Abstract
Background
Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment ...of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups.
Methods
A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals.
Results
Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake.
Conclusions
Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health.
Understanding the environmental determinants of physical activity in populations at high risk of inactivity could contribute to the development of effective interventions. Socioecological models of ...activity propose that environmental factors have independent and interactive effects of physical activity but there is a lack of research into interactive effects.
This study aimed to explore independent and interactive effects of social and physical environmental factors on self-reported physical activity in income-deprived communities.
Participants were 5,923 adults in Glasgow, United Kingdom. Features of the social environment were self-reported. Quality of the physical environment was objectively-measured. Neighbourhood walking and participation in moderate physical activity MPA on ≥5 days/week was self-reported. Multilevel multivariate logistic regression models tested independent and interactive effects of environmental factors on activity.
'Social support' (walking: OR:1.22,95%CI = 1.06-1.41,p<0.01; MPA: OR:0.79,95%CI = 0.67-0.94,p<0.01), 'social interaction' (walking: OR:1.25,95%CI = 1.10-1.42,p<0.01; MPA: OR:6.16,95%CI = 5.14-7.37,p<0.001) and 'cohesion and safety' (walking: OR:1.78,95%CI = 1.56-2.03,p<0.001; MPA: OR:1.93,95%CI = 1.65-2.27,p<0.001), but not 'trust and empowerment', had independent effects on physical activity. 'Aesthetics of built form' (OR:1.47,95%CI = 1.22-1.77,p<0.001) and 'aesthetics and maintenance of open space' (OR:1.32, 95%CI = 1.13-1.54,p<0.01) were related to walking. 'Physical disorder' (OR:1.63,95%CI = 1.31-2.03,p<0.001) had an independent effect on MPA. Interactive effects of social and physical factors on walking and MPA were revealed.
Findings suggest that intervening to create activity-supportive environments in deprived communities may be most effective when simultaneously targeting the social and physical neighbourhood environment.
Abstract
Network analysis is gaining momentum as an accepted practice to identify which factors in causal loop diagrams (CLDs)—mental models that graphically represent causal relationships between a ...system’s factors—are most likely to shift system-level behaviour, known as leverage points. This application of network analysis, employed to quantitatively identify leverage points without having to use computational modelling approaches that translate CLDs into sets of mathematical equations, has however not been duly reflected upon. We evaluate whether using commonly applied network analysis metrics to identify leverage points is justified, focusing on betweenness- and closeness centrality. First, we assess whether the metrics identify the same leverage points based on CLDs that represent the same system but differ in inferred causal structure—finding that they provide unreliable results. Second, we consider conflicts between assumptions underlying the metrics and CLDs. We recognise six conflicts suggesting that the metrics are not equipped to take key information captured in CLDs into account. In conclusion, using betweenness- and closeness centrality to identify leverage points based on CLDs is at best premature and at worst incorrect—possibly causing erroneous identification of leverage points. This is problematic as, in current practice, the results can inform policy recommendations. Other quantitative or qualitative approaches that better correspond with the system dynamics perspective must be explored.
Background Chronic stress increases chronic disease risk and may underlie the association between exposure to adverse socioeconomic conditions and adverse health outcomes. The relationship between ...exposure to such conditions and chronic stress is complex due to feedback loops between stressor exposure and psychological processes, encompassing different temporal (acute stress response to repeated exposure over the life course) and spatial (biological/psychological/social) scales. We examined the mechanisms underlying the relationship between exposure to adverse socioeconomic conditions and chronic stress from a complexity science perspective, focusing on amplifying feedback loops across different scales. Methods We developed a causal loop diagram (CLD) to interpret available evidence from this perspective. The CLD was drafted by an interdisciplinary group of researchers. Evidence from literature was used to confirm/contest the variables and causal links included in the conceptual framework and refine their conceptualisation. Our findings were evaluated by eight independent researchers. Results Adverse socioeconomic conditions imply an accumulation of stressors and increase the likelihood of exposure to uncontrollable childhood and life course stressors. Repetition of such stressors may activate mechanisms that can affect coping resources and coping strategies and stimulate appraisal of subsequent stressors as uncontrollable. We identified five feedback loops describing these mechanisms: (1) progressive deterioration of access to coping resources because of repeated insolvability of stressors; (2) perception of stressors as uncontrollable due to learned helplessness; (3) tax on cognitive bandwidth caused by stress; (4) stimulation of problem avoidance to provide relief from the stress response and free up cognitive bandwidth; and (5) susceptibility to appraising stimuli as stressors against a background of stress. Conclusions Taking a complexity science perspective reveals that exposure to adverse socioeconomic conditions implies recurrent stressor exposure which impacts chronic stress via amplifying feedback loops that together could be conceptualised as one vicious cycle. This means that in order for individual-level psychological interventions to be effective, the context of exposure to adverse socioeconomic conditions also needs to be addressed. Keywords: Socioeconomic status, Causal loop diagram, Chronic stress, Feedback loops
There is a growing body of research into the total amount and patterns of sitting, standing and stepping in office-based workers and few studies using objectively measured sitting and standing. ...Understanding these patterns may identify daily times opportune for interventions to displace sitting with activity.
A sample of office-based workers (n = 164) residing in England were fitted with thigh-worn ActivPal accelerometers and devices were worn 24 hours a day for five consecutive days, always including Saturday and Sunday and during bathing and sleeping. Daily amounts and patterns of time spent sitting, standing, stepping and step counts and frequency of sit/stand transitions, recorded by the ActivPal accelerometer, were reported.
Total sitting/standing time was similar on weekdays (10.6/4.1 hrs) and weekends (10.6/4.3 hrs). Total step count was also similar over weekdays (9682 ± 3872) and weekends (9518 ± 4615). The highest physical activity levels during weekdays were accrued at 0700 to 0900, 1200 to 1400, and 1700 to 1900; and during the weekend at 1000 to 1700. During the weekday the greatest amount of sitting was accrued at 0900 to 1200, 1400 to 1700, and 2000 to 2300, and on the weekend between 1800 and 2300. During the weekday the greatest amount of standing was accrued between 0700 and 1000 and 1700 and 2100, and on the weekend between 1000 and 1800. On the weekday the highest number of sit/stand transitions occurred between 0800 to 0900 and remained consistently high until 1800. On the weekend, the highest number occurred between 1000 to 1400 and 1900 to 2000.
Office based-workers demonstrate high levels of sitting during both the working week and weekend. Interventions that target the working day and the evenings (weekday and weekend) to displace sitting with activity may offer most promise for reducing population levels of sedentary behaviour and increasing physical activity levels, in office-based workers residing in England.
Government policies that promote healthy food environments are considered promising to reduce socioeconomic inequalities in diet. Empirical evidence of effects on these inequalities, however, is ...relatively scarce and, with a few exceptions, tends to be inconclusive. We use two contemporary theories that help to understand socioeconomic inequalities in health and health-related behaviours (Bourdieu’s capital theory and Mullainathan and Shafir’s scarcity theory) to reason how policies influencing food environments may differentially impact lower and higher socioeconomic groups. In essence, these theories enable us to understand how specific elements of broader daily living conditions (e.g. social practices that lead to habitus formation, material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups. We conclude that the application of theories on the mechanisms underlying socioeconomic inequalities in health can help to guide future empirical studies in testing theory-based hypotheses on differential effects of policies, and thereby enhance the development of effective policies tackling socioeconomic inequalities in dietary intakes.
Little is known of the patterns of physical activity, standing and sitting by office workers. However, insight into these behaviours is of growing interest, notably in regard to public health ...priorities to reduce non-communicable disease risk factors associated with high levels of sitting time and low levels of physical activity. With the advent and increasing availability of indoor tracking systems it is now becoming possible to build detailed pictures of the usage of indoor spaces. This paper reports initial results of indoor tracking used in conjunction with the ActivPAL activity monitoring device. In this paper we give an overview of the usage of the tracking system and its installation and illustrate some of the resultant data. We also provide preliminary results that investigate the relationship between location, light physical activity and sitting in a small sample of office workers (n=33) from two separate office environments in order to demonstrate the relevance and explanatory power of the technique.
Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce ...such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the "Assessing the Methodological Quality of Systematic Reviews" quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.
Background
Whole‐systems approaches (WSAs) are well placed to tackle the complex local environmental influences on overweight and obesity, yet there are few examples of WSAs in practice. Amsterdam ...Healthy Weight Approach (AHWA) is a long‐term, municipality‐led program to improve children's physical activity, diet, and sleep through action in the home, neighborhood, school, and city. Adopting a WSA, local political, physical, social, educational, and healthcare drivers of childhood obesity are viewed as a complex adaptive system. Since 2013, AHWA has reached >15,000 children. During this time, the estimated prevalence of 2–18‐year‐olds with overweight or obesity in Amsterdam has declined from 21% in 2012 to 18.7% in 2017. Declining trends are rarely observed in cities. There is a need to formally articulate AHWA program theory in order to: (i) inform future program evaluation which can interpret this decline within the context of AHWA and (ii) contribute a real‐life example of a WSA to the literature.
Methods
This study aimed to formally document the program theory of AHWA to permit future evaluation. A logic framework was developed through extensive document review and discussion, during program implementation.
Results
The working principles of the WSA underpinning AHWA were made explicit in an overarching theory of change, articulated in a logic framework. The framework was operationalized using an illustrative example of sugar intake.
Conclusions
The logic framework will inform AHWA development, monitoring, and evaluation and responds to a wider need to outline the working principles of WSAs in public health.
Ecological models of physical activity posit that social and physical environmental features exert independent and interactive influences on physical activity, but previous research has focussed on ...independent influences. This systematic review aimed to synthesise the literature investigating how features of neighbourhood physical and social environments are associated with physical activity when both levels of influence are simultaneously considered, and to assess progress in the exploration of interactive effects of social and physical environmental correlates on physical activity.
A systematic literature search was conducted in February 2016. Articles were included if they used an adult (≥15 years) sample, simultaneously considered at least one physical and one social environmental characteristic in a single statistical model, used self-reported or objectively-measured physical activity as a primary outcome, reported findings from quantitative, observational analyses and were published in a peer-reviewed journal. Combined measures including social and physical environment items were excluded as they didn't permit investigation of independent and interactive social and physical effects. Forty-six studies were identified.
An inconsistent evidence base for independent environmental correlates of physical activity was revealed, with some support for specific physical and social environment correlates. Most studies found significant associations between physical activity and both physical and social environmental variables. There was preliminary evidence that physical and social environmental variables had interactive effects on activity, although only 4 studies examined interactive effects.
Inconsistent evidence of independent associations between environmental variables and physical activity could be partly due to unmeasured effect modification (e.g. interactive effects) creating unaccounted variance in relationships between the environment and activity. Results supported multiple levels of environmental influence on physical activity. It is recommended that further research uses simultaneous or interaction analyses to gain insight into complex relationships between neighbourhood social and physical environments and physical activity, as there is currently limited research in this area.
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