PHN

considers the complex interplay between individual, relationship, community, and societal factors. ... It allows us to understand the range of factors that put people at risk for violence or protect them from experiencing or perpetrating violence.

• Risk perception
• Outcome expentancies
• Self-efficacy: the belief in one's capabilities to organize and execute the courses of action required to mange prospective situations". To be developed, you need successful experiences, seeing someone else performing this already, constructive feedback and it is indluenced by mood and emotion.
• Social approval
• Intention formation
• Cues to action
• Behavioral contracts
• Relapse prevention

=> simple models do not capture more complex or population-level dynamics; but they might be helpful when planning work on behaviour change. Each individual or community requires programming that is tailored specifically to their needs.

1. Enhance awareness/motivation (focus on why to take action)
2. Facilitate ability to act (focus on how to take action)
3. Promote environmental supports for action

Social Marketing: making no profit with it. Use the marketing strategies of the industry to reach the target population

Product: What do we want to "sell"? I.e. give up drinking high fat milk and change it to low fat milk

Price: What do the target population needs to give up? What do they have to do?

Promotion: create a sustaining for the product, so that the people really want to use it. (Advertisement)

Place: with channels do we want to use?

=> expensive and is not so attractive like a product from the industry

• It may increase the intended audience's knowledge and awareness of a health issue, problem or solution.
• It may influence perceptions, beliefs, and attitudes that may change social norms
• It may prompt action; demonstrate or illustrate healthy skills.
• It may reinforce knowledge, attitudes or behaviour
• It may show the benefit of behaviour change
• It may refute myths and misconceptions

Fear appeal: mixed results => causes high emotion which increases an audience's attention, memorability and can contribute to decision-making, causes personal and social emotions but can cause defensive processing which can inhibit persuasion and adverse effects.

Target audience can be better reached

Planners know the needs, preferences and lifestyles of the target

audience (research) ; subdivision of a population or target group into subgroups (market segmentation)

Pretests and evaluation are matter of course

Improvement of the risk perception especially through emotional messages

Focus on behavioural prevention “blame the victims”

Risk of manipulation instead of participation.

Exclusion through segmentation

Risk of false promises

Risk of discrimination

Risk of too much simplification of the contents ("over simplification")

• Applied to all healthy individual, give education in terms of food and provide a basic framework to use when planning meals. Simple language, focus on foods / portion size, that are commonly used
• Special guidelines for children, pregnant/lactating woman, elderly etc.
• Also useful for food industry and to improve food security and safety.

Problem: not everyone knows them and most of them didn't used it (result of an assessment) => you only find it, when you look for it in the internet on the website of SGE (missing publicity).

=> Effective public nutrition information tools are crucial in achieving public health goals . To find out if the implementation of FBDG are effective , effective evaluation (i.e. awareness and use of the guideline) measures need to be done. FBDG must be embedded in other interventions.

Digitalisation may decrease the cost and increase the assessebility to the PHN.

With the help of apps you can do easily risk analysis in relation to food consumption (i.e. regarding food security)

Intervention: possibilities seems to be unlimited (you can record almost everything). You might reach a big population group, because a lot of people are using smartphones (still increasing).

=> Empowerment, Adherence, Motivation, Efficiency is rising, but what is the effectiveness?

Monitoring: Self-Monitoring / Monitoring by health professionals

=> check the population-group, what are their needs?

Nudge: Secretly influencing people to do certain things without knowing. Make the healthy choice the easier choice. But you have still both choices.

Choice Architecture: Change something in the environment to make the healthy choice better assessible.

> there should be a freedom of choice, no strong (monetary) incentives and it should be transparent => not manipulating!

Techniques by provision of information (vegan option), changes to physical environment (placing food items so that it is more assessible), changing default options (salad as a side dish), use of social norms and salience (how many people choose a certain menu), affecting the senses (use bright light to show the salad bar)

=> there is little evidence that nudging interventions result in lasting behavioural changes

You need to know the needs of the specific group. Involve those people in developing the intervention (what are they interested in, what do they want?) You need a lot of time, to do that.

I.e. provide information about the most common food groups and where to get it?

=> behaviour prevention is not suffiecient, you need also the environment and structure. It is difficult to get the evaluation especially on population level (on a behavioural and structural level) and the knowledge about the population group is very important.

The prevalence of overweight and obesity is increasing (i.e. +6.5kg from 1950 to 2015 in CH-RS), also the prevalence in DM. This rises also the costs (direct - medical costs and indirect - reduced productivity)

Overweight people produce more healthcare cost => but BMI is not a good predictor.

Tobacco, poor diet and physical inactivity are explainable reasons for diseases and so aswell for death.

Health expectancy is decreasing => years without disease are decreasing

Environment does force us, to stay physical inactivity => i.e. city planning

Daily exercice increases the health. 90min per day: 35% reduced mortality).

The effect is on every disease seen. PA is mostly more effective than medication alone (i.e. metformin).

Fit vs. Fat: relative risk for CVD and all cause mortality for normal weight people is higher for physical non fit people than an increased BMI and more physical activity => physical activity is more important than BMI.

Physical activities is not always leading to weight loss => this doesn't mean, it is not effective. The health benefit is independant of weight loss!

• Mortality risk associated with obesity is largely attenuated or eliminated by moderate to high levels of PA/CRF
• Most cardiometabolic risk markers can be improved with exercise independent of weight loss.
• Increased PA or CRF are consistently associated with greater reductions in mortality risk than intentional weight loss.
• Weight cycling is associated with numerous adverse health outcomes, including increased mortality.

Muscle is an endocrine organ => physical inactivity probably leads to an altered myokine response, which could provide a potential mechanism for the association between sedentary behaviour and many chronic diseases

Regular, vigorous exercise has been necessary for survival throughout evolution. It is only during the past 50 years that it has become possible for people to go through life with minimal physical activity.

We are not genetically adapted for the sedentary lifestyle that has become so prevalent in developed nations. Lack of exercise is, therefore, abnormal and also unhealthy … A sedentary life is now so prevalent that it has become common to refer to exercise as having “healthy benefits”, even though the exercise-trained state is the biologically normal condition. It is a lack of exercise that is abnormal and carries health risks.

Total sedentary time and longer sedentary bouts as an independent risk factors for all-cause mortality (even after correction for total PA). Less effect off sitting time in physically active (and fit) people.

Important is aswell, the interuption of the sitting time => even 2min every 20min has a big effect (insulin and plasma glucose is coming down).

Walking and Biking to work is associated with higher PA and lower weight

Sport and leisure time physical activity is associated with reduced all-cause mortality and CVD and cancer mortality in a dose-response manner

=> Environmental interventions seem to have larger effects on changes in PA than educational or motivational interventions

SSBs are a problem, because it is offering a lot of sugars. But it is not a metabolic problem for active athlets. So it depense on the metabolic background.

=> we are not adapted to physical inactivity!

Evolutionary behavior => be inactive whenever possible, physical activity only for maintenance or food supply. Exeption => play (training for children). The evolutionary environment did not allow for physical inactivity!

Modern industrialised environment does allow complete physical inactivity, we have unlimited food available and we engeneered PA out of our daily life.

Our body adapts on demand => very quickly to the demands

So you have to maintain the physical activity, because the effect disapears, when you stop doing it

• Emerging evidence indicates a fundamental role for low intensity physical activity (e.g. walking or step count per day)
• With reducing background step count, we find reduced effectiveness of short exercise bouts to improve e.g. blood lipid profiles
• Physical (in)activity of less than ~8000 steps/d seems to progressively reduce the physiologic benefits of acute exercise bouts. With complete "resistance" reported for <4000 steps/d => so there is no exercice effect anymore!
• 2 days of reduced physical activity induced resistance to the physiologic benefits of an exercise bout.

• There is often a lack in the variety, less vegetables/fruit, less fibre and fisch. More sugar
• Kids like food for good taste, choice, familiarity, exposure and curiosity. They dislike the smell, texture and appearance
• Early influences on food preferences: genes to like sweet and dislike bitter and individual differences in taste and odour sensitivity; early experiences in utero (aromas from mother's food) and aswell during lactation. At weaning experience (changing from milk to solid food) with variety faciltates acceptance of new foods, in childhood: culture, family, peers and personal experience.
• High fat and sweet foods are favorite, vegetables are almost universally disliked.
• Certain textures (at begining no bits)
• Main determinants: familiarity + sweetness

• Parents can manipulate the availability or access of foods. They can use it as reward / punishment, emotional climate, strict control over food intake.
• Reward: dessert is used as a reward for eating vegetables => opposite effect, because the vegetables are getting worse and the dessert more wanted. It helps to creat a positiv environment around sweet stuff and not only offer it for "special occations".
• Control over intake: "finish your plate", limit access to food (restriction of sweet foods) => leads to overconsumtion and they don't learn, how to cope with it

• Cooking might improve dietary habits of children: cooking in school or at home
• Often are emotional aspects mentioned like they are proud of cooking something themselve and they liked cooking, independence and ownership.
• They eat more salat, if they can helo cooking. Higher feelings of "dominace" after cooking and correlated with a longer eating duration => a single session of cooking can improve the intake and liking of the prepared meal

• Unwilling to try new food, consuming a limited type and variety of food, rejecting also familiar foods. It is a common and normal behaviour aslong there are no growth deficience.
• Difference to Avoidand/Restrictive Food Intake Disorder (DSM-5): weight loss, nutrition deficiency
• Defined by the mothers percetions and can be a source of stress like "are my kids eating enough?" " are theey getting the right nutrition?"
• Energy intake and macronutrient intakes do not differ between picky and non-picky children. Intake levels are in the recommended range

Parents’ wrong perceptions lead to unhealthy parenting behaviors…

• More prompts to eat(e.g. try your caulifower) are associated with more food refusals
• More coercive-controlling practices (e.g. if you eat your broccoli you can have an ice-cream) are associated with more food refusals
• Use of pressure to eat and food restrictions: both are associated with higher levels of picky eating

Children: obesity is increasing in children and are stll rising. need for food is higher (growing), eating patterns are established, food habits are much more variable at a young age => Important window of opportunities

Influenced by food at home, behavior in freetime, mental healthl aspect (mobbing), Body image, emotional eating, availabilty of foods, ultraprocessed nature of food, advertisement, softdrink consumption and snacking

Schools: food has a impact on the concertration => socio-economic impact. Part of society. Really important opportunity to learn, how to live in school. It is not only the responsibility of the parents, but also of the society. Self-afficacy is higher, if they learn it at school.

School brings all the componences together: parents, physical activity, other children, schoolnurse/psychiatrist => positiv cicle

School meals around the world: reached a lot of children with a big impact on the child (almost for 10years) => relevant for public health outcomes!

1. Quality of implementation (is it age fitted?)
2. Educational rigour of the programme and ist integration within mainstream curricula (be proactive)
3. Positioning of school-based efforts within the context of broader educational and community efforts

Education and information about acriculture on vegetables and fruits and on overweight/obesity. More trained people in nutrtition in the health care system. "Peer to peer" support: doing cooking class (less fat/carbs, more fruits and vegetable).

Weekly classes to educate the target group, providing a fruit for free or seeds for gardening as a reward.

=> Use the local structur, try to reach the people where they are, campain on TV and social media, theaters

Implementing a tax (SSBs, oil => imported). In bigger cities you could implement sports equipment in parcs or group sports. 

Body does not have enough/right kind of food to meet his needs: energy, macronutrients, micronutrients. Most vulnerable groups: children, pregnant woman and elderly

Indicators of Child Undernutrition: underweight for one's age, log height for age (stunted: chronic malnutrition), low weght for height (wasted, only seasonal malnutrition), measure mid-uüüer arm circumgence as a proxy for weight, and head circumfence as a proxy for height, blood samples (vitamins and minerals)

Hidden hunger: problem of dietary quality/dietary diversity, chronic undersupply of micronutrients

70% of stunting takes place before the second birthday. Prevalence mostly in south africa and southern asia => dependant on social economical status

Prevalence of wasting high in africa, southeastern asia and southern asia.

Malnutrition has an effect on the intellectual development not only because it get enough calories, but also because there is less movement so less motor skills trained and less exploring; aswell less schooling (teacher don't expect much of a "small" child): stunting between 12 and 36 months of age predicted poorer cognitive performance and/or lower school grades attained in middle childhood

Circle: if the mother is malnutritioned => the child is born underweight and starts already with deficiency => not good brain developement as an adult => poor => and it starts again from the beginning "hunger carusel". Problem: stunting is mostly not detected (when a lot of children are suffering of stunting, then you can't see, that your child is smaller than it should be => and if it is not detected, it can't be treated)!

The main actors are Vitamin A, zinc, iron and iodine => severe deficiencies cause typical clinical symptom, but they are often unnoticed but have serious consequences. Almost 1/3 of people are deficient