Building capacity for the use of systems science to support local government public health planning: a case study of the VicHealth Local Government Partnership in Victoria, Australia.

OBJECTIVE: To present an approach to build capacity for the use of systems science to support local communities in municipal public health and well-being planning. DESIGN: Case study. SETTING: Local government authorities participating in the VicHealth Local Government Partnership in Victoria, Australia. PARTICIPANTS: Local government staff members were trained in community-based system dynamics (CBSD), and group model building (GMB) techniques to mobilise local community efforts. The trained local government facilitation teams then delivered GMB workshops to community stakeholder groups from 13 local government areas (LGA)s. MAIN OUTCOMES: Training in CBSD was conducted with council facilitation teams in 13 LGAs, followed by the local delivery of GMB workshops 1-3 to community stakeholders. Causal loop diagrams (CLD) representing localised drivers of mental well-being, healthy eating, active living or general health and well-being of children and young people were developed by community stakeholders. Locally tailored action ideas were generated such as well-being classes in school, faster active transport and access to free and low-cost sporting programmes RESULTS: Overall, 111 local government staff participated in CBSD training. Thirteen CLDs were developed, with the stakeholders that included children, young people and community members, who had participated in the GMB workshops across all 13 council sites. Workshop 3 had the highest total number of participants (n=301), followed by workshop 1 (n=287) and workshop 2 (n=171). CONCLUSIONS: Local facilitation of the CBSD process has developed community informed and locally relevant CLDs that will be used to lead local action to improve the well-being of children and young people. Training employees in CBSD is one approach to increase systems thinking capacity within local government.

Maternal nutrition and its intergenerational links to non-communicable disease metabolic risk factors: a systematic review and narrative synthesis.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death and disability globally, while malnutrition presents a major global burden. An increasing body of evidence suggests that poor maternal nutrition is related to the development of NCDs and their risk factors in adult offspring. However, there has been no systematic evaluation of this evidence. METHODS: We searched eight electronic databases and reference lists for primary research published between 1 January 1996 and 31 May 2016 for studies presenting data on various dimensions of maternal nutritional status (including maternal exposure to famine, maternal gestational weight gain (GWG), maternal weight and/or body mass index (BMI), and maternal dietary intake) during pregnancy or lactation, and measures of at least one of three NCD metabolic risk factors (blood pressure, blood lipids and blood glucose) in the study population of offspring aged 18 years or over. Owing to high heterogeneity across exposures and outcomes, we employed a narrative approach for data synthesis (PROSPERO= CRD42016039244, CRD42016039247). RESULTS: Twenty-seven studies from 10 countries with 62,607 participants in total met our inclusion criteria. The review revealed considerable heterogeneity in findings across studies. There was evidence of a link between maternal exposure to famine during pregnancy with adverse blood pressure, blood lipid, and glucose metabolism outcomes in adult offspring in some contexts, with some tentative support for an influence of adult offspring adiposity in this relationship. However, the evidence base for maternal BMI, GWG, and dietary intake of specific nutrients during pregnancy was more limited and revealed no consistent support for a link between these exposures and adult offspring NCD metabolic risk factors. CONCLUSION: The links identified between maternal exposure to famine and offspring NCD risk factors in some contexts, and the tentative support for the role of adult offspring adiposity in influencing this relationship, suggest the need for increased collaboration between maternal nutrition and NCD sectors. However, in view of the current scant evidence base for other aspects of maternal nutrition, and the overall heterogeneity of findings, ongoing monitoring and evaluation using large prospective studies and linked data sets is a major priority.

The double burden of malnutrition: aetiological pathways and consequences for health.

Malnutrition has historically been researched and addressed within two distinct silos, focusing either on undernutrition, food insecurity, and micronutrient deficiencies, or on overweight, obesity, and dietary excess. However, through rapid global nutrition transition, an increasing proportion of individuals are exposed to different forms of malnutrition during the life course and have the double burden of malnutrition (DBM) directly. Long-lasting effects of malnutrition in early life can be attributed to interconnected biological pathways, involving imbalance of the gut microbiome, inflammation, metabolic dysregulation, and impaired insulin signalling. Life-course exposure to early undernutrition followed by later overweight increases the risk of non-communicable disease, by imposing a high metabolic load on a depleted capacity for homoeostasis, and in women increases the risk of childbirth complications. These life-course trajectories are shaped both by societal driving factors-ie, rapidly changing diets, norms of eating, and physical activity patterns-and by broader ecological factors such as pathogen burden and extrinsic mortality risk. Mitigation of the DBM will require major societal shifts regarding nutrition and public health, to implement comprehensive change that is sustained over decades, and scaled up into the entire global food system.

The impact of maternal nutrition on offspring's risk of non-communicable diseases in adulthood: a systematic review.

BACKGROUND: A growing body of evidence suggests the impact of maternal nutrition plays a role in determining offspring's risk of non-communicable diseases (NCDs), including heart disease (CVD), type 2 diabetes (T2DM), cancer and chronic obstructive pulmonary diseases (COPD). We conducted a systematic review to investigate this relationship. METHODS: We systematically searched CINAHL, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, Database of Abstracts of Reviews of Effects, MEDLINE, EMBASE, Web of Science Core Collection and Global Health for papers published before May 2016 (PROSPERO: CRD42016039244, CRD42016039247). Included studies examined the impact of maternal nutrition (diet, vitamin status and weight) on adult offspring's NCD outcomes. RESULTS: Of 23 501 identified citations, 20 met our inclusion criteria. Heterogeneity of papers required narrative synthesis. Included studies involved 1 939 786 participants. CVD: Four papers examined maternal exposure to famine during gestation, 3 identified a resulting increased risk of CVD in offspring. Five identified an increased risk of offspring CVD with increasing maternal weight. T2DM: Six studies investigated maternal exposure to famine during gestation; three identified an increase in offspring's T2DM risk. Three found no increased risk; two of these were in circumstances where famine states persisted beyond pregnancy. Three papers found an increased risk of T2DM in offspring with increasing maternal BMI. CANCER: Four papers investigated maternal famine exposure during pregnancy - two identified a reduced risk of cancer in male offspring, and two an increased risk in female offspring. COPD: One study found low maternal vitamin D status was associated with reduced use of asthma medication. CONCLUSIONS: While there are indications that exposure to both famine (particularly when coupled with exposure to nutritional excess after birth) and maternal overweight during pregnancy is associated with offspring's risk of CVD, T2DM and cancer, currently there is a lack of evidence to confirm this relationship. Despite the lack of conclusive evidence, these finding hold important research and policy implications for a lifecycle approach to the prevention of NCDs.

Generating political commitment for ending malnutrition in all its forms: A system dynamics approach for strengthening nutrition actor networks.

Generating political commitment for ending all forms of malnutrition represents a key challenge for the global nutrition community. Without commitment, the policies, programs, and resources needed to improve nutrition are unlikely to be adopted, effectively implemented, nor sustained. One essential driver of commitment is nutrition actor network (NAN) effectiveness, the web of individuals and organizations operating within a given country who share a common interest in improving nutrition and who act collectively to do so. To inform new thinking and action towards strengthening NAN effectiveness, we use a systems dynamics theoretical approach and literature review to build initial causal loop diagrams (CLDs) of political commitment and NAN effectiveness and a qualitative group model building (GMB) method involving an expert workshop to strengthen model validity. First, a "nutrition commitment system" CLD demonstrates how five interrelated forms of commitment-rhetorical, institutional, operational, embedded, and system-wide-can dynamically reinforce or diminish one another over time. Second, we present CLDs demonstrating factors shaping NAN effectiveness organized into three categories: actor features, resources, and capacities; framing strategies, evidence, and norms; and institutional, political, and societal contexts. Together, these models generate hypotheses on how political commitment and NAN effectiveness could be strengthened in future and may provide potential starting points for country-specific conversations for doing so.

Correction: Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews.

This paper was originally published under a standard licence. This has now been amended to a CC BY licence in the PDF and HTML.

Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews.

Children and adolescents with overweight and obesity are a global health concern. This is an integrative overview of six Cochrane systematic reviews, providing an up-to-date synthesis of the evidence examining interventions for the treatment of children and adolescents with overweight or obesity. The data extraction and quality assessments for each review were conducted by one author and checked by a second. The six high quality reviews provide evidence on the effectiveness of behaviour changing interventions conducted in children <6 years (7 trials), 6-11 years (70 trials), adolescents 12-17 years (44 trials) and interventions that target only parents of children aged 5-11 years (20 trials); in addition to interventions examining surgery (1 trial) and drugs (21 trials). Most of the evidence was derived from high-income countries and published in the last two decades. Collectively, the evidence suggests that multi-component behaviour changing interventions may be beneficial in achieving small reductions in body weight status in children of all ages, with low adverse event occurrence were reported. More research is required to understand which specific intervention components are most effective and in whom, and how best to maintain intervention effects. Evidence from surgical and drug interventions was too limited to make inferences about use and safety, and adverse events were a serious consideration.

Update of the best practice dietetic management of overweight and obese children and adolescents: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: To update an existing systematic review series of randomized controlled trials (RCT) that include a dietary intervention for the management of overweight or obesity in children or adolescents.Specifically, the review questions are: In randomized controlled trials of interventions which include a dietary intervention for the management of overweight or obesity in children or adolescents.

What drives political commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of Action on Nutrition.

INTRODUCTION: Generating country-level political commitment will be critical to driving forward action throughout the United Nations Decade of Action on Nutrition (2016-2025). In this review of the empirical nutrition policy literature, we ask: what factors generate, sustain and constrain political commitment for nutrition, how and under what circumstances? Our aim is to inform strategic 'commitment-building' actions. METHOD: We adopted a framework synthesis method and realist review protocol. An initial framework was derived from relevant theory and then populated with empirical evidence to test and modify it. Five steps were undertaken: initial theoretical framework development; search for relevant empirical literature; study selection and quality appraisal; data extraction, analysis and synthesis and framework modification. RESULTS: 75 studies were included. We identified 18 factors that drive commitment, organised into five categories: actors; institutions; political and societal contexts; knowledge, evidence and framing; and, capacities and resources. Irrespective of country-context, effective nutrition actor networks, strong leadership, civil society mobilisation, supportive political administrations, societal change and focusing events, cohesive and resonant framing, and robust data systems and available evidence were commitment drivers. Low-income and middle-income country studies also frequently reported international actors, empowered institutions, vertical coordination and capacities and resources. In upper-middle-income and high-income country studies, private sector interference frequently undermined commitment. CONCLUSION: Political commitment is not something that simply exists or emerges accidentally; it can be created and strengthened over time through strategic action. Successfully generating commitment will likely require a core set of actions with some context-dependent adaptations. Ultimately, it will necessitate strategic actions by cohesive, resourced and strongly led nutrition actor networks that are responsive to the multifactorial, multilevel and dynamic political systems in which they operate and attempt to influence. Accelerating the formation and effectiveness of such networks over the Nutrition Decade should be a core task for all actors involved.