Reflections on the findings
The described Dutch model has four components (vision, process, partners, finance) which, as far as we know, have not been cohesively described like this before in the context of childhood obesity care in other countries. Still, the described care is in accordance with childhood obesity guidelines and accompanying materials for the UK, Scotland, New Zealand, the United States, Australia and Canada [
78‐
84], as well as with the recommendations of the World Health Organization [
16].
The content of the national model and accompanying materials is worth reflecting on. In contrast with the materials developed in the Netherlands, only a few countries pay attention to accompanying materials in their guidelines to support policymakers’ implementation of the guideline [
78,
80,
84]. However, more is offered in other countries to support individual healthcare professionals: for example, a sensitive approach to discussing weight is widely acknowledged and other countries also have materials facilitating positive weight-related conversations [
81‐
83].
Materials for policymakers to support local realisation of the integrated care as described in the national model and materials for healthcare professionals to support them in delivering the needed support and care seems a precondition for successful implementation of the described integrated care. The availability of these materials for a variety of professionals working at different levels (strategic, management, executive), including guidance on how they can collaborate, is a unique feature of the developed model. It should be carefully examined for each country or location where accompanying materials are needed, taking particularities into account.
An extensive description of the partners and finance as part of the national model helps realise the integrated care, since it offers a comprehensive view on what is needed for this care at the system level too. This is extra important in the Netherlands, because the support and care is financed through two domains: the social domain and the healthcare domain. The national model describes a desirable situation in which these domains strengthen each other by collaborating. Provision of support and care to families should not be hindered by miscommunications, boundaries between domains or reimbursement issues that influence the quality of the needed support and care.
The developmental process of the national model and accompanying materials yielded a number of learnings. It should be kept in mind that the development took place in the rather unique context of the Dutch healthcare system, so reproducing it in other contexts might not be easy, and the generalisability of results, learnings and recommendations outside of the Netherlands might be hampered. Still, an important implication of these findings is that the learnings regarding the process of developing such a model as well as the developed materials themselves might be applicable to other countries.
A first strength of the developmental process is that, in addition to the expertise of its project team, Care for Obesity made extensive use of science, policy and practice expertise available from other organisations. These collaborations resulted in a science- and practice-based model, thereby improving the development of the national model in all its facets. For example, it facilitated the wording of the texts in the model and all accompanying materials, making them understandable and practicable for policy and practice.
Second, the collaboration with pilot municipalities and other stakeholders also strengthened commitment to the development of a national model. This was reinforced by the local conferences that Care for Obesity and JOGG organised during the development phase.
Third, the model was developed with attention for the interests of multiple stakeholders: children and their parents/caregivers, municipalities, health insurers, healthcare professionals, JOGG, ZIN and VWS. This also contributed to the support base needed for the model and its implementation. The developmental process was likewise characterised by a carefully planned process involving multiple phases during several years and stakeholders from science, policy and practice. This automatically meant there were many interests at stake which had to be managed and many valuable views to be merged. It also meant optimal use could be made of the experience and knowledge available from all these stakeholders. By appointing a neutral national coordinator for this process – in this case a project at the university – a smooth process was facilitated and extensive support from policy and practice accomplished, resulting in an evidence- and practice-based model that was ready to be implemented beyond the eight municipalities that founded it.
Last, it seems that the procedure for the development of this model and the structure of the model can be used to develop a similar model for adults with overweight or obesity (which is in preparation), as well as models for other diseases and health/social issues in children or adults that require integrated care, such as smoking, ADHD and poverty. This implication should be further explored.
Recommendations for research, policy and practice
Future research is needed into the effectiveness and cost-effectiveness of the integrated care described in the national model. To this end it would be useful to look into other models of integrated care for other conditions, to explore how feasible and how effective they are [
85]. To gain first insights into the implementation process, a process evaluation of the local implementation was done in 2019–2021 which yielded insights into the local hindering and helping factors for implementing integrated care for children with overweight and obesity [
86]. Supporting local realisation is an important task for the coming years, with the ensuing general and cost-effectiveness study. In the meantime, local monitoring can already offer insights into how the local implementation is progressing. The module developed for monitoring the integrated care is available to this end [
50], and a more refined version of the indicators in this module, established with a Delphi study, was recently published [
87].
It is clear that the execution of the integrated care by healthcare professionals is complicated, in part due to the complexity of the disease of obesity ([
88]; van den Eynde E, Halberstadt J, Koetsier LW, Raat HJ, Seidell J, van den Akker ELT: Healthcare professionals’ perspectives on the barriers and facilitators of childhood obesity care, submitted). Additional research into the psychosocial factors causing and maintaining overweight and obesity is thus urgently needed, as well as into ways to treat children with overweight or obesity taking into account these psychosocial factors in a respectful, supportive and empowering manner. This is already being partly undertaken in the Netherlands since 2019, and has resulted in several products: a tool to assist healthcare professionals in conducting a psychosocial and lifestyle assessment [
89,
90] – development of this tool is described [
91,
92]; further development of the webtool to measure and discuss health-related quality of life of children with overweight and obesity [
93]; supporting materials for healthcare professionals and patients [
94‐
96] based on additional research into the needs and wishes of healthcare professionals [
97]; short introductory videos to facilitate healthcare professionals’ use of these tools [
98,
99]; and a folder for healthcare professionals about the words children prefer when talking to them about their weight [
100], based on earlier research by Care for Obesity [
36]. Additional research into potentially interacting psychosocial and lifestyle factors (at the child, family and parental level) could provide insights not only into integrated care for overweight and obesity, but also into care for a variety of other non-communicable diseases. Especially interesting to learn about seems to be the role of multi-problem cases and the implications of vulnerable situations of families on the provided support and care.
What could also help improve the integrated care for children with overweight and obesity is more research into the perspectives of children and parents, and the development of materials for them too. A start was made by Care for Obesity with a flyer containing tips for parents on how to talk to their child about a healthier weight [
101]. More research, including the perspectives of children and parents on aspects like their patient journey or the role of the coordinating professionals, could provide additional insights that can be translated into advice for healthcare professionals as well as materials for families that should be developed in collaboration with healthcare professionals and families themselves.
In the meantime, further work on the implementation of the national model is required. To stimulate this in the Netherlands, the national programme Child on a Healthier Weight [
102] was set up in 2019 by Care for Obesity/VU Amsterdam in collaboration with JOGG, the National Institute for Public Health and the Environment, the Netherlands Youth Institute and the Dutch Knowledge Centre Youth Health. In spring 2022 the programme was running in 40 (12%) of the total 344 municipalities in the Netherlands, including the first eight pilot municipalities. The Dutch government, which is funding this implementation, aims to reach all municipalities and thus all children that need this integrated care by 2030 [
103]. To further facilitate this, the tool to support local realisation of the national model [
49] was expanded and revised [
104], and should be updated as new insights from practice become available. The national programme Child on a Healthier Weight took on the task to facilitate local implementation to supply them with the national model and accompanying materials through local advisers, training initiatives and a regular flow of online information targeting policymakers and healthcare professionals.
An important precondition for suitable integrated childhood obesity care is education of professionals in the vision of the national model and the ways to provide the needed care in collaboration with the other professionals in the network around a family. To this end, Child on a Healthier Weight developed a training initiative for coordinating professionals [
105] that was evaluated by Care for Obesity (Koetsier LW, Boutalab L, Seidell JC, Baan CA, Halberstadt J: Training for coordinating professionals as part of the Dutch integrated care approach for childhood overweight and obesity – a mixed-method evaluation, submitted). Also, Care for Obesity developed an e-learning programme for healthcare professionals based on the previously developed training initiatives [
76,
77] for discussing weight and lifestyle with children and their parents/caretakers and for handling weight-biased attitudes and stigma among healthcare professionals [
106]. Adapting the training initiative for coordinating professionals to a version suitable for other groups of healthcare professionals is a logical next step, as is disseminating the available training initiatives as much as possible via channels like trade associations of healthcare professionals and regular educational programmes for healthcare professionals.
Last, an important obstacle to the implementation of integrated care for children with overweight or obesity is the lack of reimbursement of all aspects of this support and care. Hence a vital recommendation for policymakers is to sustainably organise the reimbursement of health care for children with obesity or at a high risk for this disease because of their overweight, monitoring the effects on the availability and eventually the quality of the support and care, as well as the costs. In the Netherlands the incorporation of the national model into the newly revised national guideline for the diagnosis, support and care for children and adults with obesity, whose section for children was initiated and led by Care for Obesity, should help facilitate this [
5].
For all aspects of developing and implementing such a model, it is important to stay closely attuned to national developments that can help or hinder the process. In the past two decades in the Netherlands, stakeholders in science and practice as well as in policy and politics have become increasingly aware of the need for support and care for childhood obesity, and are more appreciative of it and open to optimising it. This has resulted in the Integrated Health Agreement [
107] and the Healthy and Active Life Agreement [
108] reached by VWS and many umbrella organisations of e.g. health insurers, municipalities, mental health services, general practitioners and patients. The aims of these agreements are accessible, qualitative, affordable support and health care based on the specific needs of people, with collaboration between the social and the healthcare domains and a healthy lifestyle among the various focal points. Part of the agreements is for health insurers and municipalities to organise integrated care for childhood overweight and obesity and four other existing integrated care initiatives for babies, adults and the elderly by 2024. The two agreements are expected to further facilitate the implementation of the national model and thereby the optimalisation of the needed support and care.