Exploring the possibilities of further developing midwifery research in the Netherlands

On Friday February 29, Royal Dutch Organisation for midwifes (KNOV, see http://www.verloskundigeninnederland.nl/home/) 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.

Obesity prevention : A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults

This week the journal Obesity Reviews published in e-pub a systematic review of obesity prevention interventions aimed at adults, that I co-authored. Valery Lemmens is first author on this paper ( Obes Rev. 2008 Feb 19 [Epub ahead of print]).

See http://www.ncbi.nlm.nih.gov/pubmed/18298429?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Interventions aimed at reducing obesity have mainly focussed on weight loss among overweight and obese adults. Such weight loss intervention have little long-term effects. A stronger focus on obesity prevention is needed. Our review included scientific papers published on this topic from 1996 up to 2006. The results indicate that systematic interventions aiming to prevent weight gain and obesity are scarce and the current evidence of efficacy of obesity prevention interventions is thus based on a small number of studies. Some studies showed a positive impact on body mass index or weight status, but there was too much heterogeneity in terms of study design, theoretical underpinning and target population to draw firm conclusions about which intervention approaches are more effective than others. More research is urgently needed to extend the body of evidence.

A debate on public radio: nutrition education or environmental change to promote health behaviour?

http://nl.wikipedia.org/wiki/Joop_Atsma) of the Christian Democratic Party on Dutch public radio. I argued that rules and regulations will be necessary for effective obesity prevention policy in order to change the present ‘obesogenic’ environment into a more ‘obesopreventive’ environment. Mister Atsma claimed that health education is the way to go forward. Our research indicates that a health education approach will be insufficient to change people’s nutrition and physical activity behaviours for obesity prevention. Environmental changes are needed to better facilitate healthful nutrition and physical activity behaviours, and to make un-healthful choices less available and accessible. This is also what has been advocated by WHO Europe in their policy to curb the obesity epidemic (see http://www.euro.who.int/obesity/conference2006). Please visit http://omroep.vara.nl/De_VARA_op_Radio_1.2681.0.html and link to ‘Radio Kassa 26 Februari to listen to the radio debate.

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 .