Experts' perceptions on motivators and barriers of healthy and sustainable dietary behaviors among adolescents: The SWITCH project.

The interplay of influences shaping dietary behaviors of adolescents needs to be well-understood to develop effective strategies stimulating healthy and sustainable behaviors. This study aimed to identify the most relevant, urgent, changeable and effective motivators and barriers of healthy and sustainable dietary behaviors among adolescents (10-19 years), as perceived by an inter- and transdisciplinary expert panel. Experts working in practice (N = 19) and academia (N = 13) - in the field of sustainability, health, nutrition and/or education - participated in this exploratory mixed-methods study. Five online semi-structured focus groups were conducted (6-7 participants). Data was thematically analyzed by two coders independently, using the socioecological framework. Subsequently, the same experts individually selected the five most relevant determinants and rated those on their urgency, changeability and effectiveness through an online questionnaire (N = 21). Participants revealed a wide system of 31 main determinants including 173 sub-determinants that motivate or hinder healthy and sustainable eating among adolescents. This system of determinants was mapped on the different layers of the socioecological model: individual factors (25 motivators; 30 barriers), social environments (15 motivators; 13 barriers), physical environments (18 motivators; 15 barriers), macro-level environments (19 motivators; 38 barriers). 'Role of peers' (social environment) was selected most as a determinant to be targeted in interventions (N = 13; urgency (M = 6.38) changeability (M = 3.85), effectiveness (M = 5.62)), followed by 'food environment around school' (N = 9; urgency (M = 5.78) changeability (M = 3.44), effectiveness (M = 5.44)), 'social influences' (N = 7; urgency (M = 5.43) changeability (M = 4.00), effectiveness (M = 5.71)), 'autonomy in development' (N = 7; urgency (M = 6.00) changeability (M = 4.29), effectiveness (M = 5.86)) and 'food availability' (N = 7; urgency (M = 6.29) changeability (M = 3.29), effectiveness (M = 6.29)). The prioritized determinants indicate that adolescents should be provided more supportive social and physical environments that promote healthy and sustainable dietary behaviors, taking into account their growing autonomy.

Factors associated with dietary behaviour change support in patients: A qualitative study among community nurses.

AIM: To explore which factors, influencing dietary behaviour change support among patients by Dutch community nurses (CNs; nurses), are key focal points in training programmes. BACKGROUND: Nurses have an important role in counselling patients towards healthier dietary behaviour to prevent or delay long-term complications from chronic lifestyle-related diseases. Most nurses do not incorporate dietary behaviour change support in their routines to the fullest potential. DESIGN: A qualitative descriptive study. METHODS: Data were collected in the Netherlands in 2018-2019 via semi-structured face-to-face interviews with 18 nurses. Interview guide themes were informed by the COM-B model, using validated descriptions in Dutch. Data were recorded, transcribed and analysed using inductive thematic analysis. RESULTS: Factors that affected dietary behaviour change support were linked to (1) the nurse (role identity, dietary knowledge and competences such as methodical approach, behaviour change techniques and communication techniques), (2) nurse-patient encounter (building a relationship with a patient, supporting patient autonomy and tailoring the approach) and (3) cooperation and organizational context. CONCLUSION: It is of utmost importance to pay attention to nurses' role identity regarding dietary behaviour change support, as this underlies professional behaviour. This should be accompanied by improving competences on dietary behaviour change support. Focus on competences regarding the application of behaviour change technique is crucial. Furthermore, having a relationship of trust with a patient was important for discussing sensitive topics such as diet. IMPACT: The promotion of a healthy diet provides opportunities to contribute to patient autonomy and self-management. Well-fitted training offers for (senior) nurses will lead to improved professional practice of nurses, leading to healthier dietary behaviour of patients. PATIENT OR PUBLIC CONTRIBUTION: A nurse provided feedback on the interview guide.

Enhancing interprofessional teamwork between youth care professionals using an electronic health record; a mixed methods intervention study.

We aimed to investigate whether using a shared electronic patient record (EPR-Youth) strengthened interprofessional teamwork among professionals in youth care and child healthcare. Using a mixed-methods design, we compared two partly overlapping samples of professionals, who completed questionnaires before the introduction of EPR-Youth (n = 117) and 24 months thereafter (n = 127). Five components of interprofessional teamwork (interdependence, newly created professional activities, flexibility, collective ownership of goals, and reflection on processes) were assessed for this study. Midway through the study period, focus groups were held with 12 professionals to examine how EPR-Youth contributed to interprofessional teamwork. Professionals reported significantly more flexibility after the introduction of EPR-Youth than before. Professionals scored slightly -but not significantly- more positively on the other components of teamwork. Focus group participants reported that using EPR-Youth strengthened their sense of interdependence and collective ownership of goals, and contributed to newly created professional activities. At baseline, levels of interprofessional teamwork differed between organizations. Focus group participants confirmed these differences and attributed them to differences in facilitation of interprofessional teamwork. Our findings suggest that using EPR-Youth can foster interprofessional teamwork. Organizational differences underline that implementing an EPR alone is inadequate: shared definitions of teamwork and organizational facilities are needed to strengthen interprofessional teamwork.

Effects and contextual factors of a diet and resistance exercise intervention vary across settings: an overview of three successive ProMuscle interventions.

BACKGROUND: Although many effective interventions have been developed, limited interventions have successfully been implemented. An intervention that was translated across settings is ProMuscle: a diet and resistance exercise intervention for older adults. However, varying contexts often lead to varying effects due to contextual factors (characteristics of individuals, organizations, communities or society). The current study aimed to gain insights into effects and contextual factors of ProMuscle in the controlled setting (ProMuscle: PM), real-life setting (ProMuscle in Practice: PiP), and real-life setting of the implementation pilots (ProMuscle Implementation Pilots: IP). METHODS: Data from the intervention arms of PM (N = 31) and PiP (N = 82), and from IP (N = 35) were used. Physical functioning (chair-rise test) and leg strength (1-10 repetition maximum) were measured at baseline and after 12-weeks intervention. Paired t-tests and General Linear Models were used to study changes after 12 weeks and differences between interventions. To explore contextual factors, researchers of PM and physiotherapists and dietitians of PiP and IP were interviewed. Factors were categorized according to the five domains and its underlying constructs of the Consolidated Framework for Implementation Research (CFIR). RESULTS: Improvements on chair-rise performance were found in PM (-2.0 ± 7.0 s, p = 0.186), PiP (-0.8 ± 2.9 s, p = 0.019) and IP (-3.3 ± 4.2 s, p = 0.001). Similar results were found for leg strength in PM (32.6 ± 24.8 kg, p < 0.001), PiP (17.0 ± 23.2 kg, p < 0.001), and IP (47.8 ± 46.8 kg, p < 0.001). Contextual factors that contribute to explaining the relatively high effects in IP included room for adapting and tailoring the intervention, involvement of experienced professionals, availability of and access to facilities, and participants characteristics. CONCLUSIONS: Effects of the intervention appeared to be strongest in the real-life setting of the implementation pilots. Specific contextual factors contributed to explaining the different findings across settings. Future studies should investigate crucial factors that determine successful implementation of interventions in the real-life setting, to ensure that effective interventions are put into action and reach a broad population. TRIAL REGISTRATION: The ProMuscle intervention was registered in the Trial Registration (clinicaltrials.gov identifier: NCT01110369 ) on February 12th, 2010. The ProMuscle in Practice intervention was registered in the Netherlands Trial Register (NTR6038) on August 30th, 2016. Trial registration was not needed for the ProMuscle Implementation Pilots as this research did not fall within the remit of the Dutch 'Medical Research Involving Human Subjects Act'.

Sarcopenia and its relation to protein intake across older ethnic populations in the Netherlands: the HELIUS study.

Objective: To examine the prevalence of sarcopenia and its association with protein intake in men and women in a multi-ethnic population.Design: We used cross-sectional data from the HELIUS (Healthy Life in an Urban Setting) study, which includes nearly 25,000 participants (aged 18-70 years) of Dutch, South-Asian Surinamese, African Surinamese, Turkish, Moroccan, and Ghanaian ethnic origin. For the current study, we included 5161 individuals aged 55 years and older. Sarcopenia was defined according to the EWGSOP2. In a subsample (N = 1371), protein intake was measured using ethnic-specific Food Frequency Questionnaires. Descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analyses were used to study associations between protein intake and sarcopenia.Results: Sarcopenia prevalence was found to be sex- and ethnic-specific, varying from 29.8% in Turkish to 61.3% in South-Asian Surinamese men and ranging from 2.4% in Turkish up to 30.5% in South-Asian Surinamese women. Higher protein intake was associated with a 4% lower odds of sarcopenia in the subsample (OR = 0.96, 95%-CI: 0.92-0.99) and across ethnic groups, being only significant in the South-Asian Surinamese group.Conclusion: Ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia.

Co-design of a digital dietary intervention for adults at risk of type 2 diabetes.

BACKGROUND: Co-design has the potential to create interventions that lead to sustainable health behaviour change. Evidence suggests application of co-design in various health domains has been growing; however, few public-facing digital interventions have been co-designed to specifically address the needs of adults at risk of Type 2 diabetes (T2D). This study aims to: (1) co-design, with key stakeholders, a digital dietary intervention to promote health behaviour change among adults at risk of T2D, and (2) evaluate the co-design process involved in developing the intervention prototype. METHODS: The co-design study was based on a partnership between nutrition researchers and designers experienced in co-design for health. Potential end-users (patients and health professionals) were recruited from an earlier stage of the study. Three online workshops were conducted to develop and review prototypes of an app for people at risk of T2D. Themes were inductively defined and aligned with persuasive design (PD) principles used to inform ideal app features and characteristics. RESULTS: Participants were predominantly female (range 58-100%), aged 38 to 63 years (median age = 59 years), consisting of a total of 20 end-users and four experts. Participants expressed the need for information from credible sources and to provide effective strategies to overcome social and environmental influences on eating behaviours. Preferred app features included tailoring to the individual's unique characteristics, ability to track and monitor dietary behaviour, and tools to facilitate controlled social connectivity. Relevant persuasive design principles included social support, reduction (reducing effort needed to reach target behaviour), tunnelling (guiding users through a process that leads to target behaviour), praise, rewards, and self-monitoring. The most preferred prototype was the Choices concept, which focusses on the users' journey of health behaviour change and recognises progress, successes, and failures in a supportive and encouraging manner. The workshops were rated successful, and feedback was positive. CONCLUSIONS: The study's co-design methods were successful in developing a functionally appealing and relevant digital health promotion intervention. Continuous engagement with stakeholders such as designers and end-users is needed to further develop a working prototype for testing.

Strategies to increase primary school children's fruit and vegetable intake during 10AM snack time.

In this observational study, children's fruit and vegetable (F&V) consumption during the 10AM school break was assessed for two promising strategies: a 5-day-a-week F&V policy and free provision of F&V presented in an attractive fruit bowl. Schools without a school food policy served as reference group. A secondary aim was to explore the feasibility of the two strategies. A total of 569 children aged 6-9 years participated. Children's F&V consumption at school was assessed on two different week days via observations and weighing snack portions. Parents completed an online-questionnaire on their perceptions and experiences with the two strategies. Main outcomes were the proportion of children and frequency of eating F&V, and children's F&V portion sizes. Data were analysed via ANOVA and Chi-Square (p < 0.05). Average F&V consumption differed significantly between the three situations (p < 0.001): 250 g in the fruit bowl situation, 130 g in the 5-day-policy situation and 60 g in the no-policy situation. The proportion of children eating F&V was high for the 5-day-policy (97-98%) and fruit bowl situation (87-97%), whereas this was substantially lower (50-60%; p < 0.001) in the no-policy situation. The majority of parents considered both strategies as feasible. A 5-day-a-week F&V policy seems an effective, feasible and structural strategy to support children's fruit and vegetable consumption at school. The fruit bowl strategy with an additional eating moment may enhance children's intake even further, although additional requirements are needed for structural implementation at school.

How the Use of a Patient-Accessible Health Record Contributes to Patient-Centered Care: Scoping Review.

BACKGROUND: Worldwide, patient-centered care is becoming a widely used concept in medical practice, getting more and more attention because of its proven ability to improve quality of care and reduce costs. Although several studies show that patient-accessible electronic health records (PAEHRs) influence certain aspects of patient-centered care, the possible contribution of PAEHR implementation to patient-centered care as a comprehensive concept has not, to our knowledge, been structurally evaluated to date. OBJECTIVE: The objective of this study is to review whether and how the use of PAEHRs contributes to patient-centered care both in general and among specific population groups. METHODS: We followed PRISMA Extension for Scoping Reviews reporting guidelines. We identified literature in 5 databases, using the terms "patient-accessible medical records," "patient experiences," and "professional experiences" as key concepts. A total of 49 articles were included and analyzed with a charting code list containing 10 elements of patient-centered care. RESULTS: Studies were diverse in design, country of origin, functionalities of the investigated PAEHR, and target population. Participants in all studies were adults. Most studies reported positive influence of PAEHR use on patient-centered care; patient accessible health records were appreciated for their opportunity to empower patients, inform patients about their health, and involve patients in their own care. There were mixed results for the extent to which PAEHRs affected the relation between patients and clinicians. Professionals and patients in mental health care held opposing views concerning the impact of transparency, where professionals appeared more worried about potential negative impact of PAEHRs on the patient-clinician relationship. Their worries seemed to be influenced by a reluctant attitude toward patient-centered care. Disadvantaged groups appeared to have less access to and make less use of patient-accessible records than the average population but experienced more benefits than the average population when they actually used PAEHRs. CONCLUSIONS: The review indicates that PAEHRs bear the potential to positively contribute to patient-centered care. However, concerns from professionals about the impact of transparency on the patient-clinician relationship as well as the importance of a patient-centered attitude need to be addressed. Potentially significant benefits for disadvantaged groups will be achieved only through easily accessible and user-friendly PAEHRs.

Implementation of a multicomponent telemonitoring intervention to improve nutritional status of community-dwelling older adults: a process evaluation.

OBJECTIVE: The present study aimed to conduct a process evaluation of a multicomponent nutritional telemonitoring intervention implemented among Dutch community-dwelling older adults. DESIGN: A mixed-methods approach was employed, guided by the process evaluation framework of the Medical Research Council and the Unified Theory of Acceptance and Use of Technology. The process indicators reach, dose, fidelity and acceptability were measured at several time points within the 6-month intervention among participants and/or nurses. SETTING: The intervention was implemented in the context of two care organisations in the Netherlands. SUBJECTS: In total, ninety-seven participants (average age 78 years) participated in the intervention and eight nurses were involved in implementation. RESULTS: About 80 % of participants completed the intervention. Dropouts were significantly older, had worse cognitive and physical functioning, and were more care-dependent. The intervention was largely implemented as intended and received well by participants (satisfaction score 4·1, scale 1-5), but less well by nurses (satisfaction score 3·5, scale 1-5). Participants adhered better to weight telemonitoring than to telemonitoring by means of questionnaires, for which half the participants needed help. Intention to use the intervention was predicted by performance expectancy (ß=0·40; 95 % CI 0·13, 0·67) and social influence (ß=0·17; 95 % CI 0·00, 0·34). No association between process indicators and intervention outcomes was found. CONCLUSIONS: This process evaluation showed that nutritional telemonitoring among older adults is feasible and accepted by older adults, but nurses' satisfaction should be improved. The study provided relevant insights for future development and implementation of eHealth interventions among older adults.

Cost-effectiveness of the SLIMMER diabetes prevention intervention in Dutch primary health care: economic evaluation from a randomised controlled trial.

BACKGROUND: Although evidence is accumulating that lifestyle modification may be cost-effective in patients with prediabetes, information is limited on the cost-effectiveness of interventions implemented in public health and primary health care settings. Evidence from well-conducted pragmatic trials is needed to gain insight into the realistic cost-effectiveness of diabetes prevention interventions in real-world settings. The aim of this study is to assess the cost-effectiveness of the SLIMMER lifestyle intervention targeted at patients at high risk of developing type 2 diabetes compared with usual health care in a primary care setting in the Netherlands. METHODS: Three hundred and sixteen high-risk subjects were randomly assigned to the SLIMMER lifestyle intervention or to usual health care. Costs and outcome assessments were performed at the end of the intervention (12 months) and six months thereafter (18 months). Costs were assessed from a societal perspective. Patients completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. Quality Adjusted Life Years (QALY) were calculated based on the SF-36 questionnaire. Cost-effectiveness planes and acceptability curves were generated using bootstrap analyses. RESULTS: The cost-effectiveness analysis showed that the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of €28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to €13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay, WTP, of €20,000/QALY and 81% at a WTP of €80,000/QALY). CONCLUSIONS: The SLIMMER lifestyle intervention to prevent type 2 diabetes had a low to moderate probability of being cost-effective, depending on the perspective taken. TRIAL REGISTRATION: The SLIMMER study is retrospectively registered with ClinicalTrials.gov (Identifier NCT02094911) since March 19, 2014.

Effects of a multi-component nutritional telemonitoring intervention on nutritional status, diet quality, physical functioning and quality of life of community-dwelling older adults.

This study aimed to evaluate the effects of an intervention including nutritional telemonitoring, nutrition education, and follow-up by a nurse on nutritional status, diet quality, appetite, physical functioning and quality of life of Dutch community-dwelling elderly. We used a parallel arm pre-test post-test design with 214 older adults (average age 80 years) who were allocated to the intervention group (n 97) or control group (n 107), based on the municipality. The intervention group received a 6-month intervention including telemonitoring measurements, nutrition education and follow-up by a nurse. Effect measurements took place at baseline, after 4·5 months, and at the end of the study. The intervention improved nutritional status of participants at risk of undernutrition (ß (T1)=2·55; 95 % CI 1·41, 3·68; ß (T2)=1·77; 95 % CI 0·60, 2·94) and scores for compliance with Dutch guidelines for the intake of vegetables (ß=1·27; 95 % CI 0·49, 2·05), fruit (ß=1·24; 95 % CI 0·60, 1·88), dietary fibre (ß=1·13; 95 % CI 0·70, 1·57), protein (ß=1·20; 95 % CI 0·15, 2·24) and physical activity (ß=2·13; 95 % CI 0·98, 3·29). The intervention did not have an effect on body weight, appetite, physical functioning and quality of life. In conclusion, this intervention leads to improved nutritional status in older adults at risk of undernutrition, and to improved diet quality and physical activity levels of community-dwelling elderly. Future studies with a longer duration should focus on older adults at higher risk of undernutrition than this study population to investigate whether the impact of the intervention on nutritional and functional outcomes can be improved.

Effect, process, and economic evaluation of a combined resistance exercise and diet intervention (ProMuscle in Practice) for community-dwelling older adults: design and methods of a randomised controlled trial.

BACKGROUND: Exercise and nutrition are important for older adults to maintain or to regain their muscle mass, function, strength, and ultimately quality of life. The effectiveness of combined resistance exercise and diet interventions is commonly evaluated in controlled clinical studies, but evidence from real-life settings is lacking. This article describes the effectiveness, process, and economic evaluation design of a combined nutrition and exercise intervention for community-dwelling older adults in a Dutch real-life setting. METHODS: The ProMuscle in Practice study is a randomised controlled multicentre intervention study, conducted in five municipalities in the Netherlands. Two hundred community-dwelling older adults (≥65 years) who are frail or pre-frail based on Fried frailty criteria or who experience strength loss are randomised over an intervention and control group by municipality. In the first 12-week intensive support intervention, participants in the intervention group perform resistance exercise training guided by a physiotherapist twice a week and increase protein intake by consuming protein-rich products under the supervision of a dietitian. Afterwards, they continue with a 12-week moderate support intervention. The control group receives only regular care during the two 12-week periods. Effect outcomes are measured at all locations at baseline, 12 weeks, 24 weeks, 36 weeks and only at three locations at 52 weeks. The primary outcome is physical functioning (Short Physical Performance Battery). Secondary outcomes include leg muscle strength, lean body mass, activities of daily living, social participation, food intake, and quality of life. Qualitative and quantitative implementation process data are collected during the intervention. Healthcare use and intervention costs are registered for the economic evaluation. DISCUSSION: Evaluating the effects, implementation, and costs of this combined intervention provides valuable insight into the feasibility of this intervention for community-dwelling older adults and into the intervention's ability to improve or to maintain physical functioning and quality of life. TRIAL REGISTRATION: Netherlands Trial Register ( NTR6038 ) since 30 August 2016.

Translation of a tailored nutrition and resistance exercise intervention for elderly people to a real-life setting: adaptation process and pilot study.

BACKGROUND: Combining increased dietary protein intake and resistance exercise training for elderly people is a promising strategy to prevent or counteract the loss of muscle mass and decrease the risk of disabilities. Using findings from controlled interventions in a real-life setting requires adaptations to the intervention and working procedures of healthcare professionals (HCPs). The aim of this study is to adapt an efficacious intervention for elderly people to a real-life setting (phase one) and test the feasibility and potential impact of this prototype intervention in practice in a pilot study (phase two). METHODS: The Intervention Mapping approach was used to guide the adaptation in phase one. Qualitative data were collected from the original researchers, target group, and HCPs, and information was used to decide whether and how specified intervention elements needed to be adapted. In phase two, a one-group pre-test post-test pilot study was conducted (n = 25 community-dwelling elderly), to elicit further improvements to the prototype intervention. The evaluation included participant questionnaires and measurements at baseline (T0) and follow-up (T1), registration forms, interviews, and focus group discussions (T1). Qualitative data for both phases were analysed using an inductive approach. Outcome measures included physical functioning, strength, body composition, and dietary intake. Change in outcomes was assessed using Wilcoxon signed-rank tests. RESULTS: The most important adaptations to the original intervention were the design of HCP training and extending the original protein supplementation with a broader nutrition programme aimed at increasing protein intake, facilitated by a dietician. Although the prototype intervention was appreciated by participants and professionals, and perceived applicable for implementation, the pilot study process evaluation resulted in further adaptations, mostly concerning recruitment, training session guidance, and the nutrition programme. Pilot study outcome measures showed significant improvements in muscle strength and functioning, but no change in lean body mass. CONCLUSION: The combined nutrition and exercise intervention was successfully adapted to the real-life setting and seems to have included the most important effective intervention elements. After adaptation of the intervention using insights from the pilot study, a larger, controlled trial should be conducted to assess cost-effectiveness. TRIAL REGISTRATION: Trial registration number: ClinicalTrials.gov NL51834.081.14 (April 22, 2015).

Effectiveness of Taste Lessons with and without additional experiential learning activities on children's willingness to taste vegetables.

This study assessed the effectiveness of the Dutch school programme Taste Lessons with and without additional experiential learning activities on children's willingness to taste unfamiliar vegetables. Thirty-three primary schools (877 children in grades 6-7 with a mean age of 10.3 years) participated in Taste Lessons Vegetable Menu (TLVM, lessons and extra activities), Taste Lessons (TL, lessons), or a control group. A baseline and follow-up measurement was used to assess for each child: number of four familiar and four unfamiliar vegetables tasted, quantity tasted, choice of vegetable of which to eat more, and number of vegetables willing to taste again later. Furthermore, children filled out a questionnaire on daily vegetable intake and food neophobia. Multilevel and Cox regression analyses were conducted to compare changes in the outcome measures between the three study groups. No significant intervention effects were found on willingness to taste unfamiliar vegetables. Neither were effects found on familiar vegetables, except for number of familiar vegetables tasted (p < 0.05). Furthermore, no significant intervention effects were found on daily vegetable consumption and food neophobia. These results indicate that more intensive school-based nutrition education activities are needed to increase children's willingness to taste unfamiliar vegetables and increase their vegetable intake.

Process evaluation of a randomised controlled trial of a diabetes prevention intervention in Dutch primary health care: the SLIMMER study.

OBJECTIVE: To investigate (i) how the SLIMMER intervention was delivered and received in Dutch primary health care and (ii) how this could explain intervention effectiveness. DESIGN: A randomised controlled trial was conducted and subjects were randomly allocated to the intervention (10-month combined dietary and physical activity intervention) or the control group. A process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity and applicability) were collected via semi-structured interviews with health-care professionals (n 45) and intervention participant questionnaires (n 155). SETTING: SLIMMER was implemented in Dutch primary health care in twenty-five general practices, eleven dietitians, nine physiotherapist practices and fifteen sports clubs. SUBJECTS: Subjects at increased risk of developing type 2 diabetes were included. RESULTS: It was possible to recruit the intended high-risk population (response rate 54 %) and the SLIMMER intervention was very well received by both participants and health-care professionals (mean acceptability rating of 82 and 80, respectively). The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. CONCLUSIONS: The present study showed that it is feasible to implement a diabetes prevention intervention in Dutch primary health care. Higher dose received and participant acceptability were associated with improved health outcomes and dietary behaviour. Using an extensive process evaluation plan to gain insight into how an intervention is delivered and received is a valuable way of identifying intervention components that contribute to implementation integrity and effective prevention of type 2 diabetes in primary health care.

Unravelling the effect of the Dutch school-based nutrition programme Taste Lessons: the role of dose, appreciation and interpersonal communication.

BACKGROUND: To unravel the effect of school-based nutrition education, insight into the implementation process is needed. In this study, process indicators of Taste Lessons (a nutrition education programme for Dutch elementary schools) and their association with changes in behavioural determinants relevant to healthy eating behaviour are studied. METHODS: The study sample consisted of 392 Dutch primary school children from 12 schools. Data were collected using teacher and child questionnaires at baseline, and at one and six months after the intervention. Multilevel regression analyses were conducted to study the association between dose, appreciation and children's engagement in interpersonal communication (talking about Taste Lessons with others after the lessons), and change in knowledge, awareness, skills, attitude, emotion, subjective norm and intention towards two target behaviours. RESULTS: With an average implementation of a third of the programme activities, dose positively predicted change in children's subjective norm of the teacher after one month. Teachers and children highly appreciated Taste Lessons. Whereas teacher appreciation was inversely associated, child appreciation was positively associated with children's change in awareness, emotion and subjective norm of teachers after one month and in attitude and subjective norm of parents after six months. Interpersonal communication was positively associated with children's change in five determinants after one month and in attitude and intention after six months. CONCLUSIONS: The implementation process is related to the programme outcomes of Taste Lessons. Process data provide valuable insights into factors that contribute to the effect of interventions in real-life settings.

Effect of meal size reduction and protein enrichment on intake and satiety in vital community-dwelling older adults.

Undernutrition risk among community-dwelling older adults is partly caused by inadequate protein intake. Enriching readymade meals with protein could be beneficial in increasing protein intake. Moreover, reduced-size meals could suit older adults with diminished appetite. In this single-blind randomized crossover study with 120 participants (age: 70.5 ± 4.5 y, BMI: 27.2 ± 4.4 kg/m(2)), 60 participants consumed four beef meals and another 60 consumed four chicken meals on four different days, once per week. These meals were produced according to a 2 × 2 factorial design: the protein content was either ∼25 g (lower) or ∼30 g (enriched), and the portion size was either 450 g (normal) or of 400 g (reduced). Palatability evaluation, meal intake, and subsequent satiety ratings after 120 min were measured. No significant differences in palatability among meals were found. While absolute intake (g) of the normal-size meals was significantly higher than that of the reduced-size meals, the relative intake (%) of the served meals did not differ between the four meals. Both protein and energy intakes were significantly higher for the enriched meals, regardless of portion size. Protein intakes were 5.4 g and 5.1 g higher in the normal-size and reduced-size enriched beef meals, respectively, and 6.1 g and 7.1 g higher in the enriched chicken meals, respectively. The normal-size enriched beef meal and reduced-size enriched chicken meal led to slightly but significantly higher ratings of satiety than the non-enriched meals. Due to these mixed satiety findings, separate effects of meal-size reduction and protein enrichment could not be distinguished in this study. The intake findings show that palatable protein-enriched meals support higher protein and energy intakes in vital community-dwelling older adults during a single meal.

Effectiveness of Taste Lessons with and without additional experiential learning activities on children's psychosocial determinants of vegetables consumption.

Experiential learning methods seem to be promising to enhance healthy eating behaviour in children. Therefore, this study compared the effectiveness of the Dutch programme Taste Lessons with and without additional experiential learning activities on children's psychosocial determinants of vegetable consumption. In a quasi-experimental design, 800 children aged 8-11 years old from 34 elementary schools participated in a Taste Lessons (TL: 5 lessons) group, a Taste Lessons Vegetable Menu (TLVM: TL with 3 added experiential learning activities) group, and a control group. During a baseline and follow-up measurement, children completed a questionnaire on psychosocial determinants towards vegetables consumption. Multilevel regression analyses were conducted to compare changes in the determinants between the TLVM group and the TL group, and between the two intervention groups and the control group. The TLVM group showed a significantly higher increase in knowledge (p < 0.001), attitude and subjective norm of the teacher (both p < 0.05), whereas the TL group only showed a significantly higher increase in knowledge (p < 0.001) compared to the control group. Increases in knowledge (p < 0.10), subjective norm (p < 0.10) and cooking self-efficacy (p < 0.05) were higher in the TLVM group than in the TL group. Therefore, more and stronger effects were found in children who participated in the additional hands-on activities.

Effect of the Dutch school-based education programme 'Taste Lessons' on behavioural determinants of taste acceptance and healthy eating: a quasi-experimental study.

OBJECTIVE: To assess the effect of the Dutch school-based education programme 'Taste Lessons' on children's behavioural determinants towards tasting unfamiliar foods and eating healthy and a variety of foods. DESIGN: In a quasi-experimental study design, data on behavioural determinants were collected at baseline, four weeks and six months after the intervention in both the intervention and control group. Children completed consecutively three questionnaires in which knowledge, awareness, skills, attitude, emotion, subjective norm and intention towards the two target behaviours were assessed. Teachers implemented on average a third of the programme activities. Multilevel regression analyses were conducted to compare individual changes in the determinants in the intervention group with those in the control group, corrected for children's gender and age. Effect sizes were expressed as Cohen's d. SETTING: Dutch elementary schools. SUBJECTS: Forty-nine classes (1183 children, 9-12 years old) in grades 5-8 of twenty-one elementary schools. RESULTS: The intervention group showed a higher increase in knowledge (d=0·26, P<0·01), which persisted after six months (d=0·23, P<0·05). After four weeks, the intervention group showed a higher increase in number of foods known (d=0·22, P<0·05) and tasted (d=0·21, P<0·05), subjective norm of the teacher (d=0·17, P<0·05) and intention (d=0·16, P<0·05) towards the target behaviours. CONCLUSIONS: Partial implementation of Taste Lessons during one school year showed small short-term effects on increasing behavioural determinants in relation to tasting unfamiliar foods and eating healthy and a variety of foods. Full and repeated implementation of Taste Lessons in subsequent years might result in larger effects.

SLIMMER: a randomised controlled trial of diabetes prevention in Dutch primary health care: design and methods for process, effect, and economic evaluation.

BACKGROUND: Implementation of interventions in real-life settings requires a comprehensive evaluation approach. The aim of this article is to describe the evaluation design of the SLIMMER diabetes prevention intervention in a Dutch real-life setting. METHODS/DESIGN: The SLIMMER study is a randomised, controlled intervention study including subjects aged 40 through 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involves a dietary and physical activity intervention, including case management and a maintenance programme. The control group receives usual health care and written information about a healthy lifestyle. A logic model of change is composed to link intervention activities with intervention outcomes in a logical order. Primary outcome is fasting insulin. Measurements are performed at baseline and after 12 and 18 months and cover quality of life, cardio-metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), eating and physical activity behaviour, and behavioural determinants. A process evaluation gives insight in how the intervention was delivered and received by participants and health care professionals. The economic evaluation consists of a cost-effectiveness analysis and a cost-utility analysis. Costs are assessed from both a societal and health care perspective. DISCUSSION: This study is expected to provide insight in the effectiveness, including its cost-effectiveness, and delivery of the SLIMMER diabetes prevention intervention conducted in Dutch primary health care. Results of this study provide valuable information for primary health care professionals, researchers, and policy makers. TRIAL REGISTRATION: The SLIMMER study is registered with ClinicalTrials.gov (NCT02094911) since March 19, 2014.