Considerations

Answer 21

• Trade-offs between the importance of protecting the health of the population, respecting individual liberties, and controlling health expenditures
• the chronic disease could lead to increased needs for care (and higher costs) BUT if it results in lower life expectancy, it decreases lifetime health system costs (since dead people do not use healthcare), as well as lower costs for other programs (e.g. pensions)
• what criteria? How will recommendations change if you were: the deputy minister of agriculture? Of finance? Advising the restaurant association? The food industry? the diabetes association?

Question 22

Policy Instruments

Answer 22

Material Policy instruments: likely to result in changes in actual implementation practices
1. Exhortation - governments encourage stakeholders to act in a particular way (e.g. information/education, symbolic gestures)
2. Expenditure - government provides funds for a specific purpose (e.g. taxation, including tax breaks)
3. Regulation - rules are established to encourage or penalize certain types of actions (e.g. laws, meeting standards)
4. Public Ownership - government directly runs an activity (e.g. direct provisions of goods and services)

Question 23

Authority Based Rules

Answer 23

• Laws
• Regulations
• directives
  e.g. regulating the food industry
  e.g. food safety - supply chain safety of banning processed food ingredients like trans-fats

Question 24

Economic Instruments

Answer 24

• a range of policy tools - examples
• affect change or influence behaviour by putting a cost on intangibles (e.g. increasing prices of goods and services that damage health and the environment)
• incentives for investments in innovation and improved environmental technology so that both health and financial benefits are generated
• financial transfer to individuals and organizations from governments that encourage or discourage a particular activity
• The raising of revenues to achieve environmental and health objectives via tax policies

Question 25

Chances of doing a “good thing”

Answer 25

• synergy with other policies
• population health impact assessment
• feasibility to implement
• complexity
• resource base
• political commitment
• long-range policy negotiation tradition, or the persistent policy push exerted by a committed agency

Note:
equality = sameness, equity = fairness

Question 26

Stakeholders - who’s involved and who decides?

Answer 26

• government; agriculture, child and youth services/social services
• health promotion’ers’, medical specialists, Big Pharma
• Associations
• Agricultural Industry
• food industry
• the media
• institutional arrangements
• individuals

Question 27

Ethical Decision Making

Answer 27

• Structural Functionalism? Interpretivism? Critical Theory?
• What is the right thing to do?
• Virtue Ethics? Utilitarian? Personalism? Principilism?
• Consensus or conflict?
• Individualism vs. Collectivism
• Stone, 2002: Security, Liberty, Equity, Efficiency

Question 28

Policy Options

Answer 28

1. Changing the built environment
2. Taxing sugar-sweetened beverages
3. Subsidizing Healthy Foods
4. Restricting Marketing of Unhealthy Foods/Drinks
5. intensifying nutritional labels
6. education on physical activity
7. Invest in Healthcare Services
8. Incentives that promote physical activity