This chapter covers the case study of Young People at a Healthy Weight (JOGG), healthy lifestyle community-based programme targeting children 0 to 19 years in the Netherlands. The case study includes an assessment of JOGG against the five best practice criteria, policy options to enhance performance and an assessment of its transferability to other OECD and EU27 countries.
Healthy Eating and Active Lifestyles
Best Practices in Public Health
7. Young People at a Healthy Weight
Abstract
Young People at a Healthy Weight (JOGG): Case study overview
Description: The JOGG approach is a community-based programme targeting children 0 to 19 years. The approach targets young people’s health by reshaping the environment to promote healthy lifestyles with a focus on tackling excess weight and obesity. Although the JOGG approach is specifically implemented in the Netherlands, several European and North American countries have adopted a similar whole system approach. The EPODE methodology served as the basis for the JOGG approach’s way of operations. In 2020 the Epode International Network (EIN) transitioned in a new community, namely Youth Health Community, which is co‑ordinated by the Dutch JOGG organisation.
Best practice assessment:
Table 7.1. OECD best practice assessment of the JOGG approach
|
Criteria |
Assessment |
|---|---|
|
Effectiveness |
Over 95 000 life years (LYs) and 13 089 disability-adjusted life years (DALYs) are expected to be gained by scaling up JOGG across the Netherland by 2050. By reducing rates of overweight and obesity, JOGG can prevent several forms of chronic disease cases, the majority of which would be musculoskeletal disorders or cardiovascular diseases. |
|
Efficiency |
JOGG is not only cost effective, but also cost saving across the majority of OECD and EU27 countries |
|
Equity |
JOGG is designed to reduce health and social inequalities by reaching low socio‑economic status (SES) groups, as it aimed to address the lack of access to healthy food options and make outdoor environment friendlier for physical activity for children living in low SES neighbourhoods. |
|
Evidence‑base |
The quality of evidence used for this case study is “strong to moderate” in areas related to data collection methods and selection bias for two studies used as effectiveness sources Typical to most public health studies, the design of the intervention does not allow blinding and measurement |
|
Extent of coverage |
JOGG reaches approximately 30% of children aged 0‑19 years of age in the Netherlands. |
Enhancement options: to enhance the effectiveness, policy makers could incorporate at the national level changes to the educational curricula of both teachers and students to increase health literacy levels in the population. To enhance the evidence‑base, health policy makers could advocate for expansion of utilisation of electronic health records for recording BMI for future evaluations to obtain accurate data on weight status of children throughout time. To enhance equity, administrators could utilise targeted communication techniques that incorporate in its messaging the values and cultural sensibilities that are specific to groups being addressed. To enhance extent of coverage, several strategies are available for the administrators, such as continuously framing JOGG activities in a way that reduces the stigma around obesity prevention.
Transferability: the JOGG approach targets risk factors prevalent in all OECD countries, therefore the intervention is likely to receive strong political support, which is necessary when considering which interventions to transfer. Further, the origin of JOGG comes from the EPODE approach, which has been transferred to many countries such as Australia, Spain and France.
Conclusion: the JOGG approach has the potential to significantly reduce non-communicable disease incidence when scaled-up across the Netherlands and transferred to other OECD and non-OECD European countries.
Intervention description
The Netherlands has experienced a progressive increase in rates of obesity for both adults and children, with current self-reported prevalence at 14.1% across the whole population (OECD, 2019[1]). It is a well-established that overweight and obesity in children and adults contributes to worse health outcomes such as cardiovascular disease, diabetes and cancer, as well as emotional and mental health problems due to low self-esteem (OECD, 2019[2]).
There are variety of factors that contribute to the expanding waistlines of young Dutch citizens, including environmental settings – such as, food environments (which includes large portion size, and sugary drinks availability), lack of physical activity among children, and sedentary behaviour (Seidell and Halberstadt, 2020[3]). In response, in 2010, the National Jongeren op Gezond Gewicht (JOGG) Project Bureau with the support from the Dutch Ministry of Health, Welfare and Sport initiated the JOGG approach in the Netherlands, which targets children aged 0‑19 years. Currently, the JOGG-approach is carried out in 183 municipalities (more than 50% of all municipalities) in The Netherlands.
JOGG focuses on this age group given the promotion of a healthy lifestyle and prevention of obesity in childhood reduces rates of obesity in adulthood, which is associated with more complex health issues. In addition, obesity and overweight are health conditions associated with high levels of stigma, particularly among children: OECD analyses show that Dutch girls with obesity are 2.85 times more likely to be bullied than their healthy-weight counterparts (this is a slightly lower than the OECD26 average of 3.11 times more likelihood of bullying among girls) (OECD, 2019[2]). Difference in bullying among Dutch boys follows the OECD trend with an increase, where boys with obesity are 2.12 times more likely to be bullied than boys with healthy-weight (comparative to the OECD26 average of 1.78 times more likelihood) (OECD, 2019[2]). Bullying can come from peers, friends, and even family (WHO, 2017[4]). Such a harmful social environment can lead to feelings of shame, low self-esteem, poor body image, depressive moods, and even suicide (WHO, 2017[4]).
At local level JOGG municipalities work towards a healthy environment for their youth using six key principles:
Principle 1: Create structural, political, and governmental support
In order to achieve wide reaching effects, obesity interventions must have political, structural, and government support. Under JOGG, municipal executives and councillors act as ambassadors to ensure healthy environments and lifestyles are integrated and articulated in policies across sectors, predominately: health care, spatial planning, sports and economic affairs. The diversity of policy spheres allows JOGG to exert influence on various domains that affect weight related outcomes – for example, advocacy for more green spaces and outdoor play areas, increase in availability of sport facilities, changes in local food stores for healthier alternatives (Collard et al., 2019[5]).
Principle 2: Co‑operation between the public and the private sectors
Healthy environments that allow for healthy childhoods are only achievable through joint efforts from public and private parties. The private sector has a major impact on the living environment, therefore partnerships are key to structural changes. Furthermore, engagement of both private and public sector promotes the collective understanding that healthy childhood is a shared social responsibility.
Principle 3: Work with the principles of shared ownership
The “shared ownership” principle promotes the direct involvement of entire community in their well-being. It does so by asking what people want to change in their daily lives when it comes to creating a healthy environment. Individuals in communities hold the best knowledge on the barriers and opportunities within their families, districts, villages or cities to lead a healthier life. Shared ownership assumes positive collaboration between diverse professionals, local residents and parents/caretakers for healthier childhoods.
Principle 4: Monitor and evaluate the effect and process continuously
The JOGG approach is a tailor-made approach in which every step yields new knowledge. Health needs of each municipality are unique due to differences in context and environment. Thus, JOGG provides tailored solutions based on knowledge gained from previous transfers for best results. In order to expand the variety of practices and solutions, it is essential that JOGG municipalities conduct monitoring and evaluations. Findings from these evaluations allow participating municipalities to share valuable insights for collective benefit, which then inform programme adjustments.
Principle 5: Interlink preventive care and local health care structures
Principle 5 is about co‑operation between professionals and organisations from the various prevention levels (i.e. from collective to the individual). JOGG aims to create a healthy environment for all children, but it also focuses on providing proper care and support for children who are living with overweight/obesity. Specifically, kids living with overweight/obesity receive tailored care from one central provider.
Principle 6: Communication
Communication is essential for JOGG municipalities as it makes the activities of JOGG teams visible and transparent, ensures more support and contributes to achieving goals.
Further information on specific activities carried as part of JOGG are summarised in Box 7.1.
Box 7.1. Activities carried out as part of JOGG
This box outlines examples of tangible activities carried out as part of the JOGG approach:
Just under 2000 canteens are affiliated with the Team: Fit initiative (present in sport facilities and venues), which is committed to providing visitors with a healthier environment (e.g. offering healthier sandwiches, smoke free environment, and restrictions on alcohol when young people are present).
Over 500 schools covering close to 52 000 children participate in “The Daily Mile” which encourages kids to move for 15 minutes every day during schools hours, equivalent to walking one mile.
Approximately 750 schools have adopted healthy canteens under the Healthy Nutrition in Schools Agreement (e.g. substituting a puff pastry snack for a whole‑wheat sandwich or panini).
Over 1 200 companies and organisations have signed up to the healthy workplace initiative, which encourages companies to implement initiatives such as healthy work canteens and facilitates to promote active modes of transport (e.g. necessary facilities and utilities). This activity is designed for young adults (18‑19) who may begin working directly out of school.
Source: JOGG (2021[6]), “Jongeren Op Gezond Gewicht”, https://jogg.nl/jogg-aanpak.
OECD Best Practices Framework assessment
This section analyses the JOGG approach against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 7.2 for a high-level assessment of JOGG). Further details on the OECD Framework can be found in Annex A.
Box 7.2. Best practice assessment overview: JOGG approach
Effectiveness
JOGG has been shown to reduce the prevalence of overweight and obesity in children aged 0‑19 years
According to OECD simulations, JOGG would lead to 95 032 life years and 112 838 disability-adjusted life years (DALYs) gained by 2050 if expanded across the whole of the Netherlands
Across all OECD and EU27 countries, JOGG would have the largest gross impact on musculo-skeletal diseases, followed by cardiovascular diseases, diabetes, dementia and finally obesity related cancers
Efficiency
When expanded across the whole of the Netherlands it is estimated JOGG will accumulate health expenditure savings of EUR 51.94 per person by 2050
When transferred to all OECD and EU27 countries, savings equivalent to 0.06% of total health expenditure per year are expected
For the majority of OECD and EU27 countries, JOGG is not only cost effective, but also cost saving
Equity
JOGG has a process in place to adapt activities to suit the needs of priority populations – e.g. children with a low socio‑economic status
Evaluations of JOGG show the intervention has a greater impact in low SES communities
Evidence base
Two recent studies evaluated the impact of JOGG, both of which support the hypothesis that JOGG reduces rates of childhood obesity
Both studies used randomised cluster trials to evaluate the impact of JOGG, however, neither study was randomised
Extent of coverage
JOGG reaches approximately 30% of children aged 0‑19 years of age in the Netherlands.
Effectiveness
This section presents results for the Netherlands followed by remaining OECD and non-OECD European countries (see Annex 7.A for modelling assumptions specific to JOGG).
Netherlands
OECD’s SPHeP-NCDs model estimates that implementing JOGG across all municipalities in the Netherlands would lead to 16 life years (LY) and 19 disability-adjusted life years (DALYs) gained per 100 000 people, on average, per year over the period 2021‑50. These figures translate into cumulative gain of 95 032 LYs and 112 838 DALYs by 2050 (Figure 7.1).
Figure 7.1. Cumulative number of LYs and DALYs gained (2021‑50) – JOGG, The Netherlands
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
In gross terms, JOGG is expected to have the greatest impact on reducing cases of musculoskeletal (MSDs) and cardiovascular (CVDs) disease (Figure 7.2). Between 2021 and 2050, the number of MSD and CVD cases is estimated to fall by 41 360 and 13 089, respectively. Other diseases affected include diabetes, dementia and specific cancers.
Figure 7.2. Cumulative number of disease cases avoided by 2050 - JOGG, The Netherlands
Note: Musculoskeletal disorders = MSDs, CVDs = cardiovascular diseases. Related cancers include colorectal, breast, oesophageal and liver cancer.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
OECD and non-OECD European countries
Transferring JOGG to all OECD and EU27 countries is estimated to result in 27.3 and 33.9 LYs gained per 100 000 (ranging from 13.5 in Israel to 60.7 in Bulgaria) (Figure 7.3). For DALYs, the figures are even higher at 30.9 for OECD and 36.9 for EU27 countries.
Figure 7.3. LYs and DALYs gained annually per 100 000 people, 2021‑50 – JOGG, all countries
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Broadly, JOGG would have the biggest impact on MSDs with the approach leading to an estimated reduction of 2.86 million and 0.96 million cases among OECD and EU27 countries, respectively, between 2021 and 2050 (Figure 7.4). Across all countries, JOGG is also estimated to reduce the number of CVDs cases by 1.32 million, and diabetes cases by 0.58 million, dementia cases by 0.20 million, and obesity related cancer cases by 0.12 million.
Figure 7.4. Total disease cases avoided, between 2021 and 2050 – JOGG, all countries
Note: Musculoskeletal disorders =MSDs, CVDs = cardiovascular diseases. Related cancers include colorectal, breast, oesophageal and liver cancer.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Efficiency
Similar to “Effectiveness”, this section presents results for the Netherlands followed by remaining OECD and non-OECD European countries.
Netherlands
By reducing rates of obesity, the JOGG approach can reduce health care costs. Over the modelled period of 2021‑50, the OECD-SPHeP NCD model estimates the JOGG intervention would lead to cumulative health expenditure savings of EUR 51.94 per person by 2050 (Figure 7.5) or by EUR 2.72 per person, per year. Cost savings, however, are to an extent offset by intervention operating costs (see Table 7.2).
Figure 7.5. Cumulative health expenditure savings per person, EUR, 2021‑50 – JOGG, The Netherlands
Note: Savings are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
OECD and non-OECD European countries
Average annual health expenditure (HE) savings as a proportion of total HE is 0.06% for both OECD and EU27 countries (Figure 7.6). On a per capita basis, this translates into average annual savings of EUR 1.28 and EUR 1.14 for OECD and EU27 countries, respectively.
Figure 7.6. Health expenditure (HE) savings as a percentage of total HE and per capita (EUR), average 2021‑50 – JOGG, all countries
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Table 7.2 provides information on intervention costs, total health expenditure savings and the cost per DALY gained in local currency for all OECD and non-OECD European countries. Results from the analysis show JOGG is cost saving for the majority of countries, including the Netherlands. For countries with a positive cost per DALY gained, JOGG is not cost saving, however, it is still highly cost-effective based on international thresholds used to define a country’s willingness to pay for one year of life in good health (this threshold typically ranges between EUR 22 000‑80 000 (Vallejo-Torres et al., 2016[7])).
Table 7.2. Cost effectiveness figures in local currency – JOGG, all countries
* Cost per DALY gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2021‑50. Cost and benefits are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
The reduction in chronic diseases resulting from the JOGG approach has, in turn, an impact on labour market participation and productivity. By reducing obesity related disease incidence, JOGG is estimated to increase employment and reduce absenteeism, presenteeism, and early retirement. Converting these labour market outputs into full-time equivalent (FTE) workers, it is estimated that OECD and EU27 countries will gain 13.8 and 14.4 FTE per 100 000 working age people per year between 2021 and 2050, respectively. In monetary terms, this translates into average per capita labour market production of EUR 3.7 for OECD and EUR 3.0 for EU27 countries (Figure 7.7).
Figure 7.7. Labour market impacts, average per year, 2021‑50 – JOGG, all countries
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Equity
The JOGG approach targets priority population groups in particular those in vulnerable environments. At the local level, the needs of priority population groups are defined – for example, by speaking with teachers, principals, welfare professionals, sport foundations and private enterprises, such as supermarkets. Subsequently, JOGG activities are adapted to suit the needs of different groups such as children from a low socio‑economic status (SES) or different ethnic background to Dutch (Middelbeek, 2017[8]).
The impact of JOGG according to SES is available, which shows positive results. A study by Groningen University found JOGG led to greater reductions in overweight prevalence in low SES JOGG municipalities compared to middle/high SES municipalities (Kobes, Kretschmer and Timmerman, 2021[9]):
Low-SES municipalities: decline in overweight prevalence from 25.17% to 21.16% between 2013 and 2018, which was statistically significant.
Middle/high-SES municipalities: increase in overweight prevalence from 10.79% to 11.78% between 2014 and 2018, which were not statistically significant.
Evidence‑base
The findings from the University of Groningen pre‑print study were used for modelling the effectiveness of JOGG, which was imputed into the SPHeP-NCD model (Kobes, Kretschmer and Timmerman, 2021[9]). Findings from the University of Groningen report align with a previous evaluation by the Dutch National Institute for Public Health and Environment (RIVM) (Blokstra et al., 2020[10]). Specifically, both studies estimated that JOGG reduced the prevalence of overweight and obesity in children by about 9 percentage points.
In the study conducted by the researchers from University of Groningen, the prevalence of overweight was obtained from the measurements collected at school (by a school nurse) for children aged 9‑11, which were later communicated to the local public health centres, these centres in turn pooled the data at the Dutch Centre for Youth Health. The evaluation was conducted for each subsequent year for six‑year period, from 2013‑18, where a control community that did not benefit from JOGG approach was followed in parallel for comparison (Kobes, Kretschmer and Timmerman, 2021[9]).
The RIVM evaluation report collected overweight prevalence data a year before the introduction of the JOGG approach from the Health Interview Survey of Children aged 2‑19 (self-reported outcomes). Subsequent evaluations were conducted in year 1, 2, 3 and 4 after the implementation of JOGG approach in participating municipalities (Blokstra et al., 2020[10]).
The Quality Assessment Tool for Quantitative Studies rates the RIVM “strong” in reducing selection bias, while the University of Groningen was rated as strong in terms of and using reliable and validated data collection tools (Table 7.3):
The RIVM evaluation report explicitly controlled and matched each individual by neighbourhood, age, sex, origin (Dutch, Western, non-Western), household income.
The University of Groningen study had methodical approach in their collection methods and tools of the data (BMI, indicators of SES).
Table 7.3. Evidence‑based assessment, JOGG
Source: Effective Public Health Practice Project (1998[11]), “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14.
Extent of coverage
During the period from 2015‑21, the JOGG approach expanded from 91 to 183 of the 352 municipalities across the Netherlands (Figure 7.8), which equates to 30% of all children aged 0‑19 years living in the country.1
Figure 7.8. Number of JOGG municipalities – 2015‑19
Source: Reijgersberg et al. (2016[12]), “Monitor Jongeren Op Gezond Gewicht 2015”, https://www.mulierinstituut.nl/publicaties/17292/monitor-jongeren-op-gezond-gewicht-2015/; Collard et al. (2017[13]), “Monitor Jongeren Op Gezond Gewicht”, https://www.mulierinstituut.nl/publicaties/21837/monitor-jongeren-op-gezond-gewicht-2016/; Collard et al. (2018[14]), “Monitor Jongeren Op Gezond Gewicht”, https://www.mulierinstituut.nl/publicaties/23512/monitor-jongeren-op-gezond-gewicht-2017/; Collard et al. (2019[5]), “Monitor Jongeren Op Gezond Gewicht”, https://www.mulierinstituut.nl/publicaties/24468/monitor-jongeren-op-gezond-gewicht-2018/; JOGG (2021[6]), “Jongeren Op Gezond Gewicht”, https://jogg.nl/jogg-aanpak.
Policy options to enhance performance
This section summarises policy options to enhance the performance of JOGG in areas where the intervention currently operates. The policy options are also useful for policy makers in the process of, or interested in, implementing JOGG (e.g. to shape what activities are included in JOGG).
Enhancing effectiveness
The JOGG approach targets children aged 0‑19, with many of its activities undertaken in the school environment. For this reason, it is important that teachers are health literate, as well as parents to ensure good behaviours continue at home.
Continue to improve health literacy among teachers
Obesity is a complex and sensitive subject; therefore, it is important teachers receive appropriate training in order to feel confident delivering nutrition/physical activity interventions in the classroom. For example, as part of professional development programs for teachers, or, at a wider, systematic level, obesity prevention topics could be continuously explored in the curriculum for becoming a teacher.
This policy aligns with WHO’s Nutrition-Friendly Schools Initiative (NFSI), which promotes continuous “school staff training in nutrition and health related issues” (WHO, 2021[15]). The evidence behind NFSI found that investing in ongoing training, support and communication of educators has a positive effect on the health outcomes such as BMI, physical activity levels and diet (WHO, 2021[15]).
Improving health literacy among parents
To ensure healthy behaviours taught in the school environment continue in the home, it is also important to promote health literacy among parents. JOGG municipalities should therefore continue engaging parents through activities such as school information sessions, joint child-school-parent activities, school-led cooking workshops, and family activity nights (Lloyd et al., 2018[16]; Waters et al., 2011[17]). Where possible, activities should be direct (i.e. face‑to-face) given these are typically more effective than engaging indirectly (e.g. newsletters) (WHO, 2021[15]).
Gamification
Gamification incorporates elements of game design into non-game contexts, such as health promotion activities. The idea behind gamification in health promotion is to capture components of games that make them addictive (Cugelman, 2013[18]).
In a community based setting, gamification can encourage behaviour change in a fun and engaging way (OECD, 2019[19]). By doing so, activities to encourage healthy behaviours are not framed negatively – i.e. obesity prevention – but positively, which can reduce stigma associated with participation. Example activities may include:
Daily step challenges, where participants share their step count with friends. Alternatively participants may be placed into groups. Prizes for number of steps taken (or milestones reached – e.g. one week of walking 10 000 steps a day) can act as incentives to increase physical activity.
Digital “exergames” using consoles focused on activities such as fitness, dancing and cycling. A recent systematic review by Goodyear et al. (2021[20]) concluded there is convincing evidence to support the use of online interventions incorporating elements of gamification to support children and young people’s engagement in physical activity.
At present, the JOGG approach promotes active play both in and outside the home, which aligns well with gamification practices to change children’s behaviours.
Healthy food labels
The JOGG approach promotes healthier food environments by collaborating with food industry partners to provide healthy food options to children. This is especially important for families living in lower SES neighbourhoods who typically have less access to healthy foods and therefore more likely to have diets comprised of foods associated with weight gain (e.g. processed foods) (RIVM, 2016[21]).
JOGG should continue efforts to promote healthy foods in local retailers and schools. For example, JOGG could consider working with food industry partners to distribute food products with healthy food labels, in addition, to fruit and vegetables. Food labels are more effective when placed at the front of the product and are easily interpretable – e.g. see case studies for Nutri-Score and the Danish Whole Grain Partnership in Chapters 3 and 9, respectively. However, at present, neither mandatory nor voluntary front-of-pack food labels exist in the Netherlands.
Anti-bullying and de‑stigmatisation policies for children with obesity
Negative stigma associate with overweight and obesity is well documented. Recently, the WHO’s report on Weight Bias and Obesity Stigma highlighted pervasive negative attitudes towards persons with obesity and how this affects social and health capital of future generations (WHO Europe, 2017[22]). Further, individuals who seek medical care for weight loss purposes are less likely to be successfully if they perceive themselves as being judged on the basis of their weight (Gudzune et al., 2014[23]).
Some recommended actions that the JOGG approach could continue incorporating so as to reduce weight bias and stigma towards children living with obesity include (WHO Europe, 2017[22]):
Monitoring the impact of weight‑based bullying among children and young people (e.g. through anti-bullying programmes and training of educational and health professionals)
Assessment of unintended consequences of prevention initiatives on children with obesity – e.g. is stigmatising language being used in activities?
Continuing the use of children’s voices to promote health approaches that builds up their resilience
Adoption of people‑first language in all forms of institutions, especially in educational and health systems
Creating new standards that represent individuals with obesity in the media, by moving away from using imagery and language that show people with obesity in a negative light.
Enhancing efficiency
Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore, policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.
Enhancing equity
As outlined under “Equity”, JOGG had a greater impact on reducing rates of overweight and obesity in low compared to middle and high-SES areas. JOGG’s success in reducing health inequalities can be attributed to several factors such as encouraging municipalities to adapt the programme to align with their local cultural needs in the community as well as collaborating with community stakeholders (Feel4Diabetes-study group, 2020[24]).
Nevertheless, there exist opportunities for JOGG to further enhance this best practice criterion, in particular targeting public health messages regarding JOGG.
Targeted communication
There is evidence that shows disadvantaged groups in the population (i.e. those with a low-SES and a lower education level) display more anxious and suspicious attitudes to prevention messaging from public health authorities (Peretti-Watel et al., 2009[25]). Therefore, traditional communication campaigns to promote health messaging may indirectly exclude disadvantaged groups.
JOGG’s use of targeted communication messages should continue, and if not already, incorporate the following effective strategies for equitable messages (Borys et al., 2016[26]; Beacom and Newman, 2010[27]):
An assessment of existing attitudes around obesity in low-SES groups, with findings used to frame public health messaging
Use of community health workers for interpersonal communication to disseminate information regarding available services at no cost to the individual
Partnering with existing organisations that have close ties with the target group (e.g. social services, charities, and migrant centres) to help promote JOGG activities
Using educational entertainment for reaching non-seekers and avoiders of health information (e.g. animation, health information included in fictional already popularised TV media, health multi-media narratives).
Enhancing the evidence‑base
Study designs used to measure the impact of JOGG on obesity prevalence are associated with several limitations (see “Evidence‑base”). This is common for community-based obesity prevention interventions given their complexity.
To strengthen future evaluations of JOGG, it is necessary to enhance the evaluation study design based on recommendations listed below.
Collect panel data
To evaluate the long-term impact of JOGG on rates of obesity, data collected frequently using the same measures and the same individuals is ideal (i.e. panel data). Longitudinal panel data is the “gold standard” as it reduces bias by considering differences across individuals.
Collecting panel data can be difficult and expensive to implement. One possible solution is to collect data on BMI within national electronic health records (EHRs). Data from digital EHRs are considered high quality, further, information from EHRs is often accessible to academic researchers.
Based on an observational study looking at EHR use in primary care, approximately one in four people have BMI recorded in their EHR. However, this study only considered individuals who self-reported as overweight and is therefore not representative of the whole population (Verberne et al., 2018[28]).
Randomisation
Randomised control trials (RCTs) are the most scientifically rigorous method for evaluating the impact of intervention. However, they are not always feasible for economic, political or ethical reasons. Other study designs are available that mimic RCT characteristics and may be more suitable for community-based obesity interventions such as JOGG – for example, propensity score matching and regression discontinuity design with a treatment and control group.
Stratify data
To better understand the impact of JOGG across different groups of children, a breakdown of evaluation results by priority population groups is encouraged. Previous studies have done this by presenting results by SES status (Kobes, Kretschmer and Timmerman, 2021[9]), however, it is also important to understand how JOGG affects children from different ethnic backgrounds as well as by location (e.g. rural versus urban school and home settings, if possible). A breakdown of results by ethnicity, for example, would be an important contributor to the wider literature on community-based obesity interventions given the current paucity of available studies (Amini et al., 2015[29]).
Measure obesity risk factors and the obesogenic environment
One of JOGG’s main objectives is to reduce obesity prevalence. Since changes in rates of overweight and obesity can be difficult to measure and take many years to achieve, data should also be collected for related indicators – i.e. intermediate outcome indicators, which are directly related to weight. For example:
Percentage of children who consume fruits at least once per day
Percentage of children who consume vegetables at least once per day
percentage of children who consume sugary drinks
Percentage children and adolescents (5‑17 years) reported doing at least 60min or moderate to vigorous intensity physical activity daily.
Given JOGG’s whole approach is to change the obesogenic environment, structural indicators that measure the built environment may also be of interest. A non-exhaustive list of indicators are summarised below (Schäfer Elinder and Jansson, 2008[30]):
Availability of sports facilities
Green space
Access to fast-food restaurants
Share of foods with a recognised health symbol
Nutrition quality of meals in restaurants and schools
Share of schools with a ban on the sale of soft drinks
Presence of nutrition guidelines for school meals and the proportion of schools that comply.
Enhancing the extent of coverage
As discussed under “Extent of coverage”, the number of municipalities participating in JOGG has grown significantly since its inception – i.e. from 91 to 183 of the 352 municipalities in the Netherlands between 2015 and 2021.
JOGG administrators are encouraged to continue using existing methods to increase coverage as well as new methods. For example:
By framing JOGG activities as health promoting as opposed to obesity prevention in order to reduce stigma (see “Enhancing effectiveness” for further details)
Drawing upon support from government agencies to further legitimise the JOGG approach, while taking into account that certain groups may be less responsive to this type of messaging (discussed under “Enhancing equity”).
Transferability
This section explores the transferability of JOGG and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publically available data; and 3) additional considerations for policy makers interested in transferring JOGG.
Previous transfers
JOGG has been transferred across municipalities in the Netherlands as well as internationally.
Within country transfers
As outlined in Figure 7.8, since 2015, the JOGG approach has successfully expanded to a large number of municipalities in the Netherlands – specifically from 91 to 183 (out of 352) between 2015 and 2021.
To assist municipalities transfer JOGG, regional co‑ordinators and professionals knowledgeable about the local context work with the JOGG director at the municipality level. During the first six months, regional co‑ordinators receive training from JOGG coaches to implement the six principles (see “Intervention description”). Example training activities include:
Drafting a strategy plan to implement the JOGG approach
Engaging with local organisations to shape and progress JOGG in their specific area.
Support for JOGG municipalities does not end once implemented – specifically, participating municipalities receive ongoing support, for example, to develop public-private contracts.
International transfers
The JOGG approach has strong roots in the international EPODE2 methodology and is currently part of the health network called Young Health Community. This network beings together key findings and lessons learnt from implementations of the EPODE community-based approach to obesity prevention across Europe, the United States and the Middle East.
Transferability assessment
The following section outlines the methodological framework to assess transferability and results from the assessment.
Methodological framework
Details on the methodological framework to assess transferability are in Annex A. Indicators from publically available datasets to assess the transferability of JOGG are listed in Table 7.4. These cover indicators related to the population, political and economic contexts. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
Table 7.4. Indicators to assess the transferability of JOGG
Source: OECD Health Statistics 2021, https://doi.org/10.1787/health-data-en; WHO (n.d.[31]), “Global Health Observatory”, https://www.who.int/data/gho; OECD (2019[2]), The Heavy Burden of Obesity: The Economics of Prevention, https://dx.doi.org/10.1787/67450d67-en; OECD/FAO (2021[32]), OECD-FAO Agricultural Outlook 2021‑2030, https://dx.doi.org/10.1787/19428846-en; Inchley et al. (2020[33]), “Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report. Volume 1. Key findings”, https://apps.who.int/iris/bitstream/handle/10665/332091/9789289055000-eng.pdf; Eurostat (2019[34]), “General government spending on recreational and sporting services (% GDP)”, https://ec.europa.eu/eurostat; OECD (2021[35]), “Education spending”, https://dx.doi.org/10.1787/ca274bac-en.
Results
Results from the transferability assessment using publically available data are summarised below, which show mixed results (see Table 7.5 for results at the country level):
In the Netherlands, a greater proportion of the population has access to green spaces in which to be active compared to potential transfer countries – 97% compared to 92%, on average, among remaining countries.
A large proportion of teachers (86%) in the Netherlands report being motivated to influence the education of their students, compared to 93% among potential transfer countries. Given a large number of JOGG activities are undertaken in the classroom, these results indicate teachers are likely to be accepting of JOGG.
The vast majority (86%) of countries have a childhood obesity strategy, indicating JOGG would like receive political support among potential transfer countries.
Most OECD and non-OECD European countries have some sort of nutritional labelling scheme in place, which allows health messaging to be implemented as part of private public partnerships pillar of JOGG.
Spending on prevention across OECD and non-OECD countries is typically lower than in the Netherlands (i.e. only 7 of the 43 countries analysed spent the same or more on prevention than in the Netherlands). Given JOGG is a preventative intervention, this results indicate a potential affordability issue. Similarly, the Netherlands spends more on recreation and sporting services compared to other OECD and EU countries (0.5% of GDP versus an average of 0.43% among countries with available data). Nevertheless, the Netherland spends less, albeit marginally, on schools than the OECD average.
Table 7.5. Transferability assessment by country, JOGG (OECD and non-OECD European countries)
A darker shade indicates the JOGG approach is more suitable for transferral in that particular country
* The figure for Australia represent the average cross each major city and refer to access to green space within 400m. **BOP = back of pack; FOP = front-of-pack; M = mandatory; V = voluntary. ***There are a number of strategies focusing on children and young people within the proposed National Obesity Prevention Strategy (2022‑2032). ****CHE = current health expenditure. *****Includes spending on early childhood education, primary school and secondary school. The following countries do not have data for early childhood education spending: Belgium, Canada, Greece, Korea, Turkey and the United States. The shades of blue represent the distance each country is from the country in which the intervention currently operates, with a darker shade indicating greater transfer potential based on that particular indicator (see Annex A for further methodological details). n/a = no available data.
Source: OECD Health Statistics 2021, https://doi.org/10.1787/health-data-en; WHO (n.d.[31]), “Global Health Observatory”, https://www.who.int/data/gho; OECD (2019[2]), The Heavy Burden of Obesity: The Economics of Prevention, https://dx.doi.org/10.1787/67450d67-en; OECD/FAO (2021[32]), OECD-FAO Agricultural Outlook 2021‑2030, https://dx.doi.org/10.1787/19428846-en; Inchley et al. (2020[33]), “Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report. Volume 1. Key findings”, https://apps.who.int/iris/bitstream/handle/10665/332091/9789289055000-eng.pdf; Eurostat (2019[34]), “General government spending on recreational and sporting services (% GDP)”, https://ec.europa.eu/eurostat; OECD (2021[35]), “Education spending”, https://dx.doi.org/10.1787/ca274bac-en.
To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups based on indicators reported in Table 7.4. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.
Key findings from each of the clusters are below with further details in Figure 7.9 and Table 7.6:
Countries in cluster one have sector specific, political and economic arrangements in place to transfer JOGG and are therefore less likely to experience difficulty implementing and operating JOGG. This cluster includes the Netherlands, the owner country of this intervention, and Iceland, which previously transferred elements of JOGG.
Countries in cluster two have political and economic arrangements in place that support the transfer of JOGG but could consider further analysis to ensure sectors in which JOGG operates support the intervention.
Countries in cluster three should consider a number of factors before transferring JOGG such as ensuring JOGG aligns with overall political priorities and is affordable (based on funding for preventative care, schools, and recreation and sporting services).
Figure 7.9. Transferability assessment using clustering, JOGG
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD Health Statistics 2021, https://doi.org/10.1787/health-data-en; WHO (n.d.[31]), “Global Health Observatory”, https://www.who.int/data/gho; OECD (2019[2]), The Heavy Burden of Obesity: The Economics of Prevention, https://dx.doi.org/10.1787/67450d67-en; OECD/FAO (2021[32]), OECD-FAO Agricultural Outlook 2021‑2030, https://dx.doi.org/10.1787/19428846-en; Inchley et al. (2020[33]), “Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report. Volume 1. Key findings”, https://apps.who.int/iris/bitstream/handle/10665/332091/9789289055000-eng.pdf; Eurostat (2019[34]), “General government spending on recreational and sporting services (% GDP)”, https://ec.europa.eu/eurostat; OECD (2021[35]), “Education spending”, https://dx.doi.org/10.1787/ca274bac-en.
Table 7.6. Countries by cluster, JOGG
Note: Due to high levels of missing data, Costa Rica was omitted from the analysis.
New indicators to assess transferability
Data from publically available datasets is not ideal to assess the transferability of the JOGG approach. Therefore, Box 7.3 outlines several new indicators policy makers should consider before transferring this intervention.
Box 7.3. New indicators to assess transferability
In addition to the publically available data within the transferability assessment, policy makers are encouraged to collect data for the following indicators in addition to indicators outlined within the WHO’s “Making every school a health promoting school” report (WHO, 2021[15]).
Population context
What is the ethnicity and cultural diversity of the target population?
What is the level of health literacy among parents? (e.g. knowledge regarding what constitutes health eating, and the impact of healthy eating and exercise on overall health and well-being).
What is the level of parental/guardian engagement with schools and teachers?
What is the level of health literacy in the population at large?
Sector specific context (community)
What is the level of acceptability of the JOGG approach among community stakeholders?
What is the level of health literacy among teachers?
Are schools and other community-based organisations involved in existing healthy lifestyle behaviour activities?
What infrastructure is available in the community, including schools, to encourage physical activity?
Political context
Has the intervention received political support from key decision-makers?
Has the intervention received commitment from key decision-makers?
Economic context
What is the cost of implementing the intervention in the target setting?
Conclusion and next steps
The JOGG approach is a community-based childhood obesity intervention targeting children 0 to 19 years. The approach aims to alter both energy-related behaviours as well as physical and social environments that have a large influence on the weight status of children. Although the JOGG specific approach operates primarily from the Netherlands, several European and North American countries have adopted the EPODE approach, which serves as the basis for the JOGG approach’s methodology of operations.
Estimates indicate scaling-up JOGG across the Netherlands would lead to significant health and economic gains. Scaling-up JOGG across the whole of the Netherlands would lead to 16.0 LYs and 19.0 DALYs gained per 100 000 on average per year between 2021 and 2050. In terms of diseases, JOGG would have the greatest impact on reducing the incidence of musculoskeletal conditions, cardiovascular disease and diabetes. A decrease in the incidence of NCDs would result in a reduction in health care spending of EUR 2.72 per person, per year.
JOGG has the potential to narrow health inequalities, especially among population groups with a lower SES. JOGG focuses on municipalities with the highest burden of obesity, which are typically populated by people with a low SES. Further, each JOGG municipality tailors it activities to suit the needs of its local population. It is therefore not surprising that JOGG has the greatest impact among disadvantaged municipalities.
The number of participating JOGG municipalities has increased markedly since the interventions’ inception. Between 2015 and 2019, the number of participating municipalities in the Netherlands grew from 91 to 183. JOGG therefore reaches over 1 million children or 30% of the population aged 0‑19 years (i.e. the target population).
JOGG has a positive impact on many best practice criteria, however, further enhancements are possible. For example, policy makers could promote complementary policies such as changes to educational curricula for both teachers and students on the topic of health literacy. Further, to understand the long-term impact of JOGG on health outcomes, future studies could increase follow up times, for example, by drawing upon BMI data within patient electronic health records.
Community-based obesity prevention interventions similar to JOGG exist across multiple OECD countries indicating it is a transferable intervention. JOGG was developed based on the EPODE approach, which is a community-based framework for addressing childhood obesity. Other obesity prevention interventions in countries such as France, the United States, Australia, Canada and Spain also use the EPODE approach, indicating JOGG is a transferable intervention. The transferability of JOGG was also assessed using publically available data, which found mixed results – for example, JOGG would likely receive political support in most countries given childhood obesity is a top political priority, however spending on prevention is relatively low when compared to the Netherlands.
Box 7.4 outlines next steps for policy makers and funding agencies regarding JOGG.
Box 7.4. Next steps for policy makers and funding agencies
Next steps for policy makers and funding agencies to enhance the JOGG approach are listed below:
Support policy efforts to provide teachers with appropriate training to deliver nutrition and physical activity lessons, for example, by including these topics in the curriculum to become a school teacher or guidance counsellor
Support policy efforts to boost population health literacy in order to motivate both parental and child’s involvement community-based obesity programs
Ensure funding for future scale‑up and transfer efforts
Enhance support for policies and strategies that aim at improvement of lived environment, especially in low-SES areas (e.g. green spaces, equitable access to healthy food options)
Promote “lessons learnt” from regions that have transferred JOGG approach to their local setting.
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