Watching TV, using computers, body weight and promotion of healthy lifestyles

More and more studies point out that watching TV, using your computer and other sedentary behaviors are associated with being overweight or obese (see http://www.ijbnpa.org/content/4/1/44 and http://www.ijbnpa.org/content/4/1/41 for some recent examples). The strongest evidence is for TV screen time. Apart from being physically inactive while watching TV, TV and snacking go well together, and watching TV also mean being exposed to junk food advertising. Although the evidence for an association between computer screen time and overweight is less consistent, similar arguments are now valid for computer use. Personal computers used intensively for chatting, surfing the internet etc., which also comes with more and more on-screen marketing, and can easily be combined with snacking.
On the other hand, computer-tailored, and web-based personalised health education has been recognised as a promising means to promote healthy lifestyle behaviors (see http://www.ijbnpa.org/content/4/1/39 for a recent open access paper on this topic). With computer-tailoring, respondents get personalised feedback on the behaviour and behavioural determinants and an individualized behaviour change advice. However, such computer-tailored health education may also increase their screen time…

Three compulsory physical education lessons per week in schools across Europe?

The Culture and Education Committee of the European Parliament adopted by an overwhelming majority a report by the Hungarian member of parliament Pal Schmitt. This report concluded that physical education should be compulsory in primary and secondary schools and that children should at least have three physical education lessons per week. The report also calls for a better integration between sports and academic subjects in schools.

The recommendations are of great importance given the growing rates of overweight and obesity among European youth. Despite this obesity epidemic, the time allocated to physical education in schools has gone down from an average of 121 minutes per week to 109 since 2002.

The report is scheduled to be put to a plenary vote in November in Strasbourg.

Obesity prevention: the young and the old

Obesity prevention efforts are mostly aimed at young people. More and more initiatives are trying to encourage ‘ obesopreventive’ behaviours among children and adolescents not only through health education but also, for example, by introducing extra physical education and activity hours in the school curriculum, changing what is for sale in the school canteen, or otherwise trying to make the school a more health behaviour friendly environment (see for some Dutch projects example http://www.rotterdamlekkerfit.nl/, http://www.onderzoekinformatie.nl/nl/oi/nod/onderzoek/OND1293890/). The rationale behind a focus on youth is that children’s lifestyle habits may not be as firmly established and may be easier to modify and that overweight in childhood and adolescence is a strong determinant of life-long overweight.
Younger adults are another important target group for obesity prevention. Young adults in the age group of 25-35 or 40 years of age, go through important life course phases that often lead to lower physical activity levels and changes in eating habits. This group is also responsible for razing the next generation and is therefore of utmost importance for obesity prevention among children. The national prevention-of-overweight campaign of the Netherlands Nutrition Center is primarily aimed at this target group (http://www.voedingscentrum.nl/voedingscentrum/Public/Statisch/English+summary/).
However, the group with the highest prevalence of overweight and obesity is the elderly. On Thursday professor Marjolein Visser gave her inaugural address as professor of Nutrition and Health and she addressed this issue in a crystal clear manner. Professor Visser is head of the Department of Nutrition and Health (http://www.falw.vu.nl/Onderzoeksinstituten/index.cfm/home_subsection.cfm/subsectionid/6E313033-1279-D040-8BFBBC0F92E88FA1) and her chair is established at the institute of Health Sciences ate the VU University and at the EMGO Institute of the VU University Medical Center (see http://www.emgo.nl/) The evidence she provided showed that Dutch elderly today are much less physically active than a decade ago, and that the prevalence of obesity has doubled in that period among some groups of elderly people (see http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16425851&ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum). A study reported by Slingerlandt and others also indicated that Dutch elderly change their physical activity patterns when they retire (http://aje.oxfordjournals.org/cgi/content/full/165/12/1356). It is clear that obesity prevention should not be restricted to one age group, but deserves a true life course perspective with interventions specifically tailored to the different key age groups.

Obesity prevention: From health promotion to health protection.

Friday 7 September the Dutch federation of university medical centers (NFU, see http://www.nfu.nl/) organized a meeting on how to fight the obesity epidemic. After a general introduction on the obesity trends and consequences by professor Jaap Seidel, VU University, Professor Liesbeth Mathus, Amsterdam University Medical Center, gave an overview of medical treatment possibilities, showing that the most promising treatment approach, with long-term follow-up and intensity, is often unavailable in the Netherlands.
Next, the meeting focused on lifestyle interventions to promote prevention of overweight and obesity. Professor Boyd Swinburn from Deakin University, Melbourne (Aus), see http://www.deakin.edu.au/hmnbs/ens/staff/index.php?username=swinburn, has argued that obesity is a normal reaction to an abnormal environment. This environment that provides opportunities and promotes eating energy dense foods almost anytime, anywhere, and enables avoidance of almost any physical activity, is regarded as the driving force behind the obesity epidemic. Swinburn depicts the obesity epidemic as a ‘runaway weight train’ with the obesogenic environment as the down hill track (see http://www.bmj.com/cgi/content/full/329/7468/736). Although most people have freedom of choice where foods and physical activities are concerned, they have to choose in an environment in which unhealthy food choices and lack of physical activity are the easy and intensively marketed choices.
The great accomplishments in public health in countries like the Netherlands, such as the eradication of a number of infectious diseases, improvements in traffic and food safety, and also the reduction in smoking prevalence have all been accomplished by means of an integral approach in which health protection measures, i.e. regulations and environmental change measures, such as building sewage systems, establishing and enforcing traffic laws, or taxing tobacco and creating smoke-free environments, were of key importance. However, despite the environmental causes for the obesity epidemic, obesity prevention efforts are still mostly based on health education and health promotion activities. Such health education is not strong enough to help slow down the weight train. I argued that we need a health protection approach to obesity prevention to finally make a difference. Such a health protection approach should include ‘safe’ food and physical activity environments in, for example, (pre) schools and worksites, a ban on food marketing to children and on unproven direct as well as indirect health claims for foods, and taking ‘protection’ of physical activity into account in all infrastructure projects so that physical activity will again become a necessary and routine part of daily living.

European Research Funding for obesity prevention among youth?

Late last week we had our first web-based conference call for the HOPE project (Health promotion through Obesity Prevention in Europe, http://www.hopeproject.eu/), to discuss the project’s progress. Colleagues from IOTF (http://www.iotf.org/), Erasmus University Medical Centre’s department of Public Health (http://www2.eur.nl/fgg/mgz/), University of Oslo’s department of Nutrition (http://www.med.uio.no/imb/nutri/english/index.html), University of Ghent University’s department of Movement and Sports Sciences (http://www.lo-bsw.ugent.be/), Unit for Health Services Research and International Health –IRCCS Burlo, in Trieste, Institut National de la Santé et de la Recherche Médicale –INSERM, In Paris, the Karolinska Institute in Stockholm, and from the EMGO-Institute of the VU University Medical Centre (http://www.emgo.nl/) were all in front of the pc with their headsets to talk about the progress in subsequent workpackages of the EU funded project.

The HOPE project aims to further explore determinants of overweight across Europe, and to identify effective strategies for obesity prevention, based on existing data and networks.
An important extension to the HOPE project would be to use and further enrich this information to develop and test new intervention schemes for prevention of unnecessary weight gain. One of the calls for proposals within the EU 7th framework program (see http://cordis.europa.eu/fp7/home_en.html) indeed asks for such research specifically aimed at children and adolescents, and we are now in the final stages of preparing exactly such a proposal together with partners from different countries across Europe. Next week the proposal will need to be in Brussels...

Diabetes care and research center in West Friesland

Yesterday I had the pleasure to visit the West-Frisian diabetes research and care center in Hoorn, the Netherlands. This center is a truly unique initiative in which research, innovation and implementation for diabetes prevention and care is realised. This initiative started with the now internationally renowned longitudinal Hoorn study which has to date generated more than 150 scientific publications and still counting (see http://www.ncbi.nlm.nih.gov/sites/entrez, and use Hoorn study as your search term to get a nice overview).

In 1989, the Hoorn Study was designed and started to study the prevalence and determinants of type 2 diabetes in the general population in the Netherlands. The Hoorn Study cohort has been monitored ever since and has been extended to include additional study populations. In 1996, to support diabetes care in the region, Professor Giel Nijpels initiated the West-Frisian Care System with a diabetes research centre. Over the years, the number of patients with diabetes who participate in the West-Frisian Care System grew to more than 4000, and the care system encouraged new research. The number of ongoing research projects within the Hoorn Study also grew, and so, in November 2005, a new and larger diabetes research centre opened near Hoorn’s local hospital. The new centre is what I visited: a basic but pleasant building staffed by a very skilled and enthusiastic team, equipped with a vascular laboratory, an ophthalmologic examination unit, storage facilities, and test equipment. A number of researchers presented their studies: clear, well-organised presentations of exciting research related to the determinants, prevention, care and comorbidities of diabetes.

This center strives to realise true integrated diabetes care and to cover the continuum from fundamental research to implementation studies, directly linked to real practice. The Hoorn Study and the West-Frisian Care System’s research activities are part of the EMGO-institute (www.emgo.nl) of the VU University Medical Center (see www.vumc.nl/) and rightly so: it is a very good example of applied research directly linked to improving extramural health care for one of our priorities: diabetes and overweight, its main modifiable determinant.

Regionally defined healthful diets?

There is no proof beyond reasonable doubt that consumption of ecologically produced foods is more healthful than eating their non-ecological counterparts. Similarly, foods that are produced locally are probably fresher than foods that need to travel over long distances, but there is no convincing evidence that eating such locally produced foods lead to lower disease risk or longer lives.
However, ecological and preferably locally produced foods are to be preferred for environmental protection and sustainability. Protecting the environment is, as professor Johan Mackenbach so clearly describes in a recent paper in International Journal of Epidemiology (see http://jech.bmj.com/cgi/content/extract/61/2/92), of great importance for public health. Eating locally may also contribute to the protection of nutritional diversity and local food cultures as argued by the slow food movement (see http://www.slowfood.com/).

So should health promoters start to promote locally produced products as part of their nutrition education efforts to improve population health?
In promotion of healthful eating, basically two different avenues are explored. The first is the nutrients way, with a focus on identification of key nutrients and other food compounds that help to prevent disease and promote health, leading to nutrients specific recommendations and to, for example, use of dietary supplements, nutrient enrichment or fortification of foods, and the development of functional foods. This avenue has been fruitful in the past to help get rid of a number of deficiency diseases in large parts of the world.
However, this nutrient-oriented avenue in general appears to be less effective in addressing the most important present-day nutrition-related health problems that are related to over-consumption rather than deficiencies and stronger related to foods and eating patterns then to nutrients. For example, there is ample evidence that nutrition is directly or indirectly related to CVD, cancer risk and obesity (see for example http://www.hopeproject.eu/), there is only very little evidence that specific nutrients contribute to prevention of such conditions.

The second avenue is therefore food and food patterns oriented. This avenue is more closely linked to what people actually eat: foods and meals. Different food guide pyramids, food plates and other nutrition education tools build on this food-oriented avenue (see for example http://www.mypyramid.gov/; or http://www.voedingscentrum.nl/voedingscentrum/Public/Dynamisch/hoe+eet+ik+gezond/).

Some attempts have been made to take this food-oriented avenue a few steps further, by describing meal patterns or diets that incorporate the foods for which the strongest evidence has been found for a health enhancing effect such as the famous ‘Mediterranean Diet’(http://en.wikipedia.org/wiki/Mediterranean_diet), which is supposed to include olive oil, fruits, vegetables, grains (mostly unrefined), fish, diary in moderate amounts, low quantities of meat and meat products, and a regular but moderate intake of alcohol.

Several of the ingredients of the Mediterranean Diet do not grow well in many areas of the world and other ingredients are not available in large enough quantities to be included in diets across the world. Furthermore, most regions have other culturally and regionally appropriate foods that might be as health enhancing as the ingredients for the Mediterranean diet.

It is a challenge to define such alternative regionally defined diets that may contribute to health promotion and disease prevention, as well as to protection of the environment. Local food production and diversity in food cultures. Together with my Norwegian colleague Dr. Elling Bere of Agder University College, Norway, we have been working on exploring the ‘Nordic Diet’. A paper on our explorations will soon be ready to be submitted for publication! Geit Ost (Norwegian goat cheese) may not be part of such a health enhancing Nordic Diet, but it does taste great!