A break in the obesity epidemic? Explained by biases or misinterpretation of the data?

Recent epidemiologic papers are presenting prevalence data suggesting breaks and decreases in obesity rates. However, before concluding that the obesity epidemic is not increasing anymore, the validity of the presented data should be discussed more thoroughly. We had a closer look into the literature presented in recent reviews to address the major potential biases and distortions, and to develop insights about how to interpret the presented suggestions for a potential break in the obesity epidemic. Decreasing participation rates, the use of reported rather than measured data and small sample sizes, or lack of representativeness, did not seem to explain presented breaks in the obesity epidemic. Further, available evidence does not suggest that stabilization of obesity rates is seen in higher socioeconomic groups only, or that urbanization could explain a potential break in the obesity epidemic. However, follow-ups of short duration may, in part, explain the apparent break or decrease in the obesity epidemic. On the other hand, a single focus on body mass index (BMI) ⩾25 or ⩾30 kg m(-)(2) is likely to mask a real increase in the obesity epidemic. And, in both children and adults, trends in waist circumferences were generally suggesting an increase, and were stronger than those reported for trends in BMI. Studies concluding that there is a recent break in the obesity epidemic need to be interpreted with caution. Reported studies presenting a break were mostly of short duration. Further, focusing on trends in waist circumference rather than BMI leads to a less optimistic conclusion: the public health problem of obesity is still increasing.

Dutch teachers and parents about overweight prevention in pre-vocational schools.

Healthier lifestyles may contribute to prevent overweight in adolescents. Although school-based interventions show promising results, adoption and implementation by secondary schools and involvement of parents is difficult. Our study aims to gain a better understanding of the problem awareness and beliefs of school staff and parents regarding adolescents' overweight and energy balance-related behaviour, their motivation for health-promoting activities and suggested actions in the school environment. Focus group interviews were conducted with three groups of parents and three groups of school staff at three pre-vocational schools in the Netherlands. Comments concerning awareness, motivation to intervene and possible actions were analysed with the Atlas.ti program. Results showed that school staff and parents were aware of overweight as a health problem, but underestimated the prevalence and impact of overweight and unhealthy behaviour in their school. Health-related behaviour of adolescents was considered primarily the responsibility of parents, but the school staff also had a pedagogical responsibility. Parents and school staff agreed that health promotion efforts would have more impact on adolescents' behaviour, when school-based activities were supported by parents and parental efforts were supported by school health promotion. Therefore, parental efforts and school-based activities should be aligned by developing and expressing shared norms about healthy behaviour and parents should be taught how to discuss healthy dietary and physical activity behaviour with their children. To tackle peer group culture and the obese environment, parents' and school staff's efforts should be part of an integrated community approach.

Association between TV viewing, computer use and overweight, determinants and competing activities of screen time in 4- to 13-year-old children.

OBJECTIVE: TV viewing and computer use is associated with childhood overweight, but it remains unclear as to how these behaviours could best be targeted. The aim of this study was to determine to what extent the association between TV viewing, computer use and overweight is explained by other determinants of overweight, to find determinants of TV viewing and computer use in the home environment and to investigate competing activities. METHOD: A cross-sectional study was carried out among 4072 children aged 4-13 years in the city of Zwolle, the Netherlands. Data collection consisted of measured height, weight and waist circumference, and a parental questionnaire on socio-demographic characteristics, child's nutrition, physical activity (PA) and sedentary behaviour. Associations were studied with logistic regression analyses, for older and younger children, boys and girls separately. RESULTS: The odds ratio (OR) of being overweight was 1.70 (95% confidence interval (CI): 1.07-2.72) for viewing TV >1.5 h among 4- to 8-year-old children adjusted for all potential confounders. Computer use was not significantly associated with overweight. Determinants of TV viewing were as follows: having >2 TVs in the household (OR: 2.38; 95% CI: 1.66-3.41), a TV in the child's bedroom and not having rules on TV viewing. TV viewing and computer use were both associated with shorter sleep duration and not with less PA. CONCLUSION: Association between TV viewing and overweight is not explained by socio-demographic variables, drinking sugared drinks and eating snacks. Factors in the home environment influence children's TV viewing. Parents have a central role as they determine the number of TVs, rules and also their children's bedtime. Therefore, interventions to reduce screen time should support parents in making home environmental changes, especially when the children are young.

Association between sleep duration and overweight: the importance of parenting.

OBJECTIVE: Sleep duration has been related to overweight in children, but determinants of sleep duration are unclear. The aims were to investigate the association between sleep duration and childhood overweight adjusted for family characteristics and unhealthy behaviours, to explore determinants of sleep duration and to determine with sleep competing activities. METHOD: A cross-sectional study was carried out in 2006 among 4072 children aged 4-13 years in the city of Zwolle, The Netherlands. In these children, data were available on measured height, weight and waist circumference, and from a parental questionnaire, on socio-demographic characteristics, child's sleep duration, nutrition, physical activity and sedentary behaviour. Associations were studied in 2011 using logistic and linear regression analyses, adjusted for potential confounders. RESULTS: Short sleep duration was associated with overweight for 4-8-year-old boys (odds ratio (OR):3.10; 95% confidence interval (CI):1.15-8.40), 9-13-year-old boys (OR:4.96; 95% CI:1.35-18.16) and 9-13-year-old girls (OR:4.86; 95% CI:1.59-14.88). Among 4-8-year-old girls no statistically significant association was found. Determinants for short sleep duration were viewing television during a meal, permission to have candy without asking, not being active with their caregiver and a late bedtime. For all children, short sleep duration was strongly associated with more television viewing and computer use. CONCLUSIONS: Association between sleep duration and overweight is not explained by socio-demographic variables, drinking sugared drinks and eating snacks. Parents have a key role in stimulating optimal sleep duration. Improving parenting skills and knowledge to offer children more structure, and possibly with that, increase sleeping hours, may be promising in prevention of overweight.

A local consensus process making use of focus groups to enhance the implementation of a national integrated health care standard on obesity care.

BACKGROUND: Recent guidelines on obesity management promote integrated care. There is little knowledge about local opportunities and barriers, faced by health care professionals and patients, that affect implementation of an integrated national health care standard in a local setting. Our aim is to understand experiences and expectations of health care professionals and patients as part of the local implementation process. METHODS: Eight focus groups and two interviews have been conducted among 24 patients (60+) and 29 professionals from seven different care disciplines. RESULTS: Both patients and professionals have identified serious barriers to implement the national standard: older adults do not feel taken seriously and experience lacking support from professionals. Professionals give contradictory advice and recommendations do not match needs of older adults. Professionals actually feel reluctant to discuss weight-related topics due to several reasons: they do not consider obesity being a chronic disease, lack of qualifications to support self-management and perceived lack of awareness and motivation among patients. CONCLUSION: Focus groups have proven their value to ascertain the opportunities and barriers older adults and professionals foresee while improving obesity care in order to meet the standards as required in a national guideline. Our research provides an emerging picture of health care professionals and patients having contradictory views and expectations about 'the others' role and their notions on the capability to intervene on patient's weight problems. Without this emerging picture, we would have missed important information on barriers to overcome. The likelihood of successful implementation would then have been small.

The NHF-NRG In Balance-project: the application of Intervention Mapping in the development, implementation and evaluation of weight gain prevention at the worksite.

Very few examples of theory-driven and systematically developed weight gain prevention interventions for adults have been described in the literature. The present paper systematically describes the development, implementation and evaluation framework of a weight gain prevention programme directed at young adults at the worksite, namely the NHF-NRG In Balance-project. It not only can be used as a guide to systematically develop weight gain prevention interventions, but also gives an overview of the current theoretical and empirical knowledge-base in the field of obesity prevention. The outline of the paper follows the Intervention Mapping protocol, which includes a systematic inventory of important health issues, their risk behaviours and determinants of these risk behaviours, and specification of the proximal objectives of the programme directed at both energy intake and energy expenditure. The objectives are translated into behaviour change methods and strategies, which are combined in a stepwise intervention programme, and used for a detailed evaluation plan (process and effect evaluation). The NHF-NRG In Balance-project combines mass media and individually tailored communications with worksite environmental changes to raise awareness, to motivate and to enable energy balance behaviour changes. A quasi-experimental pre-test-multiple post-test control group design was applied in 12 worksites (>500 employees).

Prevalence of overweight and obesity in the Netherlands.

This paper shows the trends in the prevalence of overweight (body mass index [BMI] >or= 25 kg m-2) and obesity (BMI >or= 30 kg m-2) in the Netherlands. Overweight (obesity) prevalence in adult males increased from 37% (4%) in 1981 to 51% (10%) in 2004, and in adult females from 30% (6%) in 1981 to 42% (12%) in 2004, according to self-reported data. In boys and girls, obesity prevalence doubled or even tripled from 1980 to 1997, and again from 1997 to 2002-2004 a two- or threefold increase was seen for almost all ages. According to the most recent data, overweight (obesity) prevalence figures range, depending on age, from 9.2% to 17.3% (2.5-4.3%) in boys, and from 14.6% to 24.6% (2.3-6.5%) in girls. There is a lack of data on the national prevalence of overweight and obesity based on measured height and weight and on prevalences in different subgroups of the population. Regular national representative health examination surveys that measure height and weight are needed to assess the prevalence of overweight and obesity and its distribution over subgroups in the population, and to properly direct and evaluate prevention activities.

The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes.

Overweight and obesity are serious, large-scale, global, public health concerns requiring population-based childhood overweight and obesity prevention. The overall objective of this review is to identify aspects of successful childhood overweight prevention programmes. This objective will be met by assessing existing interventions quantitatively as well as qualitatively, identifying efficacy, effectiveness and implementation, and evaluating potential adverse effects of previous studies. This review was limited to school-based studies with a quantitative evaluation using anthropometric outcomes and that intervene on diet or activity-related behaviours. Quantitative and qualitative approaches are used to identify factors related to successful interventions as well as adverse consequences. Sixty-eight per cent of the interventions, or 17 of the 25, were 'effective' based on a statistically significant reduction in body mass index (BMI) or skin-folds for the intervention group. Four interventions were effective by BMI as well as skin-fold measures. Of these, two targeted reductions in television viewing. The remaining two studies targeted direct physical activity intervention through the physical education programme combined with nutrition education. Of the interventions reported here, one was effective in reducing childhood overweight but was also associated with an increase in underweight prevalence. Few other studies reported outcomes for underweight. The majority of overweight/obesity prevention programmes included in this review were effective. Physical education in schools and reducing television viewing are two examples of interventions that have been successful. Because few studies report on underweight prevalence, this review recommends giving more attention to preventing adverse outcomes by reporting the intervention impact on the frequency distribution for both BMI and adiposity measures.

Netherlands research programme weight gain prevention (NHF-NRG): rationale, objectives and strategies.

OBJECTIVE: To outline the rationale, objectives and strategies used in a systematically designed research programmme to study specific weight gain-inducing behaviours, their social-psychological as well as environmental determinants, and the effects of interventions aimed at the prevention of weight gain. DESIGN: The evidence for potential behavioural determinants and strategies to prevent weight gain was reviewed, and the methods applied within the Netherlands Research programme weight gain prevention (NHF-NRG) project were described. The project is designed according to the Intervention Mapping protocol. SETTING: The Netherlands. SUBJECTS: The main target groups are (a) adolescents (12-16 y) in secondary school, (b) young adults (20-40 y) at the workplace and (c) recently retired people (55-65 y) at home. INTERVENTIONS: Each intervention includes an individual component, in which computer-tailored information is provided. Additionally, interventions are aimed at changing environmental components. RESULTS: The short-term results of this project can be expected by the beginning of 2005. Guidelines for nationwide weight gain prevention, based on this research programme, will become available in 2007. CONCLUSIONS: Based on the few interventions that were evaluated to date, no robust conclusions can be drawn regarding the effectiveness of obesity prevention. The systematic and multidisciplinary design of the NHF-NRG programme enables the identification of potentially effective methods and strategies for the prevention of weight gain.

Home environmental determinants of children's fruit and vegetable consumption across different SES backgrounds.

OBJECTIVE: To investigate the association between home environmental determinants of fruit and vegetable consumption with childhood overweight separately for low, medium and high social economic status (SES) families. METHOD: A cross-sectional study was carried out in 2006 among 4072 children aged 4-13 years in the city of Zwolle, the Netherlands. Of these children, data were available on measured height and weight, and from a parental questionnaire, on sociodemographic characteristics and children's fruit and vegetables intake. Associations were studied using logistic regression analyses. RESULTS: Not eating the recommended amounts of vegetables daily was associated with overweight for children with a low SES background (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 0.66-2.07) and medium SES background (OR: 1.73; 95% CI: 1.20-2.49). Eating < 2 pieces of fruit daily was associated with a lower OR for overweight among children with a high SES background (OR: 0.66; 95% CI: 0.50-0.88). Determinants of eating vegetables < 7 d were: permission to take candy without asking, eating at the table < 7 d per week, eating a takeaway meal ≥ 1 d per week, eating a home cooked meal < 6 d per week and cooking together with caregiver less than 5 d per week. CONCLUSION: Interventions regarding vegetable consumption should be tailored to families with low and medium SES background. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis and, (ii) to promote eating a home cooked meal at the table and (iii) to involve children in the cooking process. Interventions should support parents in making these home environmental changes.

[Nutrition and health--obesity]. / Voeding en gezondheid--obesitas.

About 12% of the adult Dutch population is obese (Quetelet Index > or = 30 kg/m2). The prevalence has roughly doubled over the past 20 years. Obesity is strongly associated with a number of chronic diseases, such as type 2 diabetes mellitus, increased healthcare costs and a loss of productivity. Obesity is always the result of a mismatch between energy intake and energy expenditure. Foods with a high percentage of energy derived from fat are associated with weight gain, particularly when the rest of the energy is obtained from products containing little dietary fibre. Foods with a high content of refined added sugars or starch might be unfavourable with respect to the energy balance and the risk for type 2 diabetes mellitus and cardiovascular diseases. Slimming diets should aim for a gradual and sustained weight loss of about 10% of the initial weight over a period of six months, followed by weight maintenance over the next two years. Physical activity is an essential component of a weight loss strategy. Moderate sustained weight loss is associated with a strong reduction in the risk of type 2 diabetes mellitus in people with impaired glucose tolerance.

Characterizing the EPODE logic model: unravelling the past and informing the future.

EPODE ('Ensemble Prévenons l'Obésité De Enfants' or 'Together let's Prevent Childhood Obesity') is a large-scale, centrally coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. Since 2004, EPODE has been implemented in over 500 communities in six countries. Although based on emergent practice and scientific knowledge, EPODE, as many community programs, lacks a logic model depicting key elements of the approach. The objective of this study is to gain insight in the dynamics and key elements of EPODE and to represent these in a schematic logic model. EPODE's process manuals and documents were collected and interviews were held with professionals involved in the planning and delivery of EPODE. Retrieved data were coded, themed and placed in a four-level logic model. With input from international experts, this model was scaled down to a concise logic model covering four critical components: political commitment, public and private partnerships, social marketing and evaluation. The EPODE logic model presented here can be used as a reference for future and follow-up research; to support future implementation of EPODE in communities; as a tool in the engagement of stakeholders; and to guide the construction of a locally tailored evaluation plan.

Age standardization in mapping adult overweight and obesity trends in the WHO European Region.

This study aims to improve comparability of available data within the World Health Organization (WHO) European Region taking into account differences related to the aging of the population. Surveys were included if they were conducted on adults aged 25-64 years between 1985 and 2010 in the WHO European Region. Overweight/obesity prevalences were adjusted to the European standard population aged 25-64. Data were entered for each of the 5-year categories between 1981 and 2010. Measured height and weight data were available for males in 16 and females in 24 of the 53 countries. The 50-64-year-olds had higher prevalence of overweight and obesity as compared to the 25-49-year-olds. This pattern occurs in every country, by male and female, in almost all surveys. Age-standardized overweight prevalence was higher among males than females in all countries. Trend data showed increases in most countries. Age-standardized maps were based on self-reported data because of insufficient availability of measured data. Results showed more countries with available data as well as the higher category of obesity in the later surveys. Measured values are needed and age adjustment is important in documenting emerging overweight and obesity trends, independent of demographic changes, in the WHO European Region.

EPODE approach for childhood obesity prevention: methods, progress and international development.

Childhood obesity is a complex issue and needs multi-stakeholder involvement at all levels to foster healthier lifestyles in a sustainable way. 'Ensemble Prévenons l'Obésité Des Enfants' (EPODE, Together Let's Prevent Childhood Obesity) is a large-scale, coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. This paper describes EPODE methodology and its objective of preventing childhood obesity. At a central level, a coordination team, using social marketing and organizational techniques, trains and coaches a local project manager nominated in each EPODE community by the local authorities. The local project manager is also provided with tools to mobilize local stakeholders through a local steering committee and local networks. The added value of the methodology is to mobilize stakeholders at all levels across the public and the private sectors. Its critical components include political commitment, sustainable resources, support services and a strong scientific input--drawing on the evidence-base--together with evaluation of the programme. Since 2004, EPODE methodology has been implemented in more than 500 communities in six countries. Community-based interventions are integral to childhood obesity prevention. EPODE provides a valuable model to address this challenge.

Overweight and health problems of the lower extremities: osteoarthritis, pain and disability.

AIM: To examine the association between overweight and health problems of the lower extremities, i.e. osteoarthritis (OA), pain and disability. METHODS: Cross-sectional data from the Dutch population-based Musculoskeletal Conditions & Consequences Cohort (DMC3), comprising a random sample from the Dutch population aged >25 years (n 3664), were analysed using multivariate logistic regression. Overweight was defined as BMI > or = 25.0 kg/m2, moderate overweight as 25.0 kg/m2 < or = BMI < 30.0 kg/m2 and obesity as BMI > or = 30.0 kg/m2. Health problems of the lower extremities were: (i) self-reported OA of the hip or knee as told by a doctor; (ii) presence of self-reported chronic pain (>3 months) of the lower extremities; and (iii) disabilities in mobility as measured by the Euroqol questionnaire (EQ-5D). RESULTS: Moderate overweight was associated with self-reported OA of the hip or knee (OR = 1.7; 95 % CI 1.4, 2.1), chronic pain of the lower extremities at one or more location(s) (OR = 1.6; 95 % CI 1.3, 1.9) and disability in mobility (OR = 1.7; 95 % CI 1.4, 2.0). For obesity these odds were higher: 2.8 (95 % CI 2.1, 3.7), 2.5 (95 % CI 1.9, 3.2) and 3.0 (95 % CI 2.3, 3.9), respectively. Also, among those with OA, moderate overweight and obesity were associated with disability in mobility. CONCLUSION: There is a strong association between overweight/obesity and health problems of the lower extremities, i.e. OA, pain and disability. The increasing prevalence of overweight and obesity worldwide urges for public health action not only for diabetes and heart disease, but also OA.

Skipping breakfast, alcohol consumption and physical inactivity as risk factors for overweight and obesity in adolescents: results of the E-MOVO project.

OBJECTIVE/BACKGROUND: To investigate the association between skipping breakfast, alcohol consumption and physical inactivity with overweight and obesity in adolescents. The design comprises cross-sectional electronic health survey (E-MOVO). SUBJECTS/METHODS: Over 35 000 Dutch adolescents in grade 2 (13-14 years of age) and grade 4 (15-16 years of age) of secondary educational schools were recruited by seven community health services. Analyses were performed on 25 176 adolescents. Body mass index was calculated from self-reported body weight and height. Frequency of skipping breakfast per week, amount of alcoholic drinks consumed per occasion, and numbers of physical active days per week were considered as determinants for overweight and obesity. RESULTS: In grade 2, adjusted odds ratios for the association with overweight were 2.17 (95% CI: 1.66-2.85) for skipping breakfast, 1.86 (1.36-2.55) for alcohol consumption and 1.73 (1.19-2.51) for physical inactivity. Statistically significant associations with overweight were also found in grade 4. In grade 2, dose-response relations (P for trend <0.05) were present between all risk factors and overweight. In a multivariate model containing all risk factors, breakfast skipping showed the strongest relation with overweight (OR 1.68, 95% CI 1.43-1.97 for grade 2, OR 1.32 95% CI 1.14-1.54 for grade 4) and obesity. CONCLUSIONS: Skipping breakfast, alcohol consumption and physical inactivity were associated with overweight in second and fourth grade adolescents. The associations were strongest for younger adolescents. The most important risk factor for overweight and obesity was skipping breakfast.

Time trends (1993-1997) and seasonal variation in body mass index and waist circumference in the Netherlands.

OBJECTIVE: To compare the time trend and seasonal variation in body mass index (BMI) and waist circumference. DESIGN: Continuous monitoring health survey carried out between 1 June 1993 and 31 May 1997. SUBJECTS: A total of 8,186 men and 9,638 women aged 20-59 y from three towns in the Netherlands. MEASUREMENTS: BMI and waist circumference. Obesity was defined as BMI > or =30 kg/m(2), abdominal obesity as waist circumference > or =102 cm for men and > or =88 cm for women. RESULTS: Levels of BMI and waist circumference increased between 1 June 1993 and 31 May 1997. Among women, the time trend in abdominal obesity was stronger than that in obesity. Further, levels of BMI and waist circumference were higher in winter than in summer seasons. The seasonal variation was larger for abdominal obesity than for obesity, among both men and women. CONCLUSIONS: The time trend in women and the seasonal differences in both men and women were stronger for abdominal obesity than for obesity. Surveys on BMI and waist circumference are only comparable if season is taken into account. Furthermore, the waist circumference is a more sensitive indicator of variations in lifestyle and body composition than is body mass index.

Long-term and recent time trends in the prevalence of obesity among Dutch men and women.

OBJECTIVE: To describe long-term and recent time trends in the prevalence of obesity by age and educational level. DESIGN: :Repeated cross-sectional population based monitoring studies. SETTING: Consultation Bureau Heart Project 1976-1980, Monitoring Project on Cardiovascular Diseases 1987-1991 and Monitoring project on risk factors for chronic diseases (MORGEN-) project 1993-1997. SUBJECTS: A total of 29 141 men and women aged 37-43 y (1976-1997); and 21 926 men and women aged 20-59 y (1993-1997). MEASUREMENTS: Body mass index, ie weight divided by height squared. RESULTS: Between 1976 and 1997 the prevalence of obesity increased from 4.9 to 8.5% among men and from 6.2 to 9.3% among women aged 37-43 y. Between 1993 and 1997, the prevalence of obesity among men aged 20-59 y was 8.5% and increased by 0.54 percentage points per year (P<0.01). The prevalence of obesity among women was 9.6% and increased by 0.35 percentage points per year (P=0.07). The increase in the prevalence of obesity in the period 1993-1997 was strongest in men with a relatively low educational level and in women with a high educational level. CONCLUSIONS: There has been a steady increase in the prevalence of obesity in the last quarter of the 20th century. Also, a recent increase in the prevalence of obesity has been seen. To stop the increase in the prevalence of obesity, effective strategies for the management and prevention of obesity need to be developed.