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Primates are highly social animals and should ideally be housed together with conspecifics in social groups. Although group-housing enhances the psychological wellbeing of captive primates, it also leads to an inherent risk of some individuals becoming overweight. Indeed, overweight occurs in almost a quarter of group-housed primates. Measuring and monitoring overweight is important because overweight primates (1) perform less natural behaviour and (2) have a higher risk of health problems. The best way to measure overweight in group-housed primates is a species-specific weight-for-height index. Measuring this non-invasively minimizes disturbances to the primates. Variation in body weight can be measured non-invasively by letting individuals voluntarily step on a scale in their home enclosure. In the colony of the Biomedical Primate Research Centre (BPRC) in Rijswijk, overweight cannot be explained by differences in housing condition, stress levels or behaviour of the primates, while the natural dominance rank has a strong effect. This complicates the application of husbandry strategies to reduce overweight as social organization and dominance rank should not be disrupted. Overweight prevention should therefore be favored over overweight reduction, and this can be achieved by providing diets that mimic the natural diets of wild primates with regard to provisioning, composition and amount of food. Altogether, this thesis provides insight in the correlates, consequences and control of overweight in group-housed primates. Having an overweight management program is recommended for all facilities housing primates to ensure good primate welfare.

Primates are highly social animals and should ideally be housed together with conspecifics in social groups. Although group-housing enhances the psychological wellbeing of captive primates, it also leads to an inherent risk of some individuals becoming overweight. Indeed, overweight occurs in almost a quarter of group-housed primates. Measuring and monitoring overweight is important because overweight primates (1) perform less natural behaviour and (2) have a higher risk of health problems. The best way to measure overweight in group-housed primates is a species-specific weight-for-height index. Measuring this non-invasively minimizes disturbances to the primates. Variation in body weight can be measured non-invasively by letting individuals voluntarily step on a scale in their home enclosure. In the colony of the Biomedical Primate Research Centre (BPRC) in Rijswijk, overweight cannot be explained by differences in housing condition, stress levels or behaviour of the primates, while the natural dominance rank has a strong effect. This complicates the application of husbandry strategies to reduce overweight as social organization and dominance rank should not be disrupted. Overweight prevention should therefore be favored over overweight reduction, and this can be achieved by providing diets that mimic the natural diets of wild primates with regard to provisioning, composition and amount of food. Altogether, this thesis provides insight in the correlates, consequences and control of overweight in group-housed primates. Having an overweight management program is recommended for all facilities housing primates to ensure good primate welfare.

AIM: This study aimed to examine the extent, range and variety of research in Europe describing healthcare interventions for older people with dementia (PwD) and family caregivers. METHODS: This was a scoping review and followed the PRISMA Scoping Review guideline. MEDLINE, CINAHL and Cochrane library databases were searched for studies published between 2010 and 2020. Studies reporting healthcare interventions in Europe for PwD over 65 years and their family caregivers were included. RESULTS: Twenty-one studies from six European countries were included. The types of healthcare intervention identified were categorized as follows: (1) family unit intervention (interventions for both PwD and their family caregiver), (2) individual intervention (separate interventions for PwD or family caregivers) and (3) family caregiver only intervention (interventions for family caregivers only but with outcomes for both PwD and family caregivers). CONCLUSIONS: This review provides insight into healthcare interventions for older PwD and family caregivers in Europe. More studies are needed that focus on the family as a unit of care in dementia.

Organisations increasingly offer worksite health promotion to improve the health and lifestyle of their employees, and also because doing so has been reported to affect employees’ productivity. Worksite health promotion can take diverse forms, such as offering healthy food choices in the worksite cafeteria and providing onsite fitness facilities. Many of the positive effects of worksite health promotion are contingent on the extent to which employees use it. However, only a limited number of employees does so, and there is large variation between organisations in employee participation rates. In this dissertation, Anne van der Put studies the role of the work environment in explaining worksite health promotion use and its outcomes. To do so, she makes use of unique multilevel survey data of employees in many organisations from nine European countries. In addition, she designed and conducted a survey experiment to examine worksite health promotion for employees working from home. This dissertation contributes by answering novel questions in relation to worksite health promotion and health behaviours in the context of work. By focussing on the work environment, and social relations at work in particular, it contributes to understanding how to increase worksite health promotion use. A unique dataset with ample variation in work environments allowed for this. Furthermore, the research shows that worksite health promotion exceeds the physical limitations of the workplace, by accounting for the new context of hybrid work. Finally, examining different types of worksite health promotion provides deeper insights into its use and outcomes. The results show that the work environment matters for the use of worksite health promotion, both in the workplace and when employees work from home. Especially colleagues are important for the healthy choices employees make, both at work and outside. When colleagues encourage a healthy lifestyle, employees are more likely to participate in worksite health promotion, eat more fruits and vegetables and engage in more physical activity. The more colleagues participate in worksite health promotion, the more employees do so too. Additionally, the healthy eating behaviours of colleagues are related to each other. Organisational culture also plays a role. When work goes above and beyond everything, employees refrain from using worksite health promotion. These findings also apply when employees work from home: employees are more likely to use worksite health promotion when their colleagues do so and when this takes place during working hours. By allowing this, the organisation signals that they care about its employees’ well-being. This research furthermore shows that higher educated employees are more likely to use worksite health promotion, which translates in increased health inequalities. Employers also benefit, as the results indicate that employees that use worksite health promotion, but also those that are aware of its existence, perform better. Employers should ensure all employees are provided access to worksite health promotion, are aware of its existence and are able to use it. This will help employees in being healthy at work.

Organisations increasingly offer worksite health promotion to improve the health and lifestyle of their employees, and also because doing so has been reported to affect employees’ productivity. Worksite health promotion can take diverse forms, such as offering healthy food choices in the worksite cafeteria and providing onsite fitness facilities. Many of the positive effects of worksite health promotion are contingent on the extent to which employees use it. However, only a limited number of employees does so, and there is large variation between organisations in employee participation rates. In this dissertation, Anne van der Put studies the role of the work environment in explaining worksite health promotion use and its outcomes. To do so, she makes use of unique multilevel survey data of employees in many organisations from nine European countries. In addition, she designed and conducted a survey experiment to examine worksite health promotion for employees working from home. This dissertation contributes by answering novel questions in relation to worksite health promotion and health behaviours in the context of work. By focussing on the work environment, and social relations at work in particular, it contributes to understanding how to increase worksite health promotion use. A unique dataset with ample variation in work environments allowed for this. Furthermore, the research shows that worksite health promotion exceeds the physical limitations of the workplace, by accounting for the new context of hybrid work. Finally, examining different types of worksite health promotion provides deeper insights into its use and outcomes. The results show that the work environment matters for the use of worksite health promotion, both in the workplace and when employees work from home. Especially colleagues are important for the healthy choices employees make, both at work and outside. When colleagues encourage a healthy lifestyle, employees are more likely to participate in worksite health promotion, eat more fruits and vegetables and engage in more physical activity. The more colleagues participate in worksite health promotion, the more employees do so too. Additionally, the healthy eating behaviours of colleagues are related to each other. Organisational culture also plays a role. When work goes above and beyond everything, employees refrain from using worksite health promotion. These findings also apply when employees work from home: employees are more likely to use worksite health promotion when their colleagues do so and when this takes place during working hours. By allowing this, the organisation signals that they care about its employees’ well-being. This research furthermore shows that higher educated employees are more likely to use worksite health promotion, which translates in increased health inequalities. Employers also benefit, as the results indicate that employees that use worksite health promotion, but also those that are aware of its existence, perform better. Employers should ensure all employees are provided access to worksite health promotion, are aware of its existence and are able to use it. This will help employees in being healthy at work.

In early life, the intestinal microbiota undergoes a tremendous maturation and if disturbed this has been associated with negative effects on immune and brain development. Healthy microbiome maturation is supported by components like prebiotics like short-chain galacto-oligosaccharides (scGOS) and long-chain fructo-oligosaccharides (lcFOS) and omega-3 polyunsaturated fatty acids (n-3 PUFAs), which are present in infant formula milk to mimic human breast milk. The aim of this thesis was to evaluate the additional effects of a dietary combination of scGOS:lcFOS and n-3 PUFAs to improve health as well as to prevent cow’s milk allergy (CMA) development. In healthy mice, the combination of scGOS:lcFOS and n-3 PUFAs altered the intestinal bacterial composition in a distinct manner compared to the effects of the compounds individually. Additionally, scGOS:lcFOS improved social behaviour and reduced anxiety-like and repetitive behaviour, however, the n-3 PUFA and the combined interventions had limited to no effect on the evaluated behaviours and immune system parameters. CMA development was partly prevented by scGOS:lcFOS or n-3 PUFAs in mice but no additional effect was observed by the combination. Splenic cytokine responses were reduced and caecal butyrate level was induced by scGOS:lcFOS which tended to be impaired when combined with n-3 PUFAs, indicating the individual effects seemed to be negatively impacted when combined. It could also suggest a possible interaction between the dietary components, which was evaluated by studying modulation of intestinal Pparɣ expression, physical and chemical interaction and modulation of intestinal bacterial fermentation. It is no option to leave scGOS:lcFOS or n-3 PUFAs out of formula milk but it is essential to evaluate individual components and combinations as they might act differently than expected.

In early life, the intestinal microbiota undergoes a tremendous maturation and if disturbed this has been associated with negative effects on immune and brain development. Healthy microbiome maturation is supported by components like prebiotics like short-chain galacto-oligosaccharides (scGOS) and long-chain fructo-oligosaccharides (lcFOS) and omega-3 polyunsaturated fatty acids (n-3 PUFAs), which are present in infant formula milk to mimic human breast milk. The aim of this thesis was to evaluate the additional effects of a dietary combination of scGOS:lcFOS and n-3 PUFAs to improve health as well as to prevent cow’s milk allergy (CMA) development. In healthy mice, the combination of scGOS:lcFOS and n-3 PUFAs altered the intestinal bacterial composition in a distinct manner compared to the effects of the compounds individually. Additionally, scGOS:lcFOS improved social behaviour and reduced anxiety-like and repetitive behaviour, however, the n-3 PUFA and the combined interventions had limited to no effect on the evaluated behaviours and immune system parameters. CMA development was partly prevented by scGOS:lcFOS or n-3 PUFAs in mice but no additional effect was observed by the combination. Splenic cytokine responses were reduced and caecal butyrate level was induced by scGOS:lcFOS which tended to be impaired when combined with n-3 PUFAs, indicating the individual effects seemed to be negatively impacted when combined. It could also suggest a possible interaction between the dietary components, which was evaluated by studying modulation of intestinal Pparɣ expression, physical and chemical interaction and modulation of intestinal bacterial fermentation. It is no option to leave scGOS:lcFOS or n-3 PUFAs out of formula milk but it is essential to evaluate individual components and combinations as they might act differently than expected.

This study explores if multiple alterations of the classrooms' indoor environmental conditions, which lead to environmental conditions meeting quality class A of Dutch guidelines, result in a positive effect on students' perceptions and performance. A field study, with a between-group experimental design, was conducted during the academic course in 2020–2021. First, the reverberation time (RT) was lowered in the intervention condition to 0.4 s (control condition 0.6 s). Next, the horizontal illuminance (HI) level was raised in the intervention condition to 750 lx (control condition 500 lx). Finally, the indoor air quality (IAQ) in both conditions was improved by increasing the ventilation rate, resulting in a reduction of carbon dioxide concentrations, as a proxy for IAQ, from ~1100 to

A large proportion of the global workforce migrated home during the COVID-19 pandemic and subsequent lockdowns. It remains unclear what the exact differences between home workers and non-home workers were, especially during the pandemic when a return to work was imminent. How were building, workplace, and related facilities associated with workers’ perceptions and health? What are the lessons to be learned? Lifelines Corona Research Initiative was used to compare employees’ workplaces and related concerns, facilities, work quality, and health in a complete case analysis (N = 12,776) when return to work was imminent. Mann-Whitney U, logistic regression, and Wilcoxon matched-pairs were used for analyses. Notwithstanding small differences, the results show that home workers had less favourable scores for concerns about and facilities of on-site buildings and workplaces upon return to work, but better scores for work quality and health than non-home workers. However, additional analyses also suggest that building, workplace, and related facilities may have had the capacity to positively influence employees’ affective responses and work quality, but not always their health.

A large proportion of the global workforce migrated home during the COVID-19 pandemic and subsequent lockdowns. It remains unclear what the exact differences between home workers and non-home workers were, especially during the pandemic when a return to work was imminent. How were building, workplace, and related facilities associated with workers’ perceptions and health? What are the lessons to be learned? Lifelines Corona Research Initiative was used to compare employees’ workplaces and related concerns, facilities, work quality, and health in a complete case analysis (N = 12,776) when return to work was imminent. Mann-Whitney U, logistic regression, and Wilcoxon matched-pairs were used for analyses. Notwithstanding small differences, the results show that home workers had less favourable scores for concerns about and facilities of on-site buildings and workplaces upon return to work, but better scores for work quality and health than non-home workers. However, additional analyses also suggest that building, workplace, and related facilities may have had the capacity to positively influence employees’ affective responses and work quality, but not always their health.

Elimination of cervical cancer as a public health problem can be achieved by a combination of HPV vaccination and screening for early detection and treatment of precancerous lesions. Screening by primary HPV testing is currently replacing cytology in many organized screening programs. HPV-based programs will also be adapted multiple times in the future as they need to take into account changes such as the development of more advanced technologies and the decline in HPV infections following HPV vaccination. In this thesis, multiple aspects of HPV-based screening are described, with a focus on optimization of strategies using risk stratification. In particular, this thesis aims to I) evaluate the clinical performance of HPV self-sampling offered in the Netherlands as an alternative primary screening option, II) study risk profiles of unvaccinated women using HPV genotyping and screening history, III) study risk profiles of vaccinated women attending HPV-based screening, and IV) assess the costs of HPV testing following public tendering in Italian regional settings. I) Primary HPV testing on a self-collected sample was found to have similar accuracy but a slightly lower sensitivity as compared to HPV testing on a clinician-collected sample, thus the consensus guidelines for use in cervical screening were met although a re-evaluation of the workflow procedure is warranted to optimize its performance. II) Taking into account HPV genotyping information and screening outcomes from the previous screening round can lead to a more precise risk assessment. We found that 5-year HPV type concordance signals high CIN3+ risk which supports immediate referral for colposcopy without additional cytology triage. We also found that HPV detection and CIN3+ risk were higher among women who had a positive HPV test in the past, warranting a re-evaluation of the 10-year interval implemented in the Dutch program for women with a negative HPV test at age 40 or 50 years. III) With the use of a type-specific data-driven statistical model, we projected the lifetime CIN3+ risks under 5-yearly primary HPV screening and different HPV vaccination scenarios and found that HPV vaccination will lead to a strong decline in the lifetime CIN3+ risk supporting de-intensification of the screening program in vaccinated women. Screening vaccinated women using HPV testing and cytology triage remains feasible, although intervals beyond 5 years should be considered. IV) HPV tests can be purchased at very low prices if procured at high volume. Enhancing transparency by reporting tender-based unit prices can support health authorities in their decision to implement primary HPV screening.

Elimination of cervical cancer as a public health problem can be achieved by a combination of HPV vaccination and screening for early detection and treatment of precancerous lesions. Screening by primary HPV testing is currently replacing cytology in many organized screening programs. HPV-based programs will also be adapted multiple times in the future as they need to take into account changes such as the development of more advanced technologies and the decline in HPV infections following HPV vaccination. In this thesis, multiple aspects of HPV-based screening are described, with a focus on optimization of strategies using risk stratification. In particular, this thesis aims to I) evaluate the clinical performance of HPV self-sampling offered in the Netherlands as an alternative primary screening option, II) study risk profiles of unvaccinated women using HPV genotyping and screening history, III) study risk profiles of vaccinated women attending HPV-based screening, and IV) assess the costs of HPV testing following public tendering in Italian regional settings. I) Primary HPV testing on a self-collected sample was found to have similar accuracy but a slightly lower sensitivity as compared to HPV testing on a clinician-collected sample, thus the consensus guidelines for use in cervical screening were met although a re-evaluation of the workflow procedure is warranted to optimize its performance. II) Taking into account HPV genotyping information and screening outcomes from the previous screening round can lead to a more precise risk assessment. We found that 5-year HPV type concordance signals high CIN3+ risk which supports immediate referral for colposcopy without additional cytology triage. We also found that HPV detection and CIN3+ risk were higher among women who had a positive HPV test in the past, warranting a re-evaluation of the 10-year interval implemented in the Dutch program for women with a negative HPV test at age 40 or 50 years. III) With the use of a type-specific data-driven statistical model, we projected the lifetime CIN3+ risks under 5-yearly primary HPV screening and different HPV vaccination scenarios and found that HPV vaccination will lead to a strong decline in the lifetime CIN3+ risk supporting de-intensification of the screening program in vaccinated women. Screening vaccinated women using HPV testing and cytology triage remains feasible, although intervals beyond 5 years should be considered. IV) HPV tests can be purchased at very low prices if procured at high volume. Enhancing transparency by reporting tender-based unit prices can support health authorities in their decision to implement primary HPV screening.

The risk for development of non-communicable diseases (NCDs) can be predicted by somatic or mental symptoms and dietary alterations aimed at improvement of those symptoms could potentially delay development of NCDs. The goal of this study was to identify whether self-initiated dietary changes could reduce mental and somatic symptoms in relatively healthy individuals. Participants (n = 494) recruited from the Dutch population filled out weekly questionnaires on dietary intake, somatic and mental symptoms and physical activity at baseline and during dieting for four weeks. There was a significant reduction in mental and somatic symptoms, body weight, and waist circumference at four weeks, whereas physical activity remained unchanged. Five dietary patterns were identified by principal component analysis labelled "Processed foods", "Animal source foods", "Wheel of Five", "Traditional Dutch", and "Party". Reduction in mental symptoms was correlated to increased physical activity and increased intake of Wheel of Five foods. Reduction in somatic symptoms was correlated to body weight loss and less Processed foods, more Wheel of Five foods, and lower intake of fat and protein. Higher intake of protein and fat and lower intake of carbohydrates, however, were correlated to body weight loss. In conclusion this research showed that a self-initiated dietary change can lead to a significant reduction of mental and somatic symptoms.

The increasing temperatures due to climate change pose a major threat to human health with increasing morbidity and mortality as a result. The level of vulnerability of humans due to the heat depends on many factors, such as environmental parameters, physiological and anatomical characteristics and behaviour. The aims of the current thesis were to investigate the effects of sex and age on vulnerability in the heat and explore the use of thermal models to provide individualized advice regarding heat stress and heat strain prevention. It was shown that the critical Wet Bulb Globe Temperature limits differ between sexes. Therefore it needs to be considered to have sex as a separate factor in thermal models and indices, in line with the observation that heat-related mortality is higher in elderly women than men in the Netherlands. It is also shown that people are able to adapt to the increasing ambient temperatures by an upward shift in the minimum mortality temperature, e.g. the ambient temperature at which the least amount of people die. Furthermore, it was shown that caretakers cannot estimate heat strain of their children reliably. More effort is required to educate caretakers in thermal strain detection and reduction. The tool ClimApp was shown to be a valid and user-friendly tool to predict heat strain. It may be incorporated in heat policies to reach a broader audience and vulnerable populations to provide relevant, individually focused advice regarding the risks of the heat and precautionary measures.

Several studies found that classrooms' indoor environmental quality (IEQ) can positively influence in-class activities. Understanding and quantifying the combined effect of four indoor environmental parameters, namely indoor air quality and thermal, acoustic, and lighting conditions on people is essential to create an optimal IEQ. Accordingly, a systematic approach was developed to study the effect of multiple IEQ parameters simultaneously. Methods for measuring the IEQ and students' perceived IEQ, internal responses, and academic performance were derived from literature. Next, this systematic approach was tested in a pilot study during a regular academic course. The perceptions, internal responses, and short-term academic performance of participating students (n = 163) were measured. During the pilot study, the IEQ of the classrooms varied slightly. Significant associations (p 0.05) were observed between these natural variations and students' perceptions of the thermal environment and indoor air quality. These perceptions were significantly associated with their physiological and cognitive responses (p 0.05). Furthermore, students' perceived cognitive responses were associated with their short-term academic performance (p 0.01). The observed associations confirm the construct validity of the systematic approach. However, its validity for investigating the influence of lighting remains to be determined.

Observational learning is considered powerful to promote (implicit) motor learning. While it is a common tool in practice, little is known about the effects of video instructions on movement execution. The aim of this study was to investigate the effects of watching biomechanically optimal (OPT) and suboptimal (SUBOPT) sidestep cutting (SSC) video instructions on movement execution. Ten male basketball players (age 15.5 ± 1.2 years, height 189.9 ± 3.1 cm, mass 75.4 ± 7.1 kg) from a Regional Talent Center performed anticipated 45° SSC tasks in baseline (BASE) followed by two counterbalanced experimental conditions. Subjects watched expert videos (matched by sex and height) of OPT and SUBOPT movement executions and were asked to imitate this to the best of their ability. Kine(ma)tic data was captured with 21 reflective markers and 2 force plates. After watching the videos, subjects displayed smaller ankle dorsiflexion angles (p

Modifiable (biomechanical and neuromuscular) anterior cruciate ligament (ACL) injury risk factors have been identified in laboratory settings. These risk factors were subsequently used in ACL injury prevention measures. Due to the lack of ecological validity, the use of on-field data in the ACL injury risk screening is increasingly advocated. Though, the kinematic differences between laboratory and on-field settings have never been investigated. The aim of the present study was to investigate the lower-limb kinematics of female footballers during agility movements performed both in laboratory and football field environments. Twenty-eight healthy young female talented football (soccer) players (14.9 ± 0.9 years) participated. Lower-limb joint kinematics was collected through wearable inertial sensors (Xsens Link) in three conditions: (1) laboratory setting during unanticipated sidestep cutting at 40-50°; on the football pitch (2) football-specific exercises (F-EX) and (3) football games (F-GAME). A hierarchical two-level random effect model in Statistical Parametric Mapping was used to compare joint kinematics among the conditions. Waveform consistency was investigated through Pearson's correlation coefficient and standardized z-score vector. In-lab kinematics differed from the on-field ones, while the latter were similar in overall shape and peaks. Lower sagittal plane range of motion, greater ankle eversion, and pelvic rotation were found for on-field kinematics (p < 0.044). The largest differences were found during landing and weight acceptance. The biomechanical differences between lab and field settings suggest the application of context-related adaptations in female footballers and have implications in ACL injury prevention strategies. Highlights: Talented youth female football players showed kinematical differences between the lab condition and the on-field ones, thus adopting a context-related motor strategy. Lower sagittal plane range of motion, greater ankle eversion, and pelvic rotation were found on the field. Such differences pertain to the ACL injury mechanism and prevention strategies. Preventative training should support the adoption of non-linear motor learning to stimulate greater self-organization and adaptability. It is recommended to test football players in an ecological environment to improve subsequent primary ACL injury prevention programmes.

Modifiable (biomechanical and neuromuscular) anterior cruciate ligament (ACL) injury risk factors have been identified in laboratory settings. These risk factors were subsequently used in ACL injury prevention measures. Due to the lack of ecological validity, the use of on-field data in the ACL injury risk screening is increasingly advocated. Though, the kinematic differences between laboratory and on-field settings have never been investigated. The aim of the present study was to investigate the lower-limb kinematics of female footballers during agility movements performed both in laboratory and football field environments. Twenty-eight healthy young female talented football (soccer) players (14.9 ± 0.9 years) participated. Lower-limb joint kinematics was collected through wearable inertial sensors (Xsens Link) in three conditions: (1) laboratory setting during unanticipated sidestep cutting at 40-50°; on the football pitch (2) football-specific exercises (F-EX) and (3) football games (F-GAME). A hierarchical two-level random effect model in Statistical Parametric Mapping was used to compare joint kinematics among the conditions. Waveform consistency was investigated through Pearson's correlation coefficient and standardized z-score vector. In-lab kinematics differed from the on-field ones, while the latter were similar in overall shape and peaks. Lower sagittal plane range of motion, greater ankle eversion, and pelvic rotation were found for on-field kinematics (p < 0.044). The largest differences were found during landing and weight acceptance. The biomechanical differences between lab and field settings suggest the application of context-related adaptations in female footballers and have implications in ACL injury prevention strategies. Highlights: Talented youth female football players showed kinematical differences between the lab condition and the on-field ones, thus adopting a context-related motor strategy. Lower sagittal plane range of motion, greater ankle eversion, and pelvic rotation were found on the field. Such differences pertain to the ACL injury mechanism and prevention strategies. Preventative training should support the adoption of non-linear motor learning to stimulate greater self-organization and adaptability. It is recommended to test football players in an ecological environment to improve subsequent primary ACL injury prevention programmes.

Most people live in cities and work in offices, two contexts offering many lifestyle-related and environmental health risks. To advance their health, an analogy between urban design and facility design is introduced to explore whether health-directed design interventions in cities and facilities are related and to look for applicable cross-overs and opportunities to develop the facility management (FM) profession on the urban level. The principles of abductive reasoning as a first phase of scientific investigation were followed, by introducing a new idea and attentively observing phenomena in the communities of facility management and urban design. The method was desk research, in the context of discovery. Many possible cross-overs exist which offer opportunities for urban planners and facility managers to reinforce each other, and interesting market opportunities for the further development of urban FM. However, more systematic research is needed on efficacious and effective interventions. Furthermore, experiences and capacities of the FM sector should be unlocked and applied within a city context, as the knowledge and experiences of facility managers and urban planners can create synergy. The findings are directly applicable to facility and urban design practices, and to FM education by involving students in city design practices. Cross-overs between facilities and cities are new and can inspire both facility managers and urban planners to work together more closely for the benefit of citizens and employees.

Although it is advocated that end-users are engaged in developing evidence-based injury prevention training to enhance the implementation, this rarely happens. The ‘Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT)’ uses an ecological participatory design incorporating the perspectives of multiple stakeholders throughout the project. Within the I-PROTECT project, the current study aimed to describe the development of holistic injury prevention training specifically for youth handball players through using knowledge from both end-users (coaches and players) and researchers/handball experts. Employing action evaluation within participatory action research, the cyclical development process included three phases: research team preparation, handball expert-based preparation and end-user evaluation to develop injury prevention training incorporating both physical and psychological perspectives. To grow the knowledge of the interdisciplinary research team, rethinking was conducted within and between phases based on participants’ contributions. Researchers and end-users cocreated examples of handball-specific exercises, including injury prevention physical principles (movement technique for upper and lower extremities, respectively, and muscle strength) combined with psychological aspects (increase end-user motivation, task focus and body awareness) to integrate into warm-up and skills training within handball practice. A cyclical development process that engaged researchers/handball experts and end-users to cocreate evidence-based, theory-informed and context-specific injury prevention training specifically for youth handball players generated a first pilot version of exercises including physical principles combined with psychological aspects to be integrated within handball practice.

Although it is advocated that end-users are engaged in developing evidence-based injury prevention training to enhance the implementation, this rarely happens. The ‘Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT)’ uses an ecological participatory design incorporating the perspectives of multiple stakeholders throughout the project. Within the I-PROTECT project, the current study aimed to describe the development of holistic injury prevention training specifically for youth handball players through using knowledge from both end-users (coaches and players) and researchers/handball experts. Employing action evaluation within participatory action research, the cyclical development process included three phases: research team preparation, handball expert-based preparation and end-user evaluation to develop injury prevention training incorporating both physical and psychological perspectives. To grow the knowledge of the interdisciplinary research team, rethinking was conducted within and between phases based on participants’ contributions. Researchers and end-users cocreated examples of handball-specific exercises, including injury prevention physical principles (movement technique for upper and lower extremities, respectively, and muscle strength) combined with psychological aspects (increase end-user motivation, task focus and body awareness) to integrate into warm-up and skills training within handball practice. A cyclical development process that engaged researchers/handball experts and end-users to cocreate evidence-based, theory-informed and context-specific injury prevention training specifically for youth handball players generated a first pilot version of exercises including physical principles combined with psychological aspects to be integrated within handball practice. Also funded by:Kock’s foundationAlfred Österlund’s foundationSten K Johnson’s foundation

SamenvattingVaker buiten spelen maakt kinderen gezonder. Een actieve leefstijl is van groot belang voor een optimale groei en ontwikkeling van kinderen. De beperkingen als gevolg van het coronavirus maken dit extra zichtbaar. Het professionele netwerk ‘Zicht op Buiten’ bracht de gevolgen van te weinig buiten zijn en beweging voor de gezondheid van kinderen en jongeren in kaart, op het gebied van visus, motoriek, houding, overgewicht, slaap en psychosociale gezondheid. We bevelen sterk aan om 2 uur per dag naar buiten te gaan voor gezonde kinderogen, waarvan ten minste 1 uur matig-intensief bewegen om uithoudingsvermogen, spieren en botten te versterken. Andere leefstijlmaatregelen betreffen het verminderen van sedentair gedrag en regels over schermgebruik, evenals regelmatig afwisselen van zittende activiteiten.

It is unclear to what extent self‐employed choose to become self‐employed. This study aimed to compare the health care expenditures—as a proxy for health—of self‐employed individuals in the year before they started their business, to that of employees. Differences by sex, age, and industry were studied. In total, 5,741,457 individuals aged 25–65 years who were listed in the tax data between 2010 and 2015 with data on their health insurance claims were included. Self‐employed and employees were stratified according to sex, age, household position, personal income, region, and industry for each of the years covered. Weighted linear regression was used to compare health care expenditures in the preceding (year x–1) between self‐employed and employees (in year x). Compared with employees, expenditures for hospital care, pharmaceutical care and mental health care were lower among self‐employed in the year before they started their business. Differences were most pronounced for men, individuals ≥40 years and those working in the industry and energy sector, construction, financial institutions, and government and care. We conclude that healthy individuals are overrepresented among the self‐employed, which is more pronounced in certain subgroups. Further qualitative research is needed to investigate the reasons why these subgroups are more likely to choose to become self‐employed.

Sport and physical activity are embedded in our education systems and in wider society. This book takes the broadest possible look at this topic, across every key discipline and on different continents, opening up important new directions for the future development of sport and physical activity education. The book examines education in sport coaching, sport management, PE teacher training, physical activity and health promotion, and the emerging discipline of outdoor studies, considering how trends such as globalisation, digitalisation, and privatisation are having a profound impact on education programs. It identifies some of the most important societal issues that must be addressed by sport and physical activity educators, including healthy lifestyles, inequality, intercultural aspects, human rights, and emerging technologies, and looks at how sport and physical activity education in Europe, North America, Latin America, Asia, and Australasia is evolving to meet these challenges. Designed to invite self-reflection, to provoke debate and to open up new cross-disciplinary and international perspectives within sports organisations and higher education institutions, this book is fascinating reading for advanced students, researchers, teachers, and policy makers with an interest in sport and physical activity.

Sport and physical activity are embedded in our education systems and in wider society. This book takes the broadest possible look at this topic, across every key discipline and on different continents, opening up important new directions for the future development of sport and physical activity education. The book examines education in sport coaching, sport management, PE teacher training, physical activity and health promotion, and the emerging discipline of outdoor studies, considering how trends such as globalisation, digitalisation, and privatisation are having a profound impact on education programs. It identifies some of the most important societal issues that must be addressed by sport and physical activity educators, including healthy lifestyles, inequality, intercultural aspects, human rights, and emerging technologies, and looks at how sport and physical activity education in Europe, North America, Latin America, Asia, and Australasia is evolving to meet these challenges. Designed to invite self-reflection, to provoke debate and to open up new cross-disciplinary and international perspectives within sports organisations and higher education institutions, this book is fascinating reading for advanced students, researchers, teachers, and policy makers with an interest in sport and physical activity.

Chapter 3 describes the need for T-shaped Sport, Physical Activity and Health professionals. The authors de Jong and Skovgaard give insights on how to stimulate exercise and physical activity behaviour and counter sedentarism from a socioecological perspective. This perspective considers the complexity and systems thinking necessary to promote an active lifestyle for health. Furthermore, recommendations for a T-shaped Sport, Physical Activity, and Health professional that is educated in real-life situations (“Living Labs”) are made. From inside the classroom to outside in practice, the approach is a more congruent way of experiencing and learning how to deal with complex Sport, Physical Activity and Health challenges.

One reason for non-participation in and drop-out from sports and physical activity participation is sports related injuries where especially knee and ankle injuries contribute to this problem. Therefore, the project MOVE HEALTHY: Improving Health and Sustaining Participation of Youngsters in Sports around Europe seeks to develop free-of-charge education material to effectively support sport coaches and physical educators around Europe to prevent primary lower extremity injuries of the youngsters participating in their sport trainings and physical education (PE) classes. Therefore, MOVE HEALTHY seeks to develop exercise based routines to prevent sports and physical activity related injuries. The routines will be web-based including instruction videos. The routines will be based on the OPTIMAL motor learning theory and Self Determination Theory. It is intended that the consortium develops – by the process of co-creation with sport coaches and PE teachers – functional sports exercises that can be integrated in real world sport training and PE classes. With it, the project directly contributes to an improved sharing of good practices and develops innovative instruments in order to lower the risks of injuries and enhance sports participation in youngsters. The objective is to improve the motor competence of the youngsters, as well as to attitudinal and behavioral changes of the sport coaches and PE teachers during their practice. The ultimate goal of the MOVE HEALTHY project is that the youngsters can enjoy a lifelong, healthy sport participation

This dissertation revolves around the older and younger Chinese immigrants in the Netherlands. Specifically, the topic of study was the wellbeing of the older Chinese immigrants, and cultural elements as filial piety may play part in the in the wellbeing of this population. Comparative studies regarding frailty, loneliness and Quality of Life were conducted in China and the Netherlands, among older Chinese adults. In general, the older Chinese immigrant adults are predominantly socially vulnerable, such as a high prevalence of loneliness, whereas the native Chinese adults report a high prevalence of frailty. A second cross-national study provided insights in the cross-cultural equivalence of the De Jong Gierveld loneliness scale among the native and diasporic older Chinese adults. The cultural element filial piety is found to be relevant both to the first- and second-generation Chinese immigrants in the Netherlands. It is specifically of importance to the mental wellbeing of the older first-generation Chinese immigrants. Moreover, a qualitative study shows that filial piety frames how filial caregiving takes place among the second-generation Chinese immigrants. Lastly, a normative filial piety scale was translated to Dutch and psychometric validated among second-generation Chinese immigrants.These findings indicate that older Chinese immigrants are socially vulnerable. Secondly, filial piety is of relevance to the Chinese immigrants in the Netherlands. It is of importance to consider these aspects for professionals working both with older and younger Chinese immigrants in the Netherlands.

One reason for non-participation in and drop-out from sports and physical activity participation is sports related injuries where especially knee and ankle injuries contribute to this problem. Therefore, the project MOVE HEALTHY: Improving Health and Sustaining Participation of Youngsters in Sports around Europe seeks to develop free-of-charge education material to effectively support sport coaches and physical educators around Europe to prevent primary lower extremity injuries of the youngsters participating in their sport trainings and physical education (PE) classes. Therefore, MOVE HEALTHY seeks to develop exercise based routines to prevent sports and physical activity related injuries. The routines will be web-based including instruction videos. The routines will be based on the OPTIMAL motor learning theory and Self Determination Theory. It is intended that the consortium develops – by the process of co-creation with sport coaches and PE teachers – functional sports exercises that can be integrated in real world sport training and PE classes. With it, the project directly contributes to an improved sharing of good practices and develops innovative instruments in order to lower the risks of injuries and enhance sports participation in youngsters. The objective is to improve the motor competence of the youngsters, as well as to attitudinal and behavioral changes of the sport coaches and PE teachers during their practice. The ultimate goal of the MOVE HEALTHY project is that the youngsters can enjoy a lifelong, healthy sport participation

Equitable access to healthy food is a critical challenge in urban Asia. Food safety governance promotes modern supermarkets over more traditional markets, but supermarkets are associated with unequal access to food. This study investigates how retail policies driven by food safety impact the diets of the urban poor in Hanoi, Vietnam. We do this by linking food retail infrastructures with the food shopping practices and measured dietary intake of 400 women. Our results reveal sub-optimal dietary diversity and reliance on foods sourced through traditional markets, which do not provide formal food safety guarantees. Modern channels supply formal food safety guarantees, but are mainly frequented for purchasing ultra-processed foods. The paper uncovers a conflicting duality governing food security and suggests that the public responsibility for ensuring access of the poor to nutritious and safe foods requires a more diverse retail policy approach.

This paper reports on the research methods used in five different projects aimed at supporting people living with dementia in their everyday lives and activities of daily living. In all five projects, people living with dementia and their informal carers were involved. Applied methods ranged from passive involvement in the form of observations to very active involvement consisting of consultation rounds and think-aloud sessions. The projects highlighted that people living with dementia can still contribute to the development of solutions that support them in the self-management of their symptoms and challenges, as well as technological solutions that support them in daily living. LinkedIn: https://www.linkedin.com/in/jvhoof1980/

This chapter focuses on some of the opportunities and challenges of shifting power relations for musicians, through the particular lens of western classical musicians engaged in researching a participatory music practice in a hospital in the Netherlands. It provides some context to power relations in the field of professional music making. From such a holistic perspective, power relations that musicians experience are likely to shift as they move from the conventions of the concert stage to the context of a hospital ward. Power relations in the western classical music tradition, and professional education associated with it, are clearly strongly embedded within the cultural systems, albeit often at tacit levels and partly obscured by a dominating focus on “artistic quality”. The co-existence of such authorial and collaborative strategies to help steer through the power relations appears throughout the rest of the visit, to the point where it is hard to distinguish between them.

While activity-based working is gaining popularity worldwide, research shows that workers frequently experience a misfit between the task at hand and their work setting. In the current study, experience sampling data were used to examine how perceived fit in activity-based work environments is related to user behavior (i.e., the use of work settings and setting-switching). We found that workers’ perceived fit was higher when they used closed rather than open work settings for individual high-concentration work. Furthermore, more frequent setting-switching was related to higher perceived fit. Unexpectedly, however, this relation was observed only among workers low in activity-switching. These findings indicate that user behavior may indeed be relevant to creating fit in activity-based work environments. To optimize workers’ perceived fit, it seems to be particularly important to facilitate and stimulate the use of closed work settings for individual high-concentration work.

While activity-based working is gaining popularity worldwide, research shows that workers frequently experience a misfit between the task at hand and their work setting. In the current study, experience sampling data were used to examine how perceived fit in activity-based work environments is related to user behavior (i.e., the use of work settings and setting-switching). We found that workers’ perceived fit was higher when they used closed rather than open work settings for individual high-concentration work. Furthermore, more frequent setting-switching was related to higher perceived fit. Unexpectedly, however, this relation was observed only among workers low in activity-switching. These findings indicate that user behavior may indeed be relevant to creating fit in activity-based work environments. To optimize workers’ perceived fit, it seems to be particularly important to facilitate and stimulate the use of closed work settings for individual high-concentration work.

This chapter focuses on some of the opportunities and challenges of shifting power relations for musicians, through the particular lens of western classical musicians engaged in researching a participatory music practice in a hospital in the Netherlands. It provides some context to power relations in the field of professional music making. From such a holistic perspective, power relations that musicians experience are likely to shift as they move from the conventions of the concert stage to the context of a hospital ward. Power relations in the western classical music tradition, and professional education associated with it, are clearly strongly embedded within the cultural systems, albeit often at tacit levels and partly obscured by a dominating focus on “artistic quality”. The co-existence of such authorial and collaborative strategies to help steer through the power relations appears throughout the rest of the visit, to the point where it is hard to distinguish between them.

Context: Only 55% of the athletes return to competitive sports after an anterior cruciate ligament (ACL) injury. Athletes younger than 25 years who return to sports have a second injury rate of 23%. There may be a mismatch between rehabilitation contents and the demands an athlete faces after returning to sports. Current return-to-sports (RTS) tests utilize closed and predictable motor skills; however, demands on the field are different. Neurocognitive functions are essential to manage dynamic sport situations and may fluctuate after peripheral injuries. Most RTS and rehabilitation paradigms appear to lack this aspect, which might be linked to increased risk of second injury. Objective: This systematic and scoping review aims to map existing evidence about neurocognitive and neurophysiological functions in athletes, which could be linked to ACL injury in an integrated fashion and bring an extensive perspective to assessment and rehabilitation approaches. Data Sources: PubMed and Cochrane databases were searched to identify relevant studies published between 2005 and 2020 using the keywords ACL, brain, cortical, neuroplasticity, cognitive, cognition, neurocognition, and athletes. Study Selection: Studies investigating either neurocognitive or neurophysiological functions in athletes and linking these to ACL injury regardless of their design and technique were included. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: The demographic, temporal, neurological, and behavioral data revealing possible injury-related aspects were extracted and summarized. Results: A total of 16 studies were included in this review. Deficits in different neurocognitive domains and changes in neurophysiological functions could be a predisposing risk factor for, or a consequence caused by, ACL injuries. Conclusion: Clinicians should view ACL injuries not only as a musculoskeletal but also as a neural lesion with neurocognitive and neurophysiological aspects. Rehabilitation and RTS paradigms should consider these changes for assessment and interventions after injury.

Deze factsheet stelt de belangrijkste resultaten voor van een enquête die tussen juli en oktober 2018 werd afgenomen bij Franstalige kinderopvang in Brussel. De auteurs bespreken achtereenvolgens de inschrijvingsmodaliteiten en -criteria, de organisatie van de instap en van de eerste opvangdagen, de kenmerken van het publiek en de financiële bijdrage van de ouders. Cette fact sheet reprends les principaux résultats d’une enquête réalisée, entre les mois de juillet et d’octobre 2018, auprès de milieux d’accueil de la petite enfance francophones à Bruxelles. Elle aborde successivement les modalités et critères d’inscription, l’organisation de l’entrée et des premiers jours d’accueil, les caractéristiques du public et la contribution financière des parents. This fact sheet includes the main results of a survey of French-speaking childcare centres in Brussels between the months of July and October 2018. It deals with the registration procedures and criteria, the organisation of the first days of childcare, the characteristics of users and the financial contribution of parents.

Regular physical activity is regarded as an important component of a healthy lifestyle, decreasing the risk of many non-communicable diseases, mental health issues and increasing functioning and quality of life in older adults. Despite these benefits, a substantial segment of the older adult population remains sedentary or insufficiently physically active. In the Netherlands, depending of the definition and measurement method used, approximately 40–80% of Dutch adults aged 55 years and older can be considered physically inactive which matches data from other Western countries. For this reason, the GALM was developed. Aim of GALM was stimulating leisure-time physical activity in sedentary and underactive older adults aged 55–65 years. GALM is a community-based approach and distinguishes itself from other community-based strategies by way of the neighborhood-oriented recruitment phase and the versatile recreational sports activity program which is based on behavioral change and evolutionary-biological play theories. Since 1997, over 1.1 million older adults have been approached door-to-door, over 150.000 participated in the fitness test and over 100.000 participated in the GALM program. In this presentation, the theoretical background and short and long-term effects of participation in the GALM project on indicators of health and fitness will be presented.

Regular physical activity is regarded as an important component of a healthy lifestyle, decreasing the risk of many non-communicable diseases, mental health issues and increasing functioning and quality of life in older adults. Despite these benefits, a substantial segment of the older adult population remains sedentary or insufficiently physically active. In the Netherlands, depending of the definition and measurement method used, approximately 40–80% of Dutch adults aged 55 years and older can be considered physically inactive which matches data from other Western countries. For this reason, the GALM was developed. Aim of GALM was stimulating leisure-time physical activity in sedentary and underactive older adults aged 55–65 years. GALM is a community-based approach and distinguishes itself from other community-based strategies by way of the neighborhood-oriented recruitment phase and the versatile recreational sports activity program which is based on behavioral change and evolutionary-biological play theories. Since 1997, over 1.1 million older adults have been approached door-to-door, over 150.000 participated in the fitness test and over 100.000 participated in the GALM program. In this presentation, the theoretical background and short and long-term effects of participation in the GALM project on indicators of health and fitness will be presented.

Background and aim – The aim of this paper is present how application of the innovative Indoor Comfort Index (ICI) method reveal the actual indoor environmental quality (IEQ) and the perceived IEQ and its influence on office workers productivity. Application of this tool in a pre and post-test after an office refurbishment, will reveal the effectiveness of this intervention. The development and application of this tool, emerged from education and research in facility management, led to a spin-off consultancy firm Vital Workplace. Methods – Actual measurements of the IEQ conditions, combined with users’ perceptions of the IEQ, before and after an office refurbishment, reveals the effectiveness of a refurbishment by analysing the differences between the pre and post-test with multiple statistical analyses. Results – Regarding the IEQ, the ICI reveals not only the actual performance of an office building, also if improved conditions contribute to improved comfort of office workers. In addition, the possible influence of the IEQ on office workers productivity is revealed. This allows facility managers to determine and improve the alignment of environment quality with workers’ activities and performance. Originality – The tool combines actual and perceived environmental quality at office buildings. Practical or social implications – Education and research can be used to create spin-offs in facility management. The developed tool can be used to diagnose the current state of the office, a basis for discussion on related improvements, and by doing so, for a cost-benefit analyses of design interventions at organizations. Showing if design impact on users outweigh the costs of real estate, refurbishment, and changes in operations. Type of paper – Research paper.

Background and aim – The aim of this paper is present how application of the innovative Indoor Comfort Index (ICI) method reveal the actual indoor environmental quality (IEQ) and the perceived IEQ and its influence on office workers productivity. Application of this tool in a pre and post-test after an office refurbishment, will reveal the effectiveness of this intervention. The development and application of this tool, emerged from education and research in facility management, led to a spin-off consultancy firm Vital Workplace. Methods – Actual measurements of the IEQ conditions, combined with users’ perceptions of the IEQ, before and after an office refurbishment, reveals the effectiveness of a refurbishment by analysing the differences between the pre and post-test with multiple statistical analyses. Results – Regarding the IEQ, the ICI reveals not only the actual performance of an office building, also if improved conditions contribute to improved comfort of office workers. In addition, the possible influence of the IEQ on office workers productivity is revealed. This allows facility managers to determine and improve the alignment of environment quality with workers’ activities and performance. Originality – The tool combines actual and perceived environmental quality at office buildings. Practical or social implications – Education and research can be used to create spin-offs in facility management. The developed tool can be used to diagnose the current state of the office, a basis for discussion on related improvements, and by doing so, for a cost-benefit analyses of design interventions at organizations. Showing if design impact on users outweigh the costs of real estate, refurbishment, and changes in operations. Type of paper – Research paper.

Huge challenges and ambitions Most Dutch people are healthy and life expectancy is growing. Simultaneously, half of the Dutch population is overweight and this rate is even higher in lower socioeconomic groups. In addition, 9 out of 10 people eat too little fruit and vegetables, and nearly 30 percent of our food is of animal origin. The diet of an average Dutch person does not only lead to health losses, but also constitutes a major burden on the environment. It results in greenhouse gas emissions comparable to transport emissions. The annual food waste is 47 kilograms per person. Food in the Netherlands is mostly safe: approximately 1 in 24 people a year have a food infection, which usually is not serious. Most chemicals in food pose a negligible risk to public health. The Netherlands aims to take the lead in the international ambition for a healthy, sustainable and safe dietary pattern. To achieve this aim an integral policy is required, in which safety, health and sustainability are taken into account. Opportunities In this report, RIVM presents facts and figures about the safety, health and ecological sustainability of diets in the Netherlands and analyses the dilemmas and opportunities for an integrated food policy. Avoiding overconsumption, a diet with more plant-based and less animal-based products, and less sugar-containing and alcoholic drinks: these constitute three opportunities for a healthier and more sustainable dietary pattern. Taking advantage of these opportunities will lower the number of chronically ill, reduce health inequalities and contain the impact of food production on the environment. And, it tends to have a positive effect on the safety of our diet, as a lower meat consumption is associated with a lower rate of food infections. Dilemmas There are however dilemmas to be faced. Not all measures related to a healthy diet are sustainable and safe, and vice versa. For example, it is eco-friendly if every part of an animal is used for consumption. This also implies the consumption of processed meat, such as sausage, which in itself is less healthy. Moreover, there is a tension between abstract, long-term goals (healthier, more sustainable and safe) and concrete choices in everyday life. Many citizens and businesses consider health and sustainability to be important, but when shopping for food, consumers' choices are primarily determined by price and convenience. Companies, in turn, want to serve these consumers and make a profit. Making choices The tension between sustainable, healthy and safe diets on the one hand, and convenience, affordability and economy on the other, necessitates choices. To find a way out requires the government to take on an active role, and to cooperate with the agricultural sector, businesses, citizens and social organizations. Not only do consumers need to be well informed, but a healthier and more sustainable food supply is also needed. The same applies to an environment that promotes healthy and sustainable behaviour. Influential parties, such as purchasing organizations for supermarkets and retail, are potentially important partners. The fact that many citizens and businesses attach importance to sustainable, healthy and safe food legitimizes the government taking on this active role. Seizing opportunities There are opportunities for an integrated approach. Dutch society is characterized by entrepreneurship and innovation capacity. Presently, there are citizens' initiatives that focus on responsible diets. Companies welcome these initiatives and contribute through smart solutions that allow them to make a profit. If the government encourages and facilitates these developments, the social ambitions, entrepreneurial spirit and innovative capacity of all parties will be taken advantage of.

Huge challenges and ambitions Most Dutch people are healthy and life expectancy is growing. Simultaneously, half of the Dutch population is overweight and this rate is even higher in lower socioeconomic groups. In addition, 9 out of 10 people eat too little fruit and vegetables, and nearly 30 percent of our food is of animal origin. The diet of an average Dutch person does not only lead to health losses, but also constitutes a major burden on the environment. It results in greenhouse gas emissions comparable to transport emissions. The annual food waste is 47 kilograms per person. Food in the Netherlands is mostly safe: approximately 1 in 24 people a year have a food infection, which usually is not serious. Most chemicals in food pose a negligible risk to public health. The Netherlands aims to take the lead in the international ambition for a healthy, sustainable and safe dietary pattern. To achieve this aim an integral policy is required, in which safety, health and sustainability are taken into account. Opportunities In this report, RIVM presents facts and figures about the safety, health and ecological sustainability of diets in the Netherlands and analyses the dilemmas and opportunities for an integrated food policy. Avoiding overconsumption, a diet with more plant-based and less animal-based products, and less sugar-containing and alcoholic drinks: these constitute three opportunities for a healthier and more sustainable dietary pattern. Taking advantage of these opportunities will lower the number of chronically ill, reduce health inequalities and contain the impact of food production on the environment. And, it tends to have a positive effect on the safety of our diet, as a lower meat consumption is associated with a lower rate of food infections. Dilemmas There are however dilemmas to be faced. Not all measures related to a healthy diet are sustainable and safe, and vice versa. For example, it is eco-friendly if every part of an animal is used for consumption. This also implies the consumption of processed meat, such as sausage, which in itself is less healthy. Moreover, there is a tension between abstract, long-term goals (healthier, more sustainable and safe) and concrete choices in everyday life. Many citizens and businesses consider health and sustainability to be important, but when shopping for food, consumers' choices are primarily determined by price and convenience. Companies, in turn, want to serve these consumers and make a profit. Making choices The tension between sustainable, healthy and safe diets on the one hand, and convenience, affordability and economy on the other, necessitates choices. To find a way out requires the government to take on an active role, and to cooperate with the agricultural sector, businesses, citizens and social organizations. Not only do consumers need to be well informed, but a healthier and more sustainable food supply is also needed. The same applies to an environment that promotes healthy and sustainable behaviour. Influential parties, such as purchasing organizations for supermarkets and retail, are potentially important partners. The fact that many citizens and businesses attach importance to sustainable, healthy and safe food legitimizes the government taking on this active role. Seizing opportunities There are opportunities for an integrated approach. Dutch society is characterized by entrepreneurship and innovation capacity. Presently, there are citizens' initiatives that focus on responsible diets. Companies welcome these initiatives and contribute through smart solutions that allow them to make a profit. If the government encourages and facilitates these developments, the social ambitions, entrepreneurial spirit and innovative capacity of all parties will be taken advantage of.

To prevent overweight in children, regular physical activity is important. To stimulate childhood physical activity it seems relevant to consider motor skill competence stimulation in infants. Motor milestones can be seen as benchmarks of development in where motor coordination is central and may lead to more movement opportunities to increase physical activity. This study shows that infants who achieve their motor milestones later are physically less active and more sedentary when growing older. However, the effects are small. Although we found that infants reach their motor milestone later over the past decades, motor milestone achievement and BMI during childhood are largely independent. Instead of physical activity, aerobic fitness might have a stronger association with health outcomes during adolescence. Higher aerobic fitness reduced cardiometabolic risk in adolescents even in those with higher BMI. Therefore, stimulating high intensive physical activities to increase aerobic fitness is advised. Physical activity during childhood could be stimulated by focusing on early motor milestone achievement and by involving parents as a role-model for PA. For future studies, and comparability of studies, it would be good to have guidelines for the use and data processing of accelerometry data. Furthermore, we advise to combine accelerometry data with other measurements, like questionnaires to define the nature of the activities, and to measure aerobic fitness, because it may be more relevant for health outcomes than physical activity alone.

BACKGROUND: People with severe or profound intellectual and motor disabilities (SPIMD) encounter several risk factors associated with higher mortality rates. They are also likely to experience a cluster of health problems related to the severe brain damage/dysfunction. In order to earlier detect physical health problems in people with SPIMD, first of all, knowledge regarding the prevalence of physical health problems is necessary. The aim of this systematic review was to methodically review cross-sectional studies on the prevalence of various types of physical health problems in adults with SPIMD. METHOD: MedLine/PubMed, CINAHL, Embase, PsycINFO and Web of Science were searched for studies published between 2004 and 2015. The quality of the incorporated studies was assessed utilising an adjusted 'risk of bias tool' for cross-sectional studies. To estimate the prevalence of the health problems, the proportion and corresponding confidence interval were calculated. A random effect meta-analysis was performed when at least three studies on a specific health problem were available. RESULTS: In total, 20 studies were included and analysed. In the meta-analysis, a homogeneous prevalence rate of 70% (CI 65-75%) was determined for epilepsy. Heterogeneous results were ascertained in the meta-analysis for pulmonary/respiratory problems, hearing problems, dysphagia, reflux disease and visual problems. For the health problems identified in two studies or in a single study, the degree of evidence was low. As expected, higher prevalence rates were found in the current review compared with people with ID for visual problems, epilepsy and spasticity. CONCLUSION: This review provides an overview of the current state of the art research on the prevalence of health problems in adults with SPIMD. There is a substantial need for comprehensive epidemiological data in order to find clusters of health problems specific for people with SPIMD. This would provide insight into the excess morbidity associated with SPIMD.

BACKGROUND: People with severe or profound intellectual and motor disabilities (SPIMD) experience numerous serious physical health problems and comorbidities. Knowledge regarding the prevalence of these problems is needed in order to detect and treat them at an early stage. Data concerning these problems in individuals with SPIMD are limited. Therefore, the aim of this study was to determine the prevalence of reported physical health problems in adults with SPIMD through a review of medical records and care plans. METHOD: We conducted a cross-sectional study employing data obtained from medical and support records. A sample of adults with SPIMD was recruited in eight residential care settings. Physical health problems that had occurred during the previous 12 months or were chronic were recorded. RESULTS: The records of 99 participants were included. A wide range of physical health problems were found with a mean of 12 problems per person. Very high prevalence rates (>50%) were found for constipation, visual impairment, epilepsy, spasticity, deformations, incontinence and reflux. CONCLUSIONS: The results suggest that people with SPIMD simultaneously experience numerous, serious physical health problems. The reliance on reported problems may cause an underestimation of the prevalence of health problems with less visible signs and symptoms such as osteoporosis and thyroid dysfunction.