Obesity prevention among schoolchildren and adolescents

Yesterday Wilma Jansen, senior researcher at the Municipal Health Service of the Rotterdam-Rijnmond area, defended her thesis entitled ‘Prevention of Childhood Obesity in a Municipal Setting’. The studies presented in her thesis further confirmed that the prevalence of being overweight in the Rotterdam area among children and adolescents is high (approximately 25%), and substantially higher than in other parts of the Netherlands. Her studies further showed that many parents do not recognize or deny their children’s overweight status.
Part of her thesis research was the description and evaluation of the ‘Lekker Fit!’ (‘nice and fit’) intervention at Rotterdam schools to contribute to obesity prevention by promotion of healthful physical activity and nutrition. The Lekker Fit! intervention combined structural changes in the school and neighbourhood environment with health education activities, with involvement of different municipal services related to education, sports and recreation, and public health. The Lekker Fit! intervention resulted in somewhat lower rates of overweight and lower mean waist circumferences among the younger participants, i.e. indications that the intervention may indeed contribute to obesity prevention.
After the thesis defence, in a symposium on local and municipal obesity prevention, Drs. Frank van Lenthe of Erasmus University medical center and Mai Chin A Paw from the department of Public and Occupational Health of the EMGO+ Institute, and Prof. Jaap Seidell, from the department of Health Sciences and the EMGO+ Institute presented their views on the issue. All speakers argued that larger and multiple changes in the micro level and macro level food and physical activity environments are needed to make meaningful changes in behavioral nutrition and physical activity.
In two articles Prof. Ken Resnicow has argued that changes in behavioral nutrition and physical activity may be better described by quantum changes and chaos theory instead of the most often used more linear health behaviour theories. A characteristics of chaos theory that is often described is that small initial differences may lead to huge consequences, e.g. the butterfly clapping its wings causing a big storm at the other side of the world. However, I believe, and the literature indicates that and the speakers, especially Jaap Seidell kind of argued the same, that for obesity prevention almost the opposite is true: we need large and many enduring changes in multiple obesogenic environments to cause small but meaningful effects in eating and physical activity behaviours, as well as overweight and obesity. The EPODE initiative, i.e. Ensamble Prévenon l'Obésité Des Enfants, may be the best example of such multiple changes in multiple environments that lead to first small but extending meaningful changes in childhood rates of overweight.

Ineke Vogel defends her thesis on behavior and possible precautions related to exposure to loud music among adolescents

Listening to music is great. Listening to loud music can be a lot of fun, but too loud and too long will damage your ears. Risk of hearing impairment is nowadays especially high among youth who are exposed to long spells of loud music by listening to ‘MP3’ players and such, and by visiting discotheques and music concerts.
How big this potential problem is, who runs the highest risk, and what the possible precautionary actions are, was largely unclear. But yesterday Dr. Inke Vogel defended her doctoral thesis called “Music-listening behaviour of adolescents and hearing conservation: many risks, few precautions” successfully. Her thesis consists of 11 scientific papers of which the majority has already been published or accepted for publication in high ranking journals such as Pediatrics, American Journal of Preventive Medicine, and the American Journal of Public Health. In her series of studies, Dr. Vogel assessed what proportion of Dutch youth runs considerable risk (at least 25%), and what differentiates youth with higher risk from those with lower risk (especially level of education; youth at vocational schools have much higher exposure to loud music than youth at university preparation education). Ineke Vogel also explored what could motivate youth to take voluntary precautions and what possible other health protection measures may be considered to tackle this considerable population health problem.

Her conclusions are that exposure to long spells of loud music, especially through personal music devices, is very prevalent, may lead to extensive hearing impairments, but that there are very few opportunities to motivate youth to voluntarily reduce their exposure. Health protection measures, i.e. measures such as legal sound level limitations should be considered.

Nanna Tak defends her thesis on promoting Fruits and Vegetables among schoolchildren

Yesterday, Nannah Tak defended her thesis on the evaluation of the ‘Schoolgruiten’ project, an intervention scheme to promote fruit and vegetable intakes among school children in the Netherlands.

This intervention scheme builds on similar projects (such as Pro Children and Pro Greens) in which fruit and vegetable provision in schools is combined with health education about the merits and recommendations regarding fruit and veggie intakes.

Nannah’s thesis consists of a series of scientific papers published in such journals as Journal of Human Nutrition and Dietetics, International Journal of Behavioral Nutrition and Physical Activity, and Public Health Nutrition, and combines observational research exploring possible determinants of fruit and vegetable intakes with intervention research to assess the (cost) effectiveness of the scheme. The results indicate that Schoolgruiten was successful in promotion of fruits, but effect sizes were small.

Nannah’s thesis was well received, and her defence successful!

Auditing research quality issues within the Pro Greens project

Together with Dr. Saskia te Velde, we represent the EMGO+ Institute within the Pro Greens project. Pro Greens is coordinated by Dr. Agneta Yngve of Karolinka in Sweden, and the project is financially supported by the European Commission’s public health directorate. Pro Greens is a follow-up project on Pro Children. Both projects are aiming to promote fruit and vegetable consumption among school-aged children across Europe. In Pro Children informed by a a cross sectional survey conducted in nine countries in North, West and Southern Europe, an intervention mapping exercise was conducted that resulted in an intervention package that was tested in Norway, the Netherlands, and the Basque region of Spain.
Pro Greens build on Pro Children by adapting the intervention to be applicable in different countries, including new European Union member states, and to test these adapted interventions in these countries.
EMGO+ is responsible for the evaluation work package within Pro Greens. This means that we will do the analyses for the effect evaluation of the intervention, but we are also responsible for the internal evaluation of the project. This internal evaluation should ensure good research quality guidance and control across all the participating research teams so that quality standards are complied to, and standardized data collection and management methods are applied.
Part of this internal evaluation is auditing the Pro Greens partners that were not within the Pro Children project. Yesterday I did the first audit at the Folkhälsan Research Center in Helsinki, Finland where I met with the principal investigator of the Folkhälsan team, Dr. Eva Roos and her two associates Carola Ray and Camilla Stoor.

Based on the Research Quality handbook of the EMGO+ Institute, the Folkhälsan team had completed an audit survey before the actual audit and based on this questionnaire we discussed issues regarding sampling, data collection, storage, cleaning and privacy protection, as well as data analyses preparations.

The last EMGO annual report has been distributed

This summer the 2008 annual report (click here for a pdf of the report) of the EMGO Institute was finalised. The print report has been distributed over the last weeks, i.e. right after the summer break, and additional statistics have been published on our website. This annual report is the last one concerning the ‘old’ EMGO Institute, because from January 2009 we are the EMGO Institute for Health and care Research, or EMGO+.

The annual report shows that EMGO is going strong. This annual report proofs that the EMGO staff has again realized significant and meaningful scientific output, as indicated by a the 463 publications in international scientific international journals, a stable high citation score, and success in acquiring new grants that will enable further research in the years to come. EMGO welcomed four new full professors in 2008, with chairs in General Practice, Physical Activity and Health in Older Persons, Health Promotion and Health Policy and Participation of Patients in General Health Care, and we helped to get 36 PhD students to complete and defend their theses.
The fact that this was achieved in a year in which we intensively prepared for a major life-event in the history of the EMGO Institute, is, I believe, an indication of the strength and rigor of the institute. As said, in 2009 our institute will transfer into the interfaculty EMGO Institute for Health and Care Research, or ‘EMGO+’ in short. This new institute is an ‘interfaculty’ research institute because it will bring researchers from three faculties together, aiming to further improve public and occupational health, primary care, rehabilitation and long-term care, by means of multi and interdisciplinary research.
This 2008 annual report shows that we can give EMGO+ a good start.

Accreditation and certification of theory and evidence-based health promotion interventions

The Center for Healthful Living (Centrum Gezond Leven) and the Netherlands Youth Institute of the Netherlands National Institute for Public Health and the Environment are coordinating and leading an effort to come to better evidence-based practice in health promotion interventions in the Netherlands. The Center has developed an accreditation and certification procedure to distinguish between health promotion efforts that have no empirical basis from interventions for which different levels of evidence is available. For this purpose the Certification Commission for Interventions was started. The commission has four sub commissions, one on health promotion interventions for adults, which I will chair.
In health promotion, most often developed to promote healthy life styles for primary prevention of chronic disease, a lot is going on, but most interventions have no or an insufficient evidence-base. Such a situation is regarded as unacceptable in secondary prevention, cure or care, where evidence-based medicine is key. No one would accept, for example, that a new vaccine for Swine Flu was distributed to the population at large without careful stepwise testing in well-designed and controlled studies (see attached figure). In health promotion this is, however, common practice (the second figure shows this): mass-media or more tailored health education and health promotion interventions are designed, maybe pretested in some form of formative research, but often disseminated without any proof of effects.
The efforts of the Center for Healthy Living are aiming to help professionals and policy makers to select the available more promising and more evidence-based interventions for their health promotion purposes. The establishment of the certification procedure should also encourage organisations that develop interventions to improve their quality control and evaluation efforts.
Four levels of evidence will be distinguished (between brackets a very brief summary of the true, much better described and more detailed criteria are provided, click here for a list of criteria in Dutch):
1. Theoretically sound: The intervention’s goals, strategy and methods are well described and based established theoretical models
2. Probably effective: a series (>2) of studies of medium level design strength should suggest effectiveness
3. Proven effective: at least 2 studies with a strong research design show effectiveness
4. Proven cost-effectiveness: additional economic evaluations are available.
In the coming years it will become clear if the system will indeed lead to better evidence-based practice in health promotion.

In memoriam: Prof Herman Schaalma

Professor Herman Schaalma died suddenly of a heart attack on 25 July 2009 while riding his road bike in the Limburg hills. Last Friday I joined a crowd of 400-500 people in Eijsden near Maastricht, the Netherlands, to say goodbye during an emotional, heart breaking, but sometimes also hilariously funny ceremony.

Herman was a social psychologist and health scientist working at the Faculty of Psychology and Neuroscience of Maastricht University in the field of planned development, implementation and evaluation of theory- and evidence-based health promotion programs, with a focus on HIV/Aids. His research focused on applying (social) psychology in understanding and changing health behaviors. His recent research interests included risk perception and communication; stigma; adherence; culture, psychology and health education; and web-based health education.

I worked with Herman during the time I was at Maastricht University and occasionally after I left Maastricht to work first in Rotterdam, and now at the EMGO Institute for Health and Care Research at the VU University Medical Center in Amsterdam. In fact when in Maastricht I lived for a few years under the same roof as Herman; I lived in an apartment one floor above Herman and his family. Herman was a great colleague and a great neighbour.

The most intensive collaboration we had was when the two of us, together with Prof. Gerjo Kok edited the first edition of the Dutch handbook on health education and behaviour change. Working with Herman in this way was fun, rewarding and challenging. Fun because of his great sense of humour, rewarding because he certainly made sure that we got the job done and his input improved the book in a great way, and challenging because his razor sharp feedback and comments, no beating around the bush, made sure that you wanted to do your best before asking Herman to take a look at your output.

The field of planned, evidence-based health promotion has lost a great colleague and a great character.