educational attainment and obesity a systematic review

• Open access
• Published: 15 January 2022

Links between obesity, weight stigma and learning in adolescence: a qualitative study

• Rebecca Langford 1 ,
• Alisha Davies 2 ,
• Laura Howe 1 &
• Christie Cabral 3  

BMC Public Health volume  22 , Article number:  109 ( 2022 ) Cite this article

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Educational attainment is a key social determinant of health. Health and education are linked by multiple pathways, many of which are not well understood. One such pathway is the association between being above a healthy weight and lower academic achievement. While various explanations have been put forward to explain this relationship, evidence for causal pathways is sparse and unclear. This study addresses that evidence gap.

We interviewed 19 adults (late 20s; 14 female, 5 male) and one young person (14 years, male) from the UK in 2019/2020. Participants were recruited from the ALSPAC 1990s birth cohort, sampled to ensure diversity in socio-economic status and educational attainment, and a community-based weight management group for young people. Interviews focused on experiences of being above a healthy weight during secondary school and how this may have affected their learning and achievement. Interviews were face-to-face, digitally recorded, and transcribed verbatim. We analysed the data thematically.

We identified key pathways through which higher body weight may negatively impact educational performance and showed how these are linked within a novel theoretical model. Because larger body size is highly stigmatised, participants engaged in different strategies to minimise their exposure to negative attention. Participants sought to increase their social acceptance or become less socially visible (or a combination of both). A minority navigated this successfully; they often had many friends (or the ‘right’ friends), experienced little or no bullying at school and weight appeared to have little effect on their achievement at school. For most however, the behaviours resulting from these strategies (e.g. disruptive behaviour, truanting, not working hard) or the physical, social or mental impacts of their school experiences (e.g. hungry, tired, self-conscious, depressed) made it difficult to concentrate and/or participate in class, which in turn affected how teachers viewed them.

Conclusions

Action to combat weight stigma, both within schools and in wider society, is urgently required to help address these educational disparities that in turn can impact health in later life.

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Introduction

The relationship between education and health is synergistic. Educational attainment is a key social determinant of long-term health outcomes [ 1 , 2 , 3 ] and a predictor of adult obesity [ 4 ]. In turn, health status, particularly during adolescence, has an impact on educational attainment and lifetime social outcomes [ 5 ]. The multiple causal pathways linking education and health are complex and many gaps remain in this evidence base [ 5 , 6 , 7 ]. One such gap is the association between being above a healthy weight and lower academic achievement [ 8 , 9 , 10 , 11 ]. Various direct and indirect explanations have been posed to explain the relationship between body weight and academic achievement, including health-related absences [ 12 ], differences in cognitive processes [ 13 ], the impact of weight-related bullying [ 14 ], and the unconscious bias of teachers [ 15 ]. However, empirical evidence to support these hypotheses is scarce and inconsistent, making it hard to draw clear conclusions [ 16 , 17 ].

The pathways linking body size and academic achievement are likely to be highly complex and socially constructed. There have been surprisingly few qualitative studies which ask young people their views on this issue. Most focused on the psychosocial impact of having a larger body size or their experience of treatment for their ‘condition’ (see [ 18 ]). Of those conducted within educational settings, just three examined how weight might affect educational performance. Martin et al. [ 9 ] found teenage girls with obesity felt they spent more time on schoolwork due to the absence of friends. Brown [ 19 ] described how the physical discomfort felt by American undergraduates using chairs and desks that were too small for them made them feel unwelcome in the classroom. Kenney et al. [ 20 ] reported teachers felt students with obesity were more likely to struggle at school, with low self-esteem and weight-related bullying believed to reduce participation in class. Our current understanding of how weight status impacts on learning is therefore limited.

This study sought to build on and expand the findings of earlier literature by using in-depth interviews to explore pathways through which weight may affect learning in secondary school. We approached this project viewing obesity as resulting from the interplay between genetic predisposition and exposure to obesogenic environments [ 21 ]. However, obesity is a highly stigmatised condition and weight stigma is a stressor which can promote weight gain [ 22 , 23 ]. Adolescents may be particularly vulnerable to the negative social and emotional consequences of weight stigma [ 24 ]. Understanding these experiences and how young people react to them may help us better understand the link between weight and academic achievement during adolescence, and importantly, inform approaches to ensure all children achieve their educational potential.

Population, recruitment and sampling

We recruited adult participants from the Avon Longitudinal Study of Parents and Children (ALSPAC). This is a UK population-based birth cohort which recruited 14,541 pregnant women from Bristol and the surrounding areas between April 1991 to December 1992 [ 25 , 26 , 27 ]. Biological and behavioural data have been collected from this cohort from before birth to early adulthood; participants were 27–28 years at time of recruitment. A link between higher Body Mass Index (BMI) and lower academic attainment has been established in this cohort [ 28 ]. (Additional cohort details in supplementary material ).

We emailed participants inviting those who self-identified as being above a healthy weight during secondary school to take part in an interview. We contacted interested participants by phone/email to answer questions and collect brief background data to allow sampling of participants from diverse socio-economic situations and with a range of educational attainments based on self-reported grades.

In addition, we attempted to recruit young people who were currently above a healthy weight via community-based weight management services for young people (11–16 years). Working with services in two local authority areas (Bristol and South Gloucestershire), we invited current participants of weight-management groups to take part. Only one young person (14 year-old male, “Tim”) agreed to be interviewed.

Sample size was not pre-determined allowing data collection to continue as new ideas were identified [ 29 ]. By the final interviews (participants 16–20) we saw consistency in content with previous interviews with no new substantive themes identified. We were unable to interview two further participants who had expressed interest; all data collection with the ALSPAC cohort was suspended in March 2020 due to the Covid-19 pandemic.

Data collection

Participants were interviewed by RL (lead researcher) face-to-face between July 2019-Feb 2020. Interviews focused on participants’ experiences at school, feelings about their size, and if/how their weight affected learning at school. We developed a topic guide to facilitate a sensitive and flexible approach to interviewing (see supplementary materials ). We adapted our methods for adult and young person interviews, recognising the differences in focus: retrospective reflections or descriptions of current lived experience. Retrospective ‘life history’ interviews [ 30 ] proved useful with adult participants, allowing them to reflect on the links between weight and their educational experience as a whole. To facilitate this, we constructed a timeline with participants during the interview allowing them to identifying key moments in their educational career (e.g., moving to a new school, performance in exams, periods of bullying) while documenting changes in their weight over the same period. The topic guide for the adolescent participant did not use a timeline and focused on experiences since starting secondary school. Interviews were usually an hour long, digitally recorded, and transcribed verbatim. Audio-files, consent forms, anonymised transcripts and timelines were stored securely. We reimbursed participant travel costs and provided a £20 shopping voucher as thanks. Participant names are pseudonyms.

Data analysis

Transcripts were analysed using a thematic approach [ 31 ]. Transcripts were read by RL (lead researcher) and CC (member of the study team) to familiarise themselves with the data, independently noting potential codes. Through discussion we developed these into a coding framework which was subsequently applied to further transcripts by RL. We made additions and modifications to this framework as necessary, meeting regularly to discuss coding and development of our analysis. Codes were grouped together, split into sub-codes, subsumed into higher-level concepts and ordered hierarchically to eventually create overarching themes and sub-themes. We explored relationships between codes/themes and potential causal pathways by visually ‘mapping’ these concepts. This map was revised iteratively as analysis progressed to create our final theoretical model (Fig.  1 ). We used NVivo12™ to facilitate data management and interpretation.

How “survival strategies” adopted by students with larger bodies can affect learning. Theoretical model showing how different “survival strategies” can impact on feelings and behaviours and potentially impact on learning. The two strategies are not mutually exclusive: participants could seek to increase social acceptance while still experiencing discomfort at school (indicated by dotted line)

Public involvement

We consulted a young people’s advisory group ( https://arc-w.nihr.ac.uk/news/power-to-the-young-people/ ) and local secondary school teachers to advise on recruitment approaches, appropriate methods, and the study focus. Following this advice, we use terms such as “larger bodies” or “above a healthy weight” when discussing our data and “obese” and “overweight” when citing published literature. We discussed our findings with staff ( n  = 40+) at a local school conference and with another young people’s advisory group (17 participants, aged 16–21 years: https://decipher.uk.net/public-health-improvement-research-networks-phirns/public-involvement-alpha/ ). These were conducted online due to Covid-19 restrictions.

We interviewed 19 adults (27–28 years) and one young person (14 years) in total (14 females, 6 males). Table  1 provides a summary of participants’ educational achievement and socio-economic status.

Through our analysis we constructed three key themes. The first two – “increase social acceptance” and “be invisible” – represent "survival strategies" used by participants to navigate the complex social world as a student with a larger body. The third theme focuses on the impact of these strategies on their ability to learn. From these themes we constructed a theoretical model to explain the way(s) in which body size may affect learning (Fig. 1 ).

Theme 1: increase social acceptance

Social acceptance and friendships were key to navigating the school social world. “Loners” with larger body sizes were an “easy target”. Friends offered protection against bullying or teasing. The wider your friendship circle or the more popular your friends, the greater the protection offered against weight-based teasing. As Rachel explained, people rarely bullied her “because I was probably friends with one of their friends… I was kind of in a little safe zone.”

Participants appeared to cultivate certain social identities to enhance social acceptance. Some of these identities worked well, increasing people’s acceptance and confidence, and potentially benefiting (or not harming) their ability to learn. However, more commonly these identities were associated with behaviours likely to inhibit learning.

Several participants described themselves as one of the “naughty kids” who messed about to make people laugh. Suze explained she was “quite naughty… the class clown” and had “no respect for teachers”. She speculated this behaviour was to gain social acceptance: “I don’t know if that was trying to make people like me maybe… to get attention from the other kids?” Jack linked his class clown role to his insecurity around his weight: “In hindsight [I] probably was doing it to fit in, to impress.” Tim, the 14 year-old participant, was more matter of fact: “You want to be seen as a cool person so you’d do bad things, get sent to isolation ”.

For Kerri, her disruptive behaviour was about finding a place to fit in. To be “in” with the popular girls “you have to be really skinny and pretty”. Her exclusion from this group pushed her towards the “naughty kids” who accepted her: “ You feel like you don’t fit in so then you turn to be a bit mischievous and stuff. You get in with those sorts of people. They’re like the same.”

Gareth recognised being the “jokey kid” would make people like him, making him less of a target for bullying. As he explained, “if I’m not going to be one of the good-looking kids because of my size, then maybe being someone with a nice personality will help me make friends?” His social acceptance was cemented later in school when his size made him a valued rugby player shifting him “a bit more up the social ladder” and widening his friendship circle to include “all the cool jock kids”.

Sean benefitted from friendship with two of the most popular boys in school, former primary-school friends. This association meant he was “saved from the brunt” of weight-based teasing: “If someone did make a comment straight away, one of my other friends would’ve been like, “F*** off. Don’t talk to him like that….”

In some cases, constructed identities positively impacted on learning. Isobel was acutely insecure about her weight at her private school. Struggling initially to make friends, she developed a bookish personality:

I wasn’t able to control my weight but I can control this idea of making myself do lots of work… I definitely put a lot of energy … into making sure I would be seen in teachers’ eyes as someone who was academically able.

Amanda described herself as “ a bit nerdy.” In her private school context, her academic achievement was a valuable social identity, giving her a confidence which she described as a “shield” against negative attention. State school student Hannah used her status as a “bright” student to create links with other people: “I was able to help my friends and people that weren’t necessarily my friends… they could come to me and I could help ”.

In some cases, creating a valued identity was not about developing a more acceptable personality, but simply attaining the ideal “slim” body. Around 15/16 years Alexa became unhealthily obsessed with “major calorie counting”, rapidly losing weight over a summer holiday. Where previously she had felt “segregated” because of her size, her new slim body brought a change: “[When I] lost the weight…that bullying went away. I definitely can see there is a link.”

Similar stories were reported by other female participants. Isobel was deeply unhappy “being the fat one” and “starved” herself to lose weight. Likewise, Suze and Emma lost weight to fit in with others and increase their self-confidence. Amy naturally became slimmer in her final school years and noted the social benefits of her new slim body. Whereas before she was badly bullied, “ in Year 11 people actually started to come round and actually speak to me. That I entirely put down to the fact that I [had] a smaller body”.

Theme 2: be invisible

For participants who struggled to forge friendships and gain social acceptance, an alternative strategy was to become as invisible as possible at school. Many participants felt rejected and bullied because of their weight. Consequently, they tried to avoid attention. Though Gareth later gained popularity by being the “jokey” one, initially he tried to “fly under the radar” explaining, “you’re just the short fat kid… keep your head down… There’s no point sticking out.” Similarly, Amy described gravitating to people who did not stand out: “I put myself automatically with the people that didn’t get noticed.”

However, the strategies used to become “invisible” or the consequences of failing to remain inconspicuous often resulted in participants feeling deeply uncomfortable at school.

Physically uncomfortable

Several participants described never eating at school for fear of comments or teasing, resulting in persistent feelings of hunger or lethargy. As Matt explained “ I was really worried that if I was eating food, people would be like, “Oh my God, he’s that big and he’s eating food.“ Other participants talked about physical discomfort related to clothing. Some wore loose, baggy layers to disguise their bodies which made them deeply uncomfortable during warmer months: “Even during heat waves I would never take my jumper off. I was ill from it because I would just never want people to see my body” (Amy).

Socially uncomfortable

Most participants were extremely self-consciousness of their appearance. They described feeling “insecure”, “lacking confidence” and being acutely aware they were “different”. This social uncomfortableness could dominate their everyday experience of school. Sarah felt deeply isolated because of her weight: “just being very self-conscious with no confidence and… every day going in and being on my own ”. Rachel described a pervasive anxiety that attention might fall on her at any moment:

Even if you’re just sat in assembly … They’re chatting about the top male rugby players but you’re still like, “What if they say my name, then attention is going to be drawn to me?” You’re that worried about it.

Mentally uncomfortable

Many participants described being left out, teased or bullied about their weight throughout school. Many also described feeling unhappy about their body size. However, for some participants their experience went beyond discomfort and unhappiness into what they described as depression and/or anxiety. Lauren described the link between her mental health and weight and how this exacerbated her isolation in school: “Anxiety, depression and my weight have followed me all the way through my life… I just became very withdrawn found it hard to communicate with people… I didn’t know what to do with myself”.

In some cases, participants started to skip classes. Kerri explained she truanted because “I felt quite depressed at times. I would actually walk… out of school and go home ”. Kirsty similarly truanted, initially because she was so unhappy at school, but later to avoid further bullying: “ all my other friends were doing it then… I thought the bullying would start again, so I just followed them”.

Theme 3: impact on learning

A minority of participants appeared to successfully navigate school with no perceived detriment to learning. Amanda, Sean and Gareth were all confident, had good friends and largely avoided any weight-based bullying. Consequently, weight had little impact on their behaviour or performance at school. As Amanda concluded, “I was very well-behaved, I took part in class, had a good relationship with my teachers and I felt confident.” In another case, body size potentially improved learning and achievement. Though Isobel lacked social confidence, her insecurities also motivated her to apply herself: “[my weight] made me more insecure in school, but in a way it pushed me to be like, ‘I’m going to work harder.’”

However, most participant narratives suggested a detrimental impact on learning, through reduced participation and concentration in class or how teachers viewed them.

Participation

Participants who tried to be “invisible” at school would rarely participate in class. They talked about being “worried,” “anxious,” and even “terrified” at having to speak in class. They seldom answered questions or volunteered and were reluctant to seek help from teachers for fear of drawing negative attention.

I think a lot of it came from being in class and not wanting to be asked questions and looked at. That made me worried, it made me feel uncomfortable, and just not want to be there. (Emma)

Depression could also affect classroom participation. Lauren felt unable to participate because “you just don’t have any give in you anymore to be an active member of the class.” Overall, the common picture described by these participants was of a passive classroom experience. As Kirsty described, “I just sat there and listened and wrote in my book. I never really took part” .

Concentration

Participants described multiple ways in which their concentration was impaired. For some, it was as basic as being too hungry or tired to concentrate having skipped meals at school. Several talked about “zoning out” or “drifting off” in class: “I would be falling asleep… in lessons I wasn’t focused because I hadn’t eaten anything” (Matt).

Participants who identified as “naughty” described a lack of attention in class. Jack felt insecurities about his weight led him to mess about in class to make others like him, explaining, “I was always quite socially conscious within the classroom and never really particularly focused ”. Suze similarly played up in class to impress friends, explaining she would “just be really bad…. not listen at all, just basically talk over [the teacher] or not sit and work.”

Other participants linked poor mental health to impaired concentration. Alexa and Isobel both described persistent feelings of weight related social anxiety at school making it hard to focus on anything else: “You’re just constantly thinking that you don’t want to be that weight” (Alexa). Amy’s depression led to suicidal thoughts which meant she couldn’t focus in class: “I would just think about [suicide] all the time.” Lauren noted the profound effect depression had on her ability to learn:

I wasn’t concentrating… I wasn’t really paying attention. Because I was depressed about the way I looked nothing would go in… My brain physically couldn’t comprehend things because there was so much in there already.

How teachers view you

Some participants felt they were unfairly labelled as “troublemakers” by teachers. Matt was disciplined for swearing at a teacher and refusing to take part in PE lessons. Exposing his body while getting changed was traumatic and a key trigger for bullying (of which his teachers were unaware). Tim (14 year-old) had purposely been naughty in class the previous year to impress others, but was now working harder in school. However, he felt his teachers had failed to acknowledge his improved efforts and continued to view him as naughty “because of last year [and] how I acted.”

Some felt teachers simply saw them as shy, quiet students. Some teachers tried to get students to speak in class, which participants often found a deeply uncomfortable experience. Others seemed to realise how difficult this was and left them alone. However, as Rachel suggests, being “invisible” in class meant teachers were perhaps unaware of students’ true potential.

Half the time they probably didn’t even know you knew the answer. They just think people are shy and just need to get over it. They don’t think, “Why is that person shy?” They don’t really look.

Did participants feel their weight affected their learning?

Most participants saw a clear link between how they felt about their bodies, their behaviour and experiences in school, and their ability to learn. Several participants felt they would have been more confident and more willing to take part in class had they been thinner in school. Others suggested they would have been less likely to mess about in class. Jack felt he might have been “less of a prat” in class if he had felt more confident, while Kerri believed “if I was skinny I would be with the pretty girls wh[o] were never naughty.” Kirsty was aware she would have engaged more and truanted less if not bullied: “I would’ve participated better. I would’ve wanted to be in that class, I would’ve known a lot more than skipping it.”

Overall, many participants felt they would have done much better at school under different circumstances. Importantly, this was not just expressed by those who did less well at school, but also by those with good grades but who felt they had not fulfilled their potential:

I passed, but I could have easily got a distinction… I could have probably done better if I had focused more but…learning was really difficult because I was in an environment I didn’t want to be in all the time. (Amy)

Our study is one of the first to explicitly explore the relationship between body size/weight and educational attainment drawing on lived experience. We constructed a novel, theoretically informed model illustrating potential causal pathways. To understand our results, we drew on Major & O’Brien’s [ 32 ] Identity Threat Model of Stigma. This model suggests individuals become aware they possess a stigmatising attribute and consequently belong to a devalued group. This awareness results in a threat to their identity when the demands imposed by a stigma-relevant stressor (e.g. large body size) are viewed as a) potentially harmful to one’s social identity and b) exceeding one’s personal resources to cope with those demands ([ 32 ]:p399). Major & O’Brien link coping mechanisms with the body’s fight or flight instincts, characterising them as either “engagement” or “disengagement” strategies. Importantly, this model emphasises the variability in responses to stigma, noting that “high status” and “low status” groups will interpret and react very differently to being the target of a stigmatised stereotype.

Viewed through this lens, the behaviours and experiences described by our participants make sense. All participants were aware their weight made them vulnerable to negative attention – a potential threat to their identity. Some participants “engaged” with this threat, mitigating it by actively seeking to create social acceptance in other ways: by being “popular” or “naughty”, developing a “nerdy” identity or dramatically losing weight. Others, lacking the resources to create social value in other ways, attempted to avoid this threat by becoming inconspicuous and “invisible” as far as possible.

As predicted by the Identity Threat Model, the impact of weight stigma on learning was not universal. A minority of participants did not appear to experience negative impacts on their learning. These participants were “popular” or well-liked for some reason, giving them higher status. In this context, though aware of the stigma attached to their weight, this threat did not exceed their resources to cope with this demand. For others, the impact on their learning was more significant as their behaviours or negative experiences impacted on their ability and willingness to participate and concentrate in class. Once again, this fits with Major & O’Brien’s [ 32 ] theory, which suggests strategies employed to achieve one goal (e.g. preserve self-esteem) may hinder the achievement of others (e.g. academic performance).

Links to wider literature

Many of our participants reported a lack of engagement in classroom activities which may have impaired their learning. Student engagement comprises behavioural, emotional and cognitive elements [ 33 ] and is commonly viewed as essential to successful learning. A recent meta-analysis found engagement to be an important predictor of academic achievement [ 34 ]. The largest effect was found for the “behavioural” dimension suggesting that conduct, effort and participation in class may be driving this association. Corroborating our qualitative findings, a recent study by Finn and colleagues [ 16 ] found classroom participation was lower for students with higher BMIs and concluded this mediated the relationship between weight and academic attainment.

Difficulty concentrating in class was also raised by many of our participants, often linked to skipping meals or poor mental health. Though skipping breakfast has been associated with poorer cognitive or educational outcomes [ 35 ], the impact of skipping lunch is less clear [ 36 ]. Nonetheless, several participants discussed being distracted by feelings of hunger or lethargy in class. A minority of participants also described impairing levels of anxiety and depression during secondary school, often related to their weight. Several studies have found people with obesity are more likely to experience depression [ 37 , 38 ] and anxiety [ 39 ] and these experiences may plausibly inhibit academic attainment [ 40 ].

Our findings complement Kenney et al.’s [ 20 ] study on teacher perspectives of students with obesity. Teachers suggested these students often fell into stereotypical personality types. Most were characterised as shy, reserved and reluctant to participate, congruent with our “be invisible” theme. However, teachers also suggested they could be “class clowns” or bullies. While some of our participants identified as clowns, unsurprisingly none identified themselves as bullies. Nonetheless, such behaviour is compatible with our theoretical model as a means of creating social acceptance by picking on weaker peers.

Kenney et al. (2017) also suggested a minority of teachers held negative views about students with obesity and treated them unfairly. We found little evidence of unfair treatment in our participants’ narratives, but several suggested teachers underestimated their true potential, mistaking their lack of participation as shyness or lack of knowledge or interest. Other studies showing students with obesity are perceived as less capable [ 15 ] or are given lower grades by teachers [ 41 ] suggests unconscious teacher bias may be a route through which academic achievement is impaired.

Implications

Action is needed on multiple levels to encourage students with larger bodies to participate in class and improve educational attainment. First, schools should adopt a zero-tolerance approach to weight-based bullying with explicit reference to this in anti-bullying policies and practices. A cross-national study identified “being fat” as the most likely reason for youth bullying, far ahead of other characteristics like ethnicity or sexuality [ 42 ]. Yet a review of 10 systematic reviews and meta-analyses found none of the 275 included interventions explicitly addressed weight-related bullying [ 43 ], perhaps reflecting that weight stigma remains one of the last acceptable forms of discrimination [ 44 ].

Second, research is needed on how best to address weight stigma within educational settings. School-based interventions can increase personal body satisfaction [ 45 ], but research on reducing weight bias in school settings is scarce. A review by Daníelsdóttir et al. [ 46 ] identified only two weight-bias reduction interventions targeting adolescents (with mixed effects), while Nutter et al. [ 47 ] identified five interventions with pre- or in-service teachers (with largely positive effects). Further development, co-production and evaluation of such interventions is urgently required.

Finally, work remains to be done at a societal level to address weight bias. Beliefs that obesity is the result of unhealthy behaviours and reversible through personal effort are widespread [ 48 ], despite extensive evidence for the genetic, environmental and commercial determinants of obesity [ 21 , 49 ]. Those who view obesity as a matter of personal responsibility are also more likely to hold weight-stigmatising views [ 50 ]. The media plays a part here: Flint and colleagues found “unequivocal evidence” of weight stigmatization in UK national newspapers [ 51 ]. Even public health obesity campaigns have been accused of increasing weight stigma [ 52 , 53 , 54 ]. Interventions to address the determinants of obesity must avoid inadvertently increasing weight stigma, particularly when targeting young people.

Limitations

Participation was based on self-identification as being “above a healthy weight” during secondary school, rather than BMI measurements. Most of our interviews (19/20) were with adults and offer a retrospective ‘life history’ account of their secondary school experiences. Such interviews offer rich understandings of the experiences at a certain point in life but may be subject to recall bias and post-hoc interpretation. We also sought to recruit young people (11–16 years) to explore current lived experiences but were only able to recruit one young person. While this young person’s narrative raised similar issues to our adult participants, it presented current lived experience rather than a reflection on past events. Additional interviews with young people would have strengthened the study.

We discussed our findings with young people and teachers in two on-line discussion groups. Both groups felt our findings were largely congruent with their own experiences. Social media and cyber-bullying were raised in both groups, neither of which were prevalent when most of our participants were at school in the 1990s. These issues warrant further investigation as to how they add to or change our theory.

The interviewer (RL) is a slim white woman. She was mindful of the “slim privilege” [ 55 ] this afforded her in conducting this study. It is possible her weight status affected the data collected during these interviews. However, she developed good rapport with participants and conducted interviews with sensitivity and respect.

A growing body of evidence suggests an important link between higher body weight and reduced academic attainment which in turn influences lifetime health outcomes. Our research elucidates the pathways through which weight stigma may impact behaviours in school and thus potentially affect learning and educational achievement. Action to combat weight stigma, both within schools and in wider society, is urgently required.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. This request will be subject to the approval of ALSPAC and the Data Access Committee at the University of Bristol. Restrictions apply to the availability of these data, which were used under licence for this study.

Abbreviations

Avon Longitudinal Study of Parents and Children

Body Mass Index

United Kingdom

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Acknowledgements

We are very grateful to all the participants who took part in this study. We also offer thanks to the REACH and Alive ‘N’ Kicking teams for their help with recruitment. We thank the youth advisory groups (ALPHA and Bristol BRC/ARC West YPAG) and teachers we spoke to for their valuable input in designing the study and interpreting the findings. We thank Ali Heawood for her input into the design of the study in the early stages of the research. We acknowledge the support of the National Institute for Health Research Clinical Research Network (NIHR CRN). With reference to the wider ALSPAC study: we are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them, and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. We also offer thanks to Claire Bowring, Kristina Lewis, Emma Roberts and Amanda Hughes for their assistance on this project. Finally, we are grateful to the Health Foundation for funding this work as part of their Social and Economic Value of Health programme (award number: 807293). The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK.

This project was funded by The Health Foundation as part of their “Social and Economic value of Health” programme (award number: 807293). The UK Medical Research Council and Wellcome (grant reference: 217065/Z/19/Z) and the University of Bristol provides core support for ALSPAC. This publication is the work of the authors who will serve as guarantors for the contents of this paper. A comprehensive list of grants funding is available on the ALSPAC website ( http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf .)

The funders had no role in the design of the study; the collection, analysis and interpretation of data; the writing of this article; or the decision to submit it for publication.

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RL design the study, managed the project, recruited and interviewed participants, led the analysis and wrote the first draft of the manuscript. CC supervised RL and was involved in coding, analysis and writing of the manuscript. AD helped secure funding for the project, advised on the focus and design of the study and reviewed and edited the manuscript. LH was Principal Investigator for the project, secured funding, helped design the project and reviewed and edited the manuscript. The authors read and approved the final manuscript.

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Ethical approval for this study was obtained from the ALSPAC Ethics and Law Committee (86964) and the Faculty of Health Sciences Research Ethics Committee (85702) at the University of Bristol. The study protocol was performed in accordance with the relevant guidelines. Written, informed consent was obtained for participation in the interviews from adult participants; written informed consent was obtained from the parent of our 14 year-old participant, alongside written assent from the young person himself. Consent for the use of socio-economic data collected via questionnaires was obtained from participants following the recommendations of the ALSPAC Ethics and Law Committee at the time.

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The relationship between obesity and tertiary education outcomes: a systematic review

• Andrew J. Hill   ORCID: orcid.org/0000-0003-3192-0427 1 , 2 ,
• Rocio Rodriguez Lopez 1 &
• Ian D. Caterson 2  

International Journal of Obesity volume  43 ,  pages 2125–2133 ( 2019 ) Cite this article

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Previous reviews have documented an overall weak or uncertain association between obesity and school-based educational attainment in children and young people. However, up to half of young adults will go on to further college or university education by age 30. The study aim was to systematically review evidence on the association between obesity and tertiary education outcomes in young men and women. A search of multiple databases, including Embase, Global Health, ERIC, Medline, PsycInfo, and Science Citation Index was conducted in March 2018. Cross-sectional and longitudinal studies were included that reported on young people aged 16+, an association between obesity and academic achievement, and a comparison to healthy weight students. Risk of bias was assessed using criteria from the STROBE checklist. From 1297 records, 16 studies met all inclusion criteria. All six cross-sectional studies and 8/10 longitudinal studies reported lower educational achievement by students with obesity. All longitudinal studies were at low risk of bias but four cross-sectional studies were at medium risk and two at high risk of bias. Three of four studies showed reduced enrolment, in 6/8 graduation was less likely, and all 6 studies reporting on performance showed this was lower in those with obesity. Five of nine studies reported that obesity had a greater impact on educational achievement for women. Overall, there is compelling evidence of weight bias in that students with obesity do less well in tertiary education than their healthy weight peers. It is likely that university/college attainment is less impacted by socio-economic factors than school-based achievement. A better understanding of the processes that underpin this weight bias is needed, including stakeholder (student, staff) experiences of weight stigma, perceived or enacted. Responsive actions could mirror those to address disability or gender bias, or in health promotion in tertiary education settings.

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Hill, A.J., Rodriguez Lopez, R. & Caterson, I.D. The relationship between obesity and tertiary education outcomes: a systematic review. Int J Obes 43 , 2125–2133 (2019). https://doi.org/10.1038/s41366-018-0256-1

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Read our article in the Health Education Journal, from June 2013.  

What do we want to know?

There is currently great concern about levels of obesity in the UK, and its negative physical, psychological and social impacts. Current research suggests that there may be a relationship between obesity and poor educational attainment. It is likely that obesity and poor school performance are elements of a broader picture of inequalities in health and education, whereby disadvantaged socio-economic groups tend to have poorer health and lower levels of education. However, it is possible that other factors influence obesity and attainment, such as gender, discrimination and poor mental and emotional well-being.

This systematic review was therefore commissioned to address the question: What do we know about the relationship between childhood obesity and educational attainment, from the research literature?

Who wants to know?

This review will inform policy-makers, commissioners, practitioners, and researchers who have a remit to explore policy issues or to promote or conduct research on children and obesity; also teachers, head-teachers, local authority officers and others involved in the education system.

What did we find?

• Is there a statistical association between obesity and educational attainment?

While often conflicting, an overall pattern emerges from the research evidence suggesting that there is a weak negative association between obesity and educational attainment in children and young people; i.e. that higher weight is associated with lower educational attainment. Obesity is also associated with other variables, such as socio-economic status, and when these other variables are taken into consideration, the association between obesity and attainment becomes still weaker, and often loses statistical significance.

To what extent does the research evidence explore the influence of the broader determinants of health, and in particular socio-economic position, in explaining any link between obesity and attainment?

Place of residence, ethnicity, occupation, gender, religion, education, socio-economic status (SES) and social capital were all explored as potential moderating variables in the included research. Twenty-three of 29 studies used a measure of socio-economic status as a moderating variable. Various factors appear to contribute to low educational attainment to some extent, although given the variation in definitions, analyses and quality of data, it is impossible to point to any causative or definite risk factors.

Authors have posited theories suggesting that the link between obesity and educational attainment  is moderated by individual and societal factors. Does the research evidence support or refute these?  

Most studies explored the influence of obesity upon attainment. Only two studies examined the influence of attainment upon obesity. Many authors suggested multiple causal pathways, many of which remained untested in their studies. The moderating variables used in statistical analyses of the relationship between obesity and attainment were not consistent with the causal pathways proposed, which is probably a reflection of the constraints imposed upon authors conducting secondary analyses of pre-existing datasets (i.e. they made use of existing variables, rather than collecting their own, tailored data). The most frequently cited factors resulting from obesity and impacting upon educational attainment were poor mental health, stigmatisation and discrimination, disordered sleep, decreased time spent in physical activity and socialising, and absenteeism.

What are the implications?

First, that obesity should not be understood solely as a health issue. This review, and other research, suggests that one of the most noticeable ways in which obesity affects the lives of children and young people is in their social relationships. Given the paucity of evidence suggesting a causative physiological link between obesity and attainment, any association is likely to be mediated by social factors. We find that stigmatisation, bullying, low self-esteem and young people’s exclusion from opportunities for social interaction are suggested as underlying any relationship between obesity and lower educational attainment.

Second, that the variables used in statistical analyses failed to capture many of the potential causative factors identified by the teachers and young people (and, often, also of the researchers undertaking those analyses). If large-scale longitudinal datasets are to deliver on their potential to help us understand people’s lives, they need to engage with the social lives of their participants and amass not simply data that are straightforward to collect, but information that reflects determining characteristics of people’s social experiences, because these are often the key to understanding health and other behaviours.

Finally, we find this body of literature to be one of the least cumulative that we have reviewed. Data from the same datasets are analysed in different ways, using different variables, coming to different conclusions with minimal attempts to explain differences in findings. Different statistical models are sometimes employed with little justification for their selection and little acknowledgement that a different method might yield an entirely different result. These are important failings, and it is hoped that work associated with the EQUATOR network will in time lead to improvements (Simera et al. 2010). We should note that these criticisms do not apply to all studies in this review, but it would be true to say that they do apply to many of them.

How did we get these results?

We located studies through sensitive searches of a large number of databases, as well as specialist websites and contact with experts. Included studies were coded and quality-assessed by two reviewers independently. In order to ensure that our analysis was informed by the perspectives of teachers and young people, we held consultations in April and May 2009.

The systematic review addresses the following research questions:

• What do we know about the relationship between childhood obesity and educational attainment, from the research literature?
• To what extent does the research literature explore the influence of the broader determinants of health, and in particular socio-economic position, in explaining any link between obesity and attainment?
• To what extent did the included studies posit theories explaining the link between obesity and educational attainment as being mediated by individual and societal factors? Are these theories supported or refuted by the research evidence?

This summary was prepared by the EPPI Centre .

This report should be cited as: Caird J, Kavanagh J, Oliver K, Oliver S, O’Mara A, Stansfield C, Thomas J (2011) Childhood obesity and educational attainment: a systematic review. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London.

Related journal article: Does being overweight impede academic attainment? A systematic review . Health Education Journal, June 6, 2013 0017896913489289  

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Educational attainment and obesity: a systematic review

2013, Obesity Reviews

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Healthy lifestyle interventions within the curriculum in school-age children: systematic review and meta-analysis

Affiliation.

• 1 Centro de Investigación en Nutrición y Salud, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México.
• PMID: 38470184
• DOI: 10.1093/heapro/daae020

Childhood obesity is a major public health challenge. Previous research has identified the impact of school-based interventions for preventing and treating obesity; we hypothesized that when curricular changes are integrated, results could be exponentiated. This study aimed to systematically review and conduct a meta-analysis of the published literature analyzing information about school-based interventions inserted in the curriculum. The Cochrane Handbook methodology was followed. An electronic search was conducted in five databases, with a specific design strategy per database. Randomized controlled trials or quasi-experimental studies of children with nutrition and physical activity (PA) interventions inserted into the school curricula were included. The risk of bias was assessed with the Risk of Bias tool. The mean differences were pooled using a fixed-effects model for the meta-analysis. The certainty of the evidence was evaluated according to the guidelines of the Grading of the Recommendations, Assessment, Development, and Evaluations working group (Protocol ID: CRD42021270557). After the screening and selection process, 12 studies were included. The interventions identified, based on the school curricula, include classroom activities and homework, among others. A meta-analysis with five intervention groups presented an overall mean difference of -0.14 body mass index (BMI) Z-score (95% CI: -0.25, -0.03) after this intervention with high certainty of the evidence. This systematic review and meta-analysis suggest that nutrition and PA lessons inserted into the curricula and supported with additional activities (i.e. homework, workshops, etc.) could increase nutrition knowledge and improve attitudes toward fruit, vegetables, and water consumption, and BMI Z-score reduction.

Keywords: children; meta-analysis; obesity; school curriculum; systematic review.

© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected].

Publication types

• Meta-Analysis
• Systematic Review
• Body Mass Index
• Healthy Lifestyle
• Pediatric Obesity* / prevention & control

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Distinct association between educational attainment and overweight/obesity in unmarried and married women: evidence from a population-based study in Japan

Keiko murakami.

1 Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605 Japan

2 Department of Health and Social Behavior, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan

Takayoshi Ohkubo

Hideki hashimoto, associated data.

The use of J-SHINE data is to be approved by the J-SHINE Data Management Committee by request.

Associations between education and obesity have been consistently reported among women in developed countries, but few studies have considered the influence of marital status and husbands’ education. This study aimed to examine differences in the association between education and overweight/obesity by marital status and to determine the contribution of husbands’ education to overweight/obesity among community-dwelling Japanese women.

A questionnaire survey was conducted from 2010 to 2011 among residents aged 25–50 years in Japanese metropolitan areas. Of 2145 women who agreed to participate and completed the survey, 582 were unmarried and 1563 were married. Overweight/obesity was defined as body mass index ≥25 kg/m 2 . Multiple logistic regression analysis was conducted to determine whether women’s or their husbands’ education was associated with overweight/obesity after adjusting for age, work status, and equivalent income.

The prevalence of overweight/obesity was 11.9% among unmarried women and 10.3% among married women. Women’s own education was significantly associated with overweight/obesity among unmarried women but not among married women. The multivariate-adjusted odds ratio of high school education or lower compared with university education or higher was 3.21 (95% confidence interval: 1.59–6.51) among unmarried women. Among married women, husbands’ education was significantly associated with overweight/obesity: women whose husbands’ educational attainment was high school or lower had significantly higher odds of overweight/obesity than did those whose husbands had a university education or higher (1.67, 95% confidence interval: 1.10–2.55). Among married women whose educational attainment was college or higher, women whose husbands’ educational attainment was high school or lower had a significantly higher risk for overweight/obesity when compared with women whose husbands’ educational attainment was college or higher.

Conclusions

Associations between women’s own education and overweight/obesity varied by marital status, and husbands’ educational level was important for married women’s overweight/obesity. These findings indicate that the social influences bound to educational background affect women’s overweight/obesity.

Obesity is a serious health burden because of its association with type II diabetes mellitus, cardiovascular diseases, and some types of cancer [ 1 ]. The prevalence of obesity is also known to be strongly determined by socioeconomic status among women. In developed countries where obesity has become an epidemic [ 1 ], women with low socioeconomic status, or more specifically with low education, are consistently found to have higher risks of obesity [ 2 , 3 ]. Diverse causal mechanisms underlying the association between education and obesity have been proposed, such as knowledge about the risks of obesity, class-based norms of thinness, and the influence of social networking in groups [ 3 – 5 ].

The association between education and obesity among women is further complicated by findings indicating that this association may differ by marital status. A few studies have demonstrated an inverse association between husbands’ education and adverse health outcomes such as smoking [ 6 ], self-rated health [ 6 – 8 ], or mortality [ 9 – 14 ], whereas other studies found no such association [ 15 , 16 ]. Spousal concordance for obesity has also been well documented [ 17 ], suggesting that the social influence of close members of women’s social networks (i.e., husbands among married women) may play a significant role in shaping their behavioral and health norms. Marriage may bring about a drastic change in the sources of social influence on women’s lifestyle choice. Surprisingly, however, it remains unclear to this point whether unmarried and married women exhibit different patterns in terms of educational inequalities in health-related behaviors, including obesity.

In addition to the independent effects of spousal education, the combination of own education and spousal education has recently attracted attention. Few studies have shown that adverse health outcomes were better predicted by the combination of education for both women and their husbands, compared with their own or their husbands’ education alone [ 6 , 18 ]. Other studies have indicated that an educational discrepancy between spouses may exert a negative influence on health outcomes [ 9 ]. These suggest that it is not knowledge of health through education, but rather social influences and norms that result in educational inequalities in health among married women.

In this study, we explored these issues by comparing the associations between own education and overweight/obesity for unmarried and married women, and by testing the independent effects of husbands’ education, as well as the effect of educational discrepancies between spouses.

Data and participants

We used data from the Japanese Study of Stratification, Health, Income, and Neighborhood (J-SHINE). This dataset has been described elsewhere [ 19 – 22 ]. From October 2010 to February 2011, the J-SHINE survey was carried out in four municipalities in and around the greater Tokyo metropolitan area. Of 13,920 community-dwelling adults aged 25–50 years who were probabilistically selected from the residential registry, survey staff members were able to contact 8408 residents. Valid responses were received from 4317 adults, 2313 of whom were women. We analyzed 2145 respondents with no missing values on the variables used in the analysis, excluding income. The secondary use of the data was approved by the J-SHINE Data Management Committee.

Marital status was dichotomized into unmarried (single, divorced, or widowed) and married. Participants reported their own educational attainment. Married women also reported their husbands’ educational attainment. These ranged from (a) junior high school, (b) high school, (c) two-year college or special training school, (d) university, and (e) graduate school. Educational attainment was coded into three categories: high school or lower (a, b), college (c), and university or higher (d, e). Women’s own educational attainment, their husbands’ educational attainment, and combinations of these two variables were used as explanatory variables among married women. Combinations of women’s own and husbands’ educational attainment were generated by categorizing both variables into high school or lower (low; a, b) or college or higher (high; c, d, e) and then creating four groups: 1) both spouses with low education, 2) low-educated women with high-educated husbands, 3) high-educated women with low-educated husbands, 4) and both spouses with high education [ 20 ].

Body mass index (BMI) was calculated as self-reported body weight (kg) divided by the square of height (m 2 ). Overweight and obesity were defined as BMI ≥25 kg/m 2 and BMI ≥30 kg/m 2 , respectively, adopting the definition of the World Health Organization [ 23 ]. We combined the overweight and obesity groups, because the prevalence of BMI ≥30 kg/m 2 was very low (2.2% among respondents in this study) and the Japan Society for the Study of Obesity has defined obesity as BMI ≥25 kg/m 2 [ 24 ]. Asian populations generally have a higher proportion of body fat than white people of the same age, sex, and BMI [ 25 ].

As covariates, we chose age, work status (working, not working), equivalent income, dietary habits, smoking status, and habitual exercise [ 2 ]. In the survey, respondents selected their total annual household income from 15 response categories. Using the OECD-modified equivalence scale [ 26 ], household income was adjusted for household size. For respondents whose household income was unknown or missing but who responded on individual income, we used individual income as equivalent income. Income values that were missing after this step were imputed using single imputation based on regression analysis including variables for age, marital status, and work status. Dietary habits were measured using 5 questions (“Do you eat breakfast every day,” “Do you try to eat vegetables,” “Do you try to cut down on sugar and salt intake,” “Do you try to purchase organic vegetables and additive-free food,” and “Do you try to eat nutritionally balanced meals?”) rated on a 5-point scale from 1 ( agree ) to 5 ( disagree ). We summed the scores of these 5 responses to determine a total score (range 5–25) and defined poor dietary habits as a score of ≥16 [ 21 ]. Smoking status was categorized as current smoker, ex-smoker, or never-smoker. Habitual exercise was measured by how often participants engaged in ≥10 min of physical activity, excluding incidental ones related to work, commuting, or other non-leisure behaviors, over the past year. The responses were every day, 5–6 days a week, 3–4 days a week, 1–2 days a week, once a month, or seldom, and categorized into 3 groups: ≥1 day a week, once a month, or seldom.

Statistical analysis

Characteristics of unmarried and married respondents were compared using Student’s t test for continuous variables and the chi-squared test for categorical variables. Multiple logistic regression analyses were conducted to examine the association between education and overweight/obesity, using women’s education, husbands’ education, and the combination of these two variables as explanatory variables. First, we examined whether marital status modified the association between women’s education and overweight/obesity by including the interaction term in the models. As the significant interaction for women’s own education and marital status was detected ( P  = 0.022), we conducted analyses separately for unmarried and married women.

For unmarried women, we calculated the odds ratio (OR) and 95% confidence interval (CI) for women’s own education adjusted for age (Model 1). We made further adjustments for work status and equivalent income (Model 2), as well as dietary habits, smoking status, and habitual exercise (Model 3). For married women, these analyses were repeated adding husbands’ education as an explanatory variable.

We estimated the OR and 95% CI according to combinations of the women’s education and their husbands’ education using the group of both spouses with high education as reference, and adjusting for age, work status, and equivalent income, as well as dietary habits, smoking status, and habitual exercise.

All analyses were conducted using Stata 12.0 (StataCorp LP, College Station, TX, USA). For all analyses, a two-tailed P  < 0.05 was considered statistically significant.

The characteristics of respondents by marital status are shown in Table  1 . Married women were older, less educated and less likely to be working, and had higher incomes than unmarried women. The percentages who were overweight or obese were 11.9% and 10.3% among unmarried and married women, respectively.

Characteristics of unmarried women ( n  = 582) and married women ( n  = 1563)

a Obtained using Student’s t test for continuous variables and the chi-squared test for categorical variables, comparing unmarried and married women

b Body mass index ≥25.0 kg/m 2

c Thousand Japanese yen (/year)

Table  2 presents the ORs and 95% CIs for overweight/obesity among unmarried women. Unmarried women whose educational attainment was high school or lower had a significantly higher risk for overweight/obesity when compared with unmarried women whose educational attainment was university or higher; the age-adjusted OR (95% CI) was 3.08 (1.57–6.03), and the OR (95% CI) adjusted for age, work status, and equivalent income was 3.21 (1.59–6.51). No significant difference in the risk of overweight/obesity was detected between college education and university or higher. These associations did not materially change after adjustment for health-related behaviors. Among covariates, poor dietary habits were significantly associated with increased risk of overweight/obesity.

Odds ratios for overweight/obesity according to education among unmarried women (n = 582)

OR odds ratio, 95% CI 95% confidence interval

Model 1: adjusted for age

Model 2: adjusted for age, work status and equivalent income

Model 3: adjusted for age, work status, equivalent income, dietary habits, smoking status, and habitual exercise

Table  3 presents the ORs and 95% CIs for overweight/obesity among married women. While women’s own education was not significantly associated with overweight/obesity, husbands’ education was significantly associated with overweight/obesity. Married women whose husbands’ educational attainment was high school or lower had a significantly higher risk for overweight/obesity when compared with married women whose husbands’ educational attainment was university or higher; the age-adjusted OR (95% CI) was 1.78 (1.21–2.61), and the OR (95% CI) adjusted for age, work status, equivalent income, and women’s own education was 1.67 (1.10–2.55). Further adjustment for health-related behaviors slightly reduced the association between husbands’ educational attainment and overweight/obesity, but the significance of the association remained. Among covariates, poor dietary habits and current smoking were significantly associated with increased risk of overweight/obesity.

Odds ratios for overweight/obesity according to education among married women (n = 1563)

Model 2: adjusted for age, work status, equivalent income, and women’s/husbands’ educational attainment

Model 3: adjusted for age, work status, equivalent income, women’s/husbands’ educational attainment, dietary habits, smoking status, and habitual exercise

Among married women whose educational attainment was college or higher, women whose husbands’ educational attainment was high school or lower had a significantly higher risk for overweight/obesity when compared with women whose husbands’ educational attainment was college or higher (multivariate-adjusted OR = 1.86; 95% CI: 1.16–2.99) (Fig.  1 ). Low-educated women with high-educated husbands and low-educated women with low-educated husbands did not have significantly higher risk for overweight/obesity compared with high-educated women with high-educated husbands.

Odds ratios for overweight/obesity according to combination of women’s and husbands’ education among married women ( n  = 1563). Filled squares represent point estimates and horizontal lines denote the 95% confidence interval. Adjusted for age, work status, equivalent income, dietary habits, smoking status, and habitual exercise (Model 3)

The present study explored the associations between education and overweight/obesity among unmarried and married women in Japan. Women’s own education was significantly associated with overweight/obesity among unmarried women, but not among married women. Among married women, husbands’ education was significantly associated with overweight/obesity. In particular, highly educated women who were married to men with low education had a risk of overweight/obesity that was almost double that of highly educated women married to highly educated men.

There are several possible mechanisms through which education may influence health [ 3 – 5 ]. One is that the knowledge and skills attained through education affect cognitive function and therefore susceptibility to health education messages [ 27 ]. Education is also considered as a form of cultural capital [ 3 , 28 ]. Cultural capital in the form of health values and behavioral norms provides the non-material resources needed to promote health behaviors and deal with health problems effectively [ 28 , 29 ]. Therefore, education, as a form of cultural capital, may have implications for the extent to which an individual is influenced by societal standards of health messages, and those with higher education might prioritize the recognition and pursuit of attributes that are valued in developed societies, such as health and a thin body [ 3 , 28 ]. In addition, social networks partially account for the association between education and health behaviors [ 4 ]. Social networks provide a means by which individual resources such as education can combine with those of others to benefit or disadvantage an individual’s health [ 30 ]. Given that people with high socioeconomic status adopt healthy behaviors and associate with others with high socioeconomic status, their networks of social influence promote health within these groups, further widening socioeconomic inequalities in health [ 4 , 5 ]. Although it remains unclear which aspects of education affect overweight/obesity, our results suggest that the resources obtained from women’s own education affect overweight/obesity only among unmarried women. It is highly unlikely that marriage decreases the effect of the knowledge and skills attained through education.

Unmarried women with college education had a similar risk for overweight/obesity compared with unmarried women with university education or higher. This might be explained by the fact that women are less likely to reach a higher level of tertiary education in Japan, except short-cycle tertiary [ 31 ], although the level of educational attainment among Japanese women has been increasing. The share of female graduates is higher at the short-cycle tertiary level (62%) than the average across OECD countries (56%), while at the bachelor’s or equivalent level, 45% of graduates are women in Japan (compared with 58% across OECD countries) [ 31 ]. Also in our previous J-SHINE study, the proportions of high school education or lower were similar among men (23.5%) and women (22.5%), but the proportions of university education or higher were significantly higher among men (55.0%) than women (33.6%) [ 22 ].

Among married women, husbands’ education was significantly associated with overweight/obesity, even after adjusting for the women’s own education. Spouses are usually genetically unrelated but share a common environment, and spousal concordance for obesity has been demonstrated [ 17 ]. People form health values and behavioral norms by comparing their own attitudes with the attitudes of reference groups; they are reinforced when they are shared with the reference groups but altered when they are discrepant [ 30 ]. Obesity can follow social networking paths that influence people and cement socioeconomic inequalities in obesity [ 32 ]. Women is susceptible to social influence and to the attitudes of those around one [ 33 , 34 ]. Therefore, education may provide a proxy measure of social group belonging and its norms among women. Marriage is an important dimension of social networks, and this might explain the stronger effects of husbands’ education, compared with women’s own education, on married women’s overweight/obesity risk.

We examined whether health-related behaviors could explain the identified associations between education and overweight/obesity by adjusting for these behaviors in the model. However, adjustment for dietary habits, smoking status, and habitual exercise did not markedly change the associations between education and overweight/obesity, which suggests that these health-related behaviors could not fully explain these associations. However, all data were self-reported, and thus our adjustment could be incomplete. Further studies are needed to explore the mechanisms underlying these associations in more detail.

Educational discrepancy between spouses when highly educated women were married to less educated men resulted in a higher risk of overweight/obesity for the women. There are several explanations for this finding. One is that an unhealthy lifestyle among less educated men may influence their more highly educated wives. As spouses generally share a common environment, exposure to risk factors derived from an unhealthy lifestyle, such as secondhand smoke and dietary habits, may increase the risk of overweight/obesity among highly educated women married to less educated men. Another possible explanation is that this educational discrepancy between spouses, which runs counter to traditionally accepted norms about gender roles, may produce stress and thereby result in negative health consequences. Equivocal results have been reported, especially regarding the effects of a highly educated wife on her husband’s cardiovascular health [ 35 ]. One study in Israel found that, for highly educated women, husbands having a lower education almost doubled wives’ risk of mortality from cardiovascular disease; however, husband’s education had no effect among women with lower education [ 9 ]. Our results were mostly consistent with this study. Notwithstanding the effects of husbands’ education on health, the health risks associated with educational discrepancy between spouses have rarely been examined. Therefore, our findings further the understanding of the health risks of an educational discrepancy between spouses that runs counter to traditionally accepted norms.

These findings have several implications for health policy. Differences in associations between women’s own education and overweight/obesity by marital status and the importance of husbands’ educational level for women’s overweight/obesity suggest that interventions in public health should pay attention to the social context in which individuals live. Because people belong to households with certain lifestyle and behavior patterns, policies aimed only at individuals may not be successful in influencing people’s behaviors and norms. Our analyses have also suggested that social influences and norms, rather than knowledge and skills attained through education, affect obesity among women. This indicates that prevention programs for obesity should consider women’s susceptibility to social influences in order to reduce educational inequalities in obesity among women. Although obesity is often considered a problem only in Western countries because of the low prevalence of obesity in Asian countries, Asian populations have been shown to have an elevated risk of associated diseases at relatively low BMIs [ 25 ]. It would therefore be beneficial to examine educational inequalities in obesity in Japan, where both social structures and body compositions differ from those in Western countries.

Some limitations of this study should be considered. First, the response rate was relatively low. Several studies have found that non-respondents have lower socioeconomic status than do respondents [ 36 , 37 ]. If such a non-response bias existed in this study, educational inequalities in overweight/obesity would be underestimated. However, the respondents in the present study were fairly comparable with the target population with regard to age, sex, and educational attainment [ 19 ]. Second, height and body weight were measured based on self-report, which may cause misclassification. A nationally representative survey in Japan found that self-reported BMI was considerably underestimated among overweight and obese women, mainly because of underreports of weight [ 38 ]. If this trend was also present in this study, the observed associations would be underestimated. Third, validated questionnaires would be useful for more precise assessments of dietary habits, although the questions and definition of dietary habits in this study were used also in previous ones [ 21 ]. In addition, more detailed questionnaires about physical activities such as sedentary work style would be interesting, as well as habitual exercise. Finally, because this was a cross-sectional study, we could not determine the causal direction of the associations found. It is unlikely that adulthood obesity affects educational attainment. However, adult obesity may have some influence on husbands’ education, because individuals are more likely to marry people who share similar characteristics, such as demographics, attitudes, and behaviors [ 39 ]. Unobserved factors associated with marriage selection may confound the association between husbands’ education and obesity.

The present study found that women’s own education was significantly associated with overweight/obesity among unmarried, but not among married women. Among married women, husbands’ education was significantly associated with overweight/obesity. Highly educated women’s risk of overweight/obesity was almost doubled when they were married to less educated men, compared with highly educated women married to highly educated men. These findings indicate that social influences bound to educational background affect women’s obesity and are important in designing public health intervention to reduce socioeconomic inequalities in obesity and subsequent chronic diseases among women.

Acknowledgements

We thank the J-SHINE Data Management Committee for approving secondary use of the data.

This research was supported by a Grant-in-Aid for Scientific Research on Innovative Areas (No. 21119002) from the Ministry of Education, Culture, Sports, Science and Technology, Japan, and by a research grant from the Ministry of Health, Labour and Welfare, Japan (H27-Lifestyle-ippan-002). KM was supported by a Grant-in-Aid for Young Scientists (B) (No. 15 K21383) from the Ministry of Education, Culture, Sports, Science and Technology, Japan.

Availability of data and materials

Abbreviations, authors’ contributions.

KM conceived the study, performed the statistical analysis, and drafted the manuscript as principal author. TO and HH provided advice regarding critically important intellectual content and helped to draft the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The Research Ethics Committee of The University of Tokyo, Graduate School of Medicine approved the survey procedure of the J-SHINE (Japanese Study of Stratification, Health, Income, and Neighborhood) (No. 3073-[1]). The questionnaire was computer-assisted and self-administered, unless participants requested a face-to-face interview. Participation in this study was voluntary, and written consent was obtained from each respondent. The J-SHINE Data Management Committee approved the authors’ secondary use of the data, with personally identifiable information deleted to ensure confidentiality.

Consent for publication

There are no details on individual participants within the manuscript.

Competing interests

The authors declare that they have no competing interests.

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Contributor Information

Keiko Murakami, Phone: +81-3-3964-3615, Email: pj.ca.nimu@ykt-okiekm .

Takayoshi Ohkubo, Email: pj.ca.u-oykiet.dem@obukhot .

Hideki Hashimoto, Email: pj.ca.nimu@cric-otomihsahedih .