Young people have fresh ideas for tackling the obesity crisis in Europe, according to new research published in the journal Obesity Reviews (1).
Adolescents and young adults are the policy-makers and parents of tomorrow, and can be significant agents for change. Researchers seeking to find solutions for the obesity crisis usually follow the traditional paths of looking at diets and physical activity, but a new project funded by the European Union (2) asked young people what problems they experienced and what their priority solutions would be.
During the process of bringing young people together and developing methods for assessing their views, it became clear that the researchers were in many ways “too old” to fully comprehend the world experienced by modern youth. As one adolescent said, “You ask me about access to green spaces, but I don't live there. I live online.”
For young people, the issue of obesity is embedded in a wider context concerning their peer groups, their body image, self-confidence and self-determination, and these in turn are shaped by media influencers and role models, some of which are promoted by commercial interests from clothing and cosmetics to music and sports.
“Avoiding obesity is only one of many priorities for adolescents as they develop their self-identity and try to remain free of anxiety from peer pressure,” said Professor Knut-Inge Klepp, from the Norwegian Institute for Public Health and leader of the CO-CREATE project (3). ”If an adolescent is already living with obesity, then they need to deal with social exclusion, discrimination, bullying, media-reinforced stigma and internalised self-hatred.”
“Offering young people advice on diet or exercise is simply not enough,” he said. “The CO-CREATE project has shown that tackling obesity for young people means understanding their social and psychological experiences, supporting their psychological resilience alongside their physical health, and supporting changes to their environment to make this easier”.READ SUPPLEMENT
Besides making clear the importance of the psycho-social aspects of obesogenic environments, including social media influencers and peer pressures, other aspects of the obesogenic environment were clearly of concern. A significant output of the CO-CREATE project is the Youth Declaration, written by a group of young people, which calls for structural changes in the food environment: including banning the promotion of unhealthy foods to children under the age of 18 years in mass media and social media, taxing sugar-sweetened beverages, improving the school food environment and providing a greater variety of physical activity opportunities.
However, power relations are also of key importance for young people. There are very few opportunities for their demands for policy change to be heard by policymakers. “Excluding young people from democratic participation means their experiences and proposals are ignored,” said Professor Klepp. “But if we don’t listen, we will never know what matters for their health.”
The CO-CREATE project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 774210. The content of this media release reflects only the authors' views and the European Commission is not liable for any use that may be made of the information it contains.
- The CO-CREATE Supplement in the journal Obesity Reviews is available here: https://onlinelibrary.wiley.com/toc/1467789x/2023/24/S2
- CO-CREATE is a Euro10m project funded by the European Union’s Horizon 2020 research and innovation programme as part of the response to tackle the childhood obesity epidemic. Over a 5-year period (2018-2023), CO-CREATE has worked with young poeple to develop policy actions to promote a healthier food and physical activity environment. Details of the CO-CREATE project here: www.co-create.eu
- Contact Professor Knut-Inge Klepp, CO-CREATE project director, National Institute for Public Health, Oslo, Norway. Email Knut-Inge.Klepp@fhi.no
Summary of papers in the Obesity Reviews CO-CREATE Supplement
Adolescents in six European countries identified the role of mental wellbeing as a key driver of youth obesity. Building on these findings, a simulation model was constructed linking poor mental wellbeing to changes in dietary, physical activity, and sleep behaviours, and was found to have a good fit with known survey data and previous research. The model showed that socio-cultural pressures and stressors can be linked to emotion-related eating, lack of interest in physical activity, and sleep difficulty. It was found that if pressure on body image and psychosocial stress could be reduced by 25% it would lead to a reduction in overweight prevalence from 30% to 26% as well as improving mental wellbeing.
- Aguiar A. et al (2023) Understanding the dynamics emerging from the interplay amongst poor mental wellbeing, energy balance-related behaviours, and obesity prevalence in adolescents: A simulation-based study. Contact: Anaely.Aguiar@uib.no
Social media can benefit adolescents’ lives but may also have harmful effects on both physical and mental health. A systematic review of existing research found significant links between social media use and depressive and disordered eating symptoms, body dissatisfaction, and anxiety. The findings call for policy interventions to mitigate the impact of social media on adolescent mental health and diet. As social media platforms become increasingly sophisticated, it is important to involve adolescents in the design of research: measures of exposure to different types of online content are needed to guide policies for protecting the health of adolescents.
- Blanchard L. et al (2023) Associations between social media, adolescent mental health and diet: a systematic review. Contact: Laurence.Blanchard1@lshtm.ac.uk
Studies that report links between adolescents’ mental health and obesity may not be able to say which one might trigger the other. Research is needed which follows a group of young people over time (longitudinal study) in order to cast light on this issue. A search of the relevant scientific research found 17 longitudinal studies, and the majority showed that depression, anxiety and body dissatisfaction came before an increase in body weight.
The links were likely to be related to eating habits, screen time, physical activity, and sleep as well as stressors like peer victimisation. Furthermore, several studies showed that improved dietary patterns and physical activity may alleviate some mental ill-health.
- Nwosu E. (2023) Longitudinal relationship between adolescents’ mental health, energy balance-related behaviour (EBRB) and anthropometric changes. Contact: email@example.com
Young people are often targeted as a priority group for health education, but their views are rarely sought or put into policy recommendations. The CO-CREATE project developed a ‘dialogue tool’ with the help of designers, health and youth participation experts, researchers and young people, with the young people involved in all stages of the development process. Multiple versions were tested with more than two hundred participants from 53 countries in over 20 Dialogue Forums.
From this, a final digital and physical version of the Dialogue Forum was published and can be used to connect people across generations and sectors. The CO-CREATE Dialogue Forum Tool is the product of a three-year long process of testing, prototyping, and refinement, involving youth throughout. The tool has been used in local schools and in high-level United Nations meetings, in Malawi and Portugal, by 14-year-olds and by CEOs, and incorporates the feedback from these different people and settings. It is now freely available, and we hope it will help youth around the world to have their voices heard.
Research involving children normally requires the consent of their parents or guardians, and oversight of an ethical committee. While this can ensure protection from harm, it can be an obstacle for encouraging young people’s empowerment and self-confidence when asking about their experiences of obesity, mental health and stigma. The UN Convention on the Rights of the Child stresses how children and adolescents should be given influence over decisions important for themselves in accordance with their age and maturity.
Experience in the CO-CREATE project suggests that, if ethical committees identify no potential harm, then children and adolescents from the age of 12 years should be given legal capacity to consent to participate in the research project. Ethical committees may need to be more aware of the needs, perspectives and maturity of children and adolescents.
- Samdal O. et al (2023). Balancing protection and empowerment when involving children and adolescents in social science research and policy projects. Contact: Oddrun.Samdal@uib.no
Understanding the nature of obesogenic environments is a first step for young people to develop policies for health and the political engagement necessary to make such policies work. Using PhotoVoice software (https://photovoice.org/) adolescents undertook participatory photography, digital storytelling and self-advocacy projects which explored how potential policies were either present or absent in their neighbourhood, including retail and fast food environments, food advertising, cycling routes and public transport. The methods raised critical awareness of how policies affected the structural environment and helped empower them to contribute to advocacy for change.
- Banik A. et al (2023). What policies are there and what policies are missing? A PhotoVoice study of adolescents’ perspectives on obesity-prevention policies in their local environment. Contact: firstname.lastname@example.org
The CO-CREATE project recruited over 150 adolescents from schools and youth organisations in five European countries, to form 15 Youth Alliances to discuss policies for tackling obesity – but did this experience change the participants’ preconceptions? Using control groups for comparison, researchers asked participants about their understanding of who is responsible for preventing obesity, what drives obesogenic behaviour, and what actions should be taken. The findings suggest that involving youth in co-creating policies to prevent obesity may increase adolescents’ readiness for action and promote a shift in adolescents’ conceptualisation of obesity from an individual perspective to a societal responsibility and drivers of behaviour.
- Herstad S. et al (2023) Adolescents’ capacity to take action on obesity: a concurrent controlled before-and-after study of the European CO-CREATE project. Contact: email@example.com
A systems approach can be used to distinguish between policy interventions with the potential to make small changes to the operation of structural elements within the system from those with the potential to change how the system regulates itself, how its component parts interact, what goals the system sets out to achieve, and the deepest held beliefs, or paradigm, of the system.
Of the 106 policy ideas generated by young people to address adolescent obesity during the CO-CREATE project, 91 (86%) were categorised as changes to structural elements, with an emphasis on operational rather than systems-level responses. This echoes the emphasis on interventions to address obesity shown by most governments, which often operate at the individual level and deal with the kinds of actions and environments which do not challenge the function of the system, or lead to changes in the overall paradigm, despite evidence that deeper structural actions tend to be more effective and equitable.
- Conway-Moore K. et al (2023). Co-creating obesity prevention policies with youth: Policy ideas generated through the CO-CREATE project. Contact: Kaitlin.Conway@lshtm.ac.uk
A systematic search of proposals for tackling youth obesity found a wide range of proposed models for intervention ranging from those focused on intrapersonal factors to models cutting across multiple levels of obesogenic systems, but mechanisms for taking action were lacking. Of 15 models studied, the majority of interventions were changes to existing model parameters with less emphasis on models that alter system structure. There is a need for better quality in documentation of the models, and further research on how to best combine models and provide decision tools for policymakers.
- Aguiar A. et al (2023). System dynamics simulation models on overweight and obesity in children and adolescents: A systematic review. Contact: Anaely.Aguiar@uib.no
There is growing recognition of the need to move away from conducting research projects as a linear series of constituent parts, and towards study designs that address the true complexity of an issue, while also accounting for the complexity of conducting research as a learning ‘system’ itself. Learning from the experience of the CO-CREATE project, the authors of this paper argue that systems thinking should be embedded in research design when working with young people, for example capturing key adolescent values and concerns; working to avoid social exclusion; ensuring methodological pluralism to allow for reflection and responsiveness (with methods ranging from group model building, PhotoVoice, and small group engagement); getting policy recipients to shape key questions by understanding their views on the critical drivers of obesity early on in the project; and providing opportunity for intra-project reflection along the way.
- Knai C. et al (2023). Learning from the CO-CREATE project: a protocol for Systems Thinking Across Research (STAR). Contact: Cecile.Knai@lshtm.ac.uk