Development and validation of a Context-sensitive Positive Health Questionnaire (CPHQ): A factor analysis and multivariate regression study.

BACKGROUND: The concept of Positive Health (PH) has gained increasing attention as a way of measuring individuals' ability to adapt in the face of contextual challenges. However, a suitable measurement instrument for PH that encompasses contextual factors has not yet been developed. This paper responds to this need by developing a Context-specific Positive Health (CPH) measurement instrument that aligns with the Capability Approach (CA). METHODS: The measurement instrument was developed and tested among a representative sample of 1002 Dutch internet survey panel members with diverse sociodemographic backgrounds. The instrument was developed in two stages: a preparation phase consisting of focus groups and expert consultations, and a validation among a representative panel of Dutch citizens. The goal of the preparation phase, was to pilot test and refine previously proposed Positive Health questionnaires into an initial version of the CPHQ. The validation phase aimed to examine the initial CPHQ's factorial validity using Factor Analysis, and its concurrent validity using Multivariate Regression Analysis. RESULTS: The developed questionnaire demonstrated adequate factorial and concurrent validity. Furthermore, it explicitly includes an assessment of resilience, this being a key component of PH. CONCLUSIONS: The introduced measurement tool, the CPHQ, comprises 11 dimensions that we have labeled as follows: relaxation, autonomy, fitness, perceived environmental safety, exclusion, social support, financial resources, political representation, health literacy, resilience, and enjoyment. In this article, we present four major contributions. Firstly, we embedded the measurement in a theoretical framework. Secondly, we focused the questionnaire on a key concept of Positive Health - the "ability to adapt." Thirdly, we addressed issues of health inequality by considering contextual factors. Finally, we facilitated the development of more understandable measurement items.

Exploring timing and delivery of lifestyle advice following an acute cardiac event hospitalization: The cardiac patient's perspective.

OBJECTIVE: To explore the perspective of cardiac patients regarding the timing and manner of delivering lifestyle advice following an acute cardiac event hospitalization. METHODS: Dutch cardiac patients who experienced a cardiac event hospitalization participated in a semi-structured interview (n = 14) or a cross-sectional survey study (n = 119). RESULTS: Our findings indicate that cardiac patients are receptive to lifestyle advice throughout the care trajectory. Advice delivered by a cardiologist had the highest self-reported impact. Furthermore, receiving advice at multiple phases during the care trajectory was associated with a greater intention to change lifestyle (B = 0.37, CI = 0.17 - 0.57). Patients favored clear-cut, feasible, and friendly but confronting advice. Moreover, they stressed the importance of advice being aligned with their identity and beliefs about the causes of their disease. CONCLUSION: The period following an acute cardiac event provides a unique opportunity to offer tailored and patient-centered lifestyle advice. This "teachable window" for lifestyle change, when used wisely, may improve health outcomes for cardiac patients. PRACTICE IMPLICATIONS: Healthcare professionals should initiate lifestyle advice already during hospitalization and continue during follow-up appointments and cardiac rehabilitation. Advice should be feasible and empathy-based, as well as tailored to the patient's needs, values, and perceptions of the causes of their cardiovascular disease.

A cross-sectional analysis of factors associated with the teachable moment concept and health behaviors during pregnancy.

BACKGROUND: Pregnancy is often associated with a change in health behaviors, leading some to suggest that pregnancy could be a teachable moment for lifestyle change. However, the prevalence and underlying mechanism of this phenomenon is not well understood. The aim of this study is to explore the prevalence of a teachable moment during pregnancy, the psychosocial factors that are associated with experiencing such a moment, and its association with actual health behaviors. METHODS: In this cross-sectional study, 343 pregnant Dutch women completed an online questionnaire. Participants reported on their intentions to change lifestyle due to pregnancy, their current health behaviors, and several psychosocial factors that were assumed to be linked to perceiving a teachable moment during pregnancy: perceived risk, affective impact, changed self-concept, and social support. Multivariable linear and logistic regression were applied to the data analysis. RESULTS: Results demonstrate that 56% of the women experienced a teachable moment based on intentions to change their health behavior. Multivariate regression analyses revealed that changed self-concept (ß = 0.21; CI = 0.11-0.31), positive affect (positive ß = 0.28; CI = 0.21-0.48), and negative affect (ß = 0.12; CI = 0.00-0.15) were associated with higher intentions to change health behavior. Conversely, more perceived risk was associated with lower intentions to change health behavior (ß=-0.29; CI = 0.31 - 0.13). Multivariate regression analyses showed a positive association between intentions to change health behavior and diet quality (ß = 0.11; CI = 0.82-1.64) and physical activity (OR = 2.88; CI = 1.66-5.00). CONCLUSIONS: This study suggests that pregnancy may be experienced as a teachable moment, therefore providing an important window of opportunity for healthcare professionals to efficiently improve health behaviors and health in pregnant women and their children. Results suggest that healthcare professionals should link communication about pregnancy-related health behaviors to a pregnant women's change in identity, affective impact (predominantly positive affective impact) and risk perception to stimulate the motivation to change healthy behavior positively.

Do parental attachment and prosocial behavior moderate the impairment from depression symptoms in adolescents who seek mental health care?

We investigated parental attachment and prosocial behavior as social protective indicators in adolescents (age 11­17) with symptoms of depression in a clinical setting. Specifically, we tested the moderating effect of these factors on the relation between symptoms of depression and their impairment on daily life. The Development and Well-Being Assessment, as completed by children, mothers, and fathers, was used, and hierarchical multiple regression analyses were conducted for these three perspectives. From the adolescents' reports, we only found a significant effect of symptoms on impairment, indicating that a higher number of symptoms were related to higher impairment. For the mothers and fathers, a higher score on the adolescents' prosocial behavior was related to a lower impairment from depression symptoms on the daily life of the adolescent and the family. Only for the mothers did a higher score on prosocial behavior buffer the effect of symptoms on impairment, while a higher parental attachment score was associated with a lower impairment. Further, when examining maternal and paternal attachment separately, only the mothers reported less impairment when perceiving that the adolescent was attached to the father. Paternal attachment even buffered the effect of symptoms on impairment. To conclude, our results indicate that social protective factors, from the parent's perspective, are likely to have a beneficial effect in clinical practice and should be taken into account when examining impairment scores. Future studies should investigate whether additional protective indicators from the adolescents' perspective, such as quality of parental attachment or family climate, may have a positive impact on their daily functioning.

Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event: An interpretative phenomenological analysis.

OBJECTIVE: Previous research has shown that experiencing an acute cardiac event, such as a myocardial infarction (MI), can lead to lifestyle changes. This study aimed to explore the potential of a MI as a 'teachable moment' (TM) for positive lifestyle changes and to identify psychosocial sensemaking processes that facilitate or hinder the presence of a TM. METHOD: We conducted semi-structured interviews with 14 patients who suffered their first MI and were hospitalized in a larger Dutch city. Participants were interviewed twice, respectively one and five months after their hospitalization. They were encouraged to explain how they experienced their MI and how this had affected their lifestyle. We used an Interpretative Phenomenological Analysis approach to the data collection and analysis. FINDINGS: The participants varied in their willingness to adopt a healthy lifestyle due to their MI. Most participants experienced their event as a TM for changing specific health behaviors, for example facilitated by reflecting on self-concept or social roles and by constructing and comprehending a personal narrative of their MI. Some participants struggled to follow through on their intentions to change their behavior, for example because of a negative attitude towards a healthy behavior or because they perceived it as incongruent to their identity. Only three participants maintained most former health behaviors, for example because they failed to acknowledge their MI as severe or because of earlier life events that elicited more blunted cognitive responses. CONCLUSION: Cardiac patients may experience a TM, which is the consequence of interrelated processes of psychosocial sensemaking. As this does not occur at a singular time point, we suggest using the term 'teachable window' rather than 'moment'. Given these findings, there is a window of opportunity to provide continuous psychosocial and lifestyle support during and after hospitalization for acute cardiac events.

The inflammatory potential of diet is associated with the risk of age-related eye diseases.

BACKGROUND & AIMS: Inflammation is involved in the pathogenesis of cataract, age-related macular degeneration (AMD), and possibly open-angle glaucoma (OAG). We assessed whether the inflammatory potential of diet (quantified using the dietary inflammatory index; DII) affects the incidence of these common blinding age-related eye diseases. Serum inflammation markers were investigated as possible mediators. METHODS: Participants aged >45 years were selected from the prospective, population-based Rotterdam Study. From 1991 onwards, every 4-5 years, participants underwent extensive eye examinations. At baseline, blood samples and dietary data (using food frequency questionnaires) were collected. The DII was adapted based on the data available. Of the 7436 participants free of eye diseases at baseline, 4036 developed incident eye diseases during follow-up (cataract = 2895, early-intermediate AMD = 891, late AMD = 81, OAG = 169). RESULTS: The adapted DII (aDII) ranged from -4.26 (i.e., anti-inflammatory) to 4.53 (i.e., pro-inflammatory). A higher aDII was significantly associated with increased inflammation. A higher neutrophil-lymphocyte ratio (NLR) was associated with an increased risk of cataract and AMD. Additionally, complement component 3c (C3c) and systemic immune-inflammation index (SII) were associated with increased risks of cataract and late AMD, respectively. Every point increase in the aDII was associated with a 9% increased risk of cataract (Odds ratio [95% confidence interval]: 1.09 [1.04-1.14]). The NLR and C3c partly mediated this association. We also identified associations of the aDII with risk of AMD (early-intermediate AMD, OR [95% CI]: 1.11 [1.03-1.19]; late AMD, OR [95% CI]: 1.24 [1.02-1.53]). The NLR partly mediated these associations. The aDII was not associated with OAG. CONCLUSIONS: A pro-inflammatory diet was associated with increased risks of cataract and AMD. Particularly the NLR, a marker of subclinical inflammation, appears to be implicated. These findings are relevant for patients with AMD and substantiate the current recommendations to strive for a healthy lifestyle to prevent blindness.

The Dutch Solid Start program: describing the implementation and experiences of the program's first thousand days.

BACKGROUND: In 2018, the Dutch government initiated the Solid Start program to provide each child the best start in life. The program focuses on the crucial first thousand days of life, which span from preconception to a child's second birthday, and has a specific focus towards (future) parents and young children in vulnerable situations. A key program element is improving collaboration between the medical and social sector by creating Solid Start coalitions. This study aimed to describe the implementation of the Dutch Solid Start program, in order to learn for future practice and policy. Specifically, this paper describes to what extent Solid Start is implemented within municipalities and outlines stakeholders' experiences with the implementation of Solid Start and the associated cross-sectoral collaboration. METHODS: Quantitative and qualitative data were collected from 2019 until 2021. Questionnaires were sent to all 352 Dutch municipalities and analyzed using descriptive statistics. Qualitative data were obtained through focus group discussions(n = 6) and semi-structured interviews(n = 19) with representatives of care and support organizations, knowledge institutes and professional associations, Solid Start project leaders, advisors, municipal officials, researchers, clients and experts-by-experience. Qualitative data were analyzed using the Rainbow Model of Integrated Care. RESULTS: Findings indicated progress in the development of Solid Start coalitions(n = 40 in 2019, n = 140 in 2021), and an increase in cross-sectoral collaboration. According to the stakeholders, initiating Solid Start increased the sense of urgency concerning the importance of the first thousand days and stimulated professionals from various backgrounds to get to know each other, resulting in more collaborative agreements on cross-sectoral care provision. Important elements mentioned for effective collaboration within coalitions were an active coordinator as driving force, and a shared societal goal. However, stakeholders experienced that Solid Start is not yet fully incorporated into all professionals' everyday practice. Most common barriers for collaboration related to systemic integration at macro-level, including limited resources and collaboration-inhibiting regulations. Stakeholders emphasized the importance of ensuring Solid Start and mentioned various needs, including sustainable funding, supportive regulations, responsiveness to stakeholders' needs, ongoing knowledge development, and client involvement. CONCLUSION: Solid Start, as a national program with strong local focus, has led to various incremental changes that supported cross-sectoral collaboration to improve care during the first thousand days, without major transformations of systemic structures. However, to ensure the program's sustainability, needs such as sustainable funding should be addressed.

Implementation of a group-based lifestyle intervention programme (Healthy Heart) in general practices in The Netherlands: a mixed-methods study.

BACKGROUND: Lifestyle intervention programmes target behavioural risk factors that contribute to cardiovascular diseases (CVDs). Unfortunately, sustainable implementation of these programmes can be challenging. Gaining insights into the barriers and facilitators for successful implementation is important for maximising public health impact of these interventions. The Healthy Heart (HH) programme is an example of a combined lifestyle intervention programme. AIM: To analyse the reach, adoption, and implementation of the HH programme. DESIGN & SETTING: A mixed-methods study conducted in a general practice setting in The Netherlands. METHOD: Quantitative data were collected from the Healthy Heart study (HH study), a non-randomised cluster stepped-wedge trial to assess the effect of the HH programme on patients at high risk of developing CVDs at practice level. Qualitative data were obtained through focus groups. RESULTS: Out of 73 approached general practices, 55 implemented the HH programme. A total of 1082 patients agreed to participate in the HH study, of whom 64 patients were referred to the HH programme and 41 patients participated. Several barriers for participation were identified such as time investment, lack of risk perception, and being confident in changing lifestyle on their own. Important barriers for healthcare providers (HCPs) to refer a patient were time investment, lack of information to sufficiently inform patients, and preconceived notions regarding which patients the programme was suitable for. CONCLUSION: This study has offered insights from a patient and HCP perspective regarding barriers and facilitators for implementation of the group-based lifestyle intervention programme. The identified barriers and facilitators, and the suggested improvements, can be used by others who wish to implement a similar programme.

Anti-tissue transglutaminase antibodies (TG2A) positivity and the risk of vitamin D deficiency among children - a cross-sectional study in the generation R cohort.

BACKGROUND: Suboptimal vitamin D status is common in people with celiac disease (CeD), a disease that can be characterized by the presence of serum anti-tissue transglutaminase antibodies (TG2A) (i.e., TG2A positivity). To date, it remains unclear whether childhood TG2A positivity is associated with vitamin D status and how this potential association can be explained by other factors than malabsorption only, since vitamin D is mainly derived from exposure to sunlight. The aim of our study was therefore to assess whether childhood TG2A positivity is associated with vitamin D concentrations, and if so, to what extent this association can be explained by sociodemographic and lifestyle factors. METHODS: This cross-sectional study was embedded in the Generation R Study, a population-based prospective cohort. We measured serum anti-tissue transglutaminase antibodies (TG2A) concentrations and serum 25-hydroxyvitamin D (25(OH)D) concentrations of 3994 children (median age of 5.9 years). Children with serum TG2A concentrations ≥ 7 U/mL were considered TG2A positive. To examine associations between TG2A positivity and 25(OH)D concentrations, we performed multivariable linear regression, adjusted for sociodemographic and lifestyle factors. RESULTS: Vitamin D deficiency (serum 25(OH)D < 50 nmol/L) was found in 17 out of 54 TG2A positive children (31.5%), as compared to 1182 out of 3940 TG2A negative children (30.0%). Furthermore, TG2A positivity was not associated with 25(OH)D concentrations (ß -2.20; 95% CI -9.72;5.33 for TG2A positive vs. TG2A negative children), and this did not change after adjustment for confounders (ß -1.73, 95% CI -8.31;4.85). CONCLUSIONS: Our findings suggest there is no association between TG2A positivity and suboptimal vitamin D status in the general pediatric population. However, the overall prevalence of vitamin D deficiency in both populations was high, suggesting that screening for vitamin D deficiency among children, regardless of TG2A positivity, would be beneficial to ensure early dietary intervention if needed.

Lifestyle Intervention Randomized Controlled Trial for Age-Related Macular Degeneration (AMD-Life): Study Design.

Age-related macular degeneration (AMD) has a strong genetic basis, but environmental factors such as smoking and a healthy diet can decrease the genetic fate by up to 50%. Current guidelines for clinical management include recommendations for a healthy lifestyle and antioxidant supplementation. However, many ophthalmologists do not inform their patients of this AMD-beneficial lifestyle. An important reason is the lack of trust that transition of lifestyle will be feasible in persons of advanced age and lack of methodology to measure lifestyle or its biological effects. To address these issues, we set up the lifestyle intervention study AMD-Life. It aims to investigate whether personalized risk-profiling (including genetic testing) and/or additional coaching can motivate patients to change their lifestyle. It also explores which biomarkers best reflect lifestyle change beneficial for AMD. The first year is a three-arm, self-contained open-label randomized clinical trial. A total of 150 AMD patients aged 55-85 years were randomized into three arms: (A) merely standard recommendations; (B) A conditions plus personalized risk profiling based on genetics and lifestyle, (C) B conditions plus coaching. The second year tests sustainability of lifestyle changes without active intervention. AMD-Life can provide further insight into the relevance of these interventions for the clinical management of AMD.

Monitoring the Dutch Solid Start Program: Developing an Indicator Set for Municipalities to Monitor their First Thousand Days-Approach.

Introduction: The Dutch Solid Start program aims to improve the collaboration between the medical and social sector to offer every child the best start in life. Municipalities form local coalitions of partners within the medical and social sector to support parents and children during the first thousand days. The aim of this study was to develop an indicator set for coalitions to monitor their local Solid Start program. Methods: A modified Delphi study with three rounds was carried out among Dutch experts in Solid Start practice, policy and research (n = 39) to reach consensus. Results: The indicator set included 19 indicators covering the three phases of the Solid Start program: preconception, pregnancy and after birth (up to two years). Prioritized indicators included both social and medical topics, among which poverty, psychological/psychiatric problems, stress, smoking, cumulation of risk factors, preconception care, low literacy, premature birth, and intellectual disability. Additionally, a development agenda was established with topics and indicators that lacked data or clear operationalization (e.g. stress, unintended pregnancy, loneliness). Discussion and conclusion: The developed indicator set enhances the conversation between policymakers, managers, professionals and other stakeholders about the local situation and developments in order to prioritize interventions and policies. Next, the indicator set needs evaluation to assess its usefulness.

Optimizing the Acceptability, Adherence, and Inclusiveness of the COVID Radar Surveillance App: Qualitative Study Using Focus Groups, Thematic Content Analysis, and Usability Testing.

BACKGROUND: The COVID Radar app was developed as a population-based surveillance instrument to identify at-risk populations and regions in response to the COVID-19 pandemic. The app boasts of >8.5 million completed questionnaires, with >280,000 unique users. Although the COVID Radar app is a valid tool for population-level surveillance, high user engagement is critical to the success of the COVID Radar app in maintaining validity. OBJECTIVE: This study aimed to identify optimization targets of the COVID Radar app to improve its acceptability, adherence, and inclusiveness. METHODS: The main component of the COVID Radar app is a self-report questionnaire that assesses COVID-19 symptoms and social distancing behaviors. A total of 3 qualitative substudies were conducted. First, 3 semistructured focus group interviews with end users (N=14) of the app were conducted to gather information on user experiences. The output was transcribed and thematically coded using the framework method. Second, a similar qualitative thematic analysis was conducted on 1080 end-user emails. Third, usability testing was conducted in one-on-one sessions with 4 individuals with low literacy levels. RESULTS: All 3 substudies identified optimization targets in terms of design and content. The results of substudy 1 showed that the participants generally evaluated the app positively. They reported the app to be user-friendly and were satisfied with its design and functionalities. Participants' main motivation to use the app was to contribute to science. Participants suggested adding motivational tools to stimulate user engagement. A larger national publicity campaign for the app was considered potentially helpful for increasing the user population. In-app updates informing users about the project and its outputs motivated users to continue using the app. Feedback on the self-report questionnaire, stemming from substudies 1 and 2, mostly concerned the content and phrasing of the questions. Furthermore, the section of the app allowing users to compare their symptoms and behaviors to those of their peers was found to be suboptimal because of difficulties in interpreting the figures presented in the app. Finally, the output of substudy 3 resulted in recommendations primarily related to simplification of the text to render it more accessible and comprehensible for individuals with low literacy levels. CONCLUSIONS: The convenience of app use, enabling personal adjustments of the app experience, and considering motivational factors for continued app use (ie, altruism and collectivism) were found to be crucial to procuring and maintaining a population of active users of the COVID Radar app. Further, there seems to be a need to increase the accessibility of public health tools for individuals with low literacy levels. These results can be used to improve the this and future public health apps and improve the representativeness of their user populations and user engagement, ultimately increasing the validity of the tools.

The development and validation of scales to measure the presence of a teachable moment following a cardiovascular disease event.

Better conceptually-driven research is necessary to learn more about 1) the characteristics of life events as teachable moments (TMs) and 2) the potential of life events to evoke lifestyle change intention (LCI). This study aimed to develop and validate two scales for the purposes of TM research in the context of cardiovascular disease (CVD): the CardiacTM and CardiacLCI-scales. After the initial development of items based on a theoretical framework and literature search, six experts rated the content validity of both scales as sufficient. The item list was further adjusted after think-aloud sessions with two CVD patients. The resulting scales were presented online in a cross-sectional survey, which yielded 625 responses of Dutch CVD patients (June 2020). To test construct validity, we conducted Exploratory Factor Analysis (EFA) with Varimax rotation on a random split-half of the sample (n = 300) and evaluated the factor structure with Confirmatory Factor Analysis (CFA) on the holdout sample (n = 325). EFA and CFA on the CardiacTM-scale (α = 0.88) revealed a 28-item six-factor structure explaining 61.0% of the variance, with adequate goodness-of-fit statistics (CFI = 0.87; TLI = 0.85; SRMR = 0.07) and internally reliable factors (Affective impact, Risk CVD, Changed self-concept, CVD group identity, Risk non-communicable disease, Anticipated regret). The CardiacLCI-scale (α = 0.81) revealed an 11-item two-factor structure explaining 51.5% of the variance, with adequate model fit (CFI = 0.92; TLI = 0.90; SRMR = 0.08) and internally reliable factors (Event-related lifestyle change and General healthy lifestyle). The scales may be used to expand knowledge around life events as TMs and to support conversation regarding lifestyle after cardiac and other life events.

Food insecurity in Dutch disadvantaged neighbourhoods: a socio-ecological approach.

Food insecurity is an important public health concern; however, research into this phenomenon within the Netherlands is limited. Food insecurity is not solely related to individual factors, but can also be influenced by various factors in the social and physical environment. Therefore, this study aimed to identify determinants of food insecurity within the personal, social and physical environment, based on the social ecological model (SEM), and to identify their relative importance for experiencing food insecurity. The study population consisted of 307 participants living in disadvantaged neighbourhoods of the Dutch city The Hague, of which approximately one-quarter were food insecure. Participant characteristics showing bivariate associations P < 0⋅20 were placed in a predetermined level of the SEM, after which a multivariate logistic regression was performed for each level and the Nagelkerke pseudo R 2 was presented. Determinants of food insecurity were BMI, gross monthly income, highest educational attainment, smoking status, diet quality, employment status, marital status and religion (P < 0⋅05). The results showed that 29⋅7 % of the total variance in food insecurity status was explained by all included determinants together. The personal, social and physical environment explained 20⋅6, 14⋅0 and 2⋅4 % of the total variance, respectively. Our findings suggest that determinants within the personal environment are most important for explaining differences in experienced food insecurity. The present study contributes to furthering the knowledge about the relative importance of the personal, social and physical environment, indicating that determinants within the personal environment may be most promising for developing targeted interventions to reduce food insecurity.

[Indoor sporting during the COVID-19 pandemic: analysis with data from the COVID RADAR app]. / Binnensporten tijdens de COVID-19-pandemie: analyse met behulp van data uit de COVID RADAR app.

Indoor sporting locations have been forced to stay closed longer than outdoor sporting locations during the lockdowns introduced during the COVID-19 pandemic. This research addresses the question whether exercising indoors does raise one's risk of infection with SARS-CoV­2. This analysis was performed using data from the COVID RADAR app and accounted for user differences in age, vaccine status, sex, other risky behavior, SARS-CoV­2 prevalence and quality of living environment. Analyzing data from 1,353 users, 13.1% of which reported a positive SARS-CoV­2 test, we found that exercising indoors leads to an odds ratio of 1.8 with a positive SARS-CoV­2 test (95%-confidence interval 1.2-2.6, p = 0.003), as compared to users who exercise outdoors. This confirms the justification used in longer closing indoor sporting locations to reduce the number of infections.

Extending the Theory of Planned Behavior for Explaining Dietary Quality: The Role of Financial Scarcity and Food Insecurity Status.

OBJECTIVE: To examine whether an extended Theory of Planned Behavior (TPB) that included finance-related barriers better explained dietary quality. DESIGN: Cross-sectional survey. PARTICIPANTS: One-thousand and thirty-three participants were included from a Dutch independent adult panel. MAIN OUTCOME: Dietary quality. ANALYSIS: Five TPB models were assessed: a traditional TPB, a TPB that included direct associations between attitude and subjective norm with dietary quality, a TPB that additionally included financial scarcity or food insecurity, and a TPB that additionally included financial scarcity and food insecurity simultaneously. Structural relationships among the constructs were tested to compare the explanatory power. RESULTS: The traditional TPB showed poorest fit (χ2/degrees of freedom = 11; comparative fit index = 0.75; root mean square error of approximation [95% confidence interval], 0.10 [0.091-0.12]; standardized root mean square residual = 0.049), the most extended TPB (including both financial scarcity and food insecurity) showed best fit (χ2/degrees of freedom = 3.3; comparative fit index = 0.95; root mean square error of approximation [95% confidence interval], 0.050 [0.035-0.065]; standardized root mean square residual = 0.018). All 5 structure models explained ∼42% to 43% of the variance in intention; however, the variance in dietary quality was better explained by the extended TPB models, including food insecurity and/or financial scarcity (∼22%) compared with the traditional TBP (∼7%), indicating that these models better explained differences in dietary quality. CONCLUSIONS AND IMPLICATIONS: These findings highlight the importance of accounting for finance-related barriers to healthy eating like financial scarcity or food insecurity to better understand individual dietary behaviors in lower socioeconomic groups.

The Food Environment Around Primary Schools in a Diverse Urban Area in the Netherlands: Linking Fast-Food Density and Proximity to Neighbourhood Disadvantage and Childhood Overweight Prevalence.

In the Netherlands, the neighbourhood food environment has received little attention in initiatives to combat overweight/obesity. This study maps the food environment around primary schools in The Hague, The Netherlands, and examines associations between neighbourhood disadvantage, the school food environment and childhood overweight using Geographic Information Systems (GIS). Linear regression analyses were performed to test the association between schools' disadvantage scores (proxy for neighbourhood disadvantage) and relative fast-food density within 400 m and 1000 m and fast-food proximity. Univariable and multivariable linear regression analyses were used to test the association between the school food environment and overweight prevalence among children in the respective sub-district in which the schools is found. Multivariable analyses were adjusted for the schools' disadvantage scores. Results show that fast-food outlets were available around most primary schools. Schools in disadvantaged neighbourhoods were closer to and surrounded by a higher number of fast-food restaurants, grillrooms and kebab shops. On the sub-district level, the density of such fast-food outlets was associated with overweight prevalence among children. These findings highlight the importance of national and local policies to improve the food environment, particularly in disadvantaged neighbourhoods.

Association Between Ultra-Processed Food Intake and All-Cause Mortality: A Systematic Review and Meta-Analysis.

Consumption of ultra-processed foods (UPF) has increased worldwide during the last decades because they are hyperpalatable, cheap, and ready-to-consume products. However, uncertainty exists about their impact on health. We conducted a systematic review and meta-analysis evaluating the association of UPF consumption with all-cause mortality risk. Five bibliographic databases were searched for relevant studies. Random effects models were used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). Of 6,951 unique citations, 40 unique prospective cohort studies comprising 5,750,133 individuals were included; publication dates ranged from 1984 to 2021. Compared with low consumption, highest consumption of UPF (RR = 1.29, 95% CI: 1.17, 1.42), sugar-sweetened beverages (RR = 1.11, 95% CI, 1.04, 1.18), artificially sweetened beverages (RR = 1.14, 95% CI, 1.05, 1.22), and processed meat/red meat (RR = 1.15, 95% CI, 1.10, 1.21) were significantly associated with increased risk of mortality. However, breakfast cereals were associated with a lower mortality risk (RR = 0.85, 95% CI, 0.79, 0.92). This meta-analysis suggests that high consumption of UPF, sugar-sweetened beverages, artificially sweetened beverages, processed meat, and processed red meat might increase all-cause mortality, while breakfast cereals might decrease it. Future studies are needed to address lack of standardized methods in UPF categorization.

Food insecurity status is of added value in explaining poor health: a cross-sectional study among parents living in disadvantaged neighbourhoods in the Netherlands.

OBJECTIVES: The aim of this study was to examine the added value of food insecurity in explaining poor physical and mental health beyond other socioeconomic risk factors. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES: Data for this cross-sectional study were collected using questionnaires with validated measures for food insecurity status and health status, including 199 adult participants with at least 1 child living at home, living in or near disadvantaged neighbourhoods in The Hague, the Netherlands. To assess the added value of food insecurity, optimism-corrected goodness-of-fit statistics of multivariate regression models with and without food insecurity status as a covariate were compared. RESULTS: In the multivariable models explaining poor physical health (Physical Component Summary: PCS) and mental health (Mental Component Summary: MCS), from all included socioeconomic risk factors, food insecurity score was the most important covariate. Including food insecurity score in those models led to an improvement of explained variance from 6.3% to 9.2% for PCS, and from 5.8% to 11.0% for MCS, and a slightly lower root mean square error. Further analyses showed that including food insecurity score improved the discriminative ability between those individuals most at risk of poor health, reflected by an improvement in C-statistic from 0.64 (95% CI 0.59 to 0.71) to 0.69 (95% CI 0.62 to 0.73) for PCS and from 0.65 (95% CI 0.55 to 0.68) to 0.70 (95% CI 0.61 to 0.73) for MCS. Further, explained variance in these models improved with approximately one-half for PCS and doubled for MCS. CONCLUSIONS: From these results it follows that food insecurity score is of added value in explaining poor physical and mental health beyond traditionally used socioeconomic risk factors (ie, age, educational level, income, living situation, employment status and migration background) in disadvantaged communities. Therefore, routine food insecurity screening may be important for effective risk stratification to identify populations at increased risk of poor health and provide targeted interventions.

The interplay between fast-food outlet exposure, household food insecurity and diet quality in disadvantaged districts.

OBJECTIVE: The current study aimed to explore the interplay between food insecurity, fast-food outlet exposure and dietary quality in disadvantaged neighbourhoods. DESIGN: In this cross-sectional study, main associations between fast-food outlet density and proximity, food insecurity status and dietary quality were assessed using Generalized Estimating Equation analyses. We assessed potential moderation by fast-food outlet exposure in the association between food insecurity status and dietary quality by testing for effect modification between food insecurity status and fast-food outlet density and proximity. SETTING: A deprived urban area in the Netherlands. PARTICIPANTS: We included 226 adult participants with at least one child below the age of 18 years living at home. RESULTS: Fast-food outlet exposure was not associated with experiencing food insecurity (fast-food outlet density: b = -0·026, 95 % CI = -0·076; 0·024; fast-food outlet proximity: b = -0·003, 95 % CI = -0·033; 0·026). Experiencing food insecurity was associated with lower dietary quality (b = -0·48 per unit increase, 95 % CI = -0·94; -0·012). This association was moderated by fast-food outlet proximity (Pinteraction = 0·008), and stratified results revealed that the adverse effect of food insecurity on dietary quality was more pronounced for those with the nearest fast-food outlet located closer to the home. CONCLUSIONS: Food insecurity but not fast-food outlet density is associated with dietary quality. However, the association between food insecurity and dietary quality may be modified by the food environment. These findings could inform policymakers to promote a healthier food environment including less fast-food outlets, with particular emphasis on areas with high percentages of food insecure households.