One of the risks to developing a momentum for environment-led obesity prevention is that obesity as an issue gets combined with diabetes and cardiovascular diseases, and then most of the funding and efforts are channeled into clinical interventions and/or mass-media strategies. While the rationale for such clumping is readily defendable and these strategies are important, a primary focus on improving the environments for healthy food and physical activity choices is needed if population-based prevention is to be a priority.
Table 4 Criteria for Ideal Indicators of Obesogenic Environments
Easy to measure
Inexpensive to measure Easily understood
The environmental factor it reflects should have a significant impact on behaviors, e.g., TV advertising on food choices.
It should faithfully reflect the environmental factor in question, e.g., local government budgets for public transport support and cycleways versus major road works as a true reflection of the public investment in active transport versus car transport.
It should be able to detect small changes in the environmental factor, e.g., a yes/no question about the presence of a school food policy may not be sensitive enough to detect differences in effectiveness of policies.
The intra- and interobserver error and random error should be minimal; e.g., questionnaire-based indicators often need test-retest reliability assessments, whereas the number of cars per household from census data would be considered reliable.
Ideally it would use data which are already collected for other purposes, e.g., proportion of local government transport funding for active transport versus car transport.
Questionnaire-based indicators, e.g., sociocultural indicators will be relatively expensive to measure.
Indicators that have complex derivations and are highly adjusted are less likely to be well understood, e.g., access to recreational facilities that is measured using distance-decay formulae and adjusted for attractiveness of the facility and the type of facility.
B Keeping the Interventions Achievable and Sustainable
The vastness of the task of preventing obesity is a classic barrier to action. To build the political and community case for action, the interventions need to be doable. Expanding existing programs that have shown some success (43,63-65), limiting the geographical reach of interventions in the first instance (i.e., establishing demonstration or sentinel sites) or focusing on a small number of settings are all strategies that can overcome the ''inertia of enormity.'' However, a long-term vision (and funding) is needed for the programs to be developed, tested, evaluated, and implemented more widely.
Perhaps the strongest case for priority environments to influence are those related to children and adolescents. Nowhere does the ounce of prevention versus the pound of treatment apply more appropriately than with obesity because of the difficulty of losing excess fat once it has been gained. Also the range of achievable environmental interventions for children is greater than for adults (see below).
Most of the environments that influence eating and activity patterns lie outside the jurisdiction of health and therefore need the engagement of a range of stakeholders. The strong backing from the community, the setting stakeholders and politicians is vital to securing the momentum and funding for interventions.
A high-quality program to reduce obesity would have a long duration, be sufficiently well funded to achieve a high dose of the intervention(s) and a wide reach to priority populations, and have robust evaluations. One of the temptations for governments with a low commit- £ ment to long-term solutions for obesity is to establish one or two short-term, low-dose, high-profile interventions. Another is to shift the responsibility onto individuals (to make the healthy choices), private industry (to use market forces to create healthy environments), or the health charity sector like heart foundations and cancer societies (to fund the programs). High-dose programs over long periods are needed, and this inevitably means government vision and funding. Evalua tion is needed at every step: early formative inquiry, process evaluation (including of the implementation and roll-out phases), outcome analysis, and ongoing monitoring. Highly controlled, one-off interventions provide useful information about efficacy, but what is probably much more valuable is longitudinal evaluation studies (often less well controlled) of the real-world effectiveness of ongoing programs (66).
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