ContentslistsavailableatScienceDirect
Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
jo u r n al h om ep ag e :h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / z e f q
Evidenz in der Gesundheitsversorgung / Evidence in Health Care
Balancing one’s mood: experiences of physical activity in adults with severe obesity 18 months after lifestyle intervention
Stimmungsausgleich durch Bewegung: Erfahrungen mit körperlicher Aktivität bei Erwachsenen mit Adipositas per magna 18 Monate nach einer
Lebensstilintervention
Bente Skovsby Toft
a,∗, Claus Vinther Nielsen
b, Lisbeth Uhrenfeldt
caDepartmentofLifestyleRehabilitation,HorsensRegionalHospital,Horsens,Denmark
bAarhusUniversity,DepartmentofPublicHealth,AarhusC,DenmarkandDEFACTUM,CentralDenmarkRegion,Aarhus,DenmarkandRegionalHospital WestJutland,Herning,Denmark
cNordUniversitet,FacultyofNursingandHealthScience,Bodø,Norway
a r t i c l e i nf o
ArticleHistory:
Received:5November2019 Receivedinrevisedform:6May2020 Accepted:7May2020
Availableonline:18June2020
Keywords:
Severeobesity Lifestyle
Healthcareproviders Qualitativestudy Experiences
a b s t r a c t
Background: Patientswithsevereobesitymayhavespecialchallengesinregardtoincreasinghealth andwell-beingthroughphysicalactivity(PA).Thebiggestchallengeismaintainingtherecommended PAlevelonalong-termbasis.Yet,littlefocushasbeenputontheexperiencesofindividualswithsevere obesityduringPAwhenphysicallyactiveineverydaylifeafterinterventionhasended.
Objective:toexploretheexperiencesofbeingphysicallyactiveamongindividualswithsevereobesity ineverydaylife18monthsafterthestartofalifestyleintervention.
Design:aqualitativelongitudinalstudyofindividualfollow-upinterviewsfoundedinhermeneuticphe- nomenologyandanexistentiallifeworldtheoryofsufferingandwell-being.Thestudywasapprovedby theDanishDataProtectionAgency(J.no.1-16-02-425-15).
Setting: Interviewswereconductedbythesameinterviewerintheparticipants’homeenvironment acrossthreeoffiveregionsinDenmark.
Patients: Tenadultswithsevereobesity(BMI>40kg/m2)previouslyrecruitedfromapubliclifestyle interventionprogram.
Results:Theanalysisrevealedthatfemalesandmalesemphasiseddifferentexperiencesofbeingactive ineverydaylife.Thefemalesexperienced’Appreciationofprocessandvitality’andthemalesexperienced
’Thechallengeofanactiveandjoyfulliving’.Onecommonmainthemeemerged:’Fluctuatingmood’was foundtoinfluencephysicalactivitylevel.
Conclusions:Thestudyhighlightstheexperiencesofwell-beinginrelationtostayingphysicallyactive afterlifestyleintervention.Thefluctuationsinmoodwerepartofeverydaylifeanditwasanon-going challengetobalancemoodinordertokeepuptheefforts.TheabilitytofindsettlementandmodifyPA expectationswaspartoffeelingcapable.Healthcareprovidersaresuggestedtoaddresswell-beingin moodtohelppatientsbecomeandstayphysicallyactiveineverydaylife.
a r t i k e l i nf o
Artikel-Historie:
Eingegangen:5.November2019 Revisioneingegangen:6.Mai2020 Akzeptiert:7.Mai2020
Onlinegestellt:18.Juni2020
Schlüsselwörter:
Adipositaspermagna Lebensstil
z us a m m e n f a s s un g
Hintergrund: PatientenmitAdipositaspermagnastehenmituntervorbesonderenHerausforderun- gen,wasdieVerbesserungihresGesundheitszustandsundihresWohlbefindensdurchkörperlicheAkti vitätbetrifft.DiegrößteHerausforderungist,dasempfohlenekörperlicheAktivitätsniveaulangfristig aufrechtzuerhalten.UnddochwirddenErfahrungen,dievonAdipositaspermagnabetroffeneMenschen nachBeendigungderLebensstilinterventionmitkörperlicherAktivitätimAlltagmachen,bislangnur wenigBeachtunggeschenkt.
Ziel: Zielwares,dieErfahrungenmitkörperlicherAktivitätimAlltagbeiPersonenmitAdipositasper magna18MonatenachBeginneinerLebensstilinterventionzuuntersuchen.
∗ Korrespondenzadresse.BenteSkovsbyToft,PhD,PT,DepartmentofLifestyleRehabilitation,HorsensRegionalHospital,Sygehusvej20,8740Horsens,Denmark.
E-mail:[email protected](B.S.Toft).
https://doi.org/10.1016/j.zefq.2020.05.004 1865-9217/
Gesundheitsdienstleister QualitativeStudie Erfahrungen
Methode:QualitativeLängsschnittstudiemitindividuellenFollow-up-InterviewsaufderGrundlageder phänomenologisch-hermeneutischenMethodeundeinerlebensweltorientiertenAuffassungvonLeiden undWohlbefinden.DieStudiewurdevonderdänischenDatenschutzbehördegenehmigt(J.Nr.1-16-02- 425-15).
Setting:DieInterviewsführtejedesMalderselbeInterviewerinderhäuslichenUmgebungderStudien- teilnehmerindreivonfünfdänischenRegionen.
Studienteilnehmer: ZehnErwachsenemitAdipositaspermagna(BMI>40kg/m2),diezuvorfürdie TeilnahmeaneinemöffentlichenLebensstilinterventionsprogrammrekrutiertwordenwaren.
Ergebnisse: DieAnalyseergab, dassFrauenundMännerihreErfahrungenmitkörperlicherAktivität imAlltag unterschiedlichgewichteten.Frauen schätztenden ,,Prozessansich unddas Erleben von Vitalität‘‘,währendMännerdiekörperlicheAktivitätals,,Herausforderung,einaktivesundglückliches Lebenzuführen‘‘ erlebten.AlsverbindendesThema kristallisiertesich dieFeststellung heraus, dass ,,Stimmungsschwankungen‘‘einenEinflussaufdaskörperlicheAktivitätsniveauhaben.
Schlussfolgerungen:DievorliegendeStudiebeleuchtetdasErlebenvonWohlbefindenimZusammenhang mitderAufrechterhaltungvonkörperlicherAktivitätimAnschlussaneineLebensstilintervention.Stim- mungsschwankungengehörtenzumAlltagderTeilnehmer,undeswareineständigeHerausforderung, fürStimmungsausgleichzusorgen,umdieAnstrengungenaufrechterhaltenzukönnen.DieFähigkeit, diesesProblemzulösenunddieAktivitätserwartungenentsprechendanzupassen,trugenzueinemGefühl vonLeistungsfähigkeitbei.Therapeutenwirdempfohlen,auchaufStimmungundWohlbefindenihrer Patientenzuachten,umsiedarinzuunterstützen,imAlltagkörperlichaktivzuwerdenundaktivzu bleiben.
Introduction
AccordingtotheWorldHealthOrganization,obesityiscomplex andincompletelyunderstood,andconsideredanissueforpublic healthwithitsincreasedseverityofhealthproblems.Oneprob- lemislinkedtotheincreasedprevalenceofinactivity,especially, amongindividualswithsevereobesity[1].Inthisstudy,physical activity(PA)isdefinedasanybodilymovementproducedbyskele- talmusclesthatrequiresenergyexpenditure.PAcanbeincreased eitherbyprogrammedexerciseundertakentoimprovephysicalfit- nessorbycompletingeverydaytasks,e.g.playing,working,active transportation(walkingorcycling),housechoresandrecreational activities[1]. The benefitsof PA are related to improvedmus- cularandcardiorespiratoryfitness,functionalhealthandweight controlaswellaspreventionofdiabetes,breastand coloncan- ceranddepression[2].LifestyleinterventionthatincorporatesPA isahealthcareinitiative,throughwhichindividuals withsevere obesitymayobtainsuchhealthbenefits,butitmayrequiregreat personaleffortstobephysicallyactive[3],andstayingactivemay beanevengreaterchallenge[4].Thismaybeduetonumerous complexbarriers,whichare difficulttoovercome.A systematic reviewidentified thatthefacilitators andbarrierstoPA among individualswithsevereobesitywererelatedtoexistentialaspects [5]. Additionally, an empirical study found that experiences of well-being,lackofwell-beingandsufferinginrelationtoPAwere interactingandcounterbalancingeachotherduringlifestyleinter- vention.Theparticipants’negative senseofself and theirbody reducedwell-beinginthedomainofmoodanddrainedtheirenergy [6].Moreover,negativemoodshavebeenfoundtoinfluencethe maintenance of lifestyle changes [7] and tobe a barrier to PA inadultswithobesity[8].Inphenomenology,thebodyandthe worldareintertwined,anditisimpossibletoseparateourbodies fromwhoweareandwhatwedointheworld.Hence,physical healthcannot beaddressedwithoutaddressing theindividual’s existentialexperiences of PA,which must beunderstoodas an entitybypatientsandhealthcareproviders(HCP),whenaiming for increasedhealth and well-being. Well-being maybe a bar- riertoPAamongindividualswithsevereobesityandpromoting well-beingseemsalegitimateaimforinterdisciplinaryinterven- tionsinboththehospitalandinthehomesetting[6].Ithasbeen arguedthat normative body ideals are gendered and influence healthbehaviourinawaythatresultinmenbeinglessengaged withhealthandwell-being thanwomen duetotheirmasculine identity[9].
Themasculinebehaviourmaybeduetopotentialgenderedroles andexpectations,whichmaybeimportantinordertounderstand well-beingofapersonintheirgenderedrolesintheireveryday life[10].InsightintogenderdifferencesintheexperiencesofPA mayberelevantforincreasingwell-beingduringinterventionin ordertobeawareofand recognisegenderednormsiftheyare enacted.
Thisstudyisconcernedwiththeexperiencesofwell-beingin thedomainof moods,whichis balancedbetweendwellingand mobility,andhowitrelatestoPAamongindividualswithsevere obesity.Moodisoneofsixinteractinglifeworlddomains,whichis existentialinthatitisinescapableandexperiencedinaseamless everydaynessinanun-reflectedway.Moodisalreadypresentand cancoloureveryaspectofourexistenceasitispriortobiologi- cal,psychologicalandsocialcategories.Theexperiencesofmood areembodiedexperiencesthatmayinfluencechoicesandactions asitcloselyinteractswithenergyandvitality[11].Aspecifickind ofwell-beinginthedomainofmoodischaracterisedbyexcite- mentanddesire(mobility)orpeacefulnessandharmony(dwelling) balanced in a unified experienceof integrating peace and pos- sibility. Well-beingis contrasted byexperiences of suffering in mood,whichisexperiencedasemotionalunpleasantnessand/or depression[11].
Weight-basedstigmainfluencesthemotivationtoexerciseand PAlevel.Especially,individualswithsevereobesityareconsidered especiallyvulnerabletoweightstigmaasthestigmaincreaseswith increasedbody size[12].Theexperiences of weightstigmaare likelytoharmhealthandreducewell-being,becauseitmaydrive increasedeating,avoidanceofPAandlowermoodaswellasaddto weightgainlong-term[13].Especially,femalesexperienceweight stigmatobeabarriertoPA;hence,theyhavelowerlevelsofPA duetofeelingshame[14].Agreatchallengeinthehealthcaresys- temisthatweightstigmamayunintendedlybeenactedbyHCPs [13].
HCPsofdifferentprofessionsmayharmpatientswithobesity, iftheyassumethatthepersonisunabletocomplywiththeguide- linesonexerciseduetolackofmotivation,engagementandefforts inmakingchanges[15].Thepatientmaybeperceivedtobenon- compliantandirresponsibleandtheymayhaveblameandshame placed upon them,which willinfluencetheirsenseof selfin a negativeway[16].InexperiencedHCPsmaylackevidence-based knowledgeof howtoapproach obesityand lifestylechanges in practiceandbeforetheydevelopexperienced-basedclinicalcom- petence,theymayharmthepatientsunintendedly[17]byadding
Table1
Characteristicsoftheparticipants.
Gender Age/year
(range30-69)
BMI/
kgm-2 (range40-48)
Maritalstatusand residentchildren
Educationlevelandemployment
Female 30 40 Married
≥3children
Middleleveleducation,noemployment
Female 36 42 Single
Nochildren
Higherleveleducation,full-timeemployment
Female 42 48 Married
≤2children
Middleleveleducation,onsickleave
Female 56 46 Divorced
Adultchildren
Middleleveleducation,full-timeemployed
Female 60 43 Divorced
Nochildren
Middleleveleducation,earlyretirement
Male 26 47 Single
Nochildren
Lowleveleducation,full-timeemployment
Male 46 44 Married
≥3children
Lowleveleducation,full-timeemployment
Male 54 41 Single
Nochildren
Middleleveleducation,earlyretirement
Male 61 44,5 Married
Adultchildren
Middleleveleducation,full-timeemployment
Male 69 46 Single
Nochildren
Middleleveleducation,retired
totheirsuffering.Astartingpointforeradicatingweightstigmain thehealthcaresettingmaybetofocusonwell-beingratherthan weightlosswhentreatingindividualswithobesity[13].Thismay makeinterventionbeneficialandpreventHCPsfromdoingharm.
Anevidence-basedunderstandingofthepatient’slifeworldmay preventHCPsfromreinforcingfeelingsoffailureandblameand insteadintroduceanovelunderstandingoftheexperiencesofwell- beingamongindividualswithsevereobesity.
Moreover,aninsightintoinactivityis neededtoguideHCPs towardsamoreperson-orientedapproachinthehealthcaresetting.
Individualswithseverelyobesitymayliveasedentarylifestyleand maybenefitfromundertakingPA;however,theymaylackwell- beingindoingso.Theperspectivesofpersonslivingwithsevere obesitymaybeimportanttohelpthemunfoldPAineverydaylife, asregularPAmaypromote healthand well-beingregardlessof weight.Littleattentionhasbeenpaidtowardsunderstandingthe perspectivesofwell-being orlackofwell-being ineverydaylife afterintervention,andin-depthresearchontheexistentialexperi- encesofmoodamongindividualswithsevereobesityarelacking.
Theaimofthisstudyistoexploretheexperiencesofbeingphys- icallyactiveamongindividualswithsevereobesityineverydaylife 18monthsafterthestartoflifestyleintervention.
The three research questions were: How do severelyobese femalesandmalesexperiencephysicalactivity?Whatgenderspe- cificaspects exist?Whataretheirexperiences 18monthsafter engaginginlifestyleintervention?
Materialandmethods
This study has a qualitative design based on hermeneutic phenomenology,whichaimstoevoketheparticipants’lifeworld experiencesthroughtheexplicitinvolvementofinterpretation.The fundamentallifeworlddomains,whichareimplicatedinhuman experience,areexploredtorevealthehiddenmeaningsofwell- beinginPA.Thisisdoneinthetaken-for-grantedcontextofeach participant’severydaylife.Understandingandinterpretationare practicedthroughhermeneuticreflectionand co-createdbythe researcherandtheparticipantandmotivatedbythestructuresof fore-having,fore-sightsandfore-conceptions[18,19].
Thisstudyisapartofalongitudinalstudyofmultipleindividual interviewsconductedbythesameinterviewer(firstauthor).The interviewsarethelastofa seriesofthree individualinterviews
withthesameparticipants[6].Previousinterviewswereconducted beforeinterventionandattheendoftheinterventionsixmonths later.Theinterviewsofthisstudywereconducted18monthsafter thefirstinterview.Thetimeframewasconsideredappropriateto serveasaoneyearfollow-upaftertheendoflifestyleintervention andwaschosentoacknowledgethevariationoftimeittakesfora persontoestablishnewhabits[20].
Participants
The participantswerefive females andfive males,who had beenreferredtolifestyle interventionata publicDanishteach- inghospitalbyageneralpractitioner18monthsearlier.Theywere purposefullyrecruitedfromthewaitinglistbycriteria:>18years andBMI≥40kg/m2.Meanagewas48years(range30-69)and meanBMIwas44,2kg/m2(range40-48)(Table1).Therecruitment andadherenceofparticipantswerechallengedbycancellationsand changedappointments.
Theparticipantsunderwentanin-hospitalgroup-basedinter- vention ledby a team ofinterdisciplinary HCPs, e.g. registered nurses,dieticians,registeredphysiotherapists,occupationalther- apists and cognitive psychologists. The intervention comprises targetedhealthpromotionandpreventiontreatmentanddirected towardstobaccouse,physicalinactivity,unhealthydietand the harmful useof alcohol as wellas humanfactors suchas com- petences,respect,acceptanceandcoping.Theinterventionisnot specificallydesignedforpatientslivingwithsevereobesity,butis targetedtowardspatientslivingwithcomplexlifesituationsand healthchallenges,e.g.chronicdiseases,multimorbiditiesand/or psychosocialproblems.Eachpatientwashospitalisedthreetimes inmodulesoffourdaysduringasixmonthperiodwithtelephone counselingin-betweenmodules.Theinterventionconsistsofdia- loguebasedteachingsessions,groupdiscussions,practicalcooking, physicalactivities,mindfulnessandindividualdialogues.Between modules,patientsareexpectedtopracticetheplannedlifestyle changesineverydaylife.Theinterventionended12monthspriorto thisinterviewroundandthecontextofthispresentstudywasthe participants’homesettingduringavisitacrossthreeoffiveregions inDenmark.Theinterviewswereconductedbythefirstauthorin winter2017.
Allparticipantshadpreviouslyorrecentlyexperiencedweight cycling. The majorityreported a current or a passedhistory of
Figure1.Twodocumentsbasedonpreviousfindingswereusedduringtheinterviews:badexperiences/barriersandgoodexperiences/facilitatorsinrelationtoPA.
depression,stress,anxietyand/orothermental illnessof which somenecessitatedmedicalisationandthreeparticipantsdeclared havinghadsuicidalthoughts.
Datacollection
Individualface-to-faceinterviews(n=10)wereconducted18 monthafterthestartoflifestyleinterventionandlastedapproxi- mately50minutes.
Aninterviewguidewasdevelopedincollaborationbetweenthe firstandthelastauthorwiththepurposeoffocusingandfacilitating theinterviews.Theinterviewguidespresentedopen-endedques- tionsandservedmainlyaspreparationpriortotheinterviewsin ordertostructureand guidequestionsand enableactivelisten- inginaninformalway.Moreover,theinterviewguideincludeda briefingandade-briefing[21]andconsistedofquestionsinspired byaconceptualframeworkofdifferentlifeworlddomains[11]in combinationwithpersonalquestionsreflectingpreviouslygained understanding[6].Beingcuriousabouttheparticipant’spresent situationtheinitialquestionsoftheinterviewwere:Howareyou?
How areyou doing? Clarifying questions were posed withthe readinesstobetoldsomethingbytheparticipantrelevantforthe researchquestionsandprocessoflifestylechangewithopenness towardstheiranswers[19].Thefirstauthorhaddeveloped two figurespresentingthepreliminaryfindingsidentifiedinprevious interviews[6](Figure1).Theparticipantswereaskedtocritique theinterpretationbycommentingonwhetherornottheycould relatetothefigures.
First,thefirstauthoraskedtheinterviewquestions,secondthe figureofbarriersandthirdthefiguresoffacilitatorswerepresented.
Attheend of theinterview,the participantswereaskedabout theirfutureexpectationsanddreams.Finally,permissiontocon- tactthemforanotherfollow-upinterviewafteranother18months wasgivenonrequest.
Analysis
Interviews were audio-recorded and transcribed verbatim.
Audio recordings were listened to, transcripts and notes were read/re-readtogetasenseofthewhole.Thestepwiseprocedureof meaningcondensation,meaningcodingandmeaninginterpreta- tiondescribedbyBrinkmannandKvale[21]wasusedasamethod ofanalysis.Meaningunitsinthetranscriptswereidentifiedand
condensedbyshorteningthefindingsandatthesametimepre- servingtheessenceofthemeaningunits.Codingofthefindings wasdonebyattachingoneormorekeywordsaddressingdiffer- entthemes. Meaning interpretationsbeyondwhat wasdirectly saidwereusedtocreateastructure forthemesandsubthemes.
Theanalysiswasconductedinacircularmovementbetweenparts andwholesoftheinterviewandbetweenthefirstauthor’sunder- standing and pre-understanding of the subject matter and the interpretation was discussed with co-authors [19]. Finally, the findings were analysed by using the conceptualframework on well-being tosensitise theinterpretation[11].The genderseg- regated analysisenableda presentationof thegeneralsenseof theexperiencesamongindividualswithsevereobesityaswellas gender-specificexperiencesofbeingactive.Theaimwastopresent themaleperspectives,whichareunder-representedinthequali- tativeliterature[5].
Theory
ThestudywasbasedontheGermanphilosopherMartinHei- degger’s(1889-1976)[18]conceptofalifeworldthateveryhuman beingexperienceslivingwithin.Inthisstudy,thephilosophyunites physicalandmentalaspectsofbeingseverelyobeseinrelationto thechallengesofbeingactive.
Theconductionandanalysiswerefoundedinahermeneutical modeofinterpretingthemeaningoftheparticipants’waysofbeing activeineverydaylife.Theexplorationoftheresearchtopicwas approachedinadialecticcircleofquestioningandansweringina conversationalsituation[19].Asharedunderstandingbetweenthe firstauthorandtheparticipantswasenabledbygettingdescrip- tionsofspecificexperiencesofeveryday life.Thespokenwords wereinterpretedincollaborationwiththeco-authorsinaprocess basedonthefirstauthorspre-knowledgeandpre-understanding inthecontextoftheiroverallsituation[19].
A conceptual framework based on six existential lifeworld domains:livedtime;livedspace;livedrelations;identity;mood andthelivedbody,whichareaninterwovenandalwaysexisting setofinterrelated domains,wereused toapproachand under- standin ’wholeness’.Thedomainsinteractbythewaytheyare foregrounded as lifeworld experiences and exist as different kindsof suffering andwell-being, which are balanced between dwelling, mobility and dwelling-mobility [11]. The conceptual frameworkservedasapartofthephilosophicalandmethodological
Table2
Quotesfromparticipantssupportingthegenderedexperiencesofthemain-themeandthesub-themes.
Main-theme:’Fluctuatingmood’
Femalesub-theme:
’Appreciationofprocessandincreasedvitality’
Malesub-theme:
’Thechallengeofanactiveandjoyfulliving’
Female,31years,whoisnowgoingtothegymregularlywithher husband.Earlier,shehadbeenclosetogivinguponPAandon herselfandsherecalls:IblamedmyselfforbeingabadmotherandI wasn’tagoodpartner.Ididn’thavetheenergytochange...Iwas alreadysolost,sowhydoanything?
Male,26years,whohadexperiencedrelapseandlowereddesireinPA:I havetogetoutonthosewalksagainandachievethatcalmthatitgives me...Goingforawalkisn’thard.It’smoreaboutthepsychological barrier...wallsbuiltinsidemymind.That’swhat’sdifficultforme...Thereisa planandIhavetogetbackonitbecausethat’swhatmademehappy...IfI don’tloseweight,Iwillstillhavethosetoolstolookatpeople,lifeandmyself differentlyandthatgivesmejoyinlife.
Female,36years,whodeterminedlyworkedondevelopingher viewofselfasobeseandafailureinPA:Ihavemoreenergythan I’vehadinyears...[asoflate]therehasn’treallybeenanythingto beatmyselfupaboutbecauseweighthasn’tbeenthefocalpoint... Don’tfightforsomethingthat’simpossible.Fightforsomethingthatis realistic.Somethingyouknowyoucansucceedwithratherthanfail.
Male,46years,whohadexperiencedadditionalphysicalproblemsand weightregain:Youhavetokeepyourspiritsup...Thinkingaboutit(the problems)toomuchdoesn’thelp.Idon’tthinkthat’sgoingtosolvemy problems.
Female,42years,whohadfeltshamefulofherweightandinactive life:I’vebecomealotmoreconfident.Icansay‘‘no’’.Inowhavethe no-thank-youbutton.Ididn’thavethatbefore...I’mabletodoalot morearoundthehouseandIwanttodothingsmore...I’ma healthiermotherandabetterrolemodel...havebecomebothabetter wifeandabettermother.
Male,54years,whoforyearshadexercisedforweightlosstosurvive:The morepressurehe[I]isunderthemorehe[I]isgoingtofight.Iwon’tgiveup beforeI’msixfeetunder...ButI’vefeltupsetalotoftimesandI’vebeenlow manytimes.Reallylow...forhoursI’veprettymuchgivenup...Inanycase, therehasn’tbeenadaythatIhaven’tcriedatleastonce,whenI’mbymyself becausethingsarethewaytheyare.
Female,56years,whohadfeltweigheddownandlackedjoyand energyinlife:Oftenit’sthelittlethingsthatmakeyouhappybutthat areforgotten.ThosearethethingsIneedtobringback.It
[intervention]hasgivenmeabitofdrivetodoit.
Male,61years,whostruggledwithkeepingupregularcyclingandeating lessfood:It’sdifficultformebecauseIlikethebadhabits.Therehastobe roomforsomeofthefunstufftoo.
Male,69years,whointendedtostartexercising,butneverdid:
Exercisewillgivethebestresults.Now,I’vealsostartedmovingalittle...I exercisewaytoolittle.Now,I’vefixedupmybikesothereisnoexcuse.Iknow therecipeforweightloss.
pre-understanding,andguidedthedataanalysisinthesearchfor existentialmeaningsofwell-beingandsuffering.Inthisstudy,the domainofmoodisspecificallyforegroundedtogetabetterunder- standingofthecharacterofmoodthroughadialoguebetweenwhat isfamiliarandwhatisalienintheinterviewdata.
Ethics
TheDanishDataProtectionAgency(J.no.1-16-02-425-15)has approvedthestudy.AccordingtoDanishlaw,approvalfromthe NationalCommitteeonHealthResearchEthicswasnotrequired,as nobiomedicalinterventionwasperformed.Theparticipantswere initiallycontacted bythesecretaryofthedepartmentand they receivedwritteninformation.Priortothefirstinterviewwritten andoralinformedconsentformsweresigned,and consentwas confirmedbeforeeachinterview.
Results
Theresultspresentedin thispaperareacontinuationofthe findings of previous interviews with the same participants. In thepreviousstudytheirexperiences ofPAwithinthelifeworld domains of identity and embodiment beforeand during inter- ventionwereforegrounded.Thestudydescribedtheirstrivingfor well-beingandtheirstrugglewithenergydepletionandsenseof selfandhowtheyinitiallyfeltcaughtinaninactivityspiral[6].
Theparticipantsofthisstudycommentedontheinterpretation ofthepreviousinterviewsandrecognisedthefindingsoftheirpro- cessoflifestylechange(showninFigure1),however,twomales onlyrecognisedoneofthecircles.Theyelaborateduponhowthey allfelt theyhad moved froma circle mainlyconsisting of bad experiencesandbarrierstoPAandintoaprocesscharacterisedby positiveexperiencesandnewpossibilitiesfordoingPA.Afemale aged42yearsdescribedchangesshehadexperiencedduringthe past6months.
‘‘[Thepositivecircle]ishowitisnow;[thenegativecircle]was whereitstarted.Thereisahugedifference.Youcanreallyfeellike, goodlord,thatIdidn’ttreatmyselfverynicely’’
Moreover,theparticipantselaborateduponhowtheirexperi- encesrelatedtodifferentkindsandlevelsofwell-being,lackof well-beingandsuffering.However,theyuseddifferentterms,e.g.
themalesdidnotuse‘‘blame’’,buttalkedaboutguiltandlowself- confidence.Afemaleaged36reflecteduponherprocessofchange inrelationtothecirclesandstated:
‘‘Itisnotnecessarilythecontentofthecirclesthatmademeill, butitsurelyhasnotmademehealthier’’.
Oneyearaftertheendoftheinterventionanewmain-theme
’Fluctuating mood’ was identified as influencing well-being in everydaylifeoneyearaftertheendoflifestyleintervention.The mainthemeoverarchedtwogenderedsub-themes.Thefemalesub- themewas: ’Appreciationof processand vitality’ and themale sub-themewas:’Thechallengeofanactiveandjoyfulliving’.The
’Fluctuatingmood’wasdescribedasbeingcloselyrelatedtoenergy andvitalityandinfluencedtheexperiencesofdoingPAandbeingat rest(SeeTable2).Therewasacomplexinteractionbetweenmood andotherexistentialdomains,e.g.temporal,spatialandintersub- jectiveexperiences;howevermoodisforegroundedinthefindings ofthispaper.
’Fluctuatingmood’asageneralhumancondition
Theparticipantsforegroundedmoodasbeingalwayspresent inthemind asanunderlyingattunement totheirsenseof self, othersandtheiractivitiesindailylife.Thefluctuationsinmood weredescribedasvariationsofemotionsincluding‘‘anger,irrita- tionandfrustration’’orhappinessandoptimism.Theyexperienced moodasbalancedbetweendifferentopposingfactors;weightloss orweightgain,boredomormeaningfulactivities,blamingoneself orsettlingwithone’sefforts,disappointmentorprideofself,feeling isolatedorsupportedintheprocess,feelingdepressiveorcheer- ful.Theydescribedloweredmoodas‘‘darkclouds’’,which were
overshadowingtheirPAinitiativefromtimetotimewhenenergy andvitalitywerelow.Amaleaged46hadfeltimprisonedandtied tohissofaandweigheddownbyworriesandnegativeexpectations ofhishealth.Afterhehadstoppedexercisingwithaphysiothera- pist,hehadbecomeunabletodothegardening,housechoresand thewalkingorcyclinglikeheusedto.Hestated:
‘‘Youhavetokeepyourspiritsup.Itdoesn’thelpifIthinkabout ittoomuch.Idon’tthinkthatwillhelpmesolvetheproblems.In away,Imisshavingsomethingtofiddlearoundwith.WhenIstart gettingboredanddon’tknowwhattodo,well,thenIjust start chainsmoking’’.
Tacklingloweredmoodwasapartofalltheparticipants’pro- cess,regardlessofgenderandage,andtheyemphasisedhow it sometimesrequiredthecareofothers,e.g.HCPs,supportinggroups orfamily,whowouldlisten,inspireorcomfort.Themaleandfemale participantsrevealedhowtheysometimesfeltlonelyandhadto tackleloweredmoodbythemselves,i.e.crying,eatingorsmoking.
Ayoungmaleaged26explainedhowfeelingdepressiveandover- whelmedbysadnesswoulddrainhisenergyandcausehimtocallin sickforwork.Moreoftheparticipantswereaffectedbytheoccur- renceofprecariouslifeeventsanddiscouragingthoughts,which wereaddingtotheirfeelingsofbeingweigheddownbyworries.
Beingdiscontentwithone’sweightorappearancewasenlargedby illness,painandbodilyimpairmentsandweightcycling.Beingdis- contentwithone’sownlifebecauseofboredom,unemployment orlackofjoyfulactivitiesbroughtafeelingofstasisandloneliness, whichaccountedforagreatdealoftheirloweredmood.Finally,the experiencesofuninspiringanduncomfortablePAinfluencedtheir moodandthedesiretobephysicallyactive.However,contrast- ingexperiencesoffacilitatorsintermsofelevatedmoodwerealso emphasised,thoughtheywerelessexplicitwithfewerexamples.
Theparticipantsexperiencedelevatedmoodwiththeaccom- plishmentoftheirPAgoals,whichbroughtafeelingoftriumphand optimisticexpectations.Moreover,someexperiencedpleasurein doingPAwithpeers,familyorfriends,becauseitcontributedto highspirits,excitementandcreated‘‘joyandenthusiasm’’.Others wouldpreferbeingontheirown.Afemaleaged36hadstopped goingtothegym,whereshefeltrestless,uncomfortableandbored.
Shefeltweigheddownbyblameandshameofbeingunableto sticktobeingactive.However,buyinganAppwithdifferenthome exercisesprovidednewpossibilities.Shesaid:
‘‘I’vefoundawaytoexercisethatworksforme.ThatIwillstick to.Awaythatmeans,thatIwon’tgetboredandgiveitup.Itadds thismentalboostandenergy’’.
Theparticipantsdescribedelevatedmoodtobevitalforsus- tainedPAparticipationineverydaylifeandviceversa.Inthisway, moodandoptimisticexpectationswerecloselylinkedtofeeling hope.
Inthefollowingsection,thesub-themesaregendersegregated whenapplicable.
’Appreciationofprocessandvitality’bringsincreasedhope
Forthefemaleparticipants,the’Appreciationofprocess and vitality’waspartofstayingcommittedtohealthyliving,andtheir experiencesprovidedthemwiththedesireandcouragetocontinue theirefforts.Beinginapositiveprocessofchangeprovidedasub- sequentfeelingofprideintheirsocialrolesasmothersandwives andwerecontributingtotheiridentityofbeinghealthyandattrac- tive.Somefemaleparticipantshaddevelopedsettlementwiththeir owncapabilities,whichinturnreducedblameandself-criticism.
OtherscametopeacewiththeirPAeffortsbylowering thebar andprioritisingtheiractivitiestobeguidedbytheirmeaningful- nessorenjoyment.Theytoldtheinterviewerhowtheydeveloped theircapabilityofmakingchoicesandsettinggoalsinaccordance withtheirownpreferencesandvalues.Anincreasedconfidencein theirowndecisionmakingandspeakingoutbroughtthefemale
participantsasenseofbeingstrongandhonest.Thestrengthened senseofselfresultedincheerfulness,livelinessandhopeinthe femaleparticipants,whichtheyhadpreviouslymissed.
Despitetheexperiencesofhavingmovedintoapositivecircleof improvedhealthandwell-being,thefemaleparticipantswereinan on-goingprocessofidentifyingtheirownsolutionsandmaintain- ingprogressafterdischargefromhospital.Forsome,thesolutions hadbeentoattendpre-establishedgroupsintheirlocalcommunity forsupport,wheretheyfeltacceptedandvalued.
Thefemaleparticipantsascribedtheenhancementofpride,con- fidenceandacceptancetoimprovemood,andtheyallfeltithad providedthemwithahighlyvaluedvitality,whichenabledthem tooutliveanactiveeverydaylife.Becomingawareofmood’sinflu- enceonvitalitysomeofthefemaleparticipantsstartedtostrivefor joyineverydayliferatherthanweightloss,thoughstillaimingfor it.
’Thechallengeofanactiveandjoyfulliving’isworththefight Themaleparticipantscommentedontheanalysisofprevious findings(Figure1)anddescribedhowtheyhadfoundweightloss aninsurmountablechallenge,becausetheyfeltincapableofmaking lifestylechangesontheirown[6].Oneyearlater,theyexperienced thechallengehadbecome’Thechallengeofanactiveandjoyfulliv- ing’.Theyexperiencedthathealthylivingwasimportant,though partlyconflictingwiththeirideasofapleasurableandjoyfulliving.
Theirhealthiereatingand/orexercisewereexperiencedasanobli- gation,andtheyfeltdiscontentmentwhenincapableofbalancing healthyandjoyfullivingineverydaylife.Theiremphasisonhealth wasmainlydirectedatphysicalfactors,i.e.weightlossandmobil- ity.Therefore,exercisewasconsideredmeaningfulandessential fortheirachievements.Themaleparticipantsdescribedacommon challengeofnotfeeling‘‘inthemood’’forexercise,whichnecessi- tatedthattheywereableto‘‘kicktheirownbutts’’todoPA,e.g.one maleaged69wasincapableoftakingactionandnevergotstarted withtheexerciseheintendedtodo.Otherswerechallengedby theaimofexercisinginaccordancewithstandardguidelinesand disregardedtheirindividualpreferences,conditionsandabilities.
Othersagainwerechallengedbypainandhealthissues,whichhad madethemstoporcutdownonexerciseandmadethemfeelakind ofdespairandangeraswellassadnessandregretofbecoming inactive. Moreover,thosewho regained weightfeltout of con- trolandpowerlessintheirsituation.Twomalesaged46and69 clearlyemphasisedthattheyrefusedtothinkabouttheirworries andtheirfutureandpreferredto‘‘liveonedayatatime’’.Themale participantsexpressedagreatdealofresponsibilityfortheirown situation.Theyfeltdiscontentandguiltyforactingirresponsibly andblamedthemselvesforlivinginoppositiontotheirownhealth ideals.Someofthemaleparticipantsweredisappointedbytheir ownexerciseeffortsandachievements,butnoneofthemgaveup.
Thedisappointmentwasasourceofloweredmoodandimpatience;
howevertheyfounditworthfightingforlifestylechanges.
Whenthemaleandfemaleparticipantsaddressedtheirpro- cessesoflifestylechangeoneyearaftertheendofintervention, theyreferredtotheirexperienceswithdifferentpointsofemphasis.
Thefemaleparticipantsaddressedtheprocesswithappreciation, whereasthemaleparticipantsmainlyaddressedthechallengesof makinglifestylechanges.Hence,theyexpresseddifferentexpecta- tionsandhopesforthefutureinrelationtobecomingandstaying active.
Insummary,moodseemednevertobesteadyasitconstantly changedbetweenbeingelevatedorlowered.Therefore,theprocess oflifestylechangeimplicatedtheon-goingtaskofcounterbalancing loweredmoodtopreservevitality,hopeandtheabilityofbeing physicallyactiveineverydaylife.
Discussion
Thepresentstudyaimedtoexploretheexperiences ofbeing physicallyactiveineverydaylifeamongseverelyobeseindividu- alsafterlifestyleintervention.Thiswasfoundrelevantinorderto understandtheprocessofbecomingandstayingactivebeyondthe timeoflifestyleinterventionandtoinformpatientsandHCPsabout theprocessandtherelevanceofwell-being.
ThisstudyfoundthatPAwasinterrelatedwithwell-beingin mood,whichaffectedalltheparticipantsregardlessof whether theysufferedfromdepressionornot.Moodwasfluctuatingandthe currentstateofmoodworkedaseitherabarrierorafacilitatorfor everydayactivitiesorstructuredexercise.Beingactivewasexperi- enceddifferentlyamongthemalesandthefemales,mainlybecause thefemalesfoundappreciationinsettlingwitheverydayactivities andfindingtheirownsolutions,whichbroughtnewenergyand vitalityandafeelingofpossibilityofprogression.Incontrast,the malesfoughttoconductmoreintensiveandstructuredexercise withagreateremphasisonachievingweightlossresults.Themales seemedtospendmoreenergyonworryingandbeingfrustrated.
Mostinterestingly,itresultedinthefemalesexpressingincreased hopeandmorepositiveexpectationsfortheirfuturemobilityand healththanthemales.However,themalesdidnotexpressany intentionofgivinguponPA,liketheyhadtendedtodopriorto intervention.
Themoodofdepressionmayhaveinfluenced eachindividu- alsexperiencesandprocess,asdepressedmoodischaracterised byalackofenergyandmotivationandapessimisticoutlook,and thereforeafeelingofinabilitytomoveforwardwithchanges[11].
Moreover,anunsettledrestlessnesswithfeelingsofirritationas wellastheneedtodomoreexercisethantheyfeltableto,seemed torepresentadifferentkindofsufferinginmood[11].
Well-beinginmoodturnedouttobeinthebackgroundcom- paredtothelifeworldexperiences of identityandembodiment amongindividualswithsevereobesitybeforeandduringinterven- tion[6].Yet,itemergedasanimportantthemeinrelationtothe participants’experiencesofbeingactiveafterintervention.Accord- ingtothetheoryofdifferentkindsof well-beingbyGalvinand Todres[11],theexperienceofmoodisafeltattunement,which canbeforegroundedbythequalityofmovement,i.e.anenergized feelingofmotivationtodoPAorwiththequalityofdwelling,i.e.
akindofsettlednessandpeacefulnesswiththingsastheyareor whenhavingfulfilledone’sPAgoalthatrequiredsomeeffort.The idealisthatwell-beingisexperiencedinbothdwellingandmobil- ityinawaythatonefeelsbothexcitementanddesiretodoPA,as wellasacceptanceofone’seffortsandachievements.Thisdwelling- mobilityhasanenergeticqualityofenthusiasmandinterestaswell asthesettledqualityofbeingathomewithoneselfandtheworld ina‘‘mirror-likemultidimensionalfullness’’,whichiscomplexand canbemanythings,e.g.sadnessandhappiness[11].
Based onthefindings of this study,it is important thatthe expectationsandgoalsinrelationtoPAarerealistic andmodi- fiedtoeachindividualandaimingforafeelingofability,energy andhope. Especially,theprocess ofsettlingseemedtobechal- lenging.Someoftheparticipantsmayneedhelpdrawingattention tohowtheycanappreciatetheirachievementsandbelesscrit- icaltowardstheirefforts.Theexperienceofwell-beinginmood maybeaninnerresourceinthemidstoftheirsufferingfromtheir obesityandotherchallengesinlife[11].Theexperiencesofbeing in a processbring withit a mood thatmotivates thedesireto domeaningful activities,whichmaybea prerequisiteforlong- termengagementinPA.Wearguethatitisrelevanttodistinguish betweenwell-beingwithindwellingandmobility,i.e.toempha- sisesettlementamongtherestlessandimpatientindividuals,and topromotemobilityintheindividualsexperiencingexhaustionand stasis.
Findingsinrelationtoothersstudies
McIntoshetal.[8]conductedatsystematicreviewandidentified loweredmood,lackofpleasureandlackofenjoymentasbarriers toPAinindividualswithobesity.Theyreinforcedtheimportance ofaddressinglowmoodinindividualswithobesitywhenadvising themaboutPAandlifestylechange.Moreover,theyargued,that moodshouldalsobeaddressedafterinterventiontosupportthe individualinsustainedefforts.Ourstudycontributeswithdescrip- tionsofhowmoodisexperiencedinindividualswithsevereobesity ineverydaylifeafterlifestyleinterventionandhowitinfluences PA.Wehavedescribedhowaninitialfeelingofhopelessnessfrom livingwithinalargebody[6]candevelopwithimprovementsin moodandbringenergyandvitalityovertimeandwearguethat thewell-beingexperiencesofhopemayfacilitatePA.Thisissimi- lartoastudyreportingthatreducedwell-beingduetodepression madepatientslikelytogiveuponPAafterbariatricsurgery[22].
However,theparticipantsofourstudydidnotgiveuponPA,but strivedtobalancemoodandkeepuptheirefforts.
Thegenderedfindingsofthisstudyrevealedthatthefemale participantstendedtofindwell-beingintheiractivitiesthrough dwellingintheirpresentpossibilities.Themaleparticipantswere, toagreaterextend,seekingwell-beingthrougharational,logical approachtoPAbasedontheirpresentexperiencesofactualperfor- mance.FromaGadamerianperspective,themaleparticipantswere representingaslightlymoreunbalancedrelationshipbetweenthe doingandthedeed[19],e.g.PAwasmainlyperceivedasameansfor weightlossbythemales,ratherthannaturalandjoyfulmovement ineverydayactivities.Theireffortsmaybeanattempttomain- tainanactivitylevelwithinarangeconsistentwithpublichealth guidelinesfor weightmanagement, thoughtheysometimesfelt incapabletodoso.However,thereissomeevidencethatindivid- ualslivingwithobesitymaybenefitfromemphasisingwell-being overweightlosswhenaimingtomaintainanactivelifestyle[23]
andthatfocusingonPAisaweightneutralwayofimprovinghealth ateverysize[23].Still,itseemsimportantforHCPstoapproachPA inaperson-orientedwayandemphasisewell-being,whendoing so.
Thegenderedfindingsofthisstudyarethoughtusefulandcred- ibleforfuturequalitativesystematicreviewsandmeta-synthesis [24]regardingPAamongindividualswithsevereobesity.
Theobesebodymaycarrythecharacteristicsoflackingwilland control[25]andmaynotcomplywithprevailingsocialnormsof adequatebodyweightandshapeorhealthbehaviour.Thecontext oflifestyleinterventionmaycarrythenormsoftheideallifestyle, andHCPsmayhavestereotypicalassumptionsaboutpatientswith obesity that theylack motivation and responsibility [26]. Such normativeattitudesmayleavepatientswhodonotcomplywith existingnormswithfeelingsofshameandblame[16].Moreover, thepatientswithsevereobesitymaybeparticularlyvulnerableto feelingsoffailureinbothweightlossandPA,andfeelingfailure reduceswell-beinginmoodandleadstobingeeatingandaddi- tionalweightgain[16].
Preservingthedignityofpatients,whosufferfromobesity,isa healthcarechallenge.Arespectfullanguageisonewaytoprotect dignityandwell-being.However,itrequiresexpertknowledgeto ensurethebestpossibledignifiedandbeneficentcareforpatients toavoidapplyingthefeelingofembarrassmentandshame(malef- icence)[27].AspecificchallengeistheofficialguidelinesforPA, which aremainlybased onphysicalaspects ofhealth and may beinappropriateforpeoplelivingwithsevereobesity, whoare unlikelytocomplywiththeguidelines[28].Theguidelinesmay disregardthecomplexexperiencesofPAandthefactthatindivid- ualswithsevereobesityhavenumerousandcomplexbarriersto PA,whichmaylowertheirPAparticipation[5].Thismaycontribute totheindividual’sfeelingoffailureintheirefforts,ifHCPsdonot
understandthepatient’spossibilitiesandlimitations.Battegayand Cheetham[29]haveputforwardperspectivesontheineffective- nessofatooliteralapplicationofclinicalguidelines,e.g.whenHCPs neglectthepatients’valuesandpreferencesintherapeuticgoalset- tingandactionplanning.TheysuggesttheprinciplesofChoosing Wisely,i.e.usingone’sjudgmentskills,toensureinterventionsare beneficialandnotdoingharmtopeoplewithcomorbiditiesand withincomplexsituations.Thisseemsmostrelevantinrelationto promotionofPAamongindividualswithsevereobesity.Weagree thatnarrowandsetexercisegoalsmayimposefeelingsoffailure, blameandshameuponthepatient,whengoalsarenotreached.
Moreover,wesuggestaperson-orientedapproachwhereHCPsin clinicalpracticetalkaboutthepotentialbarriersofloweredmood andmodifyPAgoalsincollaborationwiththepatients[30].Adia- logueaboutwell-beinginmoodseemsparticularlyimportantin patientsvulnerabletodepression,andanexistentialacknowledge- mentofthepatients’experiencesmaybepartofthetreatment itself[11].Emphasisingwell-beingisfoundtoserveasaresource- orientedapproach,thatmayreduceweightstigmainhealthcare practicebyputtinglessemphasisonweightandtheamountofPA, anditmaypreventHCPsfromdoingharmtovulnerableindividuals sufferingfromsevereobesity.
Strengthsandweaknessesofthestudy
Astrength ofthis longitudinaldesign of repeatedindividual interviewsisthatthesameresearcherconductedalltheinterviews.
Thisenabledabetterviewoftheindividuals’wholesituationwhen strivingforafusionofhorizons[19]andprovidedinsightsintothe dynamicsoftheirprocessofchangebefore,duringandoneyear aftertheendoflifestyleintervention[6].Anotherstrengthofthe studyistheprolongedadherenceandcontributionofthepartici- pantsfor18months,eventhoughtheirlifeworldheldgrief,fatigue, painandlackingtime.Thiswasconsideredofgreatimportanceto beabletoidentifycontrastingstatements,e.g.amaleparticipant, whostatedthathedidnotcareorthinkabouthishealth,however, hecontradictedhimselfandactedinoppositiontothestatement.
Thefirstauthor’sexperiencesasaphysiotherapistattheDepart- ment of Lifestyle Rehabilitation, including her knowledge and pre-understandingof obesityandPA mayhave heldapotential riskofreproducingpre-understanding.However,thecontinuous contrastoffirstauthor’spre-understandingbecameastrengthto theco-authorsandfacilitatedself-reflectionandhermeneuticcon- sciousnessintheresearchprocess[19]aswellastheparticipants’
self-reflectionsduringtheinterviews.Thehermeneuticapproach ofthequalitativeinterviewswasfoundanappropriatewaytogain understandingoftheparticipants’lifeworld,asitwasmutuallycon- structedintheinteractionbetweenprofessionalexpertknowledge aswellashumanexperiencesinacontextualsetting.Theconcep- tualframeworkwasusedtosensitisetheinterpretationandprovide awideand descriptivevocabularytocoveraspectsof lifeatan existentiallevel[11].
Alimitationofthestudymaybethatonefemaleparticipantdid notundergointerventionasexpectedduetoreducedmentaland physicalhealth.However,herstatementshavebeenremovedas shecannotcontributetoresearchquestion3.Moreover,onefemale participantonlyattendedthefirstofthreeadmissions.Still,they wantedtobeinterviewedandcontributewiththeirthoughtsand experiencesaboutPA.Thesamplesizeoftenparticipantscouldbe consideredalimitation;however,itisconsideredastrengthtoget intodialoguewiththisvulnerablegroupofpatients.
Beingin dialoguewithseverelyobese participantsalsoheld certain limitations related to presenting gendered perspectives basedon fiveparticipants, among whomindividual differences existedinage,socialandeducationallevel.However,afewpartic- ipantsenabledanin-depthexplorationpresentingdescriptionand
interpretationof their experiences and thereby contributing to researchongenderedperspectivesonPAinthetargetgroup.The participantsrepresentedmainlypatientswithresourcestoengage withthehealthcaresystemforanextendedamountoftimeand whowerewillingtotalkandbeself-reflective,whichmayhave reducedtheirriskofsufferingharm.PAwasapproachedintermsof theparticipants’owndescriptionsofactivitylevel,asquantifiable measurementswerebeyondtheaimandscopeofthisstudy.
Implicationsforpractice
Thefindingsofthisstudybringevidence-basedknowledgeof theprocessofstayingactiveafterlifestyleinterventionfromthe perspectivesofadultswithsevereobesity.Theydescribeanindi- vidual,on-goinganddynamicprocessinfluencedbywell-beingin mood.HCPscanprovidebothsupportorobstructionofwell-being, andtheymustunderstandthevalueofmoodfortheprocessof lifestylechange.Itcanbeconsideredaninterdisciplinarytaskto addresswell-beingamongindividualswithsevereobesitywhen prescribing,deliveringordoingfollow-uponPAinterventionsin clinicalpractice.Agenerallackofwell-beingmayhavenegative influence on the energy to engagein PA as well as on smok- ingandeatinghabits,and indirectlythelackofwell-beingmay reducephysicalandmentalhealthinindividualswithsevereobe- sity.Moreover,itisimportantthatHCPsavoidimposingfeelingsof failurebyfocusingonperformanceinrelationtoweightlossandPA effortsasitmayharmthepatientsandbenon-beneficial.Helping eachpatienttofindsettlementwitheffortsandachievementsmay providetheenergyandvitalitytobecomeorstayactiveinevery- daylife.Aiming forincreasedwell-being isanuancedapproach tohealth,whichmayreducetheexpectationsofweightlossand challengethebarriersofshameofone’sPAlevel.
Conclusion
Thestudyhighlightstheexperiencesofwell-beinginrelation tostayingphysicallyactivityafterlifestyleintervention.Itempha- sises,thatfluctuationsinmoodwerepartofeverydaylifeandit wasanon-goingchallengetobalancemoodinordertokeepupPA efforts.TheabilitytofindsettlementandmodifyPAexpectations waspartoffeelingcapable.FeelingcapableanddoingjoyfulPA elevatedmoodandcontributedtowell-being.
Thisstudycontributes withnewperspectivesonPAof both malesandfemaleswithsevereobesity,whichmaybeusefulfor HCPtoreflectuponinrelationtoweightstigma,normsofPAand genderedbehaviours.HCPsare suggestedtoaddresswell-being inmoodtohelppatientstobecomeandstayphysicallyactivein everydaylife.
Futureresearchmaybepursuedin termsof anintervention studyapplyingtheperson-orientedapproachtoPA whendoing follow-uponpatientswithsevereobesityafterintervention.
Fundingsources
Thiswork wassupportedby HorsensRegional Hospital,the DepartmentofLifestyleRehabilitationandAarhusUniversity.All stepsoftheresearchprojectwereconductedindependentlyofthe fundingbodies.
Acknowledgements
Wethankalltheparticipantsfortheirparticipationandcontri- butionintheinterviews,andresearchsecretary,MALineJensen forlanguagerevisionofthemanuscript.Thanksalsotothetothe fundingbodiesforsupportingthisstudy.
