Could e-cycling assist individuals who have had a breast cancer diagnosis to be more physically active? 

This study aimed to explore the potential role of e-cycling for individuals with a breast cancer diagnosis. It looked at physical activity engagement levels amongst those undergoing treatment, their perception of e-bikes after a taster session and if there is an optimal time to introduce e-cycling during treatment.
The project initially began as a dissertation topic for one of the postgraduate students on the MSc Nutrition, Physical Activity and Public Health programme, in collaboration with academic and research staff, and has subsequantally been published in The International Journal for Environmental Research and Public Health.
by Jessica Bourne, Miranda Armstrong and Kirsty Way. 

The importance of physical activity in tackling breast cancer

Breast cancer is the most common cancer in the UK, generating substantial financial burdens through healthcare and lost productivity. Public Health interventions are crucial in addressing these issues.

Several risk factors contribute to developing breast cancer and survival rates. Being physically active is one lifestyle behaviour that has been shown to help aid recovery and lower your risk of cancer coming back. Exercise also helps alleviate many of the common side effects of cancer treatment, including fatigue, low mood, and lack of energy.

Physical activity guidelines for individuals with a breast cancer diagnosis are the same as for the adult population. That is, to accumulate 150 minutes of moderate-intensity activity per week (like brisk walking) or 75 minutes of vigorous activity (like jogging), plus strength training twice a week. Meeting these recommendations before and after a breast cancer diagnosis can cut the risk of breast cancer recurrence by almost half, and your risk of dying from breast cancer by nearly one-third.

However, despite the known benefits, physical activity engagement decreases following a breast cancer diagnosis, with around 50% of women not meeting guidelines. There are several reasons why women might not be physically active during treatment. These include physical limitations like shoulder problems from surgery, feeling tired and lacking energy, and not having a good space or time to exercise. Gentle exercise can help alleviate many of these symptoms so, finding activities that make getting moving easier is important.

The Potential of E-bikes

Female on e-bikeElectrically assisted bicycle (e-bikes; also known as pedelecs), provide electrical assistance to the user only when they pedal. They have become increasingly popular recently and help users to ride further with less effort. E-cycling may increase physical activity levels due to users riding them more often and for longer distances than conventional bicycles. This is despite the reduced physical effort associated with riding an e-bike in comparison to a conventional bicycle. Researchers have also found that engaging in e-cycling has a favourable impact on fitness and mental health. Given the reduced physical exertion of e-cycling in comparison to regular cycling and the promising health outcomes, e-cycling maybe an acceptable physical activity for individuals diagnosed and or being treated for breast cancer. However, no research to date has examined the perception of e-cycling among these individuals.

We conducted one-on-one interviews with 24 women who had been diagnosed with breast cancer (mean age = 57 years). On average individuals were approximately 3-years since diagnosis. We held two interviews with each individual: one before trialling an e-bike and one after. E-bike taster sessions lasted 1-hour and were conducted by qualified cycling instructors in the community. All equipment required for the taster session was provided. We looked for themes across the interviews that captured the thoughts and feelings of these individuals.

Overcoming the side-effects of treatment

The cancer treatment individuals received had a large impact on their activity levels. This was due to reduced energy, feelings of weakness, fatigue and a general lack of motivation to be active. For women who were previous cyclists, e-bikes were seen as a way of helping them to get back on the road due to the extra help provided. Women commented that the prospect of e-cycling provided a sense of independence. It was also a chance to regain their identity which they had lost due to the breast cancer diagnosis. Often women were anxious about how much effort e-cycling would need. Following the taster session women commented on the ease of e-cycling and felt it would not lead to feelings of exhaustion. While some participants saw e-bikes as a way to stay active even on low-energy days, others were cautious. They worried about pushing themselves too hard and compromising their health. Women felt it was important to listen to their bodies and prioritise rest on days when fatigue was high. For those individuals e-bikes could be a great option on good days, but sometimes taking it easy was the best choice.

A boost for the body

After the taster session many participants felt that e-cycling had raised their heart rate, and they were able to have a ‘good workout.’ They said that they worked harder than expected despite the assistance of the e-bike. Individuals felt e-cycling played a type of ‘psychological trick’ on them and their willingness to cycle. The ability to change the level of assistance was extremely important to this group. It meant they could alter their exertion level based on how they were feeling. This assistance meant that tackling hills was not a concern.

Not just about the workout

Participants said e-cycling could help with fitness, strength, and boosting their circulation. Improved circulation can help treatment drugs work better. However, they felt the biggest advantage of e-bikes was psychological. Being outdoors and breathing in the fresh air made people want to keep e-cycling. Many who first thought e-bikes weren’t for them, changed their minds after completing the taster session. They found e-cycling to be an enjoyable way to exercise, making them more likely to give it another go in the future. For some women, who often felt out of control during treatment, riding the e-bike was empowering. Feelings of achievement motivate people to sticking with exercise, especially during cancer treatment. It is also good for keeping active in the long term.

Social Interaction

A key reported benefit of e-cycling was the social opportunities that e-cycling provides. Many had not been able to cycle with others since their diagnosis, but e-bikes made it possible to join in again. The shared experience of cycling with others created a sense of encouragement and made it even more enjoyable. The electrical assistance evened out everyone’s speed. This reduced users’ anxiety about being too slow or comparing themselves to others.

This social connection is more than just having fun with friends. It can also be a powerful motivator to keep exercising. Studies show that we are more likely to stick with something if we do it with others who are cheering us on. E-bikes provide a perfect opportunity for that social support system, making physical activity less like a chore.

The downsides of e-cycling

The biggest barrier that participants mention about e-cycling was the potential financial investment. For many this would stop them from considering engaging in e-cycling in the future. Related to this were concerns around theft. Discussions arose around fear and anxiety associated with parking an e-bike in a public space for fear it would not be there on return. Several other e-bike perception studies have also reported this. Environmental changes to the availability of parking facilities for bicycle users may therefore need to change for them to become more popular.

Towards an individualised approach

Despite the challenges, e-bikes emerged as a promising option for boosting physical activity among individuals being treated for and recovering from breast cancer. E-bikes can help to overcome many barriers associated with regular cycling. They also offer both physical and mental benefits. Participants responded positively to e-bike taster sessions. This suggests that they could be a valuable tool for encouraging exercise in this group. Yet, the best time to introduce an e-bike intervention in this population is hard to pinpoint. Different patients have different experiences of breast cancer and receive different treatments. Therefore, an individual approach might be best.

Read the published study here.

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Carbohydrates, fats and type 2 diabetes – are there patterns to be found?

By James Garbutt

When it comes to managing type 2 diabetes, there are lots of extreme diets out there with passionate advocates. Avoid carbs! Reduce fat! Restrict calories! However, researching the effects of diet on health in terms of single nutrient changes can be misleading. (more…)

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Why Does Inclusion Matter? Physical Activity and Disability

Ensuring that that our research considers and promotes equality, diversity and inclusion is central to the work we do at the School for Policy Studies. Working in partnership with communities and stake holders to identify research questions that matter and ensuring that studies are co-produced wherever possible helps achieve these aims. This series of blogs posts looks at some of the ways what we research and how we go about it incorporates EDI principles.

In this post, Kate Bowen-Viner (Social Policy PhD student) explores how research in the Centre for Exercise, Nutrition and Health is helping to make physical activity guidelines more inclusive. (more…)

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Lockdown lunches

Written by Dr Laura Johnson and Dr Zoi Toumpakari

Family life has been transformed by lockdown. Since schools closed on 23rd March many families have had to create classrooms at home and juggle home-schooling with home working. But what has happened to school food at home? Are packed lunches still the norm or are family meals now the dish of the day?

Campaigners like the Food Foundation (@Food_Foundation) have already identified the most vulnerable children and are working hard to ensure that free-school meals are maintained for 18% of families with children eligible. Under half of these families have been given vouchers to buy food, another third has had food prepared for collection or delivery by schools, so provision, to some extent, has continued. But worryingly a third have not had anything. Furthermore, out of necessity food provided is often highly processed to ensure it lasts for a week or more at a time, suggesting that compared with food served in canteens, where school food standards apply, food quality may have dropped. But what about the other 82% families? Are meals worse across the board? Or is it possible that for many children lockdown lunches are a healthier option than the norm?

According to a YouGov poll in April, over half of households haven’t noticed a change in what they eat, but 1 in 3 have reported cooking from scratch more often; 1 in 5 think their diets are healthier since lockdown but 2 in 5 think they are eating more. Straw polls of families we know have reported diverse reactions. Some are more aware of what their children eat, have more control, are providing more fruit or eating meals as a family. Others have been fending off relentless biscuit requests (not always successfully). For some kids it’s meant a switch from cooked school dinners to more packed lunch type fare at home. But is that a problem? What do we know about school food pre-COVID19?

A review of studies up to 2007 comparing the nutritional quality of packed lunches to school dinners found that more energy, sugar, saturated fat and salt was in packed lunches. Back then both school dinners and packed lunches were pretty poor. However, school food standards have been in place in England since 2006 to raise the nutritional quality of food provided by schools. Around the world, as in England, the introduction of school food standards have generally improved the quality of meals provided in schools. Although intakes of vegetables and nutrients like fibre and iron still need attention, fruit intake is up, fat intakes are lower (especially saturated fat) and less salt is being consumed from school canteens.

Improvements in school-meals is great news, a real win for public health, but now the gap in the quality between school dinners and food brought from home has widened and the spotlight is firmly on packed lunches as a key area for action. Food from home still makes up 40% of meals eaten in UK schools. Recent times have seen small changes in how often sweets and how much sugary drinks are packed in lunches, but protein is lower and vegetables remain sparse, at just half a portion a day. Multiple interventions aiming to change packed lunch quality have been tested but with little success to date.

Our work on the National Diet and Nutrition Survey has used the detailed reports of what teenagers ate over 4 days to identify the key differences between meals at home vs. school. We found that most eating (two thirds) happens at home, and only 1 in 8 meals are consumed at school. Nearly 3 out of 4 school eating occasions included foods high in fat and sugar, compared with 2 out of 3 meals at home. We found that when eating at school, foods high in fat and sugar were not only eaten more often but also in larger amounts. We estimated that teenagers ate an extra 59 calories of foods high in fat and sugar in school-based meals compared with a similar meal at home, the equivalent of half a bag of Wotsits.

The kinds of foods high in fat and sugar eaten at school are similar to those eaten at home, including crisps and savoury snacks, biscuits, sugary drinks, cakes and chocolate. But there were some key differences between eating at home and school. Predictably, eating at school occurred primarily at lunchtime (about 50% of all eating) but it was also common in the morning too (40% of eating). In contrast, meals at home happen throughout the day, with around 50% occurring after 5pm (i.e. dinner time). Eating at school is more often with friends whereas at home eating is as likely to be alone (33%) as it is with family (39%).

We also went to talk with teenagers directly about what they thought influences their eating. For most teens, food choices when away from home are a result of many different factors working together. But they told us that they enjoyed eating most when they were with their friends, one said “I tend to prefer to eat at school because I’m with my friends and it’s more sociable really than with my family.”. Social drivers are clearly important. Therefore, creating social school environments that enable and actively promote healthy choices could be an element of achieving positive change in school food future. An interesting challenge in our new socially-distant world.

Many schools are opening up more widely today, what might the lifting of lockdown mean for children’s diets? Some schools, to prevent spreading the coronavirus, have banned packed lunches. In other schools, ensuring a safe school food service is a concern so packed lunches are mandated. Social distancing may limit the kind of interactions kids used to enjoy about lunch times at school, will that affect what they eat now? Times are changing fast, new normals are being created and this may be an opportunity, in the longer-term, to reset the system for the better.

About the authors

Written by Dr Laura Johnson and Dr Zoi Toumpakari, Centre for Exercise, Nutrition and Health Sciences in the School for Policy Studies at the University of Bristol. Dr Johnson is a member of the GENIUS network, funded by the UK prevention research partnership, which aims to build a community of school staff, policymakers, food providers and researchers to generate fresh insights into the challenge of ensuring healthy food in schools and reducing inequalities. Follow us in twitter @GeniusSFN

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Motivating Miles: Reflections on why The Daily Mile might be tapping in to children’s natural motivation.

Dr Simon Sebire, Centre for Exercise, Nutrition and Health Sciences, reflects on the success of the physical activity initiative, The Daily Mile.

Ten days ago I had the pleasure of being involved in the launch of The Daily Mile in Guernsey. The Daily Mile has been taken on by most schools on the Island in the last 9 months and Thursday 24th June was a celebration of the work here to date. Elaine Wyllie, the founder of The Daily Mile and John, Elaine’s husband, were in Guernsey to support the launch. This included a tour of Daily Miles at various schools around the island, a celebration mile and lunch and a special mile for some pupils around the beautiful Government House (the residence of the Lieutenant-Governor, the Crown’s personal representative in the Bailiwick of Guernsey).

It was whilst walking the mile around the Government House grounds (being lapped by happy, rosy-cheeked children in the process) that Elaine and I began discussing how my research on people’s motivation for physical activity and developing interventions could help explain why children and schools in Guernsey and around the world seem so taken by The Daily mile phenomenon.

Elaine explained her take on this by beginning the following conversation:

Elaine: Think of a happy memory you had as a child, but don’t tell me what it is.

Me: (thinking…)

Elaine: Now tell me, were you inside or outside?

Me: Outside

Elaine: Were you on your own or with others?

Me: With others

Elaine: Were you in the supervision of adults?

Me: Sort of … at a distance

(By the way, my happy memory was of when I was 7 or 8, a hot summer day, building a sand boat with family and friends to sit in as the tide rose up Port Grat beach in Guernsey. I was outside, with other children and parents were involved sporadically, but letting us play freely.)

In identifying a happy memory, Elaine had just revealed some of the core principles of The Daily Mile. These include a focus on having fun, being non-competitive, being outside and in nature, connecting with other pupils/teachers, being a simple intervention, being fully inclusive and owned by the children (i.e., jog or run at their own pace).

These core principles chime with the fundamental elements of much of my research into physical activity motivation. Using a psychological framework called Self-Determination Theory (or SDT) I have studied the foundations of and outcomes linked with high quality motivation for physical activity in children and adults. According to this approach, a person’s motivation is deemed to be high quality when it is autonomous, in other words when motivation stems from the enjoyment of being active, the satisfaction one gets from being active (or doing a mile), a feeling that being active is in harmony with a person’s sense of who they are, or that being active brings them personally valued benefits (e.g., meeting pupils in other year groups or getting fitter). People have these kinds of motivation for being active when they experience SDT’s core principles; Autonomy, Belonging and Competence (A, B, C).

Autonomy: Feelings of volition, freedom, choice, ownership and empowerment

Belonging: Feeling strong connections with others, included, understood and respected

Competence: Feeling capable, able to master a skill or task.

Importantly, according to the theory, we need to experience the A, B and C in our daily lives, interactions and activities to have optimal well-being, development and functioning.

In a number of studies (referenced below) over the last 10 years or so, my colleagues and I have found evidence to support the idea that when children and adults feel that their A, B and C is satisfied when thinking about being active, they experience high quality, autonomous motivation and that this is linked with greater physical activity. Common to all of these studies is the finding that motivation based on enjoyment and/or personal value is linked to physical activity, whereas motivation based on guilt or external pressure (such as rewards, or demands from others) is not. Accordingly, we have designed a number of physical activity interventions for children and adolescents with the A, B and C of motivation in mind.

When viewing The Daily Mile through this motivational lens, it is possible to see how the intervention expresses the A, B and C:

Of course, my retro-fitting of SDT principles to The Daily Mile is just one lens through which to study its broad appeal and apparent motivating effect on pupils. However, it is entirely possible for interventions which grow from the ground up to align in many ways with what is known from behavioural or psychological sciences even if they did not set out to do this from the start. Aligning the core principles of The Daily Mile with a framework such as SDT’s A, B, C may also allow the intervention to stay faithful to its design as it is adopted and potentially adapted in schools around the world.

I would argue that unknowingly, when implemented in line with its core principles, The Daily Mile could be tapping in to a well-known, evidence based and positive source of motivation for physical activity. At its core The Daily Mile is simple. Perhaps it is as simple as A, B, C.

Dr Simon Sebire is Senior Lecturer in Physical Activity & Public Health in the School for Policy Studies at the University of Bristol. He is also Interim Chief Executive of The Health Improvement Commission for Guernsey and Alderney.


  1. Are parents’ motivations to exercise and intention to engage in regular family-based activity associated with both adult and child physical activity?
  2. Testing a self-determination theory model of children’s physical activity motivation: a cross-sectional study.
  3. Predicting objectively assessed physical activity from the content and regulation of exercise goals: evidence for a mediational model.
  4. Examining intrinsic versus extrinsic exercise goals: cognitive, affective, and behavioral outcomes.
  5. What motivates girls to take up exercise during adolescence? Learning from those who succeed.
  6. Does exercise motivation predict engagement in objectively assessed bouts of moderate-intensity exercise? A self-determination theory perspective.
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No single food or nutrient is to blame for obesity, so what is the right balance?

Dr Laura Johnson, Senior Lecturer in the Centre for Exercise, Nutrition and Health Sciences, discusses her new paper in which she assesses the impact of dietary patterns on obesity and how modelling may help influence change in both personal habits and public policy.

No single food or nutrient is to blame for obesity. There so many routes from diet to overeating and weight gain, and in real life foods and nutrients aren’t eaten on their own. So, it’s misleading to look at foods that way in research, it’s the overall balance of diet that matters.

I realised this a while ago when I  used detailed records of food intake from children age 5 and 7 in the ALSPAC cohort to generate an overall diet score that predicted obesity later on. I thought that eating more fat, less fibre, and having a more energy dense diet (more calories in each bite) would all feature in a diet that fuels obesity (or an ‘obesogenic’ diet). I used reduced rank regression or RRR (a pimped up version of factor analysis, see excellent explanation by Andy Field here) to find the best combination of foods to capture differences in the fat, fibre and energy density of the children’s diets. RRR generates a score based on what you eat. It’s calculated by adding up the intake (grams/day) of 42 groups of foods that are weighted for importance and a higher score means your diet is more obesogenic. I showed that children with the highest pattern score at age 7 were 4 times more likely to have too much fat by the time they were 9 years old (other researchers have since seen similar associations in adolescence and adulthood).

A pretty strong result, right? But, what use is a score made up of 42 foods? Isn’t it too complicated to ever be the basis for changing behaviour? I don’t think so, not if we use computers to deal with the complex calculations. All we need to know is what foods have been eaten (by individuals or populations) and then the obesogenic score can be computed automatically. We would then have a single score indicating whether the overall balance of your diet (or the Nation’s diet if thinking in policy terms) is more or less obesogenic. A total diet score would be better than current measures which only focus on fruits and vegetables or sugar-sweetened drinks, which let’s be honest, no one believes are going to solve the obesity epidemic on their own!

In our latest paper we asked “Do the same foods make up an obesogenic diet regardless of whether you are young or old, boy or girl, rich or poor?” (Because the ALSPAC score might only matter to children living in Bristol in the late ‘90s) “Who in the UK has a more obesogenic diet?” (Because those people need the most help to change) and “Are diets getting more obesogenic over time?” (Because that might suggest national obesity policy isn’t working).

To find some answers we used diet diaries from nearly 10,000 adults and children taking part in the UK National Diet and Nutrition Survey between 2008 and 2014. We repeated the RRR in different groups and found it was remarkably stable – the same foods came out as most important to an obesogenic diet over and over again. So, we can feel confident that the obesogenic pattern score and that way foods are weighted by importance reflects the way everyone eats in the UK today. The most and least obesogenic foods we found were (sized and in order of importance):

In terms of whose diets are most imbalanced we found massive social gradients with those in manual jobs and households earning less than £15,000/year having the most obesogenic diets, which mirrors social inequalities in obesity prevalence. Among children, diets became more obesogenic between 2011 and 2014. Among adults a more obesogenic diet went hand in hand with more time spent watching shows on TV/Laptops/Tablets, less physical activity, and eating takeaways more frequently.

All these trends are a starting point for targeting and testing interventions designed to make small changes across a range of foods to shift the balance of diet. By using our score, it could be possible to gauge how multiple changes to policy or what we eat adds up to a less obesogenic diet and with luck prevent obesity in future.

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