Contextual influences on physical activity and eating habits -options for action on the community level

Inspired by the strategies outlined in the Ottawa Charter [13, 14] and Dahlgren and Whitehead’s model of the social determinants of health [15] the concept of obesogenic environments became popular at the end of the 1990s, in particular through the use of the term by Swinburn et al. [4]. Obesogenic environments are defined as the combined influences of surroundings, opportunities or conditions of life on the development of obesity in individuals or populations [4, 16]. According to Hill et al. [17], obesogenic environments foster unhealthy eating habits and physical inactivity. In contrast, the concept of leptogenic environments, another term introduced by Swinburn et al. referring to environments which encourage the achievement and maintenance of a lower bodyweight, has not been well-accepted in the literature [4].

The concept of obesogenic environments includes physical (i.e. geographic and technological), as well as economic, political, and socio-cultural (i.e. normative and attitude-specific) contextual characteristics, that may influence eating habits and physical activity [4, 16].

From the perspective of community actors, it is especially important that obesogenic environments not only influence adults’ weight development, but also childrens´ and adolescents’ [18, 19]. The relevant mechanisms can differ greatly between these age groups: For example, adults often spend time in several, sometimes very diverse and geographically distinct locations (e.g. workplace, home etc.). In contrast, due to their level of dependency (e.g. on socialization agents, institutions and structures) and their restricted mobility and limited own decision-making, children and adolescents are less capable of independently choosing where they spend their time. They are also less able to influence their surroundings or to decide whether to leave a specific environment. In addition, children and adolescents, who are undergoing constant physical and social development, are particularly vulnerable to external influences with regard to their eating and physical exercise habits [16].

Obesogenic environments can be systematized according to scale, dimension and specific effect [5]. When local environments are the focus of investigation, the scale is referred to as the micro-level. Local environments are also called settings and, for adults, include an individual’s home and workplace, as well as local infrastructures including retail outlets, transportation systems and recreational facilities. In the case of children and adolescents, typical local settings include kindergartens, schools, trade or apprenticeship centers, and sporting clubs in addition to the home and residential environments [4, 16]. Settings are geographically defined, comparatively small and can therefore be fundamentally influenced by local actors (e.g. mayors, politicians, and principals), and those who live and spend time in them [5].

This micro-level context, also called the micro-environment, is in turn influenced by the macro-level (or macro-environment) [20]. The environments on the macro-level are called sectors. Sectors include, for example, the educational and healthcare systems, the political climate, the mobility and transportation sectors, inter-regional transportation systems, food and sporting industries, and the mass media, as well as the norms, values, and cultures of a given society [4, 16]. This categorization is intended to show that the inter-regional macro-level has an effect on the local micro-level, which in turn has an effect on the lifestyle conditions of individuals. This makes the concept compatible with the social-ecological approach to public health [20]. The taxonomy of environments into settings and sectors is illustrated in Fig. 1. Both settings and sectors have physical, economic, political and socio-cultural dimensions [5]. Figure 1 also shows that specific obesogenic environments can have effects on both eating and physical activity habits. The bidirectional arrows indicate the reciprocal relationships and interactions between these individual levels. The taxonomy outlined here was developed by the Swinburn et al. working group as ANGELO-Framework (ANalysis Grid for Environments Linked to Obesity) [4].

On the local level, the risk of obesity is influenced by an individual’s physical environment, which is in turn influenced by natural and artificial, or constructed, factors. This means that an individual’s physical activity behavior is for instance influenced on the local or micro-level by the traffic density in his or her residential area, by the availability of space to undertake physical activity (green zones, jogging paths, playgrounds, skate-parks, halfpipes etc.) or by the presence of speedlimits, shade, sidewalks and bicycle paths [3, 9, 21, 22].

The food available in regional retail outlets (including weekly markets, restaurants and the foodservice industry), is relevant for individuals’ eating habits [2]. The catering offered at schools is additionally relevant for children and adolescents, and the food offered in work canteens or in restaurants close to workplaces is especially relevant for adults [9, 10, 23‐25].

In addition to the physical environment, the economic environment also plays a role in individuals’ physical activity behavior and dietary decision-making (Fig. 1). Examples include swimming pool entrance prices, the cost of public transport, parking fees, membership fees for local sporting clubs and food prices at cafeterias and canteens [2].

The political environment is also relevant in determining individual behaviors in numerous settings (Fig. 1). For children and adolescents such factors may be the restriction of the use of green zones, playgrounds and sporting fields – for example the prohibition of use after a certain hour – and institutional or familial regulations (for example, school rules, community funding policies, or family rules on watching TV, the use of media and common eating times). Factors which are especially relevant for adults include local traffic regulations (for example, access restrictions, pedestrian areas, parking bans) which have an influence on an individual’s choice of modes of transportation [8] (Fig. 1).

Within the settings mentioned, shared values and norms also play a relevant role. These influential factors, which are collectively known as the social-cultural environment, manifest themselves in school and workplace atmospheres, they create social cohesion within neighborhoods and among peer groups and contribute to the subjective feeling of safety in a residential area [2] (Fig. 1).

The physical, economic, political, and socio-cultural environments on the micro-level are influenced by factors on the macro-level. These can be produced by state institutions (such as federal and state governments) or by private enterprises, non-governmental organizations and lobby groups.

Physical facors on a macro-level include the typical inter-regional climate (amount of rainfall, heatwaves), as well as manmade factors such as inter-regionally homogenous menus in catering industry (e.g. “kids’ menu”). An example of an economic factor on a macro-level is the price of gas. This is determined by the world market price as well as national fiscal policy. This amount influences in turn the individual’s decision to use public transport or cycle, instead of driving. Classic political factors on a macro-level include laws (e.g. food legislation) and arbitration (e.g. the planning of transport routes). Socio-cultural factors on a macro-level can for instance be the movement and eating habits of a country.

An exemplary scenario may help to illustrate the multifactorial complexity of the concept. Let us imagine a small city in which a large industrial company maintains a production plant. The availability of modern, challenging jobs encourages numerous highly qualified workers with high education level and social status to move to the area over the years. This is combined with a relatively healthy and sustainable dietary culture in comparison with other communities in which more individuals with lower socioeconomic status live (changes to the socio-cultural environment on the micro-level). This healthy dietary culture may lead to the parents in this small town being dissatisfied with the food offered at the local high school cafeteria. The parents start an initiative that, in collaboration with the parents’ association at the school in question, leads to the introduction of quality control standards for the school’s catering services (changes to the political environment on the micro-level). From then on, a civil society foundation initiated by the large industrial company that employs so many of the townspeople subsidizes the cost of school cafeteria meals, which rose as a result of the introduction of the quality control standards, in order to make sure all pupils can afford the food on offer (changes to the economic environment on the micro-level). As a consequence, the pupils are provided with a healthier and more attractive selection of food, (changes to the physical environment on the micro-level). This community-based improvement of what was formerly an obesogenic environment would only move beyond the micro-level if, for example, a lobby group would come together to push for the inter-regional implementation of the new school cafeteria standards. This would require state-wide regulations by the relevant government department (e.g. the Ministry for Cultural Affairs), leading to an extension of the quality control standards to encompass all school cafeterias in the state or country, (changes to the political environment on the macro-level). We have outlined the possibilities and opportunities for societal change as a result of this specific form of lobbying elsewhere [26]. In that paper we also explained how citizen engagement can incorporate the socially disadvantaged and lead to a reduction in health-related societal equality.

In sum, the scientific empirical investigation of obesogenic environments is very much in its early stages. Due to the multifactorial etiology of excess weight gain and the complexity of the explanatory model outlined above, analytical studies looking at cultural determinants and evaluating contextual interventions face several key methodological challenges. These will be outlined in the following section: