Physical activity and sedentary behavior perceptions in overweight and obese adults: A systematic review of qualitative study

Introduction

Obesity, characterized by chronic adipose tissue inflammation and overeating, leads to sustained fat storage and influences various physiological processes.¹ It poses significant risks to human health, playing a major role in the surge of non-communicable diseases.² As per WHO, one out of every eight individual is obese globally in 2022.³ Notably, between 1980 and 2019, the prevalence of obesity experienced a dramatic increase, surging from 3.2% to 12.2% for men and from 6% to 15.7% for women.⁴ The Global Burden of Disease in 2015 reported the prevalence of obesity had doubled in more than 70 countries, resulted in 4 million deaths from 1980-2015.⁵ If these trends persist, it is projected that by 2025, 2.7 billion adults will be overweight, and over one billion will be obese globally.⁴

In addition to the abundance of endocrine, metabolic, and environmental factors, it is presently understood that the rise of the global obesity epidemic in recent decades is primarily attributed to behavioral factors such as sedentary living and a decrease in overall physical activity (PA), coupled with the consumption of unhealthy diets.⁶ Individuals who are overweight and obese often exhibit higher levels of sedentary behavior (SB),⁷ characterized by activities involving minimal energy expenditure (around 1.5 Metabolic Equivalent Units) while sitting or lying down.⁸ This SB not only contributes to additional weight gain but also leads to reduced PA levels, perpetuating the cycle of obesity.⁸

Addressing obesity’s impacts can be significantly alleviated through lifestyle modifications, including increased PA, adopting a nutritious diet, ensuring sufficient sleep, and reducing SB.² The World Health Organization promotes healthy eating and regular exercise as effective and accessible means to prevent and manage overweight and obesity and to mitigate the burden of non-communicable diseases.² Despite knowing the importance and health benefits of PA, individuals with overweight and obesity are shown to be less physically active than adults with normal weight.⁹ Thus, to address sufficient PA in this population, it is important to understand the perspective of individuals who are overweight or obese regarding their lifestyle. Systematic reviews are conducted on factors facilitating and limiting PA in various resource settings and low-middle-income countries. However, little is known about the perceptions of PA and SB at the global level from different countries and the differences noted in these countries. This work contributes to filling the gap. Qualitative studies can be considered appropriate tools to capture expressive information about beliefs, values, sentiments, and motives¹⁰ in understanding the viewpoints of individuals who are overweight and obese. This review of qualitative study aims to map and compile current literature on perceptions of adults with overweight or obesity towards PA and SB, facilitating a comprehensive understanding of their perspectives.

Methods

This systematic review was not pre-registered. We chose Arksey and O’ Malley’s¹¹ framework (2005) for its flexibility, enabling the inclusion of a diverse range of study designs and broad concepts within the systematic review process. We followed the procedural guidelines detailed in the methodology manual provided by Levac et al.¹² and quality assessment using Joanna Briggs Institute¹³ checklist. The preferred reporting items for Systematic Reviews and Meta-analysis Guidelines-Scoping Review guidelines guided this review.¹⁴ The checklist details are uploaded in Figshare as extended data document 1.²⁹

Selection of sources of evidence

Two independent reviewers (NB and MK) conducted the eligibility evaluation using Rayyan.qcri.org software.¹⁵ A total of 2881 records were identified, wherein 290 records were duplicated and deleted. A systematic title and abstracts (Ti-Ab) screening for 2591 records was conducted by NB and MK based on the predefined criteria. Among the 45 articles selected for full-text screening, nine met the eligibility criteria and were included in the review. Disagreements between the reviewers were resolved through consensus for two studies, with the reviewers (VK, AV, and AKB) stepping in when consensus was difficult to reach. The search and screening procedures, adhering to PRISMA guidelines, are visually depicted in Figure 1.

Figure 1. PRISMA flow diagram.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.

Results

A total of nine studies from different countries were included in this scoping review. Perception of PA in adults with overweight/obesity from all nine studies is represented in Table 4, where (+) and (-) indicate positive and negative understanding, respectively.

Adults with overweight/obesity demonstrated a substantial awareness of the benefits of PA and the risks associated with a sedentary lifestyle. Despite this awareness, individuals tended to neglect regular PA, influenced by various factors. Notable contributors to this behavior included a lack of motivation, lack of self-efficacy, time constraints, excessive use of technology, and responsibilities related to work, family, and community. On the positive side, studies also highlighted factors encouraging PA, such as social support, weight loss goals, positive past experiences, overall health benefits, and access to facilities.

Further detailed findings are framed under the following headings.

Discussion

This review aimed to gather insights into the perceptions of adults with overweight/obesity regarding PA and SB. By collating diverse perspectives related to PA and SB, our objective was to comprehensively understand the emerging concerns. Key findings emerged across the multiple themes, including factors influencing motivation and limitations to PA, positive and negative attitudes, and various strategies fostering consistent engagement in PA.

Commonly identified facilitators influencing PA in adults with overweight/obesity are health benefits, overall physical fitness, attractive body image, social support, positive past experiences with exercise, weight loss goals, increased self-esteem, and confidence. These factors were similar to a few studies reported in a systematic review conducted in 2021.²⁶ The importance of social support from family members or peers in encouraging and facilitating participation in PA has been highlighted, similar to the findings of a review conducted in 2023.²⁷ The social aspect of PA makes it more feasible and enjoyable and promotes regular engagement. This review also reports barriers that hinder PA, like time constraints, lack of motivation, lack of interest, fear of injuries, increased weight, societal judgment, familial obligations, negative previous experiences, and occupational responsibilities.

A significant proportion of adults with overweight lack familiarity with the term “sedentary,” associating it with prolonged sitting, low PA, relaxation, and leisure pursuits.²³ O’Donoghue et al.’s²⁸ 2016 systematic review examined factors related to SB in adults similar to this review study, including reading, driving, work-related sitting, cell phone use, and television watching. SB was linked to perceived fatigue and stress while inversely related to perceived health benefits. This review identified urbanization, technological advancements, and increased reliance on motorized work as key drivers for SB, compounded by prolonged periods of sitting during leisure activities or due to work demand. Awareness of associated health risks and effective intervention strategies remains lacking, necessitating attention from researchers and clinicians.

Most studies on this topic have been carried out in developed countries, emphasizing the impact of modernization and mechanization on lifestyle factors. Conversely, research conducted in developing nations has concentrated on issues such as limited access to exercise equipment and facilities, as well as a lack of social support. Safety concerns, particularly among women in developing countries, have also been highlighted.²¹ Studies have observed a trend toward increased use of technology among young adults, which correlates with reduced PA and a more sedentary lifestyle.^24,25 Across all studies, a common theme emerges the necessity of social or peer support and adopting time-efficient approaches to promote physical activity.

Several studies have delved into the multifaceted factors influencing obesity, focusing on diet, food habits, and nutrition alongside PA. In a study in 2015, it was reported that some adults who were overweight perceived healthy nutrition as a potential alternative to PA.²⁰ Additionally, research has identified various obstacles to adopting healthy eating habits, such as insufficient knowledge about nutritious foods, challenges in preparing healthy meals, and the pervasive availability of unhealthy food options.^21,25 Moreover, an unsupportive social environment has been highlighted as a significant barrier to maintaining a healthy diet.^21,25 Particularly, women often face dilemmas regarding whether to prioritize purchasing healthier albeit more expensive food or opting for cheaper, less nutritious alternatives.²¹

This systematic review benefits from its comprehensive screening of a substantial number of abstracts and articles, providing an extensive mapping of perceptions regarding PA and SB among adults with overweight/obesity. This systematic review focuses exclusively on qualitative studies, offering valuable insights into subjective experiences. Additionally, the review assessed the quality of articles, identifying high-quality materials for inclusion, thus ensuring rigor in the analysis. However, this study has a few limitations as the quantitative aspect of the topic was not analysed. Furthermore, researcher bias may influence the interpretation of the findings, which may limit their broader applicability.

A range of attitudes influencing the willingness and unwillingness of adults with overweight/obesity to engage in PA were uncovered, which highlights the importance of addressing psychological barriers and promoting positive self-perception as part of efforts to promote PA. Strategies to promote PA and reduce SB were identified, offering a roadmap for interventions to foster engagement and adherence among this population. Leveraging technology to improve adherence to regular PA (e.g., virtual coaching platforms, goal-setting mechanisms using fitness trackers and apps) can be explored in further research.

Conclusion

The intricate and diverse perspectives held by adults with overweight/obesity, particularly concerning their PA and SB, offer valuable insights for clinicians and researchers aiming to promote regular PA. Additionally, the study results address the unique challenges faced in workplace environments when adopting sustainable PA. Implementing cost-effective approaches is equally imperative to make interventions accessible and feasible for individuals dealing with overweight/obesity.