Feasibility of Internet-Based Physical-Cognitive Exercise for Health Benefits of Middle-Aged Obese Women

Abstract

Introduction:

Obesity in middle-aged women markedly increases the risk for non-communicable diseases, neurodegenerative diseases, and physical and cognitive problems. Exercise, particularly combined physical-cognitive exercise, has been demonstrated to have beneficial effects on both physical and cognitive health. However, middle-aged women often face barriers to engaging in exercise, which include time constraints, lack of motivation, and enjoyment. Incorporating an exercise program into a technology-based intervention in the home environment may help overcome these barriers and promote health benefits. Therefore, this study aimed to assess the feasibility of home-based, physical-cognitive internet-based exercise for middle-aged obese women.

Methods:

A total of 33 middle-aged obese women were enrolled in the study. Participants performed an intervention for 60 min/day, 3 days/week for 3 months. Feasibility outcomes (adherence, adverse events, physical performances, obesity parameters, and enjoyment of the program) were measured.

Results:

Average exercise adherence was 91.67%, and no adverse events were reported in this feasibility study. At the end of the training period, body weight and BMI were significantly decreased compared to baseline. As for physical performances, both cardiorespiratory fitness and lower limb muscle power were significantly improved at post-training when compared to baseline. Furthermore, the participants experienced a high level of exercise enjoyment, and it was maintained over the 3-month training period.

Conclusion:

These findings suggest that home-based, internet-based physical-cognitive exercise was safe and feasible for reducing obesity parameters, improving physical function, maintaining enjoyment over the course of training, and facilitating adherence to exercise in middle-aged obese women.

Introduction

Obesity, a condition of excessive fat accumulation, in middle-aged women is a global problem and public health concern in modern societies. Finding from the National Health and Nutrition Examination Survey demonstrated that the prevalence of obesity was highest among those aged 40 to 59 compared with other age groups. ¹ A recent epidemiological study reported that the highest incidence of obesity is among middle-aged women with low physical activity. ² Middle-aged women experience hormonal changes associated with the menopausal transition which may contribute to obesity. ³ In addition to physiological changes, the influencing of psychological stress, lifestyle behavior, genetic factors, and environmental factors also affect the prevalence of obesity in this population. ⁴ It has been well-recognized that the deleterious effect of obesity is an increased risk of non-communicable diseases. Emerging evidence has demonstrated that obesity is associated with various health problems, including physical, mental, and cognitive health, quality of life, and well-being.^{5 -7} Thus, the strategies to delay or prevent obesity in middle-aged women is a significant task for healthcare providers.

The World Health Organization recommends different body mass index (BMI) cut-offs for obesity in different regions of the world based on risk factors and morbidities, whereby BMI ≥ 25 kg/m² is recommended for the Asia-Pacific region. ⁸ Although BMI is widely used to determine obesity, it has certain limitations such as being unable to differentiate between lean and fat mass. Recent studies investigating cognitive function in middle-aged adults with obesity have suggested that waist-to-hip ratio (WHR) is superior to BMI as it demonstrated higher correlations with cognitive impairment than BMI.^9,10 For example, a previous study found that deficits in executive functions and episodic memory were significantly associated with higher WHR but not BMI. ¹⁰ An association between higher WHR and cognitive impairment has been consistently reported.^{9 -12}

Healthy lifestyle behaviors (eg, regular physical activity) are recommended as an important strategy to prevent obesity. Previous systematic reviews have indicated that the enhancement of physical activity (at least 150 min per week) was associated with a reduction in cardiovascular risks,^13,14 obese-related outcomes,^13,14 and cognitive impairment ¹⁵ in adults. Several studies demonstrated that physical exercise is an effective method to decrease body weight, reduce metabolic dysfunction, and improve cardiorespiratory fitness among middle-aged women with and without obesity.^{16 -18} A previous study demonstrated that middle-aged obese women with high cardiorespiratory fitness outperformed those with low cardiorespiratory fitness in cognitive performance. ¹⁹ Recent studies have suggested that simultaneously engaging in physical and cognitive training exerts larger physical and cognitive benefits than physical training alone.^20,21 To date, there is a limited number of studies that investigated the effects of combined physical and cognitive training on physical and cognitive function in middle-aged obese women. The promotion of regular physical activity that combined physical and cognitive training may have protective effects on both physical and cognitive health in middle-aged obese women.

Common barriers to engaging in physical activity for middle-aged women are lack of time, lack of motivation, and safety concerns about exercise.^{22 -24} In addition to engaging in physical programs, another difficulty associated with the promotion of physical activity among middle-aged or obese individuals is adherence to exercise.^25,26 Addressing these barriers, a physical intervention that consists of accessible, safe, and enjoyable features may promote both engagement and adherence to regular physical activity among middle-aged obese women. Recently, internet-based physical activity intervention has been used to promote physical activity and the enjoyment of exercise.^27,28 Randomized controlled trial studies demonstrated that incorporating physical activity into an internet-based intervention for 3 months was effective in improving body composition, ²⁹ metabolic function,^29,30 physical function,^29,30 and quality of life. ³¹ Additionally, internet-based physical activity videos also offer accessible, convenient, and cost-effective benefits to deliver physical activity intervention to improve physical and mental health.^{32 -34} Previous randomized clinical trial studies demonstrated that internet-based physical activity intervention (on the YouTube platform) was a feasible, acceptable, and effective approach to promoting healthy behavior.^35,36 Currently, a limited number of studies have investigated the effects of an internet-based physical activity exercise that combined physical and cognitive training on physical health in middle-aged obese women. Thus, this study aimed to explore whether incorporating physical-cognitive training into a home-based, internet intervention is feasible in middle-aged obese women.

Methods

Study Design

This feasibility study was a prospective single-arm trial, pre-post design, with a 3-month home-based program to evaluate the feasibility of internet-based physical-cognitive exercise for middle-aged obese women. This trial evaluated the feasibility of intervention by reporting on adherence, adverse events, physical benefits, and enjoyment of the program. The study protocol was approved by the Human Ethical Review Board of the primary investigator’s institution (approval number: AMSEC-63EX-102).

Recruitment and Participants

Participants were recruited from local communities, educational institutions, medical organizations, companies, and social media advertisements (eg, Facebook). The study was conducted in Chiang Mai, Thailand. The inclusion criteria were (1) women with BMI ≥ 25 kg/m² and WHR ≥ 0.80,^8,37 (2) aged between 45 and 59 years, (3) exercise less than 1 h/week, (4) had normal range of cognition (determined by the Mental State Examination T10 score), ³⁸ and (5) had a device that supports internet-based physical-cognitive exercise. Exclusion criteria were having (1) musculoskeletal or neurological problems that would be unsafe to exercise (eg, asthma, arthritis, stroke, and multiple sclerosis), (2) depressive symptoms, ³⁹ and (3) uncorrected hearing or visual impairment.

Intervention

All participants performed an internet-based physical-cognitive exercise for 60 min/day, 3 days/week for a duration of 3 months. The internet-based exercise consists of both physical and cognitive training, targeting health promotion for middle-aged obese women. The design, concept, and detail of an intervention were adapted from a previous study. ⁴⁰ Additionally, the gamification techniques including goal setting, progress bars, and scores were applied to facilitate engagement in physical-cognitive exercise through online video (YouTube platform). The summary of the characteristics of internet-based physical-cognitive exercise is presented in Table 1. The exercise program consisted of 3 levels of difficulty: level 1 (for weeks 1-4), level 2 (for weeks 5-8), and level 3 (for weeks 9-12). The physical-cognitive exercise progressed by increasing the difficulty of movement parameters (speed, number of aerobic dance steps, direction of movement, and number of repetitions) and cognitive load (amount of attention, number of stimuli, and memory load).

Table 1.

Summary of the Characteristics of the Internet-Based Physical-Cognitive Exercise.

Sessions	Descriptions
Physical session	Instructions: move upper and lower extremities following online videos Components: resistance training (eg, biceps curl with wrist weights, squat, hip extension with ankle weights) and aerobic training (eg, high knee marching, two side steps, cha cha cha) Training purposes: ↑ physical activity
Simultaneous physical-cognitive session
Part 1 (a)	Part 1 Instructions: remember the pictures (eg, animals) while moving upper and lower extremities
Part 2 (b)	Part 2 Instructions: listen to a short story and remember the content of the story as much as possible while moving upper and lower extremities
Part 3	Part 3 Instructions: move as quickly as possible to respond to the target in accordance with the picture’s criteria Criteria: Response:    Components: aerobic training and cognitive training Training purposes: ↑ physical activity, ↑ cognitive function (eg, memory and attention)
Cognitive session (c)	Instructions: solve the mathematical puzzle questions presented in the video Components: cognitive training Training purposes: ↑ cognitive function (eg, executive function)

(a): Instruction “remember this picture,” (b): Title of a story to listen to, (c): Instruction “write the correct answer in a logbook.”

All participants received a comprehensive description of the training program and instructional videos to ensure proper and safe execution. The rating of perceived exertion and the participant’s heart rate was monitored to confirm the intensity of exercise. Participants received a booklet to record their training and any adverse event. All participants were encouraged to contact the research team whenever they have questions or concerns. Furthermore, participants were asked to come to the center once a month to progress their training.

Outcome Measures

Demographic characteristics of the participants including age, weight, BMI, and education level were recorded at baseline. Adherence rate, adverse events, physical performances, and enjoyment were used to indicate the feasibility of internet-based physical-cognitive exercise for middle-aged obese women. Physical performances and obesity parameters were assessed at baseline and at the end of the 3-month exercise, while enjoyment rating scores were determined after 1 and 3 months of exercise.

Adherence and Adverse Events

All participants were instructed to fill in a logbook right after the exercise session to ensure the accuracy of the data. Adherence to the intervention was calculated as the percentage of physical-cognitive attended ((n/36 sessions) × 100). Adverse events occurring during the study (eg, injury, falls, fatigue, etc.) or any harm related to exercise were reported. In addition, all participants were asked about their training and health problems at every follow-up point in the study. They were encouraged to contact the researcher any time they have questions or concerns.

Physical Performances

Cardiorespiratory fitness and muscle power of lower limb were measured using 6-minute walk test (6MWT) ⁴¹ and 5 times sit-to-stand test (5TSTS), ⁴² respectively. The maximal oxygen consumption (VO₂ max) was calculated indirectly following this equation: ${\mathrm{VO}}_2\max (\mathrm{ml}.{\mathrm{kg}}^{-1}.{\min }^{-1})=26.9+0.014\times \mathrm{Meters}$ walked in 6MWT–0.38 × BMI (kg/m²). ⁴³ A higher level of VO₂ max indicates better cardiorespiratory fitness. As for muscle power, participants were instructed to perform 5 sit-to-stand repetitions as rapidly as possible. The amount of time to complete the task was recorded. ⁴² A lower amount of time in 5TSTS indicates greater muscle power of the lower extremities.

Enjoyment

Enjoyment during engaging in the internet-based physical-cognitive exercise was assessed using Physical Activity Enjoyment Scale (PACES). ⁴⁴ The PACES is an 8-item scale questionnaire that measures the level of enjoyment using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The scores for enjoyment were obtained through the sum of PACES scores. A higher score indicates a greater level of enjoyment.

Statistical Analyses

Descriptive statistics (eg, means and percentages) were used to describe the characteristics of participants and rating scores on the PACES. Tests of the normality of data were performed using the Shapiro-Wilk test. Paired sample t-tests (2-sided) were used to compare the difference in outcome measures between pre- and post-3-month training. All data were presented as mean (SD) or percentages, and the significance was set at P < .05.

Results

Participant Characteristics

A total of 33 middle-aged obese women were enrolled in this study. The mean age of the participants was 52.24 (3.51) years, the mean weight was 70.75 (9.94) kg, and the mean BMI was 28.67 (3.33) kg/m². Participants were mostly university graduates (61%). The participant characteristics are shown in Table 2.

Table 2.

Baseline Demographic Characteristics of Participants (n = 33).

Variables	Mean (SD) or n (%)
Age (years), mean (SD)	52.24 (3.51)
Education status, n (%)
Primary school graduate	2 (6.06%)
Secondary school graduate	1 (3.03%)
High school graduate	6 (18.18%)
University graduate	20 (60.61%)
Postgraduate	4 (12.12%)
Marital status, n (%)
Married	20 (60.61%)
Single	13 (39.39%)
Weight (kg), mean (SD)	70.56 (10.03)
BMI (kg/m2), mean (SD)	28.55 (3.32)

Adherence and Adverse Events

Mean exercise adherence over the 3 months was 91.67%. The average percentage of training attendance across the 36 sessions (3 months) was presented in Figure 1. Over the 3 months of training, no musculoskeletal complaints, injuries, falls, or adverse events were reported.

Figure 1.

Adherence to home-based, internet-based physical-cognitive exercise over 3 months (36 sessions).

Obesity Parameters and Physical Outcomes

The paired samples t-test indicated that body weight and BMI significantly decreased at the end of the training period compared to baseline (P < .001, Table 3). As for cardiorespiratory fitness and lower limb muscle power, VO₂ max was significantly increased, and the amount of time in 5TSTS was significantly decreased at post-training when compared to baseline (P < .001, Table 3).

Table 3.

Physical Performances and Obesity Parameters at Baseline and After 3 Months of Home-Based, Internet-Based Exercise (n = 33).

Variable	Baseline, mean (SD)	Post-training, mean (SD)	P-value
Weight (kg)	70.56 (10.03)	68.61 (9.99)	<.001
BMI (kg/m2)	28.55 (3.32)	27.76 (3.22)	<.001
VO2max (mL/(kg•min))	23.11 (1.68)	23.78 (1.72)	<.001
5TSTS (s)	9.98 (1.97)	8.64 (1.35)	<.001

Abbreviations: BMI, Body Mass Index; VO₂ max, Maximal Oxygen Consumption; 5TSTS, 5 Times Sit-To-Stand test.

Enjoyment

The average PACES score across 8 items after 1 month was 5.89 (1.07) (ranging between 5.61 and 6.27), and after 3 months was 6.00 (1.00) (ranging between 5.76 and 6.33), Table 4. The average total PACES score was high both after 1 month (47.09/56, 84.09%) and 3 months (48.03/56, 85.77%). The paired sample t-test analyses showed that there were no significant differences in the total PACES scores between baseline and at the end of the training period (P = .151, Figure 2).

Table 4.

Physical Activity Enjoyment Scale (PACES) Rating Scores (n = 33).

Questions	Response rating, mean (SD)
	After 1 month	After 3 months
1. I find it pleasurable	6.27 (0.91)	6.33 (0.74)
2. It’s a lot of fun	5.88 (1.02)	6.03 (0.95)
3. It’s very pleasant	5.97 (1.07)	5.91 (1.13)
4. It’s very invigorating	5.88 (1.17)	6.09 (1.10)
5. It’s very gratifying	5.73 (1.10)	5.88 (1.17)
6. It’s very exhilarating	5.82 (1.07)	5.76 (1.03)
7. It’s very stimulating	5.61 (1.17)	5.97 (0.95)
8. It’s very refreshing	5.94 (1.03)	6.06 (0.90)
Average	5.89 (1.07)	6.00 (1.00)

All items were rated on a 7-point scale from 1 (strongly disagree) to 7 (strongly agree).

Figure 2.

Average total PACES scores after 1 and 3 months of home-based, internet-based physical-cognitive exercise (n = 33).

Discussion

This study aimed to determine the feasibility of the internet-based physical-cognitive exercise designed to support independent physical activity at home for health benefits of middle-aged obese women. The findings from this study demonstrated that the internet-based physical-cognitive exercise was safe and feasible for middle-aged obese women to execute in a home-based environment, as indicated by a high adherence rate, no adverse events, maintained enjoyment over the course of the training program and improved physical performance after 3 months.

Both engagement and adherence to regular physical activity remain critical challenges for health promotion among middle-aged population, with a key barrier being a lack of motivation, lack of enjoyment, and lack of time.^{22 -24} Previous study demonstrated that high dropout rates of individuals who engage in exercise programs are generally observed within the first 6 months. ⁴⁵ A study by Kováčová et al ⁴⁶ analyzed the adherence to exercise program of women aged between 40 and 65 years old. They found that the mean adherence rate was approximately 70% which gradually decreased from 85% to 68% during the first 4 months of training. To overcome these barriers, this study incorporated physical-cognitive exercise with a gamification approach into practical and accessible tools (eg, online video, self-training at home). Our finding showed that the adherence rate was 91.67%, higher than the pooled adherence rate of 80% for home-based training reported in the previous meta-analysis study. ⁴⁷ The use of accessible technology at home setting might account for the high adherence rate in this study. This finding is consistent with previous studies which reported that internet-based intervention represents a safe, effective, and feasible approach to promote adherence to exercise.^35,36,48,49 In addition, exercise enjoyment might be another factor contributing to the high exercise adherence observed in our study. Previous studies suggested that one strategy to enhance adherence to exercise is enjoyment.^50,51 The present findings revealed that the enjoyment of physical-cognitive exercise through an online platform was maintained over 3 months. Research evidence has demonstrated that interactive training that combined both gaming and exercise are plausible alternative strategies to promote enjoyment and adherence rate.^52,53 The characteristics of exercise-based technologies that comprise gamification techniques (eg, goal setting, progress bars, and points), interactive approach (eg, simultaneous physical-cognitive session), and aerobic dancing may encourage middle-aged obese women to adhere to the intervention by reinforcing intrinsic motivation and enjoyment.

The present study also revealed the potential benefit of internet-based physical-cognitive exercise in improving cardiovascular fitness, muscle power and body weight after 3 months of training. It has been well documented that both aerobic and resistance exercise has protective effects against the negative impacts of obese conditions. ⁵⁴ A growing body of evidence suggests that multicomponent exercise provides greater physical and cognitive benefits in older population than single component exercise.^55,56 The training program in this study consisted of multicomponent exercise including aerobic and resistance exercise combined with cognitive training targeting middle-aged women with obese conditions. The results were in line with the previous studies^{57 -59} and suggested that this training could improve cardiorespiratory fitness, muscle power of the lower extremities, and body weight among obese individuals. It is worth noting that the participants’ cardiorespiratory fitness improved from low at baseline to high cardiorespiratory fitness after 3 months of training (cardiorespiratory fitness classification based on the American College of Sports Medicine’s guidelines ⁶⁰ ). Previous studies documented that high levels of cardiorespiratory fitness have been found to have a protective effect on reducing and preventing cardiovascular complications.^61,62 Additionally, the positive association between higher cardiorespiratory fitness and cognitive performance was reported in previous studies.^63,64 Taken together, results from the present study suggest that home-based, internet-based physical-cognitive exercise is a feasible and promising approach to promoting health benefits in middle-aged women with obese conditions. Evaluating the feasibility of an intervention program is an initial yet essential step before conducting a large-scale and rigorous trial. Further randomized controlled trials are required to draw a firm conclusion on the beneficial effects of home-based, internet-based physical-cognitive exercise on the physical and cognitive health of middle-aged obese women.

While the study findings are promising, it is worth noting that this physical-cognitive internet-based program was specifically designed to target middle-aged Thai women. In Thailand, the middle-aged population is familiar with dance videos, and the internet and digital devices are widely available at a reasonable cost. As sociodemographic and cultural contexts play a significant role in making the program appealing and meaningful, the acceptance and adoption of the program may be varied when implemented in other sociocultural contexts. Further, the accessibility of technology and the internet can impact the uptake of the program. Thus, this physical-cognitive internet-based program may not be applicable to regions with limited access to technology and the internet. In contrast, in regions with advanced technological infrastructure and high levels of technological literacy, a sophisticated physical-cognitive training program could be designed which in turn might lead to a more impactful training program.

Limitations

There are some limitations to the present study. The majority of participants had a relatively high educational background. Thus, findings may not be generalized beyond the studied population. While it is known that social factors and multiple responsibilities of women could be attributed to the initiation and adherence to the exercise program, only marital status was recorded in the present study. Other social factors and responsibilities such as motherhood, family caregivers, and work commitments should also be taken into account in future studies. Finally, as this study was a single group, pre-and post-test design aimed to test the feasibility of the intervention program, the effectiveness of the intervention program is warranted to be further determined in a large-scale trial with rigorous methodology.

Conclusions

The present study provides evidence that incorporating physical-cognitive exercise into an internet-based exercise at home setting was safe, feasible, and enjoyable for middle-aged obese women. The internet-based physical-cognitive exercise could be a promising program for promoting health benefits among middle-aged women with obesity.