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#JournalWatch: The obesity crisis and learning from failures in public health

As in most areas of research, public health is plagued by the erasure of non-results, where failure to witness an anticipated benefit or hypothesised outcome means a study can be left unreported.

In the latest edition of #JournalWatch, Dr Melissa Stoneham examines whether — through failing to embrace and report on non-result studies — we are missing out on valuable public health lessons, looking at the example of obesity.


Melissa Stoneham writes:

How many times have you read that Australia is facing an obesity crisis? It is certainly a common headline in the news and should be prominent given that almost 2 in 3 Australian adults are overweight or obese.  Some examples of recent media headlines are below.

  • BBC News Sydney – Is Australia facing an obesity crisis?
  • News.com.au – Obesity doubles in a decade and two-thirds of us are fat, report claims
  • Sydney Morning Herald – While politicians refuse to act, Australians become more overweight
  • Nine Today – Why Australia is facing an obesity crisis
  • ABC news – Four things Australia could do to tackle the obesity crisis

But it is not just Australia that is facing this crisis. Obesity is a worldwide problem.

The WHO has produced a heat map that indicates that developed countries have much higher rates of obesity than developing countries, and within developed countries such as Australia and America, there are population groups that have significantly higher rates.

This month’s JournalWatch reviews an editorial from the American Journal of Public Health which begins: “The United States is facing a public health crisis. More than 39% of adults and 18.5% of youths have obesity in the United States.”

Authored by Dr Allyson Kelley, who is a senior scientist from Allyson Kelley & Associates, the editorial “Obesity and Environmental Interventions in Tribal Nations”, considers the role of environmental interventions in addressing this issue particularly among the American Indian and Alaska Native (AIAN) populations.

Currently, the article states, the obesity rate in the AIAN adult population is 43.7% compared with 39% in the mainstream American population.

The editorial looks at the first ever tribal retail intervention to address obesity (THRIVE), which aimed to increase access to and consumption of healthy foods via placement, promotion and reduced pricing in tribal-owned convenience stores in the Chickasaw and Choctaw Nations. Although it does not present the results of the THRIVE study, the editorial considers its strengths and weaknesses, and discusses lessons learned.

Opportunities lost

Kelley’s editorial reinforces the importance of writing up programs even if they do not achieve their objectives.

Researchers and practitioners often shy away from documenting “failed” programs, with published papers often being overwhelmingly optimistic and positive.  However over time, authors have affirmed the value of lessons gleaned from failed programs, including the ability to resuscitate the initiative at a later date, the need to evaluate reasons for failure and opportunity to advocate for investigative bodies to uncover and communicate causes and lessons.

In her editorial, Kelley noted that THRIVE did not increase consumption of, nor change perceptions about, healthy foods. Given the overall aim of the program, I think it could safely be said that this was a deviation from expected results.

In the emerging space of obesity prevention, it is important that we learn from these failures. The authors have suggested that addressing obesity within a First Nations setting requires a holistic, social determinants approach across multiple fronts.

Australian authors agree.

Reflecting on the Dead or Deadly program — a health promotion initiative designed by and for Indigenous women that centered around health education workshops and yarning circles to promote behaviour change — authors concluded that a holistic approach is required for gains in the complex area of Indigenous health.

An article discussing strategies to improve Aboriginal and Torres Strait Islander nutrition and health, authored by Professor Amanda Lee, recommended a combination of different economic strategies to improve nutrition in Aboriginal populations including engagement with community store owners and infrastructure improvements such as functioning kitchens and serviceable refrigeration.

Kelley’s recommendations for holistic multiple social determinants solutions to obesity in AIAN populations have relevance in the Australian context, where 70% of Aboriginal and Torres Strait Islander adults are now overweight or obese compared with 63% of non-Indigenous Australians.

For the younger population, a 2014 study of weight trends of children in New South Wales showed the gap in weight status between Aboriginal and non-Indigenous children was extending. From 1997 to 2010, rates of excess weight and obesity rose 22.4% in Aboriginal children, compared with 11.8% in non-Aboriginal children.

A quiet crisis

The Kelley editorial recommends that future efforts must address obesity holistically.  It calls for multilevel interventions to increase healthy food consumption and decrease obesity in AIAN populations, with policy efforts focused on access to healthy foods, increased physical activity, and health behaviours. Pretty standard stuff. It is a shame that the authors didn’t reinforce the importance of learning from failed programs.

Maybe these type of generic recommendations, although valid, are made because it is more convenient to assume that social change is just too hard, or that policy reform is required but we are uncertain about exactly what form it should take.

Narratives and conversations around these types of questions — ultimately arising from a failed program — could lay the groundwork for new beliefs and behaviours that can guide action. They also have the potential to generate new ideas and practices from the frontlines of public health, even if the original project was not as successful as had been hoped.

It is time for the public health sector to be brave, and not only admit a program or study has failed but embrace it.

Learning from failure in public health is a major challenge that will require substantial effort and possibly some swallowing of pride. But with obesity, we face a quiet crisis.

Inactivity, overweight, obesity and their resulting physiological effects represent an unprecedented public health challenge driving a range of morbidities and mental health conditions.

No one should plan to fail, but if your program or research doesn’t meet its objectives, I think it’s time for us say “It’s okay. I was ahead of my time. But I will learn from this and let others know, so we can all aim to do it differently next time, and hopefully improve the health of our community.”

Article: Obesity and Environmental Interventions in Tribal Nations. Allyson Kelly. American Journal of Public Health; Vol 109, Issue 1; pages 21-22.

About JournalWatch

The Public Health Advocacy Institute WA (PHAIWA) JournalWatch service reviews 11 key public health journals on a monthly basis, providing a précis of articles that highlight key public health and advocacy related findings, with an emphasis on findings that can be readily translated into policy or practice.

The Journals reviewed include:

Australian & New Zealand Journal of Public Health (ANZJPH)

Journal of Public Health Policy (JPHP)

Health Promotion Journal of Australia (HPJA)

Medical Journal of Australia (MJA)

The Lancet

Environmental Health Perspectives (EHP)

Tobacco Control (TC)

American Journal of Public Health (AMJPH)

Health Promotion International (HPI)

American Journal of Preventive Medicine (AJPM)

Injury Prevention BMJ

These reviews are then emailed to all JournalWatch subscribers and are placed on the PHAIWA website. To subscribe click to Journal Watch click here.