Portal de Periódicos da CAPES

Designing effective and sustainable multifaceted interventions for obesity prevention and healthy communities

2017; Wiley; Volume: 25; Issue: 7 Linguagem: Inglês

10.1002/oby.21893

1930-739X

Christina D. Economos, Ross A. Hammond,

Child Nutrition and Feeding Issues

Obesity remains a challenge, with continued high rates across the entire population (1, 2). Particularly troubling are the entrenched disparities by sociodemographics. The recognized benefits of prevention coupled with obesity's stubborn persistence and sequelae of health consequences once developed make children a sensible priority group. There is an urgency to find sustainable and scalable solutions (3) to confront and reverse the epidemic. Building on previous experience, the field is increasingly stressing the importance of 1) early childhood prevention; 2) multisector, multilevel "whole of community" approaches; 3) purposeful, sustainable, evidence-based initiative packages; 4) coordination and connections between sectors, levels, and initiatives using systems methodologies; and 5) rigorous design and evaluation procedures. Checking all 5 of these boxes in a single study remains elusive. In this issue of Obesity, three papers present outcomes from the Massachusetts Childhood Obesity Research Demonstration project (MA-CORD), a comprehensive, systematic intervention to prevent and reduce childhood obesity among low-income children ages 2 to 12 years in two selected cities in Massachusetts (4). Controls were used for comparison when possible. Taveras et al. (5) examined the impact of the MA-CORD multicomponent clinical intervention on BMI z scores compared to routine practice, over 2 years, using electronic health records. The clinical intervention, implemented in federally qualified community health centers, was associated with modest improvement in BMI z scores in one of the intervention communities. Authors cited implementation challenges underscoring the need for scalability efforts that address the heterogeneous health care environments nationally and globally. In the context of the evolving health care system, obesity prevention efforts cannot be left behind. Franckle et al. (6) reported on the school-based component of MA-CORD examining changes in prevalence of obesity and target health behaviors for first-, fourth-, and seventh-graders. Among seventh-graders (greatest intervention exposure), a significant decrease in prevalence of obesity was reported in one intervention community. Fourth- and seventh-grade students from both communities improved behavioral targets for sugar-sweetened beverages and water and in one community they improved screen time. Schools remain a critical environment for health promotion and obesity prevention, establishing behaviors for life. Woo-Baidal et al. (7) reported on the extent to which the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) intervention (consisting of practice changes) improved BMI z scores and obesity-related behaviors among children age 2 to 4 years compared to a control program. WIC-enrolled children in both intervention sites had improved sugar-sweetened beverage consumption and sleep duration. A small improvement in BMI z scores was observed in one of two intervention sites in non-Asian children. Given that nearly 6 million US infants and children and 1.8 million women are WIC recipients each month, efforts to improve practice and delivery are poised for high return. The results, albeit modest, from these three studies reporting from clinical, school, and WIC settings collectively demonstrate the potential power of multisector, multilevel approaches to childhood obesity prevention. However, they also illustrate how resource-intensive most of these interventions still tend to be and how challenging it is to field a truly interconnected "whole of community" effort that produces significant changes in behavior and biology, especially for children. Obesity's complexity has led to increasing adoption of complex systems methodologies to model, measure, and engage, offering a signpost toward important future directions (8). Figure 1 illustrates levels of system insight that can be applied to obesity research (9). Particularly suited for community-level research are techniques like systems mapping and causal loop diagramming, which can be generated through participatory and group model building activities. These enable stakeholders to visualize how community elements and processes may interrelate and can help identify the most relevant intervention points (10). Systems modeling using agent-based (11) and other simulation (12) methods can help capture and manage the complex dynamics involved in successful and sustainable implementation of whole-of-community interventions. Methods from the systems science toolbox have the potential to advance our ability to effectively engage communities in evidence-based design and implementation and to facilitate the important task of tailoring general strategies to suit (highly heterogeneous) local contexts (13). Greater efficiency through deeper engagement and better tailoring offers the promise of enhanced sustainability and scalability. We are encouraged by early learnings from the COMPACT (Childhood Obesity Modeling for Prevention and Community Transformation) Study, a groundbreaking 5-year international collaboration to apply the principles of systems science to community-based childhood obesity interventions. The overall goal of COMPACT is to identify what works, for whom and under what circumstances, with a particular focus on the process of sustainable implementation and generalizable knowledge. Learning from successful completed obesity interventions, including Shape Up Somerville (14) in the US and Romp & Chomp (15) in Australia, an iterative process is under way to develop, test, and refine our mechanism-level understanding of whole-of-community prevention interventions using data drawn from participatory group model building exercises, social network analyses, and agent-based modeling and to leverage this new knowledge to design, plan, and conduct a new pilot intervention, "Shape Up Under-5," a redesigned systems-based version of Shape Up Somerville targeting underserved children ages 0 to 5 years and their caregivers. The three studies from MA-CORD presented in this issue underscore the potential of rigorous multisector and multilevel childhood obesity prevention interventions but also illustrate the challenge that sustainability and scalability pose for the field. We believe that deeper understanding of and engagement with the structure and dynamics of communities may hold the key to further progress in this space, and that systems science methodologies offer particular promise in uncovering both powerful general strategies and the means to tailor them for sustainable application in specific communities. The authors would like to acknowledge the many insights collectively generated by the COMPACT research team NIH #1R01HL115485 (Co-PIs: Economos and Hammond, from the National Heart, Lung, and Blood Institute and the Office for Behavioral and Social Sciences Research).