Insights in Public Health: The Continued Need for Policy, Systems, and Environmental Changes in Hawai'i to Impact Growing Rates of Obesity and Chronic Disease

The food and physical environments surrounding Hawai‘i's people have drastically changed over the past twenty years, contributing to a dramatic rise in obesity.1 Among adults, obesity in Hawai‘i has more than doubled from 10.8% in 1995 to 22.1% in 2014.2,3 More than half of all adults in Hawai‘i (58.1%) are overweight or obese.3 When compared to other US states, Hawai‘i has the third lowest adult obesity rate; however, it ranks 30th nationally in youth obesity rates.4 More than one in every ten (13.4%) public high school students is obese,5 and nearly one in three children entering kindergarten (28.6%) is already overweight or obese.6 In addition, marked disparities exist among certain sub-populations, with 19.3% of Native Hawaiian (NH) youth and 40.4% of NH adults being obese.5,7 Rates of obesity are even higher among other Pacific Islanders (PI), at 31.2% in PI youth and 57.4% in PI adults.5,7 If Hawai‘i as a state does not address the problem of obesity, by the year 2030, more than half of Hawai‘i's adults will be obese.8 Diabetes and pre-diabetes rates have also been steadily increasing in Hawai‘i; nearly one quarter of all adults in Hawai‘i (24.1%) report having diabetes or pre-diabetes.9 Alarmingly, these rates do not fully capture the burden of these conditions. Based on a study by Dall, et al, (2014), and a methodology developed by the American Diabetes Association, half of all adults in Hawai‘i (52.7%) currently have diabetes (11.2%) or pre-diabetes (41.5%), although 56.5% are unaware of their condition.10,11 A growing body of evidence supports the detrimental impact of an obesogenic food environment on our escalating obesity and chronic disease crisis. The premise of this theoretical framework is that the basic biology of people has not changed, as humans are designed to respond to cues to eat and rest. What is different are the external influences and environmental opportunities for healthy lifestyles. We are at every turn bombarded with messages and easy options to over-consume and to be sedentary. A recent Lancet Series pointed out that today's food environments “exploit people's biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods.”12 This in turn bolsters demands for foods with poor nutritional quality and further enhances the unhealthy food environments around us.12 Past efforts to impact obesity have been ineffective in reducing obesity rates.13 These efforts placed responsibility on the individual to eat healthy and exercise more, without incorporating interventions to change the surrounding environment to ensure availability of appealing healthy options.14 In the new paradigm, policy, systems and environmental changes—rather than an individualistic approach—are necessary to make an impact on the large-scale environmental and societal shifts that have created increased rates of obesity and chronic disease, which in turn require strong regulation and action from the government.12 Without leadership and major policy changes to create healthy environments and societal changes, the obesity epidemic will not be reversed. 12 This article provides an overview of the recommended policies to address Hawai‘i's growing rates of obesity and chronic disease.