You(th) matters: co-creating policies to tackle obesity

Future formulas Eurohealth — Vol.25 | No.3 | 2019 30 YOU(TH) MATTERS–CO- CREATINGPOLICIESTOTACKLE OBESITY By: Margot Neveux, Sherria Ayuandini and Knut-Inge Klepp Summary: In the past two decades, the prevalence of childhood obesity has risen dramatically, and no country has successfully reversed this trend. Current approaches to address the obesity epidemic have focused on influencing individual choices. However, children and adolescents are particularly vulnerable to the influence of the social, physical and economic environments we live in. Given the failure of traditional approaches to provide meaningful results, new innovative ideas are urgently needed. Through CO-CREATE, we will show the value of a participatory approach and co-creation with youth in the establishment of health policy priorities and ultimately in the formulation of policy proposals. Keywords: Obesity, Youth, Participatory, Policy, Co-creation Margot Neveux is Policy & Projects Coordinator, World Obesity Federation, London, United Kingdom; Sherria Ayuandini is Youth Engagement and Participatory Research Specialist, University of Amsterdam, Netherlands; Knut-Inge Klepp is Executive Director, the Norwegian Institute of Public Health, Oslo, Norway and coordinator of the CO-CREATE project. Email: mneveux@worldobesity.org Introduction The prevalence of overweight and obesity is increasing globally and in 2016, it was estimated that overweight (including obesity) was affecting 340 million school- age children. 1 Europe is no exception: in 2013, 4.5 million children between the ages of five and 18 years were living with obesity in European Union (EU) Member States. 2 Recently, the World Health Organization (WHO) has flagged childhood obesity as “one of the most serious public health challenges of the 21st century.” 3 As yet, no country has been successful in reversing this trend, and by 2025, the number of children aged five to 18 years living with obesity is projected to reach 4.8 million in the EU. 2 Overweight and obesity in youth and adolescents aged 13 to 18 years is a strong predictor of adulthood obesity and leads to an increased risk of developing a wide range of diseases, including type- 2 diabetes, hypertension, heart disease, psychosocial morbidity and certain types of cancer. Individual-level treatments of overweight and obesity, such as bariatric surgery or weight loss programmes, have been shown to be either hard to tolerate or ineffective in sustaining weight loss over time. 4 To promote the sustainability of healthy weight, prevention should be the prioritised strategy and a strong focus should be placed on adolescents. Current approaches to address the obesity epidemic have focused on influencing individual choices, but today’s social, physical and economic environments are rather complex and impact on individual decisions in unconscious ways. Obesity is driven by several factors, and we need to move towards comprehensive policies Acknowledgement: The CO-CREATE project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 774210. The content of this document reflects only the authors’ views and the European Commission is not liable for any use that may be made of the information it contains. #EHFG2019 – Forum 8: Obesity in Europe – time for a new approach? Future formulas Eurohealth — Vol.25 | No.3 | 2019 31 to address the food, physical activity systems and environments surrounding us and reshape the context to make healthy choices the easiest and most widely preferred ones. ‘‘YoungpeoplearethestimulusforchangeIn 2019, young people represent the largest part of the population globally. Increasingly around the world, we are seeing a desire for young people to have their voices heard, and the recent youth strikes on climate change have shown the potential impact of engaged youth. Producing long-lasting effects to positively impact youth health, including reducing overweight and obesity, will not only need to include young people’s input, perspective and suggestions: the initiative and leadership of young people themselves should be part of the answer. The Horizon 2020 project “Confronting obesity: Co-creating policy with youth” (CO-CREATE) aims to have young people involved and even leading the process in the development of health policies. Co-creating policy with youth Led by 14 research organisations, CO- CREATE (www.co-create.eu) 5 is the result of a large effort by the EU to curb the childhood obesity epidemic. Structured in ten work packages (WPs), CO-CREATE engages regional and international partners from different policy contexts in Europe (Norway, Netherlands, United Kingdom, Portugal, Belgium and Poland), Australia, South Africa and the United States. With a focus on equity, CO-CREATE addresses the current gaps in obesity research by placing adolescents, their perspectives and the factors that shape their health, at the centre of the project. The main aim of CO-CREATE is to prevent overweight and obesity in adolescents in Europe and the rest of the world by providing the necessary tools, knowledge and infrastructure to adolescents on policies to support making the healthiest choices the preferred ones. By politicising the issue of obesity, the project focuses on fostering multi- stakeholder involvement, including academics, policymakers, civil society organisations, relevant industry and market actors, and, most importantly, adolescents. Ultimately, CO-CREATE will demonstrate a new model to identify, generate, test and support the implementation of obesity and energy balance related behaviour (EBRB) policies at national, regional and city level. Concretely, CO-CREATE will develop a model on how to involve young people in the development of policies and priorities for obesity prevention and in the range of relevant stakeholders by providing specific obesity-related policy proposals, and by designing and testing advocacy tools and strategies for implementation and evaluation. It builds movement towards further youth involvement in policymaking in the future, looking beyond obesity to other health issues and has the ambitious goal of involving youth as much as possible in the various activities and phases of the project. The focus on adolescents as the specific target group aims to show the value of harnessing passion from youth in health policy development. They are also at an age where they gain more autonomy in their behavioural choices and longer-term behavioural habits are established. It is therefore no surprise that the empowerment and investment in adolescents as European citizens is the core vision of the EU Strategy for Youth. 6 It drives the co-creation of apprioritised set of policy objectives to tackle the obesity epidemic using a range of novel tools, and existing approaches adapted and enhanced for this purpose. CO-CREATE uses an innovative systems approach Changing the obesogenic system for – and more importantly, in collaboration with – adolescents across Europe, appears to be a key strategy to reduce obesity prevalence and the related burden of disease. In CO-CREATE, adolescents are not merely the object of an intervention designed by researchers, but are themselves agents for change, able to identify required actions and collaborate to help achieve them. A core concept underpinning the project is the need to move away from single intervention towards the development and investigation of systems-based, evidence-informed, stakeholder-involved, comprehensive policy interventions. This reinforces the need to move away from a primary focus on the ‘downstream’ individual-level, autonomous and rational choice-based determinants of nutrition and physical activity behaviours and subsequent obesity risk, towards the more ‘upstream’ drivers or determinants of these behaviours. A key element of CO-CREATE will be the use of a societal systems approach to understand how different societal factors, stakeholders and institutions associated with obesity interact at various levels, and the implications these have on policy and young people. ‘‘Itbuildsmovementtowardsfurtheryouthinvolvementin policymaking This complex systems approach underpins CO-CREATE’s activities and seeks to highlight the ways different contextual and environmental factors are interlinked, consequently leading to systems that work in a dynamic, uncertain and non-linear way. This novel approach encourages relevant stakeholders to consider other factors in the development of these policies, and to look at the process in synergy rather than in isolation, through techniques such as group model building to create ‘causal loop diagrams’ (see Figure 1). For these reasons, CO- CREATE adopted a systems approach to tackling adolescent obesity, looking at the bigger picture to deliberately explore the Future formulas Eurohealth — Vol.25 | No.3 | 2019 32 complex, ‘messy’ influences on diet and physical activity that must be considered to generate effective public health and other policies. Youth Alliances for Overweight Prevention Policies will be created In line with the community-based system dynamics approach of CO-CREATE, the project engages adolescents to collaborate in system relevant research. In Norway, the United Kingdom, the Netherlands, Poland and Portugal, CO-CREATE aims to empower adolescents by developing sustainable and transferable Youth Alliances for Overweight Prevention Policies. The alliances will bring adolescents together, train and co-create with them the most suitable organisational form for Alliances for Overweight Prevention Policy. Based on participatory action research principles, the activities conducted in the alliances “involve young people constructing knowledge by identifying, researching, and addressing social problems through youth-adult partnerships.” 9 Through regular meetings, the youth will design the core activities to support their goal of creating novel policy ideas in areas influencing obesity. Young people themselves will oversee the organisation and agenda of their meetings, as well as communication and interaction methods. Each of the countries’ alliances consist of a group of young people between 16 and 18 years old recruited through schools, existing youth organisations or other community outlets. They will be facilitated by a CO-CREATE local country staff member and a local youth representative (co-facilitator). In the alliances, young people will learn about the systemic factors affecting health-related lifestyles and receive capacity building training to support their information collection activities and enable them to refine their policy ideas. The activities in which young people engage are built on the principles of youth-led participatory action research during which young people are actively involved throughout the entire process. While CO-CREATE serves as a starting point and offers activities for young people to engage in, ultimately, the young people themselves decide which activities they would like to pursue and how the alliances are to be run. The direct involvement of Figure 1: A causal loop diagram created using the systems approach. This one was generated by CO-CREATE participants in the UK Source: 7 Future formulas Eurohealth — Vol.25 | No.3 | 2019 33 adolescents as project partners will take a complex system’s approach to enhance our understanding of how the broad range of factors at different policy and contextual levels impacts adolescents’ diet, physical activity and weight, and identify relevant policy responses. The process of building the youth alliances and their activities will be carefully monitored and evaluated throughout the project. The policy ideas generated will be shared and discussed with relevant community stakeholders, including policy makers, non-governmental organisations and private sector representatives in a series of dialogue forums. The potential impact of the proposed policy agenda will be predicted applying system dynamics modelling. All tools, methodologies and prototypes developed as part of the project will be made publicly available and disseminated widely along with the results from the study. Conclusions If we are to be successful at curbing the obesity epidemic, we need to move away from a focus on traditional health education-oriented interventions that presume rational decision-making, and high levels of individual autonomy. Rather, we need to move towards comprehensive policies addressing the food and physical activity systems and environments within which children and adolescents live, in order to make healthy choices the easiest and most widely accepted choices. The CO-CREATE project is a platform aiming to build consensus on the importance of youth-led co-creation in policymaking among all stakeholders. It involves and empowers adolescents and youth organisations to foster a participatory process of identifying and formulating relevant policies, deliberating such options with other private and public actors, thus promoting relevant policy agendas, tools and strategies for implementation. Young people are the stimulus for change, both as the inheritors of obesogenic environments and as the democratic representatives of the future. It is important that we understand the potential role of youth in developing health policies and as disruptors of the status quo for positive change. References 1 World Obesity Federation and World Health Organization. Taking Action on Childhood Obesity. http://s3-eu-west-1.amazonaws.com/wof-files/ Report_-_Childhood_Obesity.pdf 2 Jackson-Leach R, Montague F, Lobstein T. Obesity Atlas for the European Union: 2017. London. 2016. Available at: www.worldobesity.org 3 World Health Organization. Childhood overweight and obesity. Global Strategy on Diet, Physical Activity and Health, 2017. Available at: https://www.who.int/ dietphysicalactivity/childhood/en/ Published 2017. 4 Klebanoff M, Chhatwal J, Nudel J, Corey K, Kaplan L, Hur C. Cost-effectiveness of Bariatric Surgery in Adolescents With Obesity. JAMA Surg. 2017;152(2):136 – 141. 5 CO-CREATE website. Available at: www.co-create.eu 6 European Commission. EU Youth Strategy. Available at: https://ec.europa.eu/youth/policy/ youth-strategy_en 7 CO-CREATE EU. CO-CREATE is working with youth to map out the societal obstacles for leading healthy lives. Available at: https://www.fhi.no/en/ news/2019/co-create-is-working-with-youth/ 8 Anyon Y, Bender K, Kennedy H, Dechants J. A Systematic Review of Youth Participatory Action Research (YPAR) in the United States: Methodologies, Youth Outcomes, and Future Directions. Heal Educ Behav. 2018:1 – 14. Sustainable health financing with an ageing population: implications of different revenue raising mechanisms and policy options By: J Cylus, T Roubal, P Ong and S Barber Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies), 2019 Number of pages: 34; ISSN: 1997-8065 Freely available for download: http://www.euro.who.int/en/ about-us/partners/observatory/publications/policy-briefs-and- summaries This brief looks at how health and long-term care systems are financed and reports on the potential effects of population ageing on countries’ ability to generate sufficient and stable revenues for health from common funding sources (i.e. income taxes, consumption taxes, property taxes and social contributions) in the future. The analyses find that for countries where the population is comprised of a large share of relatively younger people who are likely to be active in the labour market, population ageing can have a positive impact on revenue generation from all The economics of healthy and active ageing series SUSTAINABLE HEALTH FINANCING WITH AN AGEING POPULATION Implications of different revenue raising mechanisms and policy options Jonathan Cylus Tomáš Roubal Paul Ong Sarah Barber World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17 Fax: +45 39 17 18 18 E-mail: postmaster@euro.who.int web site: www.euro.who.int Print ISSN 1997-8065 Web ISSN 1997-8073 The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its web site (http://www.healthobservatory.eu). Cover_Ageing_02.qxp_Layout 1 12/08/2019 11:34 Page 1 funding sources. This leads to the challenge in many country contexts of strengthening tax collection mechanisms to take advantage of this opportunity. However, in countries with a large (and growing) older population, relying in particular on social contributions generated from the labour market to raise revenues for health is expected to result in fewer revenues per person over the coming decades. The authors consider a number of policy options to address potential revenue shortcomings as a result of population ageing. This brief was produced jointly with the WHO Centre for Health Development, Kobe, Japan.