Foreword

I recall a lecture about prevention early in medical school, given by a wise, silver-haired professor, in which he made the provocative remark, “If we could only get people to stop smoking, drink less, be physically active and eat right, half of you could go home and do something else with your lives: we wouldn’t need so many doctors.” While one could argue with his math, thirty years of providing medical care in the United States-though this would be increasingly applicable to the developing as well as the developed world-have convinced me of the truth which was highlighted by this offhand comment. Despite-or rather in parallel to-a quarter century of progress in medical management and pharmacotherapeutics, a few basic interventions, affecting how people eat, engage in physical activity, and use substances, can have a profound impact on the health of patients and communities. A recent meta-analysis in the British Medical Journal confirmed the equivalence or superiority of exercise vs standard medical therapy in improving disease outcomes and even mortality in patients with stroke, cardiovascular disease, and diabetes [1]. This study echoed the landmark findings of the Diabetes Prevention Program (DPP), which demonstrated the superiority of lifestyle interventions vs metformin in preventing the progression of pre-diabetes to diabetes [2]. The YMCA now offers the DPP intervention as the Y-DPP which could potentially be available at any YMCA across the globe. Yet if these basic interventions are so effective, why have they not been more widely implemented? Basic, but perhaps not simple, in terms of how behavior is influenced and ultimately determined and changed. The factors that influence health-related behaviors have an impact at the individual patient, family, local community, and larger societal levels. Likewise, any strategies that would hope to change these behaviors must be thoughtfully pursued and engaged at each of these levels as well. Fortunately, this volume, Obesity and Disease in an Interconnected World: A Systems Approach to Turn Huge Challenges into Amazing Opportunities!, edited by Judith Wylie-Rosett, EdD, RD & Sunil S. Jhangiani, MD, MBA, FACP, AGAF, is a welcome and useful tool to help elucidate and frame this multi-level strategy. Specifically, as implied by the title, this is a systematic and systems-oriented examination of how to address the global epidemic of obesity and related chronic disease prevention and mitigation, in a comprehensive and coordinated way.

Recent advances in the basic science of fat metabolism, and adiposity, the related endocrinopathies and disease pathogenesis, and the multi-morbidity that affects even some organ systems not traditionally believed to be affected by obesity, have broadened the basis for understanding both the clinical impact of this epidemic and potential biomedical approaches for intervention. At the individual patient level, advances in behavioral science-for example, recent work in the area of motivational interviewing and behavior change [3]-have helped increase clinicians’ skills and sensitivity in the area of health-promotion. Local community interventions, including the promotion of local coalitions of health care providers, public health agencies, local governmental officials, and community-based organizations and advocates, have been found to improve local conditions and increase resources for healthy eating, active living, and smoking cessation and prevention [4]. An important challenge to be overcome is in encouraging and supporting the coordination between clinical (i.e., medical, health care delivery-related) and public health (i.e., population-level) systems, since these two arena have traditionally been disconnected and even potentially discordant. The advent of the Accountable Care Organization (ACO) model in the United States, particularly the beginning of an era in which population-level health outcomes become part of the measurable goals and priorities of large ACOs, provide a structural opportunity to promote this broader approach to health promotion, extending beyond the medical exam room into the local community where patients’ behaviors are largely determined and expressed [5, 6]. This approach will start to focus on creative and potentially powerful collaborations across sectors, such as strategies to implement the standardized Y-DPP educational program not only within health care delivery sites but also local community agencies, faith-based organizations, and schools, as outlined in this volume as well.

Beyond the individual and local community level, as suggested by the chapters in this eBook that address larger societal and even global issues, advocacy and coordinated policy development are essential in helping to shape the broad social priorities that have such an important impact on these health-promoting behaviors. Urban planning, local zoning, financing (from micro-finance to venture capital), health insurance incentives, taxation, marketing and the communications industry, all are examples of the kinds of key factors and areas for strategic intervention that can help determine the health of individuals, and societies. With the United Nations and World Health Organization estimating that over 50% of the chronic disease morbidity and mortality in the world is now due to non-communicable diseases [7], it is clear that one of the unintended consequences of development is to import the familiar array of obesity- and lifestyle-related diseases to many countries that had not previously experienced this-Mexico, India, and China are only a few examples of this phenomenon.

While the behaviors that need to change are basic -- again, how we eat, move, and use substances-and while the impact of behavior change on disease outcomes is clear-cut, it is the challenge of this decade and perhaps this century to create the kind of environments and communities in which these changes can and will take place. As scientists, as clinicians, as public health advocates and educators, and as citizens of our communities and the world, there is no more pressing agenda with the potential of impacting the health of billions of people worldwide. This eBook is an important addition to our efforts to accomplish this agenda for our own and future generations.