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”
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
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
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
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
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
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.
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