Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study

Abstract

Background:

Scarce evidence exists on barriers to physical activity in Mexican women. Despite evidence from other countries, no research has investigated the influence of the breast on PA in this population.

Objective:

To determine the association between the breast and physical activity in Mexican women.

Design:

Cross-sectional observational study.

Methods:

Volunteers were 279 Mexican women from Veracruz, Durango, and Baja California states, who completed a paper survey of their demographics, brassiere characteristics, breast pain, and frequency and amounts of weekly physical activity.

Results:

The first barrier to physical activity was time constraints, followed by breast-related issues. Breast pain was reported by 47.1% of women, and the breast as a barrier to physical activity participation was reported by 30.6%. Responses, such as “I am embarrassed by excessive breast movement” and “My breasts are too big” were the most frequently reported breast-related barriers to physical activity. Breast pain was associated with the menstrual cycle and exercise. Breast health knowledge and pain intensity were unrelated to moderate- and vigorous-intensity physical activity. The 36.4% and 6.7% of women did not meet weekly moderate- and vigorous-intensity physical activity guidelines, respectively. Weekly moderate- and vigorous-intensity physical activity was similar between women reporting breast pain and those who did not.

Conclusions:

Because the breast was the second most significant barrier to physical activity, it is imperative to increase breast health knowledge in Mexican women to reduce impediments to physical activity.

Plain Language Summary

Perception of Mexican women regarding their breasts as a barrier to physical activity

Physical activity provides numerous health benefits, sometimes associated with reversing or delaying several diseases. However, barriers to increasing physical activity in women remain, as the breast is an anatomical aspect that is unique to women. Breast pain has been reported in more than 50% of women who perform physical exercise. Therefore, the study aimed to determine the associations between breast characteristics and barriers to physical activity in Mexican women. Two hundred and seventy-nine women from three Mexican states voluntarily participated in the study. They answered survey questions on the history of bra use, barriers to physical activity, and essential demographic characteristics. The main findings of this study were that issues related to the breasts were reported as the second barrier to physical activity participation. In addition, time constraints were reported as the main reason impeding physical activity participation. Public health initiatives should support attempts to increase breast satisfaction among women of all breast sizes to stimulate engagement in physical activity throughout their lives.

Keywords

breast breast mass breast pain physical activity women

Introduction

Worldwide efforts have been made to increase participation in physical activities (PAs) to reduce the pandemic of a sedentary lifestyle, which is strongly associated with multiple harmful conditions, such as obesity, diabetes, hypertension, some types of cancer, metabolic syndrome, depression, and anxiety.^1
–3 Indeed, solid evidence supports the contention that regular PA provides numerous benefits, sometimes associated with reversing or delaying several diseases.^4,5 In addition, exercise has been considered an adequate intervention for several diseases.^6,7 Yet, as men generally report higher levels of PA, women are considered vulnerable.⁸ In some societies, women’s PA has been limited to domestic chores or their possibilities to enjoy and improve their quality of life due to planned PA has been restricted by dress and religious codes.^9,10 However, in other societies, women are encouraged to participate in PA or sports to improve their health and quality of life.

Despite affirmative actions, barriers to increasing PA in women remain. Some barriers to PA are perceptual, while others are objectively measured barriers that have been reported by women from different countries and ethnic origins.^9
–13 For example, barriers may be economical (i.e. lack of money to register at a fitness center), inadequate or inexistent infrastructure (e.g. no public parks or playgrounds), poor skills (i.e. women feel unable to perform a PA that involves dexterity, such as jumping or catching a ball),^12,13 social (i.e. lack of peer and family support), bullying/violence (e.g. assaults on the way to the fitness center or park, verbal abuse and harassment by men in places where exercise is practiced),¹⁴ lack of energy,¹⁵ weather conditions (e.g. too cold, too rainy), perceived loss of time,¹⁶ and the most frequent barrier being the lack of time.^9,12,17

It has been recommended that strategies for PA promotion emphasize personal enjoyment and social support.^8,18,19 Evidence suggests that women perceive multiple benefits of PA practice, such as better physical performance (i.e. more energy) and more significant social interaction.¹⁹ That might be a reason that more women are engaging in PAs; however, there is an anatomical aspect that is unique to women and has been reported as a barrier to PA for women but has received limited consideration,¹⁵ this is the breasts. There is emerging evidence^20
–23 suggesting that approximately 80% of adult women and 13%–90% of adolescents who practice PAs regularly do not wear a suitable brassiere (bra). More than 50% of women who perform physical exercise have breast pain,²⁴ and even marathon runners report the breast affecting their PA.^25,26 This phenomenon might be explained by the correlation between breast size and pain (r = 0.61), the breasts’ displacement, and friction with garment materials.²⁷ In addition, the exaggerated movement of the breasts has also been associated with a perception of discomfort and embarrassment.¹⁵ An advantage of having small breasts has been described in marathon runners, where women with smaller breast sizes reported better performance in the London marathon.²⁸

A good bra can reduce tension in the breast anatomical supporting structures, which may also prevent injuries that eventually would need surgery.²⁹ In addition, wearing a sports bra (S-BRA) can reduce breast movement by 50% or more, which might reduce breast pain and potential tissue damage. Different bras have been investigated to determine the most suitable one for performing PA that involves excessive breast movement.^30,31 Evidence suggests that the S-BRA is more efficient than other types at reducing breast movement and pain.²¹

It has been hypothesized that appropriate breast support during PA could increase adherence.^32,33 However, few studies report the potential association between the breast and bras with levels of PA in women.^15,34 For instance, in the United Kingdom,¹⁵ 249 women completed a survey about their breast and their levels of PA. The survey included questions related to bra opinions, fit, breast pain, and demographic data, and it was found that the breast was the fourth most significant barrier to PA, with the breast inhibiting PA for 17% of the participants. In addition, breast pain was associated with vigorous PA and a bra providing little breast support.¹⁵

Almost 65% of the adult female population in Mexico is sedentary.³⁵ Sedentary time has been associated with metabolic syndrome and cardiovascular disease development in Mexican women, which is a severe public health problem.^35,36 However, the association between the breast and levels of PA is unknown; therefore, the study aimed to determine the association between breast characteristics and PA in Mexican women.

Methods

Design and participants

The study design was descriptive, cross-sectional, and correlational. The convenience sample of volunteers was 279 women from three Mexican states: (a) Veracruz, (b) Durango, and (c) Baja California. Veracruz is located southeast by the Gulf of Mexico, Durango is in Northwest Mexico, and Baja California is the northernmost and westernmost of the 32 Mexican states. The sample size was estimated based on previous studies conducted in Australia³⁷ and in the United States.³⁸ The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were followed when preparing the article.³⁹

Instruments and procedures

Women of different age groups (i.e. from 18 to > 65 years) able to read and write were invited to participate voluntarily in the study. Volunteers unable to read and write were excluded from the study, as well as those with a previous mastectomy of one or both breasts. Researchers from three universities recruited women by inviting them personally, by e-mail, social media (e.g. Facebook, Tweeter), and word of mouth. Those interested in participating were informed about the project’s purpose, and upon the agreement, they were given the paper survey previously administered by Burnett et al.¹⁵ In summary, the survey consists of The Breast Pain Questionnaire and McGill Pain Questionnaire,^40,41 questions on the history of bra use and basic demographic questions.²⁰ The questions to determine barriers to PA were constructed from two instruments (Allied Dunbar National Fitness Survey and the Global Physical Activity Questionnaire).^42,43 The original instrument was translated from English to Spanish and pilot-tested and validated by bilingual (English–Spanish) physical educators and movement sciences faculty. The study protocol was approved by the Ethics Committee of the University of Veracruz (#003/2018) and the data collection, manual data entry, and analyses phases were undertaken from 2019 to 2021. An unexpected delay in the data entry and analyses occurred due to the COVID pandemic.

Statistical analysis

Statistical analysis was performed with the IBM-SPSS Statistics, version 22 (IBM Corporation, Armonk, New York). Unless otherwise noted, descriptive statistics are presented as percentages for categorical data and as mean and standard deviation (M ± SD) for continuous data. Estimates precisions are reported as the 95% confidence interval (95% CI). Breast mass was classified for further analysis as small (<350 ml), medium (350–700 ml), large (701–120 ml), and hypertrophic (>1200 ml) based on breast volume measured using three-dimensional scans from the study by Coltman, Steele.⁴⁴

Factorial 2 × 3 analysis of variance (ANOVA) determined differences in weekly PA between breast mass categories and pain reported. Partial eta squared (η_p²) reported effect size of the ANOVA test. Non-parametric Kruskal–Wallis ANOVA test was used to determine differences between breast mass and weekly PA. Non-parametric chi-square tests determined whether participants classified by breast size complied with the internationally recommended levels of moderate-intensity physical activity (MPA) and vigorous-intensity physical activity (VPA). The non-parametric Wilcoxon signed-rank test compared differences in breast pain levels between vigorous and moderate PA. In addition, the non-parametric Spearman’s rho correlation was used to study the association between how well the bra fit and the levels of PA. The criteria to interpret the correlation coefficients were: 0–0.19 (very weak), 0.2–0.39 (weak), 0.4–0.59 (moderate), 0.6–0.79 (strong), and 0.80–1.00 (very strong).⁴⁵ Statistical significance was set a priori at p ⩽ 0.05.

Results

Demographics and PA

Participants in this study were women from Veracruz (n = 97), Durango (n = 80), and Baja California (n = 102) states in México. Most participants were located in the 18- to 24-year age group category (Figure 1).

Figure 1.

Participants age groups (n = 279).

Participants considered their breast health knowledge as “average” (51.7%), “below average” (19.9%), “above average” (16.9%), “extremely poor” (6.4%), and “excellent” (5.2%). Most participants had never been measured professionally for a bra (52.9%), 32.4% wear an S-BRA daily for work, and 31.2% wear it during sports, fitness, or recreational activities. Breast pain was experienced within the last 2 years by 47.1% of women, and breast mass was positively skewed with a modal bra size of 34 B. Breast pain sufferers wore S-BRA significantly more often than non-sufferers when performing leisure-time PAs (χ² = 4.44, p = 0.040).

Participants reported performing VPA weekly during work (28.4%, Mode = 3 days) and leisure time (57.6%, Mode = 5 days). PAs requiring moderate intensity were reported during work (47.8%, Mode = 5 days) and leisure time (67.3%, Mode = 3 days). Weekly VPA and MPA time for each participant was computed and compared with current international PA guidelines.⁴⁶ The time spent completing VPA was 215.63 ± 139.02 min/week (95% CI = 175.26–255.99 min/week), and MPA was 265.42 ± 241.07 min/week (95% CI = 195.42–335.41 min/week). According to the international guidelines, 63.6% of women meet the 150 min/week recommendation of MPA, and 93.3% meet the 75 min/week recommendation of VPA.⁴⁶

Barriers to PA

Barriers to participating in PA are presented in Figure 2. The barriers were grouped in categories and the most common was time-related restrictions (67.2%), and the second was the breasts (30.6%). The barriers relating to the breast comprised “I am embarrassed by excessive breast movement” (7.9%), “My breasts are too big” (6.8%), “I don’t like the look of my breasts when I exercise” (6.5%), “I can’t find the right sports bra” (5.4%), and “I suffer with breast pain” (4.0%).

Figure 2.

Perceived barriers to increase physical activity in women. Bars in light gray color are responses related to women’s breasts.

Breast mass

Based on Coltman, Steele⁴⁴ categorization, the frequency of women’s breast mass reported was small (n = 147; 55.1%), medium (n = 93; 34.8%), large (n = 26; 9.7%), and hypertrophic (n = 1; 0.4%). There were 12 missing values (4.3%).

The number of days per week and time spent completing MPA were similar for small (M = 246.88 ± 178.42 min/week, 95% CI = 192.09–301.66 min/week), medium (M = 241.21 ± 165.23 min/week, 95% CI = 169.84–312.58 min/week), and large-breasted (M = 310.83 ± 376.38 min/week, 95% CI = 192.48–429.19 min/week) women (MPA, p = 0.982), as well as for VPA (p = 0.912) between small (M = 196.00 ± 22.01 min/week, 95% CI = 151.89–240.11 min/week), medium (M = 215.25 ± 151.93 min/week, 95% CI = 156.89–273.61 min/week), and large-breasted (M = 223.33 ± 145.72 min/week, 95% CI = 72.66–374.01 min/week) women (Figure 3).

Figure 3.

Weekly moderate- and vigorous-intensity physical activity between participants with small, medium, and large breast size.

No significant interaction was found on weekly PA between breast mass categories and pain reported (p = 0.281; η_p² = 0.049) (Figure 4). In addition, breast mass did not significantly affect whether weekly MPA (χ² = 0.99, p = 0.801) or VPA (χ² = 4.45, p = 0.108) guidelines were met.

Figure 4.

Weekly moderate- (panel a) and vigorous-intensity (panel b) physical activity across breast mass categories and incidence of breast pain.

Breast pain

Participants who reported experiencing breast pain (n = 128) reported seven general reasons that increased breast pain and six that reduced breast pain (Table 1). The menstrual cycle and exercise accounted for almost half of the most frequent factors increasing breast pain. Participants (36.5%) preferred to wait until the breast pain was gone before undertaking exercise, and those who were more proactive took medications, removed their bra, and relaxed to relieve breast pain (Table 1).

Table 1.

Variables related to increased and reduced breast pain.

Breast response	Response (%)	Examples
Increased pain
Menstrual cycle	24.2	During period
Exercise	22.5	Running, jogging, jumping, gym
Uncomfortable clothes	15.9	Skin-tight bra, close-fitting clothes
Nothing	13.3	Not sure
Direct contact	11.7	Touching, pressing, hitting
Weather	2.5	Cold
Other	9.9	Stress, drinking water, coffee, tiredness, contraceptives, bra materials, inappropriate posture
Reduced pain
Nothing	36.5	Wait until the pain is gone, it disappears
Medication	14.6	Pain killers
Remove bra	14.6	Cover chest with soft clothes
Relaxation	11.3	Lie down on a bed
Physical relief	9.8	Massage
Other	15.6	Lie down on a bed, take a bath, cold water, hot water, wear loose clothes, exercising

In relation to breast pain, it was found a slight difference in the number of symptomatic (47.1%) compared with asymptomatic women (52.9%); however, there was no significant difference between whether recommended MPA (p = 0.805) or VPA (p = 0.806) weekly levels were met. Therefore, the incidence of breast pain did not negatively impact whether women were meeting recommended international PA guidelines.⁴⁶ The incidence of breast pain was significantly higher during MPA than VPA (p ⩽ 0.001). Breast pain did not affect the duration of weekly MPA (p = 0.144) or VPA (p = 0.813) between pain sufferers and not sufferers.

Further correlations

Respondents who wore an S-BRA more often during PA did not undertake more VPA (r_ρ = 0.25, p = 0.055) and MPA (r_ρ = 0.09, p = 0.356) than those who wore an S-BRA less often. A weak association (r = 0.23, p = 0.023) was found between the respondent’s last bra fitting recency and the occurrence of breast pain during MPA. No association was found between respondents with better breast health knowledge and the likelihood of wearing an S-BRA (r = 0.08, p = 0.182). The larger respondents reported their breast health knowledge, the less frequent their last bra fitting (r = –0.23, p ⩽ 0.001).

Discussion

In this study, we described for the first time the association of the breast with PA behavior in a large sample of Mexican women. The main findings of this study were that issues related to the breast were reported as the second barrier to PA participation. In addition, time constraints were reported as the main reason impeding PA participation.

PA is an effective public health strategy to lower the proclivity of Mexicans to develop obesity, metabolic syndrome, type 2 diabetes mellitus, and other chronic diseases highly prevalent in Mexican women.³⁵ However, lack of time is reported as one of the top five barriers to decreasing PA among several populations in Africa, North America, Asia, and South America.^47
–51 Thus, women are at high risk of declining their quality of life due to reduced PA levels. For instance, in California, 143 Latin women aged 40–79 indicated that time constraints prevented them from increasing their PA levels.⁴⁷ In addition, Hispanic women in the United States are likelier to report barriers to PA than other ethnic groups (e.g. Caucasian and African-American).⁵² However, no reports have been published on intrapersonal barriers to PA in Mexican women living in Mexico. Therefore, this study, for the first time, describes the relevance of the breast as a potential barrier to engaging in PA among this population.

Breast as a research subject related to exercise behavior has recently produced relevant reports, including important information regarding breast pain, breast as a barrier to PA, and bra characteristics in active and the general population.^{24,34,38,53
–55} Breast pain is associated with VPA in European women.¹⁵ In this study, breast pain increased with the menstrual cycle and exercise; however, breast pain and health knowledge were unrelated to levels of PA. Indeed, PA levels were similar between women reporting breast pain and those who did not. In a UK sample, breast pain was lower for exercising women than in a random sample of non-exercising women (32.1% versus 43.6%, respectively).³⁴ Physically active women likely increased their pain threshold from repetitive exposure to mechanical trauma to their breasts from regular exercise.⁵⁶ Therefore, it is also probable that physically active women have better choices of S-BRAs that allow them to reduce breast pain and consequently increase their PA levels even more.⁴⁸

Compared to the Australian women assessed by Coltman, Steele,⁴⁴ there were more Mexican women with small breasts (55.1% versus 28%). In addition, Australian and Mexican samples had a similar proportion of medium-sized breasts (37% versus 34.8%). However, there were more Australian women with large (24% versus 9.7%) and hypertrophic breast volumes (11% versus 0.4%) than Mexican women. Women with larger breasts are less satisfied with their breasts, which might elicit body image concerns and reduced PA levels.⁵⁷ Evidence has also shown that breast size increases motion during exercise, and the augmented motion might be a barrier to increase PA in women. A study on 355 Australian women showed that women with more prominent breast sizes (hypertrophic) reported less PA compared to women with smaller breasts.³⁷ In addition, a study conducted on 438 women with a mean age of 22 ± 12.2 years from five states in the United States found that breast size prevented women from being physically active.⁵⁵ In the present study, women were from three Mexican states and had a similar age, and pain was reported regardless of breast size category. However, breast size was unrelated to PA levels, which also showed higher PA than a UK sample. In other words, the breast size elicited pain in women in Mexico, but the Mexican women in this study (63.6%) met PA guidelines more than the women of the UK study (33%).¹⁵ The latter is an unexpected finding since more than 60% of the Mexican adult female population is classified as sedentary.³⁵ Like other developing countries, Mexico is a large multi-ethnic country with striking contrasts and marked heterogeneities; in recent years, health authorities have set up several national surveys⁵⁸ to collect reliable epidemiological information. Nevertheless, the latter situation could render inconsistencies in the evidence presented, making it much more challenging to establish agreements with other sources.

It has been reported that ill-fitting bras can elicit musculoskeletal pain and prevent women from participating in PA.⁵⁹ The correct bra fitting criteria include bra shape, cup size, band size, and bra age. The band fit was not a commonly reported ill-fitting component in the present study. In fact, 54.9% of the respondents said they never had band fitting problems, and only 1.5% reported always having some issues. On the contrary, it has been found that 85%–90% of Australian women reported having ill-fitting bras,^59,60 with 12%–50% reporting cup size problems, 2%–62% band fitting issues, and 15%–32% wearing too old bras.⁵⁹ Nevertheless, bra fitting is an evolving subject; recommendations are made to use professional bra fitting criteria (i.e. backband, cup, underwire, straps, front band, rating of bra fit⁵⁹) as opposed to using the traditional method of bra fitting (i.e. band and cup size), which has been reported inadequate in a sample of UK women, especially for women with large breasts.⁶¹

The results of this study must be interpreted considering the limitations of the research design; first, the questionnaire’s psychometric properties were not properly determined, which might be considered a limitation of the present study. Second, the PA data were based on self-report, suggesting that the participants over-reported the time they spent performing PA. Third, the study sample included a large percentage (61%) of younger women aged 18–24, which could have contributed to the more significant percentage of women who met international PA guidelines compared to Mexican population data.³⁵ Finally, while the sample composition of the present study was not probabilistic, the sample size and the fact that we surveyed individuals who were inhabitants of three different urban geographical zones of the country should give our results some relative value. In Mexico, there is a need to incorporate the motivators, predictors, and barriers in future interventions to improve PA behavior in Mexican women successfully.

Conclusion

In Mexican women, time constraints were the main reason for reduced PA levels. In addition, women perceived their breasts to be a barrier to PA; therefore, it is imperative to increase breast health knowledge to reduce barriers to PA.⁴⁸ Public health initiatives should support attempts to increase breast satisfaction among women of all breast sizes to stimulate engagement in PA throughout their lives.

Supplemental Material

sj-doc-3-whe-10.1177_17455057241231477 – Supplemental material for Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study

Supplemental material, sj-doc-3-whe-10.1177_17455057241231477 for Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study by Gabriela Valles-Verdugo, Ivan Renteria, Julio Gómez-Figueroa, Mario Villarreal-Ángeles, Paulina Ochoa-Martínez, Javier Hall-López, Juan Gallegos-Ramírez, Yamileth Chacón-Araya and José Moncada-Jiménez in Women’ s Health

Supplemental Material

sj-docx-1-whe-10.1177_17455057241231477 – Supplemental material for Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study

Supplemental material, sj-docx-1-whe-10.1177_17455057241231477 for Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study by Gabriela Valles-Verdugo, Ivan Renteria, Julio Gómez-Figueroa, Mario Villarreal-Ángeles, Paulina Ochoa-Martínez, Javier Hall-López, Juan Gallegos-Ramírez, Yamileth Chacón-Araya and José Moncada-Jiménez in Women’ s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057241231477 – Supplemental material for Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study

Supplemental material, sj-docx-2-whe-10.1177_17455057241231477 for Breasts as a perceived barrier to physical activity in Mexican women: A cross-sectional study by Gabriela Valles-Verdugo, Ivan Renteria, Julio Gómez-Figueroa, Mario Villarreal-Ángeles, Paulina Ochoa-Martínez, Javier Hall-López, Juan Gallegos-Ramírez, Yamileth Chacón-Araya and José Moncada-Jiménez in Women’ s Health

Footnotes

Acknowledgements

The authors would like to thank all the participants from Baja California, Durango, and Veracruz for their valuable cooperation in this project.

Declarations

ORCID iD

Ivan Renteria

Supplemental material

Supplemental material for this article is available online.

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