Systems Actions to Malnutrition in All Its Forms in Chinese and South-East Asian Cities - Developing Double-Duty, Population-Level Interventions

Malnutrition in all its forms broadly includes undernutrition (e.g. underweight and lack of certain key nutrients) and overnutrition (e.g. obesity and related chronic non-communicable diseases, such as type 2 diabetes). Malnutrition in all its forms is the largest cause of disease and premature death globally and in South-East Asia (SEA). Its health impacts are twice as high as that of tobacco use and high blood pressure. This public health challenge is also associated with heavy social and economic burdens. Different forms of malnutrition share common causes, especially within food systems that are promoting these various forms of malnutrition, which can co-occur in the same individual, household or country at the same time. Locally relevant solutions will need to be generated in relation to people's eating habits and food cultures (e.g. the local food systems) as well as general living environments. Therefore, the seemingly different nutrition problems can be improved through common solutions targeting the wider systems of people's daily lives. Current approaches to interventions are not reducing undernutrition fast enough and have failed to control the rise of obesity and related chronic diseases. These problems have rarely been considered and managed together in an integrated way. To effectively combat this largely preventable public health challenge, we need a new way of working that recognises the connections between different forms and causes of malnutrition within a wider context and creates double-duty actions to address them together.

We aim to develop public health interventions in Chinese and SEA cities that are: 1) jointly enacted by multiple sectors, 2) aimed to improve multiple forms of malnutrition, and 3) expected to benefit everyone living in these cities. We will do this collectively with local policy makers from different departments and sectors as well as community representatives (e.g. those who have delivered or received existing services or programmes aimed to improve nutrition status) over three project phases using a contemporary research method called the Group Model Building (GMB). GMB is a useful tool to develop a shared understanding of complex, inter-related issues and to facilitate coordinated actions among different people. It has been successfully used by members of this research team for developing systemic-level obesity interventions in developed countries.

The proposed project (phase 1) will provide a strong foundation for subsequent project phases by:
1) co-developing systems interventions through GMB and forming intervention delivery Action Groups with local decision makers and community representatives in an Asian city; and gaining practical insights into this new intervention development method for application in other Asian cities,
2) identifying strategies to recruit SEA cities to join the project, and
3) providing information needed to support the development of an internationally comparable and sustainable tools to monitor and assess impacts of developed interventions.

In the subsequent, phase 2 project, we will 1) support the Action Groups to deliver the interventions developed in phase 1, and measure early impacts of the interventions in the first Asian city using monitoring systems informed by phase 1; and 2) recruit SEA cities, develop interventions in these cities using the GMB process and form Action Groups.

This will be the first research project to use GMB to develop malnutrition interventions in developing, Asian countries. Our findings will importantly advance the work on the Decade of Action on Nutrition towards achieving the United Nations' Sustainable Development Goals and contribute to method development and impacts of this new way of working on public health promotion globally.

Malnutrition in all its forms is the largest cause of Disability-adjusted Life-Years lost globally and in South-East Asia (SEA), doubling the burden created by the next biggest risk factors of tobacco use and high blood pressure. This public health crisis also carries substantial social and economic burdens. Different forms of malnutrition share systemic causes and solutions linked to the same food systems and urban environments. They also co-exist at individual, household and country levels. However, they have rarely been conceptualised and managed together through integrated, systems-based interventions. Current approaches of interventions are not reducing undernutrition fast enough and have failed to halt the rise of obesity and related non-communicable diseases. To effectively tackle this largely preventable public health crisis, a Systems Approach is urgently needed.

We aim to develop multi-sectoral, double-duty, population-level interventions to reduce malnutrition in all its forms in Chinese and SEA cities through a participatory systems science method (Group Model Building/GMB) and co-creation with local decision makers and community representatives over three study phases. This phase 1 study underpins subsequent studies by
1) co-developing systemic interventions and forming local delivery Action Groups; and gaining practical insights into the GMB-based process in an Asian city,
2) identifying strategies to recruit SEA cities to join the study, and
3) informing the development of an internationally comparable and sustainable intervention monitoring and evaluation mechanism.

This will be the first study to apply a Systems Approach to develop malnutrition interventions in developing, Asian cities. Our findings will significantly advance the work on the Decade of Action on Nutrition towards achieving the UN's Sustainable Development Goals and contribute to methodological development and impacts of this new approach on public health promotion globally.

1.Academia
This study will benefit 1) international scholars interested in the development, evaluation and implementation of complex public health interventions, 2) international scholars working in any forms of malnutrition, 3) international scholars of different health and non-health subjects (e.g. climate change, agriculture, water and sanitation) that are important to the UN's Sustainable Development Goals, and 4) the research team.

2. Population health and socio-economic developments in participating Chinese and South-Eastern Asian cities
The whole population living in these cities will be the primary beneficiary of the wider study. In the proposed study, all people living in the city of Nanning are expected to benefit because the interventions we aim to develop will involve multi-sectoral and system-level changes to improve the environments they live in. Effective, population-level malnutrition interventions will help to reduce morbidity and mortality in children and adults while improving their quality of life. Women, infants, children and adolescents are at increased risk of malnutrition and optimising nutrition early in life can help ensure the best possible start in life with long-term benefits. Therefore, these people are likely to benefit the most.

Moreover, a healthier population will significantly reduce the healthcare burden of the society while providing a more productive workforce. 'Nutrition is both a maker and a marker of development. Improved nutrition is the platform for progress in health, education, employment, empowerment of women and the reduction of poverty and inequality, and can lay the foundation for peaceful, secure and stable societies' (Ban Ki-moon, United Nations 8th Secretary General).

3. Policy makers in the participating Chinese and Southeast Asian cities
Policy makers from a city's diverse subsystems (e.g. public health, agriculture, transport and city planning) will be the immediate beneficiary of the proposed and subsequent studies. The proposed method to co-create double-/triple-duty, systems-based malnutrition interventions will stimulate and practise a new way of thinking and working to tackle a leading public health challenge facing the communities they serve. Despite numerous efforts that have been devoted to the reduction of malnutrition in these countries, undernutrition is not being reduced fast enough, while overweight/obesity and related non communicable diseases continue to increase. The systems-based approach we aim to apply in this study aims to promote sustainable re-orientation of existing systems. It will also allow research and policy making to take place simultaneously in a co-creation process. The decision makers will not only take part in but own the process of developing inter-sectoral interventions, to maximise intervention sustainability and impacts.

4. Capacity building
This study is designed to support knowledge translation. Local policy makers will be able to independently apply the new way of working learnt from this study to address other complex, societal challenges. Moreover, apart from employing and training a local post-doctoral researcher to develop and apply systems-based public health intervention skills through this study, other local researchers will be supported to build their research capability through confirmed financial support from our partner, the Public Health College of Guangxi Medical University.

5. Global health
The double burden of malnutrition affects LMICs more than high-income countries. For example, undernutrition explains around 45% of deaths among children under five, mostly in LMICs; whilst almost half of the world's children with overweight/obesity under five are in Asia. Therefore, the malnutrition interventions we aim to co-create with city-level policy makers in Asia have the potential to make an important, positive impact on global health if they are scaled up nationally and regionally.