Impact of a Nurse-Led Health Promotion Intervention in an Aging Population: Results From a Quasi-Experimental Study on the "Community Health Consultation Offices for Seniors".

Objective: The study evaluated the nurse-led intervention "Community Health Consultation Offices for Seniors (CHCO)" on health-related and care needs-related outcomes in community-dwelling older people (⩾60 years). Method: With a quasi-experimental design, the CHCO intervention was evaluated on health-related and care needs-related outcomes after 1-year follow-up. Older people who received the intervention were frail, overweight, or were smoking. The comparison group received care as usual. In both groups, similar data were collected on health status, falls and fractures, and care needs. In the intervention group, additional data were collected on biometric measures and health-related behavior. Results: The intervention group and the care-as-usual group included 403 seniors and 984 seniors, respectively. Health-related outcomes, behaviors, and biometric measures, remained stable. After 1 year, care needs increased for both groups, but at a lower rate for the care-as-usual group. Discussion: The CHCO intervention showed no significant improvement on health-related outcomes or stability in care needs-related outcomes.

Agreement between parent and child report of physical activity, sedentary and dietary behaviours in 9-12-year-old children and associations with children's weight status.

BACKGROUND: To date, population based surveys aimed at gaining insight in health related behaviour of children have often used either child self-reports or parent proxy reports. It remains unclear however, if surveys using different sources of information from either parents or children are comparable. In addition, (over)weight status of children can lead to under- and over reporting by parents and children as a result of social desirability bias. We aimed at gaining insight in the level of agreement between parents and child reports regarding aspects of certain dietary, physical activity and sedentary behaviours, and whether there are differences in agreement between parents and child reports in healthy-weight and overweight children. METHODS: Weighted kappa was used to determine the level of agreement between child and parent reports on health-related behaviour in 1998 parent-child dyads. We also stratified for weight status of the children. Information on children's health related behaviours was obtained by parental and children's questionnaires, and children's height and weight were measured. Associations between children's weight status and children reporting less, reporting more and reporting the same amount of health behaviour as their parents were investigated with multinomial logistic regression analysis. RESULTS: The Cohen's kappa coefficients ranged from almost perfect agreement for the variable means of transportation, fair for the variables breakfast consumption and frequency of outside play to slight for the variables duration of outside play, frequency and duration of TV/DVD viewing and family dinner. Overweight children were significantly more likely to report less breakfast consumption (OR = 2.6 (95% CI: 1.3 - 5.1)) and lower frequency of outside play than their parents (OR = 1.8 (95% CI: 1.1 - 2.9)). CONCLUSION: There can be considerable disagreement between the health related behaviours of children as reported by parents or the children themselves. Based on the present study, it cannot be concluded whether parents' or children's reports are more accurate. For future studies, social desirability and recall bias would be best demonstrated in a validation study comparing child and parent self-reports with more objective measures of physical activity and food intake.

Energy Balance-Related Behavior and Anthropometric Measures Among Adolescents Across Three Educational Levels: A Cross-Sectional Study in Dutch Schools.

Energy balance-related behavior on schooldays and beliefs about school-based interventions may differ between students in different educational levels, sexes, and BMI (body mass index) categories. In Zwolle (the Netherlands), 1,084 adolescents (13-15 years) at 9 secondary schools completed a questionnaire. Overweight prevalence (boys 18.1%, girls 19.3%) increased with decreasing educational level, especially in boys. Girls reported healthier behavior than boys regarding daily consumption of fruit (35% vs. 29%), vegetables (58% vs. 48%), ≤1 snack/candy (36% vs. 26%), ≤3 glasses of sugared drinks (80% vs. 73%; all p < .05). Unhealthier dietary behaviors were associated with lower educational level, except for eating sugary and savory snacks. Snacks and sugared drinks consumed at school were mostly brought from home (61.6% and 68.5%, respectively). Overweight students reported less frequent consumption of daily breakfast, snacks, and sugared drinks than nonoverweight students. Of all students, 40% spent ≥1 hour per day cycling to school. Lower educational level students reported less organized sports activities than higher level students, but more outside play and other activities. Overweight was associated with cycling to school (boys) and participating in organized sports (girls). More girls than boys were interested in lessons about healthy nutrition (44.4% vs. 31.7%). To stimulate physical activity, boys suggested more physical education classes (63%), girls advised more variation (47%) and choice (43%). A healthy school canteen (57%) and offering free fruit (67%) were suggested as promising interventions to stimulate healthy behavior. Educational and environmental interventions to tackle unhealthy dietary and physical activity behavior should be developed in collaboration with parents and tailored to educational level and gender.

Identifying developmental trajectories of body mass index in childhood using latent class growth (mixture) modelling: associations with dietary, sedentary and physical activity behaviors: a longitudinal study.

BACKGROUND: To date, many epidemiologic studies examining associations between obesity and dietary and sedentary/physical activity behaviors have focused on assessing Body Mass Index (BMI) at one point in time. Recent developments in statistical techniques make it possible to study the potential heterogeneity in the development of BMI during childhood by identifying distinct subpopulations characterized by distinct developmental trajectories. Using Latent Class Growth (Mixture) Modelling (LCGMM) techniques we aimed to identify BMI trajectories in childhood and to examine associations between these distinct trajectories and dietary, sedentary and physical activity behaviors. METHODS: This longitudinal study explored BMI standard deviation score (SDS) trajectories in a sample of 613 children from 4 to 12 years of age. In 2006, 2009 and 2012 information on children's health related behaviors was obtained by parental questionnaires, and children's height and weight were measured. Associations with behaviors were investigated with logistic regression models. RESULTS: We identified two BMI SDS trajectories; a decreasing BMI SDS trajectory (n = 416; 68 %) and an increasing BMI SDS trajectory (n = 197; 32 %). The increasing BMI SDS trajectory consisted of more participants of lower socio-economic status (SES) and of non-western ethnicity. Maternal overweight status was associated with being in the increasing BMI SDS trajectory at both baseline and follow-up six years later (2006: Odds Ratio (OR), 2.9; 95 % confidence interval (CI) 1.9 to 4.3; 2012 OR, 1.8; 95 % CI 1.2 to 2.6). The increasing BMI SDS trajectory was associated with the following behaviors; drinking sugared drinks > 3 glasses per day, participation in organized sports < 1 h per week, and TV viewing > 2 h per day, though participation in organized sports at follow-up was the only significant result. CONCLUSIONS: Our results indicate the importance of healthy lifestyle behaviors at a young age, and indicate that maternal BMI is a very important risk factor for the development of childhood overweight. Comprehension of heterogeneity in the development of BMI and associations with modifiable health related behaviors is interesting for prevention by targeting high risk behaviors in early childhood, especially in low SES children, children of non-western ethnicity and children whose mother is overweight.

Promoting health equity in European children: design and methodology of the prospective EPHE (Epode for the Promotion of Health Equity) evaluation study.

BACKGROUND: Reducing health inequalities is a top priority of the public health agendas in Europe. The EPHE project aims to analyse the added value of a community-based interventional programme based on EPODE methodology, adapted for the reduction of socio-economic inequalities in childhood obesity. The interventions that will be implemented by this project focus on four energy balance-related behaviours (fruit and vegetable consumption, tap water intake, physical inactivity, sleep duration) and their determinants. This article presents the design of the effect evaluation of the EPHE project. METHODS/DESIGN: This is a prospective two-year follow-up evaluation study, which will collect data on the energy balance-related behaviours and potential environmental determinants of 6-8 year olds, depending on the socio-economic status of the parents. For this purpose a parental self-reported questionnaire is constructed. This assesses the socio-economic status of the parents (5 items) and the dietary (12 items), sedentary (2 items) and sleeping (4 items) behaviour of the child. Alongside potential family-environmental determinants are assessed. The EPHE parental questionnaire will be disseminated in schools of a selected medium-sized city in seven European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands). DISCUSSION: This study will evaluate the effects of the EPHE community-based interventional programmes. Furthermore, it will provide evidence for children's specific energy balance-related behaviours and family environmental determinants related to socio-economic inequalities, in seven European countries.

The influence of the macro-environment on physical activity: a multilevel analysis of 38 countries worldwide.

BACKGROUND: As indicated by the ANGELO framework and similar models, various environmental factors influence population levels of physical activity (PA). To date attention has focused on the micro-level environment, while evidence on the macro-level environment remains scarce and mostly limited to high-income countries. This study aims to investigate whether environmental factors at macro-level are associated with PA among a broader range of countries. METHODS: Data from the World Health Survey (WHS) was used to analyze 177,035 adults from 38 (mostly low and middle income) countries. The International Physical Activity Questionnaire-Short Form (IPAQ-S) was used to measure PA. Respondents were classified as active or inactive for vigorous PA, moderate PA and walking. Multilevel logistic regression was performed to assess associations between macro-level environmental factors and the prevalence of PA, with control for individual-level socioeconomic factors. RESULTS: The prevalence of PA varied widely between countries and types of PA (5.0%-93.8%). A negative association was found between gross domestic product and PA, odds ratios for men were 0.76 (95% CI: 0.65-0.89) for moderate PA and 0.79 (95% CI: 0.63-0.98) for walking. A higher temperature was associated with less PA (all types) and higher urbanization was associated with less vigorous and moderate PA. More gender equality was also associated with more walking for women. Governmental functioning and literacy rate were not found to be associated with any type of PA. CONCLUSIONS: This exploratory study indicates that factors such as climate, economic development and cultural factors are determinants of the level of overall PA at national levels. This underlines the suggestion that the macro-environment should be regarded as an important influence on PA.

Behavioural and socio-demographic characteristics of Dutch neighbourhoods with high prevalence of childhood obesity.

OBJECTIVE: To identify neighbourhoods with increased prevalence of overweight children and to examine whether the association between neighbourhood and overweight can be explained by demographic characteristics and energy-related behaviours. METHOD: This cross-sectional study was carried out among 4,072 primary schoolchildren 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, dietary and (in)activity behaviour of their child. With multivariate logistic regressions, associations between unhealthy behaviours and neighbourhoods (defined by postal code) with high and low prevalence of childhood overweight were investigated. RESULTS: In three neighbourhoods the prevalence of overweight was significantly higher (16.5% vs. 10.6%, p < 0.05). The odds of living in these neighbourhoods were higher among children watching >2 h television/day (OR: 1.57; 95% CI: 1.15-2.14), not eating breakfast daily (OR: 2.86; 95% CI: 1.93-4.23), drinking >3 glasses/day sugared drinks (OR: 1.23; 95% CI: 1.01-1.50) on weekdays and not participating in organized sports (OR: 1.32; 95% CI: 1.09-1.59). This odds was however lower among children eating <2 fruit/day (OR: 0.83; 95% CI: 0.69-1.00) on weekends. The association between neighbourhood and overweight altered slightly after adjustment for socio-demographic and behavioural characteristics during weekdays (OR: 1.42; 95% CI: 1.05-1.92) and weekends (OR: 1.50; 95% CI; 1.11-2.02). CONCLUSION: Three neighbourhoods with higher prevalence of overweight were identified. A small part of the association between overweight and neighbourhood is explained by socio-demographic factors and unhealthy behaviours measured in this study. Neighbourhoods with higher overweight prevalence are a priority setting for targeted interventions to prevent overweight. The association between neighbourhood and overweight needs to be explored further to understand the role the neighbourhood can play in tackling overweight.

Behavioral and cognitive effects of a worksite-based weight gain prevention program: the NHF-NRG in balance-project.

OBJECTIVE: Examine the effectiveness of the worksite-based weight gain prevention program Netherlands Heart Foundation-Netherlands Research program weight Gain prevention In Balance, with regard to behavioral changes and corresponding cognitive determinants. METHODS: A nonrandomized pretest-repeated posttest control group design was applied in 12 worksites. Intervention groups received individual and environmental interventions, directed at physical activity and food intake. Measurements were executed at baseline and after 12 and 24 months. RESULTS: Nearly all behaviors in the intervention group improved more than in the control group, even though improvements in behaviors were often too small to reach statistical significance. No positive intervention effects were observed for the cognitive factors. CONCLUSION: Differential changes between the intervention and control group were observed for several important dietary and physical activity behaviors. Valuable information is gained regarding the implementation of weight gain prevention programs in worksites.

Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons.

BACKGROUND: The extent to which moderate overweight (body mass index [BMI], 25.0-29.9 [calculated as weight in kilograms divided by height in meters squared]) and obesity (BMI, >/= 30.0) are associated with increased risk of coronary heart disease (CHD) through adverse effects on blood pressure and cholesterol levels is unclear, as is the risk of CHD that remains after these mediating effects are considered. METHODS: Relative risks (RRs) of CHD associated with moderate overweight and obesity with and without adjustment for blood pressure and cholesterol concentrations were calculated by the members of a collaboration of prospective cohort studies of healthy, mainly white persons and pooled by means of random-effects models (RRs for categories of BMI in 14 cohorts and for continuous BMI in 21 cohorts; total N = 302 296). RESULTS: A total of 18 000 CHD events occurred during follow-up. The age-, sex-, physical activity-, and smoking-adjusted RRs (95% confidence intervals) for moderate overweight and obesity compared with normal weight were 1.32 (1.24-1.40) and 1.81 (1.56-2.10), respectively. Additional adjustment for blood pressure and cholesterol levels reduced the RR to 1.17 (1.11-1.23) for moderate overweight and to 1.49 (1.32-1.67) for obesity. The RR associated with a 5-unit BMI increment was 1.29 (1.22-1.35) before and 1.16 (1.11-1.21) after adjustment for blood pressure and cholesterol levels. CONCLUSIONS: Adverse effects of overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of CHD. Even for moderate overweight, there is a significant increased risk of CHD independent of these traditional risk factors, although confounding (eg, by dietary factors) cannot be completely ruled out.

Effects of retirement on lifestyle in relation to changes in weight and waist circumference in Dutch men: a prospective study.

OBJECTIVE: To study changes in lifestyle in relation to changes in body weight and waist circumference associated with occupational retirement in men. DESIGN: A prospective cohort study with 5 years of follow-up. At baseline and at follow-up, questionnaires were completed and body weight and waist circumference were measured. SETTING: The Doetinchem Cohort Study, consisting of inhabitants of Doetinchem, a town in a rural area of The Netherlands. SUBJECTS: In total 288 healthy men aged 50-65 years at baseline, who either remained employed or retired over follow-up. RESULTS: The effect of retirement on changes in weight and waist circumference was dependent on type of former occupation. Increase in body weight and waist circumference was higher among men who retired from active jobs (0.42 kg year(-1) and 0.77 cm year(-1), respectively) than among men who retired from sedentary jobs (0.08 kg year(-1) and 0.23 cm year(-1), respectively). Weight gain and increase in waist circumference were associated with a decrease in fruit consumption and fibre density of the diet, with an increase in frequency of eating breakfast, and with a decrease in several physical activities, such as household activities, bicycling, walking and doing odd jobs. CONCLUSION: Retirement was associated with an increase in weight and waist circumference among those with former active jobs, but not among those with former sedentary jobs. Retirement may bring opportunities for healthy changes in diet and physical activity, which could be used in health promotion programmes.

Cognitive determinants of energy balance-related behaviours: measurement issues.

The burden of disease as a result of overweight and obesity calls for in-depth examination of the main causes of behavioural actions responsible for weight gain. Since weight gain is the result of a positive energy balance, these behavioural actions are referred to as 'energy balance-related behaviours' (EBRBs). In the broadest sense, there are only two EBRBs: food intake and physical activity. However, both diet and physical activity are complex behavioural categories that involve a variety of actions. This article discusses the potential problems and opportunities related to the assessment of cognitive determinants of energy intake and energy expenditure behaviours. We argue for the necessity of studying determinants of EBRBs within an energy balance approach, i.e. focusing on energy input as well as output, instead of only studying dietary change or physical activity behaviour. As a result, however, theoretically sound questionnaires assessing determinants of EBRBs are likely to annoy respondents. It is especially the measurement of the behaviours and the use of belief-based constructs that cause questionnaires to be long, which may lead to low response rates and invalid data. In this article, we propose a careful and systematic consideration of the inclusion or exclusion of measures of cognitive determinants. First, if studies show that an EBRB is strongly influenced by environmental factors and is not or only to a minor extent under intentional control, measurement of cognitions is of little use. Second, only when we have proof that attitudes, norms and perceived behavioural control predict intentions, should we aim to assess the underlying beliefs. Third, since assessment of beliefs results in similar or better prediction than using belief-valuation combinations, we should not 'annoy' respondents with valuation items. Finally, we argue that the traditional paper-and-pencil survey is still the most reliable and practical data collection method. However, pilot studies applying computerised adaptive methods to determinants of EBRBs are encouraged.

Obesity and unhealthy life-years in adult Finns: an empirical approach.

BACKGROUND: Obesity is more strongly related to morbidity and disability than to mortality. Obese individuals are thus expected to have more unhealthy life-years than normal-weight persons. The objective of the present study was to quantify the number of excess unhealthy life-years in obese individuals. METHODS: A representative cohort of 19 518 Finnish men and women aged 20 to 92 years was followed for 15 years. Participation rate was 83%. Obesity was defined as a body mass index of 30.0 or higher. The number of unhealthy life-years due to premature work disability, hospitalization for coronary heart disease, and need for long-term medication was calculated per category of body mass index. RESULTS: During the follow-up of 15 years, obese men who never smoked aged 20 to 64 years had, on average, 0.63 more years of work disability, 0.36 more years of coronary heart disease, and 1.68 more years of longterm medication use, than normal-weight counterparts. Obese women had, respectively, 0.52, 0.46, and 1.49 more years from these conditions than normal weight women. The excess risks of morbidity and disability due to obesity were highest in the youngest age groups and exceeded those of mortality in all age groups. Obese men and women 65 years and older who never smoked had, respectively, 1.71 and 1.41 excess unhealthy life-years (not statistically significant) due to premature need for long-term medication compared with normal-weight subjects, but no excess unhealthy life-years due to coronary heart disease. CONCLUSIONS: Obesity has a lifetime impact on disability and morbidity. A further increase in obesity will lead to an increase in unhealthy life-years and in direct and indirect health care costs.