Complex Systems Approaches to Obesity

Key Takeaways

Complex Systems Approach to Obesity

Obesity should be viewed as a complex systems issue rather than a simple issue of individual choices. Multiple interconnected factors – including environmental, economic, genetic, and societal influences – shape obesity prevalence and response to interventions.

Global Obesity Epidemic and Corporate Influence

Despite decades of public health efforts, no country has successfully reversed the obesity epidemic. Commercial actors, such as the food industry, play a significant role in shaping obesogenic environments and influencing scientific research, often complicating obesity prevention efforts.

Public Policies and the Role of the Food Environment

Public policies like sugar-sweetened beverage taxes have demonstrated success in reducing obesity rates among children.

Evidence Gaps and the Need for a Balanced Research Base

Current obesity research is often skewed toward individual-level interventions, which are easier to study but have limited population impact. Greater emphasis on cost-effectiveness and systemic approaches is needed to build a more balanced evidence base.

Addressing Obesity with a Systems Approach

Moving beyond simplistic solutions, such as cooking classes, requires acknowledging the complex, interconnected factors driving obesity. Long-term strategies should incorporate adaptive policies, public health prevention, and political engagement to create meaningful change.

The Political Landscape and Shifting Narratives

Influencing policymakers requires reframing obesity as a societal issue rather than an individual failing. Collaborative efforts between public health professionals, researchers, and policymakers can help shift focus toward structural determinants of obesity.

Future Directions and Next Steps

• Develop stronger policies to integrate obesity prevention with treatment strategies
• Expand research on built environment interventions to support physical activity
• Promote a systems-based approach to obesity prevention

Transcripts are auto generated, if you spot an error, please email enquiries@easo.org

Speaker 1
00:00 – 03:17
Hello everyone. Nice to see you all here again and another webinar organized by EYASO Early Career Network, E-Learning Hub. Thank you for joining us. I’m welcoming you on behalf of Early Career Network. And today we will have a very interesting subject, the complex systems approach to obesity. And you can learn about the importance of conceptualizing obesity as a complex systems problem, the implication of this for the ways in which we generate and use evidence, and for how we should approach public health action. The Nova Nordisk Foundation has provided support to EASO for early career network development activities, including this webinar series. Zanova Nordisk Foundation has had no influence over content. My name is Dr. Emili Dayatli. I am Early Career Network Board Member and again let me greet you here and I would like to also introduce my colleagues who is with me today, Lisa Heiji, Eugenia Romano and I hope we’ll have a very interesting session. And I would like to remind you that the webinar, today’s webinar is being recorded and will be shared after the event. I would like again to remind that this is e-learning hub online events that are held almost every time for especially amongst students and early career professionals interested and obesity, EYASO ECN is sharing the knowledge and skill development among such specialists. And again, I would like to highlight that Early Career Network is free to join and so are these webinars. So please be active and invite your friends, invite your colleagues to join the ECN and every month join the webinars are held monthly through the year, apart from some breaks for summer and winter periods. So today we will have around 45-50 minute session and we’ll have 10-15 minutes at the end as a Q&A session. So please starting to the second half, starting to the end, you can write your questions to the chat and we’ll use an opportunity to read and answer the together with our speaker, which I’m going to introduce later. Also, I would like to remind that at the end, you will have some questionnaire, please give the feedback about webinar. It will be very important. Your comments are valued to support the development of future. Now, I would like to hand over to my colleague, Eugenio Romano, to share some news and necessary information regarding the closed events. Please, Eugenia, hand over to you.

Speaker 2
03:18 – 08:24
Thank you, Emil. So welcome everyone. Just as you might know, the ESO ECN has a lot of awards and opportunities that are available to all ECN members. You are all encouraged to join, to apply. So I will send the links for everything in the chat. but just to give a very quick list. First off we have ECO in May, it’s going to be our next in-person event, the European Congress for Obesity in Mallorca, Spain and it’s going to be between the 11th and the 14th of May 2025. The ECN as a group will gather to share research, participate in networking, career development opportunities, we’ll have a few events planned and hopefully a fun walk all together to kind of network and take some photos around. So we look forward to see you there. Upstart submission is closed but you can still register to join as a delegate. Now on to awards and travel grants. So we have the Ieso Novo Nordisk Foundation New Investigator Award. The applications are closed and the winners will be announced soon actually for ECO. There are four research grants for this award of 300,000 Danish crowns which is about 40,000 euros each and they are available for new projects in basic science, clinical research, childhood obesity and public health. If you’re coming to ICO please join the award session because yeah we need a lot of people to see who are the next great minds for the future. Next we have the ECM best thesis award. Again, applications are closed, top three candidates announced and will be presented again for ECO, so please enjoy the session on Monday the 12th of May. Anywho, the Best Thesis Award recognises the contribution of early career researchers’ thesis to the obesity field. Finally, I invite you to present the next year at ECO and the award winner will receive a certificate and 500 euros cash, which is nice. So if you want to consider it for the next round please apply. And then we have two separate travel grants available to ECN members. One is to provide support for members who have some meat in an abstract to Tendico and the applications are closed for that but again feel free to consider it for next year. The other one is a development grant to attend other obesity related events such as specialist training and it’s everything on the ESO website so if you want to apply check the website again I’ll share the links in the chat in a moment. And then in terms of trainings and career development we have recently launched the ECN exchange program. Basically participants who apply and are accepted will be able to spend three to five days visiting a specialist research site of their choice in Europe and they will be able to develop subject-specific skills to support their careers. Applications for this year 2025 have closed, so thank you for all those who applied, but applications for next year will open after summer, so keep an eye on that. We also have the ECN so-called in the past Winter School but now the name has changed and it’s going to be called the EASL Masterclass. It’s a We, the ECN board, developed the programme. We tailor it for ECN members and hope to make it as engaging as possible. This year’s Winter School will be held between the 20th and the 22nd of November, so keep an eye out for updates on when the application is open. It’s a really fun event, so please apply. We also offer spotlight moments for members of the ECN group. So basically we interview ECN members about the research and we share it widely with our community. So if you want to have your research spotlighted, kind of like be promoted a little bit, please get in touch. We’re happy to do it and to share it on our official channels. We have a WhatsApp group for quick updates where we share resources, networking across Europe, very good ahead of events like Eco and Promise. It’s a no spam WhatsApp group, but actually it’s very useful. So if you want to join it, feel free to. We are welcome to. And last but not least, if you are interested in having an active role in organizing ECN activities, by the 4th of April, you can apply to become an ECN board. So for an ECN board membership, you’re welcome to apply. We need more of you. So again, we are looking forward to receive your applications, your interest, and I’ll post all the links in the chat now. So you can go ahead, Emil.

Speaker 1
08:26 – 08:47
Thank you, Eugenia. So with great pleasure, I would like to introduce our speaker, one of the popular EASO speakers, Professor Harry Rutter, professor in global public health at the University of Bath, UK, and expert advisor for public health organizations in the UK. So please, welcome. Stage is yours, Professor Harry.

Speaker 3
08:50 – 09:30
Thank you very much, Emil. Thank you, everyone. and nice to see you all. I’d just like to echo what’s been said about the ECN. I think it’s a fantastic network and I’ve been involved in various ECN activities over the years and it’s a pleasure and a privilege to be able to contribute ’cause I think you guys do fantastic work and people like me are the past and people like you are the future. So all power to you all. I’m just gonna share my screen and I will probably then not be able to see you. so please do the usual thing of confirming that you can see it. Is that okay? – Yes. – Yeah,

Speaker 1
09:30 – 09:30
I can see.

Speaker 3
09:31 – 29:20
– Okay, great. And the other thing is I’m very, very happy to take questions. I will not be able to see the chat, but I’ll trust Emil and Eugenia to field any questions that can’t wait until the end. And probably best to leave them till the end, but if there’s something particularly difficult or particularly confusing, by all means, intervene and interrupt me at that point. Okay, so you don’t need, hang on, you don’t need me to tell you that we’ve got a growing global problem with obesity. And the real point of showing you this figure, ’cause you all kind of know this, but the real point of showing you this is just to emphasize that pretty much everyone the same trajectory. Even countries that have a low prevalence, like South Korea, are actually on the same trajectory as the United States. They’re just a few decades behind. No country in the world has successfully reversed the obesity epidemic, and we have a growing and worsening problem around the world, importantly not only in terms of the baseline prevalence, but also in terms of the severity and the inequalities that obesity reveals. So it’s a big and growing problem. So why is it happening? And at one level, that’s kind of obvious, isn’t it? It’s too much of this and not enough of this. But the nature of the public media and political discourse these, I accept oversimplified definitions. It’s not just about physical activity and diet. It’s about a whole load of other things, the composition of our food, many social and cultural factors. But if you make the mistake of listening to a politician talk about obesity or the bigger mistake of reading the below the line comments in a newspaper, what you might think is that the reason we have a global obesity epidemic is because the population have become increasingly stupid, lazy, and/or greedy. Because the way in which obesity is presented in the majority, not all, I’m pleased to say, but the majority of public discourse is to frame it as a failure of the individual, to frame it as a lack of willpower, a lack of control, a moral weakness. And that is of course not the cause of the obesity epidemic. So please don’t screenshot these photographs, these slides and stick them on social media and say this is what Harry thinks because this is the opposite of the truth. If obesity had been driven by greed and loss of willpower, and laziness, then these charts, these stupid charts would have to be true. And it’s absurd to claim that the global population has consistently across all countries become lazier, weaker willed and greedier over recent decades. What has fundamentally changed is not us as people, but the world around us. Now, I don’t know where you’re all sitting. I don’t suppose any of you are sitting in Breezewood, Pennsylvania, where this photograph was taken. And most places are not as extreme as Breezewood, Pennsylvania. But actually, this represents something that we see everywhere. Wherever you are, it is easier than it was 20 or 30 years ago to consume more energy than you need, significantly more energy than you need. And it is harder than it was 20 or 30 years ago to gain sufficient physical activity in your daily life. That does not mean for a moment that it isn’t perfectly possible for you to eat healthily and to engage in adequate physical activity, but it becomes ever harder. We have to push back harder and harder against a whole set of environmental factors, environmental cues that haven’t been designed to make us unhealthy, to give us obesity, they’ve been designed largely to make money for the people selling things to us. And the health impacts are an unwanted side effect but they’re an inevitable side effect of many of these environmental changes. Another thing I think to think about obesity is the word. There are many ways in which we should think about the word obesity. But one aspect of it is that it actually represents lots of different things. So I was part of a government office for science foresight project in the UK from 2007. And I’ll show you the famous map from it in a bit. But that project was called tackling obesities, plural. And at the time I wasn’t very impressed with that. I thought it was silly, but the more I have thought about it since, the more it has come to me that this is actually a very important way of thinking about obesity. On the right-hand side of this chart, of this figure, we now have a figure showing pathways for assessing and referring cancers in adults. So cancer is a word that we use in the singular, but actually there are many different cancers. There are many forms of cancer, there are many causes of cancer, there are many treatments for cancer, depending on the cancer that you have. We use a single word to cover all of that, but we appreciate, we fully appreciate that there are many different things going on in different people, playing out in different ways. And I don’t think we appreciate enough that actually the same principle can be applied to obesity. We have multiple obesities. For some people, what they eat is really important. For other people, how much they move around is really important and so on and so forth. And I think this oversimplification of a complex problem, reducing it to a single word is one of the challenges we face. Another challenge we face comes from corporate interference. So this is a slide showing multiple different scientists who were revealed in a leak of documents from Coca-Cola about 10 or so years ago to have received significant funding for the soft drinks industry. And some of these are very, very good scientists who had up until that point, and actually subsequently, been doing some extremely good, robust scientific research. But their research has been tainted by the fact that they have been funded by the soft drinks industry, which skews the nature of the science base in its own interests. And I haven’t got a lot of slides here to talk about commercial determinants ’cause there’s a lot of other things to cover, but the influence of commercial actors, not just the food industry, also the oil industry and the car industry, shaping the ways in which our cities are designed and how much we can move around, how easily. The commercial influences on the ways in which we live our life are hugely powerful and hugely important in a problem like obesity. So what do we do about it? Well, one of the standard things we do which we give people information. And here’s a rather poor quality picture ’cause I took it a long time ago. This was in the front lobby of a hospital of an information poster with eight guidelines for a healthy diet. It says, “Enjoy your food, eat a variety of different foods, eat plenty of fruit and vegetables.” All perfectly sensible advice. “Don’t have sugary foods and drinks too often.” Nothing here you could argue with. But this photograph was taken in the lobby of a hospital right by a Burger King. And if you’re in a hospital and at the time, this was a few years ago, you can tell from the price of the burger on the left hand side. At the time, this was pretty much the only hot food outlet, I think, in that hospital. So if you’re a visitor who’s there for a long period of time, or you’re someone who’s a patient in the hospital fed up with the rather dull hospital food, whatever it says on the poster, you’re gonna go and get the hot food that is available. So the nature of a response that focuses on just giving people information is a very weak intervention compared to the power of what is available in the environment. Another thing we do is a different form of providing people with information, which is to tell them about the calorie content or the nutritional content of the food that they buy. But as you’ll notice from this Big Mac box, this information is provided on the back of the box containing a burger that you’ve already bought. And there is some, there’s a Cochrane review out recently actually showing a bigger effect from this than I had understood there to be the case. There is a bit of an effect from providing this information, but it’s probably not distributed equally across society. So the kinds of people, you and me, who are interested in the topic, we may well respond to something like this. But we are huge outliers in society, we’re not like normal people when it comes to interpreting this kind of information. And most people respond very weakly to this kind of information provision. And of course, you know, I’m very interested in the physical activity and built environment, and we need to think about how we build our towns and cities. So I live in Oxford, in England, there are two streets for pedestrians in Oxford, and this is one of them. It’s supposed to be a pedestrian street, but it’s where the buses go, and it’s not a very pleasant environment. At least some of them are electric now, so they’re not quite as, the air is not quite as bad as it respond? Well, we can start with thinking about creating much more civilised environments for physical activity. And this does of course, go much, much further than just obesity. This is about all of the other benefits of physical activity, the social benefits of being able to interact with people in an environment like this, the autonomy and freedom it gives children and young people. One of the biggest constraints on the autonomy of children is their parents’ understandable fear of road traffic. So creating safe and civilised environments has many, many benefits, including contributing to reducing obesity. But it goes much wider than that. Although I was a bit dismissive of this kind of information provision, actually, there’s some reasonable evidence, in addition to what’s recently come out in a Cochrane review, that even if consumers don’t change their behavior very much. Actually, the requirement to publish calorie contents and nutritional information places a pressure onto providers, onto the food industry, and it can encourage them to reformulate their products in a slightly more favorable, in a slightly healthier direction. So I don’t think we should dismiss these interventions, but they may work more in a way that isn’t the one we think is the main way. They can work through different routes and that’s a complexity theme that I may come back to later. And this wasn’t me at dinner last night, but I don’t think we should ignore the social aspects of how we live our lives and the social aspects of eating. Most new homes in London, I have been told on good authority and it’s completely understandable. Most new homes in London do not have a room in which you can eat that is not the room where there is a television. Most people have a TV, and if you don’t have the space to have a separate eating area, the place you will eat is in front of the TV. Food that is eaten in front of a television tends to be different from the kind of food that you eat when you’re sitting around a table. You need to be able to hold it in your hands. Things like that, it shapes the kinds of food that we eat, and we should ignore that at our peril, as well as of course, the positive social and wider health and wellbeing benefits of this kind of social engagement as a family or as friends or whatever. Another thing that we importantly need to think about, and I’ll come back to this later, is about the economics of some of these things. And this is a photograph I took outside our Ministry of Finance, the Treasury, and the role of taxation and other policy levers to change the nature of the food and physical activity environments. But of course, in the last few years, and you know, this, today’s talk, this series, the ECN is sponsored by the Novo Nordisk Foundation. We’ve seen the rise of the GLP-1 agonists, drugs like semaglutide, incredibly powerful, incredibly effective drugs. And although I was a doctor once, but I’ve been a public health person for over 25 years, and I deal at population level, I think these drugs are amazing. And they have really transformed the landscape and provided, I think, some options for people who already have obesity that were barely there a few years ago. So I’m not a critic of these drugs, but I am a critic of a perspective that says these solve the problem of obesity. Because while they are a very valuable and powerful contributor, they don’t eliminate the problem. And we still need public health prevention activities. And I’ll say a little bit more about that now. So this John Byrne Murdoch does a lot of good data analysis Financial Times. This was from October last year. He produced a report where they’d been analysing what was happening to the obesity trends in the United States. And this was just from one source, but it was a very good source. It was from the N Haines survey, I’ve not been able to find the original data. I looked quite hard and I don’t know if it’s gone down following Trump coming in. But what what John Byrne Murdoch reported on was a certainly indications, I don’t know if there are there are no error bars on here, but certainly an indication that there appears to be a reduction in the prevalence of obesity, at least among college educated Americans. And what this probably represents is availability of healthcare because of health insurance for people who are better educated, and thus have more money, have better jobs and more money in the US. So there is an indication that there may be a change here, and the indication may be related just temporarily to the availability of this new class of drugs. And one of the objections to them is that they’re very expensive, you know, hence the difference here. That is a problem at the moment, but over the medium to long term, that problem will go. They’ll come off patent, we’ll get oral preparations, which will be much cheaper and probably better tolerated. So some of the objections in terms of inequalities, I think will pass. And we’re also seeing some other wider effects. So Walmart has pharmacies, but also sells food. And they’ve been able to analyse the shopping behaviour of people who are prescribed these drugs and see what happens. And as have others, and Morgan Stanley put out a report, I think it was last year, showing that once people start these medications, they change their purchasing patterns. And there are some indications that the food industry is getting quite concerned about this. There are also some suggestions, I don’t think the evidence could be said to be any stronger than that, that the food industry is looking into reformulating some of its foodstuffs to overcome the reduction in appeal that is brought about by these medications. So food that has been designed to be bought more by people who are on these drugs. It’s only an early suggestion, but I think it’s something that is definitely a possibility and we should certainly be keeping our eyes open for in the future. But one of the factors with these drugs is that in general, they produce a very impressive weight loss of about five to 25% in most people, but that’s a relative reduction, not an absolute, you know, it’s not saying it brings everyone into the normal weight range. So what we have is a drug that in the people who can tolerate it, a significant reduction in weight-related risk, but not the elimination of weight-related risk. If you have a body mass index up in the 40s or 50s, reducing your weight by 25% will bring you down into a much less unhealthy range, but you may not still be within the healthy range. The effects tend to plateau within about a year, year and a half. They have quite significant side effects, the extent that up to about 40% of people may stop after one year. And after people stop taking them, most of them regain their weight. There’s also been some suggestion that because of the nature of the physiological changes that are associated with the weight loss that comes with these drugs, when you put the weight back on afterwards, if you stop, you might be slightly worse off than you were before you started. I think causing more harm than good is almost certainly overstating it. And the person from whom that quote comes was someone who had a vested interest in arguing this. But I do think there are some, we do need to think about the potential for, at the very least, losing the benefit once people stop. And importantly, and I think perhaps because of the cost, in the United Kingdom, we have an organization called NICE, National Institute for Health and Care Excellence, that makes pronouncements about,

Speaker 4
29:28 – 29:29
early says that

Speaker 3
29:29 – 48:45
semaglutide should only be used for a maximum of two years. So they are, if that guidance is followed, then they’re kind of setting people up to lose weight for two years, but potentially put it straight back on afterwards. Probably these drugs will need to be taken for the rest of one’s life. And, you know, as long as they’re safe, that’s okay. I mean, you know, there are lots of drugs that people take for the rest of their lives. Antihypertensive drugs, Tharoxine, all sorts of things that people will take forever. So it doesn’t, that doesn’t necessarily, I think, count against them, but there are questions about long-term usage. So I would argue that however good these drugs are, it doesn’t remove the need to tackle unhealthy obesogenic environments. Any questions there before I move on to a slightly different part of the talk? Okay, I’ll keep going ’cause we’re short of time. So one of the things I’m talking to you, ultimately gonna be talking to you about complexity. And one of the reasons I got into thinking about and working on the complexity of obesity was because of the challenges that exist within the obesity evidence base. And I don’t think that within public health, we step back enough to think about not just what is the evidence out there, but what’s, you know, what does the evidence tell us about a problem, but what’s the nature of that evidence? What underpins that evidence? What’s the distribution of that evidence? So we kind of all understand now that tackling obesity doesn’t involve any one thing. It involves all sorts of things. And of course, this applies to all major public health problems, whatever they are, mental health problems in young people, climate change, you know, all of these big problems, not just obesity, require multiple different factors that sit together, support one another and act a bit like a wall of sandbags, preventing a flood, holding the floodwaters at bay. But when it comes to the ways in which we generate evidence, what we almost always tend to do is just take out one of those sandbags and test it on its own to see if it stops the flood. Our research system is not well designed, excuse me, for analyzing a comprehensive set of measures and thinking through how they fit together and act to affect a public health problem. It’s much easier to get funding to examine a discrete intervention in a discrete population over perhaps a 12 or 24 month period. So we have a problem with the nature of our research systems and our funding systems because they tend to skew the kinds of research that gets generated. Similarly, if we think about Jeffrey Rose and his prevention paradox, we have another problem with the nature of evidence that is available. So what Rose did in the 1980s was demonstrated that there are broadly two approaches to risk reduction and improving public health. One is the standard risk reduction approach. if you look at the green distribution curve here, and not many distributions are quite this symmetrical, but they’re all, you know, broadly, we have a distribution in society of most things. And if you have a distribution in society, there will be some people who are up the top end of the normal range. And those are people who are in a risk category. So in the context of obesity, that would be people with obesity. And of course there are many other indicators than body mass index, but if we’re using BMI, we’d say that might be, this could be a BMI curve and these could be people with a body mass index above 30. So a risk reduction approach says, okay, here’s a group of people, we’re going to provide them with a treatment or some kind of intervention to help them to move back out of that risk category into the normal range. And that’s a perfectly normal and reasonable way to do things. But what Rose showed is that there is another approach and it is complimentary. It’s not like you should do one or the other, almost invariably you should do both, which is about shifting the entire distribution curve to the left. So we reduce everyone’s risk by perhaps a very small amount, but across all of society, the overall level of risk declines in a significant and meaningful way. And one of the problems in terms of evidence is that it is relatively easy to demonstrate that someone has moved from a high risk category to a lower or non-risk category, it is much harder to show very small changes in large numbers of people across the entire population. It can be done, but it is a much harder thing to design a research project for. They generally take much longer and it’s much harder to get funding for. So we have an evidence base that is skewed. And one of the things that came out of this thinking was something that I called the dangerous olive of evidence. And it’s not really an olive, it’s just a Venn diagram. But I was at a fantastic conference in Portugal quite a few years ago now, and I had a lovely bowl of olives in front of me while I was producing my slides. So I thought I’d make it an olive, not a Venn diagram. But it’s just a Venn diagram. And the flesh of the olive is all the things you could possibly do, in this case, about obesity. The olive is stuffed with a pepper, which is the subset of them for which we’ve got evidence of effectiveness. And the pepper is stuffed with a very small piece of garlic, which is the subset of them for which we also have evidence of cost-effectiveness. So if you think about obesity, there are all sorts of things we could possibly do. I could ask you all to write down on a piece of paper your five big ideas. And what we would find is that some of them have been researched, and we’ve got some evidence of effectiveness. And some of those have also been researched to demonstrate cost-effectiveness. And it seems kind of obvious, doesn’t it, that the things we do should be the things that we know to be effective and where possible cost effective. But the trouble is that the research evidence base isn’t neutral. It’s skewed in its distribution. And here’s an example from some work I did with a student of mine, a fantastic, brilliant master student of mine a few years ago, where we thought about and used other people’s frameworks for thinking about how you might classify public health interventions. And on the left-hand side, up the y-axis, we’ve got the level of targeting from individual, highly targeted, up to population level. And across the bottom on the x-axis, we’ve got how much agency it involves. So that’s how much the individual has to be able to act of his or her own volition, how much kind of mental energy, how much willpower, to go back to the willpower from the beginning, do I have to put into this to make a difference? And so bottom left, targeted, agentic information, you can give people with type 2 diabetes education for them to manage their conditions. And that’s a good thing to do, but it requires quite a lot of willpower. At the other extreme, you can put in a structural intervention at population level, it doesn’t require any effort at all on the part of the individual. So you can just ban a problem like trans fats. So it’s a way of thinking about the distribution, the ways in which one could consider where evidence might sit across a distribution. And the reason that agency matters is that agency is not equally distributed across society. So in general, the higher up the socioeconomic scale one is, the more agency one has. It’s associated with better education, with more money, with a more stable environment. So, you know, someone like me, a well-educated university professor, I have quite a lot of agency about how I live my life. I’ve got quite a lot of control over my surroundings. Someone who is holding down three precarious jobs and struggling in many other ways to keep food on the table has much less agency than I do and will find it much harder to put these kinds of agentic interventions into place for themselves. Which isn’t to say that people like me find it easy. I mean I had my lunch a couple of hours ago, I couldn’t resist the chocolate in the cupboard and I had some very nice chocolate to finish off my lunch. You know, I know it’s not good for me But we all do it, and that’s even me as someone who ought to have find it very easy to do these things. So what we did was we analysed a whole load of research, some funded projects from our national research funder, and we found that the distribution was hugely skewed for public health research, was hugely skewed over to the agentic side. So I don’t blame the funders for for this because I bet the applications were even more skewed. But if we map that onto a distribution, so the distribution across the top of this figure, which comes from a 2011 Lancet paper by Boyd Swinburne et al, we’ve got kind of physiology on the right-hand side, we’ve got big picture structural stuff on the left-hand side, and mid-level health promotion, local environments in the middle. And what Boyd put on this figure was this wedge here that says population effects and political difficulty. So individual level interventions are generally politically easy, but they don’t have a big population effect. Whereas structural interventions, removing trans fats, or bringing in a sugar sweetened drinks tax or a fat tax can have a really big population effect, but but they’re politically very difficult. And I added these wedges at the bottom. I’ve already talked about public discourse and political mandate, but the evidence base is also skewed towards the individual. It’s much easier to do a study on a targeted intervention on a defined number of people than it is to evaluate the effectiveness of a sugar sweetened drinks tax at national level. I’ve got some evidence from an evaluation of a sugar sweetened drinks tax coming up, but it’s hard to do. And if you just take a neutral view of the evidence base and ignore this skew towards the individual, you can be kind of misled. And an example of this is the WHO, a report of the WHO Commission on Ending Chartered Obesity from a few years ago, which had, I think, 34 recommendations, half of which were relatively lightweight, individual level information in kind of interventions, and only five of which related to the activities of the food industry, which are likely to have a much bigger impact on the obesogenic environment than things like cooking classes. Not to say cooking classes are irrelevant, but the role of cooking classes in the face of relentless marketing of highly palatable, cheap, endlessly available sugar-sweetened drinks is, you know, it’s not a fair comparison. So finally, in the last 10 minutes or so, we’ll get onto some system stuff. So there are three words here, complex adaptive systems. And the point really that I’m making is to try and help us to move away from only looking at these simple linear relations. We don’t ignore them, they still exist, but we’ve got to take account of the mess that’s sitting outside in the real world and think about how we engage with that. ‘Cause if we pretend that this is all there is, we’re kind of missing the point. So one of the first things to think about is the difference between what is complicated and what is complex. So a Saturn V rocket is very, very complicated. You’ve got thousands, if not millions of parts, but if you know what you’re doing, you can build one of these, you can put three very brave little volunteers into this little cone at the top, you can send them to the moon, and you know what will happen. You know when they will come back. I heard a story on the radio today about the people who’ve been stuck in the space station. They know where to pick them up from. It’s highly predictable. This is the system map from the Foresight Project on obesity from 2007, obesities that I told you about earlier on. It’s a mess. And that’s a technical term. It’s a mess. Everything is interacting with everything else. We’ve got food on the left, physical activity on the right, social and cultural stuff on the top and biology at the bottom. These things all interact across the piece. You go to the gym, you work out for an hour, you burn three or 400 calories and you buy a 500 calorie chocolate bar from the vending machine as you walk out. These things interact. We should not pretend that these things happen in isolation. An important word that often gets forgotten is adaptive because systems adapt in response to intervention. So this is a logic model for how a sugar sweetened drinks tax might work. It seems pretty obvious, doesn’t it? You put up the price, sales go down, consumption goes down, obesity goes down. Well, even if sugar sweetened drinks were the only driver of obesity and not all the other things that also have an effect, I wouldn’t expect this actually to make a fundamental difference because at every step along the way, the system pushes back. So when there’s first a suggestion that politicians might do this, industry comes in and says, “You can’t do that. There’ll be thousands of job losses. It’s a terrible thing to do. You know, it’ll ruin the economy.” Next step is, once it does come in, they adjust their pricing patterns. So I can’t remember which company it was. It might’ve been Coca-Cola, when we had the sugar sweetened drinks tax introduced into this country, the SDIL. one of the companies, they didn’t reduce the price, they increased the price of their sugary drinks, but they also increased the price of their diet drinks. So the pricing, there was no pricing differential. And for a branded product, whether it was Coke or Pepsi or something else, for a branded product, the incentive to go for the lower calorie version was eliminated. And the company made more money actually. But not all adaptations are bad. we had enormous reformulation between the announcement and the implementation of the tax. A lot of sugar was taken out of the food supply as a result of this tax. So the system pushes back and adapts. And in the evaluation, we didn’t go for a simple logic model. We had a complex model that looked at all of these factors and how they interacted. I’ll skip past that and end by talking about time because I think one of the other things that we have lost sight of largely in public health is the dimension of time. We tend to say, what are we gonna do now? And not think really hard about what it is we’re actually trying to achieve over the medium to long-term. So if you think about an intervention like a walking school bus, which is where my kids did it when they were small, you drop them, I don’t know, a kilometre from the school and they go, they put on a high visibility vest, they go hand in hand with their friends, a teacher or parents at each end of the line of kids, 20 or 30 kids, and they get some walking in. And that’s great while they’re small, but then they get bigger and they don’t wanna do that. And what we’ve done is we’ve taught them that walking is a weird behaviour for which you need to be organised and structured and wear a high visibility vest to protect you and have teachers or parents to protect you from strangers. And we have not done anything that encourages kids to become people who walk for the rest of their lives. And actually, I would argue that there are ways to design an intervention like this, which would probably start by making safe environments in which kids don’t need to wear protective vests, you know, high visibility vests or have people with them, because they’ve just got a safe environment in which they can walk. And that is of course then a safe environment in which anyone can walk. So where next? Well, I think if we look at, if we go back to the Swinburne figure, what I’m arguing is that we don’t stop doing the things on the right hand side, but we rebalance so that we build an evidence base that is not just skewed over to the individual level, but actually provides powerful and meaningful and usable evidence that relates that works across the system. We reshape public media and discourse to reflect the reality of obesity, which is that it is fundamentally a societal and structural set of problems. And then we might have a political mandate. The politicians might be prepared to do some of the more politically difficult things on the left hand side of this figure. And one of the lines I use is “chess not checkers”. So checkers or drafts, I don’t know what it is in all of your languages, but it’s a game with flat pieces. is you play it on a chess board, but it’s a very simple game and you just move the flat pieces around. And that’s not a game of strategy. That’s just a game of tactics. You just move and move and move. Whereas chess, you play it on the same board, but it’s a much more complex and much more sophisticated game. You have an end game in sight. You kind of know what you’re aiming for. You have a set of moves mapped out. Importantly, whatever set of moves you’ve got mapped out is likely to get ruined because your opponent will do something to change the configuration of the board and you have to adapt. And I think that in public health, we need to stop playing checkers and start playing chess. We need to set ourselves a vision for where we wanna be in 20 years time. What is possible within a three, four or five year political cycle? So what’s our five year strategy? And then and only then do we say, what do I do now? So we move from what do I do now to 20 year vision, five year strategy, one year plan. And I think that taking a complexity approach is really important in that because it helps us to see the multiple different ways in which an intervention and the responses to it can play out across a system. So there’s some conclusions. We’re running out of time, so I won’t read them to you, but I hope that was helpful and I’m happy to take some questions.

Unknown Speaker
48:53 – 48:53
Yes,

Speaker 1
48:54 – 48:58
thank you, Harry. Thank you very much for a brilliant talk.

Speaker 3
49:00 – 49:05
I’ll stop sharing now. And are there any questions?

Unknown Speaker
49:06 – 49:06
Yeah,

Speaker 1
49:06 – 49:28
we have some. So Karen is asking about, we know that the systems policy tackling the food environment are more effective than individual level interventions, like cooking lessons, for example. How do we persuade politicians to make the change?

Speaker 3
49:29 – 51:15
Yeah, that’s a very good question. good question, because it’s not easy. And I think my answer would be, I’ve really rushed through this, you’ve only had an hour, this is, I do a week long course on this. So I’ve not been able to get into the detail of what I really mean by a systems approach. But I guess what I would do for whatever the complex problem is, and I think achieving political change absolutely is a complex problem is I would draw one of these maps, I start by working with a group of people who have, you know, their partners, their stakeholders in the problem, we work out what the possible factors are that will shift things. And then we think through what are the levers to achieve the changes that are required to get those shifts. So charts I showed you at the beginning, those silly straight line, straight line graphs, showing, you know, greed and willpower or whatever. So what I wanted to do with those charts, I use those in a for a politician. So when, when Boris Johnson, our former Prime Minister, before he was Prime Minister, he was Mayor of London. And while he was Mayor of London, I had a job where I was consulting to the Greater to London Authority advising on obesity. And one of the things that I thought was really important was to convey this point to Boris Johnson that obesity was not fundamentally down to a fault of the individual, it was about a set of structural factors.

Speaker 4
51:16 – 51:16
And

Speaker 3
51:16 – 52:40
I had a five minute meeting with him. So I thought I’m gonna produce three slides which might make him laugh a little bit, might appeal to him and might, they’re not gonna change his mind, but they might contribute to helping him to see something from a different angle. So those were slides I put together to try and get Boris Johnson to see that obesity was not just a failure of the individual, but is actually a set of societal failures. Whatever his political angle, I think, and I probably failed, I should say, he’s a difficult man to persuade of things, but it was worth a try. I guess what I’m saying to answer your question is that I think we need to think about what needs to change to get politicians to change. And in many cases, I think one of the first things to change and there’s no one thing, there are many things, but one of the first things that needs to change is this idea that all you need to do is shout louder at people and they’ll change their behavior or stigmatize people or belittle them or bully them. That doesn’t lead to changes in behavior. That just makes things worse. So I think enlightening them to other ways of thinking about a problem is a first step, but there’s much more beyond that.

Speaker 1
52:42 – 52:56
– Thank you, Harry. Another question, do you have any specific recommendations on how early carrier researchers can help shift public perception away from personal responsibility toward the more systemic understanding of obesity?

Speaker 3
52:59 – 55:39
– Another great question. So I think the first thing to say is that I don’t know what you all do, all of you people there on the screen, but I bet that many of you are working in an individual level, at an individual level. You’re working as clinicians or nutritionists or dietitians or whatever, and that’s great. This is not in any way saying you shouldn’t be doing that, but far from it. I think we need that. We need, absolutely need those roles. But I guess what I’m arguing is that we should all also appreciate that there is a structural set of factors going on here. And the things that we can do to contribute to reshaping those structural factors will of course depend on our role. But I think the first thing is just to appreciate through your career, your early career people, you’ve got a long career ahead of you, I hope, and appreciate through your career that there are a range of different perspectives that matter here and work with other people from different perspectives and look for the common ground. And in a slightly different field, this is something I’ve been doing recently. So I’ve, since I stopped being a doctor and went into public health, I’ve had hardly anything to do with clinical services or one-to-one treatment. But over the last couple of years, I’ve been involved in the European Lancet Liver Commission. So I’m bringing a very public health perspective, which is about the alcohol industry and an obesity angle as well for liver disease. But I’ve got, you know, most of my colleagues are working as hepatologists, dealing with patients with severe liver disease. And I think one of the really exciting things about the work is that we haven’t gone our separate ways. We’ve actually worked very hard to meet in the middle and look at the interactions between the population approach and the individual level approach and where there are tensions between the two and how we can remove those tensions and actually get some benefit in the middle as well. So some of that is about access to services. Some of that is about a very large part of it is about identifying where there are risks of inequalities getting worse and what we might do about them, and so on and so forth. So I don’t have a specific answer. It would be, again, let’s map out the problem and see what the opportunities are. But I think it would just be, look a bit wider than your own discipline and think about who else is doing things that are relevant and important in this field and think about how you might work with them.

Speaker 1
55:39 – 56:00
– Okay, thank you. Francisco is asking that so far we know a lot of strategies that haven’t worked on its own. But do you know about public policies that actually work and worsely to try and implement more broadly? Best examples that really try to. Yeah, so

Speaker 3
56:00 – 58:27
I think. Well, I’ve got examples from both physical activity and diet, actually. So I think one of the things we’ve seen is a really big shift. I’ve used an example in my talk of the sugar sweetened drinks tax in the UK. And over the last 10, 15 years, we’ve seen a huge increase in the introduction of fiscal measures. So taxes on things like sugar sweetened drinks taxes. They’re often the first thing that people pick on, because no one needs sugar sweetened drinks. It’s less complicated than a lot of other kinds of things. But what’s happened is that over time, the evidence has accumulated that these things do actually shift behavior. One of the slides I had to skip over because I was running out of time was from a paper that we produced from our evaluation of the UK sugar tax, which showed strong indications of a reduction in the prevalence of obesity of 10 to 11 year old girls. And that’s just because of the nature of the data that we collect, we collect children at the first and last year of primary school. And the girls at the end of primary school, there does seem to be a reduction in obesity associated with the introduction of the sugar-free drinks tax. So what we’re seeing is an accumulation of effort leading to an accumulation of interventions in countries around the world. And what I think that then does is it normalizes the idea of bringing in unhealthy product taxes associated with foods. From a physical activity perspective, I guess what we’ve seen is increasing attention on improving urban air quality. One of the best ways to improve urban air quality is to reduce the number of cars. Even electric cars contribute a lot of particulates to the air, so they’re still polluting even if there’s nothing polluting coming out of the back of the car. And the interaction between work on improving air quality and work to increase physical activity is something that is, I think, very fruitful. And I’ve been involved in various policy actions, including the WHO Global Action Plan on Physical Activity, which pulled out some of these kinds of connections.

Speaker 1
58:30 – 59:06
– Thank you so much, Harry, for brilliant presentation. And I will just highlight one thing. I was very surprised when I saw you first in summer school, Izansi. And from that moment, it’s been three years past in capital of Azerbaijan, Baku, we see the change in the number of pedestrians are increased. Also, we start to create a big line of the bicycle lines. So the things is changing and the system is really applied broadly. I guess the physical activity, as you say, one of the most important. That’s

Speaker 3
59:06 – 59:14
fantastic to hear. I was in Baku in, I think, 1996. And there were no bike lanes in Baku in 1996.

Speaker 1
59:16 – 59:24
It’s happened just last two years. After our first meeting in two years, we have now changed. Eugenia, yes, I see your hand, please. – Anna,

Speaker 2
59:25 – 59:30
actually there’s another question. So ignore my hand if you wanna read from you on me. – I’ve

Speaker 3
59:30 – 59:34
just seen the question. I know we need to finish, but it’s also a very good question. And it’s – Yeah, go ahead with

Speaker 2
59:34 – 59:35
that.

Speaker 3
59:35 – 01:00:46
– It’s one of my concerns. So the question is whether the GLP-1s kind of allow a relaxation from the policy makers. And that is absolutely my concern. They think that here, and these drugs are being promoted as the solution to obesity. And I think that some of the politicians see that as a very easy response. Yes, they’re expensive, but actually they can be seen to be doing something by supporting the use of these drugs. And we’ve seen this in the UK with our health minister. So I very much agree that this is a risk. There’s only so much policy attention available for any problem. And if the policy attention for obesity gets focused on medications, primarily on medications, rather than a broader focus on prevention as well as treatment, then I think there’s a risk that this will be seen as an easy win, that actually, as you’ve heard, I’m a very strong supporter of these drugs, but they do not solve the problem. And we need not to lose the focus on prevention as well as treatment.

Speaker 1
01:00:47 – 01:00:53
– Yeah, thank you. Eugenia, do you want to ask the last question? – I mean,

Speaker 2
01:00:53 – 01:01:29
this is a quick thing. Just also a comment on what Harry just said. I mean, yes, these drugs are great and they can help people but teaching people about living healthily, it goes beyond chronic diseases that some people are unfortunate and they have like BCT, diabetes. But yeah, that’s kind of a concern ’cause yeah, sure, you have this very immediate solution and it’s great if it’s available for people who need it, but there’s a lot more that we can do on top of that to increase people’s health. No, my question, yeah, go ahead, sorry.

Speaker 3
01:01:30 – 01:01:45
– Well, that was just to say, we’ve had treatment for high blood pressure for many, many years. It doesn’t mean that you don’t also reduce your salt consumption or have a healthier diet or do physical activity. So you have your treatment for high blood pressure, but you also work to make yourself healthier as well.

Speaker 2
01:01:46 – 01:02:56
– Exactly. Just like a note to the interventions that work, I might remember wrong, ’cause I remember there was a question on that. I remember that when they introduced the biking scheme in London, where you had these bikes where you would pay just one pound 50 for 30 minutes. And as long as you drop the bike to a bike station and took another one within 30 minutes, you wouldn’t pay any extra pounds. So basically you could take as many bikes as you wanted, paying just one pound 50, as long as you return the bike within 30 minutes and take another one. So basically this encouraged the fact that stations always had bikes for people to use and you wouldn’t just hoard on a bike for two hours, which was convenient, it was great. I think it was linked to a reduction in BMI in the areas where it was mostly used bikes and stuff like that. Suddenly they removed it while there was Johnson in charge. And now it’s just like, no matter how much you use the bike, you pay £1.50 every half an hour. And people are like, well, take the bus, because it’s the same

Speaker 4
01:02:56 – 01:02:58
price. It’s

Speaker 2
01:02:58 – 01:02:58
just like,

Speaker 4
01:02:59 – 01:03:00
yeah, it just

Speaker 2
01:03:00 – 01:03:09
made me think of that. And yeah, like I think that’s a very small thing that could be a great example on how to change something and make a big result.

Speaker 3
01:03:09 – 01:03:28
– Yeah, and there’s a principle in that, a complex systems principle, which is thinking about unintended consequences, which can be both positive and negative. So this is not just about using the bike, it’s about how that goes more widely and what that means for the availability of bikes and so on and so forth. So yes, a really good example.

Speaker 1
01:03:30 – 01:04:06
– Yeah. Thank you so much, Harry. Thank you very much for the brilliant presentation. And I would like to thank again all our participants for joining us. And I will remind again, please don’t forget to fill the feedback forms. It’s very valuable for us for the next time to be more useful for you. And please don’t forget to join ECN Early Career Networks, EASO. So thank you very much and see you in our next webinars.

Speaker 3
01:04:07 – 01:04:09
– Thanks very much everyone. Hope it was worthwhile.

Speaker 1
01:04:10 – 01:04:10
– Thank you.

Speaker 2
01:04:11 – 01:04:14
– Thank you, bye everyone. – Bye everyone, thanks.