Cannabis policy in The Netherlands: Rationale and design of an experiment with a controlled legal ('closed') cannabis supply chain.

Since the Dutch tolerance policy, allowing the purchase of cannabis in 'coffeeshops', is associated with problems of public order and safety as well as health risks, there has been a long debate about legalisation of cannabis production and supply. It was therefore decided to conduct an experiment with a controlled legal ('closed') cannabis supply chain for recreational use. This is of international relevance in view of the current illegal cannabis exports from the Netherlands, the importance of sharing knowledge about the effectiveness of cannabis policies, and the accumulation of evidence needed to evaluate and update international treaties. Here we describe and discuss the background, general approach and design of the experiment. An independent expert committee elaborated how the closed chain will operate and be evaluated, based on the experience with the medicinal cannabis chain, and round table discussions with stakeholders (mayors, coffeeshop owners, cannabis consumers, growers, regulators, scientists, and addiction experts). Ten trusted cannabis growers are contracted to produce and supply cannabis to the coffeeshops in intervention municipalities, with product quality control, law enforcement against criminal interference, and preventive efforts to reduce health risks being implemented. No changes will be made in the cannabis supply to the coffeeshops in participating control municipalities. A process evaluation will assess whether the chain from production to sale in the intervention municipalities was really closed. In a quasi-experimental study comparing intervention and control municipalities, the chain's effects on public health, cannabis-related crime, safety and public nuisance will be estimated. The fieldwork period is expected to start early 2024 and will take four years, including reporting to the government and parliament. These will then decide whether and what further steps towards legalisation of the production and supply of cannabis will be taken.

Psychological distress and lower health-related quality of life are associated with need for dietary support among colorectal cancer survivors with overweight or obesity.

OBJECTIVE: Two-third of colorectal cancer (CRC) survivors are overweight or obese. Psychological distress and low health-related quality of life (HRQoL) may be barriers to improving diet. We aimed to assess associations between psychological distress and HRQoL and the need for dietary support in CRC survivors with overweight or obesity. METHODS: All alive individuals diagnosed with CRC between 2000 and 2009, as registered by the Dutch population-based Eindhoven Cancer Registry, were eligible for participation and received a questionnaire. Multivariable logistic regression analyses were conducted to assess associations between HRQoL (EORTC QLQ-C30), symptoms of anxiety and depression (HADS), and self-reported need for dietary support (single-item). RESULTS: A total of 1458 completed the questionnaire (response rate 82%), and 756 (43%) had a BMI of 25.0 or higher and complete data on "need for dietary support" and were included for analyses. BMI ranged between 25.0 and 60.6 (mean, 28.9; SD, 3.6). The majority (71.7%) was overweight (BMI ≥ 25), and 28.3% obese (BMI ≥ 30). Twenty-one percent reported a need for dietary support which was associated with more psychological distress and lower HRQoL. Those who experienced symptoms of anxiety or depression were more likely to report a need for dietary support (27.6% and 28.7%) than those who did not experience symptoms of anxiety (12.3%; OR 2.02; 95% CI 1.22-3.35) or depression (13.5%; OR 1.96; 95% CI 1.19-3.22). CONCLUSIONS: Results suggest that psychological distress and lower HRQoL should be taken into account while promoting a healthy diet in overweight or obese CRC survivors since these factors may hinder adherence to a healthy diet.

Improving dietary intake during lunch through the provision of a healthy school lunch at Dutch primary schools: design of a pretest-posttest effectiveness study.

BACKGROUND: Since there is a shift from eating lunch at home to eating lunch at primary schools in the Netherlands, providing a school lunch may be an important opportunity to improve the diet quality of Dutch children. Therefore, the aim of this Healthy School Lunch project is to encourage healthy eating behavior of children at primary schools by offering a healthy school lunch, based on the guidelines for a healthy diet. In this study, two research questions will be addressed. The first research question is: What and how much do children consume from a self-served school lunch and how do they evaluate the lunch? The second research question is: Do children compensate healthier school lunches by eating less healthy outside school hours? The purpose of this paper is to report the rationale and study design of this study. METHODS: In the Healthy School Lunch project children in grades 5-8 (aged 8-12 years) of three primary schools in the Netherlands will receive a healthy school lunch for a 6-month period. To answer research question 1, lunch consumption data will be collected at baseline and again at 3- and 6-months. This will be measured with lunch photos and questionnaires among children. To answer the second research question, a quasi-experimental, pre-test post-test intervention-comparison group design (3 intervention schools and 3 comparison schools) will be carried out. Potential compensation effects will be measured with a single brief questionnaire among parents at the three intervention and three comparison schools at month 6 of the lunch period. The school lunch will also be evaluated by parents (discussion groups) and teachers and support staff (brief questionnaires). DISCUSSION: Results of this study will provide valuable information to influence future school lunch interventions and policies. TRIAL REGISTRATION: This study is registered at the Netherlands trial register (NTR): trialregister.nl, Trial NL7402 (NTR7618), registered retrospectively at 2018-11-13.

Impact of nutrition education on nutritional knowledge and intentions towards nutritional counselling in Dutch medical students: an intervention study.

OBJECTIVE: Management of diet-related chronic diseases may benefit from improved nutrition education of medical students. This study aims to investigate the effects of a nutrition education course on nutritional knowledge and intentions towards nutritional counselling in Dutch medical students. DESIGN: This is a pre-post intervention study with a comparison group. Participants completed self-reported questionnaires on nutritional knowledge and intentions towards nutritional counselling. PARTICIPANTS: In total, 118 medical students (64.4% undergraduate, 73.2% women) were recruited from two medical schools in the Netherlands (n=66 intervention group, n=52 comparison group). INTERVENTION: The intervention group completed a 25-hour course in nutritional counselling (the Students Experienced in Lifestyle and Food (SELF) course) in addition to the standard medical curriculum. The comparison group followed the standard medical curriculum. OUTCOME MEASURES: Self-reported nutritional knowledge and intentions towards nutritional counselling, including attitude, self-efficacy and social support. RESULTS: Nutritional knowledge (B: 2.42, 95% CI 1.81 to 3.02), attitude in men (B: 0.50, 95% CI 0.13 to 0.87) and self-efficacy (B: 0.78, 95% CI 0.62 to 0.95) significantly increased in the intervention group compared with the comparison group. No significant differences were found for social support (B: 0.20, 95% CI -0.02 to 0.43) and attitude in women (B: 0.08, 95% CI -0.24 to 0.31) between the two groups. CONCLUSIONS: The SELF course increased medical students' nutritional knowledge and stimulated their intentions towards nutritional counselling. Future research is needed to evaluate the long-term impact of nutrition education interventions on physician practice patterns and patient outcomes.

Youth perspectives on weight-related words used by healthcare professionals: A qualitative study.

BACKGROUND: Although healthcare professionals often consider body weight a sensitive and difficult topic to discuss with children, a contextualized and comprehensive understanding of youth perspectives on weight-related words used in healthcare has yet to be established. This qualitative study aims to explore perspectives of Dutch children on the terminology healthcare professionals use when discussing weight. METHODS: Fourteen interviews and one focus group discussion were held with children (age 8-16) who were in care because of their weight. A toolkit with customizable interview techniques was used in order to facilitate reflection and tailor the interview to each respondent. A narrative content analysis was conducted. RESULTS: Respondents attached both clear and subtle differences in meanings to (certain) weight-related words. Their perspectives were not unanimous for any single word. Moreover, at times, respondents framed certain words in positive or negative ways or used a word they disliked to describe themselves. This illustrates that meanings of weight-related words are not fixed but context and situation specific. CONCLUSION: This study revealed that meanings children assign to weight-related words are shaped by their experiences in the broader social context, especially at school, as well as with (previous) healthcare professionals. It pointed towards the importance of bedside manner, acquaintanceship, and support. Healthcare professionals treating children because of their body weight are advised to invest in a good patient-caregiver relationship, pay attention to children's previous (negative) social weight-related experiences, and reflect critically on their own preconceptions about body weight and the impact these preconceptions might have on their patient-caregiver relationships.

[Lifestyle medicine: effective cure or just snake oil?] / Leefstijlgeneeskunde: reddingsboei of los touw?

Many chronic non-communicable diseases are at least partly caused by unhealthy lifestyles; an example is type 2 diabetes mellitus (T2DM). Lifestyle interventions have been shown to substantially reduce the risk of T2DM in high-risk patients. The risk reduction diminishes over time, but a long-term (> ten years) reduction is still achieved. Better compliance with the intervention and higher quality of lifestyle counselling during a longer period of time are predictors of improved long-term risk reduction. In patients with established T2DM, lifestyle intervention can be of great benefit as well. This can result in remission in a substantial proportion of the patients (12-46%) over a one-year period. A Mediterranean diet, which is low in both refined, starch-rich foods and high-sugar drinks, seems to result in the best outcomes. However, again the compliance and quality of lifestyle counselling are of crucial importance. Lifestyle medicine deserves serious attention in clinical practice.

An exploration of needs and preferences for dietary support in colorectal cancer survivors: A mixed-methods study.

PURPOSE: To describe the proportion of colorectal cancer (CRC) survivors who perceive a need for dietary support; to examine which socio-demographic, cancer-related, and health-related characteristics are associated with this need; to explore reasons for (not) needing support; and to explore CRC survivors' specific needs and preferences with regard to lifestyle (i.e., dietary, exercise, and/or weight management) support. METHODS: This mixed-methods study comprised a cross-sectional survey among 1774 Dutch CRC survivors and three focus groups (n = 16). To examine associations, logistic regression analyses were conducted. Focus groups were audio-taped, transcribed verbatim, and analyzed using a thematic approach. RESULTS: Of 1458 respondents (82%), 1198 (67.5%) were included for analyses. 17.5% reported a need for dietary support. Characteristics associated with this need were: being younger, living without a partner, having a stoma, having diabetes, and being overweight or obese. The main reason for needing support was being unable to initiate and maintain lifestyle changes without support. CRC survivors preferred receiving information soon after diagnosis to make an autonomous, informed decision on improving their lifestyle. They preferred to receive individually-tailored lifestyle support in an autonomy-supportive environment, preferably with involvement of their family and fellow-sufferers. CONCLUSIONS: This study has provided knowledge on appropriate support for CRC survivors in need for dietary support to improve health outcomes by promoting adherence to lifestyle and body weight recommendations. Findings can be used to better identify CRC survivors in need for dietary support, and to tailor lifestyle support to their needs and preferences in order to promote uptake, adherence, and effectiveness.

Water Consumption in European Children: Associations with Intake of Fruit Juices, Soft Drinks and Related Parenting Practices.

Background: High intake of fruit juices and soft drinks contributes to excessive weight gain and obesity in children. Furthermore, parenting practices play an important role in the development of children's dietary habits. The way parents play this role in the development of their children's choices of beverages is still unclear. Objectives: To study the associations: (1) of both fruit juices and soft drinks consumption with water consumption of children and (2) The associations between parenting practices towards fruit juices and soft drinks and water consumption of children. Design: Cross-sectional data from 6 to 8 year old children from seven European communities (n = 1187) were collected. Associations among fruit juices, soft drinks, the respective parenting practices and the child's water consumption were assessed by parental questionnaires. Results: The consumption of water was inversely associated with that of soft drinks but not with the consumption of fruit juices. The child's water intake was favorably influenced when stricter parenting practices towards soft drinks were adopted (e.g., less parental allowance, low home availability and high parental self-efficacy in managing intake). There was less influence observed of parenting practices towards fruit juices. Fruit juices were consumed more often than soft drinks. Conclusions: Low consumption of soft drinks-and not of fruit juices-was associated with high water consumption in children in the current study. Moreover, parenting practices towards both fruit juices and soft drinks were associated with the water intake of the children, irrespective of their socio-economic status.

The role of systemic inflammation linking maternal BMI to neurodevelopment in children.

Children of obese mothers are at increased risk of developmental adversities. Maternal obesity is linked to an inflammatory in utero environment, which, in turn, is associated with neurodevelopmental impairments in the offspring. This is an integrated mechanism review of animal and human literature related to the hypothesis that maternal obesity causes maternal and fetal inflammation, and that this inflammation adversely affects the neurodevelopment of children. We propose integrative models in which several aspects of inflammation are considered along the causative pathway linking maternal obesity with neurodevelopmental limitations.

Overweight and obese adults have low intentions of seeking weight-related care: a cross-sectional survey.

BACKGROUND: The prevalence of obesity is growing worldwide. Obesity guidelines recommend increasing the level of weight-related care for persons with elevated levels of weight-related health risk (WRHR). However, there seems to be a discrepancy between need for and use of weight-related care. The primary aim of this study is to examine predisposing factors that may influence readiness to lose weight and intention to use weight-related care in an overweight population. METHODS: A population-based, cross-sectional survey was conducted. Data were collected using an online self-administered questionnaire sent to a population-representative sample of 1,500 Dutch adults on the Health Care Consumer Panel (n = 861 responded). Data were used from individuals (n = 445) with a mildly, moderately or severely elevated level of WRHR. WRHR status was based on self-reported data on Body Mass Index, risk assessment for diabetes mellitus type 2 (DM2) and cardiovascular disease (CVD), or co-morbidities. RESULTS: 55.1% of persons with increased WRHR were ready to lose weight (n = 245). Depending on level of WRHR; educational level, marital status, individuals with an accurate perception of their weight and better perceptions and expectations of dietitians were significantly related to readiness to lose weight. Most of them preferred individual weight-loss methods (82.0% of n = 245). 11% (n = 26 of n = 245) intended to use weight-related care. Weight-related care seeking was higher for those with moderate or severe WRHR. Expectations and trust in dietitians did not seem to influence care seeking. CONCLUSIONS: Many Dutch adults who are medically in need of weight-related care are ready to lose weight. Most intend to lose weight individually, and only a few intend to use weight-related care. Therefore, obesity prevention initiatives should focus on monitoring weight change and weight-loss plans, and timely referral to obesity management. However, many people are not ready to lose weight. For this group, strategies for behaviour change may depend on WRHR, perceptions of weight and dietitians, educational level and marital status. Obesity prevention initiatives should focus on increasing the awareness of the seriousness of their condition and offering individually appropriate weight management programmes.

[The price of healthy nutrition]. / De prijs van gezonde voeding.

Governments can influence healthy dietary choices of populations by taxing relatively unhealthy foods and drinks and/or subsidizing relatively healthy options. Experimental and modelling studies have shown that such fiscal policies can contribute to the prevention of diseases such as obesity.

[Salt and hypertension: a need for reduction on a population level?]. / Zout en hypertensie: verlaging op populatieniveau geoorloofd?

The average salt intake in the Netherlands is well above the nationally recommended maximum intake of 6 grams per day. People with high intakes, especially if they have hypertension or type 2 diabetes mellitus and/or are older than 50 years of age are advised to lower their salt intake. Decreasing the intake of highly processed foods to which salt has been added and lowering the salt content of these foods seems to be sensible advice on a population level. Salt in food is directly related to blood pressure but also increases the palatability of processed foods and increases thirst, which may contribute to obesity. Reductions in salt intake should be accompanied by an increase in food rich in potassium such as vegetables, avoidance of excessive alcohol intake and the maintenance of a healthy weight. This strategy would not only be beneficial for improved blood pressure control but would also contribute to the general prevention of non-communicable diseases.

Obesity and cardiovascular disease risk factors among the indigenous and immigrant Pakistani population: a systematic review.

AIM: The aim of this study was to systematically describe the gender and ethnic differences regarding the prevalence of general/central obesity and cardiovascular disease (CVD) risk factors such as diabetes mellitus type 2, hypertension, and hypercholesterolemia among the indigenous and immigrant Pakistani communities. METHODS: The search engine used was PubMed, supplemented with regional data from the Medical Institutes of Pakistan. The focus was on the adult Pakistani population (18 years and older). RESULTS: We found only 7 studies among the immigrant Pakistani community and 24 studies among the indigenous Pakistani community. The studies had limitations such as low participation rates and use of self-reported data. There is a higher prevalence of central obesity among women (42.2%) than among men (14.7%) (National Health Survey of Pakistan). Certain ethnicities such as Muhajir and Baluchis showed a higher prevalence of cardiovascular risk factors when compared to other ethnicities in the indigenous Pakistani population. The results also indicate that the prevalence of obesity is 10-20% higher among the immigrant Pakistanis than in the indigenous Pakistanis. CONCLUSION: The relatively high prevalence of obesity and associated CVD risk factors (especially in women) among both indigenous and immigrant Pakistani populations require the attention of the healthcare professionals and policy makers, both inside and outside Pakistan.

The effect of a comprehensive lifestyle intervention on cardiovascular risk factors in pharmacologically treated patients with stable cardiovascular disease compared to usual care: a randomised controlled trial.

BACKGROUND: The additional benefit of lifestyle interventions in patients receiving cardioprotective drug treatment to improve cardiovascular risk profile is not fully established.The objective was to evaluate the effectiveness of a target-driven multidisciplinary structured lifestyle intervention programme of 6 months duration aimed at maximum reduction of cardiovascular risk factors in patients with cardiovascular disease (CVD) compared with usual care. METHODS: A single centre, two arm, parallel group randomised controlled trial was performed. Patients with stable established CVD and at least one lifestyle-related risk factor were recruited from the vascular and cardiology outpatient departments of the university hospital. Blocked randomisation was used to allocate patients to the intervention (n = 71) or control group (n = 75) using an on-site computer system combined with allocations in computer-generated tables of random numbers kept in a locked computer file. The intervention group received the comprehensive lifestyle intervention offered in a specialised outpatient clinic in addition to usual care. The control group continued to receive usual care. Outcome measures were the lifestyle-related cardiovascular risk factors: smoking, physical activity, physical fitness, diet, blood pressure, plasma total/HDL/LDL cholesterol concentrations, BMI, waist circumference, and changes in medication. RESULTS: The intervention led to increased physical activity/fitness levels and an improved cardiovascular risk factor profile (reduced BMI and waist circumference). In this setting, cardiovascular risk management for blood pressure and lipid levels by prophylactic treatment for CVD in usual care was already close to optimal as reflected in baseline levels. There was no significant improvement in any other risk factor. CONCLUSIONS: Even in CVD patients receiving good clinical care and using cardioprotective drug treatment, a comprehensive lifestyle intervention had a beneficial effect on some cardiovascular risk factors. In the present era of cardiovascular therapy and with the increasing numbers of overweight and physically inactive patients, this study confirms the importance of risk factor control through lifestyle modification as a supplement to more intensified drug treatment in patients with CVD. TRIAL REGISTRATION: ISRCTN69776211 at http://www.controlled-trials.com.

[Obesity: more nurture than nature]. / Obesitas: meer 'nurture' dan 'nature'

Hereditary factors as a cause of obesity have long been a subject of interest. The authors of another article in the Netherlands Journal of Medicine propose that 75% of differences in BMI are determined by heredity. However, these estimates differ quite considerably from study to study. In addition even though the genetic makeup of humans has not changed for tens of thousands of years, the number of obese people has greatly increased. The discovery of genetic reasons for obesity is certainly of scientific importance, but at population level nurture remains the most important.

Interventions to promote an integrated approach to public health problems: an application to childhood obesity.

Experts stress the need to bring the childhood obesity epidemic under control by means of an integrated approach. The implementation of such an approach requires the development of integrated enabling policies on public health by local governments. A prerequisite for developing such integrated public health policies is intersectoral collaboration. Since the development of integrated policies is still in its early stages, this study aimed to answer the following research question: "What interventions can promote intersectoral collaboration and the development of integrated health policies for the prevention of childhood obesity?" Data were collected through a literature search and observations of and interviews with stakeholders. Based on a theoretical framework, we categorized potential interventions that could optimize an integrated approach regarding children's physical activity and diet. The intervention categories included education, persuasion, incentivization, coercion, training, restriction, environmental restructuring, modeling, and enablement.

Resting energy expenditure in malnourished older patients at hospital admission and three months after discharge: predictive equations versus measurements.

BACKGROUND: Predicting resting energy expenditure (REE) in malnourished hospitalized older patients is important for establishing optimal goals for nutritional intake. Measuring REE by indirect calorimetry is hardly feasible in most clinical settings. OBJECTIVE: To study the most accurate and precise REE predictive equation for malnourished older patients at hospital admission and again three months after discharge. DESIGN: Twenty-three equations based on weight, height, gender, age, fat free mass (FFM) and/or fat mass (FM) and eleven fixed factors of kcal/kg were compared to measured REE. REE was measured by indirect calorimetry. Accuracy of REE equations was evaluated by the percentage patients predicted within 10% of REE measured, the mean percentage difference between predicted and measured values (bias) and the Root Mean Squared prediction Error (RMSE). RESULTS: REE was measured in 194 patients at hospital admission (mean 1473 kcal/d) and again three months after hospital discharge in 107 patients (mean 1448 kcal/d). The best equations predicted 40% accuracy at hospital admission (Lazzer, FAO/WHO-wh and Owen) and 63% three months after discharge (FAO/WHO-wh). Equations combined with FFM, height or illness factor predicted slightly better. Fixed factors produce large RMSE's. All predictive equations showed proportional bias, with overestimation of low REE values and underestimation of high REE values. Correction by regression analysis did not improve results. CONCLUSIONS: The REE predictive equations are not adequate to predict REE in malnourished hospitalized older patients. There is an urgent need for either a new accurate REE predictive equation, or accurate easy-to-use equipment to measure REE in clinical practice.

Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults.

OBJECTIVES: To evaluate the effects of a short-term nutritional intervention with protein and vitamin D on falls in malnourished older adults. DESIGN: Randomized controlled trial. SETTING: From hospital admission until 3 months after discharge. PARTICIPANTS: Malnourished older adults (≥ 60) newly admitted to an acute hospital (n = 210). INTERVENTION: Participants were randomized to receive nutritional intervention (energy- and protein-enriched diet, oral nutritional supplements, calcium-vitamin D supplement, telephone counseling by a dietitian) for 3 months after discharge or usual care. MEASUREMENTS: Number of participants who fell, fall incidents, serum 25-hydroxyvitamin D, and dietary intake. Measurements were performed on admission to hospital and 3 months after discharge. RESULTS: Three months after discharge, 10 participants (10%) in the intervention group had fallen at least once, compared with 24 (23%) in the control group (hazard ratio = 0.41, 95% confidence interval (CI) = 0.19-0.86). There were 57 fall incidents (16 in the intervention group; 41 in the control group). A significantly higher intake of energy (280 kcal, 95% CI = 37-524 kcal) and protein (11 g, 95% CI = 1-25 g) and significantly higher serum 25-hydroxyvitamin D levels (10.9 nmol/L, 95% CI = 2.9-18.9 nmol/L) were found in participants in the intervention group than in controls. CONCLUSION: A short-term nutritional intervention consisting of oral nutritional supplements and calcium and vitamin D supplementation and supported by dietetic counseling in malnourished older adults decreases the number of patients who fall and fall incidents.

Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs.

BACKGROUND & AIMS: Older people are vulnerable to malnutrition which leads to increased health care costs. The aim of this study was to evaluate the cost-effectiveness of nutritional supplementation from a societal perspective. DESIGN: This randomized controlled trial included hospital admitted malnourished elderly (≥ 60 y) patients. Patients in the intervention group received nutritional supplementation (energy and protein enriched diet, oral nutritional support, calcium-vitamin D supplement, telephone counselling by a dietician) until three months after discharge from hospital. Patients in the control group received usual care (control). Primary outcomes were Quality Adjusted Life Years (QALYs), physical activities and functional limitations. Measurements were performed at hospital admission and three months after discharge. Data were analyzed according to the intention-to-treat principle and multiple imputation was used to impute missing data. Incremental cost-effectiveness ratios were calculated and bootstrapping was applied to evaluate cost-effectiveness. Cost-effectiveness was expressed by cost-effectiveness planes and cost-effectiveness acceptability curves. RESULTS: 210 patients were included, 105 in each group. After three months, no statistically significant differences in quality of life and physical activities were observed between groups. Functional limitations decreased significantly more in the intervention group (mean difference -0.72, 95% CI-1.15; -0.28). There were no differences in costs between groups. Cost-effectiveness for QALYs and physical activities could not be demonstrated. For functional limitations we found a 0.95 probability that the intervention is cost-effective in comparison with usual care for ceiling ratios > €6500. CONCLUSIONS: A multi-component nutritional intervention to malnourished elderly patients for three months after hospital discharge leads to significant improvement in functional limitations and is neutral in costs. A follow-up of three months is probably too short to detect changes in QALYs or physical activities.