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Volume 6: No. 3, July 2009
EDITORIAL
A Systems-Oriented
Multilevel Framework for Addressing Obesity in the 21st Century
The two main axes are the hierarchical axis, running from
bottom to top, and the time axis, running from left to right. At the
intersection of these two axes is birth weight and early exposures. From that
point and moving to the right through time are health behaviors that include
energy input (feeding behavior) and energy expenditure (physical activity). From
these Health behaviors, continuing across through time, there is body weight
change. A line indicates there is a causal connection between birth weight and
early exposures and body weight change.
Connected to body weight change is a line showing a feedback loop back
and forth to this group of factors: HPA axis, mood, metabolism, appetite,
and genes; these also are connected back and forth with health behaviors as
causal effects.
At the top of the hierarchical axis is a group of risk regulators:
cultural norms (eg, food preferences, body-image norms), area deprivation (eg,
poverty, crowding), psychosocial hazards (eg, crime, social
disorganization), built environments (eg, connectivity, walkability), local
food environment (eg, availability of fruits/veg, presence of fast food),
and commercial messaging.
This group is connected to health behaviors by a contingent (indirect)
effect and to the factors HPA axis, mood, metabolism, appetite, and genes.
Figure 1. A systems-oriented, multilevel model applied
to the study of obesity. The contingent effects of risk regulators (ie,
embodiment, opportunity, and constraint) are shown with dotted arrows. “Causal”
effects of biological and behavioral variables are shown with solid arrows.
Feedback loops existing within grouped variables are not shown. Specific effects
and multiple, time-ordered feedback loops between variables are not shown to reduce diagram complexity. Reprinted with permission from Elsevier (8).
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This model shows the determinants that influence
population energy balance at different levels. From left to right, they are International Factors, National/Regional, Community/Locality,
Work/School/Home, and Individual, which lead to the population outcome Obesity
Prevalence.
Within International Factors, the sectors are Globalization of markets,
Development, and Media programs and advertising.
- Globalization of markets is linked in International Factors to
Development, in Community/Locality to Public Transport, and in
Work/School/Home to Leisure Activity/Facilities.
- Development is linked in National/Regional to Urbanization, to
Health, and to Food and Nutrition, in Community/Locality to
Agriculture/Gardens/Local markets, and in Work/School/Home to Leisure
Activity/Facilities and to Labour.
- Media programs and advertising is linked in National/Regional to
Media and Culture, to Education, and to Food and Nutrition.
Between the International Factors and National/Regional is a marker
denoting the National perspective that is also a factor in the model.
Within National/Regional, the sectors are Transport, Urbanization,
Health, Social Security, Media and Culture, Education, and Food and
Nutrition.
- In National/Regional, the Transport sector and the Food and Nutrition
sector are linked together, and the link between these two is linked in Community/Locality
to Manufactured/Imported Food. The Urbanization sector, Health sector, and
Food and Nutrition sector are linked together.
- Transport is linked in Community/Locality to Public Transport and to
Public Safety.
- Urbanization is linked in Community/Locality to Public Transport, to
Public Safety, and to Sanitation.
- Health is linked in Community/Locality to Health Care and to
Sanitation.
- Social Security is linked in Work/School/Home to Leisure
Activity/Facilities, to Family and Home, and to School Food and
Activity.
- Media and Culture is linked in Community/Locality to
Manufactured/Imported Food, and in Work/School/Home to Worksite Food and
Activity and to Family and Home.
- Education is linked in Work/School/Home to Family and Home and to
School Food and Activity.
- Food and Nutrition is linked in Community/Locality to
Manufactured/Imported Food and to Agriculture/Gardens/Local markets, and
is linked in Work/School/Home to Family and Home and to School Food and
Activity.
Within Community/Locality, the sectors are Public Transport, Public
Safety, Health Care, Sanitation, Manufactured/Imported Food, and
Agriculture/Gardens/Local Markets.
- Public Transport is linked in the Individual sector to Energy
Expenditure.
- Public Safety is linked in Work/School/Home to Leisure
Activity/Facilities and in the Individual sector to Energy Expenditure.
- Health care is linked in Work/School/Home to Infections.
- Sanitation is linked in Work/School/Home to Infections.
- Manufactured/Imported Food is linked in Work/School/Home to Worksite
Food and Activity, to Family and Home, and to School Food and Activity,
and in the Individual sector to Food intake: Nutrient density.
- Agriculture/Gardens/Local markets is linked in Work/School/Home to
Family and Home and to School Food and Activity, and in the Individual
sector to Food intake: Nutrient density.
Within Work/School/Home, the sectors are Leisure Activity/Facilities,
Labour, Infections, Worksite Food and Activity, Family and Home, and School
Food and Activity.
- Leisure Activity/Facilities is linked in the Individual sector to
Energy Expenditure.
- Labour is linked in the Individual sector to Energy Expenditure.
- Infections, Worksite Food and Activity, Family and Home, and School
Food and Activity are each linked in the Individual sector to Energy
Expenditure and to Food intake: Nutrient density.
Within Individual are 2 sectors, Energy Expenditure and Food intake:
Nutrient density. Both are linked separately and together to the population
outcome, Obesity Prevalence.
Figure 2. Levels of determinants and sectors of society
implicated in the complex systems of obesity. Reprinted with permission (2).
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