Physical Activity Interventions for the Overweight and Obese: A focus on practical lessons (in child


Why should you care about Obesity? If you haven't heard it before, I'm going to remind you. Obesity is a worldwide epidemic that is only getting worse. In North America, the incidence of Obesity is upwards of 30% of the population, while in developing countries, obesity numbers are continuing to climb, mimicking the trends seen in North America. Not only is this detrimental to the health of our loved ones, it is also becoming a huge burden on the money spent by tax payers on health care (Billions!). Instead of spending money on developing better schools, strengthening the economy or creating new jobs, a larger proportion of our tax dollars are going directly towards treating chronic disease such as cardiovascular disease, diabetes, and OBESITY.

We can't blame those that are overweight or obesity for one specific reason: we currently live in an Obesogenic environment. This obesogenic environment includes being surrounded by a surplus of calorie dense food that is always readily available, but other influences include genetics (something the individual is "stuck with" unless you consider the influence of epigenetics), the influence of pregnancy (being the parent, or the child), illness (causing bed rest, as an example), complex psychological factors, financial barriers, and sociocultural structures.

Obesity may be a problem that your mom, dad, brother, or sister is struggling with. What if your own kid struggles with it? It may be a problem that a personal training client is struggling with. What if it's your client? The primary objective of this blog is to educate on the practical applications of research on physical activity (PA) interventions for overweight and obese individuals, in order to open your mind and broaden your perspective to looking at Obesity from a less judgemental perspective. Think of Obesity as an addiction for one moment: if someone wanted to quit smoking, would you refuse to help them because it’s their own fault? No. So how can we look at someone and say to what extent “it’s this person’s own fault” that he/she is overweight or obese?

We will dive into the environmental, psychological, financial, sociocultural, biochemical, genetic, and other factors contributing to this problem. I believe that any of the practical lessons learned from working with the issues an obese population faces, can be applied to an athletic or “average” population, especially at the youth level, so read carefully! I challenge you to find 2 points that you can’t apply to any general population, a generally active person, or even a young elite athlete.

So, here are the top 10 practical lessons learned from PA interventions in overweight and obese children and adolescents:

  1. Physical activity setting –context is important!

In preschool-aged kids, research has found that the more portable and less fixed the playground equipment, the bigger the playground size, and the less the structure of the activity, all contributed to more moderate/vigorous PA, and less sedentary time! Furthermore, the characteristics of the preschool attended by the child influenced their likelihood of participating in physical activity more than socio-demographic factors. This has implications in schools and at home to offer children more chances to participate in UNSTRUCTURED physical activity. Plus, we know that this type of physical activity develops cognitive and fundamental movement skills and social skills in correlation with frequency of their exposure to play spaces, time spent there, and the convenience of access to those play spaces. Furthermore, lack of access to facilities correlated to obesity (think: lower socioeconomic neighbourhoods, closeness of school to home, unsafe areas). Many parents think that their children can reap all the benefits of play at home versus at a community center or fitness facility, but this approach lacks the social aspect. It is important to consider that most children need to feel equal to their peers, included, and emotionally secure. Particularly in adolescence, watch for tightness of uniforms, privacy in change rooms, and the potential to work out with a buddy for motivation.

  1. Choice of fitness trainer matters!

Personal trainers can be important for increasing the perceived confidence and competence of the individual especially early on in their journey for behavior change. Important factors to consider include a positive environment, gender considerations, and timelines. Consider a same-sex trainer if possible, especially for adolescents. One study pointed out that having a personal trainer at the beginning of a fitness journey can be very important due to their extra motivation and encouragement. Over time, some youth stated that trainers played little to no role. So, it should be suggested that personal trainers at the start of a program are important but may not be needed for long-term. Also, this person should adopt position of mentor/friend, rather than parent or teacher, and should make it a fun and positive experience.

  1. Physical activity should be varied and fun!

Progressive programs are the most effective at creating bodily change over the long term, helps give the individuals a challenge, and moves them closed towards more achievable goals. Make the exercises NOT homework, and NOT like school. For younger kids, making them write what they want to work on that session or that week, or with colorful markers, can make all the difference for modifying behavior. This is an effective strategy because kids are not allowed to pick what they want to do in school, and if you’ve ever worked with kids, you know that little things like that can make a big difference. In terms of resistance or aerobic training, is is best to include a combination. For beginners with poor exercise tolerance, consider reducing bouts of aerobic (more discomfort) and interspersing them among resistance training (more fun). Lastly, music increased exercise tolerance and perseverance on treadmill test (more motivation, less distraction) so should be incorporated into a training program when possible.

  1. Role of parent/guardian should be considered

Conventional studies in the past have looked at children themselves as agents of change. A recent study has looked at interventions for modifying behavior change while targeting the parents as agents of change (Golan et al., 1998). In this study by Golan et al., kids were nine times less likely to drop out, and lost more weight compared to controls. The follow up to the study, 7 years later, found that effects were maintained - proving the effectiveness of this method for change. Kids and teens live within a system that is out of their control. They are dependent on parents for transportation, food, and physical activity. Parents can be both facilitators and barriers to lifestyle changes, so it is important to consider how to support kids with more autonomy and less parent help than in other families. Consider too, that higher adherence rates could potentially be achieved if they could choose what group they wanted to go into, which exercises they liked best, etc.

  1. Consider the individual

Dropout rates to an exercise program have been shown to be higher in boys than girls, African Americans than Caucasians, and moderate or severely obese individuals than mildly obese individuals. Studies have also shown that the largest declines in physical activity behavior occur in adolescent girls. Consider that motivations are different between genders, and target this in exercise interventions. Assess predisposition to dropout at the start of program so you can red flag certain clients. Use questionnaires, consider their stage of change, and have honest conversations with them. Get to know their home/family/environmental situation. For girls especially, it is important to frame exercise interventions around health rather than being thin, because often at an adolescent age, losing weight for appearance alone is a main motivator (at least in the beginning). Not surprisingly, boys and girls tend to have different motivators. For boys aged 8-12 years old, they tend to increase their physical activity level and have greater motivation levels in the presence of friends and peers (regardless of friends' weight status). For boys aged 13-16 years old, getting sweaty, feeling tired, and getting physical results were more motivating factors. Girls of all ages are found to be motivated by extrinsic factors (being thin, being popular), and intrinsic factors (overcoming challenges, experiencing a sense of accomplishment), primarily.

  1. Realistic goals should be set

“SMART” goals should be set as early as possible. The SMART acronym stands for Specific, Measurable, Attainable, Realistic and Timely. Visual representations of the client's goal can be effective depending on the person, and for others (such as per-adolescents), incentives can be effective. Emphasize effort and participation more so than skill mastery, and involve them in the process. The more they feel they are part of it, the more they develop a sense of autonomy, competence, which creates higher adherence.

  1. Regular reminders should be offered

“Lack of time” is stated as a major barrier to physical activity. To aid in being physically active, it can be helpful to inform your client that breaking up physical activity into small bouts, rather than one large time-consuming bout, can be just as effective. If 45-60 minutes per day of activity is the goal, breaking up that goal into 10 minute breaks/walks throughout the day can add up quickly. Furthermore, establish your patient’s preferred method of communication. There are various and numerous modes of technology that can aid in reminding to be physically active. This could include a FitBit that beeps to remind us to stand up and do 10 jumping jacks, a phone app, or an online social networking group that helps motivate the person to be active.

  1. A multidisciplinary approach should be taken

OBESITY IS COMPLEX. A team of well-qualified empathetic professionals (exercise specialists, dietitians, endocrinologists, psychologists) should work with Obese or Overweight individuals to attack the problem from every angle and offer the client the most amount of support possible. Although it is only more recently that psychologists have begun to be included in an Integrated Support Team (IST), they are crucial to the patient's modification of behavior over the long term. TESTING and MONITORING are key for program evaluation and adjustment in order to design the most effective steps towards a successful outcome. What’s working and what’s not? Adjust the program as they progress, and involve client weekly in these adjustments and modifications.

  1. Barriers should be identified early and a plan to overcome them should be developed

What do we know about barriers to physical activity? In the literature, it is clear that early interventions are more successful, that Overweight and Obese individuals perceive more barriers than the average person, that lack of family support can hinder progress immensely, and that lack of motivation or fatigue are often some of the biggest barriers to exercise. Involving the family in weekly meetings to increase the social obligation of exercising, and increasing motivation and support around the change of behavior is key. Scheduling conflicts with school, work, or family obligations should be done ahead of time so that solutions can be created prior to the arrival of the barrier. The presence of a contextual factor (bad weather, lack of transportation) often enhanced personal reasons (lack of motivation, low energy) for not attending. If more than 1 barrier was present, they did not attend. In summary, family helps overcome barriers and can help to plan to overcome future barriers.

  1. The right message should be communicated: specifically, what’s in it for them?

a) Use openness and empathy when meeting with clients beginning a physical activity program. b) Potential benefits need to be balanced by realistic expectation setting.

c) Emphasize “what’s in it for” the participant and make the exercise prescription meaningful to the participant d) Remember the family-centered approach e) Have realistic expectations f) Get the family of the participant on the same page as them

We now know that each additional year of abdominal obesity is associated with a 4% greater risk of developing diabetes mellitus, among other chronic diseases. Many youth tend to view weight loss as the main health benefit of exercising, which should be considered when designing exercise programs for youth, specifically. A new finding in a recent study found that participants appeared to gain stronger sense of importance of fitness for health (separate from weight loss) over the course of the study. Finally, when designing programs for exercise, the motivation of exercising for weight loss, which is an extrinsic motivator, should be minimized compared to the focus that should be placed on exercising for improved fitness. This motivation is more intrinsic, and has demonstrated more positive health outcomes than the latter in the research.

Strength and fitness is VITAL to the health and wellness of you and your loved ones #VitalStrength

If you would like to contact the main author of this paper, Gabrielle Heine, a classmate of mine, she can be contacted privately. Message me for more details :)

References

Alberga, A., Farnesi, B.-C., Lafleche, A., Legault, L., & Komorowski, J. (2013). The effects of resistance exercise training on body composition and strength in obese prepubertal children. The Physician and Sportsmedicine, 41(3), 103-109.

Alberga et al. (2012). Healthy eating, aerobic and resistance training in youth (HEARTY): Study rationale, design and methods. Contemporary Clinical Trials 33, 839-847.

Alberga et al. (2012). Top 10 practical lessons learned from physical activity interventions in overweight and obese children and adolescents. Applied Physiology, Nutrition & Metabolism, 38, 249-258.

Bird, A. & Hawley, J.A. (2012). Exercise and type 2 diabetes: New prescription for an old problem. Maturitas, 72, 311-316.

Fortier et al. (2011). Self-determination and Exercise Stages of Change: Results from the Diabetes Aerobic and Resistance Exercise Trial. Journal of Health Psychology, 17(1), 87-99.

Peeters et al. (2012). Perceived facilitators, barriers, and changes in a randomized exercise trial for obese youth: a qualitative inquiry. Journal of Physical Acitivity and Health, 9, 650-660.

Sigal et al. (2014). Effects of aerobic training, resistance training, or both on percentage body fat and cardiometabolic risk markers in obese adolescents. JAMA Pediatrics, doi: 10.1001/jamapediatrics.2014.1392

Sigal et al. (2007). Effects of aerobic training, resistance training, or both on glycemic control in Type 2 diabetes. Annals of Internal Medicine, 147, 357-369.

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