Social entrepreneurship in obesity prevention: A scoping review

Summary We conducted a scoping review of social ventures in obesity and developed a taxonomy of their interventions and business models. Sources included PubMed, Business Source Premier, ABI Inform, Factiva, Google, Facebook, Twitter, social entrepreneurship networks (Ashoka, Skoll, and Schwab), and social entrepreneurship competitions. Our review identified 512 social ventures in 32 countries; 93% originated from developed countries. Their areas of intervention included diet and nutrition, urban farming, physical activity, access to healthy food, and health literacy. They addressed factors beyond health such as education, affordability, employment, and the built and natural environments. To support their programs of work, social ventures developed various business models with multiple revenue or resource streams. Social ventures designed double‐duty interventions that were aligned with additional meaningful social or environmental objectives. This “bundling” of objectives allowed social ventures to appeal to a wider target audience. Most of the social ventures were initiated, supported, or sustained by local communities. Social ventures offer financially self‐sufficient approaches to obesity reduction and could potentially relieve the burden on healthcare systems. Policymakers should consider social entrepreneurs as partners in obesity prevention.


| INTRODUCTION
Despite the rising prevalence of obesity and its associated socioeconomic costs, effective strategies against it remain elusive. A Cochrane review update (2019) on obesity interventions reported that diet and physical activity interventions produced only modest weight reduction in children aged 12 and below. 1 Among adolescents aged 13 to 18, there was no strong evidence that these obesity interventions were effective for weight reduction. 1 Among adults, systematic reviews in 2018 and 2019 on nonsurgical obesity interventions reported limited effectiveness in weight loss maintenance. [2][3][4] The US National Weight Control Registry data indicated that 80% of overweight participants regained their weight within a year. 5 In the last 30 years, no country has managed to reverse the rise in obesity; all 200 World Health Organization (WHO) member countries are unlikely to meet targets to halt the rise in obesity by the year 2025. 6,7 Among 140 lower and middle-income WHO member countries, only 54 (38%) had national policies to reduce obesity; these Abbreviations: US, United States of America; WHO, World Health Organization. focused more on individual consumers and government agencies and less on businesses and civil society. 8 Obesity has multiple causes: genetics, individual behavior, and physical and social environments. It calls for multipronged and novel approaches that include a range of stakeholders. 9 Among such stakeholders are social entrepreneurs.
In recent decades, social entrepreneurs have emerged where governments and markets have failed to meet basic needs for water, sanitation, primary healthcare, or specialist care. 10 In our earlier research, we noted that social entrepreneurs share a common set of practices, applying business and entrepreneurial approaches to solve social problems of disadvantaged populations. 11 Social entrepreneurs are not a highly codified profession, but there is a set of practices that typify social entrepreneurship, as elaborated below. 12,13 Unlike charities, social entrepreneurs do not typically rely on donations or aid as their main source of funding. Social ventures aim to become self-sufficient by developing viable business models and multiple streams of financial and nonfinancial support. Social entrepreneurs often engage with the communities that they aim to serve, involving them as partners or codesigners of solutions. Because they interact with different groups of stakeholders, social entrepreneurs are likely to view problems in context and acknowledge the interrelations between health and nonhealth factors, for example, between lack of education and health-seeking behavior, or poverty and illhealth. Rather than providing products and services for free, social entrepreneurs develop frugal solutions to deliver healthcare and social services. The dual focus on affordability while empowering or educating communities allows social entrepreneurs to sustain their programs of work. We chose to focus on social ventures because strategies against obesity require community involvement or a "whole of society" approach. 14,15 Our primary objective was to conduct a scoping review of social ventures in obesity. We sought to understand the work of these social ventures by developing a taxonomy of: (a) What they did: their interventions, (b) Where they worked: their target populations and location of interventions; and (c) How they supported their work: their business models.

| METHOD
Our global scoping review of social ventures in obesity covered academic and nonacademic databases, news databases, and web-based searches of Google and social media. Our goal was not to find all obesity-related social ventures but to identify relevant and representative examples, and then develop a taxonomy of their obesity interventions, contexts, and business models.

| Information sources
Our sources included academic and news databases (PubMed, Business Source Premier, ABI Inform and Factiva), social entrepreneurship networks (Ashoka, Skoll Foundation, and Schwab Foundation), social media (Facebook and Twitter), and social entrepreneurship competitions across the United States, Europe, and Asia. We also performed Google searches. From academic databases, we identified articles, dissertations, and working papers. From Factiva, we accessed 32,000 news sources, including newspapers, magazines, television, and radio transcripts. The inclusion of unconventional data sources allowed us to search more widely for social ventures in obesity.

| Database search strategy
The objective of the search was to identify social ventures working in obesity. We searched for social ventures that addressed obesity or determinants of obesity such as diet, physical activity, and healthy food sources.
The search terms included social entrepreneurship and its related concepts (social innovation, social enterprise, and social venture). For "obesity," we used terms related to both prevention and treatment (physical activity, exercise, diet, nutrition, healthy eating, workplace health, weight loss, weight gain, ideal weight, urban farming, and indoor farming). Our search terms acknowledged obesity-relevant contexts. "Workplace health" was included because people spend a significant proportion of their waking hours at work. "Urban farming" and "indoor farming" were included because such farms are part of the food ecosystem. Urban farms address multiple determinants of obesity by diversifying diets, improving access to fresh and healthy food and encouraging physical activity.
Combining search terms related to both obesity and social entrepreneurship related yielded 28 unique search strings that were modified to match each database's search syntax. The search included truncation or asterisk wildcards for each phrase, where necessary. For example, in academic and industry databases, we used "social entrepreneur*" AND "obesity"; for Google searches, we combined "social entrepreneur" AND "obesity." For social media searches, in Facebook, we used (social entrepreneur) AND (obesity); and in Twitter, #socent and #obesity (see the supporting information for more details).
Articles dating from January 1980 to March 2020 were gathered from PubMed, Business Source Premier, ABI/Inform, and Factiva.
Google searches were performed between August to September 2019 and in March 2020. We reviewed the first 10 pages of each Google search; beyond this, hits became redundant. In Facebook, we used Advanced Search, and filtered only for pages of organizations.
On Twitter, we used Advanced Search of keywords with the option "All these words." Additional searches were done for obesity-related terms and the hashtag "#socent." From social entrepreneurship competitions in the United States, Europe, and Asia from 2015 to 2020, we reviewed finalists working on obesity. We searched the directories of Ashoka, 16 Schwab Foundation for Social Entrepreneurship, and Skoll Foundation, three organizations that promote, recognize, and support social entrepreneurs globally. Paid web links were excluded.
Each social venture was checked for existence and legitimacy using its official website and other Google searches.

| Criteria for inclusion
To be considered for inclusion, a social venture had to have at least one revenue or resource stream that partly or entirely sustained its work, and not solely or mostly provide free products and services.
These two criteria were based on key characteristics of social entrepreneurship and helped distinguish social ventures from charities and welfare organizations that relied mostly on donations. We included social ventures with activities that were commonly associated with obesity prevention. Social ventures that engaged in any of these activities individually or in combination were included. Among our social ventures were those that advocated or promoted physical activity by delivering products or services (e.g., specialized exercise equipment or fitness coaching) or by providing venues or infrastructure for physical activity. Other ventures encouraged the consumption of healthy food; they ran restaurants, kitchens, and other initiatives that provided healthy meals or instruction in cooking or nutrition. Yet other ventures increased access to healthy food (e.g., mobile food markets) or improved affordability, or boosted its supply (e.g., greenhouses).
We excluded entities without an explicit social purpose, because social ventures are defined by having a social purpose as their main objective. Hence, entities that did not explicitly mention in their websites, social media, or annual reports that they had a social purpose were excluded.
We also excluded ventures for which there were no data or record of performance, for example, early stage ventures in incubation that had no business activity, ventures that had ceased operations, and ventures with insufficient information (no website, website not in English, or incomplete information). As our search was wide-ranging, our social media search results sometimes listed organizations that worked in obesity but were not social ventures. We excluded these from the review: government entities, research trials/interventions, educational institutions (except as partners), foundations that funded social ventures but were not otherwise engaged in any social entrepreneurial activities, and healthcare institutions (unless the explicit aim was to address obesity).

| Data items and synthesis of results
We extracted the following information on each social venture: country of origin, business model, years in operation, category of obesity intervention (such as diet and nutrition, promoting physical activity), setting of obesity intervention, target beneficiaries, and impact reporting. A complete list of data items is shown in the supporting information.
We reviewed the official websites of all identified ventures. Additional information was obtained from each venture's social media sites, press releases, and financial reports, if available. All ventures identified were independently reviewed by JY and AMB using the inclusion and exclusion criteria.
Entities that met the criteria were collated into a master database of social ventures. LYW and AC adjudicated any disagreements between JY and AMB. All differences were resolved by consensus.
We developed a taxonomy of the social ventures in obesity using an iterative approach (see Figure 1). As mentioned in our criteria for inclusion, only social ventures-those with an explicitly stated social purpose-were included. Second, social ventures that worked primarily in health were distinguished from those that did not. Among health ventures, we identified those working on obesity. Obesity-related ventures were then classified according to their interventions, target population, and business models. While business models and target populations had clear, preexisting classifications, the classification of obesity interventions was developed using an iterative approach based on the information about each venture.
We examined the relationship between types of interventions (i.e., diet and nutrition, urban farming, physical activity, access to healthy food sources, and population health education) and settings of intervention (community, school, and workplace). This probed whether certain types of intervention were more commonly found in some settings or target populations. We also examined whether impact reporting was more frequently undertaken by for-profit or nonprofit ventures. For this analysis, group differences were evaluated with a chi-square test. Statistical significance was set at  In addition to obesity, almost half (45%) the social ventures in our review had social and nonhealth objectives unrelated to obesity.

| Context of operation
These diverse objectives included livelihoods for refugees, promotion of environmental business practices, and advocacy for women's rights.
Four-fifths (81%) of social ventures worked to strengthen their local communities by capacity building, education, and other means.

| Categories of intervention
We identified five categories of intervention: diet and nutrition (59%), urban farming (43%), physical activity (31%), access to healthy food sources (22%), and population health education (16%) (see supporting information for details). In each category, there were diverse and innovative approaches to preventing obesity (see Table 1 for examples).
Social ventures typically developed interventions in more than one category. Bollywood Veggies, a Singapore-based venture, organized physical activities such as rice planting for adults and conducted healthy cooking classes for children. 17 Community Foods Market, a US social venture, started as a mobile fresh food stand in a food desert neighborhood. 18 It grew into a supermarket that partnered nongovernmental organizations to run blood pressure clinics and nutrition classes at its premises (see Table 1).
We found social ventures that adopted interventions integrated across the value chain. They typically engaged in stages from farm to table, including agriculture, distribution, and food preparation and retail. Fresh Roots (see Table 1) partnered schools in Vancouver to grow food on school grounds, sell produce to local residents and prepare meals for school cafeterias. Fresh Roots is an example of a venture that created interventions spanning four of our five categories-diet and nutrition, urban farming, physical activity, and access to healthy food sources.
Whereas 68% of ventures did not target a specific age group, 30% targeted children; and 2% targeted older adults. Social ventures operated in local communities (93%), schools (39%), or workplaces

| Business models
Two-fifths (39%) of the ventures were for-profit, and the rest nonprofit. Almost half (49%) of the social ventures aimed at financial self-sufficiency, that is, zero-reliance on donations; 43% of social ventures were already self-funding. There was a range of business models including cross-subsidy, subscription, employment, leveraged, and platform models (see Table 2). Good Bowls from North Carolina, USA, used a cross-subsidy model. They sold the same healthy frozen meal for a lower price in convenience stores in low-income neighborhoods, and at a higher price in premium food stores. Customers at premium stores could choose to pay US $2 more to subsidize meals for low-income customers. 19 Other  Table 1). 20 Parakids from Bulgaria provided specialized sporting equipment and activities to children with disabilities and postural problems. 21

| Impact reporting
Of 512 social ventures, 25% reported the impact of their work. Only 16% reported their impact in the last 2 years. Three-quarters of the 16% were nonprofit ventures. Only 3% of ventures reported third-F I G U R E 2 Flowchart for inclusion of records • Operated a supermarket in a low-income neighbourhood with little access to fresh produce • Enabled residents to pay with food stamps and offer discounts to senior citizens • Ran nutritional classes and blood pressure clinics for the public Fresh International Gardens (USA) • Hired and trained refugees to farm in Alaskan climate • Integrated refugees into local community through language training, and holding farmers' markets for them to sell produce directly to local residents • Reduced local dependence on imported fresh produce party evaluations. 21 Most social ventures reported on activities and number served, rather than results, for example, efficacy of services/ products in promoting weight loss. Not-for-profit ventures were three times more likely than for-profit social ventures to report their impact in annual reports and websites (X 2 = 42.05, p < 0.001).  • Trained volunteers in organic farming and connected these volunteers to elderly residents with unused backyards • Provided materials for volunteers to build and maintain organic gardens in the elderly residents' backyards at no cost to them. • The produce was shared among volunteers, elderly residents and the social venture.

| DISCUSSION
for such social ventures. Like any other kind of business venture, social ventures need a supportive ecosystem with elements such as funding, accelerators, access to advice and social networks, links with private sector companies, and even government support. 24,25 As obesity is a challenge faced by many developed countries, it is unsurprising that the majority of social ventures in obesity (93%) originated and operated in high-income, developed countries. However, the low representation among developing countries is a cause for concern. The prevalence of overweight and obesity in developing countries is almost 30%. Nearly two-thirds (62%) of the world's people with obesity or overweight live in developing countries. 26 As we noted in Section 1, less than two-fifths of middle-to low-income countries had policies related to obesity reduction; general attention to obesity might have been affected by this lack of national agenda. In addition, as our other research suggests, public health problems such as malnutrition, maternal and infant health, and poor healthcare delivery take higher priority in developing countries. 11 Obesity has an immediate impact on a child's health, educational attainment, and quality of life. 27 Children living with obesity are likely to do so as adults and risk developing noncommunicable diseases. 28 Social ventures in our review seem to have recognized these facts, as more than a third of them focused on obesity among children, and implemented interventions in schools. It might be worth exploring how schools could collaborate with social entrepreneurs in their efforts to prevent obesity. 29 More than half of the world's population live in cities, and the United Nations has estimated that the proportion will increase from 55% in 2018 to 68% in 2050. 30 It is appropriate therefore that obesity interventions should also target the problems or opportunities  Table for Two-which originated in Japan and has since expanded to Korea, the Hungry Harvest emphasized that they reduced food waste and supported local employment (see Table 2). Similarly, results that were more locally relevant, even after we disabled the location of the computer. This was because the Internet service provider was located in Singapore. It was unfeasible for us to obtain a Virtual Private Network to various countries to run more searches.

| RECOMMENDATIONS
We hope that this review will motivate governments and healthcare

| CONCLUSION
The battle against obesity has been long and difficult, because the problem is complex.
It needs to be fought across settings (work, school, or home), sectors (government, business, and civil society), and levels (individual, societal, and national). 14 Our review found that social ventures implemented a diverse range of obesity-related interventions across different contexts. They addressed obesity together with other health and nonhealth objectives, and aligned obesity reduction with appealing causes such as environment and poverty alleviation. Many were owned by local communities, sustained by multiple streams of resources, and developed business models to sustain their work. They indicate that obesity interventions can become financially self-sufficient and potentially alleviate the burden on healthcare systems and budgets. Our review provides multiple glimpses of what the Lancet Commission calls "sustainable, profitable models that explicitly include benefits to society and the environment." 6