Young people have ideas to tackle obesity – but are we listening?

Adolescents in six European countries identified the role of mental wellbeing as a key driver of youth obesity. Building on these findings, a simulation model was constructed linking poor mental wellbeing to changes in dietary, physical activity, and sleep behaviours, and was found to have a good fit with known survey data and previous research. The model showed that socio-cultural pressures and stressors can be linked to emotion-related eating, lack of interest in physical activity, and sleep difficulty. It was found that if pressure on body image and psychosocial stress could be reduced by 25% it would lead to a reduction in overweight prevalence from 30% to 26% as well as improving mental wellbeing.

Social media can benefit adolescents’ lives but may also have harmful effects on both physical and mental health. A systematic review of existing research found significant links between social media use and depressive and disordered eating symptoms, body dissatisfaction, and anxiety. The findings call for policy interventions to mitigate the impact of social media on adolescent mental health and diet. As social media platforms become increasingly sophisticated, it is important to involve adolescents in the design of research: measures of exposure to different types of online content are needed to guide policies for protecting the health of adolescents.

Studies that report links between adolescents’ mental health and obesity may not be able to say which one might trigger the other. Research is needed which follows a group of young people over time (longitudinal study) in order to cast light on this issue. A search of the relevant scientific research found 17 longitudinal studies, and the majority showed that depression, anxiety and body dissatisfaction came before an increase in body weight.

The links were likely to be related to eating habits, screen time, physical activity, and sleep as well as stressors like peer victimisation. Furthermore, several studies showed that improved dietary patterns and physical activity may alleviate some mental ill-health.

Young people are often targeted as a priority group for health education, but their views are rarely sought or put into policy recommendations. The CO-CREATE project developed a ‘dialogue tool’ with the help of designers, health and youth participation experts, researchers and young people, with the young people involved in all stages of the development process. Multiple versions were tested with more than two hundred participants from 53 countries in over 20 Dialogue Forums.

From this, a final digital and physical version of the Dialogue Forum was published and can be used to connect people across generations and sectors. The CO-CREATE Dialogue Forum Tool is the product of a three-year long process of testing, prototyping, and refinement, involving youth throughout. The tool has been used in local schools and in high-level United Nations meetings, in Malawi and Portugal, by 14-year-olds and by CEOs, and incorporates the feedback from these different people and settings. It is now freely available, and we hope it will help youth around the world to have their voices heard.

Research involving children normally requires the consent of their parents or guardians, and oversight of an ethical committee. While this can ensure protection from harm, it can be an obstacle for encouraging young people’s empowerment and self-confidence when asking about their experiences of obesity, mental health and stigma. The UN Convention on the Rights of the Child stresses how children and adolescents should be given influence over decisions important for themselves in accordance with their age and maturity.

Experience in the CO-CREATE project suggests that, if ethical committees identify no potential harm, then children and adolescents from the age of 12 years should be given legal capacity to consent to participate in the research project. Ethical committees may need to be more aware of the needs, perspectives and maturity of children and adolescents.

• Samdal O. et al (2023). Balancing protection and empowerment when involving children and adolescents in social science research and policy projects. Contact: Oddrun.Samdal@uib.no

Understanding the nature of obesogenic environments is a first step for young people to develop policies for health and the political engagement necessary to make such policies work. Using PhotoVoice software (https://photovoice.org/) adolescents undertook participatory photography, digital storytelling and self-advocacy projects which explored how potential policies were either present or absent in their neighbourhood, including retail and fast food environments, food advertising, cycling routes and public transport. The methods raised critical awareness of how policies affected the structural environment and helped empower them to contribute to advocacy for change.

The CO-CREATE project recruited over 150 adolescents from schools and youth organisations in five European countries, to form 15 Youth Alliances to discuss policies for tackling obesity – but did this experience change the participants’ preconceptions? Using control groups for comparison, researchers asked participants about their understanding of who is responsible for preventing obesity, what drives obesogenic behaviour, and what actions should be taken. The findings suggest that involving youth in co-creating policies to prevent obesity may increase adolescents’ readiness for action and promote a shift in adolescents’ conceptualisation of obesity from an individual perspective to a societal responsibility and drivers of behaviour.

A systems approach can be used to distinguish between policy interventions with the potential to make small changes to the operation of structural elements within the system from those with the potential to change how the system regulates itself, how its component parts interact, what goals the system sets out to achieve, and the deepest held beliefs, or paradigm, of the system.

Of the 106 policy ideas generated by young people to address adolescent obesity during the CO-CREATE project, 91 (86%) were categorised as changes to structural elements, with an emphasis on operational rather than systems-level responses. This echoes the emphasis on interventions to address obesity shown by most governments, which often operate at the individual level and deal with the kinds of actions and environments which do not challenge the function of the system, or lead to changes in the overall paradigm, despite evidence that deeper structural actions tend to be more effective and equitable.

A systematic search of proposals for tackling youth obesity found a wide range of proposed models for intervention ranging from those focused on intrapersonal factors to models cutting across multiple levels of obesogenic systems, but mechanisms for taking action were lacking. Of 15 models studied, the majority of interventions were changes to existing model parameters with less emphasis on models that alter system structure. There is a need for better quality in documentation of the models, and further research on how to best combine models and provide decision tools for policymakers.

There is growing recognition of the need to move away from conducting research projects as a linear series of constituent parts, and towards study designs that address the true complexity of an issue, while also accounting for the complexity of conducting research as a learning ‘system’ itself. Learning from the experience of the CO-CREATE project, the authors of this paper argue that systems thinking should be embedded in research design when working with young people, for example capturing key adolescent values and concerns; working to avoid social exclusion; ensuring methodological pluralism to allow for reflection and responsiveness (with methods ranging from group model building, PhotoVoice, and small group engagement); getting policy recipients to shape key questions by understanding their views on the critical drivers of obesity early on in the project; and providing opportunity for intra-project reflection along the way.