Final Report Summary - SPOTLIGHT (Sustainable prevention of obesity through integrated strategies) Executive Summary:The prevalence of overweight and obesity in Europe is high and contributes to the burden of many chronic diseases. Obesity is largely determined by modifiable lifestyle behaviours such as low physical activity, sedentary behaviour and high caloric intake. There is growing evidence that influences on individuals and their lifestyle should not only be addressed in single-level interventions that focus on a distinct individual, social or environmental aspect, but rather in community-based approaches that integrate individual, community, organisational, and societal levels. SPOTLIGHT focused on integrated health promotion strategies for sustainable behaviour change contributing to prevention of overweight and obesity. For this project, researchers from thirteen organisations in eight European countries join forces, supported by a team of external advisors. The aims of SPOTLIGHT were to increase the knowledge base on obesogenic determinants in order to obtain a comprehensive overview of the factors necessary for establishing effective and sustainable lifestyle behavioural change interventions. The project also aimed to identify community-based intervention approaches that are strong in terms of their reach, effectiveness, implementation and sustainability. In short, SPOTLIGHT comprised:- a series of systematic reviews on: i) individual-level predictors of success in behaviour change obesity interventions; ii) social- and iii) physical environmental determinants of obesity; iv) the use of remote sensing to define environmental characteristics related to physical activity and dietary behaviours; and v) the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of multi-level interventions- an interactive web-atlas of currently running multi-level interventions - a qualitative exploration of enhancing and impeding factors for implementation of multi-level obesity prevention approaches- the development of tools to quantify the obesogenicity of urban environments- the design and implementation of a cross-European survey and a virtual neighbourhood audit to gain understanding of the ways in which diverse factors influence the weight status of individuals, underlying obesogenic behaviours, and the social and physical environmental contexts in which they take place.So far, the results were translated into 20 scientific (mostly Open Access) publications that were published in international peer-reviewed journals. The many project outcomes were also widely disseminated to various stakeholders through different channels.Project Context and Objectives:The prevalence of overweight and obesity in Europe is high and contributes to the burden of many chronic diseases. Obesity is largely determined by modifiable lifestyle behaviours such as low physical activity, sedentary behaviour and high caloric intake. There is growing evidence that influences on individuals and their lifestyle should not only be addressed in single-level interventions that focus on a distinct individual, social or environmental aspect, but rather in community-based approaches that integrate individual, community, organisational, and societal levels. SPOTLIGHT focused on integrated health promotion strategies for sustainable behaviour change contributing to prevention of overweight and obesity. For this project, researchers from thirteen organisations in eight European countries joined forces, supported by a team of external advisors. SPOTLIGHT aimed to increase the knowledge base on obesogenic determinants in order to obtain a comprehensive overview of the factors necessary for establishing effective and sustainable lifestyle behavioural change interventions. The project also aimed to identify community-based intervention approaches that were strong in terms of their reach, effectiveness, implementation and sustainability. The project outcomes have been widely disseminated to various stakeholders.The expected final results and impact that were formulated at the start of the project are listed below:At the end of the project we will be able to:- Provide additional multi-level entry points for community-based intervention approaches aimed at changing obesogenic behaviours; - Provide the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) of examples of multi-level intervention approaches across European Member states, and the RE-AIM of such interventions that are described in the scientific literature;- Provide factors associated with success-and failure with regard to the implementation of multi-level intervention approaches;- Provide an evidence-based model for effective multi-level intervention approaches in health promotion practice applicable across European regions, and disseminate the findings to European Member State stakeholders.Project Results:The main S & T results of the work carried out within each relevant WP during project are described below:Individual-level determinants of successful behaviour change in obesity interventions in adults have been identified through a systematic review in work package (WP) 2. A comprehensive search of peer-reviewed articles, published since 2000, was conducted on electronic databases (for example, MEDLINE) and journal reference lists. Experimental studies were considered eligible if they reported intervention effects on hypothesized mediators (self-regulatory and psychological mechanisms) and the association between these and the outcomes of interest (weight change, physical activity, and dietary intake). Quality and content of selected studies were analysed and findings summarized. Studies with formal mediation analyses were reported separately. RESULTS: Thirty-five studies were included testing 42 putative mediators. Ten studies used formal mediation analyses. Twenty-eight studies were randomized controlled trials, mainly aiming at weight loss or maintenance (n = 21). Targeted participants were obese (n = 26) or overweight individuals, aged between 25 to 44 years (n = 23), and 13 studies targeted women only. In terms of study quality, 13 trials were rated as “strong”, 15 as “moderate”, and 7 studies as “weak”. In addition, methodological quality of formal mediation analyses was “medium”. Identified mediators for medium-/long-term weight control were higher levels of autonomous motivation, self-efficacy/barriers, self-regulation skills (such as self-monitoring), flexible eating restraint, and positive body image. For physical activity, significant putative mediators were high autonomous motivation, self-efficacy, and use of self-regulation skills. For dietary intake, the evidence was much less clear, and no consistent mediators were identified. Despite limited evidence, higher autonomous motivation, self-efficacy, and self-regulation skills emerged as the best predictors of beneficial weight and physical activity outcomes; for weight control, positive body image and flexible eating restraint may additionally improve outcomes. These variables represent possible targets for future lifestyle interventions in overweight/obese populations.These findings have been translated into a scientific paper which has been published Open Access in a high-impact scientific journal. The results were also presented in an oral presentation during the annual meeting of the European Congress on Obesity (ECO) in Liverpool, in 2013, and at the annual meeting of the International Society of Behavioural Nutrition and Physical Activity (ISBNPA).Obesogenicity of environments (WP 3) Work Package 3 of the SPOTLIGHT project provided an overview of environmental determinants of overweight and obesity, focusing on their impact on dietary behaviour, physical activity and sedentary behaviour; and building on this to develop and validate an innovative protocol for the assessment of the obesogenicity of the built environment using remote imaging in multiple settings. The Work Package then assessed the actual environmental obesogenicity of selected neighbourhoods in five European Member States, and linked this with health measures and behavioural characteristics of more than 6000 inhabitants surveyed in these neighbourhoods across Europe.We started by developing a conceptual framework for the research, then conducted two systematic reviews on the social and physical environmental determinants of overweight and obesity. These reviews informed the development of a major population level survey and neighbourhood audit conducted in five European urban regions: Ghent and suburbs (Belgium), Paris and inner suburbs (France), Budapest and suburbs (Hungary), the Randstad (a conurbation including the cities Amsterdam, Rotterdam, the Hague and Utrecht in the Netherlands) and Greater London (United Kingdom). We had originally proposed doing this in four countries, but were able to add Belgium to this part of the project, taking it up to five countries. Neighbourhood sampling was based on a combination of residential density and socioeconomic status (SES) data at neighbourhood level. This resulted in four types of neighbourhoods: low SES/ low residential density, low SES/ high residential density, high SES/ low residential density and high SES/ high residential density. In each country, three neighbourhoods of each neighbourhood type were randomly sampled.We developed a virtual audit tool that allowed us to conduct assessments of the physical neighbourhood in the multiple locations across Europe. In order to do this we reviewed the existing literature, then developed and validated our own, novel, audit tool to categorise the food and physical activity environments.In addition to the neighbourhood audit, we conducted a survey among the inhabitants of the audited neighbourhoods. The survey contained questions on demographics, neighbourhood perceptions, social environmental factors, health, motivations and barriers for healthy behaviour, obesity-related behaviours and weight and height. A total of 6,037 individuals participated in the study between February and September 2014. The study was approved by the corresponding local ethics committees of participating countries and all participants to the survey provided informed consent.The projects within WP3 have generated a wide range of valuable outputs, ranging from the development of novel methodological approaches in the form of the SPOTLIGHT Virtual Audit tool and methods for assessing the self-defined local neighbourhood of survey participants, to providing insights into the role of social capital, cycling, and sleep in obesity and related behaviours. We have published a number of papers during the course of the project, but were also able to compile a set of nine research papers, accompanied by two comment articles, in a supplement to the high impact journal Obesity Reviews, edited by two members of the work package. This helpfully pulled together many of the useful findings of WP3 into one place, all freely available through open access. The published results of WP3, including those published in the Obesity Reviews journal Supplement, have been compiled and added in the supplementary files.Compiling the existing evidence on obesogenic environments.The systematic review of the scientific literature focused on associations of physical environmental factors with adult weight status, stratified by continent and mode of measurement, accompanied by a detailed risk-of-bias assessment. Only two factors, urban sprawl and land use mix, were found to be consistently associated with weight status, although only in North America. We concluded that, with the exception of urban sprawl and land use mix in the US, studies to date do not allow robust identification of ways in which that physical environment influences adult weight status, even after taking into account methodological quality. We also conducted a literature review on the associations between the social environment and adult weight status. The strongest associations with weight status were found for social capital and collective efficacy, although few studies found significant associations. We additionally found that there was substantial heterogeneity in the definitions and metrics of psychosocial environmental constructs. Also, prior to conducting a virtual audit in sampled neighbourhood across five European urban regions, we conducted a systematic literature review on the use of remote sensing to define environmental characteristics related to physical activity and dietary behaviours. Based on the available evidence, we built a new tool to assess physical environmental characteristics at neighbourhood level associated with obesogenic characteristics by using Google Street View images. This tool was validated by comparison with field audit before conducting a European-wide virtual audit of obesogenic characteristics in 5 large European urban regions.Generating new evidenceUsing data from the neighbourhood survey and environmental audit as described above (under ‘Approach’), we aimed to get a better insight into: • the mediating effects of obesity-related behaviours on the association of neighbourhood SES and neighbourhood residential density with BMI. RESULTS: Transport-related physical activity, leisure-time physical activity and vegetable intake seemed to mediate the association between neighbourhood type and BMI. Residents from low SES/low density neighbourhoods reported less transport-related physical activity, less leisure-time physical activity and less vegetable intake than high SES/high density neighbourhood residents, and these behaviours were related to having a higher BMI. As such, we concluded that the association between neighbourhood type and BMI can be explained, at least in part, by obesity-related behaviours.• the interaction between perceived barriers towards physical activity and healthy eating and local availability of opportunities (neighbourhood destinations) in relation to obesity-related behaviours in adults. RESULTS: We found that the presence of destinations influenced obesity-related behaviours, with greater influence among those perceiving more barriers. • the individual and contextual correlates of socioeconomic inequalities in neighbourhood perceptions across five urban regions in Europe. RESULTS: Results suggested that objectively observed physical environmental factors and neighbourhood-level social cohesion could explain part of these socioeconomic differences. • the mediating role of perceived presence and use of fast food outlets and fast food consumption in the association between access to geolocalized fast food outlets and obesity. RESULTS: Results showed that objectively observed accessibility to fast food outlets was not directly associated with fast food consumption or obesity. However, perceived presence and use of fast food outlets was associated with higher levels of fast food consumption whereas there was an association with reduced obesity rates among people who cited the presence of fast food restaurants but did not report consuming it. • the association of ‘truly contextual’ social constructs with obesity-related behaviours, obesity and self-rated health. RESULTS: Higher levels of social network and social cohesion were associated with better self-rated health, lower odds of obesity and higher fruit consumption, but also with prolonged sitting and less transport-related physical activity. The construct that appeared to represent contextual variation best (an average neighbourhood score, adjusted for individual scores) was associated with physical activity and sedentary behaviours only.• the self-defined neighbourhood size and overlap with predefined residential areas according to the characteristics of the sampling administrative neighbourhoods (residential density and socioeconomic status) within the five study regions and we also aimed to determine which individual or/and environmental factors are associated with variations in size of self-defined neighbourhoods. RESULTS: We showed that self-defined neighbourhood size varies according to both individual factors (age, educational level, length of residence and attachment to neighbourhood) and contextual factors. These findings have consequences for how residential neighbourhoods are defined and operationalized and can inform how self-defined neighbourhoods may be used in research on associations between contextual characteristics and health outcomes such as obesity.The findings from the research conducted in Work package 3 suggest that environmental correlates are important factors for healthy behaviours and obesity. The obesogenic (residential neighbourhood) environments can be characterised by a lack of destinations, lack of social cohesion and social networks, lack of public transport facilities, and lack of affordable, healthy foods. The field of research in this area has been furthered with conceptual, methodological, and measurement progressions.The Reach, Effectiveness, Adoption, Implementation and Maintenance of multi-level interventions (WP 4)A systematic literature review was carried out within WP4 to evaluate the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) of published studies on obesity prevention interventions that target individual-level and environmental-level factors. Electronic databases (PubMed, Embase, and The Cochrane Library) were searched to identify intervention studies published between January 2000 and April 2012. The following inclusion criteria were used: (1) interventions aiming to influence obesity-related behaviours (i.e. dietary, physical activity and sedentary behaviour), (2) targeting adults, (3) being conducted in a geographical area (e.g. city, country) or worksite, (4) being multi-level (i.e. targeting both individual and at least one environmental level), and (5) collecting data over at least one year. Evidence of the RE-AIM domains related to the selected interventions were assessed. RESULTS: The findings indicated that integrated interventions have the potential to reach a large amount of people, including those who can benefit most. Moreover, it seems that multi-level interventions are more likely to be broadly adopted and to be sustained than single-level interventions. The largest public health impact can be achieved if: 1) there is a focus on all levels, from potential program participants to organizational sponsors, at the beginning of the planning process, 2) the diffusion theory is applied to guide the implementation process, and 3) a website to disseminate the intervention is used. Despite the inconsistent report on the different RE-AIM dimensions, the reported Reach, Efficacy, Adoption, Implementation and Maintenance were positively evaluated. However, more information on external validity and sustainability is needed in order to take informed decisions on the choice of interventions that should be implemented in real-world settings to accomplish long-term changes in obesity-related behaviours.Inventory of European community based interventions (WP 5)Within WP 5 a Europe-wide survey was carried out to provide an overview of community-based multi-level approaches to prevent adult obesity through improving diet and physical activity. The results of this survey have been translated by the World Obesity Federation into an interactive web atlas detailing initiatives being taken in 24 countries in the European region. The Web Atlas is an online resource, showing summaries of the information collected in the process of the SPOTLIGHT WP5 research into multi-level interventions to tackle obesity, arranged as a database, and approached through country-level interrogation in a map-based format, according to the country in which the intervention operates.The projects and interventions selected were aimed primarily at adults, and had more than one approach within them by including both individual and environmental components. The interventions were a selection of what is available. The database is not exhaustive (some interventions are likely to be unknown to us) but it indicates the range of activities that have been developed and are active during the time of data collection.For each project or intervention the database shows the available information on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) aspects of the intervention. In providing this evaluation the authors are not endorsing or providing recommendations for future practice.The Web Atlas is available at:http://www.worldobesity.org/what-we-do/policy-prevention/projects/spotlight/intervention-atlas/Much was learned from this initiative, and we have shared the learning and struggles with peer-researchers through an Open Access scientific publication. The specific aim of that article was to provide a descriptive overview of the data collection process and general results of an assessment of on-going multi-level obesity prevention community interventions for adults in Europe, and the lessons learned from this effort. The conclusion of this paper was that found that many multi-level obesity prevention interventions among adults are currently active in Europe, although we found relatively few in Southern and Eastern Europe. Identifying interventions and obtaining detailed information proved to be a difficult, time consuming and painstaking process. We discussed some of the reasons why this might be the case and present recommendations based on our experiences. We suggested that future research uses a step-wise approach, keeping participant burden to a minimum. The use of personalised and tailored strategies is recommended, led by researchers who exercise flexibility, tact and patience during the data collection process.Success and failure factors for implementation (WP 6)The overall aim of the research was to identify factors associated with success and failure in multi-level obesity prevention interventions (case studies) for adults in three European member states, with reference to Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM).The primary research data were qualitative, although some quantitative data were collected to cross check the qualitative data. Standardised data collection tools were developed, piloted, and used in each of the case studies. This was important to enable comparisons between the case studies to be carried out. An important inclusion criterion was that case studies should include a specific focus on deprived areas/ people at the highest risk of inequalities. Within the selection criteria the research aimed to identify varied and rich case studies, which would give real insights into the diversity of success and failure factors in interventions. In-depth interviews were carried out in three country case studies (communities with high prevalence of low socio-economic groups in Denmark, the Netherlands, the United Kingdom), with interventionists including the project team, project partners, and stakeholders. Standardised data collection tools were developed, piloted, and used in each of the case studies. This was important to enable comparisons of enabling and hindering factors between these studies to be carried out. From 24 semi-structured interviews we identified 21 themes that were often common and sometimes unique to the interventions in Denmark, Netherlands and UK. Some factors were identified as both enhancing and impeding. The characteristics considered most important - effective leadership and the commitment/good working relations among staff - were enhancing factors in all RE-AIM domains except Maintenance. The most critical impeding factor was the lack of needs assessments. In the RE-AIM domains of Efficacy, Implementation and Maintenance the need for an appropriate political and economic environment was identified as necessary for success. The results indicate that in delivering complex community-based interventions there are very real tensions between delivering and maintaining a project. There are conflicts in the success factors for ‘doing’ a good quality and effective project in a short period of time and success factors for truly engaging the community and its leaders, organisations and political leaders and slowly but surely developing a community initiative which in time can become embedded and continue to contribute to the health of the community in the long-term. Factors which differentiated consistently between success and failure across all three countries have emerged in this study, despite the extent and power of the variables between case studies and countries which militated against them.The qualitative research in multilevel health promotion interventions and a RE-AIM analysis provided insights on how interventions may be improved for securing better prevention of obesity. The results suggest that enabling sufficient time for carrying out needs assessments and involving the target population in developing the bid may increase the reach, and community involvement at all stages of the project ensures long term sustainability and eventually prevention of obesity.Potential Impact:Potential impact of the SPOTLIGHT project.For decades, most obesity prevention approaches have focused on individual-level determinants to change key obesogenic behaviours. Although recent developments, such as interventions based on self-determination theory and self-regulatory mediators show promise, the targeting of individual-level determinants appear to have had little or no impact on the prevalence of obesity to date. Widely used health education interventions alone appear to be ineffective, and in so far as they are more likely to be taken up by individuals and households that have access to resources (including time, finance and skills) they would in principle widen the inequalities gap and increase the social gradient in obesity prevalence. In contrast, health practitioners and health researchers are increasingly recognising that physical, social-cultural and socio-economic environments interact with individual-level factors to create a health-promoting or health-deteriorating context in which health behaviours occur, and this interaction is driving the obesity epidemic. The sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations can be defined as the ‘obesogenicity’ of an environment. It follows that the most effective interventions relevant to obesity (a) adopt an integrated, multidisciplinary, and comprehensive approach, (b) involve a complementary range of actions, and (c) work simultaneously at different levels (i.e. individual, community, and environmental levels) to shape behaviour. This was the focus of the SPOTLIGHT project. It has built on recent advances in measurement methods to map the obesogenicity of communities, it has identified key characteristics of neighbourhoods which are linked to obesogenic environments and unhealthy behaviours, and it has examined a wide range of initiatives in which a multi-level approach is used to improve obesity-related behaviours, with in-depth interviews and with a systematic application of the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) evaluation system.As a result of this effort, SPOTLIGHT has increased our understanding of effective and sustainable multi-level behavioural interventions to prevent overweight and obesity. The findings highlight the importance of strengthening social ties in a neighbourhood, the importance of urban design in health promotion, and the need to account for individual differences in perceptions, attitudes and behaviour patterns. The researchers noted that obtaining details of community interventions is time-consuming and difficult, with project staff unwilling to spend time on providing information or discussing project outcomes or evaluation. It also concluded that it was important that all participants should be involved in the initial design of a local intervention, including the target population, delivery staff and sponsors, supported by ‘two-phase’ funding, with an initial fund for participatory design and piloting of the intervention, and a second phase to implement it if the initial phase is inclusive with the target population being supportive of further work. The research noted a lack of good evidence on the best methods to ensure participants have involvement and investment in making change, and how individuals experience physical and financial environments and make use of social environments, in shaping their behaviour. They noted the value of Europe-wide research, allowing comparisons of a range of cultures, behaviours, diets, inequalities and institutional opportunities, and the need for research to be designed to strengthen policy development. The project consortium partners have published their findings in a range of media:• in scientific publications and scientific conferences, through peer-reviewed journals (20 papers to date) and international symposia (three symposia dedicated to the SPOTLIGHT project held during the project);• in blogs, newsletters and social media, including six video interviews for YouTube and more than 30 items in independent media;• in materials designed for circulation through civil society organisations and among policy-making officials and government representatives;• in the construction of an interactive, map-based Atlas of interventions, providing details of over 80 community interventions evaluated with the RE-AIM framework, freely available in English and French;• in meetings and workshops with non-health sector professionals and staff, and particularly at the SPOTLIGHT Policy and Civil Society meeting in Brussels to assess the future needs for research on obesogenic environments.Further details of the dissemination activities are listed in Template A2 and specific reports of communication materials, scientific outputs and outputs for wider use by policy-makers and other professionals can be found in Deliverables 7.1 7.2 and 7.3.In the Description of Work the impacts of SPOTLIGHT were discussed in four categories: (1) Call-specific impacts, (2) Research impact, (3) Economic impact, (4) Societal impact. Here we review their achievement.(1) Call-specific impacts. The anticipated result of call HEALTH.2011.3.3-2 is the definition of multi-level behavioural change interventions for sustainable behaviour change that can be implemented in health promotion practice to reduce the occurrence of chronic diseases. SPOTLIGHT has successfully defined several of the factors necessary for establishing effective interventions in health promotion practice, at different levels taking into account varying contexts to sustainably reduce obesogenic behaviours. These are described in a number of outputs of the SPOTLIGHT project including several of the scientific papers, the materials for civil society organisations and policy-making, and the Atlas of interventions for health promoters (the Atlas is available in English here www.worldobesity.org/what-we-do/policy-prevention/projects/spotlight/intervention-atlas/ and in French here www.worldobesity.org/what-we-do/policy-prevention/projects/spotlight/intervention-atlas-francais/). The Atlas is also being used as a basis for a wider international mapping of policies and interventions around the world, developed by the World Obesity Federation (see http://www.worldobesity.org/resources/policies-and-interventions/). (2) Research impact. SPOTLIGHT has developed specific tools for analysing obesogenic neighbourhoods, provided a database of community interventions and evaluated these with the RE-AIM criteria, and undertaken in-depth interviews with multi-level intervention coordinators. It has also identified some of the key outstanding questions requiring further research, which were developed at a meeting of ten different EU-funded projects on obesity along with representatives of health professionals and consumer groups and senior Commission officials (for details, see Deliverable D7.1 of the SPOTLIGHT project, and see also the report of the meeting at www.worldobesity.org/site_media/uploads/Brief_meeting_report_-_v.2.pdf). Research findings from the SPOTLIGHT project will continue after the period of EU funding, including presentations at the International Congress on Obesity (Vancouver, May 2016), at an associated high-level international satellite on Systems Approaches to Obesity Prevention (Vancouver, April 2016), with a SPOTLIGHT symposium at the European Obesity Summit (Gothenburg, June 2016) and with a SPOTLIGHT symposium at the annual meeting of the International Society for Behavioral Nutrition and Physical Activity (Cape town, June 2016). (3) Economic impact. There is no doubt that overweight and obesity place an enormous burden on society. SPOTLIGHT has identified many of the modifiable determinants of obesity and ways to counteract or prevent obesity through multi-level interventions. These provide support to policy-making at local, national and Community level, and support effective advocacy for policy development and implementation, and this in turn will help to ensure that policies are likely to be most cost-effective. SPOTLIGHT has also considered some of the problems encountered in in community-based interventions which make evaluation difficult and which potentially reduce the effectiveness of the intervention, and has suggested procedural changers which can be taken up by the funding bodies for these interventions, such as two-stage application process to ensure better participation in the design of an intervention by the beneficiaries of the intervention. This is described in the report of the meeting noted above (see here www.worldobesity.org/site_media/uploads/Brief_meeting_report_-_v.2.pdf) and in a special briefing document for health promotion professionals and public health funding agencies (available here www.worldobesity.org/site_media/uploads/Briefing_on_community_interventions.pdf. (4) Societal impact. The SPOTLIGHT project has delivered valuable knowledge that is necessary to promote healthful behaviours of adults in Europe. This will facilitate effective approaches to improve health status, reduce chronic diseases and increase quality of life. SPOTLIGHT has provided useful guidance for health professionals, policy makers and regulatory authorities, local governments, advocacy organisations and funding agencies. The full impact of the results and the recommendations is achieved by the ongoing dissemination to stakeholders (there are continuing activities after the end of the EC-funded period of the project, including the production of scientific papers and presentations at scientific conferences, and the use of social media and newsletters to reach professionals and the public).