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Aim To explore the role of socioeconomic status (SES) in participation, programme attendance, programme acceptability, adherence to lifestyle guidelines, drop-out, and effectiveness in the SLIMMER diabetes prevention intervention. Methods SLIMMER was a randomised controlled intervention, carried out in a real-world setting, targeting 40- to 70-year-old adults at increased risk of developing type 2 diabetes (n = 316). The intervention group participated in a 10-month combined dietary and physical activity programme. Measurements were carried out at baseline, 12 months, and 18 months. Effectiveness was determined for fasting insulin, HbA1c, weight, BMI, waist circumference, and waist-to-height-ratio. Differences between the low SES (no, primary, or lower secondary school) and higher SES group were tested using logistic regression and ANCOVA. Results Fifty-two percent of the SLIMMER participants had a low SES. No differences in participation were observed between the low and higher SES group. The most important reason for non-participation in the low SES group was ‘lack of interest’ (32%), whereas in the higher SES group this was ‘I already exercise enough’ (31%). Attendance, acceptability, adherence, drop-out, and effectiveness after 12 months were similar in the low and higher SES group. After 18 months, the low SES group seemed to maintain slightly better effects for fasting insulin, HbA1c, and waist circumference. Conclusions The current study showed that participation, attendance, acceptability, adherence, drop-out, and effectiveness of the SLIMMER intervention were in general not modified by socioeconomic status. The SLIMMER intervention can contribute to health promotion for individuals in both low and higher socioeconomic groups.

Background Although evidence is accumulating that lifestyle modification may be cost-effective in patients with prediabetes, information is limited on the cost-effectiveness of interventions implemented in public health and primary health care settings. Evidence from well-conducted pragmatic trials is needed to gain insight into the realistic cost-effectiveness of diabetes prevention interventions in real-world settings. The aim of this study is to assess the cost-effectiveness of the SLIMMER lifestyle intervention targeted at patients at high risk of developing type 2 diabetes compared with usual health care in a primary care setting in the Netherlands. Methods Three hundred and sixteen high-risk subjects were randomly assigned to the SLIMMER lifestyle intervention or to usual health care. Costs and outcome assessments were performed at the end of the intervention (12 months) and six months thereafter (18 months). Costs were assessed from a societal perspective. Patients completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. Quality Adjusted Life Years (QALY) were calculated based on the SF-36 questionnaire. Cost-effectiveness planes and acceptability curves were generated using bootstrap analyses. Results The cost-effectiveness analysis showed that the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of €28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to €13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay, WTP, of €20,000/QALY and 81% at a WTP of €80,000/QALY). Conclusions The SLIMMER lifestyle intervention to prevent type 2 diabetes had a low to moderate probability of being cost-effective, depending on the perspective taken. Trial registration The SLIMMER study is retrospectively registered with ClinicalTrials.gov (Identifier NCT02094911) since March 19, 2014.

Duijzer G, Haveman-Nies A, Jansen SC, Ter Beek J, Van Bruggen R, Willink MGJ et al. SLIMMER diabetes voorkomen in de eerste lijn. Huisarts Wet 2017;60(4):160-3. De prevalentie van diabetes is de afgelopen jaren flink gestegen. Onderzoek toont aan dat leefstijlverandering diabetes mellitus type 2 bij hoogrisicopatienten kan uitstellen of voorkomen. De implementatie en effectiviteit van preventieprogramma’s in de praktijk blijft echter een uitdaging vanwege de noodzakelijke aanpassing aan de lokale context en beperkte (financiele) middelen. Omdat in Nederland nog geen effectief diabetespreventieprogramma voor de eerste lijn bestond, is het SLIMMER-programma ontwikkeld. SLIMMER is een gecombineerde leefstijlinterventie waarbij mensen gedurende tien maanden begeleid worden om gezonder te gaan eten en meer te bewegen. In deze beschouwing bespreken we de effectiviteit van het SLIMMER-programma in de eerste lijn en vergelijken we die met de bevindingen van andere implementatieonderzoeken op dit terrein. We hebben de effectiviteit van het SLIMMER-programma onderzocht door middel van een gerandomiseerd gecontroleerd onderzoek. SLIMMER blijkt te leiden tot verbeteringen in klinische en metabole risicofactoren, voedinginname, beweging en kwaliteit van leven. Daarbij waren klinische effecten van ons programma groter dan die van de meeste andere preventieprogramma’s. Dit kan komen door de gedegen voorbereiding, het intensieve programma, het onderhoudsprogramma en aansluiting bij de reguliere werkwijze van eerstelijnszorgverleners. De resultaten van dit onderzoek bieden waardevolle inzichten die kunnen bijdragen aan structurele verankering en financiering van effectieve diabetespreventieprogramma’s in de Nederlandse eerste lijn.

Background Although there are many effective lifestyle interventions for type 2 diabetes (T2DM) prevention, insight into effective intervention pathways, especially of long-term interventions, is often lacking. This study aims to provide insight into the effective intervention pathways of the SLIMMER diabetes prevention intervention using mediation analyses. Methods In total, 240 participants at increased risk of T2DM were included in the analyses over 18 months. The intervention was a combined lifestyle intervention with a dietary and a physical activity (PA) component. The primary and secondary outcomes were change in fasting insulin (pmol/L) and change in body weight (kg) after 18 months, respectively. Firstly, in a multiple mediator model, we investigated whether significant changes in these outcomes were mediated by changes in dietary and PA behavior. Secondly, in multiple single mediator models, we investigated whether changes in dietary and PA behavior were mediated by changes in behavioral determinants and the participants’ psychological profile. The mediation analyses used linear regression models, where significance of indirect effects was calculated with bootstrapping. Results The effect of the intervention on decreased fasting insulin was 40% mediated by change in dietary and PA behavior, where dietary behavior was an independent mediator of the association (34%). The effect of the intervention on decreased body weight was 20% mediated by change in dietary and PA behavior, where PA behavior was an independent mediator (17%). The intervention significantly changed intake of fruit, fat from bread spread, and fiber from bread. Change in fruit intake was mediated by change in action control (combination of consciousness, self-control, and effort), motivation, self-efficacy, intention, and skills. Change in fat intake was mediated by change in action control and psychological profile. No mediators could be identified for change in fiber intake. The change in PA behavior was mediated by change in action control, motivation, and psychological profile. Conclusion The effect of the SLIMMER intervention on fasting insulin and body weight was mediated by changes in dietary and PA behavior, in distinct ways. These results indicate that changing dietary as well as PA behavior is important in T2DM prevention. Electronic supplementary material The online version of this article (doi:10.1186/s12966-017-0532-9) contains supplementary material, which is available to authorized users.

Over the past decades, epidemiology has made a relevant contribution to public health by identifying health problems and analysing their determinants. Recent developments call for new and applied methods to support the planning, implementation and evaluation of public health policies and programmes. This book presents an integrated overview of such epidemiological methods, to be used within the joined working process of several public health disciplines. It provides relevant theories, concepts and tools, illustrated with practical examples in order to empower epidemiologists in public health. The first part of this book describes epidemiological history in a nutshell and explains the relationship with the public health domain. It closes with the presentation of a joint work cycle for policy, practice and research: the public health cycle. Part two presents seven steps epidemiologists should follow to strengthen their contribution to the public health cycle: conduct a needs assessment, support priority setting, formulate aims and objectives, construct a logic model, develop an evaluation plan, perform quality control, and analyse processes and outcomes. Part three illustrates the institutional architecture of public health and describes the professional fields of policy and health promotion as knowledge of these major fields facilitates interdisciplinary collaboration in each stage of the public health cycle. This book is intended for students and epidemiologists in public health practice. It was written by 20 Dutch authors with either longstanding experience or fresh enthusiasm. The editors are all affiliated with Academic Collaborative Centres for Public Health in the Netherlands, which aim to bridge the gap between policy, practice and research.

All over the world, prevalence and incidence rates of type 2 diabetes mellitus are rising rapidly. Several trials have demonstrated that prevention by lifestyle intervention is (cost-) effective. This calls for translation of these trials to primary health care. This article gives an overview of the translation of the SLIM diabetes prevention intervention to a Dutch real-life setting and discusses the role of primary health care in implementing lifestyle intervention programmes. Currently, a 1-year pilot study, consisting of a dietary and physical activity part, performed by three GPs, three practice nurses, three dieticians and four physiotherapists is being conducted. The process of translating the SLIM lifestyle intervention to regular primary health care is measured by means of the process indicators: reach, acceptability, implementation integrity, applicability and key factors for success and failure of the intervention. Data will be derived from programme records, observations, focus groups and interviews. Based on these results, our programme will be adjusted to fit the role conception of the professionals and the organization structure in which they work.

De evaluatie van interventies heeft een belangrijke plaats in de publieke gezondheid. Zowel praktijk, beleid als wetenschap zijn gebaat bij een antwoord op de vraag: werkt de interventie? Welke evaluatie-opzet gebruikt moet worden om deze vraag te beantwoorden, hangt af van het type interventie en de resultaten die men wil bereiken. Wij zijn ervan overtuigd dat zowel de evaluatie-opzet zonder controlegroep, de evaluatie-opzet met controlegroep en de randomised controlled trial (rct) bestaansrecht hebben in de publieke gezondheid. Om de juiste evaluatie-opzet te kunnen kiezen, zijn twee zaken van doorslaggevend belang. Ten eerste het niveau van resultaten dat men wil gaan meten: dichtbij of veraf van de interventie in tijd en causale keten. Voor resultaten dichtbij de interventie volstaat de evaluatie-opzet zonder controlegroep, voor resultaten verder weg is een controlegroep noodzakelijk. De tweede doorslaggevende factor is de zekerheid waarmee men de vraag: zijn de resultaten toe te schrijven aan de interventie? beantwoord wil zien. De gewenste zekerheid van conclusies bepaalt de keuze tussen de evaluatie-opzet met controlegroep en de rct. Op basis van deze principes hebben wij de Kieswijzer ontwikkeld. Deze Kieswijzer faciliteert de keuze van de evaluatie-opzet voor interventies in de publieke gezondheid.

ObjectiveTo investigate (i) how the SLIMMER intervention was delivered and received in Dutch primary health care and (ii) how this could explain intervention effectiveness.DesignA randomised controlled trial was conducted and subjects were randomly allocated to the intervention (10-month combined dietary and physical activity intervention) or the control group. A process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity and applicability) were collected via semi-structured interviews with health-care professionals (n 45) and intervention participant questionnaires (n 155).SettingSLIMMER was implemented in Dutch primary health care in twenty-five general practices, eleven dietitians, nine physiotherapist practices and fifteen sports clubs.SubjectsSubjects at increased risk of developing type 2 diabetes were included.ResultsIt was possible to recruit the intended high-risk population (response rate 54 %) and the SLIMMER intervention was very well received by both participants and health-care professionals (mean acceptability rating of 82 and 80, respectively). The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour.ConclusionsThe present study showed that it is feasible to implement a diabetes prevention intervention in Dutch primary health care. Higher dose received and participant acceptability were associated with improved health outcomes and dietary behaviour. Using an extensive process evaluation plan to gain insight into how an intervention is delivered and received is a valuable way of identifying intervention components that contribute to implementation integrity and effective prevention of type 2 diabetes in primary health care.

Background: Underage alcohol drinking is a severe public health problem. The aim of this study was to evaluate the short- and long-term effects of a Dutch community-based alcohol intervention on alcohol use of adolescents in the second and fourth grade of high school. Methods: The community intervention integrated health education, regulation, and enforcement in multiple settings, targeting adolescents as well as their environments. In order to evaluate effectiveness, a quasi-experimental pretest posttest design was used based on three independent cross-sectional surveys in 2003, 2007 and 2011, resulting in an analytical sample of approximately 5,700 and 3,100 adolescents in the intervention and reference region, respectively. For the main analyses, we compared the change in recent alcohol use and binge drinking in the intervention region with the reference region. Lineair regression was used to obtain (adjusted) prevalences of alcohol use. Results: During the study period, there was an overall decline in the prevalence of alcohol use. After 1 year of intervention, the decline was 11% (P

Background/Objectives: To assess the effectiveness of the SLIMMER combined dietary and physical activity lifestyle intervention on clinical and metabolic risk factors, dietary intake, physical activity, and quality of life after 12 months, and to investigate whether effects sustained six months after the active intervention period ended. Subjects/Methods: SLIMMER was a randomised controlled intervention, implemented in Dutch primary healthcare. In total, 316 subjects aged 40–70 years with increased risk of type 2 diabetes were randomly allocated to the intervention group (10-month dietary and physical activity programme) or the control group (usual healthcare). All subjects underwent an oral glucose tolerance test and physical examination, and filled in questionnaires. Identical examinations were performed at baseline and after 12 and 18 months. Primary outcome was fasting insulin. Results: The intervention group showed significantly greater improvements in anthropometry and glucose metabolism. After 12 and 18 months, differences between intervention and control group were -2.7 kg (95% confidence interval (CI): −3.7; −1.7) and −2.5 kg (95% CI: −3.6; −1.4) for weight, and −12.1 pmol l−1 (95% CI: −19.6; −4.6) and −8.0 pmol l−1 (95% CI: −14.7; −0.53) for fasting insulin. Furthermore, dietary intake, physical activity, and quality of life improved significantly more in the intervention group than in the control group. Conclusions: The Dutch SLIMMER lifestyle intervention is effective in the short and long term in improving clinical and metabolic risk factors, dietary intake, physical activity, and quality of life in subjects at high risk of diabetes.

Background Although lifestyle interventions have shown to be effective in reducing the risk for type 2 diabetes mellitus, maintenance of achieved results is difficult, as participants often experience relapse after the intervention has ended. This paper describes the systematic development of a maintenance programme for the extensive SLIMMER intervention, an existing diabetes prevention intervention for high-risk individuals, implemented in a real-life setting in the Netherlands. Methods The maintenance programme was developed using the Intervention Mapping protocol. Programme development was informed by a literature study supplemented by various focus group discussions and feedback from implementers of the extensive SLIMMER intervention. Results The maintenance programme was designed to sustain a healthy diet and physical activity pattern by targeting knowledge, attitudes, subjective norms and perceived behavioural control of the SLIMMER participants. Practical applications were clustered into nine programme components, including sports clinics at local sports clubs, a concluding meeting with the physiotherapist and dietician, and a return session with the physiotherapist, dietician and physical activity group. Manuals were developed for the implementers and included a detailed time table and step-by-step instructions on how to implement the maintenance programme. Conclusions The Intervention Mapping protocol provided a useful framework to systematically plan a maintenance programme for the extensive SLIMMER intervention. The study showed that planning a maintenance programme can build on existing implementation structures of the extensive programme. Future research is needed to determine to what extent the maintenance programme contributes to sustained effects in participants of lifestyle interventions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1108) contains supplementary material, which is available to authorized users.

Implementation of interventions in real-life settings requires a comprehensive evaluation approach. The aim of this article is to describe the evaluation design of the SLIMMER diabetes prevention intervention in a Dutch real-life setting. The SLIMMER study is a randomised, controlled intervention study including subjects aged 40 through 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involves a dietary and physical activity intervention, including case management and a maintenance programme. The control group receives usual health care and written information about a healthy lifestyle. A logic model of change is composed to link intervention activities with intervention outcomes in a logical order. Primary outcome is fasting insulin. Measurements are performed at baseline and after 12 and 18 months and cover quality of life, cardio-metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), eating and physical activity behaviour, and behavioural determinants. A process evaluation gives insight in how the intervention was delivered and received by participants and health care professionals. The economic evaluation consists of a cost-effectiveness analysis and a cost-utility analysis. Costs are assessed from both a societal and health care perspective. This study is expected to provide insight in the effectiveness, including its cost-effectiveness, and delivery of the SLIMMER diabetes prevention intervention conducted in Dutch primary health care. Results of this study provide valuable information for primary health care professionals, researchers, and policy makers. The SLIMMER study is registered with ClinicalTrials.gov ( NCT02094911 ) since March 19, 2014.

Objective Pilot-testing of the adapted Study on Lifestyle intervention and Impaired glucose tolerance Maastricht (SLIM) and to determine its feasibility and likelihood of achieving desired impact. Methods Pilot intervention study (a 10-month combined lifestyle intervention) using a one group pre-test post-test design with on-going process measures (i.e. reach, acceptability, implementation integrity, and applicability) and several health outcomes (e.g. body weight). Results In total, 31 subjects participated in the SLIMMER (SLIM iMplementation Experience Region Noord- en Oost-Gelderland) intervention. Participant weight loss was −3.5kg ( p =0.005). Both participants and health care professionals (i.e. practice nurses, dieticians, and physiotherapists) were satisfied with the intervention. The intervention was implemented as planned and appeared to be suitable for application in practice. Refinements have been identified and will be made prior to further implementation and evaluation. Conclusion Implementation of the SLIMMER intervention is feasible in a Dutch real-life setting and it is likely to achieve desired impact. Practising and optimising the intervention creates local support for SLIMMER among stakeholders. Practice implications Performing a pilot study on the basis of a structured approach is a meaningful step in the process of optimising the feasibility and potential impact of an evidence-based intervention in a real-life setting.

Background - Although many evidence-based diabetes prevention interventions exist, they are not easily applicable in real-life settings. Moreover, there is a lack of examples which describe the adaptation process of these interventions to practice. In this paper we present an example of such an adaptation. We adapted the SLIM (Study on Lifestyle intervention and Impaired glucose tolerance Maastricht) diabetes prevention intervention to a Dutch real-life setting, in a joint decision making process of intervention developers and local health care professionals. Methods - We used 3 adaptation steps in accordance with current adaptation frameworks. In the first step, the elements of the SLIM intervention were identified. In the second step, these elements were judged for their applicability in a real-life setting. In the third step, adaptations were proposed and discussed for those elements which were deemed not applicable. Participants invited for this process included intervention developers and local health care professionals (n=19). Results - In the first adaptation step, a total of 22 intervention elements were identified. In the second step, 12 of these 22 intervention elements were judged as inapplicable. In the third step, a consensus was achieved for the adaptations of all 12 elements. The adapted elements were in the following categories: target population, techniques, intensity, delivery mode, materials, organisational structure, and political and financial conditions. The adaptations either lay in changing the SLIM protocol (6 elements) or the real-life working procedures (1 element), or a combination of both (4 elements). Conclusions -he positive result of this study is that a consensus was achieved within a relatively short time period (nine months) between the developers of the SLIM intervention and local health care professionals on the adaptations needed to make SLIM applicable in a Dutch real-life setting. Our example shows that it is possible to combine the perspectives of scientists and practitioners, and to find a balance between evidence-base and applicability concerns.

Objective: To evaluate the scientific evidence for purported intolerance to dietary biogenic amines. Data Sources: MEDLINE was searched for articles in the English language published between January 1966 and August 2001. The keyword biogenic amin* was combined with hypersens*, allerg*, intoler*, and adverse. Additionally, the keywords histamine, tyramine, and phenylethylamine were combined with headache, migraine, urticaria, oral challenge, and oral provocation. Articles were also selected from references in relevant literature. Study Selection: Only oral challenge studies in susceptible patients were considered. Studies with positive results (ie, studies in which an effect was reported) were only eligible when a randomized, double-blind, placebo-controlled design was used. Eligible positive result studies were further evaluated according to a number of scientific criteria. Studies with negative results (ie, studies in which no effect was reported) were examined for factors in their design or methods that could be responsible for a false-negative outcome. Results of methodologically weak or flawed studies were considered inconclusive. Results: A total of 13 oral challenge studies (5 with positive results and 8 with negative results) were found. Three of them (all with positive results) were considered ineligible. By further evaluation of the 10 eligible studies, 6 were considered inconclusive. The 4 conclusive studies all reported negative results. One conclusive study showed no relation between biogenic amines in red wine and wine intolerance. Two conclusive studies found no effect of tyramine on migraine. One conclusive study demonstrated no relation between the amount of phenylethylamine in chocolate and headache attacks in individuals with headache. Conclusions: The current scientific literature shows no relation between the oral ingestion of biogenic amines and food intolerance reactions. There is therefore no scientific basis for dietary recommendations concerning biogenic amines in such patients.

Objectives: The aim of this study was to evaluate the relation between lifetime estrogen exposure and mortality and compare this with menopausal age as exposure variable. Methods: We studied a cohort of 1462 naturally postmenopausal women, aged 37–77 at enrolment in the Belgian Interuniversity Research on Nutrition and Health study. After a follow-up time of 10 years, 181 women had died, of whom 76 of cardiovascular causes. Logistic regression analysis was used to investigate the relations between lifetime estrogen exposure (calculated as menopausal age minus menarcheal age) and death as well as the relations between age at menopause and death. Results: The risk of mortality was lower in women with a longer lifetime estrogen exposure as well as in women with higher menopausal ages. For women with a lifetime estrogen exposure of 40 years the odds ratio of all-cause mortality was 0.58 (95␌onfidence interval (CI) 0.35–0.93) compared to women who had a lifetime estrogen exposure of 33 years. Women who became menopausal after the age of 53 years had a similar reduction in mortality risk (odds ratio 0.62; 95␌I 0.36–1.03) when compared to women with menopausal ages of 46 years. These decreases in mortality risk were particularly due to a reduction in mortality of cardiovascular diseases. Conclusions: This study indicates that menopausal age predicts mortality. The prediction is not improved by adding the age at menarche, to obtain an estimate for lifetime estrogen exposure