Wednesday, December 17, 2008

The Deliver study

Yesterday a symposium was held in Amsterdam in honour of Margreeth van der Meijde who stepped down as director of the Verloskunde Academie Amsterdam (the college for midwifery Amsterdam. At this symposium – the main theme was ‘ambition’-, one of the issues that was addressed and discussed was the ambition to build a stronger evidence-base for midwifery practice, especially for the extramural setting. For this purpose the midwifery colleges of Amsterdam and Groningen have started a collaboration with the In Holland University of Applied Sciences and the VU University Medical Center to establish a joint department of midwifery science. This joint department will build a master program for midwifery science, and a midwifery research infrastructure. This infrastructure will encompass an endowed chair for midwifery science, two senior and a number of junior researchers, and a nation-wide study that will form the basis for further research. The research program will be embedded within the EMGO Institute. This nation-wide study, called the Deliver Study, will help to build the necessary evidence-base. The initial research question will be:
• What is the quality of the care provided by midwives (professional quality of pre-conceptional, antenatal, natal and postnatal care, communication, client safety, client perceptions)?
• How is primary midwifery organized (gatekeeper function, role division, harmonization, responsibilities, cooperation, continuity of care, ICT, student supervision)?
• How accessible is midwifery care (proximity, care consumption, midwifery problems at GP service point)?
The study will however, form the basis for investigations of a wider range of important research questions. For this purpose, ‘add-on’ studies can be submitted to use and further help to build the Deliver data base .

Saturday, December 13, 2008

A prestigious grant for an outstanding EMGO researcher.

On Friday December 12 it was announced by the Netherlands Organization for Health Research and Development that Dr. Bregje Onwuteaka-Philipsen was awarded a Vici grant. This Vici grant is one of the most prestigious personal research grants for senior researchers in order to encourage and enable innovative health research. Bregje Onwuteaka-Philipsen is associate professor. She is the program leader of the research programme ‘quality of care’, one of the 4 research programs of the EMGO institute. Furthermore she leads the research line ‘public health at the end of life’ at the department of public and occupational health. She will use her Vici grant for further research within this research line.

Saturday, December 6, 2008

Five days in Minneapolis

These last five days I visited the Division of Epidemiology of the University of Minnesota in Minneapolis.
Drs. Simone French and Robert Jeffery invited me to give two lectures, to discuss mutual research interests, and to visit with a number of colleagues from the division as well as from the departments of psychology, kinesiology and of food science and nutrition, i.e. departments with which the division of epidemiology has close collaborations in inter- and trans-disciplinary research.
The division has a strong focus on behavioural nutrition and physical activity research, especially related to obesity prevention. The division has managed to get a number of key players in this field together in one centre, which creates the right focus and mass to do the meaningful, necessary interdisciplinary studies. The research is organised in different research centres, e.g. on nutrition, physical activity, obesity research, social epidemiology and cardiovascular research. I believe there are great similarities between the division and the EMGO Institute for Health and Care Research, and especially with its Lifestyle, Obesity and Diabetes program.
It was cold in Minneapolis, but I managed to get some outdoor physical activity by running at minus 14 Celsius along the Mississippi river. I was also treated to very good food and nutrition while here. Minneapolis restaurants serve very nice food, although I was a bbit shocked when I noticed pieces of bacon in an ice cream desert that one of my dinner companions had chosen. I was quickly informed that this was a rather innocent use of pork fat. I was told that at the Minnesota State Fair, held each year right in between the Twin Cities of Minneapolis and Saint Paul, they serve bacon lollies covered in maple syrup, and chocolate bars with pieces of bacon have even been introduced. Well, as my colleague noticed, most things taste better with chocolate while most other things taste better with bacon, so why not combine the two.

Saturday, November 29, 2008

The deliverables of the HOPE project are underway

The Health Promotion through Obesity Prevention across Europe (HOPE; project is now almost two years underway. Last Friday the HOPE consortium met at the EMGO Institute of the VU University Medical Center to discuss the project’s progress and to prepare the upcoming HOPE’s networks of networks meeting preceding the European Congress on Obesity 2008. As is usual practice in European Commission framework programs funded projects, the HOPE project work is divided in specific work packages, i.e. on obesity prevalence, risk factors, and prevention intervention success in infants and young children, school-aged children and adolescents, adults, and people from lower socio-economic position groups. Other work packages focus on an inventory of ongoing policy initiatives for obesity prevention across Europe, and on modelling future scenarios for obesity and its health consequences across Europe. During our Amsterdam meeting all HOPE work package leaders presented their progress with a specific focus on the policy recommendations based on the findings from their work packages.
Our preliminary results indicate that across Europe there is indeed evidence that obesity prevalence is still growing among school-aged children and adolescents, with a few countries that are exceptions to this rule. For younger children there is no evidence that obesity rates are growing. This should not be interpreted as evidence that obesity is no problem among younger children; the right monitoring data are just not available to explore trends in obesity prevalence in this age group in Europe.
For school-aged children it appears that school-based intervention that combine nutrition education, and that provide the right infrastructure and support for physical activity and health eating can make a difference. Such interventions are associated with more healthy behaviours as well as leaner body composition among children.
In the next few months we will finalise our finding, prepare these for publication in scientific journals, and translate these into concrete policy recommendations.

Wednesday, November 19, 2008

Injury prevention for toddlers

Hoe related unintentional injuries remain one of the main health threats for children in established market economy countries. In the Netherlands each year about 44,000 children need medical care because of such injuries, and this goes with high medical costs.

Today Tinneke Beirens defended her thesis called ‘Home-related injury prevention and safety promotion in the setting of preventive Youth Health Care (see and

Her thesis explored the possibilities of injury prevention by investigating parental safety behaviours (such as placing safety gates at the stairs in their home, and storing poisonous products, for example cleaning products or prescription drugs, in a child-safe manner), correlates of these behaviours, and the effectiveness of the so-called safety cards. These cards are the main education tool used by Child Health Clinics and developed by the Dutch Consumer Safety Institute (, to educate parents about why and how to protect their children from accidents in and around the home.

Tinneke’s research showed that many parents do engage in child protection behaviours, but there is still much room for improvement. Two interesting findings were that lower educated people on average take better precautions than the higher educated, and that parents have high intentions to take safety measures when they have their first child, but often only act on these intentions when they have their second.

Tuesday, November 4, 2008

Hand hygiene in Dutch hospitals: compliance and determinants.

Today I chaired a meeting that reported and discussed the results of a comprehensive study on hand hygiene among health care workers in IC units and surgical wards in Dutch hospitals. Hand hygiene is of utmost importance in prevention of hospital acquired infections. Earlier studies suggest that hand hygiene compliance is less than optimal, to say the least, with compliance rates of about 50%.
In this age of high tech medicine, simply adhering to basic hand hygiene instructions to prevent ill health seems so obvious. But the compliance rates indicate that washing your hands when this is necessary and according to the instructions may not be that simple and straightforward.
The study that was presented included observations in Dutch hospitals to get objective assessments of hand hygiene compliance (since most compliance data are based on self reports, which may obviously be biased), and a Delphi study and a cross-sectional survey among doctors, nurses, and trainees to explore potential determinants of hand hygiene compliance and possibilities to promote better compliance.

The study was led by Dr. Ed van Beeck of the Department of Public Health, Erasmus University Medical Center (, and Vicky Erasmus of the same department (

The study showed that observed hand hygiene compliance was even worse than expected based on self-reports. Compliance rates were below 30% overall. Especially worrying was the extremely low hand hygiene compliance before patient contacts, with hospital workers showing good hand hygiene in only a few % of the events when hand washing was needed. Somewhat better hand hygiene was observed after patient contacts, especially when the health care worker had been in contact with bodily fluid. Differences in compliance were found according to the kind of hospital investigated (small peripheral hospitals > university hospitals) and the hospital unit (surgical ward > IC unit). The observations also showed the frequency of events that require hand hygiene behavior. Basically, if appropriate hand hygiene indeed performed before or after each event that officially requires hand washing or hand alcohol, health care workers would spend a substantial part of their day ‘cleaning’ their hands. Such a time investment may just not be possible.

The exploration of potential determinants indicated that lack of knowledge of the importance of hand hygiene (among doctors only), low perceived control (i.e. most probably related to the time restraints) regarding hand hygiene practices, lack of positive descriptive norms regarding hand hygiene (among nurses only) were associated with low compliance. Furthermore, doctors were more likely to show higher compliance if they thought lack of hand hygiene could have severe health consequences for themselves, while nurses were more likely to be compliant if they perceived the potential consequences for their patients as severe.

Interventions to improve hand hygiene may include educational activities to further improve knowledge of hand hygiene recommendations, and to further stress the importance of hand hygiene practices, but should also include changes in the physical and social environments that will make compliance easier and normative.

The study was financially supported by the Netherlands Organisation for Health Research and Development, ZonMW (

Monday, October 27, 2008

TIGO: a new national inter-institutional institute for research on aging.

We live in an aging world. Within the next decades in some countries over half of the population may be over 65 years of age, i.e. the age that for many years meant retirement.

Such an aging population faces us with many challenges, often related to health. Maybe the most striking and relevant examples are to do with the work force and health care costs. In order to maintain and ensure a large enough work force to maintain economic prosperity in an era of an aging population, people should be able to remain economically active until later age. To prevent skyrocketing costs for health care, elderly people should be encouraged to adopt and maintain healthy lifestyles to prevent or delay disease and disability to realise a further compression of morbidity in the latest phase in life. In order to enable elderly people to keep out of health care institutions as long as possible, health and care monitoring and facilitating devices such as domotics ( solutions should be developed and tested for their true effectiveness.

These are the challenges that will be met by TIGO (, the Dutch national research institute for healthy aging, in which most University Medical Centers in the Netherlands, important research and health care institutes such as TNO, NIVEL and TRIMBOS, as well as key R&D departments of multinationals such as Philips and Unilever have joined forces.

Today the business plan for TIGO was presented to Mrs. Jet Bussemaker, the Dutch secretary of state for health, welfare and sports ( during a symposium. After a series of short keynotes the secretary of state congratulated the TIGO founders with their initiative and confirmed that the TIGO plans fitted well with her own ambitions to improve prevention and care for the elderly.

Sunday, October 12, 2008

Dr. Jantine Schuit inaugurated as professor of health promotion and policy.

Last Friday Jantine Schuit gave her inaugural address as professor of health promotion and policy. Her chair is at the Department of Health Sciences of the VU university, one of the partners of the soon-to-be interfaculty EMGO Institute for Health and Care Research Institute (EMGO+) ( During her presentation she argued that health promotion should be based on creating environmental opportunities for healthful behaviours and barriers for un-healthful habits, next to health education. Such environmental changes are dependent on policy initiatives at the (inter)national, regional and local levels. Prof. Schuit’s ambition is to help to narrow the gap between health scientists and health policy makers, to contribute to research on policy initiatives to promote healthful behaviour, and to develop master education on these topics. Please see for a paper on these issues published in the International Journal of Behavioral Nutrition and Physical Activity (

Wednesday, October 8, 2008

Explaining socioeconomic status differences in health behaviors.

Today Carlijn Kamphuis defended her thesis entitled ‘Explaining socioeconomic inequalities in health behaviors: The role of environmental factors’.
Inequalities in health according to income, level of education or other socio-economic status indicators have and are being observed across the world. Poorer and less educated people live shorter lives and have higher risk for a range of diseases and health threats. This is also true in a rather egalitarian country like the Netherlands.
One of the reasons why people from lower socioeconomic status groups are less healthy is the fact that these people on average live less healthy lives. Smoking prevalence, lack of physical activity and un-healthful dietary habits are more prevalent. The next question , of course, is to try to find out why that is the case. This is what Carlijn Kamphuis set out to explore in her doctoral thesis research: why do we find socioeconomic differences in physical activity and dietary habits? Her hypothesis was that contextual, or environmental factors, rather than personal factors are the main determinants. More explicitly, she especially explored whether neighbourhood physical environmental factors were important, i.e. the availability and accessibility of opportunities to be physically active and eat a healthful diet.
The thesis contains a series of papers that have been published in different international scientific journals, including two systematic reviews, qualitative research and quantitative analyses of data from the Globe study.
The results indicate that neighbourhood factors do explain only a small proportion of socioeconomic inequalities in health behaviors. It appears that individual cognitions such as attitudes and intentions, and social environmental factors, such as social modelling and support are more important.

For further reading:

Tuesday, September 30, 2008

Dietary guidelines and the obesity epidemic

In a recent issue of the American Journal of Preventive Medicine (2008;34:234-240; Paul Marantz, Elisabeth Bird and Michael Alderman from the Department of Epidemiology and Population Health of the Einstein College of Medicine, New York, published a paper in which they call for higher standards for dietary guidelines. Their paper argues that dietary guidelines are often based on indirect and sometimes weak evidence, that resulting guidelines may cause harm instead of health benefits, and that dietary guidelines may better be avoided if not based on adequate evidence. They use the fat reduction guideline as an example. In the 1980s and 90s dietary recommendations in most countries included recommendations to reduce dietary fat intake to less than 30 or 35 percent of total energy intake. The authors argue that this recommendation was not based on firm evidence (i.e. total fat is not an issue, type of fat is more important) and that the recommendation has issued changes in peoples diets and in food production and innovation towards less fat, but also towards more sugar and other carbohydrates, leading to higher calorie intakes, and thus possibly contributing to the obesity epidemic. A comment on their paper by Steven Woolf and Marion Nestle was published in the same issue (

Local produce and the 100 mile diet

'Normal' farming, with the use of loads of fertilizer, long transport distances from farms to food industry to retail to consumers causes lots of wasted energy and leaves a huge carbon foodprint. I reported here earlier on the 100 mile diet, initiated by Alisa Smith and J.B. MacKinnon, i.e. "local eating for global change" ( The 100 mile diet may be much easier for more people when 'skycraper framing' is applied: vertical farming right in the middle of urban areas.

Vertical framing is a possible means to grow grains, fruits and vegetables and fruits, raise poultry and pork, use their waste as fertilizer, and use city waste water for irrigation. A vertical farm could potentially reduce the fossil-fuel use and emissions associated with farming. Year round growth and harvesting could be possible, and consumers could get real fresh, organic produce near their city homes.

Vertical or skycraper farming ( or, i.e. a multi-storey building with integrated crop and animal farming, is one of the ideas for Earth 3.0 (, as described in the September 2008 issue of Scientific American. In these Earth 3.0 terms, Earth 1.0 was the earth that existed for billions of years untill well into the 18th century. Earth 2.0 came into existence with the industrial revolution leading to enourmous tehnological achievements and health benefits resulting in longlevity and prosperity for at least the richer part of the world.

Earth 3.0 should combine the prosperity of Earth 2.0 for all with the sustainability of Earth 1.0. With a large majority of the world population living in cities within the next few decades, vertical farming may contribute to a more sustainable and healthy food producion chain.

The technology for vertical farming does exist and the idea has received quite a bit of media attention lately (see

Sunday, September 21, 2008

Literature and medicine

Last Thursday I attended a symposium on 'addiction'. This symposium in the literature and medicine series focussed on the role of addiction in literature, in poetry, fiction, song lirics et cetera (see With bright, funny, insightful and sharp contributions of Armand Girbes (, Aafke de Groot, Jelly Brouwers, Arko Oderwald, Stefan Brijs and a musical intermezzo of Rick de Leeuw and Jan Hautekiet, it was a great afternoon. The symposium also introduced the book "Aan de Ketting" ('Chained') on addiction in literature edited by Arko Oderwald, Koos Neuvel and Willem van Tilburg.

Some citations: 'The desire for a cigarette is the desire itself" (Rutger Kopland), and "Addiction is a sanctuary without a roof" (Jelly Brouwers)

Sunday, September 7, 2008

A PhD thesis that sheds more light on computer-tailored nutrition education

Last Thursday, Dr. Willemieke Kroeze defended her thesis “Insights in the efficacy of computer-tailored nutrition education” at a public ceremony in Rotterdam, the Netherlands. The studies for her thesis indicate that computer-tailored nutrition education is more effective than generic nutrition education, as long as it incorporates personal, normative and behaviour change feedback. No differences in effectiveness were found between print-delivered and web-based computer-tailored nutrition education, but the print-delivered version was somewhat better appreciated. These effects were, however, based on self-report fat intake measures, and could not be confirmed based on objective measures, i.e. blood lipids.

The studies for this thesis have been published in international scientific journals:

Monday, September 1, 2008

EMGO seminar: visiting professor David Crawford

On September 1, professor David Crawford from the Center of Physical Activity and Nutrition Research ( gave a research seminar on environmental drivers of the obesity epidemic. His excellent presentation covered the obesity and overweight prevalence down under among children, adolescents and adults, and the potential physical and social environmental determinants of obesogenic behaviors and unnecessary weight gain. His presentation made clear that the available evidence for environmental drivers of obesogenic behaviors is not that strong. His presentation ended with 4 categories of clear recommendations to bring this research field further. One of his issues was that we may be focussing too much on environmental determinants of obesity while forgetting about more personal factors of importance, and that we need to do more in investigating mediation and interaction between personal and environmental factors as potential determinants of obesogenic behaviors and weight gain.
Dr. Frank van Lenthe from the department of Public Health at Erasmus University Medical Center in Rotterdam (, the Netherlands provided a first reaction to David Crawford’s presentation. He claimed that we need to focus even more on environmental factors, because good quality research in this field is still lacking.

Sunday, August 24, 2008

The VUmc Department of Epidemiology and Biostatistics

On September 1, the new department of Epidemiology & Biostatistics of the VU University Medical Centre will be officially launched. Last week the personnel of the department held an introductory meeting in which the organisation and leadership of the department was presented. This new department is the result of a merger between the departments of Extramural Medicine, with its strong focus on epidemiology in the extramural setting, and the department of Clinical Epidemiology and Biostatistics, with its strong focus on supporting research of the VUmc in clinical settings. With the new department, most expertise on research methodology and statistics within the VUmc is now concentrated within one department. The mission of the new department of E&B is to initiate, conduct and support excellent research in support of the five research themes of the VU University Medical Center ( The department of E&B has three sections: extramural epidemiology, clinical epidemiology and biostatistics, and four main tasks: research, education, methodology development, and methodological and biostatistical support. The logo and the organisation of the new department is presented in the attached pictures.

Tuesday, August 12, 2008

A ban on new fast food outlets?

To help to fight the obesity epidemic new policies are considered to promote healthier eating. In Los Angeles, California, city officials are considering a two year moratorium on new fast food outlets in South LA, a lower socio-economic status part of the city with very high obesity prevalence (

The Netherlands Nutrition Centre declared in a press release that the Netherlands should follow the LA initiative, especially restricting access to fast food outlets in school areas

However, professor Sally McIntyre, from the MRC Social and Public Health Sciences Unit, Glasgow University, provided evidence that it is certainly not always true that poorer neighbourhoods have poorer access to healthy nutrition ( And although eating at fast food places has indeed been found to be associated with a higher body weight, higher fat intake and lower fruit and vegetable consumption, a study conducted by professor Robert Jeffery and others from the Division of Epidemiology & Community Health, University of Minnesota School of Public Health, also showed that proximity of fast food outlets was not associated with eating ate those places or with a higher body mass index (

Furthermore, a recent study by professor David Crawford and colleagues from the Centre of Physical Activity and Nutrition Research ( from Deakin University in Melbourne, Australia, found an inversre relation between proximity of fast food outlets and body mass index: having a fast food place close to the home was associated with lower BMI (

As I have reported here before, there is certainly evidence suggesting that availability and accessibility of healthy and less healthy foods are associated with nutrition behaviours. The studies by Jeffery and Crawford indicate that these associations are, however, not as straightforward as we maybe would like them to be.

Wednesday, July 30, 2008

ENDORSE: ENvironmental Determinants of Obesity related behaviours in Rotterdam School ChildrEn; recent results.

Obesity prevalence is high and rising among children and adolescents in most developed countries. For obesity prevention, it is of utmost importance to identify the behavioural and environmental determinants of obesity among youth. The ENDORSE study was specifically designed to gain further insight in which family, school and neighbourhood characteristics predict obesity-related nutrition and physical activity behaviours among adolescents. ENDORSE is a longitudinal study with baseline measurements of BMI, waist circumference, a range of potential obesogenic behaviours, and questionnaire assessments as well as audits and observations of home, school and neighbourhood environments (for a full description of the study design and measurements, please see

Recently two papers based on the baseline measurements of ENDORSE were published by Elling Bere et al. ( and by Klazine van der Horst et al. (

Bere and colleagues explored differences in active commuting to school according to ethnicity and distance to school. Almost 50% of the adolescents reported to actively commute to school on most school days, and mode of commuting was associated with ethnicity and distance. Adolescents from Dutch ethnicity were 5 times as likely to be active commuters to school than youth from foreign ethnicity, and they were especially more likely to cycle to school. Walking to school was common up to a distance of 3k one way, while cycling was common up to a distance of 10k.
Van der Horst et al. explored associations between school environmental factors with soft drinks and snack consumption. Their study indicates that personal factors such as motivation and attitudes are more important for adolescents’ soft drink and snack intakes than availability and accessibility of these foods in the school environment.
These studies again show that different environments may have very different effects for very different energy-balance related behaviours.

Wednesday, July 16, 2008

The hundred mile diet or Prehistoric cooking?

We have been bombarded by a variety of diets over the last decades, mostly promising to help us loose weight. Concerns about the obesity epidemic are met and maybe even surpassed by concerns about global warming and other environmental issues. Agriculture and how and what we eat contributes strongly to green house gasses globally, and the CO2 ‘foot print’ of especially meat and other animal products is impressive.
The growth of the organic movement and the dissemination of organic produce in main stream supermarkets show that many people are willing to make changes in their food choices to contribute to a more sustainable way of feeding ourselves. However, now that organic foods and produce have become mainstream, the production has increased enormously, and a big challenge is to remain true to the real basis of ecological farming and production. Many organic product travel thousand of miles before they reach your supermarket, grocer or butcher, making their true contribution to a more sustainable environment rather doubtful. This issue is very nicely described and discussed in Paul Roberts (see book, ‘The end of food’.

Another interesting way to try to contribute to a more sustainable way of eating is to eat locally, and thus to reduce the transport-related CO2 fingerprint of the foods we eat. In Michael Pollan’s ( books ‘The omnivore’s Dilemma’ and ‘In defence of food’ he very clearly illustrates the possible ecological differences between foods that may carry the organic label, and locally produced foods, and a case is build for buying locally. The growth in so-called farmers markets is a sign that buying locally is getting more and more popular.

The so-called ‘hundred mile diet’ (see is a way to strive to eating more locally. This ‘diet’ is based on the experiences of Alisa Smith and James MacKinnon ( who realised that the average food they ate had travelled at least 1500 miles. They decided to try to eat only foods that were produced within a hundred mile radius from their apartment in Vancouver, British Colombia. Since then, many other have decided to try similarly.

A very different way of eating, but that links to local food production, that has received attention here in the Netherlands is the ‘Oerdis’ (see for a description in Dutch) which is prehistoric cooking (see and ) and eating. Oerdis reconstructs the way of eating and cooking of our prehistoric ancestors based on archaeological, anthropological and historical research. Some research indicates that our hunting and gathering prehistoric ancestors had similar height as we do today and may have enjoyed long and healthy lives, suggesting that such prehistoric eating habits, with, for example, more animal protein from wild omega-3 fatty-acid rich animals and fish, and less carbohydrates, contributed to a healthy diet.

Sunday, July 13, 2008

Cycling in the Alps

The past week I have been cycling the Alps together with my wife and two friends, and my mother in law as the team director. With, among others, the Joux Plane, the Colombiere, The Iseran, the Telegraph, the Galibier, the Sarenne, Glandon and Madeleine on the program we burned between 2500 and 4500 kcal on our bikes. Rather difficult to keep a neutral energy balance on such days...

Saturday, July 5, 2008

Biofuel, the food crises and the Dutch policy on healthful nutrition promotion

Today the Guardian summarizes a confidential, 'secret' report from the World Bank based on a careful analyses of the causes of the causes of the present food crisis, i.e. the growing shortages in and higher prices of food, that leads to undernutrition and hunger, especially in underdeveloped countries. The World Bank report contradicts claims made by the US government that greater demand for biofuels contributed only 3% to the raise in food prices. The World Bank report states that the demand for biofuel pushed food prices up by 75%. See

In the Netherlands, the minister of health has published his food and nutrition policy plan, called "health nutrition; from start to finish" ( In this plan the minister asks food producers and consumers to take their responsiblity, but the national government itself is not willing to do much. Two task forces will be formed to explore how food producers can reduce the salt and saturated fatty acid content of regular foodstuffs; information on food stuffs should be improved to enable consumers to make healthier choices. Food and nutrition experts as well as the Netherlands consumers organisation have expressed their disappointment with the published policy plans; they do not expect that implementation of these plans will make too much of a difference, given the voluntary nature of the measures that are proposed.

The policy plan also ask for a chance in nutrition education in the Netherlands, from a food-oriented approach, to a more total nutrition and dietary pattern oriented approach. However, one of the key recommendations is that the Dutch people should eat fish 2-3 times per week. This is clearly a food-based advise, and an advice that may be heart-healthy, but not very sustainable, given the worl-wide depletion of fish stocks because of over-fishing

Monday, June 30, 2008

VU Children’s city; a fantastic playground for hospitalized kids.

Last Friday I had the pleasure of visiting VU Kinderstad, or in English: The VU University Medical Center’s VU Children’s city ( This ‘city’ is in fact a two story ‘playgroud’ on the two top floors of the VU University Hospital (
Prof. John Roord (, the chair of the VUmc Children’s hospital and one of VUmc’s Division heads, organised a tour of the Kinderstad for the members of VUmc’s board and the other heads of Divisions.
VUmc Kinderstad is meant for children who have to stay in hospital for a longer period. Kinderstad offers them and their parents the opportunity to leave the hospital setting to enjoy a range of play and entertainment activities, from virtual racing in a Spijker sports car (, enjoying video’s from and writing directly to the Ajax soccer team ( players, surfing the internet, ‘flying’ in an almost real-life KLM airplane, making radio shows, as well as more basic every-day play activities.

Wednesday, June 25, 2008

The Internet and health education: unfulfilled promises?

The introduction and growth of the WWW has enabled swift and inexpensive distribution of nutrition education expertise and materials. Furthermore, the WWW has also been used for tailoring nutrition education to personal characteristics of the user. With the growing availability and opportunities of mobile Internet, web-based tailored nutrition education can be provided when and where it is most useful or appropriate. However, two important challenges for web-based nutrition education interventions are to realise sufficient exposure and to ensure sufficient source reliability and credibility. Only few studies have investigated the effects of web-based computer-tailored nutrition education, with some promising but mixed results.
Two recent studies by Willemieke Kroeze et al. shed further light on the potential of web-based tailored nutrition education. Her studies published in the Journal or Nutrition Education and Behavior ( and the Journal of Medical Internet Research ( suggest that an electronic, interactive web-based version of a nutrition education program that provides users with individually tailored feedback and advice to reduce saturated fat intake was as effective as the original print version of the program ( However, the print version was used and saved more often and was rated as somewhat more personally relevant (

Wednesday, June 18, 2008

Eating and Physical activity: Planned or habitual behaviour?

Every morning I take my bike to work, where I eat my muesli breakfast while reading my email. No deliberations, cognitive efforts, or reasoned planning for me to engage in these behaviours; these are pure habits.
Behavioural nutrition and physical activity research and interventions have been strongly rooted in theoretical models that presume rational decision making and a certain level of planned health behaviour. In recent years health behaviour researchers more and more argue that such an approach is too limited. Behavioural nutrition and physical activity research more and more studies environmental factors in stead of cognitions as determinants of health behaviours. Such environmental cues, e.g. easy opportunities for healthful or unhealthy behaviours, may induce habitual responses. Habitual behaviour is characterised by three important feature: a history of repetition, automaticity (expressed by uncontrollability, lack of awareness, and efficiency), and expressing identity.

Many physical activities, sedentary behaviors and dietary behaviors are typically routine behaviors. They are repeatedly performed and we may engage in them without much cognitive effort, just like my commuting and breakfast habits. As a result, the concept of habit is important in studying these behaviors, in addition to measures of behavioral frequency, duration and intensity. Two recent studies, first authored by Drs Gert-Jan de Bruijn and Stef Kremers, I was involved in provide further limited but intriguing early evidence to support the concept of habit as being important in dealing with physical activity and diet in children and adults.
Please see:

Saturday, May 24, 2008

The 7th ISBNPA conference is almost over.

In a few hours the closing ceremony of the 7th annual meeting of the International Society of Behavioral Nutrition and Physical Activity will take place. On this final day of the meeting we enjoyed a ‘battle of the giants’. Professors Tom Baranowski and Gaston Godin, two former presidents of the society and two of the founding fathers of the society held a keynote debate on objective or self-report measures of physical activity.

Measurement of physical activity and nutrition behaviors comes with many challenges. Most behavioural nutrition and physical activity research relied and still relies on self-report measures. Such measures are liable to many biases, and we just do not have truly valid self report measures. In recent years more ‘objective’ measures of nutrition and physical activity behaviours have been developed, such as biomarkers, observations, real time monitoring. But such measures may be strong interventions in itself.

Tom argued for using objective measures and moving away from self-report measures, preferably completely, since these measures have too low validity to be used in intervention or determinant studies, and he provided convincing evidence to support that. Gaston argued that we need self report measures, since the available objective measures are not by definition valid measures, and can often not be used in ‘real life’ population studies, again supported by convincing evidence.

The 7th ISBNPA conference was very interesting, with keynotes on the ethics of obesity prevention, the use of theory in development of physical activity interventions, the genetics of obesity and nutrition behaviours, symposiums on a great variety of behavioural nutrition and physical activity topics, and many more oral and poster presentations on cutting edge themes.

Next year’s conference will be in lovely Lisbon. For more information on this year’s (including the program and abstract book) and next year’s conference, see:

Thursday, May 22, 2008

ISBNPA 2008 has started.

Yesterday evening here in Banff, Alberta, Canada, the 7th annual conference of the International Society of Behavioral Nutrition and Physical Activity started with a word of welcome by Wendy Rodgers, the chair of the local organising committee, myself as president of the society, and a keynote address by Dr. Peter Katzmarzyk, professor at the Pennington Biomedical Research Center in Baton Rouge, USA.

After a full meeting of the executive committee of the society where we followed up on important issues such as renewing the society’s website, preparation for next year’s conference, the society’s financial status, et cetera, the conference actually started. Dr. Katmarzyk builds a case for research on the importance of the ‘physical activity transition’ as an important determinant of changes in mortality and morbidity trends. We are all familiar with the concept of the epidemiological transition, and most nutritionists have read Barry Popkin’s work on the nutrition transition, i.e. the changes in diet and nutrition that have driven associated changes in important burdens of disease, i.e. from infectious diseases and diseases related to under-nutrition, to diseases of affluence and over-nutrition, such as cardiovascular disease, diabetes and certain cancers. Dr. Katmarzyk argued that a physical activity transition has at least been of similar importance.

Thursday, May 15, 2008

Health promotion through Obesity Prevention across Europe (HOPE): the Geneva Network of Networks meeting.

On Tuesday and Wednesday May 13 and 14, preceding the European Conference for Obesity research, we had our first HOPE ‘Network of Networks’ meeting.
The HOPE project is a sixth framework EU DG-research funded coordination action. HOPE stands for HEALTH-PROMOTION THROUGH OBESITY PREVENTION
HEALTH POLICY. Please see for more information on the project. The HOPE project is led by researchers from Erasmus University Medical Center (see and VU University Medical Center (see; in the Netherlands and the International Obesity Task Force ( Association for the Study of Obesity (, located in London, UK. Information on all partner organisations and researchers involved in the HOPE project can be found on our website, as well as a list of the obesity prevention networks that we identified in HOPE.

The HOPE project focuses on overweight and obesity as one of the main determinants
of loss of healthy life years and of health disparities in Europe. In particular, it focuses on
expanding understanding of the key lifestyle factors nutrition and physical activity,
which are the major proximal determinants of overweight and obesity. It aims at identifying
(I) socio-economic and environmental determinants of these behaviours; and (II)
effective intervention settings and approaches to address these determinants aiming at
obesity prevention and reductions in inequalities in obesity-related health risks.
The overall objective of the present proposal is to improve the understanding of
determinants and interventions for obesity prevention in key age groups across Europe in
order to inform obesity prevention policy. HOPE focuses on obesity prevention, since treatment of obesity is largely ineffective. Specific objectives are:
- To create a network of networks of overweight and obesity research across EU Member
- To improve the understanding of overweight, obesity, nutrition and physical activity,
which may contribute to obesity prevention across Member States in infants, adolescents
and adults;
- To improve understanding of environmental determinants by assessing the impact of
both macro-policy and micro-level environmental factors at the family, school, workplace
and national policy level on obesity and obesity-preventive nutrition and physical activity
behaviours across Member States;
- To improve understanding of overweight and obesity-related health inequalities and their
determinants across Member States;
- To provide systematic reviews and inventories of evidence-based obesity prevention,
interventions and policies in and across Member States, with an emphasis on schools
and workplaces, taking into account the effectiveness and barriers for successful
- To develop scenarios of the future burden of disease of overweight and obesity, and to
forecast the impact of full implementation of best-practice policies and interventions in
European child, adolescent and adult populations.

One of the main aims is to build a network, or even better, a Network of Networks of researchers, linking with public health professionals and policy advocates, to create better mutual exchange of state-of-the-art information about obesity prevalence and prevention opportunities, and to ensure that the best available information is fed into the HOPE project’s epidemiological modelling to build evidence-based scenarios for the obesity prevention future for Europe.

In Geneva we had our mid-term Network of Networks meeting. In two half days, all the 10 work packages presented their goals and progress, that cover an inventory of obesity prevalence and trends across Europe, identification of important risk factors and behavioural determinants for unnecessary weight gain, and evidence for effectiveness of ongoing obesity prevention interventions. The presentations will be available at within the next week or so.

For each work package presentation we had invited 2-3 ‘discussants’ to review the work package, to help us identify the strengths and limitations of the work, and to help us identify opportunities for improvement. Leaders in the field from across Europe and beyond, such as professors and Drs Jaap Seidell, Boyd Swinburn, Carolyn Summerbell, Vojtech Hainer, Maia Konstantinova, Bert Koletzko, Kurt Widhalm, Lesley King, Peter Kopelman, Riva Prattala, , Francesco Branca, and Charlie Foster, representing different universities, national public health institutes and policy organisations, were kind enough to give us their feedback.

The reactions of the discussants triggered lively discussions among the other invitees.

Additionally, on the Tuesday evening we organised a dinner meeting with representatives from more recent EU member states in central and eastern Europe. During this buffet-meeting, short presentations were given by our invitees from these new members states on obesity prevalence and trends in their home countries. Contributions from Slovenia, Check Republic, Romania, Latvia, Lithuania, Poland, Bulgaria and Hungary were much appreciated, and will help us to create a more complete overview of prevalence across Europe.

The next Network of Networks meeting will be held preceding the 2009 ECO meeting, May 2009 in Amsterdam (see

Saturday, May 10, 2008

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 ( 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
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 ( 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 (, 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’ ( 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 (, professor Jan Douwe van der Ploeg (, 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.

Monday, April 28, 2008

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 ( of the faculty of Earth and Life Sciences, and different departments of the faculty of Psychology and Education ( 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 ( 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 ( 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.

Sunday, April 13, 2008

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, 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 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 ( 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, and Ilse de Boudeaudhuij from Ghent University (see 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 ( for Health and Care Research. Prof. van der Horst stressed the importance of multidisciplinary collaboration in research tot improve general practioner’s practice.

Sunday, March 30, 2008

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….

Wednesday, March 26, 2008

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 ( in cooperation with the Department of Health Education and Promotion of Maastricht University ( and was part of a project funded by the Netherlands Organisation for Health Research and Development ( 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, 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 The OPOZ (‘research program for obesity prevention in Zwolle; 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.

Sunday, March 23, 2008

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 ( 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.


Saturday, March 15, 2008

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 (, 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 ( 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.

Sunday, March 2, 2008

Exploring the possibilities of further developing midwifery research in the Netherlands

On Friday February 29, Royal Dutch Organisation for midwifes (KNOV, see installed its Scientific Committee. I was asked to chair this committee that needs to explore and promote the possibilities for midwifery research in the Netherlands. The members of the committee are mentioned in one of the attached pictures.
The call for a stronger scientific development and underpinning of the profession comes from the professionals and the schools for midwifes, based on a need for evidence-based practice and further innovations in the field. The Scientific Committee has been specifically asked to propose a research agenda, to explore funding possibilities for midwifery research, and to help to establish a scientific network for midwifery research in the Netherlands, that links to international developments in the field.