Thomas von Lengerke

Obesity and health‐related quality of life: Does social support moderate existing associations?

OBJECTIVES Obesity has been shown to be negatively related to physical health-related quality of life (HQOL) much more strongly than mental HQOL. This is remarkable given findings on obesity-related social stigmata and associations with depression. Considering obesity as a stressor, this study tests for a moderating role of social support for obesity/HQOL associations among women and men. DESIGN Data come from N=2,732 participants aged 35-74 years in a 2004-2005 general population survey in the Augsburg region, Germany. METHODS Body weight and height were assessed by anthropometric measurements (classified by body mass index using WHO standards), social support by the Social Support Questionnaire 14-item Short-Form (F-SozU-K14) and HQOL by the 12-item Short-Form Health Survey (SF-12). In multiple regression and general linear models, age, education, family status, health insurance, and place of residence were adjusted for. RESULTS Among both genders, obesity was associated with reduced physical but not mental HQOL. Among men reporting strong social support, physical HQOL was impaired neither in the moderately nor the severely obese group (compared with normal weight), while it was given less social support. Among women, poor physical HQOL was associated with obesity regardless of social support. CONCLUSIONS In this adult population sample, no association was found for obesity with mental HQOL. In contrast, a negative association with physical HQOL exists for all subgroups except men with strong social support, indicating that social support buffers obesity-related impairments in physical HQOL in men but not in women. This suggests that obese women and men with strong social support represent distinct populations, with possible implications for obesity care.

Salivary cortisol in a middle-aged community sample: results from 990 men and women of the KORA-F3 Augsburg study

OBJECTIVE Analysis of salivary cortisol concentrations and derived indices is increasingly used in clinical and scientific medicine. However, comprehensive data on these parameters in the general population are scarce. The aim of this study was to evaluate the concentrations of salivary cortisol in a large middle-aged community sample and to identify major factors associated with altered hormone levels. DESIGN We conducted a cross-sectional study within the Cooperative Health Research in the Region of Augsburg (KORA)-F3 study. A total of 1484 participants aged 50-69 years (52% women) had agreed to provide four saliva samples during a regular weekday. METHODS We measured salivary cortisol concentrations at wake-up (F0), (1/2) h (F(1/2)), 8 h (F8), and 14 h (F14) after waking. We calculated cortisol awakening response (CAR), slope, and area under the curve (AUC(G)) of the circadian cortisol secretion. Sociodemographic and clinical characteristics were evaluated by interview and questionnaires, sampling conditions by protocol. In total, 1208 participants returned saliva samples, exclusion criteria left 990 subjects for final analyses. RESULTS Salivary cortisol levels were (means+/-s.d.) F0=13.7+/-7.6, F(1/2)=20.5+/-9.8, F8=5.4+/-3.3, and F14=2.0+/-1.8 nmol/l. Earlier sampling times were associated with higher CAR and smaller slope. Cortisol secretion was also influenced by gender and smoking habits. Higher perceived social support was associated with lower AUC(G) and smaller slope. CONCLUSIONS We provide data on salivary cortisol concentrations in a large middle-aged community sample. Gender, sampling time, smoking habits, and perceived social support appeared as determinants of cortisol secretion.

Determinants of health policy impact: a theoretical framework for policy analysis.

SummaryThis paper addresses the role of policy and evidence in health promotion. The concept of von Wright’s “logic of events” is introduced and applied to health policy impact analysis.According to von Wright (1976), human action can be explained by a restricted number of determinants: wants, abilities, duties, and opportunities. The dynamics of action result from changes in opportunities (logic of events). Applied to the policymaking process, the present model explains personal wants as subordinated to political goals. Abilities of individual policy makers are part of organisational resources. Also, personal duties are subordinated to institutional obligations. Opportunities are mainly related to political context and public support. The present analysis suggests that policy determinants such as concrete goals, sufficient resources and public support may be crucial for achieving an intended behaviour change on the population level, while other policy determinants, e.g., personal commitment and organisational capacities, may especially relate to the policy implementation process. The paper concludes by indicating ways in which future research using this theoretical framework might contribute to health promotion practice for improved health outcomes across populations.

Determinants of health policy impact: comparative results of a European policymaker study.

SummaryObjectives: This article will use a new theoretical framework for the analysis of health policy impact introduced by Rütten et al. (2003). In particular, it will report on a comparative European study of policymakers’ perception and evaluation of specific determinants of the policy impact, both in terms of output (implemented measures) and outcome (health behaviour change). Policy determinants investigated are goals, resources, obligations and opportunities as related to the policymaking process. Methods: Theory is applied to a comparative analysis of prevention and health promotion policy in Belgium, Finland, Germany, The Netherlands, Spain and Switzerland. The study is MED2-part of a project that has developed a Methodology for the Analysis of the Rationality and Effectiveness of Prevention and Health Promotion Strategies (MAREPS) within the EU-BIOprogram. A mail survey of 719 policymakers on the executive and administrative level selected by a focused sample procedure was conducted. This survey used policymakers’ experience and evaluative expertise to analyse determinants of policy output and outcome. Results: Regression analyses reveal differential predictive power of policy goals, resources, obligations, as well as of political, organisational and public opportunities. For instance, whereas resources, concreteness of goals, and public opportunities have significant importance for health outcome of policy, obligations and organisational opportunities significantly predict policy output. Conclusions: Results are discussed in terms of rationality and effectiveness of health policy. They indicate that six sensitising constructs derived from the theoretical framework represent equivalent structures across nations. They comprise a validated instrument that can be used for further comparative health policy research.

Sense of coherence, health locus of control, and quality of life in obese adults: physical limitations and psychological normalcies

Summary.Objectives:To assess differences between overweight and normal- weight adults in sense of coherence (SOC), health locus of control (HLOC), and health-related quality of life (HQOL).Methods:Cross-sectional population study (Augsburg, Germany). Random sample aged 25‒4 (N = 947). Body mass index (BMI) was categorized into four groups (normal-weight: 18.5–25; pre-obesity: 25–29.9; moderate obesity: 30–34.9; severe obesity: ≥35). The associations between obesity classification and SOC-13T, MHLOC-Scales, and SF-12 summary scores were estimated via analysis of covariance.Results:Adjusted for age and socio-economic status, no differences across BMI-groups related to SOC, internal HLOC, external HLOC-’chance- and SF-12-’mental health’ HLOC-’doctors’ was marginally elevated in obese women. Larger differences pertained to SF-12-‘physical health’ in that it was considerably reduced in obese women and severely obese men.Conclusions:In this adult population sample, obesity is not associated with SOC, HLOC, and HQOL in terms of mental health, but is associated with poorer physical health, which was reported by all groups of obese women, and by severely obese men. These results underline the need to treat and prevent obesity to restore and promote physical HQOL, and to distinguish moderate vs. severe obesity in obesity research.Zusammenfassung.Kohärenzgefühl, gesundheitsbezogene Kontrollüberzeugungen und gesundheitsbezogene Lebensqualität bei adipösen Erwachsenen: physische Einschränkungen und psychische Normalitäten Ziel: Bestimmung von Unterschieden im Kohärenzgefühl (SOC), in gesundheitsbezogenen Kontrollüberzeugungen (HLOC) und in der gesundheitszogenenen Lebensqualität (HQOL) zwischen uber- und normalgewichtigen Erwachsenen.Methoden:Querschnittsurvey einer Zufallsstichprobe der Bevölkerung im Alter von 25–34 in der Region Augsburg (N = 947). Der Body Mass-Index (BMI) wurde in vier Gruppen kategorisiert (Normalgewicht: 18.5.25; Präadipositas: 25.29.9; moderate Adipositas: 30–34.9; starke Adipositas: ≥?35). Die Zusammenhänge zwischen Adipositas-Klassifikation und dem SOC-13T, den MHLOC-Skalen und den SF-12-Summenskalen wurden durch Kovarianzanalysen analysiert.Ergebnisse:Adjustiert für Alter und sozioökonomischen Status wurden keine Unterschiede zwischen den BMI-Gruppen im SOC, internalem und fatalistischem HLOC, und in der psychischen Lebensqualität (SF-12) festgestellt. HLOC-’Ärzte’ war bei adipösen Frauen geringfügig erhöht. Größere Unterschiede betrafen die physische Lebensqualitat (SF-12): die subjektive körperliche Gesundheit war bei adipösen Frauen und stark adipösen Männern im Mittel wesentlich reduziert.Schlussfolgerungen:In dieser Bevölkerungsstichprobe Erwachsener war Adipositas weder mit SOC und HLOC noch mit psychischer Lebensqualität, jedoch mit eingeschränkter körperlicher Lebensqualität assoziiert, und zwar in beiden Gruppen adipöser Frauen sowie bei stark adipösen Männer. Diese Ergebnisse unterstreichen den Bedarf an Behandlung und Prävention der Adipositas zur Wiederherstellung und Förderung körperlicher Gesundheit, und die Bedeutung der Unterscheidung von moderater vs. starker Adipositas in der Adipositasforschung.Résumé.Sentiment de cohérence, « health locus of control », et qualité de vie d’adultes obèses : limitations physiques et normes psychologiquesObjectifs:Evaluer différences présentées par des adultes de poids normal et en surpoids en matière de sentiment de cohérence (SOC), de « health locus of control » (HLOC) et de qualité de vie en lien avec la santé.Methodes:Etude populationnelle transversale (Augsbourg, Allemagne). Echantillon aléatoire (25–34 ans, N = 947). Les indices de masse corporelle (IMC) ont été répartis en quatre catégories: poids normal (18.5–25), pre obèse (25–29.9), obésité modérée (30–34.9), obésité sévère (≥35). Les associations entre cette classification de l’obésité et différentes échelles (SOC- 13T, MHLOC-Scales, SF-12 summary scores) ont été estimées au moyen d’analyses de covariances.Résultats.Après avoir ajusté pour l’âge et le statut socio-économique, aucune différence n’a été trouvée entre les groupes d’IMC en ce qui concerne le SOC, le HLOC interne, le HLOC-’hasard-externe, ainsi que le SF-12-’santé mentale’ Le HLOC-’medecinsétait marginalement élevé chez les femmes obéses. De plus grandes différences ont été constatées dans le SF-12-’santé physique-qui était considérablement réduit chez les femmes obèses et chez les hommes severement obèses.Conclusions:Dans cet échantillon populationnel d’adultes, l’obésité n’est associée ni avec le SOC, ni avec le HLOC, ni avec le HQOL en termes de santé mentale. L’obésité est par contre associée avec une mauvaise santé physique, chez tous les groupes de femmes obèses et par les hommes très obèses. Ces résultats mettent en évidence de besoin de traiter et de prévenir l’obésité de manière à rétablir et à promouvoir la qualité de vie en lien avec la santé. Il importe également de distinguer entre l’obésité modérée et l’obésité sévère dans la recherche consacrée à l’obésité.

Preventing weight gain through exercise and physical activity in the elderly: A systematic review

This review examines the role of exercise and physical activity for preventing weight gain in older people. A structured search using MeSH-vocabulary and Title/Abstract-searches was conducted in PubMed for January 2000 to June 2011, identifying weight gain and exercise or physical activity as study topics, and aged adults as target group. In study selection, all types of exercise and physical activity and any measure of weight change in aged adults (≥65 years) or postmenopausal women were considered. N=9 primary studies were identified. All were conducted in the US, with one study additionally including samples from Canada and the UK. Three studies focused on aged adults, while six concentrated specifically on postmenopausal women. Forms of exercise or physical activity comprised self-reported exercise history in four studies and low, moderate or high intensity exercise interventions in five studies. Four studies combined exercise with a hypocaloric diet and included comparison groups receiving either diet only, health education, stretching or a delayed intervention (one study each). Exercise was associated with weight loss (1.1-6 kg) in all intervention studies, all of which studied an overweight sample, and with weight maintenance in most observational studies, all of which studied a general population or otherwise overweight-unspecific sample. In sum, exercise and physical activity can effectively prevent weight gain in older adults and postmenopausal women either in terms of weight loss or maintenance. They can preserve lean body mass and thus are important for the balance between potentially positive and negative effects of weight reduction in later life. In addition, since all intervention studies were conducted with an overweight sample, it seems that primordial prevention (in terms of preventing the development of risk factors such as excess weight in the first place) might be a neglected issue in geriatric and postmenopausal prevention.

Body weight dissatisfaction by socioeconomic status among obese, preobese and normal weight women and men: results of the cross-sectional KORA Augsburg S4 population survey.

BackgroundBody weight dissatisfaction is an important factor in preventing weight gain and promoting weight loss or maintenance. This study focuses on differences in the rates of body weight dissatisfaction among obese, preobese and normal weight women and men by socioeconomic status within a general adult population in Germany.MethodsData were analyzed from 4186 adults aged 25 to 74 who participated in a cross-sectional, representative population-based health survey (KORA S4, 1999–2001, Augsburg region/Germany). Body mass was measured anthropometrically and indexed following international standards. Among the 2123 women participating in the survey, 40.3% had a normal weight, 34.9% were preobese, and 24.8% were obese (compared to 25.9%, 51.4% and 22.6% among men, respectively). Body weight dissatisfaction, educational level, household income and occupational status were assessed by computer-aided personal interviewing. An index for socioeconomic status was calculated and categorized into quintiles. Multiple logistic regressions were performed to test for differences in the odds of body weight dissatisfaction across socioeconomic strata in normal weight, preobese and obese groups. Body mass index, age, family status, place of residence and health behaviors were adjusted for.ResultsOverall, being dissatisfied with one’s body weight was more prevalent in women (48.3%) than in men (33.2%). In the normal weight group, no significant differences in the odds of being dissatisfied were found across socioeconomic groups among women or men. Among preobese men, compared to the lowest socioeconomic stratum, increased odds of being dissatisfied with one’s body weight were associated with the highest socioeconomic index group (OR = 2.3, 95% CI: 1.4–3.8), middle and high educational level (OR = 1.6, 95% CI: 1.1–2.3, and OR = 1.9, 95% CI: 1.3–3.7), high income (OR = 1.8, 95% CI: 1.2–2.7), and middle and high occupational status (both OR = 1.8, 95% CI: 1.2–2.6). Among preobese women, the odds of being dissatisfied were only significantly elevated in those with a middle educational level (OR = 1.6, 95% CI: 1.1–2.3). Among obese men, elevated odds were found in the highest socioeconomic index group (OR = 3.7, 95% CI: 1.8–7.5) and in those with a high educational level (OR = 2.3, 95% CI: 1.3–4.1), high income (OR = 2.6, 95% CI: 1.4–4.7), and middle and high occupational status (both OR = 2.2, 95% CI: 1.3–3.6). The odds of dissatisfaction among obese women were not associated with socioeconomic status as a whole, but were associated with a high educational level, albeit with a comparatively large confidence interval (OR = 3.6, 95% CI: 1.0–12.8).ConclusionsIn Germany, body weight dissatisfaction is more prevalent among obese and preobese men in high socioeconomic status groups, a pattern not found in women. The exception to this is a greater prevalence of dissatisfaction among obese and preobese women with a high educational level (albeit inconsistently). Moreover, there is a social gradient in body weight dissatisfaction, especially in obese men, which may partly explain why obesity is more prevalent in men with low socioeconomic status. It also suggests that they are a target group for obesity care in which body weight satisfaction is an important topic.

Excess direct medical costs of severe obesity by socioeconomic status in German adults

Objective: Excess direct medical costs of severe obesity are by far higher than of moderate obesity. At the same time, severely obese adults with low socioeconomic status (SES) may be expected to have higher excess costs than those with higher SES, e.g. due to more comorbidities. This study compares excess costs of severe obesity among German adults across different SES groups. Methods: In a subsample (N=947) of the KORA-Survey S4 1999/2001 (a cross-sectional health survey in the Augsburg region, Germany; age group: 25–74 years), visits to physicians, inpatient days in hospital, and received and purchased medication were assessed via computer-assisted telephone interviews (CATI) over half a year. Body mass index (BMI in kg/m²) was measured anthropometrically. SES was determined via reports of education, income, and occupational status from computer-assisted personal interviews (CAPI) (used both as single indicators, and as indexed by the Helmert algorithm); due to small subsample sizes all were median-split. Data of respondents in normal weight (18.5 ≤ BMI < 25), preobese (25 ≤ BMI < 30), moderately (class 1:30 ≤ BMI < 35) and severely obese (classes 2–3: BMI ≥ 35) range were analysed by generalized linear models with mixed poisson-gamma (Tweedie) distributions. Physician visits and inpatient days were valuated as recommended by the Working Group Methods in Health Economic Evaluation (AG MEG), and drugs were valuated by actual costs. Sex, age, kind of sickness fund (statutory/private) and place of residence (urban/rural) were adjusted for, and comorbidities were considered by the Physical Functional Comorbidity Index (PFCI). Results: Excess costs of severe obesity were higher in respondents with high SES, regardless of the SES indicator used. For instance, annual excess costs were almost three times higher in those with an above-median SES-Index as compared with those with a median or lower SES-Index (plus € 2,966 vs. plus € 1,012; contrast significant at p<.001). Mediation of excess costs of severe obesity by physical comorbidities pertained to the low SES-Index and the low occupational status groups: differences in costs between severe obesity and normal weight were still positive, but statistically insignificant, in the lower status groups after adjusting for the PFCI, but still positive and significant given higher SES. For example, severe obesity’s excess costs were € 2,406 after PFCI-adjustment in the high SES-Index group (p<.001), but € 539 in the lower status group (p=.17). At the same time, physical comorbidities as defined by the PCFI increased with BMI and decreased with SES, however the factors BMI and SES did not significantly interact in this context. Conclusions: To our knowledge, this is the first study to show in Germany that excess direct medical costs of severe obesity are not distributed equitably across different SES groups, do not reflect comorbidity status, and are significantly higher in those with high SES than in those with lower SES. Thus, allocation of health care resources spent on severely obese adults seems to be in need of readjustment towards an equitable utilization across all socioeconomic groups.

Research utilization and the impact of health promotion policy

SummaryObjectives:The conditions under which research utilization leads to policy impact are an important issue in health promotion. This analysis tests the assumption that utilization is positively associated with policy impact only if both political will (i.e., policy opportunities) and social strategies (in intervention and implementation) are present. Methods:A survey of 719 policymakers involved in four poli-cies was conducted in six European countries. Policy impact (output, i.e., program implementation, and outcome, i.e., effects on behavior) and its proposed determinants were analyzed. Results:Regression analyses reveal limited cross-national differences in research utilization, but show comparably high use in policies with a pathogenic focus. Utilization is associated with impact only if political will is lacking; for outcome, this tends to depend on social strategies. Political will is the strongest determinant of impact. Conclusions:Research utilization is not supporting health promotion policy impact if political will is favorable, but if it is poor; political will itself is the crucial determinant of impact. The study contributes to the “research utilization”-field by showing that research utilization may partially compensate for lack of, rather than depend on, political will.

Editorial: Health psychology and public health--bridging the gap.

Limburgs Univ Ctr, Diepenbeek, Belgium. Queensland Univ Technol, Brisbane, Qld, Australia. GSF, Natl Res Ctr Environm & Hlth, Neuherberg, Germany.Vinck, J, Limburgs Univ Ctr, Univ Campus, Diepenbeek, Belgium.