Shifting the Paradigm for Chronic Disease Prevention:

from simple solutions to system approaches

Diane T. Finegood, PhD

Professor, Biomedical Physiology and Kinesiology, Simon Fraser University

Executive Director, The CAPTURE Project

@DTFinegood

BC Dairy Foundation, June 8, 2011

Take Home Messages

• Chronic disease prevention is complex (not simple or even complicated).

• Accepting complexity does not mean we should give up, but we must turn to solutions appropriate for complex problems.

• Interactions between: levels, capacity & complexity, competition & cooperation, and networks are places to look for solutions.

O

ITY

PREVALE

INDIVIDUAL

Energy

Expenditure

POPULATION

%

OBESE

OR

UNDERWT

Food

intake :

Nutrient

density

FACTORS

INTERNATIONAL

Development

Globalization

of

markets

School

Food &

Activity

WORK/

SCHOOL/

HOME

Infections

Labour

Worksite

Food &

Activity

Leisure

Activity/

Facilities

Agriculture/

Gardens/

Local markets

COMMUNITY

LOCALITY

Health

Care

System

Public

Safety

Public

Transport

Manufactured/

Imported Food

Sanitation

NATIONAL/

REGIONAL

Food &

Nutrition

Urbanization

Education

Health

Social Security

Transport

Family &

Home

National

perspective

Media &

CultureMedia

programs

& advertising

Source: see Kumanyika Ann Rev Pub Health 2001; 22:293-308

“Causal Web”

Obesity System Map

http://kim.foresight.gov.uk/Obesity/Obesity.html

Characteristics of Systems

Simple or Complicated Systems Complex Systems

Homogeneous Heterogeneous

Linear Nonlinear

Deterministic Stochastic

Static Dynamic

Independent Interdependent

No feedback Feedback

Not adaptive or self-organizing Adaptive and self organizing

No connection between levels or

subsystemsEmergence

Common Responses to Complex Problems

• Retreat

• Despair

• Believe the problem is beyond hope

• Assign blame, figure out who is responsible

• Simple solutions

• Galvanize our collective efforts and invest significant resources

Bar-Yam, Y. Making Things Work, 2004.

Places to Look for Solutions to Complex Problems

• In the interaction between levels

• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks

• In the interdependence between competition and cooperation

• By influencing emergence

Levels Relevant to Obesity & Chronic Disease

• International

• National

• Regional / Municipal

• Worksites / Schools

• Home / Family

• Individuals

• Organ / Metabolic Systems

• Proteins

• Genes

O

ITY

PREVALE

INDIVIDUAL

EnergyExpenditure

POPULATION

%

OBESE

OR

UNDERWTFood

intake :Nutrient density

FACTORS

INTERNATIONAL

Development

Globalizationof

markets

SchoolFood &Activity

WORK/

SCHOOL/

HOME

Infections

Labour

Worksite Food & Activity

LeisureActivity/Facilities

Agriculture/Gardens/Local markets

COMMUNITYLOCALITY

Health Care

System

PublicSafety

PublicTransport

Manufactured/Imported Food

Sanitation

NATIONAL/

REGIONAL

Food & Nutrition

Urbanization

Education

Health

Social Security

Transport

Family &Home

Nationalperspective

Media &CultureMedia

programs& advertising

Source: see Kumanyika Ann Rev Pub Health 2001; 22:293-308

“Causal Web”

Scale and Complexity of Diets

• Accumulated dietary intake

• Daily dietary intake

• Meals

• Whole foods

• Nutrients

Increasin

g # of p

ossib

le co

mb

inatio

ns

Different paradigms driving complexity

“Eat food, not too much,mostly plants”

Michael Pollen

Places to Intervene in a complex system

1. The power to transcend paradigms

2. The paradigm that the system arises out of

3. The goal of the system

4. The power to add, change, evolve, or self-organize system structure

5. The rules of the system

6. The structure of information flow

7. The gain around driving positive feedback loops

8. The strength of negative feedback loops

9. The length of delays

10. The structure of material stocks and flows

11. The size of buffers and other stabilizing stocks

12. Constants, parameters, numbers

Effe

ctiv

enes

s

Dif

ficu

lty

D. Meadows. Thinking in Systems, A Primer, Chelsea Green, 2009.

One Approach to Scale:

Intervention Level Framework

Effe

ctiv

enes

s

Dif

ficu

lty

Level Definition

Paradigm Deepest held beliefs

Goals What trying to achieve

Structure Information flows, connectivity, trust

Feedback &delays

Self-regulation, reinforcement & adaptation

Structural elements

Subsystems, actors, operating parameters

Finegood, DT. The Complex System Science of Obesity. In: The SocialScience of Obesity, Ed. J Cawley. Oxford University Press, 2011

Intervention Levels: Obesity & NCDsEf

fect

iven

ess

Dif

ficu

lty

Level From To

ParadigmSimple solutions,reductionist approach

Accepting complexity, integrative approaches

Goals

Increased physical activity; healthier dietary habits; healthier food supply

Increased capacity and decreased complexity

Structure

Silos between research & evaluation; government, private sector, NGO’s, academia.

Increased coherence and connectivity; increased trust for cross-sectoralcollaboration

Intervention Levels: Obesity & NCDsEf

fect

iven

ess

Dif

ficu

lty

Level From To

Feedback &delays

Long loops and delays, eg in research funding, data to users, government action

More balancing (as opposed to reinforcing feedback loops)

Structural elements

Health education, social marketing, multiplefood labeling schemes, high cost of healthy food, no access to treatment, etc.

Quality daily PE, decreased marketing, simplified labeling, walkable neighborhoods, affordable healthy food, accessible treatment options, etc.

Intervention Levels: Research & EvaluationEf

fect

iven

ess

Dif

ficu

lty

Level From

ParadigmReductionism, accountability

Goals Attribution

Structure Disconnected

Feedback & delays Indirect; glacial

Structural elementsMismatched; many gaps

Intervention Levels: Research & EvaluationEf

fect

iven

ess

Dif

ficu

lty

Level From To

ParadigmReductionism, accountability

Learning

Goals Attribution Adaptation

Structure Disconnected Interdependent

Feedback & delays Indirect; glacial Continuous

Structural elementsMismatched; many gaps

Coherent

Distribution of Effort/Investments?

0

10

20

30

40

50

60

Paradigm Goals Feedback& Delays

StructuralElements

Structure

Distribution of Effort/Investments?

0

10

20

30

40

50

60

Paradigm Goals Feedback& Delays

StructuralElements

Structure

Places to Look for Solutions to Complex Problems

• In the interaction between levels

• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks

• In the interdependence between competition and cooperation

• By influencing emergence

Matching Capacity and Complexity

Bar-Yam, Y. Complexity Rising, www.necsi.org

Complexity of Environment

Complexity ofOrganism orOrganization

(Capacity)

Fail

Survive

Food Labeling Environment

By jovike

Food & Nutrition Information Sources

23

27

41

46

50

51

52

65

66

76

77

A dietitian

Fitness/ weightloss programs

Government materials

The Internet or the Web

Health association materials

A famiy physician or other health professional

Food company materials or advertisements

Radio/TV programs

Friends/relatives/colleagues

Magazines, newspapers, and books

Food product labels

Q.16 People can get information about food and nutrition from a number of different sources. Please tell me from which of

the following sources you personally got information on food and nutrition in the past year.

Base: Total Canadians, n=2014

How we cope with complexity

• Mindless eating

– Wansink suggests we make 250 decisions/day about eating

• Default

• Trust in brands

• Contextual decision making; comparisons

• Anchoring; tendency to follow earlier decision

Need tools to help match capacity to complexity

UK Design Council & Bolton Diabetes Centre

“Dealing” with Complexity

UK Design Council & Bolton Diabetes Centre

Obesity Card Examples• I feel so hungry throughout the day that I have to eat many times.

• Seeing foods I like, or being with someone who is eating makes me hungry enough to eat.

• My body size and shape influence how I value myself.

• I look for low cost or large quantity foods.

• I am confused by nutrition labels or advice.

• I am on medication that makes me gain weight.

• I don’t feel confident in my ability to be physically active when I am nervous, depressed, or tired.

• There are not many opportunities for individual or group based physical activity in my life.

• Safety concerns keep me from walking, biking, or taking public transit.

• I feel embarrassed while exercising.

• I feel I am predisposed to being overweight or obese. It’s in my genes

Results - Quantitative

• Participants selected between 5 and 41 cards (mean=25.4)

Card Selections

Places to Look for Solutions to Complex Problems

• In the interaction between levels

• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks

• In the interdependence between competition and cooperation

• By influencing emergence

Cooperation and Competition

From flicker.com by LodewijkB

Cooperation and Competition

Bar-Yam, Y. COMPLEX SYSTEMS AND SPORTS: Complex Systems insights to building effective teams

Foresight

Prevention is a cross government issue – like climate change

Foresight Programme, B. Butland, unpublished observations

ActNowBC: Promising Practices

• Leadership

• Increasing collaborative action among government sectors with diverse strategies and mechanisms

– An incentive fund of $15 million supported pilot health promotion projects by ministries other than the Ministry of Health

• The involvement of civil society organizations

http://www.phac-aspc.gc.ca/publicat/2009/ActNowBC/pdf/anbc-eng.pdf

Cooperation reduces complexity (trust is a system variable)

Lessons Learned Through Building Trust Initiative

• Regulation is needed when competition is undesirable; Regulation levels the playing field

• Within sector (private sector, NGO, government, academia) is more difficult to build than between sector trust

• Trust building to address obesity needs a safe space

Places to Look for Solutions to Complex Problems

• In the interaction between levels

• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks

• In the interdependence between competition and cooperation

• By influencing emergence

Life Cycle of Emergence• Stage 1 – Networks:

– self-organized

– for finding like-minded others

– based on self-interest

– have fluid membership

• Stage 2 – Communities of Practice:

– also self-organized

– used to share knowledge, support one another, and to intentionally create new knowledge

– people commit to be there for each other, to serve the needs of others

– good ideas move rapidly amongst members.

M Wheatley and D Frieze ©2006, USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE

Life Cycle of Emergence

• Stage 3 – Systems of Influence:

– can’t be predicted; sudden appearance of a system that has real power and influence.

– pioneering efforts that hovered at the periphery suddenly become the norm.

– their approaches and methods are quickly adopted

– policy and funding debates now include the perspectives and experiences of these pioneers.

– critics who said it could never be done suddenly become chief supporters

M Wheatley and D Frieze ©2006, USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE

Influencing Emergence

• Emergence only happens through connections

• “Act locally, connect regionally, learn globally.”

M Wheatley and D Frieze ©2006, USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE

Take Home Messages

• Chronic disease prevention is complex (not simple or even complicated).

• Accepting complexity does not mean we should give up, but we must turn to solutions appropriate for complex problems.

• Interactions between: levels, capacity & complexity, competition & cooperation, and networks are places to look for solutions.