Weight loss is often perceived as a straightforward goal, but the reality is far more intricate. It's a journey marked by both triumphs and setbacks, influenced by a web of factors ranging from individual lifestyle choices to broader societal and healthcare contexts. This article delves into the multifaceted nature of weight loss, drawing upon research, personal experiences, and expert perspectives to provide a comprehensive understanding of the challenges and potential pathways to success.
Understanding Obesity as a Complex Condition
Obesity is a complex disease with many underlying causes, not simply a lack of willpower or a matter of lifestyle. Part of the answer lies in the fact that there's more to obesity than you can see. It is estimated that 1.5%-4% of the population live with the complex chronic condition of severe obesity (Body Mass Index/BMI ≥ 40 kg/m2). The Western obesity‐promoting environment, characterised by easy access to food, reduced work-related activity, and active transportation, is unlikely to change in the near future.
The Promise and Peril of Weight Loss
If you have recently tried and failed to lose weight, it may seem hard to find the motivation to begin this process again. However, even modest weight loss can yield significant health benefits. When you lose 1-5% of your body weight, you can expect to see benefits to your cardiovascular health. If you do manage to lose over 10% of your body weight, there are even larger health benefits. A 10-year study conducted in 2004 found that those living with overweight or obesity who lost 10% of their body weight in the first year saw a 21% decrease in the chances of a heart attack or a stroke, a reduction that was not seen in those that lost less than this amount.
Despite these potential benefits, maintaining weight loss is a significant challenge. Studies have shown that up to 80% of people who have lost a significant amount of weight gain almost all of this back within 2 to 5 years. This highlights the need for sustainable strategies that address the underlying factors contributing to weight gain.
Lifestyle Interventions: A Holistic Approach
Lifestyle is a way of living based on patterns of behaviour influencing a person's health. It is determined by the interplay between personal characteristics, social interactions, and socioeconomic and environmental living conditions. A person's lifestyle is not fixed, but subject to change; however, there is no ‘optimal’ lifestyle to be prescribed for all people.
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Lifestyle interventions for persons with obesity are multidisciplinary and take motivation, barriers, facilitators, relationship with food, diet, and exercise into account. The goal is to promote behavioural changes that lead to weight loss. Along with lifestyle interventions aiming to support persons in avoiding disease and improving physical health, interventions also address the experience of well‐being. Well‐being is an integrated existential dimension connected to a person's lifestyle and health, as well as a person's ability to partake in certain everyday life activities. Thus, lifestyle interventions are complex and entail numerous aspects of each person's life.
The "Journey of Ups and Downs": A Qualitative Perspective
Maintaining a healthy living after the end of a lifestyle intervention is a challenge for persons with severe obesity. A study used a hermeneutic phenomenological approach. A purposive sample of seven adults with BMI ≥ 40 was recruited from a lifestyle intervention programme. Data were generated through individual follow‐up interviews. The analysis was based on a theoretical framework on dwelling and mobility. One overarching theme emerged: ‘The journey of ups and downs’.
Everyday life among persons with severe obesity is experienced as a dynamic process of shifting experiences of dwelling and mobility. Sustained lifestyle changes require ongoing adjustments of action, which healthcare providers can influence in ways that either support or obstruct. In everyday life, different kinds of well‐being and suffering were experienced, which generally influenced the maintenance and development of a healthy living. Ups and downs related to different aspects of life such as bodily changes and abilities; mood and mental distress; being capable and having hope. The ups and downs challenged the balance between dwelling and mobility. The constant awareness towards lifestyle changes and adjustments made little room for dwelling, and with lack of dwelling, it was difficult to experience mobility and continue fighting. Major life change events and hassles made a healthy lifestyle more difficult. Repeated relapses to earlier habits were inevitable parts of everyday life. These relapses contributed to a lack of mobility in a sense of incapacity, and to a lack of dwelling, in a sense of shamefulness of being incapable.
The Impact of Everyday Hassles
Apart from tackling and living with obesity, the participants were facing numerous hassles. Living with and tackling these hassles was exhausting and gave a reduced sense of mobility in life, where doubts about whether it was possible to recover energy and vitality added to the fear of gaining weight and becoming inactive. A man found it difficult to maintain the energy to keep on making lifestyle modifications: ‘I know it very well, I KNOW it, but I just can't do it any longer…I have lost the spark’ (P09). Some experienced that their spatial surroundings blocked their dwelling possibilities. Living in messy and unsuitable homes and being unable to get them sorted due to a lack of physical and mental resources limited the opportunity for having a breathing space, where they could relax; for creating room for having guests and prevent feeling loneliness; carrying out cooking instead of eating random food; and moving around or training at home. Moreover, poor economy was a limitation for some participants. It reduced their possibilities of buying healthy food and doing certain types of exercise, for example, when they could not afford to join a health club or to go on family trips to a swimming pool, which reduced their physical activity level. The hassles of everyday life imposed disturbing thoughts that can be viewed as an obstruction of dwelling and mobility. Being deeply concerned led to sleeplessness and tiredness, which reduced the initiative to be active during the daytime.
The Role of Self-Esteem and Acceptance
Obesity and weight loss were experienced as a daily concern that disturbed dwelling in one's view upon oneself and one's body and could make the fight for weight loss seem impossible. Without a sense of self-esteem, the failed weight loss attempts led to disappointment, powerlessness, and hopelessness. It was an experience of reduced mobility, as with this man, who was losing the energy to continue the fight: ‘I have totally given up…somehow I feel I don't give a shit. Well, I am giving up. I hardly bother doing anything to lose weight anymore…because it's going up or stays the same…it doesn't help anyway’ (P15). For the persons suffering the most, their present life with obesity was experienced to be intolerable and the future to be repellent or unliveable. Well‐being was to a great extent influenced by the idea of an ideal weight and other's expectations and opinions on body size, appearance, and attractiveness. Accepting one's large body size was hard, and body dissatisfaction raised the question of whether lifestyle change was the ‘right’ way to go or whether undergoing weight loss surgery (WLS) could be a possible short cut to permanent weight loss.
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The Influence of Healthcare Providers
Maintaining lifestyle changes was influenced by the social and healthcare systems. Health services had been used by the participants during the past three years in relation to physical and/or psycho‐social health problems. HCPs had an important role in their everyday lives. The relationship with the HCPs influenced the participants’ sense of dwelling‐mobility, that is, how to find peace in what is given in life and be able to change what is possible. Having someone trusted to talk to and to meet in one's deepest concerns was considered of great importance for a person's possibility of dwelling, for example, when feeling understood and cared about - and not like a number. The HCPs showing genuine interest, empathy and sensitivity as well as remembering a person and his/her history added a sense of positive attitude and responsiveness to the help requested. Especially for the participants, who did not have anybody close, the dialogue and the collaboration with HCPs facilitated the mobility to tackle life's hassles and move on with healthy living. A man told how HCPs could also impose suffering when pressuring him against his will: ‘I don't want to hear “group exercise” one more time in my life, because then I will stop exercising. I feel like shit …
Shifting the Focus: From Weight Loss to Well-being
For nearly two decades, the focus on weight loss has been criticised for lacking results and carrying the risk of harming the individual. The result can be yo-yo dieting with relapses, which causes feelings of defeat, failure, and shame. Persons with severe obesity may experience improved quality of life after lifestyle intervention with less binge eating and depression, as well as improved physical and mental health in everyday life. This is known to contribute to their weight management. Still, making lifestyle changes requires great personal efforts, and relapse is possible at any stage of the intervention. It is challenging for healthcare providers (HCP) to support a person in maintaining healthy behavioural changes. The HCPs may overlook the fact that facilitators and barriers to healthy living are numerous and have an underlying complex existential character. Even after ending an intervention programme, persons with obesity continue to struggle with existential challenges in everyday life.
Dwelling and Mobility: Key Concepts in Understanding the Journey
Everyday life can be described as ‘being‐in‐the‐world’ in a seamless and familiar everydayness. The everydayness is temporary because our experiences may change our understanding over time. Everydayness is holding the experience of possibility and of developing self‐fulfilment, however, always within the limited freedom of being born in a pre‐determined genetic, cultural and historical time. We are always with others in our everydayness, and the experience of well‐being cannot be detached from them. Well‐being is defined as the experience of something positive and wanted in one's everyday life and is opposed by the experiences of suffering. Together, they encompass all aspects of health across the physical, mental, social, and spiritual dimensions. Well‐being and suffering exist in different nuances balanced between dwelling, mobility, and dwelling‐mobility. Dwelling is a capacity for settling into the present moment and to feel at peace with what is there. Mobility is a capacity for moving in ways that expand one's life (metaphorically or literally).
There seems to be a tendency to overlook the everydayness nuances of dwelling and mobility in research and healthcare practice. Little is known about how the existential challenges in everyday life influence choices and actions after lifestyle intervention among persons with severe obesity. Their needs and barriers deserve further attention in order to improve lifestyle interventions.
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