EASO congratulates our colleagues in the Netherlands on the recent publication of new Dutch guidelines on overweight and obesity in adults as part of broader national guidance on overweight and obesity in children and adults. The Netherlands has been a progressive partner in developing obesity policy and is one of the earliest health systems to recognise and treat obesity as a chronic disease. Each chapter of the new guideline has a brief introduction in English, which I suspect will be reviewed with interest by colleagues across Europe.
We are pleased to meet with Dr Karen Freijer, General Manager of the Partnership Overweight Netherlands (PON) with whom we discussed the genesis, development, implementation and potential impact of the new guidelines.
Great to meet with you, Karen. Please share the origin story of guidelines related to obesity in the Netherlands.
In 2008, the multidisciplinary Guideline ‘Diagnosis and Treatment of Obesity in Adults and Children of the Quality Institute for Healthcare CBO was published, and is based on scientific evidence and international consensus as much as is possible, The CBO guideline created the basis for the Standard of Care ‘Obesity’, which was published in 2010 and describes the content of interventions as well as process organisation, structure of health care chains and the patient perspective. This Standard of Care ‘Obesity’ was developed by PON and was commissioned by and with financial support from the Dutch Ministry of Health Welfare and Sport.
The PON was established in 2008 by initiative of the Ministry of Health, Welfare and Sport as they wanted PON to write the Standard of Care ‘Obesity’. Since then, PON is an umbrella organization of 20 partners and is still growing. The partners are medical and paramedical professional associations
((para)medical professionals), patient organizations, health care insurers, scientific & public health organizations. The PON works together on an optimal approach to overweight and obesity and advises, among other things, the government on policy in the field of overweight and obesity in the Netherlands.
In 2019, again the PON was commissioned and financial supported by the Dutch Ministry of Health, Welfare and Sport to update the guideline (2008) as well as the Standard of Care ‘Obesity’ (2010). This has resulted in the recently published Dutch guideline that includes also the updated Standard of Care ‘Obesity’. The latter is the recently published national model how to effectively treat obesity. This nationwide model forms the basis of a local network approach how to handle obesity in adults. PON has developed this model in cooperation with 7 Dutch municipalities and we connect the social and medical domain in a created infrastructure. PON also has developed a separate PON website for this network approach on which all materials can be found: www.aanpakovergewicht.nl. In 2023 PON has requested and received some funding of the Dutch Ministry of Health, Welfare and Sport to further develop this model with more Dutch municipalities, to gain more experience data to establish a more robust national model which will then be implemented in the whole Netherlands.
What were some of the key updates or changes made in these new guidelines compared to previous versions?
Within the press release below, we have extensively described the new insights (see Kadertekst in that press release).
How has the team ensured that the new guidelines are inclusive and applicable to diverse populations in the Netherlands?
During a national wide bottleneck analysis it was inventoried which items are most urgent to be part of the guideline. Based on the results of the bottleneck analysis, the chairmen and the adviser drew up draft starting questions. These were discussed with the working groups, after which the working groups determined the definitive basic questions. Subsequently, the working groups inventoried which outcome measures are relevant to the patient for each initial question, looking at both desired and undesired effects. The working groups rated these outcome measures according to their relative importance in decision-making regarding recommendations, as critical (critical to decision-making), important (but not critical), and unimportant. The working groups also defined at least for the crucial outcome measures which differences they considered clinically (patient) relevant.
The guideline development was supported by the Knowledge Institute of the Federation of Medical Specialists and was financed by VU University Amsterdam and the Ministry of Health, Welfare and Sport. The financiers have had no influence whatsoever on the content of the directive.
Method of development of this guideline, under coordination of the Knowledge Institute of the Federation of Medical Specialists:
This guideline has been developed in accordance with the requirements stated in the Medical Specialist Guidelines 2.0 report of the Advisory Committee on Guidelines of the Quality Council. This report is based on the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II; Brouwers, 2010).
Could you shed light on the most challenging aspect of coordinating the process of these guideline updates?
PON ‘hired’ the Knowledge Institute of the Federation of Medical Specialists to coordinate the whole process of development. Reason: this Federation is an acknowledged national specialist in the development of medical guidelines and hosts a national medical guideline database in which the guideline can be housed and updated when necessary. This Federation is therefore of great help.
The new guideline addresses prevention and treatment of overweight and obesity in adults. With the rise in childhood obesity, how do the new guidelines specifically address this demographic?
This new guideline focuses on the best diagnostics, support and care for adults with obesity, based on the most recent literature and expert/practice-based advice. In addition, this guideline is relevant for the indicated prevention of obesity in adults (persons with overweight but without severely enlarged abdominal circumference and/or already diagnosed obesity-related conditions).
Collective prevention (for persons without overweight) is an aspect we advise the government about. They are the ones together with municipalities who are responsible for this part in the Netherlands.
Both parts – including addressing rising obesity rates (in childhood as well as in adults) are necessary. We always quote of Liesbeth: ‘the tap must be closed and the bath must be emptied’. The tap is internationally wide open: the supply of unhealthy food is bigger than healthy food, movement is not actively and sufficiently supplied (world is changing) etc etc. That is the focus of collective prevention… government together with municipalities. PON is advising in this.
The bath image is all the persons already living with overweight and obesity. They are in need of an optimal treatment and support – this part are PON projects (guideline, national model network approach etc. – see also the video of Liesbeth I have sent in which she mentions these projects)
Can you share any evidence or research findings that particularly influenced the recommendations in the new guidelines?
All the modules in the guideline are based on scientific evidence and expert opinions resulting in the recommendations for each of these modules. Each module is answering the research questions based on the aforementioned results of the bottleneck analysis.
Considerations (from evidence to recommendation)
In addition to (the quality of) scientific evidence, other aspects are also important to result in a recommendation, such as the expertise of the working group members, patient values and preferences, costs, availability of facilities and organizational matters. These aspects, insofar as they are not part of the literature summary, are listed and assessed (weighted) under the heading ‘Considerations’ and may be (partly) based on expert opinion. A structured format based on the evidence-to-decision framework of the international GRADE Working Group was used (Alonso-Coello, 2016a; Alonso-Coello, 2016b). This evidence-to-decision framework is an integral part of the GRADE methodology.
How did the team select the multidisciplinary experts involved in the development of the new guidelines?
The coordinator in this matter – Knowledge Institute of the Federation of Medical Specialists – arranged also the selection of these experts following the right process.
A multidisciplinary working group was set up in 2019 to develop the guideline, consisting of representatives of relevant specialisms involved in the support and care of children and adults with obesity or overweight in combination with risk factors and/or comorbidities.
The working group members are mandated to participate by their professional associations. The working group is responsible for the full text of this guideline.
What impact do you hope these new guidelines will have on healthcare professionals and their approach to managing overweight and obesity?
That all healthcare professionals will acknowledge obesity as a disease and treat this disease following this guideline. So not only treat the symptom(s) their patients are coming for, but also will think about the cause of that symptom and then also treat the cause.
As also stated in this guideline (based on WHO reports), more than 200 conditions are associated with obesity. Only treating these conditions and not treating the possible underlying cause of these conditions (obesity) or at least talk about this in a respectful way with the patient, is not helping these patients but also not helping themselves as it will be frustrating for them too. No real long lasting effects on multiple level for the patient (quality of life, mentally etc etc)
How does the new guideline propose to involve patients and their families in the management of overweight and obesity?
Patients and their families are at the center and the professionals are there to help them. In the Standard of Care ‘Obesity’, it is extensively described where and how to start in the cooperation of all professionals in which the patient en their families etc. are part of. This is the aforementioned nationwide model for the basis of a local network approach on how to handle obesity in adults. The steps are mentioned and extensively described together with a lot of helpful documents – all developed by PON together with some municipalities.
We also developed images about the network. One of them appears below.
We described 6 steps for an optimal treatment of adults with obesity, which begins with asking permission of the patient to talk about obesity– here we also provide tools on how to do this including a Dutch translated version of the EASO tool ‘Talking about weight’
Also included are identifying each patient’s personal situation, personal characteristics and personal health skills, which are additional key steps. We provide tools to be able to do this in an efficient and non time consuming way.
Can you briefly explain how these new guidelines tie into the broader public health strategy in the Netherlands?
In the Netherlands, a National Prevention Agreement (NPA) was established in 2018 in which PON has played an important part (represented by Liesbeth van Rossum at that time).
This NPA contains agreements to make the Dutch healthier by reducing smoking, problematic alcohol consumption and obesity. The national government has made these agreements with more than 70 civil society organizations.
The goals in the agreement focus on the year 2040 and include:
- A smoke-free generation;
- Less overweight (from 50% to 38% of adults);
- Less excessive alcohol consumption (from 8.9% to 5%).
Updating the guideline and Standard Care ‘Obesity’ were among the projects originating from this NPA.
How will these guidelines be disseminated to healthcare professionals, and how will their implementation be monitored?
PON is actively discussing this with the Netherlands MoH. PON can and wants to develop the right tools for healthcare professionals as well as for the patients (the latter in cooperation with the Dutch Association for and of persons with overweight and obesity) following the applicable guidelines.
Tools we want to develop such as webinars, e-learnings, presentations etc. etc. For this, PON needs financial support from MoH and/or other national governmental organizations as overweight and obesity is a national social problem and not only a health problem. In a recent publication we showed (estimation based on real life data of 97 patients) that the current prevalence of overweight and obesity in the Netherlands, is costing the Dutch society 79 billion euro per year.
The results show that the impact of overweight and obesity go well beyond the healthcare sector, as the costs of productivity losses have the biggest share of the total societal costs of this disease. People with obesity or overweight are not only sick more often, but also longer than are people with a healthy weight, link to this publication: https://www.maastrichtuniversity.nl/news/costs-overweight-and-obesity-over-%E2%82%AC79-billion-year
During recent years, we have seen a revolution in sophisticated, multidisciplinary obesity guidelines, beginning with the Canadian Practice Guidelines and more recently with the Irish adaptation and adoption of their new guidelines. In your opinion, how can other countries learn from the new guidelines that the Netherlands has developed?
Internationally we should join our forces – knowledge, experiences, finance .. – to establish an international unambiguous policy in approach of attacking the still rising societal challenge of obesity. Not inventing the wheel in each country separately. It is an international epidemic which only together we will be able to tackle.
The recently developed Dutch guideline for adults with overweight and obesity has therefore adopted the Canadian Guideline on obesity as basis – using all the work that has extensively been done by Canada. Next to this basis we performed additional literature research to be able to answer the topics resulting from the bottleneck analysis.