Whole systems approaches to obesity and other complex public health challenges: a systematic review

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Abstract

Background

Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs), defined as those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course. This paper reports a systematic review of WSAs targeting obesity and other complex public health and societal issues, such as healthy lifestyles for prevention of non-communicable disease.

Methods

Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken.

Results

Sixty-five articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes.

Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance.

Conclusions

Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6274-z) contains supplementary material, which is available to authorized users.

Related collections

Most cited references 62

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A Community Based Systems Diagram of Obesity Causes

Steven Allender, Brynle Owen, Jill Kuhlberg … (2015)

Introduction Application of system thinking to the development, implementation and evaluation of childhood obesity prevention efforts represents the cutting edge of community-based prevention. We report on an approach to developing a system oriented community perspective on the causes of obesity. Methods Group model building sessions were conducted in a rural Australian community to address increasing childhood obesity. Stakeholders (n = 12) built a community model that progressed from connection circles to causal loop diagrams using scripts from the system dynamics literature. Participants began this work in identifying change over time in causes and effects of childhood obesity within their community. The initial causal loop diagram was then reviewed and elaborated by 50 community leaders over a full day session. Results The process created a causal loop diagram representing community perceptions of determinants and causes of obesity. The causal loop diagram can be broken down into four separate domains; social influences; fast food and junk food; participation in sport; and general physical activity. Discussion This causal loop diagram can provide the basis for community led planning of a prevention response that engages with multiple levels of existing settings and systems.

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A community intervention reduces BMI z-score in children: Shape Up Somerville first year results.

Christina Economos, Raymond Hyatt, Jeanne P Goldberg … (2007)

The objective was to test the hypothesis that a community-based environmental change intervention could prevent weight gain in young children (7.6 +/- 1.0 years). A non-randomized controlled trial was conducted in three culturally diverse urban cities in Massachusetts. Somerville was the intervention community; two socio-demographically-matched cities were control communities. Children (n = 1178) in grades 1 to 3 attending public elementary schools participated in an intervention designed to bring the energy equation into balance by increasing physical activity options and availability of healthful foods within the before-, during-, after-school, home, and community environments. Many groups and individuals within the community (including children, parents, teachers, school food service providers, city departments, policy makers, healthcare providers, before- and after-school programs, restaurants, and the media) were engaged in the intervention. The main outcome measure was change in BMI z-score. At baseline, 44% (n = 385), 36% (n = 561), and 43% (n = 232) of children were above the 85th percentile for BMI z-score in the intervention and the two control communities, respectively. In the intervention community, BMI z-score decreased by -0.1005 (p = 0.001, 95% confidence interval, -0.1151 to -0.0859) compared with children in the control communities after controlling for baseline covariates. A community-based environmental change intervention decreased BMI z-score in children at high risk for obesity. These results are significant given the obesigenic environmental backdrop against which the intervention occurred. This model demonstrates promise for communities throughout the country confronted with escalating childhood obesity rates.

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Reducing obesity in early childhood: results from Romp & Chomp, an Australian community-wide intervention program.

Florentine de Groot, Jimmy Bell, Maree Crellin … (2010)

There is growing evidence that community-based interventions can reduce childhood obesity in older children. We aimed to determine the effectiveness of the Romp & Chomp intervention in reducing obesity and promoting healthy eating and active play in children aged 0-5 y. Romp & Chomp was a community-wide, multisetting, multistrategy intervention conducted in Australia from 2004 to 2008. The intervention occurred in a large regional city (Geelong) with a target group of 12,000 children and focused on community capacity building and environmental (political, sociocultural, and physical) changes to increase healthy eating and active play in early-childhood care and educational settings. The evaluation was repeat cross-sectional with a quasiexperimental design and comparison sample. Main outcome measures were body mass index (BMI), standardized BMI (zBMI; according to the Centers for Disease Control and Prevention 2000 reference charts), and prevalence of overweight/obesity and obesity-related behaviors in children aged 2 and 3.5 y. After the intervention there was a significantly lower mean weight, BMI, and zBMI in the 3.5-y-old subsample and a significantly lower prevalence of overweight/obesity in both the 2- and 3.5-y-old subsamples (by 2.5 and 3.4 percentage points, respectively) than in the comparison sample (a difference of 0.7 percentage points; P < 0.05) compared with baseline values. Intervention child-behavioral data showed a significantly lower intake of packaged snacks (by 0.23 serving), fruit juice (0.52 serving), and cordial (0.43 serving) than that in the comparison sample (all P < 0.05). A community-wide multisetting, multistrategy intervention in early-childhood settings can reduce childhood obesity and improve young children's diets. This trial was registered with the Australian Clinical Trials Registry at anzctr.org.au as ACTRN12607000374460.

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Author and article information

Contributors

Anne-Marie Bagnall:

ORCID: http://orcid.org/0000-0003-1512-0833

+44 (0)113 812 4333 , a.bagnall@leedsbeckett.ac.uk

Duncan Radley: duncan.radley@leedsbeckett.ac.uk

Rebecca Jones: rebecca.jones@leedsbeckett.ac.uk

Paul Gately: p.gately@leedsbeckett.ac.uk

James Nobles: james.nobles@bristol.ac.uk

Margie Van Dijk: Margie.Van.Dijk@phe.gov.uk

Jamie Blackshaw: Jamie.Blackshaw@phe.gov.uk

Sam Montel: sam.montel@phe.gov.uk

Pinki Sahota: P.Sahota@leedsbeckett.ac.uk

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 3 January 2019

Publication date PMC-release: 3 January 2019

Publication date Collection: 2019

Volume: 19

Electronic Location Identifier: 8

Affiliations

[1 ]ISNI 0000 0001 0745 8880, GRID grid.10346.30, Centre for Health Promotion Research, School of Health & Community Studies, , Leeds Beckett University, ; Portland 519, Leeds, LS1 3HE UK

[2 ]ISNI 0000 0001 0745 8880, GRID grid.10346.30, School of Sport, , Leeds Beckett University, ; Leeds, UK

[3 ]ISNI 0000 0001 0745 8880, GRID grid.10346.30, School of Clinical & Applied Sciences, , Leeds Beckett University, ; Leeds, UK

[4 ]GRID grid.57981.32, Diet & Obesity, Health Improvement Directorate, Public Health England, ; London, UK

[5 ]ISNI 0000 0004 0380 7336, GRID grid.410421.2, The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust, ; Bristol, UK

[6 ]ISNI 0000 0004 1936 7603, GRID grid.5337.2, Population Health Sciences, Bristol Medical School, University of Bristol, ; Bristol, UK

Author information

Anne-Marie Bagnall http://orcid.org/0000-0003-1512-0833

Article

Publisher ID: 6274

DOI: 10.1186/s12889-018-6274-z

PMC ID: 6318991

PubMed ID: 30606173

SO-VID: 8d93181d-7517-4847-be78-d920addcd7a3

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 2 June 2018

Date accepted : 28 November 2018

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100002141, Public Health England;

Award ID: n/a

Award Recipient : Paul Gately

Custom metadata

ScienceOpen disciplines: Public health

Keywords: whole systems approaches,obesity,systematic review,public health,complexity,systems science

Data availability: