Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20

Occupational problems and barriers reported by

individuals with obesity

Randi Nossum, Ann-Elin Johansen & Ingvild Kjeken

To cite this article: Randi Nossum, Ann-Elin Johansen & Ingvild Kjeken (2017): Occupational
problems and barriers reported by individuals with obesity, Scandinavian Journal of
Occupational Therapy, DOI: 10.1080/11038128.2017.1279211

To link to this article: http://dx.doi.org/10.1080/11038128.2017.1279211

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY, 2017
http://dx.doi.org/10.1080/11038128.2017.1279211

ORIGINAL ARTICLE

Occupational problems and barriers reported by individuals with obesity

Randi Nossuma, Ann-Elin Johansena and Ingvild Kjekenb,c
a
Department of Clinical Services, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; bDiakonhjemmet Hospital,
National Advisory Unit on Rehabilitation in Rheumatology, Oslo, Norway; cDepartment of Occupational Therapy, Prosthetics and
Orthotics, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Oslo, Norway

ABSTRACT ARTICLE HISTORY

Background: Even if occupational therapists meet many people with obesity in the course of Received 28 April 2015
their work, a majority of them do not seem to view weight management as within their area of Revised 18 November 2016
professional practice. Accepted 31 December 2016
Aim: To explore the occupational problems and barriers among persons with severe obesity
from an occupational therapy perspective. KEYWORDS
Materials and methods: The study used the Canadian Model of Occupation and Engagement Activity; obesity;
(CMOP-E) and Canadian Occupational Performance Measure (COPM) to identify and analyze pri- occupational performance;
oritized occupational performance problems and barriers perceived by 63 individuals with occupational therapy
obesity.
Results: The occupational problems individuals with obesity most frequently prioritized com-
prised playing with (grand)children, purchasing clothes, implementing regular meals and going
to the swimming pool, while the barriers they most frequently described were dyspnea, muscu-
loskeletal disorders, narrow chairs and seats, fear of glances and comments from others, and
social anxiety.
Conclusion: Persons with obesity struggle with a large variety of occupational performance
problems, which occur in the dynamic relationship between these individuals, their environment
and their occupation. Occupational therapists have the skills to take more active role in helping
persons with obesity to perform valued occupations and establish healthier everyday routines.

Introduction increase in the risk of occupational problems, from

Obesity has reached epidemic proportions worldwide
[1–3]. The World Health Organization (WHO) has
emphasized that excessive weight and obesity are the
leading risks for mortality worldwide, due to mainly
the increased risk of developing chronic diseases such
as cardiovascular diseases, diabetes, and some forms
of cancer. WHO identifies increased intake of energy-
dense, high-fat foods and decreased physical activity
as the two main causes of obesity [3].
A number of studies have demonstrated that a
combination of obesity-associated diseases, reduced
physical activity, and perceived physical and psycho-
logical barriers increases the likelihood of weight gain
as well as problems such as decreased physical func-
tion, reduced ability to perform everyday activities,
social isolation and mental distress [4–12]. Studies
have further demonstrated that the degree of disability
individuals experience increases as their body mass
index (BMI) increases, and that there is a graded
overweight relative to normal weight, with a two-fold
probability of occupational performance problems
among individuals with moderate obesity and a four-
fold probability among those with severe obesity
[10,13,14]. Obesity is therefore a health condition that
affects the whole spectrum of human life.
The consensus today is that, next to surgery, life-
style programs including the three equally important
central elements of exercise, diet and behaviour modi-
fication are the most successful in terms of weight
reduction [15–18]. Several authors have discussed the
role of occupational therapists in terms of planning
and delivering behaviour modification programs
among individuals with obesity [19,20]. Even if occu-
pational therapists meet many people with obesity in
the course of their work, the majority of them do not
seem to view weight management as within their area
of professional practice [21]. When occupational thera-
pists do engage in weight management, the most com-
mon intervention they undertake is health promotion,

CONTACT Randi Nossum randi.nossum@stolav.no Klinikk for kliniske servicefunksjoner, St. Olavs Hospital, Postboks 3250 Sluppen, 7006
Trondheim, Norway
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 R. NOSSUM ET AL.
with a focus on physical activity and environmental
adaptions, dietary advice and reducing obesity’s impact
through the efficient use of time for self-care and
through support for participation in their current
occupations [7,21,22]. Occupational therapists’ do,
however, mainly appear to focus on the environment
and the person, with limited attention devoted to
occupation [23]. According to the Canadian Model of
Occupational Performance and Engagement (CMOP-
E), the term occupation refers to ‘everything people do
to occupy themselves, including looking after them-
selves (self-care), enjoying life (leisure) and contribu-
ting to the social and economic fabric of their
communities (productivity)’, whereas occupational
performance refers to the result of interaction and
interdependence between the person(s), their environ-
ment and their occupation(s) [24]. Greater knowledge
about the complex interactions between what occupa-
tions people with obesity regard as important, but dif-
ficult to perform and the factors that hinder their
ability to perform these occupations may enable occu-
pational therapists to develop their interventions with
a clear focus on enabling people with obesity to experi-
ence more satisfaction in being able to perform pre-
ferred occupations in their daily lives.
The aim of this study was to explore the occupa-
tional performance problems and barriers for occupa-
tion experienced by persons with severe obesity from
an occupational therapy perspective.
Materials and methods
Study design
This was a cross-sectional qualitative study, which was
part of a larger trial where patients with morbid obes-
ity on a waiting list for bariatric surgery at the Centre
of Obesity at St. Olavs Hospital in Trondheim,
Norway could choose between continuing on the
waiting list or enrolling in a conservative treatment.
This study is based on the baseline data collected in
the hospital outpatient program, which was one out
of the three conservative options, the other two being
participation in a residential intermittent program or
a commercial weight loss camp. For more details
about the larger trial, see Martins et al. [25]. The
study was approved by the Regional Committee for
Medical Research Ethics in 2005 (ref. no. 4.2005.426).
Study participants
The participants in the outpatient program were
included in the study between October 2005 and
Table 1. Characteristics of 63 participants with obesity
reported as medians with range or numbers and proportions.
Characteristics
Age (years) 42.0 (20.0, 60.0)
Female 52 (81.3)
Education >12 years 21 (32.8)
Living alone 20 (31.3)
Working (paid job) 35 (54.7)
BMI 43.0 (36.4, 60.9)
Comorbidities: yes 57 (89.1)
Low back pain, osteoarthritis 46 (71.9)
Hypertension 16 (25.0)
Type 2 diabetes 8 (12.5)
Depression 21 (32.8)
February 2007, and consisted of persons with morbid
obesity whose general practitioner had referred to the
hospital. The participants received information and
provided their written consent to participate in the
trial, and chose to participate in the hospital out-
patient program. The inclusion criteria were an age
between18 and 60 years old; BMI
40 kg/m2 or BMI

35 kg/m2 with comorbidities; and a maximum travel
distance of one hour from their home to the hospital.
Exclusion criteria were pregnancy, enrollment in other
obesity treatment, previous bariatric surgery, drug or
alcohol abuse, or physical impairment, which could
interfere with the ability to comply with the
treatment.
Assessments
1. Characteristics of the participants
The characteristics of the participants are provided in
Table 1. Demographic data, body weight and height
were collected at the outpatient obesity clinic.
Participant’ age was measured in years; their marital
status was recorded as living alone or not; and work
status was classified as paid work or not. Their formal
education was recorded 12 years or >12 years.
Participant’s body weight was measured to the nearest
0.5 kg using a digital floor scale. Their standing height
was assessed by self-reporting. Their body mass index
(BMI) was computed using their weight in kilograms
divided by the square of their height in meters
(kg/m2) [26]. The presence of comorbidities was self-
reported as yes/no by asking each participant whether
they had additional diseases or conditions.
2. Occupational performance problems and barriers
The study used the Canadian Model of Occupational
Performance and Engagement (CMOP-E) as a theor-
etical approach [24]. As part of the baseline assess-
ment, the Canadian Occupational Performance
Measure (COPM) was utilized to identify qualitative

and quantitative aspects of occupational performance
problems and barriers that participants perceived
[27–29]. The COPM builds on the CMOP-E and is a
generic and client-centred measure developed by
occupational therapists to identify problems related to
occupational performance, categorized within nine
occupational areas: personal care, functional mobility,
community management (self-care); paid/unpaid
work, household management, play/school (productiv-
ity); and quiet recreation, active recreation and social-
ization (leisure) [29].
Two trained occupational therapists (RN and AEJ)
conducted the COPM assessment according to the
COPM manual, starting with a semi-structured inter-
view addressing patient-specific, obesity-related occu-
pational performance problems. The interview began
with an open question that asked the participant to
talk about occupations she or he wanted to do, had to
do, or was expected to do during the day. To ensure
that all the occupations were discussed, the nine pre-
defined occupation areas from the COPM-test form
were used as an interview guide later in the inter-
views. Each occupation in which the participant
reported a limitation was recorded in the COPM
form in the area where she or he had mentioned it.
During the interview, many participants spontan-
eously provided comments and reflections about the
barriers they experienced to occupational perform-
ance. Participants who did not spontaneously reflect
on the causes of their occupational performance prob-
lems were asked if they had any thoughts or ideas
about the topic. The therapists recorded each com-
ment as accurately as possible in the COPM form
using the same rubric as the one for occupational per-
formance problems.
Subsequently, the participant rated the importance
of each occupation on a 1-to-10-point scale in accord-
ance with the COPM test form (1 ¼ not important at
all, 10 ¼ very important) before rating the five most
important problems related to performance and satis-
faction with performance, again on 1-to-10-point
scales (where a higher score reflect better performance
or higher satisfaction). Two summary scores were
computed as medians of the prioritized COPM per-
formance and satisfaction scores, respectively. The
Norwegian version of the COPM has been tested for
feasibility, validity, responsiveness and reliability with
good results [30,31].
Data analysis
Two of the authors (RN and AEJ) independently ana-
lyzed the participants’ descriptions of occupational
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 3
performance problems and barriers with a directed,
qualitative content-analysis approach [32,33]. This
refers to a deductive and concept-driven approach in
which the key categories used in the analytic process
are derived from theory or prior research, in this case,
the CMOP-E. The analysis may also entail counting
frequency codes.
The analysis for this study was conducted in four
steps. In the first step, two of the authors (RN and
AEJ) separately read through the participants’ descrip-
tions and identified occupational performance prob-
lems. Next, the authors compared their findings to
ensure that all occupational performance problems had
been identified. Some of the occupational performance
problems were grouped into overarching categories,
such as ‘traveling by bus’ and ‘traveling by train’ which
were combined into the category ‘traveling by public
transport’. From that point onward, the categories
were linked to the occupational performance area
under which they were described in the COPM-inter-
view. In addition, frequency counts were performed
for the respective numbers of described and prioritized
occupational performance problems.
In the second step, the participants’ comments and
reflections about barriers to occupational performance
were identified and linked to occupational areas in
the same way as the occupational performance prob-
lems had been assessed, and frequency counts were
likewise performed.
The third step of the analysis process sought to
determine whether the barriers to occupational per-
formance were among the personal components or
in the environmental conditions according to the
CMOP-E. In the CMOP-E, personal performance
components are divided into physical, cognitive,
affective, and spiritual components, while the environ-
mental conditions are divided into physical, social,
cultural, and institutional conditions.
Participants’ comments that described feelings were
linked to the personal affective component; comments
that were related to reasoning, decision making,
choices, or compromises were linked to the personal
cognitive component; comments addressing problems
with physical functions were linked to the personal
physical component; and comments that reflected the
participants’ will, motivation, self-esteem, or values
were linked to the personal spiritual component. The
environmental conditions were identified by analyzing
the contexts or situations in which the participants
experienced the occupational performance problems.
Comments addressing problems in natural and built
surroundings such as workplaces, home, or public
4 R. NOSSUM ET AL.
transportation were linked to physical environmental
conditions. Comments about ethnical principles,
norms, and values were linked to cultural environ-
mental conditions; comments related to social expect-
ations were linked to social environmental conditions;
and comments concerning food prices and assortment
of suitable clothing and healthy food were linked to
institutional conditions. Again, the analysis comprised
calculation of frequency counts for each category.
In the fourth and last step in the analysis, the
authors looked for patterns of relationships between
personal performance components, environmental
conditions and occupational performance problems.
During this stage of the analysis, the authors went
through each occupation described with comments
and reflections with the aim of identifying personal
performance components and environmental condi-
tions the participants had identified as related to the
occupation.
SPSS for Windows (version 18, SPSS Inc., Chicago,
IL) was used for the analyses of the quantitative data.
Descriptive statistics for continuous variables are pro-
vided as medians with range. For categorical variables,
frequency counts and proportions are calculated.
Results
The study included a total of 63 participants. The
majority were female, middle-aged, and with
Table 2. Number of occupational performance problems prioritized by 63 participants with obesity
in COPM interviews.
Occupation Occupational area
Self care (N ¼ 34) Personal care (N ¼ 5)
Mobility (N ¼ 4)
Community management (N ¼ 25)
Productivity (N ¼ 40) Paid/unpaid work (N ¼ 2)
Household management (N ¼ 17)
Play/school (N ¼ 21)
Leisure (N ¼ 28) Quiet recreation (N ¼ 0)
Active recreation (N ¼ 20)
Socialization (N ¼ 8)
education less than 12 years. Approximately half were
engaged in paid work. The participant’ characteristics
are provided in Table 1.
Occupational performance problems
The participants listed a total of 272 occupational per-
formance problems and prioritized 102 of them; the
prioritized occupational performance problems are
presented in Table 2. Participants most frequently pri-
oritized occupational problems related to community
management (n ¼ 25). Within this area, ‘purchasing
clothes’ was the most frequently prioritized occupa-
tion. However, among all described occupational
problems, ‘playing with (grand)children’ was the sin-
gle most frequently prioritized problem (n ¼ 17).
Many of the participants also had priorities related to
diet and active recreation. The median COPM per-
formance and satisfaction scores were 3.2 (range
1.0–7.0) and 2.3 (range 1.0–7.3), respectively, indicat-
ing that participants experienced their occupational
performance as rather poor and that they were very
dissatisfied with their performance. None of the par-
ticipants described problems related to quiet recre-
ation; many talked during the interviews about
experiencing a feeling of shame because they felt
they were spending too much time on sedentary activ-
ities such as viewing television programs and video
playing games.
Occupation performance problems
Putting on socks (1)
Using the toilet (2)
Performing a pedicure (2)
Walking up slopes (2)
Walking on rough terrain (1)
Climbing stairs (1)
Purchasing clothes (12)
Financial management (7)
Traveling by public transport (5)
Attending parent meetings (1)
Performing the job (2)
Implementing regular meals (8)
Avoiding the purchase of unhealthy food (6)
Vacuum cleaning (2)
Moving the furniture (1)
Playing with children/grandchildren (17)
Playing on the floor (4)
Going to the swimming pool (8)
Hiking (7)
Travelling (2)
Playing soccer (1)
Participating in physical activities with the family (2)
Being with friends (6)
Receiving/going on visits (2)
 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 5

Occupational barriers participants described such a barrier when she said,

The participants provided a total of 240 comments
and reflections about occupational barriers. These bar-
riers were identified within all personal performance
components and environmental conditions. The most
frequently cited barriers were dyspnea and problems
with pace and exhaustion during physical exertion,
musculoskeletal disorders, narrow chairs and seats,
fear of glances and comments from others and social
anxiety. A particular barrier was often described in
relation to several occupational performance problems
and vice versa. The statement ‘I feel ashamed when
occupying more than one seat on the bus’ provides an
example of the latter, as it cites both a physical envir-
onmental barrier (narrow seats) and a personal affect-
ive barrier (shame) related to the use of public
transportation. Nearly all participants described bar-
riers related to personal physical components, such as
dyspnea when hiking with friends, and stiffness and
pain when they played with (grand)children, partici-
pated in sports, or performed housework. One of the
‘My body stiffness hinders me from playing with my
grandchildren’.
Participants also frequently mentioned emotions
and feelings as barriers to occupation, such as fear of
glances and comments from others. These barriers
were linked to the personal affective component. The
participants felt uncomfortable when they bought
clothes and stayed away from public transportation,
parent meetings, sports and social activities with
friends because of this fear.
In all these situations, the barriers were related to
attitudes participants anticipated from their surround-
ings, illustrating the interaction between personal and
environmental factors. Other barriers related to envir-
onmental conditions included clothing sizes that were
too small and a scarcity of options when buying
clothes, as well as narrow seats on the buses. In
Table 3, the CMOP-E is used to visualize the relation-
ship between occupational performance problems and
personal and environmental barriers.

Table 3. Barriers related to the four most frequently prioritized occupational performance problems described by participants
with obesity in COPM interviews.
Occupational Controlling diet (implement
performance regular meals and avoid Going to the
problems Playing with (grand)children buying unhealthy food) Purchasing clothes swimming pool
Reflections and The body stiffness hinders It’s so difficult to implement I can’t find big enough I’m afraid of glances
comments me from playing with regular meals sizes when I’m buying I’m uncomfortable in a
my grandchildren I always buy too much food clothes swimsuit
I have a bad conscience I buy the unhealthy food I’m disappointed by the I fail to live up to cultural
because I don’t follow because I think the poor range of fashion- norms of exercise and
up my children enough unhealthy food is the able clothes for people fitness
cheapest with obesity I don’t have time to do my
I can’t find suitable exercise
sportswear
Personal performance components
Affective Bad conscience about chil- Disappointment about the Feeling of discomfort
dren or grandchildren poor range of larger- Fear of glances
sized clothing
Cognitive Difficult to implement Have to compromise when Do not have time to do the
meals buying clothes exercise
Difficult to make good
choices
Physical Stiffness The available clothing does
Big body not fit a large body
Exhausting
Spirituality
Environmental conditions
Physical Small sizes/few options
(clothes)
Social The attire has significance
for self-image
Cultural Do not live up to cultural Being fit is highly valued
norms and values about
(grand)parenting
Institutional Poor knowledge among Lack of variety of clothes
people with obesity for people with obesity
about food and food
prices
6 R. NOSSUM ET AL.
Discussion
This study’s results demonstrate that persons with
severe obesity experience a wide variety of occupa-
tional problems that often take place within a
dynamic relationship between the occupation, the
person, and the environment. The most frequently
prioritized occupational performance problems were
playing with (grand)children, purchasing clothes,
implementing regular meals and going to the swim-
ming pool. The most often cited barriers were phys-
ical barriers the participants experienced due to their
large bodies, their obesity’s co-morbidities and the
fear of glances and comments from others. These
findings are in line with a previous study in which
participants described shopping for clothes, restric-
tions in caregiving roles and controlling eating behav-
iours as important occupational performance
problems [8]. Playing with (grand)children was
decidedly the most frequently prioritized occupation
performance problem. For this occupation, the bar-
riers were related to both personal physical and affect-
ive components and to cultural environmental
conditions. Drawing on our knowledge about the rela-
tionship between occupation and health, occupational
therapists can help reduce these barriers by introduc-
ing alternative techniques for performance, such as
selecting activities that can be performed sitting at a
table instead of playing on the ground, or encouraging
the client to discuss with their (grand)children
whether there are any alternative activities they could
do together. In addition, observing the client perform-
ing the occupation in a real-life situation may be a
good starting point for analyzing and discussing
possible modifications of the specific activity.
Current recommendations state that increased
physical activity is one of the most important meas-
ures to prevent obesity and obesity-related diseases
[3,34]. In this study, ‘going to the swimming pool’
emerged as one of the most frequently prioritized
occupational performance problems. Notably, this was
not because the participants were unable to perform
the activity, but rather because they were embarrassed
by glances from other people or had problems pur-
chasing sportswear and swimsuits. This finding indi-
cates that a close cooperation between individuals,
health professionals, and the community are necessary
to enhance physical activity among people with obes-
ity. One strategy to reduce the fear of other people’s
glances and comments and to enhance the possibility
for social support may be to organize pool groups,
hiking groups, or exercise groups open only to people
with obesity. In addition, discussing how to cope with
embarrassing comments may be fruitful [35].
The problem of limited opportunity to dress fash-
ionably was another occupational performance prob-
lem frequently prioritized by participants. This
problem was described as a reason why participants
did not want to participate in social activities, indicat-
ing that suitable clothing often is a prerequisite for
occupational performance. Clothing for overweight
persons has also been mentioned as part of a stigma-
tization problem in other studies, in which partici-
pants described experiences of being criticized for
their attire, receiving comments when they were shop-
ping for clothes and of having difficulties finding
clothes that fit them [5,36–38]. Previous studies also
reveal that persons with obesity often use social media
such as Twitter, Facebook and blogs to search for
information and support and to share experiences
about dressing and buying clothes [39,40].
Occupational therapists working with clients with
obesity should therefore gain the ability to guide them
to relevant distributors and websites. Especially in
countries like Norway and Sweden, where people live
scattered in rural areas, it is important to inform cli-
ents about alternative locations to procure suitable
clothing in large sizes. In addition, clothing manufac-
turers and retailers that can provide well-designed
clothes in large sizes and at reasonable prices will
likely fulfill an important need in the marketplace.
Based on WHO’ declaration, a change in diet is an
important priority in weight reduction [3]. Many of
the participants found it difficult to implement regular
meals and to make healthy choices when purchasing
food. This finding is concurrent with previous
research in which poor nutrition knowledge and lim-
ited access to healthy food are pointed out as risk fac-
tors for obesity [41]. Occupational therapist should
help clients establish healthier everyday routines by
discussing realistic options for healthy food choices,
preparing shopping lists, and making food together
with their clients. Developing written weekly plans for
when and what to shop and eat may be a fruitful
strategy to accomplish this goal.
Eating patterns, food preferences and level of phys-
ical activity are often shared within families. In a
recent Swedish study addressing child obesity, the
authors recommend focusing on occupations and
health rather than weight, and to view the family as a
unit and explore how occupational patterns form fam-
ily routines that may hinder lifestyle changes [42].
Involving the family in obesity-related interventions
may also help adults with obesity to establish healthy

family lifestyles. In addition, arranging cooking groups
where people with obesity can discuss and practice
food planning, shopping and cooking could help them
implement a healthier diet and be an arena for devel-
oping a supportive social network.
Interestingly, the participants described relatively
few prioritized occupational performance problems in
the areas of personal care, mobility and housework,
which are the areas most frequently addressed by
occupational therapists [7,21,22]. Insecurity and a lack
of established interventions may therefore be one
reason why occupational therapists make limited
efforts to help people with obesity to maintain valued
occupations. A study from Mosely et al. has, however,
emphasized our profession’s knowledge of occupation
as an important contribution to interdisciplinary
teams working with obesity; the study further sug-
gested that COPM may be a useful tool for identifying
the occupational performance problems clients experi-
ence and for setting goals that are in line with the cli-
ent’s own desires and intentions [20]. Further studies
should therefore explore the feasibility of using the
CMOP-E and COPM in weight management
programs.
In a study by Forhan et al., one informant stated
that, rather than hearing the standard phrases to eat
less and be more physically active, he wanted to be
asked about what he felt, what he wanted to do, and
what suggestions he had to enable reaching his goals
[8]. This statement illuminates the importance of a
client-centred practice and the need for a thorough
examination of how both personal components and
environmental conditions influence the occupations
clients experience as important but difficult to per-
form [43]. By focusing on clients’ needs and priorities
and collaborating with them to help them choose,
organize, and perform occupations they experience as
meaningful, occupational therapist and other health
professionals can help clients find or maintain occu-
pations that contribute to their increased physical
activity and health-related quality of life.
In general, participants reported a high number of
difficulties with community management and leisure.
These problems may again lead to a sense of injustice
and social exclusion. Occupational injustice occurs
when people are restricted from experiencing occupa-
tional rights, responsibilities, and liberties, either
deliberately or through taken-for-granted social exclu-
sion from participation in the occupations typical of
their community [44]. Occupational therapists may
enhance occupational justice by identifying the envir-
onmental and system barriers that prevent people
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 7
with obesity from engaging in occupations that pro-
mote health and quality of life, and promote change
in social attitudes which acknowledge the value of
diversity and support the engagement of all persons
in meaningful occupations.
Our study possesses some methodological and clin-
ical limitations. One is the lack of audiotaping of the
interviews. Details and nuances in the statements may
have been missed, and differences in the occupational
therapist’ interview style may have influenced the con-
tent and number of responses. In addition, height was
assessed by self-reporting alone, which may have
influenced the calculation of BMI. Also, all partici-
pants were Norwegians who had been referred to
treatment in specialist health care, and the large
majority was women. As a result, the sample may not
be representative of people with obesity in general.
Occupational performance problems and barriers
should therefore be examined in a male sample, as
well in primary care and among people from other
cultures.
One of the study’s strength is the use of the
CMOP-E as a theoretical and analytical framework,
which provided the opportunity to explore the
dynamic relationship between occupation, person, and
environment. Accordingly, the COPM was used to
identify occupational performance problems and bar-
riers. The International Classification of Functioning,
Disability and Health (ICF) [45] has been used as a
framework in some previous obesity studies [46,47].
While both the ICF and the CMOP-E provide the
opportunity to cover a broad spectrum of occupa-
tional performance problems, the ICF has been
criticized for failing to capture clients’ personal mean-
ings and importance related to activities and occupa-
tions [48]. In line with a client-centred practice, we
therefore used the CMOP-E. The strong emphasis on
theory may nevertheless have blinded us to aspects of
occupational performance problems or barriers that
are not covered in this model.
Conclusion
The results of this study demonstrate that people with
severe obesity struggle with a large variety of occupa-
tional performance problems and barriers; the study
also illustrates that occupation performance problems
occur in the relationship between these individuals,
their environment, and their occupations.
Occupational therapists, applying client- and occupa-
tion centred methods, should take a more active role
in helping people with obesity to perform valued
occupations and establish healthier everyday routines.
8 R. NOSSUM ET AL.
Disclosure statement
The authors report no conflicts of interest. The authors
alone are responsible for the content and composition of
the paper.
ORCID
Ingvild Kjeken http://orcid.org/0000-0002-3971-2852
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