7.4 Healthy lifestyles and healthy nutrition
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Healthy lifestyles and healthy nutrition in national document health policy
The national health policy is presented every four years by the Ministry of Health, Welfare and Sport (VWS). This policy was described in section 7.3 addressing sports as a national strategy. Section 7.3 also describes the publishing date, timeframe, update and type of document. The policy for the period 2011-2015, regarding healthy lifestyles and nutrition, will be discussed here. Later in this section, major revisions/updates in the policy from 2016 to 2019 will be outlined.
In the 2011-2015 health policy document of the Ministry of VWS, a special subsection mentions healthy lifestyles of youth. The introduction of this subsection mentions that the government wants to stimulate healthy behaviour and the development of resilience. They do not want to keep all possible temptations out of sight of young people, but they strive towards the implementation of broad lifestyle interventions, programmes and activities.
There are three themes that pay extra attention to youth in the coming years, namely healthy weight, substance use and sexual health. The part about healthy weight stipulates that efforts concerning healthy weight are important, because overweight young people are at greater risk of developing chronic diseases, such as diabetes and cardiovascular disease and all disadvantages that these diseases bring. In addition, overweight children experience more social exclusion through being bullied and being unable to join the group. This also has an impact on their psychological and emotional development. The government therefore invests in positive attention to a healthy and responsible dietary pattern as well as a safe, responsible place for sports, play and exercise in the lifestyle of youth. The motor skills of children have significantly worsened over the last two decades. Focused attention to a safe and responsible movement pattern in the form of injury prevention is required. Sports can help to make young people more resilient. Activities for young people who want to have a healthy weight should be available at close range, easy and attractive.
Substance use is another theme. The document explains that substance use at an early age increases the risk of addiction, is harmful to the developing brain and sometimes also causes acute health damage. Other consequences are reduced cognitive capacity, concentration disturbances and social damage such as school failure and unemployment. The risk of these consequences increases when using starts at an earlier age. Among vulnerable youth, excessive drug use is often a sign of broader issues, such as psychosocial and behavioural disorders, frequent truancy, nuisance and criminal behaviour.
The government wants to tackle addiction risks due to the use of alcohol, tobacco and drugs with a coherent approach, for example through the Healthy School and Drugs programme, which is described later in this chapter. The Ministry of VWS encourages all schools to be completely non-smoking. There should be a close relation between preventive programmes and care. But the link between stakeholders in for instance addiction care, mental health care and youth care could be better.
In 2011, young people between 14 and 18 started with an interactive online programme at school. This programme provided not only with information about the facts on alcohol, smoking and cannabis, but also insight into mechanisms such as group pressure. It taught them skills to stay with their own choices and offered healthy alternatives. It is unknown whether this programme is still being used.
The last theme is sexual health. Also with regard to sexual health, stimulating resilience and promoting healthy sexual behaviour are of great importance. Young people should have the opportunity to have relationships voluntarily, safely and pleasantly, and to prevent issues such as sexual coercion, STD’s and unwanted pregnancies. Four values are central to sexual health:
- Autonomy: The right to make one’s own choices in developing one’s sexuality without someone else deciding;
- Resilience: to be able to clarify what you want and what you do not want in sex and to have the skills to act on those preferences;
- Realization of reciprocity and respect: sexual health not only relates to personal health but also to the health of the other. The individual freedom of one person is limited to where another person’s freedom is being damaged;
- The right to access to information and to quality assistance whenever needed.
Government’s responsibilities in the field of sexual health are promoting good aid, the punishment of perpetrators and the protection of victims of sexual offences, providing information about sexual health, prevention of STD’s and unwanted pregnancies, and promoting resilience among youth. This relates to all young people. There is no additional investment into the sexual health of people with a disease or mental or physical disability or preventing stigmatization of people with HIV. There are no targeted policies for specific groups in the youth population.
Specific information about the implementation is not available, but it is to be expected that schools, sport clubs and municipalities are responsible for implementing programmes and that the Ministry provides the programmes and support. The Ministry is responsible for the national elements. Before drafting the policy document for the next four year period, the Ministry evaluates the previous policy, but it is not clear how this is done.
National policy document 2016-2019
There is a new health policy document for the period 2016-2019. In this document, government mentions that it will continue the elements described in the 2011-2015 policy.. so government keeps stimulating a healthy lifestyle for the whole Dutch population. Offering healthy food is also part of that goal. Mid-2016, the packaging of tobacco products received terrifying pictures and warnings. The ‘Schijf van Vijf’, a guideline for healthy nutrition, has been updated in 2016 based on new Healthy Nutrition guidelines. The Ministry keeps supporting the municipalities to stimulate a healthy lifestyle for their residents by offering support with programmes such as ‘Young People at a Healthy Weight’ and ‘Sport and Movement in the Neighbourhood’ (described in section 7.3). The Ministry keeps connecting with education, the environment, work and care agencies to improve health. There are no major updates/revisions of the previous policy document. Regarding evaluating and monitoring of this policy document, the Ministry works together with national knowledge institutes on presenting figures on the VWS policy about public health.
Healthy School approach
The healthy school approach (‘Gezonde school’) is a good example of a broad national programme that connects ‘education’ and ‘health’. It results in more health benefits, fewer health differences and better educational performances. The healthy school approach encourages schools in primary education, secondary education and secondary vocational education to address healthy lifestyles at school. Schools can work on one or more of the following themes:
- Physical activity and sports;
- Smoking, alcohol and drug prevention;
- Well-being, relationships and sexuality;
- Hygiene, skin and teeth;
- Indoor environment, nature and physical safety;
- Media wisdom;
- Hearing impairment.
Schools with an outstanding performance in one or more of these themes can apply for the Healthy School certificate. The approach consists of four elements, namely education, environment, signalling and policy. If all four elements of a theme have been taken into consideration, it is considered an comprehensive approach.
There are several ways in which schools can work on (one of) the themes:
- Schools can start working on a healthy lifestyle with the assistance of the website of the healthy school approach. The information on the website is current and agreed with the extensive network of partners.
- During the course of the programme,a support offer is available for 1750 schools, consisting of a sum of € 3,000 for working hours orthe use of a Healthy School activity. When granting support, there is a focus on the most vulnerable children.
- Schools designate a Healthy School Coordinator, who is in charge of health promotion and a contact point within the school. All Healthy School Coordinators have been trained.
- Schools can use the advice and support of Healthy School Advisers of the 25 GGDs. The Healthy School Advisers also receive training.
- Schools that want to show that they excel in health promotion on one or more of these themes, can apply for aHealthy School certificate for those themes.
The Healthy School programme focuses on all schools, paying particular attention to schools with a vulnerable student population. These can be children from families with low social economic status and children in special (primary and secondary) education. The current programme runs from 2017 to 2020, but it already existed several years before that. In these years, about one third of all Dutch schools already addressed one or more themes within the programme. Also almost 1,000 Healthy School certificates were handed out. With that number the ambition for this previous period was achieved. The goal for the period 2017-2020 is to reach another 1,650 schools that have not previously made use of the support offer.
The Healthy School approach is a partnership. The programme seeks to connect with programmes and projects that are also aimed at health and education. The Ministries of VWS, Education, Culture and Science (OCW), Social Affairs and Employment, and Economic Affairs together fund the Healthy School programme. Together they initiated and instructed the Steering Committee Healthy School approach. the primary education council, secondary education council and secondary vocational education council, the RIVM Centre Healthy Life and GGD GHOR Netherlands are represented in the Steering Committee. These organizations are responsible for the implementation of the programme for 2017-2020. They do so in close cooperation with regional GGDs, health funds, trade unions, social organizations and knowledge institutes in the area of healthy lifestyle. The progress and quality of the programme are monitored to report to the Ministries.
Youth on Healthy Weight (JOGG)
The Youth on Healthy Weight (JOGG) approach is an integrated approach in which local partnerships between private and public parties aim for a healthier weight among young people (0-19 years), in areas where the incidence of overweight is high. Under the umbrella of the municipality, public and private parties, such as schools, sports clubs, general practitioners (GPs), neighbourhood supermarkets and housing associations work together. This local collaboration leads to better sports, exercise and play facilities in the area, and calls for more attention to nutrition and physical activity. The JOGG approach is carried out by municipalities that join the National Youth on Healthy Weight Organization. This foundation is committed to a healthy environment in which young people and adults live and work, such as the school, the district, the sports club and the workplace. The approach exists since 2010 and is not limited in time.
Youth on Healthy Weight offers three themes nationally: Free Moving, just do it; Drink Water; and Vegetables ... Put Your Teeth In!. Youth on Healthy Weight also actively promotes the Healthy School Canteen, Healthy School programme ( described above) and, through the Healthcare Nutrition Agreement, introduces schools to a healthier dietary supply at schools.
Currently one third of Dutch municipalities participate in the approach. The JOGG municipalities help each other, exchange knowledge and experience and support each other. To get started with the JOGG approach, a municipality signs a cooperation agreement with Youth on Healthy Weight. It stipulates that the municipality will use the JOGG approach and that Youth on Healthy Weight provides support. The municipality appoints a JOGG director for at least 16 hours a week and a JOGG policy officer for 4 hours. The municipality pays an annual fee in order to make use of the support for young people on healthy weight, consisting of advice, knowledge, materials, training and a wide network. The foundation also receives a project grant from the government. Every year the foundation reports to the board and the Ministry of VWS.
Monitoring and evaluation are important elements of the JOGG approach. JOGG municipalities keep an eye on what happens within the approach and its impact. This allows municipalities to inspire the local network, justify their efforts and, if necessary, adjust them. Youth on Healthy Weight offers support in monitoring and evaluation to the municipalities. In order to map the main objectives and programme goals of youth on healthy weight on a broader level, an evaluation plan for 2015-2020 has been developed. A progress report is made annually.
Healthy school and drugs
The Healthy School and Drugs program (DGSG) is for schools that want to pay attention to prevention of alcohol, tobacco and drugs use. DGSG has existed for over 20 years and was developed by the Trimbos Institute. The impact of DGSG is wide-ranging. In addition to providing information to students, attention is paid to good school policies and the involvement of parents. The programme pays special attention to signalling and supervising students with problematic alcohol or drugs use. This joint approach in school makes young people less vulnerable in the areas of alcohol, smoking and drugs use. DGSG is part of the national Healthy School programme described above.
DGSG is available on request for the upper levels of primary education, in consultation with the local GGD or addiction care institutes. In addition, DGSG is available for secondary education, special secondary education and for secondary vocational education. The programme focuses on both students, parents, and school staff. There are no specific target groups within the youth population. The programme provides a form of universal prevention. Different aims have been formulated for the three different education levels. The goal in primary education is ‘to prevent students from using tobacco and alcohol’. The goal in secondary education is ‘to encourage students to delay alcohol use until at least 18 years old and to not use tobacco and drugs. The goal in secondary vocational education is ‘to prevent, limit and reduce smoking, excessive alcohol use and drug use among young people’.
The healthy school and drugs programme (DGSG) consists of 4 parts. Schools benefit most from the programme if all components are implemented together. These are the following: Awareness-raising classes, involving parents and caregivers, creating and managing good policy, and identifying and counselling students using substances (problematically). Various programmes are carried out within the DGSG approach, for example ‘the students’ alcohol use prevention’ programme.
The national government funds the programme. An impact study of the effects of the healthy school and drugs programme has been conducted (2009-2013). The results made clear that the programme had no effect on the development of substance use in adolescence. The advice was to renew and redevelop the programme. The expectation is that this has happened, but no further information is available. It is unclear also whether the effects of the programme will be monitored and evaluated again.
Long live love (lang leve de liefde)
Long Live Love is a programme about love, relationships and sexuality for secondary schools and vocational schools. The method makes use of three sets of teaching materials: Long Live Love for general secondary education (second year), Long Live Love for higher secondary education (4-5th year) and Long Live Love for vocational education. The teaching materials allow teachers to help students safely enjoy their emerging sexuality when they are ready. It enables them to educate students while developing their attitudes and skills with regard to relationships and sexuality. The Long Live Love themes are: puberty, falling in love, relationships, homosexuality, what you want, drawing the line and assertiveness, the internet, online predators, the first time, problems with sex, getting help, safe sex, condoms and contraception. There are no specific target groups within the youth population.
Each set of teaching materials consists of six online lessons. Each lesson takes a minimum of 50 minutes to complete. The duration also on the class, class reactions and whether the subject concerned is particularly relevant for this class. It is important to follow the order of the lessons as prescribed and to use all the available materials. The teaching materials have been developed to be used together and cover all the themes relating to relationships and sexuality. The lessons have been developed in such a manner, that they cover some themes of the mandatory biology curriculum.
In the Long Live Love series of lessons the following issues have been taken into account:
- Young people with diverse cultural backgrounds;
- Differences in values and principles relating to sexuality;
- Diversity in the way young people start relationships;
- Differences between boys and girls;
- Young people from different regions.
In 2014 an effect evaluation was conducted with positive results. It is not known if there will be more monitoring and evaluation studies. The programme has been commissioned by the Ministry of VWS. Funding sources are unknown.
Health education is not part of the curriculum of schools at upper secondary level and is not mandatory. However, health is often part of the mandatory biology lessons in school. Besides, schools can choose if and how they pay attention to health education. Programmes like the Healthy School approach described above encourage schools to pay attention to health and offer support to schools. Topics that are addressed in such programmes are: nutrition, physical activity and sports, smoking, alcohol and drug prevention and well-being, relationships and sexuality. Teachers can use available programmes such as the Healthy School approach and the Healthy School and Drugs programme.
Sex education and personal relationships education
Sexual education has been compulsory for primary and lower secondary education and special education since the end of 2012. The Ministry of OCW wants to prevent not only forced sexual acts and unacceptable behaviour, but also negative attitudes and reactions to homosexual behaviour. Instead government wishes to promote respectful behaviour and sexual resilience among students. However, in upper secondary level sexual education is not mandatory and not part of the curriculum. Schools can decide themselves if and how they pay attention to sexual education and personal relationships in upper secondary level. There are also programmes available that teachers can use for sexual education and personal relationships, for example ‘Long live love’. Schools can also use the Healthy School approach to pay attention to sex education and personal relationships.
WE CAN young
Within WE CAN Young, active youngsters (change makers) increase the awareness and positive attitude of other young people in the area of sexual and relational resilience, gender inequality and gender violence. Peer education, peer activation and peer mobilization are the strategies used. Peer education means that peers provide other young people with information and increase their awareness. In peer activation, change makers actively work on the topics by designing various actions for other young people. Peer mobilization involves the execution of the proposed actions and the transfer of the underlying message. The intention is to continue this process so that the young people who are reached become change makers too. Local project leaders guide and encourage the change makers in the process of education, activation and mobilization.
The project, which ran from May 2012 to the end of 2014, was conducted in 15 municipalities and was supported by a project team from knowledge centre Movisie. The age of the group reached with the project was between 12 and 23. There were no specific target groups within this population. The results were monitored by Movisie between May 2012 to 2014. The results are that young people, in their own opinion, have more knowledge of the topics addressed within the project. Some participants also experienced a change in their attitude towards the topics. No other monitoring or evaluation research has been conducted. The project continued in 2016, but has ended at the end of 2016. The project was funded by the Ministry of OCW, because it relates to violence against women, one of the main emancipation policy themes of the Ministry at the time.
MIND young academy
MIND Young Academy is a school project for students in lower secondary education and secondary vocational education, with the aim to make psychological problems an issue for discussion in class.
During the lessons, attention is paid to the following points: recognizing mental health issues, talking about psychological distress and knowing what to do if you suffer from it.
The lessons are given by peers who have had their own mental problems or experienced psychological problems in their environment. These so-called peer educators talk to students about common psychological complaints. Their message: just talk about it, because you're not the only one. During the lesson, a mini-documentary is shown in which two peer educators are introduced.
The fact that peer educators share their own stories, creates a safe atmosphere in the classroom. As a result students who have been experiencing psychological problems for a long time finally dare to share this in class. There is recognition and understanding. There are also many young people who dare to take the step to seek help after the project.
The project started at the end of 2016 and is an initiative of the organizations MIND and Diversion. There is no information on duration. The project receives no public funding. The project is made possible among others by crowdfunding actions. There is no information about monitoring and evaluation, or about results so far.
Kikid is a Dutch organization specializing in peer education projects on different topics.
All activities of Kikid are aimed at making young people feel good about themselves and the way they are, and to raise their awareness of the enormous power and influence they have themselves on their happiness and success . This will make them stronger and help them make the right choices in life. Kikid develops projects designed for talking with young people about important themes, such as alcohol and drugs, relationships and sexuality, money and debt, social media, group pressure and (cyber) bullying. These projects are aimed at students in secondary education. There are no specific target groups within that group of youth.
Kikid works based on the power of young people; ‘they are the experts who know how to really reach young people’. Therefore Kikid’s theatre programmes are developed with young people and performed by young people. The peer educators are close in age to the young people who participate in the programmes. Each team of peer educators consists of very different highly involved people. They receive an intensive didactic training from Kikid so they have the knowledge and specific skills to play the performance and be good conversation leaders in the classroom.
Research has been conducted to study the effects of one of the projects developed by Kikid, namely the programme Benzies & Batchies, in combination with the training I love me. Both have already been carried out at schools for a couple of years. These programmes aim at prevention and reduction of unacceptable sexual behaviour and have a positive impact on young people's views on unacceptable behaviour. The attitude, standards and trust in pupils' own ability regarding unacceptable behaviour has improved. No research was conducted on other projects of Kikid. Regarding funding, the Ministry of VWS and the Ministry of OCW are described as partners of the organization, but it is unclear if and how much public funding they receive. See the website for all projects on the different topics.
There are no known top-level initiatives that support collaboration and the formation of partnerships between schools, youth workers, health professionals and sport organizations in order to promote youth fitness and physical activity of young people. It is expected that schools, municipalities, youth workers, health professionals and sport organizations cooperate at local level, so collaboration is different in every municipality and with varying stakeholders.
Raising awareness on healthy lifestyles and on factors affecting the health and well-being of young people
In general the Ministry of VWS decides on the actions in the field of health and wellbeing. Other partners are responsible for implementation. SOAAIDS is an organization that disseminates information in national campaigns about sexual health, funded by the government. Different age categories can also find information there. The website sense.info is another example of a website where young people in particular can find information about sexual health and personal relationships. They can also seek contact with professionals when they have questions or need help or advice. Sense has been developed by SOAAIDS, the GGD, a knowledge institute and the Ministry of VWS. Sense also has consultation hours, where young people can ask questions, get help or advice and sometimes can get a pregnancy test or SOA test.
Another important website for youth is jouwggd.nl. This website deals with wider issues than sexual health only, since it also offers information about health in general (e.g. nutrition, lifestyle, physical activity, relationships, body, emotional wellbeing, substance use and media). There is also the possibility to ask questions by chat or email. It is unknown if and how much financial support these initiative receives.
Besides the Sense consultation hours, Dutch youth have the possibility to go to their general practitioner (GP) for information and counselling. The GP is also able to refer them to other professionals for help . There is no top-level framework regarding youth information and counselling structures.
NIX18 (in English: nothing 18) is a large-scale information campaign initiated by the Ministry of VWS and other national partners, such as GGD GHOR, NOC*NSF and the national Lung Fund. The aim of the campaign is to raise the social standard ‘don’t drink and smoke until you’re 18’. Youth up to 18 are the primary target group of the campaign, but it is also aimed at society at large. Everyone should think it is normal that young people do not smoke and drink before the age of 18. This campaign is accompanied by some important changes in policy. . Since 2014 it is forbidden to sell alcohol or tobacco to people under 18. Young people under 18 are also not allowed to be in possession of alcoholic beverages. The campaign makes use of a website aimed at young people and their parents. They can find information there, for example facts on substance use and how parents can make agreements with their children about drinking and smoking behaviour. The campaign was also broadcast on radio and television.
The campaign was specifically aimed at:
- Parents with children between 13 and 17 years;
- Young people between 13 and 17 years;
- General public (18+).
This campaign took place in 2016. The website still exists, but no further information has been broadcast on radio and television. The campaign was monitored and evaluated. The results show that almost all young people under 18 say they never smoke (95%). This percentage is higher in 2016 compared to 2013 (88%). Besides, a larger number of young people say they do not consume alcohol (64%) compared to 2013. More young people and parents find it normal to not smoke and drink until the age of 18. About three-quarters of parents agree with this social norm. However, the majority still thinks it is acceptable if young people under 18 drink in moderation.
Signs of depression
The large-scale campaign Signs of depression was active from September till December 2016. This campaign is part of the multi-annual Depression Prevention programme, which is described as a national strategy in 7.5. With this campaign the Ministry of VWS wants to lower the threshold to talk about depression. In addition, the campaign aims to make people more positive about offering help and seeking help in cases of depression. The campaign targeted all Dutch people over 18 years (general public) and people "involved" in depression: (potential) bystanders, victims and risk groups (young women aged 18-35 and young people aged 13-18.
The campaign strategy was addressing the subject depression and breaking the taboo around depression. In addition, it presented the signs of depression and how to recognize them. Eventually it aimed to make it easier to find information about depression. Information can be found at http://www.omgaanmetdepressie.nl. This website was also referred to in the campaign statements.
TV and radio ads were distributed to reach a wide audience and raise awareness. These ads also featured in cinemas and in social media. In the radio ads various signs of depression were mentioned. Web messages were disseminated with information about the occurrence of depression. The online messages focused on the risk groups.
The results of the campaign show that the general public recognizes more signs of depression. More people want to seek help or offer help in case of a depression.
There is still a taboo on talking about depression. Three quarters of the Dutch population finds it difficult to discuss this topic. Two-thirds of people find it normal that they can talk to friends or relatives about depressive feelings. After the campaign, depression was discussed more often. There is also a more positive attitude towards starting a conversation about depression.