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    Perceived weight discrimination linked to physical inactivity

    By Sarah Jackson, on 8 March 2017

    Rises in obesity prevalence over recent decades have corresponded with increasing stigmatisation of, and discrimination against, individuals living with obesity. Weight stigma is often justified on the basis that it might encourage people to lose weight, but a growing evidence base indicates that experiences of weight-related stigmatisation may in fact encourage behaviours that promote obesity.

    A few small studies have indicated that people who face weight stigma are more inclined to avoid physical activity, but none have been able to clearly establish what effect experiencing stigma has on actual exercise behaviour.

    In a new study published today in BMJ Open we explored the relationship between weight discrimination and physical activity. The research involved 5,480 men and women aged 50 years and older taking part in the English Longitudinal Study of Ageing, a large population-based cohort of middle-aged and older adults living in England.

    Overall, one in twenty people said they had been discriminated against because of their weight, ranging from lack of respect or courtesy to being threatened or harassed. Rates of weight discrimination varied considerably according to how overweight a person was, from 0.9% of people with a body mass index (BMI) in the overweight range (25-29.9) to 13.4% of people with obesity (BMI greater than 30).

    Importantly, we found that people who had experienced weight-related discrimination had almost 60% higher odds of being inactive and 30% lower odds of engaging in moderate or vigorous exercise once a week than their peers.

    Interestingly, a person’s BMI in itself did not affect the relationship between weight discrimination and exercise, indicating that people who experience weight-related discrimination are likely to be less physically active, regardless of their weight.

    There could be several reasons for our findings. People who feel stigmatised may be more self-conscious about exercising in front of others for fear they will attract undesirable attention, leading to embarrassment or teasing. They may also begin to believe the negative stereotypes against themselves as lazy and worthless, leaving them wondering why they should bother trying to be active.

    Given the substantial benefits of being physically active for both physical and mental health, interventions that aim to reduce weight bias at a population level – for example through schools, local communities or national campaigns – may have greater impact on health than those that encourage people to lose weight. A Health at Every Size approach may be helpful in encouraging people to develop and maintain healthy habits, including regular physical activity, for the sake of health and wellbeing as opposed to weight control.

     

    Article link:
    Jackson SE, Steptoe A. Association between perceived weight discrimination and physical activity: a population-based study in English middle-aged and older adults. BMJ Open. 2017;7:e014592.
    http://bmjopen.bmj.com/content/7/3/e014592.info

    Weight discrimination is chronically stressful

    By Sarah Jackson, on 18 October 2016

    Stigmatisation of obesity remains one of “the last acceptable forms of prejudice”.  People with obesity are widely stereotyped as lazy, weak willed and personally to blame for their weight by the media, employers, educators, health care professionals, and even their friends and family.

    Facing discrimination can understandably be very stressful in the moment.  Small experiments have shown that asking people to watch a video that stigmatises obesity, or telling them that their body size and shape are unsuitable to take part in a group activity, increases levels of the stress hormone cortisol in their saliva.

    But what wasn’t known until now was whether discrimination has lasting effects on stress levels.  This is important because acute (short-term) stress is a protective, adaptive response whereas chronic stress can have a damaging effect on the body.

    In a new study published last week in Obesity we explored the relationship between weight discrimination and chronic stress.  The research involved 563 men and women with obesity (body mass index ≥30) aged 50 years and older taking part in the English Longitudinal Study of Ageing (ELSA), a large population-based cohort of middle-aged and older adults living in England.

    Rather than measuring levels of cortisol in saliva, which are sensitive to daily fluctuations and short-term factors such as diet, we analysed cortisol levels in hair.  Measuring hair cortisol is a new technique that gives an indication of average levels of cortisol in the body over several months.  Hair grows at approximately 1 cm per month, so the 1 cm of hair nearest to the scalp represents average exposure to cortisol over the last month.

    We found that one in eight people with obesity had experienced discrimination because of their weight, ranging from lack of respect or courtesy to being threatened or harassed.  Among people with severe obesity (BMI ≥40), one in three reported discrimination.

    Importantly, our findings revealed that average levels of cortisol in hair were 33% higher in individuals who had experienced weight discrimination than those who had not.  People who experienced more frequent weight discrimination had higher hair cortisol levels than those who faced less regular discrimination.

    The results of this study provide evidence that weight discrimination is associated with the experience of stress at a biological level.  Because experiencing high levels of cortisol over a prolonged period can have a substantial impact on health and wellbeing, it is likely that weight discrimination contributes to many of the negative psychological and biological consequences of obesity.  In addition, cortisol is known to increase appetite and fat storage, making people who experience weight discrimination more likely to gain weight.

     

    Article link:

    Jackson SE, Kirschbaum C, Steptoe A. Perceived weight discrimination and chronic biochemical stress: A population-based study using cortisol in scalp hair. Obesity. First published ahead of print 14 October 2016. doi:10.1002/oby.21657

    http://onlinelibrary.wiley.com/doi/10.1002/oby.21657/full

    Cancer survivors are more dissatisfied with their sex lives – despite normal levels of sexual activity and function for their age

    By Sarah Jackson, on 17 August 2016

    Cancer survivorship rates are improving dramatically, with half of all people diagnosed with cancer in the UK now expected to survive for at least ten years. Although treatment of the cancer is the primary clinical goal, ensuring the best possible quality of life after treatment is important. Preservation of sexual function is a key component of quality of life, yet remains a commonly reported ‘unmet need’ by cancer survivors. However, sexual function declines with ageing and because the majority of cancers are diagnosed in the over-70s, it was previously unclear whether changes in sexual wellbeing reported by cancer survivors are a result of their disease or a natural by-product of ageing.

    In a new study published today in Cancer we explored differences in sexual activity, function and concerns between cancer survivors and people who had never received a cancer diagnosis. The findings revealed that a diagnosis of cancer does not seem to affect whether or not people have sex, how often they have sex, what they do when they have sex, and (in the case of men) their sexual function.  Compared with women of a similar age, women who had been diagnosed with cancer within the past five years were just as likely to be sexually active, although they were more likely to report problems with arousal.  Following the five years post-diagnosis the only difference was greater dissatisfaction with their sex lives, with 18% of women with a history of cancer reporting dissatisfaction compared to 12% of cancer-free women.  Male cancer survivors did not report any more sexual problems than their age-matched counterparts, but they were more dissatisfied with their sex lives (31% of men with cancer compared to 20% of men with no history of cancer).

    The research involved 2982 men and 3708 women aged 50 years and older taking part in the English Longitudinal Study of Ageing (ELSA), a large population-based cohort of middle-aged and older adults living in England.  Participants reported whether they had ever been diagnosed with cancer, and completed the Sexual Relationships and Activities Questionnaire, a comprehensive measure that includes questions on the frequency of sexual behaviours, problems with sexual activities and function, and concerns and worries about sexual activities, function and relationships.  It is the first study to compare sexual behaviour and concerns between cancer survivors and controls from the same population-based study using a standardised measure.

    The results of this study are generally encouraging in showing that older people with cancer do not experience greater problems with sexual activity or functioning than people of the same age without a history of cancer.  However, with more than one in five men and one in nine women reporting that they were dissatisfied with their sex lives, it is clear that there is a need to identify interventions to enhance sexual health in ageing men and women.  In the meantime, better advice on the normal changes in sexual activity and functioning that occur with ageing could help to address the mismatch between the normal sexual behaviour and lower sexual satisfaction seen in cancer survivors.

     

    Article link:

    Jackson SE, Wardle J, Steptoe A, Fisher A. Sexuality after a cancer diagnosis: a population-based study. Cancer. First published ahead of print 17 August 2016. doi:10.1002/cncr.30263

    http://onlinelibrary.wiley.com/doi/10.1002/cncr.30263/full

    Obese people lose weight following a cancer diagnosis: but is the weight loss intentional?

    By Susanne Meisel, on 9 December 2014

    As I have discussed before, the relationship with cancer and weight is complicated. However, it is not only of interest to find out how weight impacts on cancer development, but also what happens to people’s weight once cancer is diagnosed and how this relates to cancer survival. For example, medication to treat cancer might make people more prone to weight gain. This could be problematic for people who are already overweight or obese before they were diagnosed with cancer, because an unhealthy weight has been linked to a higher chance of a cancer coming back. Alternatively, it is possible that a cancer diagnosis acts as a ‘teachable moment’ which may motivate people to change their lifestyle. This may help to avoid the cancer coming back after treatment.

    Our researchers looked in two large studies, one with people from the UK, and one from the US, at how BMI changed over time in people diagnosed with cancer; and those who stayed cancer-free. Importantly, they also looked at how weight change differed according to people’s weight status before diagnosis, as emerging evidence has indicated that weight loss may improve the prognosis for cancer survivors who are overweight or obese at the point of diagnosis.

    Over a four-year period, there was no difference in weight change between normal weight cancer survivors and normal weight cancer-free individuals in either the UK or the US. However, obese cancer survivors in the UK lost an average of 1.48kg vs. cancer-free obese individuals who lost an average of 0.25kg; and in the US, obese cancer survivors lost an average of 2.35kg in comparison to cancer-free obese participants who gained an average of 0.53kg. These results indicate that being diagnosed with cancer has little impact on weight in individuals who are a healthy weight, but is associated with significant weight loss among those who are obese.

    Given that there was very little weight loss in normal weight cancer survivors vs. those who were obese, these results suggests that obese cancer survivors may have made a conscious effort to lose weight and to keep it off. However, it is also possible that people who were obese were diagnosed with cancer at a later stage (I discussed here why this is often the case), and that their weight loss was due to their cancer being more advanced, or treatment having taken a greater toll on the body. Unfortunately, the researchers had no data on the stage at which cancers were diagnosed, or whether the weight loss they observed was intentional, so we cannot say which of these options is true. It is important to do more research to see how weight loss relates to cancer survival to investigate whether keeping a healthy weight after a cancer diagnosis really has benefits for surviving longer.

    Given that, on the whole, treatment for cancer is getting better, more and more people will survive cancer. Therefore, it is really important to find out what can be done for cancer survivors to improve their quality of life and to ensure that they remain cancer-free.

     

    Reference:

    Jackson SE, Williams K, Steptoe A & Wardle J (2014): The impact of a cancer diagnosis on weight change: findings from prospective, population-based cohorts in the UK and the US, BMC Cancer , 14:926  doi:10.1186/1471-2407-14-926

    http://www.biomedcentral.com/1471-2407/14/926/abstract

    Maintaining health literacy through being web-savvy and socially active

    By Lindsay C Kobayashi, on 26 November 2014

    Ageing involves many challenges for health and well-being. One under-recognised problem is that of declining literacy skills. While we are familiar with general issues of ageing such as loss of eyesight or physical mobility, what happens to literacy skills during ageing is much less well understood. Literacy is important to health during ageing because literacy is fundamental to managing health. For example, proper taking of medications, understanding what the doctor says, and understanding of written medical information all rely on having adequate literacy. When literacy is used in health contexts such as these, we refer to it as ‘health literacy’. The American Institute of Medicine defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (1). The consequences of low health literacy include poor self-care of chronic disease, unnecessary use of emergency services, low use of preventive health services such as cancer screening, and increased risk of mortality (2–4).
    A consistent body of evidence indicates that health literacy declines during ageing (5–7). This is thought to be caused by the normal ageing-related decline in cognitive abilities such as mental processing speed and memory (5,8). In our study, we were curious to see whether cognitively stimulating activities would help older adults to maintain their health literacy skills, regardless of any cognitive decline they experienced. In particular, we examined whether internet use and engagement in several different types of social activities might help older adults to maintain health literacy. We used data from almost 4500 men and women aged 52 years and over in the English Longitudinal Study of Ageing (ELSA). The ELSA is a population-representative longitudinal study of English adults aged 50 and over, which aims to capture the experience of ageing in England. Since 2002, the study participants have been interviewed every two years about their health, economic, and social conditions. Data on health literacy was measured in 2004 and again in 2010 using a basic reading comprehension test of a medicine label.
    At the start of the study, we found that nearly one-third of adults had low health literacy, and that 18% of the study sample experienced a decline in their health literacy skills during the study follow-up period (9). People who were most at risk of declining health literacy were older, had no educational qualifications, had relatively low wealth, were ethnic minorities, and had difficulties with activities of daily living. On the positive side, consistent internet use over the six year study follow up period and engagement in cultural activities such as attending the opera, theatre, art galleries, museums, concerts, or the cinema appeared to protect against health literacy decline (9). The other types of social activities that we looked at were civic activities including being a member of a trade union, environmental group, neighbourhood group, and volunteering, and leisure activities including being a member of a sport or social club, or attending educational or musical classes. Alone, participating in civic or leisure activities had no effect on health literacy during ageing.
    When we looked at the combined effects of engaging in none, one, two, three, or four of internet use and each of civic, leisure, and cultural activities, we saw an additive effect where the more activities adults engaged in, the more likely they were to maintain health literacy skills (9). People who engaged in all four of internet use, civic activities, leisure activities, and cultural activities over the study follow-up period had half the odds of losing health literacy skills as people engaged in none of these activities. Importantly, all of these associations were independent of cognitive decline and other factors that might influence internet use and social activities such as wealth, social class, and health status.
    What does this study mean? Well, first of all, that it is not inevitable that older people lose literacy skills as they age. It appears that internet use and social activities help with the maintenance of literacy skills. Even adults who experienced cognitive decline appeared to gain a benefit from using the internet and engaging in cultural activities. However, the main concerns are social inequalities in access to the internet and that cultural activities require time, money, and transportation. Older adults who are in poor health, have low wealth, and are from deprived backgrounds are the least likely to take advantage of the internet and to participate in cultural activities. They are also the most vulnerable to the loss of literacy skills as they age. Future research is needed to improve our understanding of how internet use and social engagement promote literacy skills, and to develop strategies to enable the most vulnerable individuals to benefit from technological advances and full participation in society.

    Article reference: Kobayashi LC, Wardle J, von Wagner C. Internet use, social engagement and health literacy decline during ageing in a longitudinal cohort of older English adults. J Epidemiol Community Health 2014;epub ahead of print. doi: 10.1136/jech-2014-204733

     

    Blog references:
    1. Institute of Medicine. What is health literacy? In: Nielsen-Bohlman L, Panzer A, Hamlin B, Kindig D, editors. Health literacy: a prescription to end confusion. Washington D.C.: National Academies Press; 2004:31-58.
    2. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155:97–107.
    3. Kobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: Evidence from the English Longitudinal Study of Ageing. Prev Med 2014;61:100–5.
    4. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ 2012;344:e1602.
    5. Wolf MS, Curtis LM, Wilson EAH, Revelle W, Waite KR, Smith SG, et al. Literacy, cognitive function, and health: results of the LitCog study. J Gen Intern Med 2012;27(10):1300–7.
    6. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med 2005;20(2):175–84.
    7. Gazmararian JA, Baker DW, Williams M V, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281(6):545–51.
    8. Federman AD, Sano M, Wolf MS, Siu AL, Halm EA. Health literacy and cognitive performance in older adults. J Am Geriatr Soc 2009;57(8):1475–80.
    9. Kobayashi LC, Wardle J, von Wagner C. Internet use, social engagement and health literacy decline during ageing in a longitudinal cohort of older English adults. J Epidemiol Community Health 2014;epub ahead of print. doi: 10.1136/jech-2014-204733

    To achieve weight loss, fat shaming is not the answer

    By Susanne Meisel, on 11 September 2014

    Negative attitudes towards obese individuals therefore remain one of the ‘last socially acceptable forms of prejudice’ . One has only to glance at the ‘comments’ section of media reports discussing obesity to realise that obese people are openly subjected to labelling and stereotyping, and some outright abusive attacks. Unfortunately, stereotypes of the overweight and obese are held across all segments of society, including those working in health and social care .

    Despite solid evidence (and frequent discussion on this blog) showing conclusively that whole host of factors contribute to excessive weight gain,currently, responsibility for maintaining a healthy weight rests solely with the individual. Therefore, people may think that stigmatising those who ‘refuse’ to conform to the ‘societal imperative’ is justified . Some may go even further and claim that stigmatising overweight and obese people would encourage them to lose weight. However, when our researchers looked at the scientific literature surrounding stigma and weight loss, there was little evidence showing whether this was actually true.

    To find out whether weight and the experience of stigma are related in some way, researchers from our department looked at data from 2,944 UK adults over four years who participated in the English Longitudinal Study of Ageing (ELSA), a study of adults aged 50 or older. Participants are weighed and measured every four years, and asked questions on a range of topics every two years.

    To assess stigma, participants were asked how often they encounter five discriminatory situations: ‘In your day-to-day life, how often have any of the following things happened to you: 1) You are treated with less respect or courtesy; 2) you receive poorer service than other people in restaurants and stores; 3) people act as if they think you are not clever; 4) you are threatened or harassed; 5) you receive poorer service or treatment than other people from doctors or hospitals. Responses ranged from ‘never’ to ‘almost every day’. Participants who reported discrimination in any of the situations were asked to indicate the reason(s) they attributed their experience to from a list of options including weight, age, gender, and race. The researchers considered participants who attributed experiences of discrimination to their weight as cases of perceived weight discrimination. Because many participants reported never experiencing discrimination, the researchers divided responses to indicate whether or not respondents had ever experienced discrimination in any domain (never vs. all other options).

    Of the 2,944 eligible participants in the study, 5% reported weight discrimination. This ranged from less than 1% of those in the ‘normal weight’ category to 36% of those classified as ‘‘morbidly obese’. Men and women reported similar levels of weight discrimination.

    However, those who reported experiencing weight discrimination gained more weight than those who did not over the 4-year period. On average, after taking baseline differences in BMI, gender, age and personal wealth into account, people who reported weight discrimination gained 0.95kg whereas those who did not lost 0.71kg, a difference of 1.66kg.

    However, because this study looked only at the relationship of perceived stigma and weight gain, we cannot conclude that stigma caused weight gain – it could also be that weight gain increased perceived stigma, or that a third factor influenced both weight gain and stigma. To conclusively establish whether stigma indeed causes weight gain, we would have to run a controlled experiment with at least two groups of similarly overweight people, where one group is subjected to stigma over a period of time, and the other one is not, and then measure their weight at the end of the study. Of course, such an experiment would be highly unethical, given the damaging effects of stigma on psychological health. Another limitation of this study was that discrimination was assessed two years after the initial weight measurements and two years before the final measurements, although the researchers controlled statistically for this.

    However, regardless of its limitations, this study showed that weight discrimination is definitely not associated with weight loss. This means that there was no evidence for the idea that stigmatising overweight and obese individuals would motivate them to lose weight. in many cases, it may even hinder weight loss. Therefore, we should work towards removing prejudice and blame from weight loss advice and should focus on positively supporting those who are trying to lose weight. One way may be to teach active coping strategies and increasing acceptance-based elements into weight loss programmes because this has had some promising effects. Furthermore, we will need to continue highlighting the complex causes of obesity rather than relying on simplistic representations, and increase work to acknowledge and address weight-related stigma, to make the ‘last socially acceptable form of prejudice’ unacceptable.

     

    Article link:

    Jackson, S. E., Beeken, R. J., & Wardle, J. (2014). Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity, n/a.  http://onlinelibrary.wiley.com/doi/10.1002/oby.20891/full

     

    The darker side of weight loss – why it is important to pay attention to mood changes when losing weight

    By Susanne Meisel, on 7 August 2014

    The increasing prevalence of weight-related diseases have led health organisations world-wide to advise overweight and obese people to lose weight.  Indeed, the notion that weight loss is generally ‘a Good Thing’ for people who are overweight (BMI 25-30) or obese (BMI ≥30) seems to have been taken on board by the wider society.  Rightly or wrongly, magazines are full of stories, tips and tricks on how to achieve the ‘perfect’ weight, and the diet industry’s worth is estimated to be several billion pounds.   In a recent study of over 9000 overweight and obese adults, over 60% reported that they were ‘trying to lose weight’.

    Undoubtedly, even losing relatively small amounts of weight (5% of body weight) will reduce the risk of many obesity-related conditions and diseases, most notably, diabetes, heart disease and stroke.  There are also many reports that weight loss has psychological benefits.  Most commonly, people said that they had improved energy levels, and felt less depressed after losing weight.

    However, when researchers from our department looked more closely at the evidence for improvements in depression, it became clear that most of these reports came from people in weight loss trials.  Interestingly, mood improvements often occurred before any weight was lost in these studies, and were not related to the actual amount of weight lost.  This suggests that factors other than weight loss per se may have been responsible for the reported mood improvements.  One explanation is that personal contact (which is a central part of most weight loss trials) may have been responsible for people feeling less depressed by providing support during the weight loss process.  Furthermore, it is likely that people who take part in weight loss trials are very different from the ‘average’ weight loser in the population, so we cannot say that findings from trials will also be true for most people in the UK.

    When our researchers looked for studies that used big samples that were representative of the population, they found results from only two studies, the Health and Retirement study, and the Health ABC study.  Curiously, both of these reported slight increases in depressive symptoms in people who lost weight.  However, because these studies also included healthy weight people, and did not look at whether people wanted to lose weight, or lost weight because they got ill during the study period or had significant stress in their lives (which is often related to both weight loss and depression) it was difficult to determine what the reason behind this puzzling finding was.

    Therefore, our researchers set out to explore the relationship between weight loss and depressed mood in the English Longitudinal Study of Ageing (ELSA), a large cohort, representative of the UK population that has been going on for over 12 years.  The good thing about ELSA is that it includes lots of measures on all sorts of topics, so that it is very unlikely that people take part because they feel strongly about a certain issue, and it weighs and measures all of its participants every four years so does not rely on self-reported data.

    For this particular analysis, the researchers decided to only look at overweight and obese people because these are the people who might be advised to lose weight; a sample of 1979 people.  They also used data telling them about participants’ intention to lose weight, their mood (using an established scale for depressive symptoms), any life stressors or illnesses that occurred during the study period, and blood pressure and triglyceride levels (which were used to check that people benefitted physically from weight loss in the expected way).

    The results showed that people derived typical physical benefits from weight loss, with blood pressure and blood test results improving over a period of four years.  However, just like in the other two studies, our researchers found that overweight and obese people who lost at least 5% of their body weight (which is recommended) over four years were nearly twice as likely to be depressed than people who were weight stable, even when taking life stress and onset of illness into account.

    However, this study was not able to determine cause and effect, so it is impossible to say whether weight loss caused depressed mood, or whether depressed mood caused weight loss or a third factor that was not measured caused both weight loss and depression.  It is important to investigate these findings further in order to establish why these results were observed, and why they differ so greatly from those reported in weight loss trials; especially since there are so few other studies out there at the moment that could hint at an explanation.

    People often think that losing weight will make them happier, but these findings suggest that weight loss may not always be a positive experience.  In fact, the psychological ‘costs’ of weight loss might explain why many who do successfully lose weight struggle to keep the weight off in the long term.  However, this is not to say that people should not attempt to lose weight – after all, people in the study got physically healthier.  Rather, it seems important that service providers are mindful of the possibility that weight loss may worsen mood, and to perhaps include an assessment of mood in their weight loss programmes.  It may also be sensible for anyone trying to lose weight to be aware of any on-going mood changes and to seek psychological support from health professionals or even friends and family if they begin to struggle.

    Article reference:

    Psychological Changes following Weight Loss in Overweight and Obese Adults: A Prospective Cohort Study

    Jackson SE, Steptoe A, Beeken RJ, Kivimaki M, Wardle J (2014) Psychological Changes following Weight Loss in Overweight and Obese Adults: A Prospective Cohort Study. PLoS ONE 9(8): e104552. doi: 10.1371/journal.pone.0104552