March 20, 2017
With a plethora of health issues competing for the attention of policymakers, the politics of which diseases become national priorities is complex. Why do some health challenges receive broad support from policymakers, while others remain widely ignored?
Obesity has received increasing recognition in the health policy space over the past decade, providing an interesting case study for analyzing how political priorities are established in global health. In 2001, the United States Surgeon General, Dr. David Stacher, issued a “Call to Action to Prevent and Decrease Overweight and Obesity.” Citing the “epidemic proportions” of overweight and obese Americans, the call affirmed obesity’s significance on the national health agenda (1). Now the Centers for Disease Control (CDC) estimates the prevalence of obesity in the United States to be 36.5% (2). As Tom Frieden, the director of the CDC, described, obesity is considered “among the most urgent health challenges facing our country today” (3).
Kingdon’s Three Streams Model of Policy Analysis:
In an attempt to elucidate the intricacies of policy making, scholars have developed various frameworks to analyze why certain issues “rise to the top” of the political agenda.
The three streams model, developed by renowned political scientist John Kingdon, is a policy change framework that has been used in global health to analyze policy environments (4). The three streams model asserts that the convergence of three independent “streams” determines whether a particular policy issue will prompt political action. The problem stream involves persuading policymakers to prioritize a particular issue above other potential problems that policymakers could tackle. The policy stream concerns whether a feasible solution to the problem exists. Finally, the politics stream consists of the political factors and the political environment in which a policy is brought forth. While each of these streams acts independently, a policy will only reach the top of the political agenda when all the three simultaneously come together. Through the convergence of the three streams, a “policy window” emerges, providing an opportunity for political action.
As applied to the case of obesity in the United States, Kingdon’s three streams model of policy analysis reveals how problem, policy, and politics converged to push obesity onto the policy agenda, culminating in First Lady Michelle Obama’s “Let’s Move” campaign in 2010.
With the doubling of obesity rates in adults and tripling in children between 1980 and 2000, politicians and the general public quickly accepted obesity as an escalating concern at the turn of the 21st century (2). Its dominance on the health agenda was sustained in the early 2000s by steady climbs in obesity’s prevalence, which reached over 36% in adults and 17% in children by 2014 (2). With links to some of the nation’s leading causes of death—including heart disease, stroke, various cancers, and diabetes—obesity became a pressing concern in the U.S. public health arena (3). More so, in 2013 obesity was first recognized as a disease by the American Medical Association, solidifying the condition as a target for policymakers (5).
Beyond its high prevalence and detrimental health implications, obesity’s cost to society provided an impetus for political action. Alongside its increasing prevalence, the medical costs of obesity climbed from an estimated $78.5 billion in 1998 to $147 billion in 2008 (6). Medicare/Medicaid provided roughly half of this spending, making obesity a concern for taxpayers and politicians alike. Backed by research demonstrating obesity’s widespread morbidity and financial burden, obesity advocates constructed a convincing case for investing in obesity prevention, solidifying Kingdon’s problem stream.
Within the policy stream, the acknowledgement that external factors contribute to an individual’s obesity created an acceptable space for developing effective obesity prevention policies. Historically, the obesity epidemic has been framed as a health issue rooted in “personal responsibility,” with the dominant narrative asserting that avoiding unhealthy eating behaviors is the duty of each consumer. By placing the burden of change on individuals, the “personal responsibility” frame lends itself to “soft” policies, like nutritional education. The personal responsibility frame also discourages legislative action. Why should a government support those who are “unable to control their self-destructive appetites?” (7).
However, as obesity rates continued to climb and evidence confirmed that many obesity educational campaigns were ineffective, this view began to shift (7,8). The newer “obesogenic-environment” frame emphasizes that modern environments have created an “induced demand” for unhealthy foods, and that many individuals lack control over their diet. This frame prompted a new emphasis on developing policies regulating the availability of unhealthy foods (7).
Throughout the early 2000s, the policy stream was strengthened by the development of viable policy solutions to combat obesity. Currently, obesity is listed as one of the CDC’s six “winnable battles” due to the availability of evidence-based, cost-effective strategies for fighting the epidemic (9). Dominant multi-sectorial groups, such as the Healthy Eating Active Living Convergence Partnership, have been instrumental in developing policies to combat obesity (10). From increasing access to healthy fruits and vegetables in schools to improving opportunities for physical activity, evidence-based strategies to support healthy eating and active living emerged. Through collective action and research, the policy community began to build a consensus that regulation of food and activity environments would be necessary. The development of cost effective, evidence-based interventions to combat obesity strengthened the policy stream.
As feasible solutions to the obesity epidemic were developed, a favorable political environment was simultaneously established. By the mid 2000s, public opinion reflected a desire to address obesity. A 2005 poll conducted by the Harvard School of Public Health revealed that three-fourths of Americans regarded obesity as an extremely (34%) or a very (41%) serious public health concern (11). The National Alliance for Nutrition and Activity Coalition, unifying 300 high-interest organizations, was instrumental in pushing for early legislation regarding wellness policies and nutrition standards (8). By 2009, forty-three states had specific plans in place to lower the prevalence of obesity and related diseases (12). Among both the general public and public health interest groups, obesity had become a widely recognized national health problem, meriting large-scale political action.
Convergence of the Streams: Let’s Move
Public health agencies, advocates, researchers and politicians built the foundations of the obesity movement. With widespread recognition of the obesity epidemic and the availability of feasible policy solutions, obesity was poised to rise to the top of the policy agenda. In 2010, First Lady Michelle Obama leveraged the convergence of favorable problem, policy and politics streams to launch her “Let’s Move” campaign (8). Given her high profile and favorability, Mrs. Obama successfully pushed obesity to the top of the health policy agenda.
“Let’s Move” sought to combat obesity by improving school food environments, expanding access to healthy and affordable foods, and increasing physical activity. Results of the campaign included the United States Department of Agriculture’s revamp of nutritional labeling standards, and improvements to the National School Lunch Program. The campaign was accompanied by President Obama’s formation of the Task Force of Childhood Obesity, which convened twelve federal agencies to develop recommendations for reduction of obesity (8).
While Mrs. Obama was successful in bringing obesity to the forefront of the United States’ public health agenda, the effect of “Let’s Move” on obesity reduction has been debated. In 2014, researchers from the CDC released a report showing a slight decline in obesity among low-income children, and a sharp drop (43%) among children aged 2-5 years old (13). However, the prevalence among youth and adults has remained stagnant (13). Whether “Let’s Move” will contribute to sustained reductions in rates of obesity in the United States over the next few decades remains to be seen.
Through leveraging the convergence of the problem, policy, and politics streams, Michelle Obama successfully launched an initiative that gave new prominence to obesity prevention initiatives. While the long-term implications of the campaign will continue to emerge, “Let’s Move” exemplifies how problem recognition, the development of viable policy solutions, and political support can facilitate the implementation of large-scale health reforms. In the underfunded sphere of preventative public health, advocates constantly compete for limited resources. A deeper understanding of the conditions that produce policy change is vital for those seeking to (1) garner support for their health initiatives and (2) ensure that their own causes “rise to the top” of the policy agenda.
- Office of the Surgeon General (US). The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity [Internet]. Rockville (MD): Office of the Surgeon General (US); 2001 [cited 2016 Jan 24]. (Publications and Reports of the Surgeon General). Available from: http://www.ncbi.nlm.nih.gov/books/NBK44206/
- Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States, 2011-2014. NCHS Data Brief. 2015 Nov;(219):1–8.
- Frieden T. Nutrition, Physical Activity, Obesity: Introduction letter from CDC Director Dr. Thomas R. Frieden. [Internet]. 2011. Available from: http://www.cdc.gov/winnablebattles/obesity/pdf/obesity_wb_letter.pdf
- Parkhurst JO, Vulimiri M. Cervical cancer and the global health agenda: Insights from multiple policy-analysis frameworks. Glob Public Health. 2013;8(10):1093–108.
- American Medical Association. AMA Adopts New Policies on Second Day of Voting at Annual Meeting [Internet]. 2013. Available from: http://www.ama-assn.org/ama/pub/news/news/2013/2013-06-18-new-ama-policies-annual-meeting.page
- Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff Proj Hope. 2009 Oct;28(5):w822-831.
- Kersh R. The Politics of Obesity: A Current Assessment and Look Ahead. Milbank Q. 2009 Mar;87(1):295–316.
- Graff SK, Kappagoda M, Wooten HM, McGowan AK, Ashe M. Policies for healthier communities: historical, legal, and practical elements of the obesity prevention movement. Annu Rev Public Health. 2012 Apr;33:307–24.
- CDC Office of the Director. CDC Winnable Battles 2010-2015 Progress Report (2014) [Internet]. 2015 Apr. Available from: http://www.cdc.gov/winnablebattles/targets/pdf/winnablebattles2010-2015_progressreport2014_.pdf
- Bell J, Dorfman L. Introducing the Healthy Eating Active Living Convergence Partnership [Internet]. Health Eating Active Living Convergence Partnership; 2008. Available from: http://convergencepartnership.org/sites/default/files/cp-introduction.PDF
- Despite Conflicting Studies about Obesity, Most Americans Think the Problem Remains Serious [Internet]. Harvard School of Public Health; 2005. Available from: http://archive.sph.harvard.edu/press-releases/archives/2005-releases/press07142005.html
- Robert Wood Johnson Foundation. F as in Fat: How Obesity Policies and Failing in America [Internet]. 2009. Available from: http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf
- Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. JAMA. 2014 Feb 26;311(8):806–14.