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. Author manuscript; available in PMC: 2017 Jun 1.
Published in final edited form as: Psychiatr Rehabil J. 2016 Apr 7;39(2):137–146. doi: 10.1037/prj0000182

Perceptions of Strategies for Successful Weight Loss in Persons with Serious Mental Illness Participating in a Behavioral Weight Loss Intervention: A Qualitative Study

Roza Vazin 1, Emma E McGinty 2, Faith Dickerson 3, Arlene Dalcin 4, Stacy Goldsholl 5, Meghan Oefinger Enriquez 6, Gerald J Jerome 7, Joseph V Gennusa III 8, Gail L Daumit 9
PMCID: PMC4900940  NIHMSID: NIHMS767310  PMID: 27054900

Abstract

Objective

The purpose of this study was to describe perceptions of weight loss strategies, benefits, and barriers among persons with serious mental illness who lost weight in the ACHIEVE behavioral weight loss intervention.

Methods

Semi-structured interviews with 20 ACHIEVE participants were conducted and analyzed using an inductive coding approach.

Results

Participants perceived tailored exercise sessions, social support, and dietary strategies taught in ACHIEVE – such as reducing portion sizes and avoiding sugar-sweetened beverages – as useful weight loss strategies. Health benefits, improved physical appearance, self-efficacy, and enhanced ability to perform activities of daily living were commonly cited benefits of intervention participation and weight loss. Some participants reported challenges with giving up snack food and reducing portion sizes, and barriers to exercise related to medical conditions.

Conclusions and Implications for Practice

There is emerging evidence that behavioral weight loss interventions can lead to clinically meaningful reductions in body weight among persons with serious mental illness. The perspective of persons with serious mental illness regarding strategies for, benefits of, and barriers to weight loss during participation in behavioral weight loss programs provide insight into which elements of multicomponent interventions such as ACHIEVE are most effective. The results of this study suggest that tailored exercise programs, social support, and emphasis on non-clinical benefits of intervention participation, such as improvements in self-efficacy and the ability to participate more actively in family and community activities, are promising facilitators of engagement and success in behavioral weight loss interventions for the population with serious mental illness.

INTRODUCTION

The prevalence of obesity among persons with serious mental illness, e.g. schizophrenia and bipolar disorder, is nearly twice that of the overall US population (Allison et al., 2009; Daumit et al., 2003; Dickerson et al., 2006; McElroy et al., 2002). Elevated obesity among persons with serious mental illness is driven by multiple factors, including physical inactivity, unhealthy diets, and the obesogenic effects of certain psychotropic medications (Allison et al., 1999; Daumit et al., 2005; Dipasquale et al., 2013; Jerome et al., 2009; Lieberman et al., 2005). Rates of overweight and obesity in this population contribute to a high burden of medical conditions such as hypertension, diabetes mellitus, dyslipidemia, and cardiovascular disease among those with serious mental illness (Bresee, Majumdar, Patten, & Johnson, 2010; Carney, Jones, & Woolson, 2006; McGinty et al., 2012).

Although there have been many effective behavioral weight loss interventions in the general US population (Franz et al., 2007), comparable interventions for persons with serious mental illness have only recently been developed and evaluated (Gierisch et al., 2013; McGinty, Baller, & Daumit, 2014). To help this population lose weight, interventions need to be tailored to address the unique challenges faced by persons with serious mental illness, including deficits in memory and executive function and residual psychiatric symptoms, which can make it difficult for this group to learn and adopt new behaviors (Casagrande et al., 2010; Daumit et al., 2013). A growing body of literature, including several recent randomized controlled trials (Bartels et al., 2013; Daumit et al., 2013; Green et al., 2015; McGinty, Baller, & Daumit, 2014), suggest that tailored behavioral weight loss interventions can lead to clinically significant weight loss among persons with serious mental illness. The present study examines consumer perceptions of The Randomized Trial of Achieving Healthy Lifestyles in Psychiatric Rehabilitation, or ACHIEVE, an 18-month tailored behavioral weight loss intervention for persons with serious mental illness implemented in 10 psychiatric rehabilitation center outpatient programs in Maryland. The ACHIEVE intervention, which was designed to fit within the psychiatric rehabilitation framework, incorporates concepts from social cognitive theory, behavioral self-management, and the relapse prevention model. These models directly informed the ACHIEVE intervention components, described below (Casagrande et al., 2010). From baseline to 18-month follow-up, thirty-nine percent of ACHIEVE participants in the intervention group lost more than 5% of their initial weight, compared to 23% of control group participants (Daumit et al., 2013). Five percent weight loss can be considered one clinically relevant measure of weight change. Modest levels of weight loss of only a few pounds can decrease cardiovascular risk by lowering risk for diabetes and reducing systolic blood pressure, thus decreasing mortality from coronary heart disease and stroke (Stamler et al., 1989; Tuomilehto et al., 2001).

While ACHIEVE and other tailored behavioral interventions have been shown to lead to weight loss and/or improved physical fitness among persons with serious mental illness (Bartels et al., 2013; Gierisch et al., 2013; Green et al., 2015; McGinty et al., 2014), less is known about consumers’ perceptions of such interventions. Improving our understanding in this area is a critical step in moving successful behavioral weight loss interventions into standard practice. Participation of consumers in the planning, implementation, and evaluation of such interventions is widely acknowledged as a core part of the recovery-oriented systems of care for persons with serious mental illness (Dixon et al., 2010; Partners For Recovery, 2010; Sheedy, 2009). Understanding which intervention components participants felt were most useful in helping them achieve behavior change and weight loss could inform the development and spread of future interventions. Multicomponent, high-intensity interventions such as ACHIEVE are expensive and challenging to translate with fidelity into daily community practice. Consumers’ perceptions of what works could provide important guidance for the development of equally effective but more parsimonious interventions.

The present study builds on multiple prior studies that have primarily focused on consumers’ perceptions of the barriers to and facilitators of changing dietary and physical activity behavior and related weight loss (K. Aschbrenner et al., 2013; Aschbrenner, Mueser, Bartels, & Pratt, 2013; Cabassa, Siantz, Nicasio, Guarnaccia, & Lewis-Fernandez, 2014; Galletly & Murray, 2009; Glover, Ferron, & Whitley, 2013; Graham, Griffiths, Tillotson, & Rollings, 2013; Klingaman, Viverito, Medoff, Hoffmann, & Goldberg, 2014; Kwan et al., 2014; Lesley & Livingood, 2015; Leutwyler, Hubbard, Slater, & Jeste, 2014; McDevitt, Snyder, Miller, & Wilbur, 2006; Roberts & Bailey, 2011; Schneider, Sullivan, & Pagoto, 2011; Shiner, Whitley, Van Citters, Pratt, & Bartels, 2008; Soundy, Stubbs, Probst, Hemmings, & Vancampfort, 2014; Ussher, Stanbury, Cheeseman, & Faulkner, 2007; Van Metre, Chiappetta, Siedel, Fan, & Mitchell, 2011). Common barriers and facilitators have emerged across studies, many of which are also present in the literature on weight loss in the general population. For example, social support from peers, family members, and intervention leaders is a consistent facilitator to behavior change and weight loss success among those with serious mental illness (K. Aschbrenner et al., 2013; K. A. Aschbrenner et al., 2013; Cabassa et al., 2014; Glover et al., 2013; Graham et al., 2013; Klingaman et al., 2014; Lesley & Livingood, 2015; Leutwyler et al., 2014; McDevitt et al., 2006; Roberts & Bailey, 2011; Ussher et al., 2007). Psychiatric symptoms, fear of stigma and discrimination, environmental factors such as lack of access to healthy food and safe neighborhoods to exercise in, and low self-efficacy are barriers to weight loss frequently cited by those with serious mental illness (Cabassa et al., 2014; Glover et al., 2013; Graham et al., 2013; Klingaman et al., 2014; Lesley & Livingood, 2015; Leutwyler et al., 2014; McDevitt et al., 2006; Roberts & Bailey, 2011; Ussher et al., 2007), as well as by the clinicians and interventionists who work with this group (Galletly & Murray, 2009; Kwan et al., 2014; Soundy et al., 2014).

The current study uses qualitative research methods to examine consumers’ perceptions of strategies for successful weight loss, benefits of intervention participation, and barriers to weight loss among a convenience sample of ACHIEVE participants who successfully lost weight during the intervention. This study builds on the prior research in three main ways. First, we focus on perceptions of the intervention among a subset of participants who successfully lost weight. With a small number of exceptions, including qualitative studies of participants in another recent RCT-tested behavioral intervention (In SHAPE) (K. Aschbrenner et al., 2013; Shiner et al., 2008), most prior studies have examined consumers’ perceptions of weight loss strategies, barriers, and facilitators among samples with varied weight loss experiences (K. A. Aschbrenner et al., 2013; Cabassa et al., 2014; Eldridge et al., 2011; Glover et al., 2013; Graham et al., 2013; Klingaman et al., 2014; Leutwyler et al., 2014; McDevitt et al., 2006; Ussher et al., 2007; Van Metre et al., 2011). Second, we examine consumers’ perceptions of specific elements of the multicomponent ACHIEVE intervention in order to begin to understand which weight loss strategies included in the intervention participants found most helpful. Most prior studies on this topic focus on barriers to and facilitators of weight loss, as opposed to perceptions of RCT-tested intervention strategies (Cabassa et al., 2014; Glover et al., 2013; Graham et al., 2013; Klingaman et al., 2014; Leutwyler et al., 2014; McDevitt et al., 2006; Roberts & Bailey, 2011; Ussher et al., 2007). Finally, we study participants’ perceptions of an intervention designed and implemented in psychiatric rehabilitation programs. To our knowledge, only one other qualitative study has examined consumers’ perceptions of behavioral weight loss interventions implemented in this setting (McDevitt et al., 2006).

METHODS

Intervention

The ACHIEVE trial was a randomized, two-arm, parallel multi-site clinical trial of an 18-month behavioral weight loss intervention. Detailed descriptions of the intervention were published previously (Casagrande et al., 2010; Daumit et al., 2013). The main intervention components were group weight-management sessions, individual weight management sessions, and group physical activity sessions. The intervention included environmental prompts, self-monitoring tools, and positive reinforcement. The ACHIEVE intervention promoted six healthy behaviors: avoiding sugary drinks, avoiding junk food, eating five servings of fruits and vegetables every day, portion control, developing smart snack habits, and regular physical activity (Daumit et al., 2013). The primary clinical outcome of the ACHIEVE trial was change in weight from randomization to 18 months.

ACHIEVE intervention components – including three 50-minute group aerobic exercise sessions per week – took place on-site at the psychiatric rehabilitation programs that participants were already attending. To tailor the weight loss program to persons with serious mental illness ACHIEVE utilized cognitive adaptations such as dividing information into small components and using frequent repetition in both exercise and weight management sessions to increase participants’ comprehension and self-efficacy. In addition, the intervention incorporated environmental prompts such as pre-printed grocery shopping lists. (Casagrande et al., 2010; Daumit et al., 2013).

Study Participants

During the exit interview for the ACHIEVE trial, a convenience sample of intervention group participants who lost weight during the study were offered the option to participate in semi-structured interviews about their experiences in the study. We began by conducting and analyzing 20 interviews in order to determine whether theoretical sufficiency (i.e. no new information emerging from the data) (Andrade, 2009) could be achieved with this sample size or whether we needed to interview additional participants in order to adequately capture the breadth of their perspectives. As theoretical sufficiency was achieved after the first round of interviews, the study included 20 individuals from six psychiatric rehabilitation program sites. Institutional review boards at Johns Hopkins University and Sheppard Pratt Health System approved the study. All participants provided written informed consent.

Data Collection

ACHIEVE intervention staff used a semi-structured interview protocol to conduct interviews at the psychiatric rehabilitation center study sites. The protocol was designed to elicit responses to three primary research questions that align with the study goals: (1) Which strategies did participants with serious mental illness perceive as facilitators of successful weight loss? (2) How did participants’ perceive the benefits of participation in a behavioral weight loss program? (3) What barriers to weight loss did ACHIEVE participants who lost weight have to overcome on the road to weight loss?

The 20–30 minute interviews began with three ‘grand tour’ questions designed to elicit participants’ open descriptions of their experiences: “How do you feel about your health?” “Has/how has losing weight changed your life?” and “What did you learn in ACHIEVE?” Following these questions, the interview guide turned to researcher-driven questions directly related to the study’s aims (Table 1). Protocol questions were intended as guiding questions and interviewers had the flexibility to follow-up on responses and prompt for additional information as needed. With participants’ permission, all interviews were audiotaped and transcribed.

Table 1.

Semi-Structured Interview Protocol Questions

Grand Tour Questions
How do you feel about your health?
Has/how has losing weight changed your life?
What did you learn in ACHIEVE?
Researcher-Driven Questions
What do you believe were the keys to your success in losing weight?
If you were to tell someone how to lose weight, what would you tell them to do?
While you have been in the ACHIEVE study, what do you feel is your biggest accomplishment?
What were some of the challenges in losing weight?
Since losing weight as part of the ACHIEVE program…
 • Has/how has your quality of life changed at home?
 • Has/how has your employment changed?
 • How do you feel about your body?
Has/how has your experience at the psychiatric rehabilitation program changed?
How do you plan to continue to maintain your weight loss after ACHIEVE?
What would you change about ACHIEVE to make it better?
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Data analysis

Three authors (EEM, GLD, MOE) used an inductive coding approach (D. R. Thomas, 2006) to analyze interview transcripts. The authors reviewed transcripts and created a list of initial themes (N=62) that emerged from the data. They next developed a coding dictionary that captured the content of interest. Transcripts were then manually coded and codes were ordered and categorized using Microsoft Excel. Subsequently, through review of the codebook and re-review of the transcripts, the authors grouped individual themes into larger categories until a set of key themes (N=19), was identified. Member checks (by EEM, GLD, and MOE) were conducted to affirm the validity of themes. Any discrepancies were resolved by discussion among the three coders. All final themes were based on consensus.

RESULTS

The demographic characteristics of the 20 ACHIEVE participants who were interviewed are summarized in Table 2. The mean age of participants was 46 years. The majority of ACHIEVE participants (75%) had a primary diagnosis of schizoaffective disorder (45%) or schizophrenia (30%). The mean baseline weight of the men in the study was 219.5 pounds (SD 50.5), and the mean baseline weight for women was 209.4 pounds (63.7). The average weight loss in the study sample of 20 participants was 15.5 pounds, ranging from 1 to 40 pounds, with a standard deviation (SD) of 9.9 pounds. The mean weight loss for men was 18.7 pounds (SD 11.1), and the mean weight loss for women was 12.3 pounds (SD 7.9).

Table 2.

Demographic Characteristics of Study Participants (N=20)

Frequency (%)
Gender
Male 10 (50)
Female 10 (50)
Age (years)
20–39 6 (30)
40–54 8 (40)
55–70 6 (30)
Race
White/Caucasian 14 (70)
Black/African American 6 (30)
Education
Not a High School Graduate 8 (40)
High School Graduate 9 (45)
Some College 3 (15)
Primary Diagnosis
Schizoaffective Disorder 9 (45)
Schizophrenia 6 (30)
Major Depression 3 (15)
Bipolar Disorder 1 (5)
Other Diagnoses 1 (5)
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The key themes that emerged in response to the study’s three primary research questions are presented in Table 3. Descriptions of key themes and illustrative quotes are provided in the text below.

Table 3.

Key themes from interviews with study participants (N=20)

Interviews in which theme was mentioned (N, (%))
Strategies for weight loss
Specific dietary strategies 16 (80)
 Change portion size/consume small portions 11 (55)
 Reduce consumption of sugary products 10 (50)
 Drink more water 7 (35)
 Consume more fruits and vegetables 6 (30)
 Prepare food at home 6 (30)
Tailored, scheduled exercise sessions 8 (40)
Staying active outside of scheduled exercise sessions 7 (35)
Social support 8 (40)
Hard work and perseverance 6 (30)
Benefits of participating in the intervention
Improved physical appearance 10 (50)
 Fitting into clothes 5 (25)
Improved self-efficacy 7 (35)
Improved ability to perform activities of daily living 6 (30)
Health-related benefits 11 (50)
 Strength 6 (30)
 Increased Endurance 4 (25)
 Feeling better overall 4 (20)
Attended psychiatric rehabilitation program more frequently 4 (20)
Felt proud 4 (20)
Barriers to weight loss
Giving up snacks and junk food 3 (15)
Inability to participate in exercise due to medical conditions 2 (10)
Controlling portion size 2 (10)
Eating at night 1 (5)
Losing confidence 1 (5)
Medication-related appetite 1 (5)
Cost 1 (5)
Attendance 1 (5)
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Strategies for Weight Loss

ACHIEVE participants described several aspects of the tailored intervention that helped them lose weight and maintain their weight loss, including learning specific dietary strategies; tailored exercise sessions; and social support. Reducing portion sizes was identified as an important dietary strategy that facilitated weight loss. Of the 20 participants who were interviewed, 11 perceived reducing portion sizes as a significant reason for their success in losing weight. “I guess people offering me smaller portions and…and then me…me leaving it at that and not going back for more and things like that.” It is clear from participant interviews that repeated exposure to messages about the six healthy behaviors promoted in ACHIEVE led respondents to perceive that these strategies played an important role in their weight loss. “Out of everything I’ve learned from you guys I would say three things – eat smaller portions, drink lots of water, and exercise more.” Another participant shared: “I’ll drink more water and less soda… and eat smaller portion sizes.”

In addition to changes in portion size, many participants perceived other dietary strategies promoted in the intervention as helpful. Participants noted that in addition to learning about what foods to avoid (e.g., sugary products) identifying and preparing healthy foods, such as fruits and vegetables, helped them lose weight. “I think it’s a checklist of what you can eat because mostly when I wanted to lose weight in the past it was always what you can’t eat, and not enough of what you could eat and not how to eat. So I think that’s helped me a lot.” One participant commented on the multi-faceted aspect of the intervention, and the importance of learning dietary strategies to facilitate weight loss in addition to exercise: “…when I came into the program, I wasn’t expecting to learn about the portions, sizes, food, what to eat, what not to eat. I was thinking it was just going to be a program where you come in and do exercise.”

Participants emphasized the importance of tailored exercise sessions for weight loss success. “You know exercise can be a fun thing. It’s healthy, you know, at maintaining weight for a person that really wants to go all the way…you’re in a group, you know, and you’re--and you’re having fun. --I’ve really--I--I notice it’s--it’s a different class. It’s a different program where I can be myself, you know. I’m--you know I’m me, and you know I--I’m having fun with a group of people and I’m exercising and it makes it all worthwhile, you know.” In addition, seven of the 20 participants interviewed mentioned staying active outside of class as a reason for their successful weight loss. “And just keep getting up in the morning and keep moving—keep your body moving and walking. It was—it was a change and then coming to the class and exercising and then going to the gym, it was a lot of work. And it was –it was a big challenge.” The fact that the exercise program was tailored to persons with serious mental illness was important to participants. “And the fact that you keep moving and it didn’t matter how you moved and things were slow and catered to somebody that doesn’t do things quickly or understand quickly, I liked that a lot.”

ACHIEVE participants mentioned the social support obtained during group exercise participation as an important facilitator of weight loss. “The number one key thing that helped motivate me in general was the ACHIEVE staff there and also the –others encourage…”Of the 20 participants who were interviewed, eight stated that social support helped them lose weight. “And we’re [a] supportive group. We all work close with each other to continue going to class, continue exercising—even when days—when we didn’t feel up to it.” Another participant stated: “… it was good to be in a group and lots of people were very supportive of us and stuff. You know I think when somebody you know is going to be in there, so you can pull through, you know, and do it.” In addition, participants mentioned that hard work, perseverance, and good communication with health care providers were factors that helped them lose weight.

Perceived Benefits of Participating in the Intervention

ACHIEVE participants noted four main categories of benefits from participation in the intervention and weight loss: including positive improvements in physical appearance, self-efficacy, ability to perform daily activities, and health. Among the participants interviewed, 50% mentioned that they felt that the weight loss they achieved during the intervention improved their physical appearance. “Losing weight has changed my life just because everybody knows my appearance is different. My clothes fit me better. That’s it; my clothes fit me better. My appearance is more healthy; that’s all.” Multiple participants mentioned that seeing improvement in how their clothes fit was an important indicator of success. “Oh it’s changed it a lot because I can go in the store now and buy –pick up a size and –and know when I go in the dressing room it’s going to fit. Before I couldn’t go in there: you know I’d just get disgusted, you know. Now I want to go to the store and shop. Before, you know, you know, I couldn’t go in there. Your stomach blow up and you, you know, you can’t fasten this. You’re squeezing in that and oh man, but I’ve—I’ve lost some inches and I could tell the difference, you know, in my weight.”

Of the 20 participants, 35% said that intervention participation improved their self-efficacy to exercise and/or make healthier food choices, and 20% specifically mentioned that their successful weight loss made them feel proud that they achieved a goal and improved their confidence. “And secondly I’m doing it healthy. I’m--I’m doing a good thing for myself, you know. And I mean I--I just want to, you know, be healthy and I want to--I want to live a good long life. And I think I’ve really accomplished that.” For many participants, committing to the program, completing the intervention, and changing their behavior gave them a sense of accomplishment. “You want – you want to be able to say yeah; I finished; I went through ACHIEVE you know 18 months and I lost this amount of weight, you know.”

Many ACHIEVE participants stated that their weight loss improved their ability to complete activities of daily living. “My dad has finished a new portion of the deck he’s building and together, me and him, we’re putting up the wood.” “I can bend over easier now and I have more stamina from losing all of that weight.” Another participant shared, “It was hard for me to bend over and pick up things but I can now.” One participant mentioned improved mobility in the neighborhood as a benefit of weight loss, “Just talk to more people and go places, just walk around the neighborhood. I’m able to walk more.” Another participant mentioned a newfound ability to exercise with his/her family: “Well my niece asked me…I said let’s go to exercise. We both do it and my sister joined in and she said that’s good. It helps me more motivated and plus it helps me do a lot of good things for myself like riding a bike, going to the gym.”

Many ACHIEVE participants cope with health issues such as diabetes, high blood pressure, chronic lung disease and arthritis, and during the interviews several mentioned that the weight they lost enhanced their physical health. One participant mentioned improved control of diabetes: “To lose weight and get healthier and by losing weight and to get healthier, to limit soda helped – health issues, like pre diabetic, and that has like gone down because before I started the sugar was all high and now when they test it’s down in the normal range” Another discussed improvements in mobility and energy as benefits of weight loss. “My health is even better, you know. I get out and sometimes I could walk--I could walk to the store. Before I couldn’t go to the mall and just walk around. I could go to the mall now and walk around. Before I go in one store and that’s it. I got to go home. I’d be so tired you know. But it gives you energy; it--it--you know it’s been giving me a lot of energy that I didn’t have, you know with ACHIEVE because when you’re exercising you’re building up; you know you’re building your strength up really, you know.” Participants also mentioned feelings of pride as a benefit of intervention participation.

Barriers to Weight Loss

In contrast to perceived strategies for achieving weight loss and numerous benefits of participating in the ACHIEVE intervention; participants mentioned relatively few barriers to weight loss. Several participants reported having a hard time giving up snacks and junk food. “And then, you know, we used to love those cookies and Doritos and I can’t have them no more. I mean not that you can’t but, you know, you may---like you’re being trained by the – by the instructors and things like that.” Two participants cited inability to exercise because of other (non-obesity) medical conditions as a barrier. “The exercise was the biggest challenge because I have arthritis.” Another participant shared, “For me I hardly lose weight at all. It takes a lot; I have thyroid trouble and…—it affects everything. So I just wanted to do the best I could for myself.” Trouble reducing portion sizes was also mentioned. “You know it was hard for me at first, you know, the portions, eating the right size portions because, you know, you got something good up there. You ain’t trying to—and then you’re talking about a—a palm full. Now who is going to eat a palm full of something, especially when you don’t –you’re used to eating large portions, you know? That was the main thing, cutting back on the portions.” Other barriers, mentioned by only one participant, included the difficulty of changing eating habits - “Actually the hardest thing was –it wasn’t the exercise, walking, it was the food” – and lost confidence due to discouragement from other people, “And many people will be trying to knock me down and telling I’m not worth it and it isn’t going to help me. So I leave that alone. I don’t listen to people who are trying to – giving me negative stuff.” There were participants who also mentioned medication-related appetite, cost of healthy food, and intervention attendance requirements as barriers to weight loss.

Plans for Maintaining Weight Loss

In addition to our three primary research questions, we also explored participants’ plans for maintaining weight loss after completion of the ACHIEVE clinical trial. Participants principally mentioned carrying forward the specific strategies they learned in the ACHIEVE intervention. For example, participants mentioned plans to continue the healthy eating behaviors adopted as a result of participating in ACHIEVE. “Eat healthier, eat fruits and vegetables, exercise, and be positive that I can lose the weight and I will lose the weight and –and do those things and ---I---I—I am bound to see a change in my life.” Another participant stated, “Well I just continue to try and eat better. I’m trying to cut down on my sugar drinks now because I figured out the amount of sugar in the drinks is bad for my diabetes.” In addition, participants mentioned that the long-term nature of the 18-month ACHIEVE intervention helped them to develop behavior patterns that they plan to maintain in the future. “You’re doing the same thing, but you already got a pattern. You see what I’m saying? You—you got a pattern. You all done laid—laid the—laid the work out for us…but you got to continue that pattern.”

DISCUSSION

Study results suggest that the tailored behavioral strategies used in ACHIEVE were effective in helping participants internalize the study’s behavioral weight loss messages. The most frequently mentioned strategies for weight loss, including specific dietary strategies such as changing portion size and reducing consumption of sugary products, aligned directly with the content of the intervention. Importantly, many participants mentioned that the tailored group exercise sessions helped with weight loss (Glover et al., 2013).

Exercise classes designed specifically for persons with serious mental illness may be an important component of effective behavioral weight loss interventions for this group. This was suggested by participants who emphasized the value of an exercise class where new concepts were introduced gradually and where, “it didn’t matter how you moved and things were slow and catered to somebody that doesn’t do things quickly or understand quickly…” This finding regarding the importance of tailored exercise strategies for persons with serious mental illness is consistent with the findings in qualitative studies of In SHAPE intervention participants with serious mental illness. In SHAPE involved one-on-one fitness training and nutrition counseling tailored to meet consumers’ needs (Bartels et al., 2013), and in a 2008 study of In SHAPE, Shiner and colleagues concluded that consumers perceived the individual tailoring of the fitness training as an important component of achieving weight loss and fitness goals (Shiner et al., 2008).

In addition to the perceived benefits of tailored exercise classes, the results of our study also showed that ACHIEVE participants perceived social support from intervention leaders and their peers as an important facilitator of weight loss. This finding aligns with a large body of prior research showing that social support is an important facilitator of behavior change generally, and weight loss specifically, in the population with serious mental illness (K. Aschbrenner et al., 2013; K. A. Aschbrenner et al., 2013; Lesley & Livingood, 2015; Ussher et al., 2007; Van Metre et al., 2011). Qualitative studies of participants in the In SHAPE intervention have shown that participants perceive support from heath-promotion employees and fitness trainers to be key facilitators to meeting weight loss and fitness goals (K. Aschbrenner et al., 2013; K. A. Aschbrenner et al., 2013; Lesley & Livingood, 2015; Shiner et al., 2008). In a 2013 study, Aschbrenner and colleagues found that In SHAPE intervention participants who succeeded in losing weight and/or improving fitness had higher levels of mutual support from family members or significant others, compared to participants who did not lose weight or improve fitness (K. Aschbrenner et al., 2013). Social support from peer group leaders was also identified as an important intervention component in a qualitative case study of two Diabetes Prevention Program (DPP) participants with serious mental illness (Schneider et al., 2011). While social support as a key component of behavioral weight loss is a consistent theme in studies to date, it is still largely unclear whether certain types (e.g. emotional, practical, mutual) and sources (e.g. peers, family members, intervention leaders) of social support are more beneficial than others. Future consumer-centered research in this area is needed.

The growing literature on social support as a key component of efficacious lifestyle interventions for persons with serious mental illness suggest that settings such as psychiatric rehabilitation programs, which cater to persons with serious mental illness and provide opportunities for social support from peers, may be an optimal setting in which to implement behavioral weight loss interventions. Such programs can provide opportunities for the development of meaningful supportive relationships between program staff and consumers, who often attend multiple days per week. Further, psychiatric rehabilitation is a core component of recovery-oriented systems of care and the program focuses on many of the non-medical benefits – such as self-efficacy and ability to perform activities of daily living – that consumers report as benefits of participation in efficacious lifestyle interventions like ACHIEVE. The present study is not the first to identify the potential of this type of setting to deliver effective lifestyle interventions. McDevitt and colleagues found that consumers viewed psychiatric rehabilitation programs as a safe and comfortable setting in which to participate in physical activity interventions (McDevitt et al., 2006). In a 2015 study examining consumer perspectives on the sustainability of fitness activities following In SHAPE intervention participation, Lesley et al found that, among the participants who were studied, all of those who continued fitness activities after intervention completion were members of a psychosocial rehabilitation clubhouse with staff members who were supportive of the In SHAPE program and who provided transportation to fitness activities as needed (Lesley & Livingood, 2015). Lesley and colleagues also found that participants were more likely to report barriers to physical activity in the absence of programming to support long-term maintenance, suggesting that sustainment of behavior change adopted through ACHIEVE and other lifestyle interventions for persons with serious mental illness may require ongoing programmatic support in settings frequented by persons with serious mental illness. Further work is needed to explore the potential for psychiatric rehabilitation programs to provide ongoing, long-term behavioral interventions. Due to the episodic nature of serious mental illness, some individuals may cycle in and out of psychiatric rehabilitation programs. Collaborative efforts between psychiatric rehabilitation programs and other community organizations to deliver and sustain evidence-based behavioral interventions warrant additional study

Notably, the most frequently mentioned benefits of participating in the ACHIEVE intervention were not medical. This is consistent with prior research by Graham et al, who found that consumers’ conceptualized a healthy lifestyle within a broad framework that, in addition to healthy eating and exercise, included friendship, employment, safe housing, and spiritual and emotional good health (Graham et al., 2013). While some participants in the present study did mention improvements in strength and endurance and ‘feeling better’ as a result of the intervention, ACHIEVE participants were as or more likely to mention improvements in physical appearance, self-efficacy, and ability to perform activities of daily living than medical benefits such as weight loss or improved management of co-morbid medical conditions like diabetes. Participants’ perception of improved self-appearance as a key benefit of intervention participation seemed to be tied to both a sense of accomplishment and improved self-confidence. Relatedly, participants consistently mentioned improved self-efficacy regarding their ability to maintain a healthy diet, exercise, and lose weight as a benefit of ACHIEVE participation. In addition, participants with serious mental illness described the value of participating in the ACHIEVE behavioral weight loss intervention in terms of its effects on their daily activities, e.g. one participant described getting a raise at his/her job due to improved ability to work longer hours and bend over to lift things when needed. The value participants placed on non-health benefits of the intervention suggest that future interventions should consider emphasizing and measuring these outcomes in addition to the weight loss and cardiovascular risk factor changes commonly measured in clinical trials of behavioral weight loss interventions. Consumers’ perceptions of non-medical benefits, such as self-confidence and improved activities of daily living, have also emerged in prior qualitative studies of lifestyle intervention participants with serious mental illness. For example, one study of In SHAPE intervention participants found a perceived connection between their physical improvement and a feeling of self-confidence and self-efficacy (Shiner et al., 2008). Emphasis on these types of non-medical benefits of participation in behavioral weight loss interventions could have important implications for improving consumers’ engagement with and sustainment of intervention activities.

Some of the strategies for and benefits of weight loss described by ACHIEVE participants mirror those experienced by persons without serious mental illness, including social support as a motivator of participation in physical activity and perceived non-medical benefits of weight loss in terms of improved energy, appearance, mobility, and confidence (K. Aschbrenner et al., 2013; Roberts & Bailey, 2011; Shiner et al., 2008). Some of the barriers described by persons with serious mental illness, such as: low self-confidence, co-morbid medical conditions such as arthritis that may make it difficult to exercise, and cost, are also applicable to many individuals without serious mental illness (Sabinsky, Toft, Raben, & Holm, 2007). Highlighting these similarities is not meant to imply that persons with versus without serious mental illness can benefit from identical behavioral weight loss interventions. While weight loss strategies in the two groups revolve around the same behaviors, diet and physical activity, it is clear from the existing literature and the results of the present study that specific intervention strategies, such as exercise programs, should be tailored for persons with serious mental illness.

Limitations

The results of this study should be interpreted in the context of several limitations. Study participants were a convenience sample of a larger group of ACHIEVE participants who lost weight as a result of the intervention and are not representative of all ACHIEVE participants or all persons with serious mental illness. As the goal of our study was to understand the perspectives of individuals with serious mental illness who successfully lost weight in a behavioral weight loss intervention, the subset of ACHIEVE participants who did not lose weight was not interviewed. Examining the perspectives of persons with serious mental illness who fail to lose weight through participation in a behavioral weight loss program could provide important insights into the barriers faced by these participants. This information could inform the development of new interventions to better address these barriers and should be considered as a topic for future research.

Another potentially important limitation is the possible influence of social desirability bias on results. Interviews were conducted by ACHIEVE study staff who were known to participants. Therefore, participants may have provided answers they thought would please the interviewers. This may be one reason for the paucity of barriers to weight loss described by ACHIEVE participants, although this could also be due to the fact that our convenience sample included persons who successfully loss weight through ACHIEVE. Further, ACHIEVE participants were interviewed immediately following intervention completion. The ACHIEVE intervention was designed to overcome barriers to lifestyle change in persons with serious mental illness, and at the time of the interviews this group had likely not yet encountered barriers to sustaining learned behavior change and weight loss strategies outside the context of the RCT. In a 2015 study, Lesley and colleagues found that In SHAPE participants were more likely to report barriers to physical fitness nine months following program completion than they were toward the end of intervention participation (Lesley & Livingood, 2015).

CONCLUSION

There is emerging evidence that behavioral weight loss interventions can lead to clinically meaningful reductions in body weight among persons with serious mental illness. To move such interventions out of the trial setting and into standard community practice, it will be important to investigate which specific elements of multicomponent interventions such as ACHIEVE are most effective. The results of the present qualitative study suggest that persons with serious mental illness perceived the dietary and physical activity-based weight loss strategies taught in ACHIEVE as helpful, that social support is an important facilitator of weight loss among persons with serious mental illness, and that participants with serious mental illness felt that they accrued multiple health and non-medical benefits from intervention participation. Future studies of behavioral weight loss interventions for serious mental illness should assess and incorporate participants’ perspectives regarding key strategies for weight loss.

Contributor Information

Roza Vazin, Email: Rvazin1@jhu.edu, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 2024 East Monument Street, Room 2-620, Baltimore, MD 21287.

Emma E. McGinty, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Faith Dickerson, Department of Psychology Sheppard Pratt, Baltimore, MD.

Arlene Dalcin, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Stacy Goldsholl, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Meghan Oefinger Enriquez, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Gerald J. Jerome, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD Department of Kinesiology, Towson University, Towson, MD.

Joseph V. Gennusa, III, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Gail L. Daumit, Welch Center for Prevention, Epidemiology, and Clinical Research, Division of General Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.

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