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Table 2 Description of themes and subthemes with supporting quotes

From: A “messy ball of wool”: a qualitative study of the dimensions of the lived experience of obesity

Theme 1: Complexity and battle
“It’s a messy ball of wool, really.” (FG2, Female 45)
The experience of overweight and obesity was painted as a complex picture with many interacting parts, often interacting in unpredictable ways, with difficulty in finding a rhythm that allowed desired action to be taken. Challenges were both emotional and physical, with the deviation from a societal norm adding to life’s challenges.
It’s Complex A complex interplay of factors was at play which both precipitated and perpetuated difficulties in addressing obesity. It felt like a “vicious cycle” or a “catch 22.” Frustration occurred as participants could identify the challenges and what needed to be done but could not explain their own behaviour, which sabotaged their efforts.
This confusion prompted acknowledgement that there was no silver bullet, it wasn’t a linear process, and there was danger in considering interventions such as bariatric surgery in this light. Understanding this complexity translated to knowing that a unidimensional approach could not be successful.
If I knew probably what the barriers were, I wouldn’t be struggling so much... I should be old enough and wise enough to say “that can stay in there till tomorrow night” but no I’ve got to demolish it . . . I think I know I can’t do that, but I should, but I can’t, but I should, it’s very conflicting. (Female 48)
The worse you eat the worse you feel. (Female 32)
We order the food in and we think, yes this will fix me because we have someone dealing with my food but we forget that no one is dealing with the exercise, no one is dealing with our mental health, no one is dealing with the cleaning and no one is dealing with the 100 billion other jobs we need to do. (FG1, Female 42)
. . . looking back on it now I think I was looking at it [bariatric surgery] as a way to solve all of my problems . . .pinning all my hopes on the fact that this was going to fix everything . . . I don’t think it does that at all. (Female 32)
Fluctuating battle with self It was difficult to find balance in order to focus on spending time on weight loss management. Personal capacity and psychological challenges presented as hurdles, creating a sense of struggle, impeding change and limiting hope.
A sense of angst occurred when personal ‘wins’ or visible results were absent leading to a vicious cycle and greater hurdles to overcome.
Physically, being overweight caused everything to be more difficult - leading to a feeling of battle with one’s own body. Motivations fluctuated, with conflict between wanting to lose weight but lacking motivation.
Despite these challenges there was also a desire for this battle to be overcome regardless of how tough it was. Inevitably there were ebbs and flows, fluctuations in the battle, wins and losses, positive and negative experiences. The battle was all-encompassing.
I thought maybe it's something in my mindset . . . like a barrier . . . the light at the end of the tunnel is pretty dull. . . . [It’s a] physical strain carrying around this much weight. (Female 56)
I want to yeah to get the battle fought and won, to a place where I can be content with my weight . . .finding that balance meeting everyone else’s needs and time for me really hard. . . . to see the results you need to work hard you know um so if you don’t see the results straight away you fall off the wagon. (Female 32)
. . . it takes determination day in and day out, why doesn’t it work. . . . there is a difference between wanting to lose weight and being motivated to lose weight … I am not always motivated to lose weight, sometimes I don’t give a stuff. (Female 66a)
I struggle with motivation. I can get really really motivated and then the littlest thing will get me off that track and I will make all the excuses under the sun to to get off track and then getting back on track is really hard. (Female 59)
Words depicting a herculean effort are used: “fight,” “win,” “determination,” “tough,” “hard work,” “overwhelming.”
“It’s a yo-yo battle,” “rollercoaster,” “spiralling,”, “plateau,” “tunnel-like.”
Bodies (not) fitting in A further manifestation of the battle is the experience of being restricted, trapped, a body being squashed into a space. Normal activities such as buying clothes, cutting toenails, intimate relations, are impacted by size. Even the feeling of clothes can be a reminder of the attached stigma; accommodating regular changes in size with weight fluctuation also a consideration
Fear about ‘fitting into daily life’ resulted in limitations on participation in activities, with obesity or size accentuating the isolation experience and further impacting on interpersonal relationships. The design of the physical environment contributed to negative experiences, compounding the impact of obesity itself.
I’m trapped in the house I can’t get out I’m just trapped there… (Female 59)
I just want to get home and take my clothes off because they are too tight. (FG1, Female 69a)
…sorry we don’t have anything in your size dear, you know, before you have even tried anything on or looked at anything. (Female 56)
Well general discomfort carrying this, when I bend over to paint toenails or even to do up my shoes I start to feel quite strange. . . . it impacts on my sex life because there is this great big gut hanging there. (FG2, Female 69b)
I’m scared of my weight if I go out somewhere, you know they have got plastic tables and chairs and I’m scared to sit on a plastic chair because on one occasion, I actually had a chair collapse underneath me… there are times when say my friends wanted to go to the movies I didn’t want to go because I physically couldn’t fit in the seat. (FG3, Male 39)
One of the things I have had to work with is the fact that my trousers, I had to try and find a trouser that will accommodate the fact that I am losing weight. . . we worked out that there is a particular design that has tabs on the side. (Female 42)
Theme 2: Impediments
“I have tried so jolly hard to lose it and met with so many brick walls.” (Female 56)
“. . . it’s just a very, very hard road.” (Female 47)
Impediments were pervasive for most participants, as indicated by the three sub-themes: internal, relational, or structural. Impediments led to a negative orientation, making taking action to improve health outcomes challenging.
Internal impediments Internal impediments relate to the challenges which participants believed they should have control over them but didn’t. Understanding why a level of control could be exercised in other aspects of life, but not this, was perplexing.
A high level of psychological involvement was identified in weight related health behaviours. This was articulated in different ways with descriptions of the psychological aspect as emotions, mindset, in the head, attitudes and a “psychological thing.” This psychological element created barriers to change. There was a desire to behave in one way, however actual behaviour could be the opposite. Understanding that behaviours were contributing to weight but feeling powerless to stop them, or not knowing how to change, was frustrating. Furthermore, this led to negative self-perceptions which also impeded change. This feeling of lack of psychological control was compounded for those who found emotional solace in eating.
Habituation was more common-place than compulsivity, however there was movement in and out of ‘habits’. Coming off diets was an example of a retreat back to previous habits, as were shopping behaviours. Habits provided a level of comfort but were at the same time impediments to change.
Negative orientation toward being overweight and to the experience of attempting to lose weight led to frustration, fear, depression, guilt, despair, and a sense of failure. Negative feelings towards the process of weight loss itself aligned to both dieting and exercising. Dieting was perceived as anti-social and isolating. Exercise was perceived as difficult to achieve for reasons including the time it required, lack of motivation, finding an appropriate activity or venue, cost, lack of confidence, having no energy, and being pushed too hard.
The impact of internal impediments could be overwhelming, with no clear way out, perpetuating the sense of battle (Theme 1).
I think if I have got the willpower to do a whole lot of other stuff that I do which absolutely takes determination day in and day out. Why doesn’t it work for the food thing? And I sort of wonder what the psychology of willpower is. (Female 66a)
The emotional thing is my biggest battle it’s that whole I get upset so I turn to food, you know I get angry I turn to food, I am happy I turn to food. . . . I need someone to help me control those emotional links that I have with food, I need someone to teach me other strategies when I am feeling down. . . . I might lose weight but then I come off the diet so to speak and go back to normal eating. (Female 32)
…it is in my mind all the time, that’s in the freezer… and I will go out and I will have one, a little cone and then sit in front of the TV and think, oh that was lovely and back out and I have to have another one…and then feel quite ill and guilty. . . . Whenever I’m in hospital I eat like a horse ‘cause everyone thinks the hospital food is so awful but I just eat everything they put in front of me yeah um cause I, I don’t know, I feel comfortable. (Focus group 2, Female 61)
I find myself saying negative things about myself all the time. … I don’t like fat any more than anybody else, in fact I probably like it less than anybody else.. . . I hold on to the weight, as if I have to make myself bigger to protect myself or something, which is exactly the opposite of what I want to do. . . . Losing weight to me has been a very important goal and I just cannot achieve it. (Female 56)
We’ve been educated about food and what we should and shouldn’t be eating and doing, but we still do it, so there is an element of guilt. (FG3, Male 69)
. . . most of my eating most of my life has been comfort eating and it has been emotional. (FG3, Male 42)
I don’t feel like I’ve got any control of anything right now I’m not in control of myself. . . . I can’t get motivated, I can’t do anything right now I am just so physically and mentally exhausted. . . . Eventually I will just drop dead of a heart attack and I’m thinking well you know maybe that’s an easier way out for me, that’s an awful way to be thinking. (Female 61b)
Relational impediments Relations with others were often not helpful and sometimes an impediment. These influences could act as a barrier to positive progress.
Health professionals we important in providing information and support, however experiences were varied. Negative experiences were not uncommon, resulting from an apparent lack of understanding of the complex experiences relating to obesity. Insufficient attention to the mental health or the psychological aspects of obesity by health professionals limited the usefulness of these interactions.
Conflicting advice, not enough information, or a lack of follow through were further impediments with inadequacies related to a lack of time, an inability to adequately discuss needs or give direct advice, a focus on bariatric surgery as a silver bullet solution, and lack of familiarity regarding other resources for weight loss management.
Knowledge deficits were apparent: a lack of knowledge about health professional support; a lack of knowledge or understanding about how to achieve weight loss; and contradictions with conflicting messaging from multiple sources.
…he said it’s a mathematical equation, you put energy in, you expend energy and the result is a loss in weight, that’s it, simple….. (Female 56)
It’s amazing how you can be completely invisible and enormous at the same time. (Female 66a)
Oh I have had a skinny doctor too who just kept bagging me every time I went in there for being fatter than last time. (FG2, Female 45)
. . . you get some information from here and some information from there but you never know if it is accurate and you can try going down one path and find it a complete failure and then you can get another bit of information and try that for a while. (FG2, Female 45)
… still hadn’t heard anything so in the end I contacted her a fortnight later and I got told that she had been overseas for a week, so at this point I am totally disillusioned because I didn’t know whether or not my food diaries were right or wrong or what I was eating was right or what I was eating was wrong… (Female 42)
. . there is no-one to walk with, my girls work full-time and they’re all tired so I’m in a pickle . . . I just find that when you live on your own, you seem to put everything in the too hard basket. (FG1, Female 69a)
…you hear this about cutting your carbs down and you will be alright and then someone else says, no, no you cut your fat down and then someone else says you cut your sugar down, I don’t know maybe you are supposed to cut them all down…(FG2, Female 61a)
. . . for the last 30 years every doctor I ever tried to speak to about being depressed, straight away here’s some Zoloft... I don’t want to take that I want to deal with what’s going on. . . . ...he can be quite dismissive of things you know. (Female 61b)
It is hard to get access to personal trainers, it is hard to get access to dietitians at the hospital, there is an enormous wait to get into those things and you tend not to be able to get, my GP wouldn’t know where to start. (FG2, Female 45)
Systemic barriers Negative societal perceptions and biases towards people who are overweight were felt widely. Participants were aware of others’ attitudes and judgements about not being good enough, not trying hard enough, being excessive eaters, lovers of unhealthy food, lazy, stupid, ugly, dirty, and not deserving of respect.
For some isolation was problematic, not having someone to be there, to provide motivation, allowing negative behaviours to perpetuate.
Barriers to accessing services, community clubs, and events which could serve to promote health occurred, sometimes these barriers were practical (e.g. financial, lack of transport, responsibility for children) and sometimes they related to a negative culture within society and within organisations towards obesity. Access to health services remained an enigma, leaving participants wondering how to find the help they needed
If you are fat, you are stupid and it drives me bananas and there is that automatic you know, silly dumb woman. (Female 66a)
You have McDonalds and some you know yobbo will say ‘what are you having Maccas you fat so and so’. (FG3, Male 42)
Oh yeah you do feel like you are being looked at when you are walking around with a shopping trolley, you do. . . . I want to exercise, I really do, but I want to feel comfortable doing it somewhere and without a lot of funds I don’t know of anywhere I can do it for free in an enclosed, safe place. (FG2, Female 45)
See a mum with two kids, with depression, how can she possibly join the gym that only has sexy, beautiful girls on the poster. (FG1, Female 42)
…families are using McDonalds as it’s twenty bucks and you have fed your whole family, whereas if you go and buy fresh fruit and vegetables, which I actually do, it costs a hell of a lot. (FG1, Female 55)
…when you haven’t got transport it is very hard to get somewhere to join in. (FG1, Female 69)
With the GP for example, they don’t have time, they have a waiting room full of people. (Female 56)
When going to someone else’s place when you only eat a small portion and they get really offended and I get really worried about it. (Female 66a)
Theme 3 Positive re-orientation
“I walk every day and eat breakfast obviously something is going right at the moment; I am losing a bit of weight.” (Female 48)
Subthemes associated with positive reinforcement followed a potentially chronological process which begins with a shift to an empowered orientation, leading to positive activity, and resulting in behavioural reinforcement. As we have seen from previous themes, this linear description is too simplistic, and the complexity previously described prevails, however an understanding of this process is useful in formulating knowledge to facilitate the process.
Empowerment and motivation A positive change in mindset was the first step towards acting. Motivation played an important part in this change, intrinsic and extrinsic, often the two occurring simultaneously. Improved physical and psychological health, wanting to habitat a different shaped body, wanting a fuller engagement in family activities and to be there for children, were important motivations. Social connection could act as motivation - the focus groups themselves motivating, but ultimately there was a recognition that intrinsic motivation was key.
Knowledge and understanding the benefits of healthy eating and knowing that there are long-term effects of eating the wrong foods was also a condition to promote empowerment. Knowledge as insight was expressed as feelings, intuitive knowledge or known fact. Ownership of health was understood as personal responsibility but required knowledge of what it is preferable in terms of actions.
Overwhelmingly participants felt more empowered when their whole circumstances and health management were considered and pro-actively addressed by health professionals. This helpful interaction included the health professional being honest, respectful, listening and addressing the difficult issues as well as referral to other health professionals as required. Individualised management and planning for achieving weight loss strategies was considered necessary with the need for psychological support and adequate information.
Realisation that there had been a change in thinking and attitude toward making change occurred sometimes as a pleasant surprise.
Well my doctor said if I don’t get the weight down I’m going to become a diabetic. (FG3, Male 63)
. . . you see somebody that you know you know that’s had a battle and you see something good come out of that and it kind of inspires you a little bit. (FG3, Male 34)
I realise that I was eating too much of the wrong kind of things. . . . But the buck stops with me . . . you have to get up and just decide well today is the day I am going to change my life. (FG1, Female 55)
I know a lot of the solution has to come from me. (Female 32)
…it’s not just for me it’s for my kids I want to be able to go and do things with them, I want to be here for a long time. (Female 59)
I have been exercising, I feel as though I don’t want to eat all this horrible stuff. I am starting to get this mindset about, hey come on you are doing this now you have to keep it up with the food. (FG2, Female 61)
I know too with our children we have [to] do right so that they learn. (FG1, Female 42)
For me the best idea would be for each person to discuss, with the right, appropriate person full of information, is what do you want, do you want general fitness, do you want flexibility, do you want weight loss… and tailor something to that person. (FG2, Female 45)
I thought somebody was at last starting to take a holistic look at the problem, rather than at specifics [agreement] and I think um the approach between the dietitian and the psychology, psychological approach is the right approach. (FG3, Male 71)
Mainly for me at the moment it’s the why I do it and how to then cross that bridge in to stopping that behaviour. . . . I need someone to help me control those emotional links that I have with food, I need someone to teach me other strategies when I am feeling down. (Female 32)
. . . with us four just being here it seems to motivate me to talk about things, but then I go home and I am back to square one again, no one to talk to. (FG1, Female 69a)
Positive action Small but realistic lifestyle changes were important in achieving change and enabled positive action. Learning that it was counterproductive to exclude foods which provide pleasure was important. Becoming more physically active relied on finding the right activities in a supportive, non-judgemental environment. Support in understanding and acting on the psychological aspect of weight and the contributing behaviours enabled a holistic approach.
Finding a supportive environment with the right people to provide support helped to facilitate positive action. Finding others who had shared experiences, with a realisation that it was not necessary to go through change alone, provided a context to facilitate change.
I answer the phone standing up now… I get up, I stand up and whether it is a mobile call or the house phone I stand up and that might only be for 5 minutes or 10 minutes but it is 5 minutes or 10 minutes that I am standing up which is better than sitting down. (FG2, Female 45)
. . . never deny yourself of anything… yeah it was a matter of moderation. . . . if I need to eat a chocolate bar to be happy well I will eat a chocolate bar to be happy. (FG1, Female 42)
I used to have two big teaspoons of sugar in my coffee every day but I have cut down to a small teaspoon. The first two mornings were ‘ewh’ - it was like poison, but after that I persevered and now I am used to the one … ‘I’ve cut down on my sugars, I’m a good Mum’, I was quite pleased with myself. (FG1, Female 69)
. . . .it’s probably the first time for me in my life that I’ve ever really concentrated on doing something for me.” (FG3, Male 39)
Yes, they have all these trainers there to put you on the right track … I went yesterday and I went last week but no-one, it seems to me that no-one is judging you. Like, some are big, some are little, but we’re all there for the same reason. (FG2, Female 61)
Behavioural reinforcement Positive activity was particularly successful when associated with a learning that tackling the problem head on through behaviour change can lead to positive emotions and result in a sense of satisfaction at doing something for one’s self.
Behavioural reinforcement further promoted positive re-orientation through feeling good, physically and psychologically, triggered for example by a realisation that some weight loss had been achieved, noticing that clothes fitted better, enjoying shopping for clothes, and feeling physically fitter or healthier.
Positive reinforcement from others also occurred. Receiving compliments and significant people offering to support the desired behaviour changes.
. . . nobody mentions how wonderful you will feel if you just do that, you know, it’s a funny sort of thing. They will say “you will be better for it” but it’s not quite the same as you will really enjoy doing … something really small like how you feel after a meal if you have eaten such and such, and it is the pleasure of particular things, see it is all the things that are good for you. Nobody actually says, you will actually really enjoy the physical thing of eating. (Female 66a)
I’ve been walking a lot… I’ve been walking around the block for 30 minutes … and then I go and walk the big block and I love it. (FG2, Female 55)
I felt much better you know I could buy nice clothes which I couldn’t before, um and I can’t now, and um and I enjoyed going shopping and I used to hate going shopping and I hate going shopping now, um and you know I just felt more positive about myself in general. (Female 61b)
I think I am improving in stamina, I’m like when I first started ballroom dancing I could only do a little bit and then I was, puff, puff, puff and now I can go to the social dance and dance most of the night . . . That sort of boosts your self-esteem up straight away because years ago I used to do that sort of thing, dancing every week. (Female 56)