Sustainable prevention of obesity through integrated strategies: The SPOTLIGHT project’s conceptual framework and design

The overall prevalence of overweight and obesity across Europe is high, and has increased dramatically during recent decades in many countries [1]. More than 50% of the total European adult population is now overweight (body mass index (BMI) ≥25) and obesity rates (BMI ≥30) among adults now exceed 20% in many EU Member States [2, 3]. Overweight and obesity are, however, not evenly distributed across the European region, with large differences among and within countries, with the problem greatest among those in lower socio-economic groups [3]. Obesity is a major avoidable determinant of the burden of chronic diseases [4, 5]. The determinants of obesity - low levels of physical activity, sedentary behaviours and over-consumption of high-energy foods - offer a variety of opportunities for prevention. For decades, approaches to prevention have focused on individual-level determinants, often involving health education approaches [6]. Although more recent developments, such as interventions based on self-determination theory and self-regulatory mediators do offer some promise [7, 8], approaches that exclusively target individual-level determinants have had little or no impact on overall rates of obesity and, even those that seem to be effective in small-scale studies have little impact either over the long term or at larger scale [9]. These failures, coupled with innovative methods of geographical research, have led to a recognition that factors in the physical, social-cultural and socio-economic environments at both micro- and macro-levels are driving the obesity epidemic [10‐13]. However, while the growth of obesogenic environments may explain trends over time, the distribution of obesity reflects the interaction of environmental and individual factors [14]. The challenge is to combine measures that reduce the obesogenicity of the social and physical environment while, at the same time, reducing the negative impact on individuals of those environments [14, 15]. Or, from a health promotion perspective, stimulate individuals' obesity preventing behaviours through environmental facilitation of the behaviours. This will build on recognition that the most effective interventions to prevent obesity a) adopt a system based, integrated, multi-sectoral approach b) involve a complementary range of actions, and c) work at individual and environmental levels through local community interventions and regional/national policy initiatives [16, 17]. As has become recognised by agencies such as the World Health Organisation [18], the OECD [19], and researchers across a number of disciplines [20], a system-based, multi-level research approach for obesity prevention frames obesity as a complex systems problem, within which behaviours related to food choices, physical activity and sedentary patterns are not only a matter of individual choice or linear cause and effect, but also strongly influenced by multiple interacting levels of physical, social-cultural and economical environmental factors at micro- and macro-level [15, 21]. The different environmental factors can be categorized in the so-called Analysis Grid for Environments Linked to Obesity (ANGELO) [22], which was specifically developed to prioritize environmental factors that relate to obesity (‘obesogenic environments’) in the immediate (micro) and wider (macro) environments, involving physical, economic, policy and socio-cultural dimensions [22, 23].

The obesogenicity of an environment can be defined as the sum of influences that the surroundings, opportunities, or wider societal and economic influences have on promoting obesity in individuals or populations [22]. In addition, Kremers et al. [24] argued in their Environmental Research framework for weight Gain prevention (EnRG-) framework that environmental factors (as differentiated in the ANGELO framework) may have a direct impact on obesogenic behaviours, but these environmental influences are also likely to be mediated and moderated by individual-level factors [25]. In the SPOTLIGHT project we have adopted and adapted the EnRG framework (Figure 1), so that it can inform the planned systematic reviews, original cross-European survey research, instrument development and process evaluation research.

There is growing interest in multi-level approaches to obesity prevention [26]. Novel measurement methods can map the obesogenicity of communities [27‐29], and projects such as the European Commission-funded HOPE [30] and EURO-PREVOB [31] projects have increased understanding of the broader determinants of obesity. However, there is now a need to consolidate these insights systematically, and to extend, enrich, and operationalise evidence on system-based and integrated approaches at community and societal level. For neighbourhoods, this is of particular relevance to disciplines involved in urban planning, architecture, transportation, and environmental design [32‐37]. For national policy-making it develops the evidence base for ‘health in all policies’ and the value of tackling obesity as a multi-sectoral problem involving a wide range of actors in government, commerce, research and professional and public advocacy at national and international level.

The EU-funded SPOTLIGHT project aims to provide a comprehensive overview of the factors on multiple levels necessary to create effective and sustainable interventions to change lifestyles in the real world. These interventions should meet the criteria of Reach (the target population), Efficacy (impact on important outcomes), Adoption (by target settings or institutions), Implementation (consistency of delivery of intervention), and Maintenance (of intervention effects in individuals and settings over time) (RE-AIM) [38, 39]. The RE-AIM approach emphasises the external validity of interventions as well as scaling up and sustainability [38, 39].

The methodology to address the aims is summarised below:

SPOTLIGHT will systematically investigate the determinants of obesity and obesogenic behaviours, multi-level interventions, and factors that enhance adoption of effective interventions in an integrated fashion, applying a range of scientific approaches, including reviews, inventories, tool development, and original data collection. The project aims to improve our understanding of modifiable obesogenic determinants, entry points for intervention approaches and the enhancing and impeding factors for implementation of such measures, applicable across European regions.

The relative recent attention being paid to environmental level determinants in addition to those at individual-level is important for the development of innovative new models for understanding and promoting sustainable prevention of obesity. This is particularly the case with respect to multi-level intervention approaches, which may provide the greatest opportunities for modifying unhealthy lifestyle behaviours across the population, and thus potentially reducing the prevalence of overweight and obesity [25]. In addition, dissemination, implementation or translational research that demonstrates effectiveness in the ‘real world’ is an important next step that is rarely conducted [42, 43]. Effective uptake of health promotion interventions will be supported by: understanding how interventions are implemented in the ‘real world’; how to improve the reach of these interventions; how to encourage adoption by individuals, communities and organisations; and finally how to disseminate this understanding [44].

By providing a broad perspective for obesity prevention the project will support the development and implementation of effective obesity prevention approaches by local and national authorities and practitioners across a wide range of disciplines throughout Europe. This perspective will maximise the use of state of the art knowledge and will help policy makers to invest resources in the most effective long-term obesity prevention efforts. In addition, it will provide a direction for health and behavioural scientists to explore further possibilities to reduce obesity, minimize its burden, and decrease the social gradient associated with it and therefore improve the health of European citizens.

This paper was published on behalf of the SPOTLIGHT consortium. Information of the full consortium (including biographies) can be found at the projects’ dedicated website: http://​www.​spotlight-project.​eu.