Health-related quality of life in children under treatment for overweight, obesity or severe obesity: a cross-sectional study in the Netherlands.

BACKGROUND: It is unknown whether weight class is associated with impairment of health-related quality of life (HRQOL) for children in the Netherlands. The aim of this study was to explore generic and weight-specific HRQOL in a clinical cohort of children with overweight, obesity or severe obesity aged 5-19 years in the Netherlands. METHODS: 803 children from three clinical cohorts participated: mean age 11.5 (SD 2.9) years, 61.1% girls. The influence of weight class was explored in a subgroup of 425 children (25.2% with overweight, 32.5% obesity and 42.3% severe obesity), of whom the exact International Obesity Task Force (IOTF) BMI class was known. Generic HRQOL was measured by the PedsQL child report. Weight-specific HRQOL was measured by the IWQOL-Kids child or parent report. Average total, subscale and item scores were reported and the influence of the IOTF BMI class analyzed by multiple linear regression, corrected for age and sex. RESULTS: Children with severe obesity had lower generic and weight-specific HRQOL scores than those with obesity or overweight. IOTF BMI class was negatively associated with item scores from all subscales, especially physical, social and emotional functioning. Children with overweight reported similar HRQOL total, subscale and item scores to children with obesity. CONCLUSIONS: In the Netherlands, children treated for overweight, obesity or severe obesity experience problems on the majority of items within all subscales of generic and weight-specific HRQOL. Children with severe obesity especially report significantly more challenges due to their weight than children with obesity or overweight.

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.

Scoping literature review and focus groups with healthcare professionals on psychosocial and lifestyle assessments for childhood obesity care.

BACKGROUND: Childhood obesity is a complex disease resulting from the interaction of multiple factors. The effective management of childhood obesity requires assessing the psychosocial and lifestyle factors that may play a role in the development and maintenance of obesity. This study centers on available scientific literature on psychosocial and lifestyle assessments for childhood obesity, and experiences and views of healthcare professionals with regard to assessing psychosocial and lifestyle factors within Dutch integrated care. METHODS: Two methods were used. First, a scoping review (in PubMed, Embase, PsycInfo, IBSS, Scopus and Web of Science) was performed by systematically searching for scientific literature on psychosocial and lifestyle assessments for childhood obesity. Data were analysed by extracting data in Microsoft Excel. Second, focus group discussions were held with healthcare professionals from a variety of disciplines and domains to explore their experiences and views about assessing psychosocial and lifestyle factors within Dutch integrated care. Data were analysed using template analysis, complemented with open coding in MAXQDA. RESULTS: The results provide an overview of relevant psychosocial and lifestyle factors that should be assessed and were classified as child, family, parental and lifestyle (e.g. nutrition, physical activity and sleep factors) and structured into psychological and social aspects. Insights into how to assess psychosocial and lifestyle factors were identified as well, including talking about psychosocial factors, lifestyle and weight; the professional-patient relationship; and attitudes of healthcare professionals. CONCLUSIONS: This study provides an overview of psychosocial and lifestyle factors that should be identified within the context of childhood obesity care, as they may contribute to the development and maintenance of obesity. The results highlight the importance of both what is assessed and how it is assessed. The results of this study can be used to develop practical tools for facilitating healthcare professionals in conducting a psychosocial and lifestyle assessment.

Talking with pediatric patients with overweight or obesity and their parents: self-rated self-efficacy and perceived barriers of Dutch healthcare professionals from seven disciplines.

BACKGROUND: Many healthcare professionals (HCPs) feel uncomfortable and incompetent talking about weight with children with overweight and obesity and their parents. To optimally target interventions that can improve obesity care for children, we assessed the self-efficacy (SE) and perceived barriers (PBs) of Dutch HCPs with regard to talking about weight and lifestyle when treating children with overweight or obesity. We also analyzed interdisciplinary differences. METHODS: A newly developed, practice- and literature-based questionnaire was completed by 578 HCPs from seven disciplines. ANOVA and chi-square tests were used to analyze interdisciplinary differences on SE, PBs, and the effort to discuss weight and lifestyle despite barriers. Regression analyses were used to check whether age, sex or work experience influenced interdisciplinary differences. RESULTS: On average, the reported score on SE was 7.2 (SD 1.2; scale 1-10) and the mean number of PBs was 4.0 (SD 2.3). The majority of HCPs (94.6%) reported perceiving one or more barriers (range 0-12 out of 17). HCPs who in most cases perceived too many barriers to discuss weight and lifestyle of the child (9.6%, n = 55) reported a lower SE (mean 6.3) than professionals who were likely to discuss these topics (mean SE 7.3, p < 0.01), despite having a similar number of PBs (mean 4.5 vs 4.0, p > 0.05). In total, 14.2% (n = 82) of HCPs either felt incapable (SE ≤ 5) or reported that in most cases they did not address weight and lifestyle due to PBs. CONCLUSIONS: Although on average Dutch HCPs rated their self-efficacy as fairly good, for a subgroup major improvements are necessary to lower perceived barriers and improve self-efficacy, in order to improve the quality of care for Dutch children with obesity.

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.

Development of the 'Canteen Scan': an online tool to monitor implementation of healthy canteen guidelines.

BACKGROUND: To improve the availability and accessibility of healthier food and drinks in schools, sports and worksites canteens, national Guidelines for Healthier Canteens were developed by the Netherlands Nutrition Centre. Until now, no tool was available to monitor implementation of these guidelines. This study developed and assessed the content validity and usability of an online tool (the 'Canteen Scan') that provides insight into and directions for improvement of healthier food products in canteens. METHODS: The Canteen Scan was developed using a three-step iterative process. First, preliminary measures and items to evaluate adherence to the guidelines were developed based on literature, and on discussions and pre-tests with end-users and experts from science, policy and practice. Second, content validity of a paper version of the Canteen Scan was assessed among five end-users. Third, the online Canteen Scan was pilot tested among end-users representing school canteens. Usability was measured by comprehensibility, user-friendliness, feasibility, time investment, and satisfaction. RESULTS: The content validity of the Canteen Scan was ensured by reaching agreement between stakeholders representing science, policy and practice. The scan consists of five elements: 1) basic conditions (e.g. encouragement to drink water and availability of policy regarding the guidelines), 2) product availability offered on displays (counter, shelf) and 3) in vending machines, 4) product accessibility (e.g. promotion and placement of products), and 5) an overall score based on the former elements and tailored feedback for creating a healthier canteen. The scan automatically classifies products into healthier or less healthy products. Pilot tests indicated good usability of the tool, with mean scores of 4.0-4.6 (5-point Likert scale) on the concepts comprehensibility, user-friendliness and feasibility. CONCLUSION: The Canteen Scan provides insight into the extent to which canteens meet the Dutch Guidelines for Healthier Canteens. It also provides tailored feedback to support adjustments towards a healthier canteen and with the scan changes over time can be monitored. Pilot tests show this tool to be usable in practice.

Gallstone disease in severely obese children participating in a lifestyle intervention program: incidence and risk factors.

INTRODUCTION: Cholelithiasis is increasingly encountered in childhood and adolescence due to the rise in obesity. As in adults, weight loss is presumed to be an important risk factor for cholelithiasis in children, but this has not been studied. METHODS: In a prospective observational cohort study we evaluated the presence of gallstones in 288 severely obese children and adolescents (mean age 14.1±2.4 years, body mass index (BMI) z-score 3.39±0.37) before and after participating in a 6-month lifestyle intervention program. RESULTS: During the lifestyle intervention, 17/288 children (5.9%) developed gallstones. Gallstones were only observed in those losing >10% of initial body weight and the prevalence was highest in those losing >25% of weight. In multivariate analysis change in BMI z-score (odds ratio (OR) 3.26 (per 0.5 s.d. decrease); 95% CI:1.60-6.65) and baseline BMI z-score (OR 2.32 (per 0.5 s.d.); 95% CI: 1.16-4.70) were independently correlated with the development of gallstones. Sex, family history, OAC use, puberty and biochemistry were not predictive in this cohort. During post-treatment follow-up (range 0.4-7.8 years) cholecystectomy was performed in 22% of those with cholelithiasis. No serious complications due to gallstones occurred. CONCLUSION: The risk of developing gallstones in obese children and adolescents during a lifestyle intervention is limited and mainly related to the degree of weight loss and initial body weight.

Dietetic treatment lowers body mass index in overweight patients: an observational study in primary health care.

BACKGROUND: Greater insight into the effectiveness of usual dietetic care will contribute to the ongoing development of dietetic services. The present study examined the change in body mass index (BMI) in overweight patients after dietetic treatment in primary care, the sources of variability and factors associated with BMI change. METHODS: This population-based observational study was based on data from a Dutch registration network of dietitians in primary health care. Data were derived from electronic medical records concerning 3960 overweight adult patients (BMI ≥ 25 kg m⁻²) who received usual care from 32 registered dietitians between 2006 and 2012. Multilevel linear regression analyses were conducted. RESULTS: Patients' BMI significantly (P < 0.001) decreased by 0.94 kg m⁻² on average during treatment. An additional reduction of 0.8 kg m⁻² was observed in patients treated for longer than 6 months. BMI decreased by 0.06 kg m⁻² for each additional unit in initial BMI above 31.6. Most (97%) variability in BMI change was attributed to patients and 3% to dietitians. Part of the variance between patients (11%) and dietitians (30%) was explained by patient sociodemographic characteristics, nutrition-related health aspects, initial body weight and treatment duration. CONCLUSIONS: Dietetic treatment in primary care lowers BMI in overweight patients. Patients' change in BMI was rather similar between dietitians. Greater BMI reductions were observed in those with a high initial BMI and those treated for at least 6 months. Future research is necessary to study the long-term effects of weight loss after treatment by primary healthcare dietitians, especially because many patients drop out of treatment prematurely.

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

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

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

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

The effect of a counselling intervention on weight changes during and after pregnancy: a randomised trial.

OBJECTIVES: To evaluate the effects of a counselling intervention on excessive weight gain during pregnancy and postpartum weight retention. DESIGN: The New Life(style) study was a randomised trial with a control group (n = 113) and an intervention group (n = 106). SETTING: Midwife practices in the Netherlands. POPULATION: Women with a healthy pregnancy, expecting their first baby. METHODS: The intervention consisted of four face-to-face counselling sessions about weight, physical activity and diet during pregnancy, and one session by telephone after delivery. MAIN OUTCOME MEASURES: Weight was objectively assessed at 15, 25 and 35 weeks of gestation, and again at 8, 26 and 52 weeks postpartum. In regression models, the intervention effect on gestational weight gain and postpartum weight retention was assessed. RESULTS: Women gained on average 11.3 kg (SD 3.7 kg) from early to late pregnancy. Women were 1.0 kg (SD 5.3 kg) lighter at 52 weeks postpartum compared with early pregnancy. The intervention had no effect on gestational weight gain (B = -0.05; 95% CI -1.10 to 1.00) or postpartum weight (B = 0.94; 95% CI -2.41 to 0.53) in the total study group. In a subgroup of overweight and obese women (n = 47), a favourable trend on all outcomes was observed, but none of the differences were statistically significant. CONCLUSION: The lifestyle counselling intervention evaluated in this study did not have an effect on excessive weight gain or postpartum weight retention. Our findings for overweight and obese women need to be confirmed in a larger, well-designed randomised trial.

A lipoprotein lipase mutation (Asn291Ser) is associated with reduced HDL cholesterol levels in premature atherosclerosis.

A reduction of high density lipoprotein cholesterol (HDC) is recognized as an important risk factor for coronary artery disease (CAD). We now show in approximately 1 in 20 males with proven atherosclerosis that an Asn291Ser mutation in the human lipoprotein lipase (LPL) gene is associated with significantly reduced HDL levels (P = 0.001) and results in a significant decrease in LPL catalytic activity (P < 0.0009). The relative frequency of this mutation increases in those patients with lower HDL cholesterol levels. In vitro mutagenesis and expression studies confirm that this change is associated with a significant reduction in LPL activity. Our data support the relationship between LPL activity and HDL-C levels, and suggest that a specific LPL mutation may be a factor in the development of atherosclerosis.

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

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

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.

The process evaluation of two interventions aimed at portion size in worksite cafeterias.

BACKGROUND: In a previous study, the effectiveness of introducing a small meal in addition to the existing size and a proportional pricing strategy have been assessed in Dutch worksite cafeterias. To assess the degree of implementation and to inform the design of future interventions, the present study aimed to describe the process evaluation of both interventions. METHODS: Process evaluation components from Baranowski and Stables, and Rogers (i.e. Recruitment, Maintenance, Context, Resources, Implementation, Exposure, Contamination, and Continued use) were chosen as a theoretical basis. The process evaluation involved qualitative (e.g. structured observations, semi-structured interviews) and quantitative data (e.g. consumer questionnaires) collected from 17 intervention and eight control worksite cafeterias. RESULTS: In all intervention cafeterias, two portion sizes were offered. The pricing instructions were followed in 13 intervention cafeterias. The cafeterias managers indicated that they did not consider offering large and small meals as being complex, risky or time-consuming to implement. Some managers perceived the consumer demand as high, others as (too) low. One year after the study had ended, nine of the intervention cafeterias had continued (at least partly) to follow the protocol. CONCLUSIONS: Offering a smaller portion size in addition to the existing size, as well as proportional pricing, was generally implemented as prescribed by the protocol and can be considered promising in terms of continued use. However, additional efforts are needed to make the intervention more effective in motivating consumers to replace their large portion with a small portion.

Small portion sizes in worksite cafeterias: do they help consumers to reduce their food intake?

BACKGROUND: Environmental interventions directed at portion size might help consumers to reduce their food intake. OBJECTIVE: To assess whether offering a smaller hot meal, in addition to the existing size, stimulates people to replace their large meal with a smaller meal. DESIGN: Longitudinal randomized controlled trial assessing the impact of introducing small portion sizes and pricing strategies on consumer choices. SETTING/PARTICIPANTS: In all, 25 worksite cafeterias and a panel consisting of 308 consumers (mean age=39.18 years, 50% women). INTERVENTION: A small portion size of hot meals was offered in addition to the existing size. The meals were either proportionally priced (that is, the price per gram was comparable regardless of the size) or value size pricing was employed. MAIN OUTCOME MEASURES: Daily sales of small and the total number of meals, consumers' self-reported compensation behavior and frequency of purchasing small meals. RESULTS: The ratio of small meals sales in relation to large meals sales was 10.2%. No effect of proportional pricing was found B=-0.11 (0.33), P=0.74, confidence interval (CI): -0.76 to 0.54). The consumer data indicated that 19.5% of the participants who had selected a small meal often-to-always purchased more products than usual in the worksite cafeteria. Small meal purchases were negatively related to being male (B=-0.85 (0.20), P=0.00, CI: -1.24 to -0.46, n=178). CONCLUSION: When offering a small meal in addition to the existing size, a percentage of consumers that is considered reasonable were inclined to replace the large meal with the small meal. Proportional prices did not have an additional effect. The possible occurrence of compensation behavior is an issue that merits further attention.

The effects of using a nutrition logo on consumption and product evaluation of a sweet pastry.

Nutrition logos have received a great deal of attention to stimulate people to eat a healthier diet. However, very little is known neither about actual consumption behavior related to nutrition logos nor about potential compensatory eating behaviors due to nutrition logos. The aim of this study was to assess the effects of using an existing nutrition logo on consumption and product evaluation of a chocolate mousse cake. A cross-over design was applied with two conditions: a condition with a logo and a condition without a logo. Participants were females recruited in the university community (n = 36, mean age 22.6 ± 6.3). Data on consumption, tastefulness, perceived healthiness, dietary restraint and Body Mass Index were collected. No significant differences between conditions were found on consumption and tastefulness. The cake was rated as significantly less unhealthy in the logo condition. In conclusion, results cannot be extrapolated to other products, especially not to products that are perceived as healthy. In this study, the use of a nutrition logo did not result in an increased consumption and had no effect on the rating of taste of a sweet pastry among females from the university community.

[Guideline 'Diagnosis and treatment of obesity in adults and children']. / Richtlijn 'diagnostiek en behandeling van obesitas bij volwassenen en kinderen'.

The multidisciplinary guideline 'Diagnosis and treatment of obesity in adults and children' developed by the Dutch Institute for Healthcare Improvement (CBO) is based on published scientific evidence whenever possible. Diagnosis ofobesity requires a body-mass index (BMI) of 30 kg/m2 or more with additional assessment of waist circumference and comorbidity. For children and adolescents, use ofage-specific BMI thresholds is recommended. Treatment of obesity consists of multiple lifestyle interventions for at least 1 year, followed by long-term management aimed at weight maintenance or any further weight loss. In adults, the goal is to achieve weight loss of at least 5% and a reduction in waist circumference of at least 10% after 1 year. If weight loss after 1 year is less than 5%, the addition of pharmacological interventions to lifestyle interventions can be considered. Bariatric surgery can be considered for patients with a BMI of 40 kg/m2 or more and for those with BMI 35-40 kg/m2 with one or more comorbidities. Pharmacological and surgical interventions are not recommended for children and adolescents.