In memoriam: Prof. Marci Campbell

Early this week I received notification of the terrible news that Prof. Marci Campbell, professor at the department of nutrition at the UNC School of Global Public Health of the University of North Carolina at Chapell hill died of cancer.

Dr. Campbell’s research focused on nutrition behavior change for health promotion and disease prevention. Her research focused on investigating health communication strategies aimed at reducing risk factors for cancer and chronic diseases in minority and under-served communities. Approaches include testing effectiveness and cost-effectiveness of computer-generated, individually tailored interventions on diet, physical activity, and cancer screening behaviors for health promotion and disease prevention in diverse populations; impact of multi-level interventions including individual, social, organization and environmental approaches to address social and economic determinants and encourage healthy behaviors; and dissemination research using evidence-based interventions for obesity prevention and health promotion on a population-wide level.

I worked closely with Marci when I took my first steps in research. I was fortunate enough to spend a few months at the University of North Carolina in the early 1990’s when Marci and I were both working on our PhD theses in which we studied the development, implementation and effects of computer-tailored nutrition education. Marci published the first paper on this topic in the American Journal of Public Health. Since then Marci and I kept collaborating on a number of studies, including a reviews in the American Journal of Clinical Nutrition and in Patient Education and Counceling, and as co-advisors for the PhD research of Dr. Willemieke Kroeze, who went on to further explore and improve computer-tailored health education.

Marci was a great friend and colleague and I am grateful that I could work and spent time with her.

New book on writing health communications

This week a new book on writing health communication is out. The book, edited by prof. Charles Abraham of the University of Sussex and Dr. Marieke Kools of Maastricht University. The book provides a systematic and detailled description with lots of practical information regarding how people process information and how such insights can be used to improve health education materials. The book has chapters on message framing, the use of fear appeals, tailoring messages, using graphics, and behaviour change. Each chapter is illustrated with examples - including both good and bad practice and covering a range of health topics. Together with Anke Oenema of Maastricht University, I wrote the chapter on computer-tailored health education.

Study on reliability and validity of the ENERGY questionnaire published

The ENERGY-project is a European Commission funded cross-European project to gain more insight

in Energy Balance Related Behaviors (EBRB, i.e. specific eating, physical activity and sedentary behaviors that contribute to risk for overweight and obesity) and their potential behavioural determinants, and to inform and test a school-based and family-involved obesity prevention intervention scheme. As part of the ENERGY-project a crosssectional survey among more than 7000 children, their parents, and schools was conducted in seven countries representing different regions of Europe. This survey used questionnaires among children, parents, and school staff, as well as observations in the school and school environments. However, for the survey no established valid and reliable measures that could be administered in large populations of schoolchildren in different countries across Europe were available. Therefore, we developed a child and parent questionnaire to assess a range of EBRBs and potential individual and environmental behavioural determinants, and examined the test-retest reliability and construct validity of these two main questionnaires used in the ENERGY cross-sectional survey. The reliability study among children is now published in the International Journal of Behavioral Nutrition and Physical Activity, with Dr. Amika Singh as the first author.

Self-care is an important aspect of heart failure (HF) management. Information on possible determinants of selfcare is needed for the development of self-care promotion interventions. HF self-care includes self-care management, self-care maintenance, sodium, fluid and alcohol intake restriction, physical activity, smoking cessation, monitoring signs and symptoms and keeping follow-up appointments. To assess the evidence regarding presumed determinants of HF self-care in order to make recommendations for interventions to promote self-care behavior among HF patients, a systematic literature review was conducted. This review is now published in the journal Heart Failure Reviews, with Rony Oosterum-Calo as first author. Twenty-six original scientific articles were included in the review. Results showed that  patients’ who were diagnosis with HF longer agi, i.e. with more experience with the disease, were more likley to performe self-care maintenance. Moreover, it was found that HF patients’ perceived benefits and barriers are related to their restriction of sodium intake, and that patients with type-D personality are less likely to consult medical professionals. All other evidence was inconsistent, mainly due to insufficient evidence or lack of studies. Interventions that aim to increase the performance of self-care maintenance can teach newly diagnosed patients the skills that are usually attained with experience acquired as a result of living with HF for a longer time. Perceived benefits and barriers of restricting sodium intake could be targeted in interventions for sodium intake reduction among HF patients. Finally, interventions for the promotion of adequate consulting of medical professionals can specifically target HF patients with a type-D personality.

Trying to explain educational differences in consumption of sugary drinks

One of the possibly most important correlates and determinants of nutrition behaviour is socio-economic background. Again and again it is found that people from lower socio-economic status, as indicated by level of education, income, job status or other factors, are, for example, more likely to be overweight and eat poorer diets. Such differences are already found among children and adolescents. In a recent paper published in Public Health Nutrition, we explored mediators of gender and educational differences in sugarsweetened soft drinks consumption (SDC) and we investigated whether gender and level of future education moderate the associations of accessibility, modelling, attitudes and preferences with SDC. We were able to use data from 2870 children in 9th and 10th grade from more than thirty secondary schools in Norway.

As expected, girls and pupils planning higher education reported to drink SDC less often than boys and pupils going to higher levels of education. The differences according to future education plans were mediated by accessibility and modelling: thus children who were planning to go to higher education had lower accesibility to sugary drinks and were less likely to be exposed to peer models that drank lots of sugary drinks.

The joint Australian-New Zealand Nutrion Societies meeting

Last week I presented the results of the ENERGY study on childhood overweight and obesity and prevention of childhood overweight and obesity across Europe, at the annual meeting of the Australian and New Zealand nutrition societies. The meeting's theme was 'Lean and Green' with a focus on obesity as well as on sustainable food and nutrition. My keynote presentation was linked to the 'Lean' theme, while Prof. Tim Lang talked about the link with sustainability - via a web-video presentation. The meeting was much like similar meetings in the Netherlands or elsewhere in Europe, with similar presentations, studies and discussions, and even sponsors (e.g. similar to such events in the Netherlands, the Dairy industry was the main sponsor of the meeting).

Visiting the School of Population Health, University of Auckland

On my way to the joint annual meeting of the Australian and New Zealand Nutrition Societies in Quesnstown, New Zealand, together with Professor Kylie Ball from Deakin University, I visited the clinical trial research unit of the School of Population Health of the University of Auckland. We had meetings with the behavioral nutrition and physical activity research leaders of the unit, i.e. Cliona Ni Mhurchu and Ralph Madison, as well as a number of research fellows and PhD students. Kylie and I provided a joint symposium at lunch time.

Visiting C-PAN at Deakin University, Melbourne

This week I am visiting the Center for Phyiscal Activity and Nutrition Research (C-PAN) at Deaking University, Melbourne, Australia. C-PAN is one of the internationally leading groups in (behavioral) nutrition and physical activity research. Their focus is very similar to parts of the EMGO Institute for Health and Care Research (EMGO+), our Lifestyle, Overweight & Diabetes and Musculoskeletal Health programs in particular. The close collaboration with C-PAN has resulted in a number of joined projects, including involvement of C-PAN staff in the EMGO+ European Commission funded ENERGY project on obesity prevention in school-age children across Europe, and involvement of EMGO+ staff in C-PAN's READY project on resilience to obesity among women from lower socio-economic backgrounds, and a growing number of joint scientific publications. The accompanying photo shows (except for myself and C-PAN's director David Crawford's son Alex) the C-PAN staff that visited EMGO+ in the last couple of years, as well as another regular visitor of C-PAN, Prof. Bob Jeffery from the epidemiology unit of the University of Minnesota, USA. (Notice C-PAN in chocolate letters, in anticipation of the Dutch Sinterklaas festivities....)http://en.wikipedia.org/wiki/Sinterklaas

Health education is not enough to promote healthy diets and physical activity

Today two PhD candidates from the EMGO Institute for Health and Care Research defended there theses at the VU University here in Amsterdam. In his thesis 'Efforts to prevent diabetes and cardiovascular disease in primary care' Jeroen Lakerveld explored the effects of a health education program based on motivational interviewing and problem solving treatment to motivate and enable people with high risk to adopt health behaviors that contribute to diabetes prevention (e.g. healthy eating and physical activity). The effect study showed generally no effects of this health education approach.  Dr. Lakerveld states that the approach taken may have been too limited, and that for interventions to be effective changes in the environment, i.e. the availablity of and social support for health choices may be needed.

Willemijn Vermeer studied the role of portion sizes of foods and the development and evaluation of interventions to motivate or enable people to take smaller portion sizes. Earlier research shows that portion sizes have increase quite abit over the years, e.g. coke, candy bars, fast food entrees are sold in much bigger portion sizes nowadays than a few decades ago. Additional research strongly suggests that these increases contribute to overeating and to overweight and obesity. Dr. Vermeer research shows that policies to actually reduce portion sizes are not acceptable for the general public or for food catering organisation, while interventions that are regarded as acceptable, i.e. better labels to explain portion sizes or more choice between different portion sizes, appear to be ineffective.

Both studies suggest that health education is not enough and that people need to be nudged toward healthier behavior - that the healthy choice should be made the easy and default choice. The present Dutch government disregards this and earlier (and even stronger) evidence. Theb Dutch policy is that people are ablle and will make informed choices about their health behavior and that freedom of choice and autonomy should be promoted. In an environment that promotes supersizing and lack of physical activity, that freedom of choice appears to be quite relative.

A review on economic incentives and nutritional behavior among children in the school setting

Health behaviour may be promoted by different incentives. Economic incentives, i.e. monetary rewards or price incentives, e.g. making healthy foods less expensive and unhealthy foods more expensive, may be applied. However, the true possibilities and effects of such interventions are debated, and their applicability among children may be doubtful. The aim of a review, just published online in the journal Nutrition Reviews, was to examine the existing literature on the effectiveness of economic incentives for producing sound nutritional behavior in schools Altogether, 3,472 research publications were identified in the systematic search, of which 50 papers were retrieved. Of these, 30 publications representing 28 studies were regarded as of highe enough quality and relevant. The review indicates that price incentives are effective for altering consumption in the school setting. Other types of economic incentives have been included in combined intervention schemes, but the inclusion of other intervention elements makes it difficult to draw conclusions about their effectiveness.

A second writing workshop to publish further results of the ENERGY project

The ENERGY project stands for the "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". ENERGY consists of a series of systematic reviews, secondary data analyses, a school-based and family involved cross sectional and intervention study among 7000 and 2500 children and one of their parents respectively. Seven countries across Europe are involved. The project description and study design papers regarding the cross sectional study in general and the accelerometer study (i.e. a study to monitor schoolchildren physical activity objectively) have been published, and a number of scientific papers have been submitted for publications. These concern papers on prevalence - and differences in prevalence between the seven countries - of overweight and obesity, as well as engagement in a range of behaviors (i.e. physical activity, sedentary behaviors, dietary behaviors) associated with risk for being or becoming overweight; differences in prevalence according to ethnic background of the children. Further papers that have been submitted focus on, for example, the reliability and validity of the measures used in the ENERGY study, the relation between weather circumstances and physical activity, the association between sedentary behavior and blood markers for metabolic health, et cetera.
These days another writing workshop is ongoing in a bed-and-breakfast facility in Amsterdam to write and prepare the next series of scientific papers from the project. Scientists from the UK, Norway, Spain, Belgium and the Netherlands meet here for 3 days to write and provide feedback on a series of papers regarding for example mediators of socio-economic differences in childhood overweight, the clustering of physical activity and sedentary behavior patterns, the contribution of TV watsching to total sedentary behavior and a range of other topics. All these papers use data from the cross sectional survey of ENERGY. Data for the ENERGY intervention study targetting sedentray behavior among school children in five of the partcipating countries are now being collected and will be available later this year.

A workshop in Stockholm on grading evidence regarding public health interventions

Last Wednesday, the Swedish National Institute of Public Health organised a meeting in Stockholm to explore the do's and don't's of grading evidence regarding public health interventions to help policy makers to identify the best and most effective interventions to promote population health. In public health and health promotion the cry for better evidence-based practice is strong and obvious. However, grading the evidence in public health is more complicated as compared to medical interventions. In public health, interventions are, for example, often group or population based rather than aimed at individuals, effects are often only to be observed in the long run, and interventions are mostly complex, multi-component and context dependent. These characteristics make it more difficult to study public health interventions in research designs that are regarded as the most internally valid, i.e. randomised controlled trials (RCT). In existing systems to grade evidence for medical interventions, such as the GRADE system, evidence not based on RCT designed studies can never be strong, thus favouring individual medical interventions above population-based public health interventions. Therefore, maybe new or other systems need to be developed, or the GRADE system may need to be adapted to better accomodate public health and health promotion interventions. At the workshop I presented the Dutch acknowledgement system for health promotion interventions, led by the the Centres for Healthy Living and Youth Health of the Netherlands National Institute for Public Health and the Environment and the Netherlands Youth Institute. This system was specifically designed  and developed and is being implemented aiming to provide policy makers and professionals with more information on the quality and effectiveness of

available health promotion interventions and to promote use of good-practice and evidence-based interventions by health promotion organizations.  Four levels of recognition are distinguished inspired by the UK Medical Research Council’s evaluation framework for complex interventions to improve health: (i) theoretically sound, (ii) probable effectiveness, (iii) established effectiveness, and (iv) established cost effectiveness. Specific criteria have been set for each level of recognition, taking into account the specific evaluation researhc challenges for public health and health promotion evaluation research. The way the Ducth system works and the first experiences and results were published in a paper in Health Education Research.

Nicole Ezendam successfully defends her PhD thesis

Today Nicole Ezendam received her doctorate degree after a successful public defence of her thesis entitled “Vet is niet Vet (Fat aint Phat): studies on the prevention of excessive weight gain among adolescents.” Her thesis encompasses three studies exploring determinants of unnecessary weight gain among adolescents and four studies on the development, effects and the process of the FATaintPHAT intervention. This is a computer-tailored program to motivate and enable adolescents to adopt more healthy dietary and physical activity habits.

Her research shows that the intervention appeared to help the participants to adopt healthier dietary habits, but failed to encourage them to become more physically active

The third Alpe D'Huzes cancer rehabilitation program annual meeting

Today the third annual meeting of the Alpe D'Huzes Cancer Rehabilitation (A-Care) program was held in Amsterdam. A-Care is a comprehensive program of eight PhD studies organised in two subprograms to further our knowledge on the effects of exercise in cancer rehabilitation and survival. The first subprogram focusses on clinical research to study the effects and mechanisms of effect of different exercise regimes in different groups of cancer patients. The second subprogram focusses on ways to implement and disseminate succesful exercise interventions. Dr. Laurien Buffart, the acting coordinator of A-CaRe 1 and a recent 'Bas Mulder award laureat, organised the day.

Prof. Rob Newton (see picture), and Drs. Lee Jones and Renate Winkels provided state of the art overviews of the roles of exercise and diet in cancer rehabilitation and survival, and Prof Wim van Harten and Dr. Mai Chinapaw provided overviews of ghe progress of the two subprograms.

Prof. Christianne de Groot is inaugurated as professor of obstetrics

Yesterday, Prof. Christianne de Groot gave her inaugural address as professor and head of department of obstetrics at the VU University Medical Center. She first presented the well known facts that perinatal mortality is higher in the Netherlands than in surrounding countries. She argued that for a better perinatal care true and close collaboration between extramural and intramural care, between midwifes and obstetricians, in a true women and child care center is of crucial importance. Such close collaborations are now being developed and researched within VUmc and the EMGO Institute for Health and Care Research.

The Journal of Nutrition Education and Behavior podcast on our study on computer-tailored nutrition education

In the upcomming issues of the Journal of Nutrition Education and Behavior, a paper by Dr. Kroeze et al is published on an evaluation of computer-tailored nutrition education on saturated fat intake among adults. This evaluation was not based on self-reported intakes, but on biomarkers, i.e. blood lipids. In more detail: a group of more than 400 adults receved either computer-tailored nutrition education about their fat intake levels or not, and cholesterol levels were measured in blood samples to assess if exposure to the nutrition education resulted in better blood lipid levels. However, despite clear favorable changes in self-reported fat intake levels, no effects on blood lipids were found. If you want to learn more about this study, and how these conflicting results should ne interpreted, please listen to a podcast interview with the firts author of our paper (look for 9/8/11).

Dr Anna Timperio gives a seminar on home and family determinants of overweight in children

Yesterday, Dr. Anna Timperio, of the Center for Physical Activity and Nutrition Research of Deakin University gave a seminar on her work on home and family environment determinants of physical activity, eating behaviors, sedentary activities and overweight in children. In her seminar she presented an overview of results of the CLAN and HEAPS studies, two longitudinal studies aiming to unravel why children become overweight or not. Her work shows that family environmental factors, such as example behavior of parents, doing physical acyivities together, and the availability of physical activity equipement in the home, appear to be more important than neighbourhood factors, for children's physical activity.

Home and neighbourhood correlates of weight status among children in low socio-economic neighbourhoods in Australia

Understanding the underlying drivers of obesity-risk behaviours is needed to inform prevention initiatives. People, including children, of lower socioeconomic position groups are more likley to be overweight and obese, and understanding of the drivers of such socio-economic differences in weight status are of special importance. It is very likely that  factors in the home and local neighbourhood environments are of importance. However little research has examined such possible determinants among children from low socioeconomic backgrounds. A study conducted in Victoria, Australia, on this topic was recently published by Prof. David Crawford from the Center for Physical Activity and Nutrition of Deakin University. The study examined home, social and neighbourhood correlates of body mass index in children living in disadvantaged neighbourhoods. Data were collected from 491 women with children aged 5-12 years living in forty urban and forty rural socioeconomically disadvantaged areas (suburbs) of Victoria. Mothers completed questionnaires about the home environment, social norms and neighbourhood environment in relation to physical activity, healthy eating and sedentary behaviour. Children's height and weight were measured at school or home. The results showed that children who had a television in their bedroom  and whose mothers made greater use of food as a reward for good behaviour had higher body mass index. Increasing efficacy among mothers to promote physical activity, limiting use of food as a reward and not placing TV in children's bedrooms may be important targets for future obesity prevention initiatives in disadvantaged communities.

A new grant to further enrich computer-tailored health education

Computer-tailored health education, i.e. using ICT to provide people with individually tailored feedback and advice to motivate and enable more healthy lifestyles, is a very promising health education technique (see Brug et al for an early overview of the evidence, Oenema et al for a firts study on web-based computer-tailoring, or Kroeze et al for a more recent systematic review). One of the critiques on this form of on-line health education is that it does not include the necessary social interaction to better realise lasting behavior changes. With the development and very fast dissemination of web-based social networks, the distribution of mobile internet, and ever faster and more powerful mobile devices, the possibilities to provide computer-tailored health education where and when it matters, based on objective measures of behavioral patterns, and linking this to social network features become apparant. We have just received notice that we will receive an important research grant, with Dr. Saskia te Velde as the main applicant, in the Partnership programma STW-NIHC-Philips Research“Healthy Lifestyle Solutions” to develop and test such further innovations in computer-tailored health education promoting physical activity among young adults.

Effectiveness of workplace interventions in Europe promoting healthy eating: a systematic review

The worksite is a promising setting for health promotion. A review recently published online in the European Journal of Public Health by professor Lea Maes et al. summarizes the evidence of effect of intervention studies in European countries promoting a healthy diet solely and in combination with increasing physical activity at the workplace. The review included studies published from 1 January 1990 to 1 October 2010; worksite-based interventions promoting a healthy diet solely or in combination with physical activity aiming at primary prevention and measuring anthropometrical or behavioural change among adults (≥18 years old) were included.

Seventeen studies solely focusing on promotion of a healthy diet were identified. Eight of these studies investigated health education intervention, one studie explored the effects of changes in the worksite environment, and eight used a combination of both (i.e. multi-component interventions). None of the interventions was rated as very 'strong'. The reviewed studies showed moderately strong evidence for effects on dietary change.

In conclusion only moderate evidence was found for positive effects of nutrition interventions implemented at the workplace. Effects of workplace health promotion interventions may be improved if stronger adherence to established quality criteria for such interventions is realized.

FUSE (the centre for translational research in public health) strategy meeting

Last Tuesday I attended - as an external member of the FUSE strategy board- a strategy meeting to explore and inform the centre's policy, strategy and tactics for the years to come. The meeting was led by the centre's director, Professor Martin White, and was held after the centre's third anniversary, and two yeard before its firts term ends. FUSE is an inter-university centre for translational research in public health. It is a collaboration between  five universities in the north-east of England - Durham, Newcastle, Northumbria, Sunderland and Teesside - and works in partnership with the public and in collaboration with the National Health Service, local and regional government and other public, private and voluntary organisations in North East England. FUSE focusses on the translation from research into public health policy and practice, it aims to do practice-based research to improve evidence-based practice, and its main goal is to develop a scalable model for such translation. Such translation of research into policy and practice, and translation of policy and practice issues in research is of of great importance in the field of public health. A lot of research is being conducted but the results certainly do not always find their way into true practice, and much of policy and practice in public health is not evidence-based. In the Netherlands this translation issue is being tackled by so-called academic collaborative centre's. The EMGO Institute for Health and Care Research leads and participates in anumber of such centre's, for example for public health, for youth health care, for occupational health, and mental health.

Impact Factor of the International Journal of Behavioral Nutrition and Physical Activity

This week the new impact factor (IF) of the International Journal of Behavioral Nutrition and Physical Activity was announced: 3.17.  This is a significant increase from last year's 2.63. This means that on average the papers published in IJBNPA are now cited 3.2 times. This is an impressive IF for such a young journal. The journal was established as part of the International Society of Behavioral Nutrition and Physical Activity (ISBNPA) about 10 years ago. The society and the journal have grown into a leading society and journal in the field. Given the fact that nutrition and physical activity are important in the prevention and management of the most important chronic diseases, including diabetes, cardiovascular disease and some cancers, the ISBNPA and IJBNPA scientific platforms are timely and important.

ISBNPA 2011

Just a bit more than an hour ago the 10th annual meeting of the International Society of Behavioral Nutrition and Physical Activity, held in Melbourne Australia, ended. The conference was three days of energizing and inspiring presentations and discussions of cuting edge research on nutrition, physical activity and sedentary behaviors. The focus of the society is on the associations of these  behaviors with a variety of health outcomes, the determinants of engagement is these behaviors and ways to motivate, enable and facilitate people across the life course to engage in healthful eating and physical activity.

The conference ended today with a very funny as well as very serious debate on where the in most countries relatively tiny budget available for promotion of healthful eating and physical activity should be invested: in the young only, or not (and thus also in the old(er)). Three experts argued for each side, and in different forms, including a rap act, a home movie on one of the experts young and old dog's, preaching and plain old argumentation. Professors Jim Sallis, Louis Barr and Dr. Karen Campbell argued in favour of the proposition by binging forward that health behaviors track from childhood into adulthood, that epigenetic influences at a very young age may make people more liable for chronic disease across their life span and many arguments more. The opposition consisted of Profs. Tony Worsely, Adrian Bauman and Abby King, and they argued that the largest burden of chronic disease is in midlife and the elderly, that lifestyle behavior changes in adults and elderly have a much faster return on investment, that adults and the elderly provide role models for the young and meny arguments more. It was very lively debate, and at the end the team arguing against the propostion were declared the winners, based on the strength of theur argumentation as well as the show they performed to bring their arguments across.

The debate waa follwoed by the announcement of the prices for the best presentations from young investigators, farewell words of the outgoing president of the society (Prof Knut Inge Klepp), some words of thanks from the chair of the local organising committee and the incoming president (Prof. David Crawford), and a great performance by the chair of the local organising committee for next year's conference (in Austin, Texas), Prof. Deanna Hoelscher.

A joint EMGO+ - C-PAN pre-ISBNPA meeting

Two days before the actual kick-off of the tenth annual meeting of the International Society for Behavioral Nutrition and Physical Activity (ISBNPA) in Melbourne, we organised a pre-conference meeting to celebrate and confirm the very fruitful collaboration between the behavioral nutrition & physical activity research groups of EMGO+ (VU University and VU Medical Center) and of the Center for Physical Activity and Nutrition Research (C-PAN) (Deakin University).

After introductions and words of welcome from the two directors of EMGO+  and C-PAN, i.e. myself and Prof. David Crawford, researchers from both institutes presented overviews of different research lines, e.g. on pricing and labeling strategies to influence nutrition behaviors, on studies on disparities in behavioral nutrition and physical activity according to socio-economic status, on determinants and intervantions on sedentary behaviors, on genetic and environmental determinants of nutrition and physical activity behaviors, et cetara. Thereafter, three guests, (associate) Profs. Annie Anderson, Frank van Lenthe and Stuart Biddle, provided overviews on where they think the field of behavioral nutrition and physical activity is especially in need of further research. At the end of the day, researchers from broke out in small group sessions to develop innovative research ideas for joint projects.

The success of the collaboration between the two centers so far is illustrated by the fact that we have an intensive exchange program, with 9 researchers having visited C-PAn from EMGO+ or vice versa for a few weeks up to a couple of months, and by five joint externally funded research projects, sponsored by for example the European Commission and the World Cancer Research fund, as well as more than 10 joint international publications (the link provides some examples) and more than others 10 under review.

For whom and under what circumstances do school-based interventions to promote energy balance behaviors work?

The aim of a review recently published on-line by Mine Yildirim et al. in the International Journal of Pediatric Obesity was to systematically review the results and quality of studies investigating the so-called moderators of schoolbased interventions aimed at energy balance-related behaviors (diet, phsyical activity and sedentary behaviors). Such moderators tell us for whom and under what circumstances these interventions are effective or not. In total 61 original studies were included in our review. Gender, ethnicity, age, baseline values the different behaviors, weight status and socioeconomic status were the most frequently studied potential moderators of intervention effects. Gender was found to be a consistent moderator of intervention effects, i.e. school-based interventions appear to work differently for boys and gilrs, and our review evidence suggests that such interventions generally work better among girls.  For the other potential moderators, there were just not enough studies of good enough quality to draw further conclusions. Consequently, our review revealed that there is still lack of insight into what interventions work for whom and that future studies should do better jobs to explore if and how intervention effects differ among different target group segments.

Keep cycling!

The objective of the study recently published by Dr. Elling Bere et al. in the International Journal of Pediatric Obesity was to assess the longitudinal association between cycling to school and weight status in two cities where cycling to school is common - Kristiansand (Norway) and Rotterdam (The Netherlands). Data from the ENDORSE (Rotterdam) and YOUTH IN BALANCE (Kristiansand) studies were used. Both studies were longitudinal studies with two years between the two measurements and both studies were among students in early adolesence (13.2 and 13.4 years at the start of the study). We categorized the students according to their mode of commuting to school at the two measurements: NO cycling at both measurements, STARTED cycling to school, STOPPED cycling and CONTINUED cycling. Measured weight and height were obtained at both time points, and weight status (overweight vs. not overweight) was calculated using international classification criteria for BMI from the International Obesity Task Force. The two datasets were analyzed separately and together. The results showed that those who stopped cycling had a three times greater odds of being overweight at the end of the study while those continued cycling had more than half the odds of being overweight, as compared to the other three groups together. The same trend was observed in both study samples. This study thus indicates that kids should continue to cycle to school; it is not only a fun, fit and environmentally friendly means of transportation, it may also help to avoid becoming overweight.

Dr. Laurien Buffart is granted a ‘Bas Mulder Award’

This year for the first time the prestigious Bas Mulder Awards were granted by the Netherlands Cancer Society on behalf of the Alpe D’Huzes Foundation. This Bas Mulder Award – named after and in remembrance of Bas Mulder; who was a living example of the Alpe D’Huzes mission but who died of cancer in 2009 at the age of 24- is a personal grant aimed at “grooming talent” in the field of research that contributes to longer and better lifes for cancer patients. Laurien Buffart will receive her approximately 650,000 Euro grant on the mountain where next Thursday for the sixth year in a row thousands of cyclists will pedal up and down Alpe D'Huez to raise money for cancer research. Last year, Laurien participated in this Alpe D'Huzes event herself with two teams of VU University Medical Center researchers to contribute to the fund raiser. Laurien, who already co-leads the A-CaRe research program to improve cancer rehabilitation at the EMGO Institute for Health and Care Research, will use her award to further organise an international consortium, hire two PhD students and together build an international database of data from randomized controlled trials testing exercise and psychosocial support interventions aiming to improve quality of life of cancer patients and survivors. This database will then be used for a series of meta analyses to better understand why, for whom and under what circumstances these interventions work in order to develop better tailored quality of life improving interventions in the years to come.

Effectiveness of a primary school-based intervention to reduce overweight

'Lekker Fit! ('enjoy beging fit') is a school-based program to contribute to the prevention of overweight and obesity among schoolchildren. Recently a study to evaluate the effectiveness of this program was published in the International Journal of Pediatric Obesity by Dr. Wilma Jansen et al. The purpose of this study was to evaluate the effect on weight status indicators as well as physical fitness. In total 20 schools and 2,622 children aged 6-12 years (grades 3-8) from multi-ethnic, low income inner-city neighbourhoods in Rotterdam, the Netherlands, participated. The intervention was informed by behavioural and ecological models of health behaviors that contribute to or may help to prevent unnecessary weight gain in children. The main components of the intervention were the implementation of three physical education (PE) sessions a week by a professional PE teacher, additional sport and play activities outside school hours and an educational program. Weight status, body mass index, waist circumference and fitness (20 m shuttle run) were measured to assess effects. Children who participated in Lekker Fit! were found to be less likley to be overweight, had a smaller mean waist circumference, and performed significantly better in the shuttle run test than kids in the 'control schools', but vthese favourable results were only found among the younger children, i.e. the 6-9 year olds. 

The EMGO+ 2010 annual report is online

The annual report for 2010 of the EMGO Institute for Health & Care Research is online. The report is electronic-only this year, which makes it readily available, easy to browse through and easy to disseminate in the wider local, national and international scientific community (and it helped us to save some trees and money).

Please take some time to browse through the report. This will inform you about the very interesting range of programs, projects and research topics our institute covers, and about our infrastructure that supports our research. When reading the report you will notice that our efforts in 2010 have resulted in output and impact that is (again!) substantially better than in the year before. We have published substantially more, without a reduction in quality of the papers, our citation index remained at its constant high level, we were able to acquire another record high amount of Euros in external grant money, and we were again able to show that our work is regarded as highly relevant by our external stakeholders.

The fact that our 2010 results show better performance than the 2004-2009 period, i.e. the period that was evaluated as excellent on all counts in the report of the external international evaluation committee, is very good news for the institute.

The EMGO+ annual meeting is underway

Today we have our annual meeting of the EMGO Institute for Health and Care Research. The entire day is focussed on measurement, which is, of course, one of the cores of scientific research and progress. As Baron Kelvin said: "if you cannot measure it, then it is not science". But measurement comes in many different ways, and to quote another icon of science -Einstein-: "not everything that can be counted counts, and not everything that counts can be conted. Our program today is about computer adaptive testing, on using smart phones in measurement, on applying registrations, etc. This program was designed by Dr. Caroline Terwee, the coordinator of the Knowledge Center for Measurement of the EMGO Institute for Health and Care Research.

At the end of the meeting the societal impact and science awards were granted and celebrated, and the EMGO+ junior fellows, i.e. the mid-career researchers within the institute that are supported by EMGO+ with personal post-doctoral grants to boost their research careers - were interviewed (see photo), as well as the junior researchers who received travel grants to establish international collaborations.
Ludeke Lambeek recieved the science award for her paper in the British Medical Journal on the economic evaluation of integrated care for low back pain patients.
Hanneke Wijnhoven received the societal impact award for her work in developing, testing and disseminating the SNAQ questionnaire to detect undernutrition in the elderly.

Wendy Brouwer defends her doctoral thesis on exposure to internet health promotion interventions

Today, Dr. wendy Brouwer defended her doctoral thesis on exposure to internet-delivered interventions aiming to promote health behaviors, such as healthy eating, non smoking and physical activity. Her thesis research shows that characteristics of the users predict whether they will go to a health promotion website, but that characteristics of the intervention are crucial predictors of really using the web-based intervention and staying long enough to get exposed to the health promotion information and feedback. Major parts of her research are published in scientific journals such as the Journal of Medical Internet Research and Health Education Research.

Dr. Patti-Jean Naylor presents research on Action Schools BC

This week Dr. Patti-Jean Naylor from the University of Victoria, Canada, visited the Youth & Health research group of the EMGO Institute for Health and Care Research, led by Dr. Mai Chinapaw.

Dr. Naylor presented results on the evaluation of the Action Schools BC program, a best-practice project to provide school children in British Colombia, Canada with more options to make healthy choices regarding physical activity and healthy eating. The health outcome evaluation she presented strongly indicates that  the model was effective at increasing the physical activity level of students, and contributed to improvements in their bone health, heart health, dietary requirement awareness, and academic performance. Pilot research regarding the healthy eating part of the model suggested that the initiative was effective at changing the pattern of vegetable and fruit consumption of school children in Grades 4 to 7.

This program has strong similarities with projects conducted at EMGO, such as the DoIT, Go4it and Jump-in projects.

Mediators of effective energy-balance interventions in youth

Obesity prevention in youth requires effective interventions targeting the so-called energy balance-related behaviours (that is, physical activity, sedentary and dietary behaviours). To improve (cost-)effectiveness of these interventions, we need to know the working mechanisms underlying behavioural change. Mediation analyses is a technique that helps to explore an analyse via what pathways interventions have their effects (...or not). Identifying such mediators of intervention effects can help professionals in developing new interventions or adapting existing interventions so that these are targetted at these succesful mediators as good as possible. Dr. Maartje van Stralen and colleagues just published a systematic review of studies on  identification of psychosocial and environmental mediators of  school-based interventions for youth, aiming to change physical activity, dietary and/or sedentary behaviours. The review paper was published in the International Journal of Obesity and was conducted as part of the ENERGY project, a cross-European and European Commission funded project to inform effective prevention of overweight and obesity in schoolchildren across Europe. Twenty-four studies were identified in the scientific literature. Based on the review of these 24 studies, strong evidence for self-efficacy and moderate evidence for intention as mediators of physical activity interventions was found, i.e. improvements in physical activity were brought about via positive changes in self-efficacy and intentions. Some evidence was found that attitudes, knowledge and habit strength were mediators of dietary behaviour interventions. Too few studies were avialbale on interventions aiming to reduce sedentary time to draw any conclusions regarding potential mediators.

KLV 125 years

The Wageningen University and Research Center Alumni network (KLV) celebrates its 125 year anniversary this year. Part of the celebrations is a series of presentations and debates on emerging topics regarding food, nutrition and agriculture, with ‘How to feed the World’ as the over-arching theme. Yesterday afternoon I presented at one of these debate sessions in Nieuwspoort in the Hague.


The topic of the afternoon was how healthy and sustainable food and nutrition can and should go together. The debate focussed on whether promotion of healthy and sustainable food should be primarily be pursued via health education to encourage well-informed healthy choices, or more via health protection measures, i.e. by changes in the availability and accessibility of foods in order to make the healthy and sustainable choice more or less the ‘default’ choice.

The great public health promotion accomplishments (the US Centers of Disease Control (CDC) as well as for example the department of Public Health of Erasmus University Medical Center have made overviews succeses of prevention as well as   of the past were mostly the result of health protection measures. Two well-known examples are the building of drinking water and sewage systems that has resulted in the almost disappearance of some major infectious diseases; and traffic safety measures have resulted in an impressive reduction in (fatal) traffic accidents.

Recent research shows that our dietary choices are strongly influences by environmental cues, i.e. by what is easily available and accessible. And in our fast food nations, some of the most readily available and almost unavoidable foods are high calorie-low nutrient foods like sweet and savoury snacks, sugar-sweetened drinks.

the impact of too much sitting...

A recent systematic review conducted by Dr. Mai Chinapaw and colleagues, published in the journal Obesity Reviews, focusses on the possible health consequences of sedentary behavior. Recent research indicates that sedentary behavior, often operationalized as TV-time and other screen viewing behaviors, is associated with higher risk for being overweight and obese, as well as (other) metabolic health problems. the effects of sedentary behavior appear to be rather independent of physical activity, i.e. even when people do exercise a lot, sitting for prolonged periods of time may still increase their risk. The aim of this systematic review was to describe the prospective relationship between childhood sedentary behaviour and health indicators. 31 studies were indentified in data bases of scientific publications. In these studies 27 different cohorts were investigated. The systematic review of these studies confirmed that more  'sedentary time'- mainly TV viewing - predicts a higher body mass index (BMI) and other indicators of body fat. Evidence was also found that more sedentary time is associated with lower fitness levels, but no convincing evidence was found that sedentary time is associated with higher blood pressure, blood lipids or lower bone mass.

The successes of prevention in the Netherlands.

On March 11, the department of Public Health of Erasmus University Medical Center celebrated its 40 anniversary with a symposium on the success of prevention in the Netherlands, in the period of 1970-2010. The symposium was well attended by almost all experts in the field, as well as representatives of policy and practice organisations.


The head of the department, Prof Johan Mackenbach provided an overview of the success of prevention. This overview is more extensively documented and described in the book that he edited on the topic (see the picture), and illustrated in a short documentary.

Mackenbach argued in his presentation that the successes of prevention are often rather unnoticed, because, indeed successful prevention prevents ill health or mortality, i.e. it prevents an event from happening. This relative invisibility of the success of prevention may be one of the important reasons why policy makers have less attention for prevention and are often less willing to invest in prevention (only a few percent of the national health care budget is invested in prevention).

The successes presented by Mackenbach were identified based on the following criteria:

1. The effectiveness of the preventive action, policy or intervention should be scientifically well-documented

2. The effect of the preventive intervention should have clearly caused a reduction in mortality or morbidity because of the disease that the intervention was aiming to prevent

The team that did the analyses came up with 5 fields of prevention, i.e. prevention regarding pregnancy and youth care, prevention regarding work & health, prevention of accidents and injuries, promoting health lifestyles, and medical preventative interventions.

In terms of prevention of deaths, the antismoking efforts were by far the most successful prevention intervention in the last 40 years, with more than 6900 deaths prevented per year. Other important successes are the removal of trans fatty acids from foodstuffs (1500 deaths per year avoided), the screening on and treatment of high blood pressure (3000 per year), and traffic safety measures (2000).

Writing papers for the energy project

The last few days I spend in Ghent. Part of the team of the Energy project met there to write a series of scientific papers on overweight, obesity and energy balance behaviors in European schoolchildren. Papers were prepared on the validity of the questionnaires used for data collection in the project, on sedentary behaviors among the children and the relation with metabolic function, and on mediators and moderators of dietary, physical activity and sedentary behaviors. All these papers are prepared to further inform obesity prevention efforts in this important target group.

Bregje Onwuteaka Philipsen inaugurated

Today prof. Bregje Onwuteaka Philipsen accepted her chair in End of Life Research. In the Netherlands about 135,000 people die annually. For about 90,000 of these people, their end of life is something they foresee and something they and their important others can prepare for in this phase of end of life care. Bregje Onwuteaka Philipsen, a recent 'Vici laureat', i.e. she received one of the most prestigious personal research grants available in the Netherlands, has conducted and will conduct and lead important research to inform and improve end of life care. In her inaugural address she provided an overview of work accomplished and work to be done.

Active transportation, e.g. walking or cycling to school or work, may contribute to energy balance, i.e. preventing unwanted weight gain, and prevent becoming overweight. Some studies have been conducted looking at the association between  active commuting to school and weight status among youth, but no clear conlusion can be drawn. Some recent studies suggest that cycling to school may make a bigger difference than walking to school. The purpose of our study, recently published in the Scandinavian Journal of Medicine and Science in Sport, (with Dr. Elling Bere as first author) was to assess the association between cycling to school and weight status in two cities, Rotterdam and Kristiansand, i.e. in the Netherlands and Norway, two countries where cycling to school remains common. Data from two studies, ENDORSE (Rotterdam) and Youth in Balance (Kristiansand), were used including, respectively, 1361 and 1197 adolescents around 14 years old. The adolescents were categorized as cyclist or non-cyclist based on questionnaires asking them about their usual mode of transportation to school. Twenty-five and 18% were categorized as overweight, and 35% and 31% were categorized as cyclists, in Rotterdam and Kristiansand, respectively. Further analyses showed that youth who cycled to school were about half as likely to be overweight than their peers who did not, after adjusting for a range of other possible 'reasons' for being overweight. These results thus suggest that cycling to school may 'protect' against overweight, but more rigorous research is necessary.

The protocol of the ENERGY cross sectional study now published

ENERGY stands for European Energy balance Research to prevent excessive weight gain among youth, and is a European Commission funded project aiming to study important dietary, physical activity and sedentary behaviors among youth aged 10-12 across Europe. ENERGY also investigates determinants of engaging in such behaviors and develops and tests an intervention scheme to promote more healthful energy-balance behavior in schoolchildren. The protocol paper of the cross-sectional ENERGY study, describing the methods, procedures and measures of the study, and with Dr. Maartje van Stralen as first author, has now been published in BMC Public Health.

Research concerning elderly populations at EMGO+

Last Tuesday we show cased our research concerning elderly populations. The focus was especially on research conducted by the departments of General Practice, Nursing Home Medicine, Public & Occupational Health and Medical Humanities, i.e. the 'extramural' departments of the VU University Medical Center. Professor Guy Widdershoven chaired the afternoon symposium. Professor Dorly Deeg provided an overview of the history and scope of research among the elderly at the VU University and its medical center; Professor Henriette van der Horst shared her thoughts on the future of such research. A panel of project leaders provided their reactions to these introductions, which gave input for a general discussion with the audiende. Finally, more than 50 posters on relevant recent research were presented and discussed. 

Farewell address by Prof. Martijn Katan

Yesterday Professor Martijn Katan gave his farewell address as professor of nutrition at the department of health sciences and the EMGO Institute for health and care research. Before Martijn Katan's lecture there was a short symposium with two distinghuised invited speakers: Professors Jan Vandenbroucke and Marion Nestle. Marion Nestle presented her work on food politics and the relation between nutrition researcher, nutrtion researchers and food policies of governments and food industry. Vandenboucke and Katan himself spoke about the problems nutrition researchers face in establishing evidence-based practice. Martijn Katan used examples from his own research career - his world famous research on transfats and cafestol- to urge the future generation of nutrition researchers to go back to the reductionist approach, focussing in nutrients rather than foods or food patterns. I myself have argued that a focus on food patterns may be more fruitful; see for example the paper I wrote with Elling Bere on the Nordic Diet. However, Katan certainly has a point that internally valid research on the potential health promoting effects of food patterns is very difficult (Katan would claim it to be impossible, I think...).