NUTRIM case study

Prevention in the basic health insurance: The Combined Lifestyle Intervention in the Netherlands

Division 1: Obesity, Diabetes & Cardiovascular Health
Department of Health Promotion and the Department of Human Biology and Movement Sciences


Combined lifestyle interventions (CLIs) aim to help people who are overweight or obese to change their physical activity level and dietary behaviors and maintain the new healthier lifestyle. Typically, a lifestyle coach supports overweight or obese clients to prevent chronic lifestyle-related diseases such as Diabetes Type II. To date, many interventions have failed to translate outcomes in controlled research settings to real-world settings, due to unsuccessful or incomplete implementation.

Implementation of CLIs benefit from action oriented research, as this provides insight into the implementation process. It also helps to understand the results of the intervention and the success factors influencing both the intervention contents, its implementation and its sustainability.

Major breakthroughs

The research group led by Prof. Kremers was involved in the trajectory to design, implement, evaluate and improve CLI’s in the Netherlands from the very beginning. In 2008, Commissioned by the Dutch Ministry of Health, Welfare and Sports (VWS), we participated in the development of a lifestyle intervention called ‘BeweegKuur’, together with the Netherlands Institute for Sport and Physical Activity (NISB).

This led to a series of implementation and evaluation studies that mostly had an action-oriented research design. Dr. Judith Helmink received her PhD for her work in the BeweegKuur. We published nine reports for the Ministry of VWS, two Dutch language papers for Dutch practitioners and ten international peer-reviewed research papers with the purpose to improve the contents of the intervention and to start a sound evidence base for what was later labelled as CLI.

In 2014, we were asked by health insurance company CZ to develop and evaluate a new CLI, based on the results of our previous work. The goal for CZ was to develop an optimal system for the reimbursement of CLIs by health insurance companies, with the ultimate aim of reducing the health care costs in the longer term. We took up the challenge together with Academic Collaborative Center Tranzo in Tilburg. While our pilot study for the intervention labeled Coaching on Lifestyle (CooL) was underway, the Dutch government decided that CLIs will indeed be covered by the health insurance from 2019 onwards. This decision was largely based on the results of the studies that our group performed, led by PhD student Celeste van Rinsum.

Since various parties were waiting to see the results of a successfully implemented CLI, the CooL results came at exactly the right time and quickly accelerated practical processes throughout the Netherlands including education of future lifestyle coaches and preparation of local networks of key stakeholders. From 2019 onwards, three Dutch intervention programs qualify as CLIs that are reimbursed by health insurance companies, including both the BeweegKuur and CooL. The two owners of the CooL intervention (N. Philippens and E. Janssen) are currently involved in a PhD trajectory to evaluate the implementation and dissemination of CooL. Nationwide data are gathered to monitor the intervention and potential promoting and hindering factors for optimal implementation.

Scientific impact/Research quality

Our work has been published in high-quality journals such as the International Journal of Behavioral Nutrition and Physical Activity. Action oriented research has become the standard for implementation studies; our group can be viewed as one of the groups that have contributed to the increased adoption of such studies in the field of obesity prevention.

  Who’s involved

The team involved works within the departments of Health Promotion (Prof. Dr. Stef Kremers, Dr. Geert Rutten, Dr. Sanne Gerards, Dr. Judith Helmink, Dr. Celeste van Rinsum, Dr. Jessie Meis, Dr. Lieke Raaijmakers, Nicole Philippens, Ester Janssen) and
the department of Human Biology and Movement Sciences (Prof. Dr. Hans Savelberg, Dr. Brenda Berendsen, Dr. Marike Hendriks).

The team includes researchers from various backgrounds including psychology, health promotion, movement sciences and physiotherapy and involved two professors, three postdoctoral researchers and seven NUTRIM PhD students (two ongoing).

Selection of publications


  • Helmink, J.H.M., Meis, J.J.M., De Weerdt, I., Visser, F.N., De Vries, N.K., Kremers, S.P.J. (2010). Development and implementation of a lifestyle intervention to promote physical activity and healthy diet in the Dutch general practice setting: the BeweegKuur programme. International Journal of Behavioral Nutrition and Physical Activity, 7, 49.
  • Van Rinsum, C.E., Gerards, S.M.P.L., Rutten, G.M., Philippens, N.M.L., Janssen, E.M.J., Winkens, B., Kremers, S.P.J. (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, 15, 680.
  • Berendsen, B.A.J., Kremers, S.P.J., Savelberg, H.H.C.M., Schaper, N.C., Hendriks, M.R.C. (2015). The implementation and sustainability of a combined lifestyle intervention in primary care: mixed method process evaluation. BMC Family Practice, 16, 37 Rutten, G.M., Meis, J.J.M., Hendriks, M.R.C., Hamers, F.J.M., Veenhof, C., Kremers, S.P.J. (2014).
  • Does lifestyle coaching of overweight patients in primary care contribute to more autonomous motivation for physical activity and healthy dietary behaviour? Results of a longitudinal study. International Journal of Behavioral Nutrition and Physical Activity, 11, 86.

Societal impact

The studies presented above have been followed closely by implementation institutes (such as Netherlands Institute for Sport and Physical Activity (NISB) (1)), but also by educational institutes for lifestyle coaching (2), health insurance
companies (3), the national press (4), the Dutch government (5), the Ministry of Health, Welfare and Sports (6), Netherlands Organisation for Health Research and Development (7), the Dutch Care Institute (Zorginstituut Nederland) (8) and Dutch health promotion practitioners (9, 10). 

This resulted in multiple publications for all these stakeholders.
A brief summary is given below.
1. Helmink, J.H.M., Meis, J.J.M., Kremers, S.P.J. (2010). Een jaar BeweegKuur, en dan? Een onderzoek naar de bevorderende en
belemmerende contextuele factoren. Universiteit Maastricht.
2. AVLEG: Resultaten pilot met CZ en Universiteit Maastricht positief!
3. Van Rinsum, C.E., Gerards, S.M.P.L., Rutten, G.M., Van de Goor, L.A.M., Kremers, S.P.J. (2018). Coaching op Leefstijl
(CooL): Eindrapportage van een implementatie- en monitoringstudie. Maastricht University.
4. Algemeen Dagblad, 16-4-2018. Patiënten leren zelf te beslissen over gezondere leefstijl.
5. Johannesma, M., Van de Goor, I., Kremers. S. Leefstijlinterventies onderdeel van verzekerde curatieve zorg.
Advisory letter sent to Tweede Kamer, 21-5-2018.
6. Kamerbrief over basispakket zorgverzekeringswet.
7 ZonMw - 20 jaar preventie. Interview Stef Kremers, Maastricht University: ‘Gezond gedrag volhouden is lastiger dan een paar kilo’s kwijtraken’ 
8. Zorginstituut Nederland: Standpunt gecombineerde leefstijlinterventie (GLI) bij overgewicht en obesitas.
9. Helmink, J.M.H., Raaijmakers, L.G.M., Rutten, G.M., Kremers, S.P.J., De Vries, N.K. (2013). Gecombineerde Leefstijlinterventies in Nederland: Ervaringen uit de BeweegKuur. Tijdschrift voor Gezondheidswetenschappen, 91, 88-90.
10. Van Rinsum, C., Gerards, S., Rutten, G., Van de Goor, I., Kremers, S (2018). Coaching op Leefstijl: de leefstijlcoach als spin in het web? Tijdschrift voor gezondheidswetenschappen, 96, 189-193.

Future Perspectives

The national dissemination of the CLI will be monitored by RIVM (the National Institute for Public Health and the Environment). In depth process evaluation and implementation studies will however be executed within NUTRIM by two external PhD students (Nicole Philippens, Ester Janssen), with a specific focus on CooL. The evaluation is aimed at understanding processes of change and improving the implementation of the intervention.


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