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Narratives from a weight-stop program: A qualitative interview study

Narrativer fra et vægttabsprogram: Et kvalitativt interviewstudie
Professor, RN, MScN, PhD, University of Sydney, Faculty of Nursing and Midwifery; St. Vincent’s Hospital Sydney; University of Southern Denmark, Department of Regional Health Research

Aims: The present study examined, from a qualitative perspective, the perceptions of health held by overweight participants in a Danish weight-loss program. Methods: The study was a narrative in-depth interview study with 12 participants; eight women and four men. Results: The overweight and obese individuals did not lack information about health, diet, and exercise. Rather, their personal understandings of health and weight loss turned out to be of greater significance than the official health guidelines. The participants created coherent idiomatic narratives in which they were not personally responsible for their overweight. Conclusion: The participants were able to tell socially acceptable narratives of a life of overweight and inability to lose weight. Practitioners can utilise these insights into the narratives of overweight in planning and developing effective weight loss programs.

Background

In recent years, preventive measures against overweight and obesity have been the objects of great interest and attention in health policy. Both within Denmark and internationally, health policy initiatives have sought to reduce the number of people who are overweight and obese (1). Preventive campaigns frame the issue of excess body weight as that of people needing to be “anti-obese” in order to be healthy – weight is taken as a direct measure of health (2). Knowledge in this “anti-obesity position” is typically generated from quantitative and epidemiological studies that are embedded in medical discourse (3), and the Body Mass Index (BMI) is often used to classify overweight and obesity. Overweight is classified as a BMI between 25.0 and 29.9, and obesity as a BMI of ≥30 (4). In Denmark, it is estimated that approximately 51% of the Danish adult population is overweight, and 16.8% are obese (5).

Recent years have witnessed a rise in the implementation of weight-loss interventions designed to help overweight and obese persons to lose weight, but despite these initiatives there is no convincing decline in prevalence (6,7). There is limited evidence that primary prevention of overweight and obesity is effective; only a few primary prevention studies have been undertaken to determine whether preventive initiatives, for example obesity treatment programs, are feasible and effective (8,9).Within the social sciences, there has been an increased number of studies over the past decade that reflect critically on the anti-obesity position and its underlying assumptions about the nature and consequences of excess body weight (10). Lupton (11) emphasizes that “anti-obesity” concepts, such as overweight, adiposity and obesity, did not exist as scientific terms until it had been determined, on the basis of a particular medical discourse, that certain bodily characteristics should be given special designations. Critical perspectives point out that people are categorized based on their BMI and that this has become a dominant tool for separating people into “healthy” and “unhealthy” groups (12). Furthermore, these critics note that the obese and overweight are well aware of what they ought to eat and what is healthy, according to the anti-obesity recommendations, but they often do not live according to them (13). In Denmark, 57.5 million Danish kroner (approximately US$10 million) were allocated in 2007–2010 to the implementation of interventions promoting weight loss and weight loss maintenance among obese adults. Initiatives were implemented that were rooted in local health centres, where “weight-stop” [vægtstop] courses were used as an intervention form. The Danish Ministry of Health used the term “weight-stop” as opposed to “weight-loss” to emphasise that instructions in making small changes in diet and activity habits can lead to a healthier lifestyle and weight loss. A total of 5,065 citizens enrolled in weight-stop programs, but 2,235 of them (44%) subsequently dropped out; 83% of the participants were women and 17% men. These programs were aimed at people with a BMI of 30 or more, and the average weight loss for participants was 3.8 kg, corresponding to 3.7% (14).

Objects of investigation

The purpose of this study was to illustrate the experience and knowledge gained by Danish participants in weight-stop programs, and to examine their health literacy from a socio-cultural perspective on overweight and obesity by means of qualitative research methodology. This entailed an assumption of health being a social, historical and cultural phenomenon; and, further, that individual health literacy, learning and development needed to be examined in a wider social context (15).

Methods

This study was designed as a narrative study based on semi-structured in-depth interviews. Narrative studies are based on a theory of narratology, in which narratives are understood as a distinct form of discourse that links together discrete incidents and events, and that summarizes experience gained previously. Narrative inquiry was well-suited for this study, because narrative studies generate data that reveal how people understand and experience their own lives, as well as what events and episodes in their lives that have been important to them (16)

Sampling

The study’s inclusion criteria were: >18 years; BMI >30; enrolment in a weight-stop program in a selected district; and participation in at least the initial clinical interview in the program (see Table 1). The exclusion criteria were: participants who took part in more specialized courses, such as those who were both obese and pregnant. Letters with invitations were sent to 83 potential informants, and 12 volunteered to participate. Eight of the participants were women, and four were men; ten completed the weight stop program, while two did not. We defined participants as completers if they had been to more than three group classes and had been to at least one out of three clinical follow-up conversations. Completers and non-completers did not differ much with regard to weight loss. At the initial interview, completers had an average BMI of 32 and an average weight of 93 kg. At the 12-month follow-up, the completers (N=8, missing data on 2) had an average BMI of 31 and an average weight of 88 kg. At the initial interview, the non-completers had an average BMI of 32 and an average weight of 88 kg.

Table 1.

Study sampling, Population, Sample

N=83

N=12

Men (%)

20 (24.1)

Men (%)

4 (33.3)

Women (%)

63 (75.9)

Women (%)

8 (66.7)

Average age

52

Average age

53

Average BMI at start of intervention

>30

BMI

32.4

Narrative interviews

A narrative interview is an active interview form, which means that the interviewer assists the narrative production of meaning, for instance by offering her understanding of a participant’s accounts, cf. (17). The interview guide was semi-structured and aimed to guide stories on the way. Following Kvale and Brinkmann (18), we first thematized a range of theoretical issues, which were then reformulated in lay, everyday terms. As the study sought to study narratives, we prioritized questions that could give coherent, spontaneous and rich descriptions such as “Can you tell me about X?”, “When did you first notice X?”, and “What happened to X after that?”.

12 interviews were conducted from mid-September 2012 until the end of October 2012. Prior to these, two pilot interviews were conducted to test the interview guide. The first author conducted all interviews, which lasted 34–90 minutes (average 58 minutes). We modified Kvale and Brinkman’s (18) suggestion for a transcription system so it that was more suitable for the particular narrative approach.

Analysis

The analysis was inspired by Riessman (19) and Polkinghorne (20). We extracted plots in the individual narratives and explored commonalities in the plots across all 12 interviews. “Plot” was defined as the way in which a narrator integrates events in a story and creates a thematic thread (21). We present the results under three thematic headings. Both authors participated in the analysis and interpretation of data.

Ethics

The study complied with the Danish Data Protection Agency’s requirements for data handling. Participants signed an informed consent form before the beginning of each interview. Prior to this, all participants had received oral and written information about the study and their right to withdraw from it at any time. Finally, quotes in the “Results” section have been altered so as to protect personally identifiable information.

Results

The results were divided into three themes: experiences with the weight-stop group; narratives of obesity; personal accounts of the good life. Throughout the results section, only the term “overweight” will be used; accordingly, no distinctions are made among various BMI categories.

Experiences with the weight-stop group

A majority of participants stated that much of the information about diet and exercise that they received in the course was information they already knew. Data extract one exemplifies Participant 2’s description of how she experienced being in the weight-stop group, and her difficulties in losing weight. Participant 2 was a 51-year-old woman, who described herself as overweight since becoming a mother in her late 30s. She primarily linked her overweight to comfort eating as a response to everyday stress. Just before data extract one, she spoke about the limited weight loss from participating in the course:

Data extract one:

I lost three kilograms in a year. I don’t think that’s much. It may well be that I could have done more, but ... It’s a lot about exercise, and as [name of health consultant] said, “you move around a lot.” So that’s not where I need to step up, that’s for sure. And they also touched on feelings… I think that’s more important than one might think, and it’s not about eating fibres. Well, it is for some. [But] I think we’re already eating healthy. We know the guidelines, and we eat food made from scratch. (Participant 2).

Participant 2 explained that she had already fulfilled the course’s guidelines about diet and exercise and suggested that her lack of weight loss was instead due to conditions in her emotional life that were not directly addressed in the course. She reported that, throughout the course, she experienced no breakthrough in losing weight, and that she still found it difficult to lose weight after completing the course. When asked during the interview to specify what she lacked during the course, she could not give a concrete answer, but emphasized repeatedly and in general terms that she experienced feelings as crucial for weight loss.Participants who did lose weight reported that they had introduced changes that could be implemented in their everyday lives. This could be, for instance, through more restrictive methods such as counting calories, in which participants adopted a more biomedical view of food and diet as something that can be controlled and regulated. There were a small number of participants who successfully lost weight for a time using an incremental approach, but by the time of the interview these had regained most of the weight they had lost. In data extract two, Participant 3 describes how she lost weight with the incremental, “small-steps” approach. Participant 3 was a 69-year-old woman, who had struggled with overweight because of intolerable “nerves” that make her comfort eat unhealthy things at night. In this data extract, she speaks about the small-steps approach:

Data extract two:

We have never changed our supper routine. My husband agreed, “We’ll take one helping, and that’s it.” Of course you shouldn’t just sit and starve, but the thing where you have a meatball in your hand and another when you come out of the kitchen—I stopped that. And I ate with small plates, so it looked like there was more there, and I also accustomed myself to eating breakfast. (Participant 3).

With the small-steps approach, this participant introduced changes that she felt able to live up to in her everyday life, such as doing more exercise. But when a close family member became seriously ill, she felt that she could no longer make exercising a priority; she says later that she also began to focus less on healthy eating, with the result that she regained many of the pounds that she had lost. The participants did not perceive the weight-stop programme as a novel solution to their health and weight issues and were not convinced by the suggested changes. Only a few participants were able to change their diet and exercise habits – and only for a limited period of time.

Narratives of obesity

When participants talked about why they were overweight, they often constructed a plot in which childhood had decisive significance for the habits that were continued in adulthood. This could be a specific diet, habits, or feelings associated with food. In data extract three Participant 9, a 62-year-old woman, describes herself as “chubby” since becoming a mother in her early 20s and as having participated in several specialized diets since without managing to maintain any weight loss. In the data extract, she addresses food and her childhood relationship with her mother.

Data extract three:

I saw what my mother did with my children. “Take a cookie or a biscuit.” She didn’t say: “And then be quiet”, did she? Well, she didn’t say it, but in a way she did. So we put things in the mouth or got them put in the mouth. It was comforting. (Participant 9).

In this extract, the participant ascribes responsibility for her deeply embedded habits to her mother, who taught both her and her children to take solace in eating sweets. She reported that she took these deeply embedded habits with her into adulthood, and used food as a comfort when she was stressed or otherwise lacked mental energy.

What is more, all participants stated that everyday life and changes to it were of great significance for their weight. It could be, for example, that a participant changed jobs, and so for a time reported that he or she did not have the energy to exercise or eat healthily. In data extract four, Participant 8, a 63-year-old woman, who understood women’s weight gain as linked to changes in metabolism, explains that she believes that a stressful period had a negative impact on her weight:

Data extract four:

I think it started ten years ago. I got into such a stressful period, and was out sick for a long time, and then ... I lost my job, and then after that I was a student ... Now I didn’t weigh myself at the time, but some pounds snuck on. Actually, 10–12 kilos. I think it was there my problems with my weight began. (Participant 8).

In this extract, the informant attempts to legitimize her lack of motivation for reducing her weight by emphasizing psychological challenges that arose because of serious social and physical problems. In the narratives the participants often externalised the responsibility for health and weight issues by linking overweight and social and psychological challenges.

Personal accounts of the good life

When participants were asked whether their health was consistent with their weight, they often constructed a plot in which their personal understandings of what health is were opposed to more general accounts of health in society. The participants created narratives in which they tried to legitimize their lack of weight loss with stories about the good life in which health and weight loss were not dominant. Data extract five is taken from the interview with Participant 12, who was 43-year-old woman who had not understood herself as overweight before after giving birth to her third child. She had previously tried very strict diets that she could not follow. The data extract is from the end of the interview where the interviewer asked what health means to her:

Data extract five:

Participant 12:

Well, I suppose it’s when you’re comfortable with what you do. I wouldn’t say you’re healthy if you eat vegetables, but at the same time go around being miserable and grumpy. It has to be the fuller picture of having a happy daily life.

Interviewer:

So it doesn’t necessarily have to do with food?

Participant 12:

No, because it can also turn out to be a pain to walk around and weigh 50 kg, and then if you weigh 51 kg, then everything’s wrong. Cause I don’t believe that losing weight will make me happier. Though it’ll be easier with clothes and things like that.

This participant did not want the focus on weight to be too intrusive on her daily life, as it would ruin her capacity for joy: she disregarded a more physical notion of health in favour of a mental conception. For the participants generally, mental health was dominant compared to a more physical notion of health. Another participant stated that if she were mentally healthy, she would not spend so much energy hankering after weight loss.

In summary, the study showed that participants recounted and constructed overarching plots that justified weight gain and lack of weight loss in ways that did not make them personally responsible. In addition, the study showed that participants reported that it was not lack of knowledge about diet and exercise that prevented them from losing weight. Instead, they constructed narrative plots in which their personal understandings of health and weight loss were significant compared to the more official instructions – and could therefore legitimize, and accept, a life with weight gain or without weight loss.

Discussion

A key point forwarded by the participants in the weight-stop course was that the information provided there was not new to them. A review by Kirk et al. (22) established that no particularly good long-term impact or success was found for weight-loss interventions and the authors concluded that lifestyle interventions involving a variety of components were most effective. The incremental, small-step method that served as the basis for the weight-stop program in the present study was based on the lifestyle-change approach that Kirk et al. recommended; it was a flexible approach that encouraged participants to make changes in their everyday lives. The present study, however, indicated that the majority of participants reported that they did not benefit from it, and that less than half of the participants managed to lose weight and maintain it over a long period. A recent study by Bombak and Monaghan (23) problematized, in line with the study of Kirk et al. (22), that even though participants are instructed and guided to lose weight, weight-loss was rarely sustained. This study showed that participants understood health more in terms of their personal perspectives on the nature of the good life, and that they construct certain recurring plots in which they were not personally liable. A study by Malterud and Tonstad (24) emphasised that a rupture had emerged between the standardized knowledge embedded in medical approaches to obesity and the everyday life of overweight individuals. In line with the present study, their analysis indicated that identity and self-understanding are central to the ways in which participants rate their health. More, a study by Mik-Meyer (25) problematized how health promotion of obesity were being defined in various settings, including Denmark. The study found that obesity treatment was dominated by a bio-medical approach to the body that praised physical measurements of the body and self-control. But the study also pointed out that the understanding of a good life was very different for individual people and the article supported the present study’s findings, in which weight loss (or lack thereof) was legitimized by personal understandings of health. The narratives found in this study are therefore more comparable with attitudes and perspectives from the fat studies field (2), where health is defined as an individual and subjective understanding.

Health and personal identity may be important components of future preventive measures. A study by Sarlio-Lähteenkorva (26) also supported this: her results indicated that when participants achieve a successful weight loss, this occurred in part because they succeeded in creating a new balance in their personal identity. When participants had lost weight, there was an identity shift, and their perception of identity shifted from living with obesity to increased self-control.

Granberg (27) also found that identity was an important element of weight loss and emphasized that obese people negotiated identity continuously in the everyday context through their narratives. If it is possible to change participants’ identity through a weight loss program and the change is positive, it increases the possibility of the participant losing weight. Therefore, narratives about health perceptions as preventive measures could contribute significantly to the design of future weight-loss programs.

Strengths and limitations of the study

The strength of this qualitative study is that it shows a contextualized and deep understanding of the participants’ experience of participating in a weight-loss program.

The proportion of non-respondents in this study is high. There are several factors that might have contributed to this: for example, because the weight-stop course had little effect, there were some participants who did not want to talk about their experience. To reduce the dropout rate, a more assertive recruitment strategy could have been used, but that was not pursued here because of a shortage of time and resources. In future studies, this could be prioritized more highly in order to increase the response rate. Nevertheless, despite the low response rate, the present study is still deemed useful in providing insight into experiences in weight-loss programs, considering the lack of research in this field (28).

There was a large proportion of women in the study population and in the sample. In the present analysis, we have not examined whether there is a difference between men and women’s stories. However, this might be interesting to examine in future analyses, in particular because there is a paucity of studies highlighting men’s understanding of obesity and their beliefs and experiences with, for example, weight-loss interventions (29).

Conclusion

Given the study’s results, it is worth pointing out that participants did not evaluate their own health in terms of the health recommendations used in the course; nor did they use weight as a tool for measuring health, as it is conceived on the basis of the anti-obesity position. The study demonstrated that weight-stop students do not lack information on health, diet, or exercise, but that after participation in the course they prioritize differently in terms of health and weight. It is possible that health prevention could be optimized by focusing more on everyday life and its significance for health and obesity, and it is recommended that there be greater flexibility in terms of how “health” and “weight” are conceptualized and articulated. It is important that future research and deployment projects on preventive measures regarding overweight include systematic exploration of the experiences of overweight participants in weight-stop programs. This could be done, for example, by observing participants and interviewing them before, during, and after the course, in order to examine how narratives, health, and weight changed in relation to their experiences of success and/or failure.

Authorship declaration

Rikke Søndergaard was in charge of the design and planning of the research project. Rikke Søndergaard conducted the interviews, made the initial narrative analysis, and wrote first draft of the paper. Niels Buus participated in critically interpreting the analyses and writing the final version of the paper.

Authorship statements

Both authors met the four authorship criteria in the latest guidelines of the International Committee of Medical Journal Editors.

Disclosure

Both authors declare that they have no knowledge of any conflicts of interest.

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