Last week I looked at a study about sedentary women doing strength training. This week I thought it might be interesting to look at a recent study that considered how well overweight and obese premenopausal women adhere to a two-year twice-weekly weight training intervention. After all, if we’re all going to get out there to persuade our non-lifting friends to take up strength training, we should at least be open-minded about their likely adherence to the programme.
How well would you adhere to a programme of picking this up twice a week?
It’s a really interesting study and quite readable, so I do recommend you go and have a read of it yourself, but I’ve included some of the more interesting points below.
*****
Adherence to a strength training intervention in adult women
Arikawa A Y, O’Dougherty M, Schmitz K. J Phys Act Health 2011; 8(1):111-118. (Free copy of the study here.)
The study
This study was considering data already collected about 164 premenopausal sedentary women for the “Strong, Healthy, and Empowered” (SHE) study, reported in 2007 (Strength training and adiposity in premenopausal women: strong, healthy, and empowered study. Schmitz KH, Hannan PJ, Stovitz SD, Bryan CJ, Warren M, Jensen MD. Am J Clin Nutrition 2007; 86(3):566-72). This earlier study required the women to participate in two years of strength training. In order to assess how much the strength training made a difference it was necessary to keep note of whether the women actually did the training.
The authors of the study we’re looking at today used this subsidiary data from the 2007 study to look at whether there was any link between adherence and certain demographic variables. The demographic variables being considered were: age, self-reported race or ethnicity, education, marital status, number and ages of children living at home and their work status.
The training programmes
For the first year participants were doing two training sessions each week, lasting 60-90 minutes each, and then recording them in a file kept at the YWCA fitness centres.
The sessions were structured with a cardio warm-up and “core” exercises followed by nine common strength training exercises and finishing with a warm-down set of stretches. On the strength exercises participants did three sets of eight to ten reps for each exercise, always lifting the heaviest weight possible.
In year two participants were allowed, if they wanted, to drop down to two sets of each exercise. This is estimated as having reduced the length of the workout to 45 minutes.
Strategies to support adherence
It is worth looking at the strategies employed to try and help these women adhere to the training programme. After all, the team running the original study needed the women to do the training or they could not assess the impact. To assist with this a number of support strategies were employed, reported as follows:
- Supervised intervention – For 16 weeks they participants did two sessions a week of supervised training with a qualified fitness professional in groups of two to six participants.
- Personal booster sessions – Access to one training session with the qualified fitness professional each month and also two group booster sessions every 12 weeks to introduce new exercises, ensure form was still correct and provide social support to the participants.
- Phone and email reminders – participants were contacted by phone or email once a week if they did not report their completed strength training sessions (their logs were checked weekly).
- Social support gatherings – twice yearly events for participants to share successes and challenges. If I’ve learned nothing else from writing this blog, I’ve learned that women starting out on a strength training programme need a huge amount of social support, whether directly like this or through the internet.
- Incentives – free gifts like t-shirts or water bottles.
- Study website – this contained contact information for staff, methods to contact each other, success stories, ideas to help overcome challenges etc.
- Letters/email to significant others – study participants gave names of people they were close to who could encourage them. These people were sent letters and emails explaining what they were doing and suggesting behaviours and activities that might support the participants.
- Child care – this was provided to any participant who had children age five or younger.
- Gym membership – the participants were given a two-year membership to the Minneapolis YWCA fitness centres.
This seems like a well-considered set of strategies. However it doesn’t hit the mark with one of the biggest factors readers of this site tell me are reasons they struggle to adhere to their training programmes – a lack of time. For this study the sessions were long enough to not be able to squeeze them into a lunch break or some other convenient window, which would have compounded any time issue too.
Provision of things like child care will have helped a little with the lack of time issue but for anyone with children over five (who would still need child care) or those with busy work lives, it would be easy enough to let time become the front-runner excuse not to train. Even if the real problem is a lack of motivation, time can often be labelled, either rightly or wrongly, as the actual culprit for not training.
Results – supervised year one
The results can be found in full published together in a single table here.
On looking at them the most interesting part for me is that there was such good adherence while the participants were having their training sessions with a personal trainer. Most of the adherence is above 90%, no matter how they classified the participants.
The only group where this was not the case were unmarried women with children aged 6-12 – an age group that still requires childcare and where we might assume (correctly or incorrectly) that support at home to provide this child care is less than it might be in a marital home. These women only managed 76.7% adherence to the programme in these first few months.
Results – unsupervised year one
Even more startling is how quickly this overall adherence dropped off. In the rest of year one, once the formal supervised training had finished, adherence dropped to 50-70% for nearly all groups, although there are some noticeable splits within that. Most clearly when looking at race – white women maintained a 70.3% adherence while women of any other colouring only showed 48.6% adherence. There is more discussion on this particular split later but I don’t really know what to make of it – is it cultural?
In the unsupervised part of that first year it is also helpful to look at the marital and age of children split again. While the unmarried women with children aged 6-12 were still poor in adherence, they were safely within the main pack showing 50.9% adherence. This suggests to me that there was much more influence from external factors on whether these women were able to adhere than pure willpower and desire to train. They saw much less drop-off in adherence than all the other groups who dropped from an adherence above 90%.
The group who stand out this time were the unmarried women with children aged 13 or older, dropping from 96.7% to 36.3% adherence. While this would usually imply to me something skewing the data, this pattern continues into year two and no other cut of the data reflects this skew, despite the fact that these same women must have been included in other groups (eg. college or non-college educated women).
Results – year two (unsupervised)
By year two the adherence across the board is mostly in the mid-30-50% range. I was actually surprised by how high this adherence was in year two since it is often the second year when the love-affair with the new training routines and formats tends to finally wear off completely.
The question of race and ethnicity
Throughout this study there were results that surprised me and results that seem very easily explained.
The most extreme difference within a single comparison comes from the split between white and coloured women. For some reason, white women, who represented 58.5% of the participants, show much greater adherence and without knowing how the other demographic characteristics split between these two groups (eg. did more coloured women have children) it is impossible to say why.
The authors gave some consideration to what might be causing this difference. In particular whether
“the gym environment itself could be a deterrent for some participants and would particularly contribute to this division between white and coloured women. The authors state that the “YWCA locations were in the city of Minneapolis, which had a 32% minority population […]. The YWCA mission is painted on the entrance walls of the facilities: “The YWCA of Minneapolis works to fulfill our mission of eliminating racism and empowering women.” The gym staff and membership, while majority White, reflected the diversity of the area. According to their geographic location, mission statement, staff and membership and course offerings (including hip hop, salsa and African dance, among other courses), the fitness centers did not appear to be unwelcoming to culturally diverse women. […] data gathered in focus group discussions and interviews with a subsample of intervention participants offer some perspective. Several women mentioned having joined the study in order to obtain a free gym membership. Six women of color and 5 White women explained their choice of a gym location and/or time of work out by noting disliking a crowded gym. Three women of color emphasized the gym provided a positive family experience. One said of her children: “They are all girls and I want them to know that working out is a good thing for them and they should find time as they get older.” Another found the gym “open, friendly”. Another woman of color said she had “respect” for the YWCA community, and in part frequented the gym to join that community. Two women of color had difficulties with the day care. While specific responses differed, it seems that most women did not have problems with gym-based exercise per se, but only with specific conditions: many preferred quiet, non crowded spaces.
There were, however, 6 women (2 women of color and 6 White women) who voiced discomfort with or dislike of the environment. Four specifically said they had been “intimidated” by the gym: for one woman of color it was the machines, for two (1 woman of color and 1 White woman) it was the many men working out in the weights area. The women of color noted this sense of discomfort ended once they became familiar with using the machines. A White woman said she would prefer a woman only gym: “it feels very intimidating for a woman, especially someone who’s you know who’s overweight to try and go and use the machines, when these guys are putting on all these weights, it’s just a macho thing… If they weren’t there it would feel so much more welcoming.” Another White woman, who suggested women only time periods, suggested: “women only [gym hours] and it would be like women trying to get into shape, so it wasn’t like all Barbie dolls…I would go because I would know it would be a welcoming environment”. Two White women voiced their general dislike for being in gyms without elaboration. These responses suggested that at least some women did not want to be in a social atmosphere under observation or in a male-dominated space, or perhaps indoors at all for physical activity. Most focus group responses did not indicate reservations about gym-based exercise. Instead, they emphasized their confidence in their ability to complete strength training correctly, but noted time constraints and issues of convenience.”
Given that many of these comments are coming from white women it seems unlikely that the gym conditions were the reason for this division in adherence.
The issue with parenthood and training
The authors also took time to consider the drop in adherence by women with older children too. One of the women participating commented, “although her older children no longer required a babysitter, they needed rides to their scheduled activities.” Another participant had commented that it was easier to adhere when her children were younger and didn’t have their own schedules.
Despite this, I do disagree with a comment from the authors that parenthood in general impacts training. After all, those women without children didn’t always adhere as well as those women with children up to 5 years old who had access to child care. The problem is not with being a parent per se but with what resources you have as a parent to handle the multiple commitments that this creates.
Conclusions
So what have we learned here? Overall we have learned that there is a definite drop off over time in adherence to a training programme by overweight women. There also seems to be a particular difficulty in training when women have children to care for – especially as those children gain a social life of their own but don’t yet have the means to get about alone.
The comments about the gym environment are especially helpful as they appear to support suspicions that I already had about gym environments putting women off training. I have a private gym of sorts in my garage but even after years of training I still hate going into a public gym.
Some suggestions to improve this could include more women-only sessions being available in commercial gyms. It might also be improved if gyms offered family-friendly environments where women can bring partners and children with them to workout in some way with them. This would offer much more personal support for the women working out and also resolve some child care issues for them. However, as a general rule in the UK nobody under age 16 is allowed into a commercial gym that has weights and until they resolve that families will not be able to workout together.
If we have friends we want to encourage to start, and then stick to, a training programme there are perhaps a few things we can do to help them. We could offer to train with them until they have got used to the commercial gym environment and feel confident in going alone. And even when they do feel confident, perhaps we could still go with them from time to time. Perhaps we can offer to help with child care to allow them time to train. These certainly appear to be the biggest barriers to adherence coming out of this particular analysis of the data.
What do you think? Is there something I’ve missed here? Are you a mother who has some tips you can share in the comments on how other mothers can successfully combine workouts and parenthood? If so, I’d love to hear from you.
