Lessons learned about primary weight maintenance and secondary weight maintenance: results from a qualitative study

Among the developed countries of the world, the cause of obesity has been attributed to a complex web of behavioural, genetic, social, cultural, political, economic and environmental factors. Overweight and obesity are becoming more prevalent across the entire spectrum of socio-economic groupings. The World Health Organisation (WHO) estimates that approximately 1.9 billion adults aged 18 years and over worldwide (39 %) are overweight with 600 million (13 %) obese [1]. The impact of obesity is considerable on a personal and societal level. It places an individual at increased risk for heart disease, stroke, diabetes, sleep apnoea, musculoskeletal disorders, depression, psychological consequences and some cancers [2, 3].

Despite a plethora of interventions among various target populations globally, the trend to increased obesity continues across all ages. Approximately two thirds of the adult population in Ireland are now overweight or obese as well as 30 % of 9 year old girls and 22 % of 9 year old boys [4]. A recent report has found that 53 % of Irish adults aged 50 and over are classified as centrally obese and at substantially increased risk of metabolic complications [5]. Ireland now ranks as one of the most overweight/obese nations in the European Union [6]. To address this concern, the Minister of Health and Children appointed a National Task Force in 2005 to review the obesity trends in Ireland and to make recommendations for policy change [7], and has more recently (2011) established a special action group on obesity [8] to take action across a range of areas. While there has been little previous research on the population who successfully maintain their weight in the “normal ranges” (Body Mass Index (BMI) from 18.5-24.9) otherwise known as primary weight maintainers, much research has focused on secondary weight maintenance, that is achieving and maintaining weight loss. In their analysis of weight loss maintainers and weight loss re-gainers, Kayman et al [9] conducted telephone questionnaires to identify differences between the groups. Kayman et al’s findings suggest that those who maintain an average weight (control group) were more likely to be conscious of the type of food consumed and the quantity. The control group also used more problem focused, than emotion focused coping in response to problem situations, and sought out social supports often. Considering the current statistic that 24 % of adults between the ages of 18 to 64 are obese and 37 % are overweight, 39 % therefore fall into the normal weight range (BMI 18.5-24.9) [10]. We believe there is much to learn through engaging with this group of individuals who fall into the normal weight ranges with regards to their attitudes, knowledge, health beliefs, behaviours, cognitive processes, strategies and motivations with respect to diet, exercise and lifestyle. A deeper understanding of these factors could lead to the development of recommendations and even interventions which could promote healthy lifestyles and thus reduce or indeed avoid overweight and obesity. It has also been suggested that health promotion programs need to incorporate an “anytime, anyplace” program delivery model to address access barriers [11].

Targeting the factors that play a role in weight gain and/or dysfunctional eating may be important in managing weight loss and in weight maintenance [11]. In preceding reviews we notice the profile of “the successful weight loss maintainer” has been defined. It includes the following behaviours and cognitive abilities: active lifestyle and muscular activity in leisure time; effective self-regulation in terms of self-monitoring of eating habits, including reducing food intake, and healthy food awareness; self-sufficient, flexible control over eating behaviours; avoiding emotional instability; and effective stress management [12, 13]. The purpose of this study was to examine the behaviours, strategies and attitudes associated with primary weight maintenance, secondary weightmaintenance and weight gain amongst staff at an Irish University. We also sought to identify psychological and socio-cultural factors involved. Focus groups and in-depth personalised interviews were conducted with three groups of people.

Within the three groups some interesting differences emerged in terms of attitudes, behaviours, strategies, resilience, emotional control, levels of family/social support and will power. The one thing which was consistent between the three groups was the desire or motivation to be slim, however only those in groups one and two had been able to fulfil this desire/motivation.

In our primary weight maintainers group weight maintenance was cited as an “absolute priority” in their lives driven by vanity and health in equal amounts. The size of their waist band was the main monitoring device for weight control. In other words if they felt the waist band on clothing getting tighter this signalled a time for action, prompted them to lower their calorie intake and increase their exercise regime for a few weeks until they were back fitting comfortably into their waist bands again. They would never allow themselves to buy a bigger clothes size. Neither fad diets, nor weighing scales were a feature in this group. They were passionate about food and seemed to have a very good relationship with food. Being slim was an integral part of their lives, and was driven by vanity, health and wanting to be a good parental role model. Willpower, balance, regulation, good emotional control, and resilience were strong themes emerging within this group. Organisation and planning were key to success. Food shopping had to be done regularly ensuring well stored cupboards, fridges and freezers. At home and at work almost all meals were planned in advance. Dining out was kept to an occasional treat rather than a routine. A pattern of strict dietary intake during week days emerged with more relaxed patterns of eating allowed at weekends with an acknowledgement that “treats” were necessary. Calories from alcohol were low with intakes during the week typically at zero with some intake allowed at weekends. Moderate and regular exercise featured strongly both for weight maintenance but also for the feel good factor and mental health. There was a good awareness of portion sizes and nutrient contents across the range of foodstuffs. Low fat foods did not feature amongst this group. Good family supports seemed to be an important element in facilitating these factors to come together.

In the group who had managed to sustain weight loss (group two) the participants identified a personalised approach that had worked for them and felt strongly regarding a “no one fit for all approach”. They spoke of having to find their own route that fitted with their particular lifestyle which illustrates the need for personalised support and advice tailored to the individual. Exercise had increased in frequency and intensity and portions sizes, planning and organisation had improved. In some cases support groups such as weight watchers had worked while others had make the transition alone. Family and peers at work were identified as being important in motivating and encouraging change and hence success. In this group there was an acknowledgement that the “battle was on-going” that there was pain involved and that a lifelong effort would be required. There would be no reverting to old habits. Reasons cited for being able to make the change included also vanity and health/health scares as well as landmark events such as getting married and having children. Perseverance was cited as key to success.

In group three there was an air of despondency with weight loss being almost a pre-occupation which never materialised. Most worried about their health long term but still could not change their behaviours. Vanity featured here also with the desire to fit into nicer clothes expressed. The cost implication of larger clothes was also alluded to. Some described self-loathing and low self esteem. Fluctuations in weight status were a lifelong feature. Disarray featured strongly in their lives as a whole and not just in relation to food. Lives were described as unstructured and lacking routine. Exercise was ad hoc and not sustained. Alcohol intakes were higher and seemed to be used as a comfort during times of despondency. Family support structures around childrearing was notably absent in this group making it harder to get time out to do shopping, prepare meals ahead or get space to exercise. Secret and guilt eating were a feature. Fad diets featured strongly with only short term weight loss achieved. Support groups such as weight watchers and slimming world featured strongly. Only one participant had ever consulted a dietician. Planning around food was absent, this seemed to result in this group skipping meals and eating later in the day and hence being more hungry and therefore consuming more than they would have done if they had planned ahead and had a meal to hand when they needed it. Skipping breakfast was also a feature. Participants reported binge eating and secret eating. Lack of will power and impulsivity were identified as problematic issues. Everybody in this group acknowledged that they eat too much, and that they didn’t exercise enough so a knowledge deficit does not seem to be a major issue. Critical time points when significant weight gain had occurred included pregnancy, marriage and times of emotional stress such as moving house, jobs and relationship breakups. The notion of rowing-back evident in group one did not feature in any sense in group three and there was a sense of their weight being totally out of control, as if there was nothing they could do about it. One subject likened it as to addiction similar to alcoholism. The idea of balance between calories consumed and expended did not emerge in any of the participants in group three. While all participants in this group cited weight loss as extremely important and desirable it was not prioritised in reality, nor in practice in their lives.

These results are discussed in more details in the next section under the main categories which emerged from the data.

Obesity is a worldwide problem with dramatic impact on morbidity, mortality, quality of life and health care costs. The WHO now refers to the global pandemic of overweight and obesity as “globesity” [17]. The physical, financial and emotional outcomes of these diseases can be significant for the affected person and his/her family. In addition, the costs of these morbid conditions to society for treatment can be staggering as well, it has been previously estimated that the economic impact of obesity in Ireland is around €1.13 billion annually [6].

The findings emerging from this qualitative study illustrate the complex nature of healthy weight maintenance even amongst those who achieve it on an ongoing or lifelong basis. There are several important lessons to be learned from the primary weight maintainers included in this study, but these are not simple, and there is no one approach that can be applied to all. The nature of our society now requires a constant, cognitive effort to maintain a healthy weight, but this is not a passive process. Maintaining a healthy weight is no longer the “default consequence” of our lifestyles as it would have been some 30 years ago when the majority of the population walked/ cycled to school/work, and most had limited snacking options between meals and eating out was a treat that happened on special occasions once or twice a year. In those conditions in fact in would have been difficult for most individuals to become overweight or obese. To maintain a healthy weight now however people are required to take constant action in terms of planning, organisation, portion control, planned regular exercise, and to make these a priority in their lives. These findings appear to fit into the conceptual framework known as ‘positive deviance’. This framework has previously been used to study why some individuals achieve better weight loss outcomes than others exposed to the same resources and supports [18].

In addition will power, emotional wellbeing, resilience, good stress management, good social supports and even vanity, are all important. This highlights the interaction between and the interdependence of factors within and across all levels of a health problem [3]. Regulation, routine, balance, and individual timely recognition of weight gain, and rowing back, appear to be the cornerstone which prevents a spiral into positive energy balance and resultant weight gain. The idea of using the waist band as a marker or gauge, indicating that a rowing back is needed, is an interesting finding. As a public health message it is effective for primary weight maintainers, but it is also a simple message. In the clinical setting the waist band measurement is an important marker of central body obesity and the metabolic syndrome [19]. An important message that emerges from this study, and which may encourage those who struggle with their weight, is that lean people have to constantly strive to keep their weight in check too – that it does not just happen for them. This may bring some consolation to those who struggle.

Very few research papers have previously focused on primary weight maintainers but a recent study from Sweden [20] used a grounded theory approach to examine this in 23 primary weight maintainers. Primary weight maintainers who maintained their weight within healthy weight ranges described it as a “tightrope walk”. Maintaining balance could be easy or difficult depending on three factors: their pre-requisites for maintaining weight, their mental preparedness to maintain or change weight and the actions needed on their side to maintain weight. Interestingly very similar themes to ours emerged from their study including the need for self-control, establishing a routine, concerns around health and vanity, stress management, week day versus weekend behaviours and the value of good social supports. The Swedish paper concludes that public health advice given about weight, food habits and physical activity within the primary health care system needs to be nuanced and based on individual assessment or identification of subgroups of individuals with special needs. In our study we concur with these findings in that we highlighted balance, relaxing the rules at weekend but rowing back immediately after, sticking to a routine, advance organisation and planning around food and exercise, prioritisation, family, collegial and social supports, stress management and vanity, health and parental role modelling as motivating factors. This close corroboration of our results is all the more interesting considering the two different contexts in which the data was collected - Ireland versus Sweden and the fact that the study is a qualitative one and therefore you would not expect the results to be translatable to another population. A subsequent study by the Swedish group [21] suggested that healthy weight maintenance may be more complex for women than men due to care giving responsibilities and critical events such as childbearing. These themes also emerged in our data. Furthermore they suggest that interventions may even need to be tailored to the person’s demographic situation inclusive of age, sex, and body mass index. Again our data is also suggestive of this. We would go one further and suggest that life stage is also important as events like child bearing and transitionary periods such as starting a new job and events like relationship break up or divorce impacted on ability to maintain a healthy weight.

As a society we need to need to return to a situation where a healthy weight once again is a natural consequence of everyday living, because the effort currently required is not sustainable for the majority of the population. This will require joined-up thinking and multi-sectoral action between many agencies [7] in Ireland and far beyond, including the food industry, society and individuals. We need individuals to take responsibility for their own behaviours, within conditions that empower them to easily make healthy choices. Areas for exploration and innovation could include ways to encourage increased energy expenditure throughout the daily routine such as walking to school and creating an environment whereby supports are readily available and easily accessed by those who require them. Employer responsibilities to staff around food and exercise provision and health promotion may also be a route to explore. In some public sector settings such as the Irish Army there are programmes in place for early identification and referral pathways to the appropriate clinical staff for employees who stray out of normal BMI parameters (personal communication). Perhaps these models can be explored, and extended to other sectors of society. Early intervention and appropriate clinical staff to provide supports is an important consideration. Ready access to inexpensive professional advice may also be important, for example only one person in our group three had ever been to see a dietician, and cost seemed to be a prohibitive factor in this.

Recommendations for policy around primary prevention of weight gain may target lone families, particularly those with poor social supports, new mothers, and other subgroups at risk, in particular those in transitions in their lives such as new entrants to college/universities/work, those going through emotional upheaval such as marital breakup or grieving. There should be mandatory responsibilities for human resources in organisations to ensure that the correct conditions for health weight maintenance are in place, such as refrigeration, storage, preparation and cooking facilities for staff and students. Life coach and nutrition education should be part of mandatory training for all those in the workplace at work, and college. In addition professional expert exercise and nutrition counselling should be a service open to all employees at a reduced/minimal cost. Work place restaurants need to make the unhealthy options the opt out choice, remove unhealthy options to empower staff to make healthy options. Policies can’t make people make healthy choices but they can create the conditions that facilitate people to make good choices and conditions to promote and facilitate exercise. At an individual level it is noteworthy that logistical factors such as lack of organisation and planning were cited as deterrents to healthy choices. These factors should be relatively easily addressed by a life coach approach. The other individual factors such as willpower, and impulsivity may be more difficult issues to deal with but are not insurmountable either with the correct professional approach such as cognitive behavioural therapy by trained staff. In conclusion there is much to learn from this small study of primary weight maintenance both for individuals, society and policy makers. Further research is needed on larger samples to explore these issues.

Our results shed light on the interplay of various factors related to healthy weight maintenance including personal perceptions, and personal motivations. We have also shown the importance of home, work and environmental conditions in encouraging participation in community and social activities, and supporting personal strategies that appear fundamental to carrying out successful goals and plans.