Nudging towards better cardio metabolic health

Healthy eating and sufficient physical activity is key for cardiometabolic health. A health-promoting environment makes  a healthy lifestyle easier to adopt and maintain, and may be especially helpful to reach individuals with a lower socio-economic status (SES). In a paper just published in BMC Public Health we describe the Supreme Nudge project in which we will study the effects of pricing and nudging strategies in the supermarket – one of the most important point-of-choice settings for food choices – and of a context-specific mobile physical activity promotion app. Supreme Nudge uses a multi-disciplinary and mixed methods approach, integrating participatory action research, qualitative interviews, experimental pilot studies, and a randomized controlled trial in a real-life (supermarket) setting. First, we will identify the needs, characteristics and preferences of the target group as well as of the participating supermarket chain. Second, we will conduct a series of pilot studies to test novel, promising and feasible intervention components. Third, a final selection of intervention components will be implemented in a full-scale randomised controlled supermarket trial. Approximately 1000 adults with lower SES will be recruited across 8–12 supermarkets and randomised at supermarket level to receive 1) no intervention (control); 2) environmental nudges such as food product placement or promotion; 3) nudges and a tailored physical activity app that provides time- and context specific feedback; 4) pricing interventions, nudges, and the physical activity app. The effects on dietary behaviours, physical activity and cardiometabollic health will be evaluated. Additionally the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of the intervention will be evaluated and insights from System Innovation and Transition Management theories will be used to define the best strategies for implementation and upscaling beyond the study period.

Associations of self-reported physical activity and depression

The purpose of a study recently published in BMC Public Health was to investigate the cross-sectional associations between self-reported physical activity (PA) and depressive symptoms and status using data from of over 10,000 Irish adults from two existing datasets, i.e. The Irish Longitudinal Study on Ageing (TILDA) and The Mitchelstown Cohort Study.
The databases of the two studies were pooled  and relevant variables were harmonized. PA was measured using the short form International Physical Activity Questionnaire. Depressive symptoms were measured by the Center for Epidemiologic Studies Depression (CES-D) questionnaire. Participants were classified as meeting World Health Organization moderate-to-vigorous PA (MVPA) guidelines or not, and divided into tertiles based on weekly minutes of MVPA. A CES-D score of ≥16 indicated elevated depressive symptoms.
Significantly higher depressive symptoms were reported by women than by men. Meeting the PA guidelines was associated with 44.7% lower odds of elevated depressive symptoms., and study participants in the highest PA tertile had 50.8% lower odds of elevated depressive symptoms, than participants in the lowest PA tertile.
In conclusion: meeting the PA guidelines was associated with lower odds of elevated depressive symptoms, and increased volumes of MVPA are associated with lower odds of elevated depressive symptoms.

Data on Determinants Are Needed to Curb the Sedentary Epidemic in Europe

Societal and technological changes have resulted in sitting during most activities of daily living, such as learning, working, travelling and leisure time. Too much time spent in such sedentary activities, or 'sedentary behaviour', is a concern for public health. The European DEDIPAC (Determinants of Diet and Physical Activity) Knowledge Hub coordinated the work of 35 institutions across 12 European member states to investigate the determinants of sedentary behaviour as well as of nutrition behaviours and physical activity. In an earlier paper we provided a brief overview of relevant results of DEDIPAC. In a paper just published in the International Journal of Environment and Public Health, we summarize what was done and provide recommendations concerning research on determinants of sedentary behaviour. DEDIPAC reviewed current evidence, set a theoretical framework and harmonised the available epidemiological data.
The conclusion is that there is a dire lack of data that is exploitable across Europe to inform policy and intervention. There is an urgent need to develop international data collection compliant with FAIR (Findable, Accessible, Interoperable, Re-usable) and standardised surveillance systems for sedentary behaviour.

Recent trend in population sitting levels in Australia

In a study just published in the journal PLOS One, we explored the trend in population levels, as well as the correlates, of occupational and leisure sitting time in full-time employed Australian adults between 2007 and 2015. We used data from three Australian Health Surveys held between 2007 and 2015, in which nationally representative samples of the Australian population were interviewed. Full-time (≥35 hours/week) employed respondents reported sitting time at work and during leisure on a usual workday. Trends over time and associations between socio-demographic and health-related characteristics and sitting time were analyzed. Over 21,000 observations were included in the analyses. Across the three surveys, approximately 51% of the respondents reported 4 or more hours occupational sitting time per workday, 40% reported ≥4 hours/workday lei
sure sitting time, and 55% reported ≥7 hours/workday combined occupational and leisure sitting time. However, there were no clear trends over time, i.e. we found no evidence that sitting time increased or decreased between 2007 and 2015. All potential correlates were associated with occupational sitting time and all but educational level were associated with leisure sitting time. The directions of the associations with gender, age and leisure-time physical activity were reversed for occupational sitting time and leisure sitting time. These findings show that the average levels of occupational and leisure sitting time on workdays were high but stable over the past decade. The observed differences in correlates of occupational and leisure sitting time demonstrate the need to assess and address sedentary behaviour domains separately in research and policy.

High intensity training is more (cost) effective than low-moderate training among cancer survivors

In a study just published in the Journal of Cancer Survivorship, with Drs. Caroline Kampshoff and Hanneke van Dongen as joined first authors, we aimed to evaluate the long-term effectiveness and cost-effectiveness of high intensity (HI) versus low-to-moderate intensity (LMI) exercise on physical fitness, fatigue, and health-related quality of life (HRQoL) in cancer survivors.
Two hundred seventy-seven cancer survivors participated in the Resistance and Endurance exercise After ChemoTherapy (REACT) study and were randomized to 12 weeks of HI (n = 139) or LMI exercise (n = 138) that had similar exercise types, durations, and frequencies, but different intensities. Measurements were performed at baseline (4–6 weeks after primary treatment), and 12 (i.e., short term) and 64 (i.e., longer term) weeks later. Outcomes included cardiorespiratory fitness, muscle strength, self-reported fatigue, HRQoL, quality-adjusted life years (QALYs) and societal costs.
At longer term, we found larger intervention effects on role and social functioning for HI than for LMI exercise. Furthermore, HI exercise was cost-effective with regard to QALYs compared to LMI exercise.

Functional determinants of dietary intake in community-dwelling older adults

The identification of determinants of dietary intake is an important prerequisite for the development of interventions to improve dietary behaviors. In a systematic literature review just published in Public Health Nutrition with Eva Kiesswetter as first author, we aimed to compile the current knowledge on individual functional determinants of dietary intake in community-dwelling older adults. The paper was part of the Determinants of Diet and Physical Activity (DEDIPAC) joint action of the Healthy Diet for a Healthy Life joint programming initiative.
Thirty-six studies were included in the review. For chemosensory, cognitive and physical function only few studies were available, which reported inconsistent results regarding the relationship to dietary intake. In contrast, oral function was extensively studied in 31 studies.  As oral factors general aspects of oral health like number of teeth, dental status (inadequate v. adequate), caries or wearing dentures were investigated. Additionally, some studies focused on functional aspects by
assessing chewing ability and bite force. Only one study considered also the aspect of swallowing function as a component of an oral health indicator. The different surrogate measures of oral function were associated with food as well as nutrient intakes including lower intakes of vegetables and fibre, and dietary variety. As all except six studies had a cross-sectional design, no causal relationships could be derived.

Built environment and diabetes: a systematic review and meta-analysis

The built environment may influence behaviours like physical activity, diet and sleep. Such behaviours are important for risk of type 2 diabetes mellitus (T2DM). In a study just published in BMC Medicine, we systematically reviewed and meta-analysed evidence on the association between built environmental characteristics related to lifestyle behaviour and T2DM risk worldwide. Nicole den Braver was first author on this paper and this study is part of the ENDEAVOR project.
We included 109 studies in our review and 40 studies were meta-analysed.
Living in an urban residence was associated with a 1.4 higher T2DM risk/prevalence compared to living in a rural residence. Higher neighbourhood walkability was associated with lower T2DM risk/prevalence and we found some evidence that more green space was associated with somewhat lower T2DM risk/prevalence. No convincing evidence was found for a significant association between food environment and T2DM risk/prevalence.

Psychosocial interventions improve quality of life in patients with cancer

In a study just published in the journal Psycho-oncology -by the POLARIS consortium and with Dr. Laurien Buffart as senior author-, we present the results of an individual patient data (IPD) meta-analysis aimed to evaluate the effects of psychosocial interventions on quality of life, emotional function and social function in patients with cancer, and to study for which patients such interventions work better. Therefore we looked at moderator effects of demographic, clinical, personal, and intervention-related characteristics.
We pooled IPD from 22 randomized controlled trials (RCTs), with in total more than 4000 patients for our analyses.
Overall, we found clear evidence that psychosocial interventions significantly improve quality of life  as well as emotional and social function in patients with cancer, with largest effects for psychotherapy. We found evidence that effects of coping skills training were moderated by age, treatment type, and targeted interventions. We found some evidence that effects of psychotherapy on emotional function may be moderated by cancer type, but these analyses were based on few studies.

Happiness in European Neighbourhoods

In a paper just published in the journal PLOS One, we aimed to examine the associations of both objectively assessed and perceived physical and social neighborhood characteristics with happiness in European adults. Eva Anna Christina Hart was first author and Dr. Joreintje Mackenbach was senior author on this paper and for this study we used data from the SPOTLIGHT study. Respondents reported their level of happiness on a 5-point Likert scale, and rated their perceptions of physical and social environmental neighbourhood characteristics. Objective physical environmental characteristics were also assessed, using a Google Street View-based neighbourhood audit. Associations of 14 physical and social environmental characteristics with happiness were analysed.
Living in neighbourhoods that look better ('better aesthetics') and more water and green space was associated with being very happy. Individuals who perceived their neighbourhood to be safer, more functional and more aesthetic were more likely to be very happy. The associations of functionality and aesthetics with happiness were strongest in the Ghent region (Belgium), the Randstad (the Netherlands) and Greater London (United Kingdom). Perceived absence of air pollution was only associated with higher levels of happiness among more highly educated participants. Individuals with a larger social network, more social cohesion and who trusted their neighbours were more likely to be very happy. The association between social networks and happiness was somewhat stronger in men than in women. In general, the associations between environmental characteristics and happiness had similar directions and sizes across socio-economic and socio-demographic subgroups.

Is Home Cooking associated with access to grocery stores and restaurants?

Little is known about the relation between the neighbourhood food environment and home cooking.We explored the independent and combined associations between residential neighbourhood spatial access to restaurants and grocery stores with home cooking in European adults. For this we used data from 5076 adults from five urban areas in different countries in Europe, as part of the Spotlight study. Food retailers were classified into grocery stores and restaurants. A paper describing this study was just published in the International Journal of Behavioural Nutrition and Physical Activity, with Gabi Pinho as first author.
Our study showed that greater neighbourhood spatial access to restaurants was associated with lower frequency of home cooking, largely independent of access to grocery stores.

Access to fast food outlets and body weight in European adults

In a paper just published in the journal 'Environment and Behaviour' we examined explanatory pathways for the association between spatial access to fast food outlets and body weight in 5,076 European adults (18+) in different urban regions across Europe. Dr. Joreintje Mackenbach is first author on this paper, and we made use of the data from the Spotlight project. The total association of spatial access to fast food outlets with self-reported weight status was examined and in the analyses we took possible clustering at the neighborhood level into account. We also explored if the association between spatial access and body weight was mediated by perceived availability and usage of fast food outlets, and self-reported fast food consumption. We further explored if the associations were different according to age, gender, socioeconomic status, and urban region.
Objective spatial access to fast food outlets was not significantly related to weight status. Spatial access to fast food outlets was associated with perceptions about presence of fast food outlets and usage of fast food outlets, and this was in turn associated with greater reported fast food consumption and unhealthier weight status.

Physical activity and quality of life among head&neck cancer survivors

In a study just published on-line in the journal Supportive Care in Cancer, we again found that patient-reported levels of physical activity (PA) were associated with health-related quality of life (HRQoL); this time among head and neck cancer (HNC) survivors, a group of cancer survivors that is under-studied in this respect. This was a cross-sectional study including 116 HNC survivors. Most PA among these HNC survivors consisted of household activities.
In general, it has been found -for example in a recent individual patient data meta analysis- that PA is beneficial for cancer survivors' QoL and physical functioning, but most studies have been conducted fo the most prevalent cancers, such as women with breast cancer.

Views of policy makers and professionals on implementation and maintenance of diet & PA interventions

The uptake, implementation, and maintenance of effective interventions promoting physical activity (PA) and a healthy diet and the implementation of policies targeting these behaviors are processes not well understood. In an exploratory study just published in BMC Public Health with Saskia Muelmann from the Leibniz Institute for Prevention Research and Epidemiology (BIPS) aimed to gain a better understanding of what health promotion professionals and policy makers think are important factors that facilitate adoption, implementation, and maintenance of comprehensive interventions and policies promoting healthy eating and PA in Belgium, Germany, Ireland, Norway, and Poland.
Six interventions and six policies were explored by means of semi-structured interviews with stakeholders from various sectors to elicit information on factors impacting adoption, implementation, and maintenance of these interventions and policies.
Active involvement of relevant stakeholders in all phases of intervention/policy development and good communication between coordinating organizations were described as important factors contributing to successful adoption and implementatio
n of both interventions and policies. Additional facilitating factors included sufficient training of staff and tailoring of materials to match needs of various target groups. The respondents indicated that maintenance of implemented interventions/policies depended on whether they were embedded in existing or newly created organizational structures in different settings and whether continued funding was secured.
Despite considerable heterogeneity of interventions and health policies in the five countries, stakeholders across these countries identified very similar factors facilitating adoption, implementation, and maintenance of these interventions and policies. This study was part of the Determinants of Diet and Physical Activity (DEDIPAC) knowledge hub, the first joint action of the Joint Programming Initiative 'A Healthy Diet for a Healthy Life'.

Determinants of diet and physical activity: a summary of findings

The establishment of the Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub, 2013–2016, was the first action taken by the ‘Healthy Diet for a Healthy Life’ European Joint Programming Initiative (HDHL). DEDIPAC aimed to provide better insight into the determinants of diet, physical activity and sedentary behavior across the life course, i.e. insight into the causes of the causes of important, non-communicable diseases across Europe and beyond. DEDIPAC was launched in late 2013, and delivered its final report in December 2016. In a paper just published in International Journal of Behavioral Nutrition and Physical Activity -the same journal in which we presented the DEDIPAC plans a few year earlier-, we give an overview of what was achieved in terms of furthering measurement and monitoring, providing overviews of the state-of-the-art in the field, and building toolboxes for further research and practice. Additionally, we propose some of the next steps that are now required to move forward in this field, arguing in favor of 1) sustaining the Knowledge Hub and developing it into a European virtual research institute and knowledge centre for determinants of behavioural nutrition and physical activity with close links to other parts of the world; 2) establishing a cohort study of families across all regions of Europe focusing specifically on the individual and contextual determinants of major, non-communicable disease; and 3) furthering DEDIPAC’s work on nutrition, physical activity, and sedentary behavior policy evaluation and benchmarking across Europe by aligning with other international initiatives and by supporting harmonization of pan-European surveillance. This last recommendation is now being followed up by the HDHL Policy Evaluation Network (PEN).

Towards FAIR data sharing in behavioural nutrition and physical activity research

The utilisation of available cross-European data for secondary data analyses on physical activity, sedentary behaviours and their underlying determinants may benefit from the wide variation that exists across Europe in terms of these behaviours and their determinants. Such reuse of existing data for further research requires Findable; Accessible; Interoperable; Reusable (FAIR) data management and stewardship. In a paper just published in BMJ Open -with Dr. Jeroen Lakerveld as first author- we describe the inventory and development of a comprehensive European dataset compendium and the process towards cross-European secondary data analyses of pooled data on physical activity, sedentary behaviour and their potential determinants across the life course.
A five-step methodology was followed by the European Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub, covering the (1) identification of relevant datasets across Europe, (2) development of a compendium including details on the design, study population, measures and level of accessibility of data from each study, (3) definition of key topics and approaches for secondary analyses, (4) process of gaining access to datasets and (5) pooling and harmonisation of the data and the development of a data harmonisation platform.
A total of 114 unique datasets were found for inclusion within the DEDIPAC compendium. Of these datasets, 14 were eventually obtained and reused to address 10 exemplar research questions. The DEDIPAC data harmonisation platform proved to be useful for pooling, but in general, harmonisation was often restricted to just a few core (crude) outcome variables and some individual-level sociodemographic correlates of these behaviours.
Obtaining, pooling and harmonising data for secondary data analyses proved to be difficult and sometimes even impossible. Compliance to FAIR data management and stewardship principles currently appears to be limited for research in the field of physical activity and sedentary behaviour. In the paper in BMJ Open we discuss some of the reasons why this might be the case and present recommendations based on our experience.

Lessons learned from process evaluation of an exercise intervention among cancer patients

In a paper just published in European Journal of Cancer Care -with Saskia Persoon as first author, and as part of the Alpe D'HuZes Cancer Rehabilitation research program (A-CaRe)-, we describe the process evaluation of an 18-week supervised exercise programme in 50 patients treated with high-dose chemotherapy followed by autologous stem cell transplantation. The intervention included 30 exercise sessions with six resistance exercises and interval training. We evaluated the context, dose delivered and received, and patients' and physiotherapists' satisfaction with the intervention. Ninety-two per cent of the patients trained within 15 km of their home address, with an average session attendance of 86%. Most patients trained at the prescribed intensity for four of the six resistance exercises, but the dose delivered and received of the two remaining resistance exercises and interval training could not be determined. Both patients and physiotherapists highly appreciated the program (score of 8.3 and 7.9 out of 10 respectively).

Which exercise prescriptions improve quality of life and physical function in patients with cancer?

Certain exercise prescriptions for patients with cancer may improve quality of life (QoL) and self-reported physical function (PF). In a systematic review and meta-analysis of the scientific literature, we investigated the effects of exercise on QoL and PF in patients with cancer and studied differences in effects between different intervention-related and exercise-related characteristics. This investigation has just been published online in the British Journal of Sports Medicine, with Maike Sweegers as first author, and as part of the POLARIS (Predicting OptimaL cAncer RehabIlitation and Supportive care) study
We searched four electronic databases to identify randomised controlled trials investigating exercise effects on QoL and PF in patients with cancer. Subgroup analyses were conducted based on intervention dimensions, including timing, duration and delivery mode, and exercise dimensions, including frequency, intensity, type and time (FITT factors).

Patients in exercise interventions had significantly improved QoL and PF compared with patients in control groups. Especially supervised exercise interventions were effective. No significant differences in intervention effects were found for variations in intervention timing, duration or exercise FITT factors. Unsupervised exercise with higher weekly energy expenditure was more effective than unsupervised exercise with lower energy expenditure.
Our conclusion is that exercise interventions, especially when supervised, have statistically significant and small clinical benefit on self-reported QoL and PF in patients with cancer. Unsupervised exercise intervention effects on PF were larger when prescribed at a higher weekly energy expenditure.

Social disparities in food preparation behaviours

Socio-economic differences in nutrition and eating behaviors are important for socio-economic health disparities, and differences in food preparation practices may partly explain such differences in nutrition and eating behaviors. In a study just published in Nutrition Journal (with Dr. Caroline Méjean as first author) we investigated whether there was an independent association of socio-economic indicators (education, occupation, income) with food preparation behaviors.
A total of 62,373 adults participating in the web-based NutriNet-Santé cohort study were included in the analyses. The study was part of the Determinants of Diet and Physical Activity (DEDIPAC) joint action. Cooking skills, preparation from scratch and kitchen equipment were assessed as well as frequency of meal preparation, enjoyment of cooking and willingness to cook better/more frequently.
Participants with the lowest education, the lowest income group and female manual and office workers spent more time preparing food daily than participants with the highest education, those with the highest income and managerial staff. The lowest educated individuals were more likely to be non-cooks than those with the highest education level, while female manual and office workers and the never-employed were less likely to be non-cooks. Female manual and office workers had lower scores of preparation from scratch and were less likely to want to cook more frequently than managerial staff. Women belonging to the lowest income group had less kitchen equipment and were less likely to enjoy cooking meal daily than those with the highest income.
Lower socio-economic groups, particularly women, spend more time preparing food than high socioeconomic groups, but were less likely to prepare meals from scratch with fresh ingredients and enjoy cooking less.

Objectively measured sedentary time among five ethnic groups in Amsterdam

Sedentary behaviour is increasingly recognised as a health risk behaviour, partly independent of moderate to vigorous physical activity. An increasing number of studies focus on sedentary behaviour, but  studies on sedentary behaviour among ethnic minority groups are scarce. In a a study just published in Plos ONE -with Dr. Anne Loyen as first authors- we compared levels and socio-demographic and lifestyle-related correlates of objectively measured sedentary time in five ethnic groups in Amsterdam, the Netherlands.
Data were collected as part of the HELIUS study, a cohort study conducted in Amsterdam. The sample consisted of adults from a Dutch, Moroccan, African Surinamese, South-Asian Surinamese and Turkish ethnic origin. Data were collected by questionnaire, physical examination, and a combined heart rate and accelerometry monitor (Actiheart). Sedentary time was defined as waking time spent on activities of <1 .5="" a="" href="https://en.wikipedia.org/wiki/Metabolic_equivalent" target="_blank">metabolic equivalents
. All analyses were adjusted for gender and age.Sedentary time ranged from 569 minutes/day (9.5 hours/day) for participants with a Moroccan and Turkish origin to 621 minutes/day (10.3 hours/day) in African Surinamese participants. There were no statistically significant differences in the levels or correlates of sedentary time between the ethnic groups. Meeting the physical activity recommendations (150 minutes/week) was consistently inversely associated with sedentary time across all ethnic groups, while age was positively associated with sedentary time in most groups.

Effects of a high intensity exercise program after stem cell transplantation

In a paper just published in Plos ONE, we report on a single blind, multicenter randomized controlled trial in which we evaluate the effects of a supervised high intensity exercise program on physical fitness and fatigue in patients with multiple myeloma or lymphoma recently treated with autologous stem cell transplantation, with Saskia Persoon as first author.
A hundred and nine patients joined our study and were randomly assigned to the 18-week exercise intervention or a usual care control group. The primary outcomes included physical fitness (VO2peak and Wpeak determined using a cardiopulmonary exercise test; grip strength and the 30s chair stand test) and fatigue (Multidimensional Fatigue Inventory) and were assessed prior to randomization and after the patients in de intervention group had completed their exercise program.
Patients in the exercise intervention group a
ttended 86% of the prescribed exercise sessions. Of the patients in the control group, 47% reported to have attended more than 10 physiotherapy sessions in the same period of time. Such physiotherapy sessions most likely include supervised exercise. Thus, because the intervention group exercised less than planned, and the control group did more, the difference in exercise participation between the two groups was smaller than anticipated before the study was started.
Median improvements in physical fitness ranged between 16 and 25% in the intervention group and between 12 and 19% in the control group. Fatigue decreased in both groups. There were no statistical significant differences between the intervention and control group.