Obesity,Integral Leadership,and Health Policy

Introduction

Obesity has been called the most prevalent health epidemic among Americans, and is associated with major chronic diseases that increase morbidity and mortality across our nation. ¹ The facts about obesity have been repeated over and over in the literature.^2–5 Reversing the obesity epidemic requires leadership in the policy arena. ¹ So who is to supply such leadership? Do you have a mirror in front of you as you read this article? Leadership to eradicate obesity is not delegated only to state or national political representatives. It begins simply, within each household, within each job site, within each community, and it spreads from there. Leadership is exercised each time we purchase food from the grocery store, each time we order from a menu, each time we select a dish to serve at a function. Leadership empowers and uplifts those whose lives are affected by the disease of obesity. What is needed is an ecological approach to policy leadership that is focused on obesity and that begins within each of us.

While the debate for obesity causation vacillates among researchers, it is evident that obesity is multi-causal, with factors that include the behavioral, ⁵ genetic, ⁶ psychosocial, ⁷ nutritional, ⁸ and physical. ⁹ Trying to attach “blame” to a multifactorial disease process is not patient-centered and does much to generate stigma barriers, which further complicate the ability to address the needs of patients who are obese.^10,11 The research literature implicates individuals who are diagnosed with obesity as personally culpable ¹² for major diseases such as cancer, ¹³ diabetes, ¹⁴ cardiovascular disorders, ¹⁴ sleep disorders, ¹⁵ digestive disorders, ¹⁶ and depression. ¹⁷ Do we tell persons diagnosed with schizophrenia that they are to blame for their delusions? Do we send those individuals out the door and tell them to go home and not think about their delusions? Surely not. But we do send the obese home with the command that they should not think about eating all that food. This, then, shows us one instance in which leadership demands an enlightened, professional response.

Integral Leadership

Integral theory suggests that each of the aforementioned diseases and disorders is associated with obesity. They are interrelated, and at some level, we make choices for health that can offset genetic and environmental factors. Further, integral theory indicates that causality theories also correspond with one another, as obesity is a complex disease process, interacting dynamically within a given individual, and in aggregate, within populations. ¹⁸ Integral theory provides a framework for review of leadership in that it poses multiple truths, each lending its own weight of truthfulness and each having its own limitations. ¹⁹ Thus integral leadership and a systems approach are needed to address the complexity of obesity. Reams (2005) describes integral theory using a four quadrant approach to help one understand the interconnectedness of systems, one to the other, and of the individual to the collective. ¹⁹ In addition, developmental stages are embedded within integral theory, which helps us to comprehend how leadership abilities evolve. ¹⁹

Leadership in addressing the growing epidemic of obesity has been successful in narrowing the focus of research to define specific domains clearly. It is now time to engage consciously in leadership and in moving the research agenda for obesity to a higher level of holistic systems integration. ²⁰ This evolution in leadership will cause some tension, as perspectives held on the cause and effects of obesity are often bound up with purist thoughts. However, an interprofessional collaborative approach to setting research agendas can assist in forming policy that will support such integral leadership endeavors while addressing the multifaceted needs of efforts to halt the global obesity epidemic. ²⁰ Hammond (2009) offers a mechanism for such leadership in obesity research through modular processes, but notes that such designs offer challenges to policy makers, who often overlook the expansive array of complexities, choosing rather a special-interest approach to policy development. ²⁰

Health Policy: An Opportunity for National Leadership

Integral leadership is needed across the ecological levels of policy in order to reverse the dispiriting trends in health outcomes related to obesity. At the national level, healthcare reform legislation titled the Patient Protection and Affordable Care Act (PPACA) ¹² offers benefits and some barriers when addressing the obesity epidemic, and provides opportunity for leadership among health professionals. Benefits, to those diagnosed with obesity, are that the healthcare reform legislation (now supported by Supreme Court action) includes: (1) insurability, (2) claims processing for preexisting conditions, (3) prohibition of insurance caps, and (4) preventive and behavioral health services. ¹ Barriers created by the healthcare reform bill are: (1) premium health insurance plans will be taxed, and those costs are projected to cause a scale-down in approvals for bariatric surgery coverage; (2) obese persons on employer health insurance plans may not be discriminated against, but if they do not meet wellness criteria, they can be billed at 50% of costs for certain services; (3) bans on pharmaceutical treatment of obesity under Medicare continue; and (4) some ambiguities on the specifics of the legislation continue to be worked out in committees and advisory boards. ¹ The National PPACA legislation will give some leverage to states in the enactment of the law. It is important for both bariatric specialists and primary providers who care for those with bariatric needs to remain informed, to communicate with legislators at state and national levels, and to exercise the privilege of voting for representatives who support a holistic obesity agenda. As a health professional, you can choose to develop consciously into an integral leader representing the needs of the obese.

Health Policy: An Opportunity for State Leadership

In seeking to represent a holistic obesity agenda, health professionals who would serve as integral leaders can find many opportunities for action at the state level. Some health-professional employers prohibit legislative involvement of their employees, including lobbying activities. Integral leadership requires extensive collaboration in addressing the obesity agenda, and it is advisable to follow the principles of personal and professional ethics to guide participation in policy development. ²¹ However, belonging to obesity advocacy organizations (ones that educate legislators) is a personal and professional right that is allowed, and models exist that attend to potential ethical conflicts. ²² Service is needed by professionals who would lead within these advocacy organizations and within professional associations. Strive to serve on state or regional boards that support an obesity agenda and promote the adoption of ecological frameworks for tackling the complexities of obesity.

Health Policy: An Opportunity for Local Leadership

One must not overlook chances to serve as an integral leader within one's own community. Policy is not just set at national and state levels but at local levels as well, where the ethics of care are based upon the narratives of neighbors, family members, and sometimes the self. ²³ At the local level, seemingly small actions can be as significant as sweeping national legislation to those suffering from obesity. Local actions can be as simple as using larger scales, gowns, and chairs within a clinical practice to ensure the comfort of the obese. ²⁴ As practitioners who care for the bariatric needs of patients, we must be certain we comprehend the social and structural inequities attending obesity, and that we seek to address them on individual and population levels. ²⁵ Employing a public health model necessitates integral leadership in zoning locations of fast-food services, budgeting for sidewalks and parks, support for recreational programs in all communities, and advocacy of local farm produce markets. ²⁶ All healthcare professionals can be engaged at some level of integral leadership that seeks to develop solutions to the obesity epidemic.

Advancing Obesity Policy Reform

Policy reform reverberates through the ecological system of community, state, nation, and globe. Obesity healthcare must be humanistic in nature, not just driven by the bottom line of an accounting balance sheet. ²⁵ Yet, it is still important that obesity care be cost-effective and that it be contained in a manner led by integral theory, recognizing the interrelatedness of causation and disease factors.^27–30 Given the enormity of the obesity epidemic, the problem touches each of us on a personal level. While electronic medical records hold some promise for researching the factors of disease among those with obesity, relationship still matters. ³¹ Healthy People 2020 objectives define standards for addressing the social determinants of health related to the root causes of obesity, and note the interaction of those agents within society that lead to an advancing epidemic. ³² Consequently, Healthy People 2020 campaigns for a “health in all policies” (HIAP) approach, which is also supported by the World Health Organization and is consistent with integral leadership. ³² The health impacts of policy reform at all levels (local, state, and national) must be measured so that we can determine whether zoning rules, investment in sidewalks and recreation, or state mandates regarding vending machines at schools, or even changes implemented from the national PPACA, result in long-term changes in obesity outcomes. Obesity, with its causes and effects, brings multiple truths, each having its own weight of truthfulness and its own limitations; ¹⁹ and the same is true for the policies we develop to combat individual and population outcomes. Hence, the imperative call for integral leadership this paper seeks to deliver.