Next steps in obesity prevention: applying the systems approach

Two-Year Results of a Five-Year Personalized Integrative Obesity Coaching Program (IBO) Based upon a Systems Health Perspective and an Evolutionary Longitudinal Study Approach

This study presents the outcomes of a 5-year personalized integrative coaching program for adults with obesity (body mass index BMI ≥ 30 kg/m2), based upon a systems health perspective, during the first 2 years. This longitudinal study, which had an evolutionary design, included all adults who enrolled in the program. Health-related quality of life (HRQoL) was measured with the Short Form-36 (SF-36), and physical outcomes included weight, waist circumference, aerobic capacity, lipid profile, and HbA1c. Subsequently, participants completed questionnaires (e.g., the Symptom Checlist-90 (SCL-90) and the Checklist Individual Strength (CIS)). Seventy-nine adults with a mean BMI of 39.5 kg/m2 (SD 5.3) were included. Forty-four participants completed 2 years in the program. Compared to baseline, there were significant improvements in the SF-36 subscales 'physical functioning' (MD 9.9 points, 95% CI: 2.1-17.5, p = 0.013) and 'general health perceptions' (MD 9.3 points, 95% CI 2.9-15.7, p = 0.006). Furthermore, significant improvements in physical outcomes and psychosocial questionnaires (e.g., weight loss (MD 3.5 kg, 95% CI: 1.2-5.7, p = 0.003), waist circumference (MD 5.1 cm, 95% CI: 2.4-7.8, p < 0.001), and CIS fatigue (MD 6.8, 95% CI: 3.1-10.5, p = 0.001) were observed. This study highlights the importance of a systems health perspective supporting the development of a personalized integrative coaching program for adults with obesity in a 'real-world' setting.

Generating change through collective impact and systems science for childhood obesity prevention: The GenR8 Change case study

BACKGROUND

Community-based interventions have shown promise in reducing childhood overweight and obesity. However, they have been critiqued for using linear logic models. Participatory community-based systems approaches are posited as addressing the complexity of non-linear relationships in a local context. Community members are empowered to understand and describe obesity causation, identify and prioritise possible solutions. The application of such approaches to childhood obesity is in its infancy.

AIM

To describe the first 12 months of a participatory whole-of-community systems approach to creating collective action to tackle childhood obesity, called GenR8 Change, in a local government area of Victoria, Australia.

METHODS

Three group model building (GMB) sessions focused on the development of a causal loop diagram (CLD), prioritised evidence-informed actions, and developed implementation strategies. The collective impact framework underpinned the approach, with a local backbone group supporting community members to implement prioritised actions.

RESULTS

The first two GMB sessions included 20 key community leaders where a CLD examining the factors contributing to childhood obesity in the community was constructed and refined (22 variables GMB1, 53 variables GMB2). In the third session, 171 members of the wider community further refined the CLD, identified priorities for childhood obesity prevention (72 variables in final CLD). One-hundred and thirteen individuals signed up across 13 working groups to plan and implement 53 prioritised actions. Agreed community actions included creating sugar free zones; developing healthy policies; increasing breastfeeding rates; improving drinking water access; and increasing physical activity options. Twelve months post-GMB3, 115 actions had been implemented.

CONCLUSION

GenR8 Change is one of the first communities to apply systems thinking to childhood obesity prevention. Knowledge on how to collectively identify relevant leverage points to tackle childhood obesity can now be shared with other communities.

Characterization of a Regional Childhood Obesity Prevention and Treatment System

This project characterized the system of childhood obesity-related programs and functions based on a socioecological framework within the Kansas City region to determine strengths, weaknesses, and leverage points for informing collective impact. A mixed-method approach was employed to identify and collect data ∼260 childhood obesity-related programs provided by 89 organizations. Findings indicated no major gaps in population or location served although few programs specifically focused on service to minority groups or neighborhoods. The region has many programs working within the system, yet the distribution of programs does not occur as expected throughout the dimensions of a standard socioecological model or community health system. In addition, several organizations perform certain leadership functions such as coordination, resource allocation, or monitoring, but none perform all, indicating the lack of a traditional "backbone" organization. These findings demonstrate how a region's childhood obesity prevention and treatment programs can be evaluated using a socioecological framework.

Provider views on childhood obesity management in primary care settings: a mixed methods analysis

BACKGROUND

Pediatric providers are key players in the treatment of childhood obesity, yet rates of obesity management in the primary care setting are low. The goal of this study was to examine the views of pediatric providers on conducting obesity management in the primary care setting, and identify potential resources and care models that could facilitate delivery of this care.

METHODS

A mixed methods approach was utilized. Four focus groups were conducted with providers from a large pediatric network in San Diego County. Based on a priori and emerging themes, a questionnaire was developed and administered to the larger group of providers in this network.

RESULTS

Barriers to conducting obesity management fell into four categories: provider-level/individual (e.g., lack of knowledge and confidence), practice-based/systems-level (e.g., lack of time and resources), parent-level (e.g., poor motivation and follow-up), and environmental (e.g., lack of access to resources). Solutions centered around implementing a team approach to care (with case managers and health coaches) and electronic medical record changes to include best practice guidelines, increased ease of documentation, and delivery of standardized handouts/resources. Survey results revealed only 23.8% of providers wanted to conduct behavioral management of obesity. The most requested support was the introduction of a health educator in the office to deliver a brief behavioral intervention.

CONCLUSION

While providers recognize the importance of addressing weight during a well-child visit, they do not want to conduct obesity management on their own. Future efforts to improve health outcomes for pediatric obesity should consider implementing a collaborative care approach.

Development of a Systems Science Curriculum to Engage Rural African American Teens in Understanding and Addressing Childhood Obesity Prevention

Engaging youth from racial and ethnic minority communities as leaders for change is a potential strategy to mobilize support for addressing childhood obesity, but there are limited curricula designed to help youth understand the complex influences on obesity. Our aim was to develop and pilot test a systems science curriculum to elicit rural African American youth perspectives on childhood obesity and enhance their understanding of and support for obesity prevention solutions. The curriculum was designed so it could be integrated with existing positive youth development curricula that help youth advocate for and implement identified solutions. We conducted four workshop sessions with youth that engaged them in systems learning activities such as guided systems diagramming activities. The participants ( n = 21) completed validated surveys presession and postsession that assessed their causal attributions of obesity and support for obesity prevention policies. The youths' perception that environmental factors cause obesity increased ( p < .05), and perceptions that individual behavior and biology cause obesity did not change. Their support for policies that addressed food access and food pricing significantly increased ( p < .05). The youths' system diagrams elucidated links between multilevel factors such as personal attitudes, social influence, and the built environment, which provides important information for designing synergistic solutions. The changes we observed in youths' perceptions of obesity and support for policy changes have important implications for youths' interest and willingness to advocate for social and environmental changes in their community. The strategies have a promising role in supporting community mobilization to address childhood obesity.

How Can We Better Prevent Obesity in Children?

The aim of this review is to discuss the state of the art regarding the field of health promotion in the context of childhood obesity prevention in order to learn how we can better prevent childhood obesity. Challenges have been identified that exist within the different steps of health promotion programme development and implementation. Important steps forward include studying behaviours and determinants of behaviours as clusters, upgrading the importance of distal environmental factors in modelling determinants and understanding determinants as a dynamic system: a complex of interacting elements. An important note is that the process of implementation and the analysis thereof should more often come before the analysis of behaviours and the determinants of behaviour. In applied research, the expertise from the 'real world' practitioners should be used in an early stage to find out whether the answers on research questions really help us in preventing childhood obesity.

Our Choice/Nuestra Opción: the Imperial County, California, Childhood Obesity Research Demonstration study (CA-CORD)

BACKGROUND

Despite recent declines among young children, obesity remains a public health burden in the United States, including among Latino/Hispanic children. The determining factors are many and are too complex to fully address with interventions that focus on single factors, such as parenting behaviors or school policies. In this article, we describe a multisector, multilevel intervention to prevent and control childhood obesity in predominantly Mexican-origin communities in Southern California, one of three sites of the CDC-funded Childhood Obesity Research Demonstration (CA-CORD) study.

METHODS

CA-CORD is a partnership between a university-affiliated research institute, a federally qualified health center, and a county public health department. We used formative research, advisory committee members' recommendations, and previous research to inform the development of the CA-CORD project. Our theory-informed multisector, multilevel intervention targets improvements in four health behaviors: fruit, vegetable, and water consumption; physical activity; and quality sleep. Intervention partners include 1200 families, a federally qualified health center (including three clinics), 26 early care and education centers, two elementary school districts (and 20 elementary schools), three community recreation centers, and three restaurants. Intervention components in these sectors target changes in behaviors, policies, systems, and the social and physical environment. Evaluation activities include assessment of the primary outcome, BMI z-score, at baseline, 12-, and 18-months post-baseline, and sector evaluations at baseline, 12, and 24 months.

CONCLUSIONS

Identifying feasible and effective strategies to prevent and control childhood obesity has the potential to effect real changes in children's current and future health status.

Challenges in lifestyle and community interventions research; a call for innovation

Earlier this year the BMC portfolio was enriched by a new journal BMC Obesity. Here, we present the aims and objectives of the section on Lifestyle and Community Interventions. Innovative research is needed. Preventing or managing obesity requires addressing different determinants across multiple levels where diverse levers and stakeholders can play a critical role. Interactions of these determinants within and between systems need to be studied. How to leverage, manage and measure this complexity underlies the innovation that is needed in the next generation of obesity interventions. The ambition of the Lifestyle and Community Interventions section is to provide a space for innovative research, including research that falls outside the traditional comfort zone. We welcome studies of heterogeneous designs, including those of qualitative, quantitative, mixed and systems methodologies. Studies of interest include not only outcomes research of interventions but also process evaluation, cost-effectiveness or cost-benefit analysis, and implementation and dissemination research. Innovations that integrate diverse intervention levers or combine primary and secondary levels of prevention are particularly encouraged. The general aim of BMC Obesity's Lifestyle and Community Interventions section is to advance our ability to decide on what combinations of approaches will be required to effectively and equitably prevent obesity.

A novel system dynamics model of female obesity and fertility

OBJECTIVES

Our objective was to create a system dynamics model specific to weight gain and obesity in women of reproductive age that could inform future health policies and have the potential for use in preconception interventions targeting obese women.

METHODS

We used our system dynamics model of obesity in women to test various strategies for family building, including ovulation induction versus weight loss to improve ovulation. Outcomes included relative fecundability, postpartum body mass index, and mortality.

RESULTS

Our system dynamics model demonstrated that obese women who become pregnant exhibit increasing obesity levels over time with elevated morbidity and mortality. Alternatively, obese women who lose weight prior to pregnancy have improved reproductive outcomes but may risk an age-related decline in fertility, which can affect overall family size.

CONCLUSIONS

Our model highlights important public health issues regarding obesity in women of reproductive age. The model may be useful in preconception counseling of obese women who are attempting to balance the competing risks associated with age-related declines in fertility and clinically meaningful weight loss.