LETTERS FRAMING OBESITY—DRAWING ON THE MARGINS How we view and frame obesity matters.1 Undeniably, obesity and well-being are situated on a multidimensional continuum. As Bombak highlights,2 many analyses of the obesity---health binary mask heterogeneity through categorization. Conceding the loss of information associated with classification and the capacity for it to solidify classes as ontological entities, the construction of categories may enable understanding through juxtaposition. Furthermore, processes of simplification may facilitate insights into complex domains, such as health, where constituent constructs, here obesity, are themselves complex systems.3 While Bombak views such approaches as reductionist and deterministic, Trochim et al. dispel as false the divide between traditional scientific views and holistic systems perspectives.4 Moreover, they draw attention to the embedded nature of systems and the perceptual shift from reductionist to holistic frameworks, which transpires as the analytic boundaries of a system are redrawn.4 In seeking to reframe obesity, Bombak, it is argued, situates obesity as a “wicked problem.”5 Innately complex and difficult to define, wicked problems are shrouded in uncertainty.6 As such,
Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].
prediction and causal attribution are difficult.6 Yet in interrogating the “obesogenic environment” thesis, Bombak herself pursues absolutes. Might not there be room in population placebased efforts to employ the precautionary principle to prevent unhealthful weight gain?7 Certainly we need to lift our eyes to avoid approaches that assign an instrumental role to the obesogenic environment that would blindly entrench this context as an applied machine able to transform bodies. Here again, though, Bombak’s treatise falls short. Having focused exclusively on the objective and linear relationship between attributes of the built environment and diet, physical activity, and weight status, she sidelines novel and emerging system-based methods8 that embrace the dynamic processes advocated in the article. Also overlooked is the manner by which the structurated choice architecture of the environment nudges populations into behaviors9 and the degree to which behavioral responses arise from unconscious processes shaped by contextual influences.10 There is no doubt public health’s focus on obesity would benefit from the salutogenic approach favored by Bombak, as it would by incorporating knowledge gained through critical approaches. However, what should not be lost from the frame is the capacity for dialogue and inquiry conducted from positions of opposition to progress ideas. This is a point worth remembering, as what seems most in need is engaged discourse across disciplines wherein scientific language and methods are transcended and translated into action for the enablement and promotion of health and well-being. j
Peter Lekkas, BPty MPty Ivana Stankov BPty (Honours)
Box 2471 (IPC CWE-48), Adelaide, South Australia (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted February 28, 2014. doi:10.2105/AJPH.2014.301963
Contributors P. Lekkas and I. Stankov conceptualized the letter. P. Lekkas led the writing process. I. Stankov contributed ideas, writing, and critical review of the letter throughout its development.
Acknowledgments The authors are grateful for helpful comments from Julie Collins, PhD.
References 1. Hoyt CL, Burnette JL, Auster-Gussman L. “Obesity is a disease”: examining the self-regulatory impact of this public-health message. Psychol Sci. 2014;25(4):997---1002. 2. Bombak A. Obesity, health at every size, and public health policy. Am J Public Health. 2014;104(2):e60---e67. 3. Vandenbroeck P, Goossens J, Clemens M. Foresight. Tackling Obesities: Future Choices—Building the Obesity System Map. London, UK: Department of Innovation, Universities and Skills; 2007. 4. Trochim WM, Cabrera DA, Milstein B, Gallagher RS, Leischow SJ. Practical challenges of systems thinking and modeling in public health. Am J Public Health. 2006;96(3): 538---546. 5. Finegood DT, Karanfil O, Matteson CL. Getting from analysis to action: framing obesity research, policy and practice with a solution-oriented complex systems lens. Healthc Pap. 2008;9(1):36---41, discussion 62---67. 6. Petticrew M, Tugwell P, Welch V, et al. Better evidence about wicked issues in tackling health inequities. J Public Health (Oxf). 2009;31(3):453---456. 7. Kriebel D, Tickner J. Reenergizing public health through precaution. Am J Public Health. 2001;91(9): 1351---1355. 8. Ligmann-Zielinska A, Mcwhorter J. Agent-based modeling of obesogenic behaviors and environments exploratory analysis. Paper presented at: Association of American Geographers Annual Meeting; April 9---13, 2013; Los Angeles, CA. 9. Kremers SPJ, Eves FF, Andersen RE. Environmental changes to promote physical activity and healthy dietary behavior. J Environ Public Health. 2012; 2012:470858. 10. Baumeister RF, Masicampo EJ, Vohs KD. Do conscious thoughts cause behavior? Annu Rev Psychol. 2011;62(1):331---361.
About the Authors Peter Lekkas and Ivana Stankov are with the Spatial Epidemiology and Evaluation Research Group, Sansom Institute for Health Research, School of Population Health, University of South Australia, Adelaide. Correspondence should be sent to Peter Lekkas, School of Population Health, University of South Australia, GPO
July 2014, Vol 104, No. 7 | American Journal of Public Health
BOMBAK RESPONDS I welcome Lekkas and Stankov’s response, as I do developments in systems theory.1,2
Letters | e1
Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].
prediction and causal attribution are difficult.6 Yet in interrogating the “obesogenic environment” thesis, Bombak herself pursues absolutes. Might not there be room in population placebased efforts to employ the precautionary principle to prevent unhealthful weight gain?7 Certainly we need to lift our eyes to avoid approaches that assign an instrumental role to the obesogenic environment that would blindly entrench this context as an applied machine able to transform bodies. Here again, though, Bombak’s treatise falls short. Having focused exclusively on the objective and linear relationship between attributes of the built environment and diet, physical activity, and weight status, she sidelines novel and emerging system-based methods8 that embrace the dynamic processes advocated in the article. Also overlooked is the manner by which the structurated choice architecture of the environment nudges populations into behaviors9 and the degree to which behavioral responses arise from unconscious processes shaped by contextual influences.10 There is no doubt public health’s focus on obesity would benefit from the salutogenic approach favored by Bombak, as it would by incorporating knowledge gained through critical approaches. However, what should not be lost from the frame is the capacity for dialogue and inquiry conducted from positions of opposition to progress ideas. This is a point worth remembering, as what seems most in need is engaged discourse across disciplines wherein scientific language and methods are transcended and translated into action for the enablement and promotion of health and well-being. j
Peter Lekkas, BPty MPty Ivana Stankov BPty (Honours)
Box 2471 (IPC CWE-48), Adelaide, South Australia (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted February 28, 2014. doi:10.2105/AJPH.2014.301963
Contributors P. Lekkas and I. Stankov conceptualized the letter. P. Lekkas led the writing process. I. Stankov contributed ideas, writing, and critical review of the letter throughout its development.
Acknowledgments The authors are grateful for helpful comments from Julie Collins, PhD.
References 1. Hoyt CL, Burnette JL, Auster-Gussman L. “Obesity is a disease”: examining the self-regulatory impact of this public-health message. Psychol Sci. 2014;25(4):997---1002. 2. Bombak A. Obesity, health at every size, and public health policy. Am J Public Health. 2014;104(2):e60---e67. 3. Vandenbroeck P, Goossens J, Clemens M. Foresight. Tackling Obesities: Future Choices—Building the Obesity System Map. London, UK: Department of Innovation, Universities and Skills; 2007. 4. Trochim WM, Cabrera DA, Milstein B, Gallagher RS, Leischow SJ. Practical challenges of systems thinking and modeling in public health. Am J Public Health. 2006;96(3): 538---546. 5. Finegood DT, Karanfil O, Matteson CL. Getting from analysis to action: framing obesity research, policy and practice with a solution-oriented complex systems lens. Healthc Pap. 2008;9(1):36---41, discussion 62---67. 6. Petticrew M, Tugwell P, Welch V, et al. Better evidence about wicked issues in tackling health inequities. J Public Health (Oxf). 2009;31(3):453---456. 7. Kriebel D, Tickner J. Reenergizing public health through precaution. Am J Public Health. 2001;91(9): 1351---1355. 8. Ligmann-Zielinska A, Mcwhorter J. Agent-based modeling of obesogenic behaviors and environments exploratory analysis. Paper presented at: Association of American Geographers Annual Meeting; April 9---13, 2013; Los Angeles, CA. 9. Kremers SPJ, Eves FF, Andersen RE. Environmental changes to promote physical activity and healthy dietary behavior. J Environ Public Health. 2012; 2012:470858. 10. Baumeister RF, Masicampo EJ, Vohs KD. Do conscious thoughts cause behavior? Annu Rev Psychol. 2011;62(1):331---361.
About the Authors Peter Lekkas and Ivana Stankov are with the Spatial Epidemiology and Evaluation Research Group, Sansom Institute for Health Research, School of Population Health, University of South Australia, Adelaide. Correspondence should be sent to Peter Lekkas, School of Population Health, University of South Australia, GPO
July 2014, Vol 104, No. 7 | American Journal of Public Health
BOMBAK RESPONDS I welcome Lekkas and Stankov’s response, as I do developments in systems theory.1,2
Letters | e1
