Bulldog Obesity Overcoming Barriers to Exercise

Exercise in pregnancies complicated by obesity: achieving benefits and overcoming barriers

Abstract

An increasing number of women are entering pregnancy in an overweight or obese state. Obese women and their offspring are at increased risk of adverse perinatal outcomes, which may be improved by regular moderate-intensity antenatal exercise. Current guidelines recommend that all pregnant women without contraindications engage in 30 minutes of moderate-intensity exercise on a daily basis. However, obese women are usually less physically active and tend to further reduce activity levels during pregnancy. This commentary summarizes the potential short- and long-term benefits of antenatal exercise in obese pregnant women, highlights the challenges they face, and discusses means of improving their exercise levels. In addition, we make recommendations on exercise prescription for pregnancies complicated by obesity.

Keywords: barrier; exercise; obesity; offspring; pregnancy.

Copyright 2015 Elsevier Inc. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't

MeSH terms

• Exercise Therapy / methods*
• Exercise Therapy / psychology
• Female
• Humans
• Obesity / psychology
• Obesity / therapy*
• Pregnancy
• Pregnancy Complications / psychology
• Pregnancy Complications / therapy*
• Pregnancy Outcome
• Prenatal Care / methods*
• Prenatal Care / psychology

Barriers to Obesity Management: Patient and Physician Factors

The prevalence of obesity is increasing worldwide. Obesity is a chronic, relapsing, and progressive disease associated with serious complications and comorbidities.^1-3 Moreover, it has been associated with the increased risk of mortality due to cardiovascular diseases and most cancers.⁴ In addition, the effects of weight reduction on alleviating obesity-related comorbidities and risk factors have been well documented.⁴

Obesity treatment guidelines from various academic societies, including the Korean Society for the Study of Obesity, recommend lifestyle interventions along with pharmacotherapy if the response to dietary changes, physical activity, and behavioral changes is insufficient to reach or maintain the recommended goal of 5%10% loss of body weight.^4-6 Bariatric surgery should be considered for people with severe degree of obesity or obesity-related comorbidities.^4-6 Despite the availability of these guidelines, a minority of people with obesity (PwO) receive clinically proven lifestyle, pharmacological, and/or surgical interventions.^7,8 In other words, PwO experience variable care.⁷ In practice, nearly 25% of PwO achieve an annual weight loss 5%.

The unsatisfactory outcomes of obesity treatment reflect a failure of both patients and physicians initiating or maintaining the necessary therapies. The first step to successful management of obesity comprises identifying and understanding the barriers to the standards of care during self-management and clinician interventions. Although barriers differ by treatment modality, this review focuses on common barriers that should be identified and addressed for weight loss as well as prevention of further weight gain. The aim of this review is to summarize the existing knowledge on the barriers of obesity management from the perspectives of both patients and physicians from the perspectives of both patients and physicians ().

Patient and physician factors associated with barriers to obesity management.

PATIENT FACTORS

Lack of recognition of obesity as a chronic and relapsing disease

According to the Awareness, Care and Treatment in Obesity MaNagementan International Observation (ACTION-IO) study, most PwO and healthcare professionals (HCPs) agree that obesity is a chronic disease.⁷ The results from South Korea indicated that, compared to HCPs, a higher proportion of PwO consider obesity to have a large effect on overall health.⁸ In addition, 78% of PwO stated that they had made at least one serious weight loss effort in the past.⁸ Nonetheless, only 12% of PwO reported a loss of at least 10% of body weight over the past 3 years. Moreover, less than half of the population maintained the weight loss for at least 1 year.⁸ The low success rate can be partially attributed to the lack of preparedness of PwO to adhere to persistent treatment for maintaining weight loss. If no long-term treatment strategies exist to prevent weight regain, weight loss might be meaningless. In addition, long-term compliance with obesity medications is very low: the 1-year and 2-year persistence rates are <10% and 2%, respectively.⁹ Despite successful bariatric surgery, patients can regain weight if they fail to implement successful strategies to prevent weight regain.⁹ Therefore, PwO need to recognize that obesity is a chronic disease prone to relapse to fully appreciate the importance of long-term management.

Misbelief and misinformation about obesity management

PwO hold a wide range of attitudes and beliefs about obesity and its treatment. According to the ACTION-IO results from South Korea,⁸ 48% of PwO believe they could lose weight if they were determined. Rather than seeking advice from HCPs, they prefer alternative sources of information on weight management, such as the internet, family and friends, television programs, and smartphone applications.⁸ These sources are likely to be ineffective and might even pose significant health risks.

Environmental factors

Culture and family influence the beliefs, attitudes, knowledge, and behaviors of an individual toward obesity self-management.⁹ Dieting is common, especially among women. Participation in activities associated with food and alcohol consumption may be linked to personal behaviors. For example, it might be difficult to overcome overeating during social gatherings, and social and professional obligations can sabotage patient efforts. Furthermore, a family is a dynamic system that influences important risk factors for obesity in children and adolescents. In particular, parental work schedules and family eating habits were the most frequently cited barriers to healthy eating and exercise among studies of obese adolescents.¹⁰ For adults, the family as an environmental factor of obesity can play a role in maintaining weight loss as well as reducing body weight. Successful weight loss may depend upon family functioning or finding a support system within and/or outside the family.¹¹ Therefore, successful adherence to long-term lifestyle changes necessitates a strong support network of family, friends, or peers.

Cost

Cost of treatment is a significant barrier to obesity management, particularly for patients with a low socioeconomic status in developed countries.¹² Other major obstacles include the high cost of a healthy diet and the unaffordability of membership in commercial weight loss programs and gymnasiums.⁹ In addition, unlike medical treatments for other chronic diseases, obesity medications are generally not reimbursed by health care systems. However, the ACTION-IO study conducted in South Korea reported that fewer PwO consider their financial status as a barrier to weight loss compared to HCPs.⁸ Nevertheless, these factors can hinder weight management and interventions and must be acknowledged.

Comorbidities and medications

Multiple chronic conditions, including mental health problems, sleep disorders, cardiopulmonary diseases, or pain, can impose limitations on the physical activity of all patients. People with multiple comorbidities frequently experience barriers to obesity self-management. Obesity also is associated with several endocrine diseases including hypothyroidism, polycystic ovarian syndrome, Cushings syndrome, central hypothyroidism, and hypothalamic disorders. However, endocrine function testing cannot be justified unless there is clinical evidence to support a diagnosis other than simple obesity. Furthermore, several commonly used drugs cause iatrogenic weight gain, leading to exacerbation of comorbidities and non-compliance with therapies.¹³

PHYSICIAN FACTORS

Lack of time during general practice consultations

Lack of time with patients is one of the most frequently encountered barriers to obesity management. HCPs cite limited appointment time as the principal reason for not discussing weight management with their patients, similar to the results of the ACTION-IO study from South Korea.⁸ Therefore, certain administrative barriers must be alleviated to facilitate longer appointment times globally, but particularly in South Korea.

Insufficient training and counseling skills for obesity

HCPs perceive several barriers that prevent them from aligning their clinical practice with the current recommendations, and lack of training is one of the key barriers to obesity management. Obesity education for HCPs includes diverse fields, such as diet, nutrition, exercise, behavior therapy, and medication. Nonetheless, physicians find it difficult to provide effective weight loss counseling for PwO, which is a probably a consequence of lack of basic knowledge on exercise, nutrition, and applied clinical experience from medical schools and residency training programs.¹⁴ Moreover, a review of the U.S. Medical Licensing Examinations reported on the rare inclusion of obesity-specific content in examinations.¹⁵ Most medical school curricula in Korea do not encompass sufficient obesity education, including adequate nutrition education for medical students. Considering the impact of counseling delivered by HCPs on weight loss behaviors, medical schools must adequately address obesity education in their curricula.

Lack of a formal diagnosis of obesity

Despite its increased recognition as a chronic disease, obesity remains greatly underdiagnosed. According to the South Korean ACTION-IO study, 50% of PwO consider themselves obese. Furthermore, 55% report receiving a formal diagnosis. A substantially smaller rate of South Korean PwO (22% of PwO) had been diagnosed with obesity through weight management discussion with an HCP compared to the global proportion.⁸ PwO who receive an early diagnosis could experience fewer complications or other chronic diseases. Therefore, physicians should proactively screen for obesity and initiate discussions on obesity management.

In conclusion, obesity is a complex disease with multifactorial barriers to management. Notwithstanding the increasing perception that obesity is a chronic and progressive disease, management is much weaker than that of other chronic diseases, such as type 2 diabetes and hypertension. Therefore, obesity management must be a persistent effort for both PwO and physicians. Identifying and addressing barriers to obesity management are essential before patients can adopt necessary lifestyle changes and adhere to therapies. Further research should focus on the degree of weight loss and the development of an obesity program.

Bookshelf

Introduction

People with obesity experience discrimination from an early age that often stems from the stigma associated with the disease. The belief held thatpeople with obesityare lazy, overindulgent, and lack self-control is incorrect and has the potential to negatively impact many aspects of a patients life. Therefore, the healthcare team and the larger medical community need to acknowledge the stigma associated with obesity and its implicit bias. Acknowledging this bias and applying methods to decrease the stigma will improve the care of patients with obesity.

People who are overweight and obese experience discrimination in several areas of life, including in the workplace, education, and healthcare.[1]This stigmatization occurs at a very early age, and with the rise in childhood obesity, the discrimination faced by people with obesity is beginning at a younger and younger age.[2]Over the past three decades, several studies have demonstrated that healthcare professionals are not outliers for those stigmatizing obesity. It may serve as a barrier to delivering appropriate and effective healthcare to those with obesity.[3]

A study out of France showed that most general practitioners know that being overweight and obese are life-threatening, and 79% agree that it falls under their scope of practice; however, 30% of providers had negative attitudes towards the obese patients in their care.[4]Several Australian, British, and Israeli studies of physicians demonstrated similar beliefs about people with obesity. Australian general practitioners reported that the most common frustration of treating obesity was the lack of patient motivation and compliance.[5]

In a British qualitative study, primary care physicians expressed beliefs that the condition is caused by unhealthy eating and lack of exercise, leaving the responsibility solely on the patient.[6]An Israeli study showed that 31% of family medicine physicians believed overweight people were lazier than patients who are not overweight.[7]

Issues of Concern

The effects of the stigmatization of obesity on the health of those with the disease have been well documented. Patients with obesity who have felt stigmatized have an increased risk of binge eating disorder, increased food consumption, decreased physical activity, and increased physiologic stress response.[8]

The stigma and, in turn, discrimination impairs the care provided to the patient and the frequency at which a patient seeks care. Being aware of the impact that thestigmatization of obesity has on patients' health may help reframe clinicians' attitudes toward patients with obesity, allowing them to focus less on the weight and more on the diseases with which it is associated. Along with other tools to destigmatize obesity, this reframing may provide better health care.

The stigmatization of obesity is a proven problem for people with obesity and providing optimal health care to those patients. The Joint International Consensus Statement for Ending Stigma of Obesity recognizes that individuals affected by overweight and obesity face a social stigma. The statement aims to condemn the use of language, attitudes, and policies that stigmatize overweight and obesity and pledge to support initiatives to prevent discrimination based on their weight in the workplace, education, and healthcare settings.Reducing stigmatization can be done through concrete policies and some not-so-tangible changes. There are validated tools, such as the antifat attitudes test (AFAT), that canhelp to assess a health care provider's attitude towards people with obesity. The goal of these tools is to bring awareness and discussion that will lead to positive change in the care of this patient population.[9]

In addition to the previously documented stigma around weight and its impact on the health of those with obesity, the effects of the COVID-19 pandemic present a new area for discussion. Early during the pandemic, the CDC identified obesity as a risk factor for severe COVID-19. The implication of this fact is that people with obesity are vulnerable to biology during the pandemic, and the weight stigma is already acknowledged as a barrier to equitable healthcare. While healthcare workers may acknowledge those with COVID-19 and obesity as being at high risk for severe infection, prompting swift evaluation and treatment, those efforts can only be practical if patients seek treatment. As discussed above, patients with increased BMI are more likely to underutilize or delay healthcare.[10]

This delay in care may negatively impact the individual and potentially have deleterious effects on public health when limiting the spread of cases is paramount. "The Quarantine-15 or the Covid-15" is a term d "scribing the weight gain thought "o inevitably come with the pandemic that has gained widespread popularity with little evidence to support it. What this term does, however, is emphasize body image, focusing on the importance of self-control when it comes to diet and exercise. Messages from recognized organizations have put the responsibility on the individual to reduce their risk of severe COVID-19 infection by losing weight. The UK National Health Service'sBetter Healthinitiative aims to reduService'srden to healthcare workers by "tackling obesity" so that it may "free up their" time to treat "her sick and vulnerable patients."[11]This message not only solidifies the stig" surrounding obesity but incorrectly simplifies a disease process that is far from being completely understood.

Strategies to Reduce Stigmatization

Zero Tolerance Policies

One strategy discussed by both the Joint International Consensus and other literature is a zero-tolerance policy for using stereotypical language, images, or humor that inaccurately depicts patients with overweight and obesity as being lazy or lacking self-discipline. Verbalizing a zero-tolerancepolicy to the health care team will help bring awareness to the issue and improve the culture around treating patients with overweight and obesity.

Perspective Exercises and Emotion Regulation

A potential strategy to reduce stigmatization of obesity is increasing provider empathy through perspective-taking exercises. Use obesity simulation suits (OSS) has been used in multiple clinical settings. The OSS has been used as a teaching tool during standardized patient (SP) encounters. SPs at a German medical school were asked to wear an OSS during an encounter. Students, teachers, and the SPs were then given questionnaires about the experience. The study concluded that the use of the OSS contributed to the realistic perception of a patient with obesity. The AFAT was used and showed that students demonstrated a more substantial antifat prejudice compared to teachers and SPs.[12]

Utilizing tools such as the OSS in educational, simulated settings gives learners more opportunities to discuss topics they may otherwise be uncomfortable with, such as weight. A small qualitative study hadseven healthcare professionals wear an OSS for 2 hours in public. Surveys after the experience showed that attitudes were more empathetic and less judgmental towards those with obesity.[13]

A similarly designed study utilized a bariatric empathy suit. Nursing students wore the suit, and when surveyed after the experienceto examine thenurses' attitudes towards obesity and obese patients,they reported more positive attitudes toward obese patients.[14]Another tactic to reduce obesity prejudice in medical educationutilized standard lectures and dramatic readings. The study assigned medical students to two groups. One attended a one-hour lecture on the medical management of obesity, and the other group participated in a one-hour dramatic reading. Those in the dramatic reading group were found to have lower levels of explicit fat bias.[15]

The hope isfor better care by increasing empathy and decreasing bias. Additionally, utilizing the questionnaires and surveys previously mentioned, it is crucial to identify when a bias is present and recognize how this may make providers feel. As discussed above, providers may harbor negative attitudes towards patients they feel to be difficult or noncompliant. A strategy implementing practice in emotion regulation may manage those feelings to deliver better care. This may be in the form of meditation or deep breathing prior to an encounter.

Obesity as a Disease

Another measure is ensuring proper education of the healthcare team on the contributors to patients' weight that are outside of the patient'scontrol.[16]Weight results from the patient's genetics, socioeconomics, and psychology. Children who attributed their increased weight to external causes rather than solely responsible had higher self-esteem than those who believed the contrary. Educating providers on the epidemiology and pathophysiology of weight may allow the conversation between patient and provider to remain on science and literature topics, rather than blaming the patient.

Obesity as a Risk Factor

Discussing overweight and obesity as a risk factor for other diseases allows the patient and provider to focus on weight as being modifiable and treatable, taking the onus off the patient. The hope is this reframing will encourage patients to continue to seek medical care, even when there are setbacks, rather than avoid the doctor because of disappointment they may feel. Discussing the below conditions associated with overweight and obesity may be more appropriate topics for the visit rather than focusing on weight itself.

Body Mass Index (BMI) and central adiposity can predict type 2 diabetes mellitus (T2DM) development. Furthermore, the duration of increased body weight is a risk factor for future T2DM. Discussing the screening for T2DM and its management may serve as reasons for frequent follow-up rather than follow-up for weight alone. The risk of certain forms of canceris increased in people with obesity, such as colorectal, prostate, andbreast cancer. Discussing guideline-directed screening for these conditions may be another opportunity to address weight.

The effects that weight has on the cardiovascular system may be addressed regarding hypertension, stroke, and myocardial infarction, especially in those patients who present wanting to talk about risk reduction. Other conditions that may present an opening for a discussion on weight reduction are precisely those that impair one's quality of life, such as gout, polycystic ovarian syndrome, obstructive sleep apnea,and osteoarthritis, all of which are associated with overweight and obesity.[17]The above examples serve as a starting point for conversations between healthcare providers and patients that ultimately address weight without it being the focus of the discussion.

The Weight-Friendly Clinic Space

As mentioned above, clinicians and staff should be trained to avoid hurtful comments, jokes, or being otherwise disrespectful towards patients with obesity. Using "patient-first" language, such as "patient" with overweight or "obesity," is preferred over "obese patient." Encouraging terms such as "healthy weight," "overweight," and "body mass index" are preferred to terms such as morbidly obese, fat, and large size. Using motivational interviewing rather than providing unsolicited advice may serve as a strategy to implement patient-centered communication, which may be less threatening for patients.[18]

A study published in the journal ofObesity Surgeryshowed that while primary care providers were supportive in treating co-morbid conditions and attempts at dieting, many did not have appropriate equipment in their offices. Creating a positive office space includes having chairs, sofas, and exam tables that can handle high body weights without tipping or breaking. Having the following tools available in the clinic will also help the patient feel welcomed and avoid embarrassment: extra-large patient gowns, large blood pressure cuffs, extra-long needles to draw blood, large vaginal speculums, weight scales that can measure patients who weigh more than 400lbs and are preferably located in a private area.

Clinical Significance

There is a clear need to combat weight stigma, widespread throughout healthcare globally. An important barrier to treating high weight patients obesity is the belief that obesity is simply a consequence of personal decisions of lifestyle and behavior. Starting in 2012, major medical associations began to recognize obesity as a disease, changing the framework for recognition and management of this disease.[19][20]

Obesity is the consequence of genetic and environmental factors that trigger the complex pathophysiology of gut hormones and neuropeptides.[21]Clinicians must first accept obesity as a chronic disease, like hypertension, diabetes, and coronary artery disease, to treat it effectively.

Once a clinician accepts obesity as a chronic disease that must be treated, good patient-clinician communication and cooperation must develop a productive individualized management plan. Using people-first language is an important communication statement that prefers terms such as unhealthy weight rather than fat and morbidly obese. Using techniques of motivational interviewing and shared decision-making helps guide the patients towards healthier options and change. While patients may be focused on the cosmetic benefits of weight loss, it is important as a clinician to share the health benefits of lower body weight. As little as a 5% weight loss has significant health benefits, including reductions in most chronic diseases and all-cause mortality and improved quality of life metrics.[22][23]A weight-friendly office space makes the patient feel comfortable and welcome, encouraging them to return for follow-up.

Enhancing Healthcare Team Outcomes

The stigmatization of overweight and obesity negatively impacts the health care provided to patients. Because of this stigmatization, patients are reluctant to seek healthcare, decreasing healthcare visits. The healthcare team's conscious and subconscious biases contribute to the suboptimal care of this patient population. It is the responsibility of all healthcare team members to take whatever steps necessary to ensure the best quality of care is given to each patient. Thisis only achievable if each healthcare organization aims to end the stigma associated with weight. [Level4]

The following steps outline ways for the healthcare team to decrease the stigma of obesity and improve the care provided to these patients.

• Step 1: Recognize that obesity is a chronic disease with diverse causes.

• Step 2: Create a weight-friendly space that is sensitive to the needs of people with obesity.

• Step 3: Use motivational interviewing and coaching techniques to set individualized and realistic goals in collaboration with the patient.

• Step 4: Individualize a treatment plan including lifestyle and behavior modification, pharmacotherapy, and referrals to nutrition, psychology, physical therapy, and bariatric surgery when necessary.

• Step 5: Implement zero-tolerance policies for negative language and practices that stigmatize patients with high body weight.