An exploration of the determinants of overweight and obesity and the capacity to intervene in North-West Tasmania: A stakeholder consultation

ISSUE ADDRESSED

The capacity of communities to develop effective obesity prevention initiatives varies and should be a focus for obesity prevention intervention planning and investment. This research aimed at engaging and consulting local community stakeholders to identify determinants, needs, strategic priorities and capacity to act on overweight and obesity prevention in North-West (NW) Tasmania.

METHODS

A series of semi-structured interviews and thematic analyses was implemented to explore the knowledge, insights, experiences and attitudes of stakeholders.

RESULTS

Mental health and obesity were identified as major concerns and were often reported to share similar determinants. This study has identified health promotion capacity assets (existing partnerships, community capital, local leadership and some pockets of health promotion activity), and a range of capacity deficits (limited investment in health promotion, a small workforce, limited access to pertinent health information).

CONCLUSIONS

This study has identified health promotion capacity assets (existing partnerships, community capital, local leadership and some pockets of health promotion activity), and a range of capacity deficits (limited investment in health promotion, a small workforce, limited access to pertinent health information). SO WHAT?: Broad upstream socio-economic, cultural and environmental determinants underpin the conditions by which the local community develops overweight/obesity and/or health and wellbeing outcomes. Including stakeholder consultations as a significant technique within a comprehensive plan of action aimed at achieving a sustainable, long-term strategy for obesity prevention and/or health promotion, should be considered in future programs.

Enhancing Food Literacy and Food Security through School Gardening in Rural and Regional Communities

A qualitative case study approach with in-depth, semi-structured interviews of key school staff, and student feedback was used to assess a school kitchen and garden program in the regional area of North-West Tasmania, Australia. A detailed program description was produced to conduct a realist evaluation with a Context-Mechanism-Outcome configuration, followed by a program theory evaluation through the construction of a retrospective program logic model. Dedicated kitchen and garden spaces, knowledgeable teachers committed to the program, provision of sufficient materials and consumables, and support from the school and community were found to be the basic requirements to establish a program. Additionally, it is essential to integrate both the kitchen and garden teaching components into the school curriculum. The positive outcomes (e.g., engagement, participation, knowledge, skills, behavioral change) of the program were dependent on the underlying factors, including dedicated support of school leadership, teaching staff, and the parent body for effective student engagement in the teaching spaces and for wider engagement from families and the community. The students' feedback provided supporting evidence of increased food literacy with improvements in their understanding, abilities, and attitudes towards gardening, producing healthy food, and preparing food. This may further lead to enhanced food security for students' families and the broader community.

Habitual Diets Are More Expensive than Recommended Healthy Diets

Understanding food prices and affordability is crucial for promoting healthy dietary habits and informing policy actions. We assessed changes in the cost and affordability of habitual and recommended healthy diets in Northwest Tasmania from 2021 to 2023. The recommended diet was 16-22% less expensive than the habitual diet during the period. Notably, 60% of the total cost of the habitual diet was spent on discretionary items. The cost of the habitual diet increased by 9% in this period, whereas the cost of the recommended diet increased by only 2%. The habitual diet was unaffordable for households with median gross, minimum wage disposable or welfare-dependent incomes. The recommended diet, however, was affordable for some groups but posed a risk of food stress for those with median gross and minimum wage disposable income and remained unaffordable for those who were welfare dependent. Our findings reveal that adhering to a healthy Australian Dietary Guidelines-recommended diet can be more cost-effective than following a habitual unhealthy diet. However, adopting a healthy diet can be challenging for low-income families. Interventions such as financial support, nutrition education, community gardens and food hubs, as well as price regulation and subsidies for farmers, can help address food insecurity in Northwest Tasmania.

School Gardening and Health and Well-Being of School-Aged Children: A Realist Synthesis

School environments can create healthy settings to foster children's health and well-being. School gardening is gaining popularity as an intervention for healthier eating and increased physical activity. We used a systematic realist approach to investigate how school gardens improve health and well-being outcomes for school-aged children, why, and in what circumstances. The context and mechanisms of the specific school gardening interventions (n = 24) leading to positive health and well-being outcomes for school-aged children were assessed. The impetus of many interventions was to increase fruit and vegetable intake and address the prevention of childhood obesity. Most interventions were conducted at primary schools with participating children in Grades 2 through 6. Types of positive outcomes included increased fruit and vegetable consumption, dietary fiber and vitamins A and C, improved body mass index, and improved well-being of children. Key mechanisms included embedding nutrition-based and garden-based education in the curriculum; experiential learning opportunities; family engagement and participation; authority figure engagement; cultural context; use of multi-prong approaches; and reinforcement of activities during implementation. This review shows that a combination of mechanisms works mutually through school gardening programs leading to improved health and well-being outcomes for school-aged children.

"An Ounce of Prevention is Worth a Pound of Cure": Proposal for a Social Prescribing Strategy for Obesity Prevention and Improvement in Health and Well-being

BACKGROUND

Social and behavioral determinants of health are increasingly recognized as central to effective person-centered intervention in clinical practice, disease management, and public health. Accordingly, social prescribing (SP) has received increased attention in recent times. The rampant global prevalence of obesity indicates that the customary, reductionistic, and disease-oriented biomedical approach to health service delivery is inadequate/ineffective at arresting the spread and mitigating the damaging consequences of the condition. There is an urgent need to shift the focus from reactive downstream disease-based treatments to more proactive, upstream, preventive action. In essence, this requires more effort to affect the paradigm shift from the traditional "biomedical approach of care" to a "biopsychosocial model" required to arrest the increasing prevalence of obesity. To this end, an SP approach, anchored in systems thinking, could be an effective means of moderating prevalence and consequences of obesity at a community level.

OBJECTIVE

The proposed SP intervention has the following three key objectives: (1) build a sustainable program for Circular Head based on SP, peer education, and health screening to minimize the incidence of obesity and related lifestyle diseases; (2) increase service and workforce connectivity and collaboration and initiate the introduction of new services and activities for obesity prevention and community health promotion; and (3) enhance health and well-being and minimize preventable adverse health outcomes of obesity and related lifestyle diseases through enhancement of food literacy and better nutrition, enhancement of physical literacy and habitual personal activity levels, and improvement of mental health, community connectedness, and reduction of social isolation.

METHODS

This paper describes a prospective SP strategy aimed at obesity prevention in Circular Head, a local government area in Northwest (NW) Tasmania. SP is a prominent strategy used in the Critical Age Periods Impacting the Trajectory of Obesogenic Lifestyles Project, which is an initiative based in NW Tasmania focused on assessing obesity prevention capacity. A social prescription model that facilitates the linkage of primary health screening with essential health care, education, and community resources through a dedicated "navigator" will be implemented. Four interlinked work packages will be implemented as part of the initial plan with each either building on existing resources or developing new initiatives.

RESULTS

A multimethod approach to triangulate insights from quantitative and qualitative research that enables the assessment of impact on individuals, community groups, and the health care system will be implemented within the initial pilot phase of the project.

CONCLUSIONS

Literature is replete with rhetoric advocating complex system approaches to curtail obesity. However, real-life examples of whole-of-systems interventions operationalized in ways that generate relevant evidence or effective policies are rare. The diverse approach for primary prevention of obesity-related lifestyle diseases and strategies for improvement of health and well-being described in this instance will contribute toward closing this evidence gap.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41280.

Domains of Capacity Building in Whole-Systems Approaches to Prevent Obesity-A "Systematized" Review

Despite increased awareness of its risks, for the most part, contemporary efforts for obesity prevention have been patchy at best. As such, the burgeoning interest in whole-systems approaches (WSAs) that acknowledge the complex, dynamic nature of overweight and obesity and operate across multiple levels of society is particularly timely. Many components of "community capacity building" (CB), an essential but often neglected aspect of obesity prevention, overlap with "best practice principles" in effective/optimal community-based obesity-prevention initiatives. Rhetoric urging WSAs and community CB in public health abounds although operative and efficacious contemporary examples of these approaches to reducing obesity levels are scarce. The aim of this investigation was to undertake a systematized review of the level of capacity building incorporated in published literature on WSAs targeting obesity to better understand how domains of CB have been incorporated. A PubMed search and a recently published systematic review were utilized to identify WSAs to obesity prevention between 1995-2020. A team-based approach to qualitative thematic data analysis was used to systematically assess and describe each intervention regarding explicit capacity-building practice. Despite not being specifically designed for building capacity, a significant proportion of the WSAs studied in the current report had implemented several CB domains.

Why some do but too many don't? Barriers and enablers to physical activity in regional Tasmania - an exploratory, mixed-methods study

Background

The interconnectedness of physical inactivity and sedentarism, obesity, non-communicable disease (NCD) prevalence, and socio-economic costs, are well known. There is also strong research evidence regarding the mutuality between well-being outcomes and the neighbourhood environment. However, much of this evidence relates to urban contexts and there is a paucity of evidence in relation to regional communities. A better understanding of available physical activity (PA) infrastructure, its usage, and community perceptions regarding neighbourhood surroundings, could be very important in determining requirements for health improvement in regional communities. The aims of this research were to 1. Explore and evaluate the public’s perception of the PA environment; and 2. Evaluate the quantity, variety, and quality of existing PA infrastructure in regional Northwest (NW) Tasmania.

Methods

A mixed methods approach guided data collection, analysis, and presentation. Quality of PA infrastructure was assessed using the Physical Activity Resource Assessment (PARA) instrument and public perception about PA environment was evaluated using the International Physical Activity Questionnaire – Environmental (IPAQ-E) module. Quantitative data were analysed using descriptive summative methods and a team-based researcher triangulation approach was utilised for qualitative data.

Results

Overall, a wide array of high-quality PA infrastructure (with minimal incivilities such as auditory annoyance, litter, graffiti, dog refuse, and vandalism etc.) was available. Survey respondents rated neighbourhoods positively. The overall quality of PA infrastructure, rated on a scale from 0 to 3, was assessed as high (all rated between 2 to 3) with minimal incivilities (rated between 0 and 1.5). Of note, survey respondents confirmed the availability of numerous free-to-access recreational tracks and natural amenities across the 3 local government areas (LGAs) studied. Importantly, most respondents reported minimal disruption to their routine PA practices due to the COVID-19 pandemic.

Conclusion

This exploratory research confirmed the availability of a wide range of high-quality PA infrastructure across all three LGAs and there was an overwhelming public appreciation of this infrastructure. The challenge remains to implement place-based PA interventions that address extant barriers and further increase public awareness and utilisation of high-quality PA infrastructure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13001-6.

A Spatial Analysis of Access to Physical Activity Infrastructure and Healthy Food in Regional Tasmania

Prevalence of physical inactivity and obesity continues to increase in regional areas such as North-West (NW) Tasmania and show no signs of abating. It is possible that limited access to physical activity infrastructure (PAI) and healthier food options are exacerbating the low levels of habitual physical activity and obesity prevalence in these communities. Despite a burgeoning research base, concomitant exploration of both physical activity and food environments in rural and regional areas remain scarce. This research evaluated access (i.e., coverage, variety, density, and proximity) to physical activity resources and food outlets in relation to socioeconomic status (SES) in three NW Tasmanian communities. In all three study areas, the PAI and food outlets were largely concentrated in the main urban areas with most recreational tracks and natural amenities located along the coastline or river areas. Circular Head had the lowest total number of PAI (n = 43) but a greater proportion (30%) of free-to-access outdoor amenities. There was marked variation in accessibility to infrastructure across different areas of disadvantage within and between sites. For a considerable proportion of the population, free-to-access natural amenities/green spaces and recreational tracks (73 and 57%, respectively) were beyond 800 m from their households. In relation to food accessibility, only a small proportion of the food outlets across the region sells predominantly healthy (i.e., Tier 1) foods (~6, 13, and 10% in Burnie, Circular Head and Devonport, respectively). Similarly, only a small proportion of the residents are within a reasonable walking distance (i.e., 5–10 min walk) from outlets. In contrast, a much larger proportion of residents lived close to food outlets selling predominantly energy-dense, highly processed food (i.e., Tier 2 outlets). Circular Head had at least twice as many Tier 1 food stores per capita than Devonport and Burnie (0.23 vs. 0.10 and 0.06; respectively) despite recording the highest average distance (4.35 and 5.66 km to Tier 2/Tier 1 stores) to a food outlet. As such, it is possible that both food and physical activity environment layouts in each site are contributing to the obesogenic nature of each community.

The current global state of movement and physical activity - the health and economic costs of the inactive phenotype

Physical inactivity is one of the major contributing factors to the global pandemic of non-communicable diseases. Unfortunately, low levels of habitual movement and physical activity (PA) are seen in an increasing proportion of populations across low- and middle-income countries and high-income countries alike. This new normal - the inactive phenotype - is a significant contributor to multiple health and economic costs. Here we provide a brief historical overview of societal declines in PA, roughly consistent with major transitions in PA and nutrition in recent decades. This is followed by a synthesis of research evidence linking inactivity with poor health outcomes and prevention approaches needed to impact a perpetuation of poor lifestyle behaviors. A major focus of the paper is on the economic/health costs and the reduction of the inactive phenotype. In summary, we demonstrate that the consequences of insufficient PA are manifold, and if sustained, impact short and long-term health and quality of life, along with substantial economic costs.

Cluster patterns of behavioural risk factors among children: Longitudinal associations with adult cardio-metabolic risk factors

Much of what is known about childhood clusters of cardiovascular disease behavioural risk factors (RFs) comes from cross-sectional studies, providing little insight into the long-term health impacts of different behavioural cluster profiles. This study aimed to establish the longitudinal relationship between cluster patterns of childhood behavioural RFs and adult cardio-metabolic RFs. Data were from an Australian prospective cohort study of 1265 participants measured in 1985 (ages 9-15 yrs), and in 2004-06 (ages 26-36 yrs). At baseline, children self-reported smoking status, alcohol consumption, physical activity (PA), dietary behaviour and psychological well-being. At follow-up, participants completed questionnaires and attended study clinics where the following component indicators of the metabolic syndrome (MetS) score were measured: waist circumference, blood pressure, fasting blood glucose and lipids. TwoStep cluster analyses were carried out to identify clusters in childhood. Linear regression was used to examine the longitudinal associations between cluster patterns of childhood behavioural RFs and adult cardio-metabolic RFs. Four childhood cluster patterns of behavioural RFs labelled 'most healthy', 'high PA', 'most unhealthy', and 'breakfast skippers' were identified. The unhealthier childhood clusters predicted a significantly higher adult MetS score ('most unhealthy': β = 0.10, 95%CI = 0.01, 0.19) and adult waist circumference ('most unhealthy': β = 2.29, 95%CI = 0.90, 6.67; 'breakfast skippers': β = 2.15, 95%CI = 0.30, 4.00). These associations were independent of adult behavioural RFs and socio-economic position. These findings emphasise the impact of multiple childhood behavioural RFs on important adult health outcomes and may be useful for the development of early intervention strategies, where identification of children at higher risk of poorer adult cardio-metabolic health is vital.

Accumulated exposure to rural areas of residence over the life course is associated with overweight and obesity in adulthood: a 25-year prospective cohort study

PURPOSE

This prospective cohort study investigated whether body mass index (BMI) and weight status in mid-adulthood were predicted by trajectories of urban-rural residence from childhood to adulthood.

METHODS

Participants aged 7-15 years in 1985 (n = 8498) were followed up in 2004-2006 (n = 3999, aged 26-36 years) and 2009-2011 (n = 3049, aged 31-41 years). Area of residence (AOR) was classified as urban or rural at each time point. BMI and/or weight status was calculated from self-reported weight and height (2009-2011). We tested which of three life-course models ("accumulation," "sensitive period," "mobility") best explained the AOR-BMI and/or weight status association using a novel life-course modeling framework.

RESULTS

Accumulation and sensitive period models best described the effect of AOR on mid-adulthood BMI and weight status. Those with greater accumulated exposure to rural areas had a higher BMI (β = 0.29 kg/m² per time in a rural area, P = .005) and were more likely obese (relative risk = 1.13 per time in a rural area, P = .002). Living in rural areas at ages 26-30 years was also associated with a higher BMI and obesity in mid-adulthood.

CONCLUSIONS

Greater cumulative exposure to rurality and exposure during the "sensitive period" of young adulthood is associated with obesity in middle-aged adults. This study highlights the important contribution of context to the development of obesity over the life course.

A cross-sectional study of geographic differences in health risk factors among young Australian adults: the role of socioeconomic position

Background

It remains unclear why living outside of an urban environment affects aspects of health, particularly whether these differences can be explained by other factors such as socioeconomic position (SEP). The aim of this study was to compare health risk factors between metropolitan and non-metropolitan young Australian adults and examine whether socioeconomic position (SEP) mediates any differences.

Methods

Cross-sectional data came from an Australia-wide sample of 26–36 year-olds (n = 2567). Information on demographic characteristics, smoking, alcohol consumption, diet, physical activity (PA, mins/week) and mental health were collected by questionnaire, BMI from measured height and weight and daily steps using pedometers. Metropolitan versus non-metropolitan residence was classified from addresses. SEP included individual-level (education, occupation) and area-level measures. Prevalence ratios and ratio of means were calculated using log binomial, log multinomial and linear regression techniques.

Results

Non-metropolitan residents were less likely to meet 2 or more dietary guidelines, reported less leisure-time PA and active commuting but more occupational and domestic PA than metropolitan residents. Non-metropolitan women were more likely to smoke and be obese. No differences in mental health were found. After adjusting for SEP, differences remained significant except for leisure-time PA (men and women) and smoking (women).

Conclusions

Living outside metropolitan areas was associated with more risk factors in these young adults. Individual SEP and area-level disadvantage generally did not explain these differences, suggesting that a focus on geographic location as its own social determinant of health, beyond SEP, is warranted.