Diabetes care, obesity and the food crisis

Last Friday Laura Welschen defended her thesis in which she describes a series of studies based on the Diabetes Care system employed in the Hoorn region in the Netherlands. This Diabetes Care system organised by the Diabetes Care Centre West Friesland (http://www.diabetes-zorg.nl/) is an integrated approach including evidence-based efforts to promote patient empowerment to support self-management.
Laura’s thesis is a well written series of scientific papers, including a Cochrane review on the effects of self-monitoring of blood glucose in type 2 diabetes patients (see http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005060/frame.html).
The main risk factor for diabetes type 2 is obesity. Presently there is much to do about the ‘food crises’, i.e. the sharply rising prices of staple foods world-wide, leading to food riots by people in poorer countries that can not afford to buy enough food, and to hunger. The first of the UN millennium development goals reads (http://www.un.org/millenniumgoals/): Eradicate extreme poverty and hunger:

• Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day


• Achieve full and productive employment and decent work for all, including women and young people


• Halve, between 1990 and 2015, the proportion of people who suffer from hunger
  

The present food crisis makes reaching the hunger eradication goal even more difficult to reach. The fact that on the one hand we face an enormous epidemic of obesity and related diseases such as diabetes, cardiovascular problems as well as certain cancers (http://www.dietandcancerreport.org/), and on the other food shortages and hunger is and remains one of the worlds serious scandals. The present increase in food shortages in poorer countries is repeatedly attributed to the fact that certain foods, like corn, sugar cane, and palm oil are now more often used to produce ‘biofuel’ (http://en.wikipedia.org/wiki/Biofuel). However, only a very small percentages of the total production of these crops is indeed used to produce biofuel. A much larger proportion of agricultural land and staple foods is, for example, used to produce meats, dairy and other animal food products.
In an opinion article in one of the main Ducth national newspapers, NRC-Handelsblad (http://www.nrc.nl/opinie/), professor Jan Douwe van der Ploeg (http://www.rso.wur.nl/UK/People/Staff/vdPloeg/), professor of transition studies at Wageningen University and Research Center, argues that the production of biofuel is only a small contributor to the present food crisis, and he sees the (1) ongoing transition from farmer-based, smaller-scale agriculture to large-scale but less productive corporate agriculture; (2) the development of a world food market in stead of more regional food markets that leads to production of foods further away from consumers, and foods exported from countries where local people already have a lack of food; and (3) the domination of the food market by a few what he calls food-imperia that use food to produce processed food products, which is good for making money, but not so much for feeding the hungry.

The 2008 EMGO retreat

Thursday April 24 we had our annual EMGO retreat. The scientific committee of the EMGO Research Institute came up with a wonderful program. In the morning we first discussed the EMGO policy plans to create an interfaculty research institute on health and care research together with the department of Health Sciences (http://www.falw.vu.nl/Onderzoeksinstituten/index.cfm) of the faculty of Earth and Life Sciences, and different departments of the faculty of Psychology and Education (http://www.psy.vu.nl/fpp.php/research/). Then there was a choice of workshops on a variety of topics varying between such extremes as systematic reviews, leading efficient professional meetings, building websites, and salsa dancing.

During the afternoon, the four EMGO research programs first met to discuss strategic priorities. Thereafter, the 2007 EMGO awards were announced, after short, clear and sometimes very funny presentations from the candidates. Tessa van den Kommer received the science award for the best scientific paper by a junior researcher, for her paper on Cholesterol and oxysterols as possible early markers for cognitive decline (http://www.ncbi.nlm.nih.gov/pubmed/17888546?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum). The Societal Impact Award was given to Marian van Bokhorst for her project on identification of under nutrition in hospital settings that received major media attention in the past year.

The day ended with a nice buffet lunch followed by a smashing performance of the 8-head EMGO-band, performing songs from bands and singers as diverse as The Clash, Dandy Warhols, and Amy Winehouse.

But the day started with a good discussion on our plans to merge EMGO with important research groups from the two other faculties into a more inter- en multidisciplinary research institute for health and care research.
In his last book, “Common Wealth: Economics for a crowded planet”, Jeffrey Sachs (http://www.earth.columbia.edu/articles/view/1804) writes: Scientific research proceeds in intellectual silos that make far too little contact with one another; research in the physical sciences, biology, engineering, economics and public health is rarely intertwined, even though we must solve problems of complex systems in which all of these disciplines play a role. The problems just refuse to arrive in the neat categories of academic departments”.
I truly believe that this merger will better prepare EMGO for the future, since health and care research indeed requires input from and collaboration between, amongst others, medical researchers, health scientists, behavioural researchers, economists and paramedical experts, and concentrating such expertise within one institute will facilitate this.

Amika Singh’s PhD graduation and Henriette van der Horst’s inaugural address.

On Friday April 11 I attended two academic meetings in the mail hall of the VU University. On Friday morning Amika Singh defended her PhD thesis. Her thesis was based on the Do-IT study (see http://www.biomedcentral.com/1471-2458/6/304), a project aiming to develop, implement and evaluate a comprehensive school-based obesity prevention intervention. The intervention combined nutrition and physical activity education with school-environmental changes. The results indicate that the intervention was effective in positively changing indicators of body fatness among girls; girls in the schools that participated in Do-IT had lower skin fold thickness than girls in ‘control’ schools (see http://archpedi.ama-assn.org/cgi/content/full/161/6/565). The so-called opponents at the defence ceremony included professors Gerjo Kok from Maastricht University (one of the founding fathers of the Intervention Mapping protocol (http://www.interventionmapping.unimaas.nl/) that was the basis for the development of the Do-IT intervention), Stuart Biddle, from Loughborough University, who is an expert on behavioural physical activity and sedentary behaviour research (see http://www.lboro.ac.uk/departments/sses/contact/staff/sjhb.html), and Ilse de Boudeaudhuij from Ghent University (see http://www.ipenproject.org/debourdeaudhuijbio.htm) who supervised a similar project in Belgium. The examination committee was much impressed with Amika’s thesis.
That afternoon professor Henriette van der Horst accepted her chair as head of the General Practice department of the VUmc with her inaugural address. The General Practice department is one of the VUmc’s departments that participates in the EMGO Institute (http://www.emgo.nl/) for Health and Care Research. Prof. van der Horst stressed the importance of multidisciplinary collaboration in research tot improve general practioner’s practice.

The annual meeting of the Scottish Nutrition Society: behavioural nutrition and energy balance in the young.

On Thursday I gave a talk at an annual Nutrition Society meeting organised by its Scottish section, in Dundee. I talked about the interplay between personal and environmental determinants of nutrition and physical activity behaviours in driving the increasing prevalence of overweight and obesity.

Dr. Tim Lobstein of the International Obesity Task Force from the international association for the study of obesity presented before me. He gave a very good talk, providing the audience with ten action points to help curb the obesity epidemic, especially among children. Most of his recommendations were aiming to change the market and marketing environment for foods, and the physical environment for physical activity.

Professor John Reilly, from University of Glasgow (he is presenting in the attached picture), presented after me on the evidence that physical activity and sedentary behaviour are important for overweight and obesity in preschoolers. About 20 years ago, he reminded us, this age group was considered to be at really low risk for overweight, since such small children were thought to be moving all the time. In the last decades, things have probably changed, because more recent evidence based on objective measurements of physical activity and sedentary behaviour among 3-6 year olds shows that hardly any kids meet the recommended 60 minutes of moderate or high intensity physical activity per day. The quintile with the highest activity came up to about 45 minutes in research among UK children. Furthermore, about 80% of the waking hours were spent on sedentary ‘activities’.

To get back to my earlier item on regional foods. In his keynote, John Reilly briefly referred to a study in physical activity, sedentary behaviours and environmental determinants in South Africa he is involved in. Some of the regional speciality foods the kids there really like are ‘Walkie Talkies’. Walkie talkies are chicken heads and feet….

An expert meeting to inform the Dutch obesity prevention research agenda

Yesterday an expert meeting took place in Amersfoort, the Netherlands. This expert meeting was organised by RESCON Research & Consultancy (http://www.rescon.nl/) in cooperation with the Department of Health Education and Promotion of Maastricht University (http://www.gvo.unimaas.nl/Medewerkers/text_uk.htm) and was part of a project funded by the Netherlands Organisation for Health Research and Development (http://www.zonmw.nl/en/) to define their mid-term research agenda for obesity prevention. The organisers of the meeting had provided an overview of provisional research priorities based on literature reviews. This overview was used as the main input for two discussion sessions, one among experts involved in policy and practice related to obesity prevention in the Netherlands, the other among researchers in this field. The first group included representatives of the Dutch ministry of health, municipal health services, the Netherlands Heart Association and Diabetes Federation. The second group consisted of researchers from the university medical centres of VU University, Amsterdam University, Erasmus University Rotterdam, and Maastricht University. I chaired the discussion among the researchers.
In both the discussions it was concluded that the limited means available for obesity prevention research should not be used to start new initiatives or to fund a few more small-scale studies to investigate yet another few details that may in the end contribute to obesity prevention. Both practitioners and researchers agreed that the available funding should add to the existing larger scale ongoing initiatives in the field of obesity prevention in the Netherlands where research, policy development and practical implementations go hand in hand. Important examples of such initiatives are the recently completed NHS-NRG study (see http://www.ncbi.nlm.nih.gov/pubmed/15714217?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum), the city-wide initiatives in the cities of Rotterdam and Zwolle, and the so-called ‘academic workplaces’ in Rotterdam and Amsterdam, where universities, the municipal health services and other local health organisations work together to combine research and practice to enhance obesity prevention. See for example http://www.zonmw.nl/index.php?id=4059. The OPOZ (‘research program for obesity prevention in Zwolle; http://www.onderzoekinformatie.nl/nl/oi/nod/organisatie/ORG1242150/) program with the ChecKid study in the city of Zwolle, led by professor Jaap Seidell is arguably the most comprehensive initiative in the Netherlands to curb the obesity epidemic in a local initiative involving all stakeholders, and accompanied by good-quality research to build the evidence-base for such community-based obesity prevention.

Socioeconomic position in childhood and adulthood and associations with weight status

People who are less well-off in terms of income, education or job positions are more likely to be overweight or obese, at least in industrialized countries. Such socioeconomic inequalities in body weight have been demonstrated in numerous cross-sectional studies. With Katrina Giskes from the School of Public Health/Centre for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia (http://www.hlth.qut.edu.au/) as first author we have now investigated such inequalities from a life course and longitudinal perspective. We examined the association between child- and adulthood socioeconomic position (SEP) and body mass index BMI and overweight/obesity in 1991 and changes in BMI and the prevalence of overweight and obesity between 1991 and 2004. The findings indicated that among women, childhood SEP was more important for body weight than SEP in adulthood: at baseline, women from disadvantaged backgrounds in childhood had a higher BMI and were more likely to be overweight or obese, and they gained significantly more weight between baseline and follow-up. In contrast, adult SEP had a greater impact than childhood circumstances on men's body weight: those from disadvantaged households had a higher mean BMI and were more likely to be overweight or obese at baseline, and they gained significantly more weight between 1991 and 2004. The findings suggest that exposure to disadvantaged circumstances at critically important periods of the life course is associated with body weight and weight gain in adulthood. Importantly, these etiologically relevant periods differ for men and women, suggesting gender-specific pathways to socioeconomic inequalities in body weight in adulthood.

See http://www.ncbi.nlm.nih.gov/pubmed/18356832?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Regionally defined diets for health, the environment and cultural diversity in food habits

Last week I spent my days cross country skiing on Hardangervidda in Norway. We went from hut to hut. Some of these huts, Rauhelleren (http://www.turistforeningen.no/turplanlegger/cabin.php?x=5&y=6&v=3&ca_id=134, see the picture next to this message) in particular, serve so-called ‘lokal mat’: regionally grown or raised food. We ate salmon, wild trout, preserved berries of different kinds, some marinated elk, cauliflower soup, and the Norwegian brown cheese.

During the evenings there was plenty of time for reading. I brought Michael Pollan’s new book, In Defence of Food. Pollan argues in this book in favour of focussing on real foods and meals in stead of on nutrients and processed foods, including the so-called functional foods that claim various health benefits. Pollan builds a strong case in a book that is a very good read.

This same week a paper that I co-authored with my Norwegian colleague Elling Bere appeared in electronic pre-publication in Public Health Nutrition (http://www.ncbi.nlm.nih.gov/pubmed/18339225?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum). This paper, entitled ‘Towards health promoting and environmental-friendly regionally defined diets: A Nordic example’ argues for a similar case as Pollan does in his book. We present a Nordic ‘diet’ with foods and ingredients that are and have been appropriate and abundant in the Nordic countries, for which scientific evidence supports health enhancing effects. The best knows health promoting total diet is the so-called Mediterranean diet, but we claim that diets with similar health enhancing properties can be based on regionally appropriate foods. Such an approach will help to protect cultural diversity in eating habits, bio-diversity and the environment.