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Volume 6: No. 3, July 2009

EDITORIAL
A Systems-Oriented Multilevel Framework for Addressing Obesity in the 21st Century

The two main axes are the hierarchical axis, running from bottom to top, and the time axis, running from left to right. At the intersection of these two axes is birth weight and early exposures. From that point and moving to the right through time are health behaviors that include energy input (feeding behavior) and energy expenditure (physical activity). From these Health behaviors, continuing across through time, there is body weight change. A line indicates there is a causal connection between birth weight and early exposures and body weight change.

Connected to body weight change is a line showing a feedback loop back and forth to this group of factors: HPA axis, mood, metabolism, appetite, and genes; these also are connected back and forth with health behaviors as causal effects.

At the top of the hierarchical axis is a group of risk regulators: cultural norms (eg, food preferences, body-image norms), area deprivation (eg, poverty, crowding), psychosocial hazards (eg, crime, social disorganization), built environments (eg, connectivity, walkability), local food environment (eg, availability of fruits/veg, presence of fast food), and commercial messaging.

This group is connected to health behaviors by a contingent (indirect) effect and to the factors HPA axis, mood, metabolism, appetite, and genes.

Figure 1. A systems-oriented, multilevel model applied to the study of obesity. The contingent effects of risk regulators (ie, embodiment, opportunity, and constraint) are shown with dotted arrows. “Causal” effects of biological and behavioral variables are shown with solid arrows. Feedback loops existing within grouped variables are not shown. Specific effects and multiple, time-ordered feedback loops between variables are not shown to reduce diagram complexity. Reprinted with permission from Elsevier (8).

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This model shows the determinants that influence population energy balance at different levels. From left to right, they are International Factors, National/Regional, Community/Locality, Work/School/Home, and Individual, which lead to the population outcome Obesity Prevalence.

Within International Factors, the sectors are Globalization of markets, Development, and Media programs and advertising.

• Globalization of markets is linked in International Factors to Development, in Community/Locality to Public Transport, and in Work/School/Home to Leisure Activity/Facilities.
• Development is linked in National/Regional to Urbanization, to Health, and to Food and Nutrition, in Community/Locality to Agriculture/Gardens/Local markets, and in Work/School/Home to Leisure Activity/Facilities and to Labour.
• Media programs and advertising is linked in National/Regional to Media and Culture, to Education, and to Food and Nutrition.

Between the International Factors and National/Regional is a marker denoting the National perspective that is also a factor in the model.

Within National/Regional, the sectors are Transport, Urbanization, Health, Social Security, Media and Culture, Education, and Food and Nutrition.

• In National/Regional, the Transport sector and the Food and Nutrition sector are linked together, and the link between these two is linked in Community/Locality to Manufactured/Imported Food. The Urbanization sector, Health sector, and Food and Nutrition sector are linked together.
• Transport is linked in Community/Locality to Public Transport and to Public Safety.
• Urbanization is linked in Community/Locality to Public Transport, to Public Safety, and to Sanitation.
• Health is linked in Community/Locality to Health Care and to Sanitation.
• Social Security is linked in Work/School/Home to Leisure Activity/Facilities, to Family and Home, and to School Food and Activity.
• Media and Culture is linked in Community/Locality to Manufactured/Imported Food, and in Work/School/Home to Worksite Food and Activity and to Family and Home.
• Education is linked in Work/School/Home to Family and Home and to School Food and Activity.
• Food and Nutrition is linked in Community/Locality to Manufactured/Imported Food and to Agriculture/Gardens/Local markets, and is linked in Work/School/Home to Family and Home and to School Food and Activity.

Within Community/Locality, the sectors are Public Transport, Public Safety, Health Care, Sanitation, Manufactured/Imported Food, and Agriculture/Gardens/Local Markets.

• Public Transport is linked in the Individual sector to Energy Expenditure.
• Public Safety is linked in Work/School/Home to Leisure Activity/Facilities and in the Individual sector to Energy Expenditure.
• Health care is linked in Work/School/Home to Infections.
• Sanitation is linked in Work/School/Home to Infections.
• Manufactured/Imported Food is linked in Work/School/Home to Worksite Food and Activity, to Family and Home, and to School Food and Activity, and in the Individual sector to Food intake: Nutrient density.
• Agriculture/Gardens/Local markets is linked in Work/School/Home to Family and Home and to School Food and Activity, and in the Individual sector to Food intake: Nutrient density.

Within Work/School/Home, the sectors are Leisure Activity/Facilities, Labour, Infections, Worksite Food and Activity, Family and Home, and School Food and Activity.

• Leisure Activity/Facilities is linked in the Individual sector to Energy Expenditure.
• Labour is linked in the Individual sector to Energy Expenditure.
• Infections, Worksite Food and Activity, Family and Home, and School Food and Activity are each linked in the Individual sector to Energy Expenditure and to Food intake: Nutrient density.

Within Individual are 2 sectors, Energy Expenditure and Food intake: Nutrient density. Both are linked separately and together to the population outcome, Obesity Prevalence.

Figure 2. Levels of determinants and sectors of society implicated in the complex systems of obesity. Reprinted with permission (2).

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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.  Home  Privacy Policy | Accessibility CDC Home | Search | Health Topics A-Z This page last reviewed October 25, 2011 Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion United States Department of Health and Human Services