The development of the Dutch "National model integrated care for childhood overweight and obesity".

BACKGROUND: Childhood obesity is a chronic disease with negative physical and psychosocial health consequences. To manage childhood overweight and obesity, integrated care as part of an integrated approach is needed. To realise implementation of this integrated care, practical guidance for policy and practice is needed. The aim of this study is to describe the development of a Dutch national model of integrated care for childhood overweight and obesity and accompanying materials for policy and practice. METHODS: The development of the national model was led by a university-based team in collaboration with eight selected Dutch municipalities who were responsible for the local realisation of the integrated care and with frequent input from other stakeholders. Learning communities were organised to exchange knowledge, experiences and tools between the participating municipalities. RESULTS: The developed national model describes the vision, process, partners and finance of the integrated care. It sets out a structure that provides a basis for local integrated care that should facilitate support and care for children with overweight or obesity and their families. The accompanying materials are divided into materials for policymakers to support local realisation of the integrated care and materials for healthcare professionals to support them in delivering the needed support and care. CONCLUSIONS: The developed national model and accompanying materials can contribute to improvement of support and care for children with overweight or obesity and their families, and thereby help improve the health, quality of life and societal participation of these children. Further implementation of the evidence- and practice-based integrated care while evaluating on the way is needed.

Conducting a psychosocial and lifestyle assessment as part of an integrated care approach for childhood obesity: experiences, needs and wishes of Dutch healthcare professionals.

BACKGROUND: The causes and consequences of childhood obesity are complex and multifaceted. Therefore, an integrated care approach is required to address weight-related issues and improve children's health, societal participation and quality of life. Conducting a psychosocial and lifestyle assessment is an essential part of an integrated care approach. The aim of this study was to explore the experiences, needs and wishes of healthcare professionals with respect to carrying out a psychosocial and lifestyle assessment of childhood obesity. METHODS: Fourteen semi-structured interviews were conducted with Dutch healthcare professionals, who are responsible for coordinating the support and care for children with obesity (coordinating professionals, 'CPs'). The following topics were addressed in our interviews with these professionals: CPs' experiences of both using childhood obesity assessment tools and their content, and CPs' needs and wishes related to content, circumstances and required competences. The interviews comprised open-ended questions and were recorded and transcribed verbatim. The data was analysed using template analyses and complemented with open coding in MAXQDA. RESULTS: Most CPs experienced both developing a trusting relationship with the children and their parents, as well as establishing the right tone when engaging in weight-related conversations as important. CPs indicated that visual materials were helpful in such conversations. All CPs used a supporting assessment tool to conduct the psychosocial and lifestyle assessment but they also indicated that a more optimal tool was desirable. They recognized the need for specific attributes that helped them to carry out these assessments, namely: sufficient knowledge about the complexity of obesity; having an affinity with obesity-related issues; their experience as a CP; using conversational techniques, such as solution-focused counselling and motivational interviewing; peer-to-peer coaching; and finally, maintaining an open-minded, non-stigmatizing stance and harmonizing their attitude with that of the child and their parents. CONCLUSIONS: Alongside the need for a suitable tool for conducting a psychosocial and lifestyle assessment, CPs expressed the need for requisite knowledge, skills and attitudes. Further developing a supporting assessment tool is necessary in order to facilitate CPs and thereby improve the support and care for children with obesity and their families.

Tools for a systematic appraisal of integrated community-based approaches to prevent childhood obesity.

BACKGROUND: Evaluation and monitoring methods are often unable to identify crucial elements of success or failure of integrated community-wide approaches aiming to tackle childhood overweight and obesity, yet difficult to determine in complex programmes. Therefore, we aimed to systematically appraise strengths and weaknesses of such programmes and to assess the usefulness of the appraisal tools used. METHODS: To identify strengths and weaknesses of the integrated community-based approaches two tools were used: the Good Practice Appraisal tool for obesity prevention programmes, projects, initiatives and intervention (GPAT), a self-administered questionnaire developed by the WHO; and the OPEN tool, a structured list of questions based on the EPODE theory, to assist face-to-face interviews with the principle programme coordinators. The strengths and weaknesses of these tools were assessed with regard to practicalities, quality of acquired data and the appraisal process, criteria and scoring. RESULTS: Several strengths and weaknesses were identified in all the assessed integrated community-based approaches, different for each of them. The GPAT provided information mostly on intervention elements whereas through the OPEN tool information on both the programme and intervention levels were acquired. CONCLUSION: Large variability between integrated community-wide approaches preventing childhood obesity in the European region was identified and therefore each of them has different needs. Both tools used in combination seem to facilitate comprehensive assessment of integrated community-wide approaches in a systematic manner, which is rarely conducted. Nonetheless, the tools should be improved in line to their limitations as recommended in this manuscript.

An integrated health care standard for the management and prevention of obesity in The Netherlands.

The Partnership Overweight Netherlands (PON) is a collaboration between 18 partners, which are national organizations of health care providers, health insurance companies and patient organizations. The PON published an integrated health care standard for obesity in November 2010. The integrated health care standard for obesity involves strategies for diagnosis and early detection of high-risk individuals as well as appropriate combined lifestyle interventions for those who are overweight and obese and, when appropriate, additional medical therapies. The PON works towards a standard that transcends traditional boundaries of conventional health care systems and health care professions but, instead, focuses on competences of groups of health professionals who organize care from a patient-oriented perspective.

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.

Consuming a diet complying with front-of-pack label criteria may reduce cholesterol levels: a modeling study.

BACKGROUND/OBJECTIVES: Front-of-pack nutrition labels can help consumers to make healthier choices and stimulate healthier product development. This is the first modeling study to investigate the potential impact on cholesterol levels of consuming a diet consisting of products that comply with the criteria for a 'healthier choice logo'. SUBJECTS/METHODS: National food consumption and food composition data were used to estimate the nutrient intake of the Dutch adult population (18-70 years) before and after replacing foods that did not comply with the choices front-of-pack label criteria. Different scenarios were established. The difference in cholesterol levels in the Dutch population was assessed before and after replacement by means of equations from meta-analyses that calculate how blood lipids change when diet composition changes. RESULTS: After replacing non-complying products with products, which comply with the label's criteria (maximum scenario), saturated fatty acids median intake reduced from 14.5 to 9.8 en%. Trans-fatty acids reduced from 0.95 to 0.57 en%. The average predicted changes in low-density lipoprotein and total cholesterol levels were -0.25 and -0.31 mmol/l, respectively. Because high-density lipoprotein (HDL) cholesterol levels reduced as well (-0.05 mmol/l), overall, the result was a slightly positive change in the total cholesterol/HDL ratio (-0.03). CONCLUSIONS: Our findings suggest that the consumption of foods complying with the criteria for a front-of-pack label could contribute moderately to cardiovascular risk reduction via influencing blood lipids. These findings were independent of other potential effects on related health outcomes.

Plasma factor VII and its relation to adipose tissue fatty acids and other atherogenic risk factors in healthy men.

In this study the authors examined the relationships of plasma factor VII (F-VII) to adipose tissue fatty acid composition, as an objective index of the habitual dietary fat intake, as well as to a number of other atherogenic risk factors in 60 healthy male volunteers (aged 38 years). Significant positive correlations were found between plasma F-VII [measured as antigen (F-VIIAg) and coagulant activity, using bovine thromboplastin (F-VIIbt)] and body mass index (BMI), waist-thigh girth ratio (WTR), cigarette smoking and plasma triglyceride concentration. After adjustment for BMI, only plasma triglycerides remained positively correlated with F-VII (r = 0 center dot 27, P = 0 center dot 03, and r = 0 center dot 29, P < 0 center dot 01, for F-VIIbt and F-VIIAg respectively). A significant positive relation was found between F-VII and the total proportion of fatty acid as monounsaturated fatty acid (r = 0 center dot 26, P < 0 center dot 05, for F-VIIAg), whereas inverse relations were found between F-VII, the total proportion of fatty acid as polyunsaturated fatty acid (r = -0 center dot 26 and r = -0 center dot 25, P < 0 center dot 05, for F-VIIbt and F-VIIAg respectively), polyunsaturated-saturated fat ratio (r = -0 center dot 25, P < 0 center dot 05, for F-VIIbt) and, more significantly, between F-VII and adipose-tissue alpha-linolenic acid (r = -0 center dot 29, P < 0 center dot 01, for F-VIIbt and r = -0 center dot 49, P < 0 center dot 001, for F-VIIAg). All these correlations remained significant after matching for BMI. In a multiple linear regression analysis, only adipose tissue alpha-linolenic acid was a negative and independent predictor of F-VIIAg (P = 0 center dot 004) and, at borderline significance, of F-VIIbt (P = 0 center dot 061) when allowance was made for BMI, WTR, smoking and plasma triglycerides. In conclusion, this study shows significant relations between F-VII and adipose tissue fatty acid composition in healthy male individuals; it supports the possibility that adipose tissue poly-unsaturated fatty acids, derived from dietary intake, play a role in the relation between F-VII and coronary heart disease (CHD), thus suggesting that high dietary polyunsaturated fatty acid intake (especially alpha-linolenic acid) may reduce the risk for CHD by an improvement of a number of risk factors, including a lowering of plasma F-VII (both activity and antigen).

Do dietary and supplementary intakes of antioxidants differ with smoking status?

BACKGROUND: Differences in dietary and supplementary intake of antioxidants were determine between different categories of smokers and never-smokers. METHODS: Data from a large, cross-sectional, population-based study were used. Subjects (n = 4244) were divided into five smoking categories according to the number of cigarettes smoked per day. Differences in intake of antioxidants or frequency of supplement use were assessed using multiple linear regression analysis and multiple logistic regression analysis, adjusting for potential confounders such as age, body mass index, education level, alcohol intake, and total energy intake. RESULTS: Men who smoked > 20 cigarettes/day had significantly lower intakes of beta-carotene and especially ascorbic acid compared to those who never smoked, resulting from an almost 60% lower fruit intake. Moderate and heavy smoking women also had lower ascorbic acid and fruit intake but differences were not as large as in men. A higher percentage of female heavy smokers compared with never-smokers consumed vitamin C (21.1% versus 14.1%), vitamin E (5.6% versus 1.8%), and multivitamin supplements (18.5% versus 12.2%). Among men only the moderate smokers differed significantly from never-smokers in supplement intake, in the sense that male moderate smokers had a higher percentage of multivitamin use (15.3% versus 12.2%) compared to never-smokers. CONCLUSIONS: Male heavy smokers not only have a lower dietary antioxidant intake than never-smokers, but additionally seem to use supplementation relatively infrequently.