ABSTRACT Introduction The effectiveness of obesity prevention or obesity reduction policies is co‐determined by policy content, the implementation process, and contextual factors. This systematic review provides insight into implementation strategies used in whole‐of‐community obesity prevention policies aimed at changes in two types of outcomes: (1) a reduction in obesity/overweight prevalence, body mass index–related outcomes, and other weight‐related outcomes, or (2) a change in nutrition behaviors, physical activity, and sedentary behaviors or screen time. We specifically examined implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework, focusing on policies implemented in low socioeconomic status communities. Methods Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, eight databases were searched. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool. The efficacy of implementation strategies was considered supported if at least 66% of the studies that applied respective strategies reported significant improvements for a given outcome type across at least three studies. Results A total of 29 original studies were included. Fifteen implementation strategies from the ERIC framework were consistently associated with favorable outcomes. These strategies included altering incentive structures, assessing community readiness, and using data warehousing techniques. Six additional non–ERIC strategies (e.g., cultural adaptation and grassroots mobilization) received support across different outcome domains. Most studies (72%) had a low risk of bias. Conclusion Findings may help prioritize implementation strategies that may drive the success of whole‐of‐community obesity policies targeting disadvantaged populations. The results suggest a need to expand existing implementation taxonomies to include community‐driven strategies.

The Norwegian School Fruit Program is financed by parents or local municipalities. The aim of this study was to explore contextual barriers and facilitators that influence the adoption of the program by schools using the Context and Implementation of Complex Interventions (CICI) framework. We conducted semi-structured interviews with 21 participants (mainly principals) from 20 lower secondary schools (classes 8–10). We analyzed the data using a deductive qualitative approach based on the CICI framework. We compared findings across schools offering the program (1) with no-parental-payment, (2) by parental subscription, and schools that (3) discontinued or (4) never offered the program. Economic costs were perceived as the main barrier to adoption across all schools. Although most schools recognized the need for such a program, some preferred to make their own arrangements. Except for schools offering the parental subscription option, many schools perceived asking parents to pay for the program as unfair, not in line with Norwegian values, and unlikely to allow the program to reach those who need it the most. Further barriers were the lack of legislation making the program obligatory and potential political changes causing uncertainty regarding the programme’s continuation from one year to the next. Social aspects of eating together were recognized as a facilitator. Food provision programs should be compatible with school priorities such as academic performance and mental health. Context and setting are dynamic and should be continuously evaluated to ensure they are in line with evolving school priorities and needs.

BACKGROUND:Many implementation determinants of school nutritional interventions have been identified, but a deeper understanding of their interplay within a system is needed. The present study aimed to investigate how the Norwegian School Fruit Programme, particularly the No Parental Payment Programme (NPPP), is being implemented in schools and how it interacts with the school system structure and dynamics as perceived by school personnel and pupils. Moreover, it aimed to understand the dynamic interplay between the determinants of the Consolidated Framework for Implementation Research (CFIR) in the NPPP's context. METHOD:The overarching methodology was qualitative system dynamics modelling, with data collected through a series of group model building (GMB) workshops at four schools offering the NPPP. Using GMB scripts, facilitated discussions between school personnel and pupils were held for a better understanding of the NPPP's implementation dynamics and to create diagrams illustrating how implementation determinants interact with each other and each school's unique context. The individual school diagrams were compiled into a single diagram. The CFIR was subsequently mapped on to this diagram. RESULTS:Lack of communication with pupils, the food stores outside schools, and the NPPP's design weakened the reinforcing mechanism that fostered pupils' eating of fruit. Not eating enough of the fruit increased implementation costs because schools had to deal with leftover fruit and littering issues. Implementation costs caused schools to adopt implementation processes, like reflecting, engaging, and adapting to reduce the costs, although some of these did not work or counterintuitively decreased pupils' eating of fruit. The success of these processes was contested by the design of the NPPP and mechanisms that were shaped by the goals and priorities of the schools. CONCLUSIONS:This research employed qualitative system dynamics to investigate NPPP implementation dynamics. Recommendations for improving implementation include aligning NPPP's design with pupils' preferences, monitoring eating of fruit, and involving internal stakeholders (pupils and school personnel) for gathering feedback, and external stakeholders (municipalities) for monitoring.

OBJECTIVES:This study examined the impact of hypothetical interventions on (i) early life factors (prenatal and early postnatal) on rapid weight gain during infancy, and (ii) early life factors and child energy balance-related behaviours (EBRB) on children's body mass index (BMI)-for-age at 5 and 8 years. METHODS:Data from the Norwegian Mother, Father, and Child Cohort Study included participants aged 2 (n = 48 109), 5 (n = 18 810) and 8 (n = 10 830) years. Early life intervention variables were maternal smoking during pregnancy, maternal weight before and during pregnancy, exclusive/partial breastfeeding for 6 months, and introduction of complementary food at 6 months. Child EBRB intervention variables for the 5-year outcome included screen time, fruit and vegetable intake, and sugar-sweetened soft drink intake assessed at 3 years. For the 8-year outcome, interventions included screen time, presence of a television in the child's bedroom, sleep hours and breakfast intake assessed at 5 years. The parametric g-formula was used for analysis. RESULTS AND CONCLUSIONS:The average population-level difference in rapid weight gain during infancy at 2 years under the intervention targeting the prenatal, early postnatal factors and these factors combined with 95% confidence intervals were -0.012 (-0.017, -0.007), -0.009 (-0.012, -0.005) and -0.020 (-0.025, -0.015), respectively. The average population-level differences in children's BMI-for-age z-score for interventions targeting early life factors, child EBRB and these factors combined were -0.225 (-0.244, -0.207), 0.02 (-0.021, 0.024) and -0.223 (-0.249, -0.196), respectively among 5-year-olds and -0.265 (-0.295, -0.236), -0.020 (-0.029, -0.011) and -0.285 (-0.315, -0.256), respectively among 8-year-olds. Our results suggested joint interventions on early life factors may reduce childhood BMI-for-age z-scores.

Successful adoption of evidence-based primary prevention interventions by schools is important for public health but relies on multiple factors. Using a systems perspective enables the identification of the interconnectivity and feedback loops among these factors, which can facilitate or hinder adoption. This study aimed to conceptualize a system structure showing how adoption factors are interrelated, and which feedback loops influence schools’ decisions to adopt interventions, using the parent-paid Norwegian school fruit scheme (the parent-paid scheme) as a case. We interviewed principals and personnel (n = 7) from schools that adopted, de-adopted, or never adopted the parent-paid scheme. These interviews were analyzed using qualitative system dynamics modeling. The analysis resulted in a causal loop diagram representing a system structure driving schools’ adoption decisions. The preliminary results were validated during a workshop with new participants who hold decision-making roles in schools (n = 5). Due to previous experiences with a free scheme, some schools perceived the parent-paid scheme’s relative advantages as low, which, in synergy with schools’ preference to offer it for free to pupils, resulted in the parent-paid scheme never being adopted. Nevertheless, there were schools that adopted the parent-paid scheme, driven by feedback loops like perceived need and relative advantages. These feedback loops, however, weakened over time as de-adoption resulted from a lack of demand from parents and pupils. Taking a systems perspective offered a temporal view of adoption processes, revealing how past decisions, like de-adopting a free scheme, influence future decisions. It highlighted how reinforcing feedback loops, like perceived need, set schools on adoption paths. Finally, it identified gaps in information flow, including those necessary for adaptation, as potential missing feedback loops to continuous adoption. As such, the schools’ decision to adopt the parent-paid scheme is a dynamic process with systemic characteristics that should be considered when developing strategies to ensure adoption.

Applying youth participatory action research (YPAR) has become common practice in public health. However, there are challenges in applying YPAR and there is a need for improving the process by learning from youth that has participated in such projects. This study explores youth involvement in the CO-CREATE project which focused on developing overweight and obesity prevention policies. This is a qualitative study, based on three data sources: 1) fieldnotes taken by project staff during observation of youth (approximately 150 observations) 2) semi-structured interviews with project staff (n = 12) 3) direct feedback from participating youth through feedback forms (n = 51). Data was analyzed in NVivo, following the principles of reflexive thematic analysis. Five themes were generated which showcase youth involvement in CO-CREATE: 1) an inspired and engaged youth; 2) insights through respectful interactions; 3) a strength of voice and call to action; 4) challenges in understanding project and disengagement; and 5) interpersonal conflict and pressure to participate. Taking the time to build trust and create a feeling of equality is important. It is also important to allow youth to take the lead when they wish so and have clear ideas of how to do so. Voices of rebelliousness can be a show of strength and help reach the goals of the project. Participation in CO-CREATE may have contributed toward individual empowerment of youth.

The term behavioral nutrition was introduced at the conception of the International Journal of Behavioral Nutrition and Physical Activity (IJBNPA) twenty-one years ago but it was not formally defined. This commentary describes and contrasts behavioral nutrition against other branches of nutrition sciences such as clinical nutrition and nutritional epidemiology. Examples of how IJBNPA has contributed to the development of behavioral nutrition is provided before concluding with some suggestions for further development. We hope that this will lead to more relevant and innovative submissions of behavioral nutrition research to IJBNPA.

Adolescent obesity is a complex public health challenge with steadily increasing and variable prevalence among countries. This paper synthesises the driving feedback mechanisms of adolescent obesity studied in the CO-CREATE project, furthering our understanding of the complexity of this issue. Using systems thinking principles and causal loop diagramming, we integrated the following knowledge and perspectives derived from diverse sources into a causal loop diagram (CLD): a systems map generated by adolescents through participatory modelling workshops, a comprehensive literature review, and input from subject-matter experts during validation workshops. We used a structured and iterative approach to include drivers and to identify feedback loops exacerbating adolescent obesity. The CLD identified 27 key feedback loops across four themes: twelve related to the commercial food environment, six to the physical activity environment, four to mental wellbeing and five to social norms. These loops indicate not only diet and physical activity as drivers of obesity but also stress and other emotional and social pressures. Recognising the imperative need to integrate the perspectives and experiences of adolescents into our analysis, this work advocates for the synthesis of experiential insights with empirical research. The integrated CLD can be used as a visual tool that fosters collaboration among stakeholders and engenders a more comprehensive and inclusive system understanding that can provide holistic intervention considerations to tackle adolescent obesity. Additionally, the CLD lays a foundation for subsequent quantitative modelling works to further address this issue and develop context-based approaches to prevention and evaluation of adolescent obesity.

The steady rise in overweight and obesity in Europe disproportionately affects people and communities with a lower socio-economic position (SEP). Many obesity prevention approaches exist, but these have had limited reach and unsatisfactory effects thus far, especially in low-SEP populations. In this context, there is a need for implementation of effective individual-level and population-based preventive strategies that also tackle health inequalities. Effective strategies require consideration of the complex and cross-domain obesity risk factors across the life course. Feasible and acceptable strategies require multisectoral collaborations and innovative approaches, including a whole-of community and systems perspective. With the Horizon Europe-funded OBCT project, we aim to quantify the relative contribution of biological, socio-cultural and built environment factors to obesity and the interactions of these risks within and across various life course stages; and translate the resulting knowledge into practical, equitable, and effective tools for action. These tools will include: a comprehensive obesity risk screener; a map of the obesogenicity of neighbourhood environments as well as trends in obesity prevalence of each European country; recommendations for lifestyle behaviours (diet, physical activity, sedentary behaviours) to prevent obesity during key life transition stages; a decision support dashboard for policy makers; and co-developed toolboxes to support implementation of policy recommendations in low-SEP communities. OBCT's outputs will highlight the areas and domains in which obesity should be targeted and will empower the research community, policymakers, health professionals and residents in Europe to adapt and implement strategies to effectively reduce obesity risk, particularly in low-SEP communities.

Public policy aimed at preventing undesired phenomena has increasingly sought to engage representatives of the target population. Little is known, however, about how power dynamics function to shape the processes and outcomes of risk governance engagement interventions. In order to study the ways in which, and the extent to which, power differentials can be reduced in participatory health promotion initiatives, we develop a conceptual framework synthetising theories of participatory action, phenomenology and governmentality. Based on the empirical research into youth participation in the EU project CO-CREATE, involving 15-19-year-old adolescents in five European countries (2019-2021), we show that diverse forms of knowledge may become available in engagement interventions. We analyse the use and relative inclusion and exclusion of these different forms of knowledge in terms of a three-level framework of different depths of democratisation in participatory health promotion: risk management, risk definition and risk negotiation. Advanced democratisation can only be achieved if risk negotiation is carried out in ways which embrace and encourage a range of different, and potentially conflicting forms of knowing.

OBJECTIVE:To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status. DESIGN:Cluster-randomised controlled trial. SETTING:The HEIA study (2007-2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months). PARTICIPANTS:Adolescents (11-13-year-old) in twenty-five control schools (n 746) and twelve intervention schools (n 375). RESULTS:At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home (β: -0·1, 95 % CI -0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths. CONCLUSIONS:Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

OBJECTIVE:Implementation of school meal guidelines is often inadequate, and evidence for effective implementation strategies for school-based nutrition interventions is limited. The aim of the present study was to examine the implementation and effectiveness of a multi-strategy implementation intervention to increase adherence to the Norwegian national school meal guideline. DESIGN:The study was a school-based hybrid implementation effectiveness trial with a pre-post non-equivalent control group design, testing three implementation strategies: internal facilitation, training and an educational meeting. SETTING:Primary schools and after-school services in two counties in south-east Norway. PARTICIPANTS:School principals, after-school leaders and class teachers from thirty-three schools in the intervention county and principals and after-school leaders from thirty-four schools in a comparison county. RESULTS:There was a significant difference of 4 percentage points in change scores between the intervention and the comparison groups at follow-up, after adjusting for baseline adherence (B = 0·04, seB = 0·01, t = 3·10, P = 0·003). The intervention effect was not associated with the school's socio-economic profile. School-level fidelity was the implementation dimension that was most strongly correlated (r s = 0·48) with the change scores in the intervention group, indicating that principals' support is important for gaining the largest intervention effects. CONCLUSIONS:A school-based intervention with low intensity, based on trained teachers as internal facilitators, can increase adherence to the national school meal guideline among Norwegian primary schools, irrespective of local socio-economic conditions. Implementation fidelity, at an organisational level, may be a useful predictor for intervention outcomes in schools.

This study examined whether the built environment was associated with physical activity among adolescents in Oslo, Norway, and the role of socioeconomic position and gender as potential moderators of this association. We used data from 897 adolescents who participated in the TACKLE cross-sectional study conducted in 2020. Built environment features (recreational facilities, parks, forest, public transport, traffic calming devices, and schools) were assessed objectively using Geographical Information Systems. Physical activity data included device-measured moderate-to-vigorous physical activity, total physical activity, and self-reported active transportation to school. Using general linear models and logistic regression, we found that most built environment features were unrelated to the participants’ device-measured physical activity. Longer distances to school and to traffic calming devices were associated with decreased likelihood of participants reporting active transportation to school. Our moderated regression analysis showed that adolescents with low socioeconomic backgrounds seemed less affected by longer distances to school compared with their high socioeconomic counterparts. Furthermore, boys appeared to be more sensitive to traffic safety relative to girls. Implementing traffic calming devices may enhance active transportation to school and improve traffic safety for Norwegian adolescents.

It has increasingly been recognized that developing successful obesity prevention policies and interventions requires understanding of the complex mechanisms driving the obesity pandemic and that models could be useful tools for simulating policies. This paper reviews system dynamics simulation models of mechanisms driving childhood overweight and obesity and/or testing of preventive interventions. A systematic literature search was conducted in six databases from inception to January 2023 using terms related to overweight/obesity, children, and system dynamics. Study descriptives, mechanisms, and where to intervene (the leverage points), as well as quality assessments of the simulation models were extracted by two researchers into a predetermined template and narratively synthesized. Seventeen papers describing 15 models were included. Models describing the mechanisms ranged from only intrapersonal factors to models cutting across multiple levels of the ecological model, but mechanisms across levels were lacking. The majority of interventions tested in the simulation models were changes to existing model parameters with less emphasis on models that alter system structure. In conclusion, existing models included mechanisms driving youth obesity at multiple levels of the ecological model. This is useful for developing an integrated simulation model combining mechanisms at multiple levels and allowing for testing fundamental system changes.

Background and aims: A higher proportion of adolescents from lower socioeconomic position families tend to be less physically active than their counterparts from higher socioeconomic position families. More research is needed to understand the causes of these differences, particularly the influence of the neighbourhood environment. This qualitative study aims to explore how adolescents and their parents from higher and lower socioeconomic neighbourhoods perceive the social, organisational and physical environment influencing adolescents' physical activity behaviours. Method: We conducted six semi-structured focus groups with 35 13-14-year-olds and eight interviews with some of their parents. The interviewees were recruited from one higher and two lower socioeconomic neighbourhoods in Oslo, Norway. Theme-based coding was used for analysis, and the results discussed in light of an ecological framework. Results: The results indicate that factors like social norms in a neighbourhood could shape adolescents' physical activity behaviour, and a social norm of an active lifestyle seemed to be an essential facilitator in the higher socioeconomic neighbourhood. Higher availability of physical activity and high parental engagement seemed to facilitate higher physical activity in this neighbourhood. In the lower socioeconomic neighbourhoods, the availability of local organised physical activity and volunteer engagement from parents varied. Programmes from the municipality and volunteer organisations seemed to influence and be essential for adolescents' physical activity behaviour in these neighbourhoods. Conclusions: The results illustrate the complexity of behaviour and environment interaction, and a limitation in explaining the phenomenon by focusing primarily on the individual level rather than an ecological perspective.

Despite growing recognition of the importance of applying a systems lens to action on obesity, there has only been limited analysis of the extent to which this lens has actually been applied. The CO-CREATE project used a youth-led participatory action research approach to generate policy ideas towards the reduction of adolescent overweight and obesity across Europe. In order to assess the extent to which these youth-generated policy ideas take a systems approach, we analyzed them using the Intervention Level Framework (ILF). The ILF ascribes actions to one of five system levels, from Structural Elements, the least engaged with system change, up to Paradigm, which is the system's deepest held beliefs and thus the most difficult level at which to intervene. Of the 106 policy ideas generated by young people during the CO-CREATE project, 91 (86%) were categorized at the level of Structural Elements. This emphasis on operational rather than systems level responses echoes findings from a previous study on obesity strategies. Analyzing the distribution of systems level responses using the ILF has the potential to support more effective action on obesity by allowing identification of opportunities to strengthen systems level responses overall.

Background Even though the social and built environment characteristics of neighborhoods have been studied as potential determinants of social inequalities in obesity among adults, fewer studies have focused on children. Our first aim was to investigate whether there were differences in the food and physical activity environments between different neighborhood deprivation levels in the city of Oslo. We also explored whether there was an association between the prevalence of overweight (including obesity) among adolescents and (i) neighborhood deprivation levels and (ii) food and physical activity environments of the neighborhoods they live in. Methods We conducted a food and physical activity environment mapping (using ArcGIS Pro) in all neighborhoods of Oslo, which were defined by administrative boundaries (sub-districts). The neighborhood deprivation score was calculated based on the percentage of households living in poverty, unemployment in the neighborhood, and residents with low education. A cross-sectional study including 802 seventh graders from 28 primary schools in Oslo residing in 75 out of 97 sub-districts in Oslo was also performed. MANCOVA and partial correlations were ran to compare the built environment distribution between different neighborhood deprivation levels, and multilevel logistic regression analyses were used to explore the effect of neighborhood deprivation and the food and physical activity environments on childhood overweight. Results We found that deprived neighborhoods had greater availability of fast food restaurants and fewer indoor recreational facilities compared to low-deprived neighborhoods. Additionally, we observed that the residential neighborhoods of the adolescents with overweight had greater availability of grocery and convenience stores when compared to the residential neighborhoods of the adolescents without overweight. Adolescents living in neighborhoods with high deprivation had a two-fold higher odds (95% CI = 1.1–3.8) to have overweight compared to adolescents living in neighborhoods with low deprivation, regardless of participants’ ethnicity and parental education. However, the built environment did not determine the relationship between neighborhood deprivation and overweight in adolescents. Conclusion The neighborhoods in Oslo with higher deprivation levels had more obesogenic characteristics than the low-deprived neighborhoods. Adolescents living in high-deprived neighborhoods were more likely to have overweight than their counterparts from low-deprived neighborhoods. Thus, preventive measures targeting adolescents from high-deprived neighborhoods should be put in place in order to reduce incidence of overweight.