Are Healthy Choices Possible Without Healthy Systems?

Strategies for obesity prevention are in the midst of a great shift in emphasis – from healthy choices to healthy systems.

For decades now, public health efforts, in one way or another, have had their roots in promoting better choices. It started with efforts to educate the public to eat in more healthful ways and live more active lives. But after a time, it dawned on policy advocates that conscious choices were neither the problem nor the solution for obesity.

So the focus of public health is shifting to putting the onus on the businesses pushing bad choices on hapless consumers – “feeding us this rubbish,” as one professor recently described it. In this way of thinking, the problem is not a lack of intention to make healthy choices, it is a lack of healthy systems to make those choices likely.

Looking Beyond Food Systems

Right now, most of public health puts the blame for obesity squarely onto the food industry. A few people who think more broadly are pursuing the idea of sustainable food systems. This spreads the responsibility to stakeholders beyond the food industry industry alone.

But at the ADA Clinical Update this weekend, the CDC’s Christopher Holliday nudged us to think even more broadly for success in obesity prevention. We need to rethink social and structural systems beyond food alone – systems that make healthy choices an impossibility for large segments of the public.

The CDC Framework for Social Determinants of Health

Holliday presented five elements that the CDC Center for Chronic Disease Prevention stresses as social determinants of health. They are the built environment, community-clinical linkages, tobacco-free policy, food and nutrition security, and social connectedness.

Social connectedness surely deserves more attention. This happens when people have relationships that create a sense of belonging, being cared for, valued, and supported. Increasingly, obesity is becoming a disease of people who lack this dimension of the social determinants of health. We make it worse when we tolerate wide economic disparities, systemic racism, and, yes, weight bias.

People can rant all they want about big food “feeding us this rubbish,” and perhaps it’s justified. But we have our doubts that these rants, even if they come with with taxes and penalties for “unhealthy” food, will move the needle on obesity prevalence unless we address the unhealthy social systems that marginalize so much of the population.

Click here and here for more on the relationship between social determinants of health and obesity. For more on the need for whole systems approaches to obesity, click here.

The Tower of Babel, painting by Pieter Bruegel the Elder / WikiArt

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February 12, 2023