MHST601 Assignment #2: Multilevel Obesity Model

Modern society has found ways to combat the plight of infectious agents that once posed the greatest threat to human life (Cutler, Deaton, & Lleras-Muney, 2006, pp.99-100). Our reward? A dramatically increased life expectancy, often fraught with years of pain, illness and disability at the hands of chronic health threats. Cancer, heart disease, diabetes and renal failure represent highly prevalent ailments in modern developed countries. An increasingly mechanized and technological society contributing to a largely sedentary lifestyle, along with a readily available caloric surplus creates an imbalance that leads to a condition known to be a risk factor for each of these disease states: obesity.

Statistics describing obesity rates in New Brunswick have now soared to as high as seventy percent, prompting medical experts including leaders from the New Brunswick Medical Society, the Heart and Stroke Foundation of New Brunswick and Diabetes Canada to plead with government officials to orchestrate a coordinated, multilevel approach to remedy the predicted imminent healthcare crisis that these numbers will cause among an aging population (Knight, Sisk, & Reid, 2018). To create an effective improvement strategy, one must first understand the broad range of factors that contribute to a chronic issue such as this. “Determinants of health are the social conditions in which people are born, grow up, live, learn, work, play and age, and the systems put in place to deal with illness, shaped by political, social and economic forces” (Wang, Emrich, & Collette, 2016). By applying Bronfenbrenner’s Social Ecological Model (Riggs, E., 2018), multidimensional obesity determinants can be acknowledged so that they may then be addressed in identifying a suitable solution. This model is an appropriate tool for this task because of its focus on the environmental context in which contributing behaviours and interactions take place. Also, this model accounts for the evolving impact of determinants over the lifespan of an individual. Although obesity is determined to an extent by the biological makeup of an individual, social, environmental and behavioural factors are more influential, and more importantly, modifiable. This is an important consideration in implementing change.

Figure 1: Bronfenbrenner’s Theory and Ecological Mapping (Riggs, E., 2018)

Beginning at the most specific level of Bronfenbrenner’s classification system, the individual, one must consider the genetic factors acquired at birth that predispose children to a host of biological constraints. These may include: allergies -such as lactose, gluten or nuts- that complicate their ability to consume well-balanced nutritious meals; physical limitations that restrict participation in competitive or recreational activities (clubfoot, arthritis, or juvenile diabetes); mental health disorders affecting social integration (autism, schizophrenia, etcetera). While these are conditions that may never be completely overcome, all can be managed to varying degrees and none will predict obesity with any degree of certainty in isolation. The individual will also have his or her own personality characteristics, biases, preferences or priorities that drive behaviours. These are often influenced by factors across other levels.

The environmental context of this model is divided into a series of levels covering an increasing scope: microsystem, mesosystem, exosystem and macrosystem. The lines delineating these divisions are dynamic and allow for overlap and interaction across levels. The microsystem includes the immediate environments, factors, organizations and people affecting the individual directly. These would include the parents, teachers, colleagues and friends as well as the work, school and home environments with which the individual interacts. Corresponding attitudes toward diet and exercise, as well as conscious or unconscious biases of those around them will influence an individual. People tend to associate those attitudes by which they are surrounded with societal norms. These observations not only direct their behavior, but influence what they accept as proper.

The mesosystem encompasses the relationships between elements of the microsystem. Neighbourhood location or layout may affect healthy choices as they pertain to obesity. The presence of a candy store versus a gym across the street from one’s home will have an impact. Living close enough to walk to school versus requiring taking a bus would be another example. Familial involvement with community athletics or nutrition initiatives would have a different effect than would owning a fast food chain. Access to a nearby pool or arcade would have differing influences as well. Additionally, stressful interactions with one (or multiple) element(s) in the microsystem can impact others by affecting the mental state and thus, the ability of the individual to respond in an appropriate, healthy way.

Outside the realm of direct influence is the exosystem. This level affects the individual in an indirect or secondary manner but can play an integral role in their overall access to healthy foods and adequate activity. This may include a drought or invasive species affecting local farmers’ crops, which could lead to reduced availability of healthy produce and drive up prices, limiting access. Those living in remote regions would suffer greatest in this scenario, as obtaining supplementary produce presents more of a challenge. The same could be said of athletic opportunities; communities isolated from surrounding regions have less exposure to competition and residents may therefore be less inclined to pursue activity-based recreation. Being presented with a wide range of activities throughout early life can improve the chances that an individual finds a lifelong hobby that allows them to stay active.

The macrosystem accounts for the overlying societal, cultural and political landscapes that help to shape perceptions and actions of the individual. These are often instrumental in affecting widespread change and can come in the form of policies or laws dictating how individuals are expected to behave and think. Agurs-Collins et al. (2019, p.S87) refer to interventions in this realm as “upstream factors”, given their power as preventative measures. It is on this level that the allocation of public funds is often determined. To ensure continued implementation of best practices and modern initiatives, research should be used to direct macrosystem changes. Changes on this scale have the broadest reach and often have the greatest ability to override attitudes and barriers across all levels. Other macrosystem factors such as recession or war may themselves require a multilevel process to affect change.

As diagrammed in Figure 1 above, Bronfenbrenner’s model also includes a temporal dimension, the chronosystem. This accounts for the variance in impact and response to factors across all other layers of the model in relation to time. It is important to recognize that a message delivered during childhood will have a different effect than the same message delivered to an adult. Early in life, access, knowledge and parental support may be limiting factors, whereas motivation to change established behaviors or concerns about availability of time may represent the dominant challenges later.

The most difficult aspect of weight control is that it is not intuitive. Without the proper environment, instruction and/or modelling, the plentiful calorie-dense food options engineered by modern science to appeal to biological cravings for sugar and fat can easily disrupt the delicate balance of the energy budget. Add to this the fact that everyone comes from a unique background with a unique understanding of and perspective on nutrition and fitness, and it becomes clear that one size does not fit all when it comes to solving the obesity riddle. A child coming from a culture or family where exercise and nutrition is foremost in the mind and actions of the majority will often have the tools, support and motivation to adopt similar lifestyle behaviours and his or her health will benefit. In contrast, another child raised in a home where exercise is viewed as punishment and high-calorie, low-nutrient foods are revered will likely mirror those perspectives. In either scenario, adopting practices that conflict with the standard in one’s immediate social circle will likely lead to feelings of social isolation. To change the mindset of the individual then, one must change the collective mindset of the social network that surrounds them, which requires changing the mindset of each individual within that group and the external factors that influence or propagate their behaviors. This paradoxical logic demonstrates the complexity of the issue and reinforces the merits of using a multilevel approach to solve such complicated, multifactorial puzzles. However, even the complexity of a well-developed model will require frequent evaluation and adaptation to remain current in these dynamic environments.

Bibliography

Agurs-Collins, T., Persky, S., Paskett, E. D., Barkin, S. L., Meissner, H. I., Nansel, T. R., … Farhat, T. (2019). Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities. American Journal of Public Health, 109(S1), S86–S93. https://doi.org/10.2105/AJPH.2018.304730

Cutler, D., Deaton, A., & Lleras-Muney, A. (2006). The Determinants of Mortality. Journal of Economic Perspectives, 20(3), 97–120. Retrieved from https://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.20.3.97

Knight, A., Sisk, K., & Reid, J. (2018). The Obesity Epidemic-New Brunswick needs a strategy! Heart and Stroke Foundation of New Brunswick. Retrieved from https://www.nbms.nb.ca/news-and-updates-2/news-and-updates/the-obesity-epidemic-new-brunswick-needs-a-strategy/#.XRlDk-hKjIV

Esther Riggs. (2018, January 7). Bronfenbrenner’s Theory and Ecological Mapping [Video file]. Retrieved from https://www.youtube.com/watch?v=nULPGD0N6WM&t=52s

Wang, H., Emrich, T., & Collette, M. (2016). A Report from the Office of the Chief Medical Officer of Health Health Inequities in New Brunswick. Retrieved from www.gnb.ca/publichealth