It’s Time to Take “Individual Blame” Off the Menu:

Applying a Multi-Level Model of Health to The Rising Rates of Type 2 Diabetes in Adolescents

It’s not uncommon to open a magazine or turn on the news and see images of adolescents who have larger bodies, holding fast food or a can of pop (see Figure 1), with shocking headlines such as “childhood obesity rates skyrocket!” or “diabetes epidemic in our teenagers!”. The shock value of these images, and the assumptions these headlines give rise to are easy leaps towards a conclusion that it’s a simple matter of adolescents needing to make better food choices, or that they simply need to get out and go for a walk. While healthy food choices and physical activity are certainly health promoting activities that are correlated with a reduced risk of disease, is it really that simple? When looking at a health concern such as an increased incidence of type 2 diabetes in adolescents, newer evidence suggests it’s much more complex than this, and by simply intervening at the individual level, clinicians are missing the mark and even risking harm, in focusing their interventions solely on the individual.

Figure 1

No title

Note; Meacham, P. (2017). No Title [Photograph]. What to do if your child is overweight. https://www.stuff.co.nz/life-style/parenting/98832641/what-to-do-if-your-child-is-overweight

Rates of both type 2 diabetes and obesity among adolescents are increasing, and the link between obesity and diabetes is well documented in the literature (CDA, 2022). What is also well-documented is the disproportionate number of ethnic minorities, and children from low-income families who are diagnosed with type 2 diabetes (CDA, 2022). With both income and race being two of the social determinants of health in Canada (CMHA, n.d.), it’s no wonder then, why interventions targeting the individual are not shown to be sustainable or effective in the long term (CDA, 2022). This highlights the need to look broader than the individual when looking to improve outcomes for health conditions that are impacted by lifestyle choices such as diabetes. Other social determinants of health that have been found to be linked to increased risk of disease in adolescents include gender, housing, and exposure to adverse childhood experiences (Van Buuren et al, 2021). There are many more examples in the literature on the social determinants of health and the impact of interventions on health risk, located here.

Of further concern in targeting the individual for interventions, there exists a risk of harm that should be noted, especially when it comes to adolescents. In an opinion piece published in the journal “Health education and Research” (2005), Jennifer O’Dea discusses the numerous ways health professional risk harming the individual by intervening too heavily or ‘placing the blame’ on the adolescent. One example she discusses is how clinicians may inadvertently suggest diet or other weight loss techniques that can be harmful such as smoking, laxative abuse and/or the use of diet pills. This focus on the individual can have far lasting psychological effects and lead to further societal stigma, which paradoxically, has been shown to lead to poorer health behaviors and poorer outcomes (Lee, Hunger, & Tomiyama, 2021). So, if the evidence suggests that many of the causes of this increased risk of diabetes are beyond the individuals control and that there is the potential for harm when focusing solely on the individual, how can we intervene in a way that addresses these environmental factors that go beyond the individual? One model that can be applied is the Social-Ecological model of health. This model provides a multi-level framework with the potential to impact on many of the social determinants of health. This framework can be applied when looking at approaches targeted to prevent and manage health concerns such as increasing rates of type 2 diabetes in adolescents. The online textbook "Health Behavior and Health Education" (2008) defines the multiple levels of influences on health, including intrapersonal (biological, psychological), interpersonal (social, cultural), organizational, community, physical environmental, and policy. This model is widely cited in its application for a variety of lifestyle related health conditions, and further examples of its application in diet and nutrition related interventional studies can be found here.

One example shown in Figure 2 is an application of the Social-Ecological model of health on a commonly sought-after health outcome such as increasing intake of fruits and vegetables was published by the Office of Disease Prevention and Health Promotion (2022) and highlights the Social- Ecological levels of influence on fruit and vegetable intake.

Figure 2

Social-Ecological Model for Understanding Factors that Shape Fruit and Vegetable Access and Intake

Note; Office of Disease Prevention and Health Promotion (ODPDH). (2022, June 2). Socio-Ecological Model for Understanding factors that shape fruit and vegetable access and intake [Infographic]. Law and Health Policy: Social-Ecological Model Graphic. https://www.healthypeople.gov/2020/law-and-health-policy-social-ecological-model-graphic

This same framework can be applied to the prevention and management of type 2 diabetes in adolescents. Interventions at the level of primary care which have traditionally targeted the individual (intrapersonal) are achieving success when the families and/or social circles are included in the intervention (intrapersonal). Clinicians are recognizing the role of the family and looking for frameworks to incorporate and intervene at this level to improve outcomes, as discussed by Pratt & Skelton, (2018) in their proposed “Family systems approach”, the authors suggest that a family-based intervention can influence behavior through higher level changes in the family. This can also help reduce some of the stigma and shame on the individual by addressing some of the broader cultural and social norms that are beyond the individuals control such as how food is used in celebration, how family meals are offered, and the food purchasing practices of the household.

Moving to the institutional level which includes schools and communities, interventions such as the Feel4Diabetes study which target both the school and community level with interventions designed to promote healthy behaviors found that while certain habits were more difficult to change (such as soft drink consumption) many significant changes such as improvements in water intake, increases in fruits and vegetable intake and increased physical activity were noted as favorable outcomes (Van Stappen et al., 2021). These kinds of interventions may have a favorable impact on other determinants of health such as food security and social inclusion and may include school nutrition programs, breakfast programs and nutrition and health literacy programs in schools.

At the highest level of intervention, changes to public policies and the impact this tier has on childhood obesity and type 2 diabetes risk is an emerging opportunity. Policies such as taxes on sugar sweetened beverage, restricting fast food marketing to children as well as school food policies are discussed in the literature as strategies to curb rising trends. One smaller scale study on high school students in the US found that taxing sugar sweetened beverages led to a significant reduction in consumption (Edmondson et al, 2021). Studies have also linked fast food advertisements to increasing BMI (Russell, Croker, & Viner, 2019), which is another opportunity to intervene with policies or regulation to achieve positive outcomes in this population and can include a ban on targeted advertising of fast food to children/teens.

While having the potential to impact disease risk on a much broader scale, it is important to note that there are challenges that exist such as lobbying or public pressure when it comes to larger environmental changes. While it may seem obvious to many in healthcare the harms of soft drink consumption, change can be challenging such as the case in Mexico, where policy makers were met with the heavy hitting soft drink industry lobbyists who hold increased bargaining powers and, in a recent example, resulted in minimal policy change (Gomez, 2019). In Canada, a recent example of this push back is when Health Canada recently proposed front of package labelling for saturated fat, sugar, and sodium, in effort to curb rising rates of disease, and received pushback and media attention from the Canadian Cattlemen’s Association whose lobbyists are saying that Canadian ranchers are being “vilified” (The Canadian Press & Stephenson, 2022).

As outlined above, there is risk of harm when interventions are directed at the adolescent such as the case for obesity and type 2 diabetes in adolescents, especially without proper support and careful consideration to avoid perpetuating stigma and bias. There are many opportunities to intervene at the intrapersonal, community, institutional and policy level that can reach larger populations and don’t seem to carry the same risk of harm (and arguably, may result in farther reaching health outcomes than the individual alone approach). As health professionals who are looking at health behavior change, applying a lens or framework that considers the different levels of health such as the Social-Ecological Model of health, and intervening or advocating for change at levels beyond the individual, we can provide a greater impact (and lessen the risk of harm!) than targeting the individual. It’s time to consider opting for an upsize of policy change and taking individual blame off the menu.

References;

Canadian Diabetes Association (CDA). (2022). Type 2 Diabetes in Children and Adolescents. DiabetesCanada. Retrieved June 20, 2022, from https://www.diabetes.ca/health-care-providers/clinical-practice-guidelines/chapter-35#panel-tab_FullText

CMHA Ontario. (n.d.). Social Determinants of Health. Canadian Mental Health Association. Retrieved June 6, 2022, from https://ontario.cmha.ca/provincial-policy/social-determinants/

Edmondson, E. K., Roberto, C. A., Gregory, E. F., Mitra, N., & Virudachalam, S. (2021). Association of a Sweetened Beverage Tax with Soda Consumption in High School Students. JAMA pediatrics, 175(12), 1261–1268. https://doi.org/10.1001/jamapediatrics.2021.3991

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health Behavior and Health Education (4th ed.). Jossey-Bass. accessed June 17, 2022 from https://www.med.upenn.edu/hbhe4/part5-ch20.shtml#:~:text=The%20core%20concept%20of%20an,%2C%20physical%20environmental%2C%20and%20policy

Gómez, E.J., (2019). Coca-Cola’s political and policy influence in Mexico: understanding the role of institutions, interests and divided society, Health Policy and Planning, Volume 34, Issue 7, September 2019, Pages 520–528, https://doi.org/10.1093/heapol/czz063

Lee, K. M., Hunger, J. M., & Tomiyama, A. J. (2021). Weight stigma and health behaviors: evidence from the Eating in America Study. International journal of obesity (2005), 45(7), 1499–1509. https://doi.org/10.1038/s41366-021-00814-5

Meecham, P. (2017). No Title [Photograph]. What to do if your child is overweight. https://www.stuff.co.nz/life-style/parenting/98832641/what-to-do-if-your-child-is-overweight

O'Dea J. A. (2005). Prevention of child obesity: 'first, do no harm'. Health education research, 20(2), 259–265. https://doi.org/10.1093/her/cyg116

Office of Disease Prevention and Health Promotion (ODPDH). (2022, June 2). Socio-Ecological Model for Understanding factors that shape fruit and vegetable access and intake [Infographic]. Law and Health Policy: Social-Ecological Model Graphic. https://www.healthypeople.gov/2020/law-and-health-policy-social-ecological-model-graphic

Pratt, K. J., & Skelton, J. A. (2018). Family Functioning and Childhood Obesity Treatment: A Family Systems Theory-Informed Approach. Academic pediatrics, 18(6), 620–627. https://doi.org/10.1016/j.acap.2018.04.001

Russell, S. J., Croker, H., & Viner, R. M. (2019). The effect of screen advertising on children's dietary intake: A systematic review and meta-analysis. Obesity reviews: an official journal of the International Association for the Study of Obesity, 20(4), 554–568. https://doi.org/10.1111/obr.12812

The Canadian Press, & Stephenson, A. (2022, June 12). Ranchers’ group pushes back against Health Canada’s ‘vilification’ of beef. Global News. Retrieved July 2, 2022, from https://globalnews.ca/news/8912990/health-canada-beef-label-canadian-cattlemens-association-reaction/

Van Buuren, A., Thompson, G., & Vandermorris, A. (2021). Making social determinants of health screening truly universal means including adolescents. Canadian family physician Medecin de famille canadien, 67(1), 17–19. https://doi.org/10.46747/cfp.670117

Van Stappen, V., Cardon, G., De Craemer, M., Mavrogianni, C., Usheva, N., Kivelä, J., Wikström, K., De Miquel-Etayo, P., González-Gil, E. M., Radó, A. S., Nánási, A., Iotova, V., Manios, Y., & Brondeel, R. (2021). The effect of a cluster-randomized controlled trial on lifestyle behaviors among families at risk for developing type 2 diabetes across Europe: the Feel4Diabetes-study. The international journal of behavioral nutrition and physical activity, 18(1), 86. https://doi.org/10.1186/s12966-021-01153-4