Influences on excess weight gain amongst 0-5 year old  children: A Stakeholder produced systems map

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Causal inter-relationships of key influences on obesity (called systems maps) exist for adults and school-aged children. However, there are no maps focused on young children, where unique factors may operate including the influence of childcare providers. We developed a systems map with stakeholders to identify key factors contributing to excess weight gain in 0–5 year olds. Methods : We used an iterative stakeholder engagement approach, starting with a workshop with 23 stakeholders in the United Kingdom to produce an initial map. We ran a further discussion group with six parents, a second workshop with 22 additional stakeholders, and consulted literature to develop a final systems map. Results: The final systems map consists of 20 domains of influence and 153 factors. These influences operate at six embedded levels. Level 1 (at the centre): ‘child’ includes influences related to a child’s physiology, food preferences, and specific health and social needs. Level 2: ‘parents’ includes income and resources, mental health, life pressures, parenting style and skills, and support received on feeding. Level 3 focuses on the influence of ‘Wider family and social networks’. Level 4: ‘local’ includes the physical environment, availability of early years services, and local government services. Level 5: ‘national’ includes government policies and funding, food suppliers and retailers, and societal pressures. Level 6: ‘global’ includes events affecting food supply and prices. Financial considerations drive the majority of connections within the systems map, for example parent’s income or the funding of early years services. Conclusions: There are multiple interacting influences on excess weight gain in 0–5 year olds. Some are unique to young children, particularly the influence of parents and other caregivers. The systems map can be used to support the development and evaluation of interventions aiming to prevent or reduce excess weight amongst 0–5 year olds. For example, any intervention focused on improving parents’ knowledge and confidence around food would need to be cognisant of the multiple other influences at play. childhood growth obesity early years systems prevention Figures Figure 1 Figure 2 Figure 3 Background Excess weight gain in 0–5 year old children is a global problem. ( 1 ) In the United Kingdom (UK) in 2023/4, 22% children were overweight or living with obesity when starting school (aged 4 or 5 years). ( 2 ) Rates were higher in the most deprived areas (26.1% compared to 17% in the least deprived areas). ( 2 ) This is problematic because of the detrimental impact of living with excess weight on children’s mental and physical health. It also raises the risk of living with obesity throughout their lives and the subsequent ( 3 ) long-term health conditions that significantly impact quality of life and life expectancy. ( 4 – 6 ) Research and policy is becoming increasingly aware of the importance of a ‘whole systems approach’ to understanding the drivers of obesity at multiple levels including individual level issues like food knowledge and preferences and the wider food environment e.g. food policy and food production. ( 7 ) Maps of the systems influencing obesity have been developed for adults. A key example is the Foresight map, which considers the influence of national policies, food manufacturing processes, local infrastructure, and individual behaviours on appetite regulation. ( 8 ) A similar map has also been developed for school food systems for school food choices ( 9 ), and there is also a map that highlights interrelated determinants of health inequalities of people aged 0–25. ( 10 ) However, there is no systems map focusing on young children aged 0–5 years old, where some factors beyond the individual (i.e. the child) will be of greater importance, and where unique factors may operate. These factors may include the influence of parents, childcare providers and weaning approaches. Such a map could be used to inform the development of policies and interventions aimed at different parts of the system and understand how different interventions may interact, with potentially unforeseen and unintended consequences. ( 11 ) Given this, we aimed to employ systems thinking and integrate stakeholder input to construct a systems map that identifies the key factors contributing to excess weight gain in children aged 0–5 years across the UK. Methods Study design Systems mapping was used to identify the influences on excess weight gain in 0–5 year olds, including identifying factors and describing their interactions. ( 12 ) We co-produced the systems map with stakeholders using a sequential iterative design consisting of four phases described fully below: 1) A stakeholder workshop to produce the first draft map; 2) A discussion with a group of parents to refine the map; 3) A literature review of existing obesity frameworks and systems maps in international publications and policy documents to identify missing factors, and 4) A further stakeholder workshop to refine the map. Given the unequal distribution of obesity by socio-economic status, stakeholders were asked to consider inequalities when developing the map. 1. First stakeholder workshop Attendees and processes We held the first 6-hour workshop in a location in the North of England in the UK in March 2023. The 23 stakeholders included childcare practitioners, public health specialists, commissioners of weight management programmes, providers of weight management programmes, researchers studying obesity, and parents with children in the target range (Table 1 ). Specific roles included front-line workers delivering infant feeding programmes, early year service managers, commissioners of childhood obesity programmes, and parent wellbeing support workers. Stakeholders worked for a variety of organisations including local government regions (called Local Authorities in England), childcare providers and universities. Two parents attended. Many of the other stakeholders were also parents but attended in their professional capacity. Travel expenses were offered to enable attendance at the workshop. We used a group model-building approach to develop our systems map. ( 13 , 14 ) This involved different stakeholders working together to build a shared understanding of factors that contribute to excess weight gain in early years and the draft development of a systems map to highlight how factors interrelate. The workshop was co-led by a systems expert (AS) and a qualitative researcher (AOC). We divided attendees into five groups of 4–6 diverse stakeholders. Each group was facilitated by a member of the research team (WB, DGW, MC, AF, MB/LS). We ran the following series of activities to help each group develop their own systems map: Learning systems thinking : The workshop co-leads introduced the aim of the day and introduced stakeholders to simple ways of thinking about systems by drawing examples of factors and arrows (relationships) between them. Identifying factors : Each group then brainstormed factors that they felt impacted on excess weight gain amongst 0–5 year olds and wrote these on flip chart paper. Identifying relationships between factors : Stakeholders were then asked to consider how different factors (known as nodes within the map) related to one another (known as an edge list) by drawing lines between each factor to show these relationships. They were asked to add positive (+) or negative (-) modifiers to each connecting line to denote a positive or negative inter-relationship where possible. For example, the government subsidising healthy food for low-income families positively impacted on the ability to buy healthy food, so would be labelled as ‘+’ on an arrowed line connecting the two factors. Considering health inequalities : Prior to the workshop, a number of research team members (AF, AOC, WB and the Parent Advisory Group (see next section)) developed six vignettes or scenarios of fictional families with young children to help stakeholders consider health inequalities relating to downstream obesity impacts. For example, parents with disabilities, families living in rural areas, and single parents. Each group was given two of these vignettes and used these to identify additional factors in their systems map. Relative importance of factors : Each stakeholder was given twenty “sticky dots” (i.e. small coloured circular post-it stickers) and asked to allocate any number of these to the factors on the five maps that they felt were most important. This activity invited stakeholders to vote and hence prioritize the factors they thought were important. Creating the first iteration of the systems map After the workshop, two members of the team collated the five maps into one master map (AF and AOC). This involved reading each map to aid familiarisation, listing the factors from all the maps and grouping these into domains and factors using the concept of affinity mapping (equivalent to developing themes and sub-themes in qualitative analysis). AF and AOC then created a matrix of factors in an Excel spreadsheet, grouped within domains. AF and AOC returned to the five maps and documented the relationships between factors using (+), (-), and (*) denoting positive, negative and neutral/missing relationships respectively. The weight of different factors was also calculated by counting the frequency of the votes (i.e. ‘sticky dots’) given to each factor. This was imported into Canva (Canva Pro Licence) to draw a single map. The draft map was then shared with the wider research team – some of whom had been facilitators during the workshop - to check that it accurately represented the findings. While there was consensus that the map reflected the workshop discussion, it became evident that some known factors that influence appetite regulation (and therefore excess weight gain) were not included. We also shared the draft map with all workshop attendees to check for accuracy and comprehensiveness. We received one response, which we used to clarify the different childcare providers and early year support services in the map. The preliminary systems map generated was extensive and complex. At this stage, Bronfenbrenner’s ecological systems theory of child development was applied. ( 15 ) This theory posits that child development is influenced by multiple layers of environmental factors, with the child at the centre, surrounded by the microsystem (e.g. family), mesosystem (e.g. social welfare services), and macrosystem (e.g. culture). We subsequently categorised domains within system levels, resulting in a condensed version of the systems map. We referred to this as an ecological framework. 2. Parent Advisory Group We invited an existing ‘Parent Advisory Group’ consisting of 6 parents to contribute to the map development. All had young children and were recruited via a Children’s Centre based in a socio-economically deprived neighbourhood. Prior to the first workshop, we had an in-person discussion of the plan for the systems mapping exercise, including how best to ensure participation from parents and to sense check documents that we planned to use during the process. This Parent Advisory Group also met to provide feedback on the first iteration of the systems map. They met for 2 hours in person. At the session, AF and WB presented a large printout of the overall systems map. Parents discussed the map including suggesting missing factors. 3. Literature review of existing literature and policy documents We searched for three types of documents to check for omitted factors within our initial iteration of the map. This was not a systematic review. First, we searched for system maps and frameworks on obesity for any age group. We were signposted to these by topic experts within the research team. Second, we conducted a search of evidence reviews that described influences on early childhood obesity/excess weight in Google Scholar (search undertaken in January 2024 of the first two pages). Finally, we identified national and international policy documents and reports which focused on prevention of excess weight; for example, World Health Organisation reports. AF read these documents, specifically searching for key omissions from our map. 4. Second stakeholder workshop We conducted a second workshop in another part of the UK (Northern Ireland) to provide further perspectives on the system map. Twenty-two stakeholders attended in May 2024 (see Table 1 ). The workshop was facilitated by LM and WB. WB had facilitated the previous workshop and Parent Advisory Group. LM was a topic expert and had expertise in systems approaches. Three additional researchers supported facilitation. In the 2-hour workshop, the stakeholders reviewed the systems map. They had a systems map without the relationship arrows because the focus of the exercise was the content of the map rather than the relationships. The stakeholders identified missing factors which were predominantly related to the different geographical, cultural and political context of Northern Ireland compared with England. Stakeholders then considered relationships by drawing lines between factors on the map and using ‘+ and –’ to indicate relationships. Similar to Workshop 1, attendees were asked to apply 20 ‘sticky dots’ to factors that they felt were the most influential. The scores from the two workshops were combined to identify the most influential factors from stakeholders’ perspectives. Final systems map We developed a final iteration of the map by incorporating suggestions from both workshops, the Parent Advisory Group and the literature. At this stage, the domains, and factors within them, were classified as ‘nodes’ to be consistent with terminology used within systems mapping. We developed the systems map to include the relationships between nodes. We did this through creating edge lists which capture the relationships between the nodes. The node and edge lists were visualised in R and iGraph. ( 16 ) The solid lines on the map denote relationships between the nodes (factors). Dotted lines indicate the domains the nodes are associated with. These relationships were identified from both stakeholder workshops and the Parent Advisory Group and are weighted either as + ve, -ve, or neutral and constitute the connected part of the map. The connectivity of the parts of the map were analysed to give an additional perspective on importance placed on the different parts of the system by workshop participants. We used the relationships represented by solid lines to calculate thedifferent centrality measures of some of the nodes. This enabled us to rank nodes by establishing how connected they are to the rest of the network. After finalising the systems map, we returned to the ecological framework to ensure consistency between the two. Table 1 Types of attendees at the two workshops Type of Stakeholder Workshop 1 North of England (n = 23) Workshop 2 Northern Ireland (n = 22) Total (n = 45) Parent 2 1 3 Paediatricians/Child Health Specialists 0 3 3 General Practitioner/Family doctor 0 1 1 Front-line service provider e.g. Health Visitor, Early Years Practitioner, Infant Feeding Worker 11 10 21 Policy Maker/Commissioner/ Public Health Manager 7 7 14 Researcher 3 0 3 Results The final systems map had 20 domains (themes) and 153 factors (nodes) as shown in Fig. 1. We describe how each method contributed to the iterative development of the map in Table 2 . The ecological framework summarises the systems map within six embedded levels (Fig. 2). Iterations of the systems map 1.Contibution of the First Stakeholder workshop We developed an initial map which had 139 factors, grouped by different domains. We utilised Plain English for the factors to reflect the language used by stakeholders. The initial map included most of the factors that feature in the final systems map. The factors ranged from induvial child factors, parental influences and policies of the national government. 2. Contribution of the Parent Advisory Group During the session with the Parent Advisory Group, we learnt that parents were generally happy with the map, feeling that it resonated with their experiences. They discussed the language used, encouraging the use of Plain English and language that did not blame parents. The parents identified additional factors such as the preferences of individual children, the difficulty in determining if their child was living with excess weight, and the gendered approach to food preparation. The group felt that it was predominantly mothers rather than fathers who felt responsibility for food in the family and who attended any healthy eating courses aimed at families. 3. Contribution of literature We identified four existing maps that we used to inform our early years systems map. (i) The Foresight system map identifies seven key subsystems or themes for adults: physiology, individual’s physical activity, physical activity environment, food consumption, food production, individual’s psychology (e.g. stress), and social psychology (e.g. society, media). ( 17 ) This highlighted that physiology was a missing domain in our map because it had not been previously identified by our stakeholders). (ii) ( 18 ) considered factors that may contribute to children of any age living with obesity in Northern Ireland. It did not specifically consider younger children. It reported similar factors to the Foresight system map, but with the added factors of the influence of parents and peers. From this map, we identified that we were missing some factors relating to Foods High in Fat, Salt and Sugar and food regulations including labelling. (iii) The CONNECTS-Food systems map focused on influences on children’s diet in school. ( 9 ) It identified four key themes: leadership and curriculum, child food preference, home environment and school food environment. Some of this map was not relevant to our pre-school focus but it supported the importance of ‘child preference’ that had been added by the Parent Advisory Group in the previous iteration. (iv) Croker et al ( 19 ) focused on policy levers that governments can make to achieve system-wide change based on the Foresight system map. We did not add anything to our map from Croker et al ( 19 ) because we had already included relevant factors from the Foresight system map. We identified Campbell et al.’s ( 20 ) review describing individual level factors (biological, social, and behavioural risks), which were embedded in the child’s family environment and the community environment. This confirmed the importance of the different levels of influences in our ecological framework. The review also confirmed the importance of adding physiology to our systems map and considering demographic issues such as sex and ethnicity. Chatham and Mixer’s ( 21 ) review was important because it focused on qualitative research with ethnic minorities, bringing cultural influences into our map. They identified nine themes of: child feeding, family, gender roles, food, healthy child appearance, physical activity, sedentary behaviour, food cost and local environment and infrastructure. These did not affect the domains in our map but the ‘gender roles’ supported the Parent Advisory Group point about women largely taking responsibility for their children’s food. We felt that the theme of ‘healthy child appearance’ sat within our ‘wider family network’ domain under ‘cultural norms’. Finally, the policy documents of the National Institute for Care Excellence ( 22 ) World Health Organisation ( 23 ) and UK Government Obesity Policy ( 24 ) helped us to affirm omissions from our initial map. These were physiological causes of excess weight gain, the impact of gender and ethnicity on children’s weight, and global issues including climate change and farming practices. 4. Contribution of Workshop 2 At Workshop 2, the stakeholders supported the content of the map, feeling that parental mental health status was particularly important. The stakeholders also identified additional factors (including some that were considered to be Northern Ireland-specific issues).These included factors which were related to the commercial determinants of health e.g. marketing of food, political divisions within communities that reduce access to services, cost of childcare (there is no subsidised early years childcare provision in Northern Ireland), quality of maternity care, reliable sources of information about healthy eating, provision of physical education, access to safe outdoors play areas, maternal age and weight, the time children spend using screens and cultural beliefs including a resistance to breastfeeding and an obsession with babies gaining weight. Table 2 Contributions of methods to the iterative development of the systems map Iteration Engagement Changes made following the input 1 Workshop 1 Development of the initial map and ecological framework 2 Parent Advisory Group Reviewed language to ensure that it was in Plain English. Added in factors (nodes) related to: ● Individual preferences of children; ● Difficulty in parents knowing if their child was overweight; ● Gendered approach with women generally being responsible for their children’s food and attending healthy eating courses. 3 Contribution of literature Confirmed content of the map and the ecological framework. Added in factors (nodes) related to: ● The impact of gender and ethnicity on children’s weight; ● Global issues including climate change and farming practices. 4 Workshop 2 Added in factors related to: ● Commercial determinants of health; ● Accessibility of services in different communities; ● Cost of childcare; ● Quality of maternity care; ● Reliable sources of information about healthy eating; ● Provision of physical education; ● Access to safe outdoor play areas; ● Maternal age and weight; ● Time children spend using screens. The final systems map We grouped 153 factors in the systems map into 20 domains (Fig. 1). Below we describe the domains and factors (that is nodes on the map), organised by the embedded levels of the ecological framework: ( 1 ) child; ( 2 ) parents; ( 3 ) wider family/social networks; ( 4 ) local; ( 5 ) national; and ( 6 ) global. Level 1: Child ‘Child’ is at the centre of our ecological framework and is represented by four domains in the systems map (top left on the map, Fig. 1): ( 1 ) ‘Preferences’ describes how each child is unique in terms of desires around exercise and food; ( 2 ) ‘Specific needs’ describes variations in health and social needs, for example, different medical needs that might affect appetite and eating habits; ( 3 ) ‘Physiology’ includes birthweight, appetite and metabolism; and ( 4 ) covers demographic issues, including sex and ethnicity which might affect eating habits and weight. Level 2: Parent ‘Parent’ has the largest number of domains (n = 6), reflecting how parents have significant responsibility for younger children’s food and physical activity (top right of the map, Fig. 1). ‘Life pressures’ includes parents juggling multiple commitments of children, work, running a home and sometimes caring responsibilities for older relatives which limits the amount of time they have to focus on healthy eating and physical activity for their children. For example, this can lead to parents relying on convenience food when getting home late from work. A second domain is ‘parenting styles and skills’. Some parents feel more confident than others in setting boundaries around food and saying no to unhealthy foodstuffs. A third domain is ‘food knowledge and behaviour’. Stakeholders felt that some parents can lack knowledge about healthy eating and physical activity for themselves and their children. Or even if they have the knowledge, they struggle to implement it. For example, a parent’s own food behaviour can influence how they feed their young children, such as eating (or not eating) vegetables, or snacking when watching the television. A fourth domain is parents’ mental health status. This is called ‘Psychology’ in the Foresight map. Parents’ mental health status may lead to low motivation to plan and cook meals. The fifth domain is ‘income and resource’ constraints, where parents may not have a sufficient income to afford fresh food or have sufficient credit on their gas meter to cook. Stakeholders felt that there is an increasing number of parents working in insecure jobs that might be called ‘the working poor’. The final domain was ‘antenatal and postnatal support’ which encompasses how parents are supported with feeding and weaning babies such as breastfeeding support. Level 3: Wider family/social networks The level ‘wider family/social networks’ includes grandparents, friends and extended family who are sometimes responsible for feeding and looking after young children. It consists of 5 domains (bottom right of the map in Fig. 1). There may be generational differences in food consumption or cultural norms around infant feeding, beliefs about what a healthy child looks like, and food choices. Examples given by stakeholders included stigma around breastfeeding or parents feeling unable to enforce healthy eating rules when family members were providing childcare. Level 4: Local The ‘local’ level includes four domains (n = 4) (top left in the systems map in Fig. 1). The first domain is the local ‘physical environment’, including access to green space, leisure facilities and transport which could affect the amount of physical activity undertaken by young children. The second domain is ‘early year support services’ in the locality such as parenting courses and Heath Visitors proving information on a child’s development. Stakeholders discussed how the availability of early years support services was dependent on local and regional funding, with inconsistency in access to services by geographical location, cultural appropriateness and over time. Stakeholders described ‘a postcode lottery’ of services, with access to services particularly challenging when living in rural areas. Stakeholders also described how funding of support services was often short-term and unstable, limiting the availability of consistent and trusted services to local communities. The third domain ‘childcare providers’ can influence children’s weight because these providers have responsibility for feeding children and for their physical activity levels when children are in their care. Stakeholders described how the quality and type of food provided can be poor quality and not adhere to the same nutritional standards as schools. The final domain is ‘local governments’, which have responsibility for the provision of local services and the local physical environment. Level 5: National The ‘national’ level has three domains (n = 3) (top of the map, Fig. 1). The first domain is ‘government policies and funding’ which affects the availability of services and staff to support parents and children, influences the price and availability of healthy and unhealthy food, and influences the income and resources available to parents, (e.g. social security benefits). Food banks sat within this domain as a solution to perceived poor government policies and funding. The second domain relates to ‘food suppliers and retailers’ that stakeholders described as advertising unhealthy food for children and controlling food prices. Stakeholders perceived that it was easier to access unhealthy foods compared with healthy foods in terms of availability and cost. Stakeholders commented that food manufacturers seek to make profits, requiring government action on initiatives such as the sugar tax. Finally, the domain of ‘societal pressures’ encompasses a range of factors, including the increasing use of screen time by children, social media influencers and the wider advertising industry promoting unhealthy products, and the emphasis on large portion sizes. Level 6: Global The ‘global’ level highlighted the role of changing climate and farming practices on food supplies and eating habits. It has 5 domains (Located in the middle of the left-hand side, Fig. 1). There is the potential for armed conflict elsewhere in the world or other sources of trade disruption such as trade tariffs which affect food supply and food prices. Relative importance of different factors We considered the relative importance of the different factors. In Workshop 1, stakeholders allocated a total of 240 dots (out of a possible 460) to the factors that they felt had the most influence on excess weight in 0–5 year olds. In Workshop 2, stakeholders allocated 320 dots (out of a possible 440). We ranked the factors based on the total number of dots allocated across both workshops (see Table 3 ). Whilst there were some differences between the workshops, parent-related factors and national policies were ranked highly by stakeholders in both workshops. This included parents’ income, poverty and budget; parents’ knowledge and confidence; and parents’ mental health, government funding and policies such as the funding of early years services. Table 3 The factors ranked as most influential on excess weight in 0–5 year olds Factor Workshop 1- Number of dots (n = 240) Workshop 2- Number of dots (n = 320) Combined workshops total Rank Income, poverty & budget 18 32 50 1 Parenting confidence and knowledge of food 21 6 27 2 Government policies and funding 9 10 19 3 Parents mental health 6 13 19 3 Expensive healthy food 9 8 17 5 Early year services 6 10 16 6 Antenatal/postnatal feeding advice and support 6 9 15 7 Physical activity 11 3 14 8 Inequalities 12 12 9 Advertising 11 11 10 Use of convenience food 7 4 11 10 Relationships between factors We explored the relationships between different factors within the map. Table 4 shows summary statistics for the connected part of the map, ordered by the rank given to factors by workshop participants in descending order. We also developed the systems map (Fig. 3) though using the weighting of the factors by the statistics in Table 4 and the number of relationships one node has with other nodes in the map. In general, there was agreement between what was deemed important by workshop participants directly and what was indicated by the connectivity of the network. Financial issues were interesting in that many such as ‘Easier to find cheaper, unhealthy food’, ‘Funding of preventative services’, ‘Not having the money to follow weight management advice’ were viewed as contributing to other nodes but were not influenced by other nodes, so the relationship was one way. This highlights the importance of considering financial issues, be it on an individual or policy level when considering interventions. For example, advising how parents can cook healthier food on a budget. Table 4 Summary statistics for the influence map Node Workshop Rank Percent Rank Betweenness Degree In degree Out degree Income, poverty & budget 50 9.54 682.60 6 4 2 Parenting confidence and knowledge of food 27 5.15 0.33 2 2 0 Parents’ mental health 19 3.63 0.00 1 1 0 Expensive healthy food 17 3.24 146.00 3 0 3 Advertising 11 2.10 1.50 3 0 3 Use of convenience food 11 2.10 351.00 3 3 0 Access to food 10 1.91 95.40 3 3 0 Lack of time 10 1.91 0.00 1 1 0 Easier to find cheaper, unhealthy food 9 1.72 285.00 7 0 7 Feeding methods 9 1.72 191.00 3 3 0 Access to opportunities for physical activity 8 1.53 0.00 1 1 0 Approach to weaning 8 1.53 30.00 2 2 0 Sugar tax 7 1.34 50.00 2 1 1 Resilience 7 1.34 0.00 1 1 0 6 2.80 98.00 2 0 2 Support for parents 6 2.80 0.00 1 0 1 Anxiety 6 2.80 50.00 2 0 2 Food availability 6 1.15 0.00 1 1 0 Parenting style/skills 5 0.95 0.00 1 1 0 Food price inflation 4 0.76 4.20 2 0 2 Child 4 0.76 0.00 1 1 0 Parenting confidence 4 0.76 0.00 1 1 0 Difficulty recruiting and retaining staff 3 0.57 0.00 2 1 1 Funding of preventative services 3 0.57 257.50 7 0 7 Not having the money to follow weight management advice 3 0.57 242.40 4 3 1 Snacking 3 0.57 0.33 2 2 0 Money to pay for electricity/ gas to undertake cooking and store food 3 0.57 4.20 2 2 0 Over-consumption of sugar within diet 3 0.57 0.00 1 1 0 Indoor activities 2 0.38 50.00 2 1 1 Impact of work 2 0.38 0.00 1 1 0 Use of food as a parenting tool 2 0.38 0.00 1 1 0 Cost of childcare provision 1 0.19 0.00 1 0 1 Funding to parents 1 0.19 302.03 7 2 5 Funding of weight management services 1 0.19 420.50 6 0 6 Conflicting messages about what is healthy or not 1 0.19 0.33 2 2 0 Perceived stigma accessing help 1 0.19 0.00 1 1 0 Govt childcare policies 0 0.00 618.83 10 0 10 Industry funding as a marketing tool 0 0.00 1.50 3 0 3 Provision of affordable & accessible leisure activities 0 0.00 50.00 2 1 1 Help with cost of living crisis 0 0.00 205.13 7 2 5 Lack of availability of services and staff 0 0.00 50.00 2 1 1 Lone parents/co-parenting 0 0.00 0.00 1 0 1 Staff confidence in raising weight/eating concerns 0 0.00 0.00 2 2 0 Staff training 0 0.00 0.00 1 1 0 Budgets of childcare providers 0 0.00 0.00 1 1 0 Provision of childcare to cope with additional needs 0 0.00 0.00 1 1 0 Childcare providers cost of food 0 0.00 0.00 1 1 0 Lack of support and resources to provide healthy lifestyles including in alternative formats 0 0.00 0.00 1 1 0 Having peers to share knowledge/concerns with 0 0.00 0.00 1 1 0 Juggling multiple pressures 0 0.00 0.00 1 1 0 Cultural appropriateness of food 0 0.00 0.00 1 1 0 Can't afford to waste food 0 0.00 4.20 2 2 0 Parents’ food knowledge and behaviours 0 0.00 608.00 3 3 0 Antenatal and post-natal 0 0.00 0.00 1 1 0 Anxiety about child's eating 0 0.00 0.00 1 1 0 Not feeling safe taking children out 0 0.00 0.00 1 1 0 Access to cooking facilities 0 0.00 0.00 1 1 0 Footnote: Table 4 shows the parts of the connected part of the systems map with the rank given by participants. Discussion Summary of findings The final systems map model identifies 20 domains with 153 specific factors. These are grouped into six embedded levels of influences. ‘Child’ is central, and includes physiology, demographics, child’s food preferences, and their specific health and social needs. Parents are viewed as a key level, including parent’s income and resources, mental health, life pressures, parenting style and skills, knowledge and behaviour around food, and support received about feeding within antenatal and postnatal care. ‘Wider family and social networks’ focused on the influence of grandparents, wider family and friends. The ‘Local’ level of influence includes the local physical environment, availability of childcare providers and their food provision and support and services provided by local governments including early years services. ‘National’ includes government policies and funding, food suppliers and retailers, and societal pressures. Finally, ‘Global’ includes events that affected food supply and prices. The domains of parenting skills, parental income, and government policies and funding were considered the most significant by stakeholders. Analysis shows that financial considerations drive the majority of connections within the systems map, with access to food, feeding practices, government childcare policies, and sharing of best practice knowledge between parents as key contributing factors. Comparison with existing literature Many of our factors were similar to the Foresight map. (8) We deliberately used different language from Foresight because we wanted to use language understood by a range of stakeholders. For example, we use ‘knowledge about food’ rather than ‘food literacy’. The focus on parents and early years services in our map was a unique finding not identified in the Foresight map. Our findings were consistent with Brown et al.’s (25) systematic review who show the need for wider community‐level interventions, together with upstream environmental and policy interventions, alongside interventions aimed at individuals. Consistent with Brownson et al. (26), we identified how factors in different parts of the system potentially affect each other. Future work could build on their ‘causal loop’ work by specifically focusing on the system for 0-5 year olds. As is the case with physical activity, we identified a need to consider health inequalities. (27) Strengths and limitations This is the first systems map that we are aware of which focuses specifically on 0–5-year-olds. It is grounded in stakeholder perspectives because it was developed in conjunction with a range of stakeholders. There were four limitations. First, it was developed with stakeholders who were based in two nations of the UK. This may limit its geographic generalisability, but international research literature and policy documents were included to increase the map’s generalisability. Second, the findings from workshops are likely to suffer from the same limitation as consensus exercises, in that they are dependent on the characteristics of attendees, with stakeholders placing an emphasis on the factors within their immediate experiences. (28) Others may wish to repeat our workshops in different countries with other types of stakeholders such as dieticians. Third, we were able to identify some, but not all of the connections between different factors, as this activity was challenging for participants in the workshops. Fourth, few parents took part in the workshops, the majority of participants attended in their professional capacity. Implications for practice and research There are four implications. First, consistent with other literature, it is evident from our work that the multiple- levels of influence cannot be addressed by a single intervention. Different interventions should be aimed at different parts of the system to prevent excess weight gain amongst 0–5-year-olds. Any intervention aimed at one part of the system needs to consider how other parts of a dynamic, responsive system are affected by the intervention, or how they affect the intervention. Second, our work highlights the need to consider specific issues impacting on 0-5 year olds and how this might be achieved by working with stakeholders across the system, including parents, early years services, childcare providers and policy makers. Third, stakeholders described how parents’ knowledge about food was not simply linked to education, but about how to address barriers people face such as how to cook healthy food on a limited budget. The emphasis on poverty, income and finances within the map highlights the need for any interventions to consider the limited resources available to many parents. Fourth, future research could test the generalisability of the systems map to different contexts and exploring the relationships between different factors perhaps through social network analysis. Conclusions There are multiple interacting influences on excess weight gain in 0–5 year-olds. Some are unique to young children, particularly the influence of parents and other caregivers. Financial considerations drive a lot of the connectivity within and across factors in this systems map. Our systems map can be used to support the development and evaluation of interventions aiming to prevent or reduce excess weight amongst 0–5 year-olds. For example, any intervention focused on improving parents’ knowledge and confidence around food would have the potential to facilitate children’s healthy weight but would need to be cognisant of the multiple other influences at play. Abbreviations HENRY- Healthy Education for the Really Young NI- Northern Ireland NIHR- National Institute for Health and Care Research UK- United Kingdom Declarations Ethics approval and consent to participate- Ethical approval was received from the Department of Health Sciences’ Research Governance Committee, University of York, York (ref HSRGC/20210/428/A). All stakeholders in the workshops gave written informed consent. Availability of data and materials- The data that can be used is included within the manuscript and supplementary files. Competing interests- The authors declare that they have no competing interests Funding- This study/project is funded by the NIHR (NIHR135081). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funder was not involved in the design, data collection analysis or interpretation of data or writing the manuscript. Clinical Trial Number: ISRCTN16529380 Authors’ contributions- AOC and AF wrote the manuscript. AOC, AF and AS led on the development of Workshop 1 and development of the systems maps. PG led on the refinement of the systems maps. WB facilitated both workshops and the Parent Involvement Group. LG and AK organised Workshop 2. LS provided input as a Parent Representative. MB was the Principal Investigator. All other authors supported the systems mapping work. All authors reviewed the draft manuscript. Acknowle dgements -We are grateful to people who have supported our research. This includes the parents that attended the involvement group and people that attended the workshops. We are thankful to Vera and Danielle Logan, Dunla Gallagher and Katy Thompson for supporting Workshop 2. Finally, we appreciate the input of Dr Veronica Fibisan on producing the initial systems map and ecological framework on Canva. References Jones R, Jewell J, Saksena R, Ramos Salas X, Breda J. Overweight and Obesity in Children under 5 Years: Surveillance Opportunities and Challenges for the WHO European Region. Front Public Health. 2017;5:58. NHS Digital. National Child Measurement Programme, England, 2023/24 School Year. https://digital.nhs.uk/: NHS Digital; 2024. Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-53. Hillier F, Pedley C, Summerbell C. Evidence base for primary prevention of obesity in children and adolescents. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2011;54(3):259-64. Redsell S, Atkinson P, Nathan D, Siriwardena A, Swift J, Glazebrook C. Preventing childhood obesity during infancy in UK primary care: a mixed methods study of HCPs' knowledge, beliefs and practice. BMC Fam Pract. 2011;12:54. Redsell S, Edmonds B, Swift J, Niroshan Siriwardena A, Weng S, Nathan D, et al. Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood. Matern Child Nutr. 2016;12(1):24-38. Public Health England. Whole systems approach to obesity: a guide to support local approaches to promoting a healthy weight. 2019. Vandenbroeck I, Goossens J, Clemens M. Tackling Obesities: Future Choices — Obesity System Atlas. Foresight: Government Office for Science; 2007. Bryant M, Burton W, O'Kane N, Woodside J, Ahern S, Garnett P, et al. Understanding school food systems to support the development and implementation of food based policies and interventions. Int J Behav Nutr Phys Act. 2023;20(1):29. Jessiman P, Powell K, Williams P, Fairbrother H, Crowder M, Williams J, et al. A Systems Map of the Determinants of Child Health Inequalities in England at the Local Level. PLoS One. 2021;16(2):e0245577. Griffiths C, Radley D, Gately P, South J, Sanders G, Morris M, et al. A complex systems approach to obesity: a transdisciplinary framework for action. Perspect Public Health. 2023;143(6):305-9. Brennan L, Sabounchi N, Kemner A, Hovmand P. Systems thinking in 49 communities related to healthy eating, active living, and childhood obesity. J Public Health Manag Pract. 2015:S55-S69. Hammond R. Complex systems modeling for obesity research. Prev Chronic Dis. 2009;6(3):A97. McGlashan J, Johnstone M, Creighton D, de la Haye K, Allender S. Quantifying a systems map: network analysis of a childhood obesity causal loop diagram. PLoS One. 2016;11(10):e0165459. Bronfenbrenner U. Ecological systems theory (1992). In: Bronfenbrenner U, editor. Making human beings human: Bioecological perspectives on human development. London: Sage Publications Ltd.; 2005. p. 106-73. Csárdi G, Nepusz T. The igraph software package for complex network research. InterJournal Complex Systems; 2006. Butland B, Jebb S, Kopelman P, McPherson K, Thomas S, Mardell J, et al. Tackling Obesities: Future Choices – Project report. London: Government Office for Science; 2007. Innovation Lab. Childcare Strategic Insight Programme. Virtual Strategic Insight Lab: Department of Finance; 2021. Croker H, Russell S, Gireesh A, Bonham A, Hawkes C, Bedford H, et al. Obesity prevention in the early years: A mapping study of national policies in England from a behavioural science perspective. PLoS One. 2020;15(9):e0239402. Campbell M. Biological, environmental, and social influences on childhood obesity. Pediatr Res. 2016;79(1-2):205-11. Chatham R, Mixer S. Cultural Influences on Childhood Obesity in Ethnic Minorities: A Qualitative Systematic Review. J Transcult Nurs. 2020;31(1):87-99. NICE. Obesity in children and young people: prevention and lifestyle weight management programmes. NICE (National Institute for Health and Care Excellence); 2015. Safety DoNaF. A Primary Health Care Approach to Obesity Prevention and Management in Children and Adolescents: Policy Brief. World Health Organisation; 2023. Department of Health and Social Care. Childhood obesity: a plan for action. HM Government; 2018. Brown T, Moore T, Hooper L, Gao Y, Zayegh A, Ijaz S, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2019;7(7):CD001871. Brownson R, Kemner A, Brennan L. Applying a mixed-methods evaluation to Healthy Kids, Healthy Communities. J Public Health Manag Pract. 2015;21:S16-S26. Jones S, Porroche-Escudero A, Shearn K, Hunter R, Garcia L. Thinking about inequalities in physical activity as an emergent feature of complex systems. Int J Behav Nutr Phys Act. 2024;21(1):125. Murphy M, Black N, Lamping D, McKee C, Sanderson C, Askham J, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(3):i-iv, 1-88. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6272933","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":439511623,"identity":"903436ae-5084-4665-be53-fa725710f9dc","order_by":0,"name":"Alexis 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00:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6272933/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6272933/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81694751,"identity":"16a0c098-eb7b-4d40-8910-c30643fbd625","added_by":"auto","created_at":"2025-04-30 11:54:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2072845,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFinal Systems Map\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1SystemsMap.png","url":"https://assets-eu.researchsquare.com/files/rs-6272933/v1/c7a72041c615daa2bada7a97.png"},{"id":81693022,"identity":"eb84bb88-f4cf-4ac4-ab86-5242e7fb5319","added_by":"auto","created_at":"2025-04-30 11:46:03","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":582599,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEcological Framework\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2Frameworkofdomainsinfluencingexcessweightgain.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6272933/v1/879fffc4f89a7431e1df3cac.jpeg"},{"id":81693023,"identity":"53c34a9d-3b79-42a8-a914-e936417f19a2","added_by":"auto","created_at":"2025-04-30 11:46:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2217864,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWeighted Systems Map\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3Weightedsystemsmap.png","url":"https://assets-eu.researchsquare.com/files/rs-6272933/v1/ed21f834b9c334f999ec7696.png"},{"id":82319710,"identity":"2d89286d-c283-4ab2-9e37-44624d3cb0bf","added_by":"auto","created_at":"2025-05-09 04:31:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5995526,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6272933/v1/bc055ec6-435b-48f0-a3f2-226fe5e33552.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influences on excess weight gain amongst 0-5 year old children: A Stakeholder produced systems map","fulltext":[{"header":"Background","content":"\u003cp\u003eExcess weight gain in 0\u0026ndash;5 year old children is a global problem. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) In the United Kingdom (UK) in 2023/4, 22% children were overweight or living with obesity when starting school (aged 4 or 5 years). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Rates were higher in the most deprived areas (26.1% compared to 17% in the least deprived areas). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) This is problematic because of the detrimental impact of living with excess weight on children\u0026rsquo;s mental and physical health. It also raises the risk of living with obesity throughout their lives and the subsequent (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) long-term health conditions that significantly impact quality of life and life expectancy. (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eResearch and policy is becoming increasingly aware of the importance of a \u0026lsquo;whole systems approach\u0026rsquo; to understanding the drivers of obesity at multiple levels including individual level issues like food knowledge and preferences and the wider food environment e.g. food policy and food production. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Maps of the systems influencing obesity have been developed for adults. A key example is the Foresight map, which considers the influence of national policies, food manufacturing processes, local infrastructure, and individual behaviours on appetite regulation. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) A similar map has also been developed for school food systems for school food choices (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and there is also a map that highlights interrelated determinants of health inequalities of people aged 0\u0026ndash;25. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) However, there is no systems map focusing on young children aged 0\u0026ndash;5 years old, where some factors beyond the individual (i.e. the child) will be of greater importance, and where unique factors may operate. These factors may include the influence of parents, childcare providers and weaning approaches. Such a map could be used to inform the development of policies and interventions aimed at different parts of the system and understand how different interventions may interact, with potentially unforeseen and unintended consequences. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Given this, we aimed to employ systems thinking and integrate stakeholder input to construct a systems map that identifies the key factors contributing to excess weight gain in children aged 0\u0026ndash;5 years across the UK.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eSystems mapping was used to identify the influences on excess weight gain in 0\u0026ndash;5 year olds, including identifying factors and describing their interactions. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) We co-produced the systems map with stakeholders using a sequential iterative design consisting of four phases described fully below: 1) A stakeholder workshop to produce the first draft map; 2) A discussion with a group of parents to refine the map; 3) A literature review of existing obesity frameworks and systems maps in international publications and policy documents to identify missing factors, and 4) A further stakeholder workshop to refine the map. Given the unequal distribution of obesity by socio-economic status, stakeholders were asked to consider inequalities when developing the map.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1. First stakeholder workshop\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAttendees and processes\u003c/h2\u003e \u003cp\u003eWe held the first 6-hour workshop in a location in the North of England in the UK in March 2023. The 23 stakeholders included childcare practitioners, public health specialists, commissioners of weight management programmes, providers of weight management programmes, researchers studying obesity, and parents with children in the target range (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Specific roles included front-line workers delivering infant feeding programmes, early year service managers, commissioners of childhood obesity programmes, and parent wellbeing support workers. Stakeholders worked for a variety of organisations including local government regions (called Local Authorities in England), childcare providers and universities. Two parents attended. Many of the other stakeholders were also parents but attended in their professional capacity. Travel expenses were offered to enable attendance at the workshop.\u003c/p\u003e \u003cp\u003eWe used a group model-building approach to develop our systems map. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) This involved different stakeholders working together to build a shared understanding of factors that contribute to excess weight gain in early years and the draft development of a systems map to highlight how factors interrelate. The workshop was co-led by a systems expert (AS) and a qualitative researcher (AOC). We divided attendees into five groups of 4\u0026ndash;6 diverse stakeholders. Each group was facilitated by a member of the research team (WB, DGW, MC, AF, MB/LS). We ran the following series of activities to help each group develop their own systems map:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eLearning systems thinking\u003c/span\u003e: The workshop co-leads introduced the aim of the day and introduced stakeholders to simple ways of thinking about systems by drawing examples of factors and arrows (relationships) between them.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIdentifying factors\u003c/span\u003e: Each group then brainstormed factors that they felt impacted on excess weight gain amongst 0\u0026ndash;5 year olds and wrote these on flip chart paper.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIdentifying relationships between factors\u003c/span\u003e: Stakeholders were then asked to consider how different factors (known as nodes within the map) related to one another (known as an edge list) by drawing lines between each factor to show these relationships. They were asked to add positive (+) or negative (-) modifiers to each connecting line to denote a positive or negative inter-relationship where possible. For example, the government subsidising healthy food for low-income families positively impacted on the ability to buy healthy food, so would be labelled as \u0026lsquo;+\u0026rsquo; on an arrowed line connecting the two factors.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eConsidering health inequalities\u003c/span\u003e: Prior to the workshop, a number of research team members (AF, AOC, WB and the Parent Advisory Group (see next section)) developed six vignettes or scenarios of fictional families with young children to help stakeholders consider health inequalities relating to downstream obesity impacts. For example, parents with disabilities, families living in rural areas, and single parents. Each group was given two of these vignettes and used these to identify additional factors in their systems map.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRelative importance of factors\u003c/span\u003e: Each stakeholder was given twenty \u0026ldquo;sticky dots\u0026rdquo; (i.e. small coloured circular post-it stickers) and asked to allocate any number of these to the factors on the five maps that they felt were most important. This activity invited stakeholders to vote and hence prioritize the factors they thought were important.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCreating the first iteration of the systems map\u003c/h3\u003e\n\u003cp\u003eAfter the workshop, two members of the team collated the five maps into one master map (AF and AOC). This involved reading each map to aid familiarisation, listing the factors from all the maps and grouping these into domains and factors using the concept of affinity mapping (equivalent to developing themes and sub-themes in qualitative analysis). AF and AOC then created a matrix of factors in an Excel spreadsheet, grouped within domains. AF and AOC returned to the five maps and documented the relationships between factors using (+), (-), and (*) denoting positive, negative and neutral/missing relationships respectively. The weight of different factors was also calculated by counting the frequency of the votes (i.e. \u0026lsquo;sticky dots\u0026rsquo;) given to each factor. This was imported into Canva (Canva Pro Licence) to draw a single map. The draft map was then shared with the wider research team \u0026ndash; some of whom had been facilitators during the workshop - to check that it accurately represented the findings. While there was consensus that the map reflected the workshop discussion, it became evident that some known factors that influence appetite regulation (and therefore excess weight gain) were not included. We also shared the draft map with all workshop attendees to check for accuracy and comprehensiveness. We received one response, which we used to clarify the different childcare providers and early year support services in the map.\u003c/p\u003e \u003cp\u003eThe preliminary systems map generated was extensive and complex. At this stage, Bronfenbrenner\u0026rsquo;s ecological systems theory of child development was applied. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) This theory posits that child development is influenced by multiple layers of environmental factors, with the child at the centre, surrounded by the microsystem (e.g. family), mesosystem (e.g. social welfare services), and macrosystem (e.g. culture). We subsequently categorised domains within system levels, resulting in a condensed version of the systems map. We referred to this as an ecological framework.\u003c/p\u003e\n\u003ch3\u003e2. Parent Advisory Group\u003c/h3\u003e\n\u003cp\u003e We invited an existing \u0026lsquo;Parent Advisory Group\u0026rsquo; consisting of 6 parents to contribute to the map development. All had young children and were recruited via a Children\u0026rsquo;s Centre based in a socio-economically deprived neighbourhood. Prior to the first workshop, we had an in-person discussion of the plan for the systems mapping exercise, including how best to ensure participation from parents and to sense check documents that we planned to use during the process. This Parent Advisory Group also met to provide feedback on the first iteration of the systems map. They met for 2 hours in person. At the session, AF and WB presented a large printout of the overall systems map. Parents discussed the map including suggesting missing factors.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3. Literature review of existing literature and policy documents\u003c/h2\u003e \u003cp\u003eWe searched for three types of documents to check for omitted factors within our initial iteration of the map. This was not a systematic review. First, we searched for system maps and frameworks on obesity for any age group. We were signposted to these by topic experts within the research team. Second, we conducted a search of evidence reviews that described influences on early childhood obesity/excess weight in Google Scholar (search undertaken in January 2024 of the first two pages). Finally, we identified national and international policy documents and reports which focused on prevention of excess weight; for example, World Health Organisation reports. AF read these documents, specifically searching for key omissions from our map.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e4. Second stakeholder workshop\u003c/h3\u003e\n\u003cp\u003eWe conducted a second workshop in another part of the UK (Northern Ireland) to provide further perspectives on the system map. Twenty-two stakeholders attended in May 2024 (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The workshop was facilitated by LM and WB. WB had facilitated the previous workshop and Parent Advisory Group. LM was a topic expert and had expertise in systems approaches. Three additional researchers supported facilitation. In the 2-hour workshop, the stakeholders reviewed the systems map. They had a systems map without the relationship arrows because the focus of the exercise was the content of the map rather than the relationships. The stakeholders identified missing factors which were predominantly related to the different geographical, cultural and political context of Northern Ireland compared with England. Stakeholders then considered relationships by drawing lines between factors on the map and using \u0026lsquo;+ and \u0026ndash;\u0026rsquo; to indicate relationships. Similar to Workshop 1, attendees were asked to apply 20 \u0026lsquo;sticky dots\u0026rsquo; to factors that they felt were the most influential. The scores from the two workshops were combined to identify the most influential factors from stakeholders\u0026rsquo; perspectives.\u003c/p\u003e\n\u003ch3\u003eFinal systems map\u003c/h3\u003e\n\u003cp\u003eWe developed a final iteration of the map by incorporating suggestions from both workshops, the Parent Advisory Group and the literature. At this stage, the domains, and factors within them, were classified as \u0026lsquo;nodes\u0026rsquo; to be consistent with terminology used within systems mapping. We developed the systems map to include the relationships between nodes. We did this through creating edge lists which capture the relationships between the nodes. The node and edge lists were visualised in R and iGraph. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The solid lines on the map denote relationships between the nodes (factors). Dotted lines indicate the domains the nodes are associated with. These relationships were identified from both stakeholder workshops and the Parent Advisory Group and are weighted either as +\u0026thinsp;ve, -ve, or neutral and constitute the connected part of the map. The connectivity of the parts of the map were analysed to give an additional perspective on importance placed on the different parts of the system by workshop participants. We used the relationships represented by solid lines to calculate thedifferent centrality measures of some of the nodes. This enabled us to rank nodes by establishing how connected they are to the rest of the network. After finalising the systems map, we returned to the ecological framework to ensure consistency between the two.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTypes of attendees at the two workshops\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Stakeholder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkshop 1\u003c/p\u003e \u003cp\u003eNorth of England\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWorkshop 2\u003c/p\u003e \u003cp\u003eNorthern Ireland\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatricians/Child Health Specialists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Practitioner/Family doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFront-line service provider e.g. Health Visitor, Early Years Practitioner, Infant Feeding Worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicy Maker/Commissioner/ Public Health Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe final systems map had 20 domains (themes) and 153 factors (nodes) as shown in Fig. 1. We describe how each method contributed to the iterative development of the map in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The ecological framework summarises the systems map within six embedded levels (Fig. 2).\u003c/p\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eIterations of the systems map\u003c/h2\u003e\n \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n \u003ch2\u003e1.Contibution of the First Stakeholder workshop\u003c/h2\u003e\n \u003cp\u003eWe developed an initial map which had 139 factors, grouped by different domains. We utilised Plain English for the factors to reflect the language used by stakeholders. The initial map included most of the factors that feature in the final systems map. The factors ranged from induvial child factors, parental influences and policies of the national government.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e2. Contribution of the Parent Advisory Group\u003c/h2\u003e\n \u003cp\u003eDuring the session with the Parent Advisory Group, we learnt that parents were generally happy with the map, feeling that it resonated with their experiences. They discussed the language used, encouraging the use of Plain English and language that did not blame parents. The parents identified additional factors such as the preferences of individual children, the difficulty in determining if their child was living with excess weight, and the gendered approach to food preparation. The group felt that it was predominantly mothers rather than fathers who felt responsibility for food in the family and who attended any healthy eating courses aimed at families.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e3. Contribution of literature\u003c/h2\u003e\n \u003cp\u003eWe identified four existing maps that we used to inform our early years systems map. (i) The Foresight system map identifies seven key subsystems or themes for adults: physiology, individual\u0026rsquo;s physical activity, physical activity environment, food consumption, food production, individual\u0026rsquo;s psychology (e.g. stress), and social psychology (e.g. society, media). (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) This highlighted that physiology was a missing domain in our map because it had not been previously identified by our stakeholders). (ii) (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) considered factors that may contribute to children of any age living with obesity in Northern Ireland. It did not specifically consider younger children. It reported similar factors to the Foresight system map, but with the added factors of the influence of parents and peers. From this map, we identified that we were missing some factors relating to Foods High in Fat, Salt and Sugar and food regulations including labelling. (iii) The CONNECTS-Food systems map focused on influences on children\u0026rsquo;s diet in school. (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e) It identified four key themes: leadership and curriculum, child food preference, home environment and school food environment. Some of this map was not relevant to our pre-school focus but it supported the importance of \u0026lsquo;child preference\u0026rsquo; that had been added by the Parent Advisory Group in the previous iteration. (iv) Croker et al (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) focused on policy levers that governments can make to achieve system-wide change based on the Foresight system map. We did not add anything to our map from Croker et al (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) because we had already included relevant factors from the Foresight system map.\u003c/p\u003e\n \u003cp\u003eWe identified Campbell et al.\u0026rsquo;s (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) review describing individual level factors (biological, social, and behavioural risks), which were embedded in the child\u0026rsquo;s family environment and the community environment. This confirmed the importance of the different levels of influences in our ecological framework. The review also confirmed the importance of adding physiology to our systems map and considering demographic issues such as sex and ethnicity. Chatham and Mixer\u0026rsquo;s (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e) review was important because it focused on qualitative research with ethnic minorities, bringing cultural influences into our map. They identified nine themes of: child feeding, family, gender roles, food, healthy child appearance, physical activity, sedentary behaviour, food cost and local environment and infrastructure. These did not affect the domains in our map but the \u0026lsquo;gender roles\u0026rsquo; supported the Parent Advisory Group point about women largely taking responsibility for their children\u0026rsquo;s food. We felt that the theme of \u0026lsquo;healthy child appearance\u0026rsquo; sat within our \u0026lsquo;wider family network\u0026rsquo; domain under \u0026lsquo;cultural norms\u0026rsquo;.\u003c/p\u003e\n \u003cp\u003eFinally, the policy documents of the National Institute for Care Excellence (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e) World Health Organisation (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e) and UK Government Obesity Policy (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) helped us to affirm omissions from our initial map. These were physiological causes of excess weight gain, the impact of gender and ethnicity on children\u0026rsquo;s weight, and global issues including climate change and farming practices.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003e4. Contribution of Workshop 2\u003c/h2\u003e\n \u003cp\u003eAt Workshop 2, the stakeholders supported the content of the map, feeling that parental mental health status was particularly important. The stakeholders also identified additional factors (including some that were considered to be Northern Ireland-specific issues).These included factors which were related to the commercial determinants of health e.g. marketing of food, political divisions within communities that reduce access to services, cost of childcare (there is no subsidised early years childcare provision in Northern Ireland), quality of maternity care, reliable sources of information about healthy eating, provision of physical education, access to safe outdoors play areas, maternal age and weight, the time children spend using screens and cultural beliefs including a resistance to breastfeeding and an obsession with babies gaining weight.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eContributions of methods to the iterative development of the systems map\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIteration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEngagement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChanges made following the input\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorkshop 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDevelopment of the initial map and ecological framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParent Advisory Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReviewed language to ensure that it was in Plain English.\u003c/p\u003e\n \u003cp\u003eAdded in factors (nodes) related to:\u003c/p\u003e\n \u003cp\u003e● Individual preferences of children;\u003c/p\u003e\n \u003cp\u003e● Difficulty in parents knowing if their child was overweight;\u003c/p\u003e\n \u003cp\u003e● Gendered approach with women generally being responsible for their children\u0026rsquo;s food and attending healthy eating courses.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContribution of literature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConfirmed content of the map and the ecological framework.\u003c/p\u003e\n \u003cp\u003eAdded in factors (nodes) related to:\u003c/p\u003e\n \u003cp\u003e● The impact of gender and ethnicity on children\u0026rsquo;s weight;\u003c/p\u003e\n \u003cp\u003e● Global issues including climate change and farming practices.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorkshop 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdded in factors related to:\u003c/p\u003e\n \u003cp\u003e● Commercial determinants of health;\u003c/p\u003e\n \u003cp\u003e● Accessibility of services in different communities;\u003c/p\u003e\n \u003cp\u003e● Cost of childcare;\u003c/p\u003e\n \u003cp\u003e● Quality of maternity care;\u003c/p\u003e\n \u003cp\u003e● Reliable sources of information about healthy eating;\u003c/p\u003e\n \u003cp\u003e● Provision of physical education;\u003c/p\u003e\n \u003cp\u003e● Access to safe outdoor play areas;\u003c/p\u003e\n \u003cp\u003e● Maternal age and weight;\u003c/p\u003e\n \u003cp\u003e● Time children spend using screens.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eThe final systems map\u003c/h2\u003e\n \u003cp\u003eWe grouped 153 factors in the systems map into 20 domains (Fig.\u0026nbsp;1). Below we describe the domains and factors (that is nodes on the map), organised by the embedded levels of the ecological framework: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) child; (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) parents; (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) wider family/social networks; (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) local; (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) national; and (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) global.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eLevel 1: Child\u003c/h2\u003e\n \u003cp\u003e\u0026lsquo;Child\u0026rsquo; is at the centre of our ecological framework and is represented by four domains in the systems map (top left on the map, Fig.\u0026nbsp;1): (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) \u0026lsquo;Preferences\u0026rsquo; describes how each child is unique in terms of desires around exercise and food; (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) \u0026lsquo;Specific needs\u0026rsquo; describes variations in health and social needs, for example, different medical needs that might affect appetite and eating habits; (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) \u0026lsquo;Physiology\u0026rsquo; includes birthweight, appetite and metabolism; and (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) covers demographic issues, including sex and ethnicity which might affect eating habits and weight.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eLevel 2: Parent\u003c/h2\u003e\n \u003cp\u003e\u0026lsquo;Parent\u0026rsquo; has the largest number of domains (n\u0026thinsp;=\u0026thinsp;6), reflecting how parents have significant responsibility for younger children\u0026rsquo;s food and physical activity (top right of the map, Fig.\u0026nbsp;1). \u0026lsquo;Life pressures\u0026rsquo; includes parents juggling multiple commitments of children, work, running a home and sometimes caring responsibilities for older relatives which limits the amount of time they have to focus on healthy eating and physical activity for their children. For example, this can lead to parents relying on convenience food when getting home late from work.\u003c/p\u003e\n \u003cp\u003eA second domain is \u0026lsquo;parenting styles and skills\u0026rsquo;. Some parents feel more confident than others in setting boundaries around food and saying no to unhealthy foodstuffs.\u003c/p\u003e\n \u003cp\u003eA third domain is \u0026lsquo;food knowledge and behaviour\u0026rsquo;. Stakeholders felt that some parents can lack knowledge about healthy eating and physical activity for themselves and their children. Or even if they have the knowledge, they struggle to implement it. For example, a parent\u0026rsquo;s own food behaviour can influence how they feed their young children, such as eating (or not eating) vegetables, or snacking when watching the television.\u003c/p\u003e\n \u003cp\u003eA fourth domain is parents\u0026rsquo; mental health status. This is called \u0026lsquo;Psychology\u0026rsquo; in the Foresight map. Parents\u0026rsquo; mental health status may lead to low motivation to plan and cook meals.\u003c/p\u003e\n \u003cp\u003eThe fifth domain is \u0026lsquo;income and resource\u0026rsquo; constraints, where parents may not have a sufficient income to afford fresh food or have sufficient credit on their gas meter to cook. Stakeholders felt that there is an increasing number of parents working in insecure jobs that might be called \u0026lsquo;the working poor\u0026rsquo;.\u003c/p\u003e\n \u003cp\u003eThe final domain was \u0026lsquo;antenatal and postnatal support\u0026rsquo; which encompasses how parents are supported with feeding and weaning babies such as breastfeeding support.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eLevel 3: Wider family/social networks\u003c/h2\u003e\n \u003cp\u003eThe level \u0026lsquo;wider family/social networks\u0026rsquo; includes grandparents, friends and extended family who are sometimes responsible for feeding and looking after young children. It consists of 5 domains (bottom right of the map in Fig.\u0026nbsp;1). There may be generational differences in food consumption or cultural norms around infant feeding, beliefs about what a healthy child looks like, and food choices. Examples given by stakeholders included stigma around breastfeeding or parents feeling unable to enforce healthy eating rules when family members were providing childcare.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eLevel 4: Local\u003c/h2\u003e\n \u003cp\u003eThe \u0026lsquo;local\u0026rsquo; level includes four domains (n\u0026thinsp;=\u0026thinsp;4) (top left in the systems map in Fig.\u0026nbsp;1). The first domain is the local \u0026lsquo;physical environment\u0026rsquo;, including access to green space, leisure facilities and transport which could affect the amount of physical activity undertaken by young children.\u003c/p\u003e\n \u003cp\u003eThe second domain is \u0026lsquo;early year support services\u0026rsquo; in the locality such as parenting courses and Heath Visitors proving information on a child\u0026rsquo;s development. Stakeholders discussed how the availability of early years support services was dependent on local and regional funding, with inconsistency in access to services by geographical location, cultural appropriateness and over time. Stakeholders described \u0026lsquo;a postcode lottery\u0026rsquo; of services, with access to services particularly challenging when living in rural areas. Stakeholders also described how funding of support services was often short-term and unstable, limiting the availability of consistent and trusted services to local communities.\u003c/p\u003e\n \u003cp\u003eThe third domain \u0026lsquo;childcare providers\u0026rsquo; can influence children\u0026rsquo;s weight because these providers have responsibility for feeding children and for their physical activity levels when children are in their care. Stakeholders described how the quality and type of food provided can be poor quality and not adhere to the same nutritional standards as schools. The final domain is \u0026lsquo;local governments\u0026rsquo;, which have responsibility for the provision of local services and the local physical environment.\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eLevel 5: National\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eThe \u0026lsquo;national\u0026rsquo; level has three domains (n\u0026thinsp;=\u0026thinsp;3) (top of the map, Fig.\u0026nbsp;1). The first domain is \u0026lsquo;government policies and funding\u0026rsquo; which affects the availability of services and staff to support parents and children, influences the price and availability of healthy and unhealthy food, and influences the income and resources available to parents, (e.g. social security benefits). Food banks sat within this domain as a solution to perceived poor government policies and funding.\u003c/p\u003e\n \u003cp\u003eThe second domain relates to \u0026lsquo;food suppliers and retailers\u0026rsquo; that stakeholders described as advertising unhealthy food for children and controlling food prices. Stakeholders perceived that it was easier to access unhealthy foods compared with healthy foods in terms of availability and cost. Stakeholders commented that food manufacturers seek to make profits, requiring government action on initiatives such as the sugar tax. Finally, the domain of \u0026lsquo;societal pressures\u0026rsquo; encompasses a range of factors, including the increasing use of screen time by children, social media influencers and the wider advertising industry promoting unhealthy products, and the emphasis on large portion sizes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003eLevel 6: Global\u003c/h2\u003e\n \u003cp\u003eThe \u0026lsquo;global\u0026rsquo; level highlighted the role of changing climate and farming practices on food supplies and eating habits. It has 5 domains (Located in the middle of the left-hand side, Fig.\u0026nbsp;1). There is the potential for armed conflict elsewhere in the world or other sources of trade disruption such as trade tariffs which affect food supply and food prices.\u003c/p\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eRelative importance of different factors\u003c/h2\u003e\n \u003cp\u003eWe considered the relative importance of the different factors. In Workshop 1, stakeholders allocated a total of 240 dots (out of a possible 460) to the factors that they felt had the most influence on excess weight in 0\u0026ndash;5 year olds. In Workshop 2, stakeholders allocated 320 dots (out of a possible 440). We ranked the factors based on the total number of dots allocated across both workshops (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Whilst there were some differences between the workshops, parent-related factors and national policies were ranked highly by stakeholders in both workshops. This included parents\u0026rsquo; income, poverty and budget; parents\u0026rsquo; knowledge and confidence; and parents\u0026rsquo; mental health, government funding and policies such as the funding of early years services.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe factors ranked as most influential on excess weight in 0\u0026ndash;5 year olds\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWorkshop 1- Number of dots (n\u0026thinsp;=\u0026thinsp;240)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWorkshop 2- Number of dots (n\u0026thinsp;=\u0026thinsp;320)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCombined workshops total\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome, poverty \u0026amp; budget\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParenting confidence and knowledge of food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGovernment policies and funding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents mental health\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpensive healthy food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly year services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntenatal/postnatal feeding advice and support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInequalities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvertising\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of convenience food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eRelationships between factors\u003c/h2\u003e\n \u003cp\u003eWe explored the relationships between different factors within the map. Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows summary statistics for the connected part of the map, ordered by the rank given to factors by workshop participants in descending order. We also developed the systems map (Fig. 3) though using the weighting of the factors by the statistics in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e and the number of relationships one node has with other nodes in the map. In general, there was agreement between what was deemed important by workshop participants directly and what was indicated by the connectivity of the network. Financial issues were interesting in that many such as \u0026lsquo;Easier to find cheaper, unhealthy food\u0026rsquo;, \u0026lsquo;Funding of preventative services\u0026rsquo;, \u0026lsquo;Not having the money to follow weight management advice\u0026rsquo; were viewed as contributing to other nodes but were not influenced by other nodes, so the relationship was one way. This highlights the importance of considering financial issues, be it on an individual or policy level when considering interventions. For example, advising how parents can cook healthier food on a budget.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary statistics for the influence map\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNode\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWorkshop Rank\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent Rank\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBetweenness\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDegree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIn degree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOut degree\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome, poverty \u0026amp; budget\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e682.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParenting confidence and knowledge of food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents\u0026rsquo; mental health\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpensive healthy food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e146.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvertising\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of convenience food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e351.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e95.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEasier to find cheaper, unhealthy food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e285.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeding methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e191.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to opportunities for physical activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eApproach to weaning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSugar tax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResilience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupport for parents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood availability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParenting style/skills\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood price inflation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParenting confidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty recruiting and retaining staff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding of preventative services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e257.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot having the money to follow weight management advice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e242.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSnacking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoney to pay for electricity/ gas to undertake cooking and store food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOver-consumption of sugar within diet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndoor activities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact of work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of food as a parenting tool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCost of childcare provision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding to parents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e302.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding of weight management services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e420.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConflicting messages about what is healthy or not\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived stigma accessing help\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGovt childcare policies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e618.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndustry funding as a marketing tool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvision of affordable \u0026amp; accessible leisure activities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHelp with cost of living crisis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e205.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of availability of services and staff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLone parents/co-parenting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff confidence in raising weight/eating concerns\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBudgets of childcare providers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvision of childcare to cope with additional needs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildcare providers cost of food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of support and resources to provide healthy lifestyles including in alternative formats\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaving peers to share knowledge/concerns with\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eJuggling multiple pressures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural appropriateness of food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCan\u0026apos;t afford to waste food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents\u0026rsquo; food knowledge and behaviours\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e608.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntenatal and post-natal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety about child\u0026apos;s eating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot feeling safe taking children out\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to cooking facilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFootnote: Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the parts of the connected part of the systems map with the rank given by participants.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eSummary of findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe final systems map model identifies 20 domains with 153 specific factors. These are grouped into six embedded levels of influences. ‘Child’ is central, and includes physiology, demographics, child’s food preferences, and their specific health and social needs. Parents are viewed as a key level, including parent’s income and resources, mental health, life pressures, parenting style and skills, knowledge and behaviour around food, and support received about feeding within antenatal and postnatal care. ‘Wider family and social networks’ focused on the influence of grandparents, wider family and friends. The ‘Local’ level of influence includes the local physical environment, availability of childcare providers and their food provision and support and services provided by local governments including early years services. ‘National’ includes government policies and funding, food suppliers and retailers, and societal pressures. Finally, ‘Global’ includes events that affected food supply and prices. The domains of parenting skills, parental income, and government policies and funding were considered the most significant by stakeholders. Analysis shows that financial considerations drive the majority of connections within the systems map, with access to food, feeding practices, government childcare policies, and sharing of best practice knowledge between parents as key contributing factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison\u003c/strong\u003e \u003cstrong\u003ewith\u003c/strong\u003e \u003cstrong\u003eexisting\u003c/strong\u003e \u003cstrong\u003eliterature\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany of our factors were similar to the Foresight map. (8) We deliberately used different language from Foresight because we wanted to use language understood by a range of stakeholders. For example, we use ‘knowledge about food’ rather than ‘food literacy’. The focus on parents and early years services in our map was a unique finding not identified in the Foresight map. Our findings were consistent with Brown et al.’s (25) systematic review who show the need for wider community‐level interventions, together with upstream environmental and policy interventions, alongside interventions aimed at individuals. Consistent with Brownson et al. (26), we identified \u0026nbsp;how factors in different parts of the system potentially affect each other. Future work could build on their ‘causal loop’ work by specifically focusing on the system for 0-5 year olds. As is the case with physical activity, we identified a need to consider health inequalities. (27)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is the first systems map that we are aware of which focuses specifically on 0–5-year-olds. It is grounded in stakeholder perspectives because it was developed in conjunction with a range of stakeholders. There were four limitations. First, it was developed with stakeholders who were based in two nations of the UK. This may limit its geographic generalisability, but international research literature and policy documents were included to increase the map’s generalisability. Second, the findings from workshops are likely to suffer from the same limitation as consensus exercises, in that they are dependent on the characteristics of attendees, with stakeholders placing an emphasis on the factors within their immediate experiences. (28) Others may wish to repeat our workshops in different countries with other types of stakeholders such as dieticians. Third, we were able to identify some, but not all of the connections between different factors, as this activity was challenging for participants in the workshops.\u0026nbsp;Fourth, few parents took part in the workshops, the majority of participants attended in their professional capacity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for practice and research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are four implications. First, consistent with other literature, it is evident from our work that the multiple- levels of influence cannot be addressed by a single intervention. Different interventions should be aimed at different parts of the system to prevent excess weight gain amongst 0–5-year-olds. Any intervention aimed at one part of the system needs to consider how other parts of a dynamic, responsive system are affected by the intervention, or how they affect the intervention. Second, our work highlights the need to consider specific issues impacting on 0-5 year olds and how this might be achieved by working with stakeholders across the system, including parents, early years services, childcare providers and policy makers. Third, stakeholders described how parents’ knowledge about food was not simply linked to education, but about how to address barriers people face such as how to cook healthy food on a limited budget. The emphasis on poverty, income and finances within the map highlights the need for any interventions to consider the limited resources available to many parents. Fourth, future research could test the generalisability of the systems map to different contexts and exploring the relationships between different factors perhaps through social network analysis.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere are multiple interacting influences on excess weight gain in 0\u0026ndash;5 year-olds. Some are unique to young children, particularly the influence of parents and other caregivers. Financial considerations drive a lot of the connectivity within and across factors in this systems map. Our systems map can be used to support the development and evaluation of interventions aiming to prevent or reduce excess weight amongst 0\u0026ndash;5 year-olds. For example, any intervention focused on improving parents\u0026rsquo; knowledge and confidence around food would have the potential to facilitate children\u0026rsquo;s healthy weight but would need to be \u0026nbsp; cognisant of the multiple other influences at play.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003eHENRY- Healthy Education for the Really Young\u003c/p\u003e\n\u003cp\u003eNI- Northern Ireland\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNIHR- National Institute for Health and Care Research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUK- United Kingdom\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate-\u003c/strong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003eEthical approval was received from the Department of Health Sciences\u0026rsquo; Research Governance Committee, University of York, York (ref HSRGC/20210/428/A). All stakeholders in the workshops gave written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials-\u0026nbsp;\u003c/strong\u003eThe data that can be used is included within the manuscript and supplementary files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests-\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding-\u0026nbsp;\u003c/strong\u003eThis study/project is funded by the NIHR (NIHR135081). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funder was not involved in the design, data collection analysis or interpretation of data or writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u0026nbsp;\u003c/strong\u003eISRCTN16529380\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econtributions-\u0026nbsp;\u003c/strong\u003eAOC and AF wrote the manuscript. AOC, AF and AS led on the development of Workshop 1 and development of the systems maps. PG led on the refinement of the systems maps. WB facilitated both workshops and the Parent Involvement Group. LG and AK organised Workshop 2. LS provided input as a Parent Representative. MB was the Principal Investigator. All other authors supported the systems mapping work. All authors reviewed the draft manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowle\u003c/strong\u003e\u003cstrong\u003edgements\u003c/strong\u003e-We are grateful to people who have supported our research. This includes the parents that attended the involvement group and people that attended the workshops. We are thankful to \u0026nbsp; Vera and Danielle Logan, Dunla Gallagher and Katy Thompson for supporting Workshop 2. Finally, we appreciate the input of Dr Veronica Fibisan on producing the initial systems map and ecological framework on Canva.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJones R, Jewell J, Saksena R, Ramos Salas X, Breda J. Overweight and Obesity in Children under 5 Years: Surveillance Opportunities and Challenges for the WHO European Region. Front Public Health. 2017;5:58.\u003c/li\u003e\n \u003cli\u003eNHS Digital. National Child Measurement Programme, England, 2023/24 School Year. https://digital.nhs.uk/: NHS Digital; 2024.\u003c/li\u003e\n \u003cli\u003eWard Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-53.\u003c/li\u003e\n \u003cli\u003eHillier F, Pedley C, Summerbell C. Evidence base for primary prevention of obesity in children and adolescents. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2011;54(3):259-64.\u003c/li\u003e\n \u003cli\u003eRedsell S, Atkinson P, Nathan D, Siriwardena A, Swift J, Glazebrook C. Preventing childhood obesity during infancy in UK primary care: a mixed methods study of HCPs\u0026apos; knowledge, beliefs and practice. BMC Fam Pract. 2011;12:54.\u003c/li\u003e\n \u003cli\u003eRedsell S, Edmonds B, Swift J, Niroshan Siriwardena A, Weng S, Nathan D, et al. Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood. Matern Child Nutr. 2016;12(1):24-38.\u003c/li\u003e\n \u003cli\u003ePublic Health England. Whole systems approach to obesity: a guide to support local approaches to promoting a healthy weight. 2019.\u003c/li\u003e\n \u003cli\u003eVandenbroeck I, Goossens J, Clemens M. Tackling Obesities: Future Choices \u0026mdash; Obesity System Atlas. Foresight: Government Office for Science; 2007.\u003c/li\u003e\n \u003cli\u003eBryant M, Burton W, O\u0026apos;Kane N, Woodside J, Ahern S, Garnett P, et al. Understanding school food systems to support the development and implementation of food based policies and interventions. Int J Behav Nutr Phys Act. 2023;20(1):29.\u003c/li\u003e\n \u003cli\u003eJessiman P, Powell K, Williams P, Fairbrother H, Crowder M, Williams J, et al. A Systems Map of the Determinants of Child Health Inequalities in England at the Local Level. PLoS One. 2021;16(2):e0245577.\u003c/li\u003e\n \u003cli\u003eGriffiths C, Radley D, Gately P, South J, Sanders G, Morris M, et al. A complex systems approach to obesity: a transdisciplinary framework for action. Perspect Public Health. 2023;143(6):305-9.\u003c/li\u003e\n \u003cli\u003eBrennan L, Sabounchi N, Kemner A, Hovmand P. Systems thinking in 49 communities related to healthy eating, active living, and childhood obesity. J Public Health Manag Pract. 2015:S55-S69.\u003c/li\u003e\n \u003cli\u003eHammond R. Complex systems modeling for obesity research. Prev Chronic Dis. 2009;6(3):A97.\u003c/li\u003e\n \u003cli\u003eMcGlashan J, Johnstone M, Creighton D, de la Haye K, Allender S. Quantifying a systems map: network analysis of a childhood obesity causal loop diagram. PLoS One. 2016;11(10):e0165459.\u003c/li\u003e\n \u003cli\u003eBronfenbrenner U. Ecological systems theory (1992). In: Bronfenbrenner U, editor. Making human beings human: Bioecological perspectives on human development. London: Sage Publications Ltd.; 2005. p. 106-73.\u003c/li\u003e\n \u003cli\u003eCs\u0026aacute;rdi G, Nepusz T. The igraph software package for complex network research. InterJournal Complex Systems; 2006.\u003c/li\u003e\n \u003cli\u003eButland B, Jebb S, Kopelman P, McPherson K, Thomas S, Mardell J, et al. Tackling Obesities: Future Choices \u0026ndash; Project report. London: Government Office for Science; 2007.\u003c/li\u003e\n \u003cli\u003eInnovation Lab. Childcare Strategic Insight Programme. Virtual Strategic Insight Lab: Department of Finance; 2021.\u003c/li\u003e\n \u003cli\u003eCroker H, Russell S, Gireesh A, Bonham A, Hawkes C, Bedford H, et al. Obesity prevention in the early years: A mapping study of national policies in England from a behavioural science perspective. PLoS One. 2020;15(9):e0239402.\u003c/li\u003e\n \u003cli\u003eCampbell M. Biological, environmental, and social influences on childhood obesity. Pediatr Res. 2016;79(1-2):205-11.\u003c/li\u003e\n \u003cli\u003eChatham R, Mixer S. Cultural Influences on Childhood Obesity in Ethnic Minorities: A Qualitative Systematic Review. J Transcult Nurs. 2020;31(1):87-99.\u003c/li\u003e\n \u003cli\u003eNICE. Obesity in children and young people: prevention and lifestyle weight management programmes. NICE (National Institute for Health and Care Excellence); 2015.\u003c/li\u003e\n \u003cli\u003eSafety DoNaF. A Primary Health Care Approach to Obesity Prevention and Management in Children and Adolescents: Policy Brief. World Health Organisation; 2023.\u003c/li\u003e\n \u003cli\u003eDepartment of Health and Social Care. Childhood obesity: a plan for action. HM Government; 2018.\u003c/li\u003e\n \u003cli\u003eBrown T, Moore T, Hooper L, Gao Y, Zayegh A, Ijaz S, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2019;7(7):CD001871.\u003c/li\u003e\n \u003cli\u003eBrownson R, Kemner A, Brennan L. Applying a mixed-methods evaluation to Healthy Kids, Healthy Communities. J Public Health Manag Pract. 2015;21:S16-S26.\u003c/li\u003e\n \u003cli\u003eJones S, Porroche-Escudero A, Shearn K, Hunter R, Garcia L. Thinking about inequalities in physical activity as an emergent feature of complex systems. Int J Behav Nutr Phys Act. 2024;21(1):125.\u003c/li\u003e\n \u003cli\u003eMurphy M, Black N, Lamping D, McKee C, Sanderson C, Askham J, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(3):i-iv, 1-88.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"childhood, growth, obesity, early years, systems, prevention ","lastPublishedDoi":"10.21203/rs.3.rs-6272933/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6272933/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e There is an increase globally in the proportion of young children (0-5 year olds) who are living with excess weight. Causal inter-relationships of key influences on obesity (called systems maps) exist for adults and school-aged children. However, there are no maps focused on young children, where unique factors may operate including the influence of childcare providers. We developed a systems map with stakeholders to identify key factors contributing to excess weight gain in 0–5 year olds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We used an iterative stakeholder engagement approach, starting with a workshop with 23 stakeholders in the United Kingdom to produce an initial map. We ran a further discussion group with six parents, a second workshop with 22 additional stakeholders, and consulted literature to develop a final systems map.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The final systems map consists of 20 domains of influence and 153 factors. These influences operate at six embedded levels. Level 1 (at the centre): ‘child’ includes influences related to a child’s physiology, food preferences, and specific health and social needs. Level 2: ‘parents’ includes income and resources, mental health, life pressures, parenting style and skills, and support received on feeding. Level 3 focuses on the influence of ‘Wider family and social networks’. Level 4: ‘local’ includes the physical environment, availability of early years services, and local government services. Level 5: ‘national’ includes government policies and funding, food suppliers and retailers, and societal pressures. Level 6: ‘global’ includes events affecting food supply and prices. Financial considerations drive the majority \u0026nbsp;of connections within the systems map, for example parent’s income or the funding of early years services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThere are multiple interacting influences on excess weight gain in 0–5 year olds. Some are unique to young children, particularly the influence of parents and other caregivers. The systems map can be used to support the development and evaluation of interventions aiming to prevent or reduce excess weight amongst 0–5 year olds. For example, any intervention focused on improving parents’ knowledge and confidence around food would need to be cognisant of the multiple other influences at play.\u003c/p\u003e","manuscriptTitle":"Influences on excess weight gain amongst 0-5 year old children: A Stakeholder produced systems map","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-30 11:45:58","doi":"10.21203/rs.3.rs-6272933/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d781e430-0795-4068-a384-f6f0db0e74d5","owner":[],"postedDate":"April 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T04:23:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-30 11:45:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6272933","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6272933","identity":"rs-6272933","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}