Applying an ecological model of health to Type 2 Diabetes in Adolescents

Its not uncommon to open a magazine or turn on the news and see images of children or teenagers who have larger bodies, holding a can of pop, 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 possible public health concern such as an increased incidence of type 2 Diabetes in adolescents, newer evidence suggests its much more complex than this, and by simply intervening at the individual level, clinicians are missing the mark in where to focus their efforts.

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 in the literature is the disproportionate proportion of ethnic minorities, and children from low-income families who are diagnosed with Type 2 Diabetes (CDA, 2022). Its no wonder then, with the linkages in socioeconomic status, why interventions targeting the individual are not shown to be sustainable or effective in the long term (CDA, 2022). What is emerging in the literature however, are calls to involve the families, the schools, communities, and policy makers.

One multilevel model of health that captures several layers is described in “Health Behaviour and Health Education (2008), where Glanz, Rimer and Viswanath define the ecological model of health as a comprehensive framework with multiple levels of influence including intrapersonal, interpersonal, organizational, community, physical environments and policy. By applying this framework to public health concerns, such as rates of Type 2 diabetes in adolescents, health professionals have an opportunity to have a deeper impact on health outcomes than if they focused on the individual. Evidence suggests that there is risk of harm in targeting the individual when it comes to health behavior change. 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 placed on the individual, which paradoxically, has been shown to lead to poorer health behaviors and poorer outcomes (Lee, Hunger, & Tomiyama., 2021).

Interventions at the level of primary care which have traditionally targeted the individual (intrapersonal) are seeing 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.

Moving up to the levels to institutions such as schools and communities, interventions such as the Feel4Diabetes study (Van Stappen et al., 2021) which target both the school and community level with interventions designed to promote healthy behaviors associated with lower risk of diabetes 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.

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.

As outlined above, there is risk of harm when intervening for type 2 diabetes in children and adolescents at the interpersonal level of health, especially without proper support and careful consideration to avoid perpetuating stigma and bias against the individual. 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).

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

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 Behaviour 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

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

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

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

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