Obesity and inactivity: prevalence, consequences, and treatment
Prevalence and consequences
Obesity and lack of physical activity (PA) are among the largest contributors to shortened life expectancy in the United States. Many have termed this our “twin epidemics.” More than two-thirds (68.5%) of U.S. adults are overweight with obesity and extreme obesity affecting 34.9% and 6.4% of Americans, respectively.[1,2] Overweight and obesity impacts both genders with prevalence of 71% in men and 62% in women over the age of 20. The risk for many obesity-related diseases including, coronary heart disease, type 2 diabetes, cancers (endometrial, breast, and colon), hypertension (high blood pressure), dyslipidemia (eg, high total cholesterol or high levels of triglycerides), stroke, liver and gallbladder disease, sleep apnea and respiratory problems, osteoarthritis (a degeneration of cartilage and its underlying bone within a joint), and gynecological problems (abnormal menses, infertility) is also rising. A significant contributor to these health issues includes sedentary lifestyles and physical inactivity.[4,5]
The estimated annual cost of medical management of obesity, obesity-related illnesses in the United States is more than $200 billion. Lack of cardiorespiratory fitness and obesity together, and independently are among greatest threats to public health of our time. Small amounts of sustained weight loss (3–5%) produce clinically meaningful reductions in the risk of developing obesity-related comorbidities, and moderate PA can positively influence all-cause mortality. Yet, despite evidence for the benefits of regular PA, historically only 25% of U.S. adults meet recommended PA levels. In a recent comprehensive review, Katzmarzyk et al. reported identified a similar prevalence of 23% for those who met aerobic and muscle-strengthening guidelines with the prevalence of meeting aerobic only at 51%. Among high school students, a mere 27% met the aerobic requirements of 60 minutes of daily moderate to vigorous activity.
Approaches to weight management
Behavioral weight management programs typically focus on various types of dietary intervention, lifestyle changes directed at better self-care (improved sleep, stress management, and so on) coupled with recommendations to increase PA. Unfortunately, maintaining weight lost and initiating and maintaining increased levels of PA continues to be difficult.[10–22] To better assist in overcoming the barriers to lifestyle change, we must address individual psychological, motivational, and behavioral characteristics that influence success.[11,13,22–24]
Importance of PA
Weight losses of as little as 5–10% can reduce the likelihood of developing and or exacerbating many weight-related health problems.[25–28] Exercise aids in weight loss with and without diet. Furthermore, in several comprehensive reviews of the literature, it has been consistently documented that PA reduces mortality, prevents or improves a wide range of medical and psychological comorbidities, and contributes to improved quality of life[30–32] both with and without associated weight loss.[29,33–36] In the context of weight loss, exercise has been found to be associated with reduced visceral adipose tissue (VAT; adipose tissue that collects in the peritoneal cavity resulting in increased waist circumference). Individuals with excess VAT exhibit relatively higher risk of myocardial infarction and other coronary events than individuals with more generalized distribution of body fat.[37,38] Generally speaking, for every 1-kg reduction in weight, there is a corresponding reduction of 2–3% in VAT. Therefore, a loss of just 12 kg of body weight, which is common in most behavioral treatment programs, can lead to as much as a 30–35% reduction in VAT. For every 1-cm reduction in waist circumference, there is a corresponding reduction of 4% in VAT. These reductions lead to significant improvements in cardiovascular diseases, arteriosclerosis, hypercholesterolemia, and high triglycerides.[25,27]
In recognition of the known relationship between health and regular PA, public health recommendations have stressed the importance of regular PA. The U.S. Surgeon General’s Report (2001) recommended that people aim for 30 minutes of moderate intensity exercise most days of the week. Shape up America translated this into the common activity goal of 10,000 steps. More recently the Department of Health and Human Services published the 2008 Physical Activity Guidelines for Americans which recommends 2.5 hours (150 minutes) of moderate intensity PA or 75 minutes vigorous intensity activity per week. This is in addition to increasing baseline activity throughout the day (chores, parking further away, taking the stairs). Similarly, the American College of Sports Medicine Position Stand (2009) states that a program of regular exercise (150 min/wk) that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The United States Department of Health and Human Services Healthy People 2020 initiative recommend participation in moderate and vigorous physical activities and muscle-strengthening activities. Unfortunately, despite similar statements in Healthy People 2000, 2010, and now 2020, more than 80% of adults and adolescents do not meet the guidelines for aerobic and or muscle-strengthening activities. It is clear that we are failing to meet minimal exercise objectives even in nonoverweight populations.[5,30,39–43] Furthermore, for those who are already overweight, this amount of activity may not be enough. Data from clinical trials suggest that it may be necessary to work toward as much as 70–80 minutes per day of moderate activity or 35 minutes per day of vigorous activity to maintain weight loss over the longer-term.[44–46] Similarly, reports from The National Weight Control Registry, a self-selected registry of very successful weight loss maintainers suggests that ultra-successful maintainers are doing significantly more PA with 90% exercising at least 60 minutes per day.[47,48]
Our epidemic of physical inactivity, despite multiple guidelines directing people to exercise remains largely unchanged. Clearly, there are barriers beyond knowing what and how much we “should” do that impedes people’s efforts. Experience has shown us that it is essential to consider the situational, physical, motivational, and psychological factors that influence people’s ability to both initiate and maintain an active and healthy lifestyle. Thus, it will be necessary to look beyond traditional intervention targets and consider broader issues facing people who struggle to achieve physical health including complex psychological processes.
Psychological influences on health and exercise behavior
Motivation and the transtheoretical model: stages of change
Known predictors of successful weight management account for only about 20–30% of the total variance leaving the majority of the contributors to a person’s potential for success unknown. While many barriers to PA can be solved through commonly accepted behavioral lifestyle change strategies,[11,16,19,22] the issue of inadequate or unsustainable motivation remains a consistent issue. Affecting meaningful changes in motivational readiness has long been considered an essential target in improving health. In-depth consideration of motivation and barriers to exercise, exercise-related beliefs and attitudes and self-efficacy, and self-perceptions is needed. One frequently used framework that involves understanding an individual’s readiness to change health behavior the Transtheoretical Model, commonly referred to as Stages of Change Theory.[50–53]
The Transtheoretical Model conceptualizes motivation to change in terms 5 stages of change that represent a continuum of motivational readiness. The 5 stages of change are: (1) Precontemplation: The individual has the problem, they may or may not recognize and or value the problem as a target of change and they have no intention of changing. (2) Contemplation: An individual recognizes the problem and is seriously thinking about changing. (3) Preparation for Action: This stage is categorized by the person recognizing the problem and having intent to change the behavior (typically within the next month). They may during this stage already be reporting some initial efforts at change but the efforts have not yet reached a level of consistency that warrants a sustained behavioral change effort. (4) Action: The individual has performed consistent behavior change over a sustained period (1–6 months). (5) Maintenance: The individual maintains new behavior for 6 months or more. Overarching these theoretical stages is the “processes of change.” This refers to covert (thoughts, beliefs, attitudes, self-perceptions, psychological variables) and overt (seeking support, training, skill building, education) activities that people use to progress through the stages. Barriers to progressing through the stages and ultimately to performing the desired behavior (eg, exercise) can be addressed by incorporating strategies within the processes of change framework that allow the person to solve the barrier and to move to the next stage. There are many such strategies. Of particular relevance to our discussions here is the concept of Social Liberation where we must help the person to identify if things like self-consciousness about appearance (body image) lack of self-confidence (self-efficacy) influence their participation in PA and identify appropriate tools to remedy the situation. Stimulus Control is another relevant concept. It involves removing cues for unhealthy habits (exercise avoidance) and adding prompts or support for healthier alternatives. This might include adding new skills, strategies, or other tools but it can also include changing environmental realities. For example, by providing exercise settings that are less judgmental or reducing self-judgment and negative self-perceptions during exercise. Research investigating barriers to exercise and weight loss motivation has consistently implied that personal psychological characteristics, self-perceptions, and personal beliefs about oneself can influence motivational states. Teixeira et al.[54–56] in a study of 136 participants completing a 16 week weight loss intervention found that change in exercise-related motivational factors, with a special emphasis on intrinsic sources of motivation (eg, interest and enjoyment in exercise), play an important role in longer term weight management.[54–56]
Self-efficacy, a theoretical construct based on Erickson’s theory of competence, was first described by Bandura in the late 1970’s. According to self-efficacy theory, efficacy expectations or confidence in the ability to cope effectively with the demands of a situation determines both whether behavior will be initiated and how long it will be maintained when setbacks are encountered. The process of change is influenced by altering decisional balance (the pros and cons of change), self-efficacy (confidence in the ability to change), and situational influences that might compel engagement in problem behavior (eg, exercise avoidance). At the core of change is a heightened sense of personal control or mastery based on prior experiences with the behavior.[59,60] Interestingly, later developments in the theoretical formulation of self-efficacy expanded to include a more generalized conceptualization of self-efficacy which includes efficacy in both social and individual performance situations. These are particularly important as we consider the role of self-efficacy in health promotion programs where a complex interaction of personal, environmental, social, and psychological factors influences motivation and success. In fact self-efficacy has been shown to predict improved treatment engagement, reduced attrition rates, better weight loss and improved weight loss maintenance.[49,54,62–65]
Perhaps 1 of the more compelling examples of this process in action is seen in the results of The Diabetes Prevention Program, a randomized controlled clinical trial comparing the efficacy of intensive lifestyle change intervention versus the diabetes drug metformin in the prevention of type 2 diabetes in persons with overweight and impaired glucose tolerance. Greater readiness for change in PA levels and higher exercise self-efficacy correlated with higher levels of baseline PA and higher levels of activity after 1 year.
Body image and self-perception
Body image and self-image drive for thinness are among the psychological contributors that influence an individual’s overall motivation and success with exercise. Body image distortion refers to a disturbance in both size perception and one’s emotional relationship to one’s body that does not concur with actual body size. It was not until the early 1990’s that body image disturbance became a widely accepted psychological syndrome in both obese and normal weight persons.[66–70] Among the most salient influences on the development and maintenance of body image disturbance in those who struggle with weight are social factors including the way that body image is portrayed in the media, societal pressure to be thin, teasing, looks of disapproval, negative comments from others and often outright discrimination. As a result, these disturbances in self-perception can endure even after losing significant amounts of weight[70,72–74] and can interfere influence participation in PA.
The modern conceptualization of body image involves a combination of attitudes and perceptions about oneself, self-esteem, perceptions of competence and health, and various other dispositions including affective, cognitive, and behavioral components. It encompasses dissatisfaction with discrete body areas (eg, waist and hips) and a hyperawareness of these areas during day-to-day activities that can result in self-defeating and punitive cognitions. It includes broader behavioral, psychological, and motivational constructs.[76–78] Each of the dimensions of body image inter-relate with an individual’s overall sense of self-worth and psychological well-being and influence a range of behaviors. Using this type of conceptualization, we can see how disruptions in body image can impact exercise and health habits.
Perhaps the most comprehensive theoretical formulation of the construct is that of Thomas Cash. His multidimensional constructs encompass affective, cognitive, and behavioral aspects of appearance evaluation, fitness, and health including: (1) Appearance Evaluation, which relates to feelings of physical attractiveness or unattractiveness; (2) Appearance Orientation, which describes how invested an individual is in his or her appearance; (3) Fitness Evaluation, which describes feelings of being physically fit or unfit; (4) Fitness Orientation, which relates to the extent of investment in feeling physically fit; (5) Health Evaluation, which indicates the degree to which an individual feels free of illness; (6) Health Orientation, which describes the extent of investment in a healthy lifestyle; (7) Illness Orientation, which describes the likelihood of seeking medical attention when sick; (8) Body-Areas Satisfaction, which specifically taps satisfaction with discrete body areas; (9) Self-classified Weight, which refers to how an individual labels his or her weight from very underweight to very overweight; and (10) Overweight Preoccupation, which reflects anxiety with personal weight status along with dieting and eating restraint. If we envision body image as this complex psychological phenomenon involving such a diverse array of psychological and situational factors, it seems intuitive that this should be considered as an important area of attention when assisting people in initiating and maintaining PA programs. Furthermore, it stands to reason that distortions in this element of self-evaluation could have significant and impactful consequences for overall motivation and self-confidence.
Early work looking at the role of body image in weight loss programs primarily considered body image change as “a result” of weight loss. The majority of studies found that when people lost weight, their body image improved and if they regained weight it worsened.[73,76,79] Recent work, however, has considered body image as a predictor of success. Studies have consistently noted that body image disturbance upon entering treatment predicts less success.[54–56,80,81] In addition, a recent review of the literature examining predictors of successful weight loss maintenance identified positive changes in body image during treatment as among the predictors of successful longer-term weight management. Combined these studies indicate that body image may not simply be an outcome variable related to improved weight, but rather that body image may, in fact, influence the process of weight loss and exercise adherence. This contention is further supported by findings suggesting that even very brief participation in exercise, that has minimal impact on actual body size, can produce improvements in multiple aspects of body image, self-efficacy and ultimately maintenance of weight loss.[83,84] Adding further support, Annesi found that in a 24-week supervised PA program, Body Areas Satisfaction scale (BASS) scores and Physical Self-concept (PSC) scale scores accounted for significant portions of the variance in weight change; again suggesting that improvement in one’s body- and self-concept, may be important in motivating weight loss and improving adherence to treatments.[85–88]
Exercise self-efficacy and general self-evaluation have also been shown to be related to improvements in body image independent of changes in weight and body composition. This would suggest that the experience of one’s own body in PA settings is closely related to both psychological and physical phenomena related to motivation. In 1 study, 134 women with obesity seeking weight loss were randomly assigned to exercise treatments and assessed at baseline on body satisfaction (BASS), self-regulatory efficacy (Exercise Self-Efficacy Scale), PSC, weight and body composition and followed for 6 months. Improvement in BASS scores (satisfaction with specific body areas) was better predicted by changes in the 2 psychological measures (Exercise Self-Efficacy and PSC) than by changes in the 2 physiological measures (weight and body composition). In fact, only changes in Exercise Self-Efficacy Scale and PSE demonstrated significant unique contributions to the overall explained variance in BASS change. Further evidence suggests that changes in weight and body image may reciprocally affect each other during the course of behavioral obesity treatment. Since weight and psychosocial changes (self-esteem, body image, quality of life, and self-efficacy) co-occur during treatment, they likely influence each other dynamically. This suggests the possibility that as we modify any single physical or psychological contributor, it can additively impact other variables that when combined have a significant influence on overall motivation. Therefore, by targeting specific psychological factors (improving self-confidence, bolstering self-esteem, and reducing negative appearance evaluation) we may synergistically contribute to improved participation in weight management activities including exercise.[89–92]
One final concept related to body image that has appeared in the exercise literature is also important to consider as it represents a unique facet of body image that has implications for PA; particularly in public settings. Social Physique Anxiety[93–97] refers to a fear of negative evaluation while exercising that develops into both performance and anticipatory anxiety states that can be debilitating.
People with high social physique anxiety will likely try and avoid fitness settings for fear of being judged by others. People with high levels of social physique anxiety experience more stress during fitness tests and in exercise settings in general. They have negative thoughts about their bodies and, as a result, have a tendency to participate in fewer physical activities. Social physique anxiety can be measured by the Social Physique Anxiety Scale questionnaire.[98,99] Social PA can also lead to other observed changes in exercise behavior including training only at certain (often restrictive) times, or in certain places where there is little opportunity for physique evaluation. In some cases, just the thought or possibility of encounters with other people during exercise; no matter how unlikely become overwhelming and result in avoidance. Several studies have documented the relationship between modification and avoidance of exercise behavior and Social Physique Anxiety.[91,93–95,97–101]
Use of slimming garments
As the literature reviewed shows, the concepts of body image, self-efficacy, self-perceptions, and confidence can have a significant influence on people’s ability to initiate and maintain a variety of health and weight loss related behaviors including PA. Interventions targeting motivation and adherence have continued to evolve, and the tools we have for fighting the dual epidemics of obesity and inactivity continue to expand. Yet, adherence to recommended amounts of PA remains far from adequate. Therefore, to encourage participation in exercise and address barriers to motivation we must be open to and seek to continue to develop innovative strategies grounded in the available science. Education about the nature and impact of psychological factors provides a starting point. Building on this awareness and providing practical therapeutic interventions targeting negative self and body perceptions, low self-esteem, inadequate self-efficacy and low self-confidence is also necessary. However, some novel avenues for intervention augmentation remain unexplored in the research literature.
One such novel intervention may be the use of slimming garments as a way to influence negative self-perceptions both during and after exercise and to reduce the impact these perceptions have on motivational factors. To date, no research directly examining the use of these garments in the context of improving adherence to PA has been conducted. In fact, for many in the field of obesity, these garments are simply dismissed as either cosmetic. It is in their ability to enhance self-perceptions related to this cosmetic value that out theoretical approach is grounded. Specifically, the tendency toward negative self-perceptions arises in part from a lifetime of negative exercise experiences and societal judgments centered on body shape; particularly among those who struggle with weight. Teasing during childhood or discrimination in health care, employment, and other settings has for many led to an insurmountable internalization of these judgments. As a result, individuals participating in exercise, particularly people who have overweight or obesity, are vulnerable to environmental cues that confirm these negative internalized judgments and may result in behavioral avoidance. By using slimming garments resulting in an overall appearance of a slimmer physique, and enhancing personal confidence related to the perceptions of others, these cues related to being judged may be reduced (both internally and externally). Subsequently, the likelihood of triggering negative body image-related thoughts for the person with obesity may also be reduced leading to improved self-appraisal which can be particularly important in terms of both enjoyment of and adherence to PA.
In addition to reducing negative self-appraisal, slimming garments may also enhance the self-perception of positive results from participating in exercise by augmenting actual changes in body shape that are often quite slow in comparison to expectations. Actual changes in waist circumference, despite considerable effort and successful weight loss, are often visually difficult to detect as they are quite small especially during the early stages of exercise. Furthermore, people with obesity often minimize real and meaningful change of body areas like waist and hips. Thus, by enhancing the individual’s experience of improvement in body contours and shape through the use of a slimming garment both during and following exercise, the rewards experienced for their efforts may be heightened and serve as a motivator.
Exercisers, particularly those who struggle with weight, tend to compare themselves to those around them. That comparison, if unfavorable, can have a negative impact on self-appraisals and self-confidence. The relationship between social comparison and body dissatisfaction is an important consideration when examining exercise adherence in these settings. Social comparison theory suggests that comparing oneself unfavorably to another based on appearance, can increase dissatisfaction with one’s own appearance and influence behavior. In a meta-analysis, Myers and Crowther examined 156 studies and concluded that negative social comparison was in fact related to higher levels of body dissatisfaction. In clinical settings, we frequently attempt to alter an individual’s negative self-perceptions, beliefs and social comparisons using cognitive techniques to influence these thoughts. In addition to altering the maladaptive thoughts, we have also found that patients experience benefit in altering self-presentation until they are able to work through some of the initial discomforts. For some, this involves wearing loose-fitting clothing to reduce the visibility of body areas that are a source of discomfort and reduce perceived risk of judgment by others. The use of supportive garments that improve the appearance of a particular body area may also be of value in reducing self-presentational anxiety.
Our review has provided a theoretical framework from which we may consider the potential for slimming garments to impact motivation to participate in PA and also the subjective appraisals of the exercise experience. The use of these garments, coupled with the wide range of behavioral and psychological interventions already in use, may add incrementally to the success and comfort of our patients as they attempt to increase PA.
Herein, we have summarized several plausible psychological mechanisms through which motivation may be enhanced and barriers to PA reduced by employing slimming garments. Clearly, the determinants of exercise adherence both in public and private venues are complex and include behavioral, environmental and psychological factors. Among them, negative evaluation by self and others even in the least threatening of environments provides a significant barrier that many find difficult to overcome. People who struggle with excess weight have developed over a lifetime a set of negative internalized beliefs and attitudes related to their appearance. Those thoughts and actions can sabotage even the best-laid plans for positive health behavior change (including exercise) and contribute to a vicious cycle of failure and self-judgment. Complicating the issue is the fact that people who struggle with weight and or negative body image are often hyper-focused on specific body areas to the exclusion of all other physical and personal attributes. This creates a globalized negative self-evaluation that can eliminate real sources of internal positive feedback (failing to accurately perceive positive aspects of appearance). This can and often does ultimately result in avoidance of exercise for many people.
Changes in body shape (in addition to health) are a key goal for many who engage in weight loss and PA programs. In clinical settings, we frequently encourage a focus on feeling better in ones clothing as a surrogate for anthropometric changes, as a sign of progress, and a motivator independent of weight loss. Waist and hips are the most frequently cited areas of dissatisfaction. Changes in these areas are relatively slow and perceived as minor in comparison to expectations based on the work put in. People frequently voice dissatisfaction that the mirror doesn’t reflect their hard work and progress. From the convergence of literature reviewed, it is evident that even minor negative self-evaluations based on appearance and competence could tip the motivational balance during the processes of change and result in a failure to adhere to exercise prescriptions. Conversely, by positively influencing these motivational and behavioral barriers it may well serve as a catalyst to success in other related behaviors through a generalized increase in self-efficacy and improve adherence to additional health-related behaviors.
Therefore, it is reasonable to consider that using clothing such as slimming garments that enhance one’s appearance in such a way as to reduce the appearance of being unfit and or improve body presentation (both in terms of self-perception and perceptions by others) can serve to reduce appearance-related anxiety. In turn, this type of intervention may enhance self-confidence and motivation and increase enjoyment of participating in PA both alone and while in the presence of others by reducing negative feedback from the environment.
Future research should develop models for better understanding the role that slimming garments and other similar assistive tools may alter self-perceptions in ways that enhance exercise adherence.
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by Progress in Preventive Medicine at the discretion of the Editor-in-Chief.
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