Marloes Martens

European energy balance research to prevent excessive weight gain among youth (ENERGY) project: Design and methodology of the ENERGY cross-sectional survey

BackgroundObesity treatment is by large ineffective long term, and more emphasis on the prevention of excessive weight gain in childhood and adolescence is warranted. To inform energy balance related behaviour (EBRB) change interventions, insight in the potential personal, family and school environmental correlates of these behaviours is needed. Studies on such multilevel correlates of EBRB among schoolchildren in Europe are lacking. The ENERGY survey aims to (1) provide up-to-date prevalence rates of measured overweight, obesity, self-reported engagement in EBRBs, and objective accelerometer-based assessment of physical activity and sedentary behaviour and blood-sample biomarkers of metabolic function in countries in different regions of Europe, (2) to identify personal, family and school environmental correlates of these EBRBs. This paper describes the design, methodology and protocol of the survey.Method/DesignA school-based cross-sectional survey was carried out in 2010 in seven different European countries; Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, and Spain. The survey included measurements of anthropometrics, child, parent and school-staff questionnaires, and school observations to measure and assess outcomes (i.e. height, weight, and waist circumference), EBRBs and potential personal, family and school environmental correlates of these behaviours including the social-cultural, physical, political, and economic environmental factors. In addition, a selection of countries conducted accelerometer measurements to objectively assess physical activity and sedentary behaviour, and collected blood samples to assess several biomarkers of metabolic function.DiscussionThe ENERGY survey is a comprehensive cross-sectional study measuring anthropometrics and biomarkers as well as assessing a range of EBRBs and their potential correlates at the personal, family and school level, among 10-12 year old children in seven European countries. This study will result in a unique dataset, enabling cross country comparisons in overweight, obesity, risk behaviours for these conditions as well as the correlates of engagement in these risk behaviours.

Test-retest reliability and construct validity of the ENERGY-child questionnaire on energy balance-related behaviours and their potential determinants: the ENERGY-project.

BackgroundInsight in childrens energy balance-related behaviours (EBRBs) and their determinants is important to inform obesity prevention research. Therefore, reliable and valid tools to measure these variables in large-scale population research are needed.ObjectiveTo examine the test-retest reliability and construct validity of the child questionnaire used in the ENERGY-project, measuring EBRBs and their potential determinants among 10-12 year old children.MethodsWe collected data among 10-12 year old children (n = 730 in the test-retest reliability study; n = 96 in the construct validity study) in six European countries, i.e. Belgium, Greece, Hungary, the Netherlands, Norway, and Spain. Test-retest reliability was assessed using the intra-class correlation coefficient (ICC) and percentage agreement comparing scores from two measurements, administered one week apart. To assess construct validity, the agreement between questionnaire responses and a subsequent face-to-face interview was assessed using ICC and percentage agreement.ResultsOf the 150 questionnaire items, 115 (77%) showed good to excellent test-retest reliability as indicated by ICCs > .60 or percentage agreement ≥ 75%. Test-retest reliability was moderate for 34 items (23%) and poor for one item. Construct validity appeared to be good to excellent for 70 (47%) of the 150 items, as indicated by ICCs > .60 or percentage agreement ≥ 75%. From the other 80 items, construct validity was moderate for 39 (26%) and poor for 41 items (27%).ConclusionsOur results demonstrate that the ENERGY-child questionnaire, assessing EBRBs of the child as well as personal, family, and school-environmental determinants related to these EBRBs, has good test-retest reliability and moderate to good construct validity for the large majority of items.

Systematic prevention of overweight and obesity in adults: a qualitative and quantitative literature analysis

To date, most interventions aimed at preventing obesity have underemphasized the application of systematic intervention development, implementation and evaluation. The present review provides a thorough insight in factors promoting implementation and/or effectiveness in interventions aimed at preventing overweight/obesity among adults. A total of 46 studies evaluating interventions aimed at preventing obesity were reviewed, followed by both qualitative and quantitative analyses. The Intervention Mapping protocol and the Environmental Research framework for weight Gain prevention (EnRG) were applied to analyse and classify the included studies. The interventions were categorized by setting (workplace, community, health care) and target group (ethnic minorities, pregnant women, [pre]menopausal women, smokers, people with intellectual disabilities). Generally, interventions were found to have potential in changing energy balance‐related behaviours and anthropometric outcomes. Effect sizes for changes in body mass index ranged between −0.09 and 0.45. When the programme goal specifically aimed at weight management, the intervention was found to be more successful than interventions with programme goals that were aimed at preventing cardiovascular disease or improving general health status. Although a considerable part of studies included motivational interventions, only some actually assessed the effects on potential cognitive mediators. A general lack of reporting underlying theoretical models for behaviour change was observed as well as the inclusion of linkage groups and strategies to promote empowerment.

Krachtvoer: effect evaluation of a Dutch healthful diet promotion curriculum for lower vocational schools.

OBJECTIVE The aim of this study was to assess the behavioural effects of a school-based healthful diet promotion intervention implemented in lower vocational schools. DESIGN A cluster-randomised pre-test-post-test experimental design was used, and data were collected by means of written questionnaires. SETTING Students of 18 Dutch lower vocational schools. SUBJECTS The final sample consisted of 10 experimental schools with 13 teachers, 37 classes and 879 students, and eight control schools with 10 teachers, 31 classes and 734 students (total n = 1613). RESULTS Fixed regression analyses revealed beneficial effects on the behavioural measures relating to fruit intake (as assessed by a food frequency measure and fruit consumption during the previous day), and most behavioural measures related to high-fat snack intake (food frequency measure, and number of snacks and total fat intake from snacks during the previous day). The behavioural effects relating to breakfast habits were limited. Some positive behavioural effects occurred in the total target population, others mainly or only among students with more unfavourable intakes at baseline. Mixed regression analysis found comparable regression coefficients for the behavioural outcomes, but the effects related to fruit intake were no longer statistically significant. CONCLUSIONS Although we did not find the expected effects on all outcome indicators, the total pattern of results suggest that Krachtvoer offered a surplus value over existing curricula. However, some programme elements need to be revised to improve effectiveness and prevent negative effects, and more information is needed about the long-term effects of the programme.

Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands

BackgroundThe need to understand barriers to the implementation of health care innovations in daily practice has been widely documented, but perceived facilitators and barriers in diabetes care by Dutch health care professionals remain unknown. The aim of this study was to investigate these factors among health care professionals (HCPs) using a qualitative research design.MethodsData were collected from 18 semi-structured interviews with HCPs from all professions relevant to diabetes care. The interviews were recorded and transcribed verbatim and the data were analyzed using NVivo 8.0.ResultsMajor facilitators were the more prominent role of the practice nurses and diabetes nurses in diabetes care, benchmarking, the Care Standard (CS) of the Netherlands Diabetes federation and multidisciplinary collaboration, although collaboration with certain professional groups (i.e. dieticians, physical therapists and pharmacists), as well as the collaboration between primary and secondary care, could still be improved. The bundled payment system for the funding of diabetes care and the role of the health insurers were perceived as major barriers within the health care system. Other important barriers were reported to be the lack of motivation among patients and the lack of awareness of lifestyle programs and prevention initiatives for diabetes patients among professionals.ConclusionsOrganizational changes in diabetes care, as a result of the increased attention given to management continuity of care, have led to an increased need for multidisciplinary collaboration within and between health care sectors (e.g. public health, primary care and secondary care). To date, daily routines for shared care are still sub-optimal and improvements in facilities, such as registration systems, should be implemented to further optimize communication and exchange of information.

Appreciation and implementation of the Krachtvoer healthy diet promotion programme for 12- to 14- year-old students of prevocational schools

BackgroundKrachtvoer is a school-based healthy diet programme, developed in 2001 and revised in 2007 to meet the needs of particular segments of the target population as well as a wider target group. The main aims of the present process evaluation of the revised programme were to examine student and teacher appreciation of the programme, completeness of and adherence to its implementation, and relations between appreciation and completeness of implementation.MethodsData were collected among 22 teachers and 1117 students of 13 schools, using student evaluation forms, teacher logbooks, telephone interviews, and classroom observations.ResultsResults indicate favourable levels of teacher and student appreciation for the programme in general and the revised elements. Girls, first-year students and students with more favourable dietary intakes particularly appreciated individual programme elements. Levels of completeness of implementation were high, but several teachers did not adhere to the intended implementation period. Some moderately strong relations were found between teacher appreciation and completeness of implementation scores.ConclusionWe conclude that the revisions have resulted in a programme that was appreciated well, also by the extended target group, and was implemented with a high degree of completeness. Teacher appreciation proved potentially important for completeness of implementation. We identified several aspects requiring improvement, indicating the importance of continued programme updates and repeated evaluation.

Micro-level economic factors and incentives in Children’s energy balance related behaviours - findings from the ENERGY European cross-section questionnaire survey

BackgroundTo date, most research on obesogenic environments facing school children has focused on physical and socio-cultural environments. The role of economic factors has been investigated to a much lesser extent. Our objective was to explore the association of micro-level economic factors and incentives with sports activities and intake of soft drinks and fruit juice in 10-12 year-old school children across Europe, and to explore price sensitivity in children’s soft drink consumption and correlates of this price sensitivity.MethodsData for the study originate from a cross-sectional survey undertaken in seven European countries (Belgium, Greece, Hungary, Netherlands, Norway, Slovenia and Spain) in 2010 among 10-12 year-old school children and their parents. In total, 7234 child questionnaires and 6002 parent questionnaires were completed. The child questionnaire included questions addressing self-reported weekly intake of soft drinks and fruit juices and time spent on sports activities, perception of parental support for sports activities, use of pocket money for soft drinks and perceived price responsiveness. Parent questionnaires included questions addressing the role of budget and price considerations in decisions regarding children’s sports activities, soft drink consumption, home practices and rules and socio-demographic background variables. Data were analysed using multiple linear regression and discrete-choice (ordered probit) modelling.ResultsEconomic factors were found to be associated with children’s sports participation and sugary drink consumption, explaining 27% of the variation in time for sports activities, and 27% and 12% of the variation in the children’s soft drink and juice consumption, respectively. Parents’ financial support was found to be an important correlate (Beta =0.419) of children’s sports activities. Children’s pocket money was a strong correlate (Beta =21.034) of soft drink consumption. The majority of the responding children reported to expect that significantly higher prices of soft drinks would lead them to buy less soft drinks with their own pocket money, but a majority of parents did not expect higher soft drink prices to reduce their children’s soft drink consumption.ConclusionsWe conclude that economic factors, especially parents’ financial support and amount of pocket money, appear to be of importance for children’s sports participation and soft drink consumption, respectively.

Healthier food choices as a result of the revised healthy diet programme Krachtvoer for students of prevocational schools

BackgroundKrachtvoer is a Dutch healthy diet programme for prevocational schools, developed in 2001 and revised for a broader target group in 2007, based on the findings of an evaluation of the first version. The goal of this study was to report on the short- and longer-term total and subgroup effects of the revised programme on students’ fruit, fruit juice, breakfast, and snack consumption.MethodsSchools were randomized to the experimental condition, teaching the Krachtvoer programme, or to the control condition teaching the regular nutrition lessons. Self-reported consumption of fruit, fruit juice, breakfast and snacks was measured at baseline directly before programme implementation, one to four weeks after finishing programme implementation, and after six months. Mixed linear and logistic regression analyses were conducted.ResultsIn total 1117 students of 13 experimental schools and 758 students of 11 control schools participated in the study. Short- and longer-term favourable intervention effects were found on fruit consumption (mean difference between experimental and control group 0.15 servings at both posttests). Regarding fruit juice consumption, only short-term favourable effects were revealed (mean difference between experimental and control group 0.05 glasses). Intervention effects on breakfast intakes were limited. No changes in snack frequency were reported, but students made healthier snack choices as a result of the programme. Some favourable as well as unfavourable effects occurred in subgroups of students.ConclusionsThe effects on fruit consumption and snack choices justify the current nationwide dissemination of the programme. Achieving changes in breakfast consumption may, however, require other strategies.

Correlates of perceived self-care activities and diabetes control among Dutch type 1 and type 2 diabetics

This study examined how Dutch type 1 and type 2 diabetes patients’ perceived autonomy support, as well as their perceived competence and treatment self-regulation, are associated with their diabetes self-care activities (healthy diet, physical activity, monitoring blood glucose, medication use) and general diabetes control. A cross-sectional questionnaire study was conducted among 143 type 1 diabetics and 384 type 2 diabetics. Overall, participants felt competent, supported in their autonomy, and perceived to autonomously self-regulate their diabetes. Our results underline the importance of perceived competence in type 1 and 2 diabetics, as this was strongly associated with adhering to a healthy diet and general diabetes control. Our findings also emphasize the need for autonomy supportive health care professionals in diabetes care. Interestingly, perceived competence partially mediated the influence of autonomy support on general diabetes control.

Perceptions of Dutch health care professionals regarding the Care Standard for diabetes

BackgroundThe Netherlands can be regarded as unique in the use of the Netherlands Diabetes Federation (NDF) Care Standard (CS) for diabetes. The need to understand the barriers obstructing optimal health care, the dissemination and implementation of health care innovations into daily practice and the extent to which health care professionals actually adhere to guidelines has been emphasized repeatedly. Therefore, the aim of the present study was to suggest ways to optimize the implementation of the CS by examining the perceptions of Dutch health care professionals regarding the CS and the barriers to using it.MethodsA cross-sectional questionnaire survey was conducted among health care professionals (N = 1547) in 2010.ResultsA total of 39.6% (N = 1323) of the participating health care professionals possessed the CS. Only 15.5% of the professionals who were to some extent familiar with the CS (N = 1100) described themselves as working in complete accordance with the CS. The majority (83.9%) thought the CS contributed greatly to ensuring the quality of care; the judgment on the feasibility of working in accordance with the CS was positive (mean = 3.9 on a 5-point Likert scale). However, professionals tended to perceive the guidelines issued by the own professional association as the norm for high quality diabetes care, rather than the CS. The main barrier to using the CS was the lack of effective lifestyle interventions (or access to them) to provide care for people with diabetes or those at increased risk for the disorder.ConclusionsA limited percentage of health care professionals were found to posses the CS. It is questionable whether possession of the CS is a prerequisite for delivering high quality care. Overall, professionals were largely positive about the CS, although only a minority indicated they were working in complete accordance with it. Professionals and professional organizations should be further educated about the content of the CS and especially its added value with respect to the guidelines for their own professional group, in terms of the multidisciplinary approach to diabetes care. Furthermore, attention should be given to the most important perceived barriers, to facilitate adherence to the CS.