Weight Loss of Qualitative Research. Health & Medicine Essay

Please address these questions in this paper. The article is posted under the questions.
1. Provide a brief summary of the content and the qualitative research design used.
2. Evaluate the appropriateness of the design, and explain how ethical issues in the study were addressed.
3. Analyze how the study would have been different if a quantitative design had been used.
Abstract Objectives: Previous research with participants in weight management has primarily focused on participant weight-loss expectations. The purpose of this study was to explore participant expectations and strategies for measuring progress during a community-based weight management program. Methods: Semi-structured interviews were completed with 22 participants with overweight or obesity, who were currently enrolled in a 2-year weight management program in order to understand their expectations and strategies for measuring their progress. Results: Aside from weight loss, participants’ expectations included improved health, fitness, and mood, gaining support, and developing new habits. Participants discussed measuring their success by focusing on weight loss and changes to their body, improved health, mood, and fitness, creation of new habits, and gaining additional support. Conclusion: The results of this study suggest that participant’s in a weight management program expected benefits beyond just weight loss. Keywords Epidemiology, public health, weight loss, expectations, qualitative Date received: 19 June 2018; accepted: 24 September 2018 College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, WV, USA Corresponding author: John Spencer Ingels, College of Physical Activity and Sport Sciences, West Virginia University, 375 Birch Street, Office 219, Morgantown, WV 26505, USA. 807618SMO0010.1177/2050312118807618SAGE Open MedicineIngels et al. research-article2018 Original Article 2 SAGE Open Medicine are designed and improve our understanding of how participants evaluate their own success. Qualitative research methods have been applied in weight-loss settings to understand how an online weight-loss community supports its members,6 the experiences of individuals in weight-loss programs,7,8 and how successful and unsuccessful weight maintainers differ.9,10 One relevant study conducted interviews with 76 participants with obesity in Australia to explore their motivations for weight loss.11 Although weight loss was the primary motivating factor, participants shared a broad range of motivations beyond weight loss, such as improving health, mobility, well-being, and appearance, as well as an improved ability to spend time with family. These qualitative findings align with findings from the large, multicenter study by Dalle Grave et al.,3 which found that improving health was the primary motivation for weight loss. Finally, a recent review of qualitative research identified multiple challenges of weight maintenance and factors connected with successful maintenance, such as developing self-regulation strategies, managing motivations, and changing perception of self.12 The challenge of weight maintenance is not fully understood. Exploring the expectations and strategies for measuring progress of participants in long-term weight management across a variety of success in weight maintenance will benefit how WMPs are structured to optimize weight maintenance. The purpose of our study was to apply a qualitative method to understand what participants in a community-based WMP expected to achieve, how they measured their progress in the program, and how these expectations and strategies differed across different weight maintenance outcomes at 18months. Method Participants Participants were members of the community-based, statewide WMP run by the Public Employees Insurance Agency (PEIA) in West Virginia. This program is open to any adult policy holder (or their dependent) with a BMI over 25 or with waist circumference over 35 inches for women or 40 inches for men. The PEIA WMP is a 2-year program, which provides discounted membership to a fitness facility (US$20 per month), personal training services, an exercise physiologist, a registered dietician, and health behavior coaching. These services were provided on a standard schedule throughout the 2 years, including approximately 90min of personal training per month in the first year, and three meetings each with the exercise physiologist and the dietician. All services were delivered individually, and in-person, with the exception of voluntary health behavior coaching which was completed on the phone. In addition, a small percentage of clients (7% weight loss, moderate: 3%–6% weight loss, and those who regained. Ingels et al. 5 Health improvement. This theme captured participants expecting to improve specific health outcomes, beyond losing weight, through their participation in the program, such as improving cholesterol, reducing medications, or reducing blood sugar. For example, one moderate loss participant responded “I was sort of borderline cholesterol and borderline diabetes so I thought that if I lose weight that would help that plus just health in general” (P11). Mood improvement. This theme captured participant expectations to feel better mentally, emotionally, or psychologically, Table 2. Frequency of themes across weight-loss outcomes. Large loss (n=7) Moderate loss (n=8) Regain (n=7) Expectation themes for weight management program Weight loss Primary 4 4 4 Secondary 3 3 2 Absent 0 1 1 Fitness improvement 5 6 1 Health improvement 3 7 3 Mood improvement 1 2 2 Support 4 5 5 Habit development 0 2 3 Measurement themes of progress in program Body measurement Weight only 4 2 0 Multiple 1 5 4 None 2 1 3 Fitness improvement 5 5 3 Health improvement 1 3 1 Mood improvement 3 4 1 Habit development 4 3 4 Shift 3 3 1 Among expectation themes, weight loss was split into three subthemes: primary captured participants who reported weight loss as their primary expectation for joining program, secondary was used for participants who mentioned weight loss but had other expectations for joining, and absent indicates participant did not mention expecting weight loss. For how participants measured progress body measurement was split into three subthemes: weight only captured participants who measured progress with bodily changes only by focusing on weight, while multiple was used to capture participants who focused on multiple bodily changes, and none captured participants who did not measure progress through changes in their body. Table 3. Participant quotes and coded themes for expectations for weight management program in response to prompt: “When you first joined the program, can you tell me about what you expected, or hoped to achieve from the program?”. Group Quote Theme Large I was expecting support, I guess, a little help. I was hoping to achieve weight loss. (I: ok. And what kind of support were you hoping to get through the program?) P: Just advice, tips, suggestions … The main thing is just advice. (P23) Weight loss, secondary Support Moderate I definitely wanted to lose some weight because you know I’m overweight, I also I was sort of borderline cholesterol and borderline diabetes so I thought … if I lost weight that would help … maybe help me to get into the habit of working out because that seemed to be the hardest thing for me was actually making it a habit and just doing it. (P11) Weight loss, primary Health improvement Habit development Moderate Well in the beginning I wanted to get involved in this to just help my stamina. It seemed like I couldn’t do any type of exercise or walking, or any type of physical work without being short winded, tired, no motivation, I’ll put it that way … you didn’t see it on paper as far as when she did my measurements and my weight loss and things like that, but it helped me tremendously. Just my physical outlook and feeling better, not just about myself, but feeling better in general. (P5) Weight loss, secondary Fitness and mood improvement Regain Well I’d hoped to achieve weight loss and get on a regular exercise program. (P1) Weight loss, primary Habit development Regain Well, of course I wanted to lose weight. And, I wanted to feel better and reduce some of my medicines, and learn how to exercise properly. (P3) Weight loss, primary Health and mood improvement Support 6 SAGE Open Medicine such as expecting stress relief, improved outlook toward life, or feeling better about themselves. For example, one participant who had regained at 18months responded: It’s (life) really very stressful …You don’t have time for yourself because you’re taking care of everyone else … (Interviewer: and so prioritizing yourself sounds like one of the big goals of joining the program.) Participant: Oh, absolutely. And just some time away from the house … either I was at home, I was at my mothers home, I was at the hospital, it was very, very stressful. Very stressful. (P19) Support. This theme captured participant’s who were expecting the program to support them by providing advice, education, social connections, or helping them stay accountable to their health and wellness goals. For example, one moderate loss participant responded “I was hoping that I would have a … personal trainer showing you how to use equipment, making sure you continue to use the equipment, kind of making you accountable to keep on going” (P18). Habit development. This theme captured participant expectations focused on developing new routines or habits, such as increasing exercise or healthy eating. For example, one moderate loss participant responded “to help me get into the habit of working out because that seemed to be the hardest thing for me was actually making it a habit” (P11). Measuring progress The following themes emerged in response to “how did you measure whether or not the program was being successful or was being effective in helping you?” See Table 2 for frequency of measurement themes and Table 4 for full participant quotes and themes. Body measurement. This theme captured how participants measured changes to their body, such as weight loss or change in body shape. The following three subthemes were used to fully describe each participant’s strategy for measuring body change: weight only, multiple, or none. Weight only was used to describe participants who only focused on changes in weight when measuring progress through changes in their body. For example, one moderate loss participant responded “mine was not how many times I went but how much weight I lost. That’s how I judged it (my progress)” (P18). Multiple was used to capture participants who used multiple measures, including weight loss, but also including other measures like body fat, waist circumference, body shape, or how their clothes fit. For example, one moderate loss participant responded “first of all was weight loss. Then it was gauging how it was that I felt … and how do your clothes fit” (P8). Finally, none was coded for participants who did not mention measuring changes in body measurements as part of what they focused on. Table 4. Participant quotes and coded themes for how participants measured their progress in the weight management program. Group Quote Themes Large I hate to say I measured it in pounds but that was certainly a piece of it … but I also measured it as far as just you know feeling better. Maybe aim to do things that I couldn’t do before or struggled to do before, just to be more active. (P10) BM, weight only Fitness and mood improvement Shift Large You have to weigh in and they (the trainers) record your weight and every so often they did fit tests to see …what the progress was because they did baselines when I first went, and so you could see your progress … well now I can do 12 pushups and before I only could do 2 … when I was going through the program the very first year I saw a lot more weight drop. The second year it kinda plateaued but the body fat was changing. My body fat percent was like 58% and I think it went down to like 38% … And I never did get under the 200 pounds over the 2years, but the body fat kept changing to where, I guess I was just gaining muscle. (P2) BM, multiple Fitness improvement Shift Moderate The program that I chose was with the (gym name removed) and they are very number oriented. So, mine was not how many times I went (to the gym) but how much weight I lost. And that’s how I judged it. (P18) BM, weight only Moderate Every so often as part of the program we had to do body mass index which you know is a little bit an indicator of fat … and when I did the blood work it had helped … I don’t have any diabetes at all and the cholesterol had gone down … part of it you just feel better you don’t feel as sluggish cuz you don’t, just exercising even though I didn’t lose nearly as much as I’d like to … I had more energy because I was used to working out and I was going a lot. It really was a good habit for a long time. (P11) BM, multiple Fitness, health, and mood improvement Habit development Shift Regain We took blood pressure readings once a week … and we were also weighed on Mondays and we were encouraged to keep a food journal and turn that in weekly, and get feedback on that … and each gym had a little machine that measured like your body fat and stuff so you’d have that. (P1) BM, multiple Health improvement Habit development BM: body measurement. Ingels et al. 7 Fitness improvement. This theme captured participants who discussed measuring success in the program by focusing on improving their fitness level, such as having less fatigue, better endurance, improved fitness assessments, or the ability to do new exercises or more daily energy. For example, one large loss participant responded “different machines … I could either increase the length or … the depth of the workout, how hard it was. So I noticed from the beginning to the end there was quite a difference” (P26). Health improvement. This theme captured participants who measured improvements in their health, such as reduced blood pressure, relieving stress on joints, improved blood measurements (e.g. cholesterol and blood sugar), or decreasing medication. For example, one moderate loss participant responded “it even got to a point where I had to back off of my blood pressure medicine because my exercise was keeping my blood pressure lower” (P5). Mood improvement. This theme captured participants who measured progress through feeling better, having more motivation, having an improved outlook on life, or feeling less stress. For example, one large loss participant responded “well the mental benefits … you know if you work out you have those, you’re working out releases those feel-good serotonin or endorphins … the feel good stuff” (P12). Habit development. This theme captured participants who measured progress by developing new routines, such as increasing frequency of exercise, improving their eating habits, or keeping food journals. For example, one large loss participant responded “eating habits were more conscious … (I was more aware of) what I ate because I wanted the program to be a success” (P12). Shift. This theme included participants who described shifting focus from only weight to measuring other improvements, such as fitness, health, or mood improvements. For example, one moderate loss participant responded “I was overweight and although I only lost five pounds my overall attitude is much better. I feel better, it’s given an emphasis to exercise more and do it strategically” (P16). Discussion This study identified a variety of expectations—beyond weight loss—that participants expressed regarding their participation in a community-based WMP. In line with the prior research, weight loss was a common expectation among participants.2,11 Our analysis identified two themes within participants who expected weight loss: those whose primary expectation was weight loss and those whose weight-loss expectations came secondary to other expectations. This finding suggests that while weight loss is a common expectation, it may not be the most important theme for all participants who enroll in WMPs. The results identified improved fitness, health, mood, support, and developing new habits as important expectations for participants. Fitness improvement was a common theme, which may have been influenced by the fact that the program emphasized gym attendance and subsidized the cost of working with a personal trainer. Interestingly, fitness improvement was a common expectation among large and moderate loss groups, but not for those who regained. This result warrants further research to explore how weight maintenance success is aided by focusing on fitness improvement. Another common expectation was health improvement, adding to the findings from Dalle Grave et al.3 who found that health improvement was the primary motivation for weight loss. Individuals in our study shared wanting to improve health to prevent future illness or to manage current medical conditions. Of interest was the low number of participants who mentioned measuring their success by focusing on their health improvements, despite this being a common expectation. It is possible that participants were unable to measure health improvement and missed an opportunity to appreciate progress. Programs and practitioners can help clients quantify health improvements by sharing research findings by highlighting changes in body composition (e.g. waist circumference and body fat), blood pressure, and blood work (e.g. cholesterol and HbA1c) results may help participants appreciate their progress and thus help maintain motivation. Participants spoke of expecting to improve their mood from participating in the program by either feeling better or improving their ability to manage stress. This theme fits with prior research highlighting the benefit of exercise on mood19 and demonstrates that participants in WMPs are expecting the program to provide benefits beyond just physical changes to their body or behavior. Programs would benefit by highlighting the ability of changes to improve participant mood, as they can help participants sustain motivation through a plateau in their weight-loss progress.12,20 This boost in motivation may explain why measuring progress with mood improvement was more frequently mentioned with successful maintainers, as those who successfully maintained may have sustained their motivation by focusing on improvements in mood. Similar to expectations, measurement themes revealed that participants focused on a variety of methods in measuring their progress in the program. A majority of participants mentioned focusing on weight or body changes, yet they also spoke of a measuring progress beyond just weight or body change. Participants identified focusing on fitness and health improvements, creating new behaviors in their lives (e.g. eating better and exercising more), and feeling better emotionally as other strategies for measuring progress. Participants spoke of a shift in how they measured progress from the beginning of the program to the time of interview. This theme highlighted the dynamic nature of expectations and strategies for measuring progress. This 8 SAGE Open Medicine finding points to the important role practitioners and program processes can play in shaping participants’ expectations and strategies for measuring their own success. Our findings may also help explain some of the conflicting results among weight-loss goals and outcomes, as participants may have shifted their expectations during the study, while others’ expectations remained rigid. The lack of shift could help explain the results of prior research examining the connection between expectations and actual weightloss outcomes.3–5 The results of our study have important implications for participants’ feelings of self-efficacy for participating within a WMP. Social cognitive theory (SCT) states that individual’s expectations are an important aspect of perceived selfefficacy,21 with higher self-efficacy being linked to better weight-loss outcomes.22,23 The multiple expectations and modes of measurement suggest that participants are focused on much more than weight when evaluating their own selfefficacy as it relates to their ability to succeed in a WMP. For example, in some cases, participants may stick with a program despite not meeting weight-loss goals due to a variety of other expectations, for instance, improving their health by lowering their cholesterol. It is also possible that participants who only focus on weight loss may experience a drop in selfefficacy if they are not meeting these goals. To enhance selfefficacy while weight-loss goals are pursued, fitness professionals can help participants focus on health or mood improvements as potentially meaningful outcomes. These changes can be quite practical in nature. For example, once a participant adjusts to regular physical activity, they may experience reduced anxiety or improved energy immediately instead of waiting months to achieve their long-term weightloss goal. Similar to self-efficacy, the results support tenets of selfdetermination theory, which has highlighted the importance of developing autonomous motives for improving their health.24 The shifting of expectations from extrinsic sources to more intrinsic and diversified forms of motivation may help participants build sustained motivation, and help explain why some participants experienced substantial weight loss while others regained their initial loss. These autonomous motives and meaningful outcomes, along with fitness gains, could combine to build perceived competence and reinforce the idea that regular physical activity can build both situational-specific and global competence. Thus, the current data support the concept that physical activity may promote need fulfillment related to autonomy and competence within this theoretical perspective. Based on the goal-setting theory proposed by Locke and Latham,25 the highest level of effort occurs when goals are moderately difficult, and the lowest levels of effort occur when goals are either very easy or very hard. Previous research suggests that individuals tend to set unrealistically high weight-loss goals prior to starting a weight-loss initiative.26–28 However, there is no consensus regarding how unrealistic weight-loss goals impact weight-loss outcomes.26,27,29 The results of our study suggest that participants have multiple expectations beyond weight loss and measure their success in multiple ways. The variety of participant expectations and strategies for measuring progress may impact the relationship between unrealistic weight-loss goals and actual weight-loss outcomes. In this sense, our findings support the notion that it is important to view weight management as a long-term and complex process that has numerous benefits outside of weight loss itself.30 It is also possible that unrealistic goals can be both helpful and hurtful in terms of participant motivation. For example, an unrealistic goal to “lose 100pounds” could lead to program initiation and a great intensity of effort in the early stages of a program. Sometimes these unrealistic goals may be perceived as “more motivational” than something realistic and practical such as “lose 1–2pounds per week.” However, as participants progress through the program and measure their progress against these large goals, they may lose sustained motivation and judge the goal as “too difficult.” This dysfunctional pattern of goal setting has been outlined by researchers as “false home syndrome.”31 Future research can build upon these studies by exploring how goals and expectations, beyond weight loss, impact participants’ success in weight management. Future studies can utilize longitudinal interviews to understand baseline expectations and how these shift over time, and compare participant expectations with quantitative weightloss outcomes. Understanding how this process unfolds is another important area of study. Do participants with a variety of expectations show greater resilience when it comes to self-efficacy toward weight management than those who are just focused on weight loss? In a similar vein, the results from this study support previous research investigating the impact of participants’ baseline goals on future outcomes. It is possible that some of the mixed results regarding weight-loss goals and actual outcomes might be explained by adding additional variables to capture other goals at baseline, such as improving fitness or health, or feeling better emotionally. Finally, more research is needed to understand men’s experience in WMPs, as they were underrepresented in this study. This study is not without limitations. First, the interviews took place after participating in the program for at least 18months. It is possible that the views shared by participants in the study differed from when they enrolled in the program. A second limitation is that our results come from participants who remained engaged in the program for at least 12months and were willing to participate in interviews 18months post enrollment. Thus, the results cannot be generalized to the expectations and strategies for measurement for individuals who dropped from the program before 12months. However, the interviews took place across a variety of weight-loss outcomes and thus several levels of programmatic success were represented. Ingels et al. 9 Conclusion Semi-structured interviews with participants who completed at least 18months in a WMP revealed a variety of expectations and strategies for measuring progress beyond weight loss. Weight management practitioners would benefit by understanding individuals’ expectations and helping highlight participant progress in multiple areas beyond weight change to promote increases in self-efficacy and intrinsic sources of motivation. Acknowledgements The authors would like to thank Matt Campbell for his qualitative guidance and feedback in the development and refinement of this manuscript. Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethical approval Ethical approval for this study was obtained from the West Virginia University IRB (ID: 1606170374). Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project was supported by funding from the West Virginia Public Employees Insurance Agency (PEIA). S.Z. salary was partially funded through PEIA grant. J.S.I. and A.H. received no funding for this research. Informed consent Written informed consent was obtained from all subjects before the study. ORCID iD John Spencer Ingels https://orcid(dot)org/0000-0002-0606-0480