Despite major investment in both research and policy, many pressing contemporary public health challenges remain. To date, the evidence underpinning responses to these challenges has largely been generated by tools and methods that were developed to answer questions about the effectiveness of clinical interventions, and as such are grounded in linear models of cause and effect. Identification, implementation, and evaluation of effective responses to major public health challenges require a wider set of approaches 1,2 and a focus on complex systems. 3,4 A complex systems model of public health conceptualises poor health and health inequalities as outcomes of a multitude of interdependent elements within a connected whole. These elements affect each other in sometimes subtle ways, with changes potentially reverberating throughout the system. 5 A complex systems approach uses a broad spectrum of methods to design, implement, and evaluate interventions for changing these systems to improve public health.Complex systems are defined by several properties, including emergence, feedback, and adaptation. 3 Emergence describes the properties of a complex system that cannot be directly predicted from the elements within it and are more than just the sum of its parts. For example, the changing distribution of obesity across the population can be conceptualised as an emergent property of the food, employment, transport, economic, and other systems that shape the energy intake and expenditure of individuals. Feedback describes the situation in which a change reinforces or balances further change. For example, if a smoking ban in public places reduces the visibility and convenience of smoking, and this makes it less appealing, fewer young people might then start smoking, further reducing its visibility, and so on in a reinforcing loop. Adaptation refers to adjustments in behaviour in response to interventions, such as a tobacco company lowering the price of cigarettes in response to a public smoking ban.Rhetoric urging complex systems approaches to public health is only rarely operationalised in ways that generate relevant evidence or effective policies. 1,6 Public health problems that emerge as a property of a complex system cannot necessarily be solved with a simple, single intervention, but the interacting factors within the system can potentially be reshaped to generate a more desirable set of outcomes. 7,8 Achievement of meaningful impacts on complex multicausal problems, like obesity, requires more than single interventions, such as traffic light food labelling or exercise on prescription, many of which require high levels of individual agency, have low reach and impact, and tend to widen health inequalities. 9-11 Shifts within multiple elements across the many systems that influence obesity are required, some of which might only have small effects on individuals but can drive large changes when aggregated at population level. 12 Although randomised controlled trials of individual-level interventions are relatively strai...

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BackgroundRelapse is high in lifestyle obesity interventions involving behavior and weight change. Identifying mediators of successful outcomes in these interventions is critical to improve effectiveness and to guide approaches to obesity treatment, including resource allocation. This article reviews the most consistent self-regulation mediators of medium- and long-term weight control, physical activity, and dietary intake in clinical and community behavior change interventions targeting overweight/obese adults.MethodsA comprehensive search of peer-reviewed articles, published since 2000, was conducted on electronic databases (for example, MEDLINE) and journal reference lists. Experimental studies were eligible if they reported intervention effects on hypothesized mediators (self-regulatory and psychological mechanisms) and the association between these and the outcomes of interest (weight change, physical activity, and dietary intake). Quality and content of selected studies were analyzed and findings summarized. Studies with formal mediation analyses were reported separately.ResultsThirty-five studies were included testing 42 putative mediators. Ten studies used formal mediation analyses. Twenty-eight studies were randomized controlled trials, mainly aiming at weight loss or maintenance (n = 21). Targeted participants were obese (n = 26) or overweight individuals, aged between 25 to 44 years (n = 23), and 13 studies targeted women only. In terms of study quality, 13 trials were rated as “strong”, 15 as “moderate”, and 7 studies as “weak”. In addition, methodological quality of formal mediation analyses was “medium”. Identified mediators for medium-/long-term weight control were higher levels of autonomous motivation, self-efficacy/barriers, self-regulation skills (such as self-monitoring), flexible eating restraint, and positive body image. For physical activity, significant putative mediators were high autonomous motivation, self-efficacy, and use of self-regulation skills. For dietary intake, the evidence was much less clear, and no consistent mediators were identified.ConclusionsThis is the first systematic review of mediational psychological mechanisms of successful outcomes in obesity-related lifestyle change interventions. Despite limited evidence, higher autonomous motivation, self-efficacy, and self-regulation skills emerged as the best predictors of beneficial weight and physical activity outcomes; for weight control, positive body image and flexible eating restraint may additionally improve outcomes. These variables represent possible targets for future lifestyle interventions in overweight/obese populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0323-6) contains supplementary material, which is available to authorized users.

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To achieve WHO's target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering eff ective actions and what, specifi cally, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fi scal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifi es multiple levers for change, including quasiregulatory and other approaches that involve government-specifi ed and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of confl icts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the infl uence of private sector actors with major confl icts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives.