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

Bagnall, Anne‐Marie; Radley, Duncan; Rs, Jones; Nobles, James; Blackshaw, Jamie; Montel, S; Sahota, Pinki

doi:10.1093/eurpub/ckz185.472

Cited by 22 publications

(29 citation statements)

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“…Whilst interventions such as The Daily Mile are not going to reduce childhood obesity alone, they should be Table 3 Adjusted differences for all secondary outcomes between control and intervention arm at 4 and 12 months follow-up. considered as part of a whole system approach to childhood obesity prevention [40][41][42].…”

Section: Mean (Sd) Bmizmentioning

confidence: 99%

Effectiveness and cost-effectiveness of The Daily Mile on childhood weight outcomes and wellbeing: a cluster randomised controlled trial

Breheny

Passmore²,

Adab

et al. 2020

Int J Obes

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Background The Daily Mile is designed to increase physical activity levels with children running or walking around school grounds for 15-min daily. It has been adopted by schools worldwide and endorsed as a solution to tackle obesity, despite no robust evidence of its benefits. We conducted a cluster randomised controlled trial to determine its clinical and costeffectiveness. Methods Forty schools were randomly assigned (1:1) to either the Daily Mile intervention or control group in which only the usual school health and wellbeing activities were implemented. The primary outcome was BMI z-score (BMIz) at 12 months follow-up from baseline, with planned subgroup analysis to examine differential effects. Primary economic analysis outcome was incremental cost per Quality-Adjusted-Life-Year (QALY) gained. Results Using a constrained randomisation approach, balanced on school size, baseline BMIz and proportion of pupils eligible for free school meals, 20 schools were allocated to intervention (n = 1,153 participants) and 20 to control (n = 1,127); 3 schools withdrew (2 intervention, 1 control). At 12 months, BMIz data were available for 18 intervention schools (n = 850) and 19 control schools (n = 820 participants). Using intention-to-treat analysis the adjusted mean difference (MD) in BMIz (intervention − control) was −0.036 (95% CI: −0.085 to 0.013, p = 0.146). Pre-specified subgroup analysis showed a significant interaction with sex (p = 0.001) suggesting a moderate size benefit of The Daily Mile in girls (MD −0.097, 95% CI −0.156 to −0.037). This was consistent with the exploratory economic results that showed The Daily Mile to be highly cost-effective in girls (£2,492 per QALY), but not in boys, and overall to have a 76% chance of costeffectiveness for the whole sample, at the commonly applied UK threshold of £20,000 per QALY. Conclusions Overall the Daily Mile had a small but non-significant effect on BMIz, however, it had a greater effect in girls suggesting that it might be considered as a cost-effective component of a system-wide approach to childhood obesity prevention.

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Section: Mean (Sd) Bmizmentioning

confidence: 99%

Effectiveness and cost-effectiveness of The Daily Mile on childhood weight outcomes and wellbeing: a cluster randomised controlled trial

Breheny

Passmore²,

Adab

et al. 2020

Int J Obes

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“…The failure to establish effective physical activity interventions suggests a need to mobilise schools and align the willing support being offered by associated stakeholders. To do so, a whole-school physical activity framework is required that moves beyond the conceptual understanding of the school environment to one which presents schools as a wider 'complex adaptive subsystem' [18,19]. Complex adaptive systems possess "many heterogeneous components that dynamically interact and produce an emergent effect greater than the individual elements, which must persist and adapt to changing circumstances" [20].…”

Section: Introductionmentioning

confidence: 99%

Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

Daly-Smith

Quarmby

Archbold

et al. 2020

Preprint

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Background UK and global policies recommend whole-school approaches to improve childrens’ inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure ‘systems’ change, a framework is required that identifies all components of a whole-school PA approach. The study’s aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). Methodology Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n=9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n=6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one ‘initial’ framework. Next, stakeholders reviewed the ‘initial’ framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. Results Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers’ capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. Summary To the authors’ knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives ‘with’ schools, while abandoning outdated traditional approaches of implementing interventions ‘on’ schools.

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“…As a population-level approach to prevention, this is unlikely to be effective (28), and may indeed have negative consequences for health inequalities (20,(28)(29)(30)(31)(32)(33). Our ndings are paradoxical given the widespread agreement that upstream efforts are required to alter the obesogenic systems in which we live (2,20,31,34). This secondary analysis and the study of Nobles et al (10) provide little evidence to suggest research and practice is moving upstream with regards to obesity prevention.…”

Section: Summary Of Resultsmentioning

confidence: 81%

A Secondary Analysis of the Childhood Obesity Prevention Literature through a Wider Determinants of Health Lens: Implications for Research Funders, Researchers, Policymakers and Practitioners

Nobles

Summerbell

Brown

et al. 2020

Preprint

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Background: Over the last 25 years, we have made great advances in our understanding of the complex adaptive systems which drive childhood obesity. Within this, the important role of upstream interventions which focus on the wider determinants of health (WDoH) has been acknowledged. Concurrently, the number of intervention studies aiming to prevent childhood obesity has increased exponentially. One might anticipate that our understanding of theory has been embedded into the development and implementation of interventions in real time. Methods: We tested this hypothesis by conducting secondary analysis of the interventions included in the Cochrane Review on “Interventions for Preventing Obesity in Children”, published since 1993. All 153 randomised controlled trials (RCTs) were independently coded by two authors against the WDoH model using an adaptive framework synthesis approach. We used aspects of the Action Mapping Tool from Public Health England to facilitate our coding and to visualise our findings in contrast to 226 perceived causes of obesity. Results: We found that the proportion of interventions which targeted downstream (e.g. individual and family behaviours) as opposed to upstream (e.g. infrastructure, environmental, policy) determinants has not changed over time (from 1993 to 2015), with most intervention efforts (57.9%) aiming to change individual lifestyle factors via education-based approaches. Almost half of the interventions (45%) targeted two or more levels of the WDoH. Where interventions targeted some of the wider determinants, this was often achieved via upskilling teachers to deliver educational content to children. No notable difference in design or implementation was observed between interventions targeting children of varying ages (0-5 years, 6-12 years, 13-18 years). Conclusions: This study highlights that interventions, evaluated via RCTs, have persisted to focus on downstream, individualistic determinants of obesity over the last 25 years, despite the step change in our understanding of its complex aetiology. We hope that the findings from our analysis will challenge research funders, researchers, policymakers and practitioners to reflect upon, and critique, the evidence-based paradigm in which we operate, and call for a shift in focus of new evidence which takes a WDoH lens.

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

Cited by 22 publications

References 0 publications

Effectiveness and cost-effectiveness of The Daily Mile on childhood weight outcomes and wellbeing: a cluster randomised controlled trial

Effectiveness and cost-effectiveness of The Daily Mile on childhood weight outcomes and wellbeing: a cluster randomised controlled trial

Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

A Secondary Analysis of the Childhood Obesity Prevention Literature through a Wider Determinants of Health Lens: Implications for Research Funders, Researchers, Policymakers and Practitioners

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