Authors
- Toft, Bente Skovsby BSc., MHH (Master in Health and Humanities)
- Uhrenfeldt, Lisbeth RN, BA, MScN, PhD
Abstract
Review question/objective: The objective of this review is to identify the facilitators and barriers to physical activities (PA) experienced by morbidly obese adults in the western world
Background: Worldwide obesity and a sedentary lifestyle have become a challenge. Current literature indicates physical activity (PA) is important for lifestyle interventions preventing the problem. In terms of lifestyle, physical activity is seen as an important factor in maintaining physical and mental health and a stable body weight. However, to successfully approach activities in morbidly obese people, it is necessary to identify the experiences in this population concerning problems, challenges and barriers for participating in PA based on their everyday life.
Prevention of obesity and health promotion
Worldwide, 11% of adults (aged 20 years and over) are obese; the women-men ratio is 3:2. Obesity and overweight are the fifth leading risk for death globally. Obesity is a major risk factor for cardiovascular diseases, diabetes, musculoskeletal disorders and some cancers.1
Physical problems in particular, seem to affect health-related quality of life more so than mental health problems in obese individuals.2 However, psychological factors, such as well-being, in terms of experiences of body image, mood, identity and inter-subjectivity as well as time and space, is also considered central in the description of health.3 In the discourse about obesity, there is an explicit focus on the negative impact on both physical and psycho-social health4,5 as well as the reduction of quality of life.6 Obesity is therefore considered a multi-factorial disorder and is more complex than merely an imbalance between intake and daily requirement of nutrients7 as it is strongly influenced by micro- and macro-environmental factors as well as social and cultural factors.
Physical inactivity (PI)
A sedentary lifestyle with hours of physical inactivity (PI) seems to act as an independent risk factor for health.8 Physical exercise (PE) is therefore suggested in most lifestyle modifications as the societal tendency leans more towards inactive job functions, leisure time and transport.
Physical inactivity (PI) and low cardio-respiratory fitness are considered as important as obesity as being mortality predictors9 and are the fourth leading risk factor for global mortality.10 Conditions associated with PI include obesity, hypertension, diabetes, back pain, poor joint mobility and psychosocial problems.11 Physical inactivity is considered one of the main causes of obesity.1
It is an evidence-based given that PA promotes health12 both with or without weight loss by having a positive impact on metabolic syndrome; optimizing body composition through minimization of fat-free mass losses and maximising fat mass loss13 as well as maintaining a stable weight.7
PA and morbid obesity
Reduced PA is both a cause and consequence of obesity and public guidelines recommend overweight adults (aged 18-64) to be physically active for 45-60 minutes at moderate intensity activity daily to prevent weight gain, and promote long-term weight loss.10,13,14,15 However, doing some PA is considered better than doing none. Inactive people should start with small amounts of PA and gradually increase the duration, frequency and intensity over time.10
People with a higher BMI experience greater limitations in PA and daily activity than people with lower BMI.4,6 In the long-term, inactivity does not lead to obesity, but Petersen et al. found that those in the highest BMI group were at higher risk of becoming physically inactive.16 Higher levels of PA appeared to be beneficial at all levels of adiposity.17 Hu et al.17 found that mortality rates increased with higher body-mass-index values among women and that adiposity predicted a higher risk of death regardless of the level of physical activity.
Facilitators and barriers of PA and PE
It is often overlooked that health-enhancing exercise may involve categorically different sets of corporeal experiences for obese individuals.18 Various complications of obesity can make exercise difficult and could be one of the reasons for the low prevalence of exercise in the severely obese population.19 The paradox seems to be that people with obesity feel too fat to exercise.20
Several studies have investigated which facilitators and barriers are experienced by people with obesity.21-25 The determination of these facilitators and barriers of physical activity can provide a basis for developing interventions.23
Clinicians need to understand the morbidly obese patients' goals and objectives starting with their current physical capacity, resources and opportunities to adapt to lifestyle changes and consider intrapersonal factors. Little is known about exercise initiation or maintenance among those who are morbidly obese and to which extent weight acts as a barrier of PA. A deeper understanding of the experiences among people with morbid obesity is needed in the attempt to increase their activity levels. Time, interest, motivation and physical ability must be taken into consideration in order to make an active lifestyle realistic. An assessment of the patient's likes and dislikes is needed to make the experiences of physical activity as positive as possible.
PA and human experiences
Body experience and body perception are central data sources in the access to the life world of subjects and their personal understanding of their social context as the subject is constantly in a dialogue with the environment through perception, cognition, movement and action.26
The ability to sense the surroundings and act bodily adequate in relation to the situation is called body skills. Body skills can be developed when you learn to overcome actual barriers for acting, but it takes a lot of effort for adults to overcome these barriers and act adequately in relation to health promotion and prevention.27 Intentionality as a pre-reflective state of mind where the lived body works as a mediator to the world and our anchor in the world was primarily developed by Merleau-Ponty28 and represents a monoistic understanding of body and mind in a phenomenological tradition.
The lived body works as a "sensory organ", functioning on the basis of intentionality or perceptivity and the foundation to make the situation meaningful to the subject. We perceive the world and ourselves through our body, trying to find social contexts and situations where we have the possibility of developing positive emotions that influence our self-perception in a positive way. Positive bodily experiences and emotions in PA and sports are important.26
Patients' physical experiences during bodily activity are important in relation to the intervention of lifestyle changes among obese adults. According to Merleau-Ponty, the lived body is habitual.28
Existing literature on the topic
An initial search for articles on the topic resulted in different studies concerning mostly obese women's experiences and barriers regarding exercise.29-35 However, only one study included severely obese women.36 Three additional studies considered the attitude of severely obese adults towards physical activity. Sallinen et al.37 studied the explanations for inactivity among older people both non-obese and severely obese adults; Hwang et al38 studied the explanations for unsuccessful weight loss among bariatric surgery patients; and Wouters et al39 examined the correlation between physical activity and exercise cognitions among severely obese adults after bariatric surgery.
The conclusion of the initial search is that only a limited number of studies consider the facilitators and barriers of morbidly obese adults in relation to participation in physical activities. Also, a preliminary search of the Joanna Briggs Library of Systematic Reviews, CINAHL, PubMed and PROSPERO revealed that no available systematic reviews or protocols on this topic exist.
Definitions
Obesity/class I obesity: Body Mass Index (BMI) >= 30-34,9 (kg/m2)
Severe/class II obesity: BMI of >= 35-39,9 kg/m2
Morbid/class III obesity: BMI of >= 40 kg/m2 40
Physical activity (PA): any bodily movement produced by skeletal muscles that result in the expenditure of energy.10
Physical exercise (PE): a regular, planned, structured and repetitive bodily movement undertaken to improve or maintain physical fitness.13
Western World: countries in thewestpart of theworld,especiallyNorthAmerica andcountries in thewest of Europe.41
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include morbidly obese (BMI=>40) adults (=>18 years) in the western world e.g. the countries of Europe and North America.
The review will not consider studies involving the mentally ill, pregnant women, children and adolescents.
Phenomena of interest
This review will consider studies that investigate the experiences of facilitators and barriers for PA.
Context
The review will consider research on the experiences of physical activity in recreational and leisure-time activity, transportation (e.g. walking or cycling), occupational and household chores.
Types of studies
This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies and a citation search will also be done on especially relevant studies. All studies published in English, Danish, Swedish and Norwegian will be considered for inclusion in this review. The search will be carried out in cooperation with a librarian. The databases to be searched include:
MEDLINE, CINAHL, Embase
The search for grey literature will include: thesis and dissertations
ProQuest, Mednar and Google Scholar
Initial keywords to be used will be:
Morbid obesity, obese, adults, barriers, facilitators, participation, motivation, physical activity, exercise, experiences, lived experiences, qualitative studies.
The intended search strategy will be:
(((((((((((((("sedentary lifestyle"[Title]) OR sports[Title]) OR "activity of daily living"[Title]) OR "activities of daily living"[Title]) OR exercise*[Title]) OR "leisure activity"[Title]) OR "leisure activities"[Title]) OR "physical activities"[Title]) OR "physical activity"[Title])) AND (((obese[Title]) OR obesity[Title]) OR bariatric*[Title])) AND ("Behavior and Behavior Mechanisms"[Mesh])) AND ((((((perceived OR attitude* OR benefit* OR limitation* OR experience* OR participation OR barriers OR facilitators)) OR motivat*) OR experience*) OR "psychosocial factors") OR "physical factors"))) NOT (((((((mental illness[Title]) OR ((((child*[Title]) OR school*[Title]) OR adolescent*[Title]) OR pregnan*[Title]))) OR youth[Title])) OR materna*[Title]) OR parent*[Title]) Filters: English; German; Danish; Norwegian; Swedish
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of primary studies may be contacted for missing information or to clarify unclear data.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Conflicts of interest
None
Acknowledgements
I am grateful to Line Jensen, MA, for her work with language revision and to Karin Velbaek(librarian) for her helping with the literature search.
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Appendix I: Appraisal instruments
QARI appraisal instrument[Context Link]
Appendix II: Data extraction instruments
QARI data extraction instrument[Context Link]
Keywords: Morbid obesity; obese; adults; barriers; facilitators; participation; motivation; physical activity; exercise; experiences; lived experiences; qualitative studies