IMPRESS

Heart failure is a severe and chronic condition were the heart is unable to pump blood around the body properly, due to a structural and/or functional abnormality of the heart. It has many different causes, with the most common being hypertension and coronary artery disease. Heart failure is an unpredictable condition with sudden exacerbations of the disease, hospitalization, and will ultimately lead to death. Proper (and early) treatment may improve the symptoms of health failure and may lead to a relatively longer and better quality of life. The origin On the cardiovascular disease research agenda, as drawn up at the initiative of the Dutch Heart Foundation in 2014 and revised in 2020, the themes “Earlier recognition of cardiovascular disease” and “Heart failure” have been placed on the agenda. The DCVA also announced the Delta Plan Heart Failure in the 2022 annual plan. This resulted in the Delta Plan Heart Failure, which is initiated and financed by the Hartstichting, the Netherlands Heart Institute, and the Dutch Cardiovascular Alliance. In this national project, healthcare professionals, researchers, and patients have joined forces and will focus on the entire continuum of the disease from prevention to palliative care. The research We expect that burden of disease can largely be reduced by addressing the following key-points: Increasing public awareness of heart failure Early detection of heart failure Stimulating the collaboration among all (different) disciplines within the field of health failure Initiation of research consortia for innovative treatment and management of heart failure patients Furthermore, this project will not only focus on positively influencing survival but also on optimizing the patient’s quality of life and will pursue a strategic and operational approach.

A healthy lifestyle - a healthy diet and adequate exercise - contribute significantly to chronic disease prevention. People with a lower socioeconomic position (SEP) often have an unhealthier lifestyle than people with a higher SEP. However, interventions aimed at promoting a healthy lifestyle reach precisely this lower SEP target group poorly and may increase social inequality. A possible explanation is that interventions traditionally tend to focus on individual determinants of behavior such as knowledge, attitudes and intentions. Moreover, these interventions are often not effective, partly because they do not take into account the - social, physical and political - context in which lifestyle choices are made: unhealthy behavior can be seen as an automatic reaction to the 'obesogenic' environment. Changes in and of the environment in which people live can go a long way in promoting healthy lifestyles and reaching all target groups. Changes in the environment should ensure that the healthy choice becomes the easy choice, the obvious choice or even the only choice, especially also for the hard to reach and change target groups such as people with lower education. However, whether environmental interventions are also effective in improving cardiovascular disease risk factors in the longer term is not known and needs to be investigated. The Research Supermarkets form one of the most important point-of-choice settings with the potential to directly influence purchasing behaviors. ‘Nudges’ (small environmental encouragements) target the quick, automatic choices and do not require conscious decision making, and pricing strategies can seduce consumers to buy healthier alternatives. Such environmental cues can make it easier to initiate and maintain a healthy lifestyle, and as such, to improve cardiometabolic health. In addition, the use of theory-based mobile applications is an effective way to provide tailored and context-specific feedback on physical activity behaviors through the stimulation of ‘goal setting’ and ‘self-management’. Being incorporated in structures and systems, environmental interventions can make the healthy choice an easy choice for everyone. As such, these types of interventions are especially effective in reaching otherwise difficult-to-reach groups such as people with a lower socioeconomic position (SEP). In particular, a combination of ‘nudging’ (targeting automatic behaviors), ‘pricing’ (responding to the price-sensitivity of low income consumers) and tailored physical activity feedback and support (which works better than general education), seems promising for lowering cardiometabolic risk in individuals with low SEP. Yet, the existing evidence is mostly restricted to short-term effects on (proxies of) health behaviors, and little is known about long-term impact of such integrated interventions on cardiometabolic risk factors. With SUPREME NUDGE we expand a previous successful Dutch supermarket pricing strategy intervention, and incorporate promising elements such as nudging and ICT applications to provide real-time and context-specific physical activity feedback. We will investigate the effects of this approach on dietary behaviors, physical activity and established cardiometabolic risk factors in adults with a lower SEP. Using principles from Participatory Action Research and systems thinking, we will consult with the relevant stakeholders to explore options for upscaling and further implementation in society. Outcomes will provide policy- and practice relevant evidence with clear, stepwise and realistic leverage points for helping individuals to maintain healthy behaviors and improve their cardiometabolic health by making the healthy choice the easy choice. SUPREME NUDGE is coordinated by the Amsterdam UMC, location VU University, and includes partners from the VU University, University of Amsterdam, Utrecht University Medical Center, Utrecht University, the Dutch Nutrition Center, Te Velde Research, Nynke van der Laan (ICT developer), Duwtje (creative designers) and supermarket chain Coop. The origin The Heart Foundation aims for more people to make healthy choices, so that they feel vital and run less risk of developing (again) cardiovascular diseases, which was one of the themes of the reserach agenda. With its prevention programs, ZonMw contributes to the improvement of prevention practice, to health gains and to reducing socioeconomic health disparities. Results from research show that healthy behavior cannot be taken for granted, and is strongly influenced by people's social and physical environment and socioeconomic status. Proven effective, innovative and accessible methods to enable people to maintain a healthy lifestyle for a long time are lacking. Therefore, the Dutch Heart Foundation and ZonMw have collaborated to form the program "Gezond leven: goed voor het Hart!". SUPREME NUDGE is one of the projects funded from this program.