Effects of a lifestyle program in subjects with Impaired Fasting Glucose, a pragmatic cluster-randomized controlled trial.

BACKGROUND: The worldwide epidemic of type 2 diabetes (T2DM) underlines the need for diabetes prevention strategies. In this study the feasibility and effectiveness of a nurse led lifestyle program for subjects with impaired fasting glucose (IFG) is assessed. METHODS: A cluster randomized clinical trial in 26 primary care practices in the Netherlands included 366 participants older than 45 years with newly diagnosed IFG and motivated to change their lifestyle (intervention group, n = 197; usual care group, n = 169). The one-year intervention, consisting of four to five individual nurse-led consultations, was directed at improving physical activity and dietary habits. The primary outcome measure was body mass index (BMI). Linear and logistic multilevel analyses and a process evaluation were performed. RESULTS: Both groups showed small reductions in BMI at 1 and 2 years, but differences between groups were not significant. At both 1 and 2-year follow-up the number of participants physically active for at least 30 minutes at least five days a week was significantly improved in the intervention group compared to the usual care group (intervention group vs. usual care group: OR1year = 3.53; 95 % CI = 1.69-7.37 and OR2years = 1.97; 95 % CI = 1.22-3.20, respectively). The total drop-out rate was 24 %. Process evaluation revealed that participants in the intervention group received fewer consultations than advised, while some practice nurses and participants considered the RM protocol too intensive. CONCLUSIONS: This relatively simple lifestyle program in subjects with IFG resulted in a significant improvement in reported physical activity, but not in BMI. Despite its simplicity, some participants still considered the intervention too intensive. This viewpoint could be related to poor motivation and an absence of disease burden due to IFG, such that participants do not feel a need for behavioural change. Although the intervention provided some benefit, its wider use cannot be advised. TRIAL REGISTRATION: Current Controlled Trials ISRCTN41209683 , date of registration 16/10/2013h  .

The implementation of national action program diabetes in the Netherlands: lessons learned.

BACKGROUND: Over the past decade, the National Action program Diabetes (NAD) was implemented in the Netherlands. Its aim was to introduce the Care Standard (CS) for diabetes by means of a specific implementation plan and piloting in several regions. This study aimed to provide insight into the implementation of the NAD as, coupled with the introduction of the CS, it may function as an example for similar approaches in other countries. METHODS: A series of quantitative studies (participants 2010: N = 1726, participants 2013: N = 1370 & participants pilot regions 2013: N = 168) and qualitative studies (participants 2010: N = 18 and participants 2013: N = 4) was conducted among health care professionals (HCPs). In addition, two quantitative studies were conducted among type 1 and 2 patients (participants 2010: N = 573; participants 2013: N = 5056). RESULTS: Overall, positive changes in diabetes care were detected in the period 2010 - 2013. In 2013 significantly more HCPs were familiar with the CS (43.7 versus 37.6 %) and more HCPs perceived themselves to be working largely or completely in accordance with the CS (89.2 versus 79.0 %) than in 2010. A comparison of the results in specific pilot regions with the rest of the country revealed that HCPs in these regions scored significantly more positively on implementation and appreciation of the CS. This positive trend was reflected by the high levels of reported patient satisfaction and involvement in treatment. HCPs who were in possession of the CS had significantly better scores on the implementation of several elements of the CS than HCPs who were not in possession of the CS. CONCLUSION: The CS has become more prominent and embedded in daily health care practice. In retrospect the CS has provided momentum for the realization of various processes relating to the wider implementation of standards to improve the care for people with other chronic diseases in the Netherlands. Experiences with the NAD and CS underline the need to move towards an integrated multidisciplinary approach of diabetes care worldwide.

Restrictive rules of Dutch mothers regarding their children's dietary intake between meals.

The use of restrictive food rules by parents has been found to be associated with dietary intake in their children. The aim of this study was to explore the use of restrictive rules of Dutch mothers regarding their child's food intake between main meals in detail, to generate necessary input for setting priorities for further research and intervention development. A cross-sectional questionnaire study on nine restrictive rules was completed by 359 mothers of primary school children aged 4-12years. Mothers reported to use an average of 4.1 (SD 2.1) out of nine restrictive food rules and all rules measured in this study were used. The rules mother's reported to use most were not eating shortly before meals, not eating certain foods too often and not eating too much of certain foods. The rules varied according to different foods, but particularly applied to the intake of potato chips, nuts and savory snacks, candy and chocolate. Mothers of a younger age, lower educated mothers and mothers with a higher BMI were less likely to use (certain) restrictive rules. This study showed that mothers use a large variety of rules, particularly to restrict the intake of unhealthy foods and reported on several subgroups that were less likely to use (certain) rules. Our results direct further research and inform the development of interventions.

Correlates of perceived self-care activities and diabetes control among Dutch type 1 and type 2 diabetics.

This study examined how Dutch type 1 and type 2 diabetes patients' perceived autonomy support, as well as their perceived competence and treatment self-regulation, are associated with their diabetes self-care activities (healthy diet, physical activity, monitoring blood glucose, medication use) and general diabetes control. A cross-sectional questionnaire study was conducted among 143 type 1 diabetics and 384 type 2 diabetics. Overall, participants felt competent, supported in their autonomy, and perceived to autonomously self-regulate their diabetes. Our results underline the importance of perceived competence in type 1 and 2 diabetics, as this was strongly associated with adhering to a healthy diet and general diabetes control. Our findings also emphasize the need for autonomy supportive health care professionals in diabetes care. Interestingly, perceived competence partially mediated the influence of autonomy support on general diabetes control.

Mastery and perceived autonomy support are correlates of Dutch diabetes patients' self-management and quality of life.

OBJECTIVE: The aim of this study was to assess the associations between type 2 diabetes patients' mastery and perceived autonomy support and their self-management skills and health-related quality of life (HRQOL). METHODS: A cross-sectional questionnaire survey was conducted among 3352 patients with type 2 diabetes. Key variables were assessed with validated questionnaires. RESULTS: Patients' mastery and perceived autonomy support correlated positively with their self-management skills (r=0.34, p<0.001; r=0.37, p<0.001) and HRQOL (r=0.37, p<0.001; r=0.15, p<0.001). In the linear regression analysis, mastery and perceived autonomy support were positive correlates of self-management (ß=0.23; p<0.001; ß=0.25; p<0.001). Patients with more physical or psychological complications had significantly lower scores on mastery, perceived autonomy support, self-management and HRQOL. CONCLUSION: Our results indicate the importance of mastery in relation to diabetes patients' perceived autonomy support, self-management skills and HRQOL. PRACTICE IMPLICATIONS: Since a greater sense of mastery is likely to increase patients' autonomous motivation to cope with their disease, interventions can aim to influence patients' motivational regulation. In addition, we confirmed the need for autonomy support to improve patients' self-management skills. Professionals can be trained to be autonomy-supportive, which relates to person-centered approaches such as motivational interviewing (MI).

Emotional and instrumental feeding practices of Dutch mothers regarding foods eaten between main meals.

BACKGROUND: To assess how much of a public health problem emotional and instrumental feeding practices are, we explored the use of these feeding practices in a sample of Dutch mothers regarding their child's food intake between main meals. METHODS: A cross-sectional questionnaire study was conducted among 359 mothers of primary school children aged 4-12 years. The questionnaires were completed online at home. RESULTS: Of the mothers, 29.5% reported using foods to reward, 18.1% to punish and 18.9% to comfort their child. Mothers most frequently offered energy-dense and nutrient-poor products such as candy in the context of emotional and instrumental feeding practices. The use of these practices was associated with a lower age of both mother and child and a higher educational level of the mother. Mothers living in neighborhoods with intermediate socioeconomic position used the practices less often than mothers from low and high socioeconomic position neighborhoods. CONCLUSIONS: Our results show that mothers in our sample mainly used unhealthy products in the context of instrumental and emotional feeding practices. Research into the association between these practices and children's dietary intake is warranted, since the use of unhealthy products in the context of these practices may not necessarily lead to an increased consumption of these products. Findings regarding the frequency of use of these practices among specific subgroups can be used to carefully determine the target population for interventions and tailor the content of interventions to specific target group characteristics. Besides examining associations between personal and family characteristics and the use of emotional and instrumental feeding practices, attempts should be made to understand parents' reasons for using them.

Dietary intake by Dutch 1- to 3-year-old children at childcare and at home.

The goal of the current study was to assess dietary intake in a large sample (N=1016) of Dutch toddlers (1-3 years old), both at childcare and at home. Dietary intake during two weekdays was recorded using an observation format applied by childcare staff for intake at childcare, and partially pre-coded dietary journals filled out by parents for intake at home. Children's intake of energy, macronutrients and energy balance-related food groups (fruit, vegetables, sweet snacks, savoury snacks) were compared with Dutch dietary guidelines. In addition, differences between the dietary intake by various subgroups (based on gender, age, childcare attendance, socio-economic status of childcare centre) were explored using multilevel regression analyses, adjusting for nesting of children within centres. Energy intake was high relative to dietary guidelines, and children consumed more or less equal amounts of energy at home and at childcare. Dietary fibre, fruit and vegetable and snack intakes were low. Intake at childcare mainly consisted of carbohydrates, while intake at home contained more proteins and fat. The findings imply various opportunities for childcare centres to improve children's dietary intake, such as providing fruit and vegetables at snacking moments. In addition, the findings underline the importance of assessing dietary intake over a whole day, both at childcare and at home, to allow intake to be compared with dietary guidelines.

Perceptions of Dutch health care professionals regarding the Care Standard for diabetes.

BACKGROUND: The Netherlands can be regarded as unique in the use of the Netherlands Diabetes Federation (NDF) Care Standard (CS) for diabetes. The need to understand the barriers obstructing optimal health care, the dissemination and implementation of health care innovations into daily practice and the extent to which health care professionals actually adhere to guidelines has been emphasized repeatedly. Therefore, the aim of the present study was to suggest ways to optimize the implementation of the CS by examining the perceptions of Dutch health care professionals regarding the CS and the barriers to using it. METHODS: A cross-sectional questionnaire survey was conducted among health care professionals (N = 1547) in 2010. RESULTS: A total of 39.6% (N = 1323) of the participating health care professionals possessed the CS. Only 15.5% of the professionals who were to some extent familiar with the CS (N = 1100) described themselves as working in complete accordance with the CS. The majority (83.9%) thought the CS contributed greatly to ensuring the quality of care; the judgment on the feasibility of working in accordance with the CS was positive (mean = 3.9 on a 5-point Likert scale). However, professionals tended to perceive the guidelines issued by the own professional association as the norm for high quality diabetes care, rather than the CS. The main barrier to using the CS was the lack of effective lifestyle interventions (or access to them) to provide care for people with diabetes or those at increased risk for the disorder. CONCLUSIONS: A limited percentage of health care professionals were found to posses the CS. It is questionable whether possession of the CS is a prerequisite for delivering high quality care. Overall, professionals were largely positive about the CS, although only a minority indicated they were working in complete accordance with it. Professionals and professional organizations should be further educated about the content of the CS and especially its added value with respect to the guidelines for their own professional group, in terms of the multidisciplinary approach to diabetes care. Furthermore, attention should be given to the most important perceived barriers, to facilitate adherence to the CS.

Healthier food choices as a result of the revised healthy diet programme Krachtvoer for students of prevocational schools.

BACKGROUND: Krachtvoer is a Dutch healthy diet programme for prevocational schools, developed in 2001 and revised for a broader target group in 2007, based on the findings of an evaluation of the first version. The goal of this study was to report on the short- and longer-term total and subgroup effects of the revised programme on students' fruit, fruit juice, breakfast, and snack consumption. METHODS: Schools were randomized to the experimental condition, teaching the Krachtvoer programme, or to the control condition teaching the regular nutrition lessons. Self-reported consumption of fruit, fruit juice, breakfast and snacks was measured at baseline directly before programme implementation, one to four weeks after finishing programme implementation, and after six months. Mixed linear and logistic regression analyses were conducted. RESULTS: In total 1117 students of 13 experimental schools and 758 students of 11 control schools participated in the study. Short- and longer-term favourable intervention effects were found on fruit consumption (mean difference between experimental and control group 0.15 servings at both posttests). Regarding fruit juice consumption, only short-term favourable effects were revealed (mean difference between experimental and control group 0.05 glasses). Intervention effects on breakfast intakes were limited. No changes in snack frequency were reported, but students made healthier snack choices as a result of the programme. Some favourable as well as unfavourable effects occurred in subgroups of students. CONCLUSIONS: The effects on fruit consumption and snack choices justify the current nationwide dissemination of the programme. Achieving changes in breakfast consumption may, however, require other strategies.

Appreciation and implementation of the Krachtvoer healthy diet promotion programme for 12- to 14- year-old students of prevocational schools.

BACKGROUND: Krachtvoer is a school-based healthy diet programme, developed in 2001 and revised in 2007 to meet the needs of particular segments of the target population as well as a wider target group. The main aims of the present process evaluation of the revised programme were to examine student and teacher appreciation of the programme, completeness of and adherence to its implementation, and relations between appreciation and completeness of implementation. METHODS: Data were collected among 22 teachers and 1117 students of 13 schools, using student evaluation forms, teacher logbooks, telephone interviews, and classroom observations. RESULTS: Results indicate favourable levels of teacher and student appreciation for the programme in general and the revised elements. Girls, first-year students and students with more favourable dietary intakes particularly appreciated individual programme elements. Levels of completeness of implementation were high, but several teachers did not adhere to the intended implementation period. Some moderately strong relations were found between teacher appreciation and completeness of implementation scores. CONCLUSION: We conclude that the revisions have resulted in a programme that was appreciated well, also by the extended target group, and was implemented with a high degree of completeness. Teacher appreciation proved potentially important for completeness of implementation. We identified several aspects requiring improvement, indicating the importance of continued programme updates and repeated evaluation.

Breakfast consumption among children and adolescents in the Netherlands.

BACKGROUND: The Netherlands Nutrition Centre (NNC) recommends eating a daily breakfast preferably including products from five food groups. The aims of this study were to examine to what extent breakfast consumption among Dutch youngsters attending primary and secondary education (aged 10-19 years) is in accordance with these recommendations and whether breakfast habits differ among demographic subgroups. METHODS: A cross-sectional study was conducted among 2404 youngsters at 71 schools in the Netherlands. All Dutch schools were stratified by educational level and province, and randomly ordered within the strata. Participants completed an online questionnaire at school including food frequency items and a 24-h recall. RESULTS: The percentage of participants reporting to consume breakfast every day varied between 62.9 and 95.5 in different subgroups. Skipping breakfast was associated with being older, being a girl, attending vocational or senior general education and being of non-Dutch origin. Of the participants, <9% consumed products from five food groups as recommended. Participants especially ate products from the 'grain group', followed by the 'dairy group', the 'fats group', 'the liquids group' and the 'fruit/fruit juice group'. Bread, butter and milk were the most frequently consumed products and the majority chose healthy (i.e. low-fat) variants within food groups (i.e. wholemeal bread). CONCLUSION: Health promotion efforts should aim to stimulate breakfast consumption, particularly among vocational school students and adolescents of non-Dutch origin. Special attention should be given to breakfast quality. Future research should investigate whether better adherence to the recommendations of the NNC results in enhanced nutrient intake at breakfast.