A Scoping Review of Self-Care Within the Context of Obesity-Related Outcomes Among Faith Leaders

Abstract

Objective

Faith leaders often serve as health-related role models yet many struggle with obesity and self-care engagement. The purpose of this scoping review was to examine how the faith leader literature has defined self-care and examined obesity and obesity-related chronic disease.

Data Source

Studies were identified through database (eg, PubMed, CINAHL, PsycINFO), backward, and grey literature (eg, dissertations) searches.

Inclusion/Exclusion Criteria

Studies published in English with participants who were 18 years or older and examined leaders across all faiths. Studies also included an examination of self-care behaviors among faith leaders within the context of obesity or obesity-related chronic diseases.

Data Extraction/Synthesis

Data synthesis was qualitative and informed by the six-step framework developed by Arksey and O’Malley (2005) as well as updated recommendations by Daudt et al (2013). Of the 418 studies identified and screened, 20 met the eligibility criteria.

Results

Studies were primarily cross-sectional and participants Christian faith-leaders in the US. Most studies did not define self-care or incorporate theory, but focused on vegetarian diets and physical activity engagement. Other self-care related behaviors (eg, sleep, days off), some unique to faith leaders (eg, sabbatical), were included but not systematically.

Conclusions

Research with more diverse faith leaders and that uses theory is needed to guide development of strategies for engaging this population in self-care to reduce obesity and related chronic diseases.

Keywords

caring for self clergy behavior change chronic disease prevention coping

Objective

The prevalence of obesity among United States (US) adults is approximately 42%.¹ Individuals classified as obese are at an increased risk of developing obesity-related chronic diseases (eg, diabetes, high blood pressure, high cholesterol).^2,3 However, both obesity and obesity-related chronic diseases can be prevented or reduced through lifestyle behaviors such as physical activity and diet.^4,5 These and other lifestyle behaviors (eg, taking time off, sleep) are often included in a broader range of behaviors known as self-care behaviors.^6,7

The World Health Organization defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a health-care provider.”⁸ The enactment of self-care may be dependent on one’s view of caring for self – an important construct that enhances health outcomes and aids in the development of positive self-care behaviors.^9,10 Within the nursing profession, for example, caring for self and its role in optimizing personal health is acknowledged as important for job performance (eg, fewer sick days, reduced turnover)¹⁰ and reduced burnout.¹¹

Faith leaders (eg, Christian clergy, Buddhist Priests, Catholic nuns) are another group where caring for self and the incorporation of self-care behaviors is important in reducing burnout. In addition, enacting self-care behaviors may reduce the high prevalence of obesity and chronic disease in this population.^7,12,13 Data from studies with Christian clergy indicate obesity may range from 32 to 60% depending on the geographic location, gender, and race/ethnicity of the sample.^7,12,14-19 These faith leaders also report having high blood pressure (20-68%), high cholesterol (14-41%), diabetes (10-20%), and arthritis (14-34%).^12,14-17,19 Data on other faith leaders is more limited. In studies with Buddhist priests, while their body mass indexes (BMIs) fall within the normal range (20-24.99 kg/m²), they often report having metabolic syndrome (19-30%)^20-22 or high blood pressure (20%).²¹

The health behaviors of faith leaders also play an important role in the way they discuss health and their willingness to serve as health-related role models for their congregations.^23,24 Given faith leaders are influential figures in the communities and congregations they serve,²⁵ their ability to engage in self-care behaviors have important implications not only for their health, but for the health of those they serve. Reviews of the literature on faith leaders have focused on factors influencing their health (eg, physical, mental) or the prevalence of health outcomes (eg, depression, anxiety, and obesity).^26-29 Interventions with faith leaders have also focused on helping them engage in self-care.^30,31 However, literature aimed at understanding how self-care is defined within the context of faith leaders health or how self-care influences obesity and obesity-related outcomes among faith leaders is limited. In addition, most research to-date has focused on Christian clergy, with few studies examining the health and behaviors of faith leaders from other religious traditions (eg, Buddhism, Islam, Judaism, Hinduism).^20-22,32 Therefore, a scoping review was conducted to broaden our understanding of how self-care has been researched across faith traditions. We aimed to answer two research questions: How does the literature define self-care within the context of faith leaders? And, What research exists examining self-care behaviors within the context of obesity or obesity-related chronic disease outcomes among faith leaders?

Methods

Data Sources

The six-step framework of Arksey and O’Malley (2005)³³ and updated recommendations by Daudt et al (2013)³⁴ informed the methods used in the current scoping review (Table 1). Literature was searched that would define self-care and describe self-care within the context of obesity or obesity-related chronic disease outcomes among faith leaders. Forward literature searches were conducted using the PubMed, CINAHL and PyscINFO research databases. Search terms were developed based on the study’s research questions, expert opinion, and a review of the literature. All terms (eg, self-care, physical activity, clergy, obesity) were used across research databases (full list in Table 1). Any literature published on and before September 2^nd, 2021 was included. The original database search yielded 418 studies: PubMed (n = 310), CINAHL (n = 62), PyscINFO (n = 46). A backward search strategy was used to identify studies not found in the database search (n = 18). Additionally, grey literature (eg, dissertation, organization reports) was found through consultation with experts and manual searches by two team members (NTW, BEH) (n = 10) (See Figure 1).

Table 1.

Scoping Review Criteria Outlined by Arksey & O’Mally (2005) and Daudt et al (2013).

Stage 1: Defining the research question	RQ1: How does the clergy health literature define self-care?
Stage 1: Defining the research question	RQ2: What research exists examining self-care behaviors within the context of obesity or obesity-related chronic disease outcomes among clergy/faith leaders?
Stage 2: Identifying relevant studies	• Forward literature searches were conducted using the PubMed, CINAHL and PsycINFO research databases
	• Terms for clergy included: “Clergy”, “clergy health”, “pastor”, “pastor health”, “imam”, “Buddhist priest”, “rabbi” and were inserted into searches using OR statements
	• Terms related to self-care behaviors included: “Stress management”, “rest”, “sleep”, “physical activity”, “time management”, “diet”, “self-care behavior”, “self-care”, “self-care practices”, “caring for self”, “managing demands”, “holistic health” and were inserted using OR statements
	• Terms related to obesity and obesity-related chronic disease included: “Obesity”, “obesity-related diseases”, “chronic diseases”, “chronic health conditions”, “cancer”, “COPD”, “cardiovascular disease”, “heart disease”, “high cholesterol”, “chronic heart failure”, “diabetes”, “high blood pressure”, “at-risk population”, “metabolic syndrome” and were inserted using OR statements
	• These sets of terms were linked using an AND statement
	• Backward literature searches were also utilized to identify relevant journal articles and grey literature
Stage 3: Study selection	• Two researchers were involved in the study selection process, with one researcher was available to resolve discrepant findings between the two researchers
Stage 3: Study selection	• Inclusion criteria included: Studies published in English, participants were 18 years or older, and examined clergy or faith leaders. Additionally, selected studies included an examination of self-care behaviors among clergy or faith leaders within the context of obesity or obesity-related chronic diseases
Stage 4: Charting the data	• The authors used a thematic analysis framework to chart, interpret, and synthesize the data
Stage 4: Charting the data	• Charted study characteristics included: Author/year, study aim, study design/methods, sample size/population, self-care definition/behavior, and primary findings (See Table 2)
Stage 5: Collating, summarizing, reporting results	• Quantitative, qualitative, and reports were included and provide an overview of the current literature
Stage 6: Consultation	• Throughout the study process, meetings were held with a team of researchers, practitioners, and clergy with expertise in clergy health and caring professions to discuss the studies selected, interpretation of results, and how the data were charted

Figure 1.

Identification of studies via databases and registries.

Inclusion/Exclusion Criteria

Three researchers (NTW, MH, TC) independently screened and selected titles and abstracts based on the a priori eligibility criteria and research questions (See Table 1). A fourth researcher (BEH) was consulted if any discrepancies were found throughout the screening process. After reaching consensus on articles to screen out, the researchers independently completed a full review of each study. Before screening commenced, 53 duplicate articles were removed. Articles were excluded if they did not focus on clergy or faith leaders (n = 262), self-care or self-care behaviors (n = 21), obesity or chronic diseases (n = 13), adults (18 years or older) (n = 63), were not in English (n = 12), and were review articles (n = 2).

Data Extraction and Synthesis

After initial inclusion/exclusion screening, 38 studies were included in the analysis. Descriptive data were charted from each study including: author, year published, study aim, study design/methods, sample size/population, self-care definition/behavior, and primary findings. Data were charted using an iterative process by NTW and BEH. A draft of the charting form and data were presented to experts in clergy health and the caring professions. After consulting the research team, 18 studies were removed for not meeting the criteria of applying to clergy or faith leaders, self-care or self-care behaviors, or obesity or chronic diseases. Therefore, 20 studies were included in the final analysis.

To collate and summarize findings (Stage 5), qualitative methods were used.^33-35 These methods adhered to Braun and Clarke’s (2006) six-step thematic analysis framework including: (1) Becoming familiar with the data from each article, (2) Developing initial codes from charted data, (3) Searching for and identifying themes related to each research question, (4) Assessing identified themes, (5) Naming each theme, and (6) Writing the report.³⁶ The analysis was conducted by NTW in consultation with BEH and reviewed by the research team. Charted data were organized into three major themes: self-care definition, associations between self-care behaviors and obesity-related outcomes, and self-care as the dependent variable.

Results

Studies included in this review were published between 1982 and 2021. Most studies (n = 15) were published in 2013 or later. The majority of studies were published in the United States (n = 13),^{7,12,14,15,17,30,31,37-42} with the remaining studies published in South Korea (n = 4),^20-22,43 Sri Lanka (n = 1),³² Canada (n = 1)⁴⁴ and Britain (n = 1).⁴⁵

Study Design and Characteristics

This review included quantitative (n = 15), qualitative (n = 4), and mixed-methods studies (n = 1) (See Table 2). Most study designs were cross-sectional (n = 12),^{7,12,14,15,17,38-44} followed by: case-control studies (n = 3),^20-22 randomized controlled trials (n = 2),^30,31 focused ethnographies (n = 1),³² post-intervention participant follow-up designs (n = 1),³⁷ and longitudinal cohort studies (n = 1).⁴⁵ The faith traditions examined were Christianity (n = 15)^{7,12-15,17,30,31,37-42,44} and Buddhism (n = 5).^20-22,32,43 Five studies examined weight-related outcomes, including prevalence of obesity and body fat (eg, anthropometric and body composition measurements).^{7,12,17,37,43} Seven studies examined obesity-related chronic diseases, which included: metabolic syndrome,³⁰ reflux esophagitis,²² non-alcoholic fatty liver disease (NAFLD),²⁰ Type 2 diabetes,^14,32 cancer (eg, colorectal adenoma, breast cancer),^21,45 and high blood pressure.¹⁴ Lastly, eight studies examined what predicted self-care behavior, including: barriers (eg, lack of time), devotion to faith tradition, and detachment.^{15,31,32,38-42} Of the 20 studies included in the review, only seven used a theory or framework to guide their methodology. The theories/frameworks used were: Socio-Ecological Framework,^7,38 PEN-3 Model,³⁹ Theory of Planned Behavior,^15,30,37 and Social Cognitive Theory.³¹

Table 2.

Summary of Charted Data (N = 20).

Quantitative
Author/Year	Study aim	Study design/Methods^a	Sample size/Population	Self-care definition/behavior	Primary findings
Choi et al. (2015)	Examine the effect of a vegetarian diet on nonalcoholic fatty liver disease (NAFLD) among Buddhist priests compared to the general population	Case-control/Physical examinations, questionnaire, abdominal ultrasonography – no theoretical framework	Buddhist priest (n = 615); general population (n = 615)/Average age: 48.3 (SD = 9.8 – 9.9); All participants were south Korean, and most participants were female in both groups (n = 376, 61.2%)	Diet	No statistically significant relationship was found between vegetarianism and NAFLD. Body mass index had a statistically significant relationship with NAFLD.
Ferguson et al. (2015)	Examine the association between occupational factors and obesity among clergy	Cross-sectional secondary data analysis/Survey data from the random sample leader survey – Socio-ecological framework	Protestant (n = 378); catholic (n = 143) clergy/Average age: 53.9 (SD = 9.50). Most participants were white (95%), male (81%), and held a master’s degree or higher (88%)	Self-care practices (exercise, days off, sabbatical, support group)	Days off, sabbatical, and support groups were associated with a decreased likelihood of clergy obesity, when controlling for other factors. Among protestant clergy, exercise was associated with a decreased likelihood of clergy obesity
Gwin et al. (2013)	Examine the physical activity behaviors of Oklahoma clergy and identify factors predicting physical activity	Cross-sectional design/Survey – Theory of planned behavior	141 Christian clergy/Average age: 50.7 (SD = 11.6)/92.9% of participants were white, 86.3% male, and 71.6% held a master’s degree or higher	Behavioral Attitudes, subjective norms, perceived behavioral control, behavioral intentions	Behavioral attitudes, subjective norms, and perceived behavioral control accounted for 54.8% of the variance in intention to be active. Behavioral intention accounted for 13.8% of the variance in physical activity. Perceived behavioral control was not a significant predictor of physical activity
Jung et al. (2013)	Examine the protective effect of vegetarianism on reflux esophagitis among Buddhist priests compared to the general population	Case-control/Physical examinations, questionnaire, esophagogastroduodenoscopy, measurement of adipose Tissue – no theoretical framework	Buddhist priests (n = 148); general population (n = 148)/Average age: 52.9 (SD = 9.3); All participants were from South Korea and 53% of participants were male	Diet	Non-vegetarianism was associated with an increased risk of reflux esophagitis, when controlling for other factors
Kinlen (1982)	Examined cancer mortality between catholic nuns who abstained from meat and those who ate a lower-than-average consumption of meat	Longitudinal cohort study/Questionnaire, medical record review – no theoretical framework	2,813 Catholic Nuns	Meat and fat intake	No significant differences were found in the mortality of cloistered women who eat some or no meat when compared to population level rates of mortality
Lee et al. (2014)	Examine the protective effect of vegetarianism on colorectal cancer among Buddhist priests compared to the general population	Case-control/Questionnaire, physical examination, colonoscopy – no theoretical framework	Buddhist priest (n = 357); general population (n = 357)/Average age: 52.8 (SD = 8.5) – 53.8 (SD = 8.7). All participants were from South Korea and 57.1% of participants were female	Diet	Non-vegetarian diets increased the risk of both colorectal and advanced adenomas
Proeschold-Bell et al. (2017)	Determine the effect of a 2-year, multi-component health intervention targeting metabolic syndrome and stress	Two-year, three-arm, randomized controlled trial, design/Repeated measures – Theory of reasoned action and planned behavior	1114 Christian clergy/Average age: 51.9 (SD = 10.0). 89% of participants were white, 69.3% male, and 82.7% held a master’s degree or higher	Spirited life intervention: A multi-level weight-loss and behavior change intervention (ie, stress management, nutrition)	The prevalence of metabolic syndrome was lower than baseline at 12-, 18, and 24-months
Proeschold-Bell et al. (2020)	Examine the impact of the spirited life intervention on weight-loss maintenance	Post-intervention participant follow-up for cohort 1 (immediate intervention) & cohort 3 (2-year waitlist)/Repeated measures – Theory of reasoned action and planned behavior	719 christian clergy/Average age: 52.7 (SD = 10.0). 89.6% of participants were white, 69% were male, and 84.7% held a master’s degree or higher	Spirited life intervention: A multi-level weight-loss and behavior change intervention (ie, stress management, nutrition)	The intervention produced weight loss and, for participants with higher levels of obesity at baseline, sustained weight-loss maintenance from baseline to 421) Clergy occupational stress 2) Hours worked per week, years in ministrymonths
Lee & Krawinkel (2009)	Examined the associations between body composition and nutrient intake of buddhist and catholic nuns	Cross-sectional Design/Three-day dietary assessment, Anthropometric and body composition using segmental multi-frequency-bioelectrical impedance analysis – no theoretical framework	54 buddhist nuns; 31 catholic nuns/Average age: 30.4 (SD = 5.98) and 31.4 (SD = 4.08) years; All participants were south Korean	Diet	Body fat was found to decrease with duration of vegetarianism. Additionally, body fat was lower in the longer-term vegetarian group compared to the short-term vegetarian group
Webb & Bopp (2013)	Examine the factors associated with obesity and meeting physical activity and fruit/vegetable recommendations among clergy	Cross-sectional design/Survey – no theoretical framework	844 christian clergy/Average age: 53.48 (SD = 12.06); 92.3% of participants were white, 73.6% were male, and 84.3% held a master’s degree or higher	Health behaviors and health behavior-related beliefs (eg, physical activity, fruit/vegetable intake)	Univariate analyses showed meeting the physical activity and fruit/vegetable intake guidelines were negatively associated with obesity. Negative physical activity- and nutrition-related beliefs were positively associated with obesity. Multivariate analyses showed clergy with more chronic diseases and negative nutrition-related beliefs were more likely to be obese
Webb & Bopp (2017)	Evaluate the effectiveness of a culturally tailored physical activity program for clergy	Randomized control design/Repeated measures – Social cognitive theory	44 christian clergy/In the intervention and control group, average age: 47.1 (SD = 9.7) – 49.3 (SD = 9.9); 96% and 100% were white, 58% and 61% were male, and 79% and 83% held master’s degree or higher, respectively	Sedentary behavior and physical inactivity	Moderate time spent in physical activity increased for both intervention and control groups; time spent in sedentary behavior decreased for intervention and control groups
Webb & Chase (2019)	Examine the association between occupational distress, physical and mental health, physical activity and sedentary behavior	Cross-sectional design/Survey – no theoretical framework	221 christian clergy/Average age: 51.9 (SD = 12.1); 95% of participants were white, 74.2% were male, and 93.1% held a master’s degree or higher	(1) Clergy occupational stress	Higher scores on the CODI were associated with poor health outcomes (eg, high blood pressure, type 2 diabetes, chronic stress disorder, depression) and more time spent in sedentary behavior. More hours worked per week was associated with higher scores on the CODI.
Webb & Chase (2019)		Cross-sectional design/Survey – no theoretical framework		(2) Hours worked per week, years in ministry

Qualitative
Author/Year	Study aim	Study design/Methods^a	Sample size/population	Self-care definition/behavior	Primary findings
Chiarlitti & Kolen (2020)	Explore the perceptions of supports and barriers to physical activity among catholic priests	Cross-sectional Design/In-Depth interviews – no theoretical framework	8 catholic priests/Age range = 38 to 69 years. All participants were white males	Physical Activity	Intraindividual barriers (eg, lack of time, pain/injury) and facilitators (eg, discipline, enjoyment) as well as extra-individual barriers (eg, lack of education in seminary, weather) and facilitators (eg, being active outside)
Harmon et al. (2021)	Identify opportunities and needed resources for the development of an effective obesity-related program for clergy	Cross-sectional design/Focus groups – PEN-3 model	Christian clergy (n = 18); spouses (n = 14)/Average age: 48.4 (SD = 10.5 – 13.4). Among clergy and spouses, 88.9% and 50% held at least a graduate degree, respectively	N/A	Reported barriers and facilitators to diet, physical activity, and stress-related behavior change were: making time, establishing boundaries, church traditions. Intervention strategies reported to enhance behavior change were: tools for healthy eating and goal setting
Proeschold-Bell et al. (2011)	Develop a model of health for united methodist clergy	Cross-sectional design/Focus groups – Socio-ecological framework	59 united methodist clergy; 29 UMC superintendents/60% of participants were 51 years or older, 61% were male, and 91% were white	Conditions for the five socio-ecological levels, mediators (eg, stress, self-care and coping)	Barriers to self-care engagement were boundary setting, constant availability, church health, and itinerancy (ie, receiving a new church appointment). Mediators to poor health outcomes were: self-care and coping (eg, ways to achieve favorable health outcomes) and stress
Wijesinghe & Mendelson (2013)	Explore how Buddhist nuns managed their type 2 diabetes within restrictions on diet and physical activity	Focused Ethnography/In-depth interviews – no theoretical framework	10 Buddhist Nuns/Average age: 65 years; All participants were female	Disease management strategies with restrictions on physical activity and diet	Barrier to physical activity engagement and diet-related behaviors were: devotion (eg, strict discipline in body and mind), and detachment (eg, point at which nuns surrender to the illness)

Mixed methods
Author/Year	Study aim	Study design/Methods^a	Sample size/population	Self-care definition/behavior	Primary findings
Lindholm et al. (2014)	Assess clergy perceptions of their own health status	Cross-sectional design/Closed and open-ended questionnaire – no theoretical framework	150 united methodist clergy; 58.8% of participants were 55 years or older, 94.7% were white, and 57.3% were male	N/A	Self-reported health was overall good, but 78% of participants were overweight/obese. Personal and professional barriers to a healthy lifestyle were: lack of family time and unpredictable work schedule. The top reported solution to barriers was financial incentives

Dissertation
Author/Year	Study aim	Study design/Methods^a	Sample size/population	Self-care definition/behavior	Primary findings
Seaman (1997)	Examine why clergy do what they do (or not do) to take care of themselves	Cross-sectional design/Questionnaire, focus groups – no theoretical framework	52 presbyterian clergy (36 from questionnaire; 16 from focus groups)/Questionnaire respondents: 24 were male and 12 were female	Self-care practices (eg, spiritual, emotional, intellectual, physical)	“Healthy” pastors experienced support from other persons, and high levels of satisfaction in the four dimensions of self-care. “Borderline and “at-risk” pastors experienced lower levels of support and lower satisfaction in the four dimensions of self-care

Reports
Author/Year	Study aim	Study design/Methods^a	Sample size/population	Self-care definition/behavior	Primary findings
Duke Clergy Health Initiative (2014)	Understand and describe the multiple demands and rewards of clergy life	Cross-sectional design/Survey – no theoretical framework	1453 currently appointed united methodist clergy/52.3% of participants were 55 years or older, 89.6% were white, 68.9% were male, and 71.7% held a bachelor’s or master’s degree or higher	Sleep behavior	More pastors who were normal weight, compared to pastors who were obese, slept 7+ hours. Obese clergy, compared to clergy of normal weight, were twice as likely to sleep less than 6 hours per night
Reynolds (2009)	Assess the health and wellness of active and retired members of the Virginia conference of the united methodist church, their spouses, and families	Cross-sectional design/Survey – no theoretical framework	1105 united methodist clergy and spouses/The average age for active clergy was 53 years. The majority of respondents were white, 68% of active clergy were male, and approximately 81% held a master’s degree or higher	Health concerns, self-reported health	The top reported clergy health concerns were stress/burnout, time constraints/work load, lack of exercise, and obesity. Seventy-five percent of participants were overweight/obese. Over half of clergy rated their health as very good to excellent

^aIncluding whether or not theory was incorporated and if so, the theory used.

Self-Care Definition

Of the 20 studies examined, one study explicitly defined self-care as, “Behaviors and practices intended to promote physical health, mental/emotional health, spiritual well-being, or a combination of all the three” (pg. 705) and this was within the context of United Methodist clergy.³⁸ Two studies used the term “self-care practices” when introducing the independent variables of their study including: (1) Exercise, support groups, sabbaticals, and days off⁷; and (2) multi-dimensional self-care practices (eg, intellectual, spiritual, emotional, physical).⁴² Most studies (n = 17) made no mention of self-care, rather they examined the influence of specific behaviors on obesity, obesity-related outcomes, or obesity-related behaviors.^{7,12,14,15,17,20-22,30-32,37,39,40,43-45} These behaviors included: vegetarian diet, physical activity, occupational distress, sleep, boundary setting, and barrier reduction.

Associations between Self-Care Behaviors and Obesity-Related Outcomes

There were four studies that examined the relationship between self-care or self-care practices (eg, physical activity, diet, days off, sabbatical, support group, sleep) within the context of obesity.^7,12,17,43 Two studies found inverse associations between engaging in physical activity and obesity.^7,12 One study found days off, taking a sabbatical, and attending a support group were negatively associated with obesity.⁷ One other study identified participants of normal weight, when compared to participants who were obese, were more likely to sleep seven or more hours/night.¹⁷ One study found that a long-term vegetarian diet produced lower body fat when compared to a shorter duration vegetarian diet.⁴³ Two studies examining vegetarian diets found a positive association between non-vegetarian diets and obesity-related outcomes (eg, colorectal adenoma, reflux esophagitis).^21,22 In contrast, two studies found no protective effects of reduced meat/fat consumption on NAFLD²⁰ or cancer mortality.⁴⁵ One study found positive associations between participant occupational distress and poor health outcomes (eg, high blood pressure, type 2 diabetes).¹⁴ A multiple behavior-change intervention (eg, stress management, nutrition) produced long-term reductions in metabolic syndrome and weight outcomes.^30,37

Self-Care as the Dependent Variable

Most studies (n = 4) of self-care within the context of obesity identified factors influencing an obesity-related behavior^15,41,42 or ways to reduce barriers and increase self-care engagement.³¹ Studies (qualitative: n = 3; mixed-method: n = 1) also identified themes describing barriers to and facilitators of self-care engagement (eg, physical activity, diet, boundaries) among faith leaders. One study described both participant detachment (eg, surrendering to illness) and personal devotion to their faith tradition as barriers to diabetes self-management.³² Studies (n = 3) found some consistently reported barriers (eg, lack of time, boundary setting, constant availability) to participant self-care engagement (eg, physical activity, diet, healthy lifestyle).^38-40

Conclusions

The purpose of this review was 2-fold: (1) explore how the faith leader health literature has defined self-care, and (2) examine obesity and obesity-related chronic disease in the context of self-care among faith leaders. Based on our findings, the literature defining self-care among faith leaders is sparse with most studies focusing on some aspect of physical activity or a vegetarian diet, but without a comprehensive framework of self-care behaviors that may be important to include when working with faith leaders.

Current study findings suggest physical activity engagement and a vegetarian diet were associated with positive outcomes related to obesity and obesity-related chronic disease among faith leaders. Given the numerous health benefits received from physical activity and vegetarian diets^4,5 as well as the poor health outcomes seen among faith leaders,^7,12,13 it is no surprise most research among faith leaders has examined self-care through this lens. However, considering the challenges faith leaders experience (eg, burnout, complex time demands),^26,28,39 additional forms of self-care are likely necessary to help faith leaders find the time and/or be able to prioritize these behaviors. Unfortunately, in the literature reviewed there was no consensus on what these other forms of self-care are or how they align with promoting healthy diet and physical activity behaviors or achieving positive health outcomes.⁶ A small sample of studies did find evidence of positive health outcomes (eg, negative association with obesity, improved functioning) when faith leaders spent time in rest, on a sabbatical, and getting adequate sleep.^7,17 Moreover, some studies highlighted how faith leaders struggle with a lack of time or setting boundaries with their congregations, which may influence their time spent in self-care behaviors.^38-40 Thus, there is a need for future research examining associations with obesity-related outcomes and various self-care behaviors beyond diet and physical activity (eg, sabbatical) as well as associations with these other forms of self-care and engagement in diet and physical activity.

Research was identified related to faith leader self-care, but not within the context of obesity, obesity-related chronic disease, or obesity-related behaviors and thus beyond the scope of this review.^24,46-49 These studies, for example, explored pastoral eating and role identities, knowledge of obesity, nutrition and physical activity, spirituality and health, and self-care and job demands in other contexts (eg, mental health). Researchers focusing on obesity and chronic disease may need to explore this self-care literature to identify cross-cutting concepts that can be applied in obesity-related research.

Most studies in this review lacked a theoretical framework, making interpretations of findings and implications for future research difficult at times. It is suggested theory helps explain the meaning of predictions and findings, particularly in the context of health behavior research.⁵⁰ A subset of studies did use holistic health models or common health behavior theories to better explain the relationship between self-care and faith leader health,^{15,30,31,38,39} but the models and theories were examined in a limited context (eg, United Methodist clergy) or did not fully account for the various factors influencing faith leader health. Therefore, investigators should continue applying and adapting theory to enhance the methodological rigor of faith-based research and provide better insight into how faith leaders conceptualize and enact self-care behaviors.

This review also identified a lack of diversity across studies examining self-care among faith leaders. For example, findings show most studies reviewed were cross-sectional with samples consisting of mostly white, male, Christian clergy. This highlights the need for examining self-care and its associations with obesity with more diverse samples and across religious traditions to better understand how self-care is practiced among a variety of faith leaders. Future investigators should use different study designs and more diverse samples (eg, rural/urban clergy, race/ethnicity, gender, and denominations) as well as following participant self-care behaviors, beliefs, and attitudes longitudinally to help determine causal associations with obesity-related outcomes.

Strengths and Limitations

This scoping review has several strengths. (1) To our knowledge, this is the first scoping review to be conducted exploring self-care and health outcomes among faith leaders. (2) Peer-reviewed methodology, developed by Arksey & O’Mally (2005) and Daudt et al (2013), guided this study. (3) A rigorous multi-disciplinary approach (eg, public health, kinesiology, psychology, and theology) was used to develop the research questions and interpret findings. (4) Multiple team members analyzed and coded studies included in this review, further enhancing the accuracy of findings,

Despite the novelty and strengths of this review, there were limitations. (1) While data extraction provided an in-depth insight into each study, quality assessments of studies were not conducted. (2) The research focus was on obesity due to this being a primary focus in clergy-related research to date, but there is growing research in mental health with other outcomes yet to be explored. The review’s focus allowed for statements to be made about self-care within the context of obesity, but limited the ability to examine self-care definitions and behaviors in the context of other health outcomes among faith leaders (eg, mental health, well-being).

So What? (Implications for Health Promotion Practitioners and Researchers)

What is already known on this topic?

Faith leaders have reported a high prevalence of obesity and obesity-related chronic disease. Given the role of faith leaders, self-care engagement has important implications for their own health and the communities they serve. It is unclear how self-care has been defined in research conducted with faith leaders as well as associations between self-care variables and obesity-related outcomes among faith leaders.

What does this article add?

Findings from this review show literature defining self-care among faith leaders is sparse with most studies focusing on a few behaviors (eg, physical activity, vegetarian diet). Moreover, study findings show much of the literature examining self-care and its association with obesity-related outcomes among faith leaders has rarely incorporated theory, is primarily cross-sectional and includes mostly White and Christian faith leaders.

What are the implications for health promotion practice or research?

This study reinforces the importance of physical activity and diet when working with faith leaders on obesity and chronic disease prevention efforts. However, these are not the only self-care behaviors that may need to be addressed. Working with faith leaders to help them take time off and make room for rest and sleep may enhance health promotion efforts. Findings from this review also suggest future research is needed with more diverse faith leaders and study designs guided by theory to inform the development of evidence-based strategies for engaging this population in self-care to reduce obesity and related chronic diseases. Furthermore, faith leaders’ behaviors and behavior change, including those related to self-care, should be contextualized within their environmental settings and the social determinants of health, and thus health promotion practitioners should work to support their healthy behaviors through collaborative work on these external factors.

Footnotes

Authors’ Contribution

BEH, NTW conceived of the study and assisted with analysis and manuscript writing; TC, MH analyzed the data and assisted with manuscript writing and editing; BLW, JN, KHW, TAW, CHL assisted with manuscript writing and editing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Nathan T. West

Brook E. Harmon

References

Hales

Carroll

Fryar

Ogden

. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018; 2020. Accessed July 27, 2021.https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf. Accessibility verified December 10, 2022.

Jastreboff

Kotz

Kahan

Kelly

Heymsfield

. Obesity as a disease: The obesity society 2018 position statement. Obes. 2019;27:7-9.

Sarma

Sockalingam

Dash

. Obesity as a multisystem disease: Trends in obesity rates and obesity-related complications. Diabete Obes Metab. 2021;23:3-16.

Physical Activity Guidelines Advisory Committee . Physical Activity Guidelines Advisory Committee Report 2018; 2018. Accessed May 15, 2017.https://health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf. Accessibility verified December 10, 2022.

U.S. Department of Health and Human Services, U.S. Department of Agriculture . 2015–2020 Dietary Guidelines for Americans. 8th ed.; 2015. http://health.gov/dietaryguidelines/2015/guidelines/. Accessibility verified December 10, 2022.

Saint Onge

Krueger

. Health lifestyle behaviors among US adults. SSM Popul Health. 2017;3:89-98.

Ferguson

Andercheck

Tom

Martinez

Stroope

. Occupational conditions, self-care, and obesity among clergy in the United States. Soc Sci Res. 2015;49:249-263.

World Health Organization . Health topics: Self-care interventions for health. 2022. https://www.who.int/health-topics/self-care#tab=tab_1. Accessibility verified December 10, 2022

Watson

. Nursing: The Philosophy and Science of Caring. University Press of Colorado; 2008.

10.

Hensel

Laux

. Longitudinal study of stress, self-care, and professional identity among nursing students. Nurse Educ. 2014;39:227-231.

11.

Nelson

Thomas

Cato

, et al. Testing an international model of nurse job satisfaction to support the quadruple aim. In: Nelson

Hozak

, eds. Using Predictive Analytics to Improve Healthcare Outcomes. Hoboken, New Jersey: John Wiley & Sons; 2021.

12.

Webb

Bopp

Fallon

. Factors associated with obesity and health behaviors among clergy. J Health Behav Public Health. 2013;3:20-28.

13.

Bopp

Baruth

Peterson

Webb

. Leading their flocks to health? Clergy health and the role of clergy in faith-based health promotion interventions. Fam Community Health. 2013;36:182-192.

14.

Webb

Chase

. Occupational distress and health among a sample of Christian clergy. Pastoral Psychol. 2019;68:331-343.

15.

Gwin

Taylor

Branscum

Hofford

. Assessment of factors that predict physical activity among Oklahoma clergy: A theory of planned behavior approach. Fam Community Health. 2013;36:193-203.

16.

Wespath Benefits and Investments . Clergy well-being survey. 2017. https://www.wespath.org/assets/1/7/5058.pdf. Accessibility verified July 12, 2023.

17.

Duke Clergy Health Initiative . Summary Report: 2014 Statewide Survey of United Methodist Clergy in North Carolina. Duke Divinity School; 2014. https://divinity.duke.edu/sites/divinity.duke.edu/files/documents/chi/2014_Summary_Report_-_CHI_Statewide_Survey_of_United_Methodist_Clergy_in_North_Carolina_-_web.pdf. Accessibility verified December 10, 2022.

18.

Proeschold-Bell

LeGrand

. High rates of obesity and chronic disease among united methodist clergy. Obesity. Sep 2010;18:1867-1870.

19.

Baruth

Wilcox

Evans

. The health and health behaviors of a sample of African American pastors. J Health Care Poor Underserved. 2014;25:1-13.

20.

Choi

Kwon

, et al. A vegetarian diet does not protect against Nonalcoholic Fatty Liver Disease (NAFLD): A cross-sectional study between Buddhist priests and the general population. Turk J Gastroenterol. 2015;26:336-343.

21.

Lee

Hahn

Song

, et al. Vegetarianism as a protective factor for colorectal adenoma and advanced adenoma in Asians. Dig Dis Sci. 2014;59:1025-1035.

22.

Jung

Kang

Hahn

, et al. Vegetarianism as a protective factor for reflux esophagitis: A retrospective, cross-sectional study between Buddhist priests and general population. Dig Dis Sci. 2013;58:2244-2252.

23.

Webb

Bopp

. Practicing what they preach? Physical activity promotion among clergy. J Phys Act Res. 2017;2:80-84.

24.

Harmon

Blake

Armstead

Hebert

. Intersection of identities. Food, role, and the African-American pastor. Appetite. 2013;67:44-52.

25.

Carroll

. God’s Potters. William B. Eerdmans Publishing Co.; 2006.

26.

Sielaff

Davis

McNeil

. Literature review of clergy resilience and recommendations for future research. J Psychol Theol. 2021;49:308-323.

27.

Weaver

Larson

Flannelly

Stapleton

Koenig

. Mental health issues among clergy and other religious professionals: A review of research. J Pastoral Care Counsel. 2002;56:393-403.

28.

Jackson-Jordan

. Clergy burnout and resilience: A review of the literature. J Pastoral Care Counsel. 2013;67:1-5.

29.

Weems

Arnold

. Clergy Health a Review of Literature. Lewis Center for Church Leadership, Wesley Theological Seminary; 2009.

30.

Proeschold-Bell

Turner

Bennett

, et al. A 2-year holistic health and stress intervention: Results of an RCT in clergy. Am J Prev Med. 2017;53:290-299.

31.

Webb

Bopp

. Results of walking in faith: A faith-based physical activity program for clergy. J Relig Health. 2017;56:561-574.

32.

Wijesinghe

Mendelson

. The health behavior of Sri Lankan Buddhist nuns with type 2 diabetes: Duty, devotion, and detachment. J Relig Health. 2013;52:1319-1332.

33.

Arksey

O'Malley

. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8:19-32.

34.

Daudt

van Mossel

Scott

. Enhancing the scoping study methodology: A large, inter-professional team’s experience with Arksey and O’Malley’s framework. BMC Med Res Methodol. 2013;13:1-9.

35.

Levac

Colquhoun

O'Brien

. Scoping studies: Advancing the methodology. Implement Sci. 2010;5:1-9.

36.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101.

37.

Proeschold-Bell

Steinberg

Yao

, et al. Using a holistic health approach to achieve weight-loss maintenance: Results from the Spirited Life intervention. Transl Behav Med. 2020;10:223-233.

38.

Proeschold-Bell

LeGrand

James

Wallace

Adams

Tool

. A theoretical model of the holistic health of united methodist clergy. J Relig Health. 2011;50:700-720.

39.

Harmon

Strayhorn

West

, et al. Strategies for designing clergy and spouse obesity-related programs. Am J Health Promot. 2021;35:399-408.

40.

Lindholm

Johnston

Dong

Moore

Ablah

. Clergy wellness: An assessment of perceived barriers to achieving healthier lifestyles. J Relig Health. 2016;55:97-109.

41.

Reynolds

. Virginia Conference of the United Methodist Wellness Survey: Executive Summary and Details. Virginia United Methodist Pensions, Inc; 2009. http://www.vumpi.org/docs/Reports/VAUMC_SIR_EXECUTIVE_SUMMARY_FINAL_10-23-09.pdf. Accessibility verified December 10, 2022.

42.

Seaman

. A Comprehensive Assessment of Clergy Self-Care Practices Among Active Parish Clergy Members of Monmouth Presbytery. [Doctoral Dissertation] Princeton Theological Seminary; 1997.

43.

Lee

Krawinkel

. Body composition and nutrient intake of Buddhist vegetarians. Asia Pac J Clin Nutr. 2009;18:265-271.

44.

Chiarlitti

Kolen

. Exploring supports and barriers to physical activity in Catholic priests. J Prim Prev. 2020;41:317-329.

45.

Kinlen

. Meat and fat consumption and cancer mortality: A study of strict religious orders in Britain. Lancet. 1982;319:946-949.

46.

Terry

Cunningham

. Some rest for the weary? A qualitative analysis of clergy methods for managing demands. J Relig Health. 2021;60:1230-1247.

47.

Terry

Cunningham

. The sacred and stressed: Testing a model of clergy health. J Relig Health. 2020;59(3):1541-1566.

48.

Webb

Bopp

Fallon

. A qualitative study of faith leaders’ perceptions of health and wellness. J Relig Health. 2013;52:235-246.

49.

Watson

. Obesity, Physical Activity and Healthful Nutrition: What Does the Pastor Think? [Doctoral Dissertation]. Walden University; 2011.

50.

Glanz

Rimer

Viswanath

. Health Behavior: Theory, Research, and Practice. 5th ed. San Francisco, CA: Jossey-Bass; 2015.