The risk to young adults was recently highlighted in a JAMA study measuring weight gain in adulthood (between ages 18 and 55 for women and between ages 21 and 55 for men). Those that gained 20 kilograms or more of weight—approximately 23 percent of women and 13 percent of men—had elevated rates of type 2 diabetes, hypertension, cardiovascular disease, obesity-related cancers, and ultimately a higher mortality rate. Furthermore, as noted in a recent JAMA editorial by our coauthor Dr. William (Bill) Dietz, "the ethnic disparities in the prevalence of obesity may begin in the transition between adolescence and young adulthood."
What is behind this dangerous weight gain in the twenties and thirties? From a life course perspective, young adults face multiple transition points that potentially increase their risk of unhealthy weight gain. These transitions include university life, the start of employment, autonomous living, initiation of alcohol consumption, marriage, pregnancy, and parenthood. New research into the specific transitions and behaviors associated with obesity onset in 20–39 year olds may help identify at-risk young adults before significant weight gain occurs.
To understand more about both the opportunities and challenges in targeting young adults with stronger obesity prevention efforts, The Bridgespan Group, in partnership with Dr. Dietz, spoke with over 30 diverse experts and leaders from government, health care, the insurance industry, academia, and the social sector.
Across the obesity field, we found support for greater focus on young adults, particularly new parents. However, there are challenges in trying to address obesity among this group. First, the health care and social service systems have often been too disconnected to support an integrated effort focused on new (or soon-to-be) parents and their children. On top of this, as noted recently by Dr. Dietz in JAMA, "...many individuals, particularly men between the ages of 20 and 39 years feel healthy, and have no medical problems that precipitate a visit to a physician."
A second problem is financial. For example, unlike prevention efforts focused on people at high risk of type 2 diabetes—which could reduce health care costs in the short and medium terms—most savings produced by prevention efforts focused on new parents and young adults would only occur much later. "Savings that accrue a generation later," said one health care finance expert, "don't matter to your bottom line. They matter to someone else's bottom line." And finally, one issue that applies to the whole spectrum of obesity prevention efforts is the associated stigma. Employers and others who might play a role in prevention sometimes struggle with ways to engage at-risk groups, as they quite rightly don't want to shame people.
Despite these challenges, we encountered several bright spots. First, there is a trend toward increased integration of clinical and community services, a critical need for effective and comprehensive program delivery to families, students, and young adults. Second, the implementation of the Affordable Care Act and experimentation in the federal government and among states is beginning to realign incentives to promote long-term public health, making a focus on young adults somewhat more practical. Finally, emerging two-generation approaches that target parents and child together are better engaging families, potentially paving the groundwork for more effective obesity prevention.
Among young adults, prevention of obesity in new parents provides a novel and potentially powerful lever in the fight against adult and childhood obesity. Why new parents? First, there are a lot of them. Eighty-five percent of women and 76 percent of men will have a child by the time they reach age 40. Second, new parenthood is viewed as a behavioral window of opportunity to—as one expert told us—"hit the reset button on obesity." Parents tend to be especially focused on changes in their life when they have their first child. Third, pregnancy and a new child bring young adults—who are otherwise unlikely to see a physician regularly—into close contact with pediatricians and other medical providers (particularly for young women). Finally, parents have an enormous influence on the habits of their children, including what they eat. Obesity often runs in families: children of two parents with obesity have an 80 percent chance of developing obesity themselves. Therefore, targeting young adults before too much weight gain occurs may pay double dividends by potentially decreasing obesity in both parents and their children.
Four questions to highlight emerging opportunities
With this context in mind, what are the opportunities to better target young adults and new parents for obesity prevention? We believe the field—funders, policymakers, health care providers, human services agencies, nonprofits, and employers—should consider four main questions:
1. Are we targeting and engaging the right populations?
As the research into the demographics of obesity continues to improve, the field needs to ensure that it is focused on the right populations and sub-populations, and identify the most effective ways to engage them. The first step is identifying the most at-risk populations and the life transitions that may trigger excessive weight gain. Work by Dr. Dietz at George Washington University is seeking to identify critical periods and behaviors associated with obesity onset in 20–39 year olds. For example, since most mothers have multiple children, the period between births (interconception), may be a particularly vulnerable time requiring greater attention. Despite updated weight management guidelines from the American College of Obstetricians and Gynecologists, excessive weight gain during pregnancy remains a significant problem.
Even if we are adequately addressing the weight management needs of new mothers, how do we make sure that we are properly including young men and fathers as well? A 2017 review of childhood obesity prevention trials published in Pediatrics found that fathers represented only 6 percent of parents involved in the studies. The "What About Dads?" (WAD) study, an encouraging and innovative effort by the Harvard T.H. Chan School of Public Health, seeks to better understand the role of fathers in promoting childhood obesity prevention behaviors, and to increase participation of fathers in childhood obesity research.
2. What programs or partnerships are most likely to succeed?
As risks and transitions associated with unhealthy weight gain are recognized, how are these translated into health care delivery and prevention? Young adults and new parents and their children connect to a range of systems—and we need to look at interventions that span more than a single provider. To address obesity in young adults and new parents, the field needs to examine existing programs and delivery channels that might enhance impact. For example, the Massachusetts General Hospital (MGH) First 1,000 Days program, focusing on new parents and children from conception to age two, is coordinating across early childhood care providers and programs to prevent obesity, promote healthy lifestyles, and reduce health disparities. MGH is bringing together primary care (obstetrics, pediatrics, and adult medicine), the Massachusetts agency of the federally-funded, state-run Women, Infant, and Children (WIC) Program for low-income parents, maternal-child home visiting programs, and other community resources to provide consistent behavior change messaging to prevent and manage obesity.
3. Are we making the best use of technology?
As technology relentlessly advances, so too do opportunities to engage increasingly tech-savvy young adults and families. Technology can leverage peer and virtual reward systems to improve engagement, reduce program delivery costs, increase scale and access, enhance data collection, and improve communication between sectors working on shared prevention initiatives. In their recent Wellness in the Workplace Study, Optum noted significant increases in the number of employers using digital health technology to better engage their employees (e.g., through mobile messaging). No doubt this trend will continue in coming years.
4. Are we measuring the right things?
With the complexity of challenges around obesity prevention, it is important to measure the right dimensions to inform future efforts. For example, are there metrics beyond body mass index that give a richer view into a young adult's or family's health (e.g., diet, consumer habits, sleep)? One study in Massachusetts is investigating the holistic effects of BOKS (Build Our Kids' Success), a before-school physical activity program, by measuring psychosocial outcomes, nutrition, energy/vitality, stress, and academic performance, among other elements. Studies like these may help reveal more complex relationships between exercise/nutrition programs and family health, paving the way for more effective family interventions
Ultimately, the long-term success of obesity prevention may depend on how successfully we prevent obesity in young adults and new parents. A variety of key stakeholders, including researchers, employers, government agencies, and nonprofits can play a role.
Researchers have opportunities to understand the demographics of excessive weight gain and obesity in this age group, and the life transitions and behaviors that contribute. In addition, there are opportunities to revisit data sets while looking at the family as the unit of obesity management. For example, aggregating private health care claims and Medicaid data across individuals within a family can begin revealing interdependencies in their weight management that might ultimately inform treatment.
Employers can make a difference by better adapting current programs to engage new parents (e.g., through tailored messaging). While short-term financial incentives tend to de-prioritize obesity prevention in young adults, among employers an incentive shift from "return on investment" to "value of investment" has highlighted the benefits of a healthy workforce and healthy families, including those that are difficult to monetize. As one workforce wellness expert emphasized, "[it's an] investment, not a cost." As more employers see the broad value of investing in preventive health initiatives for their employees—in particular employers with long-term workforces, those in the wellness space (e.g., hospitals), and those where physical activity is required at the worksite—new parents may be the ideal population to target.
Government can continue efforts to decrease costs while spreading innovative new ideas, such as through the Center for Medicare & Medicaid Innovation's Accountable Health Communities Model. Thirty-two organizations were recently awarded grants under this program to help address social determinants of health under Medicare and Medicaid coverage—a promising opportunity for collaboration and innovation.
Nonprofits have opportunities to reframe current obesity prevention for young adults and new families, as many programs either broadly support the health of families (in ways unrelated to weight management) or specifically address obesity only in children, with limited overlap. For instance, research is underway with the Nurse-Family Partnership program, one of several providers of in-home support for low-income mothers during and after pregnancy, to identify improvements in health behaviors related to obesity, a "tremendous opportunity to influence family structure around eating habits" according to one researcher.
With young adults and new parents in greater focus, we have the potential to finally change the curve on obesity. Everyone involved, from pediatricians and philanthropies to employers and insurers, has a critical role to play to help us reach this goal. As one obesity researcher told us, "This is the future."
Margaret Boasberg is a partner at The Bridgespan Group and leader in its public health practice. Mike Soskis is a Bridgespan case team leader, and Pamela Hung a Bridgespan associate consultant. Dr. William (Bill) Dietz, an obesity expert, is chair of The Sumner M. Redstone Global Center for Prevention and Wellness at George Washington University's Milken Institute School of Public Health and research collaborator with Bridgespan.