How to get people to actually visit efficacious tailored health education websites, and what is needed for such education to be effective?

Last month a paper appeared in the journal Health Education that I co-authored, based on as study by Rick Crutzen, from Maastricht University. Rick and Wendy Brouwers from Erasmus University Medical Centre both work on their PhD’s based on research into why people do or do not visit, access, and stay long enough to complete e-health promotion interventions on the web. Research has indicated that so-called computer-tailored health education is more likely to result in health behaviour change than generic health education. In computer-tailoring people receive personalized feedback and advice, based on a personal assessment of the health behaviour and behavioural determinants. The web is regarded as a very promising channel to distribute such tailored advice, but studies comparing web-based and print computer-tailored intervention indicate that print-delivered versions may be more effective. One reason is that people do not visit the relevant website, or do not stay long enough to really go through the diagnosis and advice. Rick and Wendy’s studies explore why that is the case and what might make people more attentive to web-based tailored interventions.

The purpose of Rick Crutzen’s paper was to gain first insight into factors which might be associated with exposure to internet-delivered interventions. He conducted semi-structured focus group interviews with five groups of Dutch adolescents, aged 12-17 years. Several aspects of exposure, e.g. a first visit, staying long enough actually to use and process the information; and revisiting the intervention, were explored. The results indicate that word-of-mouth ‘marketing’, social comparison information, and regular reminders may help to increase exposure to web-based e-health interventions among adolescents. Further research will be conducted to test these and other issues to improve exposure.

Willemieke Kroeze recently published a paper in Health Education Research (http://her.oxfordjournals.org/) looking into what is needed for computer-tailored nutrition education to be effective. She compared three different versions of the education. A first version provided respondents with feedback about their behaviour compared to recommended intake levels, a second version provided additional feedback about the respondent’s intake compared to that of peers, and the third version also gave so-called action feedback: practical tailored information on how to make dietary changes. The results showed that the most extensive feedback was the only version that was better than non-tailored, generic nutrition information.

For abstracts of relevant papers, please see
· http://www.ncbi.nlm.nih.gov/pubmed/18209115?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
· http://www.ncbi.nlm.nih.gov/pubmed/16700634?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
· http://www.ncbi.nlm.nih.gov/pubmed/18063650?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

A three-country meeting on behavioural nutrition and physical activity

On Tuesday February 19 researchers from Cambridge, Ghent and the EMGO Institute came together in Amsterdam for a one-day meeting. This has grown into a yearly event, and this week was the fourth time these research groups met.

The three groups are interested in and have research programs on behavioural nutrition and physical activity research. The annual meetings were organised because of great similarities in research interests and ongoing studies.

During the morning program presentations by Sanne de Vries and Nannah Tak from the EMGO Institute, Kirstin Corder from Cambridge, and Leen Haerens and Benedicte Deforche from Ghent gave presentations on ongoing research on compliance to physical activity recommendations among youth and effects of school-based interventions to promote healthful behaviours among children and adolescents.

In the afternoon, research leaders from the three groups, Nick Wareham, Willem van Mechelen and Ilse de Bourdeaudhuij provided short introductions to inform discussions in smaller groups about future collaborations in research on measurement of physical activity, dietary behaviours and potential determinants, environmental determinants of physical activity and diet, computer-tailored health promotion.

One of the photos showes some good intentions that were made for further collaboration.

The development of a cancer rehabilitation research program

Last Friday we had a meeting with representatives of a number of health care and research organisations to bring the Alp d’Huzes Cancer Rehabilitation (A-CaRe) program further towards completion. Researchers from the VU, the Amsterdam and Utrecht University Medical Centres, the Netherlands Cancer Institute, the Telematica Institute, and the Veldhoven Hospital met at our VUmc campus to discuss progress and to plan the completion of the program proposal. I have reported on the Alp d’Huzes program initiative here before. Alp d-Huzes is a foundation to raise money for cancer research, The main or at least most striking activity of Alp D’Huzes is a yearly sponsored cycling even at the famous Alp d’Huez mountain (see ).
The A-CaRe program will focus on investigating cancer rehabilitation programs for different groups of cancer patients, based on physical training, including strength training and endurance training to fight fatigue, improve functioning and quality of life. The A-Care will exist of a clinical research track with four trials to develop and evaluate different interventions, an implementation and patient facilitation track to explore and promote opportunities for larger scale dissemination of interventions that have proven effective, and a public relation track to communicate about the progress and merits of the project to patients, health professionals and the general public.
We are now in the later stages of completion of the proposal, seeking adjustment between the different tracks and trials, agreement on the main outcome parameters and measurement instruments, and a good system to communicate between partners within this comprehensive program.
We aim at starting this program within the next few months.

The ethics of obesity prevention

Last Friday I participated in an expert meeting on ethical issues related to obesity prevention. Chaired by Professor Inez de Beaufort, professor in Medical Ethics, and together with different medical ethics researchers, representatives of health promotion organisations, a director of a health insurance company and colleagues in the field of behavioural nutrition and physical activity various dilemmas with ethical dimensions were discussed.

Inspired by 5 statements we discussed various ethical issues related to obesity prevention interventions.

A first issue is the lack of proven effectiveness of many obesity prevention interventions. Obesity treatments, i.e. weight loss interventions, have been shown to be largely ineffective and should therefore not be recommended. For obesity prevention, most intervention activities have not been evaluated, and it can be argued that it is unethical to ‘bother’ people with health promotion activities that may be ineffective or that may have negative side-effects. Nowadays medical new medical treatment can only be introduced if evidence-based. I can not understand why we do not demand the same from prevention interventions.

Another issue that was discussed was stigmatization. Obesity prevention interventions may lead to blaming overweight people, while experts nowadays generally agree that overweight an obesity are a normal reaction to an abnormal environment, and that weight gain and overweight are therefore only partly attributable to personal responsibility. My personal opinion is that obesity prevention should not be focussed on weight or weight loss, but on healthful eating and physical activity. Since maintaining weight loss is an illusion for the large majority of people who are overweight, we should focus on promoting healthy lifestyles. This will contribute to fitness despite fatness, and to probable prevention of further weight gain. This also means that we should be very careful to avoid stigmatization of overweight or obesity in our prevention interventions. In smoking cessation interventions we do not stigmatize lung cancer or COPD patients, but we have made smoking much less socially acceptable. A similar procedure could be considered regarding prevention of obesity: avoid stigmatization of people who are overweight, but make eating always and everywhere as well as complete lack of physical activity socially undesirable.

At the upcoming annual meeting of the International Society of Behavioral Nutrition and Physical Activity (http://www.isbnpa.org/) professor de Beaufort will give a keynote on the ethics of obesity prevention (see http://www.readeprojects.com/isbnpa/pg_ky.html) and one of the symposiums will be focussed on this topic too. Please also visit the website of a special European Commission-funded project on this topic: http://www.eurobese.com/

For an interesting report on ethical issues in public health from the Nuffield Council on Bioethics, please visit http://www.nuffieldbioethics.org/go/ourwork/publichealth/introduction .

Feeling fat rather than being fat is associated with psychological well-being

Childhood obesity has important short- and long-term consequences for physical health. In addition, the importance of psychological consequences to children is often emphasized. However, the evidence for a strong and predictive or causal relationship between childhood overweight and psychological well-being is not convincing (see for example the recent review by Wardle and Cooke; http://www.ncbi.nlm.nih.gov/pubmed/16150384?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum) . They reviewed 53 recent studies on the relation between obesity and body dissatisfaction, self esteem, and depression, distinguishing clinical and community samples. They concluded that although levels of body dissatisfaction are higher in community samples of overweight and obese children and adolescents than in their normal-weight counterparts, few are significantly depressed or have low self esteem. Furthermore, it remains unclear if psychological well being predicts weight status or the other way around.
With Wilma Jansen as first author I co-authored a recent publication in the Journal of Adolescent Health (http://www.ncbi.nlm.nih.gov/pubmed/18207090?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum) to contribute to a further exploration of the association of psychosocial well-being with overweight and weight perception among adolescents. Data from the ongoing Rotterdam Youth Health Monitor were used from just under 2000 9–10-year-olds and almost 4000 12–13-year-olds. The association of mental health indicators with being overweight (i.e. weight status based on reports of weight and height) and with feeling overweight (i.e. whether the participants thought they were overweight) was studied. We found little evidence that mental health indicators were significantly and consistently associated with weight status or with changes in weight status over time. We also did not find consistent evidence that weight status predicted mental health or changes in psychological well-being over time. However, we did find some evidence that adolescents who thought they were overweight scored lower on indicators of psychological well being. Our conclusion: feeling overweight, rather than being overweight, appears to be important. These results further stress the importance of realistic body weight perceptions.

EMGO seminar on obesity, physical activity and tailored health education

On Wednesday, January 16 we held a seminar at the EMGO Institute (http://www.emgo.nl/) featuring three distinguished scientists in the field of behavioural nutrition and physical activity research. First, Deanna Hoelscher presented data from the School Physical Activity and Nutrition (SPAN) study. This study to monitor trends and determinants of childhood overweight and obesity in Texas, shows that the rising trends in obesity prevalence that were observed in the last decades appear to have topped off or even reversed in some parts of the state of Texas. Dr. Hoelscher, who is the director of the Michael and Susan Dell Centre for Advancement of Healthy Living (http://www.sph.uth.tmc.edu/DellHealthyLiving/) and Associate Professor at the University of Texas at Houston, argued that a comprehensive approach of health education and policy change may have initiated this promising development.
Dr. Ron Iannotti from the prevention research branch of the National Institute of Child Health and Human Development (http://www.nichd.nih.gov/) presented research from the Health Behaviour in School Children study, showing that physical activity and sedentary behaviour are associated with a range of physical and mental health indicators as well as with other health behaviours among school children. His results further indicate that physical activity and sedentary behaviour are not two sides of the same coin. His research compared the US to different regions in Europe and his results indicate that patterns between physical activity, sedentary behaviour and health may differ between regions.
Finally, Dr. Kim Gans, Associate Professor at Brown University (http://www.brown.edu/) department of Community Health, presented some interesting results from two studies on tailored nutrition education. Both studies indicated that tailored nutrition education is more effective than generic nutrition education. However, her studies also indicate that multiple tailored feedback is not always more effective than single tailored feedback and that enrichment of tailored feedback with interactive motivational elements may not be superior to tailored feedback only.
The EMGO Institute was honoured to be able to host these three scientists and grateful for their contribution to the EMGO seminar program.

The Overveen ISBNPA Executive Committee Meeting

On 14-15 January 2008 the executive committee of the International Society of Behavioral Nutrition and Physical Activity (ISBNPA; http://www.isbnpa.org/) met in Overveen, near Amsterdam, the Netherlands. This was the first time we held such a midterm, in between annual society meetings (see http://www.isbnpa.org/meeting.cfm), to discuss strategic priorities and ‘SMART’ goals for further fostering the society.

ISBNPA as formally established in 2002 at the first annual meeting in Seattle, USA. Since then we held a scientific meeting every year; we went to Quebec City, Washington DC, Amsterdam, Boston and Oslo, and we will meet in Banff, Canada in May of this year. In our almost 7-year history our society we have grown steadily to a 500+ membership, we have established an open-access journal that is on its way to a good impact factor (see http://www.ijbnpa.org/), and produce monthly news letters to inform our members about issues important to research related to nutrition behavior and physical activity.

ISBNPA’s Vision Statement is:
ISBNPA will be the international leader in advancing and fostering excellence in research on nutrition behavior and physical activity.

And our Mission Statement:
We stimulate, promote and advocate innovative research and policy in the area of behavioral nutrition and physical activity toward the betterment of human health worldwide.

These statements were developed in Seattle in 2002 and have been re-confirmed at the Overveen meeting. The midterm executive committee (see http://www.isbnpa.org/committee.cfm for a list of the officers serving on the executive committee as well as other ISBNPA committees) meeting started informally at my home with dinner and drinks at our kitchen table. The more formal meeting was held at Hotel Roozendaal, and in the course of two days we discussed all aspects of our society, i.e. the annual meeting, membership issues, the journal, the website, finance, nominations for future officers, et cetera, based on SWOT (strength, weaknesses, opportunities, threats, see http://en.wikipedia.org/wiki/Swot_analysis) analyses and SMART (specific, measurable, attainable, realistic, timely, see http://en.wikipedia.org/wiki/SMART_(project_management)) strategic goals prepared by the members of the EC in advance of the meeting.

During the meeting we have decided to build a better foundation for our society by means of, amongst other things:

• Development of a annual meeting preparation handbook to facilitate the organization of our annual meetings


• Promote a further growth in the number of members, especially from countries that are now underrepresented by:

1. Establishing a scholarship program to support colleagues from developing countries to attend the annual meeting and present their research


2. Establishing an ambassador program, with ISBNPA ambassadors in underrepresented countries for promoting our society there


3. Providing free registration for people from underrepresented countries for our next annual meeting in Banff, under the condition that they become ISBNPA members

• Establishing a sounder financial basis by developing a structured sponsorship program
  Development of a new ISBNPA website that provides:

1. Better facilities to communicate with and between members


2. Better facilities to have an up-to-date administration of members and conference registration

• Further provide financial support for the ISBNPA journal (http://www.ijbnpa.org/) so that the journal can further grow into the leading journal on nutrition behavior and physical activity research

ISBNPA is now able to work on these issues because or growing membership and successful annual meeting proof that our society is here to stay, and has created the financial means to enable some further investments in our society.

A formal report on the decisions made during the Overveen meeting will be prepared for the Executive Committee and Business meetings at the Banff conference coming spring.