Shifting the Paradigm for Chronic Disease Prevention:

from simple solutions to system approaches

Professor, Biomedical Physiology and Kinesiology, Simon Fraser University

Executive Director, The CAPTURE Project@DTFinegood

Oxford Health Alliance Meeting April 14-15, 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.

Obesity System Map

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

O

ITY

PREVALE

INDIVIDUAL

EnergyExpenditure

POPULATION

%

OBESE

OR

UNDERWT

Food intake :

Nutrient density

FACTORSINTERNATIONAL

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”

Causality and Complex Systems

“….causality can only be meaningfully defined for systems with linear interactions

among their variables.”

Wagner. Biology and Philosophy 14: 83–101, 1999.From flickr.com by nerovivo

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 organizingNo connection between levels or subsystems Emergence

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

• UN Summit on NCDs

• Implementation of FCTC

• CIH Sites

• Romp and Chomp

• Angawadi workers

• Health Education

• Metformin

Scale: Relationship between the macro and the micro

From flickr.com by maliasFrom flickr.com by Ethan Hein

Coherence vs Alignment

From flickr.com by mister.crowleyFrom flickr.com by shadowfall

Places to Intervene in a complex system 1. The power to transcend paradigms2. The paradigm that the system arises out of3. The goal of the system4. The power to add, change, evolve, or self-organize system

structure5. The rules of the system 6. The structure of information flow 7. The gain around driving positive feedback loops8. The strength of negative feedback loops9. The length of delays10. The structure of material stocks and flows 11. The size of buffers and other stabilizing stocks12. Constants, parameters, numbers

Effec

tiven

ess

Diffi

culty

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

One Approach to Scale: Intervention Level Framework

Effec

tiven

ess

Diffi

culty

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: Research & EvaluationEff

ectiv

enes

s

Diffi

culty

Level From

Paradigm Reductionism, accountability

Goals Attribution

Structure Disconnected

Feedback & delays Indirect; glacial

Structural elements Mismatched; many gaps

Intervention Levels: Research & EvaluationEff

ectiv

enes

s

Diffi

culty

Level From To

Paradigm Reductionism, accountability Learning

Goals Attribution Adaptation

Structure Disconnected Interdependent

Feedback & delays Indirect; glacial Continuous

Structural elements Mismatched; many gaps Coherent

Intervention Levels: Obesity & NCDsEff

ectiv

enes

s

Diffi

culty

Level From To

Paradigm Simple solutions, reductionist approach

Accepting complexity, integrative approaches

GoalsIncreased physical activity; healthier dietary habits; healthier food supply

Increased physical activity; healthier dietary habits; healthier food supply

Structure

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

Increased coherence and connectivity; increased trust for cross-sectoral collaboration

Intervention Levels: Obesity & NCDsEff

ectiv

enes

s

Diffi

culty

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, multiple food 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.

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

Mindless eating decreases the complexity of food consumption

The average person makes around 250 decisions about food every day:

– Breakfast or no breakfast?

– Pop-tart or bagel? – Part of it or all of

it?– Kitchen or car?– Fun food or better

for you food?

Trust as a System Variable

• Trust is a way of dealing with complexity in an increasingly complex society.

• High trust societies are able to form wide-reaching and successful cooperative partnerships.

• Low trust societies tend to be economic disaster areas and can be terrible places to live.

Soloman, R.C. & Flores, F. (2001). Building trust in business, politics, relationships, and life. New York: Oxford University Press.

Building Trust to Address Obesity and Chronic Disease Prevention

Lessons Learned Through Building Trust Initiative

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

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

• Trust building to address obesity needs a safe space

http://www.youtube.com/watch?v=sZh8jAqeLAU

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

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

Diffusion of Innovation

Greenhalgh, T. et al. The Milbank Quarterly, 82 (4): 581, 2004

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.