REGULATION AND POLICY

Obesity, Integral Leadership, and Health Policy

Annette G. Greer, PhD, RN

Combating the complexities of obesity requires an integral leadership approach at national, state, and locallevels. Policies at each of these levels must employ ethical humanistic care that incorporates understanding of thesocial determinants of health. The aim of this paper is to examine the potential policy influences that theinterrelated causes and effects of obesity have at individual and population levels. Further, the aim is to increasehealth professional awareness of how they can serve as integral leaders in health reform to alleviate the obesityepidemic.

Introduction

Obesity has been called the most prevalent health epi-demic among Americans, and is associated with major

chronic diseases that increase morbidity and mortality acrossour nation.1 The facts about obesity have been repeated overand over in the literature.2–5 Reversing the obesity epidemicrequires leadership in the policy arena.1 So who is to supplysuch leadership? Do you have a mirror in front of you as youread this article? Leadership to eradicate obesity is not dele-gated only to state or national political representatives. Itbegins simply, within each household, within each job site,within each community, and it spreads from there. Leader-ship is exercised each time we purchase food from the grocerystore, each time we order from a menu, each time we select adish to serve at a function. Leadership empowers and upliftsthose whose lives are affected by the disease of obesity. Whatis needed is an ecological approach to policy leadership that isfocused on obesity and that begins within each of us.

While the debate for obesity causation vacillates amongresearchers, it is evident that obesity is multi-causal, withfactors that include the behavioral,5 genetic,6 psychosocial,7

nutritional,8 and physical.9 Trying to attach ‘‘blame’’ to amultifactorial disease process is not patient-centered and doesmuch to generate stigma barriers, which further complicatethe ability to address the needs of patients who are obese.10,11

The research literature implicates individuals who are diag-nosed with obesity as personally culpable12 for major diseasessuch as cancer,13 diabetes,14 cardiovascular disorders,14 sleepdisorders,15 digestive disorders,16 and depression.17 Do wetell persons diagnosed with schizophrenia that they are toblame for their delusions? Do we send those individuals outthe door and tell them to go home and not think about theirdelusions? Surely not. But we do send the obese home withthe command that they should not think about eating all that

food. This, then, shows us one instance in which leadershipdemands an enlightened, professional response.

Integral Leadership

Integral theory suggests that each of the aforementioneddiseases and disorders is associated with obesity. They areinterrelated, and at some level, we make choices for healththat can offset genetic and environmental factors. Further,integral theory indicates that causality theories also corre-spond with one another, as obesity is a complex diseaseprocess, interacting dynamically within a given individual,and in aggregate, within populations.18 Integral theory pro-vides a framework for review of leadership in that it posesmultiple truths, each lending its own weight of truthfulnessand each having its own limitations.19 Thus integral leader-ship and a systems approach are needed to address thecomplexity of obesity. Reams (2005) describes integral theoryusing a four quadrant approach to help one understand theinterconnectedness of systems, one to the other, and of theindividual to the collective.19 In addition, developmentalstages are embedded within integral theory, which helps us tocomprehend how leadership abilities evolve.19

Leadership in addressing the growing epidemic of obesityhas been successful in narrowing the focus of research to de-fine specific domains clearly. It is now time to engage con-sciously in leadership and in moving the research agenda forobesity to a higher level of holistic systems integration.20 Thisevolution in leadership will cause some tension, as perspec-tives held on the cause and effects of obesity are often boundup with purist thoughts. However, an interprofessional col-laborative approach to setting research agendas can assist informing policy that will support such integral leadership en-deavors while addressing the multifaceted needs of efforts tohalt the global obesity epidemic.20 Hammond (2009) offers a

Department of Bioethics and Interdisciplinary Studies, Brody School of Medicine East Carolina University, Greenville, North Carolina.

BARIATRIC NURSING AND SURGICAL PATIENT CAREVolume 7, Number 4, 2012ª Mary Ann Liebert, Inc.DOI: 10.1089/bar.2012.9957

189

mechanism for such leadership in obesity research throughmodular processes, but notes that such designs offer chal-lenges to policy makers, who often overlook the expansivearray of complexities, choosing rather a special-interest ap-proach to policy development.20

Health Policy: An Opportunity for National Leadership

Integral leadership is needed across the ecological levels ofpolicy in order to reverse the dispiriting trends in healthoutcomes related to obesity. At the national level, healthcarereform legislation titled the Patient Protection and AffordableCare Act (PPACA)12 offers benefits and some barriers whenaddressing the obesity epidemic, and provides opportunity forleadership among health professionals. Benefits, to those di-agnosed with obesity, are that the healthcare reform legislation(now supported by Supreme Court action) includes: (1) insur-ability, (2) claims processing for preexisting conditions, (3)prohibition of insurance caps, and (4) preventive and behav-ioral health services.1 Barriers created by the healthcare reformbill are: (1) premium health insurance plans will be taxed, andthose costs are projected to cause a scale-down in approvals forbariatric surgery coverage; (2) obese persons on employerhealth insurance plans may not be discriminated against, but ifthey do not meet wellness criteria, they can be billed at 50% ofcosts for certain services; (3) bans on pharmaceutical treatmentof obesity under Medicare continue; and (4) some ambiguitieson the specifics of the legislation continue to be worked out incommittees and advisory boards.1 The National PPACA leg-islation will give some leverage to states in the enactment of thelaw. It is important for both bariatric specialists and primaryproviders who care for those with bariatric needs to remaininformed, to communicate with legislators at state and nationallevels, and to exercise the privilege of voting for representativeswho support a holistic obesity agenda. As a health professional,you can choose to develop consciously into an integral leaderrepresenting the needs of the obese.

Health Policy: An Opportunity for State Leadership

In seeking to represent a holistic obesity agenda, healthprofessionals who would serve as integral leaders can findmany opportunities for action at the state level. Some health-professional employers prohibit legislative involvement oftheir employees, including lobbying activities. Integral lead-ership requires extensive collaboration in addressing theobesity agenda, and it is advisable to follow the principles ofpersonal and professional ethics to guide participation inpolicy development.21 However, belonging to obesity advo-cacy organizations (ones that educate legislators) is a personaland professional right that is allowed, and models exist thatattend to potential ethical conflicts.22 Service is needed byprofessionals who would lead within these advocacy orga-nizations and within professional associations. Strive to serveon state or regional boards that support an obesity agendaand promote the adoption of ecological frameworks fortackling the complexities of obesity.

Health Policy: An Opportunity for Local Leadership

One must not overlook chances to serve as an integralleader within one’s own community. Policy is not just set atnational 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 sweepingnational legislation to those suffering from obesity. Local ac-tions can be as simple as using larger scales, gowns, and chairswithin 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 structuralinequities attending obesity, and that we seek to address themon individual and population levels.25 Employing a publichealth model necessitates integral leadership in zoning loca-tions of fast-food services, budgeting for sidewalks and parks,support for recreational programs in all communities, andadvocacy of local farm produce markets.26 All healthcareprofessionals can be engaged at some level of integral lead-ership that seeks to develop solutions to the obesity epidemic.

Advancing Obesity Policy Reform

Policy reform reverberates through the ecological system ofcommunity, state, nation, and globe. Obesity healthcare mustbe humanistic in nature, not just driven by the bottom line of anaccounting balance sheet.25 Yet, it is still important that obesitycare be cost-effective and that it be contained in a manner led byintegral theory, recognizing the interrelatedness of causationand disease factors.27–30 Given the enormity of the obesity ep-idemic, the problem touches each of us on a personal level.While electronic medical records hold some promise for re-searching the factors of disease among those with obesity, re-lationship still matters.31 Healthy People 2020 objectives definestandards for addressing the social determinants of health re-lated to the root causes of obesity, and note the interaction ofthose agents within society that lead to an advancing epi-demic.32 Consequently, Healthy People 2020 campaigns for a‘‘health in all policies’’ (HIAP) approach, which is also sup-ported by the World Health Organization and is consistentwith integral leadership.32 The health impacts of policy reformat all levels (local, state, and national) must be measured so thatwe can determine whether zoning rules, investment in side-walks and recreation, or state mandates regarding vendingmachines at schools, or even changes implemented from thenational PPACA, result in long-term changes in obesity out-comes. Obesity, with its causes and effects, brings multipletruths, each having its own weight of truthfulness and its ownlimitations;19 and the same is true for the policies we develop tocombat individual and population outcomes. Hence, the im-perative call for integral leadership this paper seeks to deliver.

Disclosure Statement

No competing financial interests exist.

References

1. Downey M. Obesity and health care reform. J Obes 2010;1–25.

2. National Institutes of Health; National Heart, Lung andBINAA for the S of O. Guide identification, evaluation, andtreatment of overweight and obesity in adults. PracticalGuide for the Evaluation, Identification, and Treatment ofOverweight and Obesity in Adults 2000;NIH Pub.00:1–94.

3. Nguyen NT, Nguyen B, Smith B, et al. Proposal for a bar-iatric mortality risk classification system for patients un-dergoing bariatric surgery. Surg Obes Relat Dis 2011;1–8.

190 GREER

4. Walls HL, Backholer K, Proietto J, McNeil JJ. Obesity andtrends in life expectancy. J Obes 2012;1–4.

5. Shields AT. Examination of the obesity epidemic from abehavioral perspective. Int J Behav Consult Ther 2005;5:142–158.

6. Zlot A, Newell A, Silvey K, Arail K. Addressing the obesityepidemic: a genomics perspective. Prev Chron Dis 2007;4:A31.

7. Annesi JJ, Gorjala S. Changes in theory-based psychologicalfactors predict weight loss in women with class III obesityinitiating supported exercise. J Obes 2010;1–4.

8. Aller EEJG, Abete I, Astrup A, Martinez JA, Van Baak MA.Starches, sugars and obesity. Nutrients 2011;3:341–369.

9. Nantel J, Mathieu M-E, Prince F. Physical activity and obe-sity: biomechanical and physiological key concepts. J Obes2011;650230.

10. Muennig P. The body politic: the relationship betweenstigma and obesity-associated disease. BMC Pub Health2008;8:128.

11. Ogden J, Clementi C. The experience of being obese and themany consequences of stigma. J Obes 2010;1–9.

12. Yang YT, Nichols LM. Obesity and health system reform:private vs. public responsibility. J Law Med Ethics 2011;39:380–386.

13. Byers T. Obesity as a cause of cancer: epidemiologic andbiologic mechanisms. Obes Rev 2010;11:66.

14. Rana JS, Nieuwdorp M, Jukema JW, Kastelein JJP. Cardio-vascular metabolic syndrome—an interplay of, obesity, in-flammation, diabetes and coronary heart disease. DiabetesObes Metab 2007;9:218–232.

15. Magee CA, Huang X-F, Iverson DC, Caputi P. Examiningthe pathways linking chronic sleep restriction to obesity. JObes 2010;821710.

16. Patel NR, Ward MJ, Beneck D, Cunningham-Rundles S,Moon A. The association between gastroesophageal refluxdisease and obesity. J Obes 2010;2111–2122.

17. Taylor VH, MacQueen GM. The role of adipokines in un-derstanding the associations between obesity and depres-sion. J Obes 2010;748048.

18. Newell B, Proust K, Dyball R, McManus P. Seeing obesity asa systems problem. NSW Pub Health Bull 2007;18:214–218.

19. Reams J. What’s integral about leadership? A reflection onleadership and integral theory. Integ Rev 2005;1:118–131.

20. Hammond RA. Complex systems modeling for obesity re-search. Prev Chron Dis 2009;6:A97.

21. Bernheim RG. Public health ethics: the voices of practition-ers. J Law Med Ethics 2003;31:104–109.

22. Health T, Professional C, Writing A. Delivering services andinfluencing policy: health care professionals join forces toimprove maternal, newborn, and child health. Int J GynaecolObstet 2009;105:271–274.

23. Paulsen JE. A narrative ethics of care. Health Care Anal2011;19:28–40.

24. Obesity E. Medical care for obese patients: advice for healthcare professionals. Am Fam Physician 2002;65:81–88.

25. Furler JS, Palmer VJ. The ethics of everyday practice in pri-mary medical care: responding to social health inequities.Philos Ethics Humanit Med 2010;5:6.

26. MacLean L, Edwards N, Garrard M, et al. Obesity, stigmaand public health planning. Health Promot Int 2009;24:88–93.

27. Dietz WH, Benken DE, Hunter AS. Public health law and theprevention and control of obesity. Milbank Q 2009;87:215–27.

28. Pomeranz JL. Public health and democracy: the uniqueauthority of state and local health departments to addressobesity. American Journal of Public Health 2011;Online:e1–6.

29. National Research Council. For the Public’s Health: Invest-ing in a Healthier Future. Washington, DC: The NationalAcademies Press, 2012. Retrieved from: http://www.nap.edu/catalog.php?record_id=13268

30. Larson A. The American childhood obesity epidemic:probable causes and the legislative and judicial responses.Child Legal Rights J 2008;28:1–71.

31. Ventres WB, Frankel RM. Patient-centered care and elec-tronic health records: it’s still about the relationship. FamMed 2010;42:364–366.

32. Secretary’s Advisory Committee on National Health Pro-motion and Disease Prevention Objectives for 2020. HealthyPeople 2020: An Opportunity to Address Societal Determi-nants of Health in the U.S. 2010.

Address correspondence to:Annette G. Greer, PhD, RN

Department of Bioethics and Interdisciplinary StudiesBrody School of MedicineEast Carolina University

Brody 2N12600 Moye Blvd.

Greenville, NC 27834

E-mail: greera@ecu.edu

OBESITY, INTEGRAL LEADERSHIP, AND HEALTH POLICY 191