This chapter covers the case study of the Combined Lifestyle Intervention (CLI), a lifestyle‑counselling programme offered in the Netherlands, which provides dietary advice, physical activity training, and counselling on behavioural change over a period of two years. The case study includes an assessment of CLI 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
5. Combined Lifestyle Intervention
Abstract
Combined Lifestyle Intervention (CLI), the Netherlands: Case study overview
Description: The Combined Lifestyle Intervention (CLI) is a Dutch programme designed to help people living with overweight or other risk factors improve their lifestyle. Participants are referred by their general practitioner (GP) to a local CLI programme, where they get dietary advice, physical activity training, and counselling on behavioural change over a period of two years.
Best practice assessment:
Table 5.1. OECD best practice assessment of CLI, the Netherlands
|
Criteria |
Assessment |
|---|---|
|
Effectiveness |
By improving diet and physical activity, an estimated 12 565 life years (LYs) and 16 704 disability-adjusted life years (DALYs) will be gained from CLI by 2050 in the Netherlands. |
|
Efficiency |
If scaled-up to the national level and transferred to all OECD and EU27 members, CLI is estimated to be cost-effective in 95% of countries. |
|
Equity |
The intervention reaches people from different educational levels, and appears effectives across different socio‑economic groups. However, there are pronounced differences in coverage between regions |
|
Evidence‑base |
One of the key criteria for CLI programmes to be accepted and reimbursed is that there is evidence of their cost-effectiveness. The evidence resulting from the RCT of the Slimmer programme is judged as strong. To evaluate CLI as a whole in the long term, a registry is being set up to track outcomes such as weight and waist circumference, as well as demographic and socio‑economic data. There will also be an option to link the registry to claims data |
|
Extent of coverage |
While the programme is still in its early stages, the uptake so far has been relatively low due to the impact of COVID‑19 as well as a low referral rate by GPs. |
Enhancement options: Currently a number of CLI programmes are evaluating the effectiveness of delivering care digitally rather than in person. If this proves to be successful, it could help lower cost and increase coverage. To further increase coverage the referral rate by GPs may be increased. An analysis of outcomes by regions could help understand whether there are important differences in the quality of the interventions across the country.
Transferability: CLI has not been transferred nor are there plans to transfer CLI to other countries. Overweight and obesity is a top priority, therefore CLI would likely receive political support from potential transfer countries in the OECD making them good targets. CLI would also likely be accepted among stakeholders given, for example, health professionals currently offer physical activity counselling in many countries.
Conclusion: The CLI is an effective and often cost-effective programme, with a strong and growing evidence base. Further research into digital delivery and measures to increase the uptake of the programme can help increase its impact on health and the economy.
Intervention description
The Combined Lifestyle Intervention (CLI) is a Dutch programme designed to help adults with overweight or other risk factors improve their lifestyle. It was first implemented at the start of 2019, after a 12‑year process of pilots, evaluations, research and political discussions. Its cost are covered under the basic health insurance package in the Netherlands. As of March 2021, 18 000 people currently participate or previously participated in CLI, leading to a total reimbursement cost from health insurers of EUR 4.6 million (RIVM, 2021[1]).
Participants are referred by their general practitioner (GP) to a local CLI provider. These include physiotherapists, lifestyle coaches and dieticians – either working individually or in a group. Registered providers need to get a license for the specific CLI programme they intend to offer, as well as a contract with a health insurer to reimburse the programme. It is up to the insurer to decide which CLI programme(s) to reimburse. Several programmes are approved as CLIs (see Box 5.1), all of which consist of three key, compulsory components:
Healthy eating
Physical activity
Behavioural change to sustain a healthy lifestyle.
Each CLI programme last two years. The programmes start with an intervention phase, which lasts between seven and 12 months, during which participants receive advice and training from health professionals on how to improve diet, exercise and overall health. Afterwards there is a maintenance phase, with less intense involvement of health professionals. Participants are organised into groups that move through the two years together, in order to enhance motivation.
Box 5.1. Approved CLI programmes
Currently there are four recognised CLI programmes, owned and managed by different organisations, that are covered by the basic health insurance. Patient allocation to the different programme is based on local availability as well as their health insurer.
Coaching on Lifestyle (CooL) (53% of CLI participants*): this programme is delivered by an accredited lifestyle coach, or a physiotherapist or dietician with a lifestyle coach specialisation. The intervention phase lasts eight months, during which participants have one intake session of 1 hour, 2.5 hours of individual coaching and eight group sessions of 90 minutes – all with the lifestyle coach.
BeweegKuur [Move therapy] (19% of CLI participants*): this programme is delivered by a multidisciplinary team, including a GP, dietician, physical activity professional, lifestyle coach, and local sport coaches and providers. Participants meet with the various professionals to develop individual plans and participate in group sessions.
Slimmer [Smarter] (6% of CLI participants*): this programme, which focuses on diabetes prevention, is delivered by a multidisciplinary team including a GP, dietician, physical therapist, lifestyle coach and local sports coach or broker. Participants engage in a physical activity programme (24 group classes) and a nutrition programme (one nutrition analysis and treatment plan, three individual consultations and one group session) over the first seven months.
Samen Sportief in Beweging [Together sporty in motion] (no data yet): the latest programme to be approved as a CLI is a co‑operation between GPs, lifestyle coaches, physical activity professionals, nutrition professionals, sports providers and municipal sports supporters. Participants first receive an intensive eight week course, which includes eight individual sessions with a lifestyle coach, 16 group physical activity sessions and eight nutrition sessions. Afterwards participants receive a further three group sessions with a lifestyle coach as part of the intervention phase.
* Percentages based on participants at March 2021; for 22% of participants the programme was not known.
Source: RIVM (2021[1])., “Gecombineerde leefstijlinterventie 2021: verdubbeling aantal deelnemers”, https://www.rivm.nl/sites/default/files/2021-07/factsheet%20GLI%20juni%202021.pdf.
OECD Best Practices Framework assessment
This section analyses CLI against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 5.2 for a high-level assessment of CLI). Further details on the OECD Framework are in Annex A.
Box 5.2. Assessment of CLI, the Netherlands
Effectiveness
According to OECD simulations, CLI would lead to 12 565 life years (LYs) and 16 704 disability-adjusted life years (DALYs) gained by 2050 in the Netherlands
Across all studied countries, CLI would have the largest gross impact on musculo-skeletal diseases with 0.79 million cases avoided by 2050, and cardiovascular diseases with 0.63 million cases avoided by 2050.
Efficiency
By 2050, CLI will accumulative health expenditure savings equivalent to EUR 11.2 per person in the Netherlands
When transferred to all OECD and EU27 countries, savings equivalent to 0.02% of total health expenditure per year are expected (until 2050)
For the vast majority of OECD and EU27 countries, CLI is considered a cost-effective intervention
Equity
The intervention reaches people from different educational levels, and appears effectives across different socio‑economic groups. However, there are pronounced differences in coverage between regions
Evidence‑base
One of the key criteria for CLI programmes to be accepted and reimbursed is that there is evidence of their cost-effectiveness.
The evidence resulting from the randomised control trial (RCT) of the Slimmer programme is judged as strong according to the Quality Assessment Tool for Quantitative Studies
To be able to evaluate CLI as a whole and in the long term, RIVM is in the process of setting up a registry of CLI participants, which will track outcomes such as weight and waist circumference, as well as demographic and socio‑economic data. There will also be an option to link registry data with claims data.
Extent of coverage
Around 18 000 people have participated in CLI since its inception in 2019.
While still in its early stages, the uptake so far has been relatively low due to the impact of COVID‑19 as well as a low referral rate by GPs.
Effectiveness
A randomised controlled trial (RCT) of the Slimmer programme found that, after 12 months, people in the intervention group saw their BMI decrease by 0.9 points more than those in the control group. After 18 months this difference was 0.8 BMI points. The intervention group also did 1 244 MET-minutes1 of physical activity per week more than the control group after 12 months. As running 10 kilometre per hour (6 minutes per km kilometre) is roughly equivalent with a value of 10 METs, this amounts to an additional 2 hours of running per week. After 18 months, this difference was 616 MET-minutes per week, or 1 hour of running at 10 kilometre per hour. (Duijzer et al., 2017[2]).
These results were used to estimate the potential impact of the CLI programme on population health and the economy if scaled-up and transferred to all OECD and EU27 countries up until year 2050, using the OECD SPHeP-NCDs model. This microsimulation model compared a “business-as-usual” scenario, to a scenario where all countries implement the CLI programme, to be able to measure the difference in health and economic outcomes. The results presented in this section (Effectiveness) and the next (Efficiency) are based on this modelling exercise.
The referral rate of eligible people by GPs is estimated to be 1.03%, which is relatively low (see Annex 5.A for more information on modelling assumptions). This is partially due to the fact that the programme is still in its early stages, which may affect awareness among GPs and uptake, as well as the impact of the COVID‑19 pandemic. While a referral rate of 1.03% was considered the best estimate in the budget impact analysis of the programme, a higher estimate of 2.5% was also considered realistic, once awareness of and demand for CLI increased (RIVM, 2018[3]). The scenario with a 1.03% referral rate was modelled only for the Netherlands, to show the current impact the programme has. The scenario with a 2.5% referral rate was used for the Netherlands and all other countries to compare the potential impact the programme could have. (Note that the 2.5% scenario is considered the main scenario, and that any results refer to this scenario unless specifically stated that the referral rate is 1.03%)
The Netherlands
With the current referral rate of 1.03%, the CLI programme is estimate to result in a cumulative gain of 5 318 LYs and 6 951 DALYs by 2050 (Figure 5.1). The implementation of CLI with a referral rate of 2.5% in the Netherlands is estimated gain a cumulative total of 12 565 LYs and 16 704 DALYs by 2050 (Figure 5.2). This translates into a rate of 3.99 life years (LY) and 5.25 disability-adjusted life years (DALYs) gained per 100 000 people, on average, per year over the period 2021‑50.
Figure 5.1. Cumulative number of LYs and DALYs gained (2021‑50) – CLI, the Netherlands (1.03% referral rate)
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Figure 5.2. Cumulative number of LYs and DALYs gained (2021‑50) – CLI, the Netherlands (2.5% referral rate)
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
In gross terms, CLI is expected to have the greatest impact on musculoskeletal disorders (MSDs) and cardiovascular diseases (CVDs) (Figure 5.3). Between 2021 and 2050, the number of MSD and CVD cases is estimated to fall by 9 434 and 6 383 cases, respectively. Other diseases affected include mental health, diabetes, dementia and several cancers.
Figure 5.3. Cumulative number of disease cases avoided by 2050 – CLI, the Netherlands (2.5% referral rate)
Note: MSDs = musculoskeletal disorders, CVDs = cardiovascular diseases. Related cancers include colorectal, breast, oesophageal and liver cancer. The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
OECD and non-OECD European countries
Transferring CLI to all OECD and EU27 countries, with a referral rate of 2.5%, is estimated to result in 4.61 and 5.6 LYs gained per 100 000 people, respectively, on average per year between 2021‑50 (ranging from 2.29 in Switzerland to 10.47 in Bulgaria) (Figure 5.4). For DALYs, gains are even higher at 5.77 for OECD and 6.83 for EU27 countries.
Figure 5.4. LYs and DALYs gained annually per 100 000 people, 2021‑50 – CLI, all countries (2.5% referral rate)
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2020.
In gross terms, CLI would have the greatest impact on MSDs with the intervention estimated to reduce the number of cases by 0.76 million and 0.27 million among OECD and EU27 countries, respectively, between 2021 and 2050 (Figure 5.5). Across all countries, CLI would also reduce the number of CVD cases by 0.63 million cases, mental health cases by 0.28 million, diabetes cases by 0.17 million, dementia cases by 56 000, and related cancers by 50 000.
Figure 5.5. Total disease cases avoided, between 2021 and 2050 – CLI, OECD and EU27 countries (2.5% referral rate)
Note: MSDs = musculoskeletal disorders, CVDs = cardiovascular diseases. The black lines represent 95% confidence intervals.
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.
The Netherlands
By improving levels of physical activity, CLI can reduce health care costs. At the current referral rate of 1.03%, over the modelled period of 2021‑50, the OECD-SPHeP NCD model estimates CLI would lead to cumulative health expenditure savings of EUR 3.14 per person by 2050 (Figure 5.6). At a referral rate of 2.5%, CLI would lead to cumulative health expenditure savings of EUR 11.2 per person by 2050 (Figure 5.7) or EUR 0.61 on average per person, per year. Cost savings however are to an extent offset by intervention operating costs (see Table 5.2).
Figure 5.6. Cumulative health expenditure savings per person, EUR, 2021‑50 – CLI, the Netherlands (1.03% referral rate)
Note: The black lines represent 95% confidence intervals. Savings are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Figure 5.7. Cumulative health expenditure savings per person, EUR, 2021‑50 – CLI, the Netherlands (2.5% referral rate)
Note: The black lines represent 95% confidence intervals. 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 around 0.02% for both OECD and EU27 countries, at a referral rate of 2.5% (Figure 5.8). On a per capita basis, this translates into average annual savings of EUR 0.41 and EUR 0.39 for OECD and EU27 countries, respectively.
Figure 5.8. Health expenditure (HE) savings as a percentage of total HE and per capita (EUR), average 2021‑50 – CLI, all countries (2.5% referral rate)
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Table 5.2 provides information on intervention costs, total health expenditure savings and the cost per DALY gained in local currency for OECD and non-OECD European countries. Although CLI is not cost-saving in any country (i.e. as measured by a negative cost per DALY gained), it is considered cost effective in many based on international thresholds. For example, in countries such as the Netherlands, France, Austria and Germany, the cost per DALY gained ranges between EUR 28 000 and EUR 38 000, which is less than the average cost effectiveness threshold applied in European countries (i.e. EUR 50 000 based on (Vallejo-Torres et al., 2016[4])). However, due to the relatively high cost of the intervention it is close to or higher than the threshold in a couple of countries.
Table 5.2. Cost effectiveness figures in local currency – CLI, all countries
* Cost per DALY (disability-adjusted life year) gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2021‑50. Costs and benefits have been discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
The reduction in chronic diseases resulting from CLI has, in turn, an impact on labour market participation and productivity. By reducing chronic disease incidence, CLI is expected to lead to increases in employment and reductions in 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 1.82 and 1.95 FTE per 100 000 working age people per year between 2021 and 2050, respectively. In monetary terms, this translates into average per capita increase in labour market production of EUR 0.50 for OECD and EUR 0.45 for EU27 countries (Figure 5.9).
Figure 5.9. Labour market impacts, average per year, 2021‑50 – CLI, all countries (2.5% referral rate)
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2021.
Equity
Analysis of claims data found that the plurality of participants (40%) are from a moderate educational level; similar to the national distribution. At 32% of CLI participants, people with a low educational level are slightly overrepresented when compared to the national distribution. There are however regional inequalities, with rates of participation differing three‑fold between provinces (RIVM, 2021[1]).
Using data from the Slimmer RCT, Bukman et al. looked at the effectiveness of the intervention across different socio‑economic groups (Bukman et al., 2017[5]). While there were some differences regarding the reason why people did not participate, overall participation, attendance, acceptability, adherence, drop-out, and effectiveness of the Slimmer intervention were not affected by socio‑economic status. This suggests that the CLI can be used for both high and low socio‑economic groups.
The fact that CLI is covered by the basic health insurance package and does not require a co-pay ensures there are no major financial barriers to participation. Access inequalities may arise, however, if the probability of visiting a GP is lower among disadvantaged groups. This is not the case in the Netherlands with the probability of visiting a GP the same among those in the poorest and richest income quintiles. However, access inequalities exist when examining all OECD countries: 74% of those in the richest quintile visit their GP compared to 70% in the poorest quintile (OECD, 2019[6]).
Evidence‑base
One of the key criteria for CLI programmes to be accepted and reimbursed is that there is evidence of their cost-effectiveness. The Dutch public health institute, RIVM, reviews the evidence submitted by programmes and determines whether they will be recognised CLIs based on the quality of a written programme plan, effectiveness and feasibility. As such, all four of the current CLI programmes have evidence of effectiveness.
For the OECD SPHeP NCDs model, data from the Slimmer programme was used, as this was based on a RCT (Duijzer et al., 2017[2]) (Annex 5.A). The Quality Assessment Tool for Quantitative Studies rates this study as “strong” (see Table 5.3) (Effective Public Health Practice Project, 1998[7]). The study design, randomisation of participants and low drop-out rate all contribute to reliable estimates of the true effect of the intervention. The main limitation of the study is a potential selection bias, as only 54% of invited people agreed to participate in the study. It is not clear if the study was blinded to participants and assessors, but the nature of the intervention makes this difficult.
Table 5.3. Evidence‑based assessment, CLI
Source: Effective Public Health Practice Project (1998[7]), “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14.
At the moment, there is not yet an evaluation of the effectiveness of CLI as a whole. To be able to do so in the future, the RIVM is in the process of setting up a registry of CLI participants. The registry would track outcome measures over a two‑year period, including as weight and waist circumference, demographic and socio‑economic data, and can be combined with claims data on cost and care utilisation broken down by care type.
While the RIVM is working with a data storage provider and the government to set up the necessary infrastructure and data sharing agreements, CLI providers are already collecting data from participants locally. This means that once the register is up and running, data can be added retrospectively. Participation depends on the CLI providers, who report the data into the register, as well as the participants, who need to give permission.
The nation-wide and cross-programme coverage of the register, as well as the potential to link the CLI data to health insurance claims data, will provide a solid evidence base to test the effectiveness of the CLI programme, and to monitor its implementation and impact in real-time. Whether a control group can be created, potentially from an existing cohort study, is being explored.
Extent of coverage
The roll-out of the CLI programme has been affected – like many other public health initiatives – by the COVID‑19 pandemic. While the number of new participants increased over 2019, once the pandemic hit there was a pronounced dip (see Figure 5.10). However, after it was agreed in March 2020 that the group sessions could take place virtually, the number of new participants increased again. The exception to allow digital meetings is temporary, and will last until the COVID‑19 measures in the Netherlands have been lifted. However, several programme owners have indicated that they will use this time to evaluate the effectiveness of digital interventions (Zorgverzekeraars Nederland, 2020[8]).
A total of around 18 000 people have participated in CLI so far (RIVM, 2021[1]). While the programme is still in an early phase, this is considerably lower than the potential eligible population, which was estimated at 3.5 million people (RIVM, 2018[3]). This gap is mostly due to a low referral rate by GPs, which is currently estimated at around 1% of eligible people. While increased familiarity with the programme as it becomes more established may boost referrals, scepticism among GPs about the effectiveness of the programme also plays a role.
Figure 5.10. CLI monthly enrolment
Number of new participants per month
* Data for 2021 not yet reliable.
Source: Adapted from RIVM (2021[1]), “Gecombineerde leefstijlinterventie 2021: verdubbeling aantal deelnemers”, https://www.rivm.nl/sites/default/files/2021-07/factsheet%20GLI%20juni%202021.pdf.
Policy options to enhance performance
The CLI is an effective programme to improve population health and reduce health care expenditure, built on a strong evidence base. To further enhance CLI, in the Netherlands or in any transfer countries, there are a few policy options to consider.
Enhancing effectiveness
While the various CLI programmes have all been studies for their effectiveness before being included in the reimbursement scheme, it is worth exploring whether effectiveness can be further increased. The new register data will provide an invaluable source for this, as it will allow comparative analysis across programmes and population groups.
There is relatively little evidence in the literature on combined lifestyle‑type programmes, but physical activity on prescription (PAP) programmes are well-researched. These are similar to the CLI programme, with the main difference being that CLI looks at diet as well as physical activity. Studies on PAP and CLI programmes found that there are a number of factors that can increase their effectiveness. These include:
Two systematic reviews found that a longer intervention duration, as well as a longer follow-up period, are associated with a greater impact (Goryakin, Suhlrie and Cecchini, 2018[9]) (Arsenijevic and Groot, 2017[10]).
A study of adherence to physical activity prescriptions found that non-adherence was more frequent among subjects who were issued with referrals for facility-based activities rather than home‑based activities. However, low motivation was often cited as the reason for non-adherence to home‑based activities, suggesting that facility-based activities may be preferred for participants with a lower motivation (Leijon et al., 2011[11]).
An RCT looking at intensity and frequency found that prescribing a higher frequency of physical activity increased the accumulation of exercise without a decline in adherence, while a higher intensity decreased adherence (Duncan et al., 2005[12]) (Perri et al., 2002[13]).
Prescriptions need to be carefully tailored to the participant’s capability (e.g. physical capacity), opportunity (e.g. having access to appropriate activities) and motivation (e.g. finding activities that encouraged continuation) to undertake physical activity (Andersen et al., 2019[14]).
There appears to be a trade‑off between sufficient intensity to achieve results, and over-burdening participants. A study of the BeweegKuur CLI noted that dieticians reduced the number of group meetings, to ensure participation (Berendsen et al., 2015[15]).
This same study noted the importance of managing expectations. Many participants engage in the programme with the aim of losing weight, while the adoption of physical activity and a healthier diet does not necessarily lead to immediate weight loss. Managing expectations and clarifying the goal of the programme beforehand could have a positive impact on adherence and therefore effectiveness (Berendsen et al., 2015[15]).
Enhancing efficiency
The CLI is a relatively high-cost intervention. This is mainly due to the requirement (temporarily lifted due to COVID‑19) to conduct all meetings in-person. It is therefore a positive development that the various programmes are evaluating the effectiveness of digital meetings while this is temporarily allowed. Digital interventions generally have a lower per-participant cost as they can be offered to a larger group of participants. It could also address the issue regarding availability of licensed lifestyle coaches, which is one of the limiting factors to expanding programme coverage.
When evaluating the digitalisation of the CLI programme, the following elements should be considered:
Effectiveness: Do participants who receive sessions digitally have the same outcomes as those participating in in-person sessions? How does this compare to a hybrid system? Which population groups respond best to the digital intervention?
Cost-effectiveness: What is the change in per-person cost? How does this compare to the effectiveness of the programme?
Adherence: Is there is difference in adherence between the digital and the in-person programme? What is the session attendance rate?
Digital inclusion: Which population groups do not respond well to a digital intervention, and how can they be given specific consideration if digitalisation continues?
Enhancing the evidence base
The CLI already performs very well on its evidence base – for example, an RCT, which is considered the “gold standard” study design, was used to evaluate one of the four approved CLI programmes. Future evaluations of CLI, as a whole, are also like to be of high quality given the planned registry of CLI participants will include information on health outcomes and demographics, which can be linked to cost data. The registry will also allow researchers to evaluate the long-term effectiveness of CLI, as well as compare the effectiveness of the different CLI programmes to identify the most cost-effective option.
Enhancing equity
The CLI intervention appears to be equitable as far as socio‑economic distribution: claims data suggests that the CLI intervention reaches different population groups equally, and the RCT of the Slimmer programme did not show differences by socio‑economic groups (Bukman et al., 2017[5]). It will be interesting to see more analysis on this once data from the register becomes available, in particular on the long-term effectiveness in different population groups.
There is however a regional inequality, as some provinces have three‑times higher rates of CLI participation in their population than others. The programme relies on the initiative of local actors to develop and offer CLI courses, and there is no mechanism ensuring national coverage. To encourage the development of regional networks of CLI providers, the Dutch organisation for health research and development ZonMW provides subsidies of up to EUR 37 500 over a maximum period of 12 months to develop and expand regional implementation of the CLI. Currently ten such subsidies have been awarded.
It is not clear whether the outcomes differ by region. Once data from the national register becomes available, it would be valuable to conduct an analysis of outcomes by region, to ensure there are no significant differences in the quality of the programmes offered across the country.
Enhancing coverage
As described, there is significant potential to expand the coverage of the intervention. This could be done by increasing the GP referral rate, which is currently estimated at only 1.03%. A study of the Swedish Physical Activity on Prescription intervention, which also relies on health care professionals referring eligible patients to local lifestyle interventions, identified the following factors that can increase referral rates (Gustavsson et al., 2018[16]):
Increased knowledge and affirmative attitude among the health care professionals. This includes knowledge on how to talk about health behaviours in patient consultations, and knowledge of and belief in the CLI programme. Especially the latter issue may be an important factor driving the low referral rate by GPs.
Clear and supportive management. Policies and clinical guidelines need to be developed, shared and approved at all levels, central management of health care organisations needs to show clear support for the intervention and earmark time and resources for CLI referrals.
Supporting structures. This includes a centralised or local support function, such as a central co‑ordinator, tailored written routines at health care centres on when and how to do CLI referrals, and the availability of an up-to-date list of CLI providers in the area.
Transferability
This section explores the transferability of the CLI programme from the Netherlands to other OECD and non-OECD EU countries 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 CLI.
Previous transfers
The CLI has not yet been transferred to other countries.
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 can be found in Annex A.
Indicators from publically available datasets to assess the transferability of the CLI programme are listed in Table 5.4. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
Table 5.4. Indicators to assess the transferability of the CLI programme
Source: WHO Regional Office for Europe (2021[17]), “2021 Physical Activity Factsheets for the European Union Member States in the WHO European Region”, https://apps.who.int/iris/bitstream/handle/10665/345335/WHO-EURO-2021-3409-43168-60449-eng.pdf; WHO (n.d.[18]), “Global Health Observatory”, https://www.who.int/data/gho; OECD (2021[19]), “OECD Health Statistics 2021”, https://doi.org/10.1787/health-data-en.
Results
Findings from the transferability assessment using public data are summarised below, with country level results available in Table 5.5:
As in the Netherlands, overweight and obesity is a top political priority – this is reflected by the data with the vast majority of countries having developed an operational plan to address unhealthy diets and physical inactivity. Given these are the two risk factors CLI aims to address, the results indicate CLI would likely receive political support among potential transfer countries.
Among countries with available data, the majority have implemented or foresee implementing physical inactivity counselling programmes delivered by health professionals. This provides further evidence of CLI’s transferability given it aligns with existing health priorities.
Based on available data, CLI is also likely to be affordable given most countries spend proportionally more on primary care – 32% in the Netherlands compared to an average of 44% among remaining countries.
Although the Netherlands has a relatively high number of GPs per capita (0.9 per 1 000 people in the Netherlands compared to an average of 0.76), the proportion of people who visit a GP is, on average, higher among potential transfer countries. This indicates there would be ample opportunity to refer patients to CLI. In addition, health professionals in potential transfer countries would likely accept CLI given physical activity is part of their health curriculum.
Table 5.5. Transferability assessment by country, CLI (OECD and non-OECD European countries)
A darker shade indicates CLI may be more suitable for transferral in that particular country
Note: n/a = data was not available. 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).
Source: WHO Regional Office for Europe (2021[17]), “2021 Physical Activity Factsheets for the European Union Member States in the WHO European Region”, https://apps.who.int/iris/bitstream/handle/10665/345335/WHO-EURO-2021-3409-43168-60449-eng.pdf; WHO (n.d.[18]), “Global Health Observatory”, https://www.who.int/data/gho; OECD (2021[19]), “OECD Health Statistics 2021”, https://doi.org/10.1787/health-data-en.
To help consolidate findings from the transferability assessment above, countries have been clustered into one of four groups (see Figure 5.11 and Table 5.6). 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.
Countries in cluster one and two have political, economic and sector specific arrangements in place to transfer CLI. For this reason, countries in these two clusters have conditions in place to readily transfer CLI to their local context. Countries in both clusters are similar in terms of indicators reflecting the sector and political contexts, however, in general, countries in cluster one spend relatively more on primary care indicating greater long-term affordability.
Countries in cluster three have political priorities that align with CLI yet may suffer affordability issues if primary care expenditure remains relatively low. It is important to note that the Netherlands falls within cluster three meaning although relatively high spending on primary care is ideal, it is not a pre‑requisite to successfully operate CLI.
Remaining countries are in cluster four, which would benefit from policies that ensure the sector is ready to implement CLI, as well as implement overarching national policies that support physical activity and healthy diets.
Figure 5.11. Transferability assessment using clustering, CLI
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: WHO Regional Office for Europe (2021[17]), “2021 Physical Activity Factsheets for the European Union Member States in the WHO European Region”, https://apps.who.int/iris/bitstream/handle/10665/345335/WHO-EURO-2021-3409-43168-60449-eng.pdf; WHO (n.d.[18]), “Global Health Observatory”, https://www.who.int/data/gho; OECD (2021[19]), “OECD Health Statistics 2021”, https://doi.org/10.1787/health-data-en.
Table 5.6. Countries by cluster, CLI
Note: Due to high levels of missing data, the following countries were omitted from the analysis: Chile, Colombia, Costa Rica, Israel, Japan, New Zealand, Switzerland, Turkey, and the United States.
New indicators to assess transferability
Data from publically available datasets is not sufficient to assess the transferability of CLI. For example, there is no public data on the availability of certified lifestyle coaches. Moreover, there may be other successful local programmes that can be included under the CLI. Therefore, Box 5.3 outlines several new indicators policy makers should consider before transferring CLI.
Box 5.3. New indicators to assess transferability
In addition to the indicators within the transferability assessment, policy makers are encouraged to collect information on the following questions:
Population context
Who are the target population groups for this intervention?
What is the population’s attitude towards physical exercise?
What is the population’s attitude towards dietary advice?
What are the main lifestyle issues, and how can a CLI be developed to address them?
Sector specific context (primary care)
Are there existing interventions that can be accredited as a CLI?
Are the enough accredited lifestyle coaches or does a training programme need to be set up?
Is there an alternative to using lifestyle coaches?
Which health care professionals should be included in the CLI delivery team?
How can access to structured physical activity or sporting facilities be enabled?
Political context
Has the intervention received political support from key decision-makers?
Has the intervention received financial commitment from key decision-makers?
Economic context
Is there budget to include the CLI under the basic health coverage?
How much is the programme expected to cost?
How will the reimbursement mechanism work?
Conclusion and next steps
CLI in the Netherlands is a national programme to provide dietary advice, physical activity and behavioural counselling to people with high BMI and is covered under the basic health insurance. Different evidence‑based programmes have been approved for reimbursement under CLI, all of which last approximately two years with an intervention phase of between seven and 12 months, during which participants receive training and counselling from lifestyle coaches or multidisciplinary teams.
As a result of COVID‑19, a number of CLI programmes are evaluating the effectiveness of delivering care digitally rather than in person. If this proves to be successful, it could help lower cost and increase coverage. To further increase coverage the referral rate by GPs should be increased by improving knowledge among the health care professionals of the CLI programme, ensuring supportive management and putting in place the necessary supporting structures.
CLI has not been transferred outside the Netherlands. An assessment of transferability using publically available data indicates potential transfer countries would be able to afford and be supportive of CLI.
Box 5.4 outlines next steps for policy makers and funding agencies regarding CLI.
Box 5.4. Next steps for policy makers and funding agencies
Next steps for policy makers and funding agencies are listed below:
Once the registry is up and running, it will be interesting to see the impact of CLI on health and health care utilisation in the longer-term, as well as differences by population groups and regions. Insights from this data should be used to tweak the programme or to target specific groups.
Similarly, results from the evaluation studies of the digital delivery should be used to potentially make this a permanent element of the CLI – provided it has been proven effective, cost-effective and equitable.
There is considerable scope to increase the number of participants, and policy makers may want to look at increasing the GP referral rate.
References
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[1] RIVM (2021), Gecombineerde leefstijlinterventie 2021: verdubbeling aantal deelnemers, https://www.rivm.nl/sites/default/files/2021-07/factsheet%20GLI%20juni%202021.pdf (accessed on 9 August 2021).
[3] RIVM (2018), “Budget impact analyse van gecombineede leefstijlinterventie (GLI)”, https://doi.org/10.21945/RIVM-2018-0092.
[20] Schutte, B., A. Haveman-Nies and L. Preller (2015), “One-Year Results of the BeweegKuur Lifestyle Intervention Implemented in Dutch Primary Healthcare Settings”, BioMed research international, Vol. 2015, https://doi.org/10.1155/2015/484823.
[4] Vallejo-Torres, L. et al. (2016), “On the Estimation of the Cost-Effectiveness Threshold: Why, What, How?”, Value in Health, Vol. 19/5, pp. 558-566, https://doi.org/10.1016/j.jval.2016.02.020.
[21] van Rinsum, C. et al. (2018), “The Coaching on Lifestyle (CooL) Intervention for Overweight and Obesity: A Longitudinal Study into Participants’ Lifestyle Changes”, International journal of environmental research and public health, Vol. 15/4, https://doi.org/10.3390/IJERPH15040680.
[18] WHO (n.d.), Global Health Observatory, https://www.who.int/data/gho (accessed on 25 August 2021).
[17] WHO Regional Office for Europe (2021), 2021 Physical Activity Factsheets for the European Union Member States in the WHO European Region, https://apps.who.int/iris/bitstream/handle/10665/345335/WHO-EURO-2021-3409-43168-60449-eng.pdf.
[8] Zorgverzekeraars Nederland (2020), De gecombineerde leefstijlinterventie tijdens de coronacrisis [The combined lifestyle intervention during the corona crisis], https://assets.zn.nl/p/32768/files/De%20gecombineerde%20leefstijlinterventie%20tijdens%20de%20coronacrisis.pdf (accessed on 10 August 2021).
Annex 5.A. Modelling assumptions for CLI
Annex Table 5.A.1. Parameters to model the impact of CLI
Effectiveness
A 2015 before‑after study of the BeweegKuur intervention found that weight went down by 2.9 kg (3.0% of baseline) on average after one year, and light-to-moderate physical activity and vigorous physical activity increased by 2.1 (15%) and 1.7 (40%) hours per week, respectively (Schutte, Haveman-Nies and Preller, 2015[20]). A longitudinal study of the Cool intervention showed that participants lost an average of 2.3 kg after completing the intervention (8‑10 months), which corresponds to 0.8 BMI points. After 18 months, the average weight loss was still 1.8 kg, compared to the baseline (van Rinsum et al., 2018[21]). They also found positive changes in perceived autonomy, motivation, perceived barriers, lifestyle behaviours and quality of life.
The Slimmer programme was evaluated using a randomised controlled trial (RCT) in 2011 and 2012 (Duijzer et al., 2017[2]). The 316 participants were split into an intervention group, who received the Slimmer programme, and a control group, who received usual health care (yearly monitoring of blood glucose according to guidelines) and written information on the beneficial effects of a healthy diet and increased physical activity. The RCT found that, after 12 months, people in the intervention group saw their BMI decrease by 0.9 points (95% CI: −1.3 to −0.6) more than those in the control group. After 18 months this difference was 0.8 BMI points (−1.2 to −0.5). The intervention group also did 1 244 MET-minutes (‑337 to 2 829)2 of physical activity per week more than the control group after 12 months. After 18 months, this difference was 616 MET-minutes per week (‑1196 to 1 628).
Since the Slimmer programme was evaluated using an RCT, these effectiveness estimates were used to reflect the effectiveness of the overall CLI programme. It should be noted that it is not clear whether the other three CLI programmes do in fact have the same impact as the Slimmer programme.
Time to maximum effectiveness
The RCT showed that the maximum impact on physical activity was at 12 months (1 244 MET-minutes/week) and decreased to 616 at 18 months. This linear trend was assumed to continue, returning to the baseline physical activity level after 24 months. The increase in the first 12 month was also modelled linearly.
For BMI, the increase was modelled linearly to reach ‑0.9 by 12 months. At 18 months it was at ‑0.8, after which it was assumed to return to 0 over another 12 months – similar to the initial increase.
Target population
For the CLI, the inclusion criteria are:
Adults (18+) with a BMI between 25 and 30 kg/m2, and a waist circumference of >88cm (women) or >102cm (men)
Adults (18+) with a BMI between 25 and 30 kg/m2, and a comorbidity (hypertension, high cholesterol, diabetes, cardiovascular disease, arthrosis or sleep apnoea)
Adults (18+) with a BMI greater than 30 kg/m2
As the model does not contain information on waist circumference, cholesterol, arthrosis or sleep apnoea, these criteria could not be included.
Exposure
The Dutch public health institute RIVM estimated that (RIVM, 2018[3]):
GPs are estimated to refer 1.03% of eligible patients to CLI. For sensitivity analysis, a higher referral rate of 2.5% was used. As the 1.03% referral rate is quite low, this was only modelled for the Netherlands, to reflect the current situation. To understand the potential impact across countries, the higher referral rate of 2.5% was used.
Of this group, 84% of people participate in an intake session
Afterwards, 90% of people actually start the CLI
Of these people, 18.5% will drop out before the end, with
14% dropping out after the first quarter
3.5% dropping out after the second quarter
1% dropping out after the third quarter
Eligible persons can participate again in the future.
Cost of implementation and delivery
A cost-effectiveness study of the Slimmer programme estimated the average cost of the intervention at EUR 677 per participant for the entire programme (see Annex Table 5.A.2) (Duijzer et al., 2019[22]). On the insurer side, a maximum reimbursement tariff has been established for CLIs (see Annex Table 5.A.3). For 2021, the maximum reimbursement for a full two‑year CLI is EUR 835.68 – roughly in line with the intervention cost estimated for the Slimmer programme. Since the tariffs reflect an upper limit, the EUR 677 from the Slimmer study was used in the model. For people leaving the intervention early (i.e. after the intake session or during the first three‑quarters), cost were adjusted using the proportional distribution of the tariff over the various stages of the intervention (see Annex Table 5.A.4).
Annex Table 5.A.2. Combined Lifestyle Intervention average cost
Average intervention cost per participant over 18 months, EUR
Source: Duijzer et al. (2019[22]), “Cost-effectiveness of the SLIMMER diabetes prevention intervention in Dutch primary health care: economic evaluation from a randomised controlled trial”, https://doi.org/10.1186/S12913-019-4529-8.
Annex Table 5.A.3. Combined Lifestyle Intervention maximum reimbursement tariff
Maximum reimbursement tariffs per participant, EUR
Source: Nederlandse Zorgautoriteit (2021[23]), “Welke tarieven gelden voor de GLI?” https://www.nza.nl/documenten/vragen-en-antwoorden/gli-welke-tarieven-gelden-voor-de-gli.
Annex Table 5.A.4. Adjusted costs for drop-outs
Cost for drop-outs are based on the proportion of the max tariff up until drop out, EUR