by Deanne McArthur RN, MScN
Masters Student, University of Ottawa,
Faculty of Health Sciences,
School of Nursing, MScN/PHCNP Program, Ottawa, Canada
Sarah Beach MSc
Research Assistant, Ottawa Hospital Research Institute,
Clinical Epidemiology Program, Ottawa, Canada,
Dawn Stacey, RN, PhD, CON (C)
Associate Professor, University of Ottawa,
Faculty of Health Sciences, School of Nursing, Ottawa, Canada
Scientist, Ottawa Hospital Research Institute,
Clinical Epidemiology Program, Ottawa, Canada,
Author Contact Information:
Dawn Stacey RN, PhD
Objective: To explore the status of evidence-based information pertaining to body weight changes during the transition to menopause available online for Ontario women.
Methods: An environmental scan of online resources for Ontario women was undertaken to assess the availability of evidence-based information pertaining to body weight changes during the transition to menopause. A snowball approach was used starting with all 36 health units in Ontario and branching to external sites referenced by the initial resources. The websites were evaluated using the Clinical Usefulness of Evidence-Based Websites (CLUE W) (Labrecque, 2007), and analyzed descriptively.
Results: Of the 52 resources searched, 6 (11.5%) contained information specific to perimenopausal women but primarily provided general information and there was concern about its accuracy. Only the Canadian Obesity Network provided information related to the increased risk for developing obesity during the menopausal transition, the health risks associated with that weight gain, and the role of physical activity in mitigating risks for and effects of obesity. The websites scored on average 49 out of 100 (range 39.2 to 58.8) on the CLUE W tool.
Conclusions: There is a lack of evidence-based information regarding body weight changes in perimenopausal women, which is a concern, given that nurses are involved in developing health information.
Keywords: menopause, healthy weight, Internet, exercise, nutrition
Perimenopause represents a time of significant physiological change for women. Decreased estrogen causes women to experience a broad range of symptoms including sleep disruption, hot flashes, joint pain and skin and eye changes (Society of Obstetricians and Gynaecologists of Canada, 2006). Concurrently, women are at an increased risk for weight gain and the development of obesity, typically gaining between 2.25 and 4.5 kg with 20% of women gaining more (Ho, Wu, Chan & Sham, 2010; Lovejoy, Chamgagne, de Jonge, Xie & Smith, 2008; 2009; Keller, Distefano, Boehm-Smith, Records, Robilliard, Veres, Al-Zadjali & O’Brian, 2010; Sowers, Zheng, Tomey, Karvonen-Gutierrez, Jannausch, Li, Yosef & Symons, 2007).
Unfortunately obesity is associated with other diseases and it affects women’s psychosocial health. Examples of co-morbidities include hypertension, diabetes, cardiovascular disease and some types of cancer (Ho et al., 2010, Public Health Agency of Canada, 2009). Women also experience an increased risk of cardiovascular disease related to lower estrogen levels, increased testosterone, changes in glucose metabolism, increased fat oxidization and accumulation of visceral fat mass – a risk that is further exacerbated by weight gain (Keller et al., 2010, Hu, 2003). Obese women are more likely to be of lower socioeconomic status and to experience workplace discrimination compared to their non-obese counterparts (Azerbad & Gonder-Frederick, 2010, Keller et al., 2010). Furthermore, obese women are more likely to experience clinical depression (37%), suicidal ideation (23%) and attempt suicide (23%) in the last year compared to lean women (Azerbad & Gonder-Frederick, 2010).
Women are increasingly turning to the Internet to inform themselves about matters pertaining to their health. According to the Pew Internet and American Life Project (Fallows, 2005), 86% of online women will consult the Internet for health information. Another study found that seeking health information (57%) was the third most popular Internet activity among Canadians after email (93%) and browsing (90%) (Crowley, 2002). Of concern is the variable quality of health information on the Internet. Therefore a role exists for nurses to improve the potential for this medium to promote accurate, evidence-based information.
Nurses are well positioned to prepare women for body weight changes during the transition to menopause. However, they need to ensure information provided is based on current evidence and relevant to these women. Given the accessibility and rise of the Internet as a key source of health information for the public, nurses should be aware of quality website-based health information resources.
The purpose of this study was to explore the characteristics of information about body weight changes during menopause available online for Ontario women. The specific research questions included:
What current information is available for perimenopausal women related to body weight/obesity, physical activity, and nutrition available on the Internet from health organizations/agencies?
What is the quality of the evidence underlying information presented on these websites?
An environmental scan was conducted in November 2009 and updated in June 2011 to ascertain the presence and content for perimenopausal women on health care organizations and agencies websites in Ontario. All websites provided by Ontario public health units and associated health organizations were included. Excluded were commercial lifestyle sites (i.e. weight loss programs).
A snowball approach was used in the selection of web-based resources for evaluation. The search began with an assessment of the websites provided by all 36 Health Units in Ontario (see Table 1). Expansion of the search was carried out by following sources linked by those included and resulted in an additional 16 Canadian health agencies (see Table 2).
Sites with a “search” function were searched using the keywords: “menopause”, “healthy weights”, and “obesity”. “Healthy weights” and “obesity” were first searched combined with “menopause”. The terms were then separated out to ensure no documents were missed by narrowing the search criteria. If the site did not provide a search function, relevant categories within the site were investigated (i.e. “women’s health”, “healthy eating”, “lifestyle”, and so on) for documents pertaining to body weight changes during menopause. Discontinuation of the search for information on the site took place when links and citations achieved redundancy.
The websites located in the search were independently appraised for quality by the primary researcher (DM) and a research assistant (SB) using the Clinical Usefulness of Evidence-Based Websites (CLUE W) tool (Labrecque, 2007). Website appraisal findings from the two independent evaluators were compared and if there was disagreement, sites were revisited and discussed until consensus was reached on all scores. Scores were entered into an Excel spreadsheet and subjected to descriptive analysis.
CLUE W was found to have excellent inter and intra-observer measurement reliability (Frémont, Labrecque, Légaré, Baillargeon & Misson, 2001). The tool guides assessment of websites based on the following criteria: validity (transparency, timeliness, selection and assessment of information), relevance (purpose, target audience, clinical) and work (hyperlinks, ease of use, practicality, access fees and ease of evaluation). Points are awarded based on the presence and quality of each category, with a final mathematical application (0.4*V + 0.35*R + 0.25 * [100-W]) generating an overall score out of 100.
Of 36 health units in Ontario, 2 (6%) provided information about body weight, exercise, and/or nutrition specific to perimenopausal women (see Table 3). Four of the other 17 (23.5%) health agencies in Canada also provided information. These 6 identified websites resulted in CLUE W scores that ranged from 39.2 – 58.8 out of 100 (average 49).
Out of the 6 websites identified, 5 (83.3%) make reference to body weight changes commonly occurring during the transition to menopause (see Table 3). The Canadian Obesity Network provides information about postmenopausal weight gain, and the associated co-morbidities that put women at increased risk, but only cited one study (Dennis, 2007). Lambton County Health Unit (LCHU) briefly mentions weight gain during perimenopause attributable to the body’s metabolism “slowing over time” due to a reduction in muscle mass. However, it does not provide women with an understanding of the causality of the loss of muscle mass or how much weight is typically gained during perimenopause (Lambton County Health Unit, 2003, paragraph 15). The Society of Obstetricians and Gynaecologists of Canada (SOGC) provide the typical range of weight gain (5 – 9 lbs), but do not explore the physiology underlying the gain (Lovejoy, 2009). Although no evidence-based sources are provided, both of these sites (LCHU & SOGC) provide information that is consistent with the literature (Keller, 2010, Lovejoy, 2009, and Sowers et al., 2007).
Eat Right Ontario and the North American Menopause Society respectively contradict research that finds the menopausal transition to be an independent factor contributing to weight gain. For example, Eat Right Ontario (2011) states: “weight gain is part of the natural aging process… it is not usually caused by menopause” (paragraph 3).
General nutrition information was provided by all 6 websites, with 2 (33%) linking to Canada’s Food Guide (Health Canada, 2011). All of the sites discuss nutrition as part of an overall plan to achieve health, while 2 sites (33%) specifically discuss diet relative to weight control. The Canadian Obesity Network links to original research findings supporting the role of Calcium and Vitamin D in achieving and maintaining a healthy weight (Caan et al., 2007). Eat Right Ontario suggests a reduction in portion sizes as a weight loss strategy. Lambton County Health Unit and Eat Right Ontario discuss nutrition (i.e. consuming essential fatty acids) as a strategy to reduce menopausal symptoms.
Five (83.3%) sites referred to physical activity as part of a healthy lifestyle overall. Three (50%) of the sites cite exercise as promoting bone health, and 2 sites (33%) posit that physical activity helps control menopausal symptoms. Canadian Obesity Network and the Society of Obstetricians and Gynaecologists of Canada both discuss physical activity as part of a weight management strategy. The information provided is unreferenced, and none of the sites provide details about the physical activity required for perimenopausal women.
Other information that was associated with menopause covered topics including: osteoporosis, cancer risk and screening, sexual health, symptom control (i.e. hot flashes), and hormone replacement therapy. For example, a pamphlet from the Haldimand-Norfolk Health Unit encourages women to view the transition as positive and to take healthy measures to adapt to the challenges associated with this life stage (i.e. connecting with friends, seeking appropriate medical advice etc.) (Haldimand – Norfolk Health Unit, 2011).
This is the first known study to appraise the quality of Internet-based health information on body weight changes in women during the transition to menopause and we found a dearth of information accessible to Ontario women. The information available from trusted sources tends to be general in nature (i.e. referring to Canada’s Food Guide) and does not address the unique needs of perimenopausal women. Furthermore, appraisal of the information on these websites scored weak to moderate on the CLUE W tool, with only the Canadian Obesity Network referencing evidence-based sources. We were concerned that information was provided on some sites that suggested that body weight change is weakly or not at all linked to perimenopause (Eat Right Ontario, 2011 & North American Menopause Society, 2010). This information gives women the impression that weight gain is “natural” and at the same time, is not a health issue which could impact self-care during perimenopause. Nutrition and physical activity were discussed in general terms related to overall well-being without specific recommendations or suggestions suitable for perimenopausal women (Simkin-Silverman, 2003). Interestingly, none of the websites reviewed were interactive in nature.
Our findings highlight the need to expand current health organization websites in Ontario to provide more up-to-date evidence-informed information and to move toward more interactive approaches for providing health information. Given that women are higher users of the Internet for health information and outpace men in the use of social media online applications (i.e. Twitter, Facebook) (Dewing, 2005 & Fallows, 2005), there is an urgent need to consider more social media applications to promote conversations with and/or commitment from perimenopausal women about engaging in activities to minimize or manage body weight gain. In a study of perimenopausal women’s barriers and facilitators to engaging in physical activity, women identified that commitments to others was a strong facilitator (McArthur et al.presentation).
Nurses have the opportunity to improve the quality of health information on the Internet and harness the communication potential of social media to interact with clients. Just like nurses partner with clients to achieve positive health outcomes in clinical settings, they can structure online interactions as two-way conversations that promote health, rather than continuing to bombard the public with general health messages (O’Dell, 2011).
The strengths of this study lie in the comprehensive approach undertaken to review the websites and the assessment and appraisal of the websites by two independent researchers. Subsequent discussions leading to consensus on findings ensured that the merits of each site were evaluated critically, and from two perspectives: a public health nurse (DM) and a research assistant with a Master’s of Science in Public Health (SB). Familiarity with the resources sought provided a beneficial starting point to launch the extensive search used in this study.
The limitations of this environmental scan largely pertain to the fluid nature of the Internet. For example, two website resources observed by one researcher were no longer accessible for review by the other person within weeks of the original search. Secondly, it is possible that our search process may have missed some relevant online resources and our search did not include all health organization websites. Obesity prevention resources, pertaining to perimenopause, could have been “hidden’ within other documents not revealed by the use of our keywords, and the searches undertaken were not always reproducible.
As well, the CLUE W tool was limited in its applicability to our purposes. While it provided a thorough assessment guide for the validity of website resources, it appeared to be created with the intent of appraising sources accessed by nurses rather than patient or public-focused health information. The sites assessed in the present study were generated with the public at large as the target audience, and likely tailored the level of literacy, and consequently validity indices for that population. It is therefore possible that the CLUE W scores achieved by the five sites with information pertaining to perimenopausal women are not indicative of their relevance and/or strength of content as it relates to the users in question – perimenopausal women.
There are few resources available for perimenopausal women in Ontario related to weight gain during the transition to menopause and evidence-based interventions to mitigate that risk. Most of the resources available provide general information regarding perimenopausal physiology and symptom management, with links to generic nutritional recommendations (i.e. Canada’s Food Guide). While these resources are valuable, they do not address the unique needs of women transitioning through this life stage. The resources that women can access were found to lack transparency on the underlying evidence. Despite the fact that selected websites are easily accessible, they are underused as a route for translating evidence to inform perimenopausal women of interventions to manage body weight changes during the transition to menopause
Azerbad, L., & Gonder-Frederick, L. (2010). Obesity in Women. Journal of Clinical Psychiatry, 33, 423-440.
Caan, B., Neuhouser, M., Aragaki, A., Lewis, B., Jackson, R., LeBoff, M., Margolis, K., Powell, L., Uwaifo, G., Whitlock, E., Wylie-Rosett, J., & LaCroix, A. (2007). Calcium plus vitamin D supplementation and the risk of perimenopausal weight gain. Archives of Internal Medicine, 167, 9, 893 – 902, as cited by the Canadian Obesity Network. Retrieved May 2011 from: http://www.obesitynetwork.ca
Crowley, D. (2002). Where are we now? Contours of the internet in Canada. Canadian Journal of Communication, 27, 4.
Dennis, K. (2007). Obesity rates increase after menopause. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36, 5. As cited in Canadian Obesity Network. Retrieved May 2011 from: http://www.obesitynetwork.ca
Eat Right Ontario, (2011). Staying healthy through menopause and beyond. Government Of Ontario – Ministry of Health Promotion and Sport. Retrieved May 2011 from: http://www.eatrightontario.ca/en/Articles/Seniors-nutrition
Fallows, D. (2005). How women and men use the Internet. Washington, DC: Pew Research Center for People and the Press. Retrieved January 10, 2010, from: http://www.pewinternet.org/topics/Women-and-Men
Frémont, P., Labrecque, M., Légaré, F., Baillargeon, L., & Misson, L. (2001). Évaluation des sites web médicaux: Fidélité interobservateur et intraobservateur d’un outil d’évaluation. Canadian Family Physician, 42, 227 – 236.
Haldimand-Norfolk Health Unit. (2011). Menopause matters. Retrieved May, 2011 from: http://www.hnhu.org/images/stories/a_z_directory/workplace_health/menopause_matters_web.pdf
Health Canada, (2011). Eating well with Canada’s food guide. Government of Canada. Retrieved May 2011 from: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php
Ho, S., Wu, S., Chan, S., & Sham, A. (2010). Menopausal transition and changes of body composition: a prospective study in Chinese perimenopausal women. International Journal of Obesity, 10, 33, 1-10.
Hu, F. (2003). Obesity in women: Health risks and consequences. Journal of Women’s Health, 12,2, 163-173.
Keller, C., Larkey, L., Distefano, J., Boehm-Smith, E., Records, K., Robilliard, A., Veres, S.,Al-Zadjali, M., & O’Brian, A. (2010). Perimenopausal Obesity. Journal of Women’s Health, 19, 5, 987-996.
Labrecque, M. (2007). Clinical usefulness of evidence-based websites: CLUE W instrument. Quebec: Laval University.
Lambton County Health Unit (2003). Menopause on the menu. County of Lambton. Retrieved May, 2011 from: http://www.lambtonhealth.on.ca/infant/menu
Lovejoy, J., Champagne, C., de Jonge, L., Xie, H., & Smith, S. (2008). Increased visceral fat and decreased energy expenditure during the menopause transition. International Journal of Obesity, 32, 6, 949–958
Lovejoy, J. (2009). Weight gain in women at midlife: The influence of menopause. Obesity Management, 51-56.
McArthur, D. (2010). Obesity Prevention Resources available to Perimenopausal Women, Knowledge Translation Face to Face Meeting, Ottawa (oral presentation).
North American Menopause Society. (2010). Is menopause putting on the pounds? Fat chance. Retrieved June 2011 from: http://www.menopause.org/
O’Dell, A. (2011, March, 28). Health-care groups turn to social media to distribute information. Globe and Mail. Retrieved from: http://www.theglobeandmail.com/life/health/newhealth/healthnews/shareTweet/article1960349/
Public Health Agency of Canada. (2009). Obesity in Canada: Snapshot. Retrieved Nov. 17, 2009 from The Public Health Agency of Canada website: http://www.phac-aspc.gc.ca/publicat/2009/oc/index-eng.php
Simkin-Silverman, L., Wing, R., Ph.D., Boraz, M., & Kuller, M. 2003. Lifestyle intervention can prevent weight gain during menopause: results from a 5-year randomized clinical trial. Annals of Behavioural Medicine. 26,3, 212 – 220.
Society of Obstetricians and Gynaecologists of Canada. (2006). Weight Management Retrieved May, 2011 from the SOGC website: http://menopauseandu.ca/lifestyle-questions/index_e.aspx
Society of Obstetricians and Gynaecologists of Canada. (2006). What is menopause? Retrieved June 9, 2010 from the SOGC website: http://www.menopauseandu.ca/what-is-menopause_e.aspx
Sowers, M., Zheng, H., Tomey, K., Karvonen-Gutierrez, C., Jannausch, M., Li, X., Yosef, M.,& Symons, J. (2007). 6-year changes in body composition in women at mid-life: ovarian and chronological aging. Journal of Endocrinology and Metabolism, 92, 3, 895-901.
Deanne is a graduate student with the University of Ottawa, presently completing the Primary Health Care Nurse Practitioner program. She has a Master’s of Science in Nursing, with a focus on physical activity patterns in women during menopause. She is a faculty member with Trent School of Nursing and works in primary care and mental health.
Sarah is a Clinical Research Assistant at the Ottawa Hospital Research Institute. She is involved in implementing and evaluating patient decision aids in clinical practice and data extraction for systematic reviews, including the Cochrane Review of Patient Decision Aids.
Dawn is a Scientist at the Ottawa Hospital Research Institute and Associate Professor in the School of Nursing, University of Ottawa. Her research focuses on exploring methods for health professionals to support patients/public in preparing for making health decisions. She leads the Cochrane Systematic Review of Patient Decision Aids.
Financial support for this project was provided by a team grant from the Canadian Institutes of Health Research titled the Sherbrooke, Ottawa, Montreal Emerging Team (SOMET).