Thirty-four participants were included in the study. They represented all regions in Denmark and had residence in both cities and rural areas. All of the participants had a wish to lose weight. Sixteen of them were recruited from the waiting list in the municipalities, eighteen contacted the researchers because of the post on Facebook.
[Table 1 near here]
Table 1: Participants included in the study
The qualitative data analysis revealed three main themes that reflect participants’ wishes for a weight loss programme; 1. Creating a structure for success, 2. Needing supports to make up for gaps in willpower, 3. Changing to doing with positive meaning. The following sections introduce each of these themes.
- Creating a structure for success
When the participants talked about the opportunities for a weight loss they explained that it had to be one thing at a time. It was all about habits and they experienced that their days were filled up with habits related to their weight.
“I think it is about habits and there are so many. When I look at my daily life there are so many habits I need to change to reach the goal and I think it is not realistic to do it all at once.”
One participant provided an example when explaining that the changes should start with breakfast and when a healthy breakfast was integrated in her daily life, she could then move on to change the habits she had related to lunch. Another participant wanted to take one day at a time. Start with doing exercise one day a week, then two days and so on to change the habit of not doing exercise. This understanding of changing one habit at a time is based on experience with diets. Almost all the participants had experienced failure with a weight loss attempt when going on a diet. They had experienced losing weight, but also with gaining double the weight lost back.
“I lost 20 kilos in three months, it was a really bad idea. I did not eat, I just drank coffee and smoked cigarettes. I starved (………) and when I started eating my body just craved for more food and then I started getting really fat and gained 40 kilos.”
The only result from diets were an unhealthy “elevator-weight” and a feeling of failure. One participant described it as a “smack in the face”. At the same time, diets were regarded as boring and monotonous. There were so many restrictions and it felt like living in a jail:
“Yes you only live a little. It is just the same. Get up, eat the same every day, exercise. It is just the same every day. You live in a jail. It feels that way anyway. Off course, I´ve seen results but it is no fun for a longer period.”
Despite these statements, most of the participants talked about a wish to learn to be more structured and find the energy to persevere with weight loss. For some, staying engaged in meaningful activities reduced the willpower that it took to stick to healthy behaviors.
“It is better if you have something to do, so you can divert the attention from looking at the clock and see now it is 11 o´clock where I usually do this and that. But if you are on to something else at 11 o´clock, then you don´t think about eating.”
The participants described this as “replacement-activities” from which they could be able to learn to do something new and through that, change their unhealthy habits. One participant gave an example with his habit of sitting on the sofa many hours during the day. This habit was combined with eating unhealthy snacks. He explained that if the sofa-habit were to change the change of the snack-habit would follow.
- Needing supports to make up for gaps in willpower
Participants desired weight loss and hoped that they would someday be able to lose weight. They also spoke about the current and future consequences that the inability to lose weight had on their lives. Many participants expressed fears of getting sick or not being able to see their children grow up. They also spoke about clothes that they used to wear when they were slimmer and that they still kept it in their closets. Their prior experiences of not being able to maintain lost weight fed their fears about the future and negatively influenced their self-efficacy. They talked about themselves as being lazy, having a weak character and having no self-regulation. They blamed themselves for the failures.
“Yes I lost weight, I exercised but when I stopped I just couldn’t any more. If I did not eat what was on the diet plan I got so unhappy. I punished myself by saying: ´you can´t do shit´ and all that stuff. And then I just gained the weight again.”
Furthermore, the feeling of not being able to control their weight influenced their feelings about their appearance. They got sad when they looked in the mirror. Participants expressed being disappointed in their own looks and worried about how they looked to others’, especially in public.
“Oh, but it is not good when you get a bad self-image, you are a really fat girl and you are ugly and look at your breasts - they hang down at your stomach and your stomach is so big.”(….) “Frankly, I am so fat by now that I don´t want to go to the swim and have people seeing me in a bikini.”
The combination of feeling as though one had no willpower to persevere towards weight loss efforts and feeling ´fat´ resulted in a negative feedback loop where the more despondent participants became over their weight, the less willpower they had to change the situation. It was easier for them to find excuses for not changing.
“I am good at those bad excuses even without knowing what is expected of me or knowing what I could win from doing it.”
The psychological toll that obesity took on participants was also reflected in their desire for more support. They expressed that they did not think they could succeed on their own and provided examples of the types of supports they felt would be most useful. Specifically, participants noted that supports should vary and come from different networks including from families and friends, from others with obesity and from health professionals. While participants agreed that they needed support, they varied in what type of support would work for them. For example, some participants stated that they needed criticism from friends and family, such as hearing that they were “too fat” to get motivated for weight loss. For others, this type of criticism would make them start eating even more.
“…But it does not help… it will just mean that I go down to the city to buy candy and soda, ice cream and cake….”
This participant further explained that if somebody should support her in losing weight it should be somebody she respected, such as a boyfriend or a close friend.
When talking about staying committed to their weight loss efforts, the participants also noted that they needed more than verbal support. They needed friends and family to ‘do’ it with them, to agree to eat well and exercise together. One participant explained it like this:
IP: “Yes (…) that is why I often criticize my wife (laughing) because she does not want to go with me.”
I: “It would be easier if you were doing it together?”
IP: “Yes, I like running, it is so difficult for me to exercise without her.”
Being together with peers with obesity was also of great importance for many participants. They wanted to feel like a community and spend time with others in the same situation and exchange experiences, not just about weight and weight loss, but about everyday life as well.
“It doesn´t have to be about weight loss all of it, we could discuss how people integrate and do stuff that could be integrated in the everyday life as long as we do it together.”
Besides talking and listing to others, the opportunity to exercise with peers with obesity was of great importance. One participant explained that she hated running in the city because she felt that everybody saw how fat she was and how badly she was running:
“….but doing it in a community where we felt as ´US´ and none of us are used to running, would be much better.”
When losing weight the health professionals had a central role for the participants. The participants wanted health professionals to support them with knowledge and provide compliments and encouragement through the entire weight loss process. One participate described:
“It is like with alcoholics anonymous, we need the support to be available all the time.”
- Changing to doing with positive meaning
When the participants were asked directly to discuss the content that should be included in a weight loss programme most of the participants mentioned the importance of diet and exercise. Participants did not negate the need for knowledge about diet and physical activity, or the need to change their diet or activity levels. Participants emphasized, however, they wanted to have fun during the weight loss process. Further, they wanted the strategies they got from weight loss programmes to be applicable to their life circumstances. They had experienced that if this was not the case their efforts would not be successful.
Diet and exercise already had an enormous place in the participants’ lives. Many of the participants were already doing exercise, most of them in a fitness center where they described coming many times during a week. Even when they were not physically exercising, some participants explained how they were thinking about it all the time:
“Yes, I run all the time….inside my head.”
Among participants in our sample, exercise was never described as a fun activity, but more as something they had to do. Most participants discussed how they got it done on the way home from work or school, so that they could come home to relax and do the things they enjoyed.
“So I can, it is all about when it is around 2 o´clock or something like that, then, oohh, then it is like… should I go home to sleep or lay on the sofa or should I get it over with. It is the energy deciding it.”
Many of the participants talked about finding pleasure in many other activities such as reading a book or spending time with friend or families. One participant said “exercise is good, but the sofa is better.” Another participant gave an example from when she exercised regularly, as she was aiming to run five kilometers without a break. And for “every step on the way I moved further and further away from the things I liked doing.”
Furthermore, to exercise was to be continually confronted with one’s obesity. One participant explained that he got “obesity-exhausted” when doing exercise because he felt that everybody was looking at him, reminding him of his weight.
When it came to diet, participants described how they differentiated food from ‘diet’. Food was something fun to make and to share with others:
“Yes I know where the problem is but we like eating cheese and bread and in our house beer does not get too old – if you know what I mean.”
Food could be enjoyed. Diet, however, was much more sterile and prescriptive. It was about being healthy versus having enjoyment. One participant described it as going from a fun thing (making and eating food) to a healthy thing (doing exercise). Thus exercise competed or took away from other desired everyday activities, and having to constantly think about what one was eating changed the meaning of food and food-related activities.