A qualitative investigation of the need for and feasibility of weight loss programs on university campuses

Abstract

Background:

Despite the public health significance of overweight and obesity, weight management has remained a low priority for health-related programming on university campuses.

Objective:

Investigate the need for and feasibility of implementing university-based weight loss programs.

Methods:

The Practical, Robust Implementation and Sustainability Model (PRISM) was used as a framework. Semi-structured individual interviews were conducted with fifteen university staff and students from two large U.S. universities in the Northeast and Mid-Atlantic. Interviews aimed to assess readiness, preferences, characteristics, barriers and facilitators in each of the four adapted PRISM domains: 1) Organizational and Recipient (Student) Perspectives on the Intervention, 2) Recipient (Student) Characteristics, 3) Internal Environment (organizational characteristics and infrastructure), and 4) External Environment. Verbatim transcriptions were analyzed using inductive and deductive thematic analyses. Themes were extracted as outlined by Consensual Qualitative Research.

Results:

Participants supported university-based weight loss programs, but recognized barriers of resources, coordination across entities, and competing health issues taking priority for school programming. Campus built environment and students’ busy schedules were identified as barriers to maintaining healthy weight and participation in weight loss programs.

Recommendations included designing weight loss programming with a positive and holistic approach, minimizing weight-stigma, ensuring support from university leaders and students, and securing external funding.

Conclusions:

The identified themes provide recommendations for universities looking to develop and implement weight loss programming.

Introduction

Over the past few decades, the prevalence of overweight and obesity in the U.S. has continued to rise (Wang et al., 2020). According to the 2018 national Behavioral Risk Factor Surveillance System, 26% of young adults aged 18–24 years were classified as having overweight (body mass index (BMI) 25 – 29.9 kg/m²), while 18% were classified as having obesity (BMI >30 kg/m²) (U.S. Centers for Disease Control and Prevention, 2021). Similar prevalence is observed when examining colleges students specifically (American College Health Association, 2019). Other national data indicate even higher rates among slightly older young adults, with approximately 60% of young adults aged 20–34 years classified as having overweight and obesity (U.S. Centers for Disease Control and Prevention, 2019). Obesity has been associated with increased risk of cardiovascular diseases, type 2 diabetes, and certain types of cancer (U.S. Centers for Disease Control and Prevention, 2021). Further, research has identified longitudinal associations between obesity and psychological consequences, such as depression, body dissatisfaction, and low self-esteem. This body of research has posited that shared biological processes between obesity and mental health, as well as experiences of weight-stigma, may explain these associations (Gibson et al., 2017; Milaneschi et al., 2019; Quek et al., 2017).

The college years are a critical time for shaping weight-related behaviors and preventing weight gain (Racette et al., 2005). Unhealthy weight-related lifestyles adopted in college tend to persist into adulthood (Desai et al., 2008), and those with obesity at a young age are at high risk of having obesity through adulthood ( Sanyaolu et al., 2019; Ward et al., 2017). Research among college students also suggests that the majority do not meet the recommendations for physical activity and healthy diet (American College Health Association, 2019). Extant research has identified a number of intrapersonal, interpersonal, and environmental barriers to weight management among college students, including unhealthy eating habits, low motivation to exercise, stress, busy student schedules, lack of social support around healthy eating and physical activity, and limited access to healthy food on campus (Greaney et al., 2009; Johnson et al., 2018; Smith-Jackson et al., 2012; Vella-Zarb et al., 2009).

University-based weight loss services have the potential to address these barriers and reduce obesity during the transition from the college years to adulthood. Given that almost 17 million young adults were enrolled in colleges or universities in 2019 (National Center for Education Statistics, 2021), campus-based health promotion programs have the opportunity to reach large numbers of young adults. Further, many students are living away from their parents or guardians for the first time, presenting an opportunity for universities to help instill healthy habits as students learn to live on their own (Plotnikoff et al., 2015).

Despite these opportunities, the provision of weight loss services on university campuses has been deemphasized compared to other health services such as risky sexual behaviors, substance use, eating disorders, and victim services (Sparling, 2007; Lynch et al., 2016). For example, as of October 2013, only 3 out of the 10 largest public universities in the U.S. offered weight loss programming specific for undergraduate students (Lynch et al., 2016). While many small-scale obesity intervention studies show promising effects in changing college students’ weight-related behaviors and BMI status (e.g., Gow, Trace, & Mazzeo, 2010; Napolitano et al., 2013), there is a paucity of evidence assessing the feasibility and sustainability of scaling up such programs to larger university populations. Implementation barriers such as limited student engagement, staffing, and funding may exist and influence the efficacy and effectiveness of weight loss programs (Kelleher et al., 2017). Additionally, weight loss programs may also face unique barriers to implementation and sustainability, including competing health priorities and weight-stigmatization (Lynch et al., 2016).

The objective of the present qualitative study was to investigate the feasibility of implementing and sustaining weight loss programs on university campuses using the Practical, Robust Implementation and Sustainability Model (PRISM) framework. The PRISM framework was developed by Feldstein and Glasgow to guide the translation of effective interventions into implementation in real world settings (Feldstein & Glasgow, 2008). Originally conceived to integrate research findings into practice within medical settings, the PRISM framework has a series of domains for consideration: 1) Intervention, which contains the perspective of the organization as well as the recipient; 2) Recipient Domain, which contains the characteristics of the organization and the recipient where and for whom the intervention would be implemented; 3) External Environment, which includes forces and entities outside of the intervention setting; and 4) Implementation and Sustainability Infrastructure, or infrastructure that would need to be in place for the intervention to be implemented and sustained in the future (Feldstein & Glasgow, 2008). Guided by this framework, researchers interviewed key stakeholders at two large U.S. universities to gain insight into organizational and student perspectives, organizational and student characteristics, and environmental factors related to implementing and sustaining university-based weight loss services to inform their eventual development, implementation, and scale-up.

Methods

Study participants included university staff and student leaders recruited from two large U.S. universities (>15,000 undergraduate and graduate students enrolled): one public university located in the Northeast and one private university in the Mid-Atlantic. Researchers identified potential participants as university staff and administrators involved with student engagement or residential life, student health services, and campus nutrition and recreation. Student leaders included student representatives to student government or associations. The researchers considered restricting student recruitment to those with overweight or obesity, given that an existing or hypothetical weight loss program would be targeted to this population. However, in our conceptualization of this study as informed by the PRISM model, we realized that the focus was on the characteristics of the program recipients (i.e., students) as a whole, on which a more general sample of university leaders, administrators and students could comment. The PRISM model was developed to provide a framework for understanding the impact of innovations within health care practices, although it also has applicability to other settings in which health interventions are implemented, such as schools. They authors (Feldstein & Glasgow) outlined the levels of personnel from whom feedback should be obtained: “top leadership, midlevel managers and “frontline staff, i.e., clinician/support staff’. Given the suggested categories did not correspond directly to a university setting, they were adapted to include administrative and student leaders and managers or program directors who might have oversight of a program or be on the frontlines of administering a weight loss program. Given the different administrative structure across the two campuses, two authors ((MN and JW) met to discuss the categories and find comparable offices/personnel. Staff and students from both universities were invited via email to participate in one-on-one interviews with a member of the research team. A total of 15 interviews were completed between November 2018 and February 2019. Interviews lasted between 30 and 60 minutes each. Participants included key leaders of university residential and housing services (n=3), health and dietitian services (n=5), athletic and recreational services (n=2), and student activities and engagement services (n=2). Interviews were also conducted with university students who were in leadership positions in student organizations (n=2 undergraduate students and n=1 graduate student). Ten participants were staff or students from the private university and 5 were staff or students from the public university. All participants provided verbal informed consent prior to participating in the interview. The study protocol was approved by one of the participating university’s Institutional Review Board.

Figure 1 illustrates the PRISM domains and subdomains as adapted for application to a university-based weight loss program. For this qualitative investigation, the researchers examined the following PRISM domains: 1) Intervention (perspectives of organization (i.e., university) and recipients (i.e., students) on the weight loss program), 2) Recipient (Student) Characteristics (characteristics of the student that influence adoption of a weight loss program), as well as 3) Internal (i.e., university) and 4) External Environment characteristics that influence adoption and sustainability of a weight loss program in university settings. For the purpose of this study, the researchers combined the PRISM domains of Implementation and Sustainability Infrastructure and Recipient Organizational Characteristics into a new combined domain, Internal Environment, as there was considerable overlap. Given that neither university had an existing wight loss program at the time of data collection, findings related to subdomains of organizational culture, staffing, training, and program sustainability (from the Recipient Organizational Characteristics domain in the original PRISM framework) also spoke to the subdomains within the Implementation and Sustainability Infrastructure domain, which included dedicated team, training and support, protocols and procedures, and plan for sustainability (Feldstein & Glasgow, 2008). Overlap in these subdomains were observed as participants considered infrastructure and other characteristics of the university (i.e., internal) environment needed for a hypothetical weight loss program.

Figure 1:

An adaptation of the PRISM for weight loss programming on university campuses

Semi-structured interview questions were designed around these domains and aimed to explore 1) readiness, preferences, and perceived barriers and facilitators to implementing a weight loss program from the organization and student perspectives and 2) characteristics of the students, internal environment, and external environment that would impact the implementation and sustainability of a weight loss program. Table 1 presents example interview questions within each adapted PRISM domain and subdomain. Each participant was asked all interview questions, regardless of their role at the university, to maintain consistency. Author (MB) was trained in qualitative methods for health research and conducted all interviews in order to further ensure consistency across the interviews. All interviews were audio recorded and transcribed verbatim by other members of the study team.

Table 1.

Example interview questions, codes, and code categories by PRISM domain and subdomain (adapted from Feldstein & Glasgow, 2008)

Domain	Subdomain	Example Interview Questions	Code	Category*
Intervention: Organizational Perspective	Readiness of key leader to adopt	How important is weight loss programming to you and your student population? What programs exist to address weight loss?	Organizational attitudes towards program	Variant
			Priority of weight loss services	General
			Willingness to implement weight loss services	Variant
	Strength of evidence base	What do you know about the issue of obese and overweight students on college campuses? Is obesity a problem on your campus?	Knowledge about obesity	Typical
			Knowledge about eating disorders	Variant
			Weight loss as a health issue	Typical
	Burden (complexity and cost)	What resources are currently available for implementing weight lo ss services? Are there resources that could be availab1e for implementing weight loss services?	Availability of existing research programs	Variant
			Availability of existing university-sponsored programs	Variant
			Intervention complexity	Variant
			Intervention cost	Variant
Intervention Recipient (Student) Perspective	Intervention delivery preferences	Thinking about weight loss programs that are in-person vs technology-based: which do you think would be more successful on your campus?	Preferred program content	Variant
			Preferred program format	General
	Perspective about the intervention	Where should this program be housed? What are the barriers to having this program housed in these contexts? What institutional challenges exist for helping students lose weight?	Preferred program location	Typical
			Barriers to participating in program	Typical
			Facilitators to participating in program	Variant
Recipient (Student) Characteristics	Skills±	What do you perceive as barriers for students to maintain healthy weight or lose weight?	Individual barriers	Variant
	Knowledge and Beliefs±
	Social norms±
	Competing demands	What do you see as institutional challenges that exist for helping students lose weight?	Barriers to participating in program	Typical
Internal Environment	Dedicated team	What resources would be needed to implement a weigt loss program?	Availability of staff	Typical
			Staffing needs	Typical
	Training and support	What staff training would be needed to support a weight loss program?	Training	Variant
	Protocols and procedures	What would be the steps to create a program like this that would have its own center?	Funding	Typical
			Policies/programs that hinder	Variant
			Policies/programs that support	Variant
			Other resources/infrastructure that hinder	Typical
			Other resources/infrastructure that support	Typical
External Environment	Competition	How are other health services like alcohol education or sexual abuse counseling funded at your university?	Competition - other university health services	Typical
			Competition - other university weight loss services	Variant
	Regulatory en ironme it	Is there any legal or regulatory risk to having a university-sponsored weight loss program?	Regulatory restrictions	Typical
	Community resources	What does the university student health insurance plan offer in terms of weight loss services?	Community weight loss resources	Typical

^*General = code present in 100% of transcripts; typical = code present in at least 50%, but less than 100% of transcripts; variant = code present in less than 50% of transcripts

^±Emergent subdomains. The original interview guide did not include questions to specifically assess these subdomains. However, the semi-structured design of the interview guide enabled the interviewer and study participants to explore these topics as they came up naturally during conversation.

Members of the research team analyzed the interview transcripts using both inductive and deductive thematic analyses (Graneheim et al., 2017) using the Dedoose qualitative analysis software (Dedoose, 2018). The deductive, or concept-driven, method was appropriate given our use of an existing framework to guide our research, while the inductive method allowed for the possibility of identifying new themes that may not fit within the framework. Following steps outlined by Hill and colleagues (1997, 2005) for Consensual Qualitative Research (CQR), the analysts started with a list of domains, subdomains, and codes that were derived from the PRIMS framework (Table 1). These domains, subdomains, and codes made up the initial codebook and an iterative process was used to expand the codebook as more themes were revealed in the data. Analysts extracted the core ideas presented within the interview transcripts. The goal of extracting core ideas is to distill the data down into a “format that is concise, clear, and comparable across cases” (Hill et al., 2005). Core ideas were extracted by two analysts and reviewed for accuracy and consistency by the entire study team. Following the identification of core ideas, two analysts assigned codes to each core idea and any discrepancies were resolved through discussion between the analysts or the entire study team. Codes were then categorized based on how frequently they appeared in that data. Categories included general (code present in 100% of transcripts), typical (code present in at least 50%, but less than 100% of transcripts), or variant (code present in less than 50% of transcripts). The CQR method increases the reliability of study findings by incorporating the use of multiple coders and analyzers and relying on group discussion to resolve disagreements. Reliability is also increased through the process of identifying and reporting frequency counts of themes to increase transparency (Green & Thorogood, 2014; Hill et al., 2005). All analysts had received previous training in qualitative methods for health research and were trained in CQR methods specifically prior to performing data analyses by studying existing literature (e.g., Hill. Thompson, & Williams, 1997; Hill et al., 2005) and through guidance from author (MN) who has prior experience using this method for qualitative research (57).

Results

PRISM Domains Applied to Weight Loss Programming

Findings are discussed within the four adapted PRISM domains: 1) Intervention, 2) Recipient (Student) Characteristics, 3) Internal Environment (organizational characteristics and infrastructure), and 4) External Environment. Quantification classifications (i.e., general, typical, variant) for each theme are shown in Table 1. Themes also are described relevant to recommendations for developing, implementing, and sustaining a weight loss program (Table 2). We provide verbatim quotes that exemplify common themes along with participants’ leadership area and whether they were from the public or private university.

Table 2.

Intervention and infrastructure recommendations for implementing and sustaining university weight loss program

Intervention	Quotes
Content: Frame the program in a positive way and marketed as an overall health and well-being program; include competitive components and metrics to track; combine mental health components or group sessions.	I think students are a lot more attracted to the “get fit”, you know, “be the best you ” sort of thing more so than, “I’m overweight and need help ”. They tend to pursue more of the, oh thaťs a more attractive way to approach it, I’ll go to something that kind of focuses on the positive side of it more so than acknowledging a deficit or need. Student Engagement, Private University
Format: Implement the program based on a combination of technology-based and in-person formats.	I think probably a hybrid might be cool. Like leťs say you did an initial meeting with the clinician and nutritionist and maybe check-in meetings, but then you did use some of the apps which a lot of my friends, n gh ors and relatives use the apps to track calories and activity and I know it’s--I think thaťs a great resource for people who want to feel better and who want to lose weight in a healthy fashion. Student Engagement, Private University
Complexity: Tailor weight loss programs specific to each individual’s needs.	It canť just be a one size fits all, it has to be combined with how you’re eating, how you are exercising and also your overall mindset on what it means and what your goals are. Student Housing, Private University
Cost: Be supported by external funding rather than limited internal funding.	I think if iťs going to come from internal funds, given lots ofplaces where we need to put resources, I donť think we’re going to add [anything]new before we necessarily fix some things that need fixing, that may be broken. Student Housing, Private University
Infrastructure
Staffing: Have a well-rounded team with clearly defined roles focused on all the aspects related to weight loss and a coordinator who maintains connections with stakeholders.	So of course, I value my role as a dietitian, however iťs really valuable to have folks that specialize in exercise, folks that are more in the mental health aspect. So, you kind of have that team and someone may not need to see everybody, but you have those resources. Athletics and Recreation, Private University
Training: Provide minimal training to staff who have experiences in weight loss programs and student outreach.	I think our clinicians and the mental health clinicians--we’ve referred [students] to weight loss programs or to dieticians, or we counsel people on healthy weight loss as part of our practice, so I donť feel like our staff would need intensive orientation to it. Student Health, Private University
Support: Have support from both university leadership and university students.	I think almost anything that’s successful, you need the buy-in of the students. So something thaťs presented to the Student Association or works with different student groups, I think will help to get things rolling as far as people being aware of them and wanting to utilize them. Student Health, Private University You have to look at the infrastructure and I think iťs on the radar screen of the president and some of the other executives at the university, but I think the entire university has to be behind this. Student Engagement, Private University
Location: House the program in a place with no concerns about privacy and weight-stigma, like the health center.	There definitely would not be any room to put this, if this is a legitimate physical center, in our gym. But, if you ’re thinking like confidentiality, definitely with our health services since that’s more private and confidential than an open gym. Undergraduate Student, Public University
Policies and Procedures: Develop meal plans where students have healthy food options; post nutrition information in on-campus dining facilities.	There are many issues, but as an institution, why we cannot offer a place or a couple of places where the students can go and have good options at a relatively low cost and make good [nutritional food choices]. Student Health, Private University

Intervention: Organizational Perspective

Findings regarding overweight and obesity as health issues on campus were mixed. Several participants who were university staff from both the public and private university did feel that it was a significant health issue among university students. Other staff participants reported that they were unaware of how significant an issue obesity is on their campus, with several noting a lack of surveillance data on the topic.

I have no inkling about what percentage of students might be obese or affected by issues like that. Yeah, I really couldn’t tell you. I just know the larger studies and things you read in the [local newspaper] health section about obesity and how rampant it is among teens and adolescence, and I assume college students too. I think the topic I know more about is bulimia and anorexia among students. So I must say I had no inkling about what the obesity rate would be among [university] students. I really couldn’t tell you.

Student Engagement, Private University

[The year] 2013 is the last time we did this survey [on overweight and obesity], which is a long time. We would have done it every 4 years, but last year we did healthy minds instead, which didn’t look at eating, it was specific to mental health.

Student Health, Public University

By contrast, student participants from both universities did not perceive overweight/obesity to be an issue on campus.

See personally, I don’t think there is a huge problem, just from me being able to see it. I would think that, like, most people are pretty healthy and when I think of like obese, I’m thinking people that are, like, very large.

Undergraduate Student, Public University

The vast majority of study participants from both universities expressed willingness to support a weight loss program. There was general support for teaching university students healthy behaviors that would continue into later adulthood, and participants recognized the long-term health consequences associated with overweight and obesity. However, one participant who worked in student health services at the private university disagreed due to a belief that college-aged populations were not appropriate targets for weight loss interventions as their bodies are still changing, and believed that BMI indicators of overweight or obesity are not accurate measures of an individual’s health status.

I don’t focus on weight loss of college students because I think it’s inappropriate. They’re still at a young age and they’re still growing, so I can’t know for sure what their healthy set point might be. But if I do see that they’ve had a rapid weight gain or something has happened that has caused differences in their body size or their health, then I think that’s relevant for me to focus on. But if somebody came to me just in a larger body and said that they wanted to lose weight, I would have a lot of questions about other health promoting behaviors we could focus on that wouldn’t include calorie counting or simply assuming that food is the issue.

Student Health, Private University

Participants from both universities were consistent, however, in terms of their perceptions of obesity as a low priority health issue on campus, particularly compared to issues around mental health, substance use, and sexual health.

I think that for the university, and I do understand coming from a safety or security point of view, mental health or self-harm would be number one for disorderly conduct, behavioral issues. Alcohol as a drug issues is also—that they will put more effort than for a weight loss program.

Student Health, Private University

Participants were asked to describe any existing university-sponsored weight loss services. None of the participants were aware of university programming or services that were specifically dedicated to student weight loss.

I’ll be honest with you, I haven’t seen anything related to any weight loss or physical fitness type thing.

Graduate Student, Private University

Instead, participants mentioned facilities and services available on campus that may contribute to weight loss, such as the availability of fitness facilities, group fitness classes, and personal training sessions. However, the cost of the group fitness classes and personal training sessions prohibited some students from using these services.

What comes to mind for me with regard to the challenges are, I can say first off that the few folks that have reached out to me through [the fitness facility], cost is almost always an obstacle. I just, I have my own fee scale. However, that tends to be, honestly, the number one feedback that I hear, that they thought it was a free service.

Athletics and Recreation, Private University

In terms of available services, study participants also mentioned weight-related medical assessments and nutrition counseling provided by student health facilities, health fairs, and other health promotion education programs, and the availability of athletic teams and club sports that could support student weight loss. In discussions on these available programs and services, participants highlighted that none were advertised to students as a weight loss program. A few participants also mentioned awareness of a National Institutes of Health-funded research trial which was recruiting on campus, either due to direct involvement with the program, or because they had referred students to the program.

I’m unaware of any such services other than I think one of the professors in [the school of public health] asked me to push out a message about, I think probably the study. But I know very little, so if a student were to come to me, I’d probably first just refer them to the [health center] and talk with one of the doctors. I do know there’s a nutritionist on staff at [the health center] so I probably refer the student to the nutritionist. But I’m unaware of any sort of coherent program at [the university]. So, I’d probably refer them to an individual rather than a centralized site or specific program per say.

Student Engagement, Private University

Participants from both universities often cited funding as an issue for implementing a weight loss program. Several participants mentioned possible funding through grants and thought university leadership would be more supportive of a program that had external funding than a program that relied on internal funding.

In terms of adding [new programming] at this point, to what we’re already doing, it would probably have to come along with funding because we just don’t have the capacity.

Student Health, Public University

Intervention: Recipient (Student) Perspective

Study participants from both universities talked about the need for a weight loss program to be framed in positive way and as one that would improve students’ overall well-being, as opposed to highlighting the negative consequences of overweight and obesity. The intervention complexity was noted in that health care providers don’t often bring up weight issues with patients, perhaps due to weight-stigma, and that weight loss programs cannot be a “one size fits all”; they need to be tailored specific to each individual.

I think these types of initiatives that focus on student well-being, you know, holistically, work really well. I think overcoming, for many students at least here at [the university], I think that there’s a lot of pressure and stigma that they place on themselves. And so, again, I think when I would talk about the barriers, being students not necessarily even wanting to acknowledge or kind of take that step towards. If it’s a weight loss program, I would just say whatever program or initiative is developed is targeted and focused more on the fitness positive, get in shape messaging more so than the weight loss.

Student Engagement, Private University

In terms of delivering a weight loss program, most study participants from both universities thought a combination of technology-based and in-person programming would be best. Benefits of the technology-based approach cited by participants included ease of access, acceptance by students who are familiar with technology, convenience, inclusion of features such as calorie counting, avoidance of the weight-stigma associated with going to a physical location, and less resource intensive. Benefits of an in-person approach included the ability to provide students with individualized weight loss plans, accountability, the opportunity to address depression and loneliness that can accompany overweight/obesity, and the opportunity to provide motivation. Some participants suggested a program that had an initial in-person session followed by technology-based programming. Some participants mentioned using technology to meet with providers through video chat. Participants also noted that combining mental health components through reoccurring group sessions focused on mindfulness and stress management would be helpful.

It seems like the social media things – I mean that’s just sort of their world right now and I think they’d be comfortable with that. But I think there are some [students] that, you know, want the motivation of working either one-to-one or in a group situation.

Student Health, Private University

I know that more and more of these students are really using technology for their health care information and for their actual health care. But I think that sometimes students that are overweight, they also have an issue of isolation and/or depression that has to be addressed also in more of a comprehensive way. Maybe that could be long distance therapy or technology assisted therapy. But it seems to me that it has to be more than information.

Student Health, Private University

Recipient (Student) Characteristics

Characteristics of students that emerged from the data as barriers to maintaining a healthy weight or losing weight were consistent across the two universities and included limited skills and motivation, social norms, and misperceptions around a number of topics related to a healthy weight. Participants mentioned that students often have limited skills for preparing healthy foods. Additionally, several participants highlighted the transition to college, during which students have increased responsibilities and busy schedules, contributing to weight loss and other healthy behaviors being a low priority. Students also may have misperceptions in terms of what foods and behaviors are healthy, as well as misperceptions around body image. A few participants also mentioned alcohol use as a normative behavior on university campuses presents a barrier to maintaining a healthy weight due to the excess calories consumed.

I’m not sure that it’s so much of a lack of knowledge. I find that in this day and age there’s so much stuff out there and so much stuff online that they can…I sort of feel like they know more of what they should eat, but that they just don’t have the time or maybe the motivation or, if they’re particularly overweight I think it’s hard for them to know where to start. And the younger students often have never had to supply their own food. They’ve walked into a house where a parent or caretaker or guardian or somebody supplied the food. So, I think that a lot of those things are challenging for them. And the social part for those who are doing well socially, sometimes they do a lot of eating late at night while they’re studying and so there’s not a real… there’s not a real sort of plan. I believe the biggest problem [is] that they, sort of, don’t take control; they let the environment control them.

Student Health, Private University

In terms of barriers to student participation in weight loss services, the cost of program participation and weight-stigma attached to obesity and weight loss were highlighted as significant challenges by most interview participants. Additionally, the ability to capture the attention of students, who have busy schedules and are exposed to many messages across multiple mediums, was mentioned as a challenge to student participation in a weight loss program.

I think the other piece of it is, there’s going to be a stigma with someone walking into a weight loss center, in terms of their peers and [the] social stigma of it. That sort of comes to mind as being [an] issue because weight is a big part of one’s identity.

Student Engagement, Private University

[Another barrier] I would say, just in dealing with college students in general, is time and balancing [program participation] around their schedule, between classes and academics and any other extracurricular activities they do.

Athletics and Recreation, Public University

A lot of [students] have to balance school with full time or close to full time work and so they’re overwhelmed with messaging. Whether it be like through e-mail or text message marketing or, you know, all college campuses have marketing for all kinds of things posted everywhere, and so people I think are seeing [and] just become numb to it all because they have so much on their plate.

Student Housing, Public University

Internal Environment

Participants discussed the environmental barriers within the university that students face in losing weight or maintaining a healthy weight. Participants from both universities mentioned a lack of sufficient fitness facilities to accommodate the student population. Access to healthy food was also seen as a barrier, with many fast food options available on or around campus, limited calorie and nutrition information provided in university dining facilities, and the higher cost of healthy foods compared to less healthy foods.

[The] fitness center… we don’t have enough [space]; I don’t think we have enough actual facilities square foot-wise to accommodate the size of the population that we have on campus, so I think that’s an obstacle. I also think just that the actual food options on the campus aren’t very diverse.

Athletics and Recreation, Public University

One participant who worked in student engagement at the private university also mentioned the lack of coordination between the university fitness facility and the school of public health, limiting the university’s ability to provide coordinated and holistic programming to students.

Well I think one of the institutional challenges at [the university] is this fact that our health center and [school of public health] are sort of separate entities and in separate silos. I don’t think there’s a lot of collaboration that goes on, so I think that’s one barrier. The people who are either experts or practitioners in the field are not talking, at least my perception is they’re not talking a lot.

Student Engagement, Private University

Additionally, one participant felt the university did not provide students with sufficient information on weight loss.

I think students who are seeking weight loss information have no sense of where to go. And then because everything is sort of disjointed, different websites there’s not really a centralized website that can help students who might be looking for apps and also expert knowledge to help them with weight loss plans.

Student Engagement, Private University

In terms of internal environmental barriers for implementing a weight loss program, participants from both universities noted the low organizational priority for obesity treatment resulting in a lack of financial resources available for such services.

Money is a huge issue. And I know, just from sitting in meetings talking about budget, the [university] doesn’t have a lot of it.

Undergraduate Student, Public University

Honestly, our biggest challenge is resources. I mean we’re an under-resourced campus and we have significant long-standing debt issues.

Student Housing, Public University

Participants also noted issues with staffing and space.

Space, I mean when we don’t have a lot of space, you know. So it would be finding a space big enough to be able to do [a weight loss program]. It is tight.

Student Housing, Private University

External Environment

Participants reported on factors in the external environment (i.e., outside the university) that may impact the feasibility of implementing and sustaining a weight loss program on campus. Participants from both universities had low awareness of any possible regulatory restrictions that may apply when designing and implementing a weight loss program on a university campus. Participants also had limited awareness of the student health care insurance’s coverage of weight loss services. A few participants noted that weight-related medical services, such as lab work, are covered under the health plan. Some participants from both the public and private university also mentioned that the student health care plan offered discounts to local, non-university sponsored weight loss programs, such as WW® (formerly Weight Watchers®). Participants also mentioned students may be referred to non-university providers within the community who specialized in weight loss.

I don’t [know if weight loss services are covered under the student health insurance plan]. I know that there’s nutrition services that I believe are included within that, but I don’t know specifically within those if weight loss is part of that.

Student Engagement, Private University

[The student health insurance plan does] offer a discount plan, one of those wellness add-ons where they can get a discount to Weight Watchers or something like that.

Student Health, Public University

Our providers on the general medicine side will make the appropriate referrals to dieticians and nutritionists. We do not have, at this time, either of those on our staff in our health services. We have information on our website about healthy eating, and that’s really it.

Student Health, Public University

Recommendations for Implementing and Sustaining Weight Loss Program

Study results elucidated several recommendations for the design of a weight loss program in university settings, as well as the infrastructure needed to support and sustain it (Table 2).

Intervention

Several participants, both staff and students, highlighted the importance of framing a weight loss program in a positive way and as one that would improve students’ overall well-beings, as opposed to highlighting the negative consequences of overweight and obesity. Participants also noted the importance of addressing other correlates of overweight and obesity, such as mental health and stress, and providing students with access to a team of experts to address all the determinants of their health and well-being. Consistent with this, participants also noted the importance of providing students with a program that is tailored to their specific needs. A few interview participants also suggested programs that involve competition or use metrics to track individuals’ progress would be appealing and motivating to students. In terms of the format of a weight loss program, the majority of participants felt a combination of a technology and in-person aspects would be most successful. Given the significant barrier of financing a weight loss program due to limited university funds and competing health priorities, a few interview participants from both universities suggested grant funding as a potential funding mechanism.

Infrastructure

Interview participants discussed the infrastructure needed to implement and sustain a weight loss program in terms of staffing, staff training, university support, the physical location of the program, and policies and procedures. In line with findings regarding the importance of providing a holistic approach to weight loss, several participants from both universities mentioned the need for a multi-disciplinary team to address all aspects of a student’s health and well-being. While only two participants talked about staff training needs, both did not think additional training would be needed. The participants noted that the medical staff and health promotion staff have been adequately trained in providing care to students and performing outreach to promote programs and services. Multiple participants highlighted the need to have support from the university leadership, as well as from the student body, in order for a program to be successfully implemented and sustained. Several participants discussed possible locations for a weight loss program or dedicated center, with many highlighting the need for privacy given the weight-stigma associated with overweight and obesity. Almost all participants who discussed the program location felt the university health center would be an appropriate location to house a weight loss program. Finally, a few participants from both universities noted the need for the universities to provide greater access to healthy food options, as well as provide more nutritional information in university dining facilities, in order to support student weight loss.

Discussion

The current study used the PRISM framework to explore the feasibility of implementing and sustaining a university-wide weight loss program. With the exception of one participant, both staff and student participants from the two universities consistently supported the development and implementation of a weight loss program for university students. Findings were also consistent across participants’ roles within the university, with no systematic differences observed in perspectives across participants’ leadership areas (e.g., student health, housing, athletic/recreation). While the original interview guide was designed to assess factors related to program implementation and did not include questions to assess barriers for maintaining a healthy weight or losing weight among university students, this topic was repeatedly addressed by study participants, highlighting the salience of such barriers when considering weight loss programming. These barriers identified in the current study were consistent with those reported in prior research (Greaney et al., 2009; Johnson et al., 2018; Smith-Jackson et al., 2012; Vella-Zarb et al., 2009), and included limited skills for preparing healthy food, limited access to healthy food options on campus, social norms around alcohol consumption, and low motivation for weight loss given competing demands.

Despite participants’ reports of limited data on the prevalence of overweight and obesity at their university, there was widespread support for a university-wide weight loss program. This is consistent with the view that universities have an opportunity to be transformational not only in terms of education, but also in terms of the health and overall development of their students through embedding health and wellness into campus policies (Amaya et al., 2019). This opportunity for improving the health of young people through university programming is recognized by efforts such as the American College Health Association’s Healthy Campus initiative which has set objectives for health priorities among students and administrators that include nutrition, physical activity, and weight status (American College Health Association, 2020). This initiative also highlights the importance of assessing the health needs of university students (American College Health Association, 2020). These assessments and communication regarding the results and implications is an important step, as while universities may participate in these assessments, key administrators may not routinely learn the prevalence of overweight and obesity on their campus. Routine assessments and results reporting may assist university administrators in making decisions to ensure student health needs are being adequately met.

Results also indicate strong agreement across study participants that weight loss was a low priority issue as compared to issues related to mental health, substance use, and sexual health. As these health issues may more directly and immediately impact students’ health and well-being, as well as academic success, they may be seen by university administrators as priority issues for university programming. Competing priorities has also been identified by other researchers as a barrier to sustaining obesity prevention programs (Lee et al., 2021). Program implementers may find success in promoting prioritization of weight loss programming by using data to describe the need and highlighting the university years as a window of opportunity wherein students can learn healthy weight management habits that can prevent obesity and the negative health sequalae that follow. Another possible method for increasing the priority of weight-loss services could be to incorporate them into existing priorities (Lee et al., 2021). For example, layering weight-loss services on top of existing mental health services could help address these often cooccurring conditions, as well as elicit support from university leadership given the high priority given to mental health services.

Given the lack of existing weight loss services and programs at the two participating universities at the time of data collection, participants were often required to consider a hypothetical weight loss program when responding to interview questions and, therefore, focused most often on the barriers to program implementation, or the reasons why there were no existing programs. The primarily reasons that emerged included limited funding and weight loss as a low priority health topic for campus administrators in comparison to other health issues. This is consistent with findings from other researchers in their assessments of the barriers to implementing school-based health promotion programs (Dwyer, 2003; Harbison, 2008; Langley, 2010; Lee et al., 2021). In addition to campus-level barriers for implementation, individual-level barriers were also identified for students’ participation in a weight loss program. Consistent with other research on weight loss programs for young adult populations (LaRose, 2016; Sabharwal, 2018), we found low motivation and limited time for engaging in weight loss activities were commonly reported barriers. The present study also identified cost as a barrier for students to maintain a healthy weight, given the high cost of healthy foods and fitness classes or personal training sessions, for example. The finding of cost as a barrier to weight loss or healthy weight maintenance is consistent with extant literature (e.g., Hilger-Kolb & Diehl, 2019; Kosma & Buchanan, 2018; McVay et al., 2018). Weight loss programming that can be no cost to students and funded by a mechanism external to the university would likely generate greater support from both university administrators and students.

Issues around weight-stigma were frequently mentioned by study participants as potential barriers to gaining support for a weight loss program from both university administrators and students. There are a few areas embedded in these weight-stigma comments. First, a focus solely on weight loss rather than in the context of overall health can intersect with concerns regarding disordered eating or endorsing an unrealistic body shape or size. One participant who worked in student health services at the private university held the belief that college-aged populations were not appropriate targets for weight loss interventions given they were “…still at a young age and they’re still growing.” Further education is needed regarding safe and effective weight loss methods for those with excess weight (Fitzpatrick et al., 2016; Jensen et al., 2014; National Institutes of Health, 2013) and the health benefits of modest weight loss (Cefalu et al., 2015) and prevention of future weight gain (Wing et al., 2017). Second, weight-stigma and body-related shame is associated with depressive symptoms (Brewis & Bruening, 2018) and can be a barrier to student participation in physical activity or weight loss programming due to embarrassment (Lucibell et al., 2020). Providers also may not be aware of screening and referral language that is free from weight bias (Puhl et al., 2017, 2020). Participants cited the importance of holistic approach to addressing overweight and obesity with a focus on the positive aspects of improving overall health and well-being, and considering privacy and student comfort when identifying a location to house a weight loss program.

In addition to identifying barriers to implementing weight-loss programing, the current study also elucidates factors that may facilitate the creation and sustainability of such a program on a university campus. These recommendations are consistent with those identified through other researchers’ assessments of obesity prevention programs (Cheney et al., 2020; Lee et al., 2021) and include the importance of programming that is adaptable, identification of a sustainable funding source, collaboration across multiple stakeholders, and support from university leadership. Coordination and collaboration among university administrators and students, as well as other university and community stakeholders, in the development and implementation of a weight loss program could help ensure programs are tailored to the specific needs of the student population and that there is support for such programs.

Participants also provided their recommendations in terms of the format for delivering content for a weight loss program, with many participants recommending an approach that includes, at least in part, technology-based content. Not only are young people likely using technology like computer and smartphone to look up health information (Jacobs, Amuta, & Jeon, 2017; Park & Kwon, 2018; Rideout & Fox, 2018), but the recent coronavirus disease (COVID19) pandemic has increased the necessity for health intervention content to be accessed through technology. Findings from the current study as also consistent with extant research suggesting that technology-based weight loss programming would be accepted by young adults (Stephens et al., 2015) and effective for weight loss (Wang & Abrahamson, 2020). University leadership should explore technology-based interventions as cost-effective and acceptable weight loss approaches for students.

The findings from this study should be interpreted within the context of a few limitations. First, the PRISM framework was designed to examine implementation within a health care setting; although mapping the categories to a hypothetical intervention on a university campus had some challenges, the researchers believe the framework is still useful for organizing and interpreting the data. Second, data analysis included categorizing codes as general, typical, or variant depending on how frequently they emerged in the data. Some codes were closely tied to specific interview questions, and their frequency within the data may be less related to how salient the topic was for participants, but instead, due to the inclusion of a specific interview question. Additionally, findings may be biased due to the study sample. The small sample size that is common in qualitative studies may result in findings that do not capture the full range of existing opinions. However, the researchers attempted to minimize this risk by systematically sampling participants from all relevant units on campuses. Additionally, the sample size was sufficient to represent the categories identified by the authors of the PRISM framework (Feldstein & Glasgow, 2008). Further, the current study triangulated findings across the two universities and the multiple divisions within the universities, finding consistency in what participants reported, suggesting saturation (Boddy, 2016). Of note, those who were the lead or heads of a department or unit were occasionally difficult to schedule for interviews, so team members who reported to those individuals were occasionally interviewed as the representative from that unit. Results from these interviews, therefore, may not represent the opinions of the university leader, but instead, a key member of their team. In addition, researchers were only able to recruit 3 students to participate, limiting the researchers’ ability to make conclusion about student perspectives. Finally, results from this study come from 2 large universities located in urban areas on the east coast of the U.S. Due to the scope of the study and complexity of recruiting high-level university leaders, it was not feasible to include additional universities in the current study. As a result, some findings may be less applicable to schools of different sizes or with different student demographics, as well as those in different geographic locations. While the present study did not identify differences in perceptions between the students and staff of the two universities, additional research using a larger and more diverse sample of schools may reveal how school characteristics influence perceptions around weight loss programming.

Identifying ways to implement weight loss programming in university settings where health promotion resources may be limited is a challenge, as university administrators are often faced with prioritization of other immediate health risk needs such as mental health, sexual violence, and substance abuse. Identifying alternative funding opportunities or collaborations, such as partnerships with faculty experts or existing health programming on campus, may increase universities’ ability to establish weight loss services, without diverting funds allocated to other critical student health services. Tracking trends in the burden of overweight and obesity among student populations, as well as trends in the usage of available weight-related services would provide metrics to university officials looking to assess need. The findings from this study highlight the importance of a multidisciplinary team to address the conditions of overweight and obesity, as well as buy-in from both students and staff from across the university. Establishing coalitions of university students, staff, and administrators, as well as other stakeholders (e.g., university food suppliers, athletics and fitness facilities, community weight loss resources, obesity researchers) may find success in identifying existing and potential resources needed to provide weight loss programming to meet the needs of university students.