Denying obesity

In the last issue of the European Journal of Public Health Arnaud Chiolero and Fred Paccaud ask if the obesity, epidemic is a booga booga, i.e. a 'religious ritual', a 'frightening, imaginary creature', a 'way to scare the living piss out of someone in a comedic fashion', or a 'noise that people use to scare each other’. In the same issue Professor Tim Lobstein of the International Association for the Study of Obesity, and Professor David Crawford and myself were asked to write short commentaries to the paper by Chiolero and Paccaud.
As Lobstein rightly argues that "with any social crisis, someone will want to challenge the accepted science and provoke a defence from the scientists". The similarities with the global warming sceptics are obvious.
With rising and very high prevalence rates worldwide, and overwhelming evidence that obesity is indeed a major public health crisis, there is no doubt that an obesity pandemic is among us in the sense that it is ‘occurring over a wide geographic area and affecting an exceptional high proportion of the population’ (Meriam Webster online Dictionary). Please access the paper by Chiolero and Paccaud as well as the two commentaries at the European Journal of Public Health website.

The annual meeting of the Portuguese Society of the Study of Obesity

Last Friday I gave a keynote lecture at the annual meeting of the Portuguese Society of the Study of Obesity (congresso portugues de obesidad). Together with one other keynote speaker, Geoffrey Williams of the University of Rochester, we were the only ones presenting in English. Because my Portuguese is complete non existent, I did not get much off the other presentations, but I understood that the conference was mainly clinically oriented, aiming to share information on obesity treatment from a primarily clinical perspective. Professor Williams and myself were also two of very few who talked on a behavioural perspective of obesity treatment and prevention.
Professor Williams, an expert on Self Determination Theory (SDT) and on interventions using that theory for a range of health behaviour changes, including obesity treatment, gave a very nice and complete overview of the evidence for SDT-based interventions. He presented great mediation analyses that indicated that the cornerstones of SDT, autonomy and control, indeed mediate the effects of SDT-based interventions.
I provided an overview of the rationale and evidence for obesogenic social, physical and economical environments, informed by results of a number of studies I was and am involved in, such as the Health Promotion through Obesity Prevention in Europe (HOPE) project and the EuropeaN Energy balance Research to prevent excessive weight Gain among Youth (ENERGY) project. Click here for a handout of my presentation.

EMGO Institute for Health and Care Research 2009 policy day

Last Friday the program directors, department and committee chairs and a number of senior researchers from the EMGO Institute for Health and Care Research met at ‘The Tides’ in Overveen. Based on SWOT analyses of EMGO+ and its research programs, with this day we were aiming to finalize the 2010 policy plans for the four EMGO+ research programs, and to discuss EMGO’s performance and ambitions in a perspective of further internationalization of research related to EMGO’s mission. The internationalization topic was introduced by Professor Jaap Seidell who argued, based on analyses of the times higher education world university rankings and the academic ranking of world universities (‘Shanghai University Ranking’) that the VU University and the VU University Medical Center do not do very good in these rankings, despite good publication and citation indexes, and that lack of true internationalization, indicated by international staff, students, and established and formal collaborations with universities/research centers in other countries is an important determinant of our lower ranking. The policy plans that will importantly aim at further internationalization will be finalized in the next few weeks and then published on the EMGO+ website.

Cycling in Holland and Norway, associations with overweight

Active transportation is a behavior that might contribute to energy balance and obesity prevention. However, no clear association between active commuting to school and weight status has been reported in the international literature. Also, recent studies suggest that cycling to school might be more health enhancing than walking to school. As keen cyclist, I was happy to be involved in a nice study first authored by Elling Bere on this issue. The purpose of the study was to assess association between cycling to school and weight status in two European cities,
Rotterdam, the Netherlands, and Kristiansand, Norway, where cycling to school
remains common. Data from two studies, ENDORSE (Rotterdam) and Youth in Balance (Kristiansand), were used. The adolescents were categorized as cyclist or non-cyclist based on questionnaires on the usual mode of transportation to school.
A total of 25% and 18% were categorized as overweight, and 35% and 31% were categorized as cyclists, in Rotterdam and Kristiansand, respectively.
Cyclist were almost half as likely to be overweight in both cities than non-cyclists, after adjusting for possible confounders.

ENERGY project meeting in Durham, UK

Last Thursday and Friday, Professor Carolyn Summerbell and her team from Durham University hosted the second ENERGY project meeting at the Wolfson Research Institute.

ENERGY stands for “EuropeaN Energy balance Research to prevent excessive weight Gain among Youth : Theory and evidence-based development and validation of an intervention scheme to promote healthy nutrition and physical activity”. It is a European Commission funded project, within the DG Research 7th framework programme.

The project is specifically aiming to contribute to knowledge about obesity prevention among schoolchildren, aged 10-12 years

The ENERGY project is now well underway and in a critical stage. ENERGY is supported by a strong consortium of research institutes and groups throughout Europe. Teams from Deakin University, Ghent University and the EMGO Institute for Health and Care Research at VU University Medical Center have conducted a series of reviews on important risk behaviours for overweight and obesity in children, of correlates and predictors of such risk behaviours, and of mediators of intervention effects in this age group. The results of these reviews (whch will be made available via the ENERGY website) have been combined with other evidence-bases to inform the development of a questionnaire for children and their parents, as well as a school environment audit instrument. These measurement instruments will be used in a large cross-European school-based survey to further study possible determinants of obesity, overweight and their risk behaviours in this age group across Europe. Professor Yannis Manios and his team from the University of Harikopio in Greece lead the work package on this survey in close collaboration with the Rescon research organization from the Netherlands.

At the Deakin meeting the development of the questionnaire and the planning of the survey study were the central, and we made good progress to deliver final drafts of these instruments in the next days and weeks. Pretesting of the child questionnaire is scheduled to take place in the two weeks time.

Building a research infrastructure elsewhere

I have written a little bit about my university's efforts to improve the research infrastructure. We need better facilities for data-management, biobanking, and biostatistical and project management support to maintain and further improve our improved research output (as indicated by the growing number of publications, citations, and large research project acquisitions). When money is no real issue, building a research infrastructure can be done somewhat differently. In Saudi Arabia the new King Abdullah University of Science and Technology (KAUST)is being build. Science Magazine has published a story on this initative. According to the Science publication "Thinking big is in the DNA of KAUST. The university's namesake, King Abdullah bin Abdulaziz Al-Saud, decided 3 years ago to set aside billions of dollars for an institution designed to help the country move from an oil-based to a knowledge economy (Science, 8 June 2007, p. 1409)." Click here to check out the story.

ENDORSE (environmental determinants of obesity related behaviors in Rotterdam schoolchildren)

Dr. Klazine van der Horst defended her thesis today on the exploration of environmental determinants of overweight and energy-balance behaviours in Dutch youth. Het thesis is based on the ENDORSE (environmental determinants of obesity related behaviors in Rotterdam schoolchildren) study. This study is one of the first to systematically explore potential school environment, neighbourhood environment, family environment and personal correlates of behaviours that may induce unnecessary weight gain among adolescents. Her studies indicate that social environmental influences, especially parental influences such as food and physical activity related parenting practices and parental modelling behaviour, may be more important than physical environmental factors, i.e. factors related to availability and accessibility of healthy food and physical activity options.
It is very likely that the present-day obesity epidemic is caused by changes in the physical environment, i.e. changes towards an overabundant accessibility of energy-dense foods and towards a lack of unavoidable or necessary daily physical activities. However, in this physical environment, it appears that other factors, such as social environmental influences, now discriminate between young people who engage more or less in obesogenic behaviours.

The published papers included in Klazine's thesis are:

van der Horst K, Oenema A, Te Velde SJ, Brug J. Gender, ethnic and school type differences in overweight and energy balance-related behaviours among Dutch adolescents.
Int J Pediatr Obes. 2009 May 15:1-10. [Epub ahead of print]

Bere E, van der Horst K, Oenema A, Prins R, Brug J. Socio-demographic factors as correlates of active commuting to school in Rotterdam, the Netherlands.
Prev Med. 2008 Jul 8. [Epub ahead of print]

van der Horst K, Timperio A, Crawford D, Roberts R, Brug J, Oenema A.The school food environment associations with adolescent soft drink and snack consumption.
Am J Prev Med. 2008 Sep;35(3):217-23. Epub 2008 Jul 10.

van der Horst K, Oenema A, van de Looij-Jansen P, Brug J. The ENDORSE study: research into environmental determinants of obesity related behaviors in Rotterdam schoolchildren.
BMC Public Health. 2008 Apr 28;8:142.

Ferreira I, van der Horst K, Wendel-Vos W, Kremers S, van Lenthe FJ, Brug J. Environmental correlates of physical activity in youth - a review and update.
Obes Rev. 2007 Mar;8(2):129-54. Review.
Kremers SP, van der Horst K, Brug J. Adolescent screen-viewing behaviour is associated with consumption of sugar-sweetened beverages: the role of habit strength and perceived parental norms.
Appetite. 2007 May;48(3):345-50. Epub 2006 Nov 28.

van der Horst K, Kremers S, Ferreira I, Singh A, Oenema A, Brug J. Perceived parenting style and practices and the consumption of sugar-sweetened beverages by adolescents.
Health Educ Res. 2007 Apr;22(2):295-304. Epub 2006 Aug 14.
van der Horst K, Oenema A, Ferreira I, Wendel-Vos W, Giskes K, van Lenthe F, Brug J. A systematic review of environmental correlates of obesity-related dietary behaviors in youth.Health Educ Res. 2007 Apr;22(2):203-26. Epub 2006 Jul 21. Review.

The 20th anniversary of the Department of Nursing Home Medicine

Yesterday, the department of nursing home medicine of the VU University medical center celebrated its 20th anniversary. In 1989, the first training course for nursing home physicians in the world was established at the Vrije Universiteit Amsterdam (now the VU university medical center). Now, 20 years later, 750 nursing home physicians have been trained at VU medical center. Also the research at the department, embedded in the EMGO Institute for Health and Care Research, has seen a spectacular growth with more than 400 scientific publications, and an impressive list of PhD graduates. The twentieth anniversary was celebrated October 1st, in Artis Zoo Amsterdam with more than 200 visitors, many of them trained at the VUmc. They enjoyed speeches of national and international speakers. After the head as well as founding father of the department, Prof. Miel Ribbe gave a brief introduction, profs. Douwe Draaisma from Groningen University, Paul Schnabel, director of the Netherlands Institute for Social Research, and Sheryl Zimmerman from the University of North Carolina provided their entertaining, thought provoking and evidence-based views on aging, the elderly and elderly care. After a tour along the elderly animals in the Zoo, the people present, and Miel Ribbe most of all, were pleasantly surprised by the dean of VUmc, Prof. Wim Stalman, who proudly announced that Prof. Miel Ribbe was honoured by Queen Beatrix with a knighthood, among others for his excellent work in establishing, nursing, promoting and disseminating the art and science of nursing home medicine of these outstanding performances.

American Journal of Health Promotion's new definition of Health Promotion

In the September/October issue of the American Journal of Health Promotion, the journal's editor in chief, Michael O'Donnel presents his, and the journal's, definition of 'health promotion 2.0: Embracing Passion, Enhancing Motivation, Recognizing Dynamic Balance, and Creating Opportunities'. This 2.0 definition (see below) is rather complex and embracing a very broad range of health aspects, but the deifinition includes a few important messages. First of all the definition 2.0 puts (even) more emphasis on environmental conditions and opportunities for health and health practices, building upon the growing body of evidence linking environmental conditions, such as availability and accessibility of healthy options, to engagement in health behavior, and to the WHO slogan 'Making the healthy choice the easy choice'. The definition certainly also links to the behavioral determinants highlighted in well-known behavioral theories such as the Theory of Planned Behavior, Social Cognitive Theory, or Protection Motivation Theory, i.e. the determinants that have been targetted most frequently in health promotion interventions that had health education as the central change strategy. For example, the definition highlights enhancement of awareness, motivation and skills as important goals for health promotion interventions. But the definition explicitely states that creation of environmental opportunities is "most important". There is much circumstancial evidence for the importance of health promoting environments, but there is still a lack of intervention studies showing that creating opportunities that make healthier choices the easiest choices indeed lead to healthier lifestyles.

The full definition of Health Promotion 2.0 proposed by O'Donnel is:
"Health promotion is the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health, and supporting them in chnaging their lifestyle to move toward a state of optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and intelectual health. Lifestyle changes can be facilitated through a combination of learning experiences that enhance awareness, increase motivation, and build skills and, most important, through the creation of opportunities that pen access to environments that make positive health practices the easiest choice."

The A-CaRe kick off meeting

On Friday September 18 the kick off meeting of the A-CaRe (Alpe d’huzes cancer rehabilitation research program) was held in the Amsterdam Olympic stadium. In the conference rook at the Regarz meeting center in the stadium, with a view on the track and field practice going on the Olympic track itself, the A-CaRe program was presented.

A-CaRe is the first research program funded by the special Alpe D’Huzes fund from the Dutch Cancer Society. The Alpe D’Huzes foundation organises events, cycling events in particular, to raise money for caner research to develop evidence-based cancer rehabilitation and patients support programs.

Chaired by the former minister of health Dr. Els Borst, the chair (Coen van Veenendaal) and the ambassador (Peter Kapitein) of the Alpe D’Huzes foundation first presented the foundation and its philosophy mission and vision.

After their inspiring presentations, the three subprograms of A-CaRe were introduced, i.e. a subprogram on scientific research, on implementation preparations and on communication. Subprogram 1, i.e. on scientific research, is coordinated by EMGO+, by Dr. Mai Chin A Paw , Dr. Laurien Buffart, and myself and coordinated b. Two studies have now been started within subprogram 1, a study to study if intensive training or a more extensive active lifestyle works best to improve fatigue, quality of life and return to work among breast and colon cancer patients, after they completed their chemotherapy. on physical training after chemotherapy , and a study to investigate if physical training may improve fatigue and quality of life among children with cancer.

Research infrastructure at the VU University Medical Center

On Thursday 17 September, the directors of the VU University Medical Center’s (VUmc) research institutes (EMGO+, CCA/V-ici, ICarvu, NCA and MOVE) met, joined by VUmc’s experts on data management, knowledge valorisation, research project management. The meeting was led and chaired by the Dean of VUmc, Prof. Wim Stalman, and supported by his staff.

VUmc has made impressive progress in its research accomplishments and output, for example illustrated by its 2nd place in the research rank order based on the ‘CWTS crown indicator’(i.e. a measure of the relative frequency of citations of international scientific research publications) of the Dutch university medical centers. However, this grown and now relative large research output should be supported by an adequate research infrastructure including data-management, biobanking, project management and control, as well as support for valorisation of the research findings.

At the September 17 meeting these issues were discussed and the different topics were further specified and each topic was adopted by one of the participants to translate in a concrete plan for development and inclusions in the upcoming management contracts. This developments should lead to a better basis and support for the continuous research efforts and developments of VUmc.

I pleaded myself to start regarding and treating the main VUmc cohort studies, such as the NESDA study on depression and anxiety disorders, the LASA study on aging and health issues, and the HOORN studies on determinants and effects of diabetes, as part of research infrastructure in stead of mere projects. These cohort studies ensure a continuous output in terms of high ranking and often cited research papers, and university funding for the basis data management and continuation of these studies increases the chances to multiply this initial investment by external acquisition.

Obesity prevention among schoolchildren and adolescents

Yesterday Wilma Jansen, senior researcher at the Municipal Health Service of the Rotterdam-Rijnmond area, defended her thesis entitled ‘Prevention of Childhood Obesity in a Municipal Setting’. The studies presented in her thesis further confirmed that the prevalence of being overweight in the Rotterdam area among children and adolescents is high (approximately 25%), and substantially higher than in other parts of the Netherlands. Her studies further showed that many parents do not recognize or deny their children’s overweight status.
Part of her thesis research was the description and evaluation of the ‘Lekker Fit!’ (‘nice and fit’) intervention at Rotterdam schools to contribute to obesity prevention by promotion of healthful physical activity and nutrition. The Lekker Fit! intervention combined structural changes in the school and neighbourhood environment with health education activities, with involvement of different municipal services related to education, sports and recreation, and public health. The Lekker Fit! intervention resulted in somewhat lower rates of overweight and lower mean waist circumferences among the younger participants, i.e. indications that the intervention may indeed contribute to obesity prevention.
After the thesis defence, in a symposium on local and municipal obesity prevention, Drs. Frank van Lenthe of Erasmus University medical center and Mai Chin A Paw from the department of Public and Occupational Health of the EMGO+ Institute, and Prof. Jaap Seidell, from the department of Health Sciences and the EMGO+ Institute presented their views on the issue. All speakers argued that larger and multiple changes in the micro level and macro level food and physical activity environments are needed to make meaningful changes in behavioral nutrition and physical activity.
In two articles Prof. Ken Resnicow has argued that changes in behavioral nutrition and physical activity may be better described by quantum changes and chaos theory instead of the most often used more linear health behaviour theories. A characteristics of chaos theory that is often described is that small initial differences may lead to huge consequences, e.g. the butterfly clapping its wings causing a big storm at the other side of the world. However, I believe, and the literature indicates that and the speakers, especially Jaap Seidell kind of argued the same, that for obesity prevention almost the opposite is true: we need large and many enduring changes in multiple obesogenic environments to cause small but meaningful effects in eating and physical activity behaviours, as well as overweight and obesity. The EPODE initiative, i.e. Ensamble Prévenon l'Obésité Des Enfants, may be the best example of such multiple changes in multiple environments that lead to first small but extending meaningful changes in childhood rates of overweight.

Ineke Vogel defends her thesis on behavior and possible precautions related to exposure to loud music among adolescents

Listening to music is great. Listening to loud music can be a lot of fun, but too loud and too long will damage your ears. Risk of hearing impairment is nowadays especially high among youth who are exposed to long spells of loud music by listening to ‘MP3’ players and such, and by visiting discotheques and music concerts.
How big this potential problem is, who runs the highest risk, and what the possible precautionary actions are, was largely unclear. But yesterday Dr. Inke Vogel defended her doctoral thesis called “Music-listening behaviour of adolescents and hearing conservation: many risks, few precautions” successfully. Her thesis consists of 11 scientific papers of which the majority has already been published or accepted for publication in high ranking journals such as Pediatrics, American Journal of Preventive Medicine, and the American Journal of Public Health. In her series of studies, Dr. Vogel assessed what proportion of Dutch youth runs considerable risk (at least 25%), and what differentiates youth with higher risk from those with lower risk (especially level of education; youth at vocational schools have much higher exposure to loud music than youth at university preparation education). Ineke Vogel also explored what could motivate youth to take voluntary precautions and what possible other health protection measures may be considered to tackle this considerable population health problem.

Her conclusions are that exposure to long spells of loud music, especially through personal music devices, is very prevalent, may lead to extensive hearing impairments, but that there are very few opportunities to motivate youth to voluntarily reduce their exposure. Health protection measures, i.e. measures such as legal sound level limitations should be considered.

Nanna Tak defends her thesis on promoting Fruits and Vegetables among schoolchildren

Yesterday, Nannah Tak defended her thesis on the evaluation of the ‘Schoolgruiten’ project, an intervention scheme to promote fruit and vegetable intakes among school children in the Netherlands.

This intervention scheme builds on similar projects (such as Pro Children and Pro Greens) in which fruit and vegetable provision in schools is combined with health education about the merits and recommendations regarding fruit and veggie intakes.

Nannah’s thesis consists of a series of scientific papers published in such journals as Journal of Human Nutrition and Dietetics, International Journal of Behavioral Nutrition and Physical Activity, and Public Health Nutrition, and combines observational research exploring possible determinants of fruit and vegetable intakes with intervention research to assess the (cost) effectiveness of the scheme. The results indicate that Schoolgruiten was successful in promotion of fruits, but effect sizes were small.

Nannah’s thesis was well received, and her defence successful!

Auditing research quality issues within the Pro Greens project

Together with Dr. Saskia te Velde, we represent the EMGO+ Institute within the Pro Greens project. Pro Greens is coordinated by Dr. Agneta Yngve of Karolinka in Sweden, and the project is financially supported by the European Commission’s public health directorate. Pro Greens is a follow-up project on Pro Children. Both projects are aiming to promote fruit and vegetable consumption among school-aged children across Europe. In Pro Children informed by a a cross sectional survey conducted in nine countries in North, West and Southern Europe, an intervention mapping exercise was conducted that resulted in an intervention package that was tested in Norway, the Netherlands, and the Basque region of Spain.
Pro Greens build on Pro Children by adapting the intervention to be applicable in different countries, including new European Union member states, and to test these adapted interventions in these countries.
EMGO+ is responsible for the evaluation work package within Pro Greens. This means that we will do the analyses for the effect evaluation of the intervention, but we are also responsible for the internal evaluation of the project. This internal evaluation should ensure good research quality guidance and control across all the participating research teams so that quality standards are complied to, and standardized data collection and management methods are applied.
Part of this internal evaluation is auditing the Pro Greens partners that were not within the Pro Children project. Yesterday I did the first audit at the Folkhälsan Research Center in Helsinki, Finland where I met with the principal investigator of the Folkhälsan team, Dr. Eva Roos and her two associates Carola Ray and Camilla Stoor.

Based on the Research Quality handbook of the EMGO+ Institute, the Folkhälsan team had completed an audit survey before the actual audit and based on this questionnaire we discussed issues regarding sampling, data collection, storage, cleaning and privacy protection, as well as data analyses preparations.

The last EMGO annual report has been distributed

This summer the 2008 annual report (click here for a pdf of the report) of the EMGO Institute was finalised. The print report has been distributed over the last weeks, i.e. right after the summer break, and additional statistics have been published on our website. This annual report is the last one concerning the ‘old’ EMGO Institute, because from January 2009 we are the EMGO Institute for Health and care Research, or EMGO+.

The annual report shows that EMGO is going strong. This annual report proofs that the EMGO staff has again realized significant and meaningful scientific output, as indicated by a the 463 publications in international scientific international journals, a stable high citation score, and success in acquiring new grants that will enable further research in the years to come. EMGO welcomed four new full professors in 2008, with chairs in General Practice, Physical Activity and Health in Older Persons, Health Promotion and Health Policy and Participation of Patients in General Health Care, and we helped to get 36 PhD students to complete and defend their theses.
The fact that this was achieved in a year in which we intensively prepared for a major life-event in the history of the EMGO Institute, is, I believe, an indication of the strength and rigor of the institute. As said, in 2009 our institute will transfer into the interfaculty EMGO Institute for Health and Care Research, or ‘EMGO+’ in short. This new institute is an ‘interfaculty’ research institute because it will bring researchers from three faculties together, aiming to further improve public and occupational health, primary care, rehabilitation and long-term care, by means of multi and interdisciplinary research.
This 2008 annual report shows that we can give EMGO+ a good start.

Accreditation and certification of theory and evidence-based health promotion interventions

The Center for Healthful Living (Centrum Gezond Leven) and the Netherlands Youth Institute of the Netherlands National Institute for Public Health and the Environment are coordinating and leading an effort to come to better evidence-based practice in health promotion interventions in the Netherlands. The Center has developed an accreditation and certification procedure to distinguish between health promotion efforts that have no empirical basis from interventions for which different levels of evidence is available. For this purpose the Certification Commission for Interventions was started. The commission has four sub commissions, one on health promotion interventions for adults, which I will chair.
In health promotion, most often developed to promote healthy life styles for primary prevention of chronic disease, a lot is going on, but most interventions have no or an insufficient evidence-base. Such a situation is regarded as unacceptable in secondary prevention, cure or care, where evidence-based medicine is key. No one would accept, for example, that a new vaccine for Swine Flu was distributed to the population at large without careful stepwise testing in well-designed and controlled studies (see attached figure). In health promotion this is, however, common practice (the second figure shows this): mass-media or more tailored health education and health promotion interventions are designed, maybe pretested in some form of formative research, but often disseminated without any proof of effects.
The efforts of the Center for Healthy Living are aiming to help professionals and policy makers to select the available more promising and more evidence-based interventions for their health promotion purposes. The establishment of the certification procedure should also encourage organisations that develop interventions to improve their quality control and evaluation efforts.
Four levels of evidence will be distinguished (between brackets a very brief summary of the true, much better described and more detailed criteria are provided, click here for a list of criteria in Dutch):
1. Theoretically sound: The intervention’s goals, strategy and methods are well described and based established theoretical models
2. Probably effective: a series (>2) of studies of medium level design strength should suggest effectiveness
3. Proven effective: at least 2 studies with a strong research design show effectiveness
4. Proven cost-effectiveness: additional economic evaluations are available.
In the coming years it will become clear if the system will indeed lead to better evidence-based practice in health promotion.

In memoriam: Prof Herman Schaalma

Professor Herman Schaalma died suddenly of a heart attack on 25 July 2009 while riding his road bike in the Limburg hills. Last Friday I joined a crowd of 400-500 people in Eijsden near Maastricht, the Netherlands, to say goodbye during an emotional, heart breaking, but sometimes also hilariously funny ceremony.

Herman was a social psychologist and health scientist working at the Faculty of Psychology and Neuroscience of Maastricht University in the field of planned development, implementation and evaluation of theory- and evidence-based health promotion programs, with a focus on HIV/Aids. His research focused on applying (social) psychology in understanding and changing health behaviors. His recent research interests included risk perception and communication; stigma; adherence; culture, psychology and health education; and web-based health education.

I worked with Herman during the time I was at Maastricht University and occasionally after I left Maastricht to work first in Rotterdam, and now at the EMGO Institute for Health and Care Research at the VU University Medical Center in Amsterdam. In fact when in Maastricht I lived for a few years under the same roof as Herman; I lived in an apartment one floor above Herman and his family. Herman was a great colleague and a great neighbour.

The most intensive collaboration we had was when the two of us, together with Prof. Gerjo Kok edited the first edition of the Dutch handbook on health education and behaviour change. Working with Herman in this way was fun, rewarding and challenging. Fun because of his great sense of humour, rewarding because he certainly made sure that we got the job done and his input improved the book in a great way, and challenging because his razor sharp feedback and comments, no beating around the bush, made sure that you wanted to do your best before asking Herman to take a look at your output.

The field of planned, evidence-based health promotion has lost a great colleague and a great character.

Overweight and obesity in infants and pre-school children in the European Union

As part of the Health promotion through Obesity Prevention across Europe (HOPE) study, Prof. Adriano Cattaneo and collegues have conducted a systematic review on overweight and obesity prevalence and trends in countries within the European Union. The paper based on this review was recently published as e-pub ahead of print in the journal Obesity Reviews.

The data sources used in the review included WHO databases, Medline and Google, as well as data derived through contact with authors of published and unpublished documents. Data were analysed using the International Obesity Task Force reference
and cut-offs, as well as the WHO standard. The authors were able to derive data from 18 of the 27 countries. Comparisons between countries were problematic because of
different definitions and methods used in the varios reviewed studies.

The reported prevalence of overweight plus obesity at 4 years ranged from 11.8% in Romania to 32.3% in Spain. Countries in the Mediterranean region and the British islands reported the highest rates. Rates were generally higher in girls than in
boys. With the possible exception of England, there was no obvious trend towards increasing prevalence in the past 20–30 years in the five countries that had some trend data available.
The authors conclude that data on overweight and obesity in pre-school children are scarce and their interpretation difficult. Standard methods of surveillance, and research and policies on prevention and treatment, are urgently needed.

ISBNPA 2009 keynote debate: industry sponsorship of scientific societies and scientific research

The closing session of ISBNPA 2009 was the keynote debate. This year Professors Willem van Mechelen of EMGO+ at the VU University Medical Center and David Crawford of C-PAN, Deakin University, Australia debated about industry sponsorship of behavioral nutrition and physical activity research/research society. David Crawford argued against and Willem van Mechelen argued in favour. Professor Knut Inge Klepp of the department of nutrition of University of Oslo chaired the session.
After an introduction by Klepp stating the importantce and relevance of this issue, Van Mechelen started his argument by playing 'The times they are a changing' by Bob Dylan and a hylarious introduction including a reference to Aussie style football; Crawford with a picture of Van Mechelen as a clown. But after that, things got serious. Van Mechelen pointed out that without industry sponsorship we would have far less scientific research, and thus less scientific progress. Basically, he argued that scientists cannot accomplish their goals and cannot meet their performance indicators if they are too restrictive in accepting funding for research. He showed that, with some exceptions, governments in general and the Dutch government in particular are not willing to invest enough in scientific research to help evidence-based practice to progress. He further argued that as long as the process is transparent and the sponsored research is methodological sound, and the right rules regarding the data, scietific independence, disclosure and publications are set, with no publication restrictions, the risks of bias because of industry sponsoring is very low.
Crawford argued that and showed that there is evidence that industry sponsorhips can bias research results, citing, amongst others, Lesser et al's 2007 publication in Plos Medicine. He also argued that perceptions matter: sponsorship by industry may make a scientific society or a sponsored study less credible, among fellow scientists, reviewers, stakeholders as well as the broader community. David's third argument was that industry sponsorhip is no longer common; tobacco industry sponsorship of research is nowadays unheard of, and there is a growing movement against pharmaceutical industry sponsorship. David agreed with Willem that intercation with industry is important, but this should be without financial ties. Basically, David Crawford argued that the cons for accepting industry sponsorship for ISBNPA outweigh the pros.
By the way, in the preparation of the ISBNPA 2009 meeting, the Executive Committee of ISBNPA decided to not accept sponsorship from a large softdrink company for support of the society. ISBNPA 2009 was supported by non-commercial sponsors only.

Prof. Ken Resnicow argues in favour of embracing complexity and chaos theory in behavioral nutrition and physical activity

Today at ISBNPA 2009, professor Ken Resnicow gave his key note address: Moving beyond linear models of behavior change; embracing complexity and chaos.
His key note was very thought provoking. He argued that that the behavioral nutrition and physical activity field has been guided by a cognitive, rationale paradigm, described in health behavior models and theories such as the Theory of Planned Behavior, Social Cognitive Theory, and the Trans Theoretical Model.
Dr. Resnocow claimed and presented preliminary evidence that we may need a paradigm shift to move the field forward, a shift towards embracing chaos theory and complex dynamic systems in our field. Key principles from these perspectives described by Dr. Resnicow are:
1. Behavior change is often quantum rather than linear
2. Behavior change is a chaotic process that is highly variable and difficult to predict
3. Behavior change is a complex dynamic system that involves multiple component parts that interact in a non-linear way
4. Behavior change is sensitive to initial conditions
Dr. Resnicow has published his line of thinking in two published papers, one in the International Journal of Behavioral Nutrition and Physical activity, and one in the American Journal of Public Health. Click here for the IJBNPA paper and here for a reaction by Tom Baranowski and here for one by myself. The reference to the more recent paper by Resnicow in AJPH can be found here.

ISBNPA 2009 will start today

This evening the annual meeting of the International Society of Behavioral Nutrition and Physical Activity will start with an opening reception and a keynote lecture Shiriki Kumanyika. ISBNPA 2009 is at a great venue in Cascais, near Lisbon, Portugal. Today four different preconference workshops are ongoing on Introducing Intervention Mapping, conceptualising and measuring the build environment, early career mentoring, and on the role of advocacy in behavioral nutrition and physical activity.
The 2009 annual meeting will set another record; more than 600 delegates will be in Cascais to be informed and discuss the latest research in behavioral nutrition and physical activity. The local organising committee chaired by Pedro Teixeira, and the program committee chaired by the incoming president, Stuart Biddle have done a fantastic job.

Nicole Vogelzangs wins the annual publication price from the Netherlands Epidemiology Society at the annual WEON meeting in Amsterdam.

EMGO+ congratulates Nicole Vogelzangs with winning the annual publication price from the Netherlands Epidemiology Society. Nicole, who is completing her PhD within the EMGO Institute for Health and Care Research at the department of psychiatry, received the price for her paper ‘Depressive symptoms and change in abdominal obesity in older persons’, published in Archives of General Psychiatry.

WEON, the annual meeting of the Netherlands Epidemiology Society

On Thursday June 11 and Friday June 12 the Netherlands Epidemiology Society held its annual meeting (WEON) at the congress center the Meervaart in Amsterdam. The EMGO Institute for Health and Care Research organised this year’s annual meeting. An organisation committee chaired by Dr. Caroline Terwee took care of the organisation. The Netherlands Organisation for Health Research and Development and the Netherlands Cancer Society supported the WEON.
Caroline Terwee and her team decided to organise the program according to methodological issues instead of according to major diseases or health issues. Epidemiology encompasses a very multidisciplinary spectrum of contents, covering topics that can be organised according to disease (e.g. cardiovascular disease epidemiology, cancer epidemiology, infectious disease epidemiology, etc.) or according to risk factor (nutrition epidemiology) or according to setting (e.g. clinical epidemiology, social epidemiology), but it is the common methodology that units epidemiologists. This year’s WEON kicked off with a key note lecture by Dr. Dennis Revicki who informed us about the PROMIS project, with a strong focus on Item Response Theory as a means to realise efficient, and if necessary, tailored measurement in health surveys. The second part of the plenary opening session was a keynote debate between professors Jan Vandenbroucke (University Medical Center Leiden) and Bart Koes (Erasmus University Medical Center) about the merits and problems regarding the use of RCT research and observational research in striving towards evidence-based practice. Vandenbroucke argued that RCT’s are the gold standard for evaluation of therapy research, but are of much less (no?) use in discovery and explanation research, where observational designs are the way forward.
The 2009 WEON ended on Friday afternoon with two other key note debates, chaired by Dr. Lex Burdorf, on biological vs. statistical interaction (between Drs. Friedo Dekker and Mirjam Knol) and on the use and nonsense of power analyses (between profs. Jos Twisk and Martijn Berger). In between these two plenary sessions more than 90 posters and 60 orals were presented on themes such as validity of measurement instruments, screening research, diagnostic tests, prediction research, design issues, etc.

The Alpe D’HuZes challenge has been completed

Last Thursday I cycled Alpe D’Huez mountain together with more than 1000 other riders to raise money on behalf of the Alpe D’HuZes (“Alpe 6 Times”) foundation for the Dutch Cancer Society to fund cancer rehabilitation research.

I took on the mountain 6 times that day; some went as far as 9 times I heard…

The foundation raised more than 5 million Euros with the event. This enables the funding of a comprehensive cancer rehabilitation research program called A-Care, and the establishment of an endowed chair at the VU University’s faculty of psychology and education and the EMGO Institute for Health and Care Research on psychosocial support for cancer patients.

Click here for my own video impression of the event, shot from the bike...

Alpe D’HuZes is close

Just over 1 week to go before I will try to cycle up and down Alpe D’Huez mountain for the Alpe D’Huzes (“Alp –six-times”) event to raise funding for cancer research. The Alpe D’Huzes foundation has organised this event now for the forth year in a row, each year raising more money to support important cancer-related research. The EMGO Institute for Health and Care Research coordinates an Alpe D’HuZes funded research program on effectiveness of cancer rehabilitation interventions, and will host an endowed chair on psychosocial support for cancer patients.

On June 4, the cycling event will covered live on line via live.opgevenisgeenoptie.nl. Please visit http://deelnemers.alpe-dhuzes.nl/acties/HansBrug/Individuele-renners for more information on my personal sponsors for this fund raising event. The pictures attached to this message show the front and back of my shirt with the names of the larger sponsors that I will wear with pride on the day of the event.

HOPE (Health promotion through Obesity Prevention across Europe) reported its progress

In a preconference workshop at the European Congress on Obesity (ECO), organised by the European Association of the Study of Obesity, the HOPE project held its 2nd ‘Network of Networks’ meeting. HOPE stands for Health promotion through Obesity Prevention across Europe, and it’s a European Commission funded research project that aims to aims to bring the scientific knowledge on overweight, obesity and their determinants together and use the expertise of researchers all over Europe to help to tackle the obesity epidemic.
More specifically HOPE aimed to carry out quantitative analyses, modelling and systematic reviews on obesogenic physical activity and nutrition behaviours, their environmental determinants, consequences on health and health inequalities among children and adults, and prevention interventions, in order to provide an evidence-based inventory of best practices for the development of evidence-based policies and interventions for obesity prevention across the European Union.
We are now in the final stages of the HOPE project. We are now finalizing a series of systematic reviews, a series of scientific papers on secondary analyses, as well as epidemiological modelling to present scenario’s of what may happen to the obesity epidemic and its consequences on health and disability, if evidence-based interventions and policies are implemented across Europe.
These scientific reports will soon be submitted as deliverables to the European Commission, as well as to international scientific journals for peer review and publication.
At the Network of Network meeting, that I co-chaired with professor Philip James, we presented our results and the translation of these results into concrete policy recommendations to an audience of scientists, policy advisors, and government officials. We will use their feedback to fine tune our conclusions and recommendations that will be available via our website in the next few months.
Click here for some pictures of the presenters, discussants and audience at the HOPE meeting.

Experts see more in health protection than health education to help to prevent MP3 player-induced hearing loss among adolescents.

Hearing loss among adolescents is a growing concern. Exposure to loud music via personal MP3 players is one of the important risk behaviours. What can be done about this? To explore the potential determinants of engaging in such music-listening behaviour and possible intervention strategies to change such behaviours, Ineke Vogel conducted a series of studies, combining quantitative and qualitative research among adolescents as well as potential ‘intermediaries’ for preventive interventions. One of her studies was recently published in the journal Pediatrics.
In order to identify parties involved in the prevention of MP3-induced hearing loss among adolescents and potentially effective prevention strategies and interventions, thirty experts in fields such as scientific research, medical practice, community health professions, education, youth work, music entertainment, and enforcement authorities participated in a qualitative, electronic, 3-round, Web-based Delphi study.
Multiple parties involved in the prevention of MP3-induced hearing loss among adolescents were identified; the most relevant are the adolescents themselves, their parents, manufacturers of MP3 players and earphones, and governmental authorities. The experts did not expect that adolescents in general would perform the necessary protective behaviours to prevent MP3-induced hearing loss. Two environmental health protection measures were identified as both relevant and feasible to be implemented. The authors conclude that authorities, the music industry in general, and especially manufacturers of MP3 players and earphones should recognize their responsibility and create a safer MP3-listening environment by taking measures to protect today's youth from the dangers of listening to high-volume music on MP3 players.

Danielle Timmermans inaugurated as professor of Patient Participation in Healthcare Decisions

On Friday April 24 Dr. Danielle Timmermans was inaugurated as endowed chair at the EMGO Institute for Health and Care Research. Her chair focusses on research related to patient participation in health and health care decisions. An important part of her research is focussed on risk perceptions, and the role of such perceptions as a determinant of decisions and choices related to health behaviours and health care.

EMGO+ awards for Petronella van ’t Veer and Nannah Tak

At the general meeting of the EMGO Institute for Health and Care Research (see next message on this Blog!) on Wednesday April 22, the EMGO+ awards were announced. The EMGO+ Science Award for the best paper of a junior researcher was for Petronella van ‘t Veer-Tazelaar for her paper in Archives of General Psychiatry, entitled Stepped-Care Prevention of Anxiety and Depression in Late Life. This study, published in one of the highest ranked journals in the field, indicated that stepped-care intervention is effective in prevention of onset of anxiety and depression among elderly individuals.
The EMGO+ Societal Impact Award was awarded to Nannah Tak for her work on the evaluation of fruit and vegetable schemes in primary schools. Her studies, based on the ‘Schoolgruiten’ and ‘Pro Children’ projects. Showed that school-based interventions to promote fruit and vegetable consumption among school-aged children consisting of free school fruits and vegetables and a nutrition education curriculum are indeed associated with higher intakes, and such interventions are cost-effective. Her studies have received much media attention. Based on these studies and other studies in the field, the European Commission has decided to support school fruit and vegetable schemes throughout the European Union.

The EMGO Institute for Health and Care Research has started

Yesterday, the EMGO Institute for Health and Care Research, EMGO+, was officially launched with a kick off meeting in ‘Pakhuis de Zwijger’ in Amsterdam.
EMGO+ is an trans-disciplinary, and interfaculty research institute. The faculties of Medicine, of Psychology & Education, and of Earth and Life Sciences participate in this new institute, that builds on the strong foundation of the ‘old’ EMGO Institute for Extramural Medicine. Click here for some pictures of the event

The formation of EMGO+ is based on a detailed business-case and is supported by a start-up subsidy from the board of the VU University.

With a 300+ attendance, and with presentations by Prof. Lex Bouter, vice chancellor of the VU University, Prof. Wim Stalman, dean of the VU University Medical Center, and Prof. Paul van der Maas, chair of the Netherlands Health Council’s Advisory Council for Health Research we received a good overview of the chances and challenges for EMGO+, and its mission.

The mission of the Interfaculty Research Institute for health and care research is to encourage, initiate, conduct and publish excellent research of international standing to improve public and occupational health, primary care, rehabilitation and long-term care.

More specifically, by fulfilling its mission the institute is aiming to contribute to improving evidence-based:
• Public and occupational health;
• Primary health care;
• Rehabilitation practice;
• Long-term health and health care.

In these fields the institute aims to contribute to:
• Strengthening the evidence-base for current ongoing practice;
• Innovation of practice;
• Innovation of relevant research methodology;
• Provide input and direction for education and training for researchers and practitioners.

Scientific output in terms of acquisition of research grants, completion of doctoral thesis, and publications in peer reviewed international scientific journals, as well as societal impact are the indicators of the overall performance of the Interfaculty Research Institute.

Later on the day, we had the big EMGO+ quiz, the different research programs met in sub-group sessions. After some drinks and a buffet dinner, the EMGO+ Science and Societal Impact Awards were announced. The kick-off meting ended with a party with a great performance by the EMGO+ band.

Promoting physical activity and healthful diets: should we pursue more practice-based evidence in order to get to more evidence-based practice?

The obesity epidemic, sedentary lifestyles and lack of fitness, and the burden of disease related to vascular problems, asks for effective promotion of physical activity and healthful nutrition. I spite of the growing and very substantial number of behavioural nutrition and physical activity interventions that are being implemented in the Netherlands, only very few of these are evidence-based. Today, the Netherlands Organisation for Health Research and Development (ZonMW) hosted a workshop on this gap between practice and research, that I was asked to chair. On the one hand, quite a few interventions are being tested, initiated by academic researchers, while on the other hand schools, municipal health services, and national health promotion institutes are developing and implementing a range of interventions that have not been tested. Academia seems to fail to study the interventions that policy makers and practioners like, while policy and practice appear to fail to adopt the interventions that academia have tested and approved.
Prof. Larry Green, Adjunct Professor of Epidemiology and Biostatistics at the University of California at San Francisco, and, I believe, the godfather of planned health promotion, and author of the text book on this topic (Health promotion planning: an educational and ecological approach), gave an introductory lecture on the issues, after which two example projects were presented. The first one, the Krachtvoer (power food) project, initiated in academia, developed and tested according to the text books, but taking very long to get into the hearts and minds of practice. The second one, BigMove, developed and initiated in practice settings, but failing to get any funding for formal evaluation.
These presentations were followed by a general discussion and two workshops. The results and conclusions will help ZonMW to further improve their grant allocation procedures, to put what is being done in practice more in the lead to define what needs to be researched, and hopefully giving scientists the responsibility to define and develop the right methods and designs to do that. We should move from finding the appropriate research questions to the well-controlled research designs that the scientific community prefers, to finding and developing the right research designs to the research questions derived from what is going on in health promotion practice.

Physical activity promotion among the elderly

On Thursday April 16, Marijke Hopman-Rock held her inaugural address to accept her endowed chair in physical activity among the elderly, at the VU University Medical Center. Her professorship is embedded in the EMGO Institute for Health and Care Research. Prof. Hopman-Rock is also co-director of the Body@Work research program on promoting physical activity and prevention of musculoskeletal disorders.

Dr. Hopman-Rock gave a very lively and and stimulating talk on why physical activity should and can be pursued among the elderly, and what kind of research is necessary to bring this field forward in the years to come. This endowed chair is a further enrichment of EMGO’s research on healthy aging that has such a strong foundation in the Longitudinal Aging Study Amsterdam (LASA), with Dorly Deeg as its director and professor of epidemiology of the elderly, and Marjolein Visser as professor of Healthy Aging.

The Netherlands National Public Health Conference

On April 8 and 9 the annual national conference on public health was held in Rotterdam. This year’s theme was ’building bridges’ in health promotion between research, policy and practice. I attended the first day of the conference. In the opening session the Inspector General Gerrit van der Wal, of the Netherlands Health Care Inspectorate, gave a presentation that clearly showed that the inspection takes health promotion seriously, which includes that health promotion and public health practice should strive towards evidence-based practice. The director of the municipal health service of Amsterdam held the second short keynote. He argued that he strongly prefers evidence-based practice in public health, but in lack of availability of evidence-based interventions for many problems that his organisation faces, he argued that he could not wait for the evidence, and thus relies on professional experience and creativity. This opening session, as well as a debate session at the end of the day that I participated in, focussed, I believe, too much on the gap between science and practice in health promotion, in stead of the bridges that have been build in recent years. One strong example of bridges that are under construction are the so-called academic workplaces , or academic collaborative centers for public health in which public health academic research works closely together with practice organisations such as municipal health services, primary care organisations, or occupational health services, to plan and conduct research based on problems that these practice organisations face, to combine practice innovation with evaluation research, and to implement outcomes of scientific research in public health practice.
In another session during the day I gave a short introductory presentation in a workshop on the basic values and goals of public health practice: should we aim for health promotion as our most important goals, is it autonomy in making healthful or unhealthy choices that we should strive for, or is it social justice that public health practice should help to realise?

The Longitudinal Aging Study Amsterdam: a valuable advisory board meeting.

On March 25-27 I attended a meeting between the external advisory board of the Longitudinal Aging Study Amsterdam (LASA) with the LASA researchers to discuss progress, opportunities and challenges related to LASA and to advise on LASA’s future.
The LASA meeting started on Wednesday late afternoon with a dinner and post-dinner poster presentations, showing the width and depth of the LASA-related research projects. On Thursday the different general themes within LASA were presented, i.e. physical functioning, cognitive functioning, emotional functioning and social functioning. Presentations of the senior staff of LASA were followed by brief discussions. At the end of the day, the Advosry Board, chaired by Cornelius Katona, Honorary Professor at the Department of Mental Health Sciences of University College London, prepared their preliminary report that was presented and discussed on Friday morning.
In their preliminary report, the advisory board expressed great enthusiasm about the focus, scientific output and societal impact of the LASA study, and provided some strong first recommendations to further enhance the project. One of the main recommendations to the LASA team was to make as much use of the Interdisciplinary nature and possibilities of the LASA study and data, i.e. to encourage collaboration and mutual enrichment between the different research themes. An important recommendation to the LASA 'paymasters', i.e. the Ministry of Health and the VU University and the VU University Medical Center, is to start regarding LASA as crucial infrastructure in stead of 'just' a project.

An expert meeting to help to define a research agenda for midwifery research

On Friday March 19 the Science Advisory Committee of the Netherlands Royal Society of Midwifes organised an expert meeting as an important step in defining a research agenda for midwifery research. Approximately 50 midwifes, leaders of the midwifery schools in the Netherlands, and other key stakeholders met in Utrecht. Based on the results of a inventory made before the meeting, and chaired by professor Koos van der Velden, professor and head of the department of Public health at the Radboud University Nijmegen Medical Centre, a three phased discussion was held. Six preliminary research priorities were indentified. These research themes will now be further explored and defined by the Science Advisory Committee.
The meeting in Utrecht once more made clear that there is a great need for research in the field of midwifery to build a stronger evidence base for present midwifery practice and for further innovation of the field.
The Deliver study, a national midwifery study that is now being launched by the The Professional Midwifery Education Foundation in conjunction with NIVEL (Netherlands Institute for Health Services Research) and the EMGO Institute for Health and Care Research.