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. 2022 Jun 2;32(5-6):834–846. doi: 10.1111/jocn.16379

A lifelong struggle for a lighter tomorrow: A qualitative study on experiences of obesity in primary healthcare patients

Annika Imhagen 1,, Jan Karlsson 1, Stefan Jansson 1,2, Agneta Anderzén‐Carlsson 1
PMCID: PMC10084391  PMID: 35655375

Abstract

Aim

To describe experiences of living with obesity before the start of a group‐based lifestyle intervention.

Background

Obesity is a chronic disease that affects a person's physical and psychological health. Increased knowledge of experiences of living with obesity is required.

Design

A qualitative study with a descriptive design.

Methods

Semi‐structured individual interviews with 17 participants living with obesity (Body Mass Index 32–49) were conducted between October and November 2019. The interviews were analysed using qualitative content analysis. The COREQ checklist was followed.

Results

The analysis resulted in one main theme: Struggling for a lighter tomorrow and three subthemes: Suffering, Resilience and Need for support in making changes. For the majority of the participants, living with obesity was a lifelong struggle involving suffering on different levels. Yet despite this, the participants had not given up and hoped for a better life. They showed a degree of resilience and motivation, and a perceived ability to achieve lifestyle changes. However, there was a pronounced need for support to help them achieve this.

Conclusion

Living with obesity is complex and carries a risk of medical complications as well as psychosocial suffering. Healthy lifestyle habits to achieve better health and to lose weight should be encouraged, taking patient resources into account. Patients also need help in handling weight stigmatisation, and both healthcare professionals and society must engage with this.

Relevance to clinical practice

Obesity is a chronic disease, and patients need ongoing support. Therefore, care for patients with obesity in primary health care must be further developed. Patient resources and strengths have to be acknowledged and encouraged in the process of helping them adopt healthy lifestyle habits. The findings of this study can contribute to ending weight stigmatisation by increasing the knowledge of living with obesity.

Keywords: experiences, lifestyle, nursing, obesity, primary health care, qualitative research


What does this paper contribute to the wider global clinical community?

  • Obesity is a chronic disease and patients express a need for ongoing support. The care for patients with obesity in PHC must be further developed and improved.

  • HCPs need to acknowledge the resources and strengths of patients with obesity and encourage them to make use of their strengths in adopting healthy lifestyle habits.

  • Living with obesity is a complex, lifelong battle, partly because of the persisting weight stigma in both society and health care. Increased understanding of the experience of living with obesity can contribute to ending stigmatisation.

1. INTRODUCTION

Obesity or being overweight is a growing worldwide public health problem. According to the World Health Organisation (WHO) (2021), globally 13% of adults 18 years and older are obese and 39% are overweight. Obesity is defined as excessive fat accumulation that may impair health, with a risk of long‐term medical complications, such as type 2 diabetes and cardiovascular disease, as well as reduced life expectancy (Heymsfield & Wadden, 2017). Furthermore, obesity impairs quality of life (Kolotkin & Andersen, 2017). The main treatment options for obesity are lifestyle interventions, pharmacotherapy and bariatric surgery, the latter being the most effective treatment, albeit associated with greater risks (Heymsfield & Wadden, 2017). The aim of lifestyle interventions is to improve health and quality of life by achieving and maintaining a moderate weight loss and should be the basis of all weight loss treatment (Durrer Schutz et al., 2019). Cognitive behavioural therapy (CBT) is a commonly used approach for treating obesity. CBT focuses on cognitive processes and can help patients set and maintain realistic goals, improve self‐monitoring, practise stimulus control and prevent possible relapses (Castelnuovo et al., 2017). Motivation is essential in behaviour change, and motivational interviewing (MI) is a communication technique that can reinforce a patient's own motivation and be a useful tool in obesity treatment (Durrer Schutz et al., 2019). Group‐based treatment is a cost‐effective way to achieve lifestyle changes; it provides social support and enables participants to share common experiences and challenges (Tarrant et al., 2017). Research has focused on different lifestyle interventions (Burgess et al., 2017; Chopra et al., 2021) and patients' experiences of treatment (Cleo et al., 2018; Tarrant et al., 2017). However, to the best of our knowledge, there has been little research into the experiences of patients with obesity before they start a lifestyle intervention

1.1. Background

Overweight and obesity are classified using the Body Mass Index (BMI): a person's weight divided by the square of their height (kg/m2). A BMI ≥25 is defined as overweight and BMI ≥30 as obesity (WHO, 2021). Obesity is a chronic disease that impacts mental, metabolic and musculoskeletal function and is caused by a complex interaction of biological, psychological, sociological and environmental factors (Heymsfield & Wadden, 2017). One way to understand the causes of obesity is described in a report by the British Psychological Society using the bio‐psycho‐social approach to obesity (2019). This is an explanatory model that takes into account the context in which people live. In this model, behaviours that lead to obesity are affected by different interacting factors: biological (e.g. genes and stress); psychological (e.g. mental health problems and emotional coping skills); social and environmental (e.g. availability of food and ease of walking in the neighbourhood). The report seeks to reduce weight‐related stigma in the media, research and health care and aims to encourage healthcare professionals (HCPs) to abandon the prevailing belief that obesity is caused by a lack of willpower and poor self‐discipline.

There is no general experience of living with obesity, but previous research indicates that there are some common themes. Persons with obesity often experience negative physical manifestations such as pain or reduced mobility, which can result in limitations in physical activity and daily living (Cooper et al., 2018; Toft et al., 2020). Living with obesity may involve a negative self‐image and low self‐esteem (Ogden & Clementi, 2010), sometimes leading to isolation and loneliness (Homer et al., 2016). Furthermore, persons with obesity often blame themselves for their situation, experience feelings of guilt and shame, and feel less worthy than others (Ueland et al., 2019). Obesity can also be an impediment to sexuality, the body being an obstacle both physically and mentally (Granero‐Molina et al., 2020; Granero‐Molina et al., 2021). Persons with obesity regularly face various forms of weight stigma and discrimination (Rubino et al., 2020). This is usually based on judgemental views of the reasons for weight gain, and people with obesity are seen as lazy, stupid and overconsuming (Lewis et al., 2011). Research shows that persons living with obesity often feel they are unable to live the lives they desire and consider themselves to be waiting for ‘real life’ to start. They may be longing for a more normal life as well as hoping to be able to do things that are currently impossible due to their obesity (Haga et al., 2020; Ueland et al., 2019). Furthermore, people with obesity often experience a lack of adequate care and support from HCPs (Kirk et al., 2014). There is insufficient understanding of the complexity of obesity and some HCPs assume that body weight is within the patients' control, and therefore, they are blamed for not losing weight (Rand et al., 2017).

A recently published review of qualitative studies about living with obesity by Farrell et al. (2021) included 32 studies from 2011 to 2020 with participants ranging from overweight to morbidly obese (BMI ≥40). The participants had undergone or were waiting for bariatric surgery or participated in different lifestyle interventions. The review describes factors associated with the development of obesity, the effects of the disease on daily life, the impact of stigma and judgement, and experiences of accessing treatment. Farrell et al. point out that there are few qualitative studies focusing solely on the experience of the patient, given the magnitude of the phenomenon of obesity. They call for further qualitative research on the experiences of those living with obesity, focusing on using participant‐informed methods (2021). To be able to provide appropriate treatment and support for patients with obesity, it is essential for HCPs to have adequate knowledge of experiences of living with obesity. It is also important to be aware of patients' needs and expectations prior to offering treatment. Moreover, there is a call for using patient experiences in the decision‐making process in health care (Rand et al., 2019). Thus, our research question was as follows: What are the experiences of living with obesity before the start of a group‐based lifestyle intervention?

2. METHODS

2.1. Aim

The aim was to describe experiences of living with obesity, from the perspective of persons enrolled in a group‐based lifestyle intervention in primary health care.

2.2. Design

The study has a qualitative descriptive design with semi‐structured individual interviews. Qualitative research can tell the story of a person or a group and interpret how human beings construct meanings for their experiences (Patton, 2015). Qualitative interviews were chosen for data collection as they allow participants to freely express their thoughts and opinions (Patton, 2015). The world, and a text, can be interpreted in different ways, and various interpretations can be valid (Graneheim & Lundman, 2004). The aim was to analyse the interviews on both the manifest and latent level. The Consolidated criteria for reporting qualitative research checklist (COREQ) was used to safeguard explicit and comprehensive reporting (Tong et al., 2007) (Appendix S1).

2.3. Participants and setting

The inclusion criteria were that the participants should be persons aged ≥18, with overweight (BMI 28.0–29.9 with weight‐related morbidity) or obesity (BMI ≥30.0), who were able to speak and understand Swedish, and who were registered to start a lifestyle intervention in primary health care (PHC) for people with overweight or obesity. Subsequently, all participants who agreed to take part in the study had obesity.

The intervention used was Step by Step, a 6–8 month, six‐session group‐based treatment inspired by CBT and MI. The main treatment goal for the 8–12 patients in each group is to adopt and maintain healthy lifestyle habits. Each 2‐h group session has a set agenda with different topics, for example diet, physical activity, goal setting and problem solving, and there are home assignments between sessions. Patients are encouraged to share experiences with each other in order to inspire, challenge and help fellow patients (National Library of Medicine, 2019). Participants for the present study were recruited by a Step by Step group leader in a smaller town (30,000 residents) in the middle of Sweden. Consecutive sampling was used. Patients offered Step by Step in the autumn of 2019 were invited to be interviewed. Some of the patients had heard about the group treatment and applied for it by themselves, while others had been referred to it by their diabetes nurse or general practitioner. A total of 33 patients were registered to start the group treatment, and 17 agreed to participate in the interview study. The most common reasons for not participating were lack of time, stress, mental illness, language difficulties or late inclusion. One man and 16 women with obesity were included in the study (Table 1).

TABLE 1.

Participant characteristics (N = 17)

Characteristic
Gender
Male 1
Female 16
Age (years)
Range 22–60
Mean (SD) 42.2 (13)
Civil status
Married/partner 15
Single 2
Highest education
Secondary school 13
University 4
Occupational status
Employed/student 12
Part time sick leave/sick leave 4
Retired 1
Country of birth
Sweden 15
Outside Europe 2
BMI
Range 32.4–49.3
Mean (SD) 39.2 (4.4)
Obesity
Class I (BMI 30.0–34.9) 3
Class II (BMI 35.0–39.9) 7
Class III (BMI ≥40) 7

2.4. Data collection

Data were collected between October and November 2019. An interview guide with open questions regarding experiences of living with obesity was developed in the research group based on clinical experience and the relevant literature. A pilot interview, which was not included in the analysis, was performed to test and modify the interview guide, and the questions were thereafter adjusted and refined (Table 2). The interviews were performed by the first author (AI), who is a registered nurse specialised in PHC with experience of working with patients with obesity, both in groups and individually. The interviewer did not have any previous or ongoing clinical connection with the participants. The interviews were conducted in the participants' homes (n = 4), workplace (n = 1), at the nearby hospital (n = 9) or at the healthcare centre (n = 3), according to each participant's choice. The participants were encouraged to talk freely and expand on their answers. Follow‐up questions like ‘Can you tell me more …?’ or ‘Would you like to explain …?’ were used to prompt the participants to deepen their stories. The interviews were digitally recorded and lasted between 24 and 59 min (mean 38 min). They were later transcribed verbatim, and the accuracy of the transcripts was confirmed by the interviewer.

TABLE 2.

Interview guide

Stage Subject Content/example questions
Introduction Reasons and motives

Can you tell me why you wanted to join Step by Step?

What would you like to achieve?

What are your motives?

Beginning Present life

How is your life today, living with obesity?

How does your weight affect you, physically, psychologically and socially?

What are your thoughts about obesity?

How do you experience other persons' views on your weight?

Continuation Step by Step

In what way do you think Step by Step will help you?

Do you see any obstacles to participating?

What do you think you need to do to lose weight?

Development The future

In what way do you think your life would be different with a lower weight?

What are your dreams after completing Step by Step?

Closing Opportunity to add Is there anything else you would like to tell me?

2.5. Ethical considerations

The study was conducted in accordance with the Helsinki Declaration (World Medical Association, 2021) and was approved by the Swedish Ethical Review Authority (2019‐00312, 2019‐04942). Informed written consent was obtained from all participants. They were informed that participation was voluntary, that they could discontinue the interview at any point without consequences for their treatment, and that they were guaranteed confidentiality. They were also informed that professional support could be received after the interview, if needed.

2.6. Data analysis

The interviews were analysed according to the analytical steps in qualitative content analysis as described by Graneheim and Lundman (2004), Graneheim et al. (2017) and Lindgren et al. (2020). An inductive, text‐driven approach was used with the goal of moving from the concrete and specific to the more abstract and general (Graneheim et al., 2017). According to Graneheim and Lundman (2004), categories represent the manifest descriptive content of the text, that is, what the text says; themes present the latent content, a thread of underlying meaning, what the text is talking about.

The interviews were read several times to obtain an overall impression of the material. The interview text was then exported to NVivo software (QSR International Pty Ltd, 2020) to manage the data. Meaning units (sentences and paragraphs) related to the study aim were identified. The meaning units were then abstracted and labelled with a code that was close to the text and represented the content (e.g. ‘heavy to carry body weight’ and ‘choosing clothes that hide body size’). The whole context was kept in mind during this process.

The various codes were compared based on similarities and differences, and then sorted into 12 categories. This involved a lengthy iterative process in which authors AI and AAC identified, grouped and regrouped the content in order to create mutually exclusive categories that answered the research question and were close to the text. When uncertainties arose, the transcripts were reread to be reminded of the context of what had been said. The analysis process involved constant back‐and‐forth movement between the whole and parts of the text (c.f. Graneheim & Lundman, 2004).

The underlying meaning of the categories was finally formulated in one main theme and three subthemes. This was done by an interpretation of the material in which all the authors tried to go beyond the exact words of the participants and understand their emotions and underlying meanings, that is, the latent content (Lindgren et al., 2020). At this stage, three interviews were read and analysed by the other two members of the team (JK and SJ) to check for validity in the interpretation of data. Different views were discussed until consensus was reached. This discussion opened up a more nuanced interpretation of the results.

2.7. Rigour

Trustworthiness was established by following the strategies described by Shenton (2004) concerning credibility, transferability, dependability and confirmability. The wide variation in the experiences of the different participants in the interviews provided rich material. There were frequent and recurrent discussions between the authors about how to choose suitable meaning units and how to assess similarities and differences within and between categories, and the analysis was verified by multiple authors (c.f. Graneheim & Lundman, 2004).

The analysis and results were enriched by the different occupations and backgrounds of the authors (c.f. Shenton, 2004). Two were registered nurses, one was a general practitioner, and one was a psychologist. Three had experience of working with patients with obesity. Member checking with the participants was not practised. However, the two members of the team who were less involved in the analysis and who had clinical experience of the patient group could easily recognise and agree with the identified themes and categories (c.f. Patton, 2015). Appropriate quotations can enhance transferability of a result (Graneheim & Lundman, 2004), and quotations from the transcribed material were thus used to underpin and exemplify the interpretations.

The authors had regular discussions about their pre‐understandings at the time the interviews were being conducted and during the analysis process. The objective was to be open and aware of pre‐understandings throughout the process (c.f. Graneheim et al., 2017).

3. FINDINGS

The participants' characteristics are shown in Table 1. The analysis resulted in one main theme: ‘Struggling for a lighter tomorrow’ and three subthemes: ‘Suffering’, ‘Resilience’ and ‘Need for support in making changes’ (Table 3).

TABLE 3.

Overview of the main theme, subthemes and categories

Main theme Subthemes Categories
Struggling for a lighter tomorrow Suffering Carrying a history of distressing experiences
Being in poor physical condition
Having a negative self‐image
A need to explain one's body weight
Fear of what the future might bring
Resilience Content with life despite body weight
Motivators for change
Capacity and resources
Need for support in making changes Difficulty finding motivation and endurance
Inability to maintain healthy eating habits
Help to overcome shortcomings
Wishing for a toolbox

3.1. Struggling for a lighter tomorrow

The main theme indicates that the participants' lifelong struggle against obesity left them balancing between hope and despair. Yet they had not given up, and still hoped to improve their lives, while knowing that doing so would be difficult and would require help from others. Living with obesity had caused them suffering in the past and in the present, and they knew that it would continue to cause suffering in the future if their situation did not change. They demonstrated a degree of resilience that included motivation to change and belief in their own capacity to make changes. However, they were acutely aware of their need for help and support.

3.2. Suffering

Living with obesity was experienced as suffering that often started early in life with being bullied in school because of one's size. Emotional suffering was related to shame, guilt, disappointment, low self‐esteem and negative thoughts related to one's physical body. This suffering was often exacerbated by unhappiness, distress, sickness and difficult circumstances. There was also physical suffering with a body that did not work or react as desired or expected. This subtheme was derived from the following categories: Carrying a history of distressing experiences, Being in poor physical condition, Having a negative self‐image, A need to explain one's body weight and Fear of what the future might bring.

3.2.1. Carrying a history of distressing experiences

The participants had struggled with their body weight for many years, in many cases since they were children or teenagers. They had tried to lose weight many times, but had always regained it. Some grew up in dysfunctional families with alcohol abuse or incapable parents. They remembered being bullied at school, and being told to ‘watch your weight’ or called ‘hippo’ or ‘pig’. These comments still stung. As one participant said:

Because I have struggled with my weight my whole life. I have been told my whole life that I am too fat … already as a four‐year‐old I was told that ‘you eat too much, and should eat something else because it is better for you’ and so on. Of course, it has affected me a lot. Being told that you are fat by your family. All through your life, it affects you very negatively. (Interview #5)

Participants described exhaustion, weariness and stress, and a few had received professional emotional support for depression or anxiety. Their whole lives were affected by how they were feeling mentally, and this was often an obstacle in their attempts to change their lifestyle habits. They felt discriminated against and excluded from society because of their weight, and some of them had not received adequate help from health care. A few lacked support from their family members in changing their habits.

3.2.2. Being in poor physical condition

Participants described their body weight as a heavy burden to carry, which negatively affected their physical condition. Some had developed high blood pressure, and many said they were tired all the time and had low energy levels. Almost all wanted relief from pain in their back, legs or feet. The pain, in combination with the excess weight, affected their daily life. They could not engage in physical activity like walking the dog, and climbing just one stair left them breathless, regardless of their age. This is how one participant in her 30s described her situation:

Yes, it is of course much harder in general, than to weigh 84 kilos. … it is obvious, everything is very difficult; it is very difficult to walk up a stair, so it is the everyday activities I find really hard … just bending down and putting on my shoes, I lose my breath. As soon as I am to perhaps walk uphill, I get warm and sweaty and … you sort of … it is not fun. (Interview #13)

Heavy sweating could keep participants away from social activities, or otherwise, they had to bring a change of clothes. Their poor physical condition was a hindrance for them at work, in school and when socialising with family and friends.

3.2.3. Having a negative self‐image

Having obesity made the participants feel ashamed of themselves, and they shared stories of guilt, shame, failure, disappointment and self‐loathing. Many of them cried silently when they talked about their negative self‐image. They were not satisfied or comfortable with their bodies and often chose clothes to hide them. These were often clothes they did not like and would not have chosen if they had a smaller body. It was also hard to find clothes they liked. Many of the participants found it challenging to try on clothes in changing rooms and instead bought their clothes on the Internet. They avoided going out to meet family and friends, or going to a party or to the gym, because they did not want to expose their bodies to others. They chose negative words when describing themselves, such as ‘awful’ and ‘crap’, and they often put themselves down mentally. Here is how one participant described their feelings:

Yes, I am disgusted at how I look. I don't want to look at myself, at all. I am sort of … unsure of myself all the time, if I hear someone laughing behind me when I am out somewhere, then I think they are laughing at me, because I am so insecure of myself and I think I am ugly and disgusting and ridiculous and … I don't want to go out, I don't want to be among people. I stay at home, I don't have mirrors at home, because then I don't have to see myself. Because if I go out, maybe there is a mirror or a shop window, so I stay at home instead. (Interview #8)

Some participants said they were constantly thinking about their weight or body size, but they did not normally share their feelings about it. They did not feel good‐looking or attractive to their partner. Some avoided sexual interaction or had a decreased desire for sex because of their body size.

3.2.4. A need to explain one's body weight

It was important for the participants to explain to the interviewer what they thought were the causes of their obesity. They expressed a sense of personal responsibility for their excess weight, while at the same time being desperate to explain why they had ended up where they were. There were numerous explanations for the weight gain: pregnancy, vacations, a partner's bad habits, grief, unemployment, sickness, pain, mental illness, medication, working night shifts or quitting smoking. Participants speculated whether genes, hormones or increasing age could explain their obesity. A few said they could not understand or explain why their weight increased, and seemed in some ways to have become resigned to it. A common reason mentioned was inactivity. One participant came to Sweden as a refugee and gained 25 kilos in 5 years:

I sat at home all the time and just studied and I didn't go out that much … the first two years [in Sweden] it was very cold and new weather conditions … I couldn't accept this weather in the beginning [laughter]. (Interview #12)

Another participant was bedridden in hospital for several months:

And I was very immobile since I was almost totally paralyzed for a period. And then it [the weight gain] just sort of happened, I have gained more and more weight since I was discharged. Partly because of sugar cravings, perhaps, but also because I have had problems moving around. (Interview #16)

3.2.5. Fear of what the future might bring

Participants and their families were worried about their health and feared their obesity might lead to hypertension and cardiovascular disease. They expressed a fear of premature death and wanted to lose weight before they became ill:

At least under, BMI under 30 … Yes, this is too much. I am a bit scared also to get diabetes and all the other crap that follow when you are bigger … Over 35 [BMI] that is not good. Eh … then there is risk for blood clots and diabetes and I don't know what, but, but it is definitely not good, I know that. So … it scares the shit out of me. (Interview #2)

3.3. Resilience

This subtheme was derived from the categories Content with life despite body weight, Motivators for change and Capacity and resources. Living with obesity was not all struggle and darkness. Life could still be meaningful and good, and it was possible to be content with oneself and one's body. Participants tried to overcome challenges and bounced back from difficult situations. They hoped for a better life, and to varying degrees they revealed the motivation and capacity to find inner strength and resources to achieve a change in lifestyle. It was helpful to have had previous experiences of things like a healthy diet or being physically active. External resources, such as support from family and friends, were also important.

3.3.1. Content with life despite body weight

Despite their distressing experiences, poor physical shape and negative self‐image, more than half of the participants stated that their body weight was not an obstacle in their work. They seemed to have adapted to their situation and accepted that they sometimes had to wipe away sweat or rest after climbing stairs. A minority of the participants said their body weight did not affect their daily activities, here expressed by one participant who did not avoid going swimming:

No. I go to the public baths and I don't care. I stand in the [communal] shower, and I don't care at all. No. (Interview #7)

Some participants did not let their obesity stop them from travelling or going to the gym, or from practising hobbies like photography, computer gaming or dancing. Some said they were not treated differently or badly because of their obesity. One participant even stated that her main objective for participating in the group treatment was to improve her health rather than to lose weight. How much participants were affected by their body weight and circumstances varied from time to time:

Sometimes I don't feel that fat. It depends on how you feel. So sometimes you can dress up when you are going out. (Interview #2)

3.3.2. Motivators for change

The main reason participants gave for wanting to change their lifestyle and lose weight was to be able to feel better, both psychologically and physically. Above all, they expressed a desire for better self‐confidence and self‐esteem. They wanted to stop being ashamed of themselves, experience less anxiety, feel good‐looking, be content with their body and be able to live the life they wanted. They dreamt of having more energy and being more flexible and longed for better health, exemplified by less pain and lower blood pressure. Many participants said they would be in a better mood if they weighed less:

You become happier, have more strength … the mental part and the body are connected in a way, so … I am actually a very happy and playful person … but something happened and I am not the person I used to be. If you have a lower weight or are in a better shape, it will be easier. And if it is easier, then you will have a smile on your face when you walk up the stairs instead of puffing and breathing hard. (Interview #10)

Participants wanted to be more social and active, to be able to start exercising, to move freely and to play with their children or grandchildren. More specific motives for losing weight included wanting to become pregnant, wanting to be a potential kidney donor for a close relative, preparing for scheduled surgery, planning to go on holiday in the sun or being able to wear nicer clothes. Participants also wanted to show their family members that it was possible to have a healthier lifestyle. Different external factors also motivated participants to change their lifestyle. Dog owners were motivated to walk their dogs, and smart watches or phones that counted the steps taken each day prompted other participants to leave the sofa. One participant wanted to be able to use a specific type of bicycle that had weight limits, and another participant was motivated by the figures on their scales:

Primarily it was that I didn't want three digits on the scales … no, three digits, it feels like, no, 100 kilos, that is a lot. Because now I have a new [motivation] like, ‘No, I am not going to accept that weight’. (Interview #13)

In sum, all participants had something that motivated them to want to change their lifestyle and lose weight, and all were ready to start the lifestyle group treatment.

3.3.3. Capacity and resources

Some participants described themselves as competitive, able to take the initiative, and ready for change. They wanted to take responsibility for their own lives and set personal goals. They were well aware that losing weight would probably take a long time. They had lost weight before and were aware of what to eat and what to do. They mentioned various weight‐loss strategies such as diets or distracting oneself to avoid eating too much. Some of the participants had been physically active earlier in life (a few at an elite level) and thus associated physical activity with fun, being strong and a sense of well‐being. Half of them had started exercising or changed their dietary habits on their own initiative before the start of the group treatment, and had thus already begun to lose weight. One participant said:

Again my positivity will triumph. This is how I think. But, yes, there is a long way before I get there. But I have, the goal is that it [the positive thinking] will win. That's a fact. Never in my life will I lie down and give up. No, no, that is not an option, then I wouldn't be sitting here. (Interview #4)

Another resource for changing lifestyle habits was support from a partner, family, friends or colleagues. Practical examples of this were family members offering company on a walk or providing an activity watch. In some workplaces, colleagues tried to lose weight together and supported each other. Other colleagues helped participants by not eating sweets or cakes in their presence and by making encouraging comments.

3.4. Need for support in making changes

The participants stated that they needed support for changes to take place. Living with obesity and having a desire to change one's circumstances often went hand in hand with insight into one's limitations, prompting a desire for support. The participants wanted help maintaining the motivation to do the things they should do, as well as practical, concrete help to manage situations related to food, eating and physical activity. This subtheme was derived from the categories Difficulty finding motivation and endurance, Inability to maintain healthy eating habits, Help to overcome shortcomings and Wishing for a toolbox.

3.4.1. Difficulty finding motivation and endurance

Most participants said it was a struggle for them to maintain a lifestyle change. They were well aware of their limitations and normal behaviour, and they said they often tended to lose the desire to change, gave up, or did not have the energy to continue or fell back into old habits. To prevent this from happening, they wanted someone to keep an eye on them and their weight, which they hoped the leaders of the group treatment could help with. Some participants said they had trouble finding the motivation to start or to continue a change:

Very difficult with motivation and taking initiatives. I have become quite passive … I have trouble to sort of change … When I have started something it is hard for me to change tracks for example … So it is … just getting new routines that I need. (Interview #1)

More than half of the participants wished for help to get started in physical activity, and this was valid for the group of previously active participants and the less active. At the same time as the participants wanted to start to exercise they explained that it was often hard to find the time, and in particular energy, for this, mainly because of family and work and sometimes simply because it was boring to go for a walk by yourself.

3.4.2. Inability to maintain healthy eating habits

Participants talked a lot about food and their eating habits, without the question being asked. They reported what they ate, what they did not eat and what they knew was healthy to eat. Unhealthy habits were for example skipping breakfast, eating too much carbohydrates or too large portions. Many participants talked about emotional eating, food and sugar addiction, and they wanted help to achieve a healthier relationship to food and eating. One participant said she was thinking about food all the time, and that life would be meaningless if she could not eat whenever she wanted:

I felt that I did not have any meaning in life [small laughter] when I walked home and could not eat anything. So it feels so, there is no meaning me sitting there just reading a book or watching TV. So I just sit there and I do nothing, it feels like that [no meaning] just because I haven't cooked, because I haven't eaten. To cook for others and cook for myself. And to cook, I don't know [small laughter], it is meaningful, and still not. (Interview #9)

Another participant, a woman in her 60s, hid sweets from her family in different places in the house in order to conceal her inability to abstain from sugar. However, she reported that it had turned out that her family knew of all the hiding places, so in fact she was hiding it from herself.

3.4.3. Help to overcome shortcomings

Half of the participants stated they could not lose weight on their own. Many of them had earlier experiences of losing weight and regaining it, and had now realised they needed help. Some stated that they gained weight very easily, which was concerning to them. They had knowledge about healthy choices and knew what they should be doing, but knew that they lacked the strength, ability or willpower to do it.

And I have tried with ‘I am not going to’ [eat sweets]. But still … I know I shouldn't, this is what I want help with now, stop this … I know, one should not, but still you can't. (Interview #14)

Participants looked forward to being in a group with persons in the same situation, with similar experiences, and they hoped for peer support and support from the group leaders. They also wished to share their thoughts with others and to be pushed and get input from fellow group members. Some spoke about getting to know new people and maybe getting a walking companion.

3.4.4. Wishing for a toolbox

The participants hoped that the leaders of the group treatment would give specific and practical guidance that would help them to change their lifestyle. They wanted advice about how to start new routines and habits to gain a healthier life. Many of them wanted a list of what and how much they should eat, and others wanted help with their sugar cravings. Participants also asked for strategies to help them moderate their food intake at times like Christmas and holidays. Participants also wanted tools that would enable them to think and act differently, for example, when tempted by something they had decided not to eat:

I know a lot depends on planning in advance and that you sort of think ahead all the time with food and so on, plan. And that's the thing, as soon as I don't plan, then I get off the right track. So I think maybe you can get tools from this [group treatment] to think differently, even if I have not planned, maybe I will have other tools to make different choices instead, that I don't make today. (Interview #15)

4. DISCUSSION

This study describes experiences of living with obesity among persons who were just about to start a group‐based lifestyle intervention in PHC. The main theme—Struggling for a lighter tomorrow—illustrates the constant, and often lifelong battle, a person with obesity must fight. The three subthemes: Suffering, Resilience and Need for support in making changes further illustrate the complex and sometimes contradictory reality of living with obesity. Participants in this study described suffering and a hope for a better life along with an attitude of resilience and confidence in the ability to change their lives, but there was also a clear desire for support.

This study shows that the experience of living with obesity is complicated, paradoxical and individual. Our findings support previous research indicating that living with obesity involves both difficulties (Haga et al., 2019; Haga et al., 2020) and possibilities (Ogden et al., 2020; Toft et al., 2020). But whereas previous research has mainly reported negative experiences of living with obesity, such as feelings of weakness, failure and limitations in daily life (Homer et al., 2016; Salemonsen et al., 2018; Ueland et al., 2019), some of the participants in our study were relatively satisfied with life, possessed an inner capacity and had access to outer resources (e.g. family and friends) to help them. They were motivated to make lifestyle changes and mentioned a number of motivators for losing weight. These expressions of resilience and capacity have, to our knowledge, not previously been described in qualitative studies of persons with obesity. We do not know why our findings differ from previous research, but it could be that the participants in the present study had sought help, were ready for change and were well aware of the factors motivating them. It is important for HCPs to listen to patients and try to reinforce existing motivators. It is also essential to help patients identify their inner and outer resources and to encourage them to use them in the process of gaining better health (Durrer Schutz et al., 2019). One way to do this is to use the MI approach, which is employed by leaders of the Step by Step group treatment. This patient‐centred, non‐judgemental approach is suited to discussing changing lifestyle habits to improve health (Durrer Schutz et al., 2019).

The most prominent subtheme in our study is that living with obesity involves suffering—painful experiences in the past, difficulties in daily life in the present and the likelihood of more suffering in the future. Participants had experienced bullying, recurring negative weight‐related comments, and feelings of being excluded from society. The health‐related suffering inevitably impaired their quality of life, even if participants in our study did not explicitly talk about having a poor quality of life. A negative self‐image was central to the majority of participants and was expressed by tears or silent crying during the interviews. There were feelings of guilt, failure and self‐loathing, and participants did not feel comfortable or satisfied with their bodies. They used words such as ‘disgusting’ or ‘ugly’ to describe themselves, and many avoided social contexts and had thus become isolated. These findings support previous studies where persons with obesity described how their body weight impacted their self‐identity negatively (Ogden & Clementi, 2010; Toft et al., 2020; Ueland et al., 2019). In many cases, participants in our study hid their feelings and did not talk to family or friends about their negative self‐image. The study interview was one of the first times many of them shared their story with another person. This demonstrates that it is important for HCPs to learn more about the experiences and needs of patients with obesity, and the importance of inviting patients to talk about their feelings (Rand et al., 2017).

Many of the participants interviewed in this study grew up in dysfunctional families, were on full or part‐time sick leave, had problems with depression, anxiety or stress, and had an overall tough life situation. They could not manage their weight on their own and therefore had sought help. These findings support other research on experiences of patients living with overweight/obesity who were participating in some form of intervention (Haga et al., 2019, 2020; Toft et al., 2020; Ueland et al., 2019). Thus, it is most likely that this patient group would benefit from receiving coordinated care from several HCPs: general practitioners, psychologists, dietitians, nurses, physiotherapists and social workers. Despite a multi‐professional approach, it is paramount to address a patient's most urgent needs first. For example, if a patient is suffering from depression or anxiety, it may be difficult to achieve a lifestyle change without first getting help with mental health issues (Rand et al., 2017).

One category in the subtheme Suffering was a need to explain one's body weight. It seemed important for the participants to explain the causes of their obesity. The reasons given included grief, unemployment and pregnancy. In a similar Norwegian interview study, participants also gave reasons for their weight gain (Salemonsen et al., 2018). What was striking in our study is that the participants volunteered these explanations without being asked. It seems likely that the persisting weight stigma in society and health care prompts this need to justify one's body weight and life circumstances (Kirk et al., 2014; Rand et al., 2017; Rubino et al., 2020). Individuals with obesity are stigmatised based on the assumption that obesity is a choice that can be reversed by a simple decision to eat less and exercise more, even though current research demonstrates that genetic, biological and environmental factors contribute to obesity (Rubino et al., 2020). Studies have shown that behavioural treatment can have a beneficial effect on a person's handling of weight stigma, and it is essential to take this into account when planning treatment interventions (Karlsson et al., 2021). It is time to lift the shame and blame from the shoulders of persons with obesity and offer the support and care they are entitled to. This care could be provided by adopting the bio‐psycho‐social approach to obesity described by the British Psychological Society (2019), and by taking actions to decrease negative stigmatising attitudes as highlighted in the guidelines by Durrer Schutz et al. (2019).

Participants in this study expressed a need for support from health care in changing their habits, losing weight and improving their health. They anticipated that the group leaders and fellow participants would provide the help and support they needed. Some of them wanted a toolbox to help them change their habits, and they wanted the group leader to monitor them so they would not ‘cheat’. Unfortunately, healthcare resources are limited, and the Step by Step programme consists of only 6 2‐h group sessions over 6–8 months. This is probably insufficient given that obesity is a chronic disease. It is likely that patients need support for a longer period of time to achieve their treatment goals (Kirk et al., 2014; Rand et al., 2017; Salemonsen et al., 2018). The care for this patient group needs to be further developed and expanded, but finding sufficient time and resources for this in current PHC will be challenging.

A majority of the participants in the study dreamt of a lighter future, including a lower weight and an easier everyday life. They believed that if they could just lose weight and become slim, they would be happier and their anxiety, depression or negative self‐image would diminish or disappear. However, previous studies reveal that weight loss does not necessarily equate to a happier life (Bombak & Monaghan, 2017). In retrospect, persons regret believing that slimness and happiness were closely connected (Haga et al., 2019). Yet it seems that even if patients entering Step by Step were informed that they could expect weight stability or perhaps a weight loss of up to 5% of their body weight in 6–8 months, many of them did not accept or ignored this and believed they would be an exception and lose more weight. A possible explanation for this might be that a person with obesity will never lose hope of a new, slimmer body, as shown in a study by Haga et al. (2020) where patients continued to wait and hope, despite repeated failures to lose weight. There is a risk that participation in a lifestyle intervention will result in disappointment and discouragement, and it is thus important for providers of interventions to make clear what can realistically be expected. One option might be to reformulate the aim of a lifestyle intervention as a basic education about how to live with obesity as a chronic disease, in the same way as there is self‐management education for patients with type 2 diabetes or osteoarthritis (Chrvala et al., 2016; Fernandes et al., 2013). Perhaps, the focus of lifestyle interventions should shift from weight loss to a healthy lifestyle and improved quality of life and well‐being. This option is promoted by Tylka et al. (2014) in a review that evaluates the weight‐normative approach versus the weight‐inclusive approach, with the latter emphasising health and well‐being and reducing weight stigma.

Our findings offer support for further research on lifestyle interventions focusing on the mental health and well‐being of the participants, with outcome measures that go beyond weight loss to include quality of life and behavioural change. Studies evaluating the effects of behavioural treatments that aim to decrease the impact of stigmatisation are lacking. Moreover, patients need to be followed up after participating in an intervention focusing on patients' experiences to allow for suggestions for a better‐tailored programme.

4.1. Limitations

The choice to use consecutive selection of participants for this study was made for practical reasons. It meant that only one male was included in the study, which does not reflect the gender distribution in either the Step by Step groups (normally around 20% male) or in the population of people with obesity (50% men) (WHO, 2021). However, a recent review indicates that more women than men seek obesity treatment (Cooper et al., 2021), which could explain the skewed gender distribution in the current study. While the number of interviews was considered sufficient to capture the participants' experiences without risking the material becoming unnecessarily extensive (Polit & Beck, 2012), with more participants to choose from, persons of different ages, ethnicities, occupations or genders could have been included to capture additional experiences (Graneheim & Lundman, 2004).

Step by Step is available for persons troubled by their body weight, and persons with either overweight or obesity were eligible for the study. However, in this study all participants had obesity, and the results may not be transferable to persons with overweight. It is also important to note that all the participants were adults who were seeking treatment for obesity. The study thus describes the experiences of persons who had decided to change a condition they believed has a negative impact on their health and well‐being, and the results might not be transferable to other persons with obesity.

5. CONCLUSION

This study has highlighted the complexity of obesity as a phenomenon that involves bio‐psycho‐social suffering and a risk of medical complications. There is an urgent need to improve and develop treatments for persons with obesity and take into account the individual's resources and strengths. Encouraging patients to adopt long‐term healthy lifestyle habits can lead to weight loss, improved physical condition and a reduced risk of medical complications caused by obesity. Perhaps most importantly, patients with obesity need help handling weight stigmatisation, and both HCPs and society must engage with this issue more actively. Stigmatisation can be reduced with increased knowledge and understanding of the experience of living with obesity, something to which the results of the current study can contribute.

6. RELEVANCE TO CLINCAL PRACTICE

The findings indicate that care for patients with obesity in PHC must be further developed. Patients express a need for ongoing support, which could be provided, or coordinated by a clinical nurse. Nevertheless, obesity is a chronic disease and living with obesity is complex; therefore, patients could benefit from multi‐professional care. The study contributes to a deeper understanding of the psychosocial aspects of obesity, which could help clinical nurses to better care for patients with obesity, within the team. By focusing on the determinants of behaviour, and not the behaviour itself, care for patients with obesity can become more effective. Patient resources and strengths must be acknowledged and encouraged in the process of helping them adopt healthy lifestyle habits. Furthermore, by increasing the knowledge of living with obesity, the results of this study can contribute to ending weight stigmatisation, in both health care and society.

7. AUTHOR CONTRIBUTIONS

Study design, data collection, data analysis and article writing: AI; study design, data analysis and manuscript review: JK and SJ; study design, data analysis and manuscript review: AAC; final version of the manuscript: All authors.

9. CONFLICTS OF INTERESTS

No conflict of interest has been declared by the authors.

10.

Supporting information

Appendix S1

8. ACKNOWLEDGEMENTS

We would like to express our gratitude to all participants who agreed to share their experiences with us. Thanks to the ‘Step by step’ group leader for assistance in recruiting the participants.

Imhagen, A. , Karlsson, J. , Jansson, S. , & Anderzén‐Carlsson, A. (2023). A lifelong struggle for a lighter tomorrow: A qualitative study on experiences of obesity in primary healthcare patients. Journal of Clinical Nursing, 32, 834–846. 10.1111/jocn.16379

Funding information

The authors received financial support from University Health Care Research Center, Region Örebro County, Örebro, Sweden

10.1. DATA AVAILABILITY STATEMENT

The authors elect to not share data for confidentiality reasons.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1

Data Availability Statement

The authors elect to not share data for confidentiality reasons.


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