Background
Obesity is rapidly increasing around the world and is considered to be one of the most important threats to public health worldwide [
1]. Therefore, both prevention of obesity and efficient programmes for weight-loss in various contexts must be in focus in health promotion. Yet although there are many treatment regimens for obesity, successful weight-loss and maintenance have been shown to be suboptimal [
2,
3]. Most of the dietary intervention studies have focused on evaluating the effect of the intervention regarding anthropometric or metabolic variables [
2,
4]. But in order to understand why a majority of the intervention programmes have shown suboptimal long-term results, and to obtain knowledge of how future programmes ought to be designed, it is crucial to analyse the experiences of the participants. Of vital importance for designing successful weight-loss programmes is an understanding of how the participants experience barriers and facilitators to losing weight. Surprisingly, despite the high amount of quantitative studies about weight reduction, qualitative research about the experiences of participating in weight-reducing interventions is sparse [
4,
5]. There are some qualitative studies about diet interventions aimed at patients with specific diagnoses (such as diabetes, coronary heart disease, knee problems). For example, a qualitative evaluation of an intervention was performed with high cardiovascular risk participants [
6]. The study showed that the process of weight-loss was experienced as complex and challenging, due to their chronic health conditions, the pros and cons of social support (meaning that family members could either support or hinder their new diet) as well as due to the time constraints of changing the diet. Another qualitative study was performed with participants in (commercial) weight-loss programmes in a patient-based cohort study [
7]. The study found that motivation was experienced as an enabler while low self-efficacy was a recurrent barrier to weight-loss attempts. A similar study, based on an intervention among primary-health care patients, identified personalized messages and social support (from professionals and others) as facilitators to successful weight management [
4].
However, there is a lack of studies and thus little knowledge about the perceived experiences, attitudes and feelings of participants from the general population in dietary interventions. Therefore, the aim of this study was to explore barriers and facilitators to weight-loss experienced by participants in a diet intervention for middle-aged to older women in the general population in Northern Sweden.
Results
The identified categories and subcategories for barriers and facilitators to weight-loss are described below. The codes, subcategories and categories related to barriers to weight-loss are described in Table
2. The results for each category are described below.
Category: struggling with self
Four subcategories – difficulties in changing food habits, health problems, lack of self-control and insecurity – were identified in relation to Struggling with self.
The women, especially those on the PD diet, said that it was difficult to change food habits. They found the first period in the project rewarding due to heavy weight-loss and thus they thought the new diet was acceptable. However, after some time (such as after the first year) the women could long for forbidden food (like cheese, bread, potatoes and wine) and thus found the new diet extremely difficult to keep. They said that the difficulty was to avoid falling back into old habits as time went on, and they longed for excluded food. In the long run, it could be difficult to do without food they liked a lot.
It was even harder if they did not like the food in the diet intervention, for example fruit and vegetables. One participant described how she got very angry when she forced herself to eat the vegetables, which she did not like. But she continued to eat them anyway.
Another barrier to keeping the diet was health problems. New or exacerbated health problems could destroy the ambition to lose weight, because these problems could make it more difficult for them to perform daily activities, such as physical activity. For example, one participant broke her leg, and the persistent pain after the operation made it hard for her to be physically active. The increased inactivity made it difficult for her to lose weight and therefore she dropped out of the project. Another participant broke her arm, which made it very difficult to cook. Women with other ailments, such as bile problems or intolerance to e.g., fruit, experienced even more restricted diets after the exclusion of such food products. In addition, women who underwent severe life events such as health problems among partners/relatives said that the stressful situation prevented them from keeping their diet.
Lack of self-control was also identified as a major inner obstacle to weight-loss. Following a diet requires high self-control; it was considered too easy to give way to temptation.
The participants talked about cheating, i.e. eating what was not allowed according to the diet regimes. During certain periods of the diet intervention the participants kept a detailed diary of everything they ate, which they received feed-back on from the project leaders. During the food diary week, the women said that they tried their best to keep the diet, but after that week their dietary regime may not have been so perfect any longer.
Cheating was experienced as a major problem for the participants. The project was described as a help to structure their eating in order not to yield to temptation. On the other hand, it was tempting to go back to old, preferred food habits if the project did not lead to the desired weight reduction. The cheating was related to difficulties in finding motivation to change food habits. And through time, this cheating could be the reason why the women dropped out of the project. For those who did not succeed with the project the forbidden food was experienced as a comfort. Consoling oneself by eating was identified as a barrier to weight-loss.
Another reason for cheating was that the women had reached their goals for weight-loss and were able to have a more relaxed relationship to food. The project still expected the participants to keep the diet, despite weight-loss. As one participant said, after a certain time in the project with desirable weight reduction she could lean back, relax and eat some of the food she had given up because of the diet regime. A structural reason for cheating was taking retirement and spending more time at home, thus being closer to food, so to speak.
Being addicted to sweets was experienced as lack of self-control over eating. This sugar addiction seemed to be a major problem for the interviewed women. For example, one participant described herself as a sweet-alcoholic; she just had to eat sweets:
“I cannot buy sweets, which is why I call myself an alcoholic because I’m like them in that they can’t buy themselves a bottle of alcohol. And I have to eat all sweets at once. Nothing else is possible. I wish the sweets were as far away in the shop as possible.”
Another woman talked about a similar addiction to sweets. She thought that her addiction was triggered by bread, or maybe by “something in her head” and also that the problem was inherited, because her daughter was also addicted to sweets:
“and then I want that sweet. And afterwards when I have eaten it I feel sick and I think– hell, why did I eat it … when I know that I should not and that I feel bad afterwards. ”
The women could also experience a more or less total lack of control over eating. As one participant said:
“my weight only increases and increases and never goes down again”.
In her description of herself, she is not in control over her eating or her weight. The sandwich (or a bit later in the interview – the chocolate) “just goes down”.
Insecurity was the last subcategory in relation to the category Struggling with self. The women in the diet intervention had long-term experience of unsuccessful dieting and therefore they said they were often insecure about whether or not they would succeed this time. Especially those on the PD diet experienced the food as complicated and therefore a question was: What is right to eat? The women described how the PD diet could bring about too large a change compared to their usual food intake, which added to the feelings of insecurity.
An explanation for not succeeding in weight reduction was lack of inner strength, which also increased the feelings of insecurity. Good appetite in combination with difficulties in resisting eating was described as a bad combination for weight-loss. As one participant said:
“So I tried … but no, I could not mobilise the inner strength which is a pity”.
Category: struggling with implementing
Struggling with implementing was related to social relations and project-related difficulties. Barriers associated with social relations include difficulties in combining dietary changes with being together with the family, friends or workmates. The women said that their partner could be a major obstacle to weight-loss. He could be an obstacle by tempting them with forbidden food, as described by one of the drop-outs. Her new partner brought sweets or baked cakes to her all the time. During their time together he increased his weight a lot. When asked how she managed the weight reduction she answered:
“It’s hard. You can see how he really drowns his food in cream and sugar and then he looks at me like – he knows, he is conscious that this is not good”.
In other cases, the women told us that their partner did not care about their new diet, even though he did not accept eating it himself. The majority of participants said that they lived with a husband/partner who did not cook. He still expected her to make his food in the traditional way; this meant that the wife had to cook two different dishes for every meal:
“My husband had no opinion except that he … wanted to have the usual food with sauce and so on”.
So these women ended up keeping two households – the traditional one for the husband and the new diet for themselves. Only one of the interviewed women talked about the husband/partner sharing the cooking with her. Another obstacle experienced was when their grown-up children with families came to visit them, especially when they expected to be served traditional food rather than the new diet.
Friendships were also identified by the women as a possible obstacle to weight-loss. Having coffee together was described as a central part of social relations, and this coffee always included buns and cakes. The participants described feelings of isolation when they had their fruit while everyone else was having buns and cakes. And being invited to a party always meant being offered sweets, which were found difficult to resist. The women talked about their fear of hurting the hostesses who had made the food and therefore they might eat of everything rather than keep to their diet. Besides, the women were afraid that too much emphasis on their new diet could impose demands on their friends to start dieting too. These social problems were identified as a reason why the participants did not tell others about their new diet. A strategy among the participants was to invite friends to their homes for dinner rather than go to their home, because it was easier to keep the diet when you made the food yourself.
The women who were still working found it easier to keep the diet at work with restricted access to sweets, compared to being at home or invited to friends. On the other hand, it could be very difficult to keep the diet when travelling. Travelling a lot also made it difficult to keep up with the project meetings and with the data collection for the project. Also, night work could disturb any food habits, especially if you were on a new diet.
The participants also identified project-related difficulties. A barrier experienced with the PD food was that it was quite restricted. As one participant who had left the study in advance stated:
“There was too little variation for me to keep the diet over a longer time … Everything you longed for, cheese is one example.”
The quotation also indicates that it could be boring to have too little variation in the diet. One participant described how tedious it was to peel one kilogram of shrimps to give 300 grams of shrimps for breakfast every Saturday morning, while her husband could eat anything. It also felt boring to eat fruit when everyone else (at work, at home or with friends) had buns and cakes, or to follow their diet in general, because of lack of variation in the food intake. Being able to eat sweets instead of fruit was seen as adding that little extra to life.
For some of the women, especially those on the PD diet, the new food was very expensive:
“Proteins are very expensive to buy … vegetables are seasonally expensive so that made about 100 euro extra per month which is too much. I do not have the economy”.
The high costs could be a reason for leaving the project. As one participant told us, previously she could grow potatoes without any cost or buy cheap pasta, whereas now she had to buy expensive vegetables and proteins. The costs also depended on their place of living – the costs were especially high if you had no large supermarket close to your home. Participants living in the rural area told us that they had to pay much more for their new diet as compared to urban participants who had large supermarkets nearby.
The PD diet was also found to be more expensive to eat in a restaurant than the traditional diet. The women claimed that proteins together with vegetables cost much more than, for example, a pizza or pasta.
Participation in the project was experienced by some of the women as very time-consuming. This was especially the case for those living outside the main city as well as for those with shift work (including the health care staff) who regularly worked during evenings/nights. For them it was difficult to combine the group meetings and the other project activities (including taking specimens for the project) with their own work, or with long distances to travel from home. The extra time needed for participating in the project together with the extra time needed for preparing the new diet (especially the PD diet) could be an extremely stressful experience and a reason for leaving the project.
Also, some of the participants wanted more support and coaching from the project for their diet change. They said that during the project they had wanted to cook more together as well as to have more group meetings or some kind of contact with the group participants in between the group meetings. Also, one woman expressed a desire for the project to control the amount of food she ate.
Another project-related problem was disappointment about the group to which the women were randomised. The PD group was most popular because the other diet could be experienced as eating the same as their ordinary food.
Facilitators for weight-loss
The codes, subcategories and categories related to facilitators for weight-loss are described in Table
3. Two main categories were identified – striving for self-determination and receiving support. Overall, the interviews were not as rich in relation to “facilitators” as they were in relation to “barriers for weight-loss”.
Category: striving for self-determination
One subcategory – self-determination – was identified as a facilitator of weight-loss. Those who succeeded in reaching the goals of their weight-loss said that they were very motivated and had clear goals. Also, they easily accepted their new diet. Their self-determination helped them to refrain from undesirable eating. One strategy was to drink less coffee, because coffee drinking was associated with eating buns and cakes. Another strategy was to buy cheese (which many loved) with lower fat and to refrain from buying sweets. The self-control was expressed as “I do not permit myself to eat” or “I forbid myself to eat”. The women could also use their self-control and refrain from dinner invitations to stick to their diet more easily.
Category: receiving support
Two subcategories were identified in relation to this category – support from family/friends and project-related support. As stated above in relation to “barriers for weight-loss”, the partner could be an obstacle. But there were also women whose husbands/partners were supportive. One of these women said that her husband thought the new diet was super. But she stopped him from eating her diet because she believed that he was too physically active to feel good with that food. Instead he had to fix his own food.
Friends – just like husbands/partners – could either be supportive or make weight-loss more difficult. When supportive, the friends did not tempt the participants to eat forbidden food. When inviting them for dinner, the friends would cook the diet food too. Also, good friends could be really supportive in helping the participants to keep their diet.
The project-related support was described as either direct support or inspiration to diet change. The participants felt that they received support in sticking to their diet from the group meetings as well as from the dieticians and the nurses. The project was also experienced as indirectly supportive since the participants could refer to and use the project in relation to others as an excuse for refraining from certain food.
The project was described as an inspiration to try a new diet and to learn about new ingredients. This was especially true for those who had no financial problems getting hold of the new diet. And some of the participants continued to eat their new diet, especially the breakfast, even after ending the project.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AH, AFW, BL and CA designed the qualitative study, while CL and BL designed the diet intervention. AFW and CA performed interviews, which were analysed by AH, AFW and CA. AH wrote the manuscript which all co-authors commented upon. All authors read and approved the final manuscript.