Social and multi level aspects of adult obesity; the philadelphia experience

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Running Head: Social and multi-level environmental aspects of adult obesity in Philadelphia
Social and Multi-level Aspect of adult obesity in Philadelphia;
Analysisof the Currentobesity intervention.
By
Ahmed Otokiti, M.B,.B.S. CCRP.

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Social and multi-level aspects of adult obesity in Philadelphia
Ahmed Otokiti(ahmedotokiti@yahoo.com)/2013
Abstract
One third of the U.S adult population is obese or overweight and Philadelphia’s rate of obesity
surpasses the National average of 35.7%. In order to halt this menace the City had embarked on
an intervention to counter this disease. The get healthy Philly Initiative hopes to remove
Philadelphia from the list of “food desert” by increasing the availability of nutritious foods to its
citizens. This entails supporting local Grocery stores in providing and selling healthy foods and
vegetables.
In this write up, Ihave tried to analyze the problems and the intervention program from an
ecological framework perspective to health determinants. Looking at areas where the program
could use some improvements while also providing solutions for the way forward.

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Social and multi-level aspects of adult obesity in Philadelphia; an analysis of the current obesity
intervention in Philadelphia.
Introduction
Obesity has become an alarming National public health crisis. According to the CDC, in
2010, 36 states had an obesity rate of at least 25 percent, with 12 states reporting an obesity rate
of more than 30 percent. These figures compares poorly to 1990,not one U.S state had an obesity
rate greater than 14 percent. More than one third of adults and 17 percent of youth were obese as
at 2010(Cynthia, Margaret, Brian 2012).Putting the National average at about 35.7%. While in
Philadelphia, as at 2008, 64percent of adults and 57 percent of children were overweight or
obese. In Philadelphia, the prevalence of obesity is well above the National average and since
2000 approximately 24,000 Philadelphians have died from diseases caused by poor diet and
physical inactivity ( Mokdad 2004).
The impact of obesity on health stems from the fact that it is a well-documented risk factor for
heart disease, many forms of cancer and type 2 diabetes. It also leads to an economic set back as
obesity related expenditures totaled $147 billion in 2008 .(Finkelstein ,Trogdon , Cohen, Dietz,
2009). Also there has been a lot of socio economic and racial disparity in the distribution of
obesity, with a higher prevalence among the Poor, indigent minority population.(public health
Management coporation,2008). Philadelphia has the highest obesity and poorest population of
America’s big cities. In order to counter this dangerous trend, Philadelphia has embarked on an
intervention called the “Get Healthy Philly initiative”. The city had recruited 632 corner stores to
supply them with New Fridges to store produce of fresh fruits and vegetables,while also stocking

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the stores with alternative healthy snacks. It is also working with schools to help improve
nutrition and helping neighborhood farmers markets.
It is a known fact that the individual exert influences on the environment and vice versa.
However, no man is an Island and as such these influences are exerted thru various levels of
social and interpersonal relationships. The social environment of the individual include
interaction with peers,friend and family members, through such mechanism as role
modeling,social support and social norms(Mary, Karen, Ramona, Karen .Annu. Rev. Public
Health 2008.Creating Healthy food and Eating Environments, para 2). The physical
environment includes settings where people eat or procure food such as the home, work, school,
Restaurants and supermarket. The physical settings in the community influence which food to eat
and what barriers are preventing healthy eating habits(Mary, et al.Annu. Rev. Public Health
2008.Creating Healthy food and Eating Environments, para 2). Also important are the macro-
level environmental factors which play a more distal and indirect role. These factors include;
Government and its policies, Food marketing and media, Food assistance programs, food
production and distribution systems e.t.c.
Specific impact of Socialandenvironmental factors; The Philadelphia experience.
Social Network factor
People with mutual interest tend to attract one another, hence as observed by Koehly &
loscalzo, adolescent friendships tended to cluster on the basis of weight status(2009). This
further promotes the un-healthy habits. The family constitutes a huge part of the social network.
Children would naturally follow the lead of behaviors of their parents and influential family
members (role modeling). This role model effect of behavior is further supported by the fact that

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parental intake of healthyfood (fruit and vegetables) has been associated with food and
vegetables intake among youth, and may be the strongest predictor of consumption of fruit and
vegetable among children(Boehmer,Brownson,Haire-Joshu. 2004). Philadelphians drink
approximately 60 million gallons of Sugar sweetened beverages (SSBs) annually. Multiple
studies have linked obesity with increased intake of SSBs (Brownell K. 2009).Based on this
consumption by the adults;it automatically becomes a norm and a standard in the society. Thus
affecting the taste of preference of the childrenfor the rest of their lives.
Physical Environmental Factors/Settings
This pertains to the availability of healthy foods in the home,work , school or any other
settings around the individual. Factors like access, availability, barriers and opportunity
determine the possibility of obtaining healthy food and preventing obesity. Also very important
are the issues relating to proximity to healthy food, pricing and transit(Sarah . The Washington
Post, 2012. Will philadelphia’s experiment in eradicating “food desert” work?.para 25).
According to the Public health management corporation survey, one quarter of childrendo not get
enough physical activity, and nearly half of the adults exercise less than 3 times per
week,(2008).The high incidence of crime in the neighborhood has also discouraged out door
physical activity due to unsafe environment. Also the Auto-based planning of the area shifting
new development to the out-skirts have encouraged more driving and less activity.
Macro-Level Environments
Although the Government have had passed the school wellness policy which went into
effect in 2007, to encourage healthy eating habits in schools that get reimbursement from the
Government in their school nutrition program. Preliminary data showed mixed result in terms of

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compliance and implementation of the policies in schools across the country. Another Macro-
environmental factor worth mentioning, is the impact of the electronic media in promoting SSBs
and un-healthy foods. Due to the fact that most un-healthy foods are very calorie dense and you
get more calories from them per unit grams. People end up consuming a lot of it and they are
relatively cheaper than healthy foods. Hence its appeal to the poor and indigent. While the SSBs
serving have become larger over the past 15 years, targeted advertising to low-income and
minority communities have also increased.(Brownell. 2009).
Get Healthy Philly Initiative
This seeks to counter the obesity disease rate in Philadelphia by providing incentives to
corner shops and Grocery stores to encourage sale of Healthy fruits and vegetables. Direct
assistance like provision of fridges to store produce and connecting them to wholesalers is also
involved.It is also working with schools to help improve nutrition and helping neighborhood
farmers markets. This is a very good step in the right direction, like every other intervention it
comes with its drawbacks and commendable attributes.
Commendable Attribute of the Get Healthy Philly Initiative;
Root cause Approach; This approach is highly commendable due to the fact that it seeks
to tackle the problem from its origin/root. Considering the overwhelming evidences that obesity
is the root cause of many cardiovascular diseases. Just as the goal by the Obama Adminstation is
to eradicate “food deserts” by 2017.
Novel and relevant with Presence of re-evaluation mechanisms;It is also a unique
intervention as no other active intervention or study have tried to study the causal relationship
between obesity and availability of healthy food in the neighborhood. Most of the evidences

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have been retrospective analysis and data review which are less credible in the eyes of scientists
and policy makers. The intervention seeks to measure what people bought before and after the
availability of healthy foods as to determine if the intervention is effective. Researchers at the
Temple university Center for obesity Research are working with the City to determine
effectiveness of intervention and hope to publish their finding in the next year. This re-evaluation
of intervention with a time line helps to determine its effectiveness and way forward.
Get Healthy Philly Initiative Draw Backs.
Questioned Theory;The theory of the Initiative is not based on a sound practice. This is
because multiple studies have looked at retrospective data at the state and national level to find a
causal relationship between weight and access to healthy food. None was found.(Sarah ,The
Washington Post, 2012. Will philadelphia’s experiment in eradicating “food desert” work?.para
10). A lot of Analysts and pundits have expressed their doubt on the possibility of its success
because a sound intervention/practice should be based on a sound theory likewise, a sound
theory should also be based on sound practice/precedence (Karen, Barbara, Viswanath, 2008, p
7).
Need for further consideration of Profitability of the Grocery owners; There is the
need to further give incentives to the Grocery owners. I feel it is not enough to supply them
fridges and connect them to wholesalers. At the end of the day,they are in the business to make
profit and there is more money to be made in the sale of un-healthy foods.For this reason, the
sustainability of their participation is questionable and in doubt.

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Solution and Way Forward
Although this is a very bold attempt to solve the problem, I however put forward the
following additional steps. My emphasis is here is more on the macro-level environmental
impact of the Government. I believe a lot of solution lies with the Government.Taking a cue
from the ban of smoking indoors and in public places among other measures, we have
subsequently experienced a reduction in smoking.The Government’s agricultural policy should
be geared towards encouraging farmers to produce healthy foods and vegetables.The present
Government agricultural policy which encourages massive production of cereals and corn used
in sweeteners (high fructose corn Syrup) further encourages unhealthy eating habits.(Mary,
Karen, Ramona, Karen . Annu. Rev. Public Health 2008.Creating Healthy food and Eating
Environments, para 10).
I will also suggest the Government grants Grocery owners some tax breaks and tax
credits if they sell a certain amount of fruits and vegetable in a Fiscal year.This will help offset
some of the cost of loss made due to the highly perishable nature of fruits and vegetables.
Also various poverty alleviation programs should be put in place.So far we have
identified that poverty is a hydra headed problem which has been linked to obesity and other
adverse conditions.
Conclusion
The problem of obesity is a complicated one, requiring a multi-dimensional approach to
finding a solution. The solution does not lie in any one sphere of the ecological framework
determinants of health. All sphere of the ecological framework must be actively involved in its

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prevention; The individual,social environment,physical environment and the macro-level
environment.

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References
Boehmer B, Haire-joshu D, Dreisinger M, (2007).patterns of childhood obesity prevention
legislation in the United states. Prev.Chron. Dis 4(3):A56
Brownell K et al. (2009)“The Public Health and Economic Benefits of taxing Sugar-
Sweetened Beverages.” New England Journal of Medicine. 361;16:1599-1605
Cynthia L,MargaretC,Brian K, Katherine F,(2012).Prevalence of Obesity in the United States
, 2009–2010.USDHH, CDC NCHS data brief Retrieved on March 24, 2013 from
http://www.cdc.gov/nchs/data/databriefs/db82.pdf
Environments; Policy and Environmental Approaches. Annu. Rev. Public Health, 29, 253-72.
Retrieved March 24, 2013 from http://publhealth.annualreviews.org.
Finkelstein A, TrogdonG, Cohen JW, Dietz W. ( 2009.)Annual Medical Spending
Attributable To Obesity,Payer-And Service-Specific EstimatesHealth Affairs 28;5: w822-
w831.
Glanz, K., Rimer, B. K., &Viswanath, K. (2008). Health Behavior and Health Education
Theory, Research, and Practice. (4th ed.). Hoboken: John Wiley & Sons
Koehly M, Loscalzo A. (2009). Adolescent obesity and social networks.Preventative Chronic
Diseases 6(3):A99. Retrieved March 24, 2013from
http://www.cdc.gov/pcd/issues/2009/jul/08_0265.htm
Mary S., Karen M, Ramona O, Karen G.(2008). Creating Healthy food and Eating

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Mokdad A et al. “Actual Causes of Death in the U.S. 2000.” (2004) JAMA. (291)10:1238-1245
Public Health Management Corporation, Community Health Database. (2008). Southeastern
Pennsylvania Household Survey.
Sarah K.(2012). Will Philadelphia’s experiment in eradicating “food deserts” work? .The
Washington post. Retrieved March 24, 2013, from;
http://www.washingtonpost.com/blogs/wonkblog/post/will-philadelphias-experiment-in-
eradicating-food-deserts-work/2012/06/08/gJQAU9snNV_blog.html

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