Unleash 4 Innovative Tools Behind a Causal Loop Diagram (Bathtubs, Faucets, Loops, Circles) to Crush Obesity & Prevent Diabetes

Blip-Zip Executive Summary

Stop Blaming, Start Solving Obesity and Diabetes! Systems thinking is not just a buzzword but a powerful approach that empowers leaders to tackle these complex health issues. We can develop innovative solutions by understanding the interconnections and interdependencies within these systems. Discover four practical ideas and tools, including causal loop diagrams, that can be used to create healthier communities and empower individuals to thrive!

Blip-Zip Takeaways

• See Beyond the Band-Aid: Systems Thinking, especially CLDs, identify root causes of health issues, not just symptoms.
• Think in Circles: Complex problems have interconnected parts. Systems Thinking fosters collaboration for better solutions.
• Work Smarter, Not Harder: Embrace the power of collaboration across sectors to tackle complex health challenges with Systems Thinking. Your role is crucial in this collective effort.

Key Words and Themes (#Hashtags)

#SystemsThinking #PublicHealth #ObesityPrevention #DiabetesPrevention #HealthEquity #CommunityHealth #Collaboration

Introduction to Systems Thinking Tools and Causal Loop Diagrams

Mastering system thinking tools such as causal loop diagrams, bathtubs, faucets, loops, and circles is a comprehensive approach to understanding and implementing systems. These tools, particularly causal loop diagrams, are not just theoretical concepts but practical tools that can be applied in the healthcare and public health fields. They can reveal their simplicity and complexity at various levels, such as individual, team, organization, community, or national. For instance, sugary snacks can influence a child’s weight regulation system, leading to overeating and weight gain. In such cases, causal loop diagrams can help parents limit unhealthy options and promote healthy eating habits to prevent dysfunctional eating patterns.

Systems thinking is a method leaders and organizations use to visualize and solve complex problems, build on past successes, and predict the behavior of complex systems. For example, a school lunch program is a complex system where employees prepare meals based on federal guidelines. However, these guidelines may not consider student preferences. Collaboration between staff, administrators, and parents can help understand student preferences, offer healthier options, and promote student involvement in meal planning.

Understanding these tools aids leaders in analyzing system inter-relationships, interdependencies, and connections, guiding them to understand the dynamics and root causes of dysfunction and assess perverse policies. This approach is crucial for sustainable development goals, managing patient-centered medical homes, community health integration initiatives, and establishing health system policies.^1-5

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Problem and Solution: Starts at the Individual Level

Systems thinking is gaining popularity in the healthcare and personal health fields for a reason. It’s a practical and effective approach that helps us address complex societal problems like obesity. The U.S. Institute of Medicine’s 2010 report titled “Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making” underscores the importance of systems thinking in reducing obesity. This approach offers hope and optimism in the face of multifaceted problems with various interconnections and interdependencies.

Systems thinking encourages health systems to partner with trained nutritionists or peer health educators to provide tailored guidance on healthy eating and physical activity. This holistic approach creates a more personalized weight management program beyond mere identification.

Systems thinking addresses complex problems by integrating biology with social, cultural, and environmental factors. By viewing neighborhoods as complex ecosystems, communities can collaborate to address issues such as the lack of safe parks and affordable fitness programs.

This approach encourages community centers, parks departments, and local businesses to offer free fitness classes, organize community walks, and advocate for safe paths. Such initiatives create a supportive environment for healthy physical activity choices, reducing obesity, and improving the quality of life for individuals and society.

Systems thinking is a mental model that helps leaders and policymakers understand the complex structures and patterns driving complex events. It focuses on understanding the psycho-biological system of human weight and energy regulation, including behavioral acts of eating, ingestion, assimilation, storage, and use of energy plus interactions with the external environment. Federal dietary guidelines serve as a national thermostat for healthy eating. However, changing food industry practices may introduce more processed foods with hidden sugars. Systems thinking encourages policymakers to work with industry leaders to incentivize healthier product formulations and more transparent labeling.⁷

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Bathtubs (Stocks)

To illustrate the basic tool sets, the reader can use a familiar example: a bathtub. Because water, unlike energy, is something to be seen and touched, visualizing how a bathtub works is a much easier task for most individuals. Imagine observing someone filling a bathtub with water in preparation for taking a bath. Individuals who observe the process will see this: faucet opening, water flowing, and water level rising in Figure 1 below.

Figure 1: Human Interface with Simple System

The “tub-filling story” is incomplete without addressing the tub-filling goal. The goal is to fill a bathtub to a desired water level. This goal is achieved by plugging the drain, turning on the faucet, and monitoring the rise in water level. Adjustments to the faucet position slow the water flow and turn it off when the desired level is reached. A more accurate representation of this process is shown in Figure 2 below.

Figure 2: Human Interface with Other Systems

The goal of achieving a desired water level is visible not in the physical system but in the individual’s mind when manipulating faucets. This process involves a bidirectional cause-and-effect relationship between faucet opening, water flow, and rising water level. The faucet’s opening affects the water level and bathtub’s water level, and through sight, action, and habits, the faucet’s opening and closing times are controlled. This simple system demonstrates three concepts: reality operates in circles, and understanding circular information flows within systems is crucial for regulating events.

Systems at any level are the basic building blocks of all systems. All systems, whether simple or complex, can be modeled using the fundamental tool sets of systems thinking: stocks (tubs), flows (faucets), and information (causal) links.

Bathtubs (Stocks) and Faucets (Flows)

Dynamic systems, like the human body, can be modeled as stocks, flows, and rates of flow, which are interconnected through causality or information feedback loops, influencing reality and system change.

Stocks are containers or accumulators of something that increase or decrease based on how much “something” flows in or out. They are called “state variables” and are measured at one point, such as calorie intake. Stocks start with an initial value like hunger and are changed only by flows into and out of them. They are similar to the body, where a stock of fat accumulates the difference between energy in (from eating) and energy out (from physical activity). Stocks capture the “state of the system” and are measured at one point. ^2-6  

Stocks can also be a source of delay in a system. Also, in healthcare or public health settings, examples of other types of stocks include:

• Individuals with different disease states (susceptible, infective, immune)
• Stockpiled vaccines and medications
• Pregnant women
• Males or females between the ages of x and y or demographic, gender, nationality
• High-risk individuals with chronic disease types
• Health workers in all functional areas
• Medicine in stock in the ward, office, or warehouse
• Blood sugar levels
• Beds in an emergency room, ICU, operating ward, or observation unit

Health leaders, medical social scientists, and policy analysts can understand the distinction between stock (bathtub) and flow (faucet) in various health system systems using basic tool sets. This skill allows them to identify opportunities to control, modify, or eliminate flows. In discussing human weight and energy regulation systems, simple visual toolsets can be used to make sense of these systems.

Stock and flow structures in systems can be found, with energy stored in the human body being a stock (primarily fat), with food intake as its inflow rate and energy expenditure as its outflow rate. Figure 3 illustrates a simple input, process, and output model illustrating stocks, flows, and rates.

Figure 3: Simple Input, Process, and Output Model Illustrating Stocks, Flows, and Rates

Flows are visuals with pipes and valves, representing inflows and outflows. A stock is the memory of changing flows within a system. Suppose outflows exceed inflows, and stored fat levels decrease, while if outflows equal inflows, body weight remains dynamic. Self-regulation is crucial for successful weight regulation, as it is a limited resource. Stocks are equivalent to a reservoir, consumed and replenished with self-control.⁸ Stocks increase by decreasing outflows and act as delay buffers or shock absorbers in systems. They allow inflows and outflows to be coupled independently.⁹

Research shows that the human capacity for self-regulation is crucial for weight regulation but often limited. This capacity can be likened to a reservoir of physical energy, consumed and replenished through self-control and rest, similar to the storage and depletion of physical energy.^7,10  To Summarize, Table 1 identifies systems thinking tools by level to combat adult obesity.

Table 1: Stocks and Flows and Tools By Level To Combat Adult Obesity

Level	Systems Thinking Tools in Action
Individual: Imagine your body fat as a “bathtub” (stock). Calorie intake (faucet) determines the water level (fat content). However, stress eating or unhealthy emotional responses (broken feedback loop) can lead to overconsumption, raising the “water level” beyond healthy limits.	Encourage mindfulness practices like journaling or meditation to manage stress, regulate the “faucet,” and promote healthy eating habits for a balanced system.
Team: Think of a workplace cafeteria as a complex system. Lunch staff (actors) prepare meals based on perceived employee preferences (incomplete feedback loop). However, these preferences might not reflect health considerations.	Engage in collaboration between cafeteria staff, a registered dietitian, and employees through surveys or focus groups to understand healthy meal preferences. This allows staff to offer nutritious yet appealing options, influencing employee food choices and promoting healthier eating habits within the team.
Organization: Imagine a health system as a network of interconnected parts. Doctors (actors) screen patients for weight issues (feedback loop). However, limited insurance coverage for nutrition counseling (broken feedback loop) might hinder weight management support.	Partner with healthcare organizations to advocate for insurance plans that cover personalized nutrition counseling, creating a more holistic approach to weight management beyond just identification and medication.
Community: Recognize a neighborhood as a complex ecosystem. Lack of affordable grocery stores with healthy options (broken feedback loop) can limit access to nutritious food.	Establish a coalition between community leaders, local businesses, and non-profit organizations to establish farmers’ markets, offer discounts at healthy food stores, and create community gardens, promoting residents’ access to nutritious food choices.
National: Federal dietary guidelines are like a national “faucet” influencing food choices (flow). However, aggressive marketing by food companies (broken feedback loop) might promote unhealthy products.	Advocate with policymakers to work with industry leaders to incentivize healthier product formulations and more precise labeling, alongside continued refinement of dietary guidelines, ultimately influencing food choices nationally and creating a more supportive environment for healthy eating.

Information (Loops) and Causal Loop Diagrams (CLD)

The figure illustrates the concept of causal links in systems, which are informational relationships between objects. These links are often more challenging than physical objects, such as tubs, water, and food. They are often inter-relationships and interdependencies coupled with communication, making them more difficult for individuals to perceive than physical objects. Figure 4 illustrates causal links in stocks, flows, and rates.

Figure 4: Causal Links As Part Of Stocks, Flows, And Rates

The bathtub example illustrates the importance of observing the physical actions, such as faucet opening and water flow, and the information causal link, which triggers individuals to reach for food when it’s not needed. Information about the water level in the tub causes individuals to adjust the faucet position, decrease the inflow rate, and turn off the water when it reaches the desired level.^5,6

Causal links often form circles or loops, rarely working in one direction. In the bathtub example, two-way interactions form a loop, which can be learned from circles and loops. These circular processes drive system behavior at any level, such as driving a system to grow, snowball, or achieve desired goals. With feedback, a system can achieve a desired goal or health outcome.

Feedback loops are a chain of causation actions, allowing individuals to know when to stop filling a bathtub or maintain a room’s temperature. With feedback, variation, physical and mental waste, and frustration or negativity would set in, making it easier for a system to achieve desired outcomes. Figure 5 illustrates circular thinking.

Figure 5: Circular Thinking Versus Linear Thinking in Systems Thinking

The circular feedback process in regulating bathtub filling is not unique to bathtubs, as systems rely on the same structure to achieve their goals. Our body’s physiology, like weight and core temperature, maintains these goals. The figure below illustrates the two loops, the bathtub filling loop and the feedback loop, for regulating body temperature, which works almost precisely like the bathtub system.

Figure 6: illustration of causal links and loops between human functions and thinking

The human body regulates its core body temperature through a feedback process. When body temperature rises, it creates a gap between the desired and actual body temperature, causing sweat glands to instigate sweating. This evaporation cools the body down. Like a bathtub, a rise in water level causes an adjustment to the faucet position, which is turned off when the desired temperature is reached. The brain relies on sensory information to determine if the goal is achieved, such as lowering the core temperature to 98.6 degrees Fahrenheit.

Conversely, if the body temperature drops below the desired temperature, it raises it by inducing shivering. This system works well for maintaining core body temperature. However, resistance sets in if goals differ or individuals try to regulate each other through goal-seeking feedback processes like peer pressure. Like the temperature-regulating process, the human body also has feedback mechanisms to maintain fat reserves at desired levels. When significant weight loss occurs on a diet, the body interprets the loss as a deprivation crisis that needs to be contained, resulting in resistance.

The body slows its metabolism to reduce tissue depletion and energy expenditure, reducing the energy deficit of a diet and dampening weight loss. This resistance occurs because well-intentioned interventions, such as dieting, are at odds with the system’s goals of maintaining fat reserves. This wired-in feedback process, which regulates energy reserves, makes weight-loss strategies less straightforward and results in weight loss declining over time. Balancing feedback loops for goal-seeking structures and systems is highly desired, especially at policy levels. Reinforcing loops can lead to growth or collapse over time, while physical feedback can affect future behavior.

However, it cannot deliver a signal fast enough to correct a group that drove the back. Balancing feedback loops is crucial for goal-seeking structures and systems at any level. The information delivered by a feedback loop — on physical feedback — can affect future behavior; it cannot provide a signal fast enough to correct a group driving the back.^2-4 Table 1 summarizes information loops by levels to reduce diabetes.

Table 2: Information Loops and Tools By Level To Reduce Diabetes

Level	Systems Thinking Tools in Action
Individual: Imagine your blood sugar levels as a “bathtub” (stock). Carbohydrate intake (faucet) influences sugar levels (water level). However, a lack of awareness of portion sizes (broken feedback loop) can lead to overconsumption, raising blood sugar beyond healthy limits.	Encourage self-monitoring blood sugar, learning healthy portion sizes, regulating the “faucet,” and promoting balanced eating habits.
Team: Think of a hospital diabetes management team as a system. Doctors (actors) prescribe medications based on blood sugar readings (feedback loop). However, limited communication between doctors and nutritionists (broken feedback loop) might hinder personalized dietary guidance.	Engage in collaboration within the team, ensuring clear communication and joint development of treatment plans that address medication and dietary needs for effective blood sugar management.
Organization: A health insurance company is a complex network. Reimbursement policies (flows) incentivize specific treatments (practices within the system). However, limited coverage for diabetes education programs (broken feedback loop) might hinder long-term disease management.	Challenge insurance companies to re-evaluate reimbursement policies, potentially covering preventive education programs alongside medications, promoting a more holistic approach to diabetes management.
Community: Think of a neighborhood as a complex ecosystem. Lack of safe walking paths or affordable fitness centers (broken feedback loop) discourages physical activity, a key factor in diabetes management.	Lead collaboration between city planners, community centers, and public health institutions to create safe walking/biking paths and affordable fitness options, promoting increased physical activity within the community for better blood sugar control.
National: Federal public health campaigns (flows) aim to raise awareness about diabetes risk factors (information loop). However, aggressive marketing by sugary drink companies (broken feedback loop) might counteract these efforts.	Urge policymakers to work with industry leaders to promote healthier beverages and limit targeted advertising, alongside continued public health campaigns. This would ultimately influence national beverage choices and create a more supportive environment for healthy practices that reduce diabetes risk.

The three processes that aim to achieve specific goals, such as filling a bathtub, regulating body temperature, and maintaining fat reserves, function similarly. The body temperature regulation system has a fixed goal of 98.6 degrees Fahrenheit, whereas the bathtub system and fat reserves often have changing goals. To prevent and reverse weight gain, acting before establishing a higher set point is crucial.

Systems thinking is essential to address the obesity epidemic at various levels, including community and policy. Solutions should address the entire system and communities

 rather than isolated causes. Providing system support can help create communities of practice that accelerate effective action against obesity.  Systems thinking can also help health teams, leaders, and policymakers address the complexity of the obesity epidemic and develop healthcare systems that promote innovative and collaborative practices for individuals, communities, and nations dealing with obesity.

Summary And Conclusion

This article explored the power of systems thinking, particularly causal loop diagrams (CLDs), to combat complex health issues like obesity and diabetes. We delved into the concepts of stocks, flows, and information loops, demonstrating their application across various levels – individual, team, organization, community, and national. Are you ready to transform from a reactive leader to a proactive strategist? Check out the deep-dive discussion questions, professional development activities, and valuable resources to propel you toward mastering systems thinking for a healthier tomorrow!

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Deep Dive Discussion Questions

Understanding the core principles is just the beginning. To truly harness the power of systems thinking, delve deeper into the following questions:

1. Identify Broken Feedback Loops: Reflect on your current leadership role. Can you identify any broken feedback loops within your team, organization, or community contributing to health challenges? How can you leverage systems thinking to address them?
2. Building Causal Loops:  Imagine a system within your organization related to healthy behaviors. Sketch a causal loop diagram (CLD) to illustrate the interconnected factors influencing these behaviors.
3. Map Your System: Choose a specific health challenge within your influence. Sketch a causal loop diagram to visualize the critical factors at play. Identify the stocks, flows, and information loops influencing the system’s behavior.
4. Collaboration is Key: Systems thinking thrives on collaboration. Identify key stakeholders who play a role in the health challenge you identified. How can you foster collaboration to create a more supportive environment for healthy choices?
5. Long-Term Vision: Consider the unintended consequences of potential solutions. How can you leverage systems thinking to design interventions that promote long-term health and well-being?
6. Collaboration is Key: Identify a health disparity within your community. How can collaboration across sectors leverage systems thinking to address this issue?
7. Policy and Systems: Analyze a current health policy related to obesity or diabetes prevention. Does this policy consider the interconnectedness of factors within the system? How could it be improved through a systems thinking lens?
8. Personal Action: Reflect on your healthy eating and physical activity behaviors. What feedback loops influence your choices? How can you leverage these loops to promote healthier habits?
9. Individual vs. Systemic Change: Consider the concept that individual behavior change is crucial for population health outcomes but that addressing the larger system is also essential. How can leaders find a balance between these two approaches?

Professional Development and Learning Activities

Empowering yourself with the right tools and resources is crucial for successful implementation. Here are some practical activities to solidify your grasp of systems thinking:

1. Online Courses: Explore online courses offered by prestigious institutions like MIT OpenCourseWare to deepen your understanding of systems thinking methodologies.
2. Case Studies: Analyze real-world case studies that showcase successful applications of systems thinking in public health initiatives. Identify key takeaways and best practices.
3. Community of Practice: Join online or in-person communities dedicated to systems thinking in public health. Engage with peers, share challenges, and learn from collective experiences.
4. Books and Articles: Invest in a library of relevant books and articles on systems thinking and its application in public health. Stay current with the latest research and insights.
5. CLD Development Workshop: Participate in a workshop or online training on developing causal loop diagrams (CLDs). Practice building CLDs for real-world public health issues. His

References and Resources

1. Senge, P. M. (2006). The fifth discipline: The art and practice of the learning organization. Random House.
2. Sterman, J. D. (2000). Business dynamics: Systems thinking and modeling for a complex world. Irwin/McGraw-Hill.
3. A systems thinking approach for tackling the COVID-19 pandemic: A conceptual framework. Sustainability, 12(14), 5518. https://www.researchgate.net/publication/342879865_A_Systems_Thinking_approach_for_responding_to_the_COVID-19_pandemic
4. Systems thinking for sustainability. https://www.routledge.com/Systems-Thinking-and-Viable-Systems/Barile/p/book/9781032756844
5. The Obesity Society. (2023). Systems Thinking for Obesity Prevention. https://www.obesity.org/
6. World Health Organization. (2023). Systems thinking for health. https://ahpsr.who.int/publications/i/item/2009-11-13-systems-thinking-for-health-systems-strengthening

Citations

1.         Frood S, Johnston, Lee M., Matteson, Johnston, Carrie L., Finegood, Diane T. Obesity, Complexity, and the Role of the Health System. Curr Obes Rep. 2013; 2(4):320-326.

2.         Meadows D, H. Thinking and Systems: a Primer. White River Junction, Vermont: Chelsea Green Publishing; 2008.

3.         Senge PM. The Fifth Discipline: The Art & Practice of the Learning Organization. New York: Doubleday/Currency; 1990.

4.         n.a. Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making. Washington, DC: U.S. Institute of Medicine (IOM);2010.

5.         Hamid TKA. Thinking in Circles About Obesity: Applying Systems Thinking to Weight Management). Gewerbestrasse 11, CH-6330 Cham (ZG), Switzerland: Springer International Publishing; 2009.

6.         Kumanyika SK, Parker, Lynn, Sim, Leslie J. Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making. Washington DC: National Academies of Press (NAP); 2010.

7.         Hamid TKA. Thinking in Circles About Obesity. Systems Thinker. 2009. https://thesystemsthinker.com/thinking-in-circles-about-obesity/.

8.         Muraven M, Tice DM, Baumeister, R. F. . Self-control as a limited resource: Regulatory depletion patterns. Journal of Personality and Social Psychology. 1998;74.

9.         Meadows DH. Thinking in Systems, A Primer. White River Junction, VT, USA: Chelsea Green Publishing Company; 2008.

10.       M. Muraven DMT, and R. F. Baumeister. Self-control as a limited resource: Regulatory depletion patterns. Journal of Personality and Social Psychology. 1998;74.

11.       Finegood D. The importance of systems thinking to address obesity. Nestle Nutr Inst Workshop Ser 2012;73:123-137.