Faculty Mentor: Tanya Halliday (Health and Kinesiology, University of Utah)

 

ABSTRACT

The prevalence of overweight and obesity has increased in recent decades and is casually related to multiple adverse health outcomes. One area that needs further investigation is weight regain that follows planned weight loss because less than one third of adults who intentionally lose weight are able to maintain 5% weight loss during the course of one year. The inability to maintain weight loss is a major setback to individuals aiming to lose weight. The purpose of this study was to gather information about the factors that influence weight regain following planned weight loss in an effort to create an individualized adaptive intervention plan based on patient feedback. METHODS: Adults (n=25; Age: 43.32 ± 20.76; BMI: 36.55 ± 9.63) who achieved a minimum of 7% body mass reduction in the two years prior to filling out the screening questionnaire and subsequently experienced weight regain completed assessment of anthropometrics (height and weight) and a structured qualitative interview. Interviews were recorded and transcribed verbatim to allow for the coding of factors that affected weight loss maintenance. RESULTS: Participants specified that facilitators for weight loss maintenance were an intentional focus on diet and exercise and having a consistent routine, while the barriers included life events, lack of time, mental health, and stress. Specific preferences for a weight loss maintenance program, included having an expert on nutritional information such as a dietitian involved in the program. Individuals also thought the use of a mobile application would be convenient way for the program to be delivered and desired a contact frequency individualized to their specific needs. The primary advantage of the adaptive intervention approach that was expressed was individualization and the main barriers were potential cost and time needed to participate. CONCLUSIONS: There are various barriers that individuals face in aiming to maintain weight loss including diet, intentional maintenance of a new routine, life stressors, and mental health. Individuals desire the delivery of a program from an educated individual who has experience helping others lose weight, such as a dietitian. An adaptive intervention approach could be a viable option for weight loss maintenance because of the individualization to the individual, though interviewees were skeptical of the results, cost, and time needed to participate in such a program.

INTRODUCTION

The prevalence of obesity and overweight has increased globally over recent decades and doubled since 1980. In the United States nearly one third of adults are overweight and approximately two in every five adults have obesity or severe obesity.¹ Obesity is a multifaceted disease that can begin in childhood and is associated with increased mortality, type 2 diabetes, heart disease, stroke, and cancer.² Due to the variety of conditions that are comorbid with obesity and the associated increase in mortality, there is a vital need for effective strategies to combat obesity and enable individuals to both lose and maintain weight loss achieved to improve their overall health.

The etiology of obesity is complex and impacted by various factors, including lifestyle and environment. One of the primary determinants of obesity is energy balance. Positive energy balance, higher energy intake than energy output, even small, over a long period of time can cause and perpetuate obesity. It’s been estimated that of the individuals in the United States who are obese, 50- 70% are trying to lose weight.³ Most of the efforts made to lose weight include altering diet and exercising habits in an effort to create a negative energy balance. However, these strategies are often not very effective long term due to the inability to maintain the intervention.

One potential treatment for obesity that promotes weight loss and has been shown to reduce comorbidities associated with obesity is bariatric surgery, though it is not without a risk of weight regain. Despite how effective this treatment can be, many individuals who would benefit from this surgery are not good candidates for surgery and any surgery, including this one, can have post- operational complications that may lead to further health issues.⁴ Another option is taking medication for weight loss, though this also doesn’t eliminate the risk of weight regain. Weight loss strategies that focus on altering lifestyle factors are often preferable over surgical or pharmaceutical interventions for individuals trying to lose weight because of their lower cost and less invasive nature. Though lifestyle interventions may be a favorable choice for losing weight for many, there are a variety of barriers that exist for losing weight through this method.

Evidence indicates that there are multiple redundant metabolic mechanisms that exist to maintain body weight. These make it difficult for individuals to maintain weight loss because these mechanisms work against their efforts.⁵ One of these mechanisms is the decrease in resting energy expenditure (REE) that comes with weight loss.⁶ This decrease in REE persists after weight loss due to the decreased energy needs to maintain the lower body weight. Lower REE may contribute to weight regain soon after weight loss by making maintaining a negative energy balance more difficult.

Additional biological factors oppose long-term weight loss, including hedonic reward pathways in the brain that can overcome the homeostatic system and increase the desire to eat despite physiologic satiation in addition to the disruption of leptin responsiveness that may result from the intake of saturated fatty acids and subsequent hypothalamic inflammation.⁷

In addition to biological factors that work against weight loss, there are also many environmental and lifestyle factors that impact the ability of an individual to maintain weight loss long term. Some of the environmental factors include a built environment with limited opportunities for physical activity and active transport, sedentary leisure activities and jobs, pollutants that disrupt endocrine function and affect energy balance, and the prevalence of fast food and sugary beverages⁸. Lifestyle choices regarding frequency and type of physical activity in addition to diet directly impact the ability of an individual to maintain weight loss. It has been found in a meta-analysis⁹ that weight regain often begins within 36 weeks after the conclusion of a weight loss intervention. Some factors in this meta-analysis were found to favor weight loss maintenance. These included the intervention type being a dietary intervention, either alone or with exercise; the duration of the intervention lasting 12 weeks, with no increased benefit from a longer intervention; the use of professionals, such as dietitians, in small groups; and counseling with a health professional at least once a month during the maintenance period.

Studies have also indicated that some individuals with obesity don’t bring up their concerns about weight with their primary care providers (PCPs) which may be due to their skepticism about how effectively their doctor will be able to help them with weight management.¹⁰ Individuals have also reported lower trust in their providers because of perceived PCP weight-related judgment.¹¹

Individuals further noted being frustrated by receiving low-quality care and vague advice from their medical providers, in addition to expecting their providers to be better informed about treatment options.¹² This indicates that there is a need for a better understanding of what patients expect and hope for in interventions that seek to promote their weight loss and long-term weight loss maintenance. Understanding how individuals could be better supported in their ability to lose weight and maintain weight loss will enable the creation of better weight loss programs that help individuals have better results in not only their weight loss but their overall health.

The purpose of this study is to gather information about facilitators and barriers for weight loss maintenance and preferred aspects of an adaptive intervention from individuals who have experienced clinically significant¹³ weight loss in the past two years and have a history of regaining weight. The goal is to conduct a qualitative interview with each participant to discuss their perspective and insights. Gathering this information will prove vital to having a basis for the creation of an adaptive intervention based on specific patient feedback. This will enable individuals to receive the support, resources, information, and coaching they need to be able to adequately maintain their weight loss and prevent weight regain.

METHODS

Study Design

All procedures in this qualitative study were approved by the University of Utah Institutional Review Board. Each participant provided written informed consent prior to any participation in study procedures.

Participant Inclusion/Exclusion Criteria

Participants were recruited either via an online screening form posted in Facebook and Instagram advertisements or by contact through email from the DSS list from their electronic health record. Inclusion criteria included all ethnic groups, males and females between the ages of 18-65 who had experienced at least a seven percent reduction in their body weight in the past two years, an initial BMI of 27 or higher, and experience with weight regain. Efforts were made to recruit participants from a variety of ethnic backgrounds to mimic the overall ethnic population makeup of the state of Utah. Exclusion criteria included weight loss resulting from childbirth, women who were pregnant, lactating, or less than 12 months postpartum, bariatric surgery in the past five years, and recent or ongoing treatment for a diagnosed eating disorder. Participants additionally had to be willing to travel to the laboratory space on the University of Utah campus for verification of their height and weight.

Outcome Assessments

Anthropometrics

Prior to initiation of study procedures participants provided written informed consent. Following that, body weight (Tanita WB-800H Plus Digital Weight Scale) and height (Tanita WB- 800H Plus Height Rod) were measured in light clothing, without shoes by a trained research staff member, and BMI was calculated (kg/m²).¹⁴

Qualitative Interview

Then, semi-structured interviews were conducted over a recorded video call (MS Teams) by trained qualitative research staff. Interviewers asked open-ended questions about how factors that contributed to weight regain. They were then asked about what went well in times when they were able to maintain weight loss. The remainder of the interview was focused on an adaptive intervention. The concept was explained and participants were asked specific questions about what would be advantageous about this strategy and what the drawbacks would be. They were asked about who they would want to deliver the program, preferred format, and preferred contact frequency during various aspects of the program. Clarifying follow up questions were asked at the interviewer’s discretion to achieve clear responses from interviewees. Interviews were video-recorded and transcripts were created from each one for further analysis. Each participant was compensated with a $20 gift card for their participation in the study.

Data Analysis

Transcripts from each interview were the primary focus of analysis and each was uploaded into Atlas.ti for organization and coding. Two primary coders headed the project and met with two other coders who were involved in coding some of the interviews. These transcripts were read over multiple times by various researchers to ensure they were reliably understood and coders met regularly throughout the project to ensure all coding was consistent. Videos were available for reference in the case that there was any difficulty understanding the transcripts. An open-coding approach was used to develop codes based on themes raised by the interviewees. Coding outputs were evaluated and inconsistencies were discussed and resolved between researchers at regular meetings. Subcodes were created as more specific subtopics emerged throughout the interviews. A complete codebook was eventually developed and these codes and subcodes were applied across all interviews. Consensus between all researchers and coders was reached on all codes.

RESULTS

Participant Characteristics

A total of 232 individuals expressed interest in the study. Of the initial interest list, 38 qualified and responded to the research team, 26 attended the informed consent, and 25 attended the in-person interview visit. Thus, a total of 25 participants (56% female) completed the interview visit and were included in the trial. Participant characteristics are presented in Table 1.

Table 1. Participant Characteristics

Quantity of Participants (% Female)	25 (56)
Age, years (mean, standard deviation)	46.1, 13.8
BMI, kg/m2 at time of interview (mean, standard deviation)	31.8, 6.1
Self-reported % weight loss (mean, standard deviation)	18.4, 0.07
% Caucasian, White	68
% Hispanic/Latino	20
% Other	12

Themes

Three primary themes emerged throughout the data analysis: factors influencing weight maintenance, needs and preferences in a weight maintenance program, and aspects of an adaptive intervention.

Throughout these themes seven subthemes emerged as explored in following paragraphs.

Theme 1: weight maintenance factors

Interviewees explored various factors that influenced their ability to maintain weight loss and prevent weight regain. Their responses focused on both the factors that helped them maintain their weight loss and the influences that they noticed in times when they experienced weight regain.

Subtheme 1.1: weight maintenance facilitators

Interviewees described several facilitators in their efforts to maintain weight loss, with many mentioning that an intentional focus on diet and exercise was helpful.

“But remaining vigilant about meal planning and eating, like, for me, eating three meals and exercising, those have been some of the things that have helped me to maintain weight.” (1:6 ¶ 19 in ID01)

There was also a focus on finding ways to maintain motivation through a variety of sources. Some mentioned the importance of getting on the right medications to manage both weight loss and other conditions, such as mental health conditions. Participants also mentioned the importance of having a consistent routine to maintain habits.

“I feel like the biggest thing is being more motivated and making sure that I don’t lose those habits. I think that’s also been another big thing that even if something does come up, I’m still doing something to try and keep that cycle and that rhythm going.” (11:8 ¶ 26 in ID12)

“So I think the first thing that comes to my mind is just stress. … maybe there’s more on my plate and I’m not able to meal plan, or I’m not able to be as active, physically active.” (1:33 ¶ 7, in ID01)

“… I don’t know, life gets busy and then I just start eating, I’m pickin’ off my kids’ plate and whatever’s fast and easy. It was kinda hard to get back to exercising, all that, when working a lot too, so.” (9:3 ¶ 11 in ID10)

Diet was an additional factor that participants associated with weight regain after weight loss. Interviewees mentioned trying a variety of diets that either didn’t work for them or weren’t sustainable.

“[I] did a like very strict diet for several months, got to my goal weight, and then gained it all back after that. And I think it was because, for me it was just what I was doing was not sustainable for just like timewise, restricting-wise, and being able to keep up with that on a long-term basis was just kinda, it was easier just kinda go back to my old ways.” (9:44 ¶ 5 – 7 in ID10)

Theme 2: needs and preferences in a weight maintenance program

In response to inquiries about preferences for a program to assist in weight maintenance, participants mentioned several possible program components and how they would prefer that these would function.

Subtheme 2.1: program experts

Participants mentioned the value of having experts that are part of the program to help them stay accountable and have accurate information and guidance that can help them navigate weight loss maintenance.

“Well, I think, like you said, so actually having someone who is knowledgeable about weight loss or maintaining weight loss, ‘cause we’re talking about maintaining it, having someone there to guide you a little bit.” (20:19 ¶ 46 – 50 in ID21)

They also mentioned the benefit of having someone who could give them personalized, specific information that could provide support.

“Having someone to support me while I’m on the diet or the dieting program. So having like a personal counselor or a personal dietitian I think would be fantastic.” (24:12 ¶ 102 in ID25)

Interviewees mentioned various methods and tools for actually delivering a weight loss maintenance program. Some mentioned apps and emphasized the benefit of meal guidance resources such as meal planning resources, dietary tips, and food logs.

“I think apps certainly help. Recipes for meal planning would be something that could help. Just the basics on recommended dietary intakes for a certain person, for a male, for a female, that sort of thing. Or like how much fiber should a person consume in a day, you know those, some of those basic nutritional tidbits that are really important.” (1:16 ¶ 40 in ID01)

They also mentioned the benefit of exercise plans and tips for helping individuals who haven’t been to a gym much in the past. Several individuals also emphasized the importance of a low-cost option for apps or other tools used by the program.

Subtheme 2.3: communication frequency and methodology

Participants mentioned various time intervals at which they would be preferred to be contacted depending on how at risk they considered themselves for weight regain. In the short-term when low risk for weight regain, some mentioned that weekly, biweekly, or monthly check-ins would be helpful, with others desiring more frequent check-ins. For long term low risk, individuals mentioned monthly, quarterly, or even yearly check-in, with the hope that they could customize their check-in frequency.

“And maybe having a weekly check-in, being like, hey, are things going this week? Do you feel like you’re on track? Has anything come up” (11:26 ¶ 70 in ID12)

“…maybe in the short term, weekly or even more frequently if necessary.” (14:17 ¶ 60 – 61 in ID15)

“I guess once a month until I had established that it was under control and then once a quarter.” (16:17 ¶ 57 in ID17)

“During times when things are going well in the short-term, maybe two to three times a week, just to check in on my diet. Just to check in on my exercising.” (24:20 ¶ 138 in ID25)

For times when they would consider themselves at risk of regaining weight, individuals mentioned various check-in intervals, varying from daily to monthly.

“Probably at least weekly I would think. But it’s like I’m always at risk of regain, always. I mean there’s not a day that goes by that I don’t think about it so it’s always there, so maybe every day.” (14:15 ¶ 57 in ID15)

The method of preferred check-ins varied, but most individuals said they’d prefer a text because of the convenience but a phone or video call could add a nice personal touch.

“I would maybe start out with the text and say, hey, are you maybe willing to have a Zoom call or can we touch base in any way? I think if you ask the person how they’d like to be contacted by a text or in an email, then go from there.” (8:21 ¶ 128 in ID08_31)

“Yeah, I would say texting is just the easiest. But I can do email. Personally, I have social anxiety, so if I get random phone calls, I’m not a huge fan of that.” (2:22 ¶ 49 in ID02)

Theme 3: adaptive intervention

In each interview, the concept of an adaptive intervention was introduced to participants as follows: ‘Adaptive interventions use information about a person to decide when and how to intervene. In the context of weight regain prevention it would be designed to provide personalized support or coaching at the times when a participant is most likely to need it rather than being a set, ‘same for everyone’ program. The idea is that this more tailored approach will be more effective at preventing weight regain.’ Participants were then asked about their initial impressions and the potential advantages and disadvantages that they anticipated with an adaptive intervention.

Subtheme 3.1: advantages

Many of the potential advantages mentioned by interviewees related to the customization of the program to an individual and their specific needs, the adaptation of the program to meet their changing lifestyle, and the accountability of having an intervention program that would keep them accountable.

“The advantages I would see in that particular type of program would be the customization to my lifestyle. I feel that it would support me when I needed it, and then I would learn techniques to maintain my weight.” (24:9 ¶ 86 in ID25)

Some also acknowledged the benefit of having a program run by experts with a thorough knowledge of the research relating to weight loss.

“I definitely see advantage of that because you guys with the research and background could maybe guide me a little better than I can myself.” ( 20:14 ¶ 29 in ID21)

“It might be difficult to meet with someone on a regular basis. Recording, recording behaviors and recording food intake, and exercise and that, can also be a challenge.” (17:17 ¶ 79 in ID18)

Individuals also expressed skepticism about an adaptive intervention because many of them have tried so many strategies to maintain weight loss and still struggled to find success. Many were skeptical that this approach would make much of a difference.

“I don’t know. Maybe. The only thing I can think of is, here’s another opportunity to fail. And so if I’m trying this and it still doesn’t work for me, this is another opportunity to be unsuccessful. So I don’t know, I don’t know if I’d even wanna try.” (14:28 ¶ 29, in ID15)

Participants also explained that unless the individual is self-motivated to actively participate in the program, there would likely be limited success.

“I think the only reason that would keep myself or anyone from not getting help from the program is just not taking the initiative on their own, ‘cause like—it sounds like the intervention or the people are there that want to help, but ultimately it comes down to you, yourself need to want to like, engage.” (6:15 ¶ 45 – 47 in ID06)

DISCUSSION

The goal of this qualitative study is to better understand factors that impact weight loss maintenance and use patient feedback to develop an adaptive intervention to help with weight loss maintenance. From these interviews, insights were gathered about facilitators and barriers to weight loss, types of program experts, tools, and communication frequency that individuals would prefer for a program, and the advantages and drawbacks of an adaptive intervention approach. Participants explained that some of the major barriers to weight loss maintenance included the time involved, the need for constant vigilance in diet and exercise, life events and stress, and mental health. Facilitators for weight loss maintenance were intentionality with diet and exercise, motivation, and routine. In regards to the types of experts they’d hope would deliver a program, they mentioned people who are well educated on nutrition and weight loss and could give them individualized information, such as a dietitian. Helpful tools for a program that were mentioned included apps with nutrition information, meal planning resources, food and exercise logs, and exercise plans. Various check-in frequencies were suggested for both those at risk of regaining and those not at risk, but the consensus was that individuals should be able to select their preferred check-in frequency to individualize the program.

Most preferred check-in via text message, email, or phone/video call. Interviewees additionally acknowledged the benefit of having a program tailored to their needs that would provide credible education resources and allow for informed professionals to aid in their weight loss maintenance. They were skeptical of the potential success of a program in addition to the cost and time involvement, especially since many participants emphasized that they have tried using so many other programs and resources in the past with varying success.

Though various facilitators and barriers arose in the interviews as participants discussed their own experience with weight loss and weight regain, one that stood out was the influence of motivation. When focusing on factors that helped them lose weight, many discussed that they changed their eating and exercising habits, but after a while they loosened up a bit, weren’t as disciplined, or due to life events and stressors, they reverted to old habits. This indicates that the maintained motivation to lose weight and maintain that weight loss is an important part of the weight loss maintenance process. This finding aligns with previous literature that indicates that motivation is a key factor that facilitates weight loss, and waning motivation or focus can be a major barrier to weight loss maintenance¹⁵. Though individuals may regain some weight back, if they have motivation to keep trying, this may have a positive impact on their ability to maintain weight loss. It has been indicated that a motivation-focused weight loss maintenance approach has comparable results to a skill-based approach over an eighteen-month period¹⁶. Perhaps additional study can be done to investigate the effect of using motivational interviewing and other motivation-based techniques to specifically improve weight loss maintenance. The incorporation of motivation-focused resources could be incorporated into an adaptive intervention developed to aid in weight loss maintenance.

Another factor that may aid in the amount of weight loss and weight loss maintenance is the incorporation of experts into a weight loss maintenance program. Various interviewees mentioned the benefit of having experts that administer the program or take part in its delivery to individuals attempting to maintain weight loss. Participants brought up various types of experts, with several indicating that they would like the incorporation of a registered dietitian (RD) into the program. Much of their responses to questions about barriers and facilitators of weight loss maintenance specifically related to diet. It has been indicated that the incorporation of RDs into weight loss programs is significantly associated with weight loss in participants, regardless of the amount of time the RD has in the role¹⁷. A key part of the involvement of RDs into weight loss programs is the individualized consultations that they provide for individuals. A meta-analysis conducted in 2019 indicated that RDs have a small but significant impact on the amount of weight individuals lose in their weight loss attempts¹⁸. An additional systematic review and meta-analysis¹⁹ indicated that weight loss interventions specifically among those with overweight and obesity that included at least five meetings with an RD had a larger effect size than controls, compared to those with four or fewer meetings. This indicates the importance of repeated meetings with a dietitian throughout an intervention program.

Additional research should be done in regards to the direct impact of RDs on long term weight loss maintenance. The incorporation of RDs and individualized patient consultations in an adaptive intervention weight loss maintenance program would be beneficial based on this evidence and patient feedback gathered in our interviews.

Throughout their interviews, participants discussed various advantages of an adaptive intervention approach to a weight loss maintenance program in addition to expressing skepticism and concerns for the cost of such a program. The overall consensus among participants was that the adaptive intervention approach was a good idea and they’d like to take part in such a program, assuming that it could aid in their weight loss. It has been shown that the use of an adaptive intervention approach has a significant impact on the ability of individuals to maintain long term weight loss maintenance when compared to other weight loss programs that contact participants on a static once-per-month schedule²⁰. The ability of an adaptive intervention to base an algorithm for reaching out to participants on the data they input themselves about how they are doing is a key factor that enables participants to get additional intervention in times when they are at a high risk for regaining weight. The use of this adaptive intervention approach should be further studied as a method for maintaining weight loss in the long term.

Strengths and Limitations

The strengths of this study include the in-depth and thorough interviewing of a variety of participants for their feedback and insights. This is one of the first qualitive studies to specifically present participants with the idea of an adaptive intervention plan and ask for their thoughts, which is a strength. The use of multiple independent coders who came to a consensus on all codes is also an important advantage in this study.

However, this study is not without limitations. It should be understood that there may be some convenience sampling bias and response bias because participants filled out the screening form on their own from advertisements or emails. There was no randomization of participants interviewed from those who qualified; interviews were scheduled first with participants that were responsive and available. It should be noted that although height and weight for each participant were verified at the interview visits, there is no way to verify that participants truly lost or regained the amount of weight that they reported. Due to the nature of the qualitative study design, there may have been errors in understanding participant’s responses from the transcript of their interviews, especially because English is not the first language of all participants.

Conclusions

Obesity continues to be a prevalent and challenging health issue that affects much of the population. Though many individuals make efforts to lose weight, most eventually regain some or all of the weight they lose in these attempts. Individuals who have experienced weight regain have valuable insights into the unique barriers and facilitators for weight loss maintenance that should be taken into consideration by those developing weight loss maintenance intervention programs. An adaptive intervention approach could be an influential tool for promoting weight loss in a variety of individuals due to the adaptive nature, potential for individualization, use of program experts, and variety of delivery methods. The incorporation of the feedback of individuals who have experienced weight regain is a vital asset to the development of any weight loss intervention program.

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