The joint Australian-New Zealand Nutrion Societies meeting

Last week I presented the results of the ENERGY study on childhood overweight and obesity and prevention of childhood overweight and obesity across Europe, at the annual meeting of the Australian and New Zealand nutrition societies. The meeting's theme was 'Lean and Green' with a focus on obesity as well as on sustainable food and nutrition. My keynote presentation was linked to the 'Lean' theme, while Prof. Tim Lang talked about the link with sustainability - via a web-video presentation. The meeting was much like similar meetings in the Netherlands or elsewhere in Europe, with similar presentations, studies and discussions, and even sponsors (e.g. similar to such events in the Netherlands, the Dairy industry was the main sponsor of the meeting).

Visiting the School of Population Health, University of Auckland

On my way to the joint annual meeting of the Australian and New Zealand Nutrition Societies in Quesnstown, New Zealand, together with Professor Kylie Ball from Deakin University, I visited the clinical trial research unit of the School of Population Health of the University of Auckland. We had meetings with the behavioral nutrition and physical activity research leaders of the unit, i.e. Cliona Ni Mhurchu and Ralph Madison, as well as a number of research fellows and PhD students. Kylie and I provided a joint symposium at lunch time.

Visiting C-PAN at Deakin University, Melbourne

This week I am visiting the Center for Phyiscal Activity and Nutrition Research (C-PAN) at Deaking University, Melbourne, Australia. C-PAN is one of the internationally leading groups in (behavioral) nutrition and physical activity research. Their focus is very similar to parts of the EMGO Institute for Health and Care Research (EMGO+), our Lifestyle, Overweight & Diabetes and Musculoskeletal Health programs in particular. The close collaboration with C-PAN has resulted in a number of joined projects, including involvement of C-PAN staff in the EMGO+ European Commission funded ENERGY project on obesity prevention in school-age children across Europe, and involvement of EMGO+ staff in C-PAN's READY project on resilience to obesity among women from lower socio-economic backgrounds, and a growing number of joint scientific publications. The accompanying photo shows (except for myself and C-PAN's director David Crawford's son Alex) the C-PAN staff that visited EMGO+ in the last couple of years, as well as another regular visitor of C-PAN, Prof. Bob Jeffery from the epidemiology unit of the University of Minnesota, USA. (Notice C-PAN in chocolate letters, in anticipation of the Dutch Sinterklaas festivities....)http://en.wikipedia.org/wiki/Sinterklaas

Health education is not enough to promote healthy diets and physical activity

Today two PhD candidates from the EMGO Institute for Health and Care Research defended there theses at the VU University here in Amsterdam. In his thesis 'Efforts to prevent diabetes and cardiovascular disease in primary care' Jeroen Lakerveld explored the effects of a health education program based on motivational interviewing and problem solving treatment to motivate and enable people with high risk to adopt health behaviors that contribute to diabetes prevention (e.g. healthy eating and physical activity). The effect study showed generally no effects of this health education approach.  Dr. Lakerveld states that the approach taken may have been too limited, and that for interventions to be effective changes in the environment, i.e. the availablity of and social support for health choices may be needed.

Willemijn Vermeer studied the role of portion sizes of foods and the development and evaluation of interventions to motivate or enable people to take smaller portion sizes. Earlier research shows that portion sizes have increase quite abit over the years, e.g. coke, candy bars, fast food entrees are sold in much bigger portion sizes nowadays than a few decades ago. Additional research strongly suggests that these increases contribute to overeating and to overweight and obesity. Dr. Vermeer research shows that policies to actually reduce portion sizes are not acceptable for the general public or for food catering organisation, while interventions that are regarded as acceptable, i.e. better labels to explain portion sizes or more choice between different portion sizes, appear to be ineffective.

Both studies suggest that health education is not enough and that people need to be nudged toward healthier behavior - that the healthy choice should be made the easy and default choice. The present Dutch government disregards this and earlier (and even stronger) evidence. Theb Dutch policy is that people are ablle and will make informed choices about their health behavior and that freedom of choice and autonomy should be promoted. In an environment that promotes supersizing and lack of physical activity, that freedom of choice appears to be quite relative.

A review on economic incentives and nutritional behavior among children in the school setting

Health behaviour may be promoted by different incentives. Economic incentives, i.e. monetary rewards or price incentives, e.g. making healthy foods less expensive and unhealthy foods more expensive, may be applied. However, the true possibilities and effects of such interventions are debated, and their applicability among children may be doubtful. The aim of a review, just published online in the journal Nutrition Reviews, was to examine the existing literature on the effectiveness of economic incentives for producing sound nutritional behavior in schools Altogether, 3,472 research publications were identified in the systematic search, of which 50 papers were retrieved. Of these, 30 publications representing 28 studies were regarded as of highe enough quality and relevant. The review indicates that price incentives are effective for altering consumption in the school setting. Other types of economic incentives have been included in combined intervention schemes, but the inclusion of other intervention elements makes it difficult to draw conclusions about their effectiveness.

A second writing workshop to publish further results of the ENERGY project

The ENERGY project stands for the "EuropeaN Energy balance Research to prevent excessive weight Gain

among Youth : Theory and evidence-based development and validation of an intervention scheme to promote healthy nutrition and physical activity". ENERGY consists of a series of systematic reviews, secondary data analyses, a school-based and family involved cross sectional and intervention study among 7000 and 2500 children and one of their parents respectively. Seven countries across Europe are involved. The project description and study design papers regarding the cross sectional study in general and the accelerometer study (i.e. a study to monitor schoolchildren physical activity objectively) have been published, and a number of scientific papers have been submitted for publications. These concern papers on prevalence - and differences in prevalence between the seven countries - of overweight and obesity, as well as engagement in a range of behaviors (i.e. physical activity, sedentary behaviors, dietary behaviors) associated with risk for being or becoming overweight; differences in prevalence according to ethnic background of the children. Further papers that have been submitted focus on, for example, the reliability and validity of the measures used in the ENERGY study, the relation between weather circumstances and physical activity, the association between sedentary behavior and blood markers for metabolic health, et cetera.
These days another writing workshop is ongoing in a bed-and-breakfast facility in Amsterdam to write and prepare the next series of scientific papers from the project. Scientists from the UK, Norway, Spain, Belgium and the Netherlands meet here for 3 days to write and provide feedback on a series of papers regarding for example mediators of socio-economic differences in childhood overweight, the clustering of physical activity and sedentary behavior patterns, the contribution of TV watsching to total sedentary behavior and a range of other topics. All these papers use data from the cross sectional survey of ENERGY. Data for the ENERGY intervention study targetting sedentray behavior among school children in five of the partcipating countries are now being collected and will be available later this year.

A workshop in Stockholm on grading evidence regarding public health interventions

Last Wednesday, the Swedish National Institute of Public Health organised a meeting in Stockholm to explore the do's and don't's of grading evidence regarding public health interventions to help policy makers to identify the best and most effective interventions to promote population health. In public health and health promotion the cry for better evidence-based practice is strong and obvious. However, grading the evidence in public health is more complicated as compared to medical interventions. In public health, interventions are, for example, often group or population based rather than aimed at individuals, effects are often only to be observed in the long run, and interventions are mostly complex, multi-component and context dependent. These characteristics make it more difficult to study public health interventions in research designs that are regarded as the most internally valid, i.e. randomised controlled trials (RCT). In existing systems to grade evidence for medical interventions, such as the GRADE system, evidence not based on RCT designed studies can never be strong, thus favouring individual medical interventions above population-based public health interventions. Therefore, maybe new or other systems need to be developed, or the GRADE system may need to be adapted to better accomodate public health and health promotion interventions. At the workshop I presented the Dutch acknowledgement system for health promotion interventions, led by the the Centres for Healthy Living and Youth Health of the Netherlands National Institute for Public Health and the Environment and the Netherlands Youth Institute. This system was specifically designed  and developed and is being implemented aiming to provide policy makers and professionals with more information on the quality and effectiveness of

available health promotion interventions and to promote use of good-practice and evidence-based interventions by health promotion organizations.  Four levels of recognition are distinguished inspired by the UK Medical Research Council’s evaluation framework for complex interventions to improve health: (i) theoretically sound, (ii) probable effectiveness, (iii) established effectiveness, and (iv) established cost effectiveness. Specific criteria have been set for each level of recognition, taking into account the specific evaluation researhc challenges for public health and health promotion evaluation research. The way the Ducth system works and the first experiences and results were published in a paper in Health Education Research.