Cancer and Lifestyle Factors

Cancer Institute NSW Monograph

Cancer and Lifestyle Factors

Trish Cotter, Donna Perez, Anita Dessaix, Deborah Baker, Michael Murphy, Jennifer Crawford, Julie Denney, James F Bishop

December 2007

Cancer Institute NSW catalogue number: PM-2007-01 National Library of Australia Cataloguing–in–Publication data: Cancer and Lifestyle Factors SHPN (CI) 070189 ISBN 9781741871357 Key words: Cancer, Lifestyle, New South Wales, Australia.

Suggested citation: Cotter T, Perez D, Dessaix A, Baker D, Murphy M, Crawford J, Denney J, Bishop JF. Cancer and Lifestyle Factors. Sydney: Cancer Institute NSW, December 2007. Published by the Cancer Institute NSW, December 2007.

Cancer Institute NSW Level 1, Biomedical Building Australian Technology Park EVELEIGH NSW 2015 PO Box 41 Alexandria NSW 1435 Telephone

(02) 8374 5600

Facsimile

(02) 8374 5700

E–mail

[email protected]

Homepage

www.cancerinstitute.org.au

Copyright © Cancer Institute NSW December 2007. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the Cancer Institute NSW.

CONTENTS Foreword from the Minister

2

Introduction

3

SECTION ONE: OVERVIEW OF THE EVIDENCE

5

SECTION TWO: QUANTITATIVE RESEARCH LIFESTYLE AND CANCER SURVEY NOVEMBER 2006

11

Objectives

12

Executive Summary

13

Research Design

16

Conduct of Quantitative Research

17

Sample Characteristics

18

Research Findings

22

Fruit and Vegetables

29

Fat and Other

36

Overweight and Obesity

40

Alcohol

45

Skin Cancer

49

Conclusions

54

SECTION THREE: QUALITATIVE RESEARCH PHYSICAL ACTIVITY AND CANCER FEBRUARY–MARCH 2007

55

Executive Summary

56

Summary of Key Findings

57

Introduction

62

Detailed Findings

65

Physical Activity

69

Motivators to Achieving Ideals

78

Body Size and Weight

82

Food, Diet and Nutrition

90

Response to Statements

94

Conclusions

100

Topics for further research

103

Index

104

1


Foreword from the Minister The NSW Government understands that if we are to reduce the number of people affected by cancer in the future, we must invest in promoting healthy behaviours in our community today. In both the NSW State Plan and the NSW Cancer Plan 2007–2010, the Government has committed to making prevention a key element of our health strategy. A number of behaviours are known to significantly reduce the risk of cancer and other chronic diseases. They include not smoking; eating a balanced diet rich in fresh fruit and vegetables; drinking alcohol in moderation if at all; maintaining an appropriate weight through suitable and regular exercise; and adopting sun protection measures. This year the Government is investing a record amount in tobacco control measures, including a suite of new media campaigns that have attracted international attention for their boldness and impact. We have worked with stakeholders to improve our messages around diet. And we have launched a major new initiative to challenge the old Australian myth that a tan is healthy. The benefits of this work will take time to show up in our cancer statistics. It is therefore important that we have interim data to evaluate how well our messages are getting through and in what new areas our efforts need to be concentrated. This monograph presents the background and key baseline measures that will enable the Government, and the many nongovernment agencies concerned by these issues, to undertake that evaluation. I commend this report to you.

The Hon. Verity Firth MP Minister for Women Minister for Science and Medical Research Minister Assisting the Minister Health (Cancer) Minister Assisting the Minister for Climate Change, Environment and Water (Environment)

2

Introduction Global estimates of the causes of cancer and behavioural risk factors put smoking, alcohol use, and poor diet leading to increased weight and obesity as the most important causes of cancer in high-income countries, with smoking by far the most important.1 By modifying these lifestyle factors we have the potential to significantly reduce the incidence of cancer, the burden on the health system and importantly, the health burden on individuals and their families. However, it takes time to modify cancer risk factors and behaviours such as smoking, sun exposure, poor diet, excess body weight and obesity, alcohol consumption and physical inactivity. Cancer is often the last disease to see the results of behaviour change due to a lag in cause and effect. These risk factors are also causes of other diseases such as cardiovascular disease and diabetes. Thus, successful cancer prevention initiatives can show early gains elsewhere in the health system and in the general community.i Australia has one of the highest rates of overweight and obesity in the world, second only to the United States. There is evidence for a substantial risk reduction of some cancers, such as breast and colon cancer, by limiting weight gain during adult life and promoting regular physical activity.2 However, preventing weight gain and increasing physical activity in individuals, and in a population, presents a formidable challenge for future work. What people eat and how active or inactive they are is influenced by a plethora of social, cultural, structural, environmental and economic factors. While the body of scientific evidence for preventing weight gain and promoting physical activity is growing, there is still only limited knowledge of the likely effectiveness of different types of interventions. Most interventions for weight gain prevention or for promotion of physical activity have shown only modest changes that usually were not well maintained over time after the intensive intervention phase. In line with the agenda for cancer prevention set out in the New South Wales Cancer Plan 2007–2010, the Cancer Institute NSW has embarked upon a research program to: •

Inform and understand the evidence around lifestyle factors (excluding tobacco) and cancer. We have therefore conducted a desktop review of the current thinking in relation to the evidence around these connections. In doing so we have relied heavily on international expertise in this area, particularly the World Cancer Research Fund, the International Agency for Research on Cancer and the World Health Organization. The outcome of the evidence review is presented in Section One.

•

Understand the behaviour, knowledge and attitudes of the population in regard to lifestyle factors which influence the individual’s cancer risk. In order to do this, the Cancer Institute NSW conducted its first Lifestyle and Cancer Survey in November 2006. The results of this research are presented in Section Two and include behavioural measures reported in the NSW Health Survey as a reference.

i

We have excluded detailed analysis of tobacco issues from this report as it will be the subject of subsequent monographs in this series.

3


•

Gain insights into individuals’ awareness, attitudes and beliefs toward physical activity, overweight and obesity, cancer and diet which is required to design behavioural change strategies. In March 2007, the Cancer Institute NSW commissioned extensive exploratory research to explore the opportunities for program development arising from the evidence review and the Lifestyle and Cancer Survey. The results of this research are presented in Section Three. From this research, the two areas for action, with the strongest evidence for cancer prevention, were physical activity and preventing weight gain in adults.

TRISH COTTER DIRECTOR CANCER PREVENTION, CANCER INSTITUTE NSW

JAMES F BISHOP MD MMed MBBS FRACP FRCPA CHIEF CANCER OFFICER CEO, CANCER INSTITUTE NSW

4

SECTION ONE: OVERVIEW OF THE EVIDENCE

TRISH COTTER1 ANITA DESSAIX1

1

Cancer Institute NSW

5


Overview of the evidence Lifestyle factors such as physical inactivity, excess body weight, fruit and vegetable consumption and fat consumption are all inter-related and influence cancer risk.

Overweight and Obesity In recent decades, the number of Australians who are overweight or obese has continued to increase in both adults and children.3 The replacement of traditional micronutrientrich foods by heavily marketed, sugar-sweetened beverages and energy-dense fatty, salty and sugary foods coupled with increased sedentary behaviour is associated with the rising prevalence of obesity.4

In 2006, half of adults in NSW were overweight or obese.

In Australia in 2004, it was estimated that about two-thirds of adult males and just under half of adult females were overweight or obese based on calculations of body mass index (BMI). 5 The prevalence of overweight and obesity in Australian children and adolescents has doubled in the past 15 years, and it is estimated that around a quarter of children and adolescents are now overweight or obese. Many of these children will go on to become overweight or obese adults.6 Childhood obesity is an important predictor of adult obesity, regardless of whether the parents are obese. However, parental obesity more than doubles the risk of adult obesity among both obese and non-obese children less than 10 years of age.6 In 2006, half of NSW adults were overweight or obese, with more men (57.4%) than women (43.3%) reporting being overweight or obese.

6

Compared with the overall male population, a higher proportion of men aged 35–74 years (62.5% to 66.2%) were overweight or obese compared with the overall adult male population. Among women, a higher proportion of women aged 45–74 years (46.5% to 56.4%) were overweight or obese compared with the overall adult female population. However, overweight and obesity rises sharply for both NSW men and women from the age of 25.7 In the ten years between 1990 and 2000 mean BMI for NSW ‘Generation X’ men (born 1966–1970) rose dramatically from 23.5 (within healthy range) to 26 (overweight), significantly faster than other generations and certainly above average weight gain with age. These results are similar among Generation X women. It is estimated that if these trends continue that by 2010 Generation X will have the highest BMI of any generation.8, 9 These results indicate a potential increased risk for the children of Generation X becoming overweight or obese adults. It is forecast that by 2010, if trends continue, the majority of Australian adult men and women will be in the overweight range (BMI 25–30), well above our target BMI of 21.8–10 There is sufficient evidence that avoidance of weight gain can be preventive for cancer of the colon, breast (post-menopausal), endometrium, kidney (renal-cell) and oesophagus (adenocarcinoma).2

Physical Activity Physical inactivity is closely linked to overweight and obesity and is thus associated with some of the most common cancers. It is estimated that excess body weight and physical inactivity account for approximately one-fourth to one-third of breast cancers (post-menopausal) and cancers of the colon, endometrium, kidney and oesophagus.2 Furthermore, there is sufficient evidence to conclude that regular physical activity, independent of BMI, reduces the risk of breast and colon cancer. There is also limited evidence that it reduces the risk of endometrial cancer. 2, 12

In 2004, on an incidence basis, prostate (16%), colorectal (13%) and breast cancer (12%) were the three most common cancers in NSW, while kidney cancer and uterine cancer made up 3% and 4% respectively of new cancers.13 Between 1995 and 2004, incidence of localised kidney cancer rose by 37% in males and 55% in females and there was a 19% increase in cancers of the oesophagus among men.13 Australian Physical Activity Guidelines for Adults recommend at least 30 minutes of moderate-intensity physical activity everyday to enhance health.14 For both breast cancer and colon cancer, it is estimated that risk reduction begins at levels of 30–60 minutes a day of moderate to vigorous physical activity (in addition to usual daily activities).2,12 The Cancer Institute NSW recommends a minimum of 30 minutes of moderate physical activity daily and working up toward 60 minutes.15 Greater intensity, duration (both occasion and over lifetime) and frequency of physical activity, results in greater benefit in colon and breast cancer risk reduction.2 The NSW Health Survey reports adequate levels of physical activity; meaning 150 minutes per week on five separate occasions, which is comparable to the Australian Physical Activity Guidelines for Adults. In 2006 just over half (54.9%) of NSW adults reported an adequate level of physical activity. A significantly higher proportion of males (60.4%) than females (49.6%) undertook adequate physical activity.7

Diet The majority of Australians have access to a wide range of nutritious foods that are considered appropriate to meet their health needs. However, large sections of the population are not consuming adequate amounts of fruit and vegetables. The National Health and Medical Research Council (NHMRC) guidelines recommend that adults consume at least two serves of fruit and five serves of vegetables a day.11

In 2006, around half (53.4%) of NSW adults reported consuming the minimum recommended daily fruit intake of two serves, and only 9.4% of NSW adults reporting eating the minimum recommended daily intake of five serves of vegetables.7 In Australia the health care cost of colorectal, breast, lung and prostate cancer, due to low vegetable consumption (< four serves a day), is estimated to be around $58.9m a year.16 Low vegetable intake accounts for 17% of the health cost for colorectal cancer.16 Furthermore, it has been estimated that increasing average vegetable consumption by one serving per day could save $24.4m a year from the cost of colorectal, breast, lung and prostate cancers.16 In 2003, low fruit and vegetable consumption was responsible for 2.1% of the total burden of disease and injury in Australia. Of this, 14% of the burden from low fruit and vegetable consumption was due to cancer.17

Alcohol National guidelines for the consumption of alcohol published by the NHMRC is no more than an average of four standard drinks (10g alcohol/ standard drink) a day for men and two for women, with at least one alcohol-free day a week (at May 2007 these guidelines were under review).18 In 2006, just under one-third of adults (32.8%) reported any risk drinking behaviour. This was significantly higher for males (37.3%) than females (28.4%).7 Alcohol has been classified as carcinogenic to humans19 and is known to cause cancers of the upper aero-digestive tract (oral cavity, pharynx, larynx, and esophageus).

In 2006, just under one-third of adults (32.8%) reported any risk drinking behaviour.

7


Furthermore, the interaction of alcohol and smoking seems to be multiplicative for risk of these cancers. Alcohol consumption also increases the risk of liver, breast and colorectal cancers. For breast cancer, a daily consumption of 18g – less than two standard drinks – is sufficient for a statistically significant increase in relative risk.19 Although alcohol has some protective effect in cardiovascular disease, its harms appear to outweigh its benefits with alcohol contributing 3.2% to total disease burden in Australia in 2003 and preventing 0.9% of the total burden.17 From a cancer perspective, the Cancer Institute NSW recommends that alcohol consumption be limited, if consumed at all.15

Melanoma of the skin is the fourth most common cancer in NSW.

Sun Exposure Unlike many other countries, most people living in Australia are at high risk of developing melanoma due in part to Australia’s close proximity to the equator resulting in higher levels of ultraviolet radiation (UVR). But lifestyle and personal factors also contribute to skin cancer risk. 21–25 Certain skin types are more susceptible to UV radiation, including people who are light-skinned who always or usually burn and rarely or never tan.

8

High-risk populations have light skin pigmentation, light or red hair colour, blue eye colour and can have a large number of freckles or moles. Risk is also increased with previous personal history or family history of skin cancer, especially melanoma.25 Whether a person spent their childhood in Australia (including migration to Australia as a child), particularly the first 15 years, contributes to their risk. Incidence of skin cancer in populations increases with increasing proximity to the equator, furthermore much of a person’s UVR exposure occurs in the first 10 years of life.26, 27 Both pattern and duration of UVR exposure contribute to risk of skin cancer, this includes: regular exposure, increasing frequency of exposure over lifetime and intermittent but high exposure to UVR.27 A history of sunburn to the skin increases risks of basal cell carcinoma, squamous cell carcinoma and melanoma. 27 Melanoma of the skin is the fourth most common cancer in NSW. Over exposure to UVR from the sun with sunburn can lead to melanoma and other skin cancers in the long term. Overall, melanoma represents 10.2% of all cancers in males and 9.7% of those in females.13 From 1995 to 2004, the age-standardised incidence rates of melanoma of the skin rose by 18% in males and 21% in females. Melanoma was the most common cancer in males aged 25–54 and females 15–29. Males were 1.5 times more likely to be diagnosed with melanoma and 3.3 times more likely to die from melanoma when compared with females. Five-year survival from melanoma post diagnosis is 88% for males and 93% for females. Melanoma incidence and mortality rates were highest among residents of the North Coast area as well as males residing in Northern Sydney and Central Coast and females in the Hunter and New England area. Incidence rates of melanoma were highest among people of higher socio-economic status whereas mortality rates due to melanoma were highest amongst people of lower socio-economic status.13

Skin cancer is highly preventable. All people, but particularly those at increased risk, should practice sun safe behaviour by practicing the following: •

Avoid the sun in the four-hour period around midday, 11am to 3pm (during daylight savings).

And when outdoors: •

Wear a broad-brimmed hat

•

Wear protective clothing

•

Wear sunglasses

•

Use a broad spectrum waterproof sunscreen SPF30+ (reapply every two hours).15, 22

Survival from bladder cancer was better in males than females, declined with age & spread of cancer at diagnosis.

9


References

10

1

Danaei, G., Vander Hoorn, S., .Lopez, A.D., Murray, D.J.L., and Ezzati, M. Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. The Lancet 2005 Nov 19;366:1784-93.

2

International Agency for Research on Cancer. Weight Control and Physical Activity. Lyon, France: IARC Press; 2002.

3

National Health and Medical Research Council. Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents. Commonwealth of Australia; 2006.

4

World Health Organization. Population nutrient intake goals for preventing diet-related chronic diseases. World Health Organisation 2006 [cited 2006 Aug 23];Available from: URL: www.who.int/nutrition/topics/5_population_nutrient/en/print.html

5

Australian Bureau of Statistics. National Health Survey 2004-05: Summary of Results. 2006.

6

Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K.D. and Deitz, W.H. Predicting Obesity in Young Adulthood from Childhood and Parental Obesity. The New England Journal of Medicine 2006;337:869-73.

7

Centre for Epidemiology and Research. 2006 Report on Adult Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health; 2007.

8

Allman-Farinelli, M., King, L., Bonfiglioli, C. and Bauman, A. The weight of time: Time influences on overweight and obesity in men. NSW Centre for Overweight and Obesity; 2006.

9

Allman-Farinelli, M., King, L., Bonfiglioli, C. and Bauman, A. The weight of time: Time influences on overweight and obesity in women. NSW Centre for Overweight and Obesity; 2006.

10

Obesity: Preventing and Managing the Global Epidemic, Report of a WHO Consultation. World Health Organization; 2000.

11

National Health and Medical Research Council. Dietary Guidelines for Australian Adults. Canberra; 2006.

12

World Cancer Research Fund and the American Institute for Cancer Research. Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective. Washington, DC; AICR; 2007.

13

Tracey, E.A., Chen, S., Baker, D., Bishop, J. and Jelfs, P. Cancer in New South Wales: Incidence and Mortality 2004. Sydney: Cancer Institute NSW; 2006.

14

Australian Government. National Physical Activity Guidelines for Adults. Canberra: Department of Health & Aged Care; 1999 May.

15

The Cancer Prevention Plan. Sydney: Cancer Institute NSW; 2007.

16

Marks, C.G., Pang, G., Coyne, T. and Picton, P. Cancer Costs in Australia - The potential impact of dietary change. Australian Food and Nutrition Monitoring Unit., editor. 2006. Canberra, Commonwealth Department of Health and Aged Care. Ref Type: Generic.

17

Begg, S., Vos, T., Barker, B., Stevenson, C., Stanley, L. and Lopez, A.D. The burden of disease and injury in Australia, 2003. AIHW Cat.No.PHE 82 . 2007. Canberra, Australian Institute of Health and Welfare.

18

National Health and Medical Research Council. Australian Alcohol Guidelines: Health Risks and Benefi ts. Canberra: Commonwealth of Australia; 2001 Oct.

19

International Agency for Research on Cancer. Monograph Vol 96. Alcoholic Beverage Consumption and Ethyl Carbamate (Urethane). February 2007.

20

International Agency for Research on Cancer & World Health Organization. Sunscreens. Lyon: International Agency for Research on Cancer; 2001.

21

World Health Organization. Protection Against Exposure to Ultraviolet Radiation. 1994.

22

World Health Organization. Artificial tanning sunbeds: risks and guidance. 2003.

23

Lucas, R., McMichael, T., Smith, W. and Armstrong, B. Solar Ultraviolet Radiation: Global burden of disease from solar ultraviolet radiation. Geneva: World Health Organization; 2006.

24

Elwood, J.M. Who gets skin cancer: individual risk factors. In: David Hill, J. Mark Elwood, Dallas R. English, editors. Prevention of Skin Cancer. Netherlands: Kluwer Academic Publishers; 2004. p. 3-20.

25

Geis, P., Roy, C. and Udelhofen, P. Solar and ultraviolet radiation. In: David Hill, J. Mark Elwood, Dallas R. English, editors. Prevention of Skin Cancer. Netherlands: Kluwer Academic Publishers; 2004. p. 21-54.

26

Armstrong, P. How sun exposure causes skin cancer. In: David Hill, J. Mark Elwood, Dallas R. English, editors. Prevention of Skin Cancer. Netherlands: Kluwer Academic Publishers; 2004. p. 89-116.

SECTION TWO: QUANTITATIVE RESEARCH LIFESTYLE AND CANCER SURVEY NOVEMBER 2006

DONNA PEREZ1 TRISH COTTER1 ANITA DESSAIX1 DEBORAH BAKER1 JENNY CRAWFORD2 JULIE DENNEY2 JAMES F BISHOP1

1 2

Cancer Institute NSW Eureka Strategic Research, Newtown, NSW

11


Objectives The objectives of quantitative research were to broaden understanding and measure behaviours, intentions, knowledge and attitudes with respect to the following areas: • physical activity •

fruit and vegetable consumption

•

fat consumption

•

overweight/obesity

•

alcohol consumption

•

sun protection (skin cancer). i

Specifically, the research sought to: • measure fruit and vegetable consumption, fat and alcohol consumption, physical activity levels, Body Mass Index, and sun protection behaviours •

measure awareness of the recommended levels of fruit and vegetable consumption, the recommendations for physical activity, perceptions of an acceptable weight range for one’s height, and beliefs regarding acceptable alcohol consumption

•

investigate the motivations and barriers relating to each of the lifestyle factors

•

measure knowledge regarding the health consequences (particularly cancer) of low levels of fruit and vegetable consumption and physical activity, high rates of overweight/obesity, and high rates of fat and alcohol consumption, as well as the consequences of UV

•

gain an understanding of attitudes towards fruit and vegetable consumption, physical activity, overweight/ obesity, fat and alcohol consumption, and sun protection.

These objectives are illustrated in the diagram at the bottom of the page. The program undertaken to meet the research objectives and explore these issues of interest is outlined in the following section.

Measure lifestyle risk factors related to cancer

Physical activity

Behaviours

i 12

Fruit and vegetable consumption

Awareness of recommended levels

Fat consumption

Overweight/ obesity

Motivators and barriers

Analysis of tobacco use has been excluded from this survey as it is reported elsewhere.

Alcohol consumption

Attitudes

Sun protection (skin cancer)

Knowledge of health consequences

Executive Summary Research context In the NSW Cancer Plan 2007–2010, we emphasise cancer prevention as a key objective of the Cancer Institute NSW. As part of this objective, we commissioned an independent research company (Eureka Strategic Research) to conduct a telephone survey to explore behaviours, knowledge and attitudes with respect to a range of lifestyle factors. The outcomes of this research will establish key baseline measures and allow changes to be monitored over time.

motivation to exercise regularly represents an obstacle for 45% of people. Over two-fifths (42% i) report that finding time is a barrier to exercise. Knowledge of cancer as a potential consequence of inadequate physical activity was poor, with only 30% nominating cancer from a list of possible outcomes.

Fruit and vegetables

Methodology A total of 1,516 adults in NSW were randomly selected to participate in the survey. Using the Cancer Institute NSW’s standard research methodology, a list-assisted Random Digit Dialling (RDD) method was employed. The average interview length was 23.5 minutes, and the fieldwork was conducted from 23 November to 13 December, 2006. The data have been weighted to reflect the age and gender distribution of the NSW population.

Physical activity The median number of times people report taking part in moderate or vigorous physical activity in the past week is three, and the total time spent doing this activity is 1.5 hours. On the basis of the results, it seems current levels of physical activity in NSW appear to be sub-optimal, both in terms of frequency and total duration of exercise. The majority of participants could not accurately report the level of exercise that is recommended. Looking at the total amount of exercise that is implied by participants’ responses, almost half of adults underestimate the total number of hours required each week to maintain good health. Although three-fifths of participants said they intend to do more exercise in the next three months, finding the

The average daily fruit intake was found to be 2.0 serves. Although it is possible that some participants may have counted fruit juice in their calculations (because they were only advised not to if they queried whether fruit juice counted as a serve of fruit ii), the results suggest that the average adult in NSW is eating a healthy amount of fruit. By contrast, consumption of vegetables by adults in NSW is extremely low, at 2.2 serves per day. Fruit and vegetable intake among males is especially poor, with the average fruit intake being 1.8 serves per day, and the corresponding figure for vegetables being 1.9. Consumption of fruit and vegetables was found to be higher for older people than for younger people. Average intake of fruit and vegetables was also greater for people with higher levels of education. While there is a tendency to overestimate the number of serves of fruit required each day (average estimate = 2.6), knowledge of the recommended daily vegetable consumption is poor, with the average estimate being 2.8 serves per day. It is therefore likely that a significant barrier to vegetable intake is a lack of knowledge about the relevant guidelines.

We emphasise cancer prevention as a key objective of the Cancer Institute NSW.

i

Throughout this report, a number of the charts show figures to the nearest whole number. The apparent inconsistency between the charts and the text is a result of rounding. For example, the proportion that agrees with the statement relating to finding time to be physically active is 19.31% + 22.27% = 41.58%, which is 42% to the nearest whole figure.

ii

This was done for comparability with the NSW Population Health Survey, and also to minimise the impact on the subsequent statement about whether fruit juice delivers the same nutritional benefits as eating fruit.

13


In the survey, we found that more than one-fifth believes fruit juice delivers the same nutritional benefits as fruit. Earlier in the survey, when a serve of fruit was defined, those participants who asked whether a serve of fruit included fruit juice, would have been advised that it does not. Accordingly, the proportion of people in the NSW population who believe that drinking fruit juice is an acceptable substitute to eating fruit may be higher than 21%. The cost of fruit and vegetables, and not having the skills to prepare and cook them, each represent a barrier for almost a third of people in NSW. Limited access to fruit and vegetables does not appear to be a widespread barrier. Although slightly higher than awareness of cancer as a possible consequence of physical inactivity, knowledge of a poor diet being a risk factor for cancer was not widespread, with only 52% knowing this. It is also possible that knowledge of inadequate fruit and vegetable intake as a risk factor for cancer is even lower.

Knowledge of a poor diet being a risk factor for cancer was not widespread.

Fat It was found that 41% report usually using regular (i.e., whole or full cream) milk. This is a lower figure than that reported in the 2006 NSW Population Health Survey (47.9%).7

14

Nearly a fifth (19%) of people are eating fried potatoes two or more times per week, and 30% of people are, on average, having two or more serves of processed meats on a weekly basis. Further, only one-quarter (25%) are meeting the recommendation for minimum intake of two serves of wholegrain foods per day. More than one-quarter (28%) admit that they do not know the difference between unhealthy and beneficial fats, and this is likely to hinder these people’s ability to make healthy food choices. Furthermore, one-third agrees they lack the time and energy to prepare low-fat meals.

Overweight and obesity It was found that 58% of males and 37% of females are above a healthy BMI. In addition, people over 30 years old were significantly more likely to be overweight. It appears that most recognise that they are overweight, with 44% of the population indicating that they are above an acceptable weight range for their height. However, among those with a BMI above 25, more than one-quarter (28%) do not see themselves as being overweight. Despite more than two-fifths perceiving themselves as overweight, most did not believe that their current weight is harmful to their health. A key challenge, therefore, is helping people to recognise that it is not just extreme levels of obesity that put people at risk of health problems. It will be important to personalise the message that being overweight can be harmful to one’s health. There is also scope to increase awareness of the potential for excess weight to lead to cancer, as only 35% of adults currently recognise this fact.

Alcohol

Skin cancer

The research results suggest that the average consumption for females for single occasion drinking may be higher than is optimal. Males appear to underestimate single occasion drinking guidelines.

Almost three-fifths report being sunburnt in the past 12 months. More than a quarter say they have been burnt more than three times within the past year. This, coupled with the finding that consistent adoption of sun protection behaviours are currently not widespread, shows there is considerable scope to improve sun protection behaviours, particularly the re-application of sunscreen after two hours. Young people represent an important target audience for sun protection messages, given that they report higher levels of burning during the past 12 months.

More than 30% agree they should be drinking less alcohol. A lower proportion (23%), however, agreed they intend to drink less alcohol in the next three months. The majority (55%) agree that reducing alcohol intake would be good for their health, suggesting that there are a significant number of people who may be open to reducing their alcohol consumption. Given that awareness of cancer as a possible consequence of alcohol consumption is low (41% prompted awareness), this information may represent a persuasive reason for people to change their behaviour. Currently, more than a fifth only sees the relevance of monitoring their alcohol intake in the context of driving.

There is widespread acknowledgement among the respondents of the need to improve their own sun protection behaviours. Looking at the motivations for protecting themselves from the sun, avoiding skin cancer is currently the main one. Given that this risk is currently insufficient to prompt people to protect themselves from the sun in more ways, more often, it is likely that people do not perceive skin cancer as a serious issue, and/or they do not believe it is likely that they themselves are likely to experience a severe case of skin cancer. It is also probable that the desire to tan is a barrier to adopting appropriate protection from the sun, as there is still a reasonable level of agreement with the idea that a suntan is healthy. Around a fifth agree that sun protection is only required at the beach or pool. This suggests that it would be worth increasing the perceived need to adopt comprehensive sun protection in a wider range of outdoor contexts.

Almost three-fifths of participants in the survey report being sunburnt in the past 12 months.

15


Research Design Quantitative methodology Quantitative research was necessary to meet the objectives outlined above, in order to provide robust measurements so that changes over time can be accurately monitored. The survey was conducted over the telephone, using Computer Assisted Telephone Interviewing (CATI).

A sample of approximately 1,000 yields a confidence interval of around ±3.1% for a stand-alone survey, and ±4.4% for comparison between waves of research.

Sample source and participant selection A list-assisted random digit dialling (LA RDD) method was employed, using sample provided by the NSW Population Health Survey program.

Sample size The total sample for this wave of research consisted of 1,516 adults living in NSW. A sample of this size gives a 95% confidence interval of no more than ±2.5% for a stand-alone survey, and ±3.6% for comparison between waves of research. As explained below, each participant was asked four of the six key sections of the questionnaire, with the aim of achieving approximately 1,000 interviews per section.

Quotas were used on The achieved sample sizes for each of the main sections are geographic location, to broadly as follows: ect activity, the NSW •refl Physical n=1,036 population.

16

•

Fruit and vegetables, n=1,036

•

Fat, n=1,053

•

Overweight/obesity, n=1,038

•

Alcohol, n=1,042

•

Skin cancer, n=951.

A random selection procedure was used for selecting participants within households. Multiple attempts were made to contact households and selected individuals. Each household received a minimum of five call attempts. For example, if respondent selection occurred during the first call, at least another four calls would be made to try to speak to the selected respondent. If respondent selection was achieved during the second to fifth call, then at least another three calls would have been attempted in trying to speak to that person.

Quotas Quotas were used on geographic location, to broadly reflect the NSW population. This assisted in achieving a representative sample. During the analysis, the data were weighted to reflect the age and gender composition of the NSW population.

Conduct of Quantitative Research Questionnaire development and pilot testing

Fieldwork period and response rate

The questionnaire was developed in close consultation with the Cancer Institute NSW to ensure that information needs were prioritised and appropriately addressed. Key questions were designed to ensure comparability with other important research conducted within the sector, particularly the NSW Population Health Surveys. All open-ended questions contained pre-coded response frames. We only recorded verbatim when interviewers felt the participant’s response did not fall into any of the categories in the pre-coded response frame.

The fieldwork was conducted between 23 November and 13 December 2006. The Cancer Institute NSW wanted to complete the interviewing prior to Christmas, and before the campaign activity scheduled for early 2007.

A total of 10 qualitative pre-pilot interviews were coducted, with a mix of genders and ages. The qualitative pre-pilot testing phase involved Eureka’s executives interviewing people using the telephone script as a guide. These interviews explored people’s understanding of each of the questions, their feelings about the questions asked and any unintended restrictiveness in the range of questions asked or response options available. Critically, it allowed the researchers to determine whether the questions posed were being interpreted in the manner in which they were intended, and that there was not accidental ambiguity that might not be picked up during a standard piloting phase.

•

Most of the fieldwork was conducted during December, when people are particularly busy and response rates are normally lower.

•

The questionnaire exceeded 20 minutes, which would have reduced people’s propensity to participate.

•

The random selection method meant that several attempts were made to interview the selected individual within the household. It was often not possible to speak to the selected individual within the reasonably short period in which the fieldwork was conducted.

As mentioned previously, the questionnaire included six key topics. To maximise data quality, the order in which these topics were presented to participants was randomised.

Taverner Research, a market and social research company whose telephone interviewing service is accredited to IQCA standards, conducted the fieldwork. The response rate for the survey was 19%.i There are a number of reasons why a low response rate was achieved:

Although it will be important to run subsequent surveys at essentially the same time of the year, it may be advisable to schedule the fieldwork a fortnight earlier, which would help overcome the first of the issues mentioned above.

A key challenge in the design of the questionnaire was to cover a large number of topics, without making the survey too burdensome for respondents. To reduce the average interview length, four of the six key sections were presented at random to any given participant. The average interview length across the sample was 23.5 minutes.

i

A key challenge in the design of the questionnaire was to cover a large number of topics, without making the survey too burdensome for respondents.

The response rate is calculated as the proportion of contacts with a competent person where eligibility to participate was determined (i.e. the respondent cooperated with the survey). The response rate is calculated as: number that cooperated / (number that cooperated + number that refused to cooperate).

17


Sample Characteristics This sub-section reports on the demographic characteristics of the sample. Gender and age As mentioned earlier, a random selection procedure was employed. In the obtained sample, around three-fifths were female (59%), and two-fifths were male (41%). The age profile of the sample is shown in Figure 1. 25 20 20

18 17

17 15

14

% 11 10

5 3

0 18-29

Figure 1

In your thirties

In your forties

In your fifties

In your sixties

In your seventies

80 or over

Age profile of sample.

Despite the fact that a random selection method was used, it is clear that the obtained sample was biased towards females and older participants, which is not uncommon for a survey of this type. Therefore, when conducting the analysis, the data have been weighted to reflect the age and gender distribution of NSW population. Participants were asked how many children under the age of 18 years lived in their household. Over a third (36%) of households included children under the age of 18.

18

Education Participants were asked about the highest level of education they have attained. As shown in Figure 2, more than half have completed some form of tertiary education. 35 31 30

25

%

23

24

20 17 15

10

5 3

2

1

0

0

0

Refused

(Can't say / don't know)

0 No formal schooling

Figure 2

Primary school

Junior high school (years 7-10)

Senior high Tafe/technical school (years college 11-12)

University

Another tertiary instution

Other

Highest level of education attained.

19


Employment status Two-fifths of the sample was engaged in full-time work, while 18% worked part-time or as a casual. Over a quarter of the sample (26%) was retired. The results are shown in Figure 3. 45 40

40

35 30

%

26 25 20

18

15 10

8

5

3

2

4 0

0

Refused


0 Working full- Working part-time or time as a casual

Figure 3

Retired

Student

Home duties Unemployed or looking for work

Other

Employment status.

Annual household income The annual household income for the sample is shown in Figure 4. 20 17

16

16

15

15

%

11

10

10 8

7

5

0 Less than $20,000

Figure 4 20

$20,001$40,000

$40,001$60,000

Annual household income.

$60,001$80,000

$80,001$100,000

More than $100,000

Refused

Don't know

Main language and ATSI In 93% of households surveyed, English was the main language spoken at home. Participants were asked whether they were of Aboriginal or Torres Strait Islander origin, and 2% identified as such.

Smoking Status Less than a fifth (18.4%) of participants said that they smoked tobacco products at all. Of these, the majority were daily smokers, as shown in Figure 5.

90 83 80 70 60

%

50 40 30 20 11 10

5 1

0 Daily

Figure 5

At least once a week

Less often than once a week, but at least once a month

Less often than once a month

Frequency of smoking tobacco products.

21


Research Findings In this section, the health attitudes, knowledge and behaviour of adults living in NSW are detailed. Perceptions of health benefits In the survey, we investigated people’s perceptions regarding the relative health benefits of a number of lifestyle factors. When asked to choose between exercising regularly, eating a healthier diet, stopping smoking, reducing stress and limiting one’s alcohol intake, stopping smoking was seen by 38% of respondents as the factor most likely to improve a person’s health. The next most commonly selected factors were exercising regularly (24%) and eating a healthier diet (24%). Few nominated limiting alcohol intake as the most significant factor. This is illustrated in Figure 6.

50

38

40

% 30 24

24

20

10 10 2

1

0 Exercising regularly

Figure 6

Eating a healthier diet

Stopping smoking

Reducing stress

Limiting alcohol intake


Factors seen as most likely to improve someone’s health.

This question also appears in the annual Smoking and Health Survey conducted on behalf of the Cancer Institute NSW. Although it appears early in that survey, the question is asked after the screening questions, which include questions about the participant’s current smoking status. It is therefore possible that the topic of that survey is, to some extent, indirectly revealed prior to this question. In this way, it is possible that more people would have selected ‘stopping smoking’ than would otherwise have been the case. Therefore, it was decided to include this question in the Lifestyle and Cancer Survey to obtain responses that have not been affected by expectations of the survey topic. Analysing the responses of smokers in the Lifestyle and Cancer Survey, 39% said ‘stopping smoking’. In the 2006 Smoking and Health Survey, 53% of smokers said ‘stopping smoking’. The 2006 Smoking and Health Survey was conducted in March–April. While it is possible that a smaller proportion of smokers in NSW now believe that stopping smoking is the lifestyle change which would be the most likely to improve someone’s health, this is unlikely. Such a large difference between the results of the two surveys does suggest that the screening questions designed to ascertain smoking status have affected the responses to this question in the Smoking and Health Survey. 22

Physical activity Participants were asked about their current physical activity levels and their views on the amount of exercise required for maintaining good health. They were also asked about their motivations for exercising, the consequences of insufficient physical activity, and their attitudes towards exercise generally.

Behaviour Participants were asked about the amount of physical activity done during the last week. The amount of physical activity was measured against the recommendation of 30 minutes five or more days a week. On this basis, overall 67% undertook adequate levels of physical activity. The results are shown in order in Table 1. In the data, there were a number of outliers which affected the mean response.i Hence, the median has also been provided as a more conservative measure of central tendency. The last two lines in Table 1 represent aggregated data (combining the vigorous and moderate categories). The data suggest that, on average, adults in NSW walk for at least 10 minutes on most days of the week. The median total time spent walking, where each time is for at least 10 minutes, was found to be two hours. This includes walking for recreation, exercise, or to get to or from places. It is not clear whether this walking is vigorous.

Table 1

After asking about walking, participants were then asked to indicate how many times in the last week they did any vigorous physical activity that made them breathe harder or puff and pant. The median number of times was 2.0. When asked to estimate the total time spent doing this vigorous physical activity during the last week, the median response was one hour. Following this, information about moderate physical activity was obtained. The average number of times people indicated that they had done moderate physical activity during the last week was 1.4, and the median was 0.0. Similarly, as shown in Table 1, the total time spent doing other moderate physical activity in the last week was found to be very low. As was expected, it appears that most participants have counted their exercise as vigorous, rather than moderate, physical activity. This is no doubt at least partly because participants were asked about vigorous physical activity first, and were not aware that they would subsequently be asked about moderate physical activity. Also, given the definition, ‘vigorous physical activity that made you breathe harder or puff and pant’, it would be reasonable to assume that most people would count any activity that increased their breathing rate as vigorous physical activity. It is also not clear whether participants excluded walking when indicating how often and how much vigorous physical activity they had done last week. The questions were not modified from the NSW Population Health Survey, to allow the results from the two surveys to be compared if required.

Self-reported physical activity in last week.

Number of times walked last week for at least 10 minutes. Total time you spent walking in this way last week (hrs). Number of times did physical activity in the last week. Total time spent doing vigorous physical activity in last week (hrs). Number of times did other moderate physical activity in last week. Total time spent doing other moderate physical activity last week (hrs). Number of times did moderate or vigorous physical activity last week. Total time doing moderate or vigorous physical activity last week (hrs). i

Mean 7.0

Median 5.0

3.6 2.8 2.5 1.4 1.0 4.1 3.4

2.0 2.0 1.0 0.0 0.0 3.0 1.5

It is possible that some people misinterpreted Question 2.1, and rather than saying on how many separate sessions they have walked during the last week, they have provided the total number of minutes they walked. So, for example, there was one person who said they had walked 210 times during the last week. It is probable that this person intended to say that they walked for 210 minutes (i.e. 3.5 hours). Alternatively, some of these outliers may be a result of errors in data entry. Either way, it was felt to be arbitrary to decide which responses may have been inaccurate, so the outliers were not excluded from the analysis.

23


Adding up the number of times people reported doing moderate or vigorous physical activity in the last week, the median was 3.0 times, and the median total time spent doing moderate or vigorous physical activity was 1.5 hours. As mentioned above, one cannot be sure how many participants included walking when indicating how much moderate or vigorous physical activity they have done. Even so, it does appear (on the basis of the totals for moderate and vigorous physical activity) that exercise levels are currently below the recommendation of 30 minutes five–seven days a week, both in terms of frequency and total duration. A number of statistical tests were undertaken, and it was found that: •

Males reported doing more vigorous/moderate exercise than females. The average total amount of moderate and vigorous exercise for males was 4.6 hours, compared to 2.3 hours for females (p25 Admit to being overweight Admit to low activity and BMI>25

Inner Metropolitan Men Women 1 group 1 group

Outer Metropolitan Men Women 1 group 1 group

1 group

1 group

1 group

1 group

1 group

1 group

1 group

1 group

Recordings of the groups were transcribed and the transcripts thematically analysed for preparation of this report.

Recruitment

Analysis & Reporting

Recruitment was conducted by a professional recruitment agency. Participants were paid an incentive according to current market rates. An appropriate screener was developed to assist the recruitment processes.

Recordings of the groups were transcribed and the transcripts thematically analysed for preparation of this report. A selection of quotes has been included in the report. It needs to be noted that the included quotes are for illustration rather than necessarily reflecting the specific attitudes of, and differences between, each demographic group.

Group facilities The groups were conducted in locations that allowed viewing via one-way mirror. All research sessions were recorded for the purposes of analysis.

64

Detailed Findings Health issues of importance To begin each group discussion, participants were asked to nominate the health issues that were most important to them. In assessing responses, it is necessary to acknowledge the context of the research, which was that participants had been asked questions about exercise, weight and smoking during the recruitment process. Hence, they may already have been primed to be thinking about these topics. The issues that were most commonly top of mind included: •

weight loss and weight management

•

diet and eating well

•

activity and exercise, especially doing enough

•

quitting smoking

•

a range of specific illnesses

•

stress and time pressures.

Weight loss was quite obviously top of mind, and linked with participants’ recognition of the current salience of weight as an issue for the entire community, based on its prevalence in the news and entertainment media. Within this, there were some who talked specifically about losing weight as a health issue and others who talked about managing or maintaining weight. The issues of diet and activity were also top of mind, most obviously in the context of weight, but also to a lesser degree as general constructs about being healthy. Interestingly, discussion of the health issues of importance immediately prompted identification and discussion of barriers to health and to adopting healthy behaviours, indicating how important barriers are to people’s perceptions of what they need to be doing to be healthy. In this sense, the barriers were themselves experienced as the health issues.

“All the things you need to do to be healthy require either time, um, pain to your body or giving up something you enjoy. It’s very difficult to do those three things. Giving up the food that you enjoy pleasure in life … or you need to suffer pain in your body doing the exercise. They’re the three things to start off with that stop you from doing it.’”(Male, 25–44) While specific barriers are dealt with in more detail subsequently in this report, the most obvious top-of-mind barrier was time. When asked to describe how time was a barrier, essentially, the issue was related to the difficulties that people experienced in prioritising health among a range of other personal, social, work and family commitments. Specifically, the time issue was experienced by participants in terms of the competing priorities of getting physical activity to the top of their priority list, and making food choices that were about convenience rather than health. Among the younger participants, there was a tendency for health to play a secondary role to a range of personal and social factors that were related to health and health behaviours. Most obviously, participants reported being more motivated by factors associated with the functioning of the body and looks than with health per se. Across the age groups, mental health, at least in the form of well-being and self-esteem was also top-of-mind. “Trying to get buff.” (Male, 18–24) “I don’t want to die young, I don’t want to have heart problems when I’m older and all that sort of stuff but I guess pleasure in life can get in the way of that. Drinking, smoking cigarettes, just living an unhealthy life. Obviously it gets in the way.” (Male, 18–24) “Even though it is healthy, I don’t do it to be healthy.” (Male, 18–24) “Just the busy lifestyle and work and family commitments, you know, just getting time for yourself, basically.” (Male, 25–44) “On the news as well, as how Australia as a nation is becoming more, you know, we’ll have the highest – or having the highest obesity count around the world, catching up to America.” (Female, 18–24)

65


Participants were also prompted to discuss the health issues that they noticed being reported or prompted in the media. Common responses included: • weight loss programs and products • gym memberships • diets and dieting approaches • vitamins and food supplements • television programs (such as The Biggest Loser). Interestingly, The Biggest Loser was raised in almost every group, suggesting that this kind of entertainment is associated in people’s minds with health and health messages because of its focus on weight loss. When discussing programs like The Biggest Loser, it was apparent that, while participants understood how unrealistic it was for a normal person to

The Biggest Loser was raised in almost every group, suggesting that this kind of entertainment is associated with health. have a chef and full-time trainer, the message of the show was that if you were prepared to put in the effort, anyone could lose weight and improve their health. Some acknowledged the lack of reality in this message, while others seemed to be convinced by its general principle.

“I kind of think it is saying that, you know, this is what the perfect body shape should be … and if you don’t have that then you should lose weight.” (Female, 18–24)

66

Knowledge and understanding of health consequences Participants were asked to identify the health issues associated with being overweight or doing insufficient physical activity. Participants’ beliefs appeared to reflect a degree of general knowledge about these issues, and the current prominence of the topics of physical activity and weight management. The common top-of-mind understanding was that being overweight and doing insufficient physical activity were associated with a range of cardiovascular diseases, including high blood pressure, heart attack and high cholesterol, and with diabetes.

“Cardiovascular diseases … that’s the main one you think about.” (Male, 25–44) “Probably diabetes too, because you’re probably eating too much sugar.” (Male, 25–44)

Within this, there was a general belief that the diseases linked with low physical activity were similar to those associated with being overweight. There appeared to be much greater appreciation that there was a direct link between being overweight and diseases, with the association with physical activity being perceived as more of a general health issue than being related to specific diseases. For example, understanding that there was a direct link between diabetes, high cholesterol and being overweight, was much greater than awareness of a direct link between these conditions and physical activity.

Several participants commented that doing enough physical activity resulted in general benefits of feeling good, having sufficient energy and sleeping better. While participants understood that there were direct benefits of feeling good from doing physical activity, they largely attributed these self esteem benefits to the positive impact of physical activity on their body size, that is, they believed they looked better, and on their energy levels.

In this regard, perceptions about the associations between weight and cancer were similar to smokers’ acceptance that smoking was obviously associated with lung cancer, being a disease of the respiratory system, but less obviously with cancers in other systems. The link between physical activity and cancer was even less well known, with the explanation being typically associated with either weight or general well being.

“It’s mental and physical.” (Male, 25–44) “Self-esteem as well.” (Male, 25–44) “You feel lethargic.” (Male, 25–44)

A small number of participants noted that low physical activity was specifically associated with mental health conditions such as depression. A small number of participants had recently heard that being overweight was associated with some forms of cancer, but on the whole, this was new and somewhat surprising information. While participants could easily link weight with the cardio-vascular and digestive systems, and therefore accept the disease relationship in these systems, it was less clear how this could be the case with cancers in other parts of the body. Such a link was relatively easy to accept for bowel cancers, given the association between diet and the digestive system. However, the link was less understood and accepted for other cancers, as participants did not really understand how any causal association could exist. When pressed to explain how this might be the case, participants offered an acknowledgement that poor diet, low levels of activity and being overweight could be associated with generally low levels of health, well being and immunity, and that this might provide the causal link with cancer. These responses suggest that people have a reasonable understanding of general constructs of health and well being, but have insufficient knowledge of disease cause and aetiology for the details to make sense when the associations are not obvious.

“You never heard of it like that, you know, you don’t exercise you’re going to get cancer.” (Male, 25–44) “It’s good to know facts and figures like that, they keep you in line.” (Male, 25–44) “You’re more at risk, basically, just having, I dunno, a worse immune system.” (Female, 18–24) “If you don’t do enough physical activity and, in my case, you’re overweight, you’re body’s not gonna work properly. Like it’s not gonna do its job properly. So, I suppose, I would say that could put you at risk of a lot of things. I don’t know about cancer, but …” (Female, 18–24)

Providing participants with information about the association between weight, activity and cancer prompted considerable amounts of self-exempting beliefs. In essence, there was a common belief that other factors were likely to play a greater role than weight and activity in cancer risk. Commonly, participants countered that cancer was predominantly hereditary, and therefore lifestyle played a limited role. Other responses demonstrated people’s poor understanding of the epidemiological notions of causality, association and risk. Similar to the self-exempting beliefs of smokers, participants referred to people they knew of who were otherwise young, fit and healthy who developed cancer as evidence that the link was not as simple as being causal. They also referred to others who were older, overweight and with a poor diet and who had not developed cancer. In essence, people have a poor understanding of the notion of causality, and tend to assume when something is identified as causal, then this means a 100% correlation.

67


Some participants also noted that the apparent frequency of reports of factors linked with cancer left them somewhat jaded about any new findings. To an extent, they were sceptical about research, believing that it was possible to make any statistical links, and that this did not necessarily make the associations meaningful. Further, there was a perception that what was ‘new research’ knowledge one day, might be discounted by another theory or study at a later date, and therefore they tended to be reserved in their acceptance of new information, and to use internal judgements, akin to the notion of construct validity, to determine whether something ‘makes sense’ when assessing new information.

“You hear a lot of things so I sort of, um, brushed it aside really. I’m not really generally concerned about cancer. It’s not something that really bothers me. I mean, you know, it would bother me if I were to, say, have cancer but, I don’t know, they’re the sorts of things I’d rather not have to deal with and, you know, unless … you’re in this situation.” (Male, 18–24) “I’ve had a lot of relatives die of prostate cancer and most of them are very active, and I just think, where’s the link?” (Male, 25–44) “I tend to look at it with some degree of scepticism, because there are so many studies linking certain things with certain diseases, you just lose count.” (Male, 25–44)

68

Those participants who identified themselves as smokers also expressed a belief that, given the obvious and accepted health effects of smoking, it was difficult to rate weight and activity as being similarly dangerous. Hence they reasoned that, if they were going to continue smoking, the relative value of physical activity and weight maintenance would make little difference to their health, and that there was no point changing these unless they stopped smoking.

“Mate, I’m in the sun all day, every day, and I surf, you know, I smoke cigarettes. So the cancer is going to get me either way, you know.” (Male, 25–44) “Like, I suppose that I’m getting cancer anyway so … yeah. Like, to me, I don’t know, like overweight, it’s like I don’t think of cancer anyway, well now I don’t. Well, not until you just said that, now I do. But to me, it’s just like smoking that causes cancer, okay, well I’ll quit someday. But I’m not going to be able to quit until my mind is, you know, motivated to quit. So it’s just like losing weight, I guess, like I want to lose weight.” (Female, 18–24) “I already kinda thought that [there was a link between physical activity and cancer] anyway like that makes sense, but that doesn’t surprise me. But at the same time it doesn’t shock me so much that I want to do something straight away. And I think mainly because maybe if I wasn’t a smoker I’d be like ‘Oh well then maybe I should do something,’ but because I’m a smoker I’m think I’m already screwing myself anyway (?) so when I’m doing moderate physical activity I’m gonna get it from smoking anyway.” (Female, 18–24)

Physical Activity Participants were prompted to talk about physical activity issues in relation to recommendations, perceptions of norms, barriers and motivators.

Perceptions of recommendations and norms Participants were prompted to discuss what they knew and understood of the recommendations for physical activity. Overall, there was a reasonably consistent understanding that recommended amount of physical activity was somewhere between 30 and 60 minutes of activity at least three or four days a week, and up to every day. However, participants were not always confident in the specifics of their knowledge, noting that they had heard various messages about these recommendations. The basic amount of activity that participants agreed was recommended was about 30 minutes of moderate intensity walking, three to four times a week.

There was also a reasonable level of understanding that effective physical activity meant that the heart rate should be elevated, at least a bit. Similarly, participants tended to believe that, while it was important to do some level of fitness exercise, they believed that they did not need to be doing seriously high levels of aerobic workouts for basic health reasons. In this sense, participants tended to have a reasonable appreciation that there was a difference between what was required for basic health and competition levels of fitness.

“Because for me, that’s a get fit, get – whereas I’m a healthy active person but I’m not a fitness person. It’s my daily routine but it’s not … trying to get fit. I stay healthy but I’m not getting fit.” (Female, 25–44) “It’s not classified as exercise.” (Female, 25–44) “And to me, three times a week for a walk is to stay healthy, but five times a week would be getting fit. That’s where I would differentiate it …” (Female, 25–44)

“I’ve heard that so long as you do cardio for twenty to thirty minutes four or five times a week. “Is it twenty minutes?” “I think twenty minutes is the cut off point when you start to burn fat.” (Male 25–44) “Exercise means I go for a walk.” (Female, 25–44) “Something that makes you sweat … you know, you’re out of breath.” (Female, 25–44) “Well, walking, I mean that’s like walking, if you’re actually – that’s actually as good as running, if you’re walking, not power walking but, you know, like a fast walk.” (Female, 25–44) “It’s meant to be that you can’t talk, you know, you get out of breath talking, like if you can’t hold a conversation properly.” (Female, 25–44)

However, as with reactions to food recommendations, some commented that it seemed that what was being suggested changed over time and this made it difficult for them to know exactly what was right. Participants mentioned that the recommended amount of time spent on activity, and the recommended intensity and type of activity, all seemed to have changed over time. Some mentioned that at one time they had been advised that activity needed to be completed in a block for it to count, while at another time the recommendation was that small intervals over the day was sufficient. While the degree of these differences in recommendations did not seem to be as problematic with respect to activity as with food, it was apparent that changing recommendations affected people’s acceptance of the recommendations that they knew of.

“It’s supposed to be an elevated heart rate or something like that … but I can’t remember what it is exactly.” (Female, 25–44) “Something that gets your heart rate up.” (Female, 18–24) “If you feel like you’ve worked, like well, you know. You’re puffing or you’ve worked up a sweat.” (Female, 18–24)

69


“Yeah, so much for the interval thing because after I had my kids, they told me that the stop start wasn’t doing good, because you’d do the housework but they’d said nup, it’s not working, you’ve got to do continual, and now they’ve gone back to the interval stuff so …” (Female, 25–44) “By the time you get to our age you think oh, I’m going to give up, there’s just too much information out there, you don’t know which way to look.” (Female, 25–44)

While participants had a reasonable level of general knowledge, it was apparent that there were considerable gaps when it came to the specific details of these recommendations. These gaps were apparent in the kinds of questions that participants asked when considering the issue of recommendations, such as: • • • •

What intensity of activity could be counted as physical activity? Whether daily activity had to be done at once, or could be interspersed in small time blocks over the day? Similarly, whether activity needed to be done every day or could be calculated over a week? What kinds of activities could be counted as physical activity? Specifically, did daily chores such as house cleaning count?

Interestingly, when prompted to discuss physical activity, participants commonly began talking about exercise and the gym. This appeared to be especially the case amongst younger participants who tended to equate exercise with gym sessions. To some degree, this common association of exercise with gym acted as a disincentive, given the effort and barriers associated with going to the gym.

70

During these discussions it was apparent that there were some differences in perception between the terms ‘exercise’ nd ‘physical activity’. While it was understood that these terms could refer to the same thing, on the whole, there was a tendency for exercise to be seen more as a chore, something that must be done, while physical activity was more of a recreational pursuit, and potentially more pleasurable. This difference seems to be most marked for those who reported doing less activity, or who experienced substantial barriers to engaging in physical activity. On the whole, it was apparent that there were more negatives or barriers associated with the term ‘exercise’ than with the term ‘physical activity’, however there were more questions about what could legitimately be called ‘physical activity’ from the perspective of health. In this sense, ‘physical activity’ is likely to be regarded as more motivational or aspirational. “You see, exercise is kind of something you have to do … like a chore … I have to go to the gym. Whereas, you know, if I go and play tennis, I’m not doing it – well yes, it’s good and I’m working out and – but I really enjoy playing tennis with my husband … So it’s actually fun and that’s physical activity whereas if I had to go and, I don’t know, walk on the treadmill for an hour, that’s exercise.” (Female, 25–44)

As with food and body size, participants most commonly talked about gauging the amount of physical activity that was right for them simply as a matter of feel, rather than subscribing to any strict rules. They would claim that they just “felt right” when they were doing the amount of activity that suited them, and that they would use this feeling to assess what was enough. Few reported that they tried to follow the recommended guidelines.

Related to this, some participants also felt that the appropriate amount of physical activity also varied, to a degree, and that some people or body types suited more aggressive activity, such as running, endurance events or contact sports, while others were more suited to a gentler regime, such as walking.

“It’s probably different for the person. I think it’s like how the person is. I think different people can do different exercises and get different results out of it. … Like my doctor that I go to, he recommends that I do an hour. Like walk five days a week, because of the intensity level that I do physical activity, it’d be a lot more. I’d have to do a lot more to achieve the same as someone else who never did anything.” (Female, 18–24) “You feel it, you feel it if you’re doing enough.” (Male, 18–24) “It’s probably a bit of trial and error as well. I mean, like by doing it, you know, if you’re doing – just for example, if you’re doing twenty minutes a day for five weeks, you didn’t feel fit or you didn’t lose any weight, you know, you’re not doing something right or you’ve got to step it up a bit.” (Male, 25–44) “My indication is if I feel good. If I feel good and I feel energetic and happy with the way, you know, I’m presenting myself, well then I know I’ve done enough exercise.” (Male 25–44)

Barriers to achieving physical activity recommendations As noted above, the issue of barriers was typically spontaneously raised as soon as the question of how much activity people did came up, demonstrating a general feeling amongst participants that they were aware that they did not do as much as they should and a defensiveness related to all the factors that they felt made it difficult for them to achieve the ideals. There was a consistent top of mind perception that time was the major barrier, but when pushed, participants typically accepted that even if they had more time, it was unlikely that physical activity would get to the top of their priority list. Given these reactions, time should be considered more of an excuse than a real barrier, with the actual barrier being relative priority of activity over other life factors that compete for people’s time. This was especially the case amongst those who reported that work and family pressures meant that they did little or no physical activity. When these participants were prompted to discuss what they would do if they had more time, they tended to report that they would simply spend it doing more of what they already did, thus having a chance to catch up with the work, social and family commitments that they were typically behind in, rather than adding activity into their routine.

71


“It’s just finding the time to do it. There’s always something else, like you’re favourite TV show or, you know …” (Male, 18–24) “Just exhaustion. Just pure exhaustion from your work day.” (Male, 25–44) “It’s mainly timing with the kids because they’re, well the two eldest are now in high school and there’s a lot of homework. It’s getting to a time where it’s time to get them organised and make sure they’re doing what they should be doing with their homework and, um, then getting the dinner ready and, you know, the missus is studying at uni and, you know, she’s busy with her uni stuff, you know, you just don’t find the time to try and all get together to do it, you know what I mean? It’s a time thing really.” (Male, 25–44) “I get home and I’m working on the business and at the weekend I don’t really want to be walking around, I want to spend time with my daughter ... I don’t have time and all I want to do is spend time with her.” (Female, 25–44) “I think it changes depending on how old your kids are too. Like when they’re really tiny, you just – well one, you’re totally exhausted and you just don’t want to move.” (Female, 25–44) “It’s scary hearing all the messages but when you work ten hours a day, it takes me an hour to get to and from work, that’s a twelve hour day, there’s no way you want to go to the gym for an hour in that time as well. So it’s hard.” (Female, 18–24) “If life had, like, an extra day, like an eighth day and no one had to do work, like, in the middle of the week … then that would be my day for physical activity.” (Female, 18–24) “My gym bag sits in the back seat of my car, yeah, and everyday when I’m at work I sit there at lunch time and I go, ‘I can eat this today cause I’m gonna go to the gym on the way home’, and then my friends ring, I’m at the pub, or it’s a party at my house … we don’t end up doing anything, it’s really bad.” (Female, 18–24)

On the other hand, the participants who were already reasonably active seemed to be more likely to suggest that they would add to the amount of activity that they currently did if they had more time. This comparison suggested that there was a qualitative difference between those who were already engaged in reasonable levels of activity and those who did little or none, with perceived barriers for the latter group highlighting the difficulty of simply starting a regime of physical activity. In essence, participants felt that to do more or more regular physical activity, they would have to give up something of what they were already doing. And, as they felt that they could not give up work and family commitments, the time for physical activity would have to be taken from some other pleasure or recreational time. Related to this was a perception amongst some, especially older males, that those people who did focus on physical activity tended to be somewhat obsessive, and that they made choices about life priorities that were undesirable and inappropriate for those with competing priorities of family, social and work commitments. Some of the older male participants described people they knew who did plenty of exercise as “fitness freaks”.

“A lot of people I know, and this isn’t a criticism at all, but a lot of people I know that are in to fitness, but as I said before, I would like to be a fitness freak, I really would, I think, um, but … a lot of people are giving up things that I wouldn’t be prepared to give up, you know, I need time with my kids and my wife and, you know, other stuff that I’m enjoying doing and I – a lot of people that I know do a lot of it, I would consider don’t have a particularly full life.” (Male, 25–44) “I’ve got mates who are mostly fitness freaks and race bikes and stuff but they don’t have partners, they don’t – they choose not to. They choose to dedicate all their spare time to exercise. It’s very – shall I say a very shallow sort of life. They don’t have any of the things that other people might take for granted. Like, that’s their life; it’s very very narrow focused.” (Male, 25–44) “They don’t have any other commitments, they don’t have a family, they don’t have a partner, they choose low pressure jobs and no-brain jobs and stuff so they can dedicate all this extra time, but that’s the sacrifices they make.” (Male, 25–44)

72

Discussion of barriers highlighted that many activities compete with physical activity for priority in people’s schedules. Factors that were identified as competing for priority with physical activity included: •

Work . Participants commonly talked about working long hours, and noted that they found it difficult to fit a regular physical activity routine around their work commitments.

•

Shift work . Some noted that working shifts, and especially in combination with two or more jobs or with studying, meant that the times of the day that they had available for physical activity were not conducive.

•

Commuting. Some also noted that having to travel an hour or more each way for work further decreased the opportunity they had for physical activity. In particular, they noted that the long hours associated with combining work and commuting meant that it was only possible to fit physical activity into their routine either very early in the morning or quite late in the evening, neither of which were very appealing options.

•

Study. As with work and commuting, study needs generally won the competition of time, and were experienced as especially difficult for those with competing time pressures of work, study and family. Several participants commented that they planned to get more active when they finished their studies, but that they did not believe they could fit it in at the moment.

•

Family, especially for those with children. This was the case for those who looked after their children all day and who felt that there was little opportunity for them to have time to themselves for physical activity. It was also the case for those who worked and felt that they already had little time available to spend with their children. Some noted that children were less of a barrier as they got older, which meant that they could either take part in activity together or that they didn’t need full time looking after.

•

Friends and social activities. This was a barrier especially amongst the younger participants who reported that they would choose to go out eating or drinking with friends before doing physical activity. Given the spontaneity of time management within the younger age groups, they commonly reported that they planned to do some activity, but at the last minute social opportunities would arise that were more appealing.

•

Leisure and relaxation. Several participants, across the age groups but seemingly more common amongst the younger groups, commented that they would choose to relax and do nothing, watch television, spend time on the internet or play computer and video games ahead of physical activity. In particular, they noted that their busy work schedules and hectic family and social lives meant that when they had spare time, they were inclined towards doing nothing rather than exercising. Some specifically commented that they were too exhausted to add physical activity into their schedules, while others admitted that this was simply laziness.

•

Sleep. Several participants noted that the only way they could fit regular activity into their daily routines would be to get up earlier in the morning. However, they also noted that this would mean either going to bed earlier or having less sleep, neither of which were appealing options.

Given this range of competing priorities, there was a sense that implementing a regular program of physical activity into life would mean having to drop off some other activities that were more enjoyable, or responsibilities that were more critical. The need to choose physical activity over other more enjoyable or more pressing activities was in itself a considerable barrier. A related belief, for some, was that physical activity was not enjoyable, which also acted as a barrier, especially in the context of needing to forgo some other activity to fit physical activity into their schedule. As noted above, this was also something of a distinction between exercise and physical activity, with the former being regarded as more of a chore.

73


“A bit of social time there that you’d be giving up.” (Male, 18–24) “Yeah, the activities that you do, I guess in your free time, sort of thing, instead of playing Playstation and sitting on your arse watching TV, I guess some people see that as a good thing everyday, but obviously you’re not – if you’re going to work out and get fit and be healthy, you’ve got to give up some sort of things and people may see that as a bad thing because they like their favourite TV show or something like that.” (Male, 18–24) “You’ve just got to change your priorities.” (Male, 18–24) “The sacrifices you’ve got to make to allow yourself to do more exercise … getting up earlier, going later, missing out on something else to allocate time to the task.” (Male, 25–44) “Sacrifice sleep.” (Female, 18–24) “Get up earlier so you can, you know, do things earlier to finish things earlier to go and slug in the time.” (Female, 18–24) “You have to give up something there.” (Female, 18–24)

“Yeah, I put on weight when I was with him. He just was lazy and we did nothing and we just went out and we ate and as soon as we split up, I went straight to the gym … because I just needed something because I was on my own, I didn’t know what to do with myself and I just thought … I’ve gotta do something and I started exercising because it’s very therapeutic and as soon as I started, within about two months, that was it, I was off.” (Female, 25–44) “If I was single I’d do a lot more activity … Yeah, if I wasn’t in a relationship, because I’d have more time to myself … and I would be able to do it when I wanted to.” (Female, 18–24) “And I think the other thing in that is, I don’t know about anyone else, but when you’re comfortable in a relationship, you don’t worry too much about what you look like anymore. Weight isn’t an issue anymore.” (Female, 18–24) “I’ve put on twenty kilos since I moved in with my boyfriend.” (Female, 18–24) “You eat worse too, like, you go and get some take-away.” (Female, 18–24) “You do feel good after you’ve done it; it’s just getting motivated to do it.” (Female, 18–24)

While it was not a universal opinion, some, especially amongst the women, noted that being in a relationship could itself be a barrier to physical activity. They commented that they were more motivated to be healthy and to look good when they were single, and that they had more time to focus on themselves and their own needs, and were therefore more likely to include regular physical activity in their routine.

“All my friends have boyfriends, so they all do, like, go out for dinner and the movies and stuff like that. So, I don’t have a boyfriend so I’ll just kind of think, ‘I’ll go for a jog around the block’, or something like that.” (Female, 18–24) “When you have a boyfriend you just want to sit, you know, you just want to lie in front of the lounge and like, lie around.” (Female, 18–24) “A lot of my friends, when they break up with their boyfriends, their weight just goes straight away … they’re like, ‘I’m not pretty any more’.” (Female, 18–24) “It’s just getting comfortable [when you are in a relationship] and knowing that appearance doesn’t matter anymore, yeah, it’s not really the biggest priority … after a while you don’t have to kind of impress them anymore.” (Female, 18–24)

74

As noted elsewhere in this report, family could act as both a motivator and a barrier, partly dependent on the age of children. Some participants reported that, especially with older children, physical activity could be a family activity that provided more than just the physical benefits. However this was not so easily done with younger children. Some also noted that they did not really know what kinds of activities they could engage in with their young children that would provide benefits to all of them. “I think another [barrier] is not knowing what else to do. Like not knowing, as I said, with my daughter, not knowing maybe things that I could do with her that maybe would be more physical with her and me and not knowing maybe something different to do. Like I know I used to love playing tennis which is probably a bit out of fashion now, but even finding something else to do that I can do with her and enjoy it and at the same time get the physical activity, even on a weekend.” (Female, 25–44)

Participants in several of the groups talked about the difficulty of getting started, and staying committed to a regime of physical activity. For some, the perception that physical activity itself was a big effort combined with the expectation that they would need to make major changes to fit it into their lives. As a consequence they reported that they did not even start. This was a strong and consistent finding across the groups, and suggests that it is a barrier that needs to be addressed in any social marketing campaign. Again, those who were doing none or almost no physical activity tended to see the degree of effort required as a major stumbling block, while those who were already doing something, though possibly not enough were more open to the idea of increasing their physical activity levels.

“Motivation.” (Male, 18–24) “It’s not time, it’s motivation, I reckon.” (Male, 18–24) “The commitment … like … I wanted to do some more swimming in the last few weeks, but then my work hours changed and the pool that I go to closes early.” (Male, 25–44) “The initial step … to get into your routine … I mean, if you’re in your routine, then it’s much easier.” (Male, 25–44) “Well, I did say this last night. I was sitting at home with some friends and they were all like oh, you know, we’re going to go any minute because we’ve gotta get up early and one was going to the gym and the other one was going to walk to the city and I was like, no, just have one more, one more, and like after awhile they had a few more and they’re like no, we’re going now, and you know, you can get up and come for a walk with me in the morning? I’m like yeah, yeah, sounds great, and then at the end of the night I’m like no, tomorrow is out because I’m on leave and I don’t want to get up early. But it’ll be the same next week when I’m back at work. I really don’t know why, everyone – I say all my friends are really, really [active] – and I used to be but something has changed in me that I don’t know how to …” (Female, 25–44)

Related to the need for motivation, once started, participants commented that it was not always easy to maintain commitment to physical activity. In particular, several noted that the initial motivation and resultant positive feedback was not always easy to sustain, and commonly resulted in lapses.

75


“I think keeping going is pretty hard. Once you start, I mean, sometimes you get started, do it a couple of weeks and you just fall back into your old habits. You get bored, go back to watching TV, playing Playstation and forget about the gym.” (Male, 18–24) “Up until a couple of months ago I was into cycling. Um, that came to a shuddering halt because the guy that I was going with got a new job and we couldn’t seem to find a time we could both go and the motivation couldn’t [keep] going by myself.” (Male, 25–44) “The hard thing is making a start and keeping going.” (Male, 25–44) “You go in this week three times, and then next week, oh hang on, work is late tonight, and all of a sudden the routine is gone.” (Male, 25–44) For some, there were a considerable number of reasons for putting off starting a routine of physical activity, including attitudes such as:

These excuses were especially prominent amongst younger participants, but were also of relevance to some of those with children. For some of the young people in particular, the life stage of moving out of their parents home and into their own place, affected their approach to physical activity. They reported that there were so many things competing for their time and attention during this phase, that unless they were especially committed to a sport or an activity, being active for the sake of health and fitness tended to slip by the wayside.

“When I lived at home I was better, because my mum went to the gym, so I used to go with mum … now, like, I work so far away and I think I’ve done it twice. It’s just way too social at home.” (Female, 18–24) “I think my biggest thing is will power … I’ll go through phases … I’ve been living half at my parents and … half at my boyfriends … for the last three months I’ve been telling myself – once I’m in my apartment I’ll join the gym … it’s kind of a temporary thing at the moment. I go through phases.” (Female, 18–24) “Once I get back into the routine.” (Female, 18–24)

“I’ll start when I stop smoking.”

“Once I quit smoking.” (Female, 18–24)

“When I finish uni I’ll have more time to myself.” “When I set up in a new home – it’s no point beginning a gym membership if I might move soon.” “It’ll be easier when the kids get a bit older.”

76

As discussed subsequently in relation to body size, some of the younger women in particular talked about needing to be motivated to achieve a certain time or event based goal, for example wanting to be a particular size to fit clothing for a function, wedding, etc. They noted that, without something to aim for, they did not have sufficient motivation to make the effort to take up or maintain a program of physical activity.

A range of other barriers were mentioned that were not so much competition for physical activity time, but more reasons that participants gave for not doing any or enough activity. •

Sedentary lifestyles. Some commented that both work and non-work activities tended to be sedentary, and therefore, without a specific exercise regime, they could find themselves doing almost nothing other than sitting for a whole day. That is, many admitted that there was almost no incidental activity in their daily routines.

•

Cost. Some noted that gym memberships, fees for some sports and sporting equipment costs were prohibitive. However, within each group some also noted that there were low cost alternatives for physical activity. Given these reactions, cost was assessed as probably more of an excuse than a barrier.

•

•

Weather and seasons. Some noted that the recent summer had felt hotter, and that they felt less inclined to be active in the heat. Others noted that it was harder to be active during the winter when the days were shorter. Relative value of different health affecting behaviours. Some noted that, as they were smokers, and recognising the negative impact of smoking on their health, there was little value in including physical activity for health purposes unless they were prepared to quit smoking first.

Related to the issue of sedentary lifestyles, participants were prompted to discuss how they felt about whether our bodies were designed or capable of doing much more activity than people tended to do. Universally this was accepted as a truism, with participants acknowledging that our modern lifestyles meant that we were not using our bodies as much as we could or should.

As with several other observations during this research project, discussion of barriers indicated that there were substantial differences between those who were already doing some activity for health purposes (which may or may not be enough) and those who were doing none, especially in relation to motivation and perceptions of capacity. For the former group, the barriers that prevented doing more activity were about perceptions of time and relative priorities. For the latter group, the predominant barrier was inertia and the resultant perception that it was too hard or that it would take too big a change to their lives to even begin to include physical activity. “I think that’s true because we used to have a tennis court across the road … I know if I had a tennis court across from where I live now … we’d just go. I could probably very easily do it now … it’s probably very easy to do it now, it’s probably a ten minute drive, whereas if it was right there I probably would make the effort and maybe get mum to come and play with me or something.” (Female, 25–44) “Trying to sum up the energy to not just sit around on my arse when I get home form work.” (Male, 18–24) “The last thing when you get home from work is go and work out or something, you just want to veg out on the way home, pack of Tim Tams or something.” (Male, 18–24)

For smokers, the belief that smoking was the most detrimental thing they were doing to their health was itself a considerable barrier. Smokers commonly reasoned that unless they stopped smoking there was little value in them adopting other healthy behaviours, especially physical activity. A small number of smokers, on the other hand, argued that at least if they were doing enough physical activity, then smoking was not as damaging to their health. These attitudes suggest that there would be some value in specifically promoting the importance of physical activity for smokers.

77


Motivators to Achieving Ideals Participants were prompted to discuss the things that would motivate them to adopt and maintain the amount of physical activity that was recommended. Their responses could be broken down into those factors that were regarded as the benefits of physical activity and those that would encourage or assist them to incorporate physical activity into their lives.

Benefits of physical activity Participants referred to the benefits of physical activity as being those things that they would be looking to gain from doing activity. To the extent that they were motivated to achieve these outcomes, these factors were also motivators. The main benefits associated with physical activity included: Fitness. The level of fitness that was relevant to participants varied, from those who would like to be able to engage in strenuous sports to those who simply wanted to be ble to do their day to day activities and chores without being exhausted. “If you don’t do it now, then taking the flight of stairs will be not as easy.” (Male 25–44) “It’s more about lifestyle ... its running up a hill and not running out of air by the time you get there.” (Female, 25–44) Health. General health, including better immunity, increased energy and better sleep, which participants understood all tended to work together to engender a sense of well being. Participants also generally recognised that experience of these benefits could contribute to ongoing motivation to continue physical activity.

“You take it for granted that you would get healthy.” (Female, 25–44)

78

Looking good. As might be expected, this was a primary benefit the main motivation amongst some of the younger participants, and became more of a secondary benefit as people got older. Amongst the younger participants in particular, this tended to be a stronger motivator when they were single than when they were in a relationship, and was mentioned by both young men and young women. Related to looking good was the notion of physical and sexual attractiveness, as well as the benefits of clothing fitting and looking better. Losing weight was a primary aspect of physical activity resulting in looking good.

“I think if you look good your family is going to compliment you, so that’s always a good motivation to hear your parents say yeah, you look like you’ve lost weight. You might not have but it’s always a good feeling to say that.” (Male 25–44) “You can put on that dress without worrying about fat here, fat there, it looks nice without having to worry about, you know, going to beach, putting that bikini on. It makes you feel good about yourself, physically.” (Female, 25–44) “It’s a big confidence boost … yeah, with chicks and stuff … and in the back of your mind you are, this is good for me, you know, it’s the right thing to do.” (Male, 18–24) “Confidence would have changed, for sure. If you were at a point where you want to be [physically], you’d be really confident. You know, you walk into the club and, you know, um, chicks would be looking at you and so that’d be good.” (Male, 18–24) “[If you don’t exercise] your clothes get really tight … you don’t feel good because you’re getting squashed all the time.” (Male 25–44)

Self-esteem. Feeling good about oneself was directly associated with the perception that one would look good as a consequence of losing weight. Other factors that were thought to contribute to self-esteem were being fitter and healthier and simply from doing something that one knew was good for oneself. Some also talked about the direct benefit of feeling good that was immediately associated with doing exercise. “You feel energised after you train, you know … it might be a sense of achievement if you go for a run or swim a couple of k’s … but you feel better after you train ... better in yourself.” (Male 25–44) “If I’m going to go to the gym or whatever, I won’t do it to be healthy; I’ll do it … to feel better.” (Female, 25–44) “I find my run home from work very therapeutic …If I have a bad day, I run it all out of my system. I’m not very happy with my job at the moment.” (Female, 25–44) “Small achievements, you know, in your stressful, busy life, if you just manage to do anything that you’ve said – that you’ve set out to do, you feel good.” (Female, 25–44) “I think once you start feeling better within yourself. Like if you set yourself goals, like if you’re going to walk five kilometres and it takes you twenty minutes and then the next couple – in the next month, it might only take you fifteen, kind of thing, so you start to feel fitter. You get fitter.” (Female, 18–24) “It’s good stress relief.” (Female, 18–24)

Given the above perceived benefits, for some, the notion of improved health was a secondary consideration. It was assumed that they would be healthier if they were doing more physical activity, but the direct benefits that they were looking for were more often about looking good and feeling good about themselves for having done it, and the beneficial effects that looking good and feeling good had on their lives in general.

“Yeah, I’m not worried about my health at the moment, apart from smoking, cause I eat really healthy, I don’t eat any takeaway food or nothing like that. So [doing physical activity] would only be to look good.” (Female, 18–24) “My first reason for physical activity would be losing weight. It’s not to get healthy. But, in saying that, I would like to get fit to be healthy, but it’s to lose weight … look better and feel better.” (Female, 18–24)

However, in something of a contrast to this, some commented on times of their lives when they had started up regular activity routines, noting that they might have originally began the process because they wanted to lose weight and look good, and found that doing physical activity left them feeling good and as time went on, it was more the pursuit of this feeling that kept them motivated, rather than the body size goals.

Encouragers to physical activity The factors that participants felt would encourage or assist them to take up physical activity or increase the amount they were doing are documented below. Getting healthy. Participants commonly talked about phases of their lives when they were motivated to be healthy. This incorporated a focus on physical activity as well as other factors such as diet and smoking. They felt that these factors tended to work in combination, and that when they were motivated to achieve healthy practices in one area of their life, they were more motivated to also do so in other areas. These aspects of the discussions suggested that the general aim of “being healthy” can be a strong and a meaningful motivator.

79


Health scare. Amongst the older, male participants in particular there was a general agreement that some kind of lifestyle related health scare would be a motivator to change. They specifically mentioned examples of heart disease as likely to prompt them to adopt a range of healthy lifestyle practices including physical activity. “Health scare maybe.” (Male, 25–44) “That’s right, the doctor said, you know, you’ve got to lose ten kilo otherwise you’ll only live – like, you know, the way your heart is or whatever. You’d probably jump up in the morning and drink your fresh orange juice and go off for your walk and, you know …” (Male, 25–44)

Doing it with others. Several participants, especially though not exclusively, amongst the men, commented that they would be more likely to both begin and continue a more regular routine of physical activity if they were doing it with a friend. Some felt that doing activity with friends, their partner or children would also make it more likely that they did enough. They reasoned that doing an activity with others would be encouraging because it would mean that the time spent in activity was more likely to be enjoyable and that they would have a higher level of commitment to it. They commonly reasoned that it would be harder to skip a planned activity session if it involved others. “I think it is important to have someone to train with ... because you don’t push yourself hard enough.” (Male, 25–44) “If you’re doing it with someone or with a group … then if you’re not motivated, somebody else can say, ‘Oh come on’… and you feel that you have to. You’re committed because they’re doing it, so you can’t let them down.” (Male, 25–44) “And there’s other people too, you see other people walking and that motivates you. You look at everyone else running up and down and you go oh, I should keep going.” (Male, 25–44)

80

Incorporating physical activity as part of daily life. Some commented that if they could work out a way to combine physical activity with their daily routine, then they were more likely to do enough compared with having to go out of their way to include physical activity as an extra. Some commented that if they lived close enough to work to be able to walk or cycle, or if they lived close to the beach, then they would do more regular activity.

“I probably think of how to build it into my lifestyle … if you can walk a bit more on the way to work or something, so if you can make it into your lifestyle it might not seem too hard to do, because it is changing what you do and not just extra things.” (Male, 25–44) “I mean, I walk quite often to the station or at least walk home, which is just over two kilometres, so it’s like a purpose as well. Like you’ve gotta get home, it’s like your running sort of … it’s sort of a purpose as well as at least you feel as though you’re doing something.” (Female, 25–44) “We’re all walking; we’re doing it together as a family.” (Female, 25–44) “If you’re not good at motivating yourself, which I’m not, um, you know, I play netball and basketball but that’s because you make a commitment to a team and it’s a lot different when you’re trying to just go for a walk or something.” (Female, 18–24) “You’re more motivated when you go with someone rather than by yourself.” (Female, 18–24) “I go out for a walk with my dog or when I get the opportunity, play golf. To me, I’m exercising, even when I’m following my son around, you know, on Saturday morning.” (Male 25–44) “I get off and I go to the shops, shopping, and I like, if I got the bus, I might just stop one stop before and just walk it because that’s a habit. That’s like carrying weight, there are a lot of things you can do.” (Female, 25–44)

Having a dog. Several participants commented that they believed having a dog would encourage them to more regularly go for walks and those who had dogs tended to agree that this was the case. To an extent, having a dog was a specific example of incorporating physical activity into daily life.

Some participants also talked about the need for physical activity to be pleasurable, especially as they were unlikely to maintain a commitment to something that they did not enjoy. For some, this was akin to the perceived difference between physical activity and exercise.

Having a personal trainer. A small number of participants commented that having a personal trainer would also motivate them and push them to do more than they would be inclined towards on their own, and therefore ensure that they did enough. However, others typically felt that this option was probably too expensive for them.

“I think it has to be fun … I think you have to enjoy it because then you want to do it … Like dancing or something, if I could find a dance class to go to two times a week or something … then it’s something, you know, that you enjoy doing and that’s why team sports are good because you like doing them and it’s exercise at the same time.” (Female, 18–24)

As noted in relation to barriers, participants commonly talked about the need to have a plan and structure for physical activity and to be committed and disciplined about it. They felt that anything that assisted them to achieve this would work as a motivator and encourager.

“I find it difficult to do exercise for the sake of exercise. I still try and play soccer or tennis and, um, you actually do the exercise without thinking that it’s exercise.” (Male 25–44)

“Be disciplined. Making a plan and sticking to it.” (Male, 25–44)

“If I get to a point where I did regular exercise I’d probably enjoy it, whereas now I don’t really look forward to doing it. But, you know, if I became fitter I’d probably enjoy it.” (Male, 25–44)

While participants had a fair idea of what the ideal amount of physical activity was, as noted above there were several questions about what constituted the appropriate time and intensity of these recommendations. Therefore, it would be reasonable to conclude that providing clear guidelines about the recommendations would help to ensure that these were met.

81


Body Size and Weight As with physical activity, participants were prompted to talk about body size and weight issues in relation to recommendations, perceptions of norms, barriers and motivators.

Perceptions of recommendations and norms Overall, there was a reasonably good level of knowledge that there were standard recommended weight ranges for a person’s height. However, there was limited knowledge of the specific details of these recommendations. Information about healthy weight ranges for different heights had come from a range of sources, including doctors and other health professionals, magazines (including men’s magazines), and for some had been learned in various levels of education. Within each group, some had heard of BMI, up to one or two were aware of the recommended BMI healthy weight ranges and up to one or two had an idea of what their BMI was. Some others had some idea of whether they might be in the healthy weight range, but were not confident of their knowledge. A small number of participants were aware of the BMI cut off points of less than 20, over 25 and over 30 for underweight, overweight and obese respectively. The remainder had a vague idea at best. Across the research, there was a reasonably high level of participants’ knowledge of their own height and weight. Some were quite precise in their knowledge, some knew within a fairly small range and some felt that they could make a fairly good estimate. A small number of participants (less than one in each group on average) reported having little idea of either their height or weight measurements. Acknowledging that these findings are based on qualitative research data, and therefore being cautious with generalisations, there was a sense that women were more likely to have knowledge of their weight while men were more likely to know their height.

82

Participants’ knowledge of their waist measurements varied enormously, with a general trend for men to have higher awareness of this measurement than women. Men commonly reported that they knew their waist measurements because they knew their pant sizes. They typically reported these sizes in inches. However, when describing this measurement a lack of consistency in understandings of where to measure one’s waist was apparent. Some indicated that they were equating waist with hip measurements, or where they wore their pants. Women commonly reported that waist size was not something they had any reason to be aware of because their clothing did not use this measurement. On the other hand, women tended to have good knowledge of their dress size, although they also acknowledged that this varied depending on brand. Across the research only a small number of participants had heard anything about the existence of a recommended waist size, with these references being to very recent media reports. Some of these participants, although not all, recalled that the reference was about new research and that the health link was to cancer. Others had recalled a general message about waist size but were unsure what the measures were or what the disease risk was. Participants were asked how their own size compared with their friends and the general community. Responses varied, including those who reported being average compared to others, those who reported being smaller than average and those who reported being bigger than others. Given that the research recruited people who admitted to or were measured as being overweight, there was a general tendency amongst participants to be conscious of how they compared to others. This appeared to be especially the case for the bigger participants, and probably for the younger women.

There was a general acceptance of the notion that Australians were getting bigger, with a greater proportion of people in the community being overweight and obese than previously. When discussing recommended weight and size ranges, participants consistently raised doubts about these constructs, commenting that they believed whether a particular person’s body size was healthy depended on a range of other factors such as body shape, muscle mass and genetic predispositions. In each group, participants commented that they knew of fit and healthy people who would be considerably outside the recommended levels, with a common belief that muscle was heavier than fat and therefore muscular people could be heavy without being unhealthy. Several participants described themselves as being “heavy boned”, citing this as a reason for being outside the healthy weight range. Similarly, they cited examples of people they knew who were thin, but who ate poorly and were unhealthy. “I’m twenty-eight or something, right, I’m nearly obese, but I saw it – like the only reason I know mine is because I did a medical and I said mate, I’m not that big, and he goes no, not to look at. He goes – like the only true way to do it is skin fold test, to get your true, healthy weight per size ratio. So, you know, there are variables in that height squared over your weight.” (Male, 25–44)

Participants were commonly of the opinion that the most appropriate assessment of body size was their own internal sense of whether they felt right. These feelings tended to be based on a combination of looks and body functioning. Rather than being affected by prescribed rules of weight, BMI or waist sizes, they believed that they could assess their own body size on the basis of how they felt about their size.

This attitude seemed to be most common amongst the men, but was also common with women. This was similar to the attitude reported previously with respect to making an internal assessment of the amount of physical activity that was ideal for oneself, although it was even more common with body size than with activity.

“I’ve heard so many different things, I’ve given up.” (Female, 18–24) “I know I’ve been gaining muscles as well, and I know, it will make me heavier. Especially, like my friends will tell me their weight, and I’m smaller in pants and tops than them, but I’ll know I weigh more. And I hate that, I hate that. Sometimes it makes me want to cry, I know I’m smaller but I’m heavy, and I’m like I’m an elephant. It just sounds really bad because I’m standing there, and I’m like, I don’t want to say how much I weigh and it just seems really bad. And then how can you go off a chart when I’m in that situation. And that’s why, I’ve heard so many things, but I really hate it.” (Female, 18–24)

Related to the above point, when participants were asked to discuss how they thought their own body sizes and weight compared to the recommendations, they commonly referred to the idea of a self-assessment of their own body size, where they had a level of awareness of their size based predominantly on whether they felt they were about the right size or not. “If you’re happy with the way you look, the way you are, how healthy you are, don’t worry about anything else.” (Male, 18–24) Some commented that their assessment was partly related to their clothing, so that they could tell by how their clothes fitted whether they had changed in size.

83


“To me I don’t think, I wouldn’t say oh I’m in my healthy weight range, so that means I‘m healthier. I would judge myself more on how I look than whether I mean what’s been textbook determined as, and it might… Yeah like I wouldn’t be, the fact that I’m in what’s considered as my healthy weight range, wouldn’t be something that would satisfy my goal. [Moderator: Even if it was the most healthy weight for you?] No, it just a number I think to me. Even though it is scientifically proven, I need something that I can look and go, yeah I look much better than I did in that photo, like I’d look back in photos as well.” (Female, 18–24)

However, there was no sense that these feelings were a comparison with any norms; rather they were portrayed as an internal sense of what was right for the individual. Most obviously, these feelings were active at times when people had changed in size, and therefore their value would be partly dependent on how appropriate the original assessment of size was. Given this approach, several participants reported having been told that they were obese or close to obese according to normative measures (i.e. that they had a BMI of high 20s or low 30s), and that they rejected these assessments of their size because they felt that they were nowhere near obese. They tended to justify this with explanations that the norms were not appropriate for them because of their height, body shape, bone density or some other explanation.

84

“I don’t know the number but I know where I am. It’s not overweight but it’s not the right weight.” (Male, 25–44) “Mostly I look at myself.” (Male, 25–44) “I feel weight, I can feel it, I know when I’m okay … I don’t feel as strong to be able to do the things I want to do.” (Female, 25–44) “Just the feel of your clothes as well … but I think you feel that, you know when your clothes fit right.” (Female, 25–44)

Barriers to achieving body size recommendations Participants were prompted to identify and discuss the factors that made it difficult for them to get to and stay in a healthy weight range. Those issues related to physical activity have been discussed previously in this report. A range of other barriers, most obviously related to food, eating behaviours and the social and cultural context of food, are listed below. Food tastes and preferences. Some felt that the foods they believed were healthy were not as tasty as other foods. Some noted that they had a ‘sweet tooth’ or particular likings for foods that they knew were high in fat or sugar content. Several, especially amongst the younger males, commented that the take-away options were simply more appealing in terms of smell and taste, with stories being told of attempts to eat a healthier diet being thwarted by the tempting smells of fast foods in the local food court!

Cultural influences. Participants across the groups identified that there were a range of cultural factors that affected their diet and therefore the approach to and capacity for weight management. Relevant issues included the reliance of some diets on high carbohydrate foods such as bread, rice and pasta; serving sizes; sweets; fats; and the central role of food in the family and social context. “We eat a lot of carbs at home, coming from a Mediterranean background.” (Female, 25–44) “We don’t really have that many, you know, going out food but it’s just more the – we weren’t brought up on that many vegetables and stuff. I know it’s really good for you but we don’t eat that much vegetables.” (Female, 25–44)

“[Your intention to eat healthily] becomes over-ruled by what you smell.” (Male, 18–24)

Convenience. Participants across all of the groups consistently noted that fast foods were simple and quick, and therefore that they met their needs in the context of both hectic schedules and activities that competed for their time. However, they also noted that fast foods were not ideal from a health and weight management perspective. In this sense, the perception that eating healthily is difficult and time consuming is a barrier to adopting the dietary practices that would contribute to healthy weight management.

“You have the thought there but when it came to it, you go for what tastes good instead.” (Male, 18–24)

“The whole week just full of takeaway.”

“Yeah, oh, you know, while you’re sort of buttering your sandwich, should I be putting butter on the sandwich? But it’s what you do, you still do it so, whatever, yeah.” (Male, 18–24)

“That’s the other thing, when you’re buying food at work it’s hard to say no to, like, oh, it’s only 50 cents more and we’ll give you this Coke and …” (Male, 18–24)

“Oh, I reckon every time I look at whatever I’m about to eat I think gee, is this healthy or not? … It doesn’t stop me from eating it if it’s unhealthy …” (Male, 18–24)

85


Cost of healthy food. There was a consistent perception that healthy food was more expensive than unhealthy food. In making this comparison, some referred to healthy options from take-away outlets as being more expensive, with some noting that it wasn’t just the price of the meal, but that they would need to eat more of the healthy options to feel satisfied. Some also commented that buying healthy foods to prepare at home, such as fresh vegetables, was also more expensive than less healthy items. Eating patterns. Some noted that they would be more likely to eat the appropriate amount if they ate to a regular pattern. Some of the younger participants and the older ones, who reported hectic lifestyles, noted that they often ate when it was convenient rather than having a standard three meals a day. They also noted that they commonly did not plan their meals and did not sit down to a meal, with some noting that they would eat breakfast on the run as they were getting ready for work, would grab something convenient for lunch at some stage during their daily travels and would pick up whatever was convenient on their way home at night. Some provided stories of lunches that were bought from vending machines at work and the ease of drive-through food outlets as specific examples. They felt that this might contribute to eating higher fat and sugar foods. Overall, not preparing one’s own food was thought to contribute to less than ideal eating for weight management.

“I think it’s a bit about planning ahead as well. I mean, I know, like, I’ve just started a new job and I’m thinking like, I don’t get home till seven o’clock, what’s the quickest thing I can cook? Whereas if I’ve got something, I’ve got meat defrosted and a salad made in the fridge that I can do the night before, then you’re not as tempted to go and do the takeaway thing.” (Female, 18–24) “My main problem is my sleeping pattern, ‘cause I used to work in a pub and so I’d be getting home at like three thirty, four in the morning, sleeping till whenever, having dinner at whatever time.” (Female, 18–24) “It takes an effort to cook a proper meal.” (Male, 25–44) “If we’re going out at night drinking, we kind of don’t eat as much during the day … so you don’t look bloated.” (Female, 18–24)

86

“The eating healthy thing for me, is like a big thing, that’s one of the main things … because I have so little time to do things, it’s just obviously so much easier to pick up a quick snack, which is obviously not gonna be healthy. It just seems, to take more effort to eat something healthy. Like we don’t, have like heaps of food at home, and like I don’t have a fridge or anything at work where I can keep food and stuff for the week. I don’t really have those sort of chances where I just can keep healthy stuff on me. And I don’t have time to like, go searching for somewhere near my work, cause there’s like nothing near my work except a 7/11 and a Hungry Jacks, so there’s just. The opportunity to eat healthy is not there.” (Female, 18–24) “I’m the same. If I, like I don’t eat dinner at home, because I’m never home at night. I’m either at work, or at my boyfriend’s house or not home, like, just like for example tonight I’m not home. Um, and so, it’s so much harder to find something healthy out, and if you do find something healthy it’s expensive. Like you can spend $10 or $12 dollars on a healthy meal. Where as you can get a chocolate bar for like $2 bucks. And that will keep you going until like a later date sort of thing you know.” (Female, 18–24) “And even I’ve told myself every morning last week, I’ve just got to make lunch at home and take it into work, but when you’re getting up that early just to get to work, you don’t want to get up an extra 15 minutes to make your lunch. And there’s just, yeah there’s just too many take-away fast food, places.” (Female, 18–24) “You’ve got to get up an extra five minutes earlier to actually make my lunch … and not drive through lunches, sort of thing. That’s my main thing … I’m on the road in a van and it’s just between jobs, let’s drive through there and get a quick feed, drive and eat at the same time.” (Male, 18–24) “If you want to eat healthier, you find that it takes more time to cook, like, proper meals, and then, you know, you’ve got … vegetables and fruit going through the roof and you think, geeze …” (Male, 25–44) “I suppose the motivation to cook things as well, when you’re at home. You just couldn’t be stuffed doing it so you just ring up Chinese, they’re at your door.” (Male, 18–24) “I know, I’ve got to get to Maccas before three [pm], cause I’ve got to fit in my pants by six, start drinking by then too.” (Female, 18–24)

Family issues. The issue of eating for weight management was somewhat problematic for those participants who were living in a family situation where they felt that their own meals were partly dependent on the eating habits and preferences of the others in their family. This included both parents who were preparing meals for partners and children and young people who were still living with their parents and siblings.

“If you’ve got a family, you know, as you were saying earlier, it’s hard to find the time to do this and it’s easy, you sort of get in a comfort zone and it’s easy just to – you just put the weight on so easily. As that gentleman over there is saying, it’s so hard to get off again.” (Male, 25–44) “I think it’s much easier when you’re – there’s someone else in the household that’s actually agreeing to do it.” (Female, 25–44) “Someone else making the effort as well, like I find I get so sick of cooking and making the effort to do something nice and if my husband is sort of on board with it, rather than him going oh okay, I can’t be bothered, we’ll just get takeaway.” (Female, 25–44) “I think also partners, families, if they’re sitting there and they’ve gone and bought McDonald’s or they’re having that Tim Tam or something and you’re trying to be good, it’s always harder as well.” (Female, 18–24)

Portion sizes. Several participants, across the age and sex segmentations, commented that to reduce their food intake, the most obvious thing would be to reduce their portion sizes. They noted that they often ate too much at a sitting, but that they commonly didn’t realise this until sometime after they had finished eating. Shopping for food. Participants commonly reported that if they were to eat a ‘healthy’ diet, they would need to change their food shopping approach to some degree. In particular, several participants commented that they would need to include simple to prepare meals that were healthy on their shopping list. However, they were commonly unsure what this would require.

“And you’ve gotta have your partner committed, because she does shopping and things like that, you know … if they don’t buy it, I won’t eat it … I’d rather not get up the extra ten minutes earlier, I’d rather get take-away.” (Male, 25–44) “I think for me it’s, you know, actually when I shop, not having the things that I like, that I snack on, dips and crackers and, you know, lovely soft cheeses and all the things that we can sit and have all of that stuff before dinner.” (Female, 25–44) “Don’t food shop when you are hungry!” (Female, 25–44)

“It’s hard when somebody else is cooking as well, because I’m living with my parents at the moment, and dad does the cooking. I don’t get home until seven o’clock, so I just eat whatever he has cooked. So, you know, dinner – it’s never that bad but, you know, spaghetti bolognese is the healthiest thing for you but I’m not about to get out and start cooking my own dinner because I can’t be bothered and it’s there.” (Female, 18–24)

87


Motivators to achieving ideals “Vanity over health any time for me.” (18–24, female)

Participants were prompted to discuss the things that would motivate them to reach and maintain a healthy weight. Those aspects that were specifically related to the role of physical activity in achieving and maintaining a healthy weight have been documented previously.

“You’d look better, you know? You’ve dropped two pants sizes, like you said, well you’ve gotta buy new clothes, don’t you, you know? So you feel better in yourself. You know you look better.” (Male, 25–44)

The main motivators for achieving and maintaining a healthy weight were associated with looks and health.

“You get a lot of comments as well, you know, like people would notice the difference.” (Male, 25–44)

However, within this it needs to be understood that being motivated to achieve a look was not so much associated with the notion of healthy weight, and more with a perception of body ideals. Within these discussions, it was quite obvious from those who were motivated primarily by looks that if there was a discrepancy between their concept of a body size ideal and a healthy weight, they would seek to achieve the former rather than the latter.

“You just feel good about yourself, clothes feel good on you and you feel comfortable. Well then it comes back to being active, feeling more comfortable moving around and doing things … you pull on some trousers, they fit nice, they feel good and just that sort of thing.” (Male, 25–44)

“Yep, I’m the same. I would prefer to look better than be in a healthy weight rate. Hopefully they coincide but if they don’t it’s not an issue.” (Female, 18-24)

Looking good was undoubtedly a significant motivator for losing weight. As might be expected, there appeared to be age, sex and life stage relationships with this belief, with looking good being a more important motivator for younger participants, especially but not only younger women, and becoming relatively less important with age. While the health benefits were mentioned by the younger ones, this appeared to be almost lip-service for some, and these reasons seemed to become more real with age. By contrast, older participants, especially those in their forties, tended to be more focussed on the health benefits. However, looks were also a significant motivator to weight loss amongst the older groups, both male and female.

“Everything would just be easier, I think.” (Female, 18–24) “I think you’d be more confident.” (Female, 18–24)

Life stage also appeared to affect the importance of looking good as a motivator. In particular, across the age groups, those who were single, separated or divorced acknowledged that looking good was an important criterion for attracting a partner. Conversely, several of the women commented that being in a stable relationship tended to be associated with putting on weight. “Like, I’m in a relationship and all that sort of stuff already. Maybe if I was single, I’d want to be attractive and then work on the healthy thing later. But I’d just like to be healthy and know that I wasn’t going to get sick.” (Female, 18–24) “I think it’s about … your lifestyle and that sort of thing, like if you go out heaps, whatever, you probably want to look good whereas, um, if you’re sort of, I don’t know, a bit older or you have a family and that sort of thing, it’s probably more about being fit and being able to sort of keep up with the kids and that sort of thing.” (Male, 25–44) “It’s a really minor thing that I’ve never had until I had the children, I never had any wobbly bits and I never really had to do – I could eat anything. I was just – I had a really good metabolism and I was quite active and it was shocking to me to actually find that I had a tummy and things, you know, that I didn’t look good in a bikini any more and that inspired me too.” (Female, 25–44)

88

Fashion and clothing were mentioned as a component of this, with some of the younger women in particular reporting that they were motivated to reach a certain size of clothing; had been motivated to fit into a particular outfit; or had been motivated by an upcoming event they wanted to look good for. “The benefit [of doing enough exercise and being a healthy weight] … would be getting into size eight jeans … size six would be better!” (18–24, female) “You need to think back to why do I want to lost weight? Like, for example, I don’t know, you want to fit into a size ten dress for a big party. Like find a reason to it. Don’t just say oh, I want to lose weight for the hell of it because people – if you do it for the hell of it, I don’t think you do.” (Female, 25–44)

Being a healthy weight was associated with a range of other positive attributes, such as being more confident and having more energy. Health and minimising the disease risks associated with weight was a motivator for some, especially amongst the older participants. However, younger participants commonly reported that health benefits were very much secondary when it came to weight loss. Those who were motivated specifically by health factors talked of the benefits of being fit, keeping up with their children and longevity.

“If something is coming up, like … the most in shape I ever got was leading up to New Years, because I wanted to have a big New Years party and I wanted to fit into this outfit and I wanted to look great and be nice in photos.” (Female, 18–24) Some of the younger women also talked about being motivated by ideals of attractiveness to achieve what they say as an ideal size for them, but that this tended to be something of a moving target, and once they had reached a certain size, they would think that there might be benefits in getting even smaller. Some acknowledged that this had at times become something of an unhealthy motivation or even obsession with them, the idea of always wanting to get that bit skinnier. “It snowballs to you more, I suppose, more if you’re like oh, if I keep going I’ll get thinner.” (Male, 25–44) “Like for me, it’s always oh, I just want to lose a bit more. I guess, trying to get that bit more fitter and so you’re always – like you’re happy but you’re like oh, I could be a bit more toned there.” (Female, 18–24)

89


Food, Diet and Nutrition Dieting beliefs, attitudes and behaviours

“If you drink lots of water it makes a difference.” (Female, 25–44)

During the discussions it was apparent that the knowledge and beliefs that participants held about food, and especially about dieting and weight loss diets, affected eating habits, and probably therefore their capacity to manage their weight. Some of these beliefs were true, some seemed to be variations on a truth, while others were probably misconceptions.

“Everyone has heard of the carbohydrate rule after 3pm.” (Female, 18–24)

Some examples included various attitudes being expressed about the amount of water that should be drunk, about the benefits of diets that were low in carbohydrates, about the time of the day that certain foods should be eaten or limited, and a range of other topics. In identifying and discussing these factors it was apparent that participants had been exposed to a range of different food and diet messages from a variety of sources, some of which were probably fact based and others probably being trends or fads. For example, across the research there was a consistent level of acknowledgement of the importance of a ‘low-carb’ and ‘low GI’ diet, and specific comments about the importance of not eating foods high in carbohydrates late at night. It was apparent that these messages have been part of the recent food lexicon, and that they are influencing beliefs and eating behaviours.

90

“They have a whole lot of low carb beers these days …I like it, it’s good … but I don’t base my decision on whether it’s fatting, I just like the name, ‘Pure Blonde’.” (Male, 18–24)

Documenting awareness and understanding of food and diets was not part of the objectives of this research, and therefore the information provided here is not intended as a comprehensive analysis of food knowledge, beliefs, attitudes or behaviours. However, during the groups these topics inevitably came up, and some trends were observed that appear salient to understanding barriers and motivators to weight management in particular.

“But even so, what was it that came out last year, you can drink too much water. They’re telling you you’ve got to drink this amount but then they come out and tell you that you can drink too much water because it will do this and then it’s like well, what can you do?” (Female, 18–24)

“I try, key word, to have, like, my big meal at breakfast or like lunch, depending on what time I wake up, and have like a small meal at dinner … it’s very European but, um, it, um, because you burn off the – if you have a big meal during the day, you burn it off because you’re exercising, whereas if you have it at night, you’re just sleeping on it and it’s just turning into fat.” (Female, 18–24)

The diets promoted in mass-media magazines and popular television programs appeared to play a significant role in establishing and reinforcing these beliefs. The frequency of references to ‘low carbs’, indicated how quickly and pervasively diet trends such as the Atkins Diet become embedded within the culture of food, health and dieting, especially when they are promoted as weight loss diets. However, it was also apparent that, apart from a few individuals, detailed knowledge of how to put these dietary approaches into practice was limited. For example, participants used relatively simplistic understandings to identify which food components were carbohydrates, and several commented that they had little knowledge of the different components of food that were documented on food labels.

The conversation below demonstrates some of the inherent difficulties of specifying food rules. Participants were asked about the kind of approaches they used to food to help manage their weight. “Don’t have carbohydrates after 2pm.” “I thought it was 4?” “I thought it was 6?” LAUGHTER “2 sounds early” “My trainer says 3.” “… whatever time it is!” (Female, 18–24)

The notion of food as energy input that needed to be balanced with energy expenditure was somewhat familiar to participants, with a general understanding that the more that went in, the more energy expenditure that was needed, although the specific details were not widely known. “I think everyone knows that you’re putting fuel in by eating, you’ve gotta expend some, you know. You can muck around with one of them but it’s a very simple concept, it’s just hard to do.” (Male, 25–44) “I don’t know anything about calories and all that, I just know that I eat healthy. I just need to exercise more so … all everything I eat, cause I’m a vegetarian, so everything I eat, I’ll just eat vegetables, fruit and salad. … the [calorie figures] don’t matter, cause if I was eating you know, maccas and all that kind of stuff, then I’d worry about all that but I’m eating healthy so yeah. If I’m eating more calories then you know like … I wouldn’t really care cause it’s healthy food anyway.” (Female, 18–24)

Some participants, especially amongst those who reported that they had previously been involved in weight loss programs such as Weight Watchers or Jenny Craig, acknowledged they were quite conscious of this construct, especially with respect to energy input. Some reported the ‘points’ value of different foods that had been introduced during these programs, and noted that even though they were no longer engaged in the programs, they still kept a tab on the different foods they were eating. These participants tended to have an understanding of the required food intake for weight loss and weight management, however this commonly did not translate into an appreciation of the relationship between food intake and energy expenditure through physical activity. It was apparent that, even amongst these participants, considerably less attention was paid to the detail of the energy expenditure side of the equation, with the focus being primarily on food inputs. Notwithstanding, several participants commented that they used certain ‘energy rules’ that they had picked up over the years to govern their eating, for example equating a chocolate bar with a certain amount of exercise. This observation highlights the potential utility of this kind of information for some people, however, it was apparent that this approach required a substantial focus on food that was beyond what other participants were interested in. (More detail about working out the balance of input and expenditure is included in the subsequent section of this report related to relevant statements that were assessed during the research.) Participants who went to gyms reported that they took more notice of their energy expenditure as a consequence of using gym equipment that documented kilojoules.

91


As noted, while there was much discussion of ‘carbs’ and some discussion of ‘low fat’, on the whole there was relatively little acknowledgement of other components of food. Some participants admitted that they had little idea how to evaluate the contents of food or the information contained on food labels. In this sense, they were largely dependent on food packaging to help them work out whether foods were going to help or hinder their attempts to achieve and maintain a healthy weight. “I’ll pick everything [food packaging] up and … the two things I look at are the carbs and the fat content. But I don’t know what all the other stuff is.” (Female, 18–24) “We’re not going to think, eight teaspoons of sugar to a can of coke, if we want to have a coke we’re just going to have it. … it does make more sense though to think of how much exercise you would have to do … what does eight teaspoons of sugar mean?” (Male, 18–24) “That’s the hardest thing I think with me as well, I wouldn’t have a clue what was healthy and then you ask someone and they say ‘no, no that’s like,’ a good example is someone says avocado but it’s natural fat so that’s good for you. And sometimes they say it’s all fat and if you don’t do anything with it…” (Female, 18–24)

A small number of participants, most obviously amongst the women, noted that they were very aware of the energy, fat and sugar content of foods, and that they would use this awareness either regularly or in phases to make judgements about their daily diets. Some of these participants reported that they had been through periods of their lives when, in their own words, they were quite “obsessive” about dieting, and that it was this obsession that had prompted them to become aware of the various food contents.

92

“I’m a big fat counter. I always only look at the saturated fat, and that type of thing. And then I have foods that I won’t eat … like I won’t eat bacon. I won’t eat … I won’t drink full cream milk, and as a mental thing. I tell myself that that makes me feel sick. And then I won’t eat it. And then my friends go, well if she’s not having it, I want hers and like stuff like that, like that happens. Um, when I was younger, when I was a size 6, I would only eat one vegemite sandwich a day, and stuff like that, and I don’t want to go back to that, and that sort of thing. I was sick all the time, and that’s why I’m anaemic and that’s why I’ve got all these health problems now. So then you think, yeah you’ve got to start thinking… is it worth it being that small and things like that and think of life as well.” (Female, 18–24) “I went on um, the Sureslim diet, for like it lasted about 6 weeks. And I became absolutely obsessed with food … I just knew I needed to lose weigh … like portion sizing meat and portion sizing vegetables and … I was losing weight but I became obsessed with food and I didn’t like that, so I just I went off it … I got to the point where I didn’t want to eat with other people because if they, like going out to a restaurant with friends and you look at everything on the menu and you just go, ‘oh that so,’ like at an Italian restaurant for example, and you just go ‘oh god I can’t eat anything,’ or you just go ‘I’ll have an entrée’ yeah or … if I do have dinner it’ll either be with my boyfriends family or with my family. And I got to a point where I’d just sit there and look at the plate and just think, I really shouldn’t be eating that, and just feel terrible that I’d have to eat it and just try and like pick at it or something …” (Female, 18–24)

Other than these few individuals, participants tended to talk more about “eating healthy”, and specifically comparing healthy eating to “junk food”, with the latter typically being a reference to ‘fast food’ and ‘take away’. Eating healthy typically meant avoiding or minimising junk food, drinking water, including plenty of fruit and vegetables, minimising fat and sugar intake and controlling the amount of food eaten.

A small number of participants noted that it had been important for them to learn to eat according to needs, and not for some emotional reason. This meant learning to be tuned to their hunger needs and the balance of energy input and expenditure. However, they commented that this was not a simple thing to learn and that it required the help of health professionals.

In addition to the barriers mentioned in relation to weight management, there were some specific diet related barriers that contributed to less than ideal eating patterns and behaviours, and therefore affected participants’ interest in and capacity for weight management. However, it needs to be acknowledged that, given the scope of the research objectives, it was not possible within this project to comprehensively document all of the food and eating behaviour barriers. This would need to be the subject of a specific research project.

“When I used to do training I used to go to a nutritionist on a regular basis and they used to give me meal plans for energy. So, like, I know what not to eat and what to eat. So it actually, like, opened my eyes to how much I overeat because I realised when I was eating, I wasn’t just eating for energy. Now, I’m just eating for energy but before I was eating for boredom or because hey, everyone else was eating.” (Female, 18–24)

Some commented that periods of being on strict diets, specifically weight loss diets, were something of a barrier, noting that when they fell off the dieting wagon, it was likely that they would fall hard, and cycle into a period of not looking after their food habits at all.

“If you’re on a strict diet, as you’ve got to that weight, you can’t go oh, well I’ll have dessert tonight or I’ll have some alcohol or whatever and then gradually it just turns into a spiral.” (Female, 18–24)

While some acknowledged that they had gained some benefits from weight loss programs such as Jenny Craig or Weight Watchers, several of those who had been involved in these programs reported that the effort involved in keeping count of points and calories was onerous. In essence they felt that this was not a simple enough approach to eating to be sustained in an ongoing weight management model.

93


Response to Statements A number of statements were presented to participants, and while they were not specifically tested as propositions or positioning statements, they were useful as conversation stimulus during the group discussions and provide an indication of the kinds of messages that might be appropriate. Reactions are presented in this section. 1 piece of chocolate cake =14 minutes running OR =19 minutes cycling OR =35 minutes of walking On the whole, the specific detail of this statement was new information, although participants were aware that a piece of chocolate cake was not ‘healthy food’. While some indicated that they did think about food this way, it was more common in this research for participants to suggest that they did not break down their eating into individual foods in this way. Participants were prompted to discuss how they might use this kind of information. There was a sense that those who were already doing a reasonable amount of activity would eat the cake and do the extra exercise, while those who were doing little exercise reported that they would not eat the cake or only eat half of it. For the former group, adding to their existing activity regime or assessing their existing regime in terms of what it meant for their eating seemed reasonable and not onerous. For the latter group, it was apparent that these amounts of exercise seemed somewhat daunting for a relatively small amount of food. It was apparent that this interpretation left them less inclined to take notice of the message all together, and therefore that it would have little impact on either their eating or their activity behaviours. Some commented that they were more interested in comparing foods with foods, so that if they were to eat the chocolate cake, then rather than do more activity they would modify some other element of their eating during the day.

These reactions suggests that for the information to affect either eating or activity, this group would need to be already contemplating or committed to achieving a balance in energy input and expenditure, hence this information is not sufficient on its own to affect behaviour change. However, this kind of information does assist some to understand the principles of the relationship between food and activity, and therefore potentially plays a role in encouraging activity and weight management. “For me it is not the exercise, but more that if I eat this chocolate cake, that’s it, I’m having a banana for dinner.” (Female, 18–24) “I don’t eat cake or chocolate, I eat healthy food … so I don’t really have to run or walk or cycle.” (Female, 18–24) “Oh good, then at least I know how many minutes you have to walk.” (Male, 25-44) “I think it’s shit, you know, like, that you’ve gotta do that much work to burn that much – to burn that amount of food, you’ve gotta do that much work … It’s a deterrent for wanting to eat the cake.” (Male, 25–44) “If you think that way you can’t enjoy anything.” (Male, 25-44) “I don’t know, um. It just makes you feel guilty, sort of thing, and I think if you’re already doing running or cycling or whatever beforehand, um, I think you could sort of get away with it because you’re already trained to be doing that sort of exercise. But I don’t think it’s going to be much of a deterrent if you’re not already doing that exercise because you think okay, I can eat that and then do this to get rid of it but if you’re not doing that already, you’re probably not going to do that anyway so you’re just going to eat the cake and not do the exercise anyway.” (Male, 25–44) “Is that one piece of cake worth it?” (Female, 25–44) “Don’t eat the cake.” (Female, 18–24)

94

“Yeah like for a while I’d really like the measurement of that, like cause I find if I eat cake or if I eat chocolate or whatever it’s hard to measure, to count how much I need to exercise to counteract what I’ve eaten. And so for a while there I was on the weight watcher’s programme which is really good cause you’re only allowed so much points, and then after that that’s it you’ve had enough. Um, and I think that measurement I really like that, cause it tells me what to do, and when to do it.” (Female, 18–24) “It’s more relevant to me, than any of the other ones, that you’ve shown … Like it’s measure and it’s something that I can achieve, where as being underweight or being the correct weight is, like is something that will take a while to achieve. Yep where as I can go for a run 15 minutes today.” (Female, 18–24) “Yep absolutely. It’s more motivation.” (Female, 18–24) 1 bottle of beer =14 minutes running OR =19 minutes cycling OR =35 minutes of walking Participants commonly reacted with surprise to this statement, especially amongst the younger men, indicating that they tended not to think of alcohol in this way. Again, those who were engaged in activity suggested that this might be motivation to do more, while the reactions of those who did little activity were much more varied. The general issues with respect to the balance between input and expenditure, as reported in relation to the chocolate cake statement were still pertinent, with a range of additional issues related to this being a message about alcohol. The statement prompted participants to think about their beer consumption. For some, a substantial component of the shock was related to how much beer they reported drinking, and their thoughts about the large amount of additional exercise this meant that they should be doing. On the whole, and especially amongst the younger participants, this left them quite concerned about some of their weekend drinking habits.

However, for some of the younger participants, and especially amongst the women, there was a bit of a concern in reactions to this information, in that, they suggested that they were not likely to reduce their alcohol intake, and therefore, if they were concerned about energy intake and were not prepared or able to increase their physical activity levels, then the only option left was to eat less food. This obviously has health implications. “I’d probably still drink the beer, but I’d plan to do the exercise.” (Male, 18–24) “Hmm, how many bottles of beer have I drunk?” (Male, 18–24) “To associate it like that is just not my thing at all … I know when I’m healthy and I know when I’m doing the right thing but for everything, there are some things that I enjoy from time to time to have to associate with, you know, I’ve gotta do that to get rid of it, that spoils it for me. I’d rather not do it.” (Male, 25–44) “I think of it the other way around … if I’ve been having a good week and I’ve done something, I can actually have a little bit more.” (Male, 25–44) “I definitely don’t think of beer like that. It’s just a beer … it’s not food, you don’t expect fat to come from a drink.” (Female, 25–44) “I look at a chocolate cake and that’s fattening but a beer, it doesn’t feel … like anything bad.” (Female, 25–44) “I won’t eat much during the week and I, I’m not a big eater. I don’t eat breakfast, I skip meals, I’m shocking like that. And then on the weekend I don’t think of anything except I’ll just do whatever I want ‘cause I think I’ve been good during the week, I’ll drink whatever I want.” (Female, 18–24) “To be honest I don’t think, I will say I’m being healthy this whole week and I will think nothing of the fact that I’m planning to go out and write myself off for the weekend … but that won’t enter my mind that much of that’s not a healthy thing to do. That’s like my reward for the being good.” (Female, 18–24)

95


New research shows that moderate physical activity will help prevent cancer Specific reactions to the linking of physical activity and cancer were documented in an earlier section of this report. Overall, this was new information, though not especially surprising, as participants understood that activity was linked with general health. Participants initially appreciated that this was new information, and it prompted some to want to know more details about the research and its findings. Specifically, “what kind of cancer and what is moderate activity?” On the other hand, the idea of ‘new’ information prompted some to wonder how long it was going to be considered accurate. Participants talked about how they were frequently told about new ‘facts’ about food, only to find out at a later point that more ‘new research’ had lead to a completely different conclusion. These experiences had left them feeling somewhat jaded about ‘new research’, and confused about what and whose advice they should be following. The positive tone of this statement was appreciated, in that it was suggesting a solution rather than simply reporting a problem. “It’s sort of up there with wear sunscreen and a hat when you go outside …Yeah, it’s just sort of when you remember to do it you might maybe… when you get burnt, then you go under [the shade].” (Male, 18–24) “I mean, if you think about it, you think oh okay, it’s going to prevent cancer and then you say okay, how long do you have to do this for? Oh, six months a year, oh no, you’ve got to do it for sixty-five years, okay, so that’s …” (Male, 25–44) “It seems to go hand-in-hand, if you’re in good shape you can hopefully prevent anything.” (Female, 25–44)

96

“Are those facts?” (Female, 25–44) “You just go new research, where from …” (Female, 25–44) “But thing is one day they’re telling you butter is good for you, don’t eat margarine, the next minute they’re saying don’t eat margarine, butter is better … you can’t, that whole thing with foods and eat an egg a day, don’t eat too many eggs … you know, it’s kind of hard … I think new research, all it does is, you know, one minute there’s one message and the next minute there’s another one, actually no, sorry, we were wrong, you should have …” (Female, 25–44) “I don’t know about the cancer bit, but the moderate exercise is just meant to help you.” (Female, 18–24)

Being overweight or obese causes cancer In contrast to the above statements, participants commonly reacted quite negatively to this statement. In general they felt that it was too strong a statement about cause, and with not enough detail to provide any useful understanding. Within each group, some participants wanted the statement to include the word ‘can’, reflecting their understanding of the meaning of the concept of causality. Participants accepted that there could be a link between weight and cancer, but their responses suggested that this wording, and specifically including the word ‘cause’ without any qualifier, prompted strong negative reactions and rejection of the statement. Some were prompted by this statement to want to know more specific detail of the measurements for overweight or obese.

“It’s bullshit … talking about causality.” (Male, 18–24) “But then they say this food can create, this food can cause cancer or this radiation or … can cause cancer. They claim so many things can.” (Female, 18–24) “Yeah, because I think if you’re overweight, you’re probably more unhealthy, well probably a bit more unhealthy, so you’re going to be adding a risk of getting cancer and getting sick.” (Female, 18–24) “Every day they tell us something else causes cancer so it’s hard to know what to believe, you know, you can become very, um, you know, unbelieving of the news when every night.” (Female, 18–24) “I don’t see the difference between it causing cancer and it causing heart disease or causing you to have a stroke or – either way, it’s killing you.” (Female, 18–24) “Cause is a pretty strong word.” (Female, 18–24) “Because I think of all the overweight people. I mean if you believe like the ads for the Biggest Loser or whatever like 20% of so and so, and whatever age group are overweight in Australia you can’t tell me they all have cancer.” (Female, 18–24)

Physical activity prevents cancer Again, this statement was regarded as too direct and too strong. Without the inclusion of a qualifier, participants interpreted the statement as suggesting that all instances of physical activity would prevent all instances of cancer. On the other hand, they appreciated that it was a positively focused message, about cancer prevention rather than a negative one about cancer causes. Some noted that this message was universally applicable, suggesting that all people would benefit from physical activity, and not just those who were overweight.

“That one would apply to everyone … whereas the other one would apply … someone who was overweight or obese would actually look at that one there and say well that applies to me, whereas that one can apply to anyone.” (Male, 25–44) “I never really thought of physical activity preventing cancer.” (Female, 25–44) “Believe it, don’t necessarily care about it … Like not care, as in enough to do something about it, but I definitely believe it, and I’d go ‘oh that’s interesting’ probably true.” (Female, 18–24)

Weight loss prevents cancer As with some of the other statements included in this research, this was assessed as being too strong and direct, with participants commonly wanting to include a qualifier such as ‘can’. On the other hand, participants also appreciated the positive direction of the statement, again indicating that messages about prevention are more palatable than those about cause. Some questioned the appropriateness of this kind of suggestion, given that not all people would necessarily benefit from losing weight. In particular, some participants were especially concerned about how this kind of message would affect those who were thin and those who had a tendency towards eating disorders. Interestingly, this reaction came from both men and women. “‘Prevents’ is good [compared to ‘causes’].” (Male, 18–24) “I don’t think that’s a very good way of putting it because what about anorexic people? You know, you can be unhealthily light, people can have bad habits and be skinny but not do exercise.” (Male, 25–44) “Yeah, that should be about people being overweight and it’s just saying weight loss prevents cancer. What about someone who is completely normal weight … anorexia instead of cancer? … That should tell you more who should be losing weight.” (Female, 25–44) “I think you have to be careful at who you sell that to within some contexts. I mean being completely underweight and being obsessed with weight loss can be unhealthy as well.” (Female, 18–24)

97


It’s simple to measure your risk of cancer: a long belt = more risk; a short belt = less risk.

Men with a waist circumference greater than 101cm have a greater cancer risk compared with those who are 94 cm or less.

Participants understood that this was a simplified way of getting a message across about the link between cancer and waist size. It gave them a simple and visual way of understanding the message.

OR

However, irrespective of their reaction to this particular message, they felt that the statement itself was too simplistic, and some were upset that it was not sufficiently serious for the topic.

As documented previously in this report, the specifics of this message have some capacity to prompt people to measure their waist to find out whether they fit within the recommended guidelines. For some, finding themselves outside the guidelines would then be expected to be one component of motivation towards making a change, and would provide a guideline of what to aim for.

“I find it smug.” (Male, 18–24) “Sounds like they are trying to be funny … it’s serious.” (Female, 18–24) “It gives you a mental picture, like it’s sort of, just imagine someone struggling with their belt trying to get it round a big tummy compared to say, a thin guy, well not thin, but a good weight guy just sort of doing up his belt easily.” (Male, 25–44) “It’s a catchy phrase, but it’s not true.” (Female, 25–44) “I feel like it is making too light of it.” (Female, 25–44) “I just don’t think it is that simple.” (Female, 18–24) “Sounds like someone is trying to be funny.” (Female, 18–24) “Quite patronising, really, that would infuriate me.” (Female, 18–24)

Women with a waist circumference greater than 87cm have a greater cancer risk compared with those who are 80 cm or less.

However, the exact numbers also provoked some debate and a degree of confusion. In particular, participants found it hard to understand how what seemed like a relatively small difference could have the substantial impact that they felt these statements were suggesting. It was also apparent, as exemplified by their recall of other measures of recommended sizes and activity amounts, that without substantial promotion, it is not likely that people would remember these exact amounts, and therefore that the message out take would end up being a general rather than a specific one. The inclusion of an upper and lower figure created a degree of confusion. It was not always clear to participants whether this meant that it was acceptable to be in between these two figures, or whether they should aim to be less than the lower figure. As previously noted, participants were also prompted by these statements to talk about different body shapes, and to claim that these specific guidelines could not be appropriate for all individuals, as other factors such as height, racial background and genetically determined body shape would be relevant.

98

It was apparent that men had more of an idea of their waist size than did women, related to buying pants with sizes in waist measurements. However, within this, it was also apparent that men were more likely to think of their waist in inches than centimetres, as this was typical of jean sizes.

“And you don’t get cancer if you’re skinny.” (Female, 18–24) “Starve myself.” (Female, 18–24) “Maybe get liposuction.” (Female, 18–24) “Measure yourself everyday.” (Female, 18–24)

“I’ve never measured my waist before.” (Male, 18–24) “I’m 94, I think, so I’ve got to start exercising now then, keep it at 94.” (Male, 18–24)

Cancer is not indiscriminate – you can do things to change your risk

“Well, I think most blokes know their waist size, you know, so when they look at that they look at where they are at that moment in time and they compare themselves to that, whether they’re bigger.” (Male, 25–44)

Participants were somewhat confused by this statement. To an extent they interpreted the statement as a suggestion that factors such as genetics were irrelevant, and therefore rejected it.

“I’m a ninety-two so it would be good to have that knowledge so in the back of my mind I’m saying I can’t really get any bigger.” (Male, 25–44)

On the other hand, they understood that lifestyle factors such as diet also played a role in cancer, and therefore accepted the general principle.

“Yeah, and then it’s just a constant stress like oh, I’ve got to lose that extra one centimetre. That’s too many numbers for me.” (Female, 18–24)

Reactions again demonstrated the poor understanding that people have of the notions of risk and causality.

“It doesn’t sound very big.” (Female, 18–24)

Almost universally, the initial reaction to this information was a resounding ‘yes’, indicating that the lack of time was perceived to be a major barrier to physical activity. However, as noted previously, when pushed, almost all participants commented that in fact if they had more time, they were likely to do more of the things they were already doing, and were unlikely to take up physical activity if this was not already a part of their lives.

“That’s a tiny difference, seven centimetres, to all of a sudden have this greater risk.” (Female, 18–24) “I just know what clothing size I am, I wouldn’t have a clue what my waist measurement is.” (Female, 18–24) “It is a good reference point if you wanted to see … to have a goal, or whatever.” (Female, 25–44)

I would do more physical activity if I had more time

“It’d be one of those figures that, like, we couldn’t remember figures before about BMI and all that sort of stuff, you know, you go what was it again? Is it like eighty or ninety.” (Female, 18–24) “I would not go and get a tape measure out and go, ‘oh my god I’m gonna get cancer’.” (Female, 18–24)

99


Conclusions An over arching issue from this research was that the concepts of physical activity and weight management are strongly linked in the community’s perceptions of health and healthy lifestyles. Participants talked about periods of their lives when they were motivated to ‘be healthy’, and that these incorporated both eating and activity behaviours. This suggests that there would be benefits in any strategies and messages being developed to work in combination, rather than separately promoting activity and weight management. A second over arching consideration is the confounding factors associated with motivation for weight loss and weight management. Motivation for weight loss is commonly about looks, either in combination with or rather than, health, and therefore weight loss behaviours are not necessarily the same as health behaviours. Unless weight management messages are couched in a health context they risk the potential of promoting unhealthy behaviours. For example, it will be important that issues associated with eating disorders are taken into consideration in any message development. At a minimum this suggests a need to evaluate any developed communication concepts to ensure that the messages do not have the potential to promote unhealthy eating behaviours and weight management practices. When taken together, these considerations suggest that there is likely to be considerable value gained from developing the communication in the context of general messages about healthy lifestyles. The primary aim of such a campaign would be to increase the priority placed on health as a general construct, with physical activity and weight management being promoted as the mechanisms for getting there. Another consideration is the importance of acknowledging that there are different sets of needs for those who are already some way to doing the recommended amount of physical activity compared with those who are doing nothing. For the former group, information such as the cancer link is likely to add to the motivation to do more physical activity. On the other hand, this information is unlikely to be sufficient to overcome the barriers experienced by those who are a long way from the recommended healthy ideals. This suggests that it will also be necessary to ensure that whatever messages are developed are not detrimental amongst the latter group – that is, that they do not exacerbate barriers with an out take that it is too hard to achieve with regards to the recommendations for activity. In this sense, it will be important that the messages and campaign calls to action are regarded as realistic and do not create the impression that making healthy lifestyle changes are onerous. For example, promoting a staged approach to achieving the ideals would be expected to minimise barriers and self-exemptions. Similarly, there are different needs for those who are close to a healthy weight compared with those who are considerably over a healthy weight. This latter group are aware that their size is a health risk, and it was apparent that the main issues for them were about enabling them to overcome the perceived barriers to making lifestyle changes, rather than relying primarily on information as motivation. It will be important to ensure that any campaign messages do not exacerbate the weight management barriers that they experience.

100

Taking these over arching issues into consideration, this research has identified a range of beliefs and behaviours that could be affected by communication campaigns, which have the potential to affect levels of physical activity and which could potentially contribute to stemming the rise of overweight in the community. These include: •

Increasing awareness of the association between physical activity and cancer. Knowledge of the direct link between physical activity and specific diseases is lower than that for overweight, and would be considered to be one aspect of the information that could contribute to behaviour change.

•

Increasing awareness of the association between overweight and cancer, although this message is probably secondary to that of physical activity, as the health consequences of overweight are already reasonably well accepted.

•

Improving understanding of the recommendations for physical activity, especially in relation to recommended intensity, type and frequency of activity.

•

Promoting physical activity as an everyday activity. Especially for those who are currently doing none or little physical activity, the idea of starting a program of activity is itself a considerable barrier. Promoting forms of physical activity that can be fitted into everyday routines would be expected to make behaviour change more possible.

•

Similarly, promoting an approach to the uptake of physical activity and weight management that is regarded as realistic rather than onerous would minimise rejection of the message.

•

Similarly, for those who are currently doing little or no activity there is a need to promote a message that some activity is better than none, to ensure that those who don’t believe that they can immediately reach the ideals are not put off.

•

Promoting “activity” as opposed to “exercise”, as the latter has additional connotations of effort.

•

There is a specific need to promote the physical activity message to smokers, with the aim of increasing awareness amongst smokers that they are better off exercising even if they haven’t quit, rather than waiting till they stop smoking.

•

Waist measurements. Participants tend to relate their waist measurement to pant size. Commonly, and especially amongst men, this meant that they were more familiar with their size in inches than in centimetres. If specific waist size messages are used, consideration will need to be given to assisting consumers to relate the two measures.

•

Where on the body to measure waist. Men in particular commonly held a misconception that waist was measured at the waist band of their trousers. When conveying specific messages about the link between waist size and cancer, for accuracy of message out take it would be important to ensure that the location for measuring waist is clearly demonstrated in other campaign communications.

101


102

•

The risk of waist fat. To enhance understanding of the waist size message it would be valuable to provide more detailed information about why waist size is problematic. There is already some knowledge that fat around the waist is more of a health risk than fat in other parts of the body, and if the explanation for increased cancer risk is related, promotion of this message would assist understanding and acceptance.

•

Individual differences and acceptance of the message. There are very strong beliefs that individual factors such as height and body type need to be taken into account when determining healthy body sizes and weights, which act as barriers to acceptance of general waist size recommendations. If such messages are promoted, supporting campaign information will be required to document the evidence and reinforce that this message is of relevance independently of other body size factors.

•

Promoting messages about specific waist sizes. It is important to communicate that even for those who believe they can’t get to the ideal sizes; it is still worth reducing their waist size. Some of the larger people in the community will reason that these amounts are beyond them, and therefore that there is little value in reducing their size if they can’t reach what is being recommended.

•

Avoiding the encouragement of unhealthy approaches to weight management. It is also important to ensure that weight loss messages are targeted specifically at people who are in risky weight categories, and are not seen as personally relevant by those who do not need to lose weight and those who risk disordered eating behaviours.

•

Knowledge of diet, nutrition and weight management. While people have some general understandings of these issues, there was a considerable degree of confusion experienced with respect to the diverse and sometimes apparently contradictory nature of messages that exist. People who are attempting to manage their weight would appreciate simple and consistent advice with respect to an understanding of nutrition and the most effective mechanisms for weight loss and weight management.

•

Increasing understanding of the value equation between food and activity. Messages about the amount of activity that is required to use up different foods appears to be quite helpful and motivating, particularly for those who are already doing some activity. However, it is less clear whether such messages have any useful relevance for those who are not already motivated to be active.

Topics for further research Given the breadth of objectives in this project and the consequent limited depth with which some topic areas were covered, there are a range of areas that would benefit from further research into attitudes, beliefs, intentions and behaviours related to issues of weight management and physical activity. These include: •

What are the steps in the process of achieving and sustaining healthy weight and size, and what role does information about health risks play in this process?

•

Similarly, what are the steps in the process of achieving ideal levels of physical activity, and what role does information about health risks play in this process?

•

With respect to differences between people in terms of intentions and behaviours regarding body size management, what role does information about cancer risk play and for whom is it of most value?

•

What is the effectiveness of providing specific measurements for achieving and sustaining healthy weight and size management?

•

What beliefs do people have about food and weight loss diets that affect their approach to weight management? Are these beliefs accurate?

•

What is the role of self-efficacy in weight management and the uptake of physical activity, and what factors affect perceptions of self-efficacy with respect to weight management and physical activity?

•

What role does past history of attempts at weight management and physical activity play in beliefs, attitudes, intentions and behaviours?

103


Index A

F

Alcohol 7, 8, 10, 15, 16, 45

Fat 14, 16, 36

Annual household income 20

Fieldwork period and response rate 17

Awareness 24, 28, 29, 35, 44, 45, 53, 54

Food, Diet and Nutrition 90

Awareness and behaviour 29

Foreword from the Minister 2

Awareness of recommended level 24, 45

Fruit and vegetables 13, 16

B

G

Barriers to achieving body size recommendations 85

Gender and age 18

Barriers to achieving physical activity recommendations 71 Behaviour 23, 36, 45, 49 Benefits of physical activity 78

H Height and weight 40

Body Size and Weight 82 I D Diet 7, 59, 90

Intentions and attitudes 26, 27, 33, 34, 38, 39, 42, 43, 46, 47, 51, 52

Dieting beliefs, attitudes and behaviours 90

Introduction (to the report) 3

E

K

Education 19

Knowledge of health consequences 28, 35, 44, 48, 53

Employment status 20 Encouragers to physical activity 79

L Lifestyle and Cancer Survey November 2006 11–13

104

M

Q

Main language and ATSI 21

Quantitative methodology 16

Methodology 13

Questionnaire development and pilot testing 17

Motivators to achieving ideals 88

Quotas 16

Motivators to Achieving Ideals 78 R References 10 O Objectives of the Lifestyle and Cancer Survey 12 Overview of Evidence 5–9

Research context 13 Research Findings 22 Response to Statements 94

Overweight and Obesity 6, 10, 40

P

S

Parental influence on children’s physical activity and weight management 61

Sample Characteristics 18

Perceived barriers to physical activity 58 Perceived barriers to weight management 59 Perceived benefits and factors that might motivate people to establish and maintain a healthy weight 60 Perceived benefits and factors that might motivate people to increase physical activity 60

Sample size 16 Sample source and participant selection 16 Skin cancer 9, 15, 16 Skin Cancer 10, 49 Smoking Status 21 Sun Exposure 8

Perceptions of health benefits 22 Perceptions of recommendations and norms 69 Physical Activity 4, 6, 7, 10, 69 Physical Activity and Cancer: February-March 2007 101

W What would assist people in increasing physical activity 61

105


106

Contact Directory Cancer Institute NSW Level 1, Biomedical Building Australian Technology Park 1 Central Avenue Eveleigh NSW 2015 Australia PO Box 41 Alexandria NSW 1435 Tel: + 61 2 8374 5600 Fax: + 61 2 8374 5700 Email: [email protected] Web: www.cancerinstitute.org.au Service and business hours: 8.30am – 5.00pm