“No, we certainly did not make things easy for ourselves,” agrees Dr Wilma Waterlander, a lead researcher in the LIKE study. “In classical lifestyle research, you think of one specific intervention relating to exercise or a healthy diet, you put it to the test and see whether you can measure how a certain aspect of health is impacted with or without the intervention. In LIKE, we look at the complete picture. You see, lifestyle has proven to be far too complex to influence using individual interventions. That's why we use a systems approach.”
Waterlander and her colleagues outlined this systems approach last year in a publication, since frequently quoted, in The Lancet. “In the article, we explore the relationship between the pandemics of undernutrition, obesity and the global climate crisis. Only once you acknowledge that the three together form a ‘syndemic’ can you begin to develop effective ways of tackling the obesity epidemic. On a smaller scale, we believe that this also applies to the problems associated with obesity in the LIKE study area, the Amsterdam District of Oost.”
Whereas the classical approach assumes simple, linear connections between an intervention and a result, in LIKE, Waterlander and her colleagues try to find the vicious cycles in the lifestyle. “’Causal loops’, in official lingo. Then you need to consider the availability of cheap junk food. Because of its huge success, producers are able to pour even more funds into marketing, meaning that the children are even more frequently confronted with that junk food, and so on.
The trick is to find a tender spot where you can break the vicious cycle. A measure like a ‘sugar tax’ for example, which is a structural disincentive for selling and buying sugary drinks. In LIKE, instead of researching whether a sugar tax works, as we already know that, we explore how we can ensure that such a measure is actually introduced."
In LIKE, instead of researching whether a sugar tax works, as we already know that, we explore how we can ensure that such a measure is actually introduced.
Amsterdam obesity free in 2033
The secret weapon of the LIKE researchers: actively involve the various target groups in the plans. Hence: the municipal authorities, and of course the children themselves. “That is the ‘Knowledge and Experience’ in our acronym. By inviting children to have their say in, for example, what happens with physical space in the city, it's much more likely that results will be achieved,' argues Waterlander.
The five-year LIKE project is now midway. “In all fairness, I have to say that the COVID-19 pandemic has caused some delays. This is part of the reason why we are as yet unable to present concrete results, but a systems approach such as this requires patience and perseverance anyhow.”
A major partner of the LIKE study is the Amsterdam Healthy Weight Program. With this program, the City of Amsterdam wants to eradicate obesity among children in the Dutch capital by 2033. “An ambitious goal,” notes Waterlander, “but not impossible. Applying the systems perspective really is the key. If that works, I am convinced that this approach can also be applied by other municipalities and perhaps even other countries."
LIKE: Lifestyle Innovations, based on youth’s Knowledge and Experience
LIKE is a five-year research project that was launched in 2017 with funding from the Hartstichting (Dutch Heart Foundation) and the Netherlands Organization for Health Research and Development (ZonMw). The aim: to promote a healthy lifestyle amongst children aged 10 to 14 living in the Amsterdam District of Oost. It concerns aspects including diet, physical activity and sitting and sleeping behaviors. In addition to researchers from the Amsterdam UMC, the LIKE consortium also includes colleagues from the Erasmus MC, the VU Amsterdam, Maastricht University, the City of Amsterdam (including the Amsterdam Healthy Weight Program and the City District of Oost) and the Public Health Service of Amsterdam (GGD).
The Amsterdam cohort ‘ABCD’
The LIKE study is fortunate to be able to use the information that has been collected since 2003 by the Amsterdam cohort study ABCD (Amsterdam Born Children and their Development). As much information as possible is collected about the development and lifestyle of (at the outset) eight thousand children.
“An especially interesting aspect for the LIKE study is the information that we have collected in the last few years regarding the difference between how mothers and fathers influence the lifestyle of boys and girls." Says Dr Tanja Vrijkotte, project manager of the ABCD study and also involved with LIKE. “Putting it like that perhaps makes it sound blindingly obvious, but our recent research has revealed that there is a quantifiable difference between the influence that fathers and mothers have on the lifestyle of boys and girls. This relates to healthy eating, but also to sport and exercise.
By also involving the fathers in lifestyle interventions in their own way, it may be possible to achieve more
It is a significant conclusion in relation to the measures that are conceived within LIKE. It is worth the effort to develop different interventions for boys and girls, as well as different roles for fathers and mothers. Up until now, these types of studies nearly always only examined the mothers, primarily due to practical considerations. By also involving the fathers in lifestyle interventions in their own way, it may be possible to achieve more,” says Vrijkotte.