Community systems approaches: what works?

The global rise in obesity has prompted the introduction of obesity plans in many countries. These may have helped slow the rise in obesity but have yet to achieve sustained nationwide reductions. This may reflect the scale of the challenge required to tackle the underlying social, economic and commercial factors influencing weight. However, a number of community systems approaches appear to have produced positive results and are analysed here.

Community systems approaches recognise the complex range of factors fuelling the rise in obesity and seek to mobilise the strengths and resources of a range of stakeholders in the local community (usually with national or municipal coordination and support) to reduce the unhealthy, obesogenic environments children are growing up in locally. This includes, where practical, helping communities identify their own priorities for action and help to design, plan, implement and monitor programmes.

Successful approaches – learning from EPODE

Ensemble Prévenons l'Obésité Des Enfants’ (EPODE - “Together Let's Prevent Childhood Obesity”) is the longest established, best-known and most widely adopted community systems approach. Its success in reducing childhood obesity in French rural towns led to its adoption or adaptation in more than 500 communities in six countries.^1,2 This has included Jongeren op Gezond Gewicht (JOGG, “Young People at a Healthy Weight”) in the Netherlands; the Amsterdam Healthy Weight Programme (AHWP); and Vivons en Forme (VIF, “Live in Shape”), a community-based programme with a collaborative and non-stigmatising approach, which has expanded beyond EPODE’s focus on diet and exercise to include action to improve sleep and wellbeing. All approaches have seen reductions in childhood obesity.^3-8

In EPODE, community-based interventions can be implemented at four levels: central, local organisation, settings and child level.^9.10 The EPODE methodology requires:

1. Political support, from national to local level
2. Sufficient resources to fund central services and implementation at local level
3. Planning, coordinating actions and providing social marketing and support services at community level
4. Using evidence to guide implementation of EPODE interventions and to evaluate outcomes

Other successful approaches

The City of Seinäjoki in Finland saw improvements in childhood obesity following implementation of its Overcoming Obesity Programme 2013-2020. ^11-12 Finland’s Health Care Act directed cities, such as Seinäjoki, to incorporate health into all their decision-making areas. The health in all policies approach is now at the centre of the Healthy Kids of Seinäjoki model, such as all day-care centres being declared dessert-free and energy drinks forbidden in schools.

In the UK, the HENRY programme (Health, Exercise and Nutrition for the Really Young) also achieved reductions in childhood obesity in Leeds, working with the city council which had made the early years their child obesity strategy priority since 2008. ^13,14 HENRY focuses on parenting, emotional wellbeing and whole-family lifestyle as a foundation for enabling young children to develop healthy food preferences and eating and activity habits.

More recently, Brighton and Hove observed a downward trend in child obesity in comparison to national trends through a whole systems approach.¹⁵ Alongside sustained focus on early years and school-based interventions in more deprived areas, a city-wide approach was taken in tackling broader food issues, including a local food strategy which facilitated partnership and city-wide commitment.

Table 1 presents a summary of key components in the community systems approaches described above.

Discussion

Successful community systems approaches recognise that childhood obesity is often the product of a multi-factorial unhealthy, obesogenic environment and so seek to change that environment by working with a range of local stakeholders, which may include parents, pre-school centres, schools, local authorities, health professionals - and sometimes local businesses. For example, the Amsterdam Healthy Weight Programme has worked with the country’s largest supermarket chain to encourage the sale of healthier food. They typically also focus strongly on obesity prevention, including targeting the early years which shape children’s health and weight outcomes (very much the focus for HENRY) and also commit to providing time and resource over a number of years (e.g., four years per local authority for EPODE and renewable periods of three years for JOGG). A recurring model is central coordination and support (which can be provided by a national body or a city council) with local project management and delivery.

One difference is the extent to which there is partnership with business. EPODE, JOGG and AHWP are willing to accept help from businesses provided there is no conflict of interest, whereas this has not been the case for Seinäjoki and HENRY. 

One question is the potential to scale up these successful approaches to other settings and contexts, for example from a rural to an urban environment. There is also the issue of how to engender local ownership and engagement, without appearing to parachute in an external operational model, however successful that model may have been elsewhere. This may help explain why local adaptations of the EPODE model are often rebadged to provide a local flavour, as with the repositioning as JOGG in the Netherlands; why community engagement and tailoring to local contexts is so important; and the value of integration into existing services and programmes.

Systems modelling tools (such as agent-based modelling, system dynamics, group model building and social network analysis) have also emerged over the last decade, providing the means to test, track and evaluate obesity systems programmes. They allow stakeholders to visualize, interpret models and identify key leverage points with the greatest impact. Systems modelling is a promising innovation for testing components of successful obesity approaches in other settings and communities.¹⁶

Whilst community systems approaches have seen reductions in obesity, they often have limited influence over wider aspects of the obesogenic environment, such as underlying socio-economic inequalities, the advertising of highly processed food, or the recent rapid increase in the cost of healthy food. These and other factors often require government action. As with other public health interventions, not least in the UK, community-based approaches are also vulnerable to insecure funding and turnover within communities.

Conclusion

Community systems approaches have demonstrated an ability to halt and, to a limited extent, reverse the rise of childhood obesity – in particular through local stakeholders working together, with national or municipal coordination and support, to reduce the obesogenic environment locally. Complementary cross-government action is needed at a national level to tackle those aspects of the obesogenic environment outside local control.

Nicole Musuwo. June 2023. 

Table 1: Summary of successful approaches