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Food, Health, and Complexity: Towards a Conceptual Understanding to Guide Collaborative Public Health Action Shannon E

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Food, Health, and Complexity: Towards a Conceptual Understanding to Guide Collaborative Public Health Action Shannon E Majowicz et al. BMC Public Health (2016) 16:487 DOI 10.1186/s12889-016-3142-6 RESEARCH ARTICLE Open Access Food, health, and complexity: towards a conceptual understanding to guide collaborative public health action Shannon E. Majowicz1*, Samantha B. Meyer1, Sharon I. Kirkpatrick1, Julianne L. Graham1, Arshi Shaikh2, Susan J. Elliott1,3, Leia M. Minaker4, Steffanie Scott3 and Brian Laird1 Abstract Background: What we eat simultaneously impacts our exposure to pathogens, allergens, and contaminants, our nutritional status and body composition, our risks for and the progression of chronic diseases, and other outcomes. Furthermore, what we eat is influenced by a complex web of drivers, including culture, politics, economics, and our built and natural environments. To date, public health initiatives aimed at improving food-related population health outcomes have primarily been developed within ‘practice silos’, and the potential for complex interactions among such initiatives is not well understood. Therefore, our objective was to develop a conceptual model depicting how infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy can be linked via shared drivers, to illustrate potential complex interactions and support future collaboration across public health practice silos. Methods: We developed the conceptual model by first conducting a systematic literature search to identify review articles containing schematics that depicted relationships between drivers and the issues of interest. Next, we synthesized drivers into a common model using a modified thematic synthesis approach that combined an inductive thematic analysis and mapping to synthesize findings. Results: The literature search yielded 83 relevant references containing 101 schematics. The conceptual model contained 49 shared drivers and 227 interconnections. Each of the five issues was connected to all others. Obesity and food insecurity shared the most drivers (n = 28). Obesity shared several drivers with food allergy (n = 11), infectious foodborne illness (n = 7), and dietary contamination (n = 6). Food insecurity shared several drivers with infectious foodborne illness (n = 9) and dietary contamination (n = 9). Infectious foodborne illness shared drivers with dietary contamination (n = 8). Fewer drivers were shared between food allergy and: food insecurity (n = 4); infectious foodborne illness (n = 2); and dietary contamination (n = 1). Conclusions: Our model explicates potential interrelationships between five population health issues for which public health interventions have historically been siloed, suggesting that interventions targeted towards these issues have the potential to interact and produce unexpected consequences. Public health practitioners working in infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy should actively consider how their seemingly targeted public health actions may produce unintended positive or negative population health impacts. Keywords: Public health, Public policy, Health policy, Population-based planning, Foodborne diseases, Food allergy, Food insecurity, Dietary contamination, Obesity * Correspondence: [email protected] 1School of Public Health and Health Systems, University of Waterloo, 200 University Ave. West, Waterloo N2L 3G1, ON, Canada Full list of author information is available at the end of the article © 2016 Majowicz et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Majowicz et al. BMC Public Health (2016) 16:487 Page 2 of 13 Background there are no conceptual models that support thinking sys- Food and health are intimately intertwined: what we eat temically about multiple food-related population health is- simultaneously impacts our exposure to foodborne path- sues in concert, to provide a roadmap for considering how ogens [1–4], allergens [5–9], and environmental contam- targeted public health initiatives may interact in unex- inants [10, 11], our nutritional status [12, 13], body pected ways or have unintended consequences. Therefore, composition [14–16], mental health [17–19], risks for the objective of this study was to develop a conceptual and the progression of chronic diseases [20–22], and model depicting how multiple food-related population other outcomes. Furthermore, what we eat is influenced health issues can be linked via shared drivers, illustrating by a complex web of drivers, such as socioeconomic sta- the potential for complex interactions, with the ultimate tus [23–25], food security [26, 27], preferences [28–30], goal of supporting collaboration across public health culture [31–34], politics [35–37], economics [38–40], practice silos to guide informed interventions. trade [41, 42], industry [43–45], legislation [46, 47], and our built [48–50] and natural [51–53] environments. Methods To date, public health initiatives aimed at improving We applied a complex adaptive systems (CAS) lens to food-related population health outcomes have primarily the concept of population health as related to food and been developed within ‘practice silos’ (e.g., chronic dis- diet. A CAS lens suggests that a given population health ease prevention efforts typically developed independently outcome or issue is an emergent property of an under- from food safety activities), and their potential to inter- lying system of inter-related drivers including political, act or have unintended consequences has been largely environmental, social, biological, and other factors [71]. ignored. As is the case in any system, ‘solutions’ to one We developed a conceptual model depicting the shared issue may create new problems for another [54]. With drivers of five population health issues related to food respect to food and health, for example, food safety mea- (hereafter called ‘issues’): infectious foodborne illness, sures to limit microbial growth, such as the addition of food insecurity, dietary contaminants, obesity, and food salt [55, 56], can pose chronic disease risks [57, 58], and allergy. We selected these because (a) they are important the development of urban gardens to improve food public health issues for which there is significant invest- security [59–61] can increase exposure to a variety of ment in prevention and improvement, and (b) we hy- contaminants [62–65]. Therefore, understanding the po- pothesized that they had shared drivers, and we tential for complex interactions among public health ini- assembled our research team to provide expert know- tiatives aimed at improving specific aspects of population ledge in these areas. We defined ‘drivers’ broadly, as fac- health (here, as related to food) is imperative to under- tors with the potential to impact one or more issues, standing how such efforts may influence one another, or and included drivers across scales (from individual to so- influence seemingly unrelated population health out- cietal) and types of associations (e.g., direct causes, comes, in unexpected ways. higher-level proxies for more complex pathways). The Systems thinking offers public health practitioners a conceptual model was developed by identifying drivers paradigm for framing issues that explicates complexity from the peer-reviewed literature and synthesizing and interrelationships among parts of a whole, and shared drivers into a common model, using a modified facilitates identification of less obvious influences and thematic synthesis approach [72] that combined a sys- consequences [66, 67]. Systems-informed public health tematic search process, inductive thematic analysis [73], initiatives exist in the realm of food and health; perhaps and mapping to synthesize findings. the most well-known is the Foresight Obesity System In March 2015, we searched the peer-reviewed litera- Map [68], an in-depth exploration of the complex web ture in MEDLINE (via PubMed) for English-language re- of social, economic, biological, psychological, and other views published in the last five years, using the search drivers of a single food-related population health issue, terms shown (Table 1). We selected only review articles obesity. In addition to exploring the myriad of drivers for inclusion because initial topic-specific searches for one issue, the bilateral connectivity between issues returned between 800 and 54,000 articles per topic. We has been explored, for example between obesity and designed the search to identify recent, evidence-based food security [69]. Such bilateral explorations of food- descriptions of a range of drivers of the five chosen is- health issues have also been expanded to involve system sues; the search was not intended to produce a compre- actors (i.e., those whose actions influence the parts hensive nor exhaustive list of drivers, but rather to within the system) from non-health sectors. For example, identify a range of drivers, including possible shared one local public health agency integrated the economic drivers. Additional articles were identified via citation
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