Search

Breast cancer is a major public health concern, in the Netherlands, 1 in 7 women are diagnosed with breast cancer in their lifetime. In women receiving chemotherapy, weight gain and undesirable changes in body composition is a common but poorly understood phenomenon, which is associated with disease recurrence, an increased risk of cardiovascular disease and diabetes, and a lower overall survival. Lifestyle such as dietary intake and exercise during chemotherapy may contribute to this phenomenon. This study is part of the COBRA study (Change Of Body composition in Breast cancer: All-in Assessment-study) a longitudinal observational mixed-methods study. The overall aim of this thesis was to investigate the perceptions of women with breast cancer, women without breast cancer, and Health Care Professioals (HCPs) on why potential changes in dietary intake, physical activity and body weight, and quality of life occur and how they deal with these potential changes. Problems with healthy diet, physical activity, unexpected weight gain and its health risks were important concerns in women's need to contribute to their treatment and were sometimes exacerbated by a lack of information on how to deal with it. Despite HCPs indicated they considered it part of their role to provide information and support on weight gain during chemotherapy, little information was provided. HCPs experienced a lack of time and knowledge, and they preferred continued treatment to weight control. Weight gain was perceived as not an important health issue during treatment. All HCPs thought it is better that women themselves addressed their weight gain after chemotherapy. In a separate study on non-Western women, we found that culture and religion affected these women’s experience of breast cancer. Women often associated breast cancer with taboo, death or bad luck. Religion offered these women guidance, strength and meaning to the disease, but also limited women to openly talk about their disease. Women experienced barriers to accessing health care, sometimes due to language difficulties. They perceived lifestyle factors had little influence on the treatment of cancer. However, after treatment they were more aware of a healthy lifestyle and weight management. Women with breast cancer experienced physical consequences as changes in dietary intake, physical activity and body weight from both the disease and its treatment. We found in a mixed methods approach that physically active women managed to stay active and cope more easily with problems during chemotherapy than less active women with low energy intake. The latter unexpectedly gained weight, expressed a need for information on heathy diet and reported that fatigue made them even more inactive during chemotherapy. In addition to physical consequences, women experienced how psychological factors such as beliefs about their illness and coping strategies influenced the impact of diagnosis and treatment on their changes in lifestyle factors, body weight and perceived quality of life. By identifying specific characteristics, i.e., age and BMI; and prior expectations, attitude towards healthy lifestyle, confidence in own body, confidence in HCPs, and coping strategies related to level of mastery, four groups of women were distinguished: a monitoring group (active, adaptive coping), a struggling group (active, maladaptive coping), an overwhelmed group (passive, maladaptive coping) and a resigned group (passive, adaptive coping). In the current health care setting, where lifestyle modification programmes are not (yet) part of standard care, change is needed to promote and support a healthy lifestyle in women with breast cancer. With tailored specific education and behavioural support from HCPs, women in these four groups can be supported in their need to contribute to their treatment by optimally regulate their reactions to a health threat such as breast cancer and its treatment.

Breast cancer is a major public health concern, in the Netherlands, 1 in 7 women are diagnosed with breast cancer in their lifetime. In women receiving chemotherapy, weight gain and undesirable changes in body composition is a common but poorly understood phenomenon, which is associated with disease recurrence, an increased risk of cardiovascular disease and diabetes, and a lower overall survival. Lifestyle such as dietary intake and exercise during chemotherapy may contribute to this phenomenon. This study is part of the COBRA study (Change Of Body composition in Breast cancer: All-in Assessment-study) a longitudinal observational mixed-methods study. The overall aim of this thesis was to investigate the perceptions of women with breast cancer, women without breast cancer, and Health Care Professioals (HCPs) on why potential changes in dietary intake, physical activity and body weight, and quality of life occur and how they deal with these potential changes. Problems with healthy diet, physical activity, unexpected weight gain and its health risks were important concerns in women's need to contribute to their treatment and were sometimes exacerbated by a lack of information on how to deal with it. Despite HCPs indicated they considered it part of their role to provide information and support on weight gain during chemotherapy, little information was provided. HCPs experienced a lack of time and knowledge, and they preferred continued treatment to weight control. Weight gain was perceived as not an important health issue during treatment. All HCPs thought it is better that women themselves addressed their weight gain after chemotherapy. In a separate study on non-Western women, we found that culture and religion affected these women’s experience of breast cancer. Women often associated breast cancer with taboo, death or bad luck. Religion offered these women guidance, strength and meaning to the disease, but also limited women to openly talk about their disease. Women experienced barriers to accessing health care, sometimes due to language difficulties. They perceived lifestyle factors had little influence on the treatment of cancer. However, after treatment they were more aware of a healthy lifestyle and weight management. Women with breast cancer experienced physical consequences as changes in dietary intake, physical activity and body weight from both the disease and its treatment. We found in a mixed methods approach that physically active women managed to stay active and cope more easily with problems during chemotherapy than less active women with low energy intake. The latter unexpectedly gained weight, expressed a need for information on heathy diet and reported that fatigue made them even more inactive during chemotherapy. In addition to physical consequences, women experienced how psychological factors such as beliefs about their illness and coping strategies influenced the impact of diagnosis and treatment on their changes in lifestyle factors, body weight and perceived quality of life. By identifying specific characteristics, i.e., age and BMI; and prior expectations, attitude towards healthy lifestyle, confidence in own body, confidence in HCPs, and coping strategies related to level of mastery, four groups of women were distinguished: a monitoring group (active, adaptive coping), a struggling group (active, maladaptive coping), an overwhelmed group (passive, maladaptive coping) and a resigned group (passive, adaptive coping). In the current health care setting, where lifestyle modification programmes are not (yet) part of standard care, change is needed to promote and support a healthy lifestyle in women with breast cancer. With tailored specific education and behavioural support from HCPs, women in these four groups can be supported in their need to contribute to their treatment by optimally regulate their reactions to a health threat such as breast cancer and its treatment.

Previous studies found that people with obesity and type 2 diabetes, compared with lean individuals, have increased brain responses to food pictures, and reduced brain activation in response to the actual receipt of food, which results in more craving for food, while the receipt of food is less rewarding, which contributes to overeating. This thesis provides evidence that SGLT2 inhibitors can affect the central regulation of food intake in people with obesity and type 2 diabetes. We found that dapagliflozin further increased brain activation in areas regulating satiety and reward in response to food cues, paralleled by increases in carbohydrate intake and appetite scores. Together, this may contribute to the difference between observed and expected weight loss with SGLT2i treatment. This thesis confirmed previous findings that GLP-1RAs alters food-related brain responses after short-term treatment. Interestingly, we also found these GLP-1RA effects on the brain after 16 weeks of treatment. Importantly, when exenatide was combined with dapagliflozin, the dapagliflozin-induced increase in brain responses to food cues after 10 days, was not observed anymore, and after 16 weeks, even a reduced brain activation in response to food cues was observed, which may contribute to more weight loss with the combination of SGLT2i and GLP-1RA. In response to low-calorie food pictures, dapagliflozin was associated with reduced brain activation, exenatide with increased brain activation, while the combination of both showed no effect on brain activation. This suggest that that the possible induced hyperphagia with dapagliflozin treatment may be specific for high-calorie/sweet foods. This may have clinical consequences as a specific decreased preference for low-calorie foods, in combination with the previously found preference for high-calorie foods, may hamper the weight loss of SGLT2i. Eating behavior, especially emotional eating, and to a lesser extent external eating, was associated with a reduced efficacy of GLP-1RA treatment effect on brain activation, whereas restraint eating was associated with increased efficacy of GLP-1RA treatment. Eating behavior may be assessed if weight loss with GLP-1RA treatment is less than expected. The dapagliflozin-induced plasma volume contraction contributes to the measured blood pressure reduction after short-term treatment, while a reduction in SNS activity may contribute to longer-term blood pressure reduction. Combination therapy with dapagliflozin and exenatide resulted in the largest decrease in blood pressure. However, as the effect on plasma volume was comparable to dapagliflozin monotherapy, and SNS activity was not reduced, other mechanisms are likely to contribute to the blood pressure lowering effect of this combination, and needs further investigation. The combination of exenatide and dapagliflozin resulted in a larger reduction in albuminuria, eGFR, KIM-1, and metabolic risk factors compared to either therapy alone or placebo. Together, these findings provide further insight in the appetite and weight lowering mechanisms, mechanisms underlying the blood pressure, and kidney effects of SGLT2i and GLP-1RAs alone and in combination, and may lead to further development of treatment strategies for obesity and type 2 diabetes.

Om mogelijke risico's van chemische stoffen in consumentenproducten te kunnen beoordelen, is het nodig een goede schatting te maken over de blootstelling aan chemische stoffen tijdens gebruik van het product. Met behulp van het computerprogramma ConsExpo kan voor consumenten berekend worden in welke mate zij binnenshuis tijdens het gebruik van bijvoorbeeld verf, schoonmaakmiddelen of cosmetica aan een bepaalde chemische stof worden blootgesteld. In de Factsheet Algemeen staan 'standaardwaarden' die bruikbaar zijn om de blootstelling aan een stof te schatten. Door deze standaardwaarden te gebruiken, wordt de blootstellingsschatting op een transparante en gestandaardiseerde manier uitgevoerd. Op basis van nieuwe informatie en inzichten heeft het RIVM de Factsheet Algemeen herzien. Deze versie vervangt daarmee de Factsheet Algemeen uit 2006. De Factsheet Algemeen bevat standaardwaarden over de ruimtes waarin het product wordt gebruikt (bijvoorbeeld vloeroppervlak van een huiskamer) en over de persoon die blootgesteld wordt (zoals lichaamsgewicht en het oppervlak van lichaamsdelen). Er is informatie verstrekt over de inhalatiesnelheid van volwassenen en kinderen bij een verschillende mate van inspanning. Verder bevat de factsheet gegevens over de mate waarin verschillende ruimten van woningen worden geventileerd. Nieuw in deze versie van de factsheet zijn data over tijdsbesteding. Het document licht ook toe waarop de waarden zijn gebaseerd en het geeft de betrouwbaarheid van de geboden gegevens weer. Naast de Factsheet Algemeen bestaan er een aantal product-specifieke factsheets voor verf, cosmetica, speelgoed, ongediertebestrijdingsmiddelen, desinfecterende middelen, reinigingsmiddelen en doe-het-zelfproducten. Deze factsheets bevatten voor een bepaalde productcategorie informatie over onder andere de duur van de blootstelling en hoeveelheid gebruikt product.

Because of the improved survival rate, both short term and long term adverse effects of breast cancer treatment have become increasingly important. Body weight and body composition before, during, and after chemotherapy may influence side effects during treatment and survival. The aims of this thesis were to assess among stage I-IIIB breast cancer patients: 1) the association between pre-treatment body composition and dose-limiting toxicities during chemotherapy, 2) potential changes in body weight and body composition during and after chemotherapy compared to changes in age-matched women without cancer in the same time period, and 3) dietary intake during chemotherapy compared to age-matched women without cancer in the same time period. Chapter 2 describes the association between pre-treatment body composition and dose-limiting toxicities during chemotherapy. Data from 172 breast cancer patients who participated in the COBRA-study were analysed. Body composition was measured using a total body Dual Energy X-ray Absorption (DEXA) scan. Information regarding dose-limiting toxicities was abstracted from medical records. A higher BMI (kg/m2) and a higher fat mass (kg and percentage) were associated with an increased risk of dose-limiting toxicity, while lean body mass (kg) was not associated with risk of toxicities. Chapter 3 presents the findings of a meta-analysis on changes in body weight during chemotherapy in breast cancer patients. The meta-analysis showed an overall gain in body weight of 2.7 kg (95% CI: 2.0-3.3) during chemotherapy, with a high degree of heterogeneity (I2= 94.2%). Weight gain in breast cancer patients was more pronounced in papers published before 2000 and studies including cyclophosphamide, methotrexate and 5-fluorouracil as chemotherapy regime. Chapter 4 describes changes in body weight and body composition during and after chemotherapy. Data from 145 patients and 121 women of an age-matched comparison group, participating in the COBRA-study were analysed. Body composition was measured using DEXA-scan at three time points during the study period. For the patient group, these tie points were: before start of chemotherapy, shortly after chemotherapy, and 6 months after chemotherapy. For the comparison group these measurements were conducted over a similar time frame: baseline, 6 months after baseline, and 12 months after baseline. In addition, we identified determinants of changes in body weight and body composition. Shortly after chemotherapy, patients had a significantly higher body weight, BMI, and lean body mass than women in the comparison group, while fat mass was similar. Six months after chemotherapy no differences in body weight or body composition were observed between the patient and comparison group. A younger age, better appetite during chemotherapy, and an ER-receptor negative tumour were associated with greater changes in body weight over time. A younger age and better appetite during chemotherapy were associated with greater changes in fat mass over time, while the only determinant associated with greater changes in lean body mass over time was a better appetite during chemotherapy. Chapter 5 describes the dietary intake and food groups before and during chemotherapy of breast cancer patients compared with women without cancer. In addition we assessed the association between symptoms and energy intake. Data from 117 breast cancer patients and 88 women without breast cancer who participated in the COBRA-study were used. Habitual dietary intake before chemotherapy was assessed using a food frequency questionnaire. Two 24-hr dietary recalls were used to assess actual dietary intake during chemotherapy for patients and within 6 months for the comparison group. Shortly after the 24-hr dietary recall, participants filled out questionnaires about symptoms. Before chemotherapy, dietary intake was similar for both groups. During chemotherapy, breast cancer patients reported significantly lower total energy, total fat, total protein, and alcohol intake than women without cancer, which could be explained by a lower intake of specific food groups. Overall results from this thesis suggest that pre-treatment fat mass is associated with dose-limiting toxicities during chemotherapy. Weight gain during chemotherapy appeared to be more modest than we expected based on literature and changes in body composition during chemotherapy consist mainly of an increase in lean body mass, which is only temporary and returned to baseline within 6 months after chemotherapy. A higher appetite during chemotherapy was associated with changes in body weight and body composition. A younger age at diagnosis was associated with greater changes in body weight and fat mass, but not with changes in lean body mass. In addition, an ER-receptor negative tumour was associated with greater changes in body weight, but not with changes in fat mass or lean body mass. During chemotherapy women with breast cancer have a lower intake of energy, fat, protein and alcohol compared to age-matched women without cancer, which was expressed in a lower intake of specific food groups. The results of this thesis do not suggest that dietary intake is associated with weight gain during chemotherapy.

Rijnsdorp, A. D., Peck, M. A., Engelhard, G. H., Möllmann, C., and Pinnegar, J. K. 2009. Resolving the effect of climate change on fish populations. – ICES Journal of Marine Science, 66: 1570–1583. This paper develops a framework for the study of climate on fish populations based on first principles of physiology, ecology, and available observations. Environmental variables and oceanographic features that are relevant to fish and that are likely to be affected by climate change are reviewed. Working hypotheses are derived from the differences in the expected response of different species groups. A review of published data on Northeast Atlantic fish species representing different biogeographic affinities, habitats, and body size lends support to the hypothesis that global warming results in a shift in abundance and distribution (in patterns of occurrence with latitude and depth) of fish species. Pelagic species exhibit clear changes in seasonal migration patterns related to climate-induced changes in zooplankton productivity. Lusitanian species have increased in recent decades (sprat, anchovy, and horse mackerel), especially at the northern limit of their distribution areas, while Boreal species decreased at the southern limit of their distribution range (cod and plaice), but increased at the northern limit (cod). Although the underlying mechanisms remain uncertain, available evidence suggests climate-related changes in recruitment success to be the key process, stemming from either higher production or survival in the pelagic egg or larval stage, or owing to changes in the quality/quantity of nursery habitats.

Lichaamssamenstelling is een maat voor de voedingstoestand. Een groot scala aan methoden staat ter beschikking om lichaamssamenstelling te meten. Sommige van deze methoden zijn geschikt voor toepassing in de eerste lijn, zoals antropometrie en bio-impedantie. Andere, meer kostbare en geavanceerde technieken - zoals MRI, CT, DEXA en isotopen-verdunningsmethoden - zijn geschikter voor toepassing in een onderzoeksomgeving. Met name bio-impedantie wordt steeds populairder

Trudy M.A. Wijnhoven Overweight and obesity in primary-school children: a surveillance system for policy-making in Europe from 2007 onwards. Background As a follow-up to the European Ministerial Conference on Counteracting Obesity convened in 2006 in Turkey, the European Childhood Obesity Surveillance Initiative (COSI) was launched by the Regional Office for Europe of the World Health Organization (WHO). COSI, a collaboration between WHO and interested Member States, aims to monitor the magnitude of overweight and obesity among primary-school children in European countries, to allow intercountry comparisons and to identify regional differences for informed policy-making. It collects at regular intervals data on weight and height of primary-school children and on their nutrition and physical activity behaviours, as well as on school environmental characteristics supportive to healthy nutrition and physical activity. Methods The research described in this PhD thesis is based on the data collected in the first two COSI rounds by 12 European countries in school year 2007/2008 and by 13 European countries in school year 2009/2010. Nationally representative samples of children aged 6–9 years were drawn, whereby a majority of the countries applied a two-stage school-based cluster sampling approach. A total of 168 832 children in school year 2007/2008 and 224 920 children in school year 2009/2010 were included in the anthropometric intercountry data analyses. Children's weight and height were measured by trained examiners using standardized procedures. Participating countries were allowed to adhere to their local legal requirements by specified deviations from standardized procedures, such as in types of clothing worn by the children during weight and height measurements. For each country, the prevalence of overweight and obesity, as well as mean Z-scores of anthropometric indices of height, weight and body mass index (BMI) were computed. The characteristics included in the analyses on the school environment referred to the frequency of physical education lessons, the availability of school playgrounds, the possibility to obtain food items and beverages on the school premises, and the organization of school initiatives to promote a healthy lifestyle. The school form was usually completed by the school principal or the teachers involved with the sampled classes. Data from 1831 schools in school year 2007/2008 and from 2045 schools in school year 2009/2010 were used. For each school, a school nutrition environment score (range: 0–1) was determined whereby higher scores correspond to higher support for a healthy school nutrition environment and the mean of the children's BMI-for-age Z-scores calculated. Five countries in school year 2007/2008 provided children's data on 13 health-risk behaviours related to breakfast and food consumption frequency, physical activity, screen time and sleep duration (n = 15 643). These data were reported by the caregivers alone or jointly with their child. For each country, the prevalence of the risk behaviours was estimated, and associations between them and overweight and obesity examined by multilevel logistic regression analyses. Results In both school years, a wide range in overweight and obesity prevalence estimates was found that differed significantly by country, as well as by European region. In all countries, the percentage of overweight children was about 20% or more (range: 18–57%), and the percentage of obese children was 5% or more (range: 5–31%). The findings suggest the presence of a north–south gradient with the highest overweight and obesity prevalence estimates found in southern European countries. Furthermore, changes in mean BMI-for-age Z-scores (range: from –0.21 to +0.14) and prevalence of overweight (range: from –9.0% to +6.2%) from school year 2007/2008 to school year 2009/2010 varied significantly among countries, whereas a period of two years is considered too short to identify these developments. The clothes-adjusted overweight prevalence estimates were lower by as much as 12% than the unadjusted estimates. Monthly BMI-for-age Z-score values within countries did not show systematic seasonal effects. Large between-country differences were observed in both school years in the availability of food items or beverages on the school premises (e.g., fresh fruit could be obtained in 12–95% of schools) and in the organization of initiatives to promote a healthy lifestyle in the selected classes (range: 42–97%). The provision of physical education lessons and the availability of school playgrounds were more uniformly present across the countries (range: 76–100%). A large variation was also seen in school nutrition environment scores (range: 0.30–0.93) whereby countries with a low score (< 0.70) graded less than three out of five characteristics as supportive. High-score countries showed more often than low-score countries a combined absence of cold drinks containing sugar, sweet snacks and salted snacks on the school premises. The prevalence of all 13 health-risk behaviours differed significantly across countries. For instance, the percentage of children who ate ‘foods like candy bars or chocolate’ > 3 days/week ranged from 2.2% to 63.4%; this figure ranged from 1.1% to 46.5% for those who ate ‘foods like potato chips (crisps), corn chips, popcorn or peanuts’ > 3 days/week. The range for children who did not have breakfast every day was between 4.4% and 32.5%, and from 4.8% to 35.0% for those who did not play outside ≥ 1 hour/day. Not having breakfast daily and spending screen time ≥ 2 hours/day were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ > 3 days/week and playing outside < 1 hour/day. While a combination of multiple less favourable physical activity behaviours was clearly positively associated with obesity, a combination of the presence of multiple unhealthy eating behaviours did not lead to higher odds of obesity. Conclusions The results found in both COSI school years show that overweight and obesity among 6–9-year-old children are a serious public health concern, especially in southern European countries, and show the need for accelerated efforts to prevent excess body weight early in life by all participating countries. It was possible to detect relevant changes within a period of two years but to identify clear trends within countries, a longer time interval is necessary. The data on the school nutrition environment and the children's health-risk behaviours may assist policy-makers in monitoring their national policies targeting school settings and childhood obesity. In particular, promoting physical activity-related and discouraging sedentary behaviours among schoolchildren in the context of obesity preventive interventions seem to be essential.

Summary Consumption of foods containing flavonoids is associated with a reduced risk of cardiovascular diseases (CVD), possibly by lipid-lowering effects. On the other hand, for one of these flavonoids, quercetin, also genotoxicity was shown especially in in vitro bioassays. Therefore, the first aim of this thesis was to identify mechanisms underlying potential beneficial health effects of flavonoids. The focus was on hepatic lipid metabolism and circulating lipids and a molecular and physiological approach was used. Secondly, we aimed to study the potential in vivo genotoxic effects of quercetin by transcriptome analyses in liver and small intestine, since these represent the tissues of first contact exposed to relatively high levels upon oral intake of flavonoids. Circulating lipids are important CVD-related risk markers, which are in general determined with commercially available enzyme-based assays. However, the usual enzyme in these assays, peroxidase, has previously been reported to be inhibited by flavonoids. Therefore, we have studied in chapter 2 whether these assays can adequately be used in flavonoid research. We observed that various flavonoid aglycones interfere with peroxidase used in triglycerides (TG) and free fatty acids (FFA) enzymatic assays, reporting incorrect lower TG and FFA levels than actually present. Furthermore, addition of metabolites such as isorhamnetin or quercetin-3-O-glucuronide, the major metabolite of quercetin in human and rat plasma, to murine serum also resulted in a significant reduction of the detected TG levels, while a trend was seen towards reduced FFA levels. It can be concluded that when applying these biochemical assays, vigilance is needed and alternative analytical methods assessing FFA or TG levels should preferably be applied for studying the biological effects of flavonoids on TG and FFA levels. In chapter 3 mechanistic and physiological effects of quercetin on hepatic lipid metabolism were studied. C57BL/6JOlaHsd male adult mice received a mild high-fat (30 en%) diet without or with supplementation of 0.33% (w/w) quercetin for 12 weeks. Gas chromatography and 1H-NMR were used to quantitatively measure serum lipid profiles. Whole genome microarray analysis of liver tissue was used to identify potential mechanisms underlying altered circulating lipid levels by quercetin supplementation. Body weight, energy intake and hepatic lipid accumulation did not differ significantly between the quercetin and the control group. In serum of quercetin-fed mice, TG levels were decreased by 14% (p

Trudy M.A. Wijnhoven Overweight and obesity in primary-school children: a surveillance system for policy-making in Europe from 2007 onwards. Background As a follow-up to the European Ministerial Conference on Counteracting Obesity convened in 2006 in Turkey, the European Childhood Obesity Surveillance Initiative (COSI) was launched by the Regional Office for Europe of the World Health Organization (WHO). COSI, a collaboration between WHO and interested Member States, aims to monitor the magnitude of overweight and obesity among primary-school children in European countries, to allow intercountry comparisons and to identify regional differences for informed policy-making. It collects at regular intervals data on weight and height of primary-school children and on their nutrition and physical activity behaviours, as well as on school environmental characteristics supportive to healthy nutrition and physical activity. Methods The research described in this PhD thesis is based on the data collected in the first two COSI rounds by 12 European countries in school year 2007/2008 and by 13 European countries in school year 2009/2010. Nationally representative samples of children aged 6–9 years were drawn, whereby a majority of the countries applied a two-stage school-based cluster sampling approach. A total of 168 832 children in school year 2007/2008 and 224 920 children in school year 2009/2010 were included in the anthropometric intercountry data analyses. Children's weight and height were measured by trained examiners using standardized procedures. Participating countries were allowed to adhere to their local legal requirements by specified deviations from standardized procedures, such as in types of clothing worn by the children during weight and height measurements. For each country, the prevalence of overweight and obesity, as well as mean Z-scores of anthropometric indices of height, weight and body mass index (BMI) were computed. The characteristics included in the analyses on the school environment referred to the frequency of physical education lessons, the availability of school playgrounds, the possibility to obtain food items and beverages on the school premises, and the organization of school initiatives to promote a healthy lifestyle. The school form was usually completed by the school principal or the teachers involved with the sampled classes. Data from 1831 schools in school year 2007/2008 and from 2045 schools in school year 2009/2010 were used. For each school, a school nutrition environment score (range: 0–1) was determined whereby higher scores correspond to higher support for a healthy school nutrition environment and the mean of the children's BMI-for-age Z-scores calculated. Five countries in school year 2007/2008 provided children's data on 13 health-risk behaviours related to breakfast and food consumption frequency, physical activity, screen time and sleep duration (n = 15 643). These data were reported by the caregivers alone or jointly with their child. For each country, the prevalence of the risk behaviours was estimated, and associations between them and overweight and obesity examined by multilevel logistic regression analyses. Results In both school years, a wide range in overweight and obesity prevalence estimates was found that differed significantly by country, as well as by European region. In all countries, the percentage of overweight children was about 20% or more (range: 18–57%), and the percentage of obese children was 5% or more (range: 5–31%). The findings suggest the presence of a north–south gradient with the highest overweight and obesity prevalence estimates found in southern European countries. Furthermore, changes in mean BMI-for-age Z-scores (range: from –0.21 to +0.14) and prevalence of overweight (range: from –9.0% to +6.2%) from school year 2007/2008 to school year 2009/2010 varied significantly among countries, whereas a period of two years is considered too short to identify these developments. The clothes-adjusted overweight prevalence estimates were lower by as much as 12% than the unadjusted estimates. Monthly BMI-for-age Z-score values within countries did not show systematic seasonal effects. Large between-country differences were observed in both school years in the availability of food items or beverages on the school premises (e.g., fresh fruit could be obtained in 12–95% of schools) and in the organization of initiatives to promote a healthy lifestyle in the selected classes (range: 42–97%). The provision of physical education lessons and the availability of school playgrounds were more uniformly present across the countries (range: 76–100%). A large variation was also seen in school nutrition environment scores (range: 0.30–0.93) whereby countries with a low score (< 0.70) graded less than three out of five characteristics as supportive. High-score countries showed more often than low-score countries a combined absence of cold drinks containing sugar, sweet snacks and salted snacks on the school premises. The prevalence of all 13 health-risk behaviours differed significantly across countries. For instance, the percentage of children who ate ‘foods like candy bars or chocolate’ > 3 days/week ranged from 2.2% to 63.4%; this figure ranged from 1.1% to 46.5% for those who ate ‘foods like potato chips (crisps), corn chips, popcorn or peanuts’ > 3 days/week. The range for children who did not have breakfast every day was between 4.4% and 32.5%, and from 4.8% to 35.0% for those who did not play outside ≥ 1 hour/day. Not having breakfast daily and spending screen time ≥ 2 hours/day were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ > 3 days/week and playing outside < 1 hour/day. While a combination of multiple less favourable physical activity behaviours was clearly positively associated with obesity, a combination of the presence of multiple unhealthy eating behaviours did not lead to higher odds of obesity. Conclusions The results found in both COSI school years show that overweight and obesity among 6–9-year-old children are a serious public health concern, especially in southern European countries, and show the need for accelerated efforts to prevent excess body weight early in life by all participating countries. It was possible to detect relevant changes within a period of two years but to identify clear trends within countries, a longer time interval is necessary. The data on the school nutrition environment and the children's health-risk behaviours may assist policy-makers in monitoring their national policies targeting school settings and childhood obesity. In particular, promoting physical activity-related and discouraging sedentary behaviours among schoolchildren in the context of obesity preventive interventions seem to be essential.

Khaw, HL. (2014). Cooperative and uniform fish? Social interactions and variability in live body weight in the GIFT strain (Nile tilapia, Oreochromic niloticus) in Malaysia. PhD thesis, Wageningen University, the Netherlands. Social interactions are present everywhere in the living world. Such social interactions may lead to indirect genetic effects (IGE), which are heritable effects of an individual on trait values of the other individuals its interacts with. IGEs may affect the direction and magnitude of response to selection in breeding programs. Moreover, social interactions may affect variability of traits. In aquaculture, competition for resources inflates size variation within populations. In this thesis, we used the Genetically Improved Farmed Tilapia (GIFT; Oreochromis niloticus) strain to investigate the genetic basis for social interactions and variability in harvest weight for tropical finfish. Social interaction experiments were established for quantifying the genetic and non-genetic indirect effects on harvest weight in the GIFT strain. We found evidence for IGEs on harvest weight, and a negative direct-indirect genetic correlation, which suggesting heritable competitive interactions for harvest weight in GIFT. Hence, breeding schemes may need to be adapted to avoid an increase in competition. A stochastic simulation study was conducted to examine the effect of BLUP selection on the rate of inbreeding for socially affected traits. The rates of inbreeding for scenarios with IGEs were greater than for scenarios without IGE. Therefore, with IGEs there is a greater need for a selection algorithm that restricts the increase of mean kinship. In aquaculture industry, there is a wide range of commercial production environments, which may leads to genotype by environment (GxE) interaction, for example due to differential social interactions. The GIFT fish were tested in ponds and cages to study the GxE interaction. The genetic correlations between environments (0.73 to 0.85, for harvest weight and body measurements) indicate little GxE-interaction. The data collected from the social interaction experiments were also used to investigate the presence of genetic variation in uniformity for harvest weight. The genetic coefficient of variation for standard deviation of harvest weight (0.17) shows that uniformity of harvest weight is heritable and can be increased by selective breeding. In the General Discussion of this thesis, the uniformity study was extended to incorporate IGE. The result indicates that more cooperative fish are not necessary more uniform for harvest weight. Overall, our results suggest that genetic improvement in fish breeding programs can be increased by accounting for social interactions.

Summary Consumption of foods containing flavonoids is associated with a reduced risk of cardiovascular diseases (CVD), possibly by lipid-lowering effects. On the other hand, for one of these flavonoids, quercetin, also genotoxicity was shown especially in in vitro bioassays. Therefore, the first aim of this thesis was to identify mechanisms underlying potential beneficial health effects of flavonoids. The focus was on hepatic lipid metabolism and circulating lipids and a molecular and physiological approach was used. Secondly, we aimed to study the potential in vivo genotoxic effects of quercetin by transcriptome analyses in liver and small intestine, since these represent the tissues of first contact exposed to relatively high levels upon oral intake of flavonoids. Circulating lipids are important CVD-related risk markers, which are in general determined with commercially available enzyme-based assays. However, the usual enzyme in these assays, peroxidase, has previously been reported to be inhibited by flavonoids. Therefore, we have studied in chapter 2 whether these assays can adequately be used in flavonoid research. We observed that various flavonoid aglycones interfere with peroxidase used in triglycerides (TG) and free fatty acids (FFA) enzymatic assays, reporting incorrect lower TG and FFA levels than actually present. Furthermore, addition of metabolites such as isorhamnetin or quercetin-3-O-glucuronide, the major metabolite of quercetin in human and rat plasma, to murine serum also resulted in a significant reduction of the detected TG levels, while a trend was seen towards reduced FFA levels. It can be concluded that when applying these biochemical assays, vigilance is needed and alternative analytical methods assessing FFA or TG levels should preferably be applied for studying the biological effects of flavonoids on TG and FFA levels. In chapter 3 mechanistic and physiological effects of quercetin on hepatic lipid metabolism were studied. C57BL/6JOlaHsd male adult mice received a mild high-fat (30 en%) diet without or with supplementation of 0.33% (w/w) quercetin for 12 weeks. Gas chromatography and 1H-NMR were used to quantitatively measure serum lipid profiles. Whole genome microarray analysis of liver tissue was used to identify potential mechanisms underlying altered circulating lipid levels by quercetin supplementation. Body weight, energy intake and hepatic lipid accumulation did not differ significantly between the quercetin and the control group. In serum of quercetin-fed mice, TG levels were decreased by 14% (p

Khaw, HL. (2014). Cooperative and uniform fish? Social interactions and variability in live body weight in the GIFT strain (Nile tilapia, Oreochromic niloticus) in Malaysia. PhD thesis, Wageningen University, the Netherlands. Social interactions are present everywhere in the living world. Such social interactions may lead to indirect genetic effects (IGE), which are heritable effects of an individual on trait values of the other individuals its interacts with. IGEs may affect the direction and magnitude of response to selection in breeding programs. Moreover, social interactions may affect variability of traits. In aquaculture, competition for resources inflates size variation within populations. In this thesis, we used the Genetically Improved Farmed Tilapia (GIFT; Oreochromis niloticus) strain to investigate the genetic basis for social interactions and variability in harvest weight for tropical finfish. Social interaction experiments were established for quantifying the genetic and non-genetic indirect effects on harvest weight in the GIFT strain. We found evidence for IGEs on harvest weight, and a negative direct-indirect genetic correlation, which suggesting heritable competitive interactions for harvest weight in GIFT. Hence, breeding schemes may need to be adapted to avoid an increase in competition. A stochastic simulation study was conducted to examine the effect of BLUP selection on the rate of inbreeding for socially affected traits. The rates of inbreeding for scenarios with IGEs were greater than for scenarios without IGE. Therefore, with IGEs there is a greater need for a selection algorithm that restricts the increase of mean kinship. In aquaculture industry, there is a wide range of commercial production environments, which may leads to genotype by environment (GxE) interaction, for example due to differential social interactions. The GIFT fish were tested in ponds and cages to study the GxE interaction. The genetic correlations between environments (0.73 to 0.85, for harvest weight and body measurements) indicate little GxE-interaction. The data collected from the social interaction experiments were also used to investigate the presence of genetic variation in uniformity for harvest weight. The genetic coefficient of variation for standard deviation of harvest weight (0.17) shows that uniformity of harvest weight is heritable and can be increased by selective breeding. In the General Discussion of this thesis, the uniformity study was extended to incorporate IGE. The result indicates that more cooperative fish are not necessary more uniform for harvest weight. Overall, our results suggest that genetic improvement in fish breeding programs can be increased by accounting for social interactions.

Rapport is update van rapport nr. 612810009

Background: Weight status is one of the factors that influence healthy ageing. It is often assessed with anthropometric measures such as body mass index (BMI) and waist circumference (WC), which indicate underweight or excess fat. Both are associated with adverse health outcomes in adults. The first paper of this thesis investigates whether this association is consistent over calendar time, to check for possible influences of improved healthcare procedures over time. In old age, this association is unclear. Using several anthropometric measures, the subsequent five papers examine the impact of weight status and development of weight status on coronary heart disease (CHD), mortality, and quality of life (QoL) among the elderly and during ageing. Methods: A meta-regression analysis of 31 international cohort studies (n=389,212) was used to estimate the multivariable adjusted relative risk (RR) of CHD for an increased BMI and whether the RR was different between calendar periods (i.e. studies that started before 1985 and studies that started after 1985) taking account of the age of the population. Associations of BMI and changes in eight anthropometric measures with all-cause and cause-specific mortality in old age were studied by means of multivariable Cox regression analyses using data from the Survey in Europe on Nutrition and the Elderly: a concerted action study including 70–77-year-olds (n=1,061–1,970). Moreover, the association of WC with all-cause and cause-specific mortality was studied by means of a meta-analysis of 29 international cohort studies including 65–74-year-olds (n=58,609). For an ageing population, we used the Doetinchem Cohort Study including 20–70-year-olds (n=3,408–4,135) and three to four repeated measures of weight and height over a period of 10 to 15 years. In this study population, we used a multivariable regression analysis to examine the association of changes in weight and long-term BMI patterns with QoL (measured by the SF-36 questionnaire). Results: After simultaneous inclusion of calendar period and age of the population in the model, the meta-regression analysis showed no difference in the RR of CHD in the association with a high BMI between calendar periods. However, a 10-year increment in population age lowered the 1.28 [95%confidence interval (CI): 1.22–1.34] RR of CHD for a five-BMI-unit increment by 29% (95%CI: -55 to -5). Among the elderly, BMI was associated with all-cause mortality, cardiovascular disease (CVD) mortality, and mortality due to causes other than CVD, cancer, and respiratory diseases (p6 kg, resulted in a decline in QoL. Weight loss (>2 kg) did not result in large changes in QoL. However, both weight gain and weight loss were adversely associated with changes in QoL as compared to a stable weight (changes ≤2 kg). From examination of long-term BMI patterns, the lowest QoL was observed for the ‘persistent obesity (≥30 kg/ m2)’ pattern. The BMI patterns, ‘persistent obesity’, ‘developing overweight (25.0–29.9 kg/m2’, ‘developing obesity’, and ‘switching between BMI categories’ scored 1.8–11.6 points (p

Background: Weight status is one of the factors that influence healthy ageing. It is often assessed with anthropometric measures such as body mass index (BMI) and waist circumference (WC), which indicate underweight or excess fat. Both are associated with adverse health outcomes in adults. The first paper of this thesis investigates whether this association is consistent over calendar time, to check for possible influences of improved healthcare procedures over time. In old age, this association is unclear. Using several anthropometric measures, the subsequent five papers examine the impact of weight status and development of weight status on coronary heart disease (CHD), mortality, and quality of life (QoL) among the elderly and during ageing. Methods: A meta-regression analysis of 31 international cohort studies (n=389,212) was used to estimate the multivariable adjusted relative risk (RR) of CHD for an increased BMI and whether the RR was different between calendar periods (i.e. studies that started before 1985 and studies that started after 1985) taking account of the age of the population. Associations of BMI and changes in eight anthropometric measures with all-cause and cause-specific mortality in old age were studied by means of multivariable Cox regression analyses using data from the Survey in Europe on Nutrition and the Elderly: a concerted action study including 70–77-year-olds (n=1,061–1,970). Moreover, the association of WC with all-cause and cause-specific mortality was studied by means of a meta-analysis of 29 international cohort studies including 65–74-year-olds (n=58,609). For an ageing population, we used the Doetinchem Cohort Study including 20–70-year-olds (n=3,408–4,135) and three to four repeated measures of weight and height over a period of 10 to 15 years. In this study population, we used a multivariable regression analysis to examine the association of changes in weight and long-term BMI patterns with QoL (measured by the SF-36 questionnaire). Results: After simultaneous inclusion of calendar period and age of the population in the model, the meta-regression analysis showed no difference in the RR of CHD in the association with a high BMI between calendar periods. However, a 10-year increment in population age lowered the 1.28 [95%confidence interval (CI): 1.22–1.34] RR of CHD for a five-BMI-unit increment by 29% (95%CI: -55 to -5). Among the elderly, BMI was associated with all-cause mortality, cardiovascular disease (CVD) mortality, and mortality due to causes other than CVD, cancer, and respiratory diseases (p6 kg, resulted in a decline in QoL. Weight loss (>2 kg) did not result in large changes in QoL. However, both weight gain and weight loss were adversely associated with changes in QoL as compared to a stable weight (changes ≤2 kg). From examination of long-term BMI patterns, the lowest QoL was observed for the ‘persistent obesity (≥30 kg/ m2)’ pattern. The BMI patterns, ‘persistent obesity’, ‘developing overweight (25.0–29.9 kg/m2’, ‘developing obesity’, and ‘switching between BMI categories’ scored 1.8–11.6 points (p

Keywords: dietary fibre, satiation, satiety, appetite, energy intake, body weight, viscosity, eating time, gastric emptying, fermentation. Background and objective:Dietary fibre can contribute in the prevention of overweight and obesity. However, different classes of dietary fibre may have different effects on appetite and energy intake regulation. The aim of this thesis was to investigate the effect of different dietary fibre classes on appetite, and its underlying mechanisms. Both acute and long term effects of dietary fibre classes were explored by diverse study designs, comprising a systematic review, three intervention studies and an observational study. Methods:First, we systematically reviewed available literature on the relationship between dietary fibre types, satiety, acute and long term energy intake and body weight. Next, in two intervention studies we investigated whether bulking, viscous, and gel forming properties of fibre could be related to satiation (n=121) or satiety (n=29), and whether fibre consumed in different food matrices could be related to satiety (n=29). Then, in a third intervention study (n=32), the role of acute and long term exposure (16 days) to gel forming fibre on satiety and energy intake was explored. Finally, long term (6.4 year) associations between the intake of dietary fibre classes and change in body weight were studied in an elderly population-based prospective cohort (n=1,859). Results:The literature review of studies in acute settings showed that dietary fibres with viscous properties and dietary fibres consumed in a liquid food matrix increased satiety and lowered subsequent energy intake. In the intervention studies we observed that foods containing a high-dose of gel forming fibre induced earlier satiation and increased satiety. Foods containing bulking and viscous fibres did not affect satiation or satiety. We observed that the earlier satiation and increased satiety were likely mediated by the increased time that was needed to eat the foods. Satiety, but not earlier satiation, was related to a slowed down gastric emptying rate. The literature review of studies on long term effects indicated that dietary fibre may lower energy intake and body weight, and that not all dietary fibre types are equally effective. Long term changes could, however, not be associated with viscosity, solubility, fermentability or with food matrix properties. In the intervention study we found that a gelled fibre persistently increased satiety compared to control, but did not decrease energy intake or body weight. In the prospective cohort study, a higher intake of total fibre, fibre from different food sources and fibre types were not associated with changes in body weight or waist circumference, although in general inverse associations were observed. Conclusions:We conclude that fibre classes that are hydrated and thickened result in earlier satiation and increased satiety. These effects are likely mediated by an increased oro-sensory exposure time and a slowed down gastric emptying rate. Dietary fibres may decrease long term energy intake and body weight, yet, we were not able to associate the effects with specific dietary fibre classes or underlying mechanisms.

Om de blootstelling aan stoffen uit consumentenproducten en de opname daarvan door de mens te kunnen schatten en beoordelen zijn wiskundige modellen beschikbaar. Voor de berekening wordt gebruik gemaakt van het computerprogramma CONSEXPO. Het grote aantal consumentenproducten verhindert dat voor elk afzonderlijk product blootstellingmodellen en parameterwaarden vastgesteld kunnen worden. Daarom zijn een beperkt aantal hoofdcategorieen met gelijksoortige producten gedefinieerd. Voor elke hoofdcategorie wordt informatie over de blootstellingschatting in een factsheet weergegeven. Naast achtergrondinformatie worden default-modellen en default-parameterwaarden gegeven van elke product-categorie waaruit de hoofdcategorie is opgebouwd. In deze factsheet wordt informatie weergegeven die voor meerdere hoofdcategorieen van belang is om een schatting van risico's van het gebruik van consumentenproducten te kunnen maken. Aan de orde komen de randvoorwaarden die aan default-parameters gesteld worden en de manier waarop de betrouwbaarheid van de schatting van de parameterwaarden wordt weergegeven. Verder zijn defaults van algemeen gebruikte blootstellingfactoren gedocumenteerd voor: -) de inhoud en de oppervlakte van kamers in Nederlandse woningen, -) het ventilatievoud in verschillende ruimten van woningen, -) het totale lichaamsoppervlak en het oppervlak van lichaamsdelen van volwassenen, mannen, vrouwen en kinderen. De gevoeligheid van humane blootstelling en opname voor ventilatie en kamergrootte worden besproken aan de hand van een verdampingsmodel.

Om de blootstelling aan stoffen uit consumentenproducten en de opname daarvan door de mens te kunnen schatten en beoordelen zijn wiskundige modellen beschikbaar. Voor de berekening wordt gebruik gemaakt van het computerprogramma CONSEXPO. Het grote aantal consumentenproducten verhindert dat voor elk afzonderlijk product blootstellingmodellen en parameterwaarden vastgesteld kunnen worden. Daarom zijn een beperkt aantal hoofdcategorieen met gelijksoortige producten gedefinieerd. Voor elke hoofdcategorie wordt informatie over de blootstellingschatting in een factsheet weergegeven. Naast achtergrondinformatie worden default-modellen en default-parameterwaarden gegeven van elke product-categorie waaruit de hoofdcategorie is opgebouwd. In deze factsheet wordt informatie weergegeven die voor meerdere hoofdcategorieen van belang is om een schatting van risico's van het gebruik van consumentenproducten te kunnen maken. Aan de orde komen de randvoorwaarden die aan default-parameters gesteld worden en de manier waarop de betrouwbaarheid van de schatting van de parameterwaarden wordt weergegeven. Verder zijn defaults van algemeen gebruikte blootstellingfactoren gedocumenteerd voor: -) de inhoud en de oppervlakte van kamers in Nederlandse woningen, -) het ventilatievoud in verschillende ruimten van woningen, -) het totale lichaamsoppervlak en het oppervlak van lichaamsdelen van volwassenen, mannen, vrouwen en kinderen. De gevoeligheid van humane blootstelling en opname voor ventilatie en kamergrootte worden besproken aan de hand van een verdampingsmodel.

Patiënten met overgewicht die last hebben van slijtage van het heupgewricht (artrose) zijn gebaat bij behandeling die is gericht op beweging en afvallen. Ondanks dat internationale richtlijnen dit aanbevelen, krijgt slechts 10% van de patiënten deze behandeling voorgeschreven door de huisarts. UMCG-onderzoeker Nienke Paans heeft laten zien dat een gecombineerd beweeg- en afvalprogramma vóór de heupoperatie het lichamelijk functioneren van artrosepatiënten met overgewicht verbetert en pijnklachten vermindert. Paans pleit ook voor meer aandacht voor bewegen en afvallen nadat een heupprothese is geplaatst. Op 20 juni promoveert zij op de resultaten van haar onderzoek aan de Rijksuniversiteit Groningen. Patiënten met slijtage van het heupgewricht (artrose) zijn gemiddeld 7 jaar onder behandeling van hun huisarts voordat zij operatief een kunstheup krijgen. Paans stelde dit vast met behulp van de gegevens van 30.000 patiënten uit een medisch registratie netwerk van huisartsen over een periode van 10 jaar, van 1998-2008. Vicieuze cirkel Patiënten die last hebben van heupartrose lopen het risico in een vicieuze cirkel terecht te komen. “Als het lopen pijn doet vanwege de artrose, gaan mensen beweging vermijden en blijven ze in de stoel zitten. Dan bestaat de kans dat hun gewicht toeneemt. Door dit gebrek aan bewegen, met daarbij de extra belasting van het gewicht op het heupgewricht, zullen de klachten toenemen,” licht Paans toe. Bewegen en afvallen Bij artrosepatiënten met overgewicht onderzocht Paans de effecten van een programma voor bewegen en afvallen voordat zij een kunstheup krijgen. Deelname aan het programma resulteerde in een verbetering van het zelfgerapporteerde lichamelijk functioneren. Daarnaast werd een verbetering gezien in het loopvermogen. Ook vielen de patiënten af. Ten opzichte van de start van het programma waren de deelnemers na 8 maanden gemiddeld 5,6 kg lichter en was hun lichaamsvet met 3,3% afgenomen. “Het gecombineerde programma voor bewegen en afvallen betekent dat je patiënten met heupartrose meer te bieden hebt dan alleen pijnbestrijding,” legt Paans uit. “Bovendien kan het leiden tot uitstel van de heupoperatie, wat gunstig is omdat een kunstheup maar 10-15 jaar meegaat.” Na de operatie Artsen en andere behandelaars veronderstellen dat patiënten met overgewicht na plaatsing van de heupprothese weer gaan bewegen, omdat dit weer mogelijk is. Daardoor zouden ze weer kunnen afvallen. Paans stelde vast dat dit niet het geval is. “Het is belangrijk dat patiënten gaan bewegen en afvallen, omdat overgewicht het succes van de operatie beïnvloedt. Teveel lichaamsgewicht kan leiden tot vroegtijdige loslating van de prothese en dat is niet wat je wilt,” vertelt Paans. Richtlijn Paans concludeert dat Nederlandse huisartsen beter ondersteund zouden moeten worden in hun medisch beleid bij heupartrose in de periode voorafgaand aan het plaatsen van een kunstheup. De ontwikkeling van een richtlijn voor huisartsen is daartoe belangrijk. Bewegen en afvallen voor en na de operatie zouden daarin een belangrijke plaats moeten krijgen, aldus Paans

Patiënten met overgewicht die last hebben van slijtage van het heupgewricht (artrose) zijn gebaat bij behandeling die is gericht op beweging en afvallen. Ondanks dat internationale richtlijnen dit aanbevelen, krijgt slechts 10% van de patiënten deze behandeling voorgeschreven door de huisarts. UMCG-onderzoeker Nienke Paans heeft laten zien dat een gecombineerd beweeg- en afvalprogramma vóór de heupoperatie het lichamelijk functioneren van artrosepatiënten met overgewicht verbetert en pijnklachten vermindert. Paans pleit ook voor meer aandacht voor bewegen en afvallen nadat een heupprothese is geplaatst. Op 20 juni promoveert zij op de resultaten van haar onderzoek aan de Rijksuniversiteit Groningen. Patiënten met slijtage van het heupgewricht (artrose) zijn gemiddeld 7 jaar onder behandeling van hun huisarts voordat zij operatief een kunstheup krijgen. Paans stelde dit vast met behulp van de gegevens van 30.000 patiënten uit een medisch registratie netwerk van huisartsen over een periode van 10 jaar, van 1998-2008. Vicieuze cirkel Patiënten die last hebben van heupartrose lopen het risico in een vicieuze cirkel terecht te komen. “Als het lopen pijn doet vanwege de artrose, gaan mensen beweging vermijden en blijven ze in de stoel zitten. Dan bestaat de kans dat hun gewicht toeneemt. Door dit gebrek aan bewegen, met daarbij de extra belasting van het gewicht op het heupgewricht, zullen de klachten toenemen,” licht Paans toe. Bewegen en afvallen Bij artrosepatiënten met overgewicht onderzocht Paans de effecten van een programma voor bewegen en afvallen voordat zij een kunstheup krijgen. Deelname aan het programma resulteerde in een verbetering van het zelfgerapporteerde lichamelijk functioneren. Daarnaast werd een verbetering gezien in het loopvermogen. Ook vielen de patiënten af. Ten opzichte van de start van het programma waren de deelnemers na 8 maanden gemiddeld 5,6 kg lichter en was hun lichaamsvet met 3,3% afgenomen. “Het gecombineerde programma voor bewegen en afvallen betekent dat je patiënten met heupartrose meer te bieden hebt dan alleen pijnbestrijding,” legt Paans uit. “Bovendien kan het leiden tot uitstel van de heupoperatie, wat gunstig is omdat een kunstheup maar 10-15 jaar meegaat.” Na de operatie Artsen en andere behandelaars veronderstellen dat patiënten met overgewicht na plaatsing van de heupprothese weer gaan bewegen, omdat dit weer mogelijk is. Daardoor zouden ze weer kunnen afvallen. Paans stelde vast dat dit niet het geval is. “Het is belangrijk dat patiënten gaan bewegen en afvallen, omdat overgewicht het succes van de operatie beïnvloedt. Teveel lichaamsgewicht kan leiden tot vroegtijdige loslating van de prothese en dat is niet wat je wilt,” vertelt Paans. Richtlijn Paans concludeert dat Nederlandse huisartsen beter ondersteund zouden moeten worden in hun medisch beleid bij heupartrose in de periode voorafgaand aan het plaatsen van een kunstheup. De ontwikkeling van een richtlijn voor huisartsen is daartoe belangrijk. Bewegen en afvallen voor en na de operatie zouden daarin een belangrijke plaats moeten krijgen, aldus Paans

Patiënten met overgewicht die last hebben van slijtage van het heupgewricht (artrose) zijn gebaat bij behandeling die is gericht op beweging en afvallen. Ondanks dat internationale richtlijnen dit aanbevelen, krijgt slechts 10% van de patiënten deze behandeling voorgeschreven door de huisarts. UMCG-onderzoeker Nienke Paans heeft laten zien dat een gecombineerd beweeg- en afvalprogramma vóór de heupoperatie het lichamelijk functioneren van artrosepatiënten met overgewicht verbetert en pijnklachten vermindert. Paans pleit ook voor meer aandacht voor bewegen en afvallen nadat een heupprothese is geplaatst. Op 20 juni promoveert zij op de resultaten van haar onderzoek aan de Rijksuniversiteit Groningen. Patiënten met slijtage van het heupgewricht (artrose) zijn gemiddeld 7 jaar onder behandeling van hun huisarts voordat zij operatief een kunstheup krijgen. Paans stelde dit vast met behulp van de gegevens van 30.000 patiënten uit een medisch registratie netwerk van huisartsen over een periode van 10 jaar, van 1998-2008. Vicieuze cirkel Patiënten die last hebben van heupartrose lopen het risico in een vicieuze cirkel terecht te komen. “Als het lopen pijn doet vanwege de artrose, gaan mensen beweging vermijden en blijven ze in de stoel zitten. Dan bestaat de kans dat hun gewicht toeneemt. Door dit gebrek aan bewegen, met daarbij de extra belasting van het gewicht op het heupgewricht, zullen de klachten toenemen,” licht Paans toe. Bewegen en afvallen Bij artrosepatiënten met overgewicht onderzocht Paans de effecten van een programma voor bewegen en afvallen voordat zij een kunstheup krijgen. Deelname aan het programma resulteerde in een verbetering van het zelfgerapporteerde lichamelijk functioneren. Daarnaast werd een verbetering gezien in het loopvermogen. Ook vielen de patiënten af. Ten opzichte van de start van het programma waren de deelnemers na 8 maanden gemiddeld 5,6 kg lichter en was hun lichaamsvet met 3,3% afgenomen. “Het gecombineerde programma voor bewegen en afvallen betekent dat je patiënten met heupartrose meer te bieden hebt dan alleen pijnbestrijding,” legt Paans uit. “Bovendien kan het leiden tot uitstel van de heupoperatie, wat gunstig is omdat een kunstheup maar 10-15 jaar meegaat.” Na de operatie Artsen en andere behandelaars veronderstellen dat patiënten met overgewicht na plaatsing van de heupprothese weer gaan bewegen, omdat dit weer mogelijk is. Daardoor zouden ze weer kunnen afvallen. Paans stelde vast dat dit niet het geval is. “Het is belangrijk dat patiënten gaan bewegen en afvallen, omdat overgewicht het succes van de operatie beïnvloedt. Teveel lichaamsgewicht kan leiden tot vroegtijdige loslating van de prothese en dat is niet wat je wilt,” vertelt Paans. Richtlijn Paans concludeert dat Nederlandse huisartsen beter ondersteund zouden moeten worden in hun medisch beleid bij heupartrose in de periode voorafgaand aan het plaatsen van een kunstheup. De ontwikkeling van een richtlijn voor huisartsen is daartoe belangrijk. Bewegen en afvallen voor en na de operatie zouden daarin een belangrijke plaats moeten krijgen, aldus Paans

Gelden standaardadviezen en -richtlijnen ook voor een niet-gemiddeld persoon? Dat vragen veel mensen die niet standaard zijn zich af. Kleine mensen – mensen die niet langer worden dan 1,45 meter (vrouwen) of 1,55 meter (mannen) – weten bijvoorbeeld niet of de adviezen over gewicht, voeding en bewegen ook voor hen gelden. Ook artsen en diëtisten kunnen hen daarbij niet altijd helpen. Dit rapport laat aan artsen, diëtisten en (para)medici zien hoe het is om klein te zijn. Ook geeft het hen handreikingen hoe zij in hun adviezen over gewicht, gezonde voeding en bewegen rekening kunnen houden met de specifieke lichamelijke beperkingen van kleine mensen.

Gelden standaardadviezen en -richtlijnen ook voor een niet-gemiddeld persoon? Dat vragen veel mensen die niet standaard zijn zich af. Kleine mensen – mensen die niet langer worden dan 1,45 meter (vrouwen) of 1,55 meter (mannen) – weten bijvoorbeeld niet of de adviezen over gewicht, voeding en bewegen ook voor hen gelden. Ook artsen en diëtisten kunnen hen daarbij niet altijd helpen. Dit rapport laat aan artsen, diëtisten en (para)medici zien hoe het is om klein te zijn. Ook geeft het hen handreikingen hoe zij in hun adviezen over gewicht, gezonde voeding en bewegen rekening kunnen houden met de specifieke lichamelijke beperkingen van kleine mensen.