Fear of physical response to exercise among ...

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Fear of physical response to exercise among overweight and obese adults a

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Brooks C. Wingo , Retta R. Evans , Jamy D. Ard , Diane M. c

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Grimley , Jane Roy , Scott W. Snyder , Christie Zunker , a

Alison Acton & Monica L. Baskin

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Department of Nutrition Sciences, University of Alabama, Birmingham, AL, USA b

Department of Human Studies, University of Alabama, Birmingham, AL, USA c

Department of Health Behavior, University of Alabama, Birmingham, AL, USA d

North Dakota and Department of Clinical Neuroscience, University of North Dakota School of Medicine & Health Sciences, Grand Forks, ND, USA e

Department of Preventive Medicine, University of Alabama, Birmingham, AL, USA Available online: 11 Oct 2011

To cite this article: Brooks C. Wingo, Retta R. Evans, Jamy D. Ard, Diane M. Grimley, Jane Roy, Scott W. Snyder, Christie Zunker, Alison Acton & Monica L. Baskin (2011): Fear of physical response to exercise among overweight and obese adults, Qualitative Research in Sport, Exercise and Health, 3:2, 174-192 To link to this article: http://dx.doi.org/10.1080/2159676X.2011.572994

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Qualitative Research in Sport, Exercise and HealthAquatic Insects Vol. 3, No. 2, July 2011, 174–192

Fear of physical response to exercise among overweight and obese adults Brooks C. Wingoa*, Retta R. Evansb, Jamy D. Arda, Diane M. Grimleyc, Jane Royb, Scott W. Snyderb, Christie Zunkerd, Alison Actona and Monica L. Baskine a

Department of Nutrition Sciences, University of Alabama, Birmingham, AL, USA Department of Human Studies, University of Alabama, Birmingham, AL, USA c Department of Health Behavior, University of Alabama, Birmingham, AL, USA; dNorth Dakota and Department of Clinical Neuroscience, University of North Dakota School of Medicine & Health Sciences, Grand Forks, ND, USA; eDepartment of Preventive Medicine, University of Alabama, Birmingham, AL, USA


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(Received 3 January 2011; final version received 3 January 2011) Regular physical activity has been shown to have significant impact on both physical and mental health; however, over half of adults in the US do not meet current recommendations for physical activity. Pain is one of the most commonly cited barriers to physical activity among adults. Fear of pain has been shown to have a significant correlation with pain-related disorders including back pain and arthritis, but no studies have examined the role that weight plays on these fears. We conducted three focus groups (n = 21) to explore the role of fear-avoidance beliefs related to exercise among a group of overweight and obese adults. Focus group members discussed their beliefs that overweight and obese adults have more exaggerated physical responses to exercises than normal weight adults. They also endorsed a belief that overweight and obese individuals interpret similar physical responses differently than normal weight individuals, and that these interpretations lead to fear that may result in exercise avoidance. Further exploration of the role of fear in exercise avoidance will be useful in designing tailored exercise prescriptions and physical activity interventions that may increase adherence among overweight and obese adults. Keywords: fear-avoidance beliefs; exercise avoidance; weight loss; obesity; sedentary lifestyle

Introduction Physical activity is associated with multiple health benefits, including decreased risks for heart disease, diabetes, and colon and breast cancers, as well as enhanced psychological well-being through reduced anxiety and depression (Paluskai and Schwenk 2000, US Department of Health and Human Services (USDHHS) 2008). Regular activity is also a key factor in maintaining a healthy body weight and preventing loss of muscle mass during weight loss (USDHHS 1996, National Heart Lung and Blood Institute (NHLBI) 2000, USDHHS 2008). Despite the multiple benefits of exercise, physical activity levels have declined over the last 40 years, due in part to environmental changes such as occupational

*Corresponding author. Email: [email protected] ISSN 2159-676X print/ISSN 2159-6778 online Ó 2011 Taylor & Francis http://dx.doi.org/10.1080/2159676X.2011.572994 http://www.tandfonline.com


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activity and a heavy reliance on motorised transportation (French et al. 2001, Hill et al. 2003). Physical inactivity, along with poor diet was found to be the second leading actual cause of death in 2000, with 400,000 (16.6%) deaths attributed to these modifiable behaviours (Mokdad et al. 2004). According to results from the 2007 Behavioral Risk Factor Surveillance System (BRFSS), 51.2% of adults in the US did not meet the recommendations for physical activity (CDC 2008). Physical inactivity appears to be disproportionally high among some demographic groups. Discrepancies can be seen among racial groups and between genders. African-Americans or Hispanic adults are more likely to be inactive than Caucasian adults (59.6%, 57.9% and 48.3%, respectively). Additionally, 53% of females do not meet recommendations compared to 49.3% of men (CDC 2008). Another population that is particularly at-risk for sedentary lifestyle is individuals who are overweight and obese. Data from the Weight Loss Maintenance Trial suggested that physical activity declined as weight increased (Young et al. 2009). This large-scale, multi-site trial recorded physical activity using accelerometry for 1648 overweight and obese adults. Authors found that on average participants accumulated less than 16 minutes per day of moderate to vigorous physical activity. When minutes of activity were analysed by weight class, 19.6% of overweight participants met recommendations to accumulate 30 minutes or more of moderate to vigorous physical activity whereas only 14.8% of obese participants met this recommendation. Davis et al. (2006) found similar differences between overweight and normal weight participants. While 26% of normal weight participants met IOM exercise recommendations of 60 minutes of moderate-level activity per day, only13% of overweight participants met this recommendation. Qualitative studies have used focus groups and semi-structured interviews to explore barriers to exercise among overweight adult populations. Young et al. (2001) conducted a series of four focus groups with African-American women they classified as active or inactive and with successful or unsuccessful weight loss. When discussing barriers that led women to stop a routine exercise pattern, participants noted pain from arthritis and health concerns caused them to stop physical activities they once participated in regularly. Pain or disability was also noted as a barrier to exercise in other qualitative studies focusing on African-American adults (Eyler et al. 1998, Carter-Nolan et al. 1996). None of these studies explored how the inactive groups differed on pain levels compared to active groups, so one cannot infer if the active group did not experience similar pain, or if they differed in their reaction to the pain. While physical inactivity is often cited as a cause of obesity, it may be that obesity is also a cause of physical inactivity. In a study conducted from a cross-sectional population survey of 2298 Australian adults, 9.3% of respondents with a BMI over 25kg/m2 reported that they were ‘too fat to exercise’, and 13.8% reported that ‘my health is not good enough’ to exercise (Ball et al. 2000). A commonly cited deterrent to physical activity is physical pain (Clark 1999, Grubbs and Carter 2002). Sedentary individuals who begin to increase physical activity will often experience pain as a result of increased movements. Pain can be worse in people who are overweight or obese since extra body weight can induce joint pain due to the extra force exerted on the joints (Nevitt and Lane 1999, Melissas et al. 2005, Tukker et al. 2009). Overweight and obese individuals have also been found to experience increased symptoms of exertion as compared to sedentary individuals

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of normal weight. These symptoms include a higher heart rate and percentage of cardiovascular capacity used compared to a normal weight person when performing an equal amount of work. This may result in a higher rate of perceived exertion (RPE) and decreased enjoyment of activity (Ekkekakis and Lind 2006). More work is needed to explore how overweight and obese individuals interpret pain, and how those who succeed in developing regular exercise routines differ from those who avoid exercise based on their interpretation of pain.

Fear-avoidance beliefs As an individual initiates a new exercise programme, he or she will commonly experience some form of exercise-induced pain or discomfort. This pain may take the form of joint pain or cardiovascular discomfort from increased heart rate and increased respiratory rate. After exercise, the pain experienced may be from sore muscles or joint stiffness. ACSM encourages health care providers and fitness professionals to describe muscle soreness and pain after exercise as the body adapting to new movements. An ACSM statement on this topic stated, ‘Some people think they have no business exercising because exercise is ‘painful’. That’s not the case. The soreness is there simply because your muscle is learning something new, and the benefits of exercise far outweigh any initial discomfort’ (ACSM 2003). Individuals who are new to exercise should be prepared to experience some pain, and understand that pain is not always a sign of injury or harm. The fear-avoidance model proposes that individuals can interpret pain in two ways (Lethem et al. 1983). If pain is perceived as a normal part of the activity process, the individual will find ways to cope with the pain and continue with the activity. If the individual perceives pain as a warning sign of harm, he or she may begin a process of activity avoidance that will lead to continued sedentary behaviour. Avoidance of movement may also be a predictive behaviour in addition to a purely responsive one. Some individuals will avoid a movement based on the assumption that the movement will cause pain, even if they have never experienced the pain first hand. This may result in the individual avoiding interactions with movements that are perceived to cause pain, which in turn leads to fewer opportunities for the individual to perform activities and learn that they do not always cause pain. When this level of avoidance is reached, a loss of daily function often occurs. Loss of functioning, along with the preoccupation of pain-related fear, often results in psychological impairments such as depression. The process of avoiding fear-inducing activity has been referred to as the disuse syndrome (Kori et al. 1990). This term is used to characterise two facets of disuse: physical deconditioning due to reduced muscle use, and impairments in muscle coordination which can lead to guarded movements. Physical deconditioning refers to general decline in physical fitness due to avoiding activity that is thought to cause pain. Impairments in muscle coordination refer to problems that can be seen in activities such as walking. In the case of chronic pain such as back pain, an individual may overcompensate some movements to protect against pain, which can lead to gait impairments or other losses in physical function. Disability and the loss of physical function have been the primary focus of much of the research in fear-avoidance beliefs to date.



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High fear-avoidance beliefs have been found to be correlated with the level of pain an individual reports, as well as the level of physical disability reported. Fearavoidance beliefs have also been shown to be negatively correlated with results of physical function tests (Crombez et al. 1999, Geisser et al. 2000, Swinkels-Meewise et al. 2006, George et al. 2007). Despite the number of studies that have examined the role of pain-related fear in disability and physical function, very few have examined the role of pain-related fear in leisure time physical activity. Physical activity is often prescribed as treatment for chronic pain conditions, however, little is known about the effect of pain-related fear on moderate or vigorous levels of physical activity. In the only study found on this topic, Elfving et al. (2007) studied the relationship of fear-avoidance and physical activity in individuals suffering from low back pain. Odds ratios for low physical activity ranged from 4 to 8.5 for medium to high pain-related fear scores (p < 0.05). Only one study was found that addressed the role of pain-related fear in exercise-induced pain in a generally healthy sample. George et al. (2007) examined the relationship between fear-avoidance beliefs and pain in a sample of 42 healthy participants who had no history of neck or back pain. Twenty-four hours after participating in a shoulder fatigue procedure intended to induce delayed-onset muscle soreness (DOMS), fear of pain accounted for 16% (p = 0.008) of the variance in clinical pain, and 10% (p = 0.047) of variance in evoked pain tests. Fear of pain and clinical pain scores accounted for 50% (p = 0.001) of the variance in disability. While these results indicate a significant relationship between fear-avoidance beliefs and exercise-induced pain, this study did not report findings for predictability of disability based on fear of pain while controlling for pain intensity. Together the findings of these studies lend initial support for the idea that individuals may avoid physical activity due to pain-related fear, but more research is needed on the role of pain-related fear in physical activity levels and exercise avoidance among individuals with exercise-induced pain. Existing literature has primarily examined the role of fear-avoidance beliefs in disease-specific population, such as arthritis or back pain (Crombez et al. 1999, Cai et al. 2007, Coudeyre et al. 2007, Elfving and Grooten 2007). No studies have examined the role of weight in fear-avoidance beliefs. Overweight and obesity often compound pain symptoms in conditions such as arthritis, and pain has been found to be more prevalent in some overweight populations, such as older adults the (Andersen et al. 2003, Patterson et al. 2004, Heim et al. 2008). The close relationship between physical pain and weight suggests the need for additional research in the area of fear-avoidance beliefs among overweight and obese populations. The purpose of this study was to explore fear-avoidance beliefs related to exercise among a group of overweight and obese adults seeking treatment in a medical weight loss programme. Specifically, we designed this study to qualitatively explore fears related to physical responses to exercise, and the role that weight plays in interpretation of physical responses and the development of fear. Methods Participants Participants were recruited from medically-supervised weight management programmes at the University of Alabama at Birmingham (UAB). These programmes

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focus on behavioural adaptations of ineffective diet and exercise habits and many of the participants are at high risk for, or already diagnosed with, medical conditions associated with a high BMI including diabetes, hypertension, hyperlipidemia, polycystic ovarian syndrome and arthritis. A physician, registered dietician, exercise trainer and psychologist monitor patients. Treatment plans for patients in the programmes may include individualised nutrition and exercise plans, referral to physical therapy or other rehabilitative services and prescription medication. Treatment goals may include weight loss, improved health indicators or preparation for other weight loss programmes including surgical options. This study was approved by the UAB Institutional Review Board and informed consent was obtained from each participant. Participant recruitment A query of electronic patient records was conducted to find patients who met preliminary eligibility. The query used the following variables to determine preliminary eligibility: patient last name, patient first name, patient status, patient age, current BMI, and patient gender. Patient age was filtered to include only those patients aged 20–65 years. Current BMI, which gives patients’ BMI at the most recent visit, was filtered to include only those patients with BMI measurements of 25–60 kg/m2. Because an extreme BMI could skew results as outliers, an upper limit of 60 kg/m2 was set for BMI. The mean age of potentially eligible participants was 47.18 years, and the mean BMI was 36.91kg/m2. Additionally, individuals who were under instructions to avoid physical activity or limit exercise due to a medical condition were excluded. These instructions may influence participants’ perception of the safety of exercise and therefore skew responses. Patients were selected using maximum variation purposive sampling, which is intended to increase group diversity and encourage discussion of differing viewpoints. Maximum variation is a sampling strategy determined during the planning phase of a qualitative study that identifies a wide range of individuals with multiple perspectives to contribute to the meaning of the given phenomenon (Creswell 2007). It allows the researchers to purposefully choose cases to get variation on dimensions of interest (Patton 2002). We selected participants that would create groups that offered diversity in characteristics including race, age, gender, educational level, physical activity level and length of time in the programme (Krueger 1988). Participants were called or emailed to introduce the study and assess interest in participation. If the patient agreed to participate, screening questions were asked to validate eligibility criteria. Thirty-three patients were invited to participate; 23 agreed to participate and 21 attended the focus groups. Measures Body mass index Participants’ weight was taken at the time they participated in the study. Patients were weighed in light clothing without shoes, using a Tanita digital scale (Model #BWB500A). Height was measured using a wall-mounted stadiometer. BMI was calculated using the formula kilograms/meters2.


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Body composition Body composition was measured to ensure that all participants met criterion for overweight/obesity based on body fat, as well as BMI. Because individuals with a BMI in the lower range of overweight can sometimes have an increased BMI due to muscle mass, they can have health characteristics that are more representative of a normal weight individual than an overweight individual. BIA cut points were 32% for females and 24% for males (ACSM 2006). Body composition was measured using bioelectrical impedance (BIA). For this study, BIA was measured using the Tanita digital scale (Model #BWB500A). To ensure the most accurate measure of body composition participants were instructed not to eat or drink four hours prior to measurement and to avoid strenuous activities including exercise the day of participation. Physical activity Physical activity was estimated using the physical activity questions from the Behavioral Risk Factor Surveillance System (CDC 2008). This set of questions asked participants if they engaged in moderate-level activity during a normal week. If they responded yes, they were asked how many days per week they participated in these activities and the length of time the sessions lasted. This series of questions was then repeated for vigorous level activity. Responses were divided into four categories: (1) inactivity, (2) low activity, (3) medium activity, and (4) high activity, based on the current CDC recommendations. Inactivity was defined as engaging in no activity above baseline activities. Low activity was defined as engaging in more activity than baseline, but less than 150 minutes each week. Medium activity was defined as engaging in 150 to 299 minutes of activity each week. High activity was defined as engaging in 300 minutes or more of activity each week (USDHHS 2008). Effect of pain on daily function The effect of pain on daily function was measured because being overweight or obese can worsen pain-related conditions such as chronic back pain, arthritis and fibromyalgia, and many times pain from these conditions is made worse with the initiation of a new exercise routine. It is difficult to quantify pain because it is a subjective experience that will be interpreted and measured differently by each individual (Carr et al. 2005). Therefore, we chose a measure that did not attempt to quantify pain, but instead dealt with the outcome of pain, as measured by interference with daily function. The effect of pain on daily function was measured using the Pain Disability Index (PDI; Pollard 1984). This scale asked participants to measure the level to which pain interfered with various aspects of life including family and home responsibilities, recreation, social activities, occupation, sexual behaviour and lifesupport activities. Participants were asked to rate the effect of pain on a scale of 0 to 10, with 0 indicating no disability at all, and 10 indicating total disability. The scale was scored by adding the responses to the seven categories. Scores range from 0–70, with higher scores indicating greater disability. This scale was chosen due to its focus on impairment from pain, and because it relates to general

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daily impairment rather than pain level at a specific point in time or associated with a specific action. It should be noted that while this scale refers to disability from pain, the term disability, in this case, refers to the extent to which a participant perceives pain interferes with daily activity, not a diagnosed disability or functional status. Data collection We chose to conduct focus groups for this study due to the exploratory nature of the topic. Focus groups are particularly beneficial when the topic is broad, or when participants may not be familiar enough with the topic to successfully participate in an individual interview (Bogdan and Biklen 2003). The idea of fear-avoidance beliefs has never been studied in relation to weight. Although our hypothesis was that overweight and obese individuals would express this fear, we did not have enough evidence to begin with a fully developed individual interview script. Focus groups allowed us to frame the ideas we wanted to explore in broad questions. Additionally, the group setting allowed participants to generate discussion and build ideas that may not have been expressed in individual interviews. The primary goals of the focus groups were to discuss fear related to physical responses to exercise, explore how overweight and obese adults interpret these physical responses, and how fear leads to avoidance of exercise. Focus groups began with broad questions such as identifying common physical responses to exercise. These were followed by more specific questions of perceptions and interpretations of these responses (Krueger 1988, Stewart and Shamdasani 1990). A total of six questions were used for the focus group discussions (Table 1). Groups were conducted until responses were repetitive and no new information was gained. A total of three focus groups were held before saturation was reached. Groups were audio taped and the moderator and an assistant took notes. Audiotapes were transcribed and checked with notes taken during the groups. MaxQDA (VERBI Software, Berlin 2008) was used to code transcriptions. The group Table 1. Focus group discussion guide. 1. When thinking about exercise such as brisk walking, jogging, aerobic classes, or swimming, what are some typical physical responses you experience during or after exercise? These can be things you have experienced in the past, or things that you expect to experience from exercise. 2. What are some factors that would make you think responses to exercises are safe? What are some factors that would make you think responses are signaling some form of danger? 3. How are physical responses to exercise different between overweight and normal weight individuals? 4. How might a physical response be interpreted differently for an overweight person and a normal weight person? For example, would an increased heart rate mean the same thing for an overweight person as it would for a normal weight person? 5. Is exercise safe for people who are overweight? a. For those who have lost weight: Do you feel safer exercising since losing weight? Why? b. For those who have not lost weight yet: Do you think you will feel safer exercising if you lost weight? Why? 6. Tell me about any circumstances or situations that make you feel safer exercising? Tell me about any circumstances or situations that make you feel less safe exercising?


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Table 2. Demographic characteristics of focus group members. Mean (SD)


Age (years) Gender Female Male

N =21 (%)

48.57 (±11.64) 76.2% 23.8%

Ethnicity African American Ca Hispanic

28.6% 66.7% 4.8 %

Education High school or equivalent Some college Bachelor’s degree Master’s degree Professional degree (MD, JD, etc.) Other

14.3% 23.8% 23.8% 19.0% 14.3% 4.8%

BMI (kg/m2) Overweight Class I obesity Class II obesity Class III obesity

40.63 (±8.42)

Body fat

46.20 % (±7.75)

Pain disability index score (total) Weekly physical activity minutes Inactive Low activity Medium activity High activity

9.43 (±14.06) 64.5 (±41.56)

9.5% 19.0% 28.6% 42.9%

Range: 0–46 9.0% 28.6% 19.0% 23.8%

moderator reviewed each transcription multiple times and identified primary themes. The moderator and group assistants reviewed the themes individually and as a group and then further reviewed the transcriptions to identify subthemes within each theme. This process was completed with each focus group, and then themes and subthemes from each group were compared and merged. The moderator, group assistants and other members of the research team reviewed merged themes and subthemes for clarification.

Results Focus group participants The number of participants in each group ranged from 6 to 8 individuals, with 21 total participants. Demographic characteristics of the focus group members are shown in Table 2. Seventy-six per cent of participants were female. The mean age of participants was 48.57 years (±11.64). The mean BMI of group members was 40.63 kg/m2 (±8.42), and the mean body fat percentage was 46.20% (±7.75).

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Focus group themes Table 3 outlines the major themes from the focus groups and examples of quotes for each. Types of physical responses to exercise Participants discussed both positive and negative responses to exercise. The positive responses related to psychological responses and physical responses. Psychological responses included feelings of accomplishment and goal attainment. Participants


Table 3. Focus group themes. Topic area

Quote

Theme

Types of physical response to exercise

“I sleep better when I exercise.” Positive responses to exercise “When I first started [exercise], I would get really tired, and I would dread it. But I’ve learned that the more I’ve done it the more I’m energized.” “I tend to get tired, like I can’t Negative responses to exercise pick my feet up.” “My knees hurt when I walk.”

Safety of physical response to exercise

“Any tingling- in my hands or anything like that. Or any chest cramp or pain can be startling.” “When you exercise to a certain point, i know you may be fatigued, but then you catch a second wind and it gets easier. But if you get to the point that you can’t catch that second wind, or you can’t go any further, you know it’s time to stop.”

Some specific symptoms always indicate danger/harm, and exercise should be stopped if these symptoms occur. The severity and duration of a physical response are often used as determinants of safety

Perceived differences in overweight and normal weight responses

“I would imagine that would be a little more exaggerated because [overweight/obese individuals] are not in as good of physical shape.” “I’ve found that most people who are overweight have the psychological sense that they couldn’t do things.” “An overweight person would interpret certain signs and symptoms a little differently because you know there are certain risk factors associated with being overweight. So the least pain you wonder, okay, is this the result of something.”

Overweight/obese individuals experience more extreme responses to exercise than normal weight individuals. Overweight/obese individuals place a high importance on the role of psychological responses to exercise. Overweight/obese individuals often interpret physical responses in an exaggerated manner.


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Table 3. (Continued). Topic area

Quote

Theme

Factors influencing physical safety

“I had a physical and had all three of my doctors tell me ‘yes’ that should be [exercising].” “In the beginning, it should be almost like a rehab setting. Where we’re monitored while you’re exercising.” “I do strength training twice a week with a trainer. It’s stuff I could doon my own, but just having her there. . .it makes me feel better. You know, 150 pounds from now I may not need her, but right now it makes me feel a lot better.”

Medical clearance to check for health concerns is needed prior to starting exercise. Supervised exercise helps to reduce anxiety by offering instruction and continual monitoring.

endorsed that these responses were particularly related to exercising despite a lack of motivation to do so, or completing a particularly difficult workout. Physical responses included improved sleep patterns and increased energy. Several participants conveyed feelings of fatigue during and immediately after exercise, followed by an increase in overall energy level after a consistent exercise routine has been established. Participant A: “When I first started I felt tired and I was actually out of breath. Now I walk 3miles a day, and I have a lot more energy, and I look forward to it. I actually enrolled in a water aerobics class and I start next week.” Participant B: “Yeah, before starting [this program] exercise was out of the question. And when I first started I did the elliptical because that was low impact and didn’t hurt my back, because walking just hurts my back. But now I look forward to going after work and I do 45 minutes on the elliptical, and I feel really good during and afterward.”

Interestingly, energy level was also viewed as a negative response by some group members. Members all related to the feelings of fatigue during and immediately following exercise. However, some group members stated they were so tired after exercise that it discouraged them from continuing to the point of developing a consistent routine. In addition to energy level, two other types of negative physical responses were discussed: cardio-respiratory responses and pain responses. Cardio-respiratory responses included increased heart rate, laboured breathing or shortness of breath, and clammy hands or numbness in extremities. Pain responses included joint pain or stiffness and muscle pain including soreness and strained muscles. Safety of physical responses to exercise Specific Symptoms. When asked to identify differences between safe and unsafe physical responses to exercise, some participants named specific responses which

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they categorised as always indicating danger. These included numbness in hands and/or feet, clammy hands, dizziness and blurred vision. Severity/duration of symptoms. Many members reported that they based interpretations of responses such as joint pain or chest pain on the degree or severity of the response. Group members discussed that some level of pain or discomfort is to be expected with exercise; however, pain or discomfort that does not go away after a period of time, or is worse than what has been experienced during past exercise sessions, could be a sign of injury. Participants noted that there is a ‘different kind of pain’ that signals injury or unsafe conditions.


Participant A: “I do strength training twice a week with a trainer and she will push me to the point where it hurts, but you know. . .” Participant B: “It’s a good hurt.” Participant A: “Right. And she’s never pushed me past the point of that. But yeah, so when it hurts but it’s a good hurt you know it’s okay. That’s how I know – if I workout and I can’t sit down the next day – I know I’ve worked out.

Other participants noted that the expectation of pain prevented them from working hard enough to experience pain. Participant A: “I don’t want to hurt.” Participant B: “But it’s good because you know your muscles are tearing apart and then healing themselves. It’s a great feeling!” Participant A: “I’ve never felt any of that – I don’t push myself that far.”

Similar ideas were voiced in relation to cardiovascular responses. Participants stated that exercise will often cause deep breathing, but that there is a difference between breathing heavy and shortness of breath. One participant noted, “I feel okay if I am tired, but I usually catch a second wind. It’s when I can’t catch that second wind that I know I’ve gone too far.” Differences in overweight and normal weight responses Two primary themes emerged when participants were asked about differences in the way the bodies of normal weight and overweight individuals react to exercise. First, most groups members agreed that overweight and obese individuals experienced more extreme responses to exercise than normal weight individuals. Group members reported that they believed normal weight individuals were more tolerant to pain, and had more stamina, which made exercise easier for them. Words such as ‘heightened’ and ‘exaggerated’ were commonly used when describing the responses of overweight and obese individuals. Group members noted that these more intense responses may be due to deconditioning, poor circulation or decreased muscle tone, but all noted that these responses decreased as weight decreased.



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The second theme that emerged was the importance of the role of psychological responses to exercise. One member, who reported being active when she was younger and at a healthy weight, stated that she felt resentful and frustrated that she could not do the same activities she could do previously. Many members reported getting frustrated with exercise because they felt that they could not keep up in a group setting, or they felt they had to exercise at a level that was not intense enough for weight loss. Others noted that safety concerns dampened motivation to exercise. One participant noted that he felt he was ‘too heavy to walk’, but also noted that he thought that this was ‘just an excuse because I’m too heavy because I don’t walk’. Many members felt that these psychological concerns about exercise were concerns that an individual of normal weight would not experience. Participants were also asked to discuss possible differences in the way normal weight individuals and overweight individuals may interpret physical responses to exercise. The primary theme that emerged from this discussion related to an overreaction to pain or cardio-respiratory responses. Participant A: “I’ll tell you – the overweight person thinks he’s dying because he’s doing things physically that he’s never done. Like the pain in the side when you run too fast. Runners know it happens normally – I remember from gym class, when they made you run, your side hurt. But you think something’s wrong.” Participant B: “And you want to quit.” Participant A: “Exactly. And also because you don’t have the experience to know that it’s part of the process to develop a little pain so you get stronger. But initially you’re recognizing pain you don’t know, your mind doesn’t know. Psychologically you’re having a difficult time with it because your first reaction is to stop.”

Participants in each group stated that this overreaction to physical responses stems, in part, from a fear of weight-related risk factors. Many participants reported that knowing they were at an increased risk for heart attack and stroke due to their weight made them more aware of physical responses during and after exercise. One participant described one of her first experiences with walking on a treadmill: Participant A: “I think you’re so programmed by everyone like all your doctors that you’re at such risk because you’re overweight that you think this pain is like, ‘oh my gosh, I’m having the heart attack that [my doctor] said I was going to have.” Participant B: “You’re scared.” Participant A: “And the normal weight person, they know that it’s okay.”

A participant in a different focus group noted similar fear: “I think that for me, heredity factors into it. My mother had a heart attack early on – in her early 40s. And although I don’t have – I’m overweight, but I don’t have high blood pressure, all those other things, but I’m always afraid. I’m afraid that something like that will happen to me. Just (snap) something out the blue. And it makes me a little bit paranoid.”

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This fear of risk factors tended to be especially relevant to trying new activities. Participants noted that while they may feel comfortable doing a routine exercise such as walking, they would not feel safe trying new exercises such as higher intensity aerobic exercises or weight training. Some group members noted that this fear is often used as an excuse to avoid exercise. One participant discussed thoughts that overweight and obese individuals are ‘always thinking about pain’. She pointed to this as the reason that some overweight or obese individuals may overlook a potentially dangerous reaction, thinking that it is a result of weight rather than a medical condition. But she also noted that this is a reason many overweight individuals avoid exercise, explaining that they are in a constant state of pain, so they avoid intentionally increasing this pain through exercise. Other group members discussed thinking that exercise was unsafe due to their weight and found that they would talk themselves out of exercising by saying they needed to lose weight before they could exercise safely. Factors influencing physical safety When asked to discuss factors that influenced feelings of comfort or safety with exercise, two primary themes emerged: medical clearance and supervised exercise. Group members reported feeling safer after receiving medical clearance to exercise. This clearance ranged from having a physician tell the individual what exercises were physically safe or unsafe, to undergoing an exercise stress test. The second theme, supervised exercise, ranged from working with a personal trainer to having frequent interactions with a physician or other medical staff while initiating an exercise programme. Many participants noted that while they felt safe doing familiar exercise such as walking, they were not comfortable trying new exercises such as resistance training or increasing their exercise intensity without supervision from a trainer. While some participants felt safe in a gym setting that was staffed with personal trainers, others noted they felt more comfortable in a medical setting or a setting where personnel specialised in working with individuals who are overweight and obese. One difference of opinion was related to group-based exercise classes. While some participants felt safer in a group setting than exercising alone, others felt that the group setting fostered a feeling of needing to ‘keep up’, which they felt was not physically safe for individuals who are overweight or obese. While all agreed that working with a trainer individually was the ideal situation, some participants noted that they felt safer to determine their own intensity while exercising alone than follow directions of an instructor in the context of a group setting. “At one point I was working with a personal trainer and I felt safer. I felt like if something happened to me the trainer was there and she could see about it. And I have recently tried attending classes, just with a friend, like at the Y. And although I’ve enjoyed the classes, there is something in me that feels like if something happened to me it’s just, I don’t know, like something terrible could happen while I’m in the class. Like no one would– I don’t know it’s paranoia.”

Discussion Three focus groups with a total of 21 participants were conducted to explore fearavoidance beliefs related to exercise among a group of overweight and obese adults



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seeking treatment in a medical weight loss programme. Using the fear-avoidance model as a theoretical basis for our questions, we asked participants to explore how they interpreted physical responses to exercise. Figure 1 shows how the primary themes relate to the construct model that guided this study. Each of the primary themes identified correlated with a distinct phase in the interpretation of the physical responses to exercise. We believe this adds to the current fear-avoidance model by addressing how pain or discomfort is interpreted differently among different individuals. To date, the fear-avoidance model has focused primarily on the outcomes of interpretation of pain. Specifically, the current model described by Lethem et al. (1983) states that if fear is interpreted as a normal physical response the individual will cope with the pain and continue movement. If an individual interprets pain as a signal of harm, they will begin to catastrophise the meaning of the pain and enter a cycle of avoidance and continued pain. Most of the work in fear-avoidance to this point has focused on the link between the interpretation of fear as a sign of harm and outcomes such as disability and loss of physical function. Some research has explored differences in pain interpretations among groups based on gender or age. To our knowledge, this is the first study to qualitatively explore differences in pain interpretation based on more complex characteristics of BMI and weight change. When asked to describe the differences in physical responses to exercise between normal weight and overweight/obese individuals, the primary theme that emerged was that overweight and obese individuals have a heightened, more extreme physical reaction to exercise. This is in line with previous studies that have shown a higher cardiovascular response to exercise among overweight adults (Mattson et al. 1997, Hulens et al. 2003, Hills et al. 2006). These heightened

Figure 1. Focus group themes in relation to study model.


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reactions, may lead to more focus on the response, which could influence the interpretation of the response as a harmful event. In addition to describing the differences in terms of what physical responses were experienced, participants were also asked to explore how these responses are interpreted differently between normal weight and overweight/obese individuals. Participants described exaggerated interpretations of fear and increased focus on the responses than would be expected from normal weight individuals. While multiple studies have found a difference in affective response to exercise between weight groups, the researchers are unaware of any that have explored the source of these differences. Existing studies used quantitative scales of pleasure/displeasure (Ekkekakis and Lind 2006; Ekkekakis et al. 2009), or mood state batteries (Carels et al. 2006) to measure affective state. While the latter often includes screening for tension or anxiety, it does not specify whether or not the anxiety is caused by the exercise. Rather, most have evaluated the effect of exercise in improving or changing general mood state, and have not addressed exerciseinduced anxiety. While participants of these focus groups did endorse similar mood improvements related to exercise, they also expressed a separate fear that occurred as a direct result of exercise. Identifying exercise-induced fears and differentiating these from other psychological barriers to exercise such as social physique anxiety may lead to more ailored treatments and better adherence to exercise prescription. This study has limitations that should be addressed. The first relates to the level of experience that focus group members had with the topic of the study. Not all group members were able to relate to the concept of fear-avoidance, because they did not personally endorse fear of physical response to exercise. While participants were recruited in such a way as to increase group diversity on many levels, their fear-avoidance beliefs related to exercise were unknown. Some participants did not feel they had much to offer the discussion once it focused specifically on fear since they did not personally experience this. However, due to the exploratory nature of this study, it was important to have these participants in the focus group discussions. In order to fully understand the complexity and range of fears associated with exercise in this population, it was necessary to explore the interpretation of physical responses both in individuals who experience fear and those who do not. The second limitation of note is that of selection bias. Participants were recruited from a population of patients in a weight loss programme. These participants may have experiences and motivations that are inherently different from overweight or obese individuals who are not actively engaged in a weight loss attempt, or who may be attempting weight loss outside of a formal or structured programme. The results of this study may have limited generalisability beyond participants enrolled in medically-supervised weight loss programmes. Future research should focus on exploring the concept of fear-avoidance beliefs in a more heterogeneous sample including individuals not currently engaged in weight loss efforts. Additionally, these groups consisted only of individuals with BMIs in the overweight or obese categories. We asked participants to describe differences in exercise experiences between overweight/obese individuals and normal weight individuals. One goal of this comparison was to explore how the participants who had already lost weight felt differently about exercise after weight loss, and to ask those who had not yet lost weight to hypothesise how exercise would be different if they weighed less. No comparison can be made from these groups as to the real perceptional dif-



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ferences between normal weight and overweight/obese adults. Future research plans include expanding these questions to individuals who are normal weight and to compare the responses of these individuals to the current group of participants. Exercise is recommended as a primary course of treatment for overweight and obesity (NHLBI 2000), but developing an exercise prescription that patients feel confident in carrying out is often difficult due to barriers related to pain and cardiovascular conditions. The discussions of these focus group members indicated that fear of pain is often as much of a barrier as pain itself for adults who are overweight or obese. Because fear-avoidance beliefs may be predictive as well as reactive, it is important that these beliefs be identified early in the exercise prescription process to provide an exercise environment that increases self-efficacy. These fears may be difficult for patients to articulate however, and addressing fear-avoidance beliefs may prove difficult for some healthcare providers and fitness professionals. Standardised screening tools to assess fear-avoidance beliefs may prove to be a valuable source of information in both preventive care and secondary treatment of overweight and obesity, especially when compared to the proposition of quantifying an individual’s subjective experience of pain. Previous qualitative work in pain measurement indicates that attempting to measure pain in a quantitative way can be difficult and may discount the perceptions of the individual in pain (Carr et al. 2005; Sparks and Smith 2008). For this reason, it may be more productive to focus on assessing the interpretation of pain, and fear related to these interpretations, rather than attempting to quantify the pain itself. Assessing fear-avoidance beliefs in individuals who are at risk for hypokinetic diseases can assist healthcare providers and fitness professionals in creating tailored interventions designed to increase activity levels prior to the onset of disease. Assessment tools will also be useful in the secondary and tertiary treatments of overweight and obesity, as these are settings in which patients often present for treatment with habits that have been developing over a long period of time. By the time an individual seeks medical attention for weight-related health issues, he or she may have already reached the point of avoiding movement and exercise due to fear of pain. For this reason, early recognition of fearavoidance beliefs in overweight and obese individuals is important for prescription of an exercise routine that is tailored to their specific needs, which, in turn, may lead to increased self-efficacy and improvements in programme retention and adherence. Notes on contributors Brooks C. Wingo is a postdoctoral fellow in the UAB Department of Nutrition Sciences. Her research interests focus on psychosocial barriers to physical activity and dietary change in overweight and obese adults. Retta Evans is an associate professor and programme coordinator in Health Education at the University of Alabama at Birmingham. Dr Evans has published widely on various topics related to youth health, body image of adult females and health behaviour change. She has an interest in using technology to enhance health education and physical activity in the public schools. Jamy Ard is an associate professor in the UAB Department of Nutrition Sciences. His current research interests include behavioural therapies that are focused on cardiovascular risk reduction. He has a special interest in the African-American population and developing strategies for behaviour modification that are culturally appropriate for this group.

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Diane M. Grimley is a psychologist and a professor of public health at the University of Alabama at Birmingham. Her research interests include the development of theory-based, tailored, Internet– and cell phone-delivered behavioural interventions, measurement development and model testing, sexual risk behaviours and the non-medical use of prescription drugs. Jane Roy is an associate professor of exercise science in the UAB Department of Human Studies. Her research interests focus on body image, barriers to exercise and obesity.


Scott Snyder is an associate professor and associate dean at the University of Alabama at Birmingham. His research interests include psychometric theory and programme evaluation. Christie Zunker was a Research Assistant at UAB. She has a doctoral degree from the Department of Health Behavior in the School of Public Health at the University of Alabama at Birmingham. She recently moved to Fargo for a postdoctoral fellowship position to focus on obesity and eating disorders research. Her research interests include weight management, eating disorders and physical activity. Alison Acton is a fitness specialist in the UAB Department of Nutrition Sciences. Her interests lie in the obesity, and physical activity in older adults.Monica Baskin is an associate professor at the University of Alabama at Birmingham. Her research interests are behavioural weight management, minority health and health disparities, and communitybased participatory research.

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