Qualitative evaluation of a Salutogenic Healthy Eating Programme for Dutch people with type 2 diabetes.

The salutogenic model of health (SMH) is a health-promoting theory that focuses on resources, strengths, and coping capacities in everyday life as a way to improve health and wellbeing. The SMH was applied to develop a programme for enabling healthy eating practices among people with type 2 diabetes mellitus (T2DM): the SALUD programme. This study aims to gain insight in how participants with T2DM experienced the content and meaning of the SALUD programme. Three focus groups with participants (six to eight participants/group) that finished the SALUD programme were conducted. The focus groups were video-recorded, transcribed ad verbatim and thematically analysed. The SALUD programme was perceived by the participants as a positive, meaningful learning experience. Key factors why the participants described the programme as positive were that they felt a sense of social-belonging and (emotionally) safe (theme 1). The SALUD programme's positive encouraging approach presented by the coach invited participants to join an active learning process (theme 2). Performing trial-and-error experiments and weekly reflecting on goals is what characterized active learning. The meaningfulness of the learning process (theme 3) was derived from (i) positive self-confrontation; (ii) exploring mind-body connections and perceiving improved health and (iii) noticing positive changes in their social environment (theme 3). To conclude, the study uncovered that the SALUD programme incited a positive, meaningful learning process for healthy eating and the contextual factors important in this. Potential leads to further improve the SALUD programme are discussed in order to maximize the chance of inciting an inclusive, active learning process.

The incubus phenomenon: Prevalence, frequency and risk factors in psychiatric inpatients and university undergraduates.

Background: The incubus phenomenon is a paroxysmal sleep-related disorder characterized by the visuotactile sensation of a person or entity exerting pressure on one's thorax during episodes of sleep paralysis and (apparent) wakefulness. This terrifying phenomenon is relatively unknown even though a previous meta-analysis indicated a lifetime prevalence of 0.11 for individuals in the general population and of 0.41 for selected at-risk groups, including people diagnosed with schizophrenia and students. Since the studies reviewed did not always make a strict distinction between the incubus phenomenon and isolated sleep paralysis, we carried out a cross-sectional study in a contemporary patient and student sample to attain current, more detailed data on the incubus phenomenon. Materials and methods: In a cross-sectional design, we used the Waterloo Unusual Sleep Experience Questionnaire (WUSEQ) to screen patients with severe psychiatric disorders and university undergraduates to establish and compare prevalence rates, frequencies of occurrence, and risk factors for the incubus phenomenon. Results: Having interviewed 749 people, comprising 606 students and 143 patients with a schizophrenia spectrum or related disorder who had been acutely admitted to a secluded nursing ward, we computed a reported lifetime prevalence of 0.12 and 0.09, respectively, which rates were not statistically different. In both groups, the phenomenon was more common in people with a non-Western European background. Risk factors noted for the students were the use of psychotropic medication and the lifetime presence of an anxiety disorder, eating disorder, or sleeping disorder. We found no associations with age or gender in either group. Conclusion: The 0.09 and 0.12 lifetime prevalence rates we recorded for the incubus phenomenon in students and psychiatric inpatients is substantially lower than the 0.41 found in an earlier meta-analysis. We tentatively attribute this difference to an overgeneralization in previous studies but also discuss alternative explanations. The elevated prevalence among non-Western European participants may well be due to the fact that the topic continues to be part of the cultural and religious heritage of many non-Western countries.

Prenatal infant feeding intentions and actual feeding practices during the first six months postpartum in rural Rwanda: a qualitative, longitudinal cohort study.

BACKGROUND: Exclusive breastfeeding (EBF) is advocated by the WHO for the first 6 months. In Rwanda, the percentage of infants who are exclusively breastfed decreases from 94% among infants aged 0-1 month to 81% among those aged 4-5 months. Little is known about what influences mothers' breastfeeding practices. This study aimed to gain insights into expectant mothers' prenatal feeding intentions, the underlying reasons, actual practices after birth, and factors facilitating or impeding EBF for the first 6 months of a child's life in Muhanga District, Rwanda. METHODS: This qualitative longitudinal study, conducted between December 2016 and October 2017 as part of a larger study, recruited a purposive sample of 39 pregnant women attending prenatal consultations during their last trimester in two rural health centers. Women were interviewed during pregnancy, within the first week after birth and at 4 and 6 months postpartum to explore intentions, actual practices, critical transition points, and facilitating or impeding factors. Interviews were recorded, transcribed verbatim, and analyzed thematically. RESULTS: Of the 39 participants, 38 intended to breastfeed within the first hour after birth, and 32 intended to breastfeed exclusively for the first 6 months. In practice, 34 initiated breastfeeding within the first hour, and 12 breastfed exclusively for 6 months. Impeding factors include perceived breastmilk insufficiency, pressure from family members, past experiences, mothers' concerns over their infants' health, mothers' heavy workload, poverty and food insecurity. Factors facilitating early initiation and EBF include mothers' awareness of EBF's advantages, confidence in their breastfeeding ability, and support from health professionals and family members. CONCLUSION: Despite participants' intentions about breastfeeding, there was a gap between intentions and actual practices. An interplay of barriers at individual, group and societal levels impeded women from EBF for the first 6 months. EBF promotion interventions should consider supporting and equipping breastfeeding mothers with skills to deal with perceived breastmilk insufficiency and to recognize the true signs of baby hunger cues. Furthermore, important influential family and community members should be targeted to support mothers to breastfeed. Interventions that consider addressing the issue of poverty-driven food insecurity should not be overlooked either.

Challenges and responses to infant and young child feeding in rural Rwanda: a qualitative study.

BACKGROUND: Despite different interventions to improve child nutrition conditions, chronic malnutrition is still a public health concern in Rwanda, with a high stunting prevalence of 38% among under 5-year-olds children. In Rwanda, only 18% of children aged 6-23 months are fed in accordance with the recommendations for infant and young child feeding practices. The aim of this study was to explore challenges to infant and young child feeding practices and the responses applied to overcome these challenges in Muhanga District, Southern province of Rwanda. METHODS: Sixteen (16) focus group discussions were held with mothers, fathers, grandmothers, and community health workers from 4 rural sectors of Muhanga District. The discussions were recorded, transcribed verbatim, and thematically analyzed using qualitative data analysis software, Atlas.ti. RESULTS: Two main themes emerged from the data. Firstly, there was a discourse on optimal infant and young child feeding (IYCF) practices that reflects the knowledge and efforts to align with early initiation of breastfeeding, exclusive breastfeeding for the first 6 months, as well as initiation of complementary foods at 6 months recommendations. Secondly, challenging situations against optimal practices and coping responses applied were presented in a discourse on struggling with everyday reality. The challenging situations that emerged as impeding appropriate IYCF practices included perceived lack of breast milk, infant cues, women's heavy workload, partner relations and living in poverty. Family and social support from community health workers and health facility staff, financial support through casual labor, and mothers saving and lending groups, as well as kitchen gardens, were used to cope with challenges. CONCLUSION: Factors influencing IYCF practices are multifaceted. Hence, intervention strategies to improve child nutrition should acknowledge the socially embedded nature of IYCF and address economic and social environmental constraints and opportunities, in addition and above knowledge only.

Individual, social-environmental, and physical-environmental factors that underlie sense of coherence in Dutch adults.

Antonovsky's salutogenesis is a theoretical perspective on health development that explores physical, mental, and social factors that contribute to a 'healthy life orientation' and also a theoretical approach to behavior change. Previous studies applying salutogenesis show that a high sense of coherence (SOC), a composite measure from salutogenesis indicating one's capacity to cope with stress, is associated with a healthy life orientation and lifestyle behaviors, including healthy eating patterns. However, limited evidence exists on the factors that underlie SOC, which could be used to strengthen this capacity as a means to enable healthier eating. Dutch adults ( N = 781) participated in a cross-sectional study examining the relationship between SOC and a set of individual, social-environmental, and physical-environmental factors. The main findings indicate that high SOC was associated with a diverse set of factors including lower doctor-oriented health locus of control; higher satisfaction with weight; higher perceived levels of neighborhood collective efficacy; higher situational self-efficacy for healthy eating; lower social discouragement for healthy eating; and higher neighborhood affordability, accessibility and availability of healthy foods. These findings can inform the design of nutrition interventions that target these factors that strengthen SOC and provide the building blocks for a healthier life orientation.

Food stories: Unraveling the mechanisms underlying healthful eating.

The biomedical model of health (BMH) studies the causes and origins of disease. When applied to nutrition research, eating is studied as a behavior that supports physical health. However, the lack of attention the BMH pays to social and historical circumstances in which health behaviors are constructed has been widely addressed in literature. When people are studied without considering contextual influences, the relevance to everyday life is limited. As a result, how individuals actively deal with their context to manage healthful eating is poorly understood. This research applies a complementary model, salutogenic model of health (SMH), and uses life course research methodology to study a group of healthy eaters. The purpose of this research is to unravel how healthful eating develops in everyday life. Healthy eaters (n = 17) were identified and recruited from the NQplus research panel at Wageningen University, the Netherlands. Life course experiences were examined through narrative inquiry. Participants recalled and visually explored life experiences with food and health using timelines. Results indicate that healthful eating results from exposure to individual- and context-bounded factors during childhood and adulthood and involves specific mental and social capacities relevant to coping including amongst others, critical self-awareness; flexibility, craftiness, and fortitude. Through life-course learning moments, participants were able to develop proactive coping strategies which strengthened their sense of agency and helped them in overcoming stressors and challenges. Findings show that nutrition strategies should not only focus on strengthening food-specific factors like cooking skills and nutrition knowledge, but other factors like stress management, empowerment, and participation. Such factors support the development of adaptive skills and behaviors, enable individuals to deal with the demands of everyday life, and are building blocks for health promotion.

Applying the salutogenic framework to nutrition research and practice.

SYNOPSIS: Much research has identified a sea of factors related to unhealthy diets to make sense of why people struggle to eat healthy diets. However, little is known of factors that empower healthy eating. Antonovsky's salutogenesis provides an innovative framework to study these factors and identify resources and mechanisms underlying healthy eating practices. We give recommendations for future research and provide examples of how salutogenesis has inspired our own research to gain new insights into the origins of healthy eating. Lastly, implications of using future findings in designing novel nutrition promotion strategies are outlined.

Profiling healthy eaters. Determining factors that predict healthy eating practices among Dutch adults.

Research has identified multiple factors that predict unhealthy eating practices. However what remains poorly understood are factors that promote healthy eating practices. This study aimed to determine a set of factors that represent a profile of healthy eaters. This research applied Antonovsky's salutogenic framework for health development to examine a set of factors that predict healthy eating in a cross-sectional study of Dutch adults. Data were analyzed from participants (n = 703) who completed the study's survey in January 2013. Logistic regression analysis was performed to test the association of survey factors on the outcome variable high dietary score. In the multivariate logistic regression model, five factors contributed significantly (p < .05) to the predictive ability of the overall model: being female; living with a partner; a strong sense of coherence (construct from the salutogenic framework), flexible restraint of eating, and self-efficacy for healthy eating. Findings complement what is already known of the factors that relate to poor eating practices. This can provide nutrition promotion with a more comprehensive picture of the factors that both support and hinder healthy eating practices. Future research should explore these factors to better understand their origins and mechanisms in relation to healthy eating practices.

Effective interventions in overweight or obese young children: systematic review and meta-analysis.

BACKGROUND: Treatment programs for overweight and obese young children are of variable effectiveness, and the characteristics of effective programs are unknown. In this systematic review with meta-analysis, the effectiveness of treatment programs for these children is summarized. METHODS: PubMed, Embase, Web of Science, and PsycINFO databases were searched up to April 2012. Articles reporting the effect of treatment on the body weight of overweight or obese children with a mean age in the range of 3-<8 years are included. Studies reporting the change in BMI z-score with standard error were included in a meta-analysis. For this purpose, a random-effects model was used. RESULTS: The search identified 11,250 articles, of which 27 were included in this review. Eleven studies, including 20 treatment programs with 1015 participants, were eligible for the meta-analysis. The pooled intervention effect showed high heterogeneity; therefore, subgroup analysis was performed. Subgroup analysis showed that program intensity and used components partly explained the heterogeneity. The subgroup with two studies using multicomponent treatment programs (combining dietary and physical activity education and behavioral therapy) of moderate or high intensity showed the largest pooled change in BMI z-score (-0.46; I2, 0%). CONCLUSION: Although the subgroup multicomponent treatment programs of moderate to high intensity contained only two studies, these treatment programs appeared to be most effective in treating overweight young children.

'Getting things done': an everyday-life perspective towards bridging the gap between intentions and practices in health-related behavior.

In this paper, we aim to add a new perspective to supporting health-related behavior. We use the everyday-life view to point at the need to focus on the social and practical organization of the concerned behavior. Where most current approaches act disjointedly on clients and the social and physical context, we take the clients' own behavior within the dynamics of everyday context as the point of departure. From this point, healthy behavior is not a distinguishable action, but a chain of activities, often embedded in other social practices. Therefore, changing behavior means changing the social system in which one lives, changing a shared lifestyle or changing the dominant values or existing norms. Often, clients experience that this is not that easy. From the everyday-life perspective, the basic strategy is to support the client, who already has a positive intention, to 'get things done'. This strategy might be applied to those cases, where a gap is found between good intentions and bad behavior.

How science thinks and practice acts: bridging the gap in weight management interventions for adolescents.

BACKGROUND: Adolescent obesity calls for evidence-based treatment approaches given its long-term physical and psychosocial consequences. However, research shows there are many problems in the translation of scientific evidence into practice. OBJECTIVE: The aim of this study was to develop science- and practice-based recommendations for the planning of future adolescent weight management interventions. METHODS: We performed (i) literature reviews on intervention studies targeting treatment of obesity in adolescents and Dutch clinical guidelines for obesity as well as practice-based documents and grey literature on treating obesity and delivering health programs for adolescents and (ii) semi-structured interviews with eight clinicians and four non-clinicians working in obesity treatment, management and prevention to explore perspectives on treating adolescent obesity and using evidence in practice. RESULTS: After merging the results from the literature reviews and interviews, four issues emerged: (i) little reporting on theoretical models used in intervention studies, Dutch clinical guidelines and semi-structured interviews; (ii) inconsistency on age-specific considerations for treating obesity in adolescents in intervention studies and Dutch clinical guidelines; (iii) inconsistency on addressing the social nature of obesity in intervention studies and Dutch clinical guidelines and (iv) how professional responsibility should be divided is unclear from intervention studies, Dutch clinical guidelines and semi-structured interviews. CONCLUSIONS: Joined action of science and practice is required for future interventions. Future interventions should include topics relevant to the stage of adolescence and give greater focus to the complex social nature of obesity. Lastly, practitioners can generate more practice-based evidence by starting their own practice-based research.

I eat healthfully but I am not a freak. Consumers' everyday life perspective on healthful eating.

The gap between the awareness and understanding of healthful eating on the one hand and actual eating practices on the other has been addressed in several ways in the literature. In this paper, we consider it from an everyday life perspective. Using discourse analysis, we analyse how Dutch consumers account for their everyday food choices. We show how Dutch consumers use three interpretative repertoires to confirm the importance of health, while not portraying themselves as too self- and health-conscious eaters. The first repertoire associates healthful eating with common knowledge and 'scripted' actions, thereby suggesting that such eating is self-evident rather than difficult. The second repertoire constructs eating for health and pleasure as uncomplicated, by emphasizing consumers' relaxed way of dealing with both. The third repertoire constructs unhealthful eating practices as naturally requiring compensation in the form of certain products or pills. We discuss how the use of these repertoires may pose socio-interactional barriers to the pursuance of healthful eating behaviour. The depiction of one's eating habits as uncomplicated, self-evidently healthful and - when bad - easy to compensate for, does not seem to provide a basis for critical considerations about these eating habits. If structural change in eating practices is to be achieved, nutrition promotion must invest in creating a new social standard that both avoids 'overdoing' bio-medical health and challenges people's construction of their eating habits as naturally healthful.

About evidence based and beyond: a discourse-analytic study of stakeholders' talk on involvement in the early development of personalized nutrition.

This paper draws on discourse analysis to examine how Dutch stakeholders in health education, health care, health insurance, social science, the food industry and the media make sense of innovations in the field of 'personalized nutrition' and their own role and significance in an early stage of technology development. Previous research has focused on factors that help or hinder collaboration between stakeholders, and on the development, management and implementation of joint programs. However, no attention has been paid to how stakeholders themselves handle issues of responsibility and initiative in relation to early technology development and collaborative interactions. The present study shows how such stakeholders establish themselves as gatekeepers of innovation by displaying authority on what consumers 'want' and 'cannot do', while avoiding a proactive role. Uncertainty in scientific knowledge, fixed roles and responsibilities and dependency on incompetent or biased others are drawn upon to account for a wait-and-see policy.

Nutrition tailored to the individual? Not just yet - realigning nutrigenomic science with contemporary society.

About a decade ago, scientists and science journalists presented nutrigenomics as a grand promise that each of us would soon know which foods fit in our personal healthy diet. Meanwhile, expectations have been adjusted to fit a changed reality. Simultaneously, societal issues surrounding personalized nutrition continue to rise, including whether consumers need it, food industry can produce it, all relevant stakeholders are willing and able to work together, and if it is a desirable way to go for nutrition. The commentary below reports the main results of 6 research projects that focused on nutrigenomics and its role in society.

Patients, evidence and genes: an exploration of GPs' perspectives on gene-based personalized nutrition advice.

BACKGROUND: Nutrigenomics science examines the response of individuals to food compounds using post-genomics technology. It is expected that in the future, personalized nutrition advice can be provided based on information about genetic make-up. OBJECTIVES: Gene-based personalized nutrition advice emerges at the junction of different disciplines and technologies and may directly influence people's lives. Therefore, public concern is to be expected. Because GPs are gatekeepers of health care, their involvement in early stages of the development process is desirable. METHOD: In 2006, 15 GPs were interviewed to collect their perceived barriers and opportunities towards involvement in gene-based nutrition advice. The interviews were qualitatively analysed with use of Atlas.ti, a qualitative analysis programme. RESULTS: The participants held a mostly critical view towards such personalized nutrition advice. They argued that findings of nutritional studies lacked robustness, were not based on patients' needs and were often equivocal. And that a patient central perspective urges them to question consequences for patients. Participants argued that GPs should be involved in selecting and monitoring patients in nutrigenomics studies. CONCLUSIONS: Early involvement of GPs in the development process is needed to allow for the integration of their practical, social and ethical considerations in the technical and scientific agendas. However, the background of their critical attitude towards nutrigenomics-based personalized nutrition, and nutrition advice more generally, has to be explored further. To facilitate a joint learning process and to improve socio-technical decision making with respect to this innovation, initiatives that allow different stakeholders to exchange their perspectives should be organized.