Investigating system-level drivers of obesity with adolescents: a group model-building exercise

Background: Capturing voices of young people on issues that affect them is crucial for developing effective, relevant public health policies. We report the use of group model building with young people to identify their views on drivers of adolescent obesity. This is the first stage of the Co-Create project, designed to develop—with adolescents—potential interventions to reduce obesity prevalence. Methods: Co-Create uses an innovative, participatory, multi-staged methodology, underpinned by a systems approach. We followed a group model building script to generate causal loop diagrams, with 16-18-year-olds from three UK schools (mean number of participants per school 14), of factors perceived to contribute to diet and physical activity and, therefore, obesity. Schools were recruited using a sampling frame to represent three quartiles from the index of multiple deprivation ranking of local authorities. Findings: All causal loop diagrams showed that participants identified advertising, the low cost of and easy access to unhealthy food, social media, lack of physical activity, and stress, body image, and other mental health factors as drivers of diet and physical activity and, therefore, obesity. There were no notable differences in themes between the causal loop diagrams. Interpretation: Use of group model building, a participatory systems methodology, captures obesity drivers pertinent to young people, the ways these drivers are intertwined, and potential leverage points for action. This process creates a helpful abstraction from individual behaviour by drawing out system-level, rather than individual, drivers of obesity, although findings are limited to the perceptions of participants and these results represent only urban environments. The results from this first stage of the Co-Create project help generate system-level hypotheses on policy responses to obesity that resonate with young people. In subsequent Co-Create workstreams, adolescents will be recruited to explore interventions to be discussed with policy makers and other stakeholders. The potential effects of the co-created, obesity-related interventions will be simulated using systems dynamics modelling. Funding: EU Horizon 20/20 research and innovation programme for Sustainable Food Security (grant agreement 774210)

Qualitative analysis of front-of package labeling policy interactions between stakeholders and Health Canada

BackgroundFront-of-package labelling regulations proposed by Health Canada in their Healthy Eating Strategy (2016) were finally passed in 2022, but remain unimplemented. This study analyzed interactions that occurred between stakeholders and government related to this policy proposal to identify key themes and policy implications.MethodsA qualitative framework analysis was conducted on publicly available documents for stakeholder correspondences related to front-of-package that occurred between 2016 and 2019 in Health Canada’s Meetings and Correspondence on Healthy Eating database. Five sequential steps were applied: familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation. A complex systems (i.e., a dynamic system with multiple interconnecting components) lens was incorporated in the final step to deepen the analysis.ResultsHundred and seventy-three documents were included, the majority from industry stakeholders (n = 108, 62.4%). Three overarching themes were identified: industry trying to control the agenda and resist regulation; questioning the evidence supporting the policy and its impact on the agri-food industry; and dismissing the need and effectiveness of the policy. Incorporating a complex system lens found industry and non-industry stakeholders held markedly different perspectives on how cohesive the system defined by the front-of-package labelling policy was, and the policy impact on its stability. Economic and opportunity costs were the main trade-offs, and symbol misinterpretation considered an unintended consequence by industry. Finally, some stakeholders argued for wider policy scope incorporating more products, while others requested a narrower approach through exemptions.ConclusionInteractions with industry stakeholders on health food policy proposals require careful consideration, given it may suit their interests to generate delays and policy discordance. Explicitly setting out the principles of engagement and actively encouraging non-industry stakeholder representation provides a more balanced approach to policy consultation and development

Trust and responsibility in food systems transformation. Engaging with Big Food: marriage or mirage?

Concentration of power among transnational 'Big Food' companies has contributed to food systems that are unsustainable, unhealthy and inequitable for people and planet. Given these commercial determinants of health, if 'food systems transformation' is to be authentic-more than a passing narrative-then leveraging Big Food is paramount. To this end, researchers, practitioners and policy-makers are increasingly encouraged to engage with these powerful entities. However, given the conflicts of interest at stake, engagement relies on trust and transparency, that all stakeholders take responsibility for their actions and demonstrate commitment to do no harm. Given Big Food's track record in influencing policy, shifting costs and responsibility for their harms-and while profit primarily drives business decision making-we question whether it is logical to expect trust.This analysis explores concepts of responsibility and trust in relation to food systems transformation involving public-private partnerships. Through short cautionary case studies-looking at the United Nations Food Systems Summit, and Big Food's plastic burden-it argues that unless such companies take responsibility for their cross-cutting effects and earn authentic trust through demonstrably doing no harm, their participation in evidence generation and policy processes should be limited to responding to information requests and adhering to regulation. Any involvement in research agenda-setting or formulating policy solutions introduces conflicts of interest, legitimises corporate irresponsibility and jeopardises scientific integrity. Big Food has dynamism and power to address food system problems, but while it contributes to so many of these problems it should follow-not formulate-transformational evidence, policies and regulations

System mapping with adolescents: Using group model building to map the complexity of obesity

Public health research and practice is increasingly employing systems thinking to help grapple with complex issues, from obesity to HIV treatment. At the same time, there is growing recognition that to address a given problem it is essential collaborate with those most at risk of or affected by it. Group model building (GMB), a process grounded in system dynamics, combines systems thinking and participatory methods to structure and address complex issues. As part of the CO-CREATE project we conducted GMB sessions with young people in six countries to create causal loop diagrams showing the factors that they believe drive obesity. This paper describes the background to GMB and the process we used to construct causal loop diagrams; it discusses how GMB contributed to generating noteworthy and useful findings, and the strengths and limitations of the method. Using GMB, we identified areas of concern to adolescents in relation to obesity that have so far had little attention in obesity research and policy: mental health and online activity. In using GMB, we also helped answer calls for a more participatory approach to youth involvement in research and policy development.publishedVersio

Understanding the dynamics emerging from the interplay among poor mental wellbeing, energy balance-related behaviors, and obesity prevalence in adolescents: A simulation-based study

Both obesity and poor mental wellbeing have a high prevalence in European youth. Adolescents in six countries identified mental wellbeing factors as main drivers of youth obesity through systems mapping. This study sought to (1) explore the dynamics of the interplay between poor mental wellbeing, energy balance-related behaviors, and adolescent overweight and obesity prevalence and (2) test the effect of intervention point scenarios to reduce adolescent obesity. Drawing on the youth-generated systems maps and a literature synthesis, we built a simulation model that represents the links from major feedback pathways for poor mental wellbeing to changes in dietary, physical activity, and sleep behaviors. The model was calibrated using survey data from Norway, expert input, and literature and shows a good fit between simulated behavior and available statistical data. The simulations indicate that adolescent mental wellbeing is harmed by socio-cultural pressures and stressors, which trigger reinforcing feedback mechanisms related to emotional/binge eating, lack of motivation to engage in physical activity, and sleep difficulty. Targeting a combination of intervention points that support a 25% reduction of pressure on body image and psychosocial stress showed potentially favorable effects on mental wellbeing—doubling on average for boys and girls and decreasing obesity prevalence by over 4%.publishedVersio

Adolescents' Perspectives on the Drivers of Obesity Using a Group Model Building Approach: A South African Perspective.

Overweight and obesity increase the risk of a range of poor physiological and psychosocial health outcomes. Previous work with well-defined cohorts has explored the determinants of obesity and employed various methods and measures; however, less is known on the broader societal drivers, beyond individual-level influences, using a systems framework with adolescents. The aim of this study was to explore the drivers of obesity from adolescents' perspectives using a systems approach through group model building in four South African schools. Group model building was used to generate 4 causal loop diagrams with 62 adolescents aged 16-18 years. These maps were merged into one final map, and the main themes were identified: (i) physical activity and social media use; (ii) physical activity, health-related morbidity, and socio-economic status; (iii) accessibility of unhealthy food and energy intake/body weight; (iv) psychological distress, body weight, and weight-related bullying; and (v) parental involvement and unhealthy food intake. Our study identified meaningful policy-relevant insights into the drivers of adolescent obesity, as described by the young people themselves in a South African context. This approach, both the process of construction and the final visualization, provides a basis for taking a novel approach to prevention and intervention recommendations for adolescent obesity

Co-creating obesity prevention policies with youth: Policy ideas generated through the CO-CREATE project

Despite growing recognition of the importance of applying a systems lens to action on obesity, there has only been limited analysis of the extent to which this lens has actually been applied. The CO-CREATE project used a youth-led participatory action research approach to generate policy ideas towards the reduction of adolescent overweight and obesity across Europe. In order to assess the extent to which these youth-generated policy ideas take a systems approach, we analyzed them using the Intervention Level Framework (ILF). The ILF ascribes actions to one of five system levels, from Structural Elements, the least engaged with system change, up to Paradigm, which is the system's deepest held beliefs and thus the most difficult level at which to intervene. Of the 106 policy ideas generated by young people during the CO-CREATE project, 91 (86%) were categorized at the level of Structural Elements. This emphasis on operational rather than systems level responses echoes findings from a previous study on obesity strategies. Analyzing the distribution of systems level responses using the ILF has the potential to support more effective action on obesity by allowing identification of opportunities to strengthen systems level responses overall.publishedVersio

Adolescents’ Perspectives on the Drivers of Obesity Using a Group Model Building Approach: A South African Perspective

Overweight and obesity increase the risk of a range of poor physiological and psychosocial health outcomes. Previous work with well-defined cohorts has explored the determinants of obesity and employed various methods and measures; however, less is known on the broader societal drivers, beyond individual-level influences, using a systems framework with adolescents. The aim of this study was to explore the drivers of obesity from adolescents’ perspectives using a systems approach through group model building in four South African schools. Group model building was used to generate 4 causal loop diagrams with 62 adolescents aged 16–18 years. These maps were merged into one final map, and the main themes were identified: (i) physical activity and social media use; (ii) physical activity, health-related morbidity, and socio-economic status; (iii) accessibility of unhealthy food and energy intake/body weight; (iv) psychological distress, body weight, and weight-related bullying; and (v) parental involvement and unhealthy food intake. Our study identified meaningful policy-relevant insights into the drivers of adolescent obesity, as described by the young people themselves in a South African context. This approach, both the process of construction and the final visualization, provides a basis for taking a novel approach to prevention and intervention recommendations for adolescent obesity

Associations between social media, adolescent mental health, and diet: A systematic review

SummarySocial media use is integral to many adolescents' lives. It brings benefits but can also have detrimental effects on both physical and mental health. We conducted a systematic review examining associations between social media use, adolescent mental health (including body image, self‐esteem, stress, interpersonal relationships and loneliness, anxiety, and depressive symptoms), and dietary outcomes. Quantitative studies published between 2019 and 2023 investigating both mental health and diet were searched in 11 databases. The risk of bias was appraised using ROBINS‐E. Data were narratively synthesized by type of association, PROGRESS‐Plus health equity characteristics, and related to social media influencers. Twenty‐one studies were included, of which only one focused on influencers. Sex/gender was the only equity characteristic assessed (n = 8), with mixed results. The findings suggest significant positive correlations between social media use and both depressive and disordered eating symptoms, body dissatisfaction, and anxiety. Four studies identified body image, self‐esteem, or anxiety as moderators acting between social media exposure and dietary outcomes. Policy interventions mitigating the impact of social media on adolescents—particularly body image and disordered eating—are needed, alongside follow‐up studies on causal pathways, the role of influencers, equity impacts, dietary intake, and the best measurement tools to use.</jats:p