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Summary   Introduction  Despite efforts to improve adherence to physical activity interventions in youth with obesity, low adherence and attrition remain areas of great concern.    Objective  The study was designed to determine which physiological and/or psychological factors predicted low adherence in adolescents with obesity enrolled in a 6‐month exercise intervention study aimed to improve body composition.    Methods  Three hundred four adolescents with obesity aged 14–18 years who volunteered for the HEARTY (Healthy Eating Aerobic and Resistance Training in Youth) randomized controlled trial completed physiological (body mass index, waist circumference, per cent body fat, resting metabolic rate and aerobic fitness) and psychological (body image, mood, self‐esteem and self‐efficacy) measures.    Results  One hundred forty‐one out of 228 (62%) randomized to exercise groups had low adherence (completed <70% of the prescribed four exercise sessions per week) to the intervention protocol. Logistic regression revealed that there were no baseline demographic or physiological variables that predicted low adherence in the participants. Appearance concern (a subscale of body image) (odds ratio [OR] 1.46, 95% confidence interval [CI]: 1.01, 2.1,  P  = 0.04), depressive mood (OR 1.12, 95% CI: 1.01, 1.23,  P  = 0.03) and confused mood (OR 1.16, 95% CI: 1.05, 1.27,  P  = 0.003) (two subscales of mood) were significant predictors of low adherence.    Conclusions  Adolescents with obesity who had higher appearance concerns and depressive and confused moods were less likely to adhere to exercise. Body image and mood should be screened to identify adolescents who may be at high risk of poor adherence and who may need concurrent or treatment support to address these psychological issues to derive maximal health benefits from an exercise programme.

Understanding low adherence to an exercise program for adolescents with obesity: the HEARTY trial